How to Best Assess Blood Pressure?

Abstract

See related article, pp 1087-1093I t is half a century since high blood pressure (BP) measured in the doctor's office has been proved to be a strong predictor of cardiovascular morbidity and mortality. However, it soon became clear that multiple factors can significantly affect the BP measurement result (Table 1) and may thereby have considerable impact on its prognostic ability.Despite the intensive research with almost 120 000 PubMed papers on issues related to BP monitoring, the question "how to best assess BP" is still a matter of hot debate. Notwithstanding these difficulties, research in the field of BP monitoring has considerably refined the BP measurement procedure, by systematically addressing all factors listed in Table 1. Such improvement has included a better standardization of methods as well as the development of multiple approaches to BP quantification, aiming to more precise risk prediction. This was achieved not only by a more accurate estimation of mean BP, but also by the evaluation of different patterns of BP variation over time. Although, irrespective of the measurement methodology (Table 1), any BP value is by itself a powerful index of risk, several aspects of BP dynamics assessed by considering patterns of BP change over time have been proved to increase the prognostic ability of BP, over and above the information provided by conventional office measurements.Practicing physicians, as well as patients themselves (particularly those self-monitoring their BP at home), are frequently concerned by the possibility that BP fluctuations occurring in daily life, which often rise well above the average BP level, might cause additional hemodynamic stress on the heart and vasculature, increasing thereby the risk of organ damage. Indeed, the frequent occurrence of BP fluctuations, sometimes of non-negligible magnitude, is evident with all the routinely used BP-monitoring methods (office, home, and ambulatory). However, despite the accumulating evidence on the clinical relevance of BP fluctuations over and above that of average BP, 1-6 this issue largely remains an interesting hypothesis only, and in clinical practice BP values with large deviation away from the average are usually regarded as "random" and "noise" and are ignored.In this issue of the journal, Matsui et al 7 provide evidence that in untreated hypertensives the maximum systolic BP value of 14-day home monitoring is more closely related with cardiac and vascular damage than average home BP. Moreover, maximum home BP showed independent predictive ability for target organ damage, beyond that of average home BP. In a recent retrospective analysis by Rothwell et al,4 maximum BP assessed by office measurements was also a strong predictor of stroke independently of the mean BP. In the same line, a study in acute ischemic stroke showed that the maximum BP assessed during the first 3 days in hospital was closely associated with the risk of developing hemorrhagic transformation independently of the mean BP. 5 Thus, occurrence of BP peaks, wherever...

Is home blood pressure variability itself an interventional target beyond lowering mean home blood pressure during anti-hypertensive treatment?

“…Although day-to-day BPV is an index of BPV during the medium term, BPV within a 24-h period assessed by ABPM and visitto-visit variability assessed by clinic BP are indices of BP instability during the short and long terms, respectively. 16 There is no consensus on a single definition of the method to evaluate day-to-day BPV. Kikuya et al 4 evaluated measuring BP once every morning and evening to calculate day-to-day variability, while Johansson et al 17 evaluated measuring BP twice every morning and evening.…”

Blood Pressure Variability and Vascular Dysfunction in Essential Hypertension

“…How to best assess blood pressure average and variability is still a matter of the ongoing debate on the clinical value of blood pressure. 94) We must pay more careful attention focused on hypertension with blood pressure fluctuation. In order to predict the future atherosclerosis and cardiovascular events in subjects with hypertension, the adequate assessment of endothelial function is one of the most reliable markers.…”

Home monitoring is the optimal method for assessing blood pressure variability

“…However, these different components of blood pressure variability may reflect different mechanisms, are likely to provide different information on cardiovascular regulation, and might have different clinical implications that are still poorly understood. 1 The assessment of office blood pressure variability in repeated visits, although successful in the context of outcome trials such as the ASCOT 2,3 and the NHANES 4 studies, appears to be impractical for routine clinical use; first, because of poorly standardized office measurements and, second, because of the long time required for multiple visits. Regarding the 24-h ambulatory monitoring, the results of the ASCOT study and the IDACO database have been rather disappointing, 2,3,10 but further studies with more frequent readings must be performed.…”

“…1 Recently, blood pressure variability has gained significant attention due to the publication of retrospective analyses of the Anglo-Scandinavian Cardiac Outcomes Trial Blood Pressure Lowering Arm (ASCOT-BPLA) data by Rothwell et al These analyses showed, first, that systolic blood pressure variability and the maximum systolic blood pressure are strong predictors of stroke independent of the mean blood pressure 2 and, second, that different antihypertensive drugs might differently affect blood pressure variability, influencing their contribution to cardiovascular protection. 3 The NHANES study confirmed the relationship between systolic blood pressure variability and an allcause mortality in the general population.…”

“…The assessment of the blood pressure abnormality and the classification of hypertension are traditionally made on the average of multiple measurements taken in the office or by 24-hour ambulatory or self-home monitoring, whereas the blood pressure fluctuations, which often rise well above the average blood pressure level, are usually regarded as 'random' and 'noise,' and are thus ignored. 1 …”