In-Clinic Blood Pressure Prediction of Normal Ambulatory Blood Pressure Monitoring in Pediatric Hypertension Referrals

Abstract

OBJECTIVE Since younger patients have low pretest probability of hypertension and are susceptible to reactive and masked hypertension, ambulatory blood pressure monitoring can be useful. To better target use in referred patients, we sought to define in-clinic systolic blood pressure measures that predicted normal ambulatory blood pressure monitoring and target end organ damage. DESIGN,SETTING,PATIENTS,OUTCOME MEASURES Data were collected on consecutive patients referred for high blood pressure undergoing an ambulatory blood pressure monitor from 2010–13 (n=248, 33.9% female, mean age 15.5 ± 3.6 years). Candidate in-clinic predictors were systolic maximum, minimum or average blood pressures obtained by auscultative, oscillometric or both. Multivariable logistic regression models were used to determine the prediction of normal ambulatory blood pressure monitoring by in-clinic blood pressure predictors. Separate models considered predicting left ventricular hypertrophy by in-clinic systolic blood pressure versus ambulatory blood pressure monitoring-defined hypertension. Identified predictor utility was tested with receiver operator characteristic curves. RESULTS Maximum (OR 0.97 [95%CI 0.94–0.99]; p=0.047), minimum (0.96 [0.94–0.99]; p=0.002) and average (0.97 [0.95–1.00]; p=0.04) in-clinic auscultative systolic blood pressure predicted normal ambulatory blood pressure monitoring. Each had a cstatistic of 0.58. Left ventricular hypertrophy was associated with in-clinic auscultative minimum systolic blood pressure treated continuously (1.05, [1.01 – 1.10], p=0.01) or dichotomized at the 90th percentile (8.23, [1.48 – 45.80], p=0.02), as well as ambulatory blood pressure monitoring-defined hypertension (3.31, [1.23 – 8.91], p = 0.02). Both predictors had poor sensitivity and specificity. CONCLUSION In youth, normal auscultative in-clinic systolic blood pressure indices weakly predicted normal ambulatory blood pressure and target end organ damage.

Ambulatory blood pressure monitoring in children: A retrospective single-center study

“…In contrast, the results of the SHIP AHOY study suggested that clinic systolic BP of 85th percentile based on the AAP CPG reference data may be the optimal threshold to perform ABPM (5). Johnson et al (26) suggested that normal auscultative systolic BP in clinic weakly predicted normal ABPM in children. Our study did not find that clinic SBP readings help to predict the diagnosis of hypertension.…”

Prediction of Ambulatory Hypertension Based on Clinic Blood Pressure Percentile in Adolescents

“…We also found a discordance between clinic and ambulatory BP, which confirms the findings of previous retrospective pediatric studies. [9][10][11][12] In two of these studies, conducted on otherwise healthy patients referred for evaluation of HTN, 12%−17% of those with normal clinic BP/pre-hypertension had ambulatory HTN (masked HTN), while 46-55% of those with clinic HTN had normal ABP (white-coat HTN) 9,10 . In another study, conducted on a mixed population (including patients already treated for HTN and CKD and diabetes patients), 36% patients of non-hypertensive per clinic BP had masked HTN, while 36% of hypertensives actually had white-coat HTN 11 .…”

“…HTN is diagnosed based on the presence of persistent high BP in the clinic setting, 6,7 but the 2017 clinical practice guideline (CPG) recommends 24-hour ambulatory BP (ABP) for confirmation of HTN. Several studies have shown relatively poor correlation between clinic and 24-hour ABP [8][9][10][11][12] , a more robust measure of BP status, which has stronger association with target organ damage (TOD) in both adult 13,14 and pediatric [15][16][17][18][19][20][21] populations. A study by Davis et al 9 even suggested universal ABP monitoring (ABPM) as the most economic approach for the evaluation of children and adolescents with high clinic BP.…”