Management of Hypertension after Ambulatory Blood Pressure Monitoring

Grin, Jennifer M.; McCabe, Ellen J.; White, William Β.

doi:10.7326/0003-4819-118-11-199306010-00001

Cited by 42 publications

(20 citation statements)

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“…Physicians report that the results of ABPM are highly useful for their practices. 29 When ambulatory blood pressure is offered to primary care physicians as a support service, a very high percent accept advice to withhold drug treatment when average pressures are Ͻ135/85 mm Hg, resulting in a 20% reduction in treatment. 30 This pattern agrees well with the predicted reductions given in this presentation.…”

Section: Discussionmentioning

confidence: 99%

Cost-Effectiveness of Ambulatory Blood Pressure

Krakoff

2006

Hypertension

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Abstract-Accurate diagnosis of hypertension and prognosis for future cardiovascular events can be enhanced through the use of 24-hour ambulatory blood pressure monitoring. It has been suggested that the use of ambulatory monitoring as a secondary screening for hypertension might be cost-effective. Many needed studies that are related to the calculation of costeffectiveness for ambulatory monitoring have become available in recent years. More accurate estimates for cost of care, costs for testing, prevalence of white-coat hypertension, and incidence of the transition from normal pressures to hypertension have been reported. This study presents calculations of the cost savings likely to take place when ambulatory blood pressure monitoring is implemented for newly detected hypertensive subjects. These calculations are based on current estimates for cost of testing, cost of treatment, prevalence of white-coat hypertension at baseline, and varying the incidence of new hypertension after the initial screening. The results indicate a potential savings of 3% to 14% for cost of care for hypertension and 10% to 23% reduction in treatment days when ambulatory blood pressure monitoring is incorporated into the diagnostic process. At current reimbursement rates, the cost of ambulatory blood pressure monitoring for secondary screening on an annual basis would be Ͻ10% of treatment costs. Calculated savings for use of ambulatory blood pressure monitoring can take place when annual treatment costs are as little as $300. These estimates should be considered for the management of recently detected hypertension, especially when the risk of future cardiovascular is disease is low. Key Words: ambulatory blood pressure monitoring, ambulatory Ⅲ hypertension, white-coat Ⅲ cost benefit analysis P rospective surveys have established the value of ambulatory blood pressure monitoring (ABPM), compared with, or additive to, clinic pressures, for predicting the risk of fatal and nonfatal cardiovascular disease in hypertensive groups. [1][2][3][4][5][6] The use of ABPM for untreated hypertensive patients, initially detected by clinic pressures, to define those with lower daytime and/or 24-hour average pressures has led to the concept of white-coat hypertension (WCH). 7 Pooled results from several prospective observational studies have shown that the likelihood for future stroke in WCH is nearly that of normal subjects for 5-year follow-up intervals. 8 WCH hypertension may also be related to a more favorable overall cardiovascular risk profile reflected by lower body mass index and favorable serum lipid patterns. 9 These findings support recommendations in current guidelines that ABPM be used in the management of hypertension. 10 -12 ABPM is well tolerated by patients in primary care practices who consider the information provided to be helpful for their management. 13 Additional recognition of the value of ABPM has been the approval for reimbursement by the Center for Medicare and Medicaid Services of the United States (CMS).When ABPM became av...

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Section: Discussionmentioning

confidence: 99%

Cost-Effectiveness of Ambulatory Blood Pressure

Krakoff

2006

Hypertension

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“…Subjects with repeat monitoring(s) were included only once in the analyses, using data from the initial monitoring session. Patients had been referred for standard clinical indications at the discretion of the referring physician (mainly primary care practitioners who have been shown elsewhere to use ABPM for appropriate indications 22 ). The authors were not involved in the clinical care of these patients.…”

Section: Study Populationmentioning

confidence: 99%

A modified ambulatory arterial stiffness index is independently associated with all-cause mortality

et al. 2008

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Dependence of the ambulatory arterial stiffness index (AASI) on data scattering interferes with its potential clinical relevance. We assessed the correlates and all-cause mortality associations of a modified AASI (s-AASI). AASI was derived from the 24-h diastolic vs systolic blood pressure linear regression line, whereas s-AASI was derived by symmetric regression (bisecting the line of diastolic vs systolic and systolic vs diastolic). Of 2918 patients 55% were women; age was 56 ± 16 years and body mass index was 27.3 ± 4.5 kg/m 2 . Average 24-h ambulatory blood pressure was 138±16/78±10 mm Hg.Applying the modified method for calculating AASI yielded a different measure: the negative correlation between AASI and blood pressure dipping (r ¼ À0.304, Po0.0001) was abolished (r ¼ þ 0.223, Po0.0001), s-AASI was more dependent on age (r ¼ 0.266 vs r ¼ 0.089 for AASI), and prediction of all-cause mortality was enhanced; hazard ratio (95% confidence intervals) 1.17 (1.00-1.36) per 1 s.d. increase in s-AASI in the fully adjusted model as compared with 1.15 (0.97-1.36) for AASI.

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“…All of the patients were included, except those Ͻ16 years old, pregnant women, and subjects with poor-quality ABPM (Ͻ50 valid measurements). Patients were referred for standard clinical indications at the discretion of the referring physician (mainly primary care practitioners, who have been shown to use ABPM for appropriate indications 14 …”

Section: Study Populationmentioning

confidence: 99%

Predictors of All-Cause Mortality in Clinical Ambulatory Monitoring

et al. 2007

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Abstract-The prognostic value of sleep blood pressure reported by recent studies is variable. Our aim was to examine the relationship of sleep blood pressure, measured by 24-hour ambulatory blood pressure monitoring, with all-cause mortality. We studied a cohort of 3957 patients aged 55Ϯ16 (58% treated) referred for ambulatory monitoring (1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005) Key Words: ambulatory blood pressure monitoring Ⅲ dipping Ⅲ mortality Ⅲ cohort Ⅲ sleep blood pressure D ata generated by 24-hour ambulatory blood pressure monitoring (ABPM) have been used to predict cardiovascular morbidity, as well as cardiovascular and all-cause mortality. [1][2][3][4][5][6][7][8][9] There is mounting evidence that this predictive ability is in part unrelated to clinic blood pressure (BP) measurements. Conceivably, ABPM reflects physiological states that are not captured by resting clinic measurements. 9 Moreover, ABPM reduces the influence of the measurement itself on BP values, namely the white-coat effect. In addition, ambulatory monitoring may unmask abnormal BP values that were not detected in the office. Thus, it is expected that ABPM would predict mortality above and beyond clinic measurements. There is still debate, however, whether in reality this is indeed the case and whether the use of this burdensome technique in clinical care is justified and contributes to patient management. 5 Another issue under debate concerns which component of the 24-hour ambulatory monitoring incorporates the most valuable prognostic information. Measurements taken during the waking state reflect, in part, physical activity, which may differ within and between patients. Thus, we hypothesized that, compared with awake BP, sleep measurements would relate to prognosis in a more profound way. Indeed, some 1,3,5,7,10,11 but not all 2 of the outcome studies have suggested this previously.In this study, we investigated all-cause mortality among patients who underwent ambulatory monitoring in a single center since 1991. We highlight sleep BP data identified by recorded sleeping periods, including afternoon naps. 12 We show that sleep BP, as well as nocturnal BP reduction (dipping, a somewhat controversial and infrequently studied topic 7,9,10,13 ) have independent predictive power. Methods Study PopulationData were extracted from our entire ABPM service database, from 1991 through 2005. All of the patients were included, except those Ͻ16 years old, pregnant women, and subjects with poor-quality ABPM (Ͻ50 valid measurements). Patients were referred for standard clinical indications at the discretion of the referring physician (mainly primary care practitioners, who have been shown to use ABPM for appropriate indications 14 ). We were not involved in the clinical care of these patients. Baseline data collected included demographic characteristics (age: 55 years [range: 16 to 93 years], sex (53% female), ethnicity (94% Jewish and 6% non-Jewish, predominantly Moslem Arabs), height (1.67 m; range...

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Management of Hypertension after Ambulatory Blood Pressure Monitoring

Abstract: Practicing physicians use ambulatory blood pressure recordings for appropriate indications, and data from the monitoring studies affected the management of patients with hypertension.

Cited by 42 publications

References 0 publications

Cost-Effectiveness of Ambulatory Blood Pressure

Cost-Effectiveness of Ambulatory Blood Pressure

A modified ambulatory arterial stiffness index is independently associated with all-cause mortality

Predictors of All-Cause Mortality in Clinical Ambulatory Monitoring

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