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Cited by 32 publications
References 25 publications
fully appreciate the reproducibility of ABPM, the variability of office blood pressures (OBPs) using a standard mercury sphygmomanometer should be presented in comparison. We presented a direct comparison of the variability of office and 24-hour ABPs in a subsequent article,3 which, although not referenced by the authors, contributes new information on the variability of indirect blood pressures and, thus, deserves comment.For the purposes of this discussion, reliability ofblood pressures for an individual can be represented by the standard deviation of the differences (SDD) of repeated mea¬ surements obtained in patients at different visits. The re¬ liability of standard OBPs has been shown to be wide, av¬ eraging approximately ±14 mm Hg for systolic blood pressure (SBP) and ±10 mm Hg for diastolic blood pres¬ sure (DBP) across different studies (presented in reference 3). In comparison, the reliability of mean 24-hour aver¬ age ABPs between visits was found to be significantly less than that for OBPs in the same group of 50 hypertensive patients (SDDsbp, 10.6 vs 17.9mm Hg;F=2.85;P<.01;and SDDDBP, 5.8 vs 8.9 mm Hg; F=2.35; P<.01).3 Thus, in di¬ rect comparison with OBPs, ABPs proved to be more re¬ liable as an estimate of the patient's true blood pressure.Use of a more reliable estimate of blood pressure has some important clinical implications. Using OBPs alone, the false-positive diagnostic rate for hypertension may be as high as 20% to 25%, even with repeated office visits.45 At present, there is no general agreement on the defini¬ tion of a "normal" (mean±2 SDs) 24-hour ABP. However, once normal values are established, the use of the more reliable ABPs in the evaluation of patients with potentially abnormal elevations in blood pressure should reduce the number of patients labeled hypertensive. Without data com¬ paring cardiovascular morbidity and mortality in patients treated on the basis of ABPs vs OBPs, the question of the broader use of ABPM in the evaluation and management of hypertension will continue to be debated. Nevertheless, techniques to improve the reliability ofindirect blood pres¬ sure measurements should be examined-a point empha¬ sized by the authors of the current article.1 of automated ambulatory blood pressure measurements. J Fam Pract. 1992; 34:569-574.3. Bottini PB, Carr AA, Rhoades RB, Prisant LM. Variability of indirect methods used to determine blood pressures: office vs mean 24-hour automated blood pressures. Arch Intern Med. 1992;152:139-144. 4. A report by the management committee of the Australian Therapeutic Trial in mild hypertension. Lancet. 1982;1:185-191. 5. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension? JAMA. 1988;259:225-228. New Do-Not-Resuscitate PoliciesThe article by Murphy and Finucane on new do\ x=r eq-\ not-resuscitate (DNR) policies1 leaves the reader perplexed. First, the policies are not new; second, the rationale for the new policies is contradicted by the authors themselves and the data available...
fully appreciate the reproducibility of ABPM, the variability of office blood pressures (OBPs) using a standard mercury sphygmomanometer should be presented in comparison. We presented a direct comparison of the variability of office and 24-hour ABPs in a subsequent article,3 which, although not referenced by the authors, contributes new information on the variability of indirect blood pressures and, thus, deserves comment.For the purposes of this discussion, reliability ofblood pressures for an individual can be represented by the standard deviation of the differences (SDD) of repeated mea¬ surements obtained in patients at different visits. The re¬ liability of standard OBPs has been shown to be wide, av¬ eraging approximately ±14 mm Hg for systolic blood pressure (SBP) and ±10 mm Hg for diastolic blood pres¬ sure (DBP) across different studies (presented in reference 3). In comparison, the reliability of mean 24-hour aver¬ age ABPs between visits was found to be significantly less than that for OBPs in the same group of 50 hypertensive patients (SDDsbp, 10.6 vs 17.9mm Hg;F=2.85;P<.01;and SDDDBP, 5.8 vs 8.9 mm Hg; F=2.35; P<.01).3 Thus, in di¬ rect comparison with OBPs, ABPs proved to be more re¬ liable as an estimate of the patient's true blood pressure.Use of a more reliable estimate of blood pressure has some important clinical implications. Using OBPs alone, the false-positive diagnostic rate for hypertension may be as high as 20% to 25%, even with repeated office visits.45 At present, there is no general agreement on the defini¬ tion of a "normal" (mean±2 SDs) 24-hour ABP. However, once normal values are established, the use of the more reliable ABPs in the evaluation of patients with potentially abnormal elevations in blood pressure should reduce the number of patients labeled hypertensive. Without data com¬ paring cardiovascular morbidity and mortality in patients treated on the basis of ABPs vs OBPs, the question of the broader use of ABPM in the evaluation and management of hypertension will continue to be debated. Nevertheless, techniques to improve the reliability ofindirect blood pres¬ sure measurements should be examined-a point empha¬ sized by the authors of the current article.1 of automated ambulatory blood pressure measurements. J Fam Pract. 1992; 34:569-574.3. Bottini PB, Carr AA, Rhoades RB, Prisant LM. Variability of indirect methods used to determine blood pressures: office vs mean 24-hour automated blood pressures. Arch Intern Med. 1992;152:139-144. 4. A report by the management committee of the Australian Therapeutic Trial in mild hypertension. Lancet. 1982;1:185-191. 5. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension? JAMA. 1988;259:225-228. New Do-Not-Resuscitate PoliciesThe article by Murphy and Finucane on new do\ x=r eq-\ not-resuscitate (DNR) policies1 leaves the reader perplexed. First, the policies are not new; second, the rationale for the new policies is contradicted by the authors themselves and the data available...
Blood pressure monitoring of hypertensives in the ambulatory state by automated portable devices (ABPM) as compared with casual office readings (COBPM) may predict outcome with greater precision and at an overall lower cost. Prospective trials that in random fashion require evaluation and management decisions on the basis of ABPM compared with COBPM are required to determine whether the above is true. End points such as death, stroke, or myocardial infarction occur at a low frequency rate. This would require thousands of patients to be followed 5 or more years to determine if evaluation and management by ABPM compared with COBPM results in a different outcome. A much smaller population can be used if end points are changes in left ventricular mass and left ventricular ischemia, arterial wall stiffness and thickness, endogenous creatinine clearance, renal albumin excretion, antihypertensive drug requirements, and adverse reactions. Until results from such a prospective trial are available, COBPM is the method of choice for evaluation and management of hypertensives. Automated blood pressure measurement can provide useful information in special circumstances and is of value for research purposes.
Although population studies have demonstrated a relationship between casual office blood pressures and target organ events, the variability of these blood pressure measurements for individual patients has generated an interest in the role of ambulatory blood pressure monitoring for defining the presence of hypertension and assessing the response to therapy. Noninvasive devices provide fewer data than intra-arterial ambulatory blood pressure monitoring devices, but are safer. No current noninvasive device performs well during ambulation. Rigorous evaluation of these rapid proliferating electronic devices is important, as would be the case with any new antihypertensive agent. Although ambulatory blood pressure measurements correlate better with target organ damage for groups of patients than do casual office measurements, the predictability and limited data on reproducibility for individual patients does not support widespread application for routine testing for hypertensive patients. Ambulatory blood pressure monitoring should be viewed as a standard research tool for the evaluation of new cardiovascular drugs.
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