Rationale for Ambulatory and Home Blood Pressure Monitoring Thresholds in the 2017 American College of Cardiology/American Heart Association Guideline
2018; Lippincott Williams & Wilkins; Volume: 73; Issue: 1 Linguagem: Inglês
10.1161/hypertensionaha.118.11946
ISSN1524-4563
AutoresPaul Muntner, Robert M. Carey, Kenneth Jamerson, Jackson T. Wright, Paul K. Whelton,
Tópico(s)Hemodynamic Monitoring and Therapy
ResumoHomeHypertensionVol. 73, No. 1Rationale for Ambulatory and Home Blood Pressure Monitoring Thresholds in the 2017 American College of Cardiology/American Heart Association Guideline Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBRationale for Ambulatory and Home Blood Pressure Monitoring Thresholds in the 2017 American College of Cardiology/American Heart Association Guideline Paul Muntner, Robert M. Carey, Kenneth Jamerson, Jackson T. WrightJr and Paul K. Whelton Paul MuntnerPaul Muntner Correspondence to Paul Muntner, Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1700 University Blvd, Suite 450, Birmingham, AL 35294. Email E-mail Address: [email protected] From the Department of Epidemiology, University of Alabama at Birmingham (P.M.) , Robert M. CareyRobert M. Carey Department of Medicine, University of Virginia, Charlottesville (R.M.C.) , Kenneth JamersonKenneth Jamerson Department of Medicine, University of Michigan, Ann Arbor (K.J.) , Jackson T. WrightJrJackson T. WrightJr Department of Medicine, Case Western Reserve University, Cleveland, OH (J.T.W.) and Paul K. WheltonPaul K. Whelton Department of Epidemiology, Tulane University, New Orleans, LA (P.K.W.). Originally published5 Nov 2018https://doi.org/10.1161/HYPERTENSIONAHA.118.11946Hypertension. 2019;73:33–38Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 5, 2018: Ahead of Print The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults recommends classifying blood pressure (BP) into 1 of 4 levels: normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension based on the average of ≥2 measurements obtained in the office setting on ≥2 occasions (Table 1).1 Hypertension is defined in the guideline as a mean office systolic BP (SBP) ≥130 mm Hg or a mean office diastolic BP (DBP) ≥80 mm Hg. To confirm the presence of hypertension, the ACC/AHA guideline recommends measuring BP outside of the office setting using daytime ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM). The recommendation to use out-of-office BP measurements to confirm the presence of hypertension is consistent with several other guidelines, including those from the UK National Institute for Health and Care Excellence, the Canadian Hypertension Education Program, National Heart Federation of Australia, and the US Preventive Services Task Force Recommendation Statement on High Blood Pressure Screening in Adults.2–5 The ACC/AHA guideline recommends that adults not taking antihypertensive medication with SBP ≥130 but <160 mm Hg or DBP ≥80 but <100 mm Hg should be screened with ABPM or HBPM for white coat hypertension (Figure 1, left). It also recommends screening adults not taking antihypertensive medication with SBP between 120 and 129 mm Hg or DBP between 75 and 79 mm Hg for masked hypertension (Figure 1, right). ABPM and HBPM are also recommended to identify a white coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication (Figure 2).Table 1. Classification of BP According to the 2017 ACC/AHA BP GuidelineOffice BP Levels2017 ACC/AHA Guideline* ClassificationSBP, mm HgDBP, mm Hg<120and<80Normal BP120–129and<80Elevated BP130–139or80–89Stage 1 hypertension≥140or≥90Stage 2 hypertensionParticipants with SBP and DBP in 2 categories (eg, SBP <120 mm Hg and DBP between 80 and 89 mm Hg) should be designated into the higher category. ACC/AHA indicates American College of Cardiology/American Heart Association; BP, blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.*2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High BP in Adults.Reprinted from Whelton et al1 with permission. Copyright © 2017, the American College of Cardiology Foundation and the American Heart Association, Inc.Download figureDownload PowerPointFigure 1. Algorithm to screen for white coat hypertension and masked hypertension among adults not taking antihypertensive medication in the 2017 American College of Cardiology/American Heart Association blood pressure guideline. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring. Reprinted from Whelton et al1 with permission. Copyright © 2017, the American College of Cardiology Foundation and the American Heart Association, Inc.Download figureDownload PowerPointFigure 2. Algorithm to screen for white coat effect or masked uncontrolled hypertension among adults taking antihypertensive medication in the 2017 American College of Cardiology/American Heart Association blood pressure guideline. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; CVD, cardiovascular disease; and HBPM, home blood pressure monitoring. Reprinted from Whelton et al1 with permission. Copyright © 2017, the American College of Cardiology Foundation and the American Heart Association, Inc.In 2003, the Seventh Report of the Joint National Committee guideline provided BP thresholds on ABPM for defining hypertension in US adults.6 In the Seventh Report of the Joint National Committee guideline, awake and asleep hypertension were defined by mean SBP/DBP levels ≥135/85 and ≥120/75 mm Hg, respectively. These thresholds were determined assuming office SBP/DBP readings ≥140/90 mm Hg as the reference point for the definition of hypertension rather than the office SBP/DBP ≥130/80 mm Hg recommendation adopted in the 2017 ACC/AHA guideline. Many scientific statements and guidelines have published BP thresholds for defining hypertension based on ABPM and HBPM since the Seventh Report of the Joint National Committee guideline.7,8 In the current article, we describe how out-of-office BP thresholds based on ABPM and HBPM corresponding to BP levels in the office setting were selected by the 2017 ACC/AHA writing committee. To provide the context for the writing committee's decisions, we describe 3 approaches that have been used in epidemiological studies to identify ABPM and HBPM BP thresholds that are deemed high or that correspond to values obtained in an office setting. We also review data gaps and future research needs.Approaches for Defining High BP on ABPM/HBPMIn the early 1990s, BP thresholds for ABPM were identified based on populations distributions—a method called the distribution-based approach.9,10 For example, in 1 study, BP above the 95th percentile or 2 SDs above the mean was identified as being significantly elevated and a BP between 1 and 2 SDs above the mean was considered to be marginally elevated.9 In another study, the percentage of participants with an office SBP/DBP ≥140/90 mm Hg was identified, and ABPM SBP and DBP values with a similar percentage of participants above these levels were identified and used as the upper limit of normotension.11 The ABPM thresholds used to define elevated or high BP with the distribution-based approach varied markedly across populations.10,12,13 This likely reflects the enrollment of populations with different characteristics, including the proportion taking antihypertensive medication and office BP levels. Furthermore, there is no scientific basis to assume that a fixed percentage of the population has high BP on ABPM or HBPM.A second approach—the regression-based approach—uses regression models to estimate the ABPM or HBPM BP levels for any given office BP value.14–17 In many, but not all, prior studies, a standard ordinary least squares regression model has been used to regress out-of-office BP on office BP. An issue with this approach is the measurement error of office BP, the independent variable, results in an attenuated slope between office and out-of-office BP. To address this issue, models for continuous outcomes that address measurement error in the exposure variable (eg, Deming regression or ordinary least products regression) should be used instead of ordinary least squares regression. Using the intercept and β-coefficient from the regression model, the level of awake SBP that is equivalent to a specific office SBP level (eg, 120, 130, 140, and 160 mm Hg) can be estimated. Another issue with the regression-based approach is that the risk for cardiovascular disease (CVD) associated with ABPM and HBPM BP values may not correspond accurately to office BP because of white coat and masked effects.The third approach—the outcomes-based approach—identifies the incidence rate for an outcome (eg, CVD) associated with a range of office-based BP levels (eg, SBP ≥140 mm Hg). Then, the corresponding range of BP on ABPM that is associated with a similar incidence rate is identified (eg, SBP ≥135 mm Hg).18Each of these approaches can identify ABPM or HBPM SBP and DBP thresholds that correspond to BP measured in the office setting. Also, multiple ABPM and HBPM BP thresholds can be identified (eg, BP levels corresponding with normal BP, elevated BP, and hypertension). BP measured by ABPM and HBPM maintains a stronger association with CVD events compared with BP measured in the office setting.19 ABPM and HBPM also can be used to identify white coat hypertension and masked hypertension.8 Therefore, the ACC/AHA writing committee sought to identify ABPM and HBPM threshold levels associated with the office BP levels that were selected for BP classification. There is general consensus that ABPM and HBPM BP thresholds should be based on outcomes data, and the ACC/AHA writing committee agreed that this method is currently the best approach available.Selection of Threshold Values in the 2017 ACC/AHA GuidelineThe 2017 ACC/AHA guideline provides HBPM SBP and DBP values and ABPM daytime, nighttime, and 24-hour SBP and DBP values that correspond to office-measured SBP and DBP levels (Table 2). These BP levels were selected based on a review of large published prospective cohort studies of ABPM and HBPM.13,20–22 When available, the outcomes-based approach was used to identify ABPM and HBPM BP levels that corresponded to BP measured in an office setting.13,20–22 BP thresholds identified in studies that used the regression-based approach were considered when data from the outcomes-based approach were not identified.17 Given there were few studies identified and the studies that were available provided consistent results, the writing committee decided there was no need to meta-analyze the data. The ACC/AHA writing committee also reviewed guidelines and scientific statements that reported HBPM and ABPM BP levels corresponding to measurements obtained in an office setting.7,23–27Table 3 provides the ABPM thresholds identified from outcomes-based studies and from several prior guidelines and scientific statements. Table 4 provides corresponding information for HBPM. Although there were some discrepancies between the BP levels in the published research studies and prior guidelines/scientific statements, these differences were small (ie, within 5 mm Hg).Table 2. BP Thresholds for Home and ABPM That Correspond to Office BP Levels in the 2017 ACC/AHA BP GuidelineOffice BPHBPMAwake ABPMAsleep ABPM24-h ABPM120/80120/80120/80100/65115/75130/80130/80130/80110/65125/75140/90135/85135/85120/70130/80160/100145/90145/90140/85145/90Numbers in the table are SBP and DBP and are presented in mm Hg. ABPM indicates ambulatory blood pressure monitoring; ACC/AHA, American College of Cardiology/American Heart Association; BP, blood pressure; DBP, diastolic blood pressure; HBPM, home blood pressure monitoring; and SBP, systolic blood pressure.Reprinted from Whelton et al1 with permission. Copyright © 2017, the American College of Cardiology Foundation and the American Heart Association, Inc.Table 3. Awake, Asleep, and 24-h BP Thresholds for ABPM That Correspond With Office BP Levels Identified From Outcomes-Based Studies and Prior Guidelines and Scientific StatementsOffice BPOutcomes-Based StudiesPrior Guidelines/Scientific StatementsACC/AHA GuidelineOhasama* (n=1542)IDACO† (n=5682)2005 AHA2008 ASH2011 Australia2013 ESH2015 CanadaAwake BP 120/80120/80125/80130/80120/80 130/80130/80133/82135/85 140/90135/85140/85140/90135/85135/85135/85135/85 160/100145/90‡Asleep BP 120/80100/65115/65 130/80110/65120/70 140/90120/70121/70125/75120/75120/70120/70 160/100140/85‡Asleep BP 120/80115/75119/74115/75 130/80125/75125/76 140/90130/80134/79132/79130/80130/80 160/100145/90‡Numbers in the table are SBP and DBP and are presented in mm Hg.Blank cells indicate office BP levels for which thresholds on ABPM were not reported. ABPM indicates ambulatory blood pressure monitoring; ACC/AHA, American College of Cardiology/American Heart Association; ASH, American Society of Hypertension; BP, blood pressure; DBP, diastolic blood pressure; ESH, European Society of Hypertension; HBPM, home blood pressure monitoring; IDACO, International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome; and SBP, systolic blood pressure.*Ohkubo et al.22 The Ohasama study population is also included in the IDACO (Kikuya et al20).†Kikuya et al.20‡Because no data using the outcomes-based approach were identified for these BP values, the values were determined from a study using the regression-based approach (Head et al17).Table 4. BP Thresholds for HBPM Identified in Outcomes-Based Studies and Prior Guidelines and Scientific StatementsOffice BPHome BPOutcomes-Based StudiesPrior Guidelines/Scientific StatementsACC/AHA Guideline2008 Meta-Analysis*IDHOCO† (n=6470)2013 ESH2015 Canada2015 Australia120/80120/80120/80120/75130/80130/80130/80125/75140/90135/85135/85130/85135/85135/85135/85160/100145/90145/90145/90Numbers in the table are SBP and DBP and are presented in mm Hg.Blank cells indicate office BP levels for which thresholds on HBPM were not reported. ACC/AHA indicates American College of Cardiology/American Heart Association; BP, blood pressure; DBP, diastolic blood pressure; ESH, European Society of Hypertension; HBPM, home blood pressure monitoring; IDHOCO, International Database of Home Blood Pressure in Relation to Cardiovascular Outcome; and SBP, systolic blood pressure.*Staessen et al.13†Niiranen et al.21Evidence GapsThe BP thresholds selected by the ACC/AHA writing committee were based on the best evidence available at the time the guideline was prepared. However, gaps in knowledge exist. For example, none of the outcomes-based studies included blacks—a population with a high prevalence of hypertension. A 2017 analysis from the Jackson Heart Study—a cohort comprised exclusively of black adults—evaluated ABPM SBP thresholds that corresponded with office SBP values among 441 adults not taking antihypertensive medication and 575 adults taking antihypertensive medication.18 DBP thresholds were not evaluated using the outcomes-based approach because DBP, when measured in an office setting, was not associated with CVD risk in this study. Using the outcomes-based approach, the ABPM SBP levels that corresponded to office-measured SBP values of 120, 130, 140, and 160 mm Hg were higher than those recommended in the ACC/AHA guideline. These data highlight the need for additional studies to evaluate thresholds for ABPM and HBPM that correspond to BP measured in an office setting in different populations, including racial/ethnic minorities. Additionally, it is unclear whether the ABPM and HBPM BP thresholds should be uniform across different age groups, for men and women and for adults taking and not taking antihypertensive medication.28–30 In contrast to the ACC/AHA guideline, which recommends using daytime BP on ABPM, recent studies and a 2013 European Society of Hypertension position paper on ABPM suggest that daytime, nighttime, and 24-hour BP should be considered when defining white coat hypertension, masked hypertension, white coat effect, and masked uncontrolled hypertension.31–33 Additional studies are needed to determine the risk for CVD and the benefits of antihypertensive medication for individuals with these phenotypes when they are defined using BP measurements from different time periods. Also, studies are needed to identify whether alternative methods to the outcomes-based approach are available to identify ABPM and HBPM BP thresholds.The thresholds used to define normal and elevated BP and hypertension in the ACC/AHA guideline were based on office measurements.1 The analogous ABPM and HBPM BP thresholds were determined using office measurements as the referent standard as described in this article. This approach may seem counterintuitive because the association of BP with CVD outcomes is stronger for measurements obtained by ABPM and HBPM compared with readings obtained in the office setting.19 Additionally, ABPM is considered the best technique to confirm the presence of hypertension.2 However, large-scale outcome trials comparing antihypertensive medication versus placebo and trials that have compared different intensities of treatment have used office BP to determine participant eligibility and BP goal achievement. There is a lack of data from randomized controlled trials using ABPM and HBPM BP levels to guide antihypertensive medication initiation and intensification. Such data will allow BP thresholds used for classification to be directly determined from ABPM and HBPM.PerspectivesIn summary, the 2017 ACC/AHA guideline provides ABPM and HBPM BP thresholds that correspond to normal BP, elevated BP, and stage 1 and 2 hypertension in an office-based setting. Additionally, thresholds corresponding to an average SBP and DBP of 160 and 100 mm Hg, respectively, are provided. These thresholds should be used to identify adults with white coat hypertension and masked hypertension.AcknowledgmentsWe thank Drs Daichi Shimbo and Joseph E. Schwartz for their review and comments on a draft version of this manuscript.Sources of FundingP. Muntner received support from American Heart Association grant 15SFRN2390002. R.M. Carey received support from grants R1-HL128189 and P01-HL074940 from the National Heart, Lung, and Blood Institute. K. Jamerson received support from grant 5U01-DK061028 from the National Institute of Diabetes and Digestive and Kidney Diseases. P.K. Whelton received support from grant P20GM109036 from the National Institute for General Medical Sciences.DisclosuresP. Muntner, R.M. Carey, K. Jamerson, J.T. Wright, and P.K. Whelton were members of the 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. K. Jamerson reports receiving research support from Bayer Pharma AG.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Paul Muntner, Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1700 University Blvd, Suite 450, Birmingham, AL 35294. 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January 2019Vol 73, Issue 1 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.118.11946PMID: 30571569 Originally publishedNovember 5, 2018 PDF download Advertisement
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