Unattended Automated Measurements
2019; Lippincott Williams & Wilkins; Volume: 74; Issue: 6 Linguagem: Inglês
10.1161/hypertensionaha.119.13753
ISSN1524-4563
AutoresKei Asayama, Takayoshi Ohkubo,
Tópico(s)Hemodynamic Monitoring and Therapy
ResumoHomeHypertensionVol. 74, No. 6Unattended Automated Measurements Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBUnattended Automated MeasurementsOffice and Out-of-Office Blood Pressures Affected by Medical Staff and Environment Kei Asayama and Takayoshi Ohkubo Kei AsayamaKei Asayama Correspondence to Kei Asayama, Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan. Email E-mail Address: [email protected] From the Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A., T.O.) Tohoku Institute for Management of Blood Pressure, Sendai, Japan (K.A., T.O.) KU Leuven Department of Cardiovascular Sciences, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Belgium (K.A.). and Takayoshi OhkuboTakayoshi Ohkubo From the Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A., T.O.) Tohoku Institute for Management of Blood Pressure, Sendai, Japan (K.A., T.O.) Originally published7 Oct 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.13753Hypertension. 2019;74:1294–1296This article is a commentary on the followingDiagnostic Accuracy of Unattended Automated Office Blood Pressure Measurement in Screening for Hypertension in KenyaOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 7, 2019: Ahead of Print See related article, pp 1490–1498Recent investigations of the advantages of automated office blood pressure (AOBP) measurements have raised several issues regarding blood pressure measurement. In the current issue of Hypertension, Etyang et al1 present a cross-sectional study to identify the characteristics of AOBP in comparison with 24-hour ambulatory blood pressure (ABP) measurement. Their study population consisted of people not on antihypertensive drug treatment living in one of 3 sites in Kenya. AOBP was measured under a fully unattended setting by the Omron HEM-907 (Omron Healthcare Co, Ltd, Kyoto, Japan) with a 5-minute rest before the first reading. The blood pressure levels on AOBP and 24-hour ABP were almost the same as the average (systolic blood pressure difference, 0.6 mm Hg). However, overall agreement was poor, with a wide difference in individuals (95% agreement limit, −39 to 40 mm Hg). Consequently, there were significant proportions of individuals with normotension who were misclassified as hypertension by AOBP when hypertension was defined by 24-hour ABP as 130/80, 135/85, or 140/90 mm Hg (areas under the receiver operating characteristic curves, 0.68–0.69; 95% CI, 0.65–0.71).Although the standard AOBP measurements typically comprise multiple readings (≥3×) recorded automatically with the patient resting undisturbed in a quiet place in the absence of an observer (unattended),2 the definition of AOBP is still ambiguous, particularly in regard to the rest time during the antecedent and within intervals of measurements. AOBP has been measured using BpTRU (BpTRU Medical Devices, Coquitlam, Canada, which discontinued operations in 2017) by performing 6 readings and averaging only the second to sixth readings as the default setting. To discard the first reading inevitably produces a waiting time for the second; no antecedent rest time would be initially included in the AOBP definition,2 whereas the 5-minute antecedent rest in the unattended setting used in the Kenyan study1 has been used in many recent studies.3,4 Because even conventional office blood pressure measurement requires a few5 or 56 or >57 minutes of rest time before the first measurement, the antecedent rest time should now become one of the requisite conditions for AOBP measurements. Intervals between the repeated measurements have also not been defined in AOBP. Although a 30-second interval may be enough according to the recent report based on the auscultatory method,8 the minimum length of the interval required is still unclear, like that of the antecedent rest time.A recent meta-analysis9 supports the current finding by Etyang et al1 that average levels of AOBP and 24-hour ABP were similar in the population. However, it is important to note the nature of the pooled mean difference in a meta-analysis, that is, its CI does not denote the variation of differences by individual but represents a possible mean difference, and the width of the CI depends on the number of pooled studies and their population sizes. Based on self-measured home blood pressure, our research group also reported a discrepancy between the similarity in average values and the poor agreement in individuals in comparison with AOBP (systolic blood pressure difference, 0.9 mm Hg; 95% agreement limit, −34.0 to 35.8 mm Hg).4 These indicate that we cannot estimate out-of-office blood pressure values by AOBP measurements in individuals and vice versa. Meanwhile, the 3 consecutive AOBP values in each patient were almost identical, with high correlations (r≥0.90),4 and the AOBP and conventional attended office blood pressure were moderately to highly correlated.4 The AOBP can, therefore, be interpreted as an alternative that is more stable than the conventional attended blood pressure value with the average shifted to some extent. Nevertheless, the introduction of AOBP to all outpatients requires ≥1 separated rooms with a person in charge of managing the AOBP measurements. Such resource consumption makes it less feasible to use AOBP in clinical practice.4The unattended condition in AOBP measurement allows us to exclude one aspect of the white-coat effect incurred by being in the presence of medical staff.2 However, there remains the other portion of the white-coat effect on AOBP as the circumstances are fundamentally different from relaxing at home. Such a clinic effect, measured at a clinic or in a screening setting, still affects in-office readings regardless of the direct presence of observer staff.4 This leads us further into consideration of the difference between self-measured versus observer-measured blood pressure at home,10 because the latter measurement temporarily eliminates the relaxed state from one's home. The observer-measured home blood pressure can be called out-of-office blood pressure, while the measurement is performed in the opposite situation to AOBP regarding the 2 effects (Figure). Furthermore, there might be some blood pressure increase triggered by arousal or by arm-cuff inflation.11 ABP is recorded in various out-of-office settings, including nighttime asleep, and it might be a reasonable assumption that the nighttime ABP value is a strong predictor of cardiovascular diseases,12 because nighttime measurements may not be immune to arousal/alerting reactions. In this respect, AOBP cannot be an alternative to out-of-office blood pressure.Download figureDownload PowerPointFigure. Cross-classification of measurement conditions and effects. Out-of-office blood pressure measurements are presented in the left (A and C), with in-office measurements in the right (B and D). During the measurements, medical staff are in attendance (A and B) during home visit/home healthcare/surveillance (A) or not in attendance (C and D). Out-of-office blood pressure includes but is not limited to home measurements. Ambulatory blood pressure monitoring (overlaid domain) is performed at various locations, mostly out-of-office settings. For automated office blood pressure (AOBP; D), medical staff are not in attendance but supervise the measurement procedure.We have little evidence for the superiority of AOBP over conventional attended blood pressure. In SPRINT (Systolic Blood Pressure Intervention Trial), 38 of the 88 participating clinical sites complied with the definition of AOBP, but medical staff attended to measurements during the rest time, during the measurement, or during both, at the other 50 sites.3 The difference in the prognostic significance between unattended and attended blood pressures remains unclear because the average in-office blood pressure levels measured during the trial were almost identical on cross-classification of the attended and unattended site groups.3 Furthermore, AOBP-based intensive antihypertensive treatment might cause adverse health outcomes, although composite rates of serious adverse events were similar between the intensive and standard treatment arms in SPRINT.3 Even if the utility of AOBP is confirmed, and its definition is established, the clinic effect as part of the white-coat effect still affects in-office readings, regardless of the direct presence of staff or assessors.4 Based on the findings by Etyang et al,1 out-of-office blood pressure measurements are recommended for the diagnosis of hypertension,1,5–7 and they should also be used in the long-term treatment of hypertension.4,5,12AcknowledgmentsWe gratefully acknowledge Masako Terui and Tomoko Yamamura (Teikyo University School of Medicine, Tokyo, Japan) for their clerical assistance.DisclosuresK. Asayama and T. Ohkubo are consultants for Omron Healthcare.Sources of FundingNone.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to Kei Asayama, Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan. Email [email protected]orgReferences1. Etyang AO, Sigilai A, Odipo E, Oyando R, Ong'ayo G, Muthami L, Munge K, Kirui F, Mbui J, Bukania Z, Mwai J, Obala A, Barasa E. Diagnostic accuracy of unattended automated office blood pressure measurement in screening for hypertension in Kenya.Hypertension. 2019; 74:1490–1498. doi: 10.1161/HYPERTENSIONAHA.119.13574LinkGoogle Scholar2. Myers MG, Godwin M, Dawes M, Kiss A, Tobe SW, Grant FC, Kaczorowski J. Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial.BMJ. 2011; 342:d286. doi: 10.1136/bmj.d286CrossrefMedlineGoogle Scholar3. Johnson KC, Whelton PK, Cushman WC, et al; SPRINT Research Group. Blood pressure measurement in SPRINT (Systolic Blood Pressure Intervention Trial).Hypertension. 2018; 71:848–857. doi: 10.1161/HYPERTENSIONAHA.117.10479LinkGoogle Scholar4. Asayama K, Ohkubo T, Rakugi H, Miyakawa M, Mori H, Katsuya T, Ikehara Y, Ueda S, Ohya Y, Tsuchihashi T, Kario K, Miura K, Hasebe N, Ito S, Umemura S. Comparison of blood pressure values—self-measured at home, measured at an unattended office, and measured at a conventional attended office [published online June 21, 2019].Hypertens Res. 10.1038/s41440-019-0287-6Google Scholar5. Umemura S, Arima H, Arima S, et al. The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2019).Hypertens Res. 2019; 42:1235–1481. doi: 10.1038/s41440-019-0284-9CrossrefMedlineGoogle Scholar6. Williams B, Mancia G, Spiering W, et al; ESC Scientific Document Group. 2018 ESC/ESH guidelines for the management of arterial hypertension.Eur Heart J. 2018; 39:3021–3104. doi: 10.1093/eurheartj/ehy339CrossrefMedlineGoogle Scholar7. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.Hypertension. 2018; 71:e13–e115. doi: 10.1161/HYP.0000000000000065LinkGoogle Scholar8. Imamura M, Asayama K, Sawanoi Y, Shiga T, Saito K, Ohkubo T. Effects of measurement intervals on the values of repeated auscultatory blood pressure measurements [published online February 27, 2019].Clin Exp Hypertens. doi: 10.1080/10641963.2019.1583243Google Scholar9. Roerecke M, Kaczorowski J, Myers MG. Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension: a systematic review and meta-analysis.JAMA Intern Med. 2019; 179:351–362. doi: 10.1001/jamainternmed.2018.6551CrossrefMedlineGoogle Scholar10. Yano Y, Vongpatanasin W, Ayers C, Turer A, Chandra A, Carnethon MR, Greenland P, de Lemos JA, Neeland IJ. Regional fat distribution and blood pressure level and variability: the Dallas Heart Study.Hypertension. 2016; 68:576–583. doi: 10.1161/HYPERTENSIONAHA.116.07876LinkGoogle Scholar11. Asayama K, Fujiwara T, Hoshide S, Ohkubo T, Kario K, Stergiou GS, Parati G, White WB, Weber MA, Imai Y; International Expert Group of Nocturnal Home Blood Pressure. Nocturnal blood pressure measured by home devices: evidence and perspective for clinical application.J Hypertens. 2019; 37:905–916. doi: 10.1097/HJH.0000000000001987CrossrefMedlineGoogle Scholar12. Yang WY, Melgarejo JD, Thijs L, et al; International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) Investigators. Association of office and ambulatory blood pressure with mortality and cardiovascular outcomes.JAMA. 2019; 322:409–420. doi: 10.1001/jama.2019.9811CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Asayama K, Ohkubo T, Rakugi H, Miyakawa M, Mori H, Katsuya T, Ikehara Y, Ueda S, Ohya Y, Tsuchihashi T, Kario K, Miura K, Ito S and Umemura S (2021) Direct comparison of the reproducibility of in-office and self-measured home blood pressures, Journal of Hypertension, 10.1097/HJH.0000000000003026, 40:2, (398-407), Online publication date: 1-Feb-2022. Stuligross J, Hoj T, Brown B, Woolsey S and Stults B (2021) Use of unattended automated office blood pressure in Utah primary care clinics, Blood Pressure Monitoring, 10.1097/MBP.0000000000000579, 27:3, (161-167), Online publication date: 1-Jun-2022. Hernández-Aceituno A, Sánchez-Martínez M, López-García E, Guallar-Castillón P, Cruz J, Ortolá R, Graciani A, García-Esquinas E, García-Puig J, Rodríguez-Artalejo F and Banegas J (2022) A simple score to screen for isolated ambulatory hypertension in older adults. Development and validation, REC: CardioClinics, 10.1016/j.rccl.2021.07.003, 57:2, (107-115), Online publication date: 1-Apr-2022. 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Kadowaki S, Kadowaki T, Hozawa A, Fujiyoshi A, Hisamatsu T, Satoh A, Arima H, Tanaka S, Torii S, Kondo K, Kadota A, Masaki K, Okamura T, Ohkubo T, Miura K and Ueshima H (2020) Differences between home blood pressure and strictly measured office blood pressure and their determinants in Japanese men, Hypertension Research, 10.1038/s41440-020-00533-w, 44:1, (80-87), Online publication date: 1-Jan-2021. Doane J, Flynn M, Archibald M, Ramirez D, Conroy M and Stults B (2020) Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization, The Journal of Clinical Hypertension, 10.1111/jch.13840, 22:4, (598-604), Online publication date: 1-Apr-2020. Asayama K, Ohkubo T and Imai Y (2021) In-office and out-of-office blood pressure measurement, Journal of Human Hypertension, 10.1038/s41371-021-00486-8 Related articlesDiagnostic Accuracy of Unattended Automated Office Blood Pressure Measurement in Screening for Hypertension in KenyaAnthony O. Etyang, et al. Hypertension. 2019;74:1490-1498 December 2019Vol 74, Issue 6 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.119.13753PMID: 31587586 Originally publishedOctober 7, 2019 PDF download Advertisement SubjectsBlood PressureHypertension
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