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Adding Home and/or Ambulatory Blood Pressure to Office Blood Pressure for Cardiovascular Risk Prediction
Giuseppe Mancia1, Rita Facchetti2, Gino Seravalle2
1From the Policlinico di Monza (G.M.), University Milano-Bicocca, Milan, Italy.
Insights
Adding out-of-office blood pressure (BP) measurements to office BP significantly improves cardiovascular risk prediction. However, the prognostic advantage of home BP (BPHome) and 24-hour BP (BP24h) is modest and warrants careful consideration for clinical practice.
Area of Science:
- Cardiovascular Medicine
- Hypertension Research
- Clinical Epidemiology
Background:
- Office blood pressure (BPOffice) alone has limitations in predicting cardiovascular outcomes.
- Previous studies on home BP (BPHome) and 24-hour BP (BP24h) for prognostic improvement are limited by multicollinearity and lack of quantitative advantage assessment.
- The PAMELA study provides long-term data to re-evaluate the prognostic value of out-of-office BP measurements.
Purpose of the Study:
- To assess the prognostic advantage of adding residual, office-independent BPHome and BP24h to BPOffice for predicting cardiovascular and all-cause mortality.
- To quantify the improvement in risk prediction using robust statistical methods, addressing previous limitations.
Main Methods:
- Analysis of 16-year follow-up data from 1833 individuals in the PAMELA study.
- Prediction models (Cox, ROC curves, Net Reclassification Improvement) were used to evaluate cardiovascular and all-cause mortality risk.
- BPOffice was analyzed alone and with the addition of residual BPHome, BP24h, or both, to isolate independent prognostic information.
Main Results:
- Addition of residual out-of-office systolic or diastolic BP (both BPHome and BP24h) to BPOffice significantly improved prediction of cardiovascular and all-cause mortality.
- The prognostic improvement was more consistent when BPHome was added compared to BP24h.
- Adding BP24h to BPOffice plus BPHome did not yield further significant improvement in prediction accuracy.
- The overall improvement in risk prediction was quantitatively modest across all analyses, including subgroups.
Conclusions:
- Adding out-of-office BP measurements (BPHome and BP24h) to office BP improves cardiovascular risk prediction, even when accounting for multicollinearity.
- The prognostic advantage conferred by out-of-office BP measurements is limited.
- The findings raise questions about the clinical utility and widespread recommendation of extended out-of-office BP monitoring for risk stratification.
Abstract:
Home and 24-hour blood pressure (BPHome and BP24h) are believed to improve the prognostic value of office BP (BPOffice) alone, but the evidence has limitations such as that (1) these 3 BPs are characterized by multicollinearity and (2) the procedures adopted do not allow quantification of the prognostic advantage. One thousand eight hundred thirty-three individuals belonging to the PAMELA (Pressioni Arteriose Monitorate e Loro Associazioni) were followed for 16 years. Prediction of cardiovascular and all-cause mortality was determined via the goodness of fit of individual data (Cox model), the area underlying the receiving operator curves and the net reclassification improvement of cardiovascular and all-cause mortality risk. Calculations were made for BPOffice alone and after addition of BPHome, BP24h, or both, limited to their residual portion which was found to be unexplained by, and thus independent on, BPOffice. With all methods addition of residual out-of-office systolic or diastolic BP to BPOffice significantly improved cardiovascular and all-cause mortality prediction. The improvement was more consistent when BPHome rather than BP24h was added to BPOffice and, compared with BPOffice plus BPHome, no better prediction was found when addition was extended to BP24h. With all additions, however, the improvement was quantitatively modest, which was the case also when data were separately analyzed in younger and older individuals or in dippers and nondippers. Thus, addition of out-of-office to BPOffice improves prediction of cardiovascular risk, even when data analysis avoids previous limitations. The improvement appears to be limited, however, which raises the question of the advantage to recommend their extended use in clinical practice.
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