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Algorithm for diagnosing hypertension using out-of-office blood pressure measurements
Je Sang Kim1, Moo-Yong Rhee1, Chee Hae Kim1
1Cardiovascular Center, Dongguk University Ilsan Hospital, Goyang, South Korea.
Insights
A new diagnostic algorithm improves hypertension detection by strategically using ambulatory blood pressure (BP) measurements. This approach enhances accuracy compared to relying solely on office or home BP readings for intermediate BP zones.
Area of Science:
- Cardiology
- Diagnostic Medicine
- Hypertension Research
Background:
- Accurate hypertension diagnosis is crucial for patient management.
- Traditional office and home blood pressure (BP) measurements have limitations in diagnostic accuracy.
- Ambulatory BP monitoring (ABPM) offers a more comprehensive assessment but is resource-intensive.
Purpose of the Study:
- To develop and validate a diagnostic algorithm that optimizes the use of ambulatory BP measurements.
- To determine optimal cut-off values for office and home BP to guide the need for ABPM.
- To improve the diagnostic accuracy for hypertension by integrating multiple BP measurement methods.
Main Methods:
- Patients with high office BP (≥140/90 mm Hg) underwent office, home, and ambulatory BP measurements.
- Office and home BP values were categorized into hypertension, intermediate, and normotension zones.
- Receiver operator characteristic (ROC) curve analysis determined cut-off values for the intermediate zone (95% sensitivity and specificity for daytime ambulatory hypertension).
- Three algorithms were developed and validated: OBP-ABP, OBP-HBP-ABP, and HBP-ABP.
Main Results:
- The developed algorithms demonstrated significantly higher diagnostic accuracies compared to office BP alone (75.8%) and home BP alone (76.2%).
- The OBP-ABP algorithm achieved 96.5% accuracy, OBP-HBP-ABP achieved 93.4% accuracy, and HBP-ABP achieved 94.9% accuracy in the development population.
- Similar improvements in diagnostic accuracy were observed in the validation population.
Conclusions:
- The developed algorithm effectively integrates ambulatory BP measurement into the diagnostic pathway for patients with intermediate office or home BP readings.
- This strategy enhances the overall diagnostic accuracy for hypertension.
- The algorithm provides a more precise and efficient approach to diagnosing hypertension, reducing unnecessary ABPM referrals.
Abstract:
The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut-off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut-off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP-ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP-HBP-ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP-ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1-80.9) for office BP alone and 76.2% (95%CI 70.5-81.3) for home BP alone as follows: 96.5% (95%CI: 93.4-98.4) for OBP-ABP, 93.4% (95%CI: 89.6-96.1) for OBP-HBP-ABP, and 94.9% (95%CI: 91.5-97.3%) for HBP-ABP. In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.
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Prepare for the Procedure:
01:17Measurement of Blood Pressure
01:10Pre-Procedural Guidelines for Assessing Blood Pressure
01:28Special considerations while measuring blood pressure
Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.