Monitoring of Blood Pressure: Benefits of Home Monitoring
The role of home blood pressure monitoring in the diagnosis and treatment of hypertension is not yet fully delineated. In JNC VI, it is recognized that home blood pressure monitoring may provide useful information for the initial evaluation of patients with hypertension and for monitoring the response to treatment. The four general benefits of home blood pressure monitoring that are outlined in JNC VI include distinguishing sustained hypertension from white-coat hypertension, assessing response to antihypertensive medication, improving adherence to treatment, and potentially reducing costs.The World Health OrganizationInternational Society of Hypertension Guidelines acknowledged similar advantages to home blood pressure monitoring, with the exception that the potential for cost reduction is not included. The American Society of Hypertension ad hoc panel (1996) encouraged home monitoring with a validated digital device or an aneroid monitor for the “majority of patients with hypertension.” The American Association of Clinical Endocrinologists recommends that patients with type 2 diabetes and hypertension monitor blood pressure frequently at home. Home blood pressure monitoring is not addressed in the American Diabetes Association Clinical Recommendations 2001 or in the 1993 Treatment of Hypertension in Diabetes consensus statement.
White-coat Hypertension
White-coat hypertension, which may be more appropriately termed “isolated office hypertension,” is a condition in patients whose blood pressure is consistently elevated in the clinician’s office but normal at other times. A considerable portion of patients thought to have resistant or uncontrolled hypertension on the basis of office readings actually have white-coat hypertension and may not need more aggressive therapy. However, most patients treated for hypertension who have persistently high office readings also have high out-of-office readings. The potential for increased cardiovascular risk in patients with white-coat hypertension is still being debated.
Studies comparing home blood pressure monitoring and ambulatory monitoring have found home monitoring has a low positive predictive value for detecting white-coat hypertension. Recommendations from the ad hoc panel of the American Society of Hypertension suggest using home BP monitoring as a screening test for white-coat hypertension. If a normal home blood pressure is found (positive result), it should be confirmed by ambulatory monitoring. If a high blood pressure is found (negative result), then no further testing is needed. Because of its high specificity and reasonable cost, home BP monitoring may also be appropriate for long-term follow-up of patients with white-coat hypertension.
Assessing Response to Therapy
Home BP monitoring can be helpful in assessing response to antihypertensive therapy. It can be used to ensure adequate blood pressure control across the drug-dosing interval during awake hours, to evaluate effects of increasing or decreasing amounts of therapy, to ascertain whether poor office blood pressure response to increasing treatment represents overtreatment or true resistance, and to evaluate the relation of blood pressure levels to presumed side effects of therapy.
Adherence
Hypertension is a “silent disease,” often without signs or symptoms. Home blood pressure monitoring provides tangible signs of disease control. It may increase patients’ participation in their own care, and possibly help them cope with the disease. In general, adherence may be improved.
Costs
Home monitoring may provide a simple and cost-effective means for obtaining a large number of blood pressure readings. A study of 200 patients randomized either to usual care or to home monitoring in a closed model HMO found that self-measurement of blood pressure may be cost-effective. At the end of one year the costs of care were 29% lower in the self-monitoring group (not statistically significant), and blood pressure was equally well controlled in both groups. Appel and Stason estimated the costs of routine use of home blood pressure monitoring on all 50 million people in the U.S. with hypertension would be $2.5 billion. However, they assumed no savings from home monitoring. Potential savings from the use of home blood pressure monitoring, which have not yet been evaluated fully in clinical trials, include reductions in costs of medication for patients with white-coat hypertension, less need for clinic visits, and possibly, reductions in costs associated with cardiovascular morbidity.
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