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In a draft recommendation statement, the U.S. Preventive Services Task Force is calling for ambulatory blood pressure measurement to confirm hypertension before diagnosis in a draft statement that also advocated more frequent hypertension screening for many adults.

One exception to the grade A recommendation for out-of-office confirmation of hypertension: cases for which therapy should begin immediately.

People 40 and older as well as higher-risk groups should be re-screened every year after a normal blood pressure finding, while others can be screened every 3 to 5 years, the draft statement recommended.

Guidelines have generally advocated every 2 or 5 years for screening intervals, so the shift to annual screening for so many patients will be a major shift, , chief of cardiology at Lyndon B. Johnson General Hospital in Houston, told 乌鸦传媒.

Change for Practice

American College of Cardiology president-elect Kim A. Williams Sr., MD, chief of cardiology at Rush University Medical Center in Chicago, praised the change to ambulatory confirmation of hypertension.

"This will help solve problems of overestimation of blood pressure in the clinic with the 'office hypertension' phenomenon and, in my experience, fully engages patients in the control of the blood pressure," he told 乌鸦传媒. "When you measure it, you don't ignore it."

But just how ambulatory monitoring can be operationalized on a large scale remains to be seen, he noted.

Most physician offices don't actually have the equipment for ambulatory monitoring, , director of outpatient cardiology services at New York's University of Rochester Medical Center and president-elect of the American Society of Hypertension, told 乌鸦传媒.

"The guidelines, if put into play, will really have a big change on this because there will be an expectation that every physician's office, every hypertension specialist's office, will have one of these devices or many of these devices to confirm the diagnosis of hypertension," he said.

American Heart Association president , of Brigham and Women's Hospital and Harvard in Boston, agreed that the change could present a challenge, although perhaps less so than in the past.

"It makes great sense to perform ambulatory blood pressure monitoring," he told 乌鸦传媒. "This has been known for quite a while. The problem was that it has been difficult to implement because of the lack of equipment to do this."

"Now it's easier to do," he said, pointing to the increasing availability of smartphone and table-connected digital wrist or arm-cuff blood pressure devices that patients can use at home and simply email the results to their physician.

Ambulatory monitoring hasn't been prominent in joint guidelines from the organizations, Antman noted. But he predicted that could change too.

"It's quite likely we will see revision to the definition of what constitutes hypertension and of whether treatment has been effective in controlling hypertension," he suggested in an interview, adding "the hypertension guideline is in the process of being updated. So I know that there will be interest in evaluating ambulatory blood pressure monitoring as part of those recommendations."

Ambulatory confirmation of hypertension before initiating treatment is already the standard in British practice, , director of the Clinical Hypertension Program at University Hospitals Case Medical Center in Cleveland, noted in an editorial in the Annals of Internal Medicine.

"Availability of this diagnostic method in the U.S. is currently hindered by the reluctance of insurers to reimburse for it," he noted. "This review for the U.S. Preventive Services Task Force will hopefully lead to greater availability of ambulatory blood pressure monitoring."

The Rationale

A supporting evidence review published simultaneously online in Annals showed that ambulatory blood pressure monitoring was better at predicting long-term cardiovascular outcomes.

Each 10-mmHg higher 24-hour ambulatory systolic blood pressure was associated with 28% to 40% higher risk of fatal or nonfatal events independent of in-office blood pressure measurements across 11 studies meta-analyzed.

The review found that 5% to as many as 65% of patients found to be hypertensive in the office across 27 studies fell in the normal range on confirmatory testing outside the office.

Those with so-called white-coat hypertension had cardiovascular outcomes similar to those normotensive on initial in-office screening, , of the Kaiser Permanente Center for Health Research in Portland, and colleagues found.

While the review identified little risk of harm from ambulatory blood pressure monitoring -- sleep disturbance, discomfort, and restrictions in daily activities during use of the device -- there is potential harm of unnecessary treatment if it's not used, they noted.

The review wasn't able to determine a single best interval for repeat screening. The studies showed variably high incidence of hypertension using different intervals of up to 6 years, with higher yield at shorter intervals for those on the high end of the normal blood pressure range and those in certain higher-risk groups.

The USPSTF ended up recommending annual rescreening for the following groups:

• People ages 40 and older
• People with blood pressure in the 130/85 to 139/89 mmHg range on the initial screen
• African Americans
• Obese or overweight individuals

The screening interval for younger adults without such risk factors after an initial screening with normal blood pressure should be every 3 to 5 years, the draft recommendations said.

The draft recommendation statement will be through Jan. 26, 2015.

From the American Heart Association: