Does ABPM replace office blood pressure measurement in the clinical evaluation of patients?

Abstract

Automated noninvasive ambulatory blood pressure monitoring (ABPM) has been used since the early 1980's as a research tool and since the mid 1990's also for clinical purposes. Although it has several obvious advantages over isolated office readings, including the fact that it yields multiple blood pressure measurements during all of the subject's activities, it remains controversial whether it should or not replace conventional office blood pressure measurements in daily practice. The suggestion to favor use of ABPM instead of office measurements, because short, hurried visits to the clinical practice which do not allow for proper office blood pressure measurements is, in fact, hardly acceptable. Office blood pressure is still the corner stone of clinical management of hypertensive patients, although the reference "normal" values have evolved from <180/110 mmHg in the 1950's to <140/90 mmHg or less (for diabetic and renal patients) in the last decade. In spite of its usefulness, however, this time-honored approach suffers from a number of limitations: inaccuracy of readings in several settings, restricted number of measurements possible in 24 hours, inability to account for the pronounced physiological variability of blood pressure over 24 hours and the often significant interference of the so-called "white-coat effect"1 . It has been suggested that an heightened patient's reaction to blood pressure measurement by a physician may be responsible for the phenomenon defined as white coat hypertension, i.e. a condition characterized by daytime blood pressure <135/85 mmHg and office blood pressure >140/90 mmHg 2 . Findings from Verdecchia et al, using daytime blood pressure cut-off values of 130/80 mmHg for ABPM normalcy and the white coat hypertension definition, showed an increased incidence of stroke during long term follow-up, when compared to normotensives 3 , suggesting on the one hand the possible risk associated with isolated office blood pressure elevation and, on the other the usefulness of setting the "normal limit" for ABPM daytime blood pressure near to 130/80 mmHg, as pointed out in the PAMELA study 4 . Recently Mancia et al. 5 , in the analysis of a longitudinal follow-up in the PAMELA study, while confirming the prognostic importance of ambulatory blood pressure, also showed that each blood pressure increase (office, home or ambulatory) implies an increased mortality risk in addition to that of other blood pressure increases. In the Office versus Ambulatory Study 6 , office blood pressure measurements were strongly correlated to occurrence of cardiovascular events, and this was true also for patients with office systolic blood pressure >160 mmHg but a 24-hour ambulatory systolic blood pressure <130 mmHg. However, patients with normal office blood pressure but elevated ambulatory blood pressure (defined as "masked hypertensives") clearly have a greater cardiovascular risk, higher than that of patients with "White Coat Hypertension" 5 . The foregoing emphasizes that blood pressure increase, independent o...

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