The potential for overdiagnosis and underdiagnosis because of blood pressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESH and 2019 NICE hypertension guidelines

Bell, Katy J.L.; Doust, Jenny; McGeechan, Kevin; Horvath, Andrea R.; Barratt, Alexandra; Hayen, Andrew; Semsarian, Christopher; Irwig, Les

doi:10.1097/hjh.0000000000002614

Cited by 20 publications

(15 citation statements)

References 46 publications

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“…In patients with hypertension, 3,4 diabetes, [5][6][7] chronic kidney disease, 8,9 and chronic systolic HF, 10 the average of several measurements over time provided useful information on the risk of adverse health outcomes. [3][4][5][6][7][8][9][10] Given these characteristics and the recognition in guidelines that excessive BPV carries risk, 37 doctors might assess BPV in support of clinical decision making, although until now randomized clinical trials focusing on reducing BPV have not yet been published.…”

Section: Heartmentioning

confidence: 99%

Visit-to-Visit Blood Pressure Variability and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

et al. 2021

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Whether visit-to-visit blood pressure variability (BPV) is associated with adverse outcomes in patients with heart failure (HF) with preserved ejection fraction is unclear. We assessed these associations in 3184 patients with HF (51.0% women; mean age, 68.6 years) with preserved ejection fraction (≥45%) enrolled in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist). BPV indexes were the SD, variability independent of the mean, and average real variability. The primary end point consisted of total mortality, myocardial infarction, stroke, and hospitalized HF. We computed hazard ratios for the risks associated with 1-SD increase in BPV indexes, using multivariable Cox regression to adjust for the BP level and confounders. In the placebo group (n=1577), the primary composite end point, stroke, and hospitalized HF were significantly associated with systolic and diastolic BPV (hazard ratios, ≥1.28; P ≤0.008) and total mortality with systolic BPV (hazard ratios ≥1.20; P ≤0.010). In the spironolactone group (n=1607), the primary end point and hospitalized HF were associated with both systolic and diastolic BPV (hazard ratios ≥1.17; P ≤0.006). Sensitivity analyses stratified by sex, median age, and region generated confirmatory results. Most of the interactions between randomized group and BPV indexes were not significant. In conclusion, in patients with HF with preserved ejection fraction, greater systolic and diastolic BPV were associated with adverse health outcomes over and beyond the BP level.

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Section: Heartmentioning

confidence: 99%

Visit-to-Visit Blood Pressure Variability and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

et al. 2021

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“…It could also be related to cuff fit, with many individuals who require an extra-large BP cuff having arms with a conicotruncal shape. 22 Regardless of cause, the potential clinical effect among those requiring larger cuff sizes includes overdiagnosis of not just hypertension, but also stage 2 hypertension. The mean BP in those requiring an extra-large cuff based on measured mid-arm circumference was 144/87 mm Hg when a regular BP cuff was used, which is in the stage 2 hypertension range in the US, whereas the mean BP when using an appropriately sized cuff was 125/79 mm Hg, a reading in the elevated BP range.…”

Section: Discussionmentioning

confidence: 99%

Effects of Cuff Size on the Accuracy of Blood Pressure Readings

Ishigami,

Charleston,

Miller

et al. 2023

JAMA Intern Med

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ImportanceClinical practice guidelines recommend selecting an appropriately sized cuff based on mid-arm circumference prior to measuring blood pressure (BP). To our knowledge, the effect of miscuffing on BP measurement when using an automated BP device has not been quantified.ObjectiveTo determine the effect of using a regular BP cuff vs an appropriately sized BP cuff on automated BP readings.Design, Setting, and ParticipantsThis randomized crossover trial of community-dwelling adults with a wide range of mid-arm circumferences took place between March 16 and October 25, 2021, in Baltimore, Maryland. Participants were recruited via BP screening events at a public food market and a senior housing facility, targeted mailings to prior research participants, placement of study brochures in hypertension clinics at Johns Hopkins University, and referrals from physicians providing hypertension care to adults.InterventionsParticipants underwent 4 sets of triplicate BP measurements, with the initial 3 sets using an appropriate, too-small, or too-large BP cuff in random order; the fourth set of triplicate measurements was always completed with an appropriate BP cuff.Main Outcomes and MeasuresThe primary outcome was the difference in mean BP when measured with a regular BP cuff compared with an appropriate BP cuff. The secondary outcome was the difference in BP when using too-small or too-large BP cuffs vs an appropriate BP cuff across all cuff sizes. Results were also stratified by systolic BP (≥130 mm Hg vs &lt;130 mm Hg) and body mass index (calculated as weight in kilograms divided by height in meters squared; ≥30 vs &lt;30).ResultsA total of 195 adults (mean [SD] age, 54 [16] years; 67 [34%] male; 132 [68%] Black; 100 [51%] with hypertension) were randomized for inclusion. Among individuals requiring a small BP cuff, use of a regular BP cuff resulted in a statistically significant lower BP reading (mean systolic BP difference, −3.6 [95% CI, −5.6 to −1.7] mm Hg). In contrast, among individuals requiring a large or extra-large BP cuff, use of a regular BP cuff resulted in a statistically significant higher BP reading (mean systolic BP difference, 4.8 [95% CI, 3.0-6.6] mm Hg and 19.5 [95% CI, 16.1-22.9] mm Hg, respectively). For the secondary outcome, BP differences with overcuffing and undercuffing by 1 and 2 cuff sizes were greater among those requiring larger BP cuffs. The results were consistent in stratified analyses by systolic BP and body mass index.Conclusions and RelevanceIn this randomized crossover trial, miscuffing resulted in strikingly inaccurate BP measurements. This is particularly concerning for settings where 1 regular BP cuff size is routinely used in all individuals, regardless of arm size. A renewed emphasis on individualized BP cuff selection is warranted.Trial RegistrationClinicalTrials.gov Identifier: NCT04610775

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“…Globally, 500 000 people a year are overdiagnosed with thyroid cancer, including in low and middle income countries45; 70 000 women a year may be overdiagnosed with breast cancer in the US, and 4000 a year in Australia; and 8000 Australian men a year are overdiagnosed with prostate cancer 67. Overdiagnosis affects all ages and life stages 8910111213. In the UK, the problem of overdiagnosis and overtreatment is of such concern to the Royal College of General Practitioners that a standing group on overdiagnosis has been established, which has advanced recommendations to try to combat it 14.…”

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confidence: 99%