The Rational Clinical Examination: Evidence-Based Clinical Diagnosis

Adult Hypertension

David L. Simel; Anthony J. Viera; Yuichiro Yano; Feng-Chang Lin; Jonathan Yun; Gaurav Dave; Ann Von Holle; Laura A. Viera; Daichi Shimbo; Shakia T. Hardy; Katrina E. Donahue; Alan Hinderliter; Christiane E. Voisin; Daniel E. Jonas

Make the Diagnosis: Does This Adult Patient Have Hypertension?

David L. Simel, MD, MHS

Prior Probability

The prevalence of hypertension depends on the blood pressure (BP) threshold that categorizes high BP as present, the population studied, and the case definition of hypertension. The case definition for hypertension is a 24-hour mean BP of ≥ 130 mm Hg/80 mm Hg or a mean awake BP of ≥ 135 mm Hg/85 mm Hg.¹ In studies with a median participant age of 55 years that compared home blood pressure monitoring (HBPM) (at a threshold of ≥ 135/85 mm Hg considered at risk for hypertension) to a reference standard of 24-hour ambulatory blood pressure monitoring (ABPM) among patients without known or treated hypertension, the prevalence of hypertension was 54% (95% CI, 39%-69%). In studies with a median participant age of 50 years that compared office BP (at a threshold of ≥ 140/90 mm Hg considered at risk for hypertension) to a reference standard of 24-hour ABPM among patients without known or treated hypertension, the prevalence of hypertension was 49% (95% CI, 39%-60%).

In ongoing cross-sectional surveys where BP was measured by trained physicians using a standardized protocol of averaging 3 measurements taken 30 seconds apart during home visits, the frequency of blood pressure ≥ 130/80 mm Hg was 22% for those ages 18 years to 39 years, 54% for those 40 to 59 years, and 74% for those 60 years or older.² These results show the effect of age on blood pressure, but hypertension was not evaluated with 24-hour ABPM.

Population Who Should Be Screened for Hypertension

The US Preventive Services Task Force recommends that all adults undergo screening for hypertension with office BP measurement and that BP measurements outside of the clinical setting should be obtained to confirm the diagnosis before initiating treatment.¹ There are several techniques for measuring blood pressure (Table 110-1). When comparing BP measured in a clinician’s office with ABPM, patients fall into 1 of 4 categories: sustained hypertension, masked hypertension, white coat hypertension, and normotension (Table 110-2).

Table 110-1.Current Blood Pressure (BP) Assessment Techniques

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Table 110-1. Current Blood Pressure (BP) Assessment Techniques

Technique

Description

Office aneroid

BP is measured manually by inflating a brachial cuff and listening for Korotkoff sounds as a spring device and metal membrane translates the column of air into signals that operate a needle in the gauge; manometer is subject to easy miscalibration and manual technique is subject to observer biases

Office oscillometric

BP measurement is estimated using an algorithm that translates a pressure waveform from a brachial cuff into systolic and diastolic; relies on proper technique but mitigates observer biases

Automated office BP measurement

Provides repeated oscillometric brachial cuff measurements automatically and averages them; can be attended or unattended (no observer present); may mitigate white coat effect

Home BP monitoring (oscillometric)

Patient measures BP using an oscillometric device, typically multiple times per day over several days

Ambulatory BP monitoring (oscillometric)

Device is worn over a 24-h period and automatically (via programming) provides repeated measurements throughout the day and night (including during sleep); ideally should have a minimum of 20 awake readings and 7 nighttime (sleep) readings³

Table 110-2.Blood Pressure (BP) Classifications Based on Concordance Between Office and Out-of-Office Measurements

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Table 110-2. Blood Pressure (BP) Classifications Based on Concordance Between Office and Out-of-Office Measurements

Office BP

Out-of-office BP

Not elevated

Elevated

Not elevated

Sustained normotension (true negative office)

Masked hypertension (false-negative office)

Elevated

White-coat hypertension (false-positive office)

Sustained hypertension (true positive office)

Assessing the Likelihood of Hypertension

When comparing office measures (with a threshold of ≥ 140/90 mm Hg considered positive for hypertension) to 24-hour ABPM, the sensitivity is low (Table 110-3), which means that some patients with hypertension will be missed (masked hypertension; LR–, 0.56). Home blood pressure monitoring is a better way to identify those patients less likely to have hypertension at a threshold of mean ≥ 135/85 mm Hg (LR–, 0.33). The combination of office BP (elevated vs not elevated) results with HBPM (elevated vs not elevated) may work best with higher diagnostic accuracy: sustained hypertension (LR, 10.0; 95% CI, 5.3-20.0), masked hypertension (LR, 3.6; 95% CI, 2.4-5.4), white coat hypertension (LR, 1.6; 95% CI, 0.91-2.7), and normotension (LR, 0.41; 95% CI, 0.36-0.47).

Table 110-3.Sensitivity, Specificity, and Likelihood Ratios of Office Oscillometric and Home Blood Pressure Monitoring Compared With Ambulatory Blood Pressure Monitoring

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Table 110-3. Sensitivity, Specificity, and Likelihood Ratios of Office Oscillometric and Home Blood Pressure Monitoring Compared With Ambulatory Blood Pressure Monitoring

Screening test

Sensitivity (95% CI), %

Specificity (95% CI), %

Likelihood ratio (95% CI)

Positive

Negative

Office, ≥ 140/90 mm Hg

51 (36-67)

88 (80-96)

4.2 (2.5-6.0)

0.56 (0.42-0.69)

Home, mean ≥ 135/85 mm Hg

75 (65-86)

76 (65-86)

3.1 (2.2-4.0)

0.33 (0.20-0.47)

Reference Standard Tests

The reference standard for diagnosing hypertension is 24-hour ambulatory blood pressure monitoring with hypertension confirmed by a 24-hour mean BP ≥ 130 mm Hg/80 mm Hg or a mean awake BP ≥ 135 mm Hg/85 mm Hg.

References

Krist AH, Davidson KW, Mangione CM, et al; US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325(16):1650–1656. Medline:33904861 doi:10.1001/jama.2021.4987

Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017-2018. NCHS Data Brief. April 2020. Accessed October 27, 2021. https://www.cdc.gov/nchs/data/databriefs/db364-h.pdf

Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35–e66. Medline:30827125 doi:10.1161/HYP.0000000000000087

Original Article: Does This Adult Patient Have Hypertension?

Anthony J. Viera, Yuichiro Yano, Feng-Chang Lin, David L. Simel, Jonathan Yun, Gaurav Dave, Ann Von Holle, Laura A. Viera, Daichi Shimbo, Shakia T. Hardy, Katrina E. Donahue, Alan Hinderliter, Christiane E. Voisin, Daniel E. Jonas

Clinical Scenarios

In the following cases, the clinician wants to determine whether the patient has hypertension.

Case 1

A 51-year-old healthy woman presented to her physician’s office for a routine wellness visit. She felt well, exercised by walking 1 to 2 miles 3 days per week, and was taking no medications. Her body mass index was 23.6 and her office blood pressure (BP), averaging 2 measures, was 155/83 mm Hg when measured by the medical assistant using the office-based oscillometric device with an appropriately sized cuff and proper positioning. Findings of her cardiovascular examination were otherwise normal. She recorded her home BP using proper technique and cuff size at about the same time daily for 5 consecutive days after the physician visit, and mean BP was 129/77 mm Hg.

Case 2

A 34-year-old physician presented to his physician’s office for a pretravel consultation. He reported not exercising regularly, drinking 1 to 2 glasses of wine per night, and taking a statin for familial hypercholesterolemia. His body mass index was 28. His office-based BP, measured by the medical assistant using the appropriately sized cuff and proper positioning, was 128/78 mm Hg. Findings of his cardiovascular examination were otherwise normal.

How certain is it that these patients do or do not have hypertension?

Background

Accurate measurement of BP is important, yet challenging.^1,2 With mercury sphygmomanometers removed from practice, offices use either aneroid manual sphygmomanometers or automatic oscillometric devices. Manual measurement is particularly prone to errors, including rapid cuff deflation, auscultatory gap, and terminal digit preference.^2-4 Proper technique (including brief rest before measurement, proper positioning, and correct cuff size) is also required during oscillometric measurement, but is seldom followed.^2-4 Even when BP is measured with no technical errors, isolated BP readings may not represent a person’s usual BP because of many factors that influence BP variability.^2-5 An initially elevated BP in the office setting (which can be considered a positive screening measurement) calls for follow-up BP measurements to confirm or refute the presence of hypertension.

Although newer guidelines recommend out-of-office measurements of BP, preferably by 24-hour ambulatory blood pressure monitoring (ABPM), to confirm a suspected diagnosis of hypertension,^1,6 the practice of obtaining such measurements in the US is limited in part due to lack of health care centers and clinicians offering the services.⁷ Additionally, in current practice, a nonelevated office BP measurement has typically not been an indication for further testing. The combined effect of this approach is that it can lead to misclassification (Table 110-4), assigning an elevated BP status to a person whose BP is usually not elevated (a false-positive) or assigning a “normal” BP status to a person whose BP is usually elevated (false-negative).

Table 110-4.Blood Pressure (BP) Classifications Based on Concordance Between Office and Out-of-Office Measurements

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Table 110-4. Blood Pressure (BP) Classifications Based on Concordance Between Office and Out-of-Office Measurements

Office BP

Out-of-office BP

Not elevated

Elevated

Not elevated

Sustained normotension (true negative office)

Masked hypertension (false-negative office)

Elevated

White-coat hypertension (false-positive office)

Sustained hypertension (true positive office)

Another contemporary method of BP assessment (Table 110-5) is automated office BP (AOBP) measurement, an in-office alternative in which the oscillometric device is programmed to take multiple readings sequentially (with or without an observer present) and the device provides a mean BP measurement.³ Currently, 24-hour ABPM is considered the reference standard because of the large evidence base demonstrating its strong association with future cardiovascular events, as noted in the 2021 US Preventive Services Task Force (USPSTF) Recommendation Statement on Screening for Hypertension in Adults, which reaffirmed the 2015 USPSTF recommendation.⁶

Table 110-5.Current Blood Pressure (BP) Assessment Techniques

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Table 110-5. Current Blood Pressure (BP) Assessment Techniques

Technique

Description

Office aneroid

Office oscillometric

BP measurement is estimated using an algorithm that translates a pressure waveform from a brachial cuff into systolic and diastolic; relies on proper technique but mitigates observer biases

Automated office BP measurement

Provides repeated oscillometric brachial cuff measurements automatically and averages them; can be attended or unattended (no observer present); may mitigate white coat effect

Home BP monitoring (oscillometric)

Patient measures BP using an oscillometric device, typically multiple times per day over several days

Ambulatory BP monitoring (oscillometric)

This review was conducted to summarize the literature on the accuracy of these current methods of BP measurement compared with ABPM as the reference standard for diagnosing hypertension in patients receiving no treatment for hypertension.

Methods

Search Strategy

PubMed/MEDLINE, Embase, Cochrane Library, ClinicalTrials.gov, and DARE databases and the American Heart Association website were searched from inception to April 28, 2021, using a combination of MeSH (Medical Subject Headings) terms and keywords (Table 1 in the Supplement). The reference lists of included articles were also searched. An experienced medical librarian (C.E.V.) with expertise in systematic reviews developed the search strategy and conducted the searches.

Article Eligibility

Articles were eligible for inclusion if they described results of an analysis designed to compare conventional office oscillometric BP measurement with 24-hour ABPM, HBMP with 24-hour ABPM, or AOBP with 24-hour ABPM. HBPM was defined as self-performed serial measurements of BP using an oscillometric device at the person’s home. Additionally, eligible articles had to indicate that analyzed participants (or precise subsets) were not receiving BP-lowering medication at the time of measurement, and the study had to include participants with both elevated and nonelevated office or home BP measurements in its analysis, applying the reference standard (24-hour ABPM) to both groups. Articles had to report data (directly or calculable) on the number of individuals classified as having or not having hypertension based on the reference standard. The reference standard for hypertension was defined by either mean BP during 24-hour ABPM or mean BP while awake during ABPM.¹

Exclusion of Articles

On agreement by 2 authors working independently, articles were excluded for any of the following reasons: non-English language, not original research, ineligible study design (no comparison directly to 24-hour ABPM), unable to calculate sensitivity and specificity from data, use of mercury or aneroid sphygmomanometry, exposure to BP-lowering medication, or ineligible population for this review (eg, children, individuals with kidney failure, pregnant women). Studies comparing kiosk or pharmacy-type monitors or wrist cuff devices were excluded.

Data Abstraction

Data were abstracted into separate tables (by one author and verified by a second author) by category of types of BP measurement methods, noting author, year, sample size/population, BP measurement technique, and the parameters for the comparison with 24-hour ABPM. The number of individuals with and without hypertension confirmed by 24-hour ABPM was recorded along with the number who would then be considered to have true positive results (comparator technique also showed BP elevation), true negative results (comparator technique also showed no BP elevation), false-positive results (comparator technique showed BP elevation when 24-hour ABPM did not), and false-negative results (comparator technique showed no BP elevation when 24-hour ABPM showed BP elevation).

Quality Assessment

Articles meeting inclusion criteria were independently evaluated by 2 reviewers to assess methodological quality using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies, version 2)⁸ tool and The Rational Clinical Examination⁹ levels of evidence. Any differences were resolved by discussion or assessment by a third reviewer. Level 1 studies included those that provided an independent blinded comparison to 24-hour ABPM among at least 100 consecutive participants. Level 2 studies provided an independent blinded comparison to 24-hour ABPM among a smaller number of consecutive participants. Level 3 studies provided a comparison to 24-hour ABPM among a nonconsecutive sample.

Diagnostic Thresholds Between Studies

Included studies used an office threshold of at least 140 mm Hg for systolic BP and at least 90 mm Hg for diastolic BP. Studies varied in the number of measurements used for office (during a single visit) or HBPM assessment (across multiple days). Consistent with guideline-based recommendations, home BP threshold was a mean systolic BP of at least 135 mm Hg or mean diastolic BP of at least 85 mm Hg for all included studies.¹ To define hypertension, all studies used either mean systolic BP of at least 130 mm Hg or mean diastolic BP of at least 80 mm Hg during 24-hour ABPM or mean systolic BP of at least 135 mm Hg or mean diastolic BP of at least 85 mm Hg while awake during ABPM.¹

Analysis

The sensitivity, specificity, and likelihood ratios (LRs) for each study were calculated, followed by a meta-analysis (if > 2 studies) to calculate the random-effects bivariable summary measures (Proc NLMixed, SAS 9.4 TS Level 1M4 [SAS Institute]).¹⁰ These bivariable summary measures for office vs home measures were compared,¹¹ and estimates of the positive and negative predictive values were made using random-effects bivariable measures that took the correlation between prevalence and predictive value into account.¹² To address heterogeneity, the methods and study populations of the data are described using bivariable random-effects methods when combining results, and width of the CIs provides insights into the precision of the parameters.

Results

The searches identified 12 604 titles, of which 17 articles ultimately met the inclusion criteria (Table 110-6 and Table 110-7; Supplemental Figure).^13-29 Nine studies (n = 4368) compared office or home measures with mean BP while awake during ABPM as the reference standard,^{13,16,18-20,22,24,25,27} 5 studies (n = 3191) compared results with mean BP during 24-hour ABPM,^{14,15,17,21,26} and 2 studies (n = 1183) compared results with both mean BP while awake during ABPM and mean BP during 24-hour ABPM.^23,28

Table 110-6.Studies Comparing Conventional Office Oscillometric Blood Pressure With Ambulatory Blood Pressure Monitoring (ABPM)

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Table 110-6. Studies Comparing Conventional Office Oscillometric Blood Pressure With Ambulatory Blood Pressure Monitoring (ABPM)

Source

Setting

Sample size (% with hypertension on ABPM)

Mean age, y

Female sex, %

Country of study

Race and/or ethnicity

Mean ABPM threshold, mm Hg

No. of office measurements

Gill et al,¹³ 2017

General practices

211 (41)

46% White; 26% South Asian; 27% African Caribbean

Awake: ≥ 135/85

Ishikawa et al,¹⁴ 2010

Clinic visit

129 (34)

Japan

Not reported

24-h: ≥ 130/≥ 80

Kang et al,¹⁵ 2015

Specialty clinic visit

573 (64)

China

Not reported

24-h: ≥ 130/≥ 80

Kim et al,¹⁶ 2011

Research visit

121 (54)

South Korea

Not reported

Awake: > 135/> 85

≥ 2

Ommen et al,¹⁷ 2007

Clinic

178 (25)

61% White; 31% Black; 30% Hispanic

24-h: ≥ 130/≥ 80

Poudel et al,¹⁸ 2019

Research visit

432 (38)

52% Black

Awake: > 135/> 85

3 (mean of second and third taken)

Selenta et al,¹⁹ 2000

Research visit

319 (27)

70% White; 30% Asian

Awake systolic: > 135

Shin et al,²⁰ 2015

Specialty clinic visit

1262 (61)

Korea

Not reported

Awake: > 135/> 85

Tocci et al,²¹ 2018

Specialty clinic visit

2209 (67)

Italy

Not reported

24-h: ≥ 130/≥ 80

Viera et al,²² 2014

Research visit

411 (76)

75% White; 21% Black

Awake: ≥ 135/≥ 85

3 (mean of second and third taken)

Wojciechowska et al,²³ 2016

Research visit

201 (33)

Not reported

Poland

Not reported

24-h: ≥ 130/≥ 80; awake: > 135/85; or nighttime: > 120/70

Zhang et al,²⁴ 2015

Secondary care

831 (62)

China

Not reported

Awake: ≥ 135/≥ 85

Table 110-7.Studies Comparing Home Blood Pressure Monitoring With Ambulatory Blood Pressure Monitoring

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Table 110-7. Studies Comparing Home Blood Pressure Monitoring With Ambulatory Blood Pressure Monitoring

Source

Setting

Sample size (% with hypertension on ABPM)

Mean age, y

Female sex, %

Country

Race and ethnicity

Mean ABPM threshold, mm Hg

No. of home measurements

Gill et al,¹³ 2017

General practices

211 (41)

46% White; 26% South Asian; 27% African Caribbean

Awake: ≥ 135/85

12 minimum from ≥ 4 d (mean excluded day 1 measurement)

Ishikawa et al,¹⁴ 2010

Research visit

129 (34)

Japan

Not reported

24-h: ≥ 130/80

12 (mean of all measurements)

Kang et al,¹⁵ 2015

Specialty clinic visit

573 (64)

China

Not reported

24-h: ≥ 130/80

12-70

Nunan et al,²⁵ 2015

Research visit

203 (54)

90% White

Awake: ≥ 135/85

12-24 (mean excludes the 4 readings taken on day 1)

Zhang et al,²⁴ 2015

Outpatient clinic

831 (62)

China

Not reported

Awake: ≥ 135/85

42 (mean of 24 readings)

Zhuo et al,²⁶ 2009

Community volunteers

102 (71)

China

Not reported

24-h: ≥ 130/80^a

6 (mean of 4 readings)

^aUsed awake mean ≥ 135/85 for the false-positive assessment.

The summary prevalence of hypertension by 24-hour ABPM was 49% (95% CI, 39%-60%) in the studies that evaluated conventional office measures and 54% (95% CI, 39%-69%) in the studies that evaluated home measures. Two studies of AOBP vs 24-hour ABPM among untreated patients across the spectrum of office BP measurements were found, with prevalence of hypertension of 16% and 35%.^27,28 Only 3 studies were level 1 and provided comparison to 24-hour ABPM using a consecutive sample^21,24,27; the remainder of the studies were level 3 (Table 2 in the Supplement).

Conventional Office Oscillometric BP vs 24-Hour ABPM

A total of 12 studies compared office oscillometric BP measurements with 24-hour ABPM, including both initially elevated BP levels as well as nonelevated office BP levels (Table 110-6).^13-24 Sample sizes ranged from 117 to 2209 participants. Four studies were conducted in the US.^17-19,22 For a threshold of at least 140/90 mm Hg, the summary sensitivity of oscillometric office BP (mean of 1-5 measures from single visit) for diagnosing hypertension was 51% (95% CI, 36%-67%), specificity was 88% (95% CI, 80%-96%), positive LR was 4.2 (95% CI, 2.5-6.0), and negative LR was 0.56 (95% CI, 0.42-0.69) (Table 110-8).

Table 110-8.Sensitivity, Specificity, and Likelihood Ratios of Office Oscillometric and Home Blood Pressure Monitoring Compared With Ambulatory Blood Pressure Monitoring^a

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Table 110-8. Sensitivity, Specificity, and Likelihood Ratios of Office Oscillometric and Home Blood Pressure Monitoring Compared With Ambulatory Blood Pressure Monitoring^a

Screening test

No. of studies

Sensitivity (95% CI), %

Specificity (95% CI), %

Likelihood ratio (95% CI)

Positive

Negative

Office

12^13-24

51 (36-67)

88 (80-96)

4.2 (2.5-6.0)

0.56 (0.42-0.69)

Home

6^13,14,21-23

75 (65-86)

76 (65-86)

3.1 (2.2-4.0)

0.33 (0.20-0.47)

^aSee Table 3 in the Supplement for results from individual studies.

HBPM vs 24-Hour ABPM

A total of 6 studies compared home oscillometric BP measurements with 24-hour ABPM, including both initially elevated BP levels and nonelevated office BP levels (Table 110-7).^{13-15,21,25,26} Sample sizes ranged from 102 to 831 participants. None of the studies were conducted in the US. For a threshold of at least 135/85 mm Hg, HBPM (mean of multiple measurements) had a summary sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47) (Table 110-8).

Office Oscillometric Measurement vs HBPM

Office BP had low sensitivity for diagnosing hypertension, whereas HBPM had higher sensitivity (51% vs 75%; P = .04) and no significant difference in specificity (76% vs 88%; P = .15). The positive LRs were not significantly different for office BP vs HBPM (P = .37), whereas the negative LR was lower for HBPM (P = .04). The thresholds for defining hypertension and the prevalence of hypertension were similar in office BP measurement and home BP measurement studies, and the estimated predictive values of office oscillometric BP measures and HBPM were numerically nearly identical (office BP: positive predictive value, 78% [95% CI, 67%-85%]; negative predictive value, 68% [95% CI, 59%-76%]; HBPM: positive predictive value, 78% [95% CI, 69%-86%]; negative predictive value, 71% [95% CI, 60%-80%]).

Office Measurement and HBPM as a Composite Measure

One study²⁴ had an adequate sample size and provided enough data that allowed calculating the serial LR for each combination of office and home BP measurements compared with 24-hour ABPM (Table 4 in the Supplement). There was a stepwise lower LR for the office HBPM hypertension statuses in Table 110-4, suggesting higher diagnostic accuracy when home measures are added to office measures for sustained hypertension (LR, 10.0 [95% CI, 5.3-20.0]), masked hypertension (LR, 3.6 [95% CI, 2.4-5.4]), white coat hypertension (LR, 1.6 [95% CI, 0.91-2.7]), and normotension (LR, 0.41 [95% CI, 0.36-0.47]).

AOBP Monitoring vs 24-Hour ABPM

Two studies from 2019 assessed unattended automated office (AOBP) measurement compared with 24-hour ABPM among untreated participants (Table 110-9).^27,28 In a study of a consecutive sample of 578 adults, AOBP (using a cutoff of 135/85 mm Hg) had a sensitivity of 48% (95% CI, 38%-58%) and specificity of 91% (95% CI, 88%-93%) compared with mean BP while awake during ABPM (positive LR, 5.3 [95% CI, 3.4-7.2]; negative LR, 0.57 [95% CI, 0.46-0.69]).²⁷ In another study of 982 adults from a general population in Kenya, mean AOBP had a sensitivity of 51% (96% CI, 46%-57%) and specificity of 80% (95% CI, 77%-83%) compared with BP while awake during ABPM (positive LR, 2.6 [95% CI, 2.2-3.2]; negative LR, 0.60 [95% CI, 0.50-0.70]).²⁸ Compared with the 24-hour mean, AOBP had a similar sensitivity (55% [96% CI, 49%-60%]) and specificity (81% [95% CI, 77%-84%]).²⁸ The studies differed in how they calculated the mean AOBP, with the first study using 5 readings and the second using 3 readings. One study (n = 309) compared attended AOBP (using a cutoff of 140/90 mm Hg from the mean of the second and third reading) with 24-hour ABPM.²⁹ In this study, sensitivity of AOBP was 87.6% (95% CI, 83.0%-92.1%) and specificity was 24.1% (95% CI, 16.0%-32.2%).

Table 110-9.Studies Comparing Automated Office Blood Pressure (AOBP) Monitoring With Ambulatory Blood Pressure Monitoring (ABPM)

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Table 110-9. Studies Comparing Automated Office Blood Pressure (AOBP) Monitoring With Ambulatory Blood Pressure Monitoring (ABPM)

Source

Setting

Sample size (% with hypertension on ABPM)

Mean age, y

Female sex, %

Country

Race and/or ethnicity

Mean ABPM threshold, mm Hg

No. of AOBP measurements averaged

Armanyous et al,²⁷ 2019

Healthy volunteers at a clinic

578 (16)

11% Black

Awake: ≥ 135/85

Etyang et al,²⁸ 2019

Random sample recruited to research clinics

982 (35)

Kenya

Not reported

Awake: ≥ 135/85

Michea et al,²⁹ 2021

Cohort referred from primary health care centers

309 (65)

Chile

Not reported

24-hour: ≥ 130/≥ 80; awake: > 135/85; nighttime: > 120/70

Discussion

Due to limited sensitivity and specificity, conventional office BP measurements should not be relied on for making a diagnosis of hypertension or for definitively ruling out a diagnosis of hypertension. Although currently available data are more limited, AOBP does not appear to have sufficiently high sensitivity and specificity for this measurement to serve as a replacement for conventionally measured office BP performed with careful attention to recommended technique. HBPM performed over a few days also has limited sensitivity and specificity for diagnosing hypertension. HBPM is an important complement to office BP, because when office BP and HBPM measurements are concordant, the clinician can be more confident that the diagnosis is correct. When office and HBPM measurements are not in agreement and diagnostic clarification is needed, 24-hour ABPM should be considered.

The USPSTF issued a reaffirmation in April 2021 of its recommendation to screen adults for hypertension with office BP measurement and obtain BP measurements outside of the clinical setting to confirm the diagnosis before initiating treatment.⁶ The task force noted that ABPM provides the most evidence-based risk information for subsequent cardiovascular events.^6,30

ABPM is not widely available in the US, so HBPM is recommended by both the USPSTF and the American College of Cardiology/American Heart Association (ACC/AHA) guidelines as an alternative.^1,6 Home BP level is a more reliable predictor of cardiovascular outcomes than office BP.^3,31 In addition to its usefulness in clarifying the diagnosis of hypertension, HBPM offers the additional advantages of ongoing monitoring of BP, possibly also promoting improved BP control.³² Patients should use proper technique for HBPM and should be instructed on the frequency, timing, and recording of measurements.³

A diagnosis of hypertension is generally not pursued when the office BP is within normal range. However, clinicians should be aware that individuals with masked hypertension have nearly the same risk for target organ damage and cardiovascular disease events as patients with sustained hypertension.^1,33 To date, no randomized trials have evaluated the management of masked hypertension, but given its risks and its progression to sustained hypertension, identification and management may have significant public health implications.¹ Although some risk factors for masked hypertension have been identified, the most robust predictor appears to be office BP level.³⁴ Patients with office BP level closer to the threshold for office hypertension are more likely to have masked hypertension.³⁴

The 2017 ACC/AHA guideline lowered the threshold for hypertension to systolic BP of at least 130 mm Hg or diastolic BP of at least 80 mm Hg.¹ The 2017 guideline also noted out-of-office BP monitoring to be critical in the diagnosis and management of hypertension, with HBPM suggested as an alternative to 24-hour ABPM. For patients with an office BP (untreated) in the elevated, but not hypertensive, range (120-129 mm Hg systolic or 75-79 mm Hg diastolic), the guideline states that obtaining out-of-office measurements to evaluate for masked hypertension is reasonable.

The current review focused on screening for undiagnosed hypertension using oscillometric methods and thus excluded evaluations of patients already receiving treatment, studies using mercury or aneroid sphygmomanometry, and analyses for which the reference standard was used only for individuals with elevated office BP. Multiple studies have evaluated the use of out-of-office BP measurements for both confirming elevated office BP and for comparing BP assessment methods among treated patients.^1,3,35 These studies are consistent in showing the importance of out-of-office BP measures in assessing overall BP pattern.

The Centers for Medicare & Medicaid Services recently expanded coverage for 24-hour ABPM (maximum once per year) to include masked hypertension as well as white coat hypertension. Current Procedural Terminology 2020 also includes codes for self-measured BP that support patient education and collection of data. It remains to be seen whether updated payment structures will lead to increased use of HBPM and 24-hour ABPM.

Practices interested in offering 24-hour ABPM will need to purchase the devices and software, develop a protocol for testing procedures, and train staff (Box 110-1).^3,36,37 The cost is typically $2000 to $2500 per device.³⁶ Each manufacturer has its own accompanying software. A variety of cuff sizes is typically included. Cuffs can be washed between uses. Clinic staff involved in the service must be trained to fit 24-hour ABPM devices and to counsel patients. Clinicians interpreting data and generating reports must become familiar with the software as well as 24-hour ABPM protocols and thresholds.

Box 110-1. Implementation of Ambulatory Blood Pressure Monitoring (ABPM) Define need and establish goals

Estimate the anticipated number of patients requiring monitoring per week and whether home BP monitoring will be asked of a patient before proceeding to ABPM.

Purchase devices and software

Choose a device that has been independently validated; considerations include cost and ease of use of software for programming, retrieving data, and generating reports. Order the number of devices based on anticipated need. Batteries will also be needed and should be replaced or recharged between sessions.

Create team and define roles

A dedicated coordinator will be needed to schedule patients and counsel them ahead of time about the procedure (expectations, wearing the monitor, troubleshooting). The interpreting clinician (or another team member) will need to preprogram the monitor. A medical assistant or nurse can place the monitor the day of the appointment and provide additional guidance about wearing the monitor for the 24 hours (including during sleep), how to reposition the cuff if needed, how to keep a diary during the session, and when/where to return the next day.

Train staff on scheduling, fitting, and retrieving monitors

The monitor is worn by the patient for 24 hours, so consider implications for scheduling. A well-prepared patient is key to successful ABPM. Staff must be trained on cuff selection and placement, assisting the patient in wearing the device (belt or harness), and positioning the tubing. The return of the monitor is straightforward; the patient can be instructed to remove it and drop it off or can have the device removed by office staff. Have a phone number patients can call to ask questions if any issues arise.

Ensure interpreting clinicians are familiar with software and ABPM interpretation

The retrieved monitor must then be provided to the interpreting clinician who will download the data, render an interpretation (including assessing quality of data), and generate a report to send to the ordering clinician. The monitor can then be prepared for the next scheduled session.

Mean thresholds for ABPM Daytime/awake

Stage 1 hypertension: 130/80 mm Hg

Stage 2 hypertension: 135/85 mm Hg

Nocturnal/asleep

Stage 1 hypertension: 110/65 mm Hg

Stage 2 hypertension: 120/70 mm Hg

24-hour

Stage 1 hypertension: 125/75 mm Hg

Stage 2 hypertension: 130/80 mm Hg

Scenario Resolutions

Case 1

The diagnostic dilemma is whether this patient has white coat hypertension, (ie, BP is elevated in the office setting but below diagnostic thresholds outside the office). This patient’s systolic BP in the office setting of 155/83 mm Hg was greater than 140 mm Hg, which has a positive LR of 4.2 for hypertension. The magnitude of the BP elevation raises the concern about true (sustained) hypertension rather than white coat hypertension. However, the studies in this review did not include data that allowed the estimation of LR as a function of the degree of hypertension. The prevalence of hypertension (using office BP threshold of ≥ 140/90 mm Hg) in individuals aged 40 to 59 years is approximately 33%.³⁸ Thus, the likelihood that 24-hour ABPM could confirm hypertension is at least 67%, and possibly higher given this patient’s measured office systolic BP. HBPM that confirms the elevation of systolic BP would support the diagnosis and allow proceeding to treatment. However, the HBPM measurement suggests white coat hypertension. The combination of an elevated office BP and a normal HBPM level has an LR of 1.6 for true hypertension, which places this patient at approximately 44% probability of having hypertension. If available, 24-hour ABPM should be used before making a diagnosis. Carefully repeating the patient’s BP measurement at subsequent office visits, while potentially a reasonable approach, is still subject to the possibility of white coat (false-positive) hypertension.

Case 2

The diagnostic dilemma is whether this patient has masked hypertension, (ie, BP is below the diagnostic threshold in the office setting, but BP measurement outside the office setting would reveal elevated BP). This patient’s BP in the office of 128/78 mm Hg has an LR of 0.56 for hypertension. The prevalence of hypertension in those aged 18 to 39 years is approximately 7.5%.³⁸ Thus, the below-threshold office BP suggests a probability of hypertension of approximately 4%. However, this patient’s BP level is close to the ACC/AHA guideline threshold of 130/80 mm Hg for hypertension,¹ and HBPM could be useful to decide whether to pursue 24-hour ABPM. HBPM levels that suggest hypertension is present (LR of 3.6 for the combination of normal office BP and elevated home BP) would increase the probability of hypertension to approximately 23%. In such an instance, 24-hour ABPM could be used to clarify this patient’s status, particularly given his other cardiovascular risk factors.

Limitations

This review has several limitations. First, a limited number of studies that tested the diagnostic accuracy of oscillometric office BP measurement among untreated adults proceeded to conduct further 24-hour ABPM testing of patients with nonelevated office or home BP levels. Second, studies varied in the number and type of measurements used to calculate mean office or home BP. Third, few studies were conducted in the US, and only a small number of studies included Black participants. Fourth, some studies used clinic visit BP for office measurement, whereas other studies used research study visit BP for office measurement, and research visit BP measurements tend to be lower than actual clinical visit measurements.³⁹ Fifth, some eligible articles may have been missed, and non-English–language publications were not considered in the review. However, other major systematic reviews support the recommendations of this review.^30,31,35 Sixth, although it is the accepted reference standard, 24-hour ABPM does not perform perfectly.^3,6,30 In addition, although mean awake BP has been used commonly as the reference, 24-hour data (which includes sleep BP measures) may be preferred.³

Seventh, only 3 studies were included that involved untreated participants for whom AOBP measurement at a single visit was compared with 24-hour ABPM among participants with elevated and nonelevated office BP measurements.^27-29 Another study that compared 3 days of AOBP to 24-hour ABPM found that 3 days of AOBP had a higher sensitivity than a single-visit office BP measurement, but lower sensitivity than HBPM.¹³ Studies of patients with hypertension have consistently shown that AOBP on average provides BP measurements that correlate more closely with mean BP while awake during ABPM and mitigate the white coat effect.^40-42 The optimal threshold for hypertension using unattended AOBP may be different than that of conventional office BP.³

Eighth, the available studies consistently used 140/90 mm Hg as the office BP threshold, with an HBPM threshold of 135/85 mm Hg, both compared with the reference standard of 130/80 mm Hg for mean BP during 24-hour ABPM and 135/85 mm Hg for mean BP while awake during ABPM. Clinicians should keep these thresholds in mind (as well as prevalence) when applying the LRs. New office and out-of-office BP thresholds, as defined in the ACC/AHA guideline,¹ may alter the prevalence of masked hypertension and white coat hypertension. One study that compared the new ACC/AHA thresholds to the aforementioned thresholds found that the prevalence of white coat hypertension and masked hypertension increased only slightly, while there was a substantial increase in sustained hypertension (from 9% to 27%) and decrease in sustained normotension (from 61% to 39%).¹⁸

Ninth, because hypertension is not truly a dichotomous state, applying standard diagnostic test operating characteristics, while useful, is inherently limited. None of the included studies evaluated the consistency of BP classification solely by 24-hour ABPM across multiple sessions. However, mean BP (both awake and 24-hour) measured via 24-hour ABPM has demonstrated good reproducibility in most studies, although regression to the mean also occurs.^3,43 The decision to initiate medical treatment for hypertension must consider not only the average BP level measured in the most accurate and feasible manner, but also the patient’s overall risk for cardiovascular disease and the potential benefits vs harms of treatment.

Clinical Bottom Line

All forms of BP measurement should be performed with validated devices using proper positioning and correct cuff size.³ Health care personnel and individuals performing BP measurements should be trained, even when using oscillometric devices. However, even when performed correctly, office BP measurements alone may not be sufficient to establish a diagnosis of hypertension for most individuals, particularly age groups with lower pretest probability. For diagnosing hypertension in adults, out-of-office BP assessment should be considered for most patients with elevated BP and for individuals who have upper-level “normal” office BP measurements. The combination of results from office BP measurement and HBPM has better diagnostic accuracy than the independent results alone, and when concordant, is likely sufficient for diagnosis. However, 24-hour ABPM should be considered when results are discordant, especially for patients with a higher pretest probability of hypertension.

Conclusions

Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

Acknowledgment

The following disclosures were reported at the time this original article was first published in JAMA.

Conflict of Interest Disclosures: Dr Simel reported receiving honoraria for contributions to JAMAEvidence.com outside the submitted work. Dr Yun reported receiving grants from the Health Resources and Services Administration (T32-HP14001) during the conduct of the study. Dr Shimbo reported being a consultant for Abbott Vascular, Edward Lifesciences, Medtronic, and Tryton Medical and conducting event ascertainment for trials that they are conducting (testing coronary and valvular disease interventions), which have nothing to do with blood pressure measurement and hypertension, make no products in the area of blood pressure measurement and hypertension (including treatment), and are not related to the content area of the manuscript. No other disclosures were reported.

Funding/Support: Dr Viera reported past funding from the National Heart, Lung, and Blood Institute to study out-of-office blood pressure monitoring. Dr Yun’s work was supported by the Health Resources and Services Administration (grant No. T32-HP14001). Dr Simel’s work was supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (CIN 13-410) at the Durham VA Health Care System. Dr Hardy’s work was supported by R01HL139716 from the National Heart, Lung, and Blood Institute.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13–e115. Medline:29133356 [PubMed: 29133356]

Reeves RA. The Rational Clinical Examination: does this patient have hypertension? how to measure blood pressure. JAMA[JAMA and JAMA Network Journals Full Text]. 1995;273(15):1211–1218. Medline:7707630 doi:10.1001/jama.1995.03520390071036

Kallioinen N, Hill A, Horswill MS, Ward HE, Watson MO. Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review. J Hypertens. 2017;35(3):421–441. Medline:27977471 doi:10.1097/HJH.0000000000001197

Parati G, Stergiou GS, Dolan E, Bilo G. Blood pressure variability: clinical relevance and application. J Clin Hypertens (Greenwich). 2018;20(7):1133–1137. Medline:30003704 doi:10.1111/jch.13304

Krist AH, Davidson KW, Mangione CM, et al; US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA[JAMA and JAMA Network Journals Full Text]. 2021;325(16):1650–1656. Medline:33904861 doi:10.1001/jama.2021.4987

Kronish IM, Kent S, Moise N, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens. 2017;11(9):573–580. Medline:28734798 doi:10.1016/j.jash.2017.06.012

Whiting PF, Rutjes AW, Westwood ME, et al; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–536. Medline:22007046 doi:10.7326/0003-4819-155-8-201110180-00009

Simel DL. A primer on the precision and accuracy of the clinical examination. In Simel DL, Rennie D, eds. The Rational Clinical Examination. McGraw-Hill; 2009.

10.

Simel DL, Bossuyt PM. Differences between univariate and bivariate models for summarizing diagnostic accuracy may not be large. J Clin Epidemiol. 2009;62(12):1292–1300. Medline:19447007 doi:10.1016/j.jclinepi.2009.02.007

11.

Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive Meta-Analysis, Version 3. Biostat; 2013.

12.

Leeflang MM, Deeks JJ, Rutjes AW, Reitsma JB, Bossuyt PM. Bivariate meta-analysis of predictive values of diagnostic tests can be an alternative to bivariate meta-analysis of sensitivity and specificity. J Clin Epidemiol. 2012;65(10):1088–1097. Medline:22742916 doi:10.1016/j.jclinepi.2012.03.006

13.

Gill P, Haque MS, Martin U, et al. Measurement of blood pressure for the diagnosis and management of hypertension in different ethnic groups: one size fits all. BMC Cardiovasc Disord. 2017;17(1):55. Medline:28178928 doi:10.1186/s12872-017-0491-8

14.

Ishikawa J, Hoshide S, Eguchi K, et al. Masked hypertension defined by ambulatory blood pressure monitoring is associated with an increased serum glucose level and urinary albumin-creatinine ratio. J Clin Hypertens (Greenwich). 2010;12(8):578–587. Medline:20695934 doi:10.1111/j.1751-7176.2010.00286.x

15.

Kang YY, Li Y, Huang QF, et al. Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension. J Hypertens. 2015;33(8):1580–1587. Medline:26103131 doi:10.1097/HJH.0000000000000596

16.

Kim SK, Bae JH, Nah DY, Lee DW, Hwang TY, Lee KS. Frequency and related factors of masked hypertension at a worksite in Korea. J Prev Med Public Health. 2011;44(3):131–139. Medline:21617339 doi:10.3961/jpmph.2011.44.3.131

17.

Ommen ES, Schröppel B, Kim JY, et al. Routine use of ambulatory blood pressure monitoring in potential living kidney donors. Clin J Am Soc Nephrol. 2007;2(5):1030–1036. Medline:17702722 doi:10.2215/CJN.01240307

18.

Poudel B, Booth JN III, Sakhuja S, et al. Prevalence of ambulatory blood pressure phenotypes using the 2017 American College of Cardiology/American Heart Association blood pressure guideline thresholds: data from the Coronary Artery Risk Development in Young Adults study. J Hypertens. 2019;37(7):1401–1410. Medline:31145711 doi:10.1097/HJH.0000000000002055

19.

Selenta C, Hogan BE, Linden W. How often do office blood pressure measurements fail to identify true hypertension? an exploration of white-coat normotension. Arch Fam Med. 2000;9(6):533–540. Medline:10862216 doi:10.1001/archfami.9.6.533

20.

Shin J, Park SH, Kim JH, et al. Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group. Korean J Intern Med. 2015;30(5):610–619. Medline:26354055 doi:10.3904/kjim.2015.30.5.610

21.

Tocci G, Presta V, Figliuzzi I, et al. Prevalence and clinical outcomes of white-coat and masked hypertension: analysis of a large ambulatory blood pressure database. J Clin Hypertens (Greenwich). 2018;20(2):297–305. Medline:29370477 doi:10.1111/jch.13181

22.

Viera AJ, Lin FC, Tuttle LA, et al. Reproducibility of masked hypertension among adults 30 years or older. Blood Press Monit. 2014;19(4):208–215. Medline:24842491 doi:10.1097/MBP.0000000000000054

23.

Wojciechowska W, Stolarz-Skrzypek K, Olszanecka A, et al. Subclinical arterial and cardiac damage in white-coat and masked hypertension. Blood Press. 2016;25(4):249–256. Medline:26953075 doi:10.3109/08037051.2016.1150563

24.

Zhang L, Li Y, Wei FF, et al. Strategies for classifying patients based on office, home, and ambulatory blood pressure measurement. Hypertension. 2015;65(6):1258–1265. Medline:25870194 doi:10.1161/HYPERTENSIONAHA.114.05038

25.

Nunan D, Thompson M, Heneghan CJ, Perera R, McManus RJ, Ward A. Accuracy of self-monitored blood pressure for diagnosing hypertension in primary care. J Hypertens. 2015;33(4):755–762. Medline:25915880 doi:10.1097/HJH.0000000000000489

26.

Zhuo S, Wen W, Li-Yuan M, Shu-Yu W, Yi-Xin W. Home blood pressure measurement in prehypertension and untreated hypertension: comparison with ambulatory blood pressure monitoring and office blood pressure. Blood Press Monit. 2009;14(6):245–250. Medline:19918171 doi:10.1097/MBP.0b013e328332fd25

27.

Armanyous S, Ohashi Y, Lioudis M, et al. Diagnostic performance of blood pressure measurement modalities in living kidney donor candidates. Clin J Am Soc Nephrol. 2019;14(5):738–746. Medline:30948455 doi:10.2215/CJN.02780218

28.

Etyang AO, Sigilai A, Odipo E, et al. Diagnostic accuracy of unattended automated office blood pressure measurement in screening for hypertension in Kenya. Hypertension. 2019;74(6):1490–1498. Medline:31587589 doi:10.1161/HYPERTENSIONAHA.119.13574

29.

Michea L, Toro L, Alban N, et al. Attended automated office blood pressure measurement versus ambulatory blood pressure monitoring in a primary healthcare setting in Chile. South Med J. 2021;114(2):63–69. Medline:33537784 doi:10.14423/SMJ.0000000000001206

30.

Guirguis-Blake JM, Evans CV, Webber EM, Coppola EL, Perdue LA, Weyrich MS. Screening for hypertension in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA[JAMA and JAMA Network Journals Full Text]. 2021;325(16):1657–1669. Medline:33904862 doi:10.1001/jama.2020.21669

31.

Ward AM, Takahashi O, Stevens R, Heneghan C. Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens. 2012;30(3):449–456. Medline:22241136 doi:10.1097/HJH.0b013e32834e4aed

32.

Cappuccio FP, Kerry SM, Forbes L, Donald A. Blood pressure control by home monitoring: meta-analysis of randomised trials. BMJ. 2004;329(7458):145. Medline:15194600 doi:10.1136/bmj.38121.684410.AE

33.

Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. J Hypertens. 2007;25(11):2193–2198. Medline:17921809 doi:10.1097/HJH.0b013e3282ef6185

34.

Viera AJ, Lin FC, Tuttle LA, et al. Levels of office blood pressure and their operating characteristics for detecting masked hypertension based on ambulatory blood pressure monitoring. Am J Hypertens. 2015;28(1):42–49. Medline:24898379 doi:10.1093/ajh/hpu099

35.

Hodgkinson J, Mant J, Martin U, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ. 2011;342:d3621. Medline:21705406 doi:10.1136/bmj.d3621

36.

Kronish IM, Hughes C, Quispe K, Viera AJ. Implementing ambulatory blood pressure monitoring in primary care practice. Fam Pract Manag. 2020;27(3):19–25. Medline:32393015 [PubMed: 32393015]

37.

Hinderliter AL, Voora RA, Viera AJ. Implementing ABPM into clinical practice. Curr Hypertens Rep. 2018;20(1):5. Medline:29404785 [PubMed: 29404785]

38.

Fryar CD, Ostchega Y, Hales CM, Zhang G, Kruszon-Moran D. Hypertension Prevalence and Control Among Adults: United States, 2015–2016. National Center for Health Statistics; 2017.

39.

Myers MG, Godwin M, Dawes M, Kiss A, Tobe SW, Kaczorowski J. Measurement of blood pressure in the office: recognizing the problem and proposing the solution. Hypertension. 2010;55(2):195–200. Medline:20038756 doi:10.1161/HYPERTENSIONAHA.109.141879

40.

Roerecke M, Kaczorowski J, Myers MG. Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension: a systematic review and meta-analysis. JAMA Intern Med. 2019;179(3):351–362. Medline:30715088 doi:10.1001/jamainternmed.2018.6551

41.

Myers MG, Matangi M, Kaczorowski J. Comparison of awake ambulatory blood pressure and automated office blood pressure using linear regression analysis in untreated patients in routine clinical practice. J Clin Hypertens (Greenwich). 2018;20(12):1696–1702. Medline:30328275 doi:10.1111/jch.13409

42.

Pappaccogli M, Di Monaco S, Perlo E, et al. Comparison of automated office blood pressure with office and out-off-office measurement techniques. Hypertension. 2019;73(2):481–490. Medline:30624994 doi:10.1161/HYPERTENSIONAHA.118.12079

43.

Moore MN, Atkins ER, Salam A, et al. Regression to the mean of repeated ambulatory blood pressure monitoring in five studies. J Hypertens. 2019;37(1):24–29. Medline:30499921 doi:10.1097/HJH.0000000000001977

Supplementary Online Content

Supplemental Table 1.Literature Search

View Table||Download (.pdf)

Supplemental Table 1. Literature Search

PubMed legacy version, searched 01/29/2020

"Hypertension"[Mesh:NoExp] OR "Hypertension, Renal"[Mesh]

245506

hypertens*[All Fields]

534768

(#1 OR #2)

534768

("Blood Pressure"[Mesh:NoExp] OR "Blood Pressure Determination"[Mesh] OR "Sphygmomanometers"[Mesh])

290490

(Sphygmomanometer* OR ("blood pressure"[All Fields] AND (monitor* OR determin*)) OR ABPM[tiab])

133672

((#4 or #5)

332218

("Ambulatory Care"[Mesh:NoExp] OR "Ambulatory Care Facilities"[Mesh:NoExp] OR "Outpatient Clinics, Hospital"[Mesh:NoExp])

73808

"Monitoring, Ambulatory"[Mesh:NoExp]

7956

(ambula* AND care)

100225

#10

(#7 or #8 or #9)

119304

#11

(#3 and #6)

122397

#12

(#3 and #6 and #10)

2680

#13

(diagnost* OR diagnosi* OR diagnose*)

4940761

#14

(physical exam*[All Fields] OR clinical exam*[All Fields])

144213

#15

stress test*[All Fields]

13973

#16

(sensitiv* OR specific* OR predictive value* OR ppv OR npv OR likelihood ratio* OR interobserver OR intraobserver)

4641166

#17

(accuracy OR precision OR reliability OR validity)

748830

#18

("Diagnostic Techniques and Procedures"[Mesh:NoExp])

3226

#19

"Diagnostic Errors"[Mesh]

114795

#20

"Diagnostic Tests, Routine"[Mesh:NoExp]

11621

#21

("Sensitivity and Specificity"[Mesh])

571181

#22

("Diagnosis"[Mesh:NoExp] OR "Diagnosis, Differential"[Mesh:NoExp])

461957

#23

(#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22)

9084467

#24

(#12 and #23)

1541

#25

"Hypertension/diagnosis"[Majr:NoExp]

8919

#26

(#6 or #12)

332218

#27

(#25 and #26)

5195

#28

(#24 or #27)

6148

#29

(sensitiv*[Title/Abstract] OR “sensitivity and specificity”[MeSH Terms] OR diagnose[Title/Abstract] OR diagnosed[Title/Abstract] OR diagnoses[Title/Abstract] OR diagnosing[Title/Abstract] OR diagnosis[Title/Abstract] OR diagnostic[Title/Abstract] OR diagnosis[MeSH:noexp] OR “diagnosis, differential”[MeSH:noexp] OR diagnosis[Subheading:noexp])

5301440

#30

(#12 and #29)

1355

#31

(#24 or #27 or #28)

6148

#32

(#30 or #31)

6148

#33

("intra-arterial"[All Fields] OR intraarterial[All Fields])

31790

#34

(#33 and #11)

1115

#35

(#32 or #34)

7200

#36

(#32 or #34) Filters: Humans

6712

#37

(#32 or #34) Filters: Humans; Adult: 19+ years

4034

#38

(#37 AND (Editorial[pt] OR Comment[pt] OR Letter[pt] OR News[pt])

107

#39

(#37 not #38)

3927

#40

(#37 not #38) Filters: Publication date from 2018/05/08 to 2020/12/31

209

#41

(#37 not #38) Filters: Publication date from 2018/05/08 to 2020/12/31; English

198

#42

(#40 NOT #41)

Cochrane Library (Wiley), 1996 – January 2020, searched 01/29/2020

[mh ^Hypertension] or [mh ^"Hypertension, Renal"]

16799

hypertens*

66765

#1 or #2

66765

[mh ^"Blood Pressure"] or [mh "Blood Pressure Determination"] or [mh Sphygmomanometers]

27240

Sphygmomanometer* or ("blood pressure" and (monitor* or determin*)) or ABPM

30895

#4 or #5

49052

[mh ^"Ambulatory Care"] or [mh ^"Ambulatory Care Facilities"] or [mh ^"Outpatient Clinics, Hospital"]

4103

[mh ^"Monitoring, Ambulatory"]

540

ambula* AND care

10900

#10

#7 or #8 or #9

11744

#11

#3 and #6

18688

#12

#3 and #6 and #10

818

#13

diagnost* or diagnosi* or diagnose*

232448

#14

physical exam* or clinical exam*

163260

#15

stress test*

19926

#16

sensitiv* or specific* or predictive value* or ppv or npv or likelihood ratio* or interobserver or intraobserver

196274

#17

accuracy or precision or reliability or validity

49637

#18

[mh ^"Diagnostic Techniques and Procedures"]

#19

[mh ^"Diagnostic Errors"]

276

#20

[mh ^"Diagnostic Tests, Routine"]

221

#21

[mh "Sensitivity and Specificity"]

16292

#22

[mh ^Diagnosis] or [mh ^"Diagnosis, Differential"]

1532

#23

#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22

495363

#24

#12 and #23

464

#25

[mh ^Hypertension/DI]

995

#26

#6 or #12

49052

#27

#25 and #26

776

#28

#24 or #27

1132

#29

sensitiv*:ti or sensitiv*:ab or [mh "sensitivity and specificity"] or diagnose:ti or diagnose:ab or diagnosed:ti or diagnosed:ab or diagnoses:ti or diagnoses:ab or diagnosing:ti or diagnosing:ab or diagnosis:ti or diagnosis:ab or diagnostic:ti or diagnostic:ab or [mh ^diagnosis] or [mh ^"diagnosis, differential"] or [mh ^diagnosis]

199817

#30

#12 and #29

158

#31

#24 or #27 or #28

1132

#32

#30 or #31

1132

#33

"intra-arterial" or intraarterial

3180

#34

#33 and #11

141

#35

#32 or #34

1266

#36

#35 with Cochrane Library publication date Between May 2018 and Jan 2020

174

#37

#36 and (Editorial:pt or Comment:pt or Letter:pt or News:pt)

#38

#36 not #37

171

Embase, 1974 - 01/29/2020, searched 01/30/2020

'hypertension'/de OR 'hypertension'/exp OR hypertension

1,000,067

renal AND ('hypertension'/de OR hypertension)

136,689

#1 OR #2

1,000,067

'blood pressure'/de OR 'blood pressure determination'/de OR 'sphygmomanometer'/de OR 'sphygmomanometers'/de

309,736

sphygmomanometer* OR ('blood pressure' AND (monitor* OR determin*)) OR abpm

189,324

#4 AND #5

77,344

'ambulatory care'/de OR 'ambulatory care facilities'/de OR 'outpatient clinics, hospital'/de

104,790

'monitoring, ambulatory'/de

11,315

ambula* AND care

102,170

#10

#7 OR #8 OR #9

175,590

#11

#3 AND #6

36,170

#12

#3 AND #6 AND #10

2,842

#13

diagnost* OR diagnosi* OR diagnose*

6,638,554

#14

'physical exam' OR 'physical exams' OR 'physical examination'/exp OR 'physical examination' OR 'physical examinations' OR 'clinical exam' OR 'clinical exams' OR 'clinical examination'/exp OR 'clinical examination' OR 'clinical examinations'

419,740

#15

'stress test'/exp OR 'stress test' OR 'stress tests' OR 'stress testing'

100,965

#16

((sensitiv* OR specific* OR predictive) AND value* OR ppv OR npv OR likelihood) AND ratio* OR interobserver OR intraobserver

188,127

#17

'accuracy'/exp OR accuracy OR 'precision'/exp OR precision OR 'reliability'/exp OR reliability OR 'validity'/exp OR validity

1,275,966

#18

'diagnostic techniques and procedures'/de

94,566

#19

'diagnostic errors'/exp

95,697

#20

'diagnostic tests, routine'/de

77,093

#21

'sensitivity and specificity'/exp

344,350

#22

'diagnosis'/de OR 'diagnosis, differential'/de

1,707,054

#23

#13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22

7,726,639

#24

#12 AND #23

1,521

#25

'hypertension'/mj/dm_di

12,968

#26

#6 OR #12

77,344

#27

#25 AND #26

2,340

#28

#24 OR #27

3,295

#29

sensitiv*or AND 'sensitivity and specificity'/dm_di AND exp OR diagnose OR diagnosed OR diagnoses OR diagnosing OR diagnostic OR 'diagnosis'/dm_di OR 'diagnosis, differential'/dm_di

2,718,024

#30

#12 AND #29

581

#31

#24 OR #27 OR #28

3,295

#32

#30 OR #31

3,295

#33

'intra-arterial' OR 'intraarterial' OR intraarterial

58,458

#34

#11 AND #33

404

#35

#32 OR #34

3,637

#36

#35 AND [embase]/lim

3,005

#37

#36 AND ([animal cell]/lim OR [animal experiment]/lim OR [animal model]/lim OR [animal tissue]/lim) AND [embase]/lim

111

#38

#36 NOT #37 AND [embase]/lim

2,894

#39

(editorial:it OR comment:it OR letter:it OR news:it) AND [embase]/lim

1,338,873

#40

#38 NOT #39 AND [embase]/lim

2,772

#41

#40 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim

1,435

#42

#41 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim AND [2018-2020]/py

137

#43

#42 AND [english]/lim AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim AND [2018-2020]/py

135

#44

#42 NOT #43

Gap searches for "Blood Pressure Monitoring, Ambulatory"[Mesh]

PubMed, 5/06/2020

"Hypertension"[Mesh:NoExp] OR "Hypertension, Renal"[Mesh] OR hypertens*[All Fields]

542,191

("Blood Pressure"[Mesh:NoExp] OR "Blood Pressure Determination"[Mesh] OR "Sphygmomanometers"[Mesh]) OR ((Sphygmomanometer* OR ("blood pressure"[All Fields] AND (monitor* OR determin*)) OR ABPM[tiab]))

334,529

#1 AND #2

123,577

"Blood Pressure Monitoring, Ambulatory"[Mesh] NOT "Monitoring, Ambulatory"[Mesh:NoExp]

9,677

#1 AND #2 AND #5

8,297

(diagnost* OR diagnosi* OR diagnose*) OR (physical exam*[All Fields] OR clinical exam*[All Fields]) OR stress test*[All Fields] OR (sensitiv* OR specific* OR predictive value* OR ppv OR npv OR likelihood ratio* OR interobserver OR intraobserver) OR accuracy OR precision OR reliability OR validity OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Errors"[Mesh] OR "Diagnostic Tests, Routine"[Mesh:NoExp] OR "Sensitivity and Specificity"[Mesh] OR “Diagnosis"[Mesh:NoExp] OR "Diagnosis, Differential"[Mesh:NoExp]

9,965,366

#6 AND #7

5,158

"Hypertension/diagnosis"[Majr:NoExp]

9,026

#10

#2 OR #6

334,529

#11

#9 AND #10

5,265

#12

#8 OR #11

8,775

#13

((sensitiv*[Title/Abstract] OR “sensitivity and specificity”[MeSH Terms] OR diagnose[Title/Abstract] OR diagnosed[Title/Abstract] OR diagnoses[Title/Abstract] OR diagnosing[Title/Abstract] OR diagnosis[Title/Abstract] OR diagnostic[Title/Abstract] OR diagnosis[MeSH:noexp] OR “diagnosis, differential”[MeSH:noexp] OR diagnosis[Subheading:noexp]))

5,378,022

#14

#6 AND #13

4,108

#15

#8 OR #11 OR #12

8,775

#16

#14 OR #15

8,775

#17

"intra-arterial"[All Fields] OR intraarterial[All Fields]

33,087

#18

#17 AND #4

1,219

#19

#16 OR #18

9,920

#20

#16 OR #18

Limit: Humans

9,410

#21

#16 OR #18

Limit: Humans, Adult: 19+ years

6,148

#22

#21 NOT (Editorial[pt] OR Comment[pt] OR Letter[pt] OR News[pt])

6,019

#23

#21 NOT (Editorial[pt] OR Comment[pt] OR Letter[pt] OR News[pt]) Limits: English

5,239

#24

#22 NOT #23

780

Cochrane Library, 5/08/2020

[mh ^Hypertension] or [mh ^"Hypertension, Renal"] OR hypertens*

66065

[mh ^"Blood Pressure"] or [mh "Blood Pressure Determination"] or [mh Sphygmomanometers] or Sphygmomanometer* or ("blood pressure" and (monitor* or determin*)) or ABPM

50107

#1 AND #2

18905

[mh "Blood Pressure Monitoring, Ambulatory"] NOT [mh ^"Monitoring, Ambulatory"]

1423

#3 AND #4

1255

diagnost* OR diagnosi* OR diagnose* OR physical exam* OR clinical exam* OR stress test* OR sensitiv* OR specific* OR predictive value* OR ppv OR npv OR likelihood ratio* OR interobserver OR intraobserver OR accuracy OR precision OR reliability OR validity OR [mh ^"Diagnostic Techniques and Procedures"] OR [mh ^"Diagnostic Errors"] OR [mh ^"Diagnostic Tests, Routine"] OR [mh "Sensitivity and Specificity"] OR [mh ^Diagnosis] or [mh ^"Diagnosis, Differential"]

484914

#5 AND #6

547

[mh ^Hypertension/DI]

984

#2 OR #5

50107

#10

#8 AND #9

775

#11

#7 OR #10

1075

#12

192792

#13

#5 AND #12

178

#14

#7 OR #10 OR #11

1075

#15

#13 OR #14

1075

#16

"intra-arterial" or intraarterial

3129

#17

#3 AND #16

143

#18

#15 OR #17

1212

#19

#18 NOT (Editorial:pt or Comment:pt or Letter:pt or News:pt)

1200

Blood pressure update searches October 28-29, 2020

PubMed, new version, 10-28-2020

("Hypertension"[Mesh:NoExp] OR "Hypertension, Renal"[Mesh]) OR hypertens*[All Fields]

556,699

339,127

#1 OR #2

769,910

"Ambulatory Care"[Mesh:NoExp] OR "Ambulatory Care Facilities"[Mesh:NoExp] OR "Outpatient Clinics, Hospital"[Mesh:NoExp] OR "Monitoring, Ambulatory"[Mesh:NoExp] OR "Blood Pressure Monitoring, Ambulatory"[Mesh] OR (ambula* AND care)

133,000

#1 AND #2

125,916

#5 AND #4

10,047

(diagnost* OR diagnosi* OR diagnose*) OR (physical exam*[All Fields] OR clinical exam*[All Fields]) OR stress test*[All Fields] OR (sensitiv* OR specific* OR predictive value* OR ppv OR npv OR likelihood ratio* OR interobserver OR intraobserver) OR accuracy OR precision OR reliability OR validity OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Errors"[Mesh] OR "Diagnostic Tests, Routine"[Mesh:NoExp] OR "Sensitivity and Specificity"[Mesh] OR "Diagnosis"[Mesh:NoExp] OR "Diagnosis, Differential"[Mesh:NoExp]

10,280,159

#7 AND #6

6,140

"Hypertension/diagnosis"[Majr:NoExp]

9,268

#3 OR #6

769,910

#10 AND #9

9,268

#8 OR #11

13,473

(sensitiv*[Title/Abstract] OR "sensitivity and specificity"[MeSH Terms] OR diagnose[Title/Abstract] OR diagnosed[Title/Abstract] OR diagnoses[Title/Abstract] OR diagnosing[Title/Abstract] OR diagnosis[Title/Abstract] OR diagnostic[Title/Abstract] OR diagnosis[MeSH:noexp] OR "diagnosis, differential"[MeSH:noexp] OR diagnosis[Subheading:noexp])

5,526,754

#6 AND #13

4,889

#8 OR #11 OR #14

13,473

#14 OR #15

13,473

("intra-arterial"[All Fields] OR intraarterial[All Fields])

33,374

#17 AND #3

5,099

#18 OR #16

18,480

#18 OR #16

Humans

15,991

#18 OR #16

Humans, English

12,807

#18 OR #16

Humans, English, Adult: 19+ years

8,335

#22 AND (Editorial[pt] OR Comment[pt] OR Letter[pt] OR News[pt])

191

#22 NOT #23

8,144

(#24) AND (("2019/07/29"[Date - Publication] : "3000"[Date - Publication]))

234

Cochrane Library, 1996 – October 2020, searched 10-28-2020

[mh ^Hypertension] or [mh ^"Hypertension, Renal"]

17685

hypertens*

67734

#1 or #2

67734

[mh ^"Blood Pressure"] or [mh "Blood Pressure Determination"] or [mh Sphygmomanometers]

27584

Sphygmomanometer* or ("blood pressure" and (monitor* or determin*)) or ABPM

32822

#4 or #5

51146

[mh ^"Ambulatory Care"] or [mh ^"Ambulatory Care Facilities"] or [mh ^"Outpatient Clinics, Hospital"]

4140

[mh ^"Monitoring, Ambulatory"] OR [mh "Blood Pressure Monitoring, Ambulatory"]

1990

ambula* AND care

11289

#10

#7 or #8 or #9

13316

#11

#3 and #6

19281

#12

#3 and #6 and #10

1889

#13

diagnost* or diagnosi* or diagnose*

230962

#14

physical exam* or clinical exam*

168105

#15

stress test*

21450

#16

sensitiv* or specific* or predictive value* or ppv or npv or likelihood ratio* or interobserver or intraobserver

196038

#17

accuracy or precision or reliability or validity

46205

#18

[mh ^"Diagnostic Techniques and Procedures"]

#19

[mh ^"Diagnostic Errors"]

272

#20

[mh ^"Diagnostic Tests, Routine"]

230

#21

[mh "Sensitivity and Specificity"]

15311

#22

[mh ^Diagnosis] or [mh ^"Diagnosis, Differential"]

1444

#23

#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22

503137

#24

#12 and #23

906

#25

[mh ^Hypertension/DI]

1013

#26

#6 or #12

51146

#27

#25 and #26

798

#28

#24 or #27

1419

#29

198885

#30

#12 and #29

309

#31

#24 or #27 or #28

1419

#32

#30 or #31

1419

#33

"intra-arterial" or intraarterial

3153

#34

#33 and #11

145

#35

#32 or #34

1555

#36

#35 with Cochrane Library publication date Between July 2019 and Dec 2020

115

#37

#36 and (Editorial:pt or Comment:pt or Letter:pt or News:pt)

#38

#36 not #37

113

Embase, 1974 - present, searched 10-29-2020

'hypertension'/de OR 'hypertension'/exp OR hypertension

1,047,080

renal AND ('hypertension'/de OR hypertension)

142,567

#1 OR #2

1,047,080

'blood pressure'/de OR 'blood pressure determination'/de OR 'sphygmomanometer'/de OR 'sphygmomanometers'/de

317,346

sphygmomanometer* OR ('blood pressure' AND (monitor* OR determin*)) OR abpm

197,911

#4 AND #5

79,757

'ambulatory care'/de OR 'ambulatory care facilities'/de OR 'outpatient clinics, hospital'/de

109,731

'blood pressure monitoring'/exp OR 'monitoring, ambulatory'/de

56,561

ambula* AND care

106,944

#10

#7 OR #8 OR #9

226,840

#11

#3 AND #6

37,319

#12

#3 AND #6 AND #10

9,621

#13

diagnost* OR diagnosi* OR diagnose*

6,926,274

#14

440,435

#15

'stress test'/exp OR 'stress test' OR 'stress tests' OR 'stress testing'

107,343

#16

((sensitiv* OR specific* OR predictive) AND value* OR ppv OR npv OR likelihood) AND ratio* OR interobserver OR intraobserver

214,354

#17

'accuracy'/exp OR accuracy OR 'precision'/exp OR precision OR 'reliability'/exp OR reliability OR 'validity'/exp OR validity

1,364,369

#18

'diagnostic techniques and procedures'/de

96,144

#19

'diagnostic errors'/exp

102,143

#20

'diagnostic tests, routine'/de

79,285

#21

'sensitivity and specificity'/exp

369,627

#22

'diagnosis'/de OR 'diagnosis, differential'/de

1,728,206

#23

#13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22

8,088,151

#24

#12 AND #23

4,333

#25

'hypertension'/mj/dm_di

13,296

#26

#6 OR #12

79,757

#27

#25 AND #26

2,423

#28

#24 OR #27

5,445

#29

sensitiv*or AND 'sensitivity and specificity'/dm_di AND exp OR diagnose OR diagnosed OR diagnoses OR diagnosing OR diagnostic OR 'diagnosis'/dm_di OR 'diagnosis, differential'/dm_di

2,873,268

#30

#12 AND #29

1,681

#31

#24 OR #27 OR #28

5,445

#32

#30 OR #31

5,445

#33

'intra-arterial' OR 'intraarterial' OR intraarterial

59,279

#34

#11 AND #33

409

#35

#32 OR #34

5,766

#36

#35 AND [embase]/lim

4,952

#37

#36 AND ([animal cell]/lim OR [animal experiment]/lim OR [animal model]/lim OR [animal tissue]/lim) AND [embase]/lim

120

#38

#36 NOT #37 AND [embase]/lim

4,832

#39

(editorial:it OR comment:it OR letter:it OR news:it) AND [embase]/lim

1,396,902

#40

#38 NOT #39 AND [embase]/lim

4,617

#41

#40 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim

2,470

#42

#41 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim AND [2018-2020]/py

261

#43

#42 AND [english]/lim AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim AND [2018-2020]/py

258

GRAY LITERATURE UPDATES, October 29, 2020

1) ClinicalTrials.gov

19 Studies found (Expert Search):

AREA[ConditionSearch] (Ambulator* OR diagnost* or diagnosi* or diagnose* OR physical exam* or clinical exam* OR stress test* OR sensitiv* or specific* or predictive value* or ppv or npv or likelihood ratio* or interobserver or intraobserver OR EXPAND[Concept] "intra-arterial") AND (blood pressure OR hypertension) AND AREA[LastUpdatePostDate] EXPAND[Term] RANGE[01/31/2020, 10/29/2020]
2) CRD Databases (includes DARE)

http://www.crd.york.ac.uk/CRDWeb/

Any field:

(blood pressure OR hypertension OR sphygmomanometers OR sphygmomanometer) FROM 01/31/2020 – 10/29/2020

0 Results (databases no longer updated)
3) AHA website searching guidelines and statements here:

American Heart Association: https://professional.heart.org/en/guidelines-and-statements/guidelines-and-statements-search

Searched by title since topic isn't part of the search anymore: “Blood Pressure” OR hyperten* – 2 retrieved published in 2020 are pasted below.

2 Titles

Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association

Published Jun 2020

Clinical Management of Stable Coronary Artery Disease in Patients With Type 2 Diabetes Mellitus: A Scientific Statement From the American Heart Association

Published Apr 2020

Blood pressure update searches 4-28-2021

Searching publication dates April 28, 2020 to present (6 months overlap with previous update Oct. 28 2020)

PubMed

172 results; 135 imported to previous update database from October 2020

Search number

Query

Filters

Results

("Hypertension"[Mesh:NoExp] OR "Hypertension, Renal"[Mesh]) OR hypertens*[All Fields]

572,125

343,681

#1 OR #2

787,593

136,356

#1 AND #2

128,213

#5 AND #4

10,284

(diagnost* OR diagnosi* OR diagnose*) OR (physical exam*[All Fields] OR clinical exam*[All Fields]) OR stress test*[All Fields] OR (sensitiv* OR specific* OR predictive value* OR ppv OR npv OR likelihood ratio* OR interobserver OR intraobserver) OR accuracy OR precision OR reliability OR validity OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Techniques and Procedures"[Mesh:NoExp] OR "Diagnostic Errors"[Mesh] OR "Diagnostic Tests, Routine"[Mesh:NoExp] OR "Sensitivity and Specificity"[Mesh] OR "Diagnosis"[Mesh:NoExp] OR "Diagnosis, Differential"[Mesh:NoExp]

10,608,074

#7 AND #6

6,308

"Hypertension/diagnosis"[Majr:NoExp]

9,603

#3 OR #6

787,593

#10 AND #9

9,603

#8 OR #11

13,902

5,687,876

#6 AND #13

5,027

#8 OR #11 OR #14

13,902

#14 OR #15

13,902

("intra-arterial"[All Fields] OR intraarterial[All Fields])

33,675

#17 AND #3

5,125

#18 OR #16

18,935

#18 OR #16

Humans

16,431

#18 OR #16

Humans, English

13,216

#18 OR #16

Humans, English, Adult: 19+ years

8,560

#22 AND (Editorial[pt] OR Comment[pt] OR Letter[pt] OR News[pt])

202

#22 NOT #23

8,358

(#24) AND (("2020/04/28"[Date - Publication] : "3000"[Date - Publication]))

172

Cochrane Library

77 results total

Reviews = 22; 10 imported

Protocols = 3; 3 imported

Trials = 52; 30 imported

Hits

[mh ^Hypertension] or [mh ^"Hypertension, Renal"]

17960

hypertens*

70205

#1 or #2

70205

[mh ^"Blood Pressure"] or [mh "Blood Pressure Determination"] or [mh Sphygmomanometers]

27893

Sphygmomanometer* or ("blood pressure" and (monitor* or determin*)) or ABPM

34666

#4 or #5

53126

[mh ^"Ambulatory Care"] or [mh ^"Ambulatory Care Facilities"] or [mh ^"Outpatient Clinics, Hospital"]

4206

[mh ^"Monitoring, Ambulatory"] OR [mh "Blood Pressure Monitoring, Ambulatory"]

2029

ambula* AND care

11709

#10

#7 or #8 or #9

13758

#11

#3 and #6

19859

#12

#3 and #6 and #10

1930

#13

diagnost* or diagnosi* or diagnose*

244700

#14

physical exam* or clinical exam*

178268

#15

stress test*

22708

#16

sensitiv* or specific* or predictive value* or ppv or npv or likelihood ratio* or interobserver or intraobserver

206721

#17

accuracy or precision or reliability or validity

48979

#18

[mh ^"Diagnostic Techniques and Procedures"]

#19

[mh ^"Diagnostic Errors"]

276

#20

[mh ^"Diagnostic Tests, Routine"]

241

#21

[mh "Sensitivity and Specificity"]

15503

#22

[mh ^Diagnosis] or [mh ^"Diagnosis, Differential"]

1448

#23

#13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22

532790

#24

#12 and #23

938

#25

[mh ^Hypertension/DI]

1047

#26

#6 or #12

53126

#27

#25 and #26

827

#28

#24 or #27

1471

#29

212550

#30

#12 and #29

318

#31

#24 or #27 or #28

1471

#32

#30 or #31

1471

#33

"intra-arterial" or intraarterial

3198

#34

#33 and #11

149

#35

#32 or #34

1611

#36

#35 with Cochrane Library publication date Between Apr 2020 and Apr 2021

#37

#36 and (Editorial:pt or Comment:pt or Letter:pt or News:pt)

#38

#36 not #37

Embase

65 results: 49 imported

No.

Query

Results

'hypertension'/de OR 'hypertension'/exp OR hypertension

1,087,155

renal AND ('hypertension'/de OR hypertension)

149,201

#1 OR #2

1,087,200

'blood pressure'/de OR 'blood pressure determination'/de OR 'sphygmomanometer'/de OR 'sphygmomanometers'/de

323,608

sphygmomanometer* OR ('blood pressure' AND (monitor* OR determin*)) OR abpm

205,859

#4 AND #5

81,884

'ambulatory care'/de OR 'ambulatory care facilities'/de OR 'outpatient clinics, hospital'/de

114,249

'blood pressure monitoring'/exp OR 'monitoring, ambulatory'/de

59,613

ambula* AND care

110,952

#10

#7 OR #8 OR #9

237,084

#11

#3 AND #6

38,289

#12

#3 AND #6 AND #10

9,911

#13

diagnost* OR diagnosi* OR diagnose*

7,151,652

#14

456,760

#15

'stress test' OR 'stress tests' OR 'stress testing'

25,938

#16

((sensitiv* OR specific* OR predictive) AND value* OR ppv OR npv OR likelihood) AND ratio* OR interobserver OR intraobserver

225,435

#17

'diagnostic techniques and procedures'/de

97,321

#18

'diagnostic errors'/exp

106,921

#19

'diagnostic tests, routine'/de

80,764

#20

'sensitivity and specificity'/exp

388,516

#21

'diagnosis'/de OR 'diagnosis, differential'/de

1,746,492

#22

'accuracy'/exp OR accuracy OR 'precision'/exp OR precision OR 'reliability'/exp OR reliability OR 'validity'/exp OR validity

1,432,494

#23

#13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22

8,310,276

#24

#12 AND #23

4,387

#25

'hypertension'/mj/dm_di

13,506

#26

#6 OR #12

81,885

#27

#25 AND #26

2,486

#28

#24 OR #27

5,532

#29

sensitiv*or AND 'sensitivity and specificity'/dm_di AND exp OR diagnose OR diagnosed OR diagnoses OR diagnosing OR diagnostic OR 'diagnosis'/dm_di OR 'diagnosis, differential'/dm_di

2,997,841

#30

#12 AND #29

1,729

#31

#24 OR #27 OR #28

5,532

#32

#30 OR #31

5,532

#33

'intra-arterial' OR 'intraarterial' OR intraarterial

59,911

#34

#11 AND #33

414

#35

#32 OR #34

5,857

#36

#35 AND [embase]/lim

5,026

#37

#36 AND ([animal cell]/lim OR [animal experiment]/lim OR [animal model]/lim OR [animal tissue]/lim) AND [embase]/lim

119

#38

#36 NOT #37 AND [embase]/lim

4,907

#39

(editorial:it OR comment:it OR letter:it OR news:it) AND [embase]/lim

1,436,866

#40

#38 NOT #39 AND [embase]/lim

4,690

#41

#40 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [embase]/lim

2,529

#42

#40 AND ([adult]/lim OR [middle aged]/lim OR [aged]/lim OR [very elderly]/lim) AND [2020-2021]/py

204

#43

#42 AND [28-4-2020]/sd NOT [29-4-2021]/sd

157

#44

#43 AND ([medline]/lim OR [pubmed-not-medline]/lim)

#45

#43 NOT #44

ClinicalTrials.gov

20 results; 9 imported

AREA[ConditionSearch] (Ambulator* OR diagnost* or diagnosi* or diagnose* OR physical exam* or clinical exam* OR stress test* OR sensitiv* or specific* or predictive value* or ppv or npv or likelihood ratio* or interobserver or intraobserver OR EXPAND[Concept] "intra-arterial") AND (blood pressure OR hypertension) AND AREA[LastUpdatePostDate] EXPAND[Term] RANGE[10/01/2020, 04/28/2021]

CRD Databases (includes DARE)

http://www.crd.york.ac.uk/CRDWeb/

Any field:

(blood pressure OR hypertension OR sphygmomanometers OR sphygmomanometer) FROM 2020 – 2021

0 results

AHA website

AHA website searching guidelines and statements here:

American Heart Association: https://professional.heart.org/en/guidelines-and-statements/guidelines-and-statements-search

Searched by title since topic isn't part of the search anymore: “Blood Pressure” OR hyperten* – 0 retrieved published 2020-2021

Supplemental Figure 1.

PRISMA Flow Diagram¹

View Full Size||Download Slide (.ppt)

Supplemental Table 2.Quality of Included Studies

View Table||Download (.pdf)

Supplemental Table 2. Quality of Included Studies

Study

Consecutive participants

Size of sample

Independent comparison

Valid standard

Level*

Armanyous²

Yes

578

Yes

Etyang³

982

Yes

Gill⁴

211

Yes

Ishikawa⁵

181

Yes

Kang⁶

1774

Yes

Mixed

Kim⁷

121

Yes

Michea⁸

309

Yes

Nunan⁹

203

Yes

Ommen¹⁰

178

Yes

Poudel¹¹

432

Yes

Selenta¹²

319

Yes

Shin¹³

1262

Yes

Tocci¹⁴

Yes

2209

Yes

Viera¹⁵

411

Yes

Wojciechowska¹⁶

201

Yes

Zhang¹⁷

Yes

831

Yes

Zhou¹⁸

122

Yes

*Level 1: provided independent blinded comparison to ambulatory BP monitoring among at least 100 consecutive participants

Level 2: provided independent blinded comparison to ambulatory BP monitoring among a smaller number of consecutive participants

Level 3: provided comparison to ambulatory BP monitoring among a nonconsecutive sample

Supplemental Table 3.Results from individual studies

View Table||Download (.pdf)

Supplemental Table 3. Results from individual studies

Author

Screening Test

Total N (hypertension %)

True positive

False positive

False negative

True negative

Sensitivity (95% CI

Specificity (95% CI)

LR+ (95% CI

LR- (95% CI)

Gill⁴

Office BP

211 (41)

113

0.27 (0.18-0.37)

0.90 (0.84-0.95)

2.8 (1.5-5.3)

0.81 (0.70-0.93)

Ishikawa⁵

Office BP

129 (34)

0.70 (0.57- 0.84)

0.87 (0.80- 0.94)

5.4 (2.3- 8.6)

0.34 (0.18- 0.50)

Kang⁶

Office BP

573 (64)

266

102

130

0.72 (0.68- 0.77)

0.63 (0.57- 0.70)

2.0 (1.6- 2.4)

0.43 (0.35- 0.52)

Kim⁷

Office BP

121 (54)

0.52 (0.40- 0.64)

0.95 (0.89- 1.00)

9.8 (0- 20.8)

0.50 (0.37- 0.64)

Ommen¹⁰

Office BP

178 (25)

0.55 (0.40- 0.69)

0.71 (0.63- 0.79)

1.9 (1.2- 2.6)

0.64 (0.42- 0.86)

Poudel¹¹

Office BP

432 (38)

122

262

0.25 (0.18-0.31)

0.97 (0.95-0.99)

8.3 (2.2-14.5)

0.77 (0.71-0.85)

Selenta¹²

Office BP

319 (27)

233

0.14 (0.07- 0.22)

1.00 (0.99- 1.00)

33.0 (0- 100)

0.86 (0.79- 0.94)

Shin¹³

Office BP

1262 (61)

554

188

222

298

0.71 (0.68-0.75)

0.61 (0.57-0.66)

1.8 (1.6-2.1)

0.47 (0.41-0.53)

Tocci¹⁴

Office BP

2209 (67)

1332

351

149

377

0.90 (0.88-0.91)

0.52 (0.48-0.55)

1.9 (1.7-2.0)

0.19 (0.16-0.23)

Viera¹⁵

Office BP

411 (76)

109

205

0.35 (0.29- 0.40)

0.95 (0.90- 0.99)

6.7 (0.9- 12.6)

0.69 (0.62- 0.75)

Wojciechowska¹⁶

Office BP

201 (33)

115

0.62 (0.50-0.74)

0.85 (0.79-0.91)

4.1 (2.3-6.1)

0.45 (0.30-0.59)

Zhang¹⁷

Office BP

831 (62)

197

321

287

0.38 (0.34- 0.42)

0.92 (0.89- 0.95)

4.6 (2.8- 6.3)

0.68 (0.62- 0.73)

Gill⁴

HBPM

211 (41)

0.72 (0.61-0.81)

0.76 (0.68-0.83)

3.0 (2.1-4.2)

0.37 (0.26-0.52)

Ishikawa⁵

HBPM

120 (33)

0.55 (0.40- 0.70)

0.84 (0.76- 0.92)

3.4 (1.4- 5.3)

0.54 (0.35- 0.73)

Kang⁶

HBPM

573 (64)

247

121

150

0.67 (0.62- 0.72)

0.73 (0.67- 0.79)

2.5 (1.9- 3.1)

0.45 (0.37- 0.52)

Nunan⁸

HBPM

203 (54)

102

0.94 (0.89-0.98)

0.51 (0.41-0.61)

1.9 (1.5-2.3)

0.12 (0.03-0.22)

Zhang¹⁷

HBPM

831 (62)

295

223

280

0.57 (0.53- 0.61)

0.89 (0.86- 0.93)

5.4 (3.6- 7.2)

0.48 (0.43- 0.53)

Zhuo¹⁸

HBPM

102 (71)

0.88 (0.80- 0.95)

0.73 (0.57- 0.89)

3.3 (1.3- 5.3)

0.17 (0.06- 0.28)

Armanyous²

AOBP*

578 (16)

444

0.48 (0.38-0.58)

0.91 (0.88-0.93)

5.3 (3.4-7.2)

0.57 (0.46-0.69)

Etyang³

AOBP*

982 (35)

189

124

158

511

0.55 (0.49-0.60)

0.81 (0.77-0.84)

2.8 (2.3-3.4)

0.60 (0.50-0.64)

Michea⁸

AOBP^†

309 (65)

176

0.87 (0.83-0.92)

0.24 (0.16-0.32)

1.2 (1.02-1.29)

0.52 (0.26-0.77)

Abbreviations, BP, Blood pressure; HBPM, home blood pressure monitoring; AOBP, automated office blood pressure; LR, likelihood ratio

*Threshold 135/85 mm Hg

^†Threshold 140/90 mm Hg

Supplemental Table 4.Serial Likelihood Ratios Using Combination of Office BP and Home BP Monitoring

View Table||Download (.pdf)

Supplemental Table 4. Serial Likelihood Ratios Using Combination of Office BP and Home BP Monitoring

Study

Result Combination

95% CI

Zhang¹⁷

Office+Home+

153

365

304

5.3-20

Office-Home+

142

376

289

3.6

2.4-5.4

Office+Home-

474

296

1.6

0.91-2.7

Office-Home-

179

263

339

0.41

0.36-0.47

Ishikawa⁵

Office+Home+

6.3

2.7-15

Office-Home+

0.86

0.23-3.1

Office+Home-

11*

4.4

1.6-4.4

Office-Home-

0.23

0.11-0.45

*Low numbers in these cells likely yield unreliable estimates

TP, true positive

FP, false positive

FN, false negative

TN, true negative

LR, likelihood ratio

CI, confidence interval

Supplemental References

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. [PubMed: 19621072]

Armanyous S, Ohashi Y, Lioudis M, et al. Diagnostic Performance of Blood Pressure Measurement Modalities in Living Kidney Donor Candidates. Clin J Am Soc Nephrol. 2019 May 7;14(5):738–746. doi: 10.2215/CJN.02780218.

Etyang AO, Sigilai A, Odipo E, et al. Diagnostic Accuracy of Unattended Automated Office Blood Pressure Measurement in Screening for Hypertension in Kenya. Hypertension. 2019 Dec;74(6):1490–1498. doi: 10.1161/HYPERTENSIONAHA.119.13574.

Kim SK, Bae JH, Nah DY, Lee DW, Hwang TY, Lee KS. Frequency and related factors of masked hypertension at a worksite in Korea. J Prev Med Public Health. 2011;44(3):131–9. [PubMed: 21617339]

Michea L, Toro L, Alban N, et al. Attended Automated Office Blood Pressure Measurement Versus Ambulatory Blood Pressure Monitoring in a Primary Healthcare Setting in Chile. South Med J. 2021 Feb;114(2):63–69. [PubMed: 33537784]

Nunan D, Thompson M, Heneghan CJ, et al. Accuracy of self-monitored blood pressure for diagnosing hypertension in primary care. J Hypertens. 2015;33(4):755–62. [PubMed: 25915880]

10.

Ommen ES, Schröppel B, Kim JY, et al. Routine use of ambulatory blood pressure monitoring in potential living kidney donors. Clin J Am Soc Nephrol. 2007;2(5):1030–6. [PubMed: 17702722]

11.

Poudel B, Booth JN 3rd, Sakhuja S, et al. Prevalence of ambulatory blood pressure phenotypes using the 2017 American College of Cardiology/American Heart Association blood pressure guideline thresholds: data from the Coronary Artery Risk Development in Young Adults study. J Hypertens. 2019;37(7):1401–1410. doi:10.1097/HJH.0000000000002055

12.

Selenta C, Hogan BE, Linden W. How often do office blood pressure measurements fail to identify true hypertension? An exploration of white-coat normotension. Arch Fam Med. 2000;9(6):533–40. [PubMed: 10862216]

13.

14.

Tocci G, Presta V, Figliuzzi I, et al. Prevalence and clinical outcomes of white-coat and masked hypertension: Analysis of a large ambulatory blood pressure database. J Clin Hypertens. 2018;20(2):297–305.

15.

Viera AJ, Lin FC, Tuttle LA, et al. Reproducibility of masked hypertension among adults 30 years or older. Blood Press Monit. 2014;19(4):208–15. [PubMed: 24842491]

16.

Wojciechowska W, Stolarz-Skrzypek K, Olszanecka A, et al. Subclinical arterial and cardiac damage in white-coat and masked hypertension. Blood Press. 2016:249–56. doi: 10.3109/08037051.2016.1150563

17.

Zhang L, Li Y, Wei FF, et al. Strategies for classifying patients based on office, home, and ambulatory blood pressure measurement. Hypertension. 2015;65(6):1258–65. [PubMed: 25870194]

18.

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Make the Diagnosis: Does This Adult Patient Have Hypertension?

Prior Probability

Population Who Should Be Screened for Hypertension

Assessing the Likelihood of Hypertension

Reference Standard Tests

References

Original Article: Does This Adult Patient Have Hypertension?

Clinical Scenarios

Case 1

Case 2

Background

Methods

Search Strategy

Article Eligibility

Exclusion of Articles

Data Abstraction

Quality Assessment

Diagnostic Thresholds Between Studies

Analysis

Results

Conventional Office Oscillometric BP vs 24-Hour ABPM

HBPM vs 24-Hour ABPM

Office Oscillometric Measurement vs HBPM

Office Measurement and HBPM as a Composite Measure

AOBP Monitoring vs 24-Hour ABPM

Discussion

Scenario Resolutions

Case 1

Case 2

Limitations

Clinical Bottom Line

Conclusions

Acknowledgment

References

Supplementary Online Content

Supplemental Figure 1.

Supplemental References

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