Relationship Between Outpatient Clinic and Ambulatory Blood Pressure Measurements and Mortality.

PURPOSE OF REVIEW: This review aims to summarize and discuss the relationship between outpatient clinic and ambulatory blood pressure (BP) measurements and cardiovascular morbidity and mortality. RECENT FINDINGS: Contemporary clinical practice guidelines worldwide recommend ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. Recent epidemiological studies and systematic reviews showed ABPM predicts cardiovascular events and mortality independent of clinic BP. Ambulatory BP appears to be prognostically superior to clinic BP. ABPM characterizes BP phenotypes that would not have otherwise identified with clinic BP measurement only. Identification of white coat hypertension, which carries a prognosis almost similar to normotension, and masked hypertension, which carries a prognosis almost similar to sustained hypertension, can be accomplished only by ABPM. Randomize controlled trials to assess the cardiovascular effects of hypertensive patients managed with ABPM vs. clinic BP measurement and cost-effective studies of ABPM are warranted.

Blood pressure and mortality among hemodialysis patients.

Blood pressure measured before and after dialysis does not agree well with those recorded outside the dialysis unit. Whether recordings obtained outside the dialysis unit are of greater prognostic value than blood pressure obtained just before and after dialysis remains incompletely understood. Among 326 patients on long-term hemodialysis, blood pressure was self-measured at home for 1 week, over an interdialytic interval by ambulatory recording and before and after dialysis over 2 weeks. Over a mean follow-up of 32 (SD 20) months, 102 patients died (31%), yielding a crude mortality rate of 118/1000 patient years. Systolic but not diastolic blood pressure was found to be of prognostic importance. Adjusted and unadjusted multivariate analyses showed increasing quartiles of ambulatory and home systolic blood pressure to be associated with all-cause mortality (adjusted hazard ratios for increasing quartiles of ambulatory: 2.51, 3.43, 2.62; and for home blood pressure: 2.15, 1.7, 1.44). Mortality was lowest when home systolic blood pressure was between 120 to 130 mm Hg and ambulatory systolic blood pressure was between 110 to 120 mm Hg. Blood pressure recorded before and after dialysis was not statistically significant (P=0.17 for predialysis, and P=0.997 for postdialysis) in predicting mortality. Out-of-dialysis unit blood pressure measurement provided superior prognostic information compared to blood pressure within the dialysis unit (likelihood ratio test, P<0.05). Out-of-dialysis unit blood pressure among hemodialysis patients is prognostically more informative than that recorded just before and after dialysis. Therefore, the management of hypertension among these patients should focus on blood pressure recordings outside the dialysis unit.

Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study.

BACKGROUND: Studies in hypertensive patients suggest that ambulatory blood pressure (BP) is prognostically superior to office BP. Much less information is available in the general population, however. Obtaining this information was the purpose of the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. METHODS AND RESULTS: Office, home, and 24-hour ambulatory BP values were obtained in 2051 subjects between 25 and 74 years of age who were representative of the general population of Monza (Milan, Italy). Subjects were followed up for an average of 131 months, during which time cardiovascular and noncardiovascular fatal events were recorded (n=186). Office, home, and ambulatory BP values showed a significant exponential direct relationship with risk of cardiovascular or all-cause death. The goodness of fit of the relationship was greater for systolic than for diastolic BP and for night than for day BP, but its overall value was not better for home or ambulatory than for office BP. The slope of the relationship, however, was progressively greater from office to home and ambulatory BP. Home and night BP modestly improved the goodness of fit of the risk model when added to office BP. CONCLUSIONS: In the PAMELA population, risk of death increased more with a given increase in home or ambulatory than in office BP. The overall ability to predict death, however, was not greater for home and ambulatory than for office BP, although it was somewhat increased by the combination of office and outside-of-office values. Systolic BP was almost invariably superior to diastolic BP, and night BP was superior to day BP.