Office blood pressure measurements misclassified nearly 30% of patients as having uncontrolled hypertension, as only 69% of those uncontrolled by office criteria were confirmed uncontrolled by 24-hour ABPM.
Cross-Sectional (n=1,142)
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Does 24-hour ABPM compared to office chart measurements change the proportion of treated hypertensive patients considered to have uncontrolled blood pressure?
Office blood pressure measurements may overestimate the proportion of treated hypertensive patients who are truly uncontrolled due to the white coat effect, highlighting the utility of 24-hour ABPM.
BACKGROUND: In most western countries 20% of adults have hypertension. Reports in the literature suggest that from 31 to 86% of treated patients are not at recommended target levels. However it is important to consider how we are determining whether targets are unmet and the degree to which they are unmet. Our underlying hypothesis is that white coat effect is partially responsible for the reported low rates of control of hypertension by primary care practitioners. METHODS: The study population consists of 1142 patients who are being assessed for enrollment in two community-based randomized controlled trials. Patients must have essential hypertension, be on antihypertensive medication, and must not have met their blood pressure targets. We are reporting on the proportion of patients who have not achieved target, and the degree to which they have not achieved their target. We also report on the mean daytime blood pressures on 24 hour ABPM and compare these to mean blood pressures found on the patients' charts. RESULTS: We identified 3284 patient charts of patients with hypertension. Of these, 1142 were determined to be "out of control" (did not achieve target) and 436 agreed to undergo 24 hour ABPM for final determination of eligibility. Overwhelmingly (95.8% of the time) it was the systolic blood pressure that was not under control. However, most of the patients who had not achieved target according to our criteria were within 10 mmHg of the recommended targets. Isolated systolic blood pressure was the best predictor of elevated mean daytime blood pressure on 24 hour ABPM. CONCLUSIONS: At least 35% of patients had not achieved target blood pressure levels and this is primarily due to lack of control of systolic blood pressure. The best predictor of continuing hypertension on 24 hour ABPM was the mean systolic blood pressure on the patients chart. However, only 69% of patients who were uncontrolled according blood pressures recorded in the chart were uncontrolled according to 24 hour ABPM criteria. This suggests that the white coat effect makes blood pressure measurements in the doctor's offices, at least as currently done, not sufficiently accurate for determining treatment endpoint.
Godwin et al. (Mon,) conducted a cross-sectional in Essential hypertension (n=1,142). Office blood pressure measurement vs. 24-hour ambulatory blood pressure monitoring was evaluated on Proportion of patients with uncontrolled hypertension confirmed by 24-hour ABPM. Office blood pressure measurements misclassified nearly 30% of patients as having uncontrolled hypertension, as only 69% of those uncontrolled by office criteria were confirmed uncontrolled by 24-hour ABPM.