Future developments in ambulatory blood pressure monitoring and self-blood pressure monitoring in clinical practice

A number of factors interact to promote the increased clinical use of both ambulatory blood pressure monitoring (ABPM) and self-blood pressure monitoring (SBPM). These include the phasing out of mercury, evidence of the unreliability of clinic measurements, technical advances in automated blood pressure measurement, increasing evidence that out-of-office measurements give the best risk assessment, and a gradual recognition by payers of the clinical utility of ABPM and SBPM. Both ABPM and SBPM have been endorsed by the two major guidelines for managing hypertensive patients (World Health Organization-International Society of Hypertension and Joint National Committee VI). The use of SBPM has grown enormously over the past few years, mostly because of direct sales to patients. Although SBPM may give a better estimate of the true blood pressure than clinic readings, there are concerns about the accuracy of the monitors in individual patients. The main clinical indication for ABPM is the diagnosis of white-coat hypertension. This requires the demonstration that the blood pressure is normal outside the clinic, which can be established using SBPM and confirmed by ABPM. Even though ABPM may save drug costs in patients with white-coat hypertension, its use may also lead to increased drug expenditure in others in whom it demonstrates suboptimal blood pressure control. SBPM has the potential to reduce the number of clinic visits and also to improve blood pressure control. The ultimate validation of both procedures will be whether they can prevent cardiovascular morbidity. There have been suggestions that a non-dipping pattern of nocturnal blood pressure may carry a bad prognosis, but this may apply only to certain disease end-points. The greater recognition of the relevance of dipping status should provide an additional stimulus to the growth of both procedures. It is anticipated that, in the future, hypertension will be managed by the 'virtual hypertension clinic', using ABPM for the initial diagnosis, and SBPM with electronic linkage between the patient and the health-care provider for maintenance and follow-up.