![](\"https:\/\/medical.andonline.com\/wp-content\/uploads\/2021\/08\/AHA-Guidelines-Chart-2-1030x624.jpeg\" "AHA Guidelines Chart")
<\/div><\/div><\/div><\/div>Diagnosing Hypertension<\/span><\/h3>\n<\/div><\/section>
\nWhy is it So Hard to Diagnose\u00a0Hypertension?<\/strong><\/span>
\nIn some cases, hypertension may be easy enough for\u00a0medical professionals to diagnose, but in others, it can pose quite a challenge because of its dynamic nature in\u00a0relation to constantly changing and underlying influences, both internal and external.
\nIn order to control for variables not normally present during\u00a0the patient\u2019s office visits, studies validate enlisting patients to perform home blood pressure monitoring (HBPM) in their\u00a0environment for more definitive diagnosis than in-clinic monitoring6<\/sup>.
\nUnfortunately, however, there are several BP patterns that\u00a0are not reflected in office or HBPM because they reflect a snapshot measurement and may not uncover some of the\u00a0diagnosis patterns below.<\/p>\n<\/div><\/section><\/p><\/div>BP Patterns<\/span><\/h3>\n<\/div><\/section>
\nBlood Pressure Diagnosis Patterns<\/strong><\/span>
\nAs discussed, diagnosing hypertension can be\u00a0complicated by myriad BP patterns that may not be\u00a0immediately apparent when the patient presents in the\u00a0office for a consultation or checkup. In order to ensure\u00a0proper and timely diagnosis, the full scope of BP patterns\u00a0must be understood, especially given that many of these\u00a0patterns are\u00a0associated with increased complications.
\nCritical to the understanding of BP patterns is BP load:\u00a0the percent of abnormally elevated BP measurements, specific to day and night guidelines. BP load is associated\u00a0with future cardiovascular morbidity and mortality7<\/sup>\u00a0and can be experienced via several types of BP patterns.<\/p>\n<\/div><\/section><\/p><\/div><\/div><\/div><\/div><\/div><\/div>BP Pattern: White Coat Hypertension<\/strong><\/span>
\nWhite Coat Hypertension (WCH) is when a patient\u2019s BP\u00a0is normal outside of the clinic but elevated in the clinic.\u00a0The name \u201cWhite Coat Hypertension\u201d was assigned due\u00a0to the suggestion that being in the presence of a medical\u00a0provider can be stressful, thus raising BP. If a provider\u00a0assumes that the patient\u2019s BP is always at hypertensive\u00a0levels when, in fact, they are truly experiencing WCH,\u00a0it could lead to over-medicating, resulting in potential\u00a0patient complications second to misdiagnoses.
\nBest practices suggest that WCH should be ruled out and\u00a0monitored with suspicion, as there is growing evidence that a portion of patients with WHC have elevations in\u00a0other stressed-induced situations as well6,8<\/sup>.<\/p>\n<\/div><\/section><\/div>
\n![](\"https:\/\/medical.andonline.com\/wp-content\/uploads\/2021\/08\/Welcome-1050-2-1030x589.jpeg\" "Welcome 1050")
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\nMasked Hypertension<\/span><\/strong>
\nMasked Hypertension is when a patient presents with\u00a0a normal BP in the clinic, but their BP is elevated\u00a0outside the clinic. Detection of many masked or hidden\u00a0hypertension patterns is impossible in the clinic, and, for\u00a0the most part, by HBPM6<\/sup>. A study of 64,000 adults found\u00a0that masked hypertension was associated with greater\u00a0risk of all causes of mortality than sustained hypertension\u00a0or WCH9<\/sup>.
\nStress-Induced Hypertension<\/span><\/strong>
\nStress-Induced Hypertension is identified when there is\u00a0variability of BP during the patient\u2019s daily life that is not\u00a0likely to be captured in-clinic or HBPM6<\/sup>. An example may\u00a0be a patient with a stressful job where their BP would\u00a0consistently be considered hypertensive, even though\u00a0their levels may return to normal outside of the stress-inducing\u00a0situation10<\/sup>.
\nMorning Hypertension<\/span><\/strong>
\nMorning Hypertension, also known as Morning BP Surge\u00a0(MBPS), is when average BP is \u2265 130\/80 in the first 2 hours after awakening. MBPS is the dynamic phenomenon of BP\u00a0changes in early morning hours. Morning hypertension is the single most powerful predictor of stroke, cardiovascular\u00a0events, renal disease, and total mortality6<\/sup>.
\nNocturnal Hypertension<\/span><\/strong>
\nNocturnal Hypertension is defined as an average BP\u00a0\u2265110\/65 mmHg during sleep hours, usually between 1 and\u00a06 AM and when BP does not dip 10-20% during sleep, as is\u00a0normal. Data supports Nocturnal Hypertension as a better\u00a0predictor of worsened outcomes than daytime BP, and it\u00a0is known to correlate with advanced brain, heart, kidney\u00a0disease and poorer prognosis with increased cardiovascular\u00a0events, hospitalizations and deaths6<\/sup>.
\nWithin the Nocturnal Hypertension category are several\u00a0sub-types:<\/p>\n\n- With Sustained Nocturnal Hypertension, the\u00a0uncontrolled daytime BP stays elevated during\u00a0sleep.<\/li>\n
- Nighttime Surge is a temporary increase in\u00a0BP. Increased BP variability during sleep can\u00a0explain nighttime\u00a0surge and is a unique and\u00a0critical factor for increased cardiovascular\u00a0events. Each of the below sub-types are\u00a0abnormal patterns where BP doesn\u2019t decrease,\u00a0as normal, and it can be higher while sleeping\u00a0than during awake periods:<\/li>\n<\/ul>\n
\n\n \n\nNon-Dippers<\/strong><\/td>\nBP decline of \u226410%<\/td>\n<\/tr>\n \nReverse Dippers (Risers)<\/strong><\/td>\nBP dips \u22640% compared to waking hours<\/td>\n<\/tr>\n \nExtreme Dippers\u00a0<\/strong><\/td>\nBP dips abnormally, > 20%6<\/sup><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\nRegardless of the specific sub-type of nocturnal BP\u00a0patterns a patient is diagnosed with, the increased BP\u00a0variability during sleep is a unique and critical factor for\u00a0increased cardiovascular events6<\/sup>.
\nOrthostatic Changes<\/span><\/strong>
\nOrthostatic Hypertension occurs when a BP is elevated\u00a0while a patient is standing. In contrast, Orthostatic\u00a0Hypotension occurs when a BP drops by 20 mmHg\u00a0when a patient is standing. Orthostatic Hypotension\u00a0often precipitates syncope or falls in the frail or elderly\u00a0population, which can lead to a host of adverse and\u00a0potentially life-threatening events6<\/sup>.
\nBP Variability<\/span><\/strong>
\nBP Variability (BPV) is diagnosed when there are transient\u00a0fluctuations in BP that is independent of the mean BP.\u00a0It is often associated with arterial stiffness and poor\u00a0cardiovascular outcomes. The instability of BPV is seen\u00a0in many of the above hypertension patterns, including\u00a0orthostasis-related position changes6<\/sup>.
\nResistant Hypertension<\/span><\/strong>
\nResistant Hypertension is an elevated BP in patients who\u00a0are not controlled after use of a variety of antihypertensive agents. Resistant Hypertension often calls for further\u00a0evaluation of treatment efficacy11,6<\/sup>.
\nThe full scope of BP\u00a0patterns that can affect a diagnosis\u00a0of hypertension is nuanced before even considering\u00a0additional internal and external influences. Consequently,\u00a0traditional in-office and HBPM techniques may not be\u00a0sufficient to diagnose hypertension.<\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div><\/div>\nThe Solution<\/span><\/h3>\n<\/div><\/section>
\nThe Solution: Ambulatory Blood\u00a0Pressure Monitoring<\/strong><\/span>
\nDue to the complexities of diagnosing hypertension,\u00a0scores of studies have provided convincing evidence\u00a0that\u00a0ambulatory blood pressure monitoring (ABPM) is the\u00a0recommended technique for diagnosing hypertension\u00a0because it accounts for many of the internal and external\u00a0influences that can obfuscate in-office diagnosis, even\u00a0when\u00a0supplemented by HBPM.
\nAdditionally, ABPM has been proven to not only better\u00a0diagnose hypertension, but it may help providers\u00a0understand the state of BP and better predict\u00a0cardiovascular, cerebral, and end organ damage better\u00a0than any other non-invasive BP measuring tool12<\/sup>.\u00a0ABPM also has the unique ability to help providers better\u00a0diagnose their patients via thorough data analysis of BP\u00a0load and patterns so appropriate therapeutic treatment\u00a0plans can be implemented.<\/p>\n<\/div><\/section><\/p><\/div>![](\"https:\/\/medical.andonline.com\/wp-content\/uploads\/2021\/08\/WhyConnected-doctorimage-2.png\" "WhyConnected-doctorimage")
<\/div><\/div><\/div><\/div>\n- White Coat Hypertension<\/strong>: ABPM is so\u00a0successful in monitoring and diagnosing these\u00a0cases that CMS began reimbursing ABPM as\u00a0the gold standard for confirming suspected\u00a0diagnosis of WCH in 200213<\/sup>.<\/li>\n
- Masked Hypertension<\/strong>: HBPM may\u00a0occasionally be enough to pick up on\u00a0hypertensive readings and diagnose Masked\u00a0Hypertension, yet people often remain\u00a0inadequately diagnosed and controlled with\u00a0conventional BP monitoring15<\/sup>. Therefore, ABPM\u00a0is the preferred monitoring tool4,14<\/sup>\u00a0because the\u00a0automatic monitoring\u00a0captures BP load at preset\u00a0intervals during normal activities of daily living without interruption.<\/li>\n
- Stress-Induced Hypertension<\/strong>: Due to its\u00a0round-the-clock nature, ABPM is used to\u00a0identify cycles or periods of elevated BP without\u00a0interrupting the patterns of the patient, a critical\u00a0factor in diagnosis of this BP pattern.<\/li>\n<\/ul>\n<\/div><\/section><\/div>
\n- Morning Hypertension<\/strong>: ABPM or automated\u00a0timed monitoring are the only non-invasive tools\u00a0that can detect\u00a0Morning Hypertension correctly6<\/sup>.<\/li>\n
- Nocturnal Hypertension<\/strong>: ABPM should be the\u00a0preferred method for identification of nighttime\u00a0dipping and\u00a0other nocturnal BP patterns due to\u00a0its ability to monitor consistently, even while the\u00a0patient is asleep6<\/sup>.<\/li>\n
- Orthostatic Hypertension<\/strong>: Because of its\u00a0correlation with syncope and falls, ABPM\u00a0is preferred in diagnosing Orthostatic\u00a0Hypertension because it provides the most\u00a0conclusive interpretation of the underlying BP\u00a0pattern6<\/sup>.<\/li>\n
- BP Variability<\/strong>: Due to the nature of BP\u00a0Variability, fully understanding the BP patterns\u00a0a patient experiences\u00a0throughout the course of\u00a0the day is essential. ABPM is the only method\u00a0that can achieve such tracking.<\/li>\n
- Resistant Hypertension<\/strong>: ABPM is valuable\u00a0in order to better tailor interventions, such as\u00a0choice of\u00a0antihypertensives based on their\u00a0pharmacologic characteristics, timing of dosing,\u00a0and even integrated\u00a0specialty support to\u00a0achieve constant BP control.<\/li>\n<\/ul>\n
Correctly diagnosing the hypertension pattern via ABPM\u00a0will aid in guiding interventions and treatment toward\u00a0normalizing BP because it provides clinicians with more data\u00a0for better choice and timing of medications, and it will reduce\u00a0variability in measurements. In sum, the improved insights\u00a0gained from utilizing ABPM in a variety of BP pattern cases\u00a0can not only help provide the most conclusive interpretation\u00a0of the underlying BP pattern, but it can minimize preventable\u00a0morbidity and mortality due to the tailored treatment plans\u00a0possible with improved data from ABPM.<\/p>\n<\/div><\/section><\/div><\/div><\/div><\/div><\/div><\/div>
Screening with ABPM<\/span><\/h3>\n<\/div><\/section><\/div>Who Should Be Screened with\u00a0Ambulatory BP Monitoring?<\/strong><\/span>
\nABPM should be used adjunctly with HBPM for\u00a0threshold staging for accurate diagnosis and therapeutic\u00a0management.
\nSpecifically, ABPM should be routinely used for high risk\u00a0patients as a reference standard to confirm the diagnosis of\u00a0hypertension12<\/sup>. High risk patients are those with HBPM \u2265\u00a0120\/80, a history of cardiovascular event, suspected WCH, suspected nocturnal hypertension (based on comorbidities\u00a0of sleep apnea, diabetes, chronic kidney disease), and\u00a0documented organ damage.
\nBeyond typical high-risk patients, ABPM screening is\u00a0also recommended for those with a predicted prevalence\u00a0for developing hypertension of \u2265 16%, based on the\u00a0Hypertension Prevalence Estimator Tool, which is used\u00a0to predict the percent of the patient population that will\u00a0develop hypertension16<\/sup>.
\nAdditionally, age, gender, race, and many comorbidities\u00a0impact the development of hypertension and should also be considered when considering ABPM screening. With even\u00a0one comorbidity, such as obesity or diabetes, the risk for hypertension increases exponentially, as seen in Table 1.<\/p>\n<\/div><\/section><\/div>
\n![](\"https:\/\/medical.andonline.com\/wp-content\/uploads\/2021\/08\/Who-Should-Be-Screened-1030x975.png\" "Who Should Be Screened")
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\nTable 1<\/em>
\n<\/p>\n\n\n\n<\/th>\n <\/th>\n <\/th>\n White<\/th>\n <\/th>\n <\/th>\n Black<\/th>\n <\/th>\n <\/th>\n Hispanic<\/th>\n <\/th>\n<\/tr>\n \nAGE<\/td>\n CoMorbidity<\/td>\n Male<\/td>\n Total
\n6%<\/td>\n Female<\/td>\n Male<\/td>\n Total
\n9.7%<\/td>\n Female<\/td>\n Male<\/td>\n Total
\n3.5%<\/td>\n Female<\/td>\n<\/tr>\n \n18-44<\/td>\n 0<\/td>\n 8.40%<\/td>\n <\/td>\n 3.50%<\/td>\n 9.90%<\/td>\n <\/td>\n 9.30%<\/td>\n 5.20%<\/td>\n <\/td>\n 1.70%<\/td>\n<\/tr>\n \n1<\/td>\n 21.10%<\/td>\n 16.30%<\/td>\n 11.60%<\/td>\n 27.80%<\/td>\n 22.60%<\/td>\n 17.40%<\/td>\n 13.90%<\/td>\n 10.90%<\/td>\n 7.90%<\/td>\n<\/tr>\n \n2<\/td>\n 38.20%<\/td>\n 37.70%<\/td>\n 37.30%<\/td>\n 64.80%<\/td>\n 58.50%<\/td>\n 52.20%<\/td>\n 54.60%<\/td>\n 39.60%<\/td>\n 24.70%<\/td>\n<\/tr>\n \n<\/td>\n<\/tr>\n \n45-64<\/td>\n 0<\/td>\n 32.30%<\/td>\n 29.50%<\/td>\n 26.80%<\/td>\n 46.10%<\/td>\n 46%<\/td>\n 45.90%<\/td>\n 26.30%<\/td>\n 25.10%<\/td>\n 23.90%<\/td>\n<\/tr>\n \n1<\/td>\n 46.90%<\/td>\n 48%<\/td>\n 49.20%<\/td>\n 60%<\/td>\n 63.20%<\/td>\n 66.40%<\/td>\n 44%<\/td>\n 41.10%<\/td>\n 38.30%<\/td>\n<\/tr>\n \n2<\/td>\n 70.90%<\/td>\n 69.10%<\/td>\n 67.30%<\/td>\n 87%<\/td>\n 86.50%<\/td>\n 86.10%<\/td>\n 64.50%<\/td>\n 66%<\/td>\n 67.60%<\/td>\n<\/tr>\n \n<\/td>\n<\/tr>\n \n65-74<\/td>\n 0<\/td>\n 51.90%<\/td>\n 53.60%<\/td>\n 55.30%<\/td>\n 71.50%<\/td>\n 70.60%<\/td>\n 69.70%<\/td>\n 41.10%<\/td>\n 53.20%<\/td>\n 65.30%<\/td>\n<\/tr>\n \n1<\/td>\n 64.20%<\/td>\n 66.50%<\/td>\n 68.80%<\/td>\n 80.90%<\/td>\n 84.50%<\/td>\n 88%<\/td>\n 63.80%<\/td>\n 69.80%<\/td>\n 75.80%<\/td>\n<\/tr>\n \n2<\/td>\n 77%<\/td>\n 83.50%<\/td>\n 90%<\/td>\n 86.10%<\/td>\n 89.10%<\/td>\n 92.10%<\/td>\n 74.50%<\/td>\n 79.50%<\/td>\n 84.50%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/center>
For example, for age 18-44 whites with 0 risk, 1 risk factor, 2 risk factors the prevalence would be 6%, 16.3%, 38%, respectively, of developing hypertension and further disease.<\/em><\/center>\u00a0<\/center>By using ABPM to screen adults who have a certain\u00a0percentage, say 16% or 20% or more prevalence of\u00a0developing hypertension, healthcare providers can detect\u00a0morbid hypertension patterns which otherwise would\u00a0go undiscovered until advanced disease occurs. Early\u00a0diagnosis and halting of preventable and irreversible\u00a0effects of cardiovascular disease through early\u00a0intervention is possible with ABPM screening.<\/center><\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div><\/div>\nABPM Usage<\/span><\/h3>\n<\/div><\/section>\nHow is ABPM Used, and What Data\u00a0Will it Provide?<\/span><\/strong>
\nABPMs can easily be configured by a nurse or medical\u00a0assistant to monitor the patient\u2019s BP at specific preset\u00a0time periods, such as every 20-30 minutes in the awake\u00a0hours, and every 60 minutes during the patient\u2019s reported\u00a0anticipated sleep period.
\nThe device should be worn for a minimum of 24 hours so it\u00a0can capture dynamic readings while the patient is engaged in usual activity, in their home and work environments, and\u00a0during their sleep periods.
\nAfter the 24 hours, the information is downloaded to a\u00a0computer for review.
\nThe numerous readings provide a plethora of information\u00a0for clinical decision making as to the person\u2019s actual BP load and BP patterns as well as time and date stamped\u00a0BP and pulse measurements. Additionally, some ABPM\u00a0devices provide other critical details, such as activity levels,\u00a0ambient temperature, and barometric pressure, which may\u00a0aid in diagnosis.
\nBeyond the basic raw data, the software will provide the\u00a0clinician helpful tools, such as graphs and diagrams, to\u00a0highlight the BP loads, sleep percentages, a variety of\u00a0means (including 24-hour, daytime, and nighttime means), high\/low BP measurements, Circadian\/Nocturnal rhythms,\u00a0and irregular pulses.
\nAltogether, this data paints a picture of not only\u00a0hypertension but of the patient\u2019s unique patterns to elicit\u00a0proper\u00a0decision making for clinical management.
\nThe initial target of managing BP should be aimed at\u00a0evaluating morning BP. After morning control, the next goal\u00a0would be to measure dynamic BP during the sleep cycles\u00a0with ABPM and with a goal to keep nocturnal BP\u00a0controlled\u00a0at <110\/656.\nWhat Type of Providers Should Use\u00a0ABPM?<\/strong><\/span>
\nGiven the urgency aimed at lowering BP thresholds,\u00a0including a focus on early intervention to reverse heart\u00a0and brain disease progression, morbidity and mortality,\u00a0ABPM should be used by primary care providers, health\u00a0departments, obesity and diabetic clinics, wellness centers, managed health groups, nurse or pharmacy hypertensive\u00a0clinics, along with cardiology and renal specialty clinics.
\nWith its wide range of diagnostic capabilities, efficiency,\u00a0and ease of use, ABPM should be used early and\u00a0frequently when hypertension is suspected, given the large\u00a0number of patients who are going undiagnosed or suffering\u00a0consequences of uncontrolled hypertension.
\nABPM has been recognized by many as a gold standard\u00a0in diagnosing hypertension5,6<\/sup>, and as of 2015, the United States Preventative Services Task Force (USPSTF)\u00a0found it to be the best method to diagnose and confirm\u00a0hypertension12<\/sup>. The CMS also set the standard that ABPM\u00a0is a valid, useful and cost-effective tool for diagnosing\u00a0hypertension WCH when it added reimbursements for the\u00a0procedure in 200213<\/sup>.
\nBeyond medical providers, ABPM is becoming the standard\u00a0of care among groups like AETNA17<\/sup>, HealthNet, Kaiser and\u00a0Columbia University when diagnosing and evaluating BP\u00a0patterns such as WCH, Masked Hypertension, and more.<\/p>\n<\/div><\/section>\n<\/div><\/div><\/div><\/div><\/div>Benefits of ABPM<\/span><\/h3>\n<\/div><\/section>
\nHow Can ABPM Improve Patient\u00a0Satisfaction, Increase Survival Rates,\u00a0and Decrease Cost?<\/strong><\/span>
\nABPM has been shown to improve the accuracy of a\u00a0hypertension diagnosis and the clinician\u2019s understanding\u00a0of BP patterns that a patient may experience, but how\u00a0does it improve outcomes and increase survival, all while\u00a0decreasing costs?<\/p>\n<\/div><\/section><\/p><\/div>Improved Patient Satisfaction<\/span><\/strong>
\nPatients experience increased satisfaction when they\u00a0are given education about how the results are used to\u00a0guide appropriate lifestyle, nutritional, pharmaceutical,\u00a0and other medical specialty interventions.
\nPatients who\u00a0participate by wearing ABPM and who are involved in their\u00a0self-care are more capable of improving their conditions.
\nAdditionally, use of ABPM reduces repetitive office visits for\u00a0BP monitoring for diagnosis, so patients will have less loss\u00a0of work and lifestyle changes that accompany physical and\u00a0psychological limitations of consequences of uncontrolled\u00a0hypertension.<\/p>\n<\/div><\/section><\/div>
\n![](\"https:\/\/medical.andonline.com\/wp-content\/uploads\/2021\/08\/ActTrac_Hero_0-1030x687.png\" "ActTrac_Hero_0")
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\nIncreased Survival Rates and Decreased Costs<\/strong><\/span>
\nFor the patient, ABPM can help increase survival rates while\u00a0decreasing their costs because, while hypertension is a\u00a0preventable disease, it is a predictor for other, more serious\u00a0conditions, such as heart attack, stroke, and cardiovascular\u00a0events, among others. By controlling hypertension, the\u00a0patient does not experience those health or financial risks of\u00a0future complications they might have experienced.
\nFor example, a heart attack victim can have between\u00a0$760,000 and $1 million in healthcare-related costs18<\/sup>.\u00a0It is estimated that ABPM screening in Japan alone will\u00a0save patients nearly $90 billion dollars over 10-year\u00a0period.\u00a0Potentially even more importantly, the same study\u00a0estimates that during this same time period, ABPM will also\u00a0save over 10,000 lives and reduce strokes by 60,00019<\/sup>.
\nAnother study found that the use of ABMP to be cost\u00a0effective for patients, even if total annual hypertension\u00a0treatment costs were as little as $30020<\/sup>\u00a0due to reduced\u00a0heart attacks and strokes and other financial savings,\u00a0such as the cost of unnecessary treatments due to WCH,\u00a0repetitive office visits, subsequent costs due to uncontrolled\u00a0hypertension and resulting conditions, and more.
\nOn the clinician\u2019s side, many providers are seeing the\u00a0benefits of regularly using ABPM in their practices because\u00a0it is so useful in uncovering hidden hypertensive patterns\u00a0via\u00a0reimbursable procedures<\/a>\u00a0that no other non-invasive\u00a0modality can detect. Additionally, ABPM data gives way for\u00a0clinicians to diagnose and make management decisions\u00a0that they could not without this screening tool. For this\u00a0reason, ABPM pays for itself by reducing the clinician\u2019s\u00a0time spent diagnosing and managing each potentially hypertensive\u00a0case or advanced disease states.
\nAdditionally,\u00a0some devices\u00a0<\/a>even offer the ability to double\u00a0as an office BP monitor when not in use in an ambulatory\u00a0capacity, further improving the ROI of the device.<\/p>\n<\/div><\/section><\/div><\/div><\/div><\/div><\/div><\/div>
Why is it So Hard to Diagnose\u00a0Hypertension?<\/strong><\/span> Blood Pressure Diagnosis Patterns<\/strong><\/span> BP Pattern: White Coat Hypertension<\/strong><\/span> Masked Hypertension<\/span><\/strong> Regardless of the specific sub-type of nocturnal BP\u00a0patterns a patient is diagnosed with, the increased BP\u00a0variability during sleep is a unique and critical factor for\u00a0increased cardiovascular events6<\/sup>. The Solution: Ambulatory Blood\u00a0Pressure Monitoring<\/strong><\/span> Correctly diagnosing the hypertension pattern via ABPM\u00a0will aid in guiding interventions and treatment toward\u00a0normalizing BP because it provides clinicians with more data\u00a0for better choice and timing of medications, and it will reduce\u00a0variability in measurements. In sum, the improved insights\u00a0gained from utilizing ABPM in a variety of BP pattern cases\u00a0can not only help provide the most conclusive interpretation\u00a0of the underlying BP pattern, but it can minimize preventable\u00a0morbidity and mortality due to the tailored treatment plans\u00a0possible with improved data from ABPM.<\/p>\n<\/div><\/section><\/div><\/div><\/div><\/div><\/div><\/div> Who Should Be Screened with\u00a0Ambulatory BP Monitoring?<\/strong><\/span> Table 1<\/em> <\/center> How is ABPM Used, and What Data\u00a0Will it Provide?<\/span><\/strong> How Can ABPM Improve Patient\u00a0Satisfaction, Increase Survival Rates,\u00a0and Decrease Cost?<\/strong><\/span> Improved Patient Satisfaction<\/span><\/strong> Increased Survival Rates and Decreased Costs<\/strong><\/span>
\nIn some cases, hypertension may be easy enough for\u00a0medical professionals to diagnose, but in others, it can pose quite a challenge because of its dynamic nature in\u00a0relation to constantly changing and underlying influences, both internal and external.
\nIn order to control for variables not normally present during\u00a0the patient\u2019s office visits, studies validate enlisting patients to perform home blood pressure monitoring (HBPM) in their\u00a0environment for more definitive diagnosis than in-clinic monitoring6<\/sup>.
\nUnfortunately, however, there are several BP patterns that\u00a0are not reflected in office or HBPM because they reflect a snapshot measurement and may not uncover some of the\u00a0diagnosis patterns below.<\/p>\n<\/div><\/section><\/p><\/div>BP Patterns<\/span><\/h3>\n<\/div><\/section>
\n
\nAs discussed, diagnosing hypertension can be\u00a0complicated by myriad BP patterns that may not be\u00a0immediately apparent when the patient presents in the\u00a0office for a consultation or checkup. In order to ensure\u00a0proper and timely diagnosis, the full scope of BP patterns\u00a0must be understood, especially given that many of these\u00a0patterns are\u00a0associated with increased complications.
\nCritical to the understanding of BP patterns is BP load:\u00a0the percent of abnormally elevated BP measurements, specific to day and night guidelines. BP load is associated\u00a0with future cardiovascular morbidity and mortality7<\/sup>\u00a0and can be experienced via several types of BP patterns.<\/p>\n<\/div><\/section><\/p><\/div><\/div><\/div><\/div><\/div><\/div>
\nWhite Coat Hypertension (WCH) is when a patient\u2019s BP\u00a0is normal outside of the clinic but elevated in the clinic.\u00a0The name \u201cWhite Coat Hypertension\u201d was assigned due\u00a0to the suggestion that being in the presence of a medical\u00a0provider can be stressful, thus raising BP. If a provider\u00a0assumes that the patient\u2019s BP is always at hypertensive\u00a0levels when, in fact, they are truly experiencing WCH,\u00a0it could lead to over-medicating, resulting in potential\u00a0patient complications second to misdiagnoses.
\nBest practices suggest that WCH should be ruled out and\u00a0monitored with suspicion, as there is growing evidence that a portion of patients with WHC have elevations in\u00a0other stressed-induced situations as well6,8<\/sup>.<\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div>
\n
\nMasked Hypertension is when a patient presents with\u00a0a normal BP in the clinic, but their BP is elevated\u00a0outside the clinic. Detection of many masked or hidden\u00a0hypertension patterns is impossible in the clinic, and, for\u00a0the most part, by HBPM6<\/sup>. A study of 64,000 adults found\u00a0that masked hypertension was associated with greater\u00a0risk of all causes of mortality than sustained hypertension\u00a0or WCH9<\/sup>.
\nStress-Induced Hypertension<\/span><\/strong>
\nStress-Induced Hypertension is identified when there is\u00a0variability of BP during the patient\u2019s daily life that is not\u00a0likely to be captured in-clinic or HBPM6<\/sup>. An example may\u00a0be a patient with a stressful job where their BP would\u00a0consistently be considered hypertensive, even though\u00a0their levels may return to normal outside of the stress-inducing\u00a0situation10<\/sup>.
\nMorning Hypertension<\/span><\/strong>
\nMorning Hypertension, also known as Morning BP Surge\u00a0(MBPS), is when average BP is \u2265 130\/80 in the first 2 hours after awakening. MBPS is the dynamic phenomenon of BP\u00a0changes in early morning hours. Morning hypertension is the single most powerful predictor of stroke, cardiovascular\u00a0events, renal disease, and total mortality6<\/sup>.
\nNocturnal Hypertension<\/span><\/strong>
\nNocturnal Hypertension is defined as an average BP\u00a0\u2265110\/65 mmHg during sleep hours, usually between 1 and\u00a06 AM and when BP does not dip 10-20% during sleep, as is\u00a0normal. Data supports Nocturnal Hypertension as a better\u00a0predictor of worsened outcomes than daytime BP, and it\u00a0is known to correlate with advanced brain, heart, kidney\u00a0disease and poorer prognosis with increased cardiovascular\u00a0events, hospitalizations and deaths6<\/sup>.
\nWithin the Nocturnal Hypertension category are several\u00a0sub-types:<\/p>\n\n
\n
\n Non-Dippers<\/strong><\/td>\n BP decline of \u226410%<\/td>\n<\/tr>\n \n Reverse Dippers (Risers)<\/strong><\/td>\n BP dips \u22640% compared to waking hours<\/td>\n<\/tr>\n \n Extreme Dippers\u00a0<\/strong><\/td>\n BP dips abnormally, > 20%6<\/sup><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
\nOrthostatic Changes<\/span><\/strong>
\nOrthostatic Hypertension occurs when a BP is elevated\u00a0while a patient is standing. In contrast, Orthostatic\u00a0Hypotension occurs when a BP drops by 20 mmHg\u00a0when a patient is standing. Orthostatic Hypotension\u00a0often precipitates syncope or falls in the frail or elderly\u00a0population, which can lead to a host of adverse and\u00a0potentially life-threatening events6<\/sup>.
\nBP Variability<\/span><\/strong>
\nBP Variability (BPV) is diagnosed when there are transient\u00a0fluctuations in BP that is independent of the mean BP.\u00a0It is often associated with arterial stiffness and poor\u00a0cardiovascular outcomes. The instability of BPV is seen\u00a0in many of the above hypertension patterns, including\u00a0orthostasis-related position changes6<\/sup>.
\nResistant Hypertension<\/span><\/strong>
\nResistant Hypertension is an elevated BP in patients who\u00a0are not controlled after use of a variety of antihypertensive agents. Resistant Hypertension often calls for further\u00a0evaluation of treatment efficacy11,6<\/sup>.
\nThe full scope of BP\u00a0patterns that can affect a diagnosis\u00a0of hypertension is nuanced before even considering\u00a0additional internal and external influences. Consequently,\u00a0traditional in-office and HBPM techniques may not be\u00a0sufficient to diagnose hypertension.<\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div><\/div>The Solution<\/span><\/h3>\n<\/div><\/section>
\n
\nDue to the complexities of diagnosing hypertension,\u00a0scores of studies have provided convincing evidence\u00a0that\u00a0ambulatory blood pressure monitoring (ABPM) is the\u00a0recommended technique for diagnosing hypertension\u00a0because it accounts for many of the internal and external\u00a0influences that can obfuscate in-office diagnosis, even\u00a0when\u00a0supplemented by HBPM.
\nAdditionally, ABPM has been proven to not only better\u00a0diagnose hypertension, but it may help providers\u00a0understand the state of BP and better predict\u00a0cardiovascular, cerebral, and end organ damage better\u00a0than any other non-invasive BP measuring tool12<\/sup>.\u00a0ABPM also has the unique ability to help providers better\u00a0diagnose their patients via thorough data analysis of BP\u00a0load and patterns so appropriate therapeutic treatment\u00a0plans can be implemented.<\/p>\n<\/div><\/section><\/p><\/div><\/div><\/div><\/div><\/div>\n
\n
Screening with ABPM<\/span><\/h3>\n<\/div><\/section><\/div>
\nABPM should be used adjunctly with HBPM for\u00a0threshold staging for accurate diagnosis and therapeutic\u00a0management.
\nSpecifically, ABPM should be routinely used for high risk\u00a0patients as a reference standard to confirm the diagnosis of\u00a0hypertension12<\/sup>. High risk patients are those with HBPM \u2265\u00a0120\/80, a history of cardiovascular event, suspected WCH, suspected nocturnal hypertension (based on comorbidities\u00a0of sleep apnea, diabetes, chronic kidney disease), and\u00a0documented organ damage.
\nBeyond typical high-risk patients, ABPM screening is\u00a0also recommended for those with a predicted prevalence\u00a0for developing hypertension of \u2265 16%, based on the\u00a0Hypertension Prevalence Estimator Tool, which is used\u00a0to predict the percent of the patient population that will\u00a0develop hypertension16<\/sup>.
\nAdditionally, age, gender, race, and many comorbidities\u00a0impact the development of hypertension and should also be considered when considering ABPM screening. With even\u00a0one comorbidity, such as obesity or diabetes, the risk for hypertension increases exponentially, as seen in Table 1.<\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div>
\n
\n\n\n
\n <\/th>\n <\/th>\n <\/th>\n White<\/th>\n <\/th>\n <\/th>\n Black<\/th>\n <\/th>\n <\/th>\n Hispanic<\/th>\n <\/th>\n<\/tr>\n \n AGE<\/td>\n CoMorbidity<\/td>\n Male<\/td>\n Total
\n6%<\/td>\nFemale<\/td>\n Male<\/td>\n Total
\n9.7%<\/td>\nFemale<\/td>\n Male<\/td>\n Total
\n3.5%<\/td>\nFemale<\/td>\n<\/tr>\n \n 18-44<\/td>\n 0<\/td>\n 8.40%<\/td>\n <\/td>\n 3.50%<\/td>\n 9.90%<\/td>\n <\/td>\n 9.30%<\/td>\n 5.20%<\/td>\n <\/td>\n 1.70%<\/td>\n<\/tr>\n \n 1<\/td>\n 21.10%<\/td>\n 16.30%<\/td>\n 11.60%<\/td>\n 27.80%<\/td>\n 22.60%<\/td>\n 17.40%<\/td>\n 13.90%<\/td>\n 10.90%<\/td>\n 7.90%<\/td>\n<\/tr>\n \n 2<\/td>\n 38.20%<\/td>\n 37.70%<\/td>\n 37.30%<\/td>\n 64.80%<\/td>\n 58.50%<\/td>\n 52.20%<\/td>\n 54.60%<\/td>\n 39.60%<\/td>\n 24.70%<\/td>\n<\/tr>\n \n <\/td>\n<\/tr>\n \n 45-64<\/td>\n 0<\/td>\n 32.30%<\/td>\n 29.50%<\/td>\n 26.80%<\/td>\n 46.10%<\/td>\n 46%<\/td>\n 45.90%<\/td>\n 26.30%<\/td>\n 25.10%<\/td>\n 23.90%<\/td>\n<\/tr>\n \n 1<\/td>\n 46.90%<\/td>\n 48%<\/td>\n 49.20%<\/td>\n 60%<\/td>\n 63.20%<\/td>\n 66.40%<\/td>\n 44%<\/td>\n 41.10%<\/td>\n 38.30%<\/td>\n<\/tr>\n \n 2<\/td>\n 70.90%<\/td>\n 69.10%<\/td>\n 67.30%<\/td>\n 87%<\/td>\n 86.50%<\/td>\n 86.10%<\/td>\n 64.50%<\/td>\n 66%<\/td>\n 67.60%<\/td>\n<\/tr>\n \n <\/td>\n<\/tr>\n \n 65-74<\/td>\n 0<\/td>\n 51.90%<\/td>\n 53.60%<\/td>\n 55.30%<\/td>\n 71.50%<\/td>\n 70.60%<\/td>\n 69.70%<\/td>\n 41.10%<\/td>\n 53.20%<\/td>\n 65.30%<\/td>\n<\/tr>\n \n 1<\/td>\n 64.20%<\/td>\n 66.50%<\/td>\n 68.80%<\/td>\n 80.90%<\/td>\n 84.50%<\/td>\n 88%<\/td>\n 63.80%<\/td>\n 69.80%<\/td>\n 75.80%<\/td>\n<\/tr>\n \n 2<\/td>\n 77%<\/td>\n 83.50%<\/td>\n 90%<\/td>\n 86.10%<\/td>\n 89.10%<\/td>\n 92.10%<\/td>\n 74.50%<\/td>\n 79.50%<\/td>\n 84.50%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
\n<\/div><\/div><\/div><\/div><\/div>ABPM Usage<\/span><\/h3>\n<\/div><\/section>\n
\nABPMs can easily be configured by a nurse or medical\u00a0assistant to monitor the patient\u2019s BP at specific preset\u00a0time periods, such as every 20-30 minutes in the awake\u00a0hours, and every 60 minutes during the patient\u2019s reported\u00a0anticipated sleep period.
\nThe device should be worn for a minimum of 24 hours so it\u00a0can capture dynamic readings while the patient is engaged in usual activity, in their home and work environments, and\u00a0during their sleep periods.
\nAfter the 24 hours, the information is downloaded to a\u00a0computer for review.
\nThe numerous readings provide a plethora of information\u00a0for clinical decision making as to the person\u2019s actual BP load and BP patterns as well as time and date stamped\u00a0BP and pulse measurements. Additionally, some ABPM\u00a0devices provide other critical details, such as activity levels,\u00a0ambient temperature, and barometric pressure, which may\u00a0aid in diagnosis.
\nBeyond the basic raw data, the software will provide the\u00a0clinician helpful tools, such as graphs and diagrams, to\u00a0highlight the BP loads, sleep percentages, a variety of\u00a0means (including 24-hour, daytime, and nighttime means), high\/low BP measurements, Circadian\/Nocturnal rhythms,\u00a0and irregular pulses.
\nAltogether, this data paints a picture of not only\u00a0hypertension but of the patient\u2019s unique patterns to elicit\u00a0proper\u00a0decision making for clinical management.
\nThe initial target of managing BP should be aimed at\u00a0evaluating morning BP. After morning control, the next goal\u00a0would be to measure dynamic BP during the sleep cycles\u00a0with ABPM and with a goal to keep nocturnal BP\u00a0controlled\u00a0at <110\/656.\nWhat Type of Providers Should Use\u00a0ABPM?<\/strong><\/span>
\nGiven the urgency aimed at lowering BP thresholds,\u00a0including a focus on early intervention to reverse heart\u00a0and brain disease progression, morbidity and mortality,\u00a0ABPM should be used by primary care providers, health\u00a0departments, obesity and diabetic clinics, wellness centers, managed health groups, nurse or pharmacy hypertensive\u00a0clinics, along with cardiology and renal specialty clinics.
\nWith its wide range of diagnostic capabilities, efficiency,\u00a0and ease of use, ABPM should be used early and\u00a0frequently when hypertension is suspected, given the large\u00a0number of patients who are going undiagnosed or suffering\u00a0consequences of uncontrolled hypertension.
\nABPM has been recognized by many as a gold standard\u00a0in diagnosing hypertension5,6<\/sup>, and as of 2015, the United States Preventative Services Task Force (USPSTF)\u00a0found it to be the best method to diagnose and confirm\u00a0hypertension12<\/sup>. The CMS also set the standard that ABPM\u00a0is a valid, useful and cost-effective tool for diagnosing\u00a0hypertension WCH when it added reimbursements for the\u00a0procedure in 200213<\/sup>.
\nBeyond medical providers, ABPM is becoming the standard\u00a0of care among groups like AETNA17<\/sup>, HealthNet, Kaiser and\u00a0Columbia University when diagnosing and evaluating BP\u00a0patterns such as WCH, Masked Hypertension, and more.<\/p>\n<\/div><\/section>\n<\/div><\/div><\/div><\/div><\/div>Benefits of ABPM<\/span><\/h3>\n<\/div><\/section>
\n
\nABPM has been shown to improve the accuracy of a\u00a0hypertension diagnosis and the clinician\u2019s understanding\u00a0of BP patterns that a patient may experience, but how\u00a0does it improve outcomes and increase survival, all while\u00a0decreasing costs?<\/p>\n<\/div><\/section><\/p><\/div>
\nPatients experience increased satisfaction when they\u00a0are given education about how the results are used to\u00a0guide appropriate lifestyle, nutritional, pharmaceutical,\u00a0and other medical specialty interventions.
\nPatients who\u00a0participate by wearing ABPM and who are involved in their\u00a0self-care are more capable of improving their conditions.
\nAdditionally, use of ABPM reduces repetitive office visits for\u00a0BP monitoring for diagnosis, so patients will have less loss\u00a0of work and lifestyle changes that accompany physical and\u00a0psychological limitations of consequences of uncontrolled\u00a0hypertension.<\/p>\n<\/div><\/section><\/div>
\n<\/div><\/div><\/div><\/div>
\n
\nFor the patient, ABPM can help increase survival rates while\u00a0decreasing their costs because, while hypertension is a\u00a0preventable disease, it is a predictor for other, more serious\u00a0conditions, such as heart attack, stroke, and cardiovascular\u00a0events, among others. By controlling hypertension, the\u00a0patient does not experience those health or financial risks of\u00a0future complications they might have experienced.
\nFor example, a heart attack victim can have between\u00a0$760,000 and $1 million in healthcare-related costs18<\/sup>.\u00a0It is estimated that ABPM screening in Japan alone will\u00a0save patients nearly $90 billion dollars over 10-year\u00a0period.\u00a0Potentially even more importantly, the same study\u00a0estimates that during this same time period, ABPM will also\u00a0save over 10,000 lives and reduce strokes by 60,00019<\/sup>.
\nAnother study found that the use of ABMP to be cost\u00a0effective for patients, even if total annual hypertension\u00a0treatment costs were as little as $30020<\/sup>\u00a0due to reduced\u00a0heart attacks and strokes and other financial savings,\u00a0such as the cost of unnecessary treatments due to WCH,\u00a0repetitive office visits, subsequent costs due to uncontrolled\u00a0hypertension and resulting conditions, and more.
\nOn the clinician\u2019s side, many providers are seeing the\u00a0benefits of regularly using ABPM in their practices because\u00a0it is so useful in uncovering hidden hypertensive patterns\u00a0via\u00a0reimbursable procedures<\/a>\u00a0that no other non-invasive\u00a0modality can detect. Additionally, ABPM data gives way for\u00a0clinicians to diagnose and make management decisions\u00a0that they could not without this screening tool. For this\u00a0reason, ABPM pays for itself by reducing the clinician\u2019s\u00a0time spent diagnosing and managing each potentially hypertensive\u00a0case or advanced disease states.
\nAdditionally,\u00a0some devices\u00a0<\/a>even offer the ability to double\u00a0as an office BP monitor when not in use in an ambulatory\u00a0capacity, further improving the ROI of the device.<\/p>\n<\/div><\/section><\/div><\/div><\/div><\/div><\/div><\/div>