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• W3083962144 abstract "HomeHypertensionVol. 76, No. 4Masked Hypertension Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessEditorialPDF/EPUBMasked HypertensionFragile in More Ways Than One Jordana B. Cohen Jordana B. CohenJordana B. Cohen Correspondence to Jordana B. Cohen, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 423 Guardian Dr, 831 Blockley, Philadelphia, PA 19104. Email E-mail Address: [email protected] https://orcid.org/0000-0003-4649-079X From the Renal-Electrolyte and Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Search for more papers by this author Originally published9 Sep 2020https://doi.org/10.1161/HYPERTENSIONAHA.120.15859Hypertension. 2020;76:1079–1080This article is a commentary on the followingShort-Term Reproducibility of Masked Hypertension Among Adults Without Office HypertensionSee related article, pp 1169–1175In-office blood pressure (BP) has been the cornerstone of hypertension screening for several decades. As guidelines recommend increasingly stringent BP thresholds for the diagnosis of hypertension,1 we require increasingly accurate approaches to measure BP to avoid misdiagnosis and over or undertreatment of hypertension. However, many individuals have discordant BP readings in the office compared to outside of the office setting, including masked hypertension (normal office BP with elevated out-of-office BP) and white coat hypertension (elevated office BP with normal out-of-office BP). Since individuals spend the majority of their time outside of the doctor’s office, it is not surprising that BPs obtained outside of the office are more strongly linked with long-term cardiovascular risk than those obtained in the office.2 Growing evidence supporting the prognostic value of out-of-office BP monitoring has culminated in several national and international guidelines calling for the widespread use of out-of-office BP monitoring for the diagnosis of hypertension.1,2Twenty-four–hour ambulatory BP monitoring (ABPM) is often described as the reference standard of BP measurement due to its distinctively strong association with long-term cardiovascular outcomes. However, there are several provider-level barriers very likely preventing wider adoption of 24-hour ABPM.3 Notably, 24-hour ABPM devices are expensive and require purchasing proprietary software and investing time in patient education, application, and interpretation. For many years, the United States Center for Medicare Services only consistently reimbursed for 24-hour ABPM performed for suspected white coat hypertension in individuals without a previous diagnosis of hypertension.4 In 2019, the Center for Medicare Services announced that it would expand coverage of 24-hour ABPM to include suspected masked hypertension.5 This expansion of coverage was a welcome improvement but was limited to a single 24-hour ABPM session per year. In contrast, internationally (including in most European and many Asian countries), 24-hour ABPM has been widely recommended and reimbursed for many years, without being limited to a single 24-hour ABPM session per year. With mounting evidence suggesting that 24-hour ABPM profiles may only be moderately (68%–88%) reproducible in the short-term,6–8 a single ABPM session may be inadequate.In the current study,6 Cohen et al performed a rigorous evaluation of the short-term reproducibility of masked hypertension using successive 24-hour ABPMs, collected ≈1 month apart, in a community-based sample of 254 adults who were not on antihypertensive medications and had normal office BPs. For their primary analyses, the authors used the American Heart Association/American College of Cardiology 2017 Hypertension Clinical Practice Guideline’s definition of masked hypertension (mean office BP <130/80 mm Hg and mean awake ABPM BP ≥130/80 mm Hg).1 Eligible participants were relatively young (mean age 38 years), 25% Black, 59% Hispanic, with low rates of comorbidities (<1% diabetic and 5% chronic kidney disease), and the majority endorsed moderate alcohol use (73%). Office BPs were on average lower than expected in patients with masked hypertension (mean 109/71 mm Hg).1,9The authors evaluated the reproducibility of masked hypertension across successive ABPM sessions by calculating the proportion of participants who consistently were classified as having (or not having) masked hypertension across the 2 ABPM sessions, described as agreement. The authors also calculated the κ statistic, a formal metric of agreement across repeated measurements; a κ statistic of one constitutes perfect agreement, a κ statistic of 0 constitutes agreement that would happen by chance alone, and a κ statistic of 0.5 represents moderate agreement. The authors observed that 24% to 26% of participants had masked hypertension, with 81% agreement in the diagnosis of masked hypertension between the first and second ABPM sessions (κ statistic 0.50 [95% CI, 0.38–0.62]). The results were similar using 24-hour and asleep ABPM, and oscillometric, as opposed to manual, office BP measurements to define masked hypertension. In sensitivity analyses applying mean office BP <140/90 mm Hg and mean awake ABPM BP ≥135/85 mm Hg for the definition of masked hypertension, there was slightly improved reproducibility (88% agreement between sessions, κ statistic 0.62 [95% CI, 0.51–0.72]).A small number of limited studies have previously evaluated the reproducibility of masked hypertension, using older diagnostic thresholds, and generally showing similar or worse short-term reproducibility of masked hypertension compared with the current study.7,8 Cohen et al improved upon prior studies by restricting the cohort to those individuals who were eligible to have masked hypertension (ie, those with normal office BPs), consistent with guideline recommendations for screening for masked hypertension. The authors observed that the newer thresholds were associated with slightly poorer reproducibility of masked hypertension on ABPM than older, less stringent thresholds. These findings support the need for greater precision in BP measurement as diagnostic thresholds for hypertension decrease.There remain important gaps in our understanding of the short-term reproducibility of masked hypertension. Twenty-four–hour ABPM is particularly useful for BP measurement, in part, because it captures BPs during day-to-day activities and during sleep. ABPM, in essence, serves as a sensitive source of data collection of our BP responses to routine daily exposures. For these same reasons, ABPM may be uniquely susceptible to inconsistencies across measurements. Factors that could feasibly contribute to short-term discordance in BP readings include differences in activity level, drug exposures (eg, caffeine, alcohol, tobacco, nonsteroidal anti-inflammatory drugs), sleep duration or quality, stress levels, and mood between ABPM sessions. However, there is a dearth of data on the reasons and risk factors for short-term irreproducibility of masked hypertension by 24-hour ABPM. Acknowledging the multitude of potential contributors to differences in ABPM readings across sessions, we have little guidance on which patients may require repeated out-of-office BP measurements to appropriately diagnose masked hypertension.The current study contributes important information to our knowledge of the limitations of ABPM. While the authors’ findings likely do not impact the prognostic implications of identifying masked hypertension by ABPM, they highlight the need to improve upon our current screening practices, in order to avoid misdiagnosis and over or undertreatment of hypertension. With the recent necessary expansions of telehealth amidst the novel coronavirus pandemic, out-of-office BP monitoring is undoubtedly being used with accelerated frequency. We should be strongly considering self-BP measurement at home (using appropriate technique, with a validated device) to aid in the diagnosis of hypertension, due to greater tolerability of repeated, longitudinal measurement and similar prognostic value to 24-hour ABPM.10 ABPM has a distinctive role in identifying high-risk BP phenotypes (particularly nocturnal hypertension), but self-BP measurement can be a valuable supplement to those readings obtained by 24-hour ABPM. Furthermore, while also susceptible to irreproducibility,7 self-BP measurement can be more readily repeated in the short-term.In conclusion, as healthcare providers, we need to more broadly adopt the notion that the diagnosis of hypertension should be thought of as an iterative process. No single method of BP measurement is without flaws, including our reference standard, ABPM. Several factors have been associated with greater likelihood of masked hypertension and may be helpful to guide screening practices, including male sex, higher body mass index, current smoking, and higher office systolic BP (eg, close to, but not above, the office threshold for hypertension).9 However, we have no clear way to identify which patients require repeated out-of-office readings to determine the presence of masked hypertension. Furthermore, the Center for Medicare Services currently only covers a single 24-hour ABPM session annually, and patients may not be willing to undergo repeated ABPM in the short-term, regardless of insurance coverage, due to poor tolerance and loss of productivity. To accurately diagnose, and thus appropriately treat, hypertension, we must rely upon multiple data points. We should be building a culture of BP measurement that integrates BPs obtained from several, complimentary sources, including office visits, ABPM, and self-BP measurement at home.Sources of FundingJ.B. Cohen is supported by the National Institutes of Health-National Heart, Lung, and Blood Institute K23-HL133843DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to Jordana B. Cohen, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 423 Guardian Dr, 831 Blockley, Philadelphia, PA 19104. Email [email protected]upenn.eduReferences1. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, 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:e13–e115. doi: 10.1161/HYP.0000000000000065LinkGoogle Scholar2. Piper MA, Evans CV, Burda BU, Margolis KL, O’Connor E, Smith N, Webber E, Perdue LA, Bigler KD, Whitlock EP. Screening for high blood pressure in adults: a systematic review for the U.S. Preventive Services Task Force.US Preventive Services Task Force Evidence Syntheses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2014:1–48.Google Scholar3. Kronish IM, Kent S, Moise N, Shimbo D, Safford MM, Kynerd RE, O’Beirne R, Sullivan A, Muntner P. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States.J Am Soc Hypertens. 2017; 11:573–580. doi: 10.1016/j.jash.2017.06.012CrossrefMedlineGoogle Scholar4. Kent ST, Shimbo D, Huang L, Diaz KM, Viera AJ, Kilgore M, Oparil S, Muntner P. Rates, amounts, and determinants of ambulatory blood pressure monitoring claim reimbursements among Medicare beneficiaries.J Am Soc Hypertens. 2014; 8:898–908. doi: 10.1016/j.jash.2014.09.020CrossrefMedlineGoogle Scholar5. Centers for Medicare and Medicaid Services. Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM) (CAG-00067R2).https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=294. Accessed July 13, 2020.Google Scholar6. Cohen LP, Schwartz JE, Pugliese DN, Anstey DE, Christian JP, Jou S, Muntner P, Shimbo D, Bello NA. Short-term reproducibility of masked hypertension among adults without office hypertension.Hypertension. 2020; 76:1169–1175. doi: 10.1161/HYPERTENSIONAHA.120.15287LinkGoogle Scholar7. Viera AJ, Hinderliter AL, Kshirsagar AV, Fine J, Dominik R. Reproducibility of masked hypertension in adults with untreated borderline office blood pressure: comparison of ambulatory and home monitoring.Am J Hypertens. 2010; 23:1190–1197. doi: 10.1038/ajh.2010.158CrossrefMedlineGoogle Scholar8. de la Sierra A, Vinyoles E, Banegas JR, Parati G, de la Cruz JJ, Gorostidi M, Segura J, Ruilope LM. Short-term and long-term reproducibility of hypertension phenotypes obtained by office and ambulatory blood pressure measurements.J Clin Hypertens (Greenwich). 2016; 18:927–933. doi: 10.1111/jch.12792CrossrefMedlineGoogle Scholar9. Sheppard JP, Fletcher B, Gill P, Martin U, Roberts N, McManus RJ. Predictors of the home-clinic blood pressure difference: a systematic review and meta-analysis.Am J Hypertens. 2016; 29:614–625. doi: 10.1093/ajh/hpv157CrossrefMedlineGoogle Scholar10. Shimbo D, Artinian NT, Basile JN, Krakoff LR, Margolis KL, Rakotz MK, Wozniak G; American Heart Association and the American Medical Association. Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association.Circulation. 2020; 142:e42–e63. doi: 10.1161/CIR.0000000000000803LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesShort-Term Reproducibility of Masked Hypertension Among Adults Without Office HypertensionLaura P. Cohen, et al. Hypertension. 2020;76:1169-1175 October 2020Vol 76, Issue 4Article InformationMetrics Download: 58 © 2020 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.120.15859PMID: 32903109 Originally publishedSeptember 9, 2020 PDF download SubjectsHypertensionHigh Blood Pressure" @default.
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