Hypertension and its sequelae are r...

Hypertension and its sequelae are responsible for many visits to family physicians. Office-based measurement of descendants pressure using aneroid or poison ivy sphygmomanometry is central to like visits. In this issue of American Family Physician, Marchiando and Elston (1) review a different, nevertheless certainly not new, approach to measurement of progeny pressure. Once regarded solely as a research instrument, noninvasive 24-hour ambulatory house pressure monitoring (ABPM) has emerg as a useful tool for clinicians faced with the challenges of establishing accurate diagnoses and adjusting antihypertensive therapy. Among its many indications, ABPM can provide useful information in the evaluation of borderline hypertension, antihypertensive efficacy, suspected white coat hypertension, and treatment resistance. (2)

In addition to multiple automated readings taken during normal daily activities, ambulatory monitoring enables posterity pressure to be measured during rest and permits evaluation of circadian patterns in children pressure. Some evidence indicates that these readings correlate more closely with surrogate measures of fall of the curtain organ damage than do office posterity pressure (OBP) values. (3) Furthermore, late outcome studies have strengthened the belief that ABPM is superior to office posterity pressure readings for cardiovascular risk stratification and can be prosperously used to direct therapy. (45) However, a fresh Agency for Healthcare Quality and Research (AHRQ) Evidence Report points gone out that the literature in this field is insufficient, and more research is necessary to determine the greatest in quantity efficacious, practical, and cost-effective approach to measuring posterity pressure. (6)

Despite advantages from one side of to the other traditional office measurements, diffusion of ABPM into routine practice is complicated according to unique barriers. Access to the technology is frequently limited to academic medical center and ambulatory house pressure measurements are generally lower than office measurements, equal in normotensive patients, making direct correlations between ABPM and OBP difficult. This lack of normative data has been addressed between the sides of analysis of population-based registries, and Marchiando and Elston (1) use a table in their article to summarize instant ABPM thresholds for treatment.

in the greatest degree hypertension intervention studies have used OBP exclusively for decisions regarding antihypertensive therapy, and OBP values provide the basis of our instant operational thresholds for defining hypertension. Clinical guidelines emphasize OBP should remain the standard of measurement in succession which most medication interventions should be based, although they acknowledge that ABPM may be beneficial in certain situations at providing important information not available from OBP (37) While the cost-effectiveness of ABPM has been questioned, (6) a evidence exists that ABPM technology is cost-neutral or saves wealth (8-11) At present, third-party reimbursement for the exhibition remains highly variable, although Medicare now reimburses for patients with suspected white coat hypertension.

If made readily available, use of ambulatory monitoring will likely increase. This has been our experience after establishing an ABPM referral service for primary care physicians at the University of Iowa. Nearly sum of two units years after establishing this service, we find our physicians make routine and appropriate use of the technology for rareed patients and integrate the rises of ABPM into their clinical decision-making.

Which patients should receive ABPM? A carte blanche recommendation that ABPM should be performed forward all patients with hypertension is certainly not a judicious use of resources and should be discouraged. Faced with the possibility of overusing this convenient technology, it is important to identify patients for whom ABPM is appropriate. As Marchiando and Elston (1) point gone out ABPM should supplement but not substitute office measurements. A series of multiple office or hearthstone blood pressure measurements has been shown to be as reliable as ABPM (1213); unfortunately, many patients fail to consistently obtain and provide these readings. Twenty-four hour ABPM is a logical progression. Based in succession our clinical experience and a review of the literature, we present an algorithm (see accompanying figure) for appropriate use of ABPM that incorporates abiding-place and office measurements. (14)

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Hypertension will continue to be a significant enigma faced by family physicians. Sensible and rational use of ABPM technology provides us with a useful tool to improve results for carefully selected patients.

References

(1) Marchiando RJ Elston MP Automated ambulatory kindred pressure monitoring: clinical utility in the family practice setting. Am Fam Physician 2003; 67:2343-502353-4

(2) O'Brien E Coats A, Owens P et al. Use and interpretation of ambulatory offspring pressure monitoring: recommendations of the British Hypertension Society. BMJ 2000;320:1128-34

(3) Verdecchia P Prognostic value of ambulatory house pressure: current evidence and clinical implications. Hypertension 2000;35:844-51