NEW YORK, May 22 -- Patients with hypertension should routinely monitor their blood pressure at home, and the cost of doing so should be reimbursed, according to a joint statement by the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association.
The "call to action" statement, the first to offer detailed guidelines on home monitoring, appeared online in Hypertension, the Journal of the American Society of Hypertension, and the Preventive Cardiovascular Nurses' Association, and in the June issue of the Journal of Cardiovascular Nursing.
Action Points
- Explain to patients who ask that those with hypertension or with borderline high blood pressure are advised to track their pressure with a home monitor, according to a joint scientific statement from the American Heart Association and associated groups.
High blood pressure is notoriously difficult to treat. Many patients fail to reach their target goal despite treatment, whereas studies show that home monitoring can help, said Thomas G. Pickering, M.D., of Columbia University here, chair of the statement writing group.
Hypertension affects more than 65 million persons in the U.S., according to data from the National Health and Nutrition Examination Survey, 1999-2000.
This estimate may be conservative because, the authors said, it uses only the typical parameters of ≥140 mmHg systolic or ≥90 mm Hg diastolic to define hypertension. It does not broaden the range to a systolic of ≥130 mm Hg or diastolic BP of ≥80 mm Hg for patients with either diabetes of chronic kidney disease, the authors said.
There is strong evidence that the traditional office or clinic measures of blood pressure in adults can be misleading, often caused by the so-called white-coat effect, they said.
It is also believed that people with normal pressure in their doctor's office may have pressures that spike to potentially dangerous levels in other situations, Dr. Pickering said.
In the past 30 years, home monitoring has become increasingly popular. Many monitors can take multiple readings during each session and can be used at different times of the day. Many devices store and average blood pressure readings over time, and may cost less than $100, the authors said.
In addition, prospective studies have shown that home monitoring expresses risk better than office readings, and is especially useful for elderly patients, and those with diabetes or kidney disease, as well as pregnant women.
Despite this, home monitoring has been only cursorily endorsed in current guidelines, and there have been no detailed recommendations for how use of the monitors should be incorporated into routine clinical practice, Dr. Pickering said.
Earlier American Heart Association guidelines have included home monitors, but this is the first statement to offer detailed recommendations for their use, the investigators said.
Defining the target for treatment as
- Patients should be advised to purchase an oscillometric monitor that measures blood pressure on the upper arm with an appropriate cuff size and should be shown how to use the monitor by their healthcare provider.
- Finger models should not be used; wrist monitors are not reliable.
- Patients should take two or three readings after five minutes of rest in the seated position, both in the morning and at night, over a period of one week.
- No tobacco or caffeine for 30 minutes before measurement; arm at heart level and feet flat on the ground.
- A total of 12 or more readings are recommended for making clinical decisions.
Patients for whom the associations recommend home monitoring include the majority of patients with known or suspected hypertension, diabetics, the elderly, pregnant women, and patients with kidney disease.
Home monitoring is also indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis.
For patients with prehypertension, home monitoring may be useful for detecting masked hypertension. Cost should not prevent patients from receiving the documented benefits of home monitoring, the authors wrote.
They recommend that patients be reimbursed for a monitor prescribed by their healthcare provider and that providers, in turn, be reimbursed for their services. Payment should be allowed from replacement monitors after five years or if they are shown to be inaccurate.
The statement authors urged that studies be conducted to evaluate actual cost savings of home monitoring.
Given the substantial mortality, morbidity, and cost associated with poorly controlled blood pressure, identification of low-cost strategies to improve control should be a high priority, the authors concluded.
| Dr. Pickering reported a research grant to his institution from Omron Healthcare and Microlife, as well as speakers' honoraria from Boehringer-Ingelheim, and Omron Healthcare. |
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Primary Source
Hypertension
Pickering TG, et al Hypertension 2008; 52: DOI: 1061.hypertensionaha.1107.189010