This study aims at estimating the resources consumed and subsequent costs for hypertension management, using home blood pressure (BP) monitoring (HBPM) alone versus combined clinic measurements and ambulatory blood pressure monitoring (C/ABPM). One hundred sixteen untreated hypertensive subjects were randomized to use HBPM or C/ABPM for antihypertensive treatment initiation and titration. Health resources utilized within 12-months follow-up, their respective costs, and hypertension control were assessed. The total cost of the first year of hypertension management was lower in HBPM than C/ABPM arm (€1336.0 vs. €1473.5 per subject, respectively; P < .001). Laboratory tests' cost was identical in both arms. There was no difference in achieved BP control and drug expenditure (HBPM: €233.1 per subject; C/ABPM: €247.6 per subject; P = not significant), whereas the cost of BP measurements and/or visits was higher in C/ABPM arm (€393.9 vs. €516.9, per patient, respectively P < .001). The cost for subsequent years (>1) was €348.9 and €440.2 per subject, respectively for HBPM and C/ABPM arm and €2731.4 versus €3234.3 per subject, respectively (P < .001) for a 5-year projection. HBPM used alone for the first year of hypertension management presents lower cost than C/ABPM, and the same trend is observed in 5-year projection. The results on the resources consumption can be used to make cost estimates for other health-care systems.

Whether blood pressure thresholds for hypertension should differ according to sex or age remains debated. We did a subject-level meta-analysis of 5018 people untreated for hypertension and randomly recruited from 5 populations (women, 56.7%; ≥60 years, 42.3%). We used multivariable-adjusted Cox regression and a bootstrap procedure to determine home blood pressure (HBP) levels yielding 10-year cardiovascular risks similar to those associated with established systolic/diastolic thresholds (140-160/80-100 mm Hg) for the conventional blood pressure (CBP). Conversely, we estimated CBP thresholds providing 10-year cardiovascular risks similar to those associated established HBP levels (125-135/80-85 mm Hg). All analyses were stratified for sex and age (<60 versus ≥60 years). During 8.3 years (median), 414 participants experienced a cardiovascular event. The sex differences between HBP thresholds derived from CBP and between CBP thresholds derived from HBP were all nonsignificant (P≥0.24), ranging from -4.6 to 3.6 mm Hg systolic and from -4.3 to 2.1 mm Hg diastolic. The age differences between HBP thresholds derived from CBP and between CBP thresholds derived from HBP ranged from -6.7 to 8.4 mm Hg systolic and from -1.9 to 1.7 mm Hg diastolic and were nonsignificant (P≥0.08), except for HBP thresholds derived from CBP levels of 140 mm Hg systolic and 80 mm Hg diastolic (P≤0.04). Sensitivity analyses based on cardiac or cerebrovascular complications were confirmatory. In conclusion, our findings based on outcome-driven criteria support contemporary guidelines that propose single blood pressure thresholds that can be indiscriminately applied in both sexes and across the age range.

In the last two decades, considerable evidence on home blood pressure monitoring has accumulated and current guidelines recommend its wide application in clinical practice. First, several outcome studies have shown that the ability of home blood pressure measurements in predicting preclinical target organ damage and cardiovascular events is superior to that of the conventional office blood pressure measurements and similar to that of 24-hour ambulatory monitoring. Second, cross-sectional studies showed considerable agreement of home blood pressure measurements with ambulatory monitoring in detecting the white-coat and masked hypertension phenomena, in both untreated and treated subjects. Third, studies have shown larger blood pressure decline by using home blood pressure monitoring instead of office measurements for treatment adjustment. Fourth, in treated hypertensives, home blood pressure monitoring has been shown to improve long-term adherence to antihypertensive drug treatment and thus, has improved hypertension control rates. These data suggest that home blood pressure should no longer be regarded as only a screening tool that requires confirmation by ambulatory monitoring. Provided that an unbiased assessment is obtained according to current recommendations, home blood pressure monitoring should have primary role in diagnosis, treatment adjustment, and long-term follow-up of most cases with hypertension.

Given the increasing use of ambulatory blood pressure monitoring (ABPM) in both clinical practice and hypertension research, a group of scientists, participating in the European Society of Hypertension Working Group on blood pressure monitoring and cardiovascular variability, in year 2013 published a comprehensive position paper dealing with all aspects of the technique, based on the available scientific evidence for ABPM. The present work represents an updated schematic summary of the most important aspects related to the use of ABPM in daily practice, and is aimed at providing recommendations for proper use of this technique in a clinical setting by both specialists and practicing physicians. The present article details the requirements and the methodological issues to be addressed for using ABPM in clinical practice, The clinical indications for ABPM suggested by the available studies, among which white-coat phenomena, masked hypertension, and nocturnal hypertension, are outlined in detail, and the place of home measurement of blood pressure in relation to ABPM is discussed. The role of ABPM in pharmacological, epidemiological, and clinical research is also briefly mentioned. Finally, the implementation of ABPM in practice is considered in relation to the situation of different countries with regard to the reimbursement and the availability of ABPM in primary care practices, hospital clinics, and pharmacies.

The absence of an outcome-driven reference frame for self-measured pulse pressure (PP) limits its clinical applicability. In an attempt to derive an operational threshold for self-measured PP, we analyzed 6470 participants (mean age 59.3 years; 56.9% women; 22.5% on antihypertensive treatment) from 5 general population cohorts included in the International Database on HOme blood pressure in relation to Cardiovascular Outcome. During 8.3 years of follow-up (median), 294 cardiovascular deaths, 393 strokes and 336 cardiac events occurred. In 3285 younger subjects (<60 years), home PP only predicted all-cause and cardiovascular mortality (P⩽0.036), whereas in 3185 older subjects (⩾60 years) PP predicted total and cardiovascular mortality (P⩽0.0067) and all cardiovascular and coronary events (P⩽0.044). However, PP did not substantially refine risk prediction based on classical risk factors including mean blood pressure (generalized R(2) statistic ⩽0.20%). In older subjects, the adjusted hazard ratios expressing the risk in the upper decile of home PP (⩾76 mm Hg) versus the average risk in whole population were 1.41 (95% confidence interval, 1.09-1.81; P=0.0081) for all-cause mortality, 1.62 (1.11-2.35; P=0.012) for cardiovascular mortality and 1.31 (1.00-1.70; P=0.047) for all fatal and nonfatal cardiovascular end points combined. The low number of events precluded an analysis by tenths of the PP distribution in younger participants. In conclusion, a home PP of ⩾76 mm Hg predicted cardiovascular outcomes in the elderly with the exception of stroke, whereas in younger subjects no threshold could be established.

White-coat hypertension is defined by elevated office and normal out-of-office blood pressure (home or ambulatory) in untreated subjects. This condition is common in clinical practice and requires appropriate work-up for detection and management. Many studies have examined the relationship between white-coat hypertension and cardiovascular risk but with marked heterogeneity in the definitions and methodology applied. Thus, the results have been inconsistent leading to confusion in scientific research and clinical practice. Some but not all the relevant studies suggested that white-coat hypertension is associated with subclinical target-organ damage, yet the cross-sectional design of these studies and the fact that these indices are only surrogate end points do not allow firm conclusions to be drawn. In recent years, longitudinal studies have examined the prognostic significance of white-coat hypertension in terms of cardiovascular morbidity and mortality. Most of them indicate that white-coat hypertensive compared with normotensive subjects present a moderate-in most cases not significant-increase in risk. Meta-analyses of raw data from large databases, such as the International Database on Ambulatory blood pressure and Cardiovascular Outcomes (IDACO) and the International Database on HOme blood pressure in relation to Cardiovascular Outcomes (IDHOCO) allowed separate powered analyses in untreated subjects and provided a clearer picture regarding the modest risk associated with white-coat hypertension, especially in the long term. White-coat hypertension is regarded as an intermediate phenotype between normotension and hypertension associated with increased risk of developing sustained hypertension, and therefore requires regular follow-up using nonpharmacological measures.

Cross-sectional studies have shown that ambulatory and home blood pressure (ABP and HBP, respectively) measurements are more closely associated with preclinical organ damage than are office measurements. This study investigated the association between treatment-induced changes in BP assessed by the three methods and the corresponding changes in organ damage. Untreated hypertensives were evaluated with office, ABP and HBP measurements and indices of organ damage (echocardiographic left-ventricular mass index (LVMI), pulse wave velocity (PWV), albuminuria) before and after 12 months of treatment. A total of 116 subjects completed the study (mean age 50.7±10.5 years, 69 men (59%), mean follow-up 13.4±1.4 months). The treatment-induced change in the LVMI was correlated with changes in BP and pulse pressure (PP) assessed by all methods. The change in PWV was correlated with changes in home systolic and ABP and PP and with the change in home diastolic BP. Albuminuria showed no correlations. In linear regression models, changes in home BP and PP had the strongest predictive ability for the change in the LVMI, whereas the change in ABP was the strongest predictor of the change in PWV. The change in office BP had no predictive value. HBP and ABP measurements appear to be superior to office BP measurements and should be considered complementary rather than interchangeable methods for monitoring the effects of antihypertensive treatment on target-organ damage.

Accumulating evidence suggests that day-by-day blood pressure (BP) variability assessed using self-measurements by patients at home (HBPV) provides useful information beyond that of average home BP. This systematic review summarizes the current evidence on day-by-day HBPV. A systematic literature search (PubMed) revealed 22 eligible articles. Independent prognostic value of day-by-day HBPV for cardiovascular events and total mortality was demonstrated in two outcome studies, whereas novel indices of variability had minimal or no independent prognostic ability. Although findings are not consistent among the studies, the evidence suggests that HBPV has an independent role in the progression of preclinical cardiac, arterial and renal damage and is affected by age, gender, average BP and heart rate level, antihypertensive treatment, antihypertensive drug class and other factors. However, there is large diversity among the available studies in the home BP monitoring protocols, the indices used to quantify HBPV and the end points selected for evaluation. Overall, these preliminary data largely based on heterogeneous studies indicate an important and independent role of day-by-day HBPV in the pathogenesis of hypertension-induced cardiovascular damage. Yet, fundamental questions remain unanswered, including the optimal variability index, the optimal home monitoring schedule required, the threshold that defines increased HBPV and the impact of treatment-induced variability change on organ damage and cardiovascular events. Until these questions are adequately addressed in future studies, HBPV should largely remain a research issue with limited practical value for individual patients.

Home blood pressure monitoring is useful in detecting white-coat and masked hypertension and is recommended for patients with suspected or treated hypertension. The prognostic significance of white-coat and masked hypertension detected by home measurement was investigated in 6458 participants from 5 populations enrolled in the International Database of HOme blood pressure in relation to Cardiovascular Outcomes. During a median follow-up of 8.3 years, 714 fatal plus nonfatal cardiovascular events occurred. Among untreated subjects (n=5007), cardiovascular risk was higher in those with white-coat hypertension (adjusted hazard ratio 1.42; 95% CI [1.06-1.91]; P=0.02), masked hypertension (1.55; 95% CI [1.12-2.14]; P<0.01) and sustained hypertension (2.13; 95% CI [1.66-2.73]; P<0.0001) compared with normotensive subjects. Among treated patients (n=1451), the cardiovascular risk did not differ between those with high office and low home blood pressure (white-coat) and treated controlled subjects (low office and home blood pressure; 1.16; 95% CI [0.79-1.72]; P=0.45). However, treated subjects with masked hypertension (low office and high home blood pressure; 1.76; 95% CI [1.23-2.53]; P=0.002) and uncontrolled hypertension (high office and home blood pressure; 1.40; 95% CI [1.02-1.94]; P=0.04) had higher cardiovascular risk than treated controlled patients. In conclusion, white-coat hypertension assessed by home measurements is a cardiovascular risk factor in untreated but not in treated subjects probably because the latter receive effective treatment on the basis of their elevated office blood pressure. In contrast, masked uncontrolled hypertension is associated with increased cardiovascular risk in both untreated and treated patients, who are probably undertreated because of their low office blood pressure.