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AMBULATORY AND HOME BLOOD
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PRESSURE MONITORING
CHAPTER 2
Blaise W. Abramovitz, DO, and Jordana B. Cohen, MD, MSCE
QUESTIONS
1. What is out-of-office blood pressure monitoring?
Out-of-office blood pressure (BP) monitoring is the assessment of BP outside of the clinic setting using either
ambulatory BP monitoring (ABPM) or self-monitoring of BP at home, also known as home BP monitoring (HBPM).
2. Why is out-of-office BP monitoring performed?
Out-of-office BP monitoring is performed to confirm the diagnosis of hypertension and to assist with titration of
antihypertensive medications.
between BPs measured in versus outside of the clinic, including masked and white coat hypertension (Fig. 2.1).
Masked hypertension (MH) and masked uncontrolled hypertension (MUCH)4:
• DenedasnormalclinicBPwithelevatedout-of-ofceBP
• MH occurs in patients not yet on antihypertensive therapy
• MUCH occurs in patients on antihypertensive therapy
• Associatedwithsimilarlyelevatedcardiovascularriskassustainedhypertension
• Mostcommoninmen,individualsofAfricandescent,individualswithchronickidneydisease,andindividuals
with obstructive sleep apnea
• Considerscreeningpatientswith:
• Evidence of target organ damage disproportionate to their degree of BP control in the clinic
• Clinic BPs less than 10 mm Hg below their goal
• Labile clinic BPs
White coat hypertension (WCH) and white coat effect (WCE)5:
• DenedaselevatedclinicBPwithnormalout-of-ofceBP
• WCH occurs in patients not yet on antihypertensive therapy
• WCE occurs in patients on antihypertensive therapy
• WCHisassociatedwith:
• Elevated cardiovascular risk that is lower in magnitude than sustained hypertension
• High risk of transitioning to sustained hypertension
• WCEisnotassociatedwithelevatedcardiovascularrisk
• Mostcommoninwomen,children,olderadults,andpatientswithapparenttreatmentresistanthypertension
• Considerscreeninginpatientswith:
• Apparent treatment resistant hypertension
• Treated hypertension and symptoms of low BPs outside of the office
• Labile clinic BPs
• Newly elevated clinic BPs
1–3
Out-of-office BP monitoring is particularly useful for identifying discrepancies
3. What is ABPM?
ABPM is a noninvasive method of out-of-office BP monitoring in which BPs are measured repeatedly over a 24- to
48-hour period, during routine daily activities and sleep, using a fully automated device.
4. Why is ABPM performed?
ABPM is considered to be the reference standard for the diagnosis of hypertension because it is the method of BP
measurement that is most strongly associated with adverse cardiovascular outcomes and provides an assessment
of overall BP load beyond the office snapshot.6 ABPM can determine the presence of MH, MUCH, WCH, and WCE.
A distinctive part of the prognostic value of ABPM is the ability to identify elevated nocturnal BPs and non-dipping
(i.e., the absence of a 10% decline in BP during sleep). Non-dipping and elevated nocturnal BPs are independently
associated with an elevated risk of major cardiac events, including myocardial infarction, stroke, and heart failure.7 ABPM is also helpful for identifying short-term BP variability, which is associated with elevated cardiac risk,8
as well as for monitoring the effectiveness of antihypertensive therapy over a full day.
8
6
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Fig. 2.1 Blood pressure (BP) patterns determined using the combination of clinic and out-of-office BP monitoring.
5. How is ABPM performed?
Key steps for clinicians when performing ABPM
6,9
:
• Programthemonitortoperformreadingsatpredeterminedintervals,typicallyevery15to30minutesduring
the day and every 30 to 60 minutes at night over 24 hours
• Applythecufftothepatient’snondominantarmunlessthereisacontraindication,suchasanarteriovenous
fistula or prior lymph node dissection
• Provideadvancedinstructionstothepatienttoprepareaccordingtothefollowing:
• Wear a loose-fitting or sleeveless shirt so that the cuff can be applied to a bare arm
• Plan to wear the monitor for a full 24-hour period during a routine day
• The device may disrupt some activities and sleep
• Plan to return to the office within a reasonably short time period (e.g., 1–2 days) to return the monitor
• Provideverbalandwritteninstructionstothepatientonthedaythemonitorisappliedtodothefollowing:
• Maintain a diary documenting, at minimum:
• Time of awakening
• Time to sleep
• Time, name, and dose of any prescribed and over-the-counter medications taken
• Symptoms such as lightheadedness, dizziness, or palpitations
• Avoid showering or immersion in water while wearing the device
• Continue with a normal daily routine
• Keep the arm still when the device is initiating and inflating
• Avoid rigorous exercise while wearing the device
• Refit the cuff if it migrates downward, rotates, or needs to be temporarily removed
• Uponreturnofthemonitortotheclinic,thedatashouldbedownloadedtoasecuredeviceandinterpretedby
the provider
6. How is ABPM interpreted?
Key components of ABPM interpretation
6,9
:
• Mean24-hoursystolicanddiastolicBP
• Used to determine the diagnosis of the BP patterns outlined in Fig. 2.1
10 PATIENT ASSESSMENT
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Fig. 2.2 Examples of 24-hour ambulatory blood pressure monitoring, with (A) ≥10% decline in blood pressure (BP) while sleeping (i.e.,
nocturnal “dipping”) and (B) <10% decline in BP while sleeping (i.e., nocturnal “non-dipping”).
• Meandaytime(i.e.,awake)systolicanddiastolicBP
• Used to determine the diagnosis of the BP patterns outlined in Fig. 2.1, typically with a higher threshold than
the overall 24-hour mean
• Meannocturnal(i.e.,asleep)systolicanddiastolicBP(Fig. 2.2)
• BP typically declines by 10% to 20% during sleep compared to daytime BP
• Elevated nocturnal BP and non-dipping (absence of a ≥10% decline in BP during sleep) are associated with
elevated risk of adverse outcomes
• Nocturnal dosing of antihypertensives may improve non-dipping in some patients, although further evidence
is needed to determine if this reduces long-term risk
• Cardiovascular risk attenuation addressing other cardiovascular risk factors (such as hyperlipidemia and
obstructive sleep apnea) is recommended
AMBULATORY AND HOME BLOOD PRESSURE MONITORING 11
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Other components of ABPM interpretation to be aware of:
• SystolicanddiastolicBPload
• ProportionofBPsduringthedaythatareabovethepatient’sgoal(>40% is considered “abnormal”)
• Considered to provide additional information about the duration of elevated readings and BP variability
• Does not seem to provide added prognostic value beyond the mean daytime BP
• Morningsurge
• Difference between early morning BPs and nocturnal BPs
• No consensus on best approach to calculating
• May be associated with elevated risk of adverse cardiovascular events
• Short-termBPvariability
• May be due to several factors, such as poor exercise tolerance, stress, anxiety, vascular stiffness, and
autonomic dysfunction
• No consensus on best approach to calculating, but average real variability (the sum of the difference of each
successive BP measurement divided by the total number of measurements minus one) is the most strongly
linked with adverse outcomes
7. What is HBPM?
HBPM allows patients to monitor their BPs at home over a long period of time using a semiautomated device that
is activated by the patient.
8. Why is HBPM performed?
Similar to ABPM, HBPM is performed to detect discrepant BPs outside of the clinic compared to those measured in the
clinic and thus to identify MH, MUCH, WCH, and WCE. In contrast to ABPM, HBPM is better suited for long-term monitoring of BP and titration of medications due to greater reproducibility of the readings over time,10 better tolerability,11
and easier access to monitors for many patients. However, HBPM is not as strongly linked to adverse cardiovascular
outcomes as ABPM,12 in part, because HBPM does not typically include the measurement of BPs during sleep.
9. How is HBPM performed?
Unlike ABPM, HBPM requires individual patient education on correct BP measurement technique. Patients should
be provided with verbal and written instructions on how to perform HBPM appropriately.
Key steps for performing HBPM
6,13,14
:
• Emptythebladderandavoidrigorousexercise,caffeine,alcohol,andcigarettesmokingforatleast30minutes
before measurement
• WearshortorloosesleevesortakethearmoutofthesleevesotheBPcanbeperformedonabarearm
• Sitinacomfortablechairwiththebacksupported
• Placethearmthroughthecuffloopofthenondominantarm
• Slidethecuffupthearmsothebottomedgeisabout1inch(2–3cm)abovetheelbowandthetuberunsalong
the inside of the arm; tighten the cuff
• Restfor3to5minutesbeforethemeasurementwithnodistractionsinaquietroom
• Armsupportedneartheleveloftheheart
• Feetatontheoor
• Aftertherstreadingiscomplete,waitapproximately1minuteandthenperformasecondBPreading
• Recordthetworeadingswiththetimeanddate
• Performmeasurementsinthemorningbeforetakingmedicationsandintheeveningforaminimumof3days,
ideally 5 to 7 consecutive days
Patient education should be reiterated over time to ensure ongoing adherence to correct BP measurement
technique. Preferably, patients should bring their home device into the clinic to confirm the accuracy of the device
against a manual clinic reading and to confirm that they are using appropriate measurement technique.
10. How is HBPM interpreted?
HBPM is interpreted using the mean of the systolic and diastolic BP measurements. Some guidelines recommend
discarding BP measurements performed on the first day of HBPM when calculating the mean of the home BPs.
Similar to daytime ABPM, the mean HBPM BPs are used to determine the diagnosis of normotension and
sustained, white coat, and masked hypertension, typically with a higher threshold than the overall 24-hour mean.
Current guidelines recommend antihypertensive treatment targeting home BP thresholds over clinic thresholds
due to greater prognostic utility of HBPM and elevated cardiovascular risk associated with MH.
11. Are there important differences in the information obtained using ABPM vs. HBPM?
Both ABPM and HBPM have stronger prognostic value than clinic BPs. However, in contrast to ABPM, HBPM
measurements occur exclusively while awake and at rest. Consequently, the readings obtained by ABPM are not
always consistent with those obtained by HBPM.
values is not well understood. Whereas some studies show similar associations of BPs obtained by ABPM and
HBPM with cardiac risk, those measured by ABPM are more consistently associated with long-term risk.
15,16
The prognostic significance of conflicting ABPM and HBPM
13,14
5,12
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Table 2.1 International Validated Blood Pressure Monitor Device Listings
SPONSORING MEDICAL SOCIETY WEBSITE
European Society of Hypertension and
https://www.stridebp.org
International Society of Hypertension
Hypertension Canada https://hypertension.ca/hypertension-and-you/managing-
hypertension/measuring-blood-pressure/devices2/
British and Irish Hypertension Society https://bihsoc.org/bp-monitors/
American Medical Association https://www.validatebp.org
12. Does it matter what device is used to perform ABPM and HBPM?
AccurateBPmeasurementdependsonusingacuffthatistheappropriatesizeforthepatient’sarmcircumference and selecting a monitor that has undergone validation using a widely accepted protocol.17 Automated BP
monitors use proprietary algorithms to estimate the systolic and diastolic BPs. These devices require populationwide and individual-level validation to ensure accuracy. Most countries do not require that devices be validated in
order to be marketed to the public, and less than 15% of commercially available BP measurement devices have
undergone validation.18 Hypertension Canada, the British and Irish Hypertension Society, the International Society
of Hypertension, the American Medical Association, and other international medical societies maintain online
listings of validated devices available in their region (Table 2.1). Wrist and finger BP devices are generally not
recommended, as they often perform poorly in validation studies.
KEY POINTS
1. Out-of-office BP monitoring with ABPM or HBPM should be used for the diagnosis and monitoring of
hypertension due to the ability to identify abnormal BP patterns that cannot be identified using clinic BP
monitoring alone
2. ABPM uses fully automated devices to measure BPs repeatedly over a 24-hour period, whereas HBPM relies
upon patients to activate a semiautomated device to measure BP longitudinally
3. HBPM has greater reproducibility, tolerability, and accessibility to most patients compared to ABPM
4. ABPM is more strongly associated with adverse cardiac outcomes than HBPM, in large part, due to the distinct
ability to identify nocturnal BPs
5. It is critical to use a validated device
RefeRences
1. Whelton PK, Carey RM, Aronow WS, 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.
2. NerenbergKA,ZarnkeKB,LeungAA,etal.HypertensionCanada’s2018guidelinesfordiagnosis,riskassessment,prevention,and
treatment of hypertension in adults and children. Can J Cardiol. 2018;34:506–525.
3. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J.
2018;39:3021–3104.
4. Pierdomenico SD, Pierdomenico AM, Coccina F, et al. Prognostic value of masked uncontrolled hypertension. Hypertension.
2018;72:862–869.
5. Cohen JB, Lotito MJ, Trivedi UK, Denker MG, Cohen DL, Townsend RR. Cardiovascular events and mortality in white coat
hypertension: a systematic review and meta-analysis. Ann Intern Med. 2019;170(12):853–862.
6. Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart
Association. Hypertension. 2019;73(5):e35–e66.
7. Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive role of the nighttime blood pressure. Hypertension.
2011;57:3–10.
8. Parati G, Stergiou GS, Dolan E, Bilo G. Blood pressure variability: clinical relevance and application. J Clin Hypertens (Greenwich).
2018;20:1133–1137.
9. ParatiG,StergiouG,O’BrienE,etal.EuropeanSocietyofHypertensionpracticeguidelinesforambulatorybloodpressure
monitoring. J Hypertens. 2014;32:1359–1366.
10. Guo QH, Cheng YB, Zhang DY, et al. Comparison between home and ambulatory morning blood pressure and morning hypertension
in their reproducibility and associations with vascular injury. Hypertension. 2019;74:137–144.
11. Kronish IM, Kent S, Moise N, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension
screening in the United States. J Am Soc Hypertens. 2017;11:573–580.
12. Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P. Studies comparing ambulatory blood pressure and home blood pressure
on cardiovascular disease and mortality outcomes: a systematic review. J Am Soc Hypertens. 2016;10:224–234e17.
AMBULATORY AND HOME BLOOD PRESSURE MONITORING 13
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13. Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension practice guidelines for home blood pressure monitoring.
J Hum Hypertens. 2010;24:779–785.
14. Stergiou GS, Nasothimiou EG, Kalogeropoulos PG, Pantazis N, Baibas NM. The optimal home blood pressure monitoring schedule
based on the Didima outcome study. J Hum Hypertens. 2010;24:158–164.
15. Kang YY, Li Y, Huang QF, et al. Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and
masked hypertension. J Hypertens. 2015;33:1580–1587.
16. Anstey DE, Muntner P, Bello NA, et al. Diagnosing masked hypertension using ambulatory blood pressure monitoring, home blood
pressure monitoring, or both? Hypertension. 2018;72:1200–1207.
17. Cohen JB, Padwal RS, Gutkin M, et al. History and justification of a national blood pressure measurement validated device listing.
Hypertension. 2019;73:258–264.
18. SharmanJE,O’BrienE,AlpertB,etal.LancetCommissiononHypertensiongrouppositionstatementontheglobalimprovementof
accuracy standards for devices that measure blood pressure. J Hypertens. 2020;38:21–29.
CLINICAL EVALUATION OF THE PATIENT
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WITH HYPERTENSION
CHAPTER 3
Trisha Patel, DO, Arun Kumar, MD, ABIM, Edgar V. Lerma, MD, and
George L. Bakris, MD, MA
QUESTIONS
1. What are the objectives of clinical evaluation of a patient with hypertension?
• Toidentifypotentiallycorrectablecausesofhypertension
• Toidentifyothercardiovascularriskfactorsorconcomitantdisordersthatmayinuenceprognosisandguide
treatment
• Toassessend-organdamage(whichmayaffecttherapy)andidentifybaselineabnormalities
• Toassessprevioustreatmentexperiencesandobstaclestotherapy
2. What is the appropriate method to check blood pressure?
See Chapter 1: Measurement of Blood Pressure in the Office
3. What are the appropriate requisites when taking blood pressure readings?
Belowaretherecommendationsforbloodpressure(BP)monitoring:
• Condition
• Quietroomwherethereiscomfortableseatingwithoutdistraction
• Avoidcaffeine,cigarettes,andotherstimulants30minutesbeforetakingtheBP
• Waitatleast30minutesafterameal
• IfonBPmedication,taketheBPreadingbeforetakingthemedication
• Emptythebladderbeforehand
• Position
• Keepthebacksupported
• Keepfeetatontheoor
• Sitwithlegsuncrossed
• Keeparmsupported,palmup,andmusclesrelaxed
• PositionarmsoBPcuffisattheheartlevel
• PuttheBPcuffonthebarearm,abovetheelbowatmid-arm
• Device
• Validatedelectronic(oscillometric)upper-armcuffdevice
• Alternativelyuseacalibratedauscultatorydevice(aneroid,orhybridasmercurysphygmomanometersare
bannedinmostcountries)withrstKorotkoffsoundforsystolicBPandfthfordiastolicBPwithalow
deationrate
• Cuff
• Sizeaccordingtoarmcircumference(i.e.,smallercuffoverestimatesBP,andlargercuffunderestimatesBP
[Table3.1])
• Protocol
• Restfor5minuteswhileinpositionbeforestarting
• Taketwoorthreemeasurements,1minuteapart
• Keeprelaxedandinpositionduringmeasurements
• Sitquietlywithoutdistractionsduringmeasurements(i.e.,avoidconversations,television,telephones,and
otherdevices)
• Recordmeasurementswhennished
See Chapter 1: Measurement of Blood Pressure in the Office, and Chapter 2: Ambulatory and Home Blood
Pressure Monitoring
4. What pertinent information should be obtained during history taking in the patient who
initially presents with hypertension?
Patientswithhypertensionaretypicallyasymptomatic;itisimportanttopayparticularattentiontohistoricalclues
thatcanpointtounderlyingsecondaryhypertensionaswellashypertensivecomplicationsthatwarrantfurther
investigation.
14
CLINICAL EVALUATION OF THE PATIENT WITH HYPERTENSION 15
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Table 3.1 Recommended Cuff Sizes for Accurate Measurement of Blood Pressure
ARM CIRCUMFERENCE BP CUFF SIZE
22–26cm 12×22cm(Smalladult)
27–34cm 16×30cm(Adult)
35–44cm 16×36cm(Largeadult)
BP,Bloodpressure.
(Fromhttps://targetbp.org/wp-content/uploads/2016/10/How-to-Measure-Blood-Pressure-at-Home.pdf.)
• Blood pressure
Thisshouldbeobtainedinallpatientsatallappropriatevisitstoassesscardiovascularriskandmonitoreffects
ofantihypertensivetreatment.
• Newonsethypertension,duration,previousBPreadings,antihypertensiveagents(currentandprevious),
othermedications(includingherbalmedications,nutritionalsupplements)thatmaypotentiallyaffect
BP,historyofadverseeventsrelatedtomedications(angiotensin-convertingenzymeinhibitorinduced
angioedema,erectiledysfunctionduetobeta-blockers),hypertensiondiagnosedwithpregnancyorwhile
takingoralcontraceptives)
• Risk factors
• Personalhistoryofcardiovasculardisease(myocardialinfarction,heartfailure,stroke,transientischemicattack,
peripheralvasculardisease),diabetes,dyslipidemia,chronickidneydisease(nephrolithiasis);tobaccouse;alcoholintake;illicitdruguse;analgesicuse;sodaconsumption;physicalactivity;psychosocialaspects(employment,levelofeducation)thatmayaffectaccesstocare/medicationsorinuenceadherencetotreatment
• Familyhistoryofhypertension,prematurecardiovasculardisease(early-onsetstroke),diabetes,hypercho-
lesterolemia,chronickidneydisease(polycystickidneydisease,nephrolithiasis)
• Signs and symptoms
• Hypertension/comorbidillnesses
• Headaches,visualdisturbances,chestpain,shortnessofbreath,palpitations,claudication,peripheral
edema,nocturia,hematuria
• Secondaryhypertension(commonlyassociatedwithresistanthypertension)
• Hypokalemia(spontaneousordiureticinduced);musclecrampsorweakness(primary aldosteronism)
See Chapter 8: Primary Aldosteronism and Mineralocorticoid Excess
• Centralobesity;“moon”facies;dorsalandsupraclavicularfatpads(buffalohump);wide1-cmviolaceous
striae,easybruisability;hirsutism;proximalmuscleweakness(Cushing syndrome)
See Chapter 9: Glucocorticoid Excess
• Paroxysmalhypertensionorcrisissuperimposedonsustainedhypertension;“spells”ofBPlability,head-
ache,sweating,palpitations,pallor(pheochromocytoma)
See Chapter 10: Pheochromocytoma and Paraganglioma
• Skinstigmataofneurobromatosis(i.e.,café-au-laitspots);neurobromas(paraganglioma)
See Chapter 10: Pheochromocytoma and Paraganglioma
• Dryskin,coldintolerance,constipation,weightgain,delayedanklereex,periorbitalpufness,slow
movement(hypothyroidism)
See Chapter 11: Other Endocrine Causes of Hypertension
• Warm,moistskin;heatintolerance;diarrhea;weightloss;proximalmuscleweakness;lidlag;netrem-
orsofoutstretchedhands(hyperthyroidism)
See Chapter 11: Other Endocrine Causes of Hypertension
• NewonsetofworseningordifculttocontrolBP,ashpulmonaryedema,holosystolicepigastricbruit
withdiastoliccomponent,bruitsoverotherarteries(i.e.,carotid,femoral[renovascular disease])
See Chapter 12: Renovascular Hypertension
• Poorsleepquality,snoring,breathingpausesduringsleep,daytimesleepinessortiredness(obstructive
sleep apnea)
• Youngpatient(∼ <30years)withhypertension;higherBPinuppervs.lowerextremities;absent
femoralpulses;continuousmurmurheardoverpatient’sback,chest,orabdominalbruit(coarctation
of the aorta)
See Chapter 14: Obstructive Sleep Apnea
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• Recurrenturinarytractinfections;obstructiveuropathygrosshematuria;urinaryurgency,frequency,or
dysuria;peripheraledema;elevatedserumcreatinine;abnormalurinalysis(i.e.,microscopichematuria,
proteinuria[chronic kidney disease])
5. What pertinent findings on physical examination should one look for during evaluation of a
patient with hypertension?
Athoroughanddetailedphysicalexaminationshouldbeperformedintheinitialevaluationofthepatientwith
hypertension.Thishelpsnotonlyinestablishingthediagnosisofhypertensionbutalsoinidentifyingfeaturesthat
pointtounderlyingsecondaryhypertension.Thisshouldinclude:
• General
• Height,weight(bodymassindex,BMI),waistcircumference
• Heartandcirculation
• Heartrate/rhythm,jugularvenouspulse/pressure,apicalimpulse,extraheartsounds(murmurs,gallops),
adventitioussounds(rales),peripheraledema,bruits,radiofemoraldelay
• Otherorgansystems
• Skin:striaeandfattydeposits
• Funduscopy
TheKeith,Wagener,andBarkerhypertensiveretinopathyclassicationisbasedonthelevelofseverityofthe
retinalndings:
GRADE CLASSIFICATION
Grade I (mild hypertension) Mild,generalized,retinal,arteriolarnarrowingorsclerosis
Grade II (more marked
hypertensive retinopathy)
Grade III (mild angiospastic
retinopathy)
Grade IV SeveregradeIIIandpapilledema
Denitefocalnarrowingandarteriovenouscrossings,moderateto
markedsclerosisoftheretinalarterioles,exaggeratedarteriallightreex
Retinalhemorrhages,exudates,andcottonwoolspots;sclerosisand
spasticlesionsofretinalarterioles
• Neckcircumference(>40cmmaypointtoobstructivesleepapnea)
• Palpablyenlargedthyroidgland(goiter)
• Palpablyenlargedkidneys(polycystickidneydisease)
6. What laboratory and diagnostic tests should be performed as part of hypertension evaluation?
Althoughthereappearstobesomegeneralconsensusbetweenvariousguidelinesasfarasroutinelaboratoryand
ancillarytestsintheevaluationofapatientwithhypertension,therearealsosomeminordifferences.
ACC/AHA 2017
ROUTINE
Bloodtests
Urinetests Urinalysis Urinealbuminto
Others 12-LeadEKG • 12-LeadEKG
• Completeblood
count
• Chemistries
(sodium,potassium,calcium,
creatininewith
eGFR,TSH)
ESC/ESH
2018
Serumcreatinine
andeGFR
creatinineratio
• Funduscopy
Hypertension
Canada 2020 ISH 2020
Chemistries(sodium,
potassium,creatinine:
Grade D;fastingblood
glucoseand/orHgbA1C:
Grade D;Lipidprole:
Grade D)
Urinalysis(Grade D) Dipstickurinetest
12-LeadEKG(Grade C) 12-LeadEKG
Chemistries(sodium,potassium,serumcreatinine,
eGFR)
Ifavailable,lipidprole
andfastingbloodglucose
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ACC/AHA 2017
NON ROUTINE • 2DECHO
• Serumuricacid
• Urinealbuminto
creatinineratio
ESC/ESH
2018
• 2DECHO,
carotid
ultrasound,
abdominal
ultrasound,
anddoppler
studies
• Pulsewave
velocity(PWV)
• Anklebrachial
index
• Cognitive
functiontesting
• Brainimaging
Hypertension
Canada 2020 ISH 2020
• Urinealbumin
excretionindiabetics
(Grade C)
• Pregnancytestprior
toinitiationofhealth
behaviormanagementchangesor
drugtherapy(Grade
D; NEW 2020
recommendation)
• 2DECHOforall
hypertensivepatients
isnotrecommended
(Grade D)
• 2DECHO(forassessmentofLVM,systolic
anddiastolicLVfunction)forhypertensive
patientssuspectedof
havingLVdysfunction
orCAD(Grade D)
• 2DECHOorNuclear
imaging(forassess-
• 2DECHO,carotidultrasound,kidneys/kidney
arteryandadrenal
imaging,fundoscopy,
brainCT/MRI
• Functionaltests,
additionallaboratory
investigations
• Ankle-brachialindex
• Furthertestingfor
secondaryhypertensionifsuspected
(aldosterone-renin
ratio,plasmafree
metanephrines,
late-nightsalivary
cortisol,orother
screeningtestsfor
cortisolexcess)
• Urinealbumin/
creatinineratio
• Serumuricacid
• Liverfunctiontests
mentofLVEF)for
patientswithevidence
ofheartfailure
(Grade D)
GradeC(HypertensionCanada2020):Recommendationsareonthebasisoftrialsthathavelowerlevelsofinternalvalidityand/or
precision,ortrialsforwhichunvalidatedsurrogateoutcomeswerereported,orresultsfromnonrandomizedobservationalstudies.
GradeD(HypertensionCanada2020):Recommendationsareonthebasisofexpertopinionalone.
CAD,Coronaryarterydisease;C T,computedtomography;2D ECHO,Two-dimensionalechocardiogram;eGFR,estimated
glomerularltrationrate;EKG,electrocardiogram;ESC,EuropeanSocietyofCardiology;ESH,EuropeanSocietyofHypertension;
ISH,InternationalSocietyofHypertension;JNC,JointNationalCommittee;LV, leftventricular;LVEF,leftventricularejection
fraction;LVM,leftventricularmyocardium;MRI,magneticresonanceimaging;TSH,thyroidstimulatinghormone.
7. Which patients require additional diagnostic testing?
• Thosewithhistoricalandclinicalfeaturesthatsuggestsecondarycausesofhypertension
• ThosewithresistanthypertensiondenedbyBP>140/90mmHg(160/90mmHgforpatients>60yearsold)
onmaximaldosesofatleastthreeappropriateantihypertensivesagent
• ThosewithpreviousgoodBPcontrolwithacuteunexplainedexacerbation
• Thosewithhypertensionassociatedwithgrade3orgrade4retinopathy
• Thosewithnewonsethypertensionaftertheageof60years
• Thosewithneworworseningtargetend-organdamage
8. What is pseudohypertension?
Pseudohypertensionisthoughttooccurinelderlyindividualswhohavestifforrigidarteries.Inparticular,measuringtheBPwithacalibratedauscultatorydevicecanleadtoanoverestimationofthetrueintraarterialpressure
becauseoftheincreasedpressurerequiredforthecufftocompressthestiffartery.
Withseveralproposeddenitions,therehasbeennogeneralconsensus.Acutoffof10to15mmHghas
beenarbitrarilyusedasthecutoffdifferencebetweencuffpressuresandintraarterialpressuresinmostpublished
studies.
Соседние файлы в папке Библиотека им академика М.И. Перельмана