Home blood pressure monitoring: what does the evidence say?

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REVIEW

Home blood pressure monitoring: what does the evidence say? Teck K Khong,1 Henry Fok1,2 1 Clinical Pharmacology, St George's, University of London, London, UK 2 Clinical Pharmacology, King's College British Heart Foundation Centre, London, UK Correspondence to Dr Teck K Khong; ​tkhong@​sgul.​ac.​uk

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Key learning points ►► Home blood pressure monitoring (HBPM) is superior to clinic blood pressure measurements in predicting future cardiovascular events. ►► HBPM is relatively inexpensive and acceptable to patients, but its uptake in the UK has been slower than in other countries. ►► Current evidence, professional bodies and clinical guidelines support the use of HBPM for confirmation of hypertension and also for

identification and management of white coat and masked hypertension.

►► Evidence on the role of HBPM in long-­term management of hypertension is evolving, with education, ongoing support and

engagement with patients appearing to be important to its success.

►► Relatively short-­term studies suggest that combining HBPM with additional interventions such as telemonitoring may be helpful in

improving blood pressure levels and adherence to treatment.

►► Blood pressure measured at home is lower than when measured in clinics, with greater differences at higher levels of blood pressure,

so it is important that an adjustment of +5/+5 mm Hg is added to readings acquired from HBPM for equivalence with clinic values at blood pressure levels around the threshold for diagnosis of hypertension.

Introduction Hypertension affects 25% of the global population and is a major preventable cause of premature disability and mortality.1 Importantly, symptoms are usually absent and as a result patients are often undiagnosed and undertreated—this, despite the unequivocal evidence confirming the health and economic benefits of blood pressure (BP) lowering in hypertension. Non-­invasive brachial artery BP measurement has been central to the screening, assessment and treatment monitoring of hypertension in clinical practice and has traditionally been undertaken in the clinic. This practice has shifted in the past decade, with major international hypertension societies endorsing the use of home blood pressure monitoring (HBPM) as a standard of care for hypertension management.2–7 This is supported by accumulating evidence that HBPM is reproducible and accurate provided that patients are taught to perform BP measurements using validated devices under standardised conditions.8 HBPM is useful in identifying important phenotypes, such as white coat and masked hypertension, and is also superior to clinic blood pressure measurements (CBPM) in predicting future cardiovascular events.9 Furthermore, HBPM is both relatively inexpensive and acceptable to patients. Therefore, it has the potential to widen access to hypertension screening and improve long-­term adherence to antihypertensive drug treatment by empowering patients to monitor and manage their hypertension.10–13 This article reviews the practical considerations of HBPM and its limitations, and discusses the added value of HBPM to CBPM and contrasts this approach with 24-­hour ambulatory blood pressure monitoring (ABPM).

HBPM: what is it for and how to use it? HBPM refers to self-­monitoring of BP at home using a validated sphygmomanometer under standardised conditions. Recommendations are that measurements are made over at least 4 and ideally 7 days, preferably two times per day, with one measurement in the morning and another in the evening. Readings from the first day should be excluded and the average of the

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remaining readings calculated for decision making by a clinician for confirming the diagnosis of hypertension or monitoring long-­term treatment. HBPM is increasingly popular and has been driven by increased ownership of sphygmomanometers by patients over the last 30 years and the endorsement of HBPM by major hypertension guidelines across the world. Surprisingly, the uptake of HBPM in the UK has been slower compared with other countries, despite and even after the National Institute for Health and Care Excellence (NICE) became the first to recommend its use in 2011.14–17 A survey conducted in 2015 among British general practitioners suggested that only 38% of patients with hypertension self-­monitor their BP. Although this represented an increase of 10% since 2011, other countries such as Italy, France and Poland achieve HBPM in more than 70% of patients in their respective surveys.12–14 18 The advantages and limitations of HBPM are well described and are summarised in table 1. In the UK, the NICE guideline on hypertension (NG136) recommends the use of HBPM, as an alternative to ABPM, when the latter is unsuitable, for confirming the diagnosis of hypertension. It also recommends HBPM for evaluation and monitoring of patients in sinus rhythm with white coat or masked hypertension.19 The main clinical indications for HBPM are summarised in box 1. Factors that must be considered for optimal performance of HBPM are discussed below. Adjustment of home BP readings for equivalence with clinic BP readings and threshold for white coat hypertension In individuals, BP readings measured at home are recognised to be lower than those in the clinic. There is considerable interindividual variation in such differences between home and clinic BP, with larger differences generally seen at higher levels of BP. Guidelines currently recommend that an adjustment of +5/+5 mm Hg be made to home BP measurements in order to achieve equivalence with clinic BP readings. It is vital this adjustment is made so as not to underdiagnose or undertreat hypertension. Accordingly, the diagnostic threshold for hypertension is an average value

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Review Table 1  Home blood pressure monitoring: key advantages and limitations Advantages ►► ►► ►► ►►

►► ►► ►►

More reproducible than CBPM. More tolerable than 24-­ hour ABPM. Identifies white coat and masked hypertension. Higher cardiovascular prognostic value than CBPM. Longer term blood pressure data than 24-­hour ABPM. Cost-­effective. May remove anxiety with clinic BP measurements.

Limitations ►►

►► ►► ►► ►►

Limited evidence to support its use in patients with arrhythmia (eg, AF), pregnant women and children. Patient needs to have a level of manual dexterity and cognition. Requires patient training and motivation. Anxiety-­inducing and excessive monitoring (in some people). Potential for inaccuracies from misreporting of BP data, use of non-­validated sphygmomanometers, inappropriate cuff size, inappropriate data analysis.

ABPM, ambulatory blood pressure monitoring; AF, atrial fibrillation; BP, blood pressure; CBPM, clinic blood pressure measurements.

of ≥135/85 mm Hg, and the same as that for ABPM daytime average thresholds. Otherwise, as the white coat effect is greater in clinic than home measurement and vice versa for masked hypertension,18 white coat and masked hypertension are defined by the difference of >20/10 mm Hg between clinic BP measurements and average home BP measurements, respectively, where absolute BP values cross the diagnostic threshold for hypertension. Device factors Most automated sphygmomanometers for HBPM use the well-­ established oscillometric method coupled with the individual device’s algorithm to produce BP measurements. Individual sphygmomanometers are traditionally validated against manual measurements obtained from reference mercury sphygmomanometers using one of the three protocols published by the British and Irish Hypertension Society (BIHS), the European Society of Hypertension (ESH) and the Association for the Advancement of Medical Instrumentation (AAMI). In 2018, a universal standard for validation was agreed between the ESH, AAMI and the International Organisation for Standardisation to simplify and standardise the validation procedures globally.20–22 The accuracy and precision of BP measurements are poor in non-­validated devices and therefore it is vital to advise patients to purchase validated devices for HBPM.23–25 It is also important

Box 1  Clinical indications for home blood pressure monitoring ►► Confirmation of the diagnosis of hypertension where APBM

is not suitable or tolerated

►► Evaluate and follow up the efficacy of treatment for patients

to note that validation must be carried out for each model as the algorithm is highly variable even for different models manufactured by the same company. Adherence to validation protocols by manufacturers has been known to be variable and data from published journals are sometimes questioned.26 Nevertheless, the BIHS maintains an up-­to-­date web page listing a variety of recommended automated sphygmomanometers for home use. A patient information sheet is also available to download to ensure patients perform HBPM in a standardised fashion.17 The list of recommended sphygmomanometers contains devices with wrist or upper arm cuffs. If a wrist cuff device is used by the patient, it is important to recommend correct arm positioning at the level of the heart to minimise inaccuracy and variability in BP measurements. Some hypertension societies do not recommend wrist cuff devices due to a higher tendency for inaccurate measurements mainly from incorrect arm positioning,3 but they can be useful for patients with very large upper arms or when upper arm cuff measurements are too painful or distressing for the patient. For upper arm cuff devices, it is important to measure upper arm circumference to ensure the patient uses the correct size of cuff. Cuffs that are too small or too large can produce artificially elevated or lowered BP measurements, respectively. Atrial fibrillation (AF) is more common in patients with hypertension. The evidence on the use of automated sphygmomanometers remains inconclusive in patients with AF, with the preferred method and protocol for measurement debated for this group of patients.27–29 The validation protocols all exclude patients with AF and most of the uncertainties stem from heterogeneous validation results in this patient population from published literature.28 29 The NICE 2019 guideline and the ESH 2010 practice guideline8 on HBPM both discourage the use of automated sphygmomanometers in AF and recommend manual BP measurements only. A pragmatic way to overcome this if patients with AF remain keen to self-­monitor their BP is to explain the uncertainties in BP measurements with oscillometric devices and that conducting triplicate measurements and reporting the average of these results can potentially minimise inaccuracies.30 There are several validated automated sphygmomanometers that can screen for AF during BP measurements, with one endorsed specifically by NICE.31 While these machines can be useful in providing opportunistic screening for AF, their accuracy in measuring BP in AF is not superior to other validated automated sphygmomanometers.29 It is recognised that HBPM is relatively low-­cost, with basic validated models costing less than £20. However, this still represents a significant barrier for some people.32 Surveys suggest the availability of automated sphygmomanometers to lend to patients for HBPM in UK general practice is between 46% and 85%, with variation possibly due to bias in survey data and/ or regional variation in health provision.13 25 33 More expensive sphygmomanometers for home use have additional functions for memory and mobile applications to record results and detect AF. Although additional features (such as memory functions to address the criticisms about selective reporting of home BP measurements by patients)3 8 may be desirable, they are not essential in HBPM.

with white coat hypertension or masked hypertension.

►► Evaluate drug-­resistant hypertension by excluding white ►► ►► ►► ►►

coat effect. Evaluate symptomatic hypotension. Evaluate postprandial hypotension. Inform equivocal treatment decisions. Empowering patients to manage their condition by raising awareness and promoting behaviour changes in lifestyle and to sustain high level of drug adherence if patient is motivated.

Patient factors HBPM is not a demanding technique to learn for most patients, but requires sufficient manual dexterity and more importantly motivation especially on a long-­term basis.16 32 34 Motivation is key not just to sustain long-­term engagement with HBPM but also for performing measurements accurately and engaging with any change to treatment.13 34 For example, one study showed that patients monitored BP at home but without communication with their general practitioners for fear of the need to intensify

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Review their treatment.34 Periodic engagement and education about the correct use of sphygmomanometers and explanation of HBPM results to patients are likely to be crucial to use HBPM successfully, but this is known to be inadequate in practice.12 13 Furthermore, the best approach to implement HBPM is not known but is likely to differ significantly between health systems.13 35 Boxes 2 and 3 summarise the conditions, recommended schedules of monitoring and analysis of results for HBPM. It is important to note that favourable data supporting the use of HBPM are from the adult general population, and evidence supporting its use in children and in pregnant women remains inconclusive.36 37 Overall, long-­term support of patients who are motivated to perform HBPM is crucial to optimal performance. Clinician factors There is mounting evidence to suggest clinical inertia and suboptimal clinician knowledge in HBPM are significant barriers to the successful implementation of HBPM.13 35 38 Common barriers include the following: zz zz

zz zz

Knowledge gap in the correct analysis and interpretation of HBPM results. Burdensome logistics in terms of providing sphygmomanometers, interval sphygmomanometer checks and the need to summarise results. Lack of confidence in patients’ measurement technique and reporting of results. Concerns about provoking patient anxiety from BP measurements and the associated increase in patient visits and telephone calls.39

A particularly important finding in clinician knowledge gap appears to be the need to adjust BP readings acquired at home to achieve equivalence.13

Evidence for HBPM Patient adherence and prescriber inertia with HBPM HBPM alone, without other supportive measures, does not appear to improve adherence to antihypertensive medication.40 Studies combining HBPM with telemonitoring have been shown to achieve better BP lowering and drug adherence and to be cost-­effective. However, these studies are of lower quality.40–42 Moreover, the addition of telemedicine to standard care in a study conducted in 142 general practices in the UK did not appear to show significant added value.43

Box 2  Conditions for home blood pressure monitoring ►► Avoid smoking, eating, caffeine intake and exercise 30 min ►► ►►

►► ►►

before measurements. Ensure the room is quiet and free of distractions (eg, mobile phone or television). The person should sit upright comfortably with the arm supported at the level of the heart, legs uncrossed, both feet flat on the floor and avoid talking. Use appropriate cuff size for upper arm cuffs and place the cuff approximately 2 cm above the elbow*. Ensure measurement records are accessible so that blood pressure readings are noted immediately.

*Cuffs recommended by the manufacturer should be used. It is recommended that the bladder cuff width should be about 40% of the arm circumference and the bladder cuff length should be at least 80% (but not more than 100%) of the arm circumference.

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Box 3  Monitoring schedule and analysis of results ►► Preferably conducted over 7 consecutive days (minimum

►►

►►

►►

►► ►►

4 days)*. If this is for treatment monitoring, it should be conducted a week before the appointment†. For each BP recording, take two consecutive measurements at least 1 minute apart. Additional measurements should be taken if the first two measurements are >10 mm Hg different. Measurements should be recorded two times per day in the morning (06:00–12:00) (before antihypertensive treatment if appropriate) and evening (18:00–00:00) at similar time intervals. The average of the readings should be calculated, ignoring the first day as first-­day BP measurements have a tendency for higher variability. If appropriate, medication history and time of dosing should be recorded. Interval comparison of the patient’s and clinic sphygmomanometers to promote education on the correct technique for BP monitoring and to account for any difference in BP recordings.

*Guidelines from international societies vary on the recommended minimum days of consecutive monitoring. †BP can be measured less frequently than above, for example, a maximum of once or twice per week in longer term monitoring and for patients whose BP is stable. This should be judged on a case-­by-­case basis to avoid provoking anxiety associated with overuse of home blood pressure monitoring. BP, blood pressure. Overall BP control with HBPM There is considerable interest to ascertain whether HBPM is superior to CBPM in long-­term monitoring of treated patients who are motivated to carry out HBPM. Randomised controlled trials addressing this have heterogeneous designs, with follow-­up periods typically less than 12 months, and have mostly used BP lowering as the primary outcome.9 10 42 44 Earlier studies comparing CBPM and HBPM in treated patients confirmed a small but statistically significant short-­term improvement in BP control,45 but two subsequent meta-­analyses did not find a statistically significant difference in BP at 12 months.10 44 It is worth noting that NICE has not endorsed HBPM for long-­term monitoring of treated patients, but rather agreed that the updated guideline should support home monitoring for people who wish to use it. Role of HBPM, ABPM, CBPM and newer technologies In practice, both ABPM and HBPM are conducted for similar indications as listed in box 1. At present, there is no unifying consensus on the acceptability of HBPM and ABPM in patients. Small studies have shown that some patients preferred HBPM over ABPM as they perceive ABPM to be uncomfortable and restrictive in their daily activities.46 For instance, HBPM may be preferred by patients who have trouble attending regular appointments or by those in manual labour or other work where ABPM may be too disruptive. Otherwise, it is possible that many patients may undertake HBPM without informing their general practitioners, so active enquiry about this should be considered. However, ABPM and HBPM provide different sets of out-­of-­ office BP data that are useful and complementary for in-­depth understanding of specific phenotypes of hypertension. ABPM is typically conducted over a 24-­hour period and can provide an array of measurements, but primarily provides averages of 24-­hour,

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Review daytime and night-­time BP readings. By contrast, HBPM provides average BP over a period of days and is unable to provide shorter term variability data, such as an early morning BP surge and night-­ time BP dipping, although the newest generations of automated sphygmomanometers for home use are likely to be able to measure the latter reproducibly.47 48 CBPM is highly variable, and by comparison ABPM and HBPM have higher reproducibility and prognostic significance. Thus, most guidelines recommend ABPM or HBPM to confirm the diagnosis of hypertension in patients in sinus rhythm.10 49 ABPM has more established evidence and greater specificity than HBPM in the diagnosis of hypertension and thus is considered the gold standard test to confirm hypertension.46 50 Several small studies where patients underwent both ABPM and HBPM have shown good diagnostic agreement between the two methods and so HBPM is recommended as an alternative when ABPM is not available or tolerated.42 44 Both ABPM and HBPM also have a role in the long-­ term monitoring of hypertension. However it is important to note that HBPM alone is ineffective in improving long-­term BP control or adherence. Concomitant interventions that include patient education, healthcare professional engagement and dose titration are required to maximise its clinical benefit.11 There is an increasing body of evidence that shows such interventions can be delivered via telemonitoring to achieve target BP.40 43

more expensive than HBPM (£53.40 vs £38.00), cost utility analysis carried out by NICE showed that ABPM is more cost-­effective than HBPM, with the major factor determining this conclusion being the lower diagnostic performance of HBPM in comparison with ABPM.19

Cost-effectiveness Overall, the cost-­effectiveness of HBPM depends in large part on the health system: HBPM is cost-­saving in an insurance-­based system where the cost of ABPM is not reimbursed.51 In the UK, although the per unit cost of ABPM to confirm hypertension is

Provenance and peer review  Commissioned; externally peer reviewed.

Information for patients ►► Having high blood pressure (BP) or hypertension increases

►►

►►

►►

►►

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your risk of suffering from cardiovascular diseases such as heart attacks, heart failure, kidney failure and strokes, but these risks can be greatly reduced by keeping your BP level under control. Home blood pressure monitoring (HBPM) involves you using a BP machine at home to measure your BP level. It is relatively easy to perform and has advantages over measuring at the clinic or surgery in that it is more accurate and can give a better overall view of your BP level, if done correctly and especially when combined with ongoing support from your healthcare professional. When undertaking HBPM, it is important you use a validated machine that has been approved for accuracy. Examples of such machines are listed by various charitable societies dedicated to management of hypertension, such as the British and Irish Hypertension Society (https://bihsoc.org/ bp-monitors/). HBPM measurements should be made over at least 4 and ideally 7 days, preferably two times per day, with one measurement in the morning and another in the evening. Readings from the first day should be discarded. Using HBPM does not necessarily mean you will have to take more BP medication, but it does allow you and your healthcare professional to make better judgements on how well your BP is controlled and whether you are taking enough, not enough or too much medication for your BP. It is important to remember that BP levels are generally lower when measured at home. So when comparing home BP readings with those taken in the clinic or surgery, you have to add 5 mm Hg to the figures you get at home.

Conclusion Current evidence indicates that HBPM is an appropriate alternative to ABPM for confirmation of hypertension and for identification and management of white coat and masked hypertension. In addition, it could also be useful for long-­term monitoring of BP if patients are motivated to receive long-­term support. Although it seems a simple and useful adjunct to recommend to patients with hypertension, it requires careful consideration to implement successfully, including training clinical staff to actively identify patients who are motivated to carry out HBPM, to educate patients to obtain reproducible measurements using validated sphygmomanometers and to interpret HBPM results and engage with patients accordingly. HBPM offers a more patient-­centred approach to the management of hypertension, but the evidence does not at present support this as the sole or indeed first-­line modality for confirmation and monitoring of hypertension. Competing interests  None declared. Refer to the online supplementary files to view the ICMJE form(s). © Author(s) (or their employer(s)) 2021. No commercial re-­use. See rights and permissions. Published by BMJ.

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DOI: 10.1136/dtb.2021.000025

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