Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.
The meta-analysis by Law, Morris and Wald (1) recommends
antihypertensives to be prescribed according to risk rather than blood
pressure readings. Additionally, Keenan, Hayen, Neal and Irwig (2)
conclude that “blood pressure monitoring intervals can be lengthened for
most patients.” Both studies point towards less activity in clinic,
because the benefit aimed for is independent from close monitoring. As
monitoring activity is costly, the promise of good outcomes with less cost
is certainly attractive. The editorial by McManus and Mant (3) sums up the
significance of the studies, concluding: “The place of the
sphygmomanometer in the doctor’s office for monitoring blood pressure
lowering treatment no longer seems secure”. Let us hope so.
The point is that we have known for a long time how unreliable office
blood pressure measurements are; we know about the large numbers of false
positives for the diagnosis of hypertension, as found by Campbell et all
(4), and the resulting “overtreatment of patients”; those patients will
then suffer side-effects, develop iatrogenic conditions and waste scarce
resources. In 2006 we analysed the concordance between 3 consecutive
measurements of blood pressure in clinic and the ambulatory blood pressure
monitor (ABPM) record in a primary care setting (5). The positive
predictive value of a clinic-based diagnosis of hypertension (for true
hypertension diagnosed by ABPM) was 71%, and the indication for treatment
based on the 3 consecutive readings in clinic (average > 160/100) was
supported by the ABPM in a sobering 25% of cases only! So maybe it should
be no surprise that outcomes are largely independent from clinic blood
pressure measurements.
Home monitoring empowers patients and seems to provide a picture well
correlated to ABPM results (and to objective outcomes (6, 7)). It is time
to stop acting on indefensibly unreliable diagnostic tests and accept the
demise of the sphygmomanometer for the diagnosis of hypertension in clinic
– and get ourselves moving away from a traditional approach which caused
much unnecessary ill-health.
1. Law M, Morris J and Wald N. Use of blood pressure lowering drugs
in the prevention of cardiovascular disease: meta-analysis of 147
randomised trials in the context of expectations from prospective
epidemiological studies. BMJ 2009;338:b1665
2. Keenan K, Hayen A, Neal B and Irwig L. Long term monitoring in
patients receiving treatment to lower blood pressure: analysis of data
from placebo controlled randomised controlled trial. BMJ 2009;338:b1492
3. McManus R and Mant J. Management of blood pressure in primary
care. BMJ 2009;338:b940
4. Campbell N, Culleton B and McKay D. Misclassification of blood
pressure measurement in ambulatory physician practices. AmJHypert, Dec
2005; 18(12):1522-1527
5. Hutchinson L and Calinas-Correia J. Preliminary results of the
evaluation of the Positive Predictive Value of current standard
methodology for the diagnosis of Hypertension. Report, Research Capacity
Development Grant, Trent Research Development Support Unit, 2007
6. Fagard R, Staessen J, Thijs L and Amery A. Multiple standardized
clinic blood pressures may predict left ventricular mass as well as
ambulatory monitoring: A metaanalysis of comparative studies. AmJHypert,
May 1995; 8(5): 533-540
7. Mancia G et al. Ambulatory blood pressure is superior to clinic
blood pressure in predicting treatment-induced regression of left
ventricular hypertrophy. SAMPLE Study Group. Study on Ambulatory
Monitoring of Blood Pressure and Lisinopril Evaluation. Circulation, March
1997; 95(6): 1464-1470
Sphygmomanometers and blood pressure monitoring: we already knew it does not work, now we hear it is not even helpful... but is there the will to change?
The meta-analysis by Law, Morris and Wald (1) recommends
antihypertensives to be prescribed according to risk rather than blood
pressure readings. Additionally, Keenan, Hayen, Neal and Irwig (2)
conclude that “blood pressure monitoring intervals can be lengthened for
most patients.” Both studies point towards less activity in clinic,
because the benefit aimed for is independent from close monitoring. As
monitoring activity is costly, the promise of good outcomes with less cost
is certainly attractive. The editorial by McManus and Mant (3) sums up the
significance of the studies, concluding: “The place of the
sphygmomanometer in the doctor’s office for monitoring blood pressure
lowering treatment no longer seems secure”. Let us hope so.
The point is that we have known for a long time how unreliable office
blood pressure measurements are; we know about the large numbers of false
positives for the diagnosis of hypertension, as found by Campbell et all
(4), and the resulting “overtreatment of patients”; those patients will
then suffer side-effects, develop iatrogenic conditions and waste scarce
resources. In 2006 we analysed the concordance between 3 consecutive
measurements of blood pressure in clinic and the ambulatory blood pressure
monitor (ABPM) record in a primary care setting (5). The positive
predictive value of a clinic-based diagnosis of hypertension (for true
hypertension diagnosed by ABPM) was 71%, and the indication for treatment
based on the 3 consecutive readings in clinic (average > 160/100) was
supported by the ABPM in a sobering 25% of cases only! So maybe it should
be no surprise that outcomes are largely independent from clinic blood
pressure measurements.
Home monitoring empowers patients and seems to provide a picture well
correlated to ABPM results (and to objective outcomes (6, 7)). It is time
to stop acting on indefensibly unreliable diagnostic tests and accept the
demise of the sphygmomanometer for the diagnosis of hypertension in clinic
– and get ourselves moving away from a traditional approach which caused
much unnecessary ill-health.
J. Calinas Correia
dr.j.calinas@doctors.org.uk
1. Law M, Morris J and Wald N. Use of blood pressure lowering drugs
in the prevention of cardiovascular disease: meta-analysis of 147
randomised trials in the context of expectations from prospective
epidemiological studies. BMJ 2009;338:b1665
2. Keenan K, Hayen A, Neal B and Irwig L. Long term monitoring in
patients receiving treatment to lower blood pressure: analysis of data
from placebo controlled randomised controlled trial. BMJ 2009;338:b1492
3. McManus R and Mant J. Management of blood pressure in primary
care. BMJ 2009;338:b940
4. Campbell N, Culleton B and McKay D. Misclassification of blood
pressure measurement in ambulatory physician practices. AmJHypert, Dec
2005; 18(12):1522-1527
5. Hutchinson L and Calinas-Correia J. Preliminary results of the
evaluation of the Positive Predictive Value of current standard
methodology for the diagnosis of Hypertension. Report, Research Capacity
Development Grant, Trent Research Development Support Unit, 2007
6. Fagard R, Staessen J, Thijs L and Amery A. Multiple standardized
clinic blood pressures may predict left ventricular mass as well as
ambulatory monitoring: A metaanalysis of comparative studies. AmJHypert,
May 1995; 8(5): 533-540
7. Mancia G et al. Ambulatory blood pressure is superior to clinic
blood pressure in predicting treatment-induced regression of left
ventricular hypertrophy. SAMPLE Study Group. Study on Ambulatory
Monitoring of Blood Pressure and Lisinopril Evaluation. Circulation, March
1997; 95(6): 1464-1470
Competing interests:
None declared
Competing interests: No competing interests