Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review
The article "Relative effectiveness of clinic and home blood pressure
monitoring compared with ambulatory blood pressure monitoring in diagnosis
of hypertension: systematic review" by Hodgkinson et al (BMJ
2011;342:doi:10.1136/bmj.d3621) suggests that ambulatory blood pressure
monitoring (ABPM) should serve as a "gold standard", and if we accept
this, then about 25% of diagnosed hypertension cases are actually
overdiagnosis and should not be treated.
This view has a logical basis more than an evidence basis. The
approach to diagnosing and treating high blood pressure was never based on
ABPM. Assuming target values that were defined on one technique to be
valid on another is uncertain. It is likely that borderline cases will be
missed if we adopt the suggestion of the authors to perform ABPM before
starting any blood pressure lowering treatment.
Hypertension is probably on a continuous spectrum rather than a
distinct state. The suggestion of using ABPM rather than repeated BP
measuring to decide about treatment is equivalent to shifting the
threshold of treatment. Not to mention that ABPM is much less convenient
to the patient and more expensive to the system. And it will not stop
there; it makes the same sense to do the follow up using ABPM before any
decision on dosage change. We replace a simple method of patient self-
monitoring with a cumbersome technique that is probably needed only
occasionally.
Rapid Response:
An inconvenient way of shifting the threshold
The article "Relative effectiveness of clinic and home blood pressure
monitoring compared with ambulatory blood pressure monitoring in diagnosis
of hypertension: systematic review" by Hodgkinson et al (BMJ
2011;342:doi:10.1136/bmj.d3621) suggests that ambulatory blood pressure
monitoring (ABPM) should serve as a "gold standard", and if we accept
this, then about 25% of diagnosed hypertension cases are actually
overdiagnosis and should not be treated.
This view has a logical basis more than an evidence basis. The
approach to diagnosing and treating high blood pressure was never based on
ABPM. Assuming target values that were defined on one technique to be
valid on another is uncertain. It is likely that borderline cases will be
missed if we adopt the suggestion of the authors to perform ABPM before
starting any blood pressure lowering treatment.
Hypertension is probably on a continuous spectrum rather than a
distinct state. The suggestion of using ABPM rather than repeated BP
measuring to decide about treatment is equivalent to shifting the
threshold of treatment. Not to mention that ABPM is much less convenient
to the patient and more expensive to the system. And it will not stop
there; it makes the same sense to do the follow up using ABPM before any
decision on dosage change. We replace a simple method of patient self-
monitoring with a cumbersome technique that is probably needed only
occasionally.
yuval@lab.co.il
Competing interests: No competing interests