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Selection of patients for ambulatory monitoring in a primary care setting

Journal of Human Hypertension volume 21, pages 509–510 (2007)Cite this article

Any clinical measurement of blood pressure (BP) is effectively a surrogate measure for the ‘true’ BP of the patient, which might be defined pragmatically as the average level of BP over a prolonged period of time. Two methods have been developed to improve the estimation of ‘true’ BP: ambulatory blood pressure monitoring (ABPM) and home monitoring (or self-monitoring) of BP.1 But in a primary care setting – where the majority of the workload for detecting and treating hypertension lies – the logistics, costs and feasibility of performing ABPM or home monitoring are significant constraints. It is unrealistic to expect that ABPM will be available to all patients undergoing routine assessment of BP in primary care, but good clinical management requires an accurate diagnosis and it is difficult to differentiate patients with (true) hypertension from those with white-coat hypertension and so-called masked hypertension using clinic BP measurements alone. Thus, for routine practice in the community, there needs to be more specific guidance on how these techniques can be used selectively and sparingly to maximum benefit in specific clinical circumstances, for example, in assessing new patients when there is a high index of suspicion of a white-coat effect (WCE) or reverse WCE. An important practical question is whether serial measurements of clinic BP can be analysed in a way that helps to identify patients with these characteristic patterns of BP variation in whom more detailed BP monitoring is likely to be worthwhile.

The study by Larkin et al.2 in this issue of the Journal of Human Hypertension evaluates the predictive utility of measures of BP ‘habituation’ in the clinic – that is sequential changes in BP over time during a single visit and across separate visits – in identifying patients with a WCE and reverse WCE in a cohort of 54 patients. The authors demonstrate that patients with a WCE show greater habituation across clinic BP measurements (i.e, a bigger fall in both systolic and diastolic BP between visit 1 and visit 3), and correspondingly patients with a reverse WCE show significantly less habituation of BP both during a single visit and across visits. Furthermore, the degree of change in systolic BP between the first and third clinic visits was predictive of the magnitude of the WCE. As in previous studies, a WCE was more common in women and in patients with higher body mass index but rather surprisingly, in contrast to earlier research (e.g., Mansoor et al.3), Larkin et al.2 found that self-monitored BP added nothing to the predictive model.

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  1. Centre for Integrated Systems Biology and Medicine, School of Medical & Surgical Sciences, University of Nottingham, Nottingham, UK

    R Donnelly & G Manning

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  1. R Donnelly
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Correspondence to G Manning.

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Donnelly, R., Manning, G. Selection of patients for ambulatory monitoring in a primary care setting. J Hum Hypertens 21, 509–510 (2007). https://doi.org/10.1038/sj.jhh.1002183

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