Blood Pressure Screening Methods and Rescreening Intervals: An

Updated Systematic Review for the USPSTF

PracticeUpdate 2015-01-07 07:38 4393

2014 11 23
40
1~6 6
BMI
Ronald G Victor
2014 11 23 2014
JNC8 JNC8
BP> 160/100 mmHg
JNC8 BP
Meta
10 6000 96%
64 146/84 mmHg
vs vs BP 4/2mmHg
5 28% 25% 22%<150mmHg
60 JNC 8

USPSTF 2011 NICE

2013 / BP
BP JNC 8
27 5%~65% BP

30% 40% BP
/
CMS BP /

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The authors of this review summarize evidence on blood pressure (BP) rescreening intervals and accuracy
of different BP methods. Evidence supports ambulatory BP monitoring as a reference standard for
confirming elevated office BP screening results to avoid misdiagnosis of patients with isolated clinic
hypertension. Data from 40 studies showed that the incidence of hypertension after rescreening varied
considerably when measured at yearly intervals up to 6 years.
Individuals at higher risk for hypertension on rescreening within 6 years include older individuals, blacks,
those with BP in the high-normal range, and those with above-normal BMI.
Expert Comment
Two studies published this week in the Annals of Internal Medicine challenge two major tenets of the JNC 8
Report, namely that hypertension trials have: (1) enrolled patients with mainly Stage 2 hypertension
(baseline BP > 160/100 mmHg) and thus provide no convincing evidence for benefits of treating mild
hypertension, which is far more common; (2) relied strictly on conventional office-based BP measurements
to show the benefits of therapy. Results of the Blood Pressure (BP) Treatment Trialists Collaboration metaanalysis challenges the first tenet by providing new evidence that treatment of even mild hypertension
significantly reduces the risk of stroke and death. They analyzed patient-specific data from 10 trials in which
over 6,000 patients (96% of whom had diabetes) who were free of overt cardiovascular disease, mean age
of 64 years, and mean baseline BP of 146/84 mmHg were randomized to either active therapy vs. placebo
or more intensive vs. less intensive therapy. Mild additional BP reductions of only 4/2 mm Hg in active
treatment groups versus comparison groups were accompanied 5 years later by 28% fewer strokes, 25%
fewer cardiovascular deaths, and 22% fewer total deaths. Virtually identical results were found in the small
subgroup of patients with systolic BP < 150 mmHg, age > 60, and no diabetesthus directly challenging the
strongest but also most controversial recommendation of the JNC 8 Report. Stroke is so tightly linked to
systolic BP that I consider treating such mild hypertension with my patients whose major concern is to avoid
a stroke.
Next, a systemic review by the U.S. Preventive Services Task Force challenges the second tenet by
confirming the widely held conclusion of both the 2011 British (National Institute for Clinical Excellence)
Hypertension Guidelines and the 2013 European Society of Hypertension/European Society of Cardiology
Guidelines that ambulatory BP monitoring is far superior to conventional office BP in predicting long-term
cardiovascular outcomes. Across 27 studies, 5% to 65% of persons with no prior diagnosis of hypertension
and an elevated BP at initial office screening were subsequently found to be normotensive by ambulatory
monitoringi.e., to have white coat hypertension. Other studies have shown that up to 30% of patients with
diabetes and 40% of patients with chronic kidney disease will have masked hypertensionnormotensive BP
readings in the office but clearly high BP during their daily lives and/or at night by ambulatory monitoring. In
my opinion, time is long overdue for our governmentspecifically the Center for Medicare and Medicaid
Services (CMS)to join the British and European governments in routinely reimbursing ambulatory BP
monitoring both to confirm/reject the initial diagnosis of hypertension and to screen for masked hypertension
in high risk patients. This would eliminate millions of cases in the U.S. of both over-treatment and undertreatment of hypertension.

Annals of Internal Medicine

Diagnostic and Predictive Accuracy of Blood Pressure Screening Methods With Consideration of
Rescreening Intervals: An Updated Systematic Review for the US Preventive Services Task Force
Ann. Intern. Med 2014 Dec 23;[EPub Ahead of Print], MA Piper, CV Evans, BU Burda, KL Margolis, E
O'Connor, EP Whitlock
From MEDLINE/PubMed, a database of the U.S. National Library of Medicine.
This abstract is available on the publisher's site.
Access this abstract now
Copyright 2015 Elsevier Inc. All rights reserved.