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Clinicians do not follow guidelines for diagnosing hypertension

AHA Hypertension 2020
Reuters Health - 10/09/2020 - Clinicians commonly do not follow U.S. Preventive Services Task Force (USPSTF) recommendations for diagnosing hypertension, according to a survey and a related study.

USPSTF recommends out-of-office blood pressure measurements before making a new diagnosis of hypertension, using 24-hour ambulatory (ABPM) or home blood pressure monitoring.

"We need more out-of-office BP monitoring," Dr. Beverly Green of Kaiser Permanente Washington Health Research Institute, in Seattle, told Reuters Health by email. "BPs from one clinic visit, even when done with an automated office BP protocol (AOBP), should not be used to replace out-of-office BPs for diagnosing hypertension."

Dr. Green and colleagues presented their findings at the American Heart Association Hypertension 2020 Virtual Scientific Sessions.

The team evaluated provider knowledge, beliefs, and practices about blood pressure diagnostic tests in their survey of 282 providers, including 102 medical assistants, 28 licensed practical nurses, 33 registered nurses, 86 primary care physicians and 33 advanced practitioners.

More than three-quarters of providers (78.8%) believed that blood pressure measured manually using a stethoscope and ABPM were very or highly accurate ways to measure blood pressure when making a new diagnosis of hypertension.

Almost all providers (95.7%), however, reported that they always or almost always relied on clinic blood pressure measurements for making a new diagnosis of hypertension, although 60.5% of physicians and advanced practitioners would prefer using ABPM were it readily available.

Almost all physicians and advanced practitioners used a clinic blood pressure threshold of 140/90 mmHg for making a new diagnosis of hypertension, and very few reported guideline-concordant home or ABPM diagnostic thresholds, according to the conference poster.

Dr. Jordana Cohen of Perelman School of Medicine, University of Pennsylvania, in Philadelphia, who has also demonstrated the importance of integrating out-of-office blood pressure in the diagnosis and management of hypertension, told Reuters Health by email, "We need an overhaul of the current approach to push for much broader (appropriate) use of out-of-office blood pressure monitoring, including ambulatory and self-monitoring of blood pressure at home by patients."

"For self-monitoring of blood pressure at home," she added, "patients need access to appropriate education, individual validation of their home devices, and team-based care to provide updated education and feedback/appropriate medication titration based on home blood pressures."

"We need to do a much better job of educating providers about best practices in hypertension, particularly that typical in-office blood pressure measurement using manual devices is prone to miscalibration, several sources of measurement inaccuracy, and white-coat hypertension," she said.

Dr. Cohen, who was no involved in the new work, concluded, "We need to do a much better job of educating providers on the front line about the evidence-driven need to be screening and monitoring blood pressure outside of the office."

Dr. C. Venkata S. Ram of Apollo Hospitals, in Hyderabad, India, director of World Hypertension League, told Reuters Health by email, "Somehow the doctors in U.S. have not taken the new definition of hypertension (HTN) seriously. They need to be educated about the critical definition of HTN 130/80 mmHg. Anyone not following this simple directive should be counseled and/or admonished/scolded for putting the patients at risk."

Dr. Ram, who also was not involved in the study, added, "Get away from manual BP measurements. Throw away your manual devices, trash them. And don't use a stethoscope to measure the BP, ever. Please use automated office BP machines only."

In the related study, Dr. Green and colleagues evaluated the effects of the presence/absence of an attendant in the room and varying amounts of rest time on AOBP measurements. They also compared the diagnostic performance of AOBP in making a new diagnosis of hypertension compared with ABPM.

Systolic blood pressure averaged 3.9 mmHg lower and diastolic blood pressure averaged 2.9 mmHg when measured by AOBP than when using mean daytime ABPM.

AOBP showed no significant within-person differences between attended versus unattended measurements or after 5 versus 15 minutes of rest.

Using daytime mean ABPM of 135/85 mmHg as the diagnostic threshold, AOBP was only 71.0% sensitive and 54.1% specific for making a new diagnosis of hypertension.

"I found it interesting that blood pressure measurements taken using an AOBP (rest 5 minutes, then take 3 BPs one minute apart and average these) were lower than daytime mean 24-hour ambulatory BP," Dr. Green said. "This led to missing people with true hypertension."

Dr. Dennis Bloomfield of Richmond University Medical Center, in New York City, who has researched various aspects of hypertension, told Reuters Health by email, "I find the study neither surprising nor particularly interesting in its conclusion that the AOPB is better than the ABPM in diagnosing hypertension."

"While it shows a mathematically statistical difference, there is no practical difference in a measure of 3.9 systolic and 2.9 diastolic mmHg in the clinical diagnosis of hypertension. During the waking hours, blood pressure varies over a very much greater range and differs from day to day," he said.

By Will Boggs MD

SOURCE: https://bit.ly/3k6uTjW AHA Hypertension 2020 Scientific Sessions, September 10, 2020.

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