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Office Measurement vs. Ambulatory BP Monitoring
Quick Takes
- Ambulatory SBP parameters were more closely associated with all-cause, CV, and non-CV death than office SBP.
- Furthermore, diabetes mellitus increased risk associated with all SBP parameters with an almost doubling of event rates.
- These data support current major guideline recommendations for strict BP control in patients with metabolic disease guided by ambulatory BP monitoring.
Study Questions:
What is the relationship between office and ambulatory blood pressure (BP) measurements as well as different hypertension phenotypes with mortality in a large cohort of patients in primary care?
Methods:
The investigators assessed outcome data from the Spanish Ambulatory Blood Pressure Monitoring (ABPM) Registry in 59,124 patients with complete available data. The associations between office, mean, daytime, and nighttime ambulatory BP with the risk in patients with or without diabetes were explored. The effects of diabetes on mortality in different hypertension phenotypes (i.e., sustained hypertension, white-coat hypertension, and masked hypertension) compared with normotension were studied. Analyses were done with Cox regression analyses and adjusted for demographic and clinical confounders.
Results:
A total of 59,124 patients were recruited from 223 primary care centers in Spain. The majority had an office systolic BP (SBP) >140 mm Hg (36,700 patients), and 23,128 (40.6%) patients were untreated. Diabetes was diagnosed in 11,391 patients (19.2%). Concomitant cardiovascular (CV) disease was present in 2,521 patients (23.1%) with diabetes and 4,616 (10.0%) without diabetes. Twenty-four-hour mean, daytime, and nighttime ambulatory BP were associated with increased risk in diabetes and no diabetes, while in office BP, there was no clear association with no differences with and without diabetes. While the relative association of BP to CV death risk was similar in diabetes compared with no diabetes (mean interaction p = 0.80, daytime interaction p = 0.97, and nighttime interaction p = 0.32), increased event rates occurred in diabetes for all ABPM parameters for CV death and all-cause death.
White-coat hypertension was not associated with risk for CV death (hazard ratio, 0.86; 95% confidence interval, 0.72–1.03) and slightly reduced risk for all-cause death in no diabetes (hazard ratio, 0.89; confidence interval, 0.81–0.98) but without significant interaction between diabetes and no diabetes. Sustained hypertension and masked hypertension in diabetes and no diabetes were associated with even higher risk. There were no significant interactions in hypertensive phenotypes between diabetes and no diabetes and CV death risk (interaction p = 0.26), while some interaction was present for all-cause death (interaction p = 0.043) and non-CV death (interaction p = 0.053).
Conclusions:
The authors report that ambulatory SBP parameters were more closely associated with all-cause, CV, and non-CV death than office SBP.
Perspective:
This study reports that ambulatory SBP parameters were more closely associated with all-cause, CV, and non-CV death than office SBP. Furthermore, diabetes mellitus increased risk associated with all SBP parameters with an almost doubling of event rates. Of note, masked and sustained hypertension had the highest association with mortality, whereas white-coat hypertension was not associated with increased risk. These data support current major guideline recommendations for strict BP control in patients with metabolic disease guided by ABPM. To facilitate these implementations, ABPM across nations and regions should be broadly reimbursed.
Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention
Keywords: Blood Pressure Monitoring, Ambulatory, Diabetes Mellitus, Cardiometabolic Risk Factors
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