Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore

Figures & data

Table 1 Blood pressure monitoring-related guidance from international guidelines commonly referred to in Singapore

Parameter	NICE 2011^Citation3	ESH/ESC 2013^Citation1	JSH 2014^Citation4
Hypertension (ABPM)	Daytime average BP: ≥135/≥85 mmHg*	Daytime/awake BP: ≥135/85 mmHg Night-time/asleep BP: ≥120/70 mmHg 24-hour BP: ≥130/≥80 mmHg	24-hour BP: ≥130/80 mmHg
Hypertension (HBPM)	BP ≥135/≥85 mmHg*	BP ≥135/≥85 mmHg	BP ≥135/85 mmHg‡
White-coat hypertension	A discrepancy of >20/10 mmHg between clinic BP and average daytime ABPM or average HBPM	Elevated clinic BP (≥140/90 mmHg) at multiple visits but normal BP (<130/85 mmHg) on either ABPM or HBPM	Clinic BP ≥140/90 mmHg with BP <135/85 mmHg on HBPM or mean 24-hour BP <130/80 mmHg on ABPM
Masked hypertension	ND	Clinic BP <130/85 mmHg with BP ≥140/90 mmHg on ABPM or HBPM	Clinic BP <140/90 mmHg with BP >135/85 mmHg on HBPM or mean 24-hour BP >130/80 on ABPM
24-hour BP control	Daytime average BP targets on ABPM or HBPM of <135/85 mmHg (age <80 years) or <145/85 mmHg (age ≥80 years)	Lists methods to improve adherence to physicians’ recommendations as a way of improving BP control	BP control over 24 hours is important HBPM and ABPM can be used to assess diurnal changes in BP

Notes:

* In addition to clinic BP ≥140/90 mmHg (use ABPM first, then HBPM if ABPM not tolerated);

‡ If clinic BP differs from home BP, the HBPM-based diagnosis should take priority.

Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; ESC, European Society of Cardiology; ESH, European Society of Hypertension; HBPM, home blood pressure monitoring; JSH, Japanese Society of Hypertension; ND, not discussed; NICE, National Institute for Health and Care Excellence.

Figure 1 Physician recruitment.

Abbreviations: GPs, general practitioners; HTN, hypertension.

Table 2 Practice setting and patient comorbidities

	GPs (n=30)	Cardiologists (n=20)	Nephrologists (n=10)
Practice setting, n (%)
GP clinic	15 (50)	0	0
Group practice	15 (50)	0	0
Restructured	0	8 (40)	9 (90)
Private	0	12 (60)	1 (10)
Treated patients by comorbidity, %*
No comorbidities	37	17	16
Diabetes	33	31	53
Hyperlipidemia	39	42	56
Stroke	6	13	13
Angina	4	31	17
Atrial fibrillation	3	18	12
Heart failure	4	17	19
Myocardial infarction	5	24	18
Other	0	1	32

Notes:

* Total percentages may be >100% as patients may have more than one comorbidity.

Abbreviation: GPs, general practitioners.

Figure 2 Proportion of physicians providing different instructions for morning home blood pressure measurement to their patients.

Note: Values are the percentage of physicians.

Table 3 Recommended frequencies of home blood pressure monitoring and measurements

Parameter	Physicians making recommendation, n (%)
	Total (n=60)	GPs (n=30)	Cardiologists (n=20)	Nephrologists (n=10)
Frequency of HBPM
Every day	24 (40)	14 (47)	8 (40)	2 (20)
5 days every week	4 (7)	3 (10)	1 (5)	0 (0)
4 days every week	6 (10)	2 (7)	1 (5)	3 (30)
3 days every week	18 (30)	7 (23)	7 (35)	4 (40)
2 days every week	5 (8)	3 (10)	1 (5)	1 (10)
1 day every week	3 (5)	1 (3)	2 (10)	0 (0)
Number of measurements
One	9 (15)	4 (13)	3 (15)	2 (20)
Two	41 (68)	21 (70)	14 (70)	6 (60)
Three	10 (17)	5 (17)	3 (15)	2 (20)
Duration
Lifelong	38 (63)	18 (60)	13 (65)	7 (70)
For 1 year	2 (3)	1 (3)	1 (5)	0 (0)
For several months	10 (17)	6 (20)	3 (15)	1 (10)
For 1 month	5 (8)	3 (10)	2 (10)	0 (0)
For 1 week	5 (8)	2 (7)	1 (5)	2 (20)
Measurements to document
All	23 (38)	9 (30)	9 (45)	5 (50)
Mean of all	10 (17)	5 (17)	2 (10)	2 (20)
Mean of first and second	8 (13)	4 (13)	2 (10)	2 (20)
First	7 (12)	5 (17)	1 (5)	10 (10)
Second	6 (10)	3 (10)	3 (15)	0 (0)
Mean second and third	5 (8)	2 (7)	3 (15)	0 (0)
Other	1 (6)	2 (7)	0 (0)	0 (0)
Timing of evening measurement
Before dinner	7 (12)	1 (3)	6 (30)	0 (0)
After dinner	9 (15)	6 (20)	2 (10)	1 (10)
Before bedtime	28 (47)	16 (53)	4 (20)	8 (80)
No instructions	16 (27)	7 (23)	8 (40)	1 (10)

Abbreviations: GPs, general practitioners; HBPM, home blood pressure monitoring.

Figure 3 Indications for ABPM overall and by physician specialty; comparative overall values for HBPM are included, where available.

Note: Values are the percentage of physicians.
Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; BPV, blood pressure variability; CVD, cardiovascular disease; GPs, general practitioners; HBPM, home blood pressure monitoring.

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