Understanding short-term blood-pressure-variability phenotypes: from concept to clinical practice

Figures & data

Table 1 Recommendations for OBP monitoring from key guidelines on hypertension

	JSH 2014^Citation39	NICE 2011^Citation142	ESH/ESC 2013^Citation94	CHEP 2015^Citation143	AHA 2017^Citation105
Measurement devices	Auscultation using mercury/aneroid sphygmomanometry should be used. Electronic sphygmomanometry may also be used. Measuring devices should be properly validated, maintained, and regularly recalibrated. Cuff sizes appropriate for the patient’s arm circumference should be used.	Direct auscultation over the brachial artery using mercury/aneroid sphygmomanometry should be used. Aneroid sphygmomanometry may be less accurate than mercury-operated sphygmomanometry. Automated devices may also be used, except if there is pulse irregularity. Measuring devices should be properly validated, maintained, and regularly recalibrated. Cuff sizes appropriate for the patient’s arm circumference should be used.	Auscultatory/oscillometric semiautomatic sphygmomanometry is recommended, since mercury sphygmomanometry is no longer used in European countries. Measuring devices should be properly validated, maintained, and regularly recalibrated. Bladder dimensions should be suited to the arm circumference of the patient. An automated recording of clinic BP readings with the patient seated alone in an isolated room (AOBP) might produce more reliable readings than traditional OBP readings.	Measurements should be taken with electronic sphygmomanometry. If not available, a recently calibrated aneroid device may be used. Measuring devices should be properly validated, maintained, and regularly recalibrated. Choose a cuff with an appropriate bladder size. An automated recording of clinic BP readings with the patient seated alone in an isolated room (AOBP) is preferred over traditional OBP.	A validated and recently calibrated BP-measurement device should be used. Appropriate cuff size, such that the bladder covers 80% of the arm circumference, should be used.
Measurement conditions	BP should be measured in a quiet environment at room temperature after resting for a few minutes in a seated position on a chair with support for the back with the legs uncrossed. Talking during measurement should be avoided. Smoking and alcohol/caffeine consumption should be avoided before measurement. The arm cuff should be maintained at the heart level of the patient. The cuff should not be placed over thick clothing or on the elbow. Avoid tight compression of the measuring arm by folded sleeves.	A quiet and comfortable environment at normal room temperature is ideal. The patient should not have the need to pass urine or have eaten recently. Smoking or consumption of caffeine or exercise should be avoided prior to the measurement. Patient should be allowed to rest for at least 5 minutes before measurement. It is recommended that measurements be taken while seated. The patient’s arm should be out-stretched and rested on a table level with their heart and in line with their midsternum.	The patient should be allowed to sit for 3–5 minutes before BP measurements. The cuff should be at the heart level, regardless of the position of the patient. BP to be measured in both arms initially to spot possible variability between arms, after which the arm with the higher BP reading should be used.	The patient should be allowed to rest for about 5 minutes before the measurement. Patient should be in a seated position with back support with legs uncrossed. The measuring arm should be bare and supported at the heart level. The lower edge of the cuff should be 3 cm above the elbow crease and centered over the brachial artery. There should be no talking during the measurement.	The patient should be relaxed and seated in a chair with feet on floor and back supported for >5 min. Ensure that the patient has emptied his/her bladder. Avoid consumption of caffeine, physical activity, and smoking for at least 30 minutes before measurement. Patient and observer should not talk during the measurement. Patient’s measuring arm should be supported on a table. The location of cuff placement on the arm should have all clothing or covering removed. The middle of the cuff should be placed on the patient’s upper arm at the level of the midpoint of the sternum.
Measurement method	At least two BP measurements should be taken at 1- to 2-minute intervals in one clinic visit and the average value of the readings recognized as the OBP value. If the two measurements differ significantly, additional measurement should be performed. Hypertension should be diagnosed based only on the BP values measured over at least two different visits.	BP readings should be taken in both arms initially, and the arm with the higher reading should be selected for subsequent measurements. It is recommended to take two BP readings: one at the beginning and the other at the end of the visit.	Take at least two BP measurements in the sitting position with 1- to 2-minute intervals. If the first two readings are significantly different, take additional readings. Taking the average of these BP readings should be considered if deemed appropriate. Take repeated measurements in patients with arrhythmias, such as atrial fibrillation, for better assessment.	BP readings should be recorded to the closest 2 mmHg on the manometer or 1 mmHg on electronic devices. BP should be measured initially in both arms for at least one visit, and the arm with the higher pressure should be subsequently used for measurement. Seated BP should be used to diagnose and monitor treatment decisions, while standing BP should be used to monitor for presence of postural hypotension. In patients with arrhythmia, additional readings should be taken via auscultation to estimate average BP. When using AOBP, the first measurement should be taken by a health professional to verify cuff position and validity of the measurement. After this, the patient should be left alone for subsequent readings to be taken by an automatic device. When using traditional OBP, at least three readings to be measured in the same arm. The first reading should be discarded and the latter two averaged. To avoid venous congestion, it is recommended to space the readings at-least one minute apart.	BP should be measured in both arms initially to spot possible variability between arms, after which the arm with the higher BP reading should be used for subsequent readings. Repeated measurements should be taken only after at least 1–2 minutes. An average of at least two or more readings obtained on at least two or more visits should be used to estimate the individual’s BP.

Abbreviations: OBP, office blood pressure; JSH, Japanese Society of Hypertension; NICE, National Institute for Health and Care Excellence; ESH, European Society of Hypertension; ESC, European Society of Cardiology; CHEP, Canadian Hypertension Education Program; AHA, American Heart Association; OBPM, OBP monitoring; AOBP, automated OBP.

Figure 1 Measurement of home blood pressure (BP).

Note: Image created as per recommendations from JSH³⁹ and NICE¹⁴² guidelines.
Abbreviations: JSH, Japanese Society of Hypertension; NICE, National Institute for Health and Care Excellence.

Table 2 Recommendations on out-of-office BP measurements from key international guidelines on hypertension

Indications	JSH 2014^Citation39	NICE 2011^Citation142	ESH/ESC 2013^Citation94	CHEP 2015^Citation143	AHA 2017^Citation105
Confirmatory diagnosis of hypertension	If OBP is ≥140/90 mmHg, first offer HBPM to confirm the diagnosis of hypertension. Offer ABPM if confirmatory diagnosis of hypertension with HBPM is difficult, such as when HBP fluctuates around high-normal values of 125/80–134/84 mmHg.	If OBP is ≥140/90 mmHg, offer ABPM or HBPM (if the patient is unable to tolerate ABPM) to confirm the diagnosis of hypertension. However, if the patient has severe hypertension (ie, BP ≥180/110 mmHg), start antihypertensive treatment immediately without waiting for the results of ABPM or HBPM.	Out-of-office BP should be considered to confirm the diagnosis of hypertension. It is recommended to confirm borderline or abnormal findings on HBPM with ABPM.	If first-visit mean AOBP is ≥135/85–109 mmHg or the mean non-AOBP is ≥140/90 mmHg, ABPM or HBPM should be performed before the second visit. If during the first visit, mean AOBP or non-AOBP SBP is ≥180/110 mmHg, hypertension is diagnosed without the need for out-of-office BP measurements.	Diagnosis of hypertension for patients with OBP of ≥130/80 mmHg should be confirmed with corresponding HBPM or ABPM values.
Identification and management of white-coat hypertension	If OBP is ≥140/90 mmHg, first offer HBPM to detect white-coat hypertension. When a definitive diagnosis of white-coat hypertension cannot be made based on the HBP level, offer ABPM.	When an untreated patient has persistently elevated OBP readings, but has normal HBP or ABP values of <135/85 mmHg, white-coat hypertension may be present. When a hypertensive patient has disproportionately higher OBPM readings than HBPM or ABPM readings, a white-coat effect may be present.	HBPM or ABPM is recommended to detect white-coat hypertension in untreated individuals with grade I hypertension without the presence of asymptomatic organ damage and at low total CV risk. HBPM or ABPM should also be used in identification of the white-coat effect in hypertensive patients.	ABPM is the gold standard for diagnosis of white-coat hypertension. HBPM can also be used to diagnose white-coat hypertension, but it should be confirmed by repeated HBPM or ABPM. The use of HBPM on a regular basis is recommended for hypertensive patients who have previously demonstrated a white-coat effect.	In untreated patients with OBP ≥130/80 mmHg but <160/100 mmHg despite 3 months of lifestyle modification, offer ABPM or HBPM to screen for white-coat hypertension. In treated patients with OBP ≥5–10 mmHg above target BP despite use of three or more antihypertensive agents, offer HBPM or ABPM to detect white-coat hypertension.
Identification and management of masked hypertension	If OBP is <140/90 mmHg, first offer HBPM to detect masked hypertension. When a definitive diagnosis of masked hypertension cannot be made based on the HBP level, offer ABPM.	When a patient has normal OBP readings of <140/90 mmHg but elevated daytime ABPM and/or HBPM measurements of ≥135/85 mmHg, masked hypertension may be present.	HBPM or ABPM is recommended to detect masked hypertension in patients with high-normal OBP and/or normal OBP with asymptomatic organ damage or high total CV risk.	HBPM is useful for the diagnosis of masked hypertension, and its use on a regular basis should be considered for hypertensive patients who have previously demonstrated masked hypertension.	In untreated patients with OBP systolic BP 120–129 mmHg and diastolic BP <80 mmHg despite 3 months of lifestyle modification, offer ABPM or HBPM to screen for masked hypertension. In treated patients who are meeting OBP goal but at increased CVD risk or target-organ damage, offer HBPM or ABPM to detect masked hypertension.
Assessment and management of short-term BPV	Out-of-office BP measurements, such as HBPM and ABPM, should be used to monitor short-term BP changes, such as nocturnal dipping and early-morning BP surge to maximize CV-risk reduction.	Not discussed	ABPM is recommended to assess nocturnal dipping status and nocturnal hypertension or in cases where absence of dipping is suspected, such as in patients with sleep apnea, CKD, or diabetes.	The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy based on ABPM results.	Not discussed
Assessment and management of hypertension treatment	HBPM is recommended for evaluation of effectiveness of current treatment, as well as to assess patient’s adherence to treatment.	For patients identified as having a white-coat effect, consider ABPM or HBPM as an adjunct to OBPM measurements to monitor their response to treatment.	Out-of-office measurements should always be used together with office measurements to evaluate treatment targets, despite the current lack of direct evidence on BP targets for HBPM or ABPM.	HBPM should be used to monitor and improve compliance if a patient is suspected of non-adherence to treatment. ABPM should be used to monitor patients who are below their target BP, despite receiving appropriate chronic antihypertensive therapy.	HBPM and/or ABPM measurements are recommended in treatment evaluation, such as titration of BP-lowering medication in conjunction with telehealth counseling or clinical interventions.

Abbreviations: BP, blood pressure; JSH, Japanese Society of Hypertension; NICE, National Institute for Health and Care Excellence; ESH, European Society of Hypertension; ESC, European Society of Cardiology; CHEP, Canadian Hypertension Education Program; AHA, American Heart Association; BPV, BP variability; OBP, office BP; OBPM, office BP monitoring; HBP, home BP; HBPM, HBP monitoring; ABP, ambulatory BP; ABPM, ABP monitoring; AOBP, automated OBP; CV, cardiovascular; CVD, cardiovascular disease; CKD, chronic kidney disease.

Table 3 Recommendations from key international guidelines on diagnosis of hypertension using OBP and out-of-office BP monitoring

	JSH 2014^Citation39	NICE 2011^Citation142	ESH/ESC 2013^Citation94	CHEP 2015^Citation143	AHA 2017^Citation105
OBP	≥140/90 mmHg	≥140/90 mmHg	≥140/90 mmHg	AOBP ≥135/85 mmHg or non-AOBP ≥140/90 mmHg	OBP ≥130/80 mmHg with estimated 10-yr CV risk ≥10%
Home BP	≥135/85 mmHg	≥135/85 mmHg	≥135/85 mmHg	≥135/85 mmHg	≥130/80 mmHg with estimated 10-yr CV risk ≥10%
Ambulatory daytimea BP	≥135/85 mmHg	≥135/85 mmHg	≥135/85 mmHg	≥135/85 mmHg	≥130/80 mmHg with estimated 10-yr CV risk ≥10%
Ambulatory nighttimeb BP	≥120/70 mmHg	–	≥120/70 mmHg	–	≥110/65 mmHg with estimated 10-yr CV risk ≥10%
Ambulatory 24-hourc BP	≥130/80 mmHg	–	≥130/80 mmHg	≥130/80 mmHg	≥125/75 mmHg with estimated 10-yr CV risk ≥10%

Notes:

a Average of BP readings taken while patient is awake;

b average of BP readings taken while patient is asleep;

c average of BP readings taken over a whole day (24 hours).

Abbreviations: OBP, office blood pressure; JSH, Japanese Society of Hypertension; NICE, National Institute for Health and Care Excellence; ESH, European Society of Hypertension; ESC, European Society of Cardiology; CHEP, Canadian Hypertension Education Program; AHA, American Heart Association; AOBP, automated OBP; CV, cardiovascular.

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