Florian Rader, MD, MSc, on At-Home Blood Pressure Monitoring for High-Risk Patients
It is understood that out-of-office blood pressure (BP) can predict cardiovascular (CV) complications better than clinic BP. And now, new findings show that out-of-office BP is superior to clinic BP for predicting hypertensive heart disease, as well—especially among non-Hispanic blacks.1
The study authors used cardiac magnetic resonance imaging to analyze the 2 BP monitoring methods’ ability to predict left ventricular hypertrophy among black and white individuals. By doing this, Florian Rader, MD, MSc, lead physician of the Hypertension Center of Excellence and co-director of the Hypertrophic Cardiomyopathy Clinic at the Cedars-Sinai Smidt Heart Institute, and colleagues came to the conclusion that out-of-office hypertension management programs are crucial for the prevention of hypertensive heart disease.
We asked Dr Rader about the importance of out-of-office BP monitoring—especially among high-risk black patients—and how practitioners can encourage their patients to do so properly.
CARDIOLOGY CONSULTANT: What prompted you to conduct this study?
Florian Rader: Non-Hispanic black patients with hypertension are known to have higher rates of masked hypertension (higher home than office BP). It is also known from BP monitoring studies that daytime home BP is a stronger predictor for CV complications than office BP. In this substudy of the Dallas Heart Study, we had the unique opportunity to study office and out-of-office BP readings and how they relate to left ventricular hypertrophy from hypertension, which is a strong predictor of CV complications as well.
CARDIO CON: In what ways do your results highlight the importance of protocol-driven supervised out-of-office BP monitoring?
FR: Our results show that out-of-office BP measurements correlate much closer with left ventricular hypertrophy. Such hypertrophy is an adaptation of the heart in response to long-standing pressure-overload and, as mentioned previously, is a strong predictor of CV complications such as myocardial infarctions, heart failure, and stroke. Our study highlights that assessment of out-of-office BP is crucial, and its control may have a larger impact on CV risk reduction than assessing—and treating—office BP alone.
CARDIO CON: How should cardiologists approach a conversation about the importance of out-of-office BP monitoring with their non-Hispanic black patients with hypertension?
FR: Any practitioner who treats hypertension should intermittently assess out-of-office BP, irrespective of ethnicity or race. However, our study suggests that this is even more important in non-Hispanic black individuals with hypertension. We can simply ask the patient to measure BP at home in a standardized fashion. Even better than home BP measurement is assessment of out-of-office BP with an automated ambulatory BP monitor, which eliminates the alerting reaction from self-monitoring—a similar reaction to BP measuring as seen with white coat hypertension in the office—and provides an assessment of nighttime BP, which may be even more important than daytime out-of-office BP. Unfortunately, we did not have ambulatory BP measurements available in this study.
CARDIO CON: What does a successful out-of-office BP monitoring routine look like? And what tips might cardiologists give to their patients to ensure that the monitoring is done successfully?
FR: I typically recommend measuring home BP at set times in a standardized fashion. Ideally, 3 measurements are taken in the morning—after using the bathroom and before taking antihypertensive medications— and again 3 measurements in the evening for 1 week at a time. Overburdening patients with self-monitoring of BP can be counterproductive and may create an obsessive focus and, in some patients, unnecessary worries about BP. Therefore, self-monitoring is best limited to times when antihypertensive medications are adjusted or intermittently every few months to confirm continuous adequate BP control.
CARDIO CON: What are the barriers to out-of-office BP monitoring—particularly among non-Hispanic black patients—and how can the barriers be overcome?
FR: There are few barriers with home BP monitoring. The cost of BP cuffs has come down, and they are affordable for almost every person. We still recommend using a validated BP monitor with a soft upper arm cuff. There are online resources to identify such recommended monitors. Compliance with self-monitoring could be an issue, but on the flipside, self-monitoring may improve medication adherence, as it provides feedback about BP control and engages the patient.
Practitioners should emphasize the importance of out-of-office BP measurements, and oversight of these is becoming easier with newer devices that can send home BP readings to the patients’ electronic medical chart. Doctors’ offices will soon have to find ways to monitor such incoming data, which are important for hypertension management but also may pose a certain degree of liability.
Reference:
- Rader F, Franklin SS, Mirocha J, Vongpatanasin W, Haley RW, Victor RG. Superiority of out-of-office blood pressure for predicting hypertensive heart disease in non-Hispanic black adults. Hypertension. 2019;74(5):1192-1199. doi:10.1161/HYPERTENSIONAHA.119.13542.