SOURCE: Verdeechia P, et al. Twenty-four hour ambulatory blood pressure monitoring to all? Comments to the US Preventive Services Task Force document. J Am Soc Hypertens 2015;9:911-915.
In 2011, the British were the first to include a recommendation that all patients identified with elevated blood pressure in the office undergo 24-hour ambulatory blood pressure monitoring (ABPM) before finalizing the diagnosis. They estimated that routinely employing ABPM would save tens of millions of dollars. In 2015, the United States Preventive Services Task Force evaluated the very same issue, and came to the same conclusion: ABPM should be routinely included as a diagnostic tool before confirming the diagnosis of hypertension. Why should we listen to this new advice?
It has been shown that a substantial minority of patients who demonstrate elevated office blood pressure (OBP), when monitored by ABPM, are determined not to have hypertension at all; rather, they have what is usually called white-coat hypertension, a transient phenomenon seen among patients whose anxiety during medical encounters raises their blood pressure into the hypertensive range. As many as one-third of patients originally diagnosed with hypertension through OBP are ultimately determined to have white-coat hypertension. Fortunately, the epidemiologic data looking at outcomes among patients with white-coat hypertension suggests that cardiovascular outcomes are essentially no different than normotensive patients.
Patients with white-coat hypertension, whether treated or not, typically show declines in blood pressure over time. When unnecessarily treated, they sustain the costs, adverse effects, and consequences of misdiagnosis (i.e., epidemiologic data have shown that simply being diagnosed as hypertensive is associated with lower quality-of-life scores).
ABPM is readily available, has little or no adverse effects, and is not costly (typically around $100-$150). Considering that it could save a patient years of unnecessary treatment, we should follow the advice the British adopted long ago: ABPM for all initially diagnosed hypertensives to confirm the diagnosis.