Perspective
Blood Pressure Measurement: A KDOQI Perspective

https://doi.org/10.1053/j.ajkd.2019.08.030Get rights and content

The majority of patients with chronic kidney disease (CKD) have elevated blood pressure (BP). In patients with CKD, hypertension is associated with increased risk for cardiovascular disease, progression of CKD, and all-cause mortality. New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend new thresholds and targets for the diagnosis and treatment of hypertension in patients with and without CKD. A new aspect of the guidelines is the recommendation for measurement of out-of-office BP to confirm the diagnosis of hypertension and guide therapy. In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we review the recommendations for accurate BP measurement in the office, at home, and with ambulatory BP monitoring. Regardless of location, validated devices and appropriate cuff sizes should be used. In the clinic and at home, proper patient preparation and positioning are critical. Patients should receive information about the importance of BP measurement techniques and be encouraged to advocate for adherence to guideline recommendations. Implementing appropriate BP measurement in routine practice is feasible and should be incorporated in system-wide efforts to improve the care of patients with hypertension. Hypertension is the number 1 chronic disease risk factor in the world; BP measurements in the office, at home, and with ambulatory BP monitoring should adhere to recommendations from the AHA.

Introduction

The number of US adults with hypertension is now more than 100 million according to the new guidelines from the American College of Cardiology/American Heart Association (ACC/AHA).1 Of these individuals, more than 80 million qualify for treatment with antihypertensive medications.1 Hypertension is an especially important comorbid condition in patients with chronic kidney disease (CKD); 86% of participants in the Chronic Renal Insufficiency Cohort (CRIC) Study had hypertension at baseline.2 A key component for quality of care in adults with hypertension is measurement of blood pressure (BP).

In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we summarize recommendations for proper clinic/office, home, and ambulatory BP measurements and highlight areas that are especially pertinent in patients with CKD. A separate KDOQI commentary discussed the relevance of the 2017 ACC/AHA guidelines for management of BP in patients with CKD.3

Section snippets

Office BP

Introduction of cuff-based sphygmomanometry by Riva-Rocci4 in 1896 provided the first practical method for estimation of systolic BP. Diastolic BP readings became feasible in 1905 when Korotkov5 described his auscultatory measurement method. These methods were disseminated rapidly and by 1918, all US insurance companies considered measurement of BP to be an essential part of their eligibility examination.6 The fact that BP varies dramatically from one reading to another was recognized and as

Use of Home BP Monitoring and ABPM

The current ACC/AHA guideline for the detection and treatment of hypertension recommends use of out-of-office BP measurement to confirm the diagnosis of hypertension and to monitor treatment.14 This recommendation is based on observational studies showing that out-of-office BPs are associated with adverse events. Ambulatory BPs are more strongly associated with cardiovascular disease events and mortality than clinic BPs.35, 36, 37, 38 Home BP measurements also show a stronger association with

Patient Education Regarding Proper BP Measurement Technique

A common concern regarding the validity of applying SPRINT findings to routine clinical practice is that SPRINT BP measurements were “research protocol” measurements and therefore cannot be applied in the busy clinical practice. The major flaw with this argument is that standardization of techniques has been the norm in most of the landmark BP–cardiovascular disease risk and antihypertensive treatment trials. In the context of diagnosis and management of high BP, evidence-based medicine assumes

Systems Design Approaches for Optimal Assessment and Management of Hypertension

Management of patients with hypertension is amenable to a systems design approach. Many studies have demonstrated that multifaceted team-based interventions are effective at improving BP control rates.14 However, only a few of these investigations have included improvement of BP measurement techniques as a component of their interventions. The Kaiser Permanente Northern California hypertension program included a registry, reports on control rates, dissemination of effective strategies to

Conclusion

Proper BP measurement technique has been a cornerstone of both the observational studies that have established hypertension as one of the leading risk factors for chronic disease and the clinical trials that have demonstrated the benefits of treating elevated BP. Regardless of whether BP is measured in the clinic, at home, or with ABPM, proper technique is critically important to ensure as accurate an assessment as possible given the inherent variability of BP. Several issues can complicate the

Article Information

Authors’ Full Names and Academic Degrees

Paul E. Drawz, MD, MHS, MS, Srinivasan Beddhu, MD, Holly J. Kramer, MD, Michael Rakotz, MD, Michael V. Rocco, MD, MSCE, and Paul K. Whelton, MB, MD, MSc.

Support

There was no monetary or nonmonetary support for the preparation of the manuscript. Dr Drawz was supported by grant R01HL136679 from the National Heart, Lung, and Blood Institute.

Financial Disclosure

Dr Beddhu reports research grants/funding from NIH, VA, Boeringher Ingelheim, and Bayer, as well as consultant fees from Reata and Bayer. The other authors declare

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