PerspectiveBlood Pressure Measurement: A KDOQI Perspective
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
References (61)
- et al.
Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline
J Am Coll Cardiol
(2018) - et al.
Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study
Am J Kidney Dis
(2010) - et al.
KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline
Am J Kidney Dis
(2019) - et al.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
J Am Coll Cardiol
(2018) - et al.
Blood pressure assessment in adults in clinical practice and clinic-based research: JACC Scientific Expert Panel
J Am Coll Cardiol
(2019) - et al.
Assessment of achieved clinic and ambulatory blood pressure recordings and outcomes during treatment in hypertensive patients with CKD: a multicenter prospective cohort study
Am J Kidney Dis
(2014) - et al.
Prognostic importance of clinic and home blood pressure recordings in patients with chronic kidney disease
Kidney Int
(2006) - et al.
Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease
Kidney Int
(2006) Un nuovo sfigmomanometro
Gazz Medi Torino
(1896)To the question of methods of determining the blood pressure
Rep Imp Military Acad
(1905)
The Association of Life Insurance Medical Directors of America 100 years of progress
J Insur Med
The Clinical Study of Blood-Pressure
The history of blood pressure measurement
J Hum Hypertens
The variability of measurements of casual blood pressure. II. Survey experience
Clin Sci
The variability of measurements of casual blood pressure. I. A laboratory study
Clin Sci
Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension: a systematic review and meta-analysis
JAMA Intern Med
BP measurement in clinical practice: time to SPRINT to guideline-recommended protocols
J Am Soc Nephrol
Clinical implications of different blood pressure measurement techniques
Curr Hypertens Rep
2018 ESC/ESH guidelines for the management of arterial hypertension
Eur Heart J
Measurement of blood pressure in humans: a scientific statement from the American Heart Association
Hypertension
Blood pressure measurement in SPRINT (Systolic Blood Pressure Intervention Trial)
Hypertension
Unattended versus attended automated office blood pressure: systematic review and meta-analysis of studies using the same methodology for both methods
J Clin Hypertens (Greenwich)
Self-recording of blood pressure in the management of hypertension
Can Med Assoc J
Home blood pressure determination. Value in borderline (“labile”) hypertension
JAMA
Masked hypertension and elevated nighttime blood pressure in CKD: prevalence and association with target organ damage
Clin J Am Soc Nephrol
Variations in 24-hour BP profiles in cohorts of patients with kidney disease around the world: the I-DARE Study
Clin J Am Soc Nephrol
Validation of the SpaceLabs 90207 ambulatory blood pressure device for hemodialysis patients
Blood Press Monit
European Society of Hypertension position paper on ambulatory blood pressure monitoring
J Hypertens
Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review
J Hum Hypertens
Validation of an oscillometric home blood pressure monitor in an end-stage renal disease population and the effect of arterial stiffness on its accuracy
Blood Press Monit
Cited by (27)
Clinical Value of Ambulatory Blood Pressure Monitoring in CKD
2023, American Journal of Kidney DiseasesKDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD
2022, American Journal of Kidney DiseasesCitation Excerpt :KDIGO defines standardized office BP as measurement of BP using a technique that is adherent to guideline-recommended preparations and steps. These include appropriate cuff size, patient positioning, rest prior to readings, and obtaining multiple readings at each clinic visit.14 Standardized office BP measurements are, on average, lower than routine office BPs.
Resistant Hypertension in People With CKD: A Review
2021, American Journal of Kidney DiseasesCitation Excerpt :ABPM is useful to detect nondipping and is preferred over HBPM for identifying MH in patients with advanced CKD.32 If white-coat effect or MH is established, HBPM or ABPM should be used to guide further management decisions.32 Recommendations for HBPM are shown in Box 3.33
Effect of overweight/obesity and metabolic syndrome on frailty in middle-aged and older Japanese adults
2024, Obesity Science and Practice
Complete author and article information provided before references.