High Blood Pressure: Screening and Home Monitoring -- Adults


General

Grade: A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Frequency of Service

The USPSTF recommends annual screening for adults aged 40 years or older and for those who are at increased risk for high blood pressure.

Risk Factor Information

The USPSTF recommends annual screening for adults aged 40 years or older and for those who are at increased risk for high blood pressure. Persons at increased risk include those who have high-normal blood pressure (130 to 139/85 to 89 mm Hg), those who are overweight or obese, and African Americans. Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years. The USPSTF recommends rescreening with properly measured office blood pressure and, if blood pressure is elevated, confirming the diagnosis of hypertension with ABPM.


Clinical

Patient Population Under Consideration

This recommendation applies to adults aged 18 years or older without known hypertension.

Screening Tests

Office Blood Pressure Measurement

Office measurement of blood pressure is most commonly done with a manual or automated sphygmomanometer. Little research has been done on the best approach to measuring blood pressure in the office setting. Most clinical trials of hypertension treatment, at a minimum, used the mean of 2 measurements taken while the patient was seated (some used the mean of the second and third measurements), allowed for at least 5 minutes between entry into the office and blood pressure measurement, used an appropriately sized arm cuff, and placed the patient’s arm at the level of the right atrium during measurement. Multiple measurements over time have better positive predictive value for hypertension than a single measurement. Automated office blood pressure, which is an average of multiple automated measurements taken while the patient is alone in a room, may yield results similar to those of daytime ABPM.Blood pressure is affected by various short-term factors, such as emotions, stress, pain, physical activity, and drugs (including caffeine and nicotine). In addition to within-patient temporal variability, isolated clinic hypertension in the medical setting and in the presence of medical personnel (known as “white coat” hypertension) is well-documented. Epidemiologic data suggest that 15% to 30% of the population believed to have hypertension may have lower blood pressure outside of the office setting. The disadvantages of diagnosing hypertension solely in the office setting include measurement errors, the limited number of measurements that can be made conveniently, and the confounding risk for isolated clinic hypertension.

Ambulatory and Home Blood Pressure Monitoring

In addition to office blood pressure measurement, ABPM and HBPM may be used to confirm a diagnosis of hypertension after initial screening. Ambulatory blood pressure monitoring devices are small, portable machines that record blood pressure at regular intervals over 12 to 24 hours while patients go about their normal activities and while they are sleeping. Measurements are typically taken at 20- to 30-minute intervals. Home blood pressure measurement devices are fully automated oscillometric devices that record measurements taken from the patient’s brachial artery. Many of these devices are available for retail purchase, and some have undergone technical validation according to recommended protocols.

The USPSTF found convincing evidence that ABPM is the best method for diagnosing hypertension. Although the criteria for establishing hypertension varied across studies, there was significant discordance between the office diagnosis of hypertension and 12- and 24-hour average blood pressures using ABPM, with significantly fewer patients requiring treatment based on ABPM (Figure 1).  Elevated ambulatory systolic blood pressure was consistently and significantly associated with increased risk for fatal and nonfatal stroke and cardiovascular events, independent of office blood pressure (Figure 2). For these reasons, the USPSTF recommends ABPM as the reference standard for confirming the diagnosis of hypertension.

Good-quality evidence suggests that confirmation of hypertension with HBPM may be acceptable. Several studies showed that elevated home blood pressure was significantly associated with increased risk for cardiovascular events, stroke, and all-cause mortality, independent of office blood pressure (Figure 3). However, fewer studies have compared HBPM with office blood pressure measurement, so the evidence is not as substantial as it is for ABPM. Therefore, the USPSTF considers ABPM to be the reference standard for confirming the diagnosis of hypertension. However, the USPSTF acknowledges that the use of ABPM may be problematic in some situations. Home blood pressure monitoring using appropriate protocols is an alternative method of confirmation if ABPM is not available. Measurements from the office, HBPM, and ABPM all must be interpreted with care and in the context of the individual patient. Patients with very high blood pressure or signs of end-organ damage may need immediate treatment.

Screening Interval

The USPSTF recommends annual screening for adults aged 40 years or older and for those who are at increased risk for high blood pressure. Persons at increased risk include those who have high-normal blood pressure (130 to 139/85 to 89 mm Hg), those who are overweight or obese, and African Americans. Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years. The USPSTF recommends rescreening with properly measured office blood pressure and, if blood pressure is elevated, confirming the diagnosis of hypertension with ABPM.

Treatment

The benefits of treatment of hypertension in preventing important health outcomes are well-documented. Moderate- to high-quality randomized, controlled trials (RCTs) demonstrate the efficacy of treatment of the general population of persons aged 60 years or older to a target blood pressure of 150/90 mm Hg in reducing the incidence of stroke, heart failure, and coronary heart disease events. Similarly, RCTs demonstrate the efficacy of treatment of younger adults to a target diastolic blood pressure of less than 90 mm Hg in reducing cerebrovascular events, heart failure, and overall mortality.  In the absence of sufficient RCT data, expert opinion has been used to establish a target systolic blood pressure of 140 mm Hg in adults younger than 60 years and some experts believe that this should also be maintained in those aged 60 years or older. However, published results from a recently completed large RCT, the Systolic Blood Pressure Intervention Trial, are not yet available to inform current treatment goals. Clinicians should consult updated blood pressure treatment guidelines informed by this trial as they become available.

For nonblack patients, initial treatment consists of a thiazide diuretic, calcium-channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker. For black patients, initial treatment is thiazide or a calcium-channel blocker. Initial or add-on treatment for patients with chronic kidney disease consists of either an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker (not both).

Suggestions for Implementation

Screening for high blood pressure may be done in the office setting by using the proper methods described previously. However, the USPSTF recommends confirmation outside of the clinical setting before a diagnosis of hypertension is made and treatment is started. Confirmation may be done by using HBPM or ABPM. Because blood pressure is a continuous value with natural variations throughout the day, repeated measurements over time are generally more accurate in establishing a diagnosis of hypertension. The USPSTF did not find evidence for a single gold standard protocol for HBPM or ABPM. However, both may be used in conjunction with proper office measurement to make a diagnosis and guide management and treatment options. Blood pressure cuffs used for HBPM should be compliant with sphygmomanometer standards set by the Association for the Advancement of Medical Instrumentation.

Research Needs and Gaps

Most of the evidence supports ABPM as the best method for confirming a diagnosis of hypertension. More research is needed on the accuracy of HBPM versus ABPM and the best HBPM protocols for follow-up of elevated office blood pressure. The diagnostic accuracy of blood pressure measurements taken by a visiting nurse or another health care worker in the home setting also merits more research. Self-use blood pressure measurement kiosks in community settings, such as pharmacies and grocery stores, may be frequently used by the public but are not regulated by the U.S. Food and Drug Administration. More research on the accuracy of kiosk measurements is needed. New technology has been developed that uses a wireless brachial blood pressure monitor that connects to a smartphone, a desktop computer, or the Internet for recording and analysis. More research is needed on the accuracy of these monitors, their use in primary prevention, and their association with long-term health outcomes.  



Rationale

Importance

High blood pressure is a prevalent condition, affecting approximately 30% of the adult population. It is the most commonly diagnosed condition at outpatient office visits. High blood pressure is a major contributing risk factor to heart failure, heart attack, stroke, and chronic kidney disease. In 2010, it was the primary or contributing cause of death for more than 362,000 Americans.

Detection

The evidence on the benefits of screening for high blood pressure is well-established. In 2007, the USPSTF reaffirmed its 2003 recommendation to screen for hypertension in adults aged 18 years or older (A recommendation). Previous evidence reviews commissioned by the USPSTF found good-quality evidence that screening for hypertension has few major harms and provides substantial benefits. However, these reviews did not address the diagnostic accuracy of different blood pressure measurement protocols or identify a reference standard for measurement confirmation. For the current recommendation, the USPSTF examined the diagnostic accuracy of office blood pressure measurement, ambulatory blood pressure monitoring (ABPM), and home blood pressure monitoring (HBPM). The USPSTF also assessed the accuracy of these blood pressure measurements and methods in confirming the diagnosis of hypertension. In addition, it reviewed data on optimal screening intervals for diagnosing hypertension in adults.

Benefits of Early Detection and Treatment

The USPSTF found good evidence that screening for and treatment of high blood pressure in adults substantially reduces the incidence of cardiovascular events.

Harms of Early Detection and Treatment

The USPSTF found good evidence that screening for and treatment of high blood pressure has few major harms.

USPSTF Assessment

The USPSTF concludes with high certainty that the net benefit of screening for high blood pressure in adults is substantial.


Others

The Eighth Joint National Committee does not address the diagnosis of hypertension in its 2014 guidelines. The Seventh Joint National Committee recommends screening for high blood pressure at least once every 2 years in adults with blood pressure less than 120/80 mm Hg and every year in adults with blood pressure of 120 to 139/80 to 89 mm Hg. The American Heart Association recommends blood pressure measurement at each regular health care visit or at least once every 2 years in adults with blood pressure less than 120/80 mm Hg. The American Academy of Family Physicians’ recommendation is similar to that of the USPSTF.The American Congress of Obstetricians and Gynecologists recommends blood pressure screening as part of women’s annual health care visits.


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