AMBULATORY BLOOD-PRESSURE MONITORING AND BLOOD-PRESSURE SELF-MEASUREMENT IN THE DIAGNOSIS AND MANAGEMENT OF HYPERTENSION

Objective: To review published evidence on the use of ambulatory and s elf-measurement devices in the diagnosis and management of hypertensio n. Data Sources: Computerized literature searches and manual review of bibliographies. Study Selection: Articles documenting original resear ch pertaining to the diagnosis, treatment, or prognosis of hypertensio n using ambulatory or self-measurement devices. Results: Studies that have compared office, self-measured, and ambulatory blood pressures ha ve documented substantial, but nonsystematic, differences. Such findin gs have raised concern over the appropriateness of diagnosing hyperten sion and initiating drug therapy in individuals with high office blood pressure but comparatively low self-measured or ambulatory blood pres sure (''office'' or ''white coat'' hypertension). Evidence from a larg e number of cross-sectional studies and a single prospective study sug gests that blood pressure- related end-organ damage is more closely as sociated with ambulatory than with office blood pressure. Less evidenc e supports self-measured blood pressure in this regard, and data are i nsufficient to compare ambulatory and self-measured blood pressure in terms of cardiovascular disease risk prediction. The estimated resourc e cost of an ambulatory blood pressure test is approximately $120, whe reas charges range from $100 to $450. The annualized resource cost of blood pressure self-measurement is $50 or less. On a national level, t he annual direct costs of ambulatory blood pressure monitoring could b e as high as $6 billion, if this technique were used routinely to diag nose and monitor hypertensive patients. The extent to which direct cos ts would be offset by savings from less frequent or more efficient tre atment for hypertension cannot be estimated reliably. Several practica l and technical issues also detract from the potential usefulness of a mbulatory and self-measurement devices. Finally, there is some evidenc e that office blood pressures measured by well-trained nonphysicians m ay serve as an alternative to ambulatory and self-measurement techniqu es in estimating usual blood pressure. Conclusion: Limited clinical ap plications of ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension appea r to be warranted. Endorsement of these technologies for routine clini cal use, however, will require more convincing evidence of their clini cal effectiveness.