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hypertension
According to JNC VI1, measurement
of blood pressure
outside the clinician’s office may provide valuable information
for the initial evaluation of patients with hypertension and
for monitoring the response to treatment. Self-measurement has
four general advantages: (1) distinguishing sustained hypertension
from “white-coat hypertension,” a condition noted
in patients whose blood pressure is consistently elevated in
the physician’s office or clinic but normal at other times;
(2) assessing response to antihypertensive medication; (3) improving
patient adherence to treatment; and (4) potentially reducing
costs.
“Home
blood pressure monitoring is becoming an invaluable tool in
the management of hypertension,” according to Dr. Thomas
Mengden, an internationally recognized authority on hypertension.
“It helps to diagnose white coat hypertension, correlates
better with target organ damage, improves prediction of hypertension-related
morbidity as compared to office blood pressure readings, improves
patient compliance with therapy, and allows for faster therapy
adjustment and better blood pressure control.” 2
However, Mendgen and other have shown that
patient-reported readings are so prone to error that “…if
self-taken pressures are to be used for any important purpose,
objective instrument recorded pressures must be available,”
according to Dr. Lawrence Krakoff, former President of the
American Society of Hypertension.3 Telemonitoring
offers clinicians reliable, instrument-recorded home blood
pressure readings, enabling them to make better treatment
decisions with fewer office visits.
White Coat Hypertension
Home blood pressure telemonitoring enables clinicians to differentiate
white coat hypertension (high readings in the doctor’s
office but normal in daily life) from true hypertension. Most
patients with white coat hypertension do not need drug therapy,
yet they are often prescribed drugs because physicians are
unable to distinguish white coat from true hypertension. This
exposes patients to an unnecessary risk of side effects and
the psychosocial burden of a chronic disease they do not really
have, and wastes money on drugs they do not need. About 25%
of people diagnosed with hypertension in a doctor’s
office actually have white coat hypertension.
Improving Blood Pressure Control
Only one quarter of Americans with hypertension have their
blood pressure under control. By providing immediate feedback
to patients, home blood pressure telemonitoring improves medication
compliance. Telemonitoring data enables clinicians to rapidly
assess the response to antihypertensive medication or lifestyle
change. Adjusting dosage or changing medication can usually
be done by phone, cutting office visits in half and controlling
blood pressure faster. Home blood pressure telemonitoring
has been shown to double the rate of blood pressure control
in primary care practices in a managed care setting.
Resistant Hypertension
About half of patients who appear to have resistant hypertension
while on antihypertensive medication actually have their blood
pressure well controlled, but they appear to be resistant
due to a white coat effect superimposed on good blood
pressure control. Among patients referred to hypertension
clinics for resistant hypertension, 40-60% were found to have
pseudo-resistant hypertension when blood pressure was monitored
at home.4,5
Pseudo-resistant hypertension is more prevalent
in elderly patients, and often leads to overmedication. Excess
blood pressure lowering in the elderly increases the risk
of stroke, as well as cognitive dysfunction, dizziness and
falls. Telemonitoring differentiates true resistance from
pseudo-resistance, avoiding overmedication.
1 Sixth Report of the Joint National
Committee on Prevention, Detection, Evaluation and Treatment
of Hypertension.
2 Mengden T et al. Telemonitoring of Home Blood Pressure.
Blood Pressure Monitoring 2001;6:185-189.
3 Krakoff L. Myth and Fact: Reliability of Self-Reported Blood
Pressures (editorial.) Am J Hypertens 1998;11:1432.
4 Wittenberg C et al. Overdiagnosis of hypertension
in the elderly. J Hum Hypertens 1992;6(5):349-51.
5 Penny MJ et al. Incidence of white coat effect
in patients with loss of blood pressure control. J Hypertens
1998; 17 (suppl 3) (abstr.)
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