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. 2000 Oct 7;321(7265):894.

Use of ambulatory blood pressure monitoring

Elegant new test needs clinical indication

A M Rouse 1
PMCID: PMC1118688  PMID: 11021878

Editor—O'Brien et al in their paper state that monitoring ambulatory blood pressure may be useful for diagnosing white coat hypertension, a diagnosis that should be considered before drugs are prescribed.1 But they do not give criteria that can be used to identify which patients with raised blood pressure should be selected for monitoring. This, perhaps, is not surprising since O'Brien et al admit that white coat hypertension has no clinical characteristics to help in diagnosis. We must therefore presume that they believe that all newly diagnosed patients with hypertension would benefit from ambulatory monitoring of blood pressure.

O'Brien et al make no claims that ambulatory monitoring is likely to improve the process of care when they state that the role of ambulatory measurement in guiding drug treatment has not been fully established. They seem to doubt the value of readings of ambulatory blood pressure when they say that deciding what constitutes normal blood pressure and what constitutes abnormal in ambulatory measurement is controversial. O'Brien et al do not say that monitoring ambulatory blood pressure improves a patient's prognosis.

So should doctors monitor ambulatory blood pressure in all patients with newly diagnosed hypertension to exclude patients with white coat hypertension? On the evidence provided, quite clearly the answer is no. Monitoring ambulatory blood pressure, like so many other tests, is yet another elegant new test in want of a clinical indication.

References

  • 1.O'Brien E, Coats A, Owens P, Petrie J, Padfield PL, Littler WA, de Swiet M, Mee F. Use and interpretation of ambulatory blood pressure monitoring: recommendations of the British Hypertension Society. BMJ. 2000;320:1128–1134. doi: 10.1136/bmj.320.7242.1128. (22 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Oct 7;321(7265):894.

Author's reply

Eoin O'Brien 1

Editor—Rouse is correct in his reading of our paper when he reiterates the clear message that white coat hypertension should be considered before prescribing blood pressure lowering drugs, which may not be necessary in many people who have a spurious rather than sustained rise in blood pressure. His interpretive ability does not fail him either when he concludes that a technique such as ambulatory blood pressure measurement is needed to diagnose white coat hypertension as there are no clinical characteristics to identify the condition. He then presumes that we believe that “all newly diagnosed hypertensive patients would benefit from ambulatory blood pressure monitoring.” If ambulatory monitoring saves patients from unnecessary lifelong drug treatment it follows that they will benefit from the technique. Let me go further and say that I would seek another opinion if a doctor measured my blood pressure using the conventional technique and then proceeded to write me a prescription.

Rouse is also irritated by the fact that the recommendations acknowledge that the role of ambulatory measurement in guiding drug treatment has not yet been fully established and that there is controversy over the exact cut-off points for ambulatory blood pressure. These are statements of fact—we have been careful to indicate in our paper where there is uncertainty and doubt.

Rouse is incorrect when he says: “[we] do not say that ambulatory monitoring improves a patient's prognosis.” In the introduction we state: “Although the results of a number of ongoing, longitudinal studies are forthcoming, there is now firm evidence that ambulatory blood pressure measurement is a more sensitive predictor of cardiovascular outcome than conventional measurement.” We later say that the technique predicts outcome more accurately than conventional measurement in white coat hypertension, elderly people, patients with nocturnal hypertension, and pregnancy.

Rouse's negative strictures remind me of another commentator of similar outlook, who, writing in 1895 on the newly introduced technique of sphygmomanometry, acknowledged that “the middle-aged and successful physician may slowly and imperceptibly lose the exquisite sensitiveness of his finger tips through repeated attacks of gouty neuritis” but was confident that the sphygmomanometer would not be welcomed by the “overworked and underpaid general practitioner, already loaded with thermometer, stethoscope, etc.”1-1

Footnotes

On behalf of the British Hypertension Society Working Party on Blood Pressure Measurement

References

  • 1-1.Blake E. Recent British researches on arterial tension. Med Times Gaz. 1895;23:29. [Google Scholar]

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