Abstract
Automated office blood pressure (AOBP) measurement, attended or unattended, eliminates the white coat effect (WCE) showing a strong association with awake ambulatory blood pressure (ABP). This study examined the difference in AOBP readings, with and without 5 minutes of rest prior to three readings recorded at 1‐min intervals. Cross‐sectional data from 100 randomized selected hypertensives, 61 men and 39 women, with a mean age of 52.2 ± 10.8 years, 82% treated, were analyzed. The mean systolic AOBP values without preceding rest were 127.0 ± 18.2 mm Hg, and the mean systolic AOBP values with 5 minutes of preceding rest were 125.7 ± 17.9 mm Hg (P = .05). A significant order effect was observed for the mean systolic BP values when AOBP without 5 minutes of preceding rest was performed as the first measurement (130.0 ± 17.7 vs 126.5 ± 16.2, P = .008). When we used a target systolic AOBP ≥ 130 mm Hg, awake ABP yielded lower readings, while at a target systolic AOBP value of < 130 mm Hg higher awake ABP values were obtained. Our findings indicate that systolic AOBP can be initially checked without any preceding rest and if readings are normal can be accepted. Otherwise, when AOBP is ≥ 130 mm Hg, measurements should be rechecked with 5 minutes of rest.
Keywords: automated office blood pressure, awake ambulatory blood pressure, preceding rest
1. INTRODUCTION
Automated office blood pressure (AOBP) taken with the patient seated alone in the examining room, shown to reduce or eliminate the “white coat effect” (WCE), has been acknowledged in recent guidelines as the technique that improves the reproducibility of blood pressure (BP) measurement in the doctor's office.1 The BP values of AOBP are consistently at least 5‐15 mm Hg lower than those obtained by conventional, attended oscillometric, or manual office BP measurement and are closely related to those provided by awake ambulatory blood pressure (ABP).2 The Systolic Blood Pressure Intervention Trial (SPRINT), which involved a high‐risk population with a clinic systolic BP ≥ 130 mm Hg without diabetes mellitus or history of stroke, used programmable automated oscillometric devices to measure BP.3 In this study, participants were assigned to a standard treatment group with a systolic BP target < 140 mm Hg or to an intensive treatment group with a systolic BP target < 120 mm Hg. However, the applicability of the study's results in clinical practice has been debated. The findings of the SPRINT Ambulatory Blood Pressure Ancillary Study have also attracted criticism.4 That study of 897 participants compared the intense treatment group to the standard treatment group 27 months after the beginning of the study. The AOBP values were found to be lower than awake ABP in both groups suggesting that office BP values in the lower range of normal were lower than the awake ABP. Taking these findings into account, Colella et al5 compared AOBP using the Omron HEM 907 monitor, with and without preceding rest, and concluded that in the lower normal range AOBP recorded without preceding rest should be higher and closer to the awake ABP although 24‐hours ABP was not performed. Consequently, we conducted this study to clarify whether AOBP readings, in treated and untreated hypertensives, can be used without a rest period using also awake ABP monitoring as a comparator.
2. METHODS
2.1. Study participants
This was a method comparison study performed in 100 consecutive hypertensive patients. Specifically, we evaluated all patients referred for suspected hypertension by their family physicians to the Hypertension and Cardiovascular Disease Prevention Center at the “Evangelismos” General Hospital, in Athens, Greece. The inclusion criteria were as follows: (a) individuals aged ≥18 years who had never taken or who had not received antihypertensive medication for at least the previous 6 months and (b) subjects on stable antihypertensive medication for at least 4 weeks. Hypertension was obtained by an average office reading of systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg on three consecutive visits, based on semi‐automated oscillometric technique. Exclusion criteria were the following: secondary hypertension, atrial fibrillation, gross proteinuria (24‐hour urinary protein excretion > 1 g/dL per day), renal failure with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 or heart failure (HF) with ejection fraction < 30%. Written informed consent was obtained from all patients, and the study was approved by the scientific board of the hospital.
2.2. Study procedures
2.2.1. BP measurements
Three types of readings were obtained (a) AOBP with preceding 5 minutes of rest, (b) AOBP without preceding rest, and (c) 24‐h ABP. Following a diagnosis of hypertension based on oscillometric office BP measurements from prior visits, subjects were subsequently monitored by unattended AOBP and ABP techniques. AOBP was recorded using the Omron HEM 907 sphygmomanometer as follows:
Method 1:5 minutes of rest prior to 3 AOBP readings recorded at 1‐min intervals (SPRINT‐like measurements).
Method 2:0 minutes of rest prior to 3 AOBP readings recorded at 1‐min intervals.
The order of performing the two methods was randomized to avoid bias caused by order effect. Randomization was done by using a random number table, and allocation was not concealed from researchers and participants due to the nature of the study. When AOBP without rest was performed as a second measurement, the study personnel entered into the examination room and had a brief discussion with the patient so that they would disrupt his/her quietness. Although there is no any evidence that a brief discussion reverses the effect of 5‐min rest, the interruption of the patient's quietness resulted in insufficient rest period and produces higher systolic and diastolic BP than did for a sufficient period of time preceding the measurement.6
Appropriate bladder size was used in all instances, and training and assessment of observers for accurate BP measurement were ensured. For all AOBP measurements, participants were seated on an upright chair with arms supported by adjustable armrests at heart level and with feet firmly placed uncrossed on the floor. The recorder was set to automatically time the period of rest at 0 or 5 minutes with 1‐min intervals between the three BP readings. After activating the device, the study personnel left the room returning after the three readings were accomplished. The same device was used for each within‐person visit.
Twenty‐four‐hour ABP was then monitored using validated oscillometric arm devices (Microlife WatchBPO3, Microlife). Measurements were performed at 20‐minutes intervals for 24 hours, and study participants were instructed to remain still with the forearm extended during each BP reading. Awake and nighttime periods were defined according to the patients’ diaries (awake and asleep periods). ABP recordings with less than 70% usable BP readings were excluded. All valid awake and nighttime ABP readings were averaged to provide a single awake and nighttime ABP value per study participant.
2.3. Statistical analyses
Continuous variables are reported as mean ± standard deviation (SD). Frequencies are given as percentages. Differences between mean systolic and diastolic AOBP values and heart rate (HR) were assessed using paired t tests for both “order effect” and “no order effect” measurements. Similarly, differences between mean systolic and diastolic AOBP and 24‐hour awake ABP values and heart rate (HR) were also assessed using paired t tests. We compared agreement between BP measurements in two ways: We used the method of Bland and Altman with bias (defined as the mean value of the differences) and 95% limits of agreement with their confidence intervals; in addition, we calculated the intraclass correlation coefficient (ICC) for all sets of systolic and diastolic BP measurements. Because the devices do not retain the replicate measurements but provide only the average, the study follows a paired measurements’ design. We used IBM SPSS version 22.
3. RESULTS
A total of a hundred consecutive hypertensives fulfilling the criteria for enrollment were included in the study, 61 men and 39 women, with a mean age of 52.2 ± 10.8 years, 82% treated. Their clinical characteristics and their BP measurements are shown in Table 1.
Table 1.
Study population (N = 100)
| Variables | Mean value ± SD |
|---|---|
| Age, years | 52.2 ± 10.8 |
| Systolic AOBP with 5 min of rest, mm Hg | 125.7 ± 17.9 |
| Diastolic AOBP with 5 min of rest, mm Hg | 77.9 ± 13.8 |
| HR on AOBP with 5 min of rest, mm Hg | 72.3 ± 13.8 |
| Systolic AOBP without 5 min of rest, mm Hg | 127.0 ± 18.2 |
| Diastolic AOBP without 5 min of rest, mm Hg | 78.6 ± 13.8 |
| HR on AOBP without 5 min of rest, mm Hg | 72.5 ± 11.9 |
| Systolic awake ABP, mm Hg | 126.6 ± 12.9 |
| Diastolic awake ABP, mm Hg | 78.5 ± 10.4 |
| HR on awake ABP, mm Hg | 76.5 ± 10.7 |
| Systolic nighttime BP, mm Hg | 112.3 ± 13.4 |
| Diastolic nighttime BP, mm Hg | 65.7 ± 9.5 |
| HR on nighttime BP, bpm | 65.3 ± 9.6 |
| Systolic 24‐h mean BP, mm Hg | 122.5 ± 12.2 |
| Diastolic 24‐h mean BP, mm Hg | 74.8 ± 9.6 |
| HR on 24‐h mean BP, bpm | 73.2 ± 10.1 |
| N (%) | |
|---|---|
| Gender | |
| Males | 61 (61) |
| Females | 39 (39) |
| Treated hypertensives | 82 (82) |
| Drug classes | % |
| RAAS blocker | 88 |
| Beta‐blocker | 5 |
| Diuretic | 33 |
| Calcium channel blocker | 34 |
| A‐blocker | 1 |
| Untreated hypertensives | 18 (18) |
Abbreviations: ABP, ambulatory blood pressure; AOBP, automated office blood pressure; HR, heart rate; SD, standard deviation.
A significant order effect was observed for the mean systolic BP values when AOBP without 5 minutes of preceding rest was performed as the first measurement (130.0 ± 17.7 vs 126.5 ± 16.2, P = .008).
Furthermore, neither systolic AOBP with 5 minutes of preceding rest nor systolic AOBP without 5 minutes of preceding rest exhibited a statistically significant difference when compared to awake ABP values (125.7 ± 17.9 mm Hg vs 126.6 ± 12.9 mm Hg, P = .45 for AOBP with 5 minutes of rest vs awake ABP and 127.0 ± 18.2 mm Hg vs 126.6 ± 12.9 mm Hg, P = .74 for AOBP without 5 minutes of rest vs awake ABP, respectively) (Table 2).
Table 2.
AOBP and HR values after 0 and 5 min of rest (without and with order effect)
| AOBP technique (with order effect) N = 55 | 5 min of rest first | 0 min of rest second | |
|---|---|---|---|
| Mean ± SD systolic AOBP, mmHg | 124.9 ± 19.4 | 124.6 ± 18.4 | .63 |
| Mean ± SD diastolic AOBP, mmHg | 77.6 ± 14.7 | 77.9 ± 13.9 | .58 |
| Mean ± SD HR, bpm | 73.1 ± 14.1 | 71.6 ± 10.9 | .35 |
| AOBP technique (with order effect) N = 45 | 0 min of rest first | 5 min of rest second | |
|---|---|---|---|
| Mean ± SD systolic AOBP, mm Hg | 130.0 ± 17.7 | 126.5 ± 16.2 | .008 |
| Mean ± SD diastolic AOBP, mm Hg | 79.5 ± 13.8 | 78.3 ± 12.7 | .08 |
| Mean ± SD HR, bpm | 73.6 ± 12.9 | 71.3 ± 13.5 | .02 |
Abbreviations: AOBP, automated office blood pressure; HR, heart rate; SD, standard deviation.
p value < 0.05 indicates statistical significance
The percentage of patients with WCE in our study was 16% including both treated and untreated hypertensives. Specifically, the difference in mmHg of AOBP performed after 5 minutes of rest to daytime ABP was higher among subjects with WCE (−2.69 ± 12.4 vs 8.13 ± 9.7, P = .001). Similar results were obtained when AOBP was measured with no waiting period (−1.64 ± 12.6 vs 11.19 ± 10.4, P = .001).
For further evaluation, we used systolic AOBP < 130 mm Hg, as readings in the lower part of the normal range appear to be devoid of a WCE, and office BP values are less than awake ABP.
When mean systolic AOBP values with or without preceding rest were ≥ 130 mm Hg, lower awake ABP values were obtained (Table 3).
Table 3.
AOBP (with or without rest), awake ABP, and HR values, among patients with systolic AOBP ≥ 130 mm Hg (N = 37)
| Study population (N = 100) | AOBP with 5 min of rest | Awake ABP | P value |
|---|---|---|---|
| Mean ± SD systolic BP, mmHg | 143.3 ± 14.1 | 135.7 ± 11.9 | .002 |
| Mean ± SD diastolic BP, mmHg | 86.8 ± 15.2 | 84.4 ± 11.1 | .17 |
| Mean ± SD HR, bpm | 73.5 ± 14.7 | 76.8 ± 11.1 | .03 |
| AOBP without 5 min of rest | Awake ABP | ||
|---|---|---|---|
| Mean ± SD systolic BP, mmHg | 144.2 ± 15.3 | 135.7 ± 11.9 | .001 |
| Mean ± SD diastolic BP, mmHg | 87.4 ± 15.2 | 84.4 ± 11.1 | .09 |
| Mean ± SD HR, bpm | 75.2 ± 12.5 | 76.8 ± 11.1 | .24 |
Abbreviations: ABP, ambulatory blood pressure; AOBP, automated office blood pressure; BP, blood pressure; HR, heart rate; SD, standard deviation.
p value < 0.05 indicates statistical significance.
In contrast, when systolic AOBP values with or without preceding rest were < 130 mm Hg, awake ABP yielded higher BP readings (Table 4).
Table 4.
AOBP (with or without rest), awake ABP, and HR values, among patients with systolic AOBP < 130 mm Hg (N = 63)
| Study population (N = 100) | AOBP with 5 min of rest | Awake ABP | P value |
|---|---|---|---|
| Mean ± SD systolic BP, mmHg | 115.3 ± 10.2 | 121.3 ± 10.2 | .001 |
| Mean ± SD diastolic BP, mmHg | 72.7 ± 9.7 | 75.0 ± 8.2 | .03 |
| Mean ± SD HR, bpm | 71.5 ± 13.3 | 76.2 ± 10.4 | .007 |
| AOBP without 5 min of rest | Awake ABP | ||
|---|---|---|---|
| Mean ± SD systolic BP, mmHg | 117.0 ± 10.7 | 121.3 ± 10.2 | .001 |
| Mean ± SD diastolic BP, mmHg | 73.5 ± 9.9 | 75.0 ± 8.2 | .01 |
| Mean ± SD HR, bpm | 70.9 ± 11.3 | 76.2 ± 10.4 | .001 |
Abbreviations: ABP, ambulatory blood pressure; AOBP, automated office blood pressure; BP, blood pressure; HR, heart rate; SD, standard deviation.
p value < 0.05 indicates statistical significance
Bland‐Altman plots for the comparison of the mean systolic AOBP with the systolic awake ABP, among patients with mean systolic AOBP ≥ 130 mm Hg who underwent AOBP with preceding 5 minutes of rest either as the first (N = 55) or the second (N = 45) measurement, are shown in Figure 1A,B, respectively. Mean systolic AOBP was calculated as the average between the two AOBP modalities.
Figure 1.
A, Bland‐Altman plot comparing mean systolic AOBP (mm Hg) and systolic awake ABP (mm Hg) in patients with mean systolic AOBP ≥ 130 mm Hg who underwent AOBP with preceding 5 min of rest as the first measurement. Solid lines, mean bias; dashed lines, 95% limits of agreement. B, Bland‐Altman plot comparing mean systolic AOBP (mm Hg) and systolic awake ABP (mm Hg) in patients with mean systolic AOBP ≥ 130 mm Hg who underwent AOBP with preceding 5 min of rest as the second measurement. Solid lines, mean bias; dashed lines, 95% limits of agreement
A positive bias (ie, mean of the differences) was observed for the mean systolic AOBP for both AOBP modalities among patients with mean systolic AOBP ≥ 130 mm Hg.
In contrast, a negative bias was observed for the mean systolic AOBP for both AOBP modalities among patients with mean systolic AOBP < 130 mm Hg (Figure 2A,B).
Figure 2.
A, Bland‐Altman plot comparing mean systolic AOBP (mm Hg) and systolic awake ABP (mm Hg) in patients with mean systolic AOBP < 130 mm Hg who underwent AOBP with preceding 5 min of rest as the first measurement. Solid lines, mean bias; dashed lines, 95% limits of agreement. B, Bland‐Altman plot comparing mean systolic AOBP (mm Hg) and systolic awake ABP (mm Hg) in patients with mean systolic AOBP < 130 mm Hg who underwent AOBP with preceding 5 min of rest as the last measurement. Solid lines, mean bias; dashed lines, 95% limits of agreement
The ICC for systolic AOBP with or without 5 minutes of preceding rest was 0.96 (P < .001; 95% confidence interval, 0.94‐0.97). Similarly, high coefficients were found when AOBP with or without rest was compared with awake ABP values. The ICCs for all sets of systolic and diastolic BP measurements are shown in Table 5.
Table 5.
Intraclass correlation coefficients for all sets of systolic and diastolic BP measurements in the total population (N = 100)
| BP measurements | ICC | P value | 95% CI |
|---|---|---|---|
| Systolic AOBP with rest‐systolic AOBP without rest | 0.96 | <.001 | 0.94 to 0.97 |
| Diastolic AOBP with rest‐diastolic AOBP without rest | 0.98 | <.001 | 0.97 to 0.99 |
| Systolic AOBP with rest‐systolic awake ABPe | 0.81 | <.001 | 0.71 to 0.87 |
| Diastolic AOBP with rest‐Diastolic awake ABP | 0.84 | <.001 | 0.76 to 0.89 |
| Systolic AOBP without rest‐systolic awake ABP | 0.79 | <.001 | 0.69 to 0.86 |
| Diastolic AOBP without rest‐diastolic awake ABP | 0.81 | <.001 | 0.72 to 0.88 |
Abbreviations: ABP, ambulatory blood pressure; AOBP, automated office blood pressure; BP, blood pressure; CI, confidence intervals; ICC, intraclass correlation coefficient.
4. DISCUSSION
This study compared the values between AOBP readings taken with and without 5 minutes of resting period before the readings and examined for any differences in the mean AOBP when these readings were obtained with 5 minutes of rest as a first or as a second measurement. AOBP values were also evaluated against awake ABP, which is generally accepted as a more sensitive risk predictor than office BP of CV events, in order to investigate any differences between AOBP and awake ABP values. The close association between AOBP and awake ABP values could be partially influenced by the similar method of detection using the oscillometric technique. It should be highlighted that these are two different techniques office versus out‐of‐office BP and as such should be considered.
Our findings show that using Omron HEM‐907 XL device, mean systolic AOBP was lower when readings with preceding 5‐min rest were taken second. In contrast, mean systolic AOBP had similar values when readings with preceding 5‐min rest were taken as a first measurement. Since patients who underwent AOBP with 5 minutes of rest as the first measurement did not exhibit an order effect, it is unlike that 5 more minutes of rest would have influenced significantly BP values. Similar results were presented by Colella et al in a recent study of 100 patients in cardiac rehabilitation, of whom only 46 had hypertension.5 Using the Omron HEM‐907 XL device, they concluded that when systolic AOBP readings decrease to values <130 mm Hg the technique could be used without any preceding rest, since such readings, <130 mm Hg without rest, are close to those of awake ABP. Hence, this approach can be performed in less than half the time taken to obtain the readings in SPRINT. Interestingly, AOBP represents a valuable approximation to 24‐hour ABP as in SPRINT AOBP values have been found to be different and lower than ABP. In contrast, a recent meta‐analysis showed that due to the significant heterogeneity it is believed that use of the AOBP should not replace daytime ABP as the reference standard.7 However, it is also known that clinic BP values are higher than awake ABP in a high range of clinic BP distribution, but this difference becomes progressively smaller when the clinic BP is lower. Notably, 24‐h ABP was not performed in the study of Collela et al That study drew criticism that focused on the AOBP variability suggesting that the reported limits of agreement spanned nearly 30 mm Hg.8 However, it was advocated that the white coat effect is not common when BP is normal, further supporting AOBP readings without preceding rest.9 In our study, the ICC showed high reproducibility among those who underwent AOBP measurement with and without rest (ICC = 0.96, P < .001).
We also evaluated AOBP settings against awake ABP with and without 5 minutes of rest before measurements. To our knowledge, this is the first study in which AOBP, with and without preceding rest, and 24‐hours ABP were performed simultaneously in order to clarify the differences between the two modalities. The agreement between systolic AOBP and awake ABP in our study was high: The mean AOBP with 5 minutes of rest was 126 mm Hg and without rest 130 mm Hg, findings that are comparable with 127 mm Hg of mean awake systolic ABP, taken that AOBP is an accurate technique measurement in the evaluation of an individual's true BP status. Despite this finding, AOBP may not always correlate well to daytime ABP values but expresses well short‐term BP variability.10
Interestingly, it should be highlighted that systolic AOBP values were higher than awake ABP for AOBP values greater than 130 mm Hg (143 mm Hg vs 136 mm Hg) and lower than awake ABP when AOBP values were lower 130 mm Hg (115 vs 121 mm Hg). Such a finding could be attributed at least partially to the regression to the mean effect. We selected the threshold of 130 mm Hg for systolic BP because patients with systolic BP levels higher than 130 mm Hg are at increased risk of cardiovascular disease a finding supported by the SPRINT study and the most recent guidelines.3, 11 Our findings are in accordance with those of PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni)12 and ELSA (European Lacidipine Study on Atherosclerosis)13 where clinic BP values were higher than awake ABP values in the higher range of BP distribution. The lower the clinic BP, the progressively smaller the difference becomes, until the two sets of BP values are superimposable at systolic BP levels of 115‐117 mm Hg, below which ABP values become progressively higher than conventional clinic BP.14 It is remarkable that in SPRINT patients, in the Ambulatory Blood Pressure Ancillary Study, a similar relationship between clinic BP and 24‐h ABP was not observed.4
Taking into account that there is no concern regarding the time required to record AOBP when screening for hypertension, Myers concluded that when office BP readings are within the normal range of systolic BP < 130 mm Hg, it may be possible to use the Omron HEM‐907 device without rest; otherwise, adding 5 minutes of rest could produce readings which are much lower than the corresponding awake ABP.15 In another AOBP study without a rest period, Moore found that only two AOBP readings may be needed to be comparable with awake ABP.16
AOBP is recommended as the preferable technique for office BP measurement by the Canadian Hypertension Education Program17 and by the position statement of the European Society of Hypertension working group on BP monitoring and variability.18 It is also advised by the 2018 ESC/ESH guidelines1 for office BP screening as this technique obtained by unattended office BP measurements provides lower readings than conventional office systolic BP. AOBP readings had similar values when BP measurements were taken with or without the presence of medical staff, and they were more comparable with awake ABP than conventional office values.19 The main advantage of our study is that all participants were diagnosed as having hypertension and that their BP measurements were obtained with and without rest as a first or second measurement in a randomized manner followed by 24‐hours ABP at the same visit. It should be mentioned that the entrance of the study personnel into the examination room before recording AOBP without rest cannot completely eliminate the preceding resting effect of the previous measurement. Furthermore, the relatively small size of the study population may limit generalization of study results.
In conclusion AOBP readings can be used without rest when systolic readings are found to be <130 mm Hg as these are very close to awake ABP but they should be repeated with 5‐min rest period when readings show higher office values. Based on the present results, AOBP measurements taken without rest before readings showed similar with awake ABP readings when systolic AOBP is <130 mm Hg and as such should be performed. In contrast, higher AOBP values should be re‐evaluated with 5 minutes of rest. The resting period before AOBP measurements is hypothesized as the reason for these results and thus enhances the use of AOBP in clinical practice.
CONFLICT OF INTEREST
None.
AUTHOR CONTRIBUTIONS
The corresponding author (Emmanuel A. Andreadis) is responsible for the design of the study, the preparation of the first draft, and the completion of the whole manuscript.
Charalampia V Geladari and Epameinondas T. Angelopoulos have conducted the statistical analysis. All authors have read and given final approval of the version to be published.
ACKNOWLEDGMENTS
We thank our center's nurse Ioulia Bali for her contribution in recording the automated office blood pressure values of the studied population.
Andreadis EA, Geladari CV, Angelopoulos ET. Automated office blood pressure measurements obtained with and without preceding rest are associated with awake ambulatory blood pressure. J Clin Hypertens. 2020;22:32–38. 10.1111/jch.13748
Funding information
The purchase of BP monitors used in the study was supported by the “Hellenic Society of Hypertension” which did not otherwise sponsor this study and was not involved in the study design, data analysis, data interpretation, article preparation, and publication.
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