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Cardiology

Does This Adult Patient Have Hypertension?The Rational Clinical Examination Systematic Review

Educational Objective
To review the clinical diagnosis of hypertension.

1 Credit CME

JAMA

Published Online: July 27, 2021

The Rational Clinical Examination

Article Information and Disclosures

Anthony J. Viera, MD, MPH¹;

Yuichiro Yano, MD, PhD^1,2;

Feng-Chang Lin, PhD³;

David L. Simel, MD⁴;

Jonathan Yun, MD, MPH⁵;

Gaurav Dave, MD, DrPH⁶;

Ann Von Holle, PhD⁷;

Laura A. Viera, MA⁸;

Daichi Shimbo, MD⁹;

Shakia T. Hardy, PhD¹⁰;

Katrina E. Donahue, MD, MPH^11,12;

Alan Hinderliter, MD¹³;

Christiane E. Voisin, MSLS¹²;

Daniel E. Jonas, MD, MPH^6,12,14

Author Affiliations

¹Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
²Center for Novel and Exploratory Clinical Trials, Yokohama City University, Yokohama, Japan
³Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
⁴Durham Veterans Affairs Health System and Department of Medicine, Duke University School of Medicine, Durham, North Carolina
⁵Maine General Internal Medicine, Waterville
⁶Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill
⁷Research Triangle Park, Durham, North Carolina
⁸North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill
⁹Department of Medicine, Columbia University Irving Medical Center, New York, New York
¹⁰Department of Epidemiology, University of Alabama at Birmingham
¹¹Department of Family Medicine, University of North Carolina at Chapel Hill
¹²Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
¹³Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill
¹⁴now with Department of Internal Medicine, Division of General Internal Medicine, The Ohio State University

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Key Points

Question How can clinicians best identify adult patients likely to have hypertension?

Findings Conventional office blood pressure (BP) measurements from a single visit or home BP monitoring performed over a few days each have limited sensitivity and specificity for diagnosing hypertension, especially when the pretest probability is low. The combination of elevated mean office BP plus elevated mean BP on home BP monitoring is most indicative of hypertension, using 24-hour ambulatory BP monitoring as the reference standard.

Meaning Out-of-office BP measurements should be obtained to complement office BP before diagnosing hypertension in adults.

Abstract

Importance Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment.

Objective To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM.

Data Sources PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles.

Data Extraction and Synthesis Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed.

Main Outcomes and Measures Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard.

Results A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%).

Conclusions and Relevance Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

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Article Information

Corresponding Author: Anthony J. Viera, MD, MPH, Duke University School of Medicine, 2200 W Main St, Ste 400, Durham, NC 27705 (anthony.viera@duke.edu).

Accepted for Publication: May 24, 2021.

Author Contributions: Drs Viera and Lin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: A. Viera, Yano, Simel, Voisin, Jonas.

Acquisition, analysis, or interpretation of data: A. Viera, Yano, Lin, Simel, Yun, Dave, Von Holle, L. Viera, Shimbo, Hardy, Donahue, Hinderliter, Jonas.

Drafting of the manuscript: A. Viera, Lin, Simel, Yun.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lin, Simel, Hardy.

Administrative, technical, or material support: Yun, Dave, Von Holle, L. Viera, Shimbo, Hardy, Voisin, Jonas.

Supervision: A. Viera, Yano, Jonas.

Other - Abstract and text reviewer: Dave.

Conflict of Interest Disclosures: Dr Simel reported receiving honoraria for contributions to JAMAEvidence.com outside the submitted work. Dr Yun reported receiving grants from the Health Resources and Services Administration (T32-HP14001) during the conduct of the study. Dr Shimbo reported being a consultant for Abbott Vascular, Edward Lifesciences, Medtronic, and Tryton Medical and conducting event ascertainment for trials that they are conducting (testing coronary and valvular disease interventions), which have nothing to do with blood pressure measurement and hypertension, make no products in the area of blood pressure measurement and hypertension (including treatment), and are not related to the content area of the manuscript. No other disclosures were reported.

Funding/Support: Dr Viera reported past funding from the National Heart, Lung, and Blood Institute to study out-of-office blood pressure monitoring. Dr Yun's work was supported by the Health Resources and Services Administration (grant No. T32-HP14001). Dr Simel’s work was supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (CIN 13-410) at the Durham VA Health Care System. Dr Hardy’s work was supported by R01HL139716 from the National Heart, Lung, and Blood Institute.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Simel, section editor of The Rational Clinical Examination, was not involved in the editorial review of or decision to publish this article.

Additional Contributions: The authors would like to thank Jeffrey Kravetz, MD (Connecticut Veterans Affairs Healthcare System and Yale University, New Haven, CT); Benjamin Powers, MD (St Luke’s Internal Medicine, Boise, ID; University of Washington, Seattle, WA); and Michael Goldstein, MD (Veterans Health Administration National Center for Health Promotion and Disease Prevention, Durham, NC), for their advice and expertise in manuscript preparation. These contributors were not financially compensated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.