From the Journals

24-hour ambulatory BP measurements strongly predict mortality


Key clinical point: Ambulatory (24-hour) BP measurements were stronger predictors of cardiovascular and all-cause mortality than were clinic measurements.

Major finding: Modeling showed a stronger association between ambulatory systolic pressure and all-cause mortality (adjusted HR, 1.58 per 1-SD pressure increase) than between clinic systolic pressure and all-cause mortality (adjusted HR, 1.02).

Study details: Retrospective analysis of mortality from a cohort of 63,910 adults recruited to a registry in Spain during 2004-2014.

Disclosures: Lacer Laboratories, the Spanish Society of Hypertension, and some European government agencies supported the study. Dr. Banegas reported grants from Fondo de Investigación Sanitaria and personal fees from Lacer. Coauthors reported disclosures related to Vascular Dynamics USA, Relypsa USA, Novartis Pharma USA, Daiichi Sankyo, Boehringer Ingelheim, Pfizer, Lacer Laboratories Spain, and others.

Source: Banegas JR et al. N Engl J Med 2018;378:1509-20.

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Registries valuable for ambulatory BP assessment

The investigation by Dr. Banegas and colleagues confirms that ambulatory blood pressure monitoring is useful for assessing blood pressure, the most important and treatable factor contributing to death and disability.

The registry study addresses several clinically relevant issues. In particular, ambulatory blood pressure measures more strongly predicted all-cause and cardiovascular mortality as compared with blood pressure measured in the clinic.

Moreover, the highest hazard ratio of death was seen in patients with masked hypertension, or those with normal clinic-measured blood pressure but elevated ambulatory measurements.

Finally, patients with white coat hypertension (elevated clinic but normal ambulatory blood pressure) had a risk of cardiovascular death twice as high as patients with normal clinic and ambulatory values.

The ominous effect of white coat hypertension has been noted by others, and it is probably related to the increasing magnitude (that is, the difference between clinic blood pressure and ambulatory blood pressure) to white coat hypertension with age.

Ambulatory blood pressure monitoring equipment has evolved and is much lighter than in the past, making it more acceptable to patients.

With more patients undergoing ambulatory blood pressure monitoring, several countries established ambulatory monitoring registries, such as the Spanish registry evaluated in this study.

Ultimately, one hopes the results of this registry study would serve as one more spur to providers and device manufacturers to initiate a registry in the United States.

Raymond R. Townsend, MD, is from the University of Pennsylvania, Philadelphia. These comments are based on his editorial that appeared in the New England Journal of Medicine . Dr. Townsend reported disclosures related to Medtronic, AXIO, and CLARUS Therapeutics, among others.



Ambulatory measurements of blood pressure more strongly predicted all-cause and cardiovascular mortality than did BP measured in the clinic, according to analysis of a large patient registry in Spain.

The results also showed an increased risk of death associated with white coat hypertension and an even stronger association between death and masked hypertension. They were published in the New England Journal of Medicine.


Previous investigations had found that 24-hour ambulatory BP measurements were better predictors of patient outcomes than those obtained in the clinic or at home, but those investigations were small or population based.“In these studies, the number of clinical outcomes was limited, which reduced the ability to assess the predictive value of clinic blood pressure data as compared with ambulatory data,” reported José R. Banegas, MD, of the department of preventive medicine and public health at the Autonomous University of Madrid and his colleagues.

To better define the prognostic value of 24-hour ambulatory blood pressure measurement, Dr. Banegas and his colleagues looked at data on a large cohort of primary care patients in the Spanish Ambulatory Blood Pressure Registry. Their analysis included 63,910 adults recruited to the registry during 2004-2014.

Patients had blood pressure measurements taken in the clinic according to standard procedures. Afterward, they had ambulatory blood pressure monitoring that used an automated device programmed to record BP every 20 minutes during the day and every 30 minutes at night.

They found that overall clinic and ambulatory blood pressure measurements had a relatively similar magnitude of association with all-cause and cardiovascular mortality.

However, clinic systolic pressure lost its predictive power for all-cause mortality after adjustment for 24-hour ambulatory systolic pressure. The hazard ratio for all-cause mortality dropped from 1.54 before the adjustment to 1.02 after the adjustment, Dr. Banegas and his colleagues reported.

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