成田 圭佑

The diagnosis and management of hypertension have been based primarily on blood pressure (BP) measurement in the office setting. Higher out-of-office BP is associated with an increased risk of cardiovascular disease, independent of office BP. Home BP monitoring (HBPM) consists of the measurement of BP by a person outside of the office at home and is a validated approach for out-of-office BP measurement. HBPM provides valuable data for diagnosing and managing hypertension. Another validated approach, ambulatory BP monitoring (ABPM), has been considered to be the reference standard of out-of-office BP measurement. However, HBPM offers potential advantages over ABPM including being a better measure of basal BP, wide availability to patients and clinicians, evidence supporting its use for better office BP control, and demonstrated efficacy when using telemonitoring along with HBPM. This state-of-the-art review examines the current state of HBPM and includes discussion of recent hypertension guidelines on HBPM, advantages of using telemonitoring with HBPM, use of self-titration of antihypertensive medication with HBPM, validation of HBPM devices, best practices for conducting HBPM in the clinical setting, how HBPM can be used as an implementation strategy approach to improve BP control in the United States, health equity in HBPM use, and HBPM use among specific populations. Finally, research gaps and future directions of HBPM are reviewed.

We investigated whether the combination of medical therapy plus percutaneous transluminal renal angioplasty (PTRA) provides superior clinical outcomes compared to those afforded by medical therapy alone in patients with hypertension due to atherosclerotic renal artery stenosis (ARAS) by conducting a systematic review and meta-analysis of the relevant randomized controlled trials (RCTs). The evaluated outcomes included: (1) cardiovascular disease (CVD)-related mortality, (2) the incidence of CVD events, (3) changes in blood pressure (BP), (4) suppression of renal function decline, (5) changes in the number of antihypertensive drugs used, and (6) serious adverse events. Nine RCTs involving 2275 patients were analyzed, revealing that the combination therapy significantly reduced the number of antihypertensive drugs compared to medical therapy alone (mean difference: -0.42, 95% confidence interval: -0.71 to -0.12). However, there were no significant differences between the combination therapy and medical therapy alone in CVD mortality, the incidence of CVD events, BP changes, suppression of renal function decline, or serious adverse events. The included studies demonstrated a low-to-moderate risk of bias, with performance and detection bias being the most prominent concerns. Together our findings demonstrate that compared to medical therapy alone, the combination of medical therapy + PTRA reduced the number of antihypertensive drugs used but did not improve adverse CVD or renal outcomes. The quality of the included RCTs represents a potential limitation of this analysis.

BACKGROUND: The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline recommends ambulatory BP monitoring (ABPM) for diagnosing masked hypertension among adults not taking antihypertensive medication with borderline office BP (i.e., office systolic BP [SBP] 120 to <130 mmHg or diastolic BP [DBP] 75 to <80 mmHg). METHODS: Using data from the Improving the Detection of Hypertension Study, sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios for a positive and negative test of having borderline office BP (i.e. office SBP 120 to <130 mmHg or DBP 75 to <80 mmHg) for diagnosing masked hypertension (i.e. mean awake SBP ≥130 mmHg or mean awake DBP ≥80 mmHg) were determined among 263 participants who had a mean office SBP <130 mmHg and mean DBP <80 mmHg. Likelihood ratios for a positive test >10, 5 to 10, and <5 were considered strong, moderate, and weak, respectively. Likelihood ratios for a negative test <0.1, 0.1 to 0.2, and >0.2 were considered strong, moderate, and weak, respectively. RESULTS: Among the 263 participants, mean±SD age was 39.2±12.8 years, 62.4% were female, 38.4% had borderline office BP, and 26.2% had masked hypertension. SN, SP, PPV, and NPV were 0.754, 0.747, 0.515, and 0.895, respectively. The likelihood ratios for a positive and negative test were 2.984 (weak) and 0.330 (weak), respectively. CONCLUSIONS: The use of borderline office BP thresholds recommended in the 2017 ACC/AHA BP guideline did not sufficiently rule in or rule out masked hypertension.