Margaret A. Piper, PhD, MPH; Corinne V. Evans, MPP; Brittany U. Burda, MPH; Karen L. Margolis, MD, MPH; Elizabeth O'Connor, PhD; Evelyn P. Whitlock, MD, MPH
Note: This review was conducted by the Kaiser Permanente Research Affiliates Evidence-based Practice Center under contract to the AHRQ. AHRQ staff provided oversight for the project and assisted in the external review of the companion draft evidence synthesis. The views expressed in this manuscript do not represent and should not be construed to represent a determination or policy of the AHRQ or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank the following for their contributions to this project: AHRQ staff; the USPSTF; David B. Callahan, MD, Beverly B. Green, MD, MPH, Joel Handler, MD, James A. Hodgkinson, MD, MSc, Carla I. Mercado, PhD, MS, Martin G. Myers, MD, and George S. Stergiou, MD, for providing expert review of the report; Ning Smith, PhD, for providing statistical expertise; Elizabeth Webber, MS; Leslie A. Perdue, MPH; Keshia Bigler, BS; and Kevin Lutz, MFA, and Smyth Lai, MLS, at the Kaiser Permanente Center for Health Research.
Financial Support: By contract HHSA-290-2012-00151-I, Task Order no. 2 from the AHRQ.
Disclosures: Dr. Piper reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Ms. Evans reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Ms. Burda reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr. Margolis reports grants from the Agency for Healthcare Research and Quality during the conduct of the study and grants from the National Heart, Lung, and Blood Institute outside the submitted work. Dr. O'Connor reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr. Whitlock reports grants from the Agency for Healthcare Research and Quality during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1539.
Requests for Single Reprints: Reprints are available from the AHRQ Web site (www.ahrq.gov).
Current Author Addresses: Drs. Piper, O'Connor, and Whitlock; Ms. Evans; and Ms. Burda: Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227.
Dr. Margolis: HealthPartners Institute for Education and Research, Mail Stop 21111R, PO Box 1524, Minneapolis, MN 55440.
Author Contributions: Conception and design: M.A. Piper, C.V. Evans, B.U. Burda, K.L. Margolis, E.P. Whitlock.
Analysis and interpretation of the data: M.A. Piper, C.V. Evans, B.U. Burda, K.L. Margolis, E. O'Connor, E.P. Whitlock.
Drafting of the article: M.A. Piper, C.V. Evans, B.U. Burda.
Critical revision of the article for important intellectual content: M.A. Piper, C.V. Evans, B.U. Burda, K.L. Margolis, E.P. Whitlock.
Final approval of the article: M.A. Piper, C.V. Evans, B.U. Burda, K.L. Margolis, E. O'Connor, E.P. Whitlock.
Statistical expertise: E. O'Connor.
Obtaining of funding: E.P. Whitlock.
Administrative, technical, or logistic support: B.U. Burda.
Collection and assembly of data: M.A. Piper, C.V. Evans, B.U. Burda, K.L. Margolis.
Elevated blood pressure (BP) is the largest contributing risk factor to all-cause and cardiovascular mortality.
To update a systematic review on the benefits and harms of screening for high BP in adults and to summarize evidence on rescreening intervals and diagnostic and predictive accuracy of different BP methods for cardiovascular events.
Selected databases searched through 24 February 2014.
Fair- and good-quality trials and diagnostic accuracy and cohort studies conducted in adults and published in English.
One investigator abstracted data, and a second checked for accuracy. Study quality was dual-reviewed.
Ambulatory BP monitoring (ABPM) predicted long-term cardiovascular outcomes independently of office BP (hazard ratio range, 1.28 to 1.40, in 11 studies). Across 27 studies, 35% to 95% of persons with an elevated BP at screening remained hypertensive after nonoffice confirmatory testing. Cardiovascular outcomes in persons who were normotensive after confirmatory testing (isolated clinic hypertension) were similar to outcomes in those who were normotensive at screening. In 40 studies, hypertension incidence after rescreening varied considerably at each yearly interval up to 6 years. Intrastudy comparisons showed at least 2-fold higher incidence in older adults, those with high-normal BP, overweight and obese persons, and African Americans.
Few diagnostic accuracy studies of office BP methods and protocols in untreated adults.
Evidence supports ABPM as the reference standard for confirming elevated office BP screening results to avoid misdiagnosis and overtreatment of persons with isolated clinic hypertension. Persons with BP in the high-normal range, older persons, those with an above-normal body mass index, and African Americans are at higher risk for hypertension on rescreening within 6 years than are persons without these risk factors.
Agency for Healthcare Research and Quality.
ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CHD = coronary heart disease; CVD = cardiovascular disease; ESKD = end-stage kidney disease; HBPM = home blood pressure monitoring; HF = heart failure.
* Defined as the threshold for pharmacologic treatment.
Appendix Table 1. Overall Summary of Evidence, by Key Question
Summary of evidence search and selection.
KQ = key question.
* Surveillance search results through August 2014 for trials reporting direct benefits of screening were not included; no additional trials were identified.
Appendix Table 2. ABPM Device Characteristics
Risk for cardiovascular and mortality outcomes: systolic 24-h ABPM, adjusted for OBPM.
Results of included studies for key question 3a. ABPM = ambulatory blood pressure monitoring; CV = cardiovascular; HF = heart failure; HR = hazard ratio; MI = myocardial infarction; OBPM = office blood pressure measurement.
Risk for cardiovascular and mortality outcomes: systolic HBPM, adjusted for OBPM.
Results of included studies for key question 3a. CV = cardiovascular; HBPM = home blood pressure monitoring; HR = hazard ratio; MI = myocardial infarction; OBPM = office blood pressure measurement; TIA = transient ischemic attack.
Proportion of elevated OBPM results confirmed by ABPM or HBPM.
Results of included studies for key question 3b. ABPM = ambulatory blood pressure monitoring; HBPM = home blood pressure monitoring; OBPM = office blood pressure measurement; PPV = positive predictive value.
Scatterplot of hypertension incidence, by rescreening interval.
Results of included studies for key question 4a. The size of the symbol represents the number of participants in the study. HTN = hypertension.
Appendix Table 3. Weighted Mean Hypertension Incidence at Various Rescreening Intervals in Subgroups Identified a Priori
Appendix Table 4. Hypertension Incidence, by Age
Appendix Table 5. Hypertension Incidence in Studies Reporting 3 BP Categories
Appendix Table 6. Hypertension Incidence at Various Rescreening Intervals, by Sex
Table 1. Hypertension Incidence at Various Rescreening Intervals, by BMI
Table 2. Hypertension Incidence at Various Rescreening Intervals, by Race/Ethnicity
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Nancy Tondreau Neely, M.D.
February 22, 2015
Accurate BP measurements
How about "taking back" some mercury from the squiggly light bulbs and accurately measuring blood pressures?
Piper MA, Evans CV, Burda BU, Margolis KL, O'Connor E, Whitlock EP. Diagnostic and Predictive Accuracy of Blood Pressure Screening Methods With Consideration of Rescreening Intervals: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;162:192-204. doi: 10.7326/M14-1539
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Published: Ann Intern Med. 2015;162(3):192-204.
Cardiology, Coronary Risk Factors, Hypertension, Nephrology, Prevention/Screening.
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