Gerontology 1992;38:99-104
Olivier Raccaud Bernard Waeber Antonio Petrillo Paul Wiesel Jean-René Hofslelter Hans R. Brunner
Ambulatory Blood Pressure Monitoring as a Means to Avoid Overtreatment of Elderly Hypertensive Patients
KeyWords Ambulatory blood pressure Hypertensive therapy Overtreatment
Abstract Do elderly similarly to younger hypertensive patients tend to be overtreated if therapeutic decisions are based exclusively on blood pressure measured by the physician in his office? Eighteen hypertensive patients (10 previously treated) aged 70 years or more had repeatedly office systolic blood pressure > 170 mm Hg and/or diastolic blood pressure >: 100 mm Hg. The physicians in charge were asked to reduce blood pressure within 4 months to a target of < 160/95 mm Hg using any drug regimen. Blood pressure was monitored during daytime using a noninvasive blood pressure recorder, but the results of the recording were not available to the physicians until the end of the study. At the outset, 11 patients had a mean ambulatory recorded blood pressure < 170/100 mm Hg. Those patients who exhibited high blood pressures only in the doctor’s pres ence did not reduce their ambulatory blood pressure when antihypertensive therapy was initiated or intensified in order to reduce office blood pressure. This contrasted with the sig nificant fall in ambulatory blood pressure observed in the presence of the doctor. Thus ambulatory blood pressure moni toring seems useful to avoid overtreatment not only of youn ger but also of elderly hypertensive patients.
Received: November 14. 1990 Accepted: April 30, 1991
H.R. Brunner, MD Division d ’Hvpertension CHUV C H -1011 Lausanne (Switzerland)
©1992 S. Karger AG, Basel 0304-324X/92/ 0382-009952.75/0
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
Division of Hypertension, Centre Hospitalier Universitaire Vaudois. and Policlinique Médicale Universitaire, Lausanne, Switzerland
Patients and Methods
Advancing age is associated in industrial ized countries with a progressive rise in blood pressure [1]. Hypertension becomes a com mon disease in the elderly and represents a major risk factor for cardiovascular complica tions [2]. It is now well established that anti hypertensive therapy provides benefits in the aged hypertensive patients in terms of cardio vascular morbidity and mortality [3-5]. Prac tically everything known about hypertension in the elderly is based on blood pressure read ings taken conventionally by a physician. It is however well established today that such ca sual blood pressure readings may greatly dif fer in the individual patient from those pre vailing during everyday activities [6, 7], In a recent retrospective study, we assessed the usefulness of ambulatory blood pressure monitoring using a noninvasive device in the management of elderly hypertensive patients [8]. Introduction or modification of existing antihypertensive therapy reduced, as expected, blood pressure measured in the doctor’s office. Disparate responses were observed when tak ing into account ambulatory blood pressure recordings obtained at the same time. A signif icant reduction could be found only in patients considered to have abnormally high ambula tory blood pressures during initial evaluation. Furthermore, similar results were obtained in a prospective trial in younger hypertensive patients suggesting that there is little benefit in initiating or intensifying antihypertensive treatment if the mean daytime ambulatory blood pressure is not clearly elevated [9], The findings urged us to undertake a simi lar prospective trial in elderly patients exhib iting repeatedly elevated blood pressures at their doctor’s office. Our purpose was to de fine the response of ambulatory blood pres sure to therapeutic efforts to normalize office blood pressure.
100
A total of 18 hypertensive patients (11 women) aged 70 years or more (mean = 78 years) were in cluded. The study protocol is outlined in figure 1. At recruitment, 10 patients were already being treated with one or more antihypertensive agents and 8 were newly diagnosed, untreated hypertensives. After a minimum of 6 weeks with either the same drug regi men or no treatment, blood pressure obtained from seated patients with a conventional mercury sphygmo manometer were > 170 mm Hg for systolic and/or > 1 0 0 mg Hg for diastolic. During this equilibration period, the patients were seen three times at the outpa tient clinic. Within the last 2 weeks before the begin ning of the active part of the trial, all patients had their blood pressure monitored on an ambulatory basis dur ing everyday activities. This was done noninvasively using the Remler M2000 System (Remler, San Fran cisco, Calif., USA) a portable patient-activated blood pressure recorder known to provide accurate blood pressure readings [10]. This apparatus was fitted to the patient between 7.30 and 8.30 a.m., as described pre viously. After leaving the clinic, the patients recorded their blood pressure every 30 min for 12 h. A decoding unit (Remler M 3000) was used to read the blood pres sure levels from the magnetic tape. Every physician then attempted to reduce office blood pressure within 4 months to 220 -
§ 200 levels at three consecutive visits during a 6-week period in elderly hypertensive patients. Ten patients had never been treated prior to the study (dotted lines). In the 8 pa tients on antihypertensive therapy at the time of enrollment, the drug regimen was maintained un changed (solid lines). Means ± SD.
g
1 80-
+
I 160 £ “ • 140 -
1 120 " ®
5
100
*
-
80 60 40 -
1
Results Figure 2 illustrates the individual values of office blood pressure measured at three con secutive visits during the equilibration peri od. A steady baseline was achieved in un treated patients as well as in those who were already on therapy. At the start of the study, 7 of the 18 patients had a mean ambulatory blood pres sure > 170 mm Hg for systolic and/or > 100 mm Hg for diastolic. In these patients, office blood pressures were reduced significantly
2
3
Visits
during the course of the trial from 173/104 ± 12/12 to 151/91 ± 9/10 mmHg (fig. 3). Am bulatory blood pressures fell similarly from 167/101 ± 11/5 to 147/89 ± 19/8 mm Hg (fig. 3). A significant fall in office blood pressure from 179/103 ± 14/10 to 156/91 ± 26/15 mm Hg was also obtained in the 11 patients exhibiting an initial ambulatory recorded blood pressure 180
Beginning
End
180
X
E £
150
150
CL CD
120
120
CL
co
90 60
I
blood pressure (142/84 ± 13/11 mm Hg at the beginning versus 149/88 ± 20/11 mm Hg at the end of the observation period).
Discussion It is essential when treating hypertension to take the risk:benefit ratio into account. This is true particularly in the elderly patient. There is today no doubt that lowering blood pressure of the elderly patient is effective in reducing the incidence of cardiovascular com plications [3-5]. At the same time, there is also a growing concern about the target blood pressure to be reached during therapy. Poten tial hazards may exist if diastolic blood pres sure, a major determinant of coronary perfu sion, is reduced below a certain critical limit [11], The danger of causing myocardial isch
102
emia is probably greatest in patients with preexisting coronary heart disease, whether silent or symptomatic. Such a condition is likely to be encountered in old persons, espe cially in those who have been suffering from hypertension for many years. In fact, the data provided by the European Working Party on Hypertension in the Elderly, a double-blind placebo-controlled, randomized trial, are compatible with a higher incidence of cardio vascular mortality during antihypertensive therapy in patients having a diastolic pressure already < 90 mm Hg before the initiation of treatment [12]. The ultimate clinical proof that excessive blood pressure reduction may increase the risk of myocardial ischemia is however still missing. However, antihypertensive therapy may adversely influence the life of elderly patients by another way. The likelihood of side effects
Raccaud/Waeber/Petrillo/Wiesel/ Hofstetter/Brunner
Ambulatory Blood Pressure Monitoring
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
Fig. 3. Office (a, c) and ambulatory recorded blood pressure (b, d) at the beginning and at the end of the study. Patients were divided in two groups according to the level of ambulatory bood pressure recorded during baseline evaluation, a, b Initial ambulatory recorded blood pressure > 170 and/or > 100 mm Hg (n = 7). c, d Initial ambulatory recorded blood pressure < 170/100 mm Hg(n = 11). BP = Blood pressure. * p < 0.05, ** p < 0.01. *** p < 0.001, vs. beginning.
Generally, blood pressures measured away from the medical environment tend to be lower than those determined by a doctor in his office [6, 7], Thus, one might expect that basing the therapeutic strategy solely on office blood pressure readings should lead to over treatment of some hypertensive patients. This hypothesis was tested in a prospective study involving unselected treated hypertensive pa tients with persistently high blood pressures measured by the physician [9]. In patients who started with a normal ambulatory blood pressure, treatment adjustments did not re sult in any further reduction in blood pres sures monitored outside the doctor’s office. This contrasted sharply with the significant fall in ambulatory blood pressure found at the beginning of the study in those patients who exhibited an elevation not only of office but also of ambulatory recorded pressures. The present study performed according to a very similar protocol in aged hypertensive patients yielded results which strongly support the pre vious observations made in a younger popula tion. These findings corroborate previous re sults obtained in a retrospective analyis of elderly hypertensive patients [8], Office blood pressure was significantly re duced by the drug intervention even in the subgroup of patients characterized by a low initial ambulatory blood pressure. How could a progressive decline in blood pressure be explained in the absence of a parallel change in ambulatory recorded blood pressure? This may reflect a phenomenon of familiarization of the patient with his doctor or of regression to the mean. In fact, the behavior of office and ambulatory recorded pressures seen in these patients is comparable with the response ex pected to occur after administration of a pla cebo. Thus, a number of reports have yielded convincing evidence that placebo attenuates the blood pressures rise ellicited by the pres ence of a doctor, but has actually no lowering
103
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
arising during pharmacological treatment ap pears indeed to increase with age even though the deleterious impact of antihypertensive drugs in the elderly has probably been overes timated [13]. Certainly, there exists no ideal blood pressure-lowering agent universally well tolerated so that it is still necessary to individualize the therapeutic approach in bal ancing the benefits and the risks linked to a drug-induced blood pressure decrease. Individualization of antihypertensive ther apy should of course be based on a precise evaluation of the risk to a patient. For this purpose, measuring blood pressure conven tionally at the doctor’s office may be inade quate [14], Blood pressures measured in the office have been shown repeatedly to be poorly representative of those prevailing when the patients are away from the medical environment. In fact, it is impossible to pre dict, in the individual subject, the magnitude of the difference between office and ambula tory pressures, whether recorded intra-arteri ally or noninvasively [6, 7], The discrepancy between blood pressures determined in the presence and absence of a doctor persists dur ing treatment. This is a real problem since there exists a considerable body of evidence accumulated during recent years suggesting a closer correlation of cardiovascular risk with ambulatory than with office blood pressures [15-19], One has to admit, however, that a large-scale study characterizing cardiovascu lar risk on the basis of ambulatory blood pres sure monitoring has not yet been conducted. It is therefore not possible to set definitive limits of normal values for ambulatory blood pressure recordings. This should nevertheless no preclude the use of this new way of assess ing blood pressure in an attempt to improve the detection of high-risk patients, particu larly in the presence of a mild elevation of blood pressure and in the absence of target organ damage.
action on ambulatory recorded blood pres sure [20, 21]. Recording blood pressure out side the doctor’s office allows therefore to detect those patients who are prone to become less hypertensive, as judged by office blood pressure measurements, when the medical visits are repeated and becoming, most likely, less stressful. In summary, these data obtained in pro spective fashion indicate that ambulatory blood pressure monitoring may be used to
avoid overtreatment of elderly hypertensive patients. It should be possible by this way to better define the cardiovascular risk and to individualize optimally antihypertensive therapy.
Acknowledgements This work was supported by grants from the Swiss National Science Foundation and the Cardiovascular Research Foundation.
References 9 Waeber B, Scherrer U, Petrillo A, Bidiville J, Nussberger J, Waeber G, Hostetter JR. Brunner HR: Are some hypertensive patients over treated? Results of a prospective study of ambulatory blood pressure recordings. Lancet 1987;ii:732—734. 10 Hinman AT, Engel BT, Bickford AF: Portable blood pressure record er: Accuracy and preliminary use in evaluating intradaily variations in pressure. Am Heart J 1962;63:663—
104
Raccaud/Waeber/Petrillo/Wiesel/ Hofstetter/Brunner
668. 11 Cruickshank JM, Thorp JM, Za charias FJ: Benefits and potential harm of lowering high blood pres sure. Lancet 1987;ii:581—584. 12 Birkenhäger WH. De Lceuw PW: Impact of systolic blood pressure on cardiovascular prognosis. J Hypertens 1988; 6(suppl 1): 21-24. 13 Lamy PP: Potential adverse effects of antihypertensive drugs in the el derly. J Hypertens 1988;6(supppl 1): 81-85. 14 O’Brien E, Fitzgerald D, O'Malley K: Blood pressure measurement: Current practice and future trends. Br Med J 1985;290:729-734 15 Devereux RB, Pickering TG, Harshfield GA, Kleinert HD, Denby L, Clark L, Pregibon D, Jason M, Kleiner B, Borer JS, Laragh JH: Left ventricular hypertrophy in patients with hypertension: Importance of blood pressure response to regularly recurring stress. Circulation 1983; 68:470-476.
16 Perloff D, Sokolow M, Cowan R: The prognostic value of ambulatory blood pressure. JAMA 1983,249: 2792-2798. 17 Parati G, Pomidossi G. Albini F, Malaspina D, Mancia G: Relation ship of 24-hour blood pressure mean and variability to severity of targetorgan damage in hypertension. J Hypertens 1987;5:93-98. 18 Hebcr ME, Bridgen GS, Prince, Lahiri A, Raftery EB: Is there a rela tionship between ambulatory intra arterial blood pressure and left ven tricular function? Hypertension 1988;11:464-469. 19 White WB, Schulman P. McCabe EJ, Dey HM: Average daily blood pressure, not office blood pressure, determines cardiac function in pa tients with hypertension. JAMA 1989;261:873-877. 20 Gould BA. Mann S, Davies AB. Alt man DG, Raftery EB. Does placebo lower blood pressure? Lancet 1981; ii: 1377-1381. 21 Drayer JI, Weber MA, De Young JL, Brewer DD: Long-term blood pressure monitoring in the evalua tion of antihypertensive therapy. Arch Intern Med 1983:143:898— 901.
Ambulatory Blood Pressure Monitoring
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
1 Sowers JR: Hypertension in the el derly. Am J Med 1987;82:1-8. 2 Vokonas PS, Kannel WB, Cupples LA: Epidemiology and risk of hyper tension in the elderly: The Fram ingham Study. J Hypcrtens 1988; 6(suppl 1):3—9. 3 European Working Party: Mortality and morbidity results from the Eu ropean Working Party on high blood pressure in the elderly trial. Lancet 1985;i: 1349—1354. 4 Coope J, Warrender TS: Random ized trial of treatment of hyperten sion in the elderly in primary care. Br Med J 1986;293:1145-1151. 5 Davidson RA, Caranasos GJ: Should the elderly hypertensive be treated? Evidence from clinical trials. Arch Intern Med 1987;147: 1933-1937. 6 Floras JS, Jones JV, Hassan MO, Osikowska B, Sever PS, Sleight P: Cuff and ambulatory pressure in subjects with essential hypertension. Lancet 1981 ;i: 107-109. 7 Waeber B, Burnier M. Perret F, Nussberger J, Brunner HR: Ambu latory blood pressure measurement and antihypertensive therapy. J Hypertens 1989;7(suppl 3): 33-39. 8 Torriani S, Waeber B, Petrillo A, Di Stefano R, Mooser V, Scherrer U, Nussberger J, Hofstetter JR, Brun ner HR: Usefulness of ambulatory blood pressurre monitoring in the elderly hypertensive patient. J Hypertens 1988;6(suppl I ):25—27.
Olivier Raccaud Bernard Waeber Antonio Petrillo Paul Wiesel Jean-René Hofslelter Hans R. Brunner
Ambulatory Blood Pressure Monitoring as a Means to Avoid Overtreatment of Elderly Hypertensive Patients
KeyWords Ambulatory blood pressure Hypertensive therapy Overtreatment
Abstract Do elderly similarly to younger hypertensive patients tend to be overtreated if therapeutic decisions are based exclusively on blood pressure measured by the physician in his office? Eighteen hypertensive patients (10 previously treated) aged 70 years or more had repeatedly office systolic blood pressure > 170 mm Hg and/or diastolic blood pressure >: 100 mm Hg. The physicians in charge were asked to reduce blood pressure within 4 months to a target of < 160/95 mm Hg using any drug regimen. Blood pressure was monitored during daytime using a noninvasive blood pressure recorder, but the results of the recording were not available to the physicians until the end of the study. At the outset, 11 patients had a mean ambulatory recorded blood pressure < 170/100 mm Hg. Those patients who exhibited high blood pressures only in the doctor’s pres ence did not reduce their ambulatory blood pressure when antihypertensive therapy was initiated or intensified in order to reduce office blood pressure. This contrasted with the sig nificant fall in ambulatory blood pressure observed in the presence of the doctor. Thus ambulatory blood pressure moni toring seems useful to avoid overtreatment not only of youn ger but also of elderly hypertensive patients.
Received: November 14. 1990 Accepted: April 30, 1991
H.R. Brunner, MD Division d ’Hvpertension CHUV C H -1011 Lausanne (Switzerland)
©1992 S. Karger AG, Basel 0304-324X/92/ 0382-009952.75/0
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
Division of Hypertension, Centre Hospitalier Universitaire Vaudois. and Policlinique Médicale Universitaire, Lausanne, Switzerland
Patients and Methods
Advancing age is associated in industrial ized countries with a progressive rise in blood pressure [1]. Hypertension becomes a com mon disease in the elderly and represents a major risk factor for cardiovascular complica tions [2]. It is now well established that anti hypertensive therapy provides benefits in the aged hypertensive patients in terms of cardio vascular morbidity and mortality [3-5]. Prac tically everything known about hypertension in the elderly is based on blood pressure read ings taken conventionally by a physician. It is however well established today that such ca sual blood pressure readings may greatly dif fer in the individual patient from those pre vailing during everyday activities [6, 7], In a recent retrospective study, we assessed the usefulness of ambulatory blood pressure monitoring using a noninvasive device in the management of elderly hypertensive patients [8]. Introduction or modification of existing antihypertensive therapy reduced, as expected, blood pressure measured in the doctor’s office. Disparate responses were observed when tak ing into account ambulatory blood pressure recordings obtained at the same time. A signif icant reduction could be found only in patients considered to have abnormally high ambula tory blood pressures during initial evaluation. Furthermore, similar results were obtained in a prospective trial in younger hypertensive patients suggesting that there is little benefit in initiating or intensifying antihypertensive treatment if the mean daytime ambulatory blood pressure is not clearly elevated [9], The findings urged us to undertake a simi lar prospective trial in elderly patients exhib iting repeatedly elevated blood pressures at their doctor’s office. Our purpose was to de fine the response of ambulatory blood pres sure to therapeutic efforts to normalize office blood pressure.
100
A total of 18 hypertensive patients (11 women) aged 70 years or more (mean = 78 years) were in cluded. The study protocol is outlined in figure 1. At recruitment, 10 patients were already being treated with one or more antihypertensive agents and 8 were newly diagnosed, untreated hypertensives. After a minimum of 6 weeks with either the same drug regi men or no treatment, blood pressure obtained from seated patients with a conventional mercury sphygmo manometer were > 170 mm Hg for systolic and/or > 1 0 0 mg Hg for diastolic. During this equilibration period, the patients were seen three times at the outpa tient clinic. Within the last 2 weeks before the begin ning of the active part of the trial, all patients had their blood pressure monitored on an ambulatory basis dur ing everyday activities. This was done noninvasively using the Remler M2000 System (Remler, San Fran cisco, Calif., USA) a portable patient-activated blood pressure recorder known to provide accurate blood pressure readings [10]. This apparatus was fitted to the patient between 7.30 and 8.30 a.m., as described pre viously. After leaving the clinic, the patients recorded their blood pressure every 30 min for 12 h. A decoding unit (Remler M 3000) was used to read the blood pres sure levels from the magnetic tape. Every physician then attempted to reduce office blood pressure within 4 months to 220 -
§ 200 levels at three consecutive visits during a 6-week period in elderly hypertensive patients. Ten patients had never been treated prior to the study (dotted lines). In the 8 pa tients on antihypertensive therapy at the time of enrollment, the drug regimen was maintained un changed (solid lines). Means ± SD.
g
1 80-
+
I 160 £ “ • 140 -
1 120 " ®
5
100
*
-
80 60 40 -
1
Results Figure 2 illustrates the individual values of office blood pressure measured at three con secutive visits during the equilibration peri od. A steady baseline was achieved in un treated patients as well as in those who were already on therapy. At the start of the study, 7 of the 18 patients had a mean ambulatory blood pres sure > 170 mm Hg for systolic and/or > 100 mm Hg for diastolic. In these patients, office blood pressures were reduced significantly
2
3
Visits
during the course of the trial from 173/104 ± 12/12 to 151/91 ± 9/10 mmHg (fig. 3). Am bulatory blood pressures fell similarly from 167/101 ± 11/5 to 147/89 ± 19/8 mm Hg (fig. 3). A significant fall in office blood pressure from 179/103 ± 14/10 to 156/91 ± 26/15 mm Hg was also obtained in the 11 patients exhibiting an initial ambulatory recorded blood pressure 180
Beginning
End
180
X
E £
150
150
CL CD
120
120
CL
co
90 60
I
blood pressure (142/84 ± 13/11 mm Hg at the beginning versus 149/88 ± 20/11 mm Hg at the end of the observation period).
Discussion It is essential when treating hypertension to take the risk:benefit ratio into account. This is true particularly in the elderly patient. There is today no doubt that lowering blood pressure of the elderly patient is effective in reducing the incidence of cardiovascular com plications [3-5]. At the same time, there is also a growing concern about the target blood pressure to be reached during therapy. Poten tial hazards may exist if diastolic blood pres sure, a major determinant of coronary perfu sion, is reduced below a certain critical limit [11], The danger of causing myocardial isch
102
emia is probably greatest in patients with preexisting coronary heart disease, whether silent or symptomatic. Such a condition is likely to be encountered in old persons, espe cially in those who have been suffering from hypertension for many years. In fact, the data provided by the European Working Party on Hypertension in the Elderly, a double-blind placebo-controlled, randomized trial, are compatible with a higher incidence of cardio vascular mortality during antihypertensive therapy in patients having a diastolic pressure already < 90 mm Hg before the initiation of treatment [12]. The ultimate clinical proof that excessive blood pressure reduction may increase the risk of myocardial ischemia is however still missing. However, antihypertensive therapy may adversely influence the life of elderly patients by another way. The likelihood of side effects
Raccaud/Waeber/Petrillo/Wiesel/ Hofstetter/Brunner
Ambulatory Blood Pressure Monitoring
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
Fig. 3. Office (a, c) and ambulatory recorded blood pressure (b, d) at the beginning and at the end of the study. Patients were divided in two groups according to the level of ambulatory bood pressure recorded during baseline evaluation, a, b Initial ambulatory recorded blood pressure > 170 and/or > 100 mm Hg (n = 7). c, d Initial ambulatory recorded blood pressure < 170/100 mm Hg(n = 11). BP = Blood pressure. * p < 0.05, ** p < 0.01. *** p < 0.001, vs. beginning.
Generally, blood pressures measured away from the medical environment tend to be lower than those determined by a doctor in his office [6, 7], Thus, one might expect that basing the therapeutic strategy solely on office blood pressure readings should lead to over treatment of some hypertensive patients. This hypothesis was tested in a prospective study involving unselected treated hypertensive pa tients with persistently high blood pressures measured by the physician [9]. In patients who started with a normal ambulatory blood pressure, treatment adjustments did not re sult in any further reduction in blood pres sures monitored outside the doctor’s office. This contrasted sharply with the significant fall in ambulatory blood pressure found at the beginning of the study in those patients who exhibited an elevation not only of office but also of ambulatory recorded pressures. The present study performed according to a very similar protocol in aged hypertensive patients yielded results which strongly support the pre vious observations made in a younger popula tion. These findings corroborate previous re sults obtained in a retrospective analyis of elderly hypertensive patients [8], Office blood pressure was significantly re duced by the drug intervention even in the subgroup of patients characterized by a low initial ambulatory blood pressure. How could a progressive decline in blood pressure be explained in the absence of a parallel change in ambulatory recorded blood pressure? This may reflect a phenomenon of familiarization of the patient with his doctor or of regression to the mean. In fact, the behavior of office and ambulatory recorded pressures seen in these patients is comparable with the response ex pected to occur after administration of a pla cebo. Thus, a number of reports have yielded convincing evidence that placebo attenuates the blood pressures rise ellicited by the pres ence of a doctor, but has actually no lowering
103
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
arising during pharmacological treatment ap pears indeed to increase with age even though the deleterious impact of antihypertensive drugs in the elderly has probably been overes timated [13]. Certainly, there exists no ideal blood pressure-lowering agent universally well tolerated so that it is still necessary to individualize the therapeutic approach in bal ancing the benefits and the risks linked to a drug-induced blood pressure decrease. Individualization of antihypertensive ther apy should of course be based on a precise evaluation of the risk to a patient. For this purpose, measuring blood pressure conven tionally at the doctor’s office may be inade quate [14], Blood pressures measured in the office have been shown repeatedly to be poorly representative of those prevailing when the patients are away from the medical environment. In fact, it is impossible to pre dict, in the individual subject, the magnitude of the difference between office and ambula tory pressures, whether recorded intra-arteri ally or noninvasively [6, 7], The discrepancy between blood pressures determined in the presence and absence of a doctor persists dur ing treatment. This is a real problem since there exists a considerable body of evidence accumulated during recent years suggesting a closer correlation of cardiovascular risk with ambulatory than with office blood pressures [15-19], One has to admit, however, that a large-scale study characterizing cardiovascu lar risk on the basis of ambulatory blood pres sure monitoring has not yet been conducted. It is therefore not possible to set definitive limits of normal values for ambulatory blood pressure recordings. This should nevertheless no preclude the use of this new way of assess ing blood pressure in an attempt to improve the detection of high-risk patients, particu larly in the presence of a mild elevation of blood pressure and in the absence of target organ damage.
action on ambulatory recorded blood pres sure [20, 21]. Recording blood pressure out side the doctor’s office allows therefore to detect those patients who are prone to become less hypertensive, as judged by office blood pressure measurements, when the medical visits are repeated and becoming, most likely, less stressful. In summary, these data obtained in pro spective fashion indicate that ambulatory blood pressure monitoring may be used to
avoid overtreatment of elderly hypertensive patients. It should be possible by this way to better define the cardiovascular risk and to individualize optimally antihypertensive therapy.
Acknowledgements This work was supported by grants from the Swiss National Science Foundation and the Cardiovascular Research Foundation.
References 9 Waeber B, Scherrer U, Petrillo A, Bidiville J, Nussberger J, Waeber G, Hostetter JR. Brunner HR: Are some hypertensive patients over treated? Results of a prospective study of ambulatory blood pressure recordings. Lancet 1987;ii:732—734. 10 Hinman AT, Engel BT, Bickford AF: Portable blood pressure record er: Accuracy and preliminary use in evaluating intradaily variations in pressure. Am Heart J 1962;63:663—
104
Raccaud/Waeber/Petrillo/Wiesel/ Hofstetter/Brunner
668. 11 Cruickshank JM, Thorp JM, Za charias FJ: Benefits and potential harm of lowering high blood pres sure. Lancet 1987;ii:581—584. 12 Birkenhäger WH. De Lceuw PW: Impact of systolic blood pressure on cardiovascular prognosis. J Hypertens 1988; 6(suppl 1): 21-24. 13 Lamy PP: Potential adverse effects of antihypertensive drugs in the el derly. J Hypertens 1988;6(supppl 1): 81-85. 14 O’Brien E, Fitzgerald D, O'Malley K: Blood pressure measurement: Current practice and future trends. Br Med J 1985;290:729-734 15 Devereux RB, Pickering TG, Harshfield GA, Kleinert HD, Denby L, Clark L, Pregibon D, Jason M, Kleiner B, Borer JS, Laragh JH: Left ventricular hypertrophy in patients with hypertension: Importance of blood pressure response to regularly recurring stress. Circulation 1983; 68:470-476.
16 Perloff D, Sokolow M, Cowan R: The prognostic value of ambulatory blood pressure. JAMA 1983,249: 2792-2798. 17 Parati G, Pomidossi G. Albini F, Malaspina D, Mancia G: Relation ship of 24-hour blood pressure mean and variability to severity of targetorgan damage in hypertension. J Hypertens 1987;5:93-98. 18 Hebcr ME, Bridgen GS, Prince, Lahiri A, Raftery EB: Is there a rela tionship between ambulatory intra arterial blood pressure and left ven tricular function? Hypertension 1988;11:464-469. 19 White WB, Schulman P. McCabe EJ, Dey HM: Average daily blood pressure, not office blood pressure, determines cardiac function in pa tients with hypertension. JAMA 1989;261:873-877. 20 Gould BA. Mann S, Davies AB. Alt man DG, Raftery EB. Does placebo lower blood pressure? Lancet 1981; ii: 1377-1381. 21 Drayer JI, Weber MA, De Young JL, Brewer DD: Long-term blood pressure monitoring in the evalua tion of antihypertensive therapy. Arch Intern Med 1983:143:898— 901.
Ambulatory Blood Pressure Monitoring
Downloaded by: East Carolina University - Laupus Library 150.216.68.200 - 1/13/2019 2:16:16 AM
1 Sowers JR: Hypertension in the el derly. Am J Med 1987;82:1-8. 2 Vokonas PS, Kannel WB, Cupples LA: Epidemiology and risk of hyper tension in the elderly: The Fram ingham Study. J Hypcrtens 1988; 6(suppl 1):3—9. 3 European Working Party: Mortality and morbidity results from the Eu ropean Working Party on high blood pressure in the elderly trial. Lancet 1985;i: 1349—1354. 4 Coope J, Warrender TS: Random ized trial of treatment of hyperten sion in the elderly in primary care. Br Med J 1986;293:1145-1151. 5 Davidson RA, Caranasos GJ: Should the elderly hypertensive be treated? Evidence from clinical trials. Arch Intern Med 1987;147: 1933-1937. 6 Floras JS, Jones JV, Hassan MO, Osikowska B, Sever PS, Sleight P: Cuff and ambulatory pressure in subjects with essential hypertension. Lancet 1981 ;i: 107-109. 7 Waeber B, Burnier M. Perret F, Nussberger J, Brunner HR: Ambu latory blood pressure measurement and antihypertensive therapy. J Hypertens 1989;7(suppl 3): 33-39. 8 Torriani S, Waeber B, Petrillo A, Di Stefano R, Mooser V, Scherrer U, Nussberger J, Hofstetter JR, Brun ner HR: Usefulness of ambulatory blood pressurre monitoring in the elderly hypertensive patient. J Hypertens 1988;6(suppl I ):25—27.
