Implementing Home Blood Pressure Monitoring into Clinical Practice
Purpose of Review
To review data supporting the use of home blood pressure monitoring (HBPM) and provide practical guidance to clinicians wishing to incorporate HBPM into their practice.
HBPM more accurately reflects the risk of cardiovascular events than office blood pressure measurement. In addition, there is high-quality evidence that HBPM combined with clinical support improves blood pressure control. Therefore, HBPM is increasingly recommended by guidelines to confirm the diagnosis of hypertension and evaluate the efficacy of blood pressure-lowering medications. Nevertheless, HBPM use remains low due to barriers from the patient, clinician, and healthcare system level. Understanding these barriers is crucial for developing strategies to effectively implement HBPM into routine clinical practice.
HBPM is a valuable adjunct to office blood pressure measurement for diagnosing hypertension and guiding antihypertensive therapy. Following recommended best practices can facilitate the successful implementation of HBPM and impact how hypertension is managed in the primary care setting.
KeywordsHome blood pressure monitoring Ambulatory blood pressure monitoring Hypertension Screening Implementation Barriers
Dr. Kronish and Dr. Phillips received support from the Agency for Healthcare Research and Quality (R01 HS024262.)
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Piper MA, Evans CV, Burda BU, Margolis KL, O’Connor E, Smith N, et al. Screening for high blood pressure in adults: a systematic evidence review for the US Preventive Services Task Force. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Rockville (MD)2014.Google Scholar
- 8.Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224–60.PubMedPubMedCentralCrossRefGoogle Scholar
- 9.Centers for Disease C, Prevention. CDC Grand Rounds: the million hearts initiative. MMWR Morb Mortal Wkly Rep. 2012;61(50):1017–21.Google Scholar
- 10.Michael Rakotz M. Improving blood pressure control: Measure, Act and Partner (M.A.P.) to help patients control blood pressure and ultimately prevent heart disease. 2015 [Available from: https://edhub.ama-assn.org/steps-forward/module/2702688. Accessed 20 Jan 2019
- 11.•• Reboussin DM, Allen NB, Griswold ME, Guallar E, Hong Y, Lackland DT, et al. Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e595–616 This systematic review and meta-analysis provides an estimate of the blood pressure and adverse cardiovascular event-lowering effect of self-measured blood pressure monitoring versus office blood pressure measurement.PubMedCrossRefGoogle Scholar
- 18.Kario K, Saito I, Kushiro T, Teramukai S, Ishikawa Y, Mori Y, et al. Home blood pressure and cardiovascular outcomes in patients during antihypertensive therapy: primary results of HONEST, a large-scale prospective, real-world observational study. Hypertension. 2014;64(5):989–96.PubMedCrossRefGoogle Scholar
- 20.Hoshide S, Yano Y, Haimoto H, Yamagiwa K, Uchiba K, Nagasaka S, et al. Morning and evening home blood pressure and risks of incident stroke and coronary artery disease in the Japanese general practice population: the Japan Morning Surge-Home Blood Pressure Study. Hypertension. 2016;68(1):54–61.PubMedCrossRefGoogle Scholar
- 27.Imai Y, Ohkubo T, Sakuma M, Tsuji II, Satoh H, Nagai K, et al. Predictive power of screening blood pressure, ambulatory blood pressure and blood pressure measured at home for overall and cardiovascular mortality: a prospective observation in a cohort from Ohasama, northern Japan. Blood Press Monit. 1996;1(3):251–4.PubMedGoogle Scholar
- 28.Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. 2005;111(14):1777–83.PubMedCrossRefGoogle Scholar
- 36.Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52(1):1–9.PubMedPubMedCentralCrossRefGoogle Scholar
- 41.•• Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269–324 This article summarizes the most up-to-date US hypertension practice guidelines. The guidelines include a recommended clinical protocol for conducting home blood pressure monitoring, as well as thresholds for diagnosing sustained hypertension, white coat hypertension, and masked hypertension.CrossRefGoogle Scholar
- 43.Stergiou GS, Baibas NM, Gantzarou AP, Skeva II, Kalkana CB, Roussias LG, et al. Reproducibility of home, ambulatory, and clinic blood pressure: implications for the design of trials for the assessment of antihypertensive drug efficacy. Am J Hypertens. 2002;15(2 Pt 1):101–4.PubMedCrossRefGoogle Scholar
- 46.Marquez-Contreras E, Martell-Claros N, Gil-Guillen V, de la Figuera-Von Wichmann M, Casado-Martinez JJ, Martin-de Pablos JL, et al. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens. 2006;24(1):169–75.PubMedCrossRefGoogle Scholar
- 57.•• Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. PLoS Med. 2017;14(9):e1002389 This study conducts a systematic review and meta-analysis of the effect of blood pressure self-monitoring with and without clinician support on blood pressure control.PubMedPubMedCentralCrossRefGoogle Scholar
- 60.McManus RJ, Mant J, Haque MS, Bray EP, Bryan S, Greenfield SM, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014;312(8):799–808.PubMedCrossRefGoogle Scholar
- 61.• McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson J, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391(10124):949–59 This article describes the results of a pragmatic randomized clinical trial that compares self-monitored blood pressure with and without telemonitoring versus office blood pressure management of hypertension. The authors found that self-monitored blood pressure with or without telemonitoring was superior to office blood pressure management, resulting in a 4.7-mmHg and 3.5-mmHg reduction in blood pressure, respectively.PubMedPubMedCentralCrossRefGoogle Scholar
- 71.Stergiou GS, Alpert B, Mieke S, Asmar R, Atkins N, Eckert S, et al. A universal standard for the validation of blood pressure measuring devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) collaboration statement. Hypertension. 2018;71(3):368–74.PubMedCrossRefGoogle Scholar
- 72.• Bello NA, Woolley JJ, Cleary KL, Falzon L, Alpert BS, Oparil S, et al. Accuracy of blood pressure measurement devices in pregnancy: a systematic review of validation studies. Hypertension. 2018;71(2):326–35 This article informs home blood pressure monitoring protocols by providing empiric data on how increasing the frequency of home blood pressure readings affects the reliability of home blood pressure estimates. Among patients without severely elevated blood pressure, as few as 3 days of HBPM readings may be sufficient to obtain reliable blood pressure estimates.PubMedCrossRefGoogle Scholar
- 80.Jones MI, Greenfield SM, Bray EP, Hobbs FR, Holder R, Little P, et al. Patient self-monitoring of blood pressure and self-titration of medication in primary care: the TASMINH2 trial qualitative study of health professionals’ experiences. Br J Gen Pract. 2013;63(611):e378–85.PubMedPubMedCentralCrossRefGoogle Scholar
- 86.Tientcheu D, Ayers C, Das SR, McGuire DK, de Lemos JA, Khera A, et al. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension: analysis from the Dallas Heart Study. J Am Coll Cardiol. 2015;66(20):2159–69.PubMedPubMedCentralCrossRefGoogle Scholar
- 93.Mondal S, Mondal H, Dutta R, Pal A, Acharya SS, Baidya C. Competency in home blood pressure monitoring and effect of training program on competency 2018.Google Scholar
- 99.• Carter EJ, Moise N, Alcantara C, Sullivan AM, Kronish IM. Patient barriers and facilitators to ambulatory and home blood pressure monitoring: a qualitative study. Am J Hypertens. 2018;31(8):919–27 This study highlights barriers and facilitators to home blood pressure monitoring from the perspective of patients recruited from underserved areas of New York City.PubMedCrossRefGoogle Scholar
- 104.• Kronish IM, Kent S, Moise N, Shimbo D, Safford MM, Kynerd RE, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens. 2017;11(9):573–80 This study describes key barriers to home blood pressure monitoring from the perspective of primary care physicians practicing in two regions of the USA.PubMedPubMedCentralCrossRefGoogle Scholar
- 115.Liao JM, Navathe AS, Press MJ. Medicare’s approach to paying for services that promote coordinated care. JAMA. 2018.Google Scholar