Maldonado João, Pereira Telmo
Instituto de Investigação e Formação Cardiovascular Penacova, Portugal.
Rev Port Cardiol. 2009 Jan;28(1):7-21.
The clinical usefulness of home blood pressure monitoring (HBPM) is still uncertain, and is currently a major topic of scientific debate. Some studies have stressed its potential role in the clinical decision-making process, but there have been few prospective studies addressing this subject. The AMPA study is intended to contribute to this debate, exploring the potential usefulness of this methodology in the clinical setting of arterial hypertension using a prospective, observational and multicenter design.
The study included 685 hypertensive patients (346 female), with a mean age of 54.2 +/- 11.1 years (range: 17-86 years). All patients were being followed in primary care centers by their family doctors, and were being treated for arterial hypertension and other comorbidities. Forty-seven patients were smokers (6%), 90 (13%) had a personal history of cardiovascular disease, 42 (6%) were diabetic, 255 (37%) had dyslipidemia, and 31 (5%) were both diabetic and dyslipidemic. Blood pressure (BP) was measured in the brachial artery with a validated automatic blood pressure measurement device (Colson MAM BP 3AA1-2; Colson, Paris). This device has solid state memory (sufficient for 60 measurements) and an adaptable printer. A cuff appropriate for the arm size of each patient was used. All patients were instructed on how to operate the device correctly and how to perform the measurements in compliance with the study protocol. BP was always measured after a 5-minute resting period in a seated position. The protocol consisted of an HBP program over a period of five working days. Each day the patient performed six BP measurements in two different periods: three in the morning (between 6 and 10 am) and three in the evening (between 6 and 10 pm). Other clinical and anthropometric data were also collected. The HBP reference values adopted were 135 mmHg for systolic and 85 mmHg for diastolic BP.
Analysis of BP behavior over time demonstrated a significant white-coat effect, with regression to the mean of BP levels after the first day of the HBP program. As a consequence, the first day values were excluded in determining mean HBP. This behavior was independent of gender, and was more pronounced in diabetic patients. Analysis of diagnostic concordance between office BP and HBP showed discrepancies in 27.4% of the patients. This prompted a change in diagnosis based on HBP values, with 133 patients (19.4%) presenting uncontrolled office BP levels but normal HBP values, while 55 patients (8%) had elevated HBP in contrast to normal office BP.
These first results of the AMPA study illustrate the superiority of HBP compared with office BP in the evaluation of hypertensive patients. HBP provides a better characterization of each patient's BP profile, and hence may help improve therapeutic and clinical decisions. Confirmation of the potential of HBP monitoring will be addressed in a prospective analysis (6-year follow-up) of the AMPA study in the near future.
家庭血压监测（HBPM）的临床实用性仍不确定，目前是科学辩论的一个主要话题。一些研究强调了其在临床决策过程中的潜在作用，但针对该主题的前瞻性研究很少。AMPA研究旨在为这场辩论做出贡献，采用前瞻性、观察性和多中心设计，探索这种方法在动脉高血压临床环境中的潜在实用性。
该研究纳入了685名高血压患者（346名女性），平均年龄为54.2±11.1岁（范围：17 - 86岁）。所有患者均由其家庭医生在初级保健中心进行随访，并接受动脉高血压和其他合并症的治疗。47名患者吸烟（6%），90名（13%）有心血管疾病个人史，42名（6%）患有糖尿病，255名（37%）患有血脂异常，31名（5%）既患有糖尿病又患有血脂异常。使用经过验证的自动血压测量设备（科尔森MAM BP 3AA1 - 2；科尔森，巴黎）测量肱动脉血压。该设备具有固态存储器（足以存储60次测量）和一台可适配的打印机。使用适合每位患者手臂尺寸的袖带。所有患者都接受了如何正确操作设备以及如何按照研究方案进行测量的指导。血压总是在坐位休息5分钟后测量。方案包括一个为期五个工作日的家庭血压（HBP）程序。患者每天在两个不同时间段进行六次血压测量：早上三次（上午6点至10点之间）和晚上三次（下午6点至10点之间）。还收集了其他临床和人体测量数据。采用的HBP参考值为收缩压135 mmHg和舒张压85 mmHg。
对血压随时间变化的分析显示出显著的白大衣效应，在HBP程序第一天后血压水平向均值回归。因此，在确定平均HBP时排除了第一天的值。这种行为与性别无关，在糖尿病患者中更为明显。对诊室血压和HBP之间诊断一致性的分析显示，27.4%的患者存在差异。这促使根据HBP值改变诊断，133名患者（19.4%）诊室血压水平未得到控制但HBP值正常，而55名患者（8%）与诊室血压正常相比HBP升高。
AMPA研究的这些初步结果说明了在评估高血压患者时HBP优于诊室血压。HBP能更好地描述每位患者的血压特征，因此可能有助于改善治疗和临床决策。HBP监测潜力的确认将在不久的将来对AMPA研究进行的前瞻性分析（6年随访）中得到解决。
