Appel L J, Stason W B
Johns Hopkins University School of Medicine, Baltimore, MD.
Ann Intern Med. 1993 Jun 1;118(11):867-82. doi: 10.7326/0003-4819-118-11-199306010-00008.
To review published evidence on the use of ambulatory and self-measurement devices in the diagnosis and management of hypertension.
Computerized literature searches and manual review of bibliographies.
Articles documenting original research pertaining to the diagnosis, treatment, or prognosis of hypertension using ambulatory or self-measurement devices.
Studies that have compared office, self-measured, and ambulatory blood pressures have documented substantial, but nonsystematic, differences. Such findings have raised concern over the appropriateness of diagnosing hypertension and initiating drug therapy in individuals with high office blood pressure but comparatively low self-measured or ambulatory blood pressure ("office" or "white coat" hypertension). Evidence from a large number of cross-sectional studies and a single prospective study suggests that blood pressure- related end-organ damage is more closely associated with ambulatory than with office blood pressure. Less evidence supports self-measured blood pressure in this regard, and data are insufficient to compare ambulatory and self-measured blood pressure in terms of cardiovascular disease risk prediction. The estimated resource cost of an ambulatory blood pressure test is approximately $120, whereas charges range from $100 to $450. The annualized resource cost of blood pressure self-measurement is $50 or less. On a national level, the annual direct costs of ambulatory blood pressure monitoring could be as high as $6 billion, if this technique were used routinely to diagnose and monitor hypertensive patients. The extent to which direct costs would be offset by savings from less frequent or more efficient treatment for hypertension cannot be estimated reliably. Several practical and technical issues also detract from the potential usefulness of ambulatory and self-measurement devices. Finally, there is some evidence that office blood pressures measured by well-trained nonphysicians may serve as an alternative to ambulatory and self-measurement techniques in estimating usual blood pressure.
Limited clinical applications of ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension appear to be warranted. Endorsement of these technologies for routine clinical use, however, will require more convincing evidence of their clinical effectiveness.
回顾已发表的关于使用动态血压监测和自测血压设备进行高血压诊断和管理的证据。
计算机文献检索和参考文献手工查阅。
记录使用动态血压监测或自测血压设备进行高血压诊断、治疗或预后相关原始研究的文章。
比较诊室血压、自测血压和动态血压的研究表明存在显著但不系统的差异。这些发现引发了对高血压诊断以及对诊室血压高但自测血压或动态血压相对较低的个体（“诊室”或“白大衣”高血压）启动药物治疗的适宜性的担忧。大量横断面研究和一项前瞻性研究的证据表明，与血压相关的靶器官损害与动态血压的相关性比与诊室血压的相关性更密切。在这方面，支持自测血压的证据较少，且数据不足以在心血管疾病风险预测方面比较动态血压和自测血压。一次动态血压检测的估计资源成本约为120美元，而收费范围为100至450美元。血压自测的年度资源成本为50美元或更低。在全国范围内，如果常规使用该技术诊断和监测高血压患者，动态血压监测的年度直接成本可能高达60亿美元。因高血压治疗频率降低或效率提高而节省的费用能抵消多少直接成本尚无法可靠估计。一些实际和技术问题也削弱了动态血压监测和自测血压设备的潜在效用。最后，有证据表明，训练有素的非医生测量的诊室血压在估计日常血压方面可替代动态血压监测和自测血压技术。
动态血压监测和自测血压在高血压诊断和管理中的临床应用似乎有限。然而，要认可这些技术用于常规临床，将需要更有说服力的临床有效性证据。
