USPSTF Releases Draft Blood Pressure Screening Guidelines

Ricki Lewis, PhD

December 24, 2014

The US Preventive Services Task Force (USPSTF) has issued a draft recommendation statement supporting high blood pressure screening in adults, extending past recommendations.

Hypertension is prevalent, silent, actionable, and can be deadly if untreated. Controlling hypertension "substantially decreases the incidence of cardiovascular events," the draft states.

The recommendation differs from past statements in comparing the accuracy of three methods: office blood pressure measurement (universally electronic), ambulatory blood pressure monitoring, and home blood pressure monitoring. Ambulatory monitoring measures blood pressure every 20 to 30 minutes over the course of 24 to 48 hours of normal activity.

The task force concluded that ambulatory blood pressure monitoring should be the "reference standard for confirming" office-based diagnosis. As reported by Medscape Medical News, a recent evidence review showed that ambulatory monitoring can rule out white coat hypertension, in which patients have elevated blood pressure only in a medical setting.

Home blood pressure monitoring "may be acceptable," but fewer data exist for that method than for ambulatory monitoring. More evidence is also needed to assess the accuracy of "kiosk measurements" taken in public settings such as pharmacies, according to the recommendation.

Michael Weber, MD, professor of medicine at SUNY Downstate College of Medicine, Brooklyn, New York, calls the statement "a radical departure from anything recommended up until now." In the United Kingdom, ambulatory blood pressure monitoring is routine to diagnose hypertension, but in the United States, the evidence has not been considered to be strong enough to support that recommendation, he told Medscape Medical News. Dr Weber was part of the team that published a key paper on white coat hypertension 2 decades ago ( Circulation. 1994;90:2291-2298).

Increased use of ambulatory blood pressure monitoring to rule out white coat hypertension can also identify individuals who are at risk but are not yet diagnosed.

"People who have high blood pressure with the doctor but normal pressure elsewhere are not exactly the same as true normotensive people. They're more likely to have enlargement of the heart, evidence of insulin resistance, and abnormal lipids," Dr Weber said. Studies have shown that such patients usually become hypertensive in a few years and face the same cardiovascular risks as patients whose hypertension persisted during ambulatory measurement.

Although "harms" associated with ambulatory blood pressure monitoring may seem minor (eg, disturbed sleep, discomfort, and restricted movements), failure to confirm a diagnosis can lead to unnecessary use of antihypertensives, the report notes.

The task force advises annual blood pressure screening for adults aged 40 years and older and individuals at elevated risk, including those whose blood pressure is at the top of the normal range (130 - 139/85 - 89 mm Hg), are overweight or obese, or are black. Adults between ages 18 and 39 years with normal blood pressure (<130/85 mm Hg) and no risk factors should be rescreened every 3 to 5 years.

A limitation of the task force recommendations is that they do not consider cost, and health insurance plans and Medicaid do not cover ambulatory blood pressure monitoring, Dr Weber pointed out. He also questioned the repeated citing of guidelines from the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) that call for a target blood pressure for adults older than 60 years without chronic kidney disease or diabetes lower than 150/90 mm Hg, because that committee disbanded over a minority opinion that the cutoff should be 140/90 mm Hg.

The draft recommendations conclude that "the benefits of screening for high blood pressure in adults to prevent cardiovascular morbidity and mortality are substantial, and the harms of screening are small. The USPSTF concludes with high certainty that the net benefit of screening is substantial."

The draft is open for public comment until January 26, after which the final recommendation statement will be issued.

"I think this new recommendation from the US Preventive Services Task Force is going to meet with a fair amount of discussion and may not be universally accepted," said Dr Weber.

Dr Weber has disclosed no relevant financial relationships.

"Draft Recommendation Statement: High Blood Pressure in Adults: Screening." US Preventive Services Task Force. December 2014. Full text

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