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NEW ORLEAN – The introduction of ambulatory sphygmomanometers in the clinic remains a challenge for many centers, and the fact that available devices provide inaccurate readings has not helped.
The 2017 hypertension guidelines from the American College of Cardiology and the American Heart Association have given the class ABPM IIa recommendations for screening for hypertension at white or masked coat in some groups.
But when two oscillometric air pressure measurement laboratories (SunTech Medical's Oscar 2 and Spacelabs 90207/90217) were tested in the lab, they both objected to hand-held mercury column readings at benchmark: systolic blood pressure (AP) of Oscar of at least 5 mm Hg in 90% of cases and Spacelabs devices in 70%, according to V. Patteson Lombardi, PhD, of University of Oregon at Eugene.
Lombardi and his colleagues presented a poster at the annual meeting on hypertension of the American Heart Association. This group had previously associated Accutracker II auscultatory MAPA with excessive variability between devices and increased misclassification of patients.
Currently available GPAA: a problem of trust
"Oscillometric ABPMs Oscar and Spacelabs are erratic in the estimation of individual PAs, have a low degree of agreement and may differ clinically and statistically from observers using a Hg column in a controlled laboratory," the authors said. .
"Our results (…) do not guarantee the reliability of 24-hour measurements while patients are active and adopt multiple postures.At least, US and international protocols for validation of ABPM must develop stricter standards. and require postural testing, so we have trouble trusting BP's ambulatory monitors, "they concluded.
In the new study, 10 people (70% normotensive) had several readings of the tension in different positions.
Each time, one arm underwent an assessment of the MAPA, while the other was submitted to a mercury column by a trained observer. The arms were then exchanged and each reading performed in triplicate. Observers were blinded by the results of others.
The mean overestimation of systolic BP was 8.8 mmHg for Oscar and 5.4 mmHg for Spacelabs. With regard to diastolic blood pressure, these figures were respectively 1.2 mm Hg and 1.4 mm Hg.
In addition, the proportion of readings indicating that the patients' blood pressure status was misclassified (according to the US recommendations of 2017) was 20% with the Oscar 2 device and 10% with Spacelabs.
"These inaccuracies are becoming increasingly important with the new US guidelines that are moving the definition of hypertension to lower levels," said Lombardi and his colleagues.
They also found that deviations from baseline arterial pressure varied by posture: a systolic overvoltage of 3.5 mm Hg (and a diastolic pressure of 6.5 mm Hg) at the dorsal decubitusP<0.05) and 4.7 mm Hg sitting (P<0.01); Overestimations of systolic BP of Spacelabs by posture did not reach statistical significance, but diastolic BP was underestimated by 5.8 mmHg (5%).P<0.05) and 6.4 mm Hg overestimated in the supine position (P<0.05).
"Note the variability of the two ABPMs as a function of posture and progressive progression of diastolic pressure differences from supine to standing, indicating static nomogram equations that do not adjust for posture" , according to the authors.
The implementation of MAPA
However, even if a MAPA proves reliable, many problems can arise when setting up a new ambulatory surveillance program, said some during another session when the meeting on hypertension.
Even though the UK has been recommending ATMs since 2011, they still have not implemented it properly. "But of course, we are even further behind them," said Anthony Viera, MD, MPH, of Duke University in Durham, North Carolina. In fact, some clinicians confuse even outpatient with home BP surveillance.
Viera told attendees at the meeting that it was difficult to get an MPA in his establishment.
One of the obstacles to implementation is the cost of each monitor, which can generate between $ 2,000 and $ 3,000 on average, he said. One study showed that Medicare paid a median of $ 52 for MAPA claims submitted from 2007 to 2010; An informal 2016 repayment log between Viera and her colleagues showed payments ranging from as low as $ 39 from Medicare to $ 155 from private insurers.
Despite the cost, however, "you probably need more MAPA than you think," according to panelist Joshua Samuels, MD, MPH, of UTHealth's McGovern Medical School in Houston.
Another problem is the difficulty of finding qualified staff who can work with patients in the ABPM process.
"In reality, the MPA requires work, you are not just doing it," said Gbenga Ogedegbe, committee member, MD, MPH, NYU School of Medicine, New York. "Do not underestimate the staff you need for MAPA."
On the one hand, the staff must explain the practical aspects of ABPM to the patient and prepare him to have "a cord hanging behind him" and a machine that rings regularly all the time. Staff must also schedule patients for two days in a row, which can be a problem, for example, for people working in teams, according to Viera.
Then there are the challenges in incorporating MAPA readings into the electronic health record system: it's "not such a slam dunk for the moment, it's not that simple", said the speaker.
Lombardi has revealed no relevant relationship with the industry.
2019-09-07T16: 00: 00-0400
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