This was a purely observational study with no intervention and no prospective hypothesis to test. Any references to “statistical significance” are notional rather than definitive.
Part 1: Triplicate home blood pressure measurements
There is disagreement between guidelines for self-measured BPMs at home: (i) the European Society of Hypertension [
1] and the 2012 Canadian Hypertension Education Program [
2] recommend duplicate HBPMs in the morning and evening; (ii) the American Society of Hypertension [
3] recommends triplicate HBPMs [
4]; (iii) the Japanese Society of Hypertension recommends at least one HBPM [
5]. As reported here and elsewhere [
6,
7], the 1st HPPM in a triplicate tends to be higher than the 2nd and 3rd. The differences are quite small. The statistical significances attached to the values in Table
2 and Table
3 arise more from their consistency than from their size. They amount, on average, to 3 – 4 mmHg for systolic BP, 1 mmHg for diastolic and 1 – 2 mmHg for the heart rate. These amount respectively to about 18–25%, 9% and 9–10% of the associated standard deviations. Inverting the simple power calculations to obtain numbers of triplicates needed to have 80% power to attach significance at the 5% level gives 268 – 475 triplicates for systolic BP, 2077 – 2453 for diastolic, and 393–2077 for heart rate. The repeated measures element of the Friedman test that was applied would have provided somewhat more discriminating power because it separated differences in measurement within triplicate from differences between triplicates. However the extra discriminating power was not sufficient for the significance of the differences in diastolic pressure and heart rate that were seen for the 5997 triplicates represented in Table
2 to be apparent also in the 270 triplicates in Table
3.
Nonetheless, the differences between triplicates have been sufficient in at least one study for the diagnosis of “hypertension” to be made more frequently with the first than with the mean of the 2nd and 3rd [
8]. Consequently, they may have some effect on selecting patients for inclusion in trials of antihypertensive medication, or conceivably commencement or modification of anti-hypertensive therapy. However it is hardly conceivable that patients would be started on such therapy solely on a BPM if that measurement was so close to the chosen criterion that the differences in measurement in a triplicate would be crucial. The decision would surely have to be based on a more comprehensive assessment of risk.
Some of the guidelines recommend discarding the higher HBPMs that are often measured initially, but this refinement had no impact in explanatory modelling of cardiovascular risk [
9] or organ damage [
10]. In keeping with the greater precision evident in Table
2 than in Table
3, one would expect the precision in estimating CVR to increase with the number of measurements contributing to the estimate of BP, though possibly only up to a point. For example, Niiranen et al. [
10] found that the most precise predictions were achieved by including all values of duplicates measured twice per day over 7 days, though the measurements made over the first 3 days were more influential than those made later.
Timing of the HBPMs and choice of subject may also be important. For example, in a mixture of normotensives and hypertensive patients seen in the clinic, evening HBPMs predicted stroke more reliably than casual HBPM regardless of the number of measurements [
11]. On the other hand, morning HBPMs predicted stroke more reliably than evening HBPMs in patients on hypertensive medication but not in normotensive patients [
12]. Likewise, the
variability in HBPM had an additional predictive power beyond mean systolic HBPM only in hypertensive patients [
13].
Kawabe et al. [
14] reported that the 1st systolic HBPM in morning triplicates had a larger coefficient of variation (CV) than the 2nd and was probably affected by the subject’s gender and smoking habits. In our Tables
2 and
3, the standard deviations did not seem very different between measurements in the triplicates.
The gender differences obtained in our small sample were consistent with those in the review by Reckelhoff [
15].
Part 2: Comparison of ambulatory and home blood pressure measurements
ABPM was developed before HBPM and remains more copiously documented. It can also identify a larger number of features than either clinic or HBPM (e.g. “white coat hypertension”, night-time ABPM, the night-to-day BP ratio and “dipping” status - which are significant predictors of outcome [
16]). It has therefore acquired ”gold standard” status though this does not necessarily mean that average or median ABPM is, by itself, the most accurate indicator of true normo-/hypertensive status. Unlike ABPMs,
self-measured HBPMs can only be obtained while the patient is awake. The best agreement between ABPM and HBPM appeared to be in the morning between the first HBPM of the day and the mean of the 4 observations taken in the second hour after the patient had wakened [
17]. We have restricted our comparison to
daytime ABPMs and HBPMs.
A systematic review including six comparisons of HBPM and ABPM found that blood pressures over the criterion of 135/85 mmHg were obtained more frequently overall with HBPMs [
5]. However, in the three studies with the largest numbers of HBPMs (29 to 56), the average ABPMs were higher than the HBPMs, to a lesser or greater degree. In one [
18], the difference was similar to that found in our previous study [
19] with a similar number of HBPM measurements.Our present results were from a data set that included an average of 45 HBPM and 63 ABPM measurements per participant. The comparison are in terms of the indices of distribution of the sets of observations of HBPM and ABPM in each subject across a set of subjects, as illustrated in our Figure
2 and Figure
3. For the 1st, 2nd and 3rd quartiles: (i) increases in individual ABPMs between patients tended to correlate reasonably well with increases of the corresponding HBPMs (r close to 0.7 in plots 2, 3 and 4 in Figure
2); (ii) ABPM tended to be greater than the corresponding HBPM by amounts that increased with increase in BP (by 10 mm Hg for the median of the 1st quartiles, 14 mm Hg for the 2nd and 19.5 mm Hg for the 3rd, Figure
3). At the extremes of the distributions: (i) there was less correspondence between the increases in ABPM and HBPM (r less than 0.3 for plots 1 and 5 in Figure
2); (ii) the spans of the distributions of the minima and maxima were wider, and the minima of the distributions of the 1st, 2nd 3rd quartiles were at negative values of (ABPM – HBPM, Figure
3).
It is a plausible conjecture that the behaviour of the measurements at the extremes of their range may be partly due to movement-related measurement artefacts in the ABPMs: the subject may be less inclined to interrupt his or her activity every 15 minutes for the duration of each ABPM whereas he or she might be more likely to stop and be settled for the HBPMs, at least by the time the 2nd and 3rd measurement in each triplicate has been made. The relative symmetry of both distributions in our Figure
2 about their medians is consistent with the observation of Lijarcio [
20] who demonstrated, that for HBPM, the medians and means are more or less interchangeable – which was corroborated by detailed comparisons within our data set. The observations in Figure
2 are consistent with our previous observations [
20] that, with duplicate HBPMs 3 times per day for a week, the coefficient of variation of the HBPMs was smaller than that of daytime ABPM obtained between 7 am and 10 pm on a single day, (4.2% compared with 5.5%).
Irrespective of whether it is the ABPM or HBPM that gives a “truer” picture of whether or not a subject should be labelled “hypertensive” at a particular time, we have argued previously on pragmatic grounds [
19] that the smaller CVs associated with HBPM should make them more useful for detecting sooner and more reliably if, when, and how quickly a change in the subject’s underlying blood pressure has taken place, whether in response to institution or modification of treatment, or to other intercurrent influences. A further pragmatic advantage of HBPMs for
longer-term monitoring is that because of resource limitations, facilities for ABPMs are usually only available over a
shorter time and are more intrusive on activities of daily living.