Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis

Abstract

Background: Clinic blood pressure measurement (CBPM) is currently the most commonly used form of screening for hypertension, however it might have a problem detecting white coat hypertension (WCHT) and masked hypertension (MHT). Home blood pressure measurement (HBPM) may be an alternative, but its diagnostic performance is inconclusive relative to CBPM. Therefore, this systematic review aimed to estimate the performance of CBPM and HBPM compared with ambulatory blood pressure measurement(ABPM) and to pool prevalence of WCHT and MHT.

Methods: Medline, Scopus, Cochrane Central Register of Controlled Trials and WHO's International Clinical Trials Registry Platform databases were searched up to 23rd January 2020. Studies having diagnostic tests as CBPM or HBPM with reference standard as ABPM, reporting sensitivity and specificity of both tests and/or proportion of WCHT or MHT were eligible. Diagnostic performance of CBPM and HBPM were pooled using bivariate mixed-effect regression model. Random effect model was applied to pool prevalence of WCHT and MHT.

Results: Fifty-eight studies were eligible. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of CBPM, when using 24-h ABPM as the reference standard, were 74% (95% CI: 65-82%), 79% (95% CI: 69%, 87%), and 11.11 (95% CI: 6.82, 14.20), respectively. Pooled prevalence of WCHT and MHT were 0.24 (95% CI 0.19, 0.29) and 0.29 (95% CI 0.20, 0.38). Pooled sensitivity, specificity, and DOR of HBPM were 71% (95% CI 61%, 80%), 82% (95% CI 77%, 87%), and 11.60 (95% CI 8.98, 15.13), respectively.

Conclusions: Diagnostic performances of HBPM were slightly higher than CBPM. However, the prevalence of MHT was high in negative CBPM and some persons with normal HBPM had elevated BP from 24-h ABPM. Therefore, ABPM is still necessary for confirming the diagnosis of HT.

Keywords: Clinic blood pressure measurement; Home blood pressure measurement; Hypertension; Meta-analysis; Systematic review; diagnostic performance.

Fig. 1

Flow chart of study selection

Fig. 2

Pooled sensitivity and specificity of clinic blood pressure measurements compared with 24-h and daytime ambulatory blood pressure measurements. “n” referred to number of hypertensive patients who had positive clinic blood pressure measurement and number of non-hypertensive patients who had negative clinic blood pressure measurement for pooling sensitivity and specificity, respectively. “N” referred to number of hypertensive patients and non-hypertensive patients for pooling sensitivity and specificity, respectively. Reference line referred to pooled sensitivity or pooled specificity

Fig. 3

Fagan’s plot of clinic and home blood pressure measurements compared with 24-h ambulatory blood pressure measurement

Fig. 4

Pooled sensitivity and specificity of home blood pressure measurements compared with 24-h and all types ambulatory blood pressure measurements. “n” referred to number of hypertensive patients who had positive home blood pressure measurement and number of non-hypertensive patients who had negative home blood pressure measurement for pooling sensitivity and specificity, respectively. “N” referred to number of hypertensive patients and non-hypertensive patients for pooling sensitivity and specificity, respectively. Reference line referred to pooled sensitivity or pooled specificity

Fig. 5

Pooled prevalence of white coat hypertension and masked hypertension using daytime and 24-h ambulatory blood pressure measurements as the reference standards. “n” referred to number of false positive and false negative clinic blood pressure measurements for pooling prevalence of white coat and masked hypertension, respectively. “N” referred to number of positive and negative clinic blood pressure measurements for pooling prevalence of white coat and masked hypertension, respectively. Reference line referred to pooled prevalence of white coat or masked hypertension