345cardiovascular events, while office BP measurements were not. Salles et al. [ 7 ] also
demonstrated that in patients with RH, one standard deviation increase in ambula-
tory night time SBP and DBP was associated with 38 and 36% higher risk of future
cardiovascular events, respectively. These authors also demonstrated that office BP
results were not associated with adverse cardiovascular events.
One additional benefit of implementing ABPM in the diagnosis and management
of RH is recognition of masked hypertension (MH). MH is fairly common (up to
20% of the population) and is associated with adverse cardiovascular outcomes [ 8 ].
Unfortunately, there is no way to diagnose MH solely with office BP measurements,
because ABPM is not generally ordered in patients who are found to be normoten-
sive in the office.
The role of ABPM in the diagnosis and monitoring of RH is much less studied in
patients with kidney disease. In a study of 156 patients with chronic kidney disease
(CKD) and RH, prevalence of white-coat RH, MH, and true RH were 29.5, 5.8 and
58.3%, respectively. Thus, if ABPM had not been performed, one in every three
patients would be managed inappropriately just based on office blood pressure mea-
surements. Then, this would lead to increased cost and adverse events owing to
inappropriate management of RH [ 9 ]. A larger and more recent study conducted on
patients with stages 1–5 chronic kidney disease found that misclassification of BP
control at the office was observed in one out of three patients with hypertension.
Thus, this latter study reinforces the importance of implementation of ABPM in
monitoring of hypertensive patients as well [ 10 ].
ABPM takes on greater importance in patients with CKD and hypertension,
because high-risk features which can only be identified by ABPM such as MH and
nondipping status are more common in patients with CKD [ 11 ]. Better prognostic
role of ABPM has also been shown in CKD patients compared to office BP mea-
surements [ 12 ].
Routine use of ABPM in the diagnosis of hypertension is still an active matter of
debate. Only British guidelines recommend routine use of ABPM to exclude white-
coat hypertension while making a diagnosis of hypertension [ 13 ]. Only some coun-
tries have included ABPM in reimbursement plans and in limited settings [ 14 ].
Thus, there is still some time ahead for implementation of ABPM as a standard
diagnostic and monitoring tool of hypertension in the general practice (also in the
evaluation of RH). In the meantime, home blood pressure monitoring (HBPM)
seems a reasonable alternative.
Home Blood Pressure Monitoring
HBPM, if the measurement device is appropriate and calibrated, can provide mul-
tiple daytime measurements. However, HBPM is prone to errors owing to greater
role of the patient in the process and cannot offer data during sleep, which is impor-
tant prognostically. In a very recent study, Muxfeldt et al. [ 15 ] evaluated 240 patients
who provided ABPM and 5-day HBPM results. The authors found a good
22 Resistant Hypertension and the General Practitioner (Monitoring and Treatment)