Introduction
Blood pressure (BP) determines the amount of blood pumped by the heart per unit of time and the amount of vascular resistance to blood flow. As part of the definition of BP, systolic and diastolic values are used depending on the phase of the cardiac cycle. It is accepted that normal BP is 100-139 mmHg for systolic and 60-89 mmHg for diastolic. Abnormalities accompany deviations from these values, so effective protocols for assessing and detecting conditions are required. In particular, masked hypertension (high blood pressure) is of particular concern and requires careful and accurate diagnostic procedures.
Background
Arterial hypertension is characterized by an increase in systolic pressure above 140 mm Hg and a concomitant increase in diastolic pressure above 89 mm Hg. Although hypertension may have no significant symptoms, it significantly increases the risk of cardiovascular disease (Penmatsa, Biyani& Gupta, 2020). These include coronary heart disease, stroke, chronic heart failure, and a host of other diseases in related systems.
Masked hypertension is a type of arterial hypertension in which elevated BP is found only in outpatient or home care settings. In this case, the BP at the doctor’s (clinical/office) remains normal. BP rises under the influence of environmental factors that cause psycho-emotional stress (Cuspidi et al., 2023). The combination of these influences leads to a rise in BP and several other symptoms (Penmatsa, Biyani & Gupta, 2020).
For example, there is heart pain, difficulty in movement, shortness of breath, and decreased performance. This condition does not allow a person to live without restrictions and increases risks as much as normal hypertension. Hypertension is challenging to treat because the associated risks are too challenging to manage (Parati et al., 2021). Therefore, early and timely detection of latent hypertension may allow the development of complications to be preempted.
Criteria for Inclusion in Risk Groups
The need to monitor all individuals with optimal elevated BP should be recognized. Penmatsa, Biyani, and Gupta (2020) indicate that they are included at risk and may have latent hypertension. They state that there is a need to screen ECG dynamics and assess biochemical parameters to predict the emerging effects of the latent hypertension phenotype. Seeman, Šuláková, and Stabouli (2023) indicate that there is a need to screen individuals with a family history of latent hypertension. In particular, they point to the increasing prevalence of the disease in childhood. They suggest that assessment of the course of chronic disease and even maternal birth characteristics may have an impact on the course of latent hypertension.
Tracking BP while performing a routine is essential, so daily activity can also determine BP trends. Cuspidi et al. (2023) point out that elevated exercise BP is also a risk for the development of latent hypertension, where 24-hour monitoring is critical for proper assessment of the condition. Finally, the international community recommends including risk groups of all those with a marked decrease in performance with normal health at home (Parati et al., 2020). The risks of diabetes, kidney disease, impaired synthesis of substances necessary for BP control, and unhealthy habits such as smoking or alcohol dependence are also significant.
Barriers to the Evaluation of Masked Hypertension
Arterial hypertension has different phenotypes, and latent hypertension (office hypertension) is a complex phenotype. The typical diagnostic protocol includes in-office BP monitoring but remains inaccurate (Parato et al., 2021). Among the challenges of in-office diagnosis is the high risk of inadvertent error arising from pinpointing BP. Online BP monitoring is not available, and the influence of various factors has not been studied in dynamics.
Authors 3 also believe measurement inaccuracies will exacerbate patient attitudes and reduce patient engagement in diagnosis and treatment. Penmatsa, Biyani, and Gupta (2020) highlight another barrier – the problem of white coat hypertension (WCE). WCE refers to an increase in BP in the presence of medical staff due to anxiety and ambiance, so it also reduces diagnostic performance even in the out-of-hospital setting.
Diagnosis
First of all, daily ambulatory BP monitoring (ABPM) is recommended. ABPM is a technology for measuring BP over 24 hours, assessing the dynamics of BP changes, and predicting subsequent BP behavior. The main advantage of ABPM is the determination of circadian rhythms and continuous assessment of BP, allowing the analysis of the influence of external factors on the subject’s life (Parati et al., 2020).
Such a method solves the problem of lack of insight into the complex influence of the environment on BP. Huang et al. (2021) point out that the ABPM allows the optimization of diagnostic costs and the prediction of the risks of sudden death. In particular, they suggest that nighttime monitoring allows for the stratification of risks and the establishment of a treatment plan for latent forms of hypertension.
Home BP monitoring (HBPM) is a method in which patient involvement in diagnosis is exceptionally high. HBPM is thought to complement ABPM and establish stress factors’ role in the home environment (Huang et al., 2021). It may provide more accurate results because patients are more likely to be willing to have their BP measured than in an outpatient setting.
Parati et al. (2020) point out that the availability of the method is a significant advantage that offloads the healthcare system and thus improves in-hospital diagnosis. Empowering patients and educating them to assess their cardiovascular health can significantly improve the implemented therapeutic plans. Self-assessment is an essential criterion for the value of HBPM, which reduces risks from ABPM.
Finally, telemonitoring promotes familiarity with BP measurement technologies and the adoption of modern BP assessment methods. The availability of statistical tools in software and intelligent tonometers increases the value of data obtained from patients after HBPM and ABPM. Parat et al. (2020) believe that interactive techniques for BP diagnosis are critical in timely risk identification, even in self-monitoring.
Automated office-based BP measurement improves the accuracy and sensitivity of BP determination because it offers both frequent measurement and convenience. Kario (2020) suggests introducing wrist-worn oscillometric devices that do not interfere with patients’ daily routines. They point out that compared with ABPM and HBPM, handheld devices cause less discomfort. In addition, the rise of application tonometry allows for improved accuracy rates and the inclusion of direct BP measurement in diagnosis. Pathologic BP spikes will be detected more effectively using computer technology and medical biophysics.
Conclusion
Thus, the diagnosis of latent hypertension involves a set of measures, including daily, home, and automated monitoring. These technologies overcome some barriers because of the difficulty of diagnosis due to the absence of elevated BP at the doctor’s office. ABPM contributes to improved measurement accuracy, and HBPM eases the healthcare burden and promotes more frequent BP measurements. Interactive methods and advanced biophysical invasive and non-invasive techniques increase measurement sensitivity and make the BP measurement process comfortable for patients.
References
Cuspidi, C., Gherbesi, E., Faggiano, A., Sala, C., Carugo, S., Grassi, G., & Tadic, M. (2023). Masked hypertension and exaggerated blood pressure response to exercise: A review and meta-analysis. Diagnostics (Basel, Switzerland), 13(6). Web.
Huang, Q. F., Yang, W. Y., Asayama, K., Zhang, Z. Y., Thijs, L., Li, Y., O’Brien, E., & Staessen, J. A. (2021). Ambulatory blood pressure monitoring to diagnose and manage hypertension. Hypertension (Dallas, Tex. :1979), 77(2), 254–264. Web.
Kario K. (2020). Management of hypertension in the digital era: Small wearable monitoring devices for remote blood pressure monitoring. Hypertension (Dallas, Tex. : 1979), 76(3), 640–650. Web.
Parati, G., Lombardi, C., Pengo, M., Bilo, G., & Ochoa, J. E. (2021). Current challenges for hypertension management: From better hypertension diagnosis to improved patients’ adherence and blood pressure control. International Journal of Cardiology, 331, 262–269. Web.
Penmatsa, K. R., Biyani, M., & Gupta, A. (2020). Masked hypertension: Lessons for the future. The Ulster Medical Journal, 89(2), 77–82. Web.
Seeman, T., Šuláková, T., & Stabouli, S. (2023). Masked hypertension in healthy children and adolescents: Who should be screened?Current Hypertension Reports, 25(9), 231–242. Web.
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