Diagnosing hypertension in primary care: a retrospective cohort study to investigate the importance of night-time blood pressure assessment

BackgroundAmbulatory blood-pressure monitoring (ABPM) has become less frequent in primary care since the COVID-19 pandemic, with home blood-pressure monitoring (HBPM) often the preferred alternative; however, HBPM cannot measure night-time blood pressure (BP), and patients whose night-time BP does not dip, or rises (reverse dipping), have poorer cardiovascular outcomes.AimTo investigate the importance of measuring night-time BP when assessing individuals for hypertension.Design and settingRetrospective cohort study of two patient populations — namely, hospital patients admitted to four UK acute hospitals located in Oxfordshire, and participants of the BP in different ethnic groups (BP-Eth) study, who were recruited from 28 UK general practices in the West Midlands.MethodUsing BP data collected for the two cohorts, three systolic BP phenotypes (dipper, non-dipper, and reverse dipper) were studied.ResultsAmong the hospital cohort, 48.9% (n= 10 610/21 716) patients were ‘reverse dippers’, with an average day–night systolic BP difference of +8.0 mmHg. Among the community (BP-Eth) cohort, 10.8% (n= 63/585) of patients were reverse dippers, with an average day–night systolic BP difference of +8.5 mmHg. Non-dipper and reverse-dipper phenotypes both had lower daytime systolic BP and higher night-time systolic BP than the dipper phenotype. Average daytime systolic BP was lowest in the reverse-dipping phenotype (this was 6.5 mmHg and 6.8 mmHg lower than for the dipper phenotype in the hospital and community cohorts, respectively), thereby placing them at risk of undiagnosed, or masked, hypertension.ConclusionNot measuring night-time BP puts reverse-dippers (those with a BP rise at night-time) at risk of failure to identify hypertension. As a result of this study, it is recommended that GPs should offer ABPM to all patients aged ≥60 years as a minimum when assessing for hypertension.