Hypertension in the Consulting Room Versus the Bedroom: Nocturnal Blood Pressure and the Case for Routine Ambulatory Monitoring

Abstract

A single office blood pressure reading is the reference point for most hypertension diagnoses worldwide, yet ambulatory blood
pressure monitoring (ABPM) repeatedly shows that the office reading and the 24-hour, out-of-office picture disagree often
enough, and in clinically important enough directions, that guideline bodies now recommend confirming a diagnosis outside
the clinic before starting treatment. Reverse dipping, not non-dipping in general, carries the excess nocturnal cardiovascular
risk; masked hypertension, invisible at the office visit, carries a near-tripling of cardiovascular event odds; and even
white-coat hypertension, long treated as reassuring, shows a modest excess risk when untreated that resolves once blood
pressure is actually controlled. Home blood pressure monitoring (HBPM) is the practical, guideline-endorsed alternative to
ABPM, and it performs comparably for confirming sustained hypertension, but its sensitivity falls to roughly six in ten cases
for the two phenotypes, masked and white-coat hypertension, that a single office reading gets wrong. This review sets out the
evidence for out-of-office measurement, and closes with the complication that undercuts calling it routine: guideline-preferred
ABPM reaches a claimed fraction of one percent of Medicare beneficiaries, a gap in access and reimbursement, not evidence,
that a cost-effectiveness case for ABPM has not closed.