高血压指南建议家庭或动态血压监测是诊室血压测量后必不可少的。但是否优先进行家庭血压监测还是动态血压监测尚不明。因此，上海瑞金医院李燕、张璐等对上述问题开展了一项研究。

        研究者们纳入了831例未经治疗的门诊患者(平均年龄50.6岁，女性49.8%)，对其分别评估了诊室(3次来诊)、家庭(7天)和24小时动态血压指标。根据高血压指南将患者交叉分类为血压正常、白大衣高血压、隐匿性高血压或持续性高血压。

        结果显示，根据诊室和家庭血压监测结果，白大衣高血压、隐匿性高血压或持续性高血压的患者数分别为61 例(10.3%)、166例(20.0%)和 162例 (19.5%)。应用白天(8：00-18：00)血压代替家庭血压监测在575例患者(69.2%)中确认了交叉分类，风险从隐匿性高血压降为血压正常和从持续性高血压降为白大衣高血压的患者数分别为24例和9例，共占4.0%;但风险从血压正常升至隐匿性高血压和白大衣高血压升至持续性高血压的患者数分别为179例和44例，共占26.8%。基于24小时动态血压分析证实了结果。

        未校正分析显示，升至高风险分类患者的尿白蛋白与肌酐比值和动脉波传导速度均较高，分别增加了20.6%和0.30 m/s。靶器官损害指标和中央增强指数与重新分类的可能性呈正相关关系。

        该研究表明，为明确高血压诊断和起始治疗时机，应当在测量诊室血压后进行动态血压监测。应用家庭血压监测代替动态血压监测会漏掉超过25%患者的隐匿性或持续性高血压高危诊断。论文4月13日在线发表于《高血压》(Hypertension)杂志。

        参考文献：Lu Zhang, Yan Li,et al. Hypertension2015;first published onApril 132015asdoi:10.1161/HYPERTENSIONAHA.114.05038

Strategies for Classifying Patients Based on Office, Home, and Ambulatory Blood Pressure Measurement

• Lu Zhang,
• Yan Li,
• Fang-Fei Wei,
• Lutgarde Thijs,
• Yuan-Yuan Kang,
• Shuai Wang,
• Ting-Yan Xu,
• Ji-Guang Wang,
• and Jan A. Staessen
Hypertension 2015; first published on April 13 2015 asdoi:10.1161/HYPERTENSIONAHA.114.05038
Abstract
Hypertension guidelines propose home or ambulatory blood pressure monitoring as indispensable after office measurement. However, whether preference should be given to home or ambulatory monitoring remains undetermined.
In 831 untreated outpatients (mean age, 50.6 years; 49.8% women), we measured office (3 visits), home (7 days), and 24-h ambulatory blood pressures. We applied hypertension guidelines for cross-classification of patients into normotension or white-coat, masked, or sustained hypertension. Based on office and home blood pressures, the prevalence of white-coat, masked, and sustained hypertension was 61 (10.3%), 166 (20.0%), and 162 (19.5%), respectively. Using daytime (from 8 AM to 6 PM) instead of home blood pressure confirmed the cross-classification in 575 patients (69.2%), downgraded risk from masked hypertension to normotension (n=24) or from sustained to white-coat hypertension (n=9) in 33 (4.0%), but upgraded risk from normotension to masked hypertension (n=179) or from white-coat to sustained hypertension (n=44) in 223 (26.8%). Analyses based on 24-h ambulatory blood pressure were confirmatory. In adjusted analyses, both the urinary albumin-to-creatinine ratio (+20.6%; confidence interval, 4.4–39.3) and aortic pulse wave velocity (+0.30 m/s; confidence interval, 0.09–0.51) were higher in patients who moved up to a higher risk category. Both indexes of target organ damage and central augmentation index were positively associated (P≤0.048) with the odds of being reclassified.
In conclusion, for reliably diagnosing hypertension and starting treatment, office measurement should be followed by ambulatory blood pressure monitoring. Using home instead of ambulatory monitoring misses the high-risk diagnoses of masked or sustained hypertension in over 25% of patients.