The potential for overdiagnosis and underdiagnosis because of bloodpressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESHand 2019 NICE hypertension guidelines

Objective: To estimate the extent that BP measurement variability may drive over- and underdiagnosis of `hypertension' when measurements are made according to current guidelines. Methods: Using data from the National Health and Nutrition Examination Survey and empirical estimates of within-person variability, we simulated annual SBP measurement sets for 1 000 000 patients over 5 years. For each measurement set, we used an average of multiple readings, as recommended by guidelines. Results: The mean true SBP for the simulated population was 118.8mmHg with a standard deviation of 17.5mmHg. The proportion overdiagnosed with 'hypertension' after five sets of office or nonoffice measurements using the 2017 American College of Cardiology guideline was 3- 5% for people with a true SBP less than 120 mmHg, and 65-72% for people with a true SBP 120- 130 mmHg. These proportions were less than 1% and 14-33% using the 2018 European Society of Hypertension and 2019 National Institute for Health and Care Excellence guidelines (true SBP <120 and 120130 mmHg, respectively). The proportion underdiagnosed with 'hypertension' was less than 3% for people with true SBP at least 140mmHg after one set of office or nonoffice measurements using the 2017 American College of Cardiology guideline, and less than 18% using the other two guidelines. Conclusion: More people are at risk of overdiagnosis under the 2017 American College of Cardiology guideline than the other two guidelines, even if nonoffice measurements are used. Making clinical decisions about cardiovascular prediction based primarily on absolute risk, minimizes the impact of blood pressure variability on overdiagnosis.

Automated summary

This study analyzed simulated blood pressure measurement data and found that measurements according to the 2017 American College of Cardiology guideline may lead to more people being overdiagnosed with "hypertension" compared to the other two guidelines. This highlights the importance of making clinical decisions based on absolute risk prediction to minimize the impact of blood pressure variability on overdiagnosis.