1. Is ABPM needed to diagnose hypertension?
In one of the biggest changes to NICE's previous guidance, published in 2006, the guideline recommends that a diagnosis of primary hypertension (HTN) should be confirmed using 24-hour ambulatory blood pressure monitoring (ABPM), or home blood pressure monitoring (HBPM), rather than be based solely on measurements of blood pressure (BP) taken in the clinic.

The recommendation draws on substantial new evidence, suggesting that ABPM is more accurate than both clinic and home monitoring in defining the presence of HTN, and that implementation of a diagnostic strategy for HTN using ambulatory monitoring following an initial raised clinic reading would reduce misdiagnosis and be cost saving for the NHS.
However, personally I am not totally convinced. Based on the following statements in its NICE Guideline for HTN Management 2011, I doubt ABPM is necessary or indicated in our daily practice at the momentary climate of Taiwan Medicare System (National Health Insurance)

(1) High BP is one of the most important preventable causes of premature ill health and death, even in the UK (said in NICE guideline). It is a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. The risk associated with increasing BP is continuous, with each 2 mmHg rise in systolic BP associated with a 7% increased risk of mortality from ischemic heart disease and a 10% increased risk of mortality from stroke.

(2) There are currently about 12 million people in the UK (said in NICE guideline) who have HTN (blood pressure ?140/90mmHg), and more than half of those are over the age of 60 years. Around 5.7 million people have hypertension which is undiagnosed. Are we in Taiwan having better done than in UK?

(3) There is no simple identifiable cause of the raised BP; the HTN may be related, in part, to obesity, dietary factors such as salt intake, physical inactivity or genetic inheritance. (said in NICE guideline) It means that流行率/ 發病率『只會 ↑、不會 ↓』 (personal believing) in here Taiwan, and we need to identify them earlier the better, rather than exclude them by ABPM. (Guidelines of Taiwan highlighted the unacceptable rate of HTN control at time being, and secondly, emphasize once more that early reduction in high BP is able to decrease risk of subsequent cardiovascular events.)

2. The guideline may need to pay more attention to the epidemiology of obesity and metabolic syndrome in Taiwan. The progressively increasing prevalence of overweight/obesity and waist circumference of population in Taiwan my offset or at least hinder the improvement of BP control in past 10 years.

3. The guideline may need to address the importance of Statins-adding as a co-treatment strategy in treating HTN. BP should be viewed all the time in all the cardiovascular (CV) situations; however, to maximize the treatment benefits for our HTN patients (pts.), it needs more than means just to lower BP.

In conclusion, in treating patients with high BP, a guideline for HTN (one of the leading risk factor in perspective CV continuum) management needs to emphasize the need to: (1) optimize earlier and appropriate Rx. strategies to maximize the beneficial effects of EB-Rx.; (2) the strategy should apply to lower-risk HTN pts. as well.