KEEP THE FIRST READING: AN ARGUMENT FOR THE IMPORTANCE OF THE FIRST OFFICE BLOOD PRESSURE READING IN CHILDREN

Objective: Lately, clinicians are using oscillometric devices with repeated blood pressure (BP) measurements (on the same occasion) to diagnose hypertension in children. It is unclear which of these measurements, or which combination of measurements, is the most predictive of ambulatory hypertension. Our objective was to determine which measurements of office BP correlate best with the 24-hour automated BP (ABPM). Design and method: We consecutively enrolled all pediatric patients, aged 1–18 years, who underwent ABPM in the last 3 years at The Children's Hospital of Eastern Ontario; all patients also had 3 consecutive oscillometric office blood pressure readings at the same time. We compared the first, second, and third and the average of all three measurements as well as the average of the last 2 readings with daytime BP from ABPM. All BP readings were converted to Z-scores based on published, normative paediatric data for office and ABPM. Results: Two-hundred and forty-five children (male=133) were included in the study. The median [IQR] of first, second and third systolic BP Z-scores (SBPz) were 2.29[1.44,3.21], 1.91[1.13,2.72] and 1.65[0.82, 2.47], respectively, and all were significantly different from one another (p < 0.001). The largest difference/effect size was noted between the first and third measurement of SBPz (Cohen-d 0.51). Similar differences were observed in diastolic blood pressure Z-scores (DBPz), with medians [IQR] of 0.97[0.00, 1.87], 0.77[-0.19, 1.75] and 0.55[-0.37, 1.54] respectively (p < 0.001, Cohen-d between first and third reading 0.32). On multivariate analysis, the only significant predictor of systolic daytime BP was the first office systolic BP reading (p = 0.001, relative importance 43%). Similarly, the only significant predictor of diastolic daytime BP was the first office diastolic BP reading (p < 0.001, relative importance 43%). The first office SBPz and DBPz were also the best predictors of daytime systolic (ABPM SBPz > 1.65) and diastolic (ABPM DBPz > 1.65) hypertension on ROC with area under the curve (AUC) analysis (SBPz AUC = 0.69, DBPz AUC = 0.81). Conclusions: We observed significant differences between first, second and third office BP measurements. The first office systolic and diastolic BP readings appear to be the best predictors of ABPM daytime systolic and diastolic BP.

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