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View Public Comments for Ambulatory Blood Pressure Monitoring (ABPM) (CAG-00067R2)

barnhart-hinkle, blair
Director, Government Relations
Cleveland Clinic

Cleveland Clinic strongly supports a NCD Reconsideration of the coverage of ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension. We are concerned that limiting the coverage of ABPM to those with white coat hypertension (a syndrome whereby a patient's feeling of anxiety in a medical environment results in an abnormally high reading when their blood pressure is measured) will significantly impact the morbidity and mortality of individuals with other forms of hypertension (that are distinct from white coat hypertension), by not allowing them access to technology that provides a wealth of diagnostic and prognostic information.

ABPM is clearly a useful tool for the diagnosis of white-coat hypertension, however more recent data demonstrate the prognostic information gleaned from ABPM, and the clear increase in all-cause mortality amongst patient with masked hypertension and sustained hypertension (N Engl J Med 2018;378:1509-20.) Simply using clinic blood pressure measurement, which is now how the vast majority of these patients are now managed, is insufficient and does not properly assess an individual’s increased risk of a cardiovascular event (Hypertension. 2005;46(1):156.) In fact, the most recent American Heart Association / American College of Cardiology Blood Pressure Guidelines support out-of-office blood pressure monitoring as a Class 1A recommendation for the diagnosis of hypertension and titration of blood pressure lowering medication (JACC 2018, 71 (19) e127-e248.) Although periodic home blood pressure monitoring by patients can be useful, it is not sufficient to identify nocturnal blood pressure patterns that include non-dipping and reverse-dipping (i.e. blood pressure does not decrease during sleep.) These are forms of masked hypertension which are more prevalent amongst the aged population, consistent with Medicare beneficiaries (Chronobiol Int. 2013 Mar;30(1-2):176-91.)

ABPM is the gold standard for the accurate diagnosis of hypertension and its sub-classifications (white-coat, sustained, masked, and masked uncontrolled hypertension.) The need for appropriate reimbursement and coverage is critical for a the Medicare population given the increasing data that appropriate control of blood pressure decreases cardiovascular events in the aged (N Engl J Med 2015; 373:2103-2116), prevents mild cognitive impairment (and possible dementia), and slows development of white matter lesions in brain (Blood Press. 2018 Oct;27(5):247-248.) Thank you for your reconsideration of this National Coverage Determination.

Luke Laffin, MD
Staff Cardiologist, Section of Preventive Cardiology