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Gregory M. Garrison, MD, MS Sara Oberhelman, MD
Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
PURPOSE Hypertension is the most common diagnosis in ambulatory care, yet
little evidence exists regarding recommended screening intervals or the sensitivity and specificity of a routine office-based blood pressure measurement, the most common screening test. Screening for hypertension is usually performed by measuring blood pressure at every outpatient visit, which often results in transiently elevated findings among adults who do not have a diagnosis of hypertension. We hypothesize that a more limited annual screening strategy may increase specificity while maintaining sensitivity.
METHODS A retrospective case-control study of 372 adults without hypertension
and 68 patients with newly diagnosed hypertension was conducted to compare the usual screening practice of checking blood pressure at every visit with a second strategy that considered only annual blood pressure measurements.
RESULTS Specificity improved from 70.4% (95% CI, 65.5%-75.0%) for the usual
practice to 82.0% (95% CI, 77.7%-85.8%) for the annual screening strategy. No statistically significant difference in sensitivity existed between the 2 methods.
CONCLUSION A limited annual screening strategy for hypertension can improve
specificity without sacrificing sensitivity when compared with routine screening at every visit in previously normotensive adults.
Ann Fam Med 2013;11:116-121. doi:10.1370/afm.1467.
ypertension is the most common diagnosis for which patients seek ambulatory care in the United States, representing more than 42 million visits in 2007.1 Yet there is little evidence to recommend a screening interval2 or to deﬁne the sensitivity and speciﬁcity of the most common screening test, a routine ofﬁce-based blood pressure measurement performed by manual sphygmomanometry. There is universal agreement among major national primary care organizations, including The Joint National Committee on Prevention, Detection and Treatment of Hypertension (JNC-7), the United States Preventative Service Task Force (USPSTF), the American Academy of Family Physicians, and the American College of Physicians on the utility of screening for hypertension.2-4 JNC-7 recommends a 2-year screening interval for normotensive individuals (systolic blood pressure less than 120 mm Hg and diastolic blood pressure less than 80 mm Hg) and a 1-year interval for individuals with prehypertension (systolic blood pressure of 120-139 mm Hg or diastolic blood pressure of 80-89 mm Hg), but it does not cite any references for these recommendations.3 The USPSTF mentions the JNC-7 recommendations regarding screening intervals but states, “the optimal interval for screening adults for hypertension is not known.” 2 Throughout the country, many primary care clinics routinely screen for hypertension by checking blood pressures at every clinic encounter regardless of the patient’s chief complaint, previous blood pressures, or
Conﬂicts of interest: authors report none.
Gregory M. Garrison, MD, MS Department of Family Medicine Mayo Clinic 200 First St SW Rochester, MN 55905 email@example.com
A NNALS O F FAMILY MED ICINE
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All patients had signed a research authorization allowing retrospective review of their electronic medical record. leading to inaccurate and often elevated results.org/src/base/R2/R-2.5-8 In addition. a diagnosis of hypertension requires “the average of 2 or more properly measured. were not pregnant.x (hypertension) before the start of the study and who were subsequently given an ICD-9 code 401. Patients with diagnosed hypertension and patients in the group Figure 1. Statistical analysis was carried out using R 2. We excluded patients with type 1 or 2 diabetes. coronary artery disease. clinic blood pressures are often not taken according to JNC-7 speciﬁcations. Even so.0 statistical software (http://cran.2 medical ofﬁce visits per year and the majority of these occurring in primary care. Proposed limited annual screening algorithm for hypertension. peripheral edema.x during the study period. PostSQL Global Development Group.3 This pilot study compares the current clinical practice of screening for hypertension by checking every patient’s blood pressure at every visit vs a more limited strategy that screens for hypertension annually.x. not pregnant. CAD = coronary artery disease. The great majority of blood pressure measurements were obtained by a licensed practical nurse using a calibrated aneroid device. seated. an estimated 30% of individuals with hypertension are unaware they have the disease.3. running on Mac OS 10. plus patient factors of acute pain. HTN = hypertension. illness. N O. or other reasons at any point during the study period before a diagnosis of hypertension. We screened for antihypertensive medication use with a computerized text-matching algorithm. we simulated a second strategy by considering blood pressures obtained only at general medical examination visits and any other visit when it had been more than 1 year since the last blood pressure measurement was obtained (Figure 1). To compare the screening strategies.1. We entered data from all study patients regarding blood pressure values at various outpatient visits. more limited screening strategy for hypertension that meets JNC-7’s recommendations. make interpreting clinic blood pressure values as a screening test for hypertension difﬁcult. we excluded patients taking any antihypertensive medications for migraine prophylaxis.15.tar. WWW.AN N FA MME D. Subjects were family medicine patients at Mayo Clinic Rochester who were aged 18 to 75 years at the start of the study period. Low-Risk Patient Age >18 y. We randomly selected 236 patients who received a diagnosis of hypertension during the study period and 500 normotensive patients using the SAS procedure survey select (SAS 9.12 there is ample opportunity to design a better. medications. no DM. and had at least 1 ofﬁce blood pressure recorded during the study period. Because we hypothesized that a limited annual screening strategy would increase speciﬁcity while maintaining sensitivity.O R G ✦ VO L.3). as well as patients who never had an ICD-9 code 401.7. DM = diabetes mellitus.9. we conducted a retrospective study for the 5 years preceding August 1. A NNALS O F FAMILY MED ICINE ✦ The study was reviewed and approved by our Institutional Review Board. With Americans making an average 3. the so-called white coat effect. and demographics into a relational database (PostgreSQL 8. CKD = chronic kidney disease. blood pressure readings on each of 2 or more ofﬁce visits. HTN. remained active patients for the entire 5 years. or stage 3 or 4 chronic kidney disease because of the differing standards for treatment of blood pressure in these individuals. and the investigators conducted a manual chart review of all patients.10 These factors. not on antihypertensive medication Health maintenance visit? No Yes Last BP >1 y Ago No Yes Record screening BP No BP screening necessary BP = blood pressure.0.r-project. SAS Institute Inc). or anxiety. We used an administrative database containing International Classiﬁcation of Disease (ICD-9) billing codes for the past 16 years to construct pools of patients with hypertension diagnosed during the study period and patients who did not have hypertension based on the inclusion and exclusion criteria deﬁned previously.3.H Y P ER T ENS I O N S C R E ENIN G the interval since the last blood pressure was obtained. The ﬁrst strategy is the usual clinical practice of measuring a patient’s blood pressure at every visit.15. We looked for patients never having an ICD-9 code 401. CAD. 2 ✦ MA RCH/A P R IL 2013 117 .gz) running on Mac OS 10.3 According to JNC-7.7. METHODS We compared 2 screening strategies for low-risk patients. because of the effect on blood pressure.”3 It is well known that clinic blood pressures tend to be higher than ambulatory blood pressures. 11. Additionally. CKD. 2010.2.
6 kg/m2.3) visits per year (P = .7 kg/m2.8 vs 28.5 (SD = 2.14 there were substantial differences from the actual clinical notes among the 236 potential patients with hypertension diagnosed during the study period and the 500 Figure 2. SD = 8.096). SD = 12.001) and heavier (body mass index 33. SD = 10. consistent with the criteria for diagnosis. For instance. 34 patients never had 77 32 a diagnosis of hypertension but Antihypertensive medication 9 mistakenly were given an ICD401.AN N FA MME D.7 years. 34 No HTN After elimination of the miscoded patients. There were. however.x billing code. respectively.H Y P ER T ENS I O N S C R E ENIN G with no hypertension were compared using Fisher’s exact test for categorical data and t tests for numerical data. Any blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic or greater was considered a positive screening test. no hypertension.4 years vs 41.6 years. These 440 patients had 4. P values of less than . Sex and smoking sta68 372 tus did not differ between those BP = blood pressure.x billing code in the administrative database (Figure 2). Assuming a sensitivity of 95% and a speciﬁcity of 75%.13. 2 ✦ MA RCH/A P R IL 2013 118 . A physician’s diagnosis of hypertension was considered the reference standard for positive disease.O R G ✦ VO L. Patients with hypertension were older than patients with no hypertension (47. respectively.6 kg/m2.287 blood pressures recorded. and Manual Chart Review 43 12 patients in the hypertension Elevated BP without HTN group and 4 patients in the group with no hypertension were found to have a clinical diagnosis of hypertension before the start of 12 4 the study that was not recorded as a ICD-9 401. 43 patients Patients With Patients in the hypertension group had a Diagnosed With No Hypertension Hypertension diagnosis of elevated blood pressure without hypertension that was mistakenly coded as ICD-9 code 401. CKD = chronic kidney disease. Table 1 summarizes these results. it was estimated 73 patients with diagnosed hypertension and 288 patients without hypertension would be needed. with desired 95% conﬁdence intervals of 5%. As expected. CAD = coronary artery disease. The screening strategy of checking blood pressures at every visit identiﬁed all 68 patients with hypertension diagnosed during the study period who had at least 1 positive screening blood pressure higher than 140/90 mm Hg.9 (SD = 1. with hypertension and those with HTN = hypertension. Case and control selection.8) visits per year and the patients with no hypertension averaging 1. Sensitivity and speciﬁcity.2 years. P <. P <.x. N O. often during a procedure or hospitalization. 11. SD = 6. potential patients without hypertension. including 95% conﬁdence intervals. DM = diabetes mellitus. average blood pressures were higher in the patients with hypertension than the patients with no hypertension. 110 (29.6%) patients in the group with no hypertension who were found to have at least 1 blood pressure measurement higher than 140/90 mm Hg WWW. RESULTS As is typical for administrative or billing databases.001). with the patients with hypertension averaging 2.05 were considered signiﬁcant. were calculated for each screening strategy using the patient as the unit of analysis. we analyzed data Exclusion criteria met from 68 patients with hypertenAge >18 92 sion diagnosed during the 5-year 2 CAD/DM/CKD study period and 372 patients Pregnancy with no hypertension during the No BPs recorded same period. The number A NNALS O F FAMILY MED ICINE ✦ of visits per patient per year was also similar.
Usual practice.1) 193 (51. 6. which improves speciﬁcity while maintaining sensitivity. (%) Never Quit Current Visits per year.3 (11. The annual screening strategy failed.4) 70.001 . 77. % (95% CI) 63 5 67 305 92.6) 82. (SD) Average blood pressure Systolic.4 (65. as the 95% conﬁdence intervals overlapped.4% (95% CI.5 (2.5) 35 (51. N O. year (SD) BMI.6 (8.7-85. P = .15 As expected.7) 83 (58.6% (95% CI.2%-100%). Thus. mm Hg (SD) BMI = body mass index.0%) blood pressures obtained in this group were at or higher than 140/90 mm Hg.8) 1. The annual screening strategy retained 39.7 (11. 2 ✦ MA RCH/A P R IL 2013 119 . Table 2 contrasts the results obtained by both methods.2-100) 70. Table 1. 266 of 3. 95% CI. No. Demographic Information on Patients With Diagnosed Hypertension and Patients With No Hypertension Characteristic Sex. It is essential to understand the implications of a screening test’s characteristics to interpret results and design a screening strategy effectively.AN N FA MME D.3) 18 (12. No. Sensitivity and Specificity of Blood Pressure Screening Strategies Hypertension Strategy Typical practice (all visits) Positive Negative Limited strategy (annual screening) Positive Negative 68 0 110 262 100 (92. In fact. had identiﬁed 100% of patients with diagnosed hypertension (sensitivity 100%.5-75.999 <. 65. kg/m2 (SD) Smoking status.4%) patients with hypertension on or before the date of their original diagnosis.9 (1.4) 33. Given the slowly progressive nature of morbidity resulting ✦ WWW.7-97. This difference was not signiﬁcant.0 (77. Screening less frequently resulted in only 67 patients in the group (18.1%. 95% CI.686) of the 4. The proposed annual screening strategy failed to identify 7. % (95% CI) Specificity. This initial pilot study proposes an annual screening strategy for hypertension using the most common screening test.9) 40 (28.1) 2. a negative result tends to rule out the possibility of disease. to identify 5 (7.6 (10.3%. 11.7) 11 (26. the falsenegative or type 2 error rate is negligible.6 (6. 95% CI. with a speciﬁcity of 70.7 (6.373 (7.692) with blood pressures at or higher than 140/90 mm Hg.7%-97.096 <. Sensitivity A NNALS O F FAMILY MED ICINE ✦ describes a test’s ability to classify correctly those with disease (Table 3).6%) and a speciﬁcity of 82. 92.8%).001 <. 83.4% of newly hypertensive patients as quickly as the baseline strategy. however.5) P Value >.8) Table 3.7) No Hypertension (n = 372) 179 (48.5%-75. Hypertension (n = 68) 33 (48.4%-9.2%9. the baseline practice of checking blood pressure at every visit yielded 100% sensitivity.1 (7. with 106 of 1. With a highly sensitive test. mm Hg (SD) Diastolic.001 <. (%) Male Female Age. 7.1) 82.7%-85. This method yielded a sensitivity of 92.530 . No.5) 47. the ofﬁce-based manual blood pressure measurement.2 (12.7) 28. This method found the same rate of elevated blood pressures among the retained readings from patients with no hypertension.0%).3) 114.0%) with no hypertension having elevated blood pressures.299 (8. Sensitivity An objective of any screening strategy is to classify correctly those individuals with hypertension.8) 135.001 Table 2. as expected.3% (1.0% (95% CI.O R G VO L.8) 28 (66.0) Yes (Cases) No (Controls) Sensitivity.9) 41. A 2 x 2 Table for Screening Tests for Hypertension Elevated Screening Blood Pressure Yes DISCUSSION Yes True positive False negative (type II error) Sn = TP TP + FN No False positive (type I error) True negative Sp = TN TN + FP Hypertension screening is an No Sensitivity important part of preventive health care delivered by primary care physicians.H Y P ER T ENS I O N S C R E ENIN G during the study period.287 blood pressures obtained during the study period.7%.2) 3 (7.6 (83.
It can increase clinic efﬁciency.17 Obviously. 2 ✦ MA RCH/A P R IL 2013 120 . laboratory testing.6% to 18.3 In the typical busy family medicine clinic with 15-minute appointments. This simplistic approach makes the algorithm easy to understand and implement.6% of adults who never had hypertension diagnosed had at least 1 elevated blood pressure reading. Further studies with longer time frames and other endpoints are required to answer these questions.3 In slowly progressive diseases.O R G VO L. One way to compensate for a screening test’s poor speciﬁcity is to target a limited population for screening.5 visits per year. such as ofﬁce blood pressure screening.15 If large numbers of disease-free individuals are screened repeatedly. that take multiple readings over several minutes may be used. JNC-7 speciﬁes that an accurate blood pressure measurement should be the mean of 2 auscultatory readings taken with an appropriately sized cuff with the patients’ feet on the ﬂoor and arm supported at heart height after being seated quietly in a chair for 5 minutes. The reduced frequency of screening produced a signiﬁcant decrease in the false-positive rate from 29.7%. During the 5-year study period. Mild to moderate hypertension is a slowly progressive chronic disease that causes complications and target organ damage over the course of years. delaying the diagnosis of actual hypertension. patients are all too often rushed down the hallway from a waiting room.”11 they can lull the physician into a sense of complacency. These elevated readings can lead to follow-up visits. N O. oscillometric devices. or as in “The Shepherd’s Boy and the Wolf.H Y P ER T ENS I O N S C R E ENIN G from hypertension. Determining a group of patients with no hypertension was also problematic. Manual chart review revealed substantial inaccuracies leading to fewer patients than originally forecast.0% of nonhypertensive adult patients over a 5-year period.16 Given a test with high sensitivity but poor speciﬁcity. we did not design our study to examine the effect that our proposed screening strategy might have on morbidity from hypertension. For instance. The fewer patients did not affect the study’s primary aim of detecting differences in speciﬁcity.19 Limitations Identifying patients with newly diagnosed hypertension by ICD-9 codes proved problematic. and thus we do not know what happens in the future to patients who did not have hypertension diagnosed but who had elevated blood pressures. as treatment would affect these blood pressure values. This study used a 5-year time frame to look for the development of hypertension. performing it too frequently increases false-positive results but does not improve disease detection. Thus it was impossible to ascertain whether and when these patients would have had hypertension diagnosed using the proposed annual screening strategy. With a highly speciﬁc test the false-positive or type I error rate is minimal. there is no time for this method for every patient at every visit. A positive result therefore rules in a disease. another way to compensate for poor speciﬁcity is to reduce the frequency of screening. when it is easily treated and before morbidity develops. Less frequent screening is the tactic applied by our proposed annual screening strategy. for which patients must undergo further testing. and patient anxiety. Reducing the number of unnecessary blood pressures screenings in healthy adults provides beneﬁts in addition to improving the false-positive rate.18 Instead.16 whether this delay in diagnosis is clinically relevant is debatable. which limited the study’s ability to detect differences in sensitivity between the 2 methods. ✦ WWW. The proposed annual screening for hypertension (in line with selection criteria for blood pressure measurements in this analysis) would entail measuring blood pressure for each patient at all preventive care visits or if it had been at least 1 year since the last blood pressure measurement. the delay is unlikely to be more than a few months. then even highly speciﬁc tests can generate unwieldy numbers of false-positive results. but it may overlook other important clinical factors. JNC-7 recommendations clearly indicate the need to screen all adults for hypertension.4%. such as the BpTRU (BpTRU Medical Devices). it results in 232 fewer patients needing further workup over 5 years. Considering that hypertensive patients had an average of 2. clinical considerations come into play as the screening needs to occur frequently enough to detect the disease in its earliest stages. It reduced the number of screenings performed by 60. however. 11. Specificity Speciﬁcity describes a test’s ability to correctly classify those without disease (Table 3). we could not consider visits that occurred after a diagnosis of hypertension was made. however.000 healthy adults cared for by a typical family physician. reduce clerical burdens. 29. Reducing the frequency of screening blood pressures may allow clinical staff time to measure blood pressures more accurately. Do they go on later in life to develop hypertension? Additionally. This study found that the baseline practice of screening for hypertension by checking blood pressures at every ofﬁce visit has a poor sensitivity of 70.AN N FA MME D. In this study. and a blood pressure is immediately measured.6. and focus attention on accurately obtaining screening blood pressure measurements. A NNALS O F FAMILY MED ICINE ✦ Applied to the roughly 2.
Escobar A.org/content/11/2/116.cdc. A longitudinal study of hypertension risk factors and their relation to cardiovascular disease: the Strong Heart Study. Hypertension. Target organ damage in hypertension. 16. 7. Godwin M.10 Thus using the JNC-7 deﬁnition as the reference standard for hypertension in this study was impractical. N O. Dawes M.annfammed. Patel CO.338: b2307.gov/ nchs/fastats/docvisit. Burger K. 4. Haynes RB.9. lightheadedness. Preventive Services Task Force reaffirmation recommendation statement. Santin E. and Blood Institute Joint National Committee on Prevention. Am Fam Physician. seated blood pressure readings on each of 2 or more ofﬁce visits. and Treatment of High Blood Pressure. 1995. How long shall the patient rest before clinic blood pressure measurement? Am J Hypertens. 2011. Multicentre Aneurysm Screening Study Group. ed. it is not necessarily a weakness. Clinical Epidemiology: A Basic Science for Clinical Medicine.8(6):591-597. J Cardiovasc Risk. White-coat effect in normotension and hypertension.7(5): 271-276. Kotsis VT.gov/nchs/data/nhsr/nhsr027. Evaluation. 6. sensitivity and specificity. Key words: hypertension. blood pressure. Arias IC. Chobanian AV. Screening for high blood pressure: reaffirmation and recommendation statement. Cherry DK.”3 Unfortunately. National High Blood Pressure Education Program Coordinating Committee. 2008:404–408. 2012. submitted. Fabsitz RR. 13. 2012. et al. 20. 9. see it online at http://www. Bailey K. The Seventh Report of the Joint National Committee on Prevention. MA: Little. Boston. Townsend GF. Hsiao. Khan N. 1987. Ambulatory care use and physician visits. but the purpose is not to screen for hypertension. 2010. Kiss A. Without their expertise. Pitiriga VCh. 11(4):252-258. Finally. US Preventive Services Task Force.147(11):783-786. JABFM. This study does not suggest that these blood pressures should not be obtained. 18.26(6 Pt 2):1204-1206. Such differences did not affect our sensitivity and speciﬁcity analysis.pdf. Godwin M. very few routinely obtained. accepted August 21.2(1):1-3. such as chest pain. Hypertension. as there was no guarantee that the retrospectively obtained blood pressures met the rigorous requirements. http://www. JAMA. 15.19(7):713-717. References 1. 2009.cdc. Submitted March 13. Magrini F. Detection. 14.htm. Rescaldani M. 2002.55(2):195-200. Accessed May 29. no 27. 2003. Hemmelgarn BR. Acknowledgments: We would like to thank Melissa Gregg and Julie Maxson for their assistance with data collection. Scott RA. Screening for high blood pressure: U.3 JNC-7 provides a deﬁnition for hypertension as “the average of 2 or more properly measured.136(4):357-360. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. Kay LE. 2. 2007. A NNALS O F FAMILY MED ICINE ✦ WWW. Ashton HA. There are many clinical scenarios. Lee ET. Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial. Botero A. 11. Black HR. and severe infections. To read or post commentaries in response to this article.H Y P ER T ENS I O N S C R E ENIN G Age and body mass index are well-established risk factors for hypertension. where obtaining a blood pressure measurement is necessary to guide diagnosis and treatment decisions. Evaluation. 12. 2009. Li L. 11. U. 2012. Sheps SG.S. this study would not have been possible. 2012. 19. Prevalence of white coat effect in treated hypertensive patients in the community. Hypertension.20. Villegas I. July 28. Brown. 2008. BMJ. Blood Press Monit. 1991. Joyner CD. National Ambulatory Medical Care Survey: 2007 Summary. palpitations. Thompson SG.21 and the observed differences between patients with diagnosed hypertension and patients with no hypertension are not surprising. Graves JW. 5. et al. 21. Tobe SW.342:d286.O R G ✦ VO L. National Heart. preventive health services. Ann Intern Med. Friedman C. Although a limitation. Hypertension Outcome and Surveillance Team of the Canadian Hypertension Education Programs. CMAJ. Buck CW. Kaczorowski J. The choice of a physician diagnosis of hypertension as the reference standard for disease may underestimate its prevalence in the study population. Myers MG. Centers for Disease Control and Prevention website. 2nd ed. Zanchetti A.79(12):1087-1088.54(6):1423-1428. Hyattsville. blood pressure determination. and Treatment of High Blood Pressure: the JNC 7 report. MD: National Center for Health Statistics. Nash C. et al. Amazon Digital. Dawes M. Evaluation of the technique used by health-care workers for taking blood pressure.47(3):403-409. Clinical decisionmaking in hypertension using an automated (BpTRU) measurement device.AN N FA MME D.289(19):2560-2572. Zakopoulos NA. 2006. Donner AP/ Factors affecting the incidence of hypertension. 2012. which do not always meet the strict JNC-7 requirements. Myers MG. 2006. 1995. there is a distinction between obtaining a blood pressure reading for hypertension screening purposes and obtaining a blood pressure reading because it is clinically relevant. Myers MG. Hypertension. Reeves RA. Oh PI. 2003. Preventive Services Task Force. 8. Chase HS. National health statistics reports. 3. http:// www. BMJ. Detection. et al. Accuracy of blood pressure measurement in the family practice center. mass screening Funding support: Funding was provided by Mayo Clinic Department of Family Medicine. Lung. Gao L. revised.S. 1995. 10. Bakris GL. Measurement of blood pressure in the office: recognizing the problem and proposing the solution. only that they should be interpreted cautiously when diagnosing hypertension. Weng C. Aesop’s Fables.17(12):823-827. Comparing ICD9encoded diagnoses and N LP-processed discharge summaries for clinical trials pre-screening: a case study. Beatty PC. Sackett DL. et al. CJ. 17. Am J Hypertens. because the purpose of this study was to investigate the screening utility of routinely obtained typical ofﬁcebased blood pressure measurements. 2 ✦ MA RCH/A P R IL 2013 121 . Sala C. ofﬁce-based blood pressure measurements meet the requirements of this deﬁnition. FastStats. 2010. 2009. Guyatt GH. AMIA Annu Symp Proc. Wang W. Tugwell P. Validation of a case definition to define hypertension using administrative data. J Hum Hypertens. 1998. Quan H.