Ambulatory blood pressure monitoring

DR AHMED SAGHIR AL QUDAIMI MSC.MD.FAHA

H Y P E R T E N S I O N D A Y 1 ST M A R C H 2 0 1 2 SANAA

What is this?

Ambulatory blood pressure monitoring (ABPM) is a noninvasive method of obtaining blood pressure readings over twenty-four hours, whilst the patient is in their own environment, representing a true reflection of their blood pressure.

Ambulatory blood pressure measurement

What the patients do need to do during 24hour blood pressure monitoring?

To allow the machine to work properly, it is important to make sure that the tube to the machine is not twisted or bent. Also, just before the machine is about to take a reading, it will beep. When this happens you should: sit down, if possible keep the cuff at the same level as your heart keep your arm steady.

Many studies have now confirmed that blood pressure measured over a 24-hour period is superior to clinic blood pressure in predicting future cardiovascular events and target organ damage.

Wexler R South Med J. 2010 May;103(5):447-52.

Upper limit of normal ambulatory blood pressure monitoring values

Normal ambulatory BP during the day is <135/<85 and <120/<70 at night. Levels above 140/90 during the day, and 125/75 at night should be considered as abnormal.

Wexler R South Med J. 2010 May;103(5):447-52

Dippers and non-dippers

Blood pressure will fall at night in normotensive

individuals. In hypertensive patients the blood pressure may fall excessively at night (>10%), leading to describing patients as 'dippers', which is associated with a poor outcome. In 'non-dippers' the blood pressure remains high, i.e. less than 10% lower than daytime average. This has also been reported to be associated with a poor outcome.

What are the uses of ambulatory blood pressure monitoring?

To obtain a twenty-four hour record - more reliable than one-off

measurements. Studies have shown that increased blood pressure readings on ABPM are more strongly correlated to end-organ damage than one-off measurements, e.g. left ventricular hypertrophy. To detect white coat hypertension. It has use in hypertension research, e.g. reviewing 24-hour profile of antihypertensive medication. It may have prognostic use - higher readings on ABPM are associated with increased mortality. Response to treatment. Masked hypertension. Episodic dysfunction. Autonomic dysfunction. Hypotensive symptoms whilst on antihypertensive medications. It may be more cost-effective in the long-term.

Who should be referred for ambulatory blood pressure monitoring?

Any patient with persistently raised blood pressure readings or labile blood

pressure should be considered for ABPM (whether or not on treatment). However, it is not a screening tool. Borderline readings in clinic. Poorly controlled hypertension, e.g. suspected drug resistance. Patients who have developed target organ damage despite control of blood pressure. Patients who develop hypertension during pregnancy. High-risk patients, e.g. those with diabetes mellitus, those with cerebrovascular disease and renal transplant recipients. Suspicion of white coat hypertension - high blood pressure readings in clinic which are normal at home. Suspicion of reversed white coat hypertension, i.e. blood pressure readings are normal in clinic but raised in the patient's own environment. Postural hypotension (in elderly pt with syncopal episodes) Elderly patients with systolic hypertension. Hypotensive episodes.

How are the results of ambulatory blood pressure monitoring provided?

This varies according to the machines used. Night-time mean, daytime mean and overall mean are

also provided. Usually, they have individual systolic and diastolic pressures. These may also be represented in a graphic form. Blood pressure load - the percentage or proportion of readings that are higher than a predetermined level in twenty-four hours. Day and night blood pressure: there is some evidence that night-time blood pressure gives crucial information, such as higher night-time readings being more associated with risk of developing target end-organ damage.

Autonomic dysfunction.

Persons autonomic nervous system controls

involuntary body systems, such as heart rate, breathing and sweating. Patients with disorders of the autonomic nervous system will have a different ABPM profile than healthy patients. Signs of autonomic dysfunction that may be determined by ABPM include:

Low blood pressure during waking hours High blood pressure during sleep Episodes of low blood pressure during the day, especially when rising from a seated or lying position (orthostatic hypotension) Abrupt lowering of blood pressure after meals Little or no variations of heart rate occurring along with the episodes of lower blood pressure

Standardized interpretive ABPM values

1-Day-time ABPM values: <130/85 mmHg 2-Night-time ABPM value: <120/70 mmHg 3-24-hour ABPM value: 130/80 mmHg (125/80 to 130/80) 4-Nocturnal dipping in BP and HR values: 10% (10-20%) 5-Nocturnal SBP dipping: dipper 10--<20% extreme dipper:20% non dipper: <10% rise: <0.0% 6-Coefficient of variation (BP variability): 0.2 7-Morning SBP Surge (MBPS): MS > 55mmHg non-MS 55mmHg BHJ 2011

Definitions of ABPM variables

Morning BP Surge (MBPS). Morning BP. Evening BP. Lowest BP. Pre- wake BP. Nocturnal dipping of SBP.

Nocturnal dipping of SBP:

The normal dipping of BP usually occurs 2 hours after the induction of sleep. Therefore, in dippers cardiac events occurs most frequently in the pre-waking hours (03:00 AM to 06:00AM). Nocturnal dipping of BP may be lost in patients with insulin resistance /metabolic syndrome because of increased sympathetic activity. Thus , cardiac events occur with greater frequency in the nondippers in the wee hours ( midnight to 03:00 AM). Therefore, in non-dippers one of the prescribed antihypertensive medications may be moved from the morning to the evening or bedtime.
(Niselen FS et al Diabet Med 1999;16:555-562)

Calculation of nocturnal SBP dipping

It is the difference between daytime mean SBP and nighttime mean SBP values expressed as percentage (%). Nocturnal SBP dipping=
[(daytime mean SBP-nighttime mean SBP) x 100]/(daytime mean SBP).

ABPM Report
The main components of an ABPM report should contain

the following: number of measurements (> 14 daytime and > 7 nighttime measurements) and causes of poor data such as poor technique, arrhythmia (e.g., atrial fibrillation), vigorous activity during study, small pulse volume, and inability of device to measure blood pressure. Also, the report should display the mean daytime and nighttime systolic and diastolic blood pressures, mean heart rate, maximum and minimum systolic and diastolic blood pressures and heart rates, mean 24-hour systolic and diastolic blood pressures and heart rate, and blood pressure load, and it should plot the data and map the activity log.

Take Home messages

The frequency and severity of target-organ damage

have been shown to be greater in patients with high levels of blood pressure variability.

In elderly patients with systolic hypertension, 24-

hour ambulatory blood pressure has been shown to be a significant predictor of cardiovascular risk over and above conventional blood pressure.

 Several studies have examined the utility of 24-hour

ABPM in pregnancy. Some of these studies describe blunted nocturnal dip in blood pressure in women and increased risk for preeclampsia.
Patients

with hyper-tension who were taking antihypertensive therapy showed a significant association between progressive visual field deterioration and nocturnal hypotension by ABPM.

 End-organ damage associated with hypertension is more

closely related to ambulatory blood pressure (ABP) than clinic or casual blood pressure measurements.
ABPM is indicated to exclude "white coat" hypertension

and has a role in assessing apparent drug-resistant hypertension, symptomatic hypotension or hypertension, in the elderly, in hypertension in pregnancy, and to assess adequacy of control in patients at high risk of cardiovascular disease.

 Interpretation of ABP is very important.

Clinicians should become familiar with ABPM and

consider using it judiciously in a number of clinical situations to provide additional guidance in the treatment of patients with hypertension.

Thank you