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ambulatory blood pressure monitoring (ABPM)

Indications: 1) assessment of 'white coat' hypertension 2) borderline hypertension with target-organ damage 3) abrupt changes in blood pressure, episodic hypertension 4) hypotensive symptoms with treatment of chronic hypertension [4] 5) possible nocturnal rise in blood pressure - due to inadequate duration of antihypertensive therapy 6) hypertension resistant to drug therapy 7) possible autonomic dysfunction - heart rate patterns do not correlate with blood pressure 8) reference standard for confirming a diagnosis of chronic hypertension [5] Contraindications: - not indicated for evaluation of prehypertension [1] Reference interval: - 24 hour average blood pressure < 115/75 mm Hg - daytime average blood pressure < 120/80 mm Hg - nighttime average blood pressure < 100/65 mm Hg [1] Clinical significance: - goals: daytime systolic BP < 135 mm Hg; night systolic BP < 125 mm Hg - systolic BP goals correspond with threshold for treatment with antihypertensive agent [1] - systolic BP correlates more with all-cause & cardiovascular mortality than diastolic BP [12] - results correlate with left ventricular hypertrophy better than office-based measurements - 24 hour ambulatory BP appears to have independent prognostic value, beyond that office measurements [2,12] - better predictor of cardiovascular outcomes than office-based blood pressure measurements, including left ventricular hypertrophy & cardiac death [1] - hypertension assessed by ambulatory blood pressure monitoring is associated with a higher risk of cardiovascular death than hypertension determined in the office or at home [1] - 24 hour ambulatory systolic BP better predictor of all-cause & cardiovascular mortality than clinic systolic BP [12] - nighttime systolic BP better predictor of all-cause & cardiovascular mortality than daytime systolic BP [12] (24 hour ambulatory monitoring) - patients with masked hypertension at risk for excess all-cause mortality whereas patients with white-coat hypertension are not [12] - for each level of office BP, 24 hour systolic BPs of > 135 mm Hg have 2-3 fold increased risk of adverse cardiovascular events [2] - mean 24 hour BPs are generally lower than mean of office-based BPs, 21/9 mm Hg in one study [2] - ambulatory BP is, on average, 7/2 mm Hg higher than clinic BP [8] - 15-20% of ambulatory BP measurements elevated not a concern if average ambulatory BP ok [1] - nocturnal blood pressure should be ~15% lower than daytime blood pressure (example of 16%/12% lower nocturnal BP ok) [1] - nocturnal hypertension may be more predictive of mortality [4] - increased systolic BP during sleep is associated with higher risks for stroke & cardiovascular disease [10] - a graphene bioimpedance tattoo placed over the radial artery & ulnar artery, just above the wrist can monitor arterial blood pressure for > 300 minutes with high accuracy [1] Notes: - cost-effective in primary care [3] - home blood pressure monitoring may be an acceptable alternative [1] - Proof BP calculator suggested as a surrogate for ambulatory blood pressure monitor [9]

General

clinical procedure

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021.
  2. Journal Watch 23(14):109, 2003 Clement DL, De Buyzere ML, De Bacquer DA et al Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. NEJM 348(24):2407, 2003 PMID: 12802026
  3. Lovibond K et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: A modelling study. Lancet 2011 Aug 24 PMID: 21868086 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61184-7/fulltext
  4. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  5. Siu AL on behalf of the U.S. Preventive Services Task Force Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. Published online 13 October 2015 PMID: 26458123 http://annals.org/article.aspx?articleid=2456129 - Shimbo D et al. Role of ambulatory and home blood pressure monitoring in clinical practice: A narrative review. Ann Intern Med 2015 Oct 13 PMID: 26457954
  6. Minutolo R et al Prognostic Role of Ambulatory Blood Pressure Measurement in Patients With Nondialysis Chronic Kidney Disease Arch Intern Med. 2011;171(12):1090-1098. PMID: 21709109 http://archinte.ama-assn.org/cgi/content/short/171/12/1090
  7. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens. 2011 Jan;24(1):52-8. PMID: 20847724
  8. Schwartz JE, Burg MM, Shimbo D et al Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population. Circulation. 2016;134:1794-1807 PMID: 27920072 http://circ.ahajournals.org/content/134/23/1794
  9. Sheppard JP et al. Prospective external validation of the Predicting Out-of-Office Blood Pressure (PROOF-BP) strategy for triaging ambulatory monitoring in the diagnosis and management of hypertension: Observational cohort study. BMJ 2018 Jun 27; 361:k2478 PMID: 29950396 Free PMC Article https://www.bmj.com/content/361/bmj.k2478
  10. Kario K et al. Nighttime blood pressure phenotype and cardiovascular prognosis: Practitioner-based nationwide JAMP study. Circulation 2020 Nov 2; PMID: 33131317 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.049730
  11. Kireev D et al. Continuous cuffless monitoring of arterial blood pressure via graphene bioimpedance tattoos. Nat Nanotechnol 2022 Jun 20 PMID: 35725927 https://www.nature.com/articles/s41565-022-01145-w
  12. Staplin N et al. Relationship between clinic and ambulatory blood pressure and mortality: An observational cohort study in 59,124 patients. Lancet 2023 May 5; PMID: 37156250 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00733-X/fulltext