UNDERSTANDING AMBULATORY

BLOOD PRESSURE MONITORING

By
Abhishek jha
Jr 2
MODERATOR
Prof. ARVIND GUPTA
MD, DNB(Nephrology)
Department of Medicine
MLN Medical College
Allahabad
 What is this?

• Ambulatory blood pressure monitoring

(ABPM) is a non-invasive method of obtaining
blood pressure readings over a 24-hour
period, whilst the patient is in their own
environment, representing a true reflection of
their blood pressure.
What does ambulatory blood pressure
monitoring involve?
Blood pressure is measured over a 24-hour
period, using auscultatory or oscillometry
devices, and requires use of a cuff.
Working principle of ABPM
device
The processor in this apparatus is programmable.
We can program it by downloading the schedule
obtained by using special software from the PC.

When the device is initialized and it is worn by human

the processor controls a cuff inflation by compressor
according to this schedule. Deflating the cuff is
controlled through an automated valve.
In addition, the processor receives, processes and
records sensor signals into the memory chip
Depending on the quality of the signal it can also
change the schedule.
Sensors record the pressure in the pneumatic
system and the physical phenomena caused by
the pulsation of the brachial artery during the
cuff inflation and deflation.

If the method of blood pressure registration is

auscultatory the sensor is located on the inner
side of the brachial cuff.
The sensor may be situated inside the pneumatic
system if this method is, for example,
oscillometric.
 Parts of ABPM device

air compressor (1); processor (2);

pneumatic system (3) ended with
brachialcuff (4);
sensors (5 or 5 and 6); power batteries (7)
PC (8).
 Why ABPM?

• If pt is suspected of having white-coat

hypertension.
This means that pts BP may be high due to
anxiety when pt is near doctors, hospitals or
surgeries, but that pt BP will fall to normal when
he is away from the medical environment.
• If pt suspected of having masked (or hidden)
hypertension, which means that pt BP may be
normal when doctor measures it but the average
BP on ABPM is high.
• If one is suspected of having night time
hypertension or a non-dipping pattern of BP at
night, which is especially common with sleep
apnoea (stopping breathing during sleep)
• If pts BP does not reduce despite taking
medication to lower BP.
• If pt have dizziness or weakness that is suspected
to be due to low BP.
• Doctor may want to use ABPM as a measure of
the effectiveness of the medication prescribed to
lower pts BP.
• ABPM is being used increasingly in pregnancy and
in children.
 Some practical points

One should note the following points:

• Keep the arm steady when the monitor inflates the cuff
• Make sure that the tubing does not become kinked
• When the monitor indicates that a BP measurement is
being taken (usually with a bleep), if possible sit down
and keep the arm steady at heart level (such as resting
on a table)
• Put the monitor under the pillow or beside you on the
bed at night
• Continue normal daily activities between
measurements
• Make sure to take your BP medication
• Do not shower, take a bath or swim
• If you are given a diary card enter your activity
and any symptoms at the time of BP
measurement
• Return the monitor after 24-hours
 What the ABPM will show?
The ABPM data will be transferred from the monitor
to a computer, which will provide an analysis of all
the measurements taken over the 24-hour period.
These will include:
• Your average BP during the day and night
• Your average heart rate during the day and night
• The report may provide your average BP
during the first hour of measurement – the
white coat window
• The report may provide results of the ABPM
together with BP measurement s during the
day and night
• The report may also provide an analysis
showing a comparison of the latest ABPM
with previous ABPMs
 Will a repeat ABPM be done?

An ABPM may be repeated in the following

circumstances:

• To confirm your ABPM pattern and elevation

• To confirm that you have white coat hypertension
• To confirm that you have night time hypertension
• To assess your response to treatment
• On an annual basis to confirm BP control
• If the first ABPM is technically unsatisfactory
 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 - eg, left
ventricular hypertrophy.[3]
• To detect white coat hypertension.
• It has use in hypertension research - eg,
reviewing 24-hour profile of antihypertensive
medication.
• It may have prognostic use - higher readings on
ABPM are associated with increased mortality.[4]
• Response to treatment.[3]
• Masked hypertension.[2]
• Episodic dysfunction.[2]
• Autonomic dysfunction.[2]
• Hypotensive symptoms whilst on
antihypertensive medications.[2]
• It may be more cost-effective in the long term
than office blood pressure measurement
 Who should be referred for ambulatory
blood pressure monitoring?
• The National Institute for Health and Care Excellence
(NICE) recommends that if a clinic blood pressure is
140/90 mm Hg or higher, ABPM should be offered to
confirm the diagnosis of hypertension. If a person is
unable to tolerate ABPM, home blood pressure
monitoring (HBPM) is a suitable alternative to confirm
the diagnosis of hypertension.[5]
• Poorly controlled hypertension - eg, suspected drug
resistance.
• Patients who have developed target organ damage
despite control of blood pressure.
• Patients who develop hypertension during pregnancy.
• High-risk patients - eg, those with diabetes
mellitus, those with cerebrovascular disease, and
kidney transplant recipients.[6][7]
• Suspicion of white coat hypertension - high blood
pressure readings in clinic which are normal at
home.
• Suspicion of reversed white coat hypertension, ie
blood pressure readings are normal in clinic but
raised in the patient's own environment.
• Postural hypotension.
• Elderly patients with systolic hypertension.[8]
 Upper limit of normal ambulatory blood
pressure monitoring values
• Normal ambulatory blood pressure during the
day is <135/<85 mm Hg and <120/<70 mm Hg
at night.
• Levels above 140/90 mm Hg during the day
and 125/75 mm Hg at night should be
considered as abnormal.
 Downside to ambulatory blood pressure
monitoring
• It is not universally available although this is improving.
• It requires specialist training.
• Some patients find inflation of the cuff unbearable.
• Sleep disturbance.
• Bruising where the cuff is located.
• Background noise may lead to interference (less with
oscillometric methods).
• Poor technique and arrhythmias may cause poor readings.[9]
• There is some evidence that HBPM may be better than ABPM
for predicting cardiovascular risk at every level below severe
hypertension (≥160/≥100 mm Hg). However, these findings
need to be confirmed by larger trials.[10]
 How are the results of ambulatory
blood pressure monitoring provided?
This varies according to the machines used.
• 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.
• NICE recommends ensuring that at least two
measurements per hour are taken during the person's
usual waking hours (for example, between 08:00 and 22:00
hours). Use the average value of at least 14 measurements
taken during the person's usual waking hours to confirm a
diagnosis of hypertension
 Dippers and non-dippers
• Blood pressure will fall at night in normotensive
individuals. People who undergo this normal
physiological change are described as
'dippers'.[11]
• In 'non-dippers' the blood pressure remains high,
ie less than 10% lower than daytime average.
There is also the phenomenon of 'reverse
dippers' whose blood pressure actually rises at
night. Both these conditions have also been
reported to be associated with a poor outcome.
 Ambulatory blood pressure measurement allows a better
risk stratification compared to clinic blood pressure
measurement. Non-dipping status and low LVEF is closely
related to severe renal and cardiovascular damage in CKD
patients. Low LVEF and 24-hour ABPM can be used as
prognostic markers non-diabetic CKD patients, and
lowering of nocturnal BP will reduce the renal and
cardiovascular risk in these patients.

• [ Choudhary L, Gupta P, Gupta A, Saxena P, Chaurasia AK. 24 hour

ambulatory blood pressure monitoring and left ventricular ejection
fraction- prognostic markers in chronic kidney disease. Int J Adv
Med 2016;3:xxx-xx ]

• [Non-dipping Pattern of Blood Pressure Raises Risk of Target Organ

Damage in Non Diabetic CKD Patients
Choudhary L, Saxena P, Gupta A, Gupta P, Chaurasia A.K.]
 reading & references
• Choudhary L, Gupta P, Gupta A, Saxena P, Chaurasia AK. 24 hour ambulatory blood pressure monitoring and left ventricular
ejection fraction- prognostic markers in chronic kidney disease. Int J Adv Med 2016;3:xxx-xx

• Hermida RC, Ayala DE, Mojon A, et al; Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces
cardiovascular risk. J Am Coll Cardiol. 2011 Sep 6;58(11):1165-73. doi: 10.1016/j.jacc.2011.04.043.
• Ogedegbe G, Pickering T; Principles and techniques of blood pressure measurement. Cardiol Clin. 2010 Nov;28(4):571-86. doi:
10.1016/j.ccl.2010.07.006.
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3. Posokhov IN, Kulikova NN, Starchenkova IV, et al; The "Pulse Time Index of Norm" highly correlates with the left ventricular
mass index in patients with arterial hypertension. Vasc Health Risk Manag. 2014 Mar 19;10:139-44. doi:
10.2147/VHRM.S58351. eCollection 2014.
4. O'Brien E et al; European Society of Hypertension Position Paper on Ambulatory Blood Pressure Monitoring, Journal of
Hypertension 2013, 31:1731–1768
5. Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
6. Ernst ME, Bergus GR; Ambulatory blood pressure monitoring. South Med J. 2003 Jun;96(6):563-8.
7. Haydar AA, Covic A, Jayawardene S, et al; Insights from ambulatory blood pressure monitoring: diagnosis of hypertension
and diurnal blood pressure in renal transplant recipients. Transplantation. 2004 Mar 27;77(6):849-53.
8. Fagard RH, Staessen JA, Thijs L, et al; Relationship between ambulatory blood pressure and follow-up clinic blood pressure
in elderly patients with systolic hypertension. J Hypertens. 2004 Jan;22(1):81-7.
9. Ambulatory blood pressure monitoring; British Heart Foundation, 2011
10. Asayama K, Thijs L, Brguljan-Hitij J, et al; Risk stratification by self-measured home blood pressure across categories of
conventional blood pressure: a participant-level meta-analysis. PLoS Med. 2014 Jan;11(1):e1001591. doi:
10.1371/journal.pmed.1001591. Epub 2014 Jan 21.
11. Mahabala C, Kamath P, Bhaskaran U, et al; Antihypertensive therapy: nocturnal dippers and nondippers. Do we treat them
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THANK YOU