Ambulatory blood pressure monitoring in clinical practice: a review

Implementing ABPM into Clinical Practice

PURPOSE OF REVIEW

To review the data supporting the use of ambulatory blood pressure monitoring (ABPM), and to provide practical guidance for practitioners who are establishing an ambulatory monitoring service.

RECENT FINDINGS

ABPM results more accurately reflect the risk of cardiovascular events than do office measurements of blood pressure. Moreover, many patients with high blood pressure in the office have normal blood pressure on ABPM-a pattern known as white coat hypertension-and have a prognosis similar to individuals who are normotensive in both settings. For these reasons, ABPM is recommended by the US Preventive Services Task Force to confirm the diagnosis of hypertension in patients with high office blood pressure before medical therapy is initiated. Similarly, the 2017 ACC/AHA High Blood Pressure Clinical Practice Guideline advocates the use of out-of-office blood pressure measurements to confirm hypertension and evaluate the efficacy of blood pressure-lowering medications. In addition to white coat hypertension, blood pressure phenotypes that are associated with increased cardiovascular risk and that can be recognized by ABPM include masked hypertension-characterized by normal office blood pressure but high values on ABPM-and high nocturnal blood pressure. In this review, best practices for starting a clinical ABPM service, performing an ABPM monitoring session, and interpreting and reporting ABPM data are described. ABPM is a valuable adjunct to careful office blood pressure measurement in diagnosing hypertension and in guiding antihypertensive therapy. Following recommended best practices can facilitate implementation of ABPM into clinical practice.

Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke

Our purpose was to evaluate the value of blood pressure variability within the first 24 hours after admission in predicting outcomes of patients with acute ischemic stroke (AIS). A greater variability in systolic blood pressure (adjusted odds ratio [OR] = 1.801, 95% confidence interval [CI] = 1.167-2.779) was associated with poor discharge outcome, especially for nondiabetics (adjusted OR = 1.948, 95% CI = 1.184-3.205) and cardioembolism-related patients with AIS (OR = 7.650, 95% CI = 1.370-42.713). However, this correlation was not observed with a long-term (3-month or 6-month) outcome in patients with AIS. There was no association between diastolic blood pressure variability within the first 24 hours after admission and outcome. In conclusion, systolic blood pressure variability within the first 24 hours after admission is a critical predictor for short-term outcome of patients with AIS.

Screening for Hypertension and Lowering Blood Pressure for Prevention of Cardiovascular Disease Events

Hypertension affects 1 in 3 American adults. Blood pressure (BP)-lowering therapy reduces the risk of cardiovascular disease. The United States Preventive Services Task Force recommends all adults be screened for hypertension. Most patients whose office BP is elevated should have out-of-office monitoring to confirm the diagnosis. Ambulatory BP monitoring is preferred for out-of-office measurement, but home BP monitoring is a reasonable alternative. Guidelines for treatment are stratified by age (<60 vs >60 years) and include cutoffs for recommended treatment BPs and target BP goals. Quality of hypertension care is improved by incorporating population health management using registries and medication titration.

Ambulatory Blood Pressure Monitoring: A Complementary Strategy for Hypertension Diagnosis and Management in Low-Income and Middle-Income Countries

Ambulatory blood pressure monitoring (ABPM) can assess out-of-clinic blood pressure. ABPM is an underutilized resource in low-income and middle-income countries but should be considered a complementary strategy to clinic blood pressure measurement for the diagnosis and management of hypertension. Potential uses for ABPM in low-income and middle-income countries include screening of high-risk individuals who have concurrent communicable diseases, such as HIV, and in task-shifting health care strategies.

Ambulatory blood pressure monitoring phenotypes among individuals with and without diabetes taking antihypertensive medication: the Jackson Heart Study

Ambulatory blood pressure monitoring (ABPM) can detect phenotypes associated with increased cardiovascular disease (CVD) risk. Diabetes is associated with increased CVD risk but few data are available documenting whether blood pressure (BP) phenotypes, detected by ABPM, differ between individuals with versus without diabetes. We conducted a cross-sectional analysis of 567 participants in the Jackson Heart Study, a population-based study of African Americans, taking antihypertensive medication to evaluate the association between diabetes and ABPM phenotypes. Two clinic BP measurements were taken at baseline following a standardized protocol. ABPM was performed for 24 h following the clinic visit. ABPM phenotypes included daytime, sustained, nocturnal and isolated nocturnal hypertension, a non-dipping BP pattern, and white coat, masked and masked isolated nocturnal hypertension. Diabetes was defined as fasting glucose ⩾126 mg dl-1, haemoglobin A1c ⩾6.5% (48 mmol mol-1) or use of insulin or oral hypoglycaemic medications. Of the included participants (mean age 62.3 years, 71.8% female), 196 (34.6%) had diabetes. After multivariable adjustment, participants with diabetes were more likely to have daytime hypertension (prevalence ratio (PR): 1.32; 95% confidence interval (CI): 1.09-1.60), masked hypertension (PR: 1.46; 95% CI: 1.11-1.93) and masked isolated nocturnal hypertension (PR: 1.39; 95% CI: 1.02-1.89). Although nocturnal hypertension was more common among participants with versus without diabetes, this association was not present after adjustment for daytime systolic BP. Diabetes was not associated with the other ABPM phenotypes investigated. This study highlights the high prevalence of ABPM phenotypes among individuals with diabetes taking antihypertensive medication.

Ambulatory Blood Pressure Monitoring – Clinical Practice Recommendations

Ambulatory blood pressure monitoring (ABPM) became a subject of considerable scientific interest. Due to the increasing use of the ABPM in everyday clinical practice it is important that all the users have a correct knowledge on the clinical indications, the methodology of using the device including some technical issues and the interpretation of results. In the last years several guidelines and position papers have been published with recommendations for the monitoring process, reference values, for clinical practice and research. This paper represents a summary of the most important aspects related to the use of ABPM in daily practice, being a synthesis of recommendations from the recent published guidelines and position papers. This reference article presents the practical and technical issues of ABPM, the use of this method in special situations, the clinical interpretation of measured values including the presentation of different ABPM patterns, derived parameters, the prognostic significance and the limitations of this method.

Comparison of patients' confidence in office, ambulatory, and home blood pressure measurements as methods of assessing for hypertension

OBJECTIVE

Uncertainty exists when relying on office (clinic) blood pressure (BP) measurements to diagnose hypertension. Home BP monitoring and ambulatory BP monitoring (ABPM) provide measurements that are more strongly associated with cardiovascular disease. The degree to which patients exhibit uncertainty about office BP measurements is unknown, as is whether they would have less uncertainty about other BP measurement methods. We therefore assessed people's confidence in methods of BP measurement, comparing perceptions about office BP monitoring, home BP monitoring, and ABPM techniques.

METHODS

We surveyed adults who were 30 years or older (n=193), all whom had undergone office BP measurements, two sessions of 24-h ABPM, and two 5-day periods of home BP monitoring. Respondents were asked to indicate their level of confidence on a 1 to 9 scale that BP measurements represented their 'usual' BP.

RESULTS

Respondents had least confidence that assessments of BP made by office measurements (median 6) represented usual BP and greater confidence that assessments made by home BP monitoring (median 7, P<0.0001 vs. office) and ABPM (median 8, P<0.0001 vs. office) did so. Confidence levels did not vary significantly by BP levels, age, sex, race, or education level.

CONCLUSION

The finding that patients do not have a great deal of confidence in office BP measurements, but have a higher degree of confidence in home BP and ambulatory BP assessment methods may be helpful in guiding strategies to diagnose hypertension and improve antihypertensive medication adherence.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows

Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

The relationship between red blood cell distribution width and blood pressure abnormal dipping in patients with essential hypertension: a cross-sectional study

OBJECTIVE

To investigate whether red blood cell distribution width (RDW) is associated with the blood pressure (BP) reverse-dipper pattern in patients with hypertension.

DESIGN

Cross-sectional study.

SETTING

Single centre.

PARTICIPANTS

Patients with essential hypertension were included in our study (n=708). The exclusion criteria included age <18 or >90 years, incomplete clinical data, night workers, diagnosis of secondary hypertension, under antihypertensive treatment, intolerance for the 24 h ambulatory BP monitoring (ABPM) and BP reading success rate <70%.

MEASUREMENT

Physical examination and ABPM were performed for all patients in our study. The value of RDW was measured using an automated haematology analyser.

STATISTICAL METHODS

The distribution of RDW in patients with hypertension among different circadian BP pattern groups was analyzed using analysis of variance (ANOVA). Multinomial logistic regression was applied to explore the associations of RDW and other relevant variables with ABPM results.

RESULTS

There was significantly increased RDW in reverse dippers (13.52 ± 1.05) than dippers (13.25 ± 0.85) of hypertension (p=0.012). Moreover, multinomial logistic regression analysis showed that RDW (OR 1.325, 95% CI 1.037 to 1.692, p=0.024) and diabetes mellitus (OR 2.286, 95% CI 1.380 to 3.788, p=0.001) were significantly different when comparing the reverse-dipper BP pattern with the dipper pattern. However, there was no difference of RDW between the non-dipper pattern and the reverse-dipper pattern (OR 1.036, 95% CI 0.867 to 1.238, p=0.693). In addition to this, RDW was negatively correlated with the decline rate of nocturnal systolic BP (r=-0.113; p=0.003) and diastolic BP (r=-0.101; p=0.007).

CONCLUSIONS

Our results suggested that RDW might associate with the abnormal dipper BP patterns of either reverse dipping or non-dipping homogeneously examined with 24 h ABPM.

The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults

The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.

Acute reduction in blood pressure following consumption of anthocyanin-rich cherry juice may be dose-interval dependant: a pilot cross-over study

A pilot cross-over study assessed the acute effects on blood pressure and plasma biomarkers associated with consumption of a 300 ml anthocyanin-rich fruit juice, provided in differing dose-intervals. Young adults (n = 6) and older adults (n = 7) received in random order, either a single 300 ml dose or 3 × 100 ml doses of high-flavonoid cherry juice provided at 0, 1 and 2 h. Blood pressure and plasma levels of phenolic metabolites were measured at 0, 2 and 6 h.The single 300 ml dose of cherry juice resulted in a significant reduction in systolic (p = 0.002), and diastolic blood pressure (p = 0.008) and heart-rate (p = 0.033) 2 h after consumption, before returning to baseline levels at 6 h post-consumption. The 3 × 100 ml dose provided over 2 h did not result in significant blood pressure reductions. Plasma phenolic metabolites increased at 2 and 6 h; however, fluctuations were higher after the single 300 ml dose in older adults. These findings have implications for design of intervention studies that investigate vascular effects associated with flavonoid-rich foods.

Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.

Dietary Approaches to Stop Hypertension diet retains effectiveness to reduce blood pressure when lean pork is substituted for chicken and fish as the predominant source of protein

BACKGROUND

Hypertension is a major, modifiable risk factor for cardiovascular and kidney disease and premature mortality that is improved by the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet emphasizes increased consumption of fruit and vegetables, whole grains, low-fat dairy, nuts, and poultry and fish and reduced intakes of fats, red meats (including pork), sodium, and added sugars.

OBJECTIVE

We sought to evaluate whether the consumption of lean pork compared with the consumption of chicken and fish as the predominant protein source in a DASH-style diet affected blood pressure (BP) control in men and women with elevated BP.

DESIGN

In a randomized crossover study, 13 women and 6 men [mean ± SEM age: 61 ± 2 y; BMI (in kg/m²): 31.2 ± 1.4] with elevated BP [systolic blood pressure (SBP)/diastolic blood pressure (DBP): 130 ± 2/85 ± 2 mm Hg] consumed a DASH-style diet for two 6-wk controlled dietary interventions (with a 4-wk diet washout between interventions) with either lean pork [DASH diet with pork (DASH-P)] or chicken and fish [DASH diet with chicken and fish (DASH-CF), the control diet] as the major protein source (55% of total protein intake). SBP and DBP were measured manually and with a 24-h BP monitoring system on 3 d before and 3 d at the end of each diet intervention.

RESULTS

Preintervention manual BP (DASH-P: 130/84 ± 2/1 mm Hg; DASH-CF: 129/84 ± 2/1 mg Hg) and postintervention manual BP (DASH-P: 122/79 ± 2/1 mm Hg; DASH-CF: 123/78 ± 3/1) were not different between the DASH-P and DASH-CF. Consumption of these DASH-style diets for 6 wk reduced all measures of BP (P < 0.05) with no differences in responses between the DASH-CF and DASH-P.

CONCLUSION

The results indicate that adults with elevated BP may effectively incorporate lean pork into a DASH-style diet for BP reduction.

Ageing modifies the effects of beetroot juice supplementation on 24-hour blood pressure variability: An individual participant meta-analysis

OBJECTIVES

Abnormal circadian oscillations of blood pressure (BP) and nocturnal-diurnal BP differences (i.e., dipping) increase cardiovascular risk. Whether inorganic nitrate supplementation influences 24-hr BP variability is currently unknown. We studied the effects of high-nitrate beetroot juice supplementation on BP variability measured by 24-hr ambulatory BP monitoring (24-hr ABPM) in older subjects.

METHODS

Data from four independent randomised clinical trials were collated. Eighty-five older participants (age range: 55-76 years) were included in the final database. Two trials had an open-label, parallel design and two trials had a cross-over, double-blind design. Participants were randomised to either beetroot juice or placebo. Changes in 24-hr ABPM (daily, diurnal, nocturnal), variability (weighted-SDs), night-dipping, morning surge for systolic and diastolic BP were measured. Meta-analysis was conducted to obtain pooled estimates of the effect size for each BP outcome. Sub-group analyses were conducted to evaluate the influence of age, BMI, gender, BP status and changes in nitrite concentrations on the effect size.

RESULTS

The pooled effect of beetroot juice on all BP outcomes was not significant. Beetroot juice ingestion determined a significant decrease in nocturnal systolic BP variability in subjects aged less than 65 y (2.8 mmHg, -4.5 -1.0, p = 0.002) compared to the older group (≥ 65 y; 1.0 mmHg, -2.2 4.2, p = 0.54). A greater change in NO2(-) concentrations after beetroot supplementation was associated with significant differences for nocturnal mean (-3.4 mmHg, -0.6 -2.4, p = 0.02) and variability (-0.8 mmHg, -1.5 -0.06, p = 0.03) of systolic BP.

CONCLUSIONS

The vascular responsiveness to inorganic nitrate may be modified by mechanisms of vascular ageing influencing the reducing capacity to convert inorganic nitrate into nitrite and tissue-specific responses to dietary nitrate supplementation.