Given the increasing use of ambulatory blood pressure monitoring (ABPM) in both clinical practice and hypertension research, a group of scientists participating in the European Society of Hypertension Working Group on monitoring of blood pressure and cardiovascular variability, in 2013 published a comprehensive position document that addresses all aspects of the technique, based on the scientific evidence available for ABPM.
The present work represents an updated schematic summary of the most important aspects related to the use of ABPM in daily practice, and aims to provide recommendations for the appropriate use of this technique in a clinical setting by specialists and practicing physicians. The article details the requirements and methodological issues that need to be addressed to use ABPM in clinical practice.
The clinical indications for ABPM suggested by the available studies, among which the phenomena of white coat, masked hypertension, and nocturnal hypertension are detailed and the place of home blood pressure measurement in relation to ABPM is discussed. .
The role of ABPM in pharmacological, epidemiological and clinical research is also briefly mentioned. Finally, the implementation of ABPM in practice is considered in relation to the situation in different countries regarding reimbursement and availability of ABPM in primary care practices, hospital clinics and pharmacies.
| Indications for ambulatory blood pressure monitoring |
In clinical practice, the most established indication for using ABPM is to identify untreated patients who have high office BP readings but normal readings during usual daily activities outside of this setting, i.e., white coat (or office) hypertension. isolated), and to identify different 24-h BP profiles.
The traditional definition of white coat hypertension is based on elevated office blood pressure (140 mm Hg SBP and/or 90 mm Hg DBP) on repeated visits with a waking BP below currently accepted thresholds for daytime ambulatory hypertension (mean awake ambulatory SBP/DBP <135 and <85 mm Hg in untreated individuals).
However, in recent years, there has been increasing interest in BP values during sleep , and nighttime BP is now recognized to be superior to daytime BP in predicting cardiovascular risk. It seems illogical, therefore, to exclude this period in a definition of white coat hypertension and the ESH Position Paper 2013 proposes to diagnose this condition also in patients with office readings of at least 140/90 mm Hg and a mean pressure of 24 h below 130/80mmHg, thus incorporating nocturnal BP into the definition. |
Since the prevalence of white coat hypertension in the community is significantly high (20-25%), it is important to make an accurate diagnosis, which can be best achieved by monitoring ABPM for 24 hours and/or BP at home. (LMWH) before prescribing antihypertensive drug therapy.
The ESH position paper recommends that people with white coat hypertension have the diagnosis confirmed within 3–6 months and should be followed at yearly intervals with ABPM or home BP monitoring, to detect if and when sustained hypertension occurs. produces. It is emphasized that the term white coat hypertension should be restricted to people who do not take antihypertensive medications.
As with the definition of white coat hypertension , it is not appropriate to exclude nocturnal BP as well when defining masked hypertension , and the definition should be extended to also include 24-h BP values of at least 130/80 mm Hg. along with low office BP.
Regarding the question of whether the definition of masked hypertension should also be applied to people taking medication and not only to untreated people, it is agreed that the term should not be applied to people on treatment, because by definition in people treated, hypertension has already been diagnosed and cannot be "masked".
Therefore, the term "masked uncontrolled hypertension" is proposed as more appropriate for treated individuals. Patients with masked hypertension or masked uncontrolled hypertension should be offered effective therapeutic BP control throughout the 24-h period to prevent the cardiovascular consequences of uncontrolled hypertension.
| Advantages of ABPM over office measurements |
• Provides a much larger number of readings. |
| Limitations of the MAP |
• Limited availability in general practice. |
| Clinical indications of ABPM |
| Absolute indications |
• Identification of white coat hypertension phenomena. |
| Additional information |
• Evaluation of morning hypertension and sudden increase in BP. |
| Definition of white coat hypertension and masked hypertension |
• White coat hypertension (isolated office hypertension). • Untreated individuals with elevated blood pressure 140/90 mm Hg and 24-hour BP < 130/80 mm Hg and awakening BP < 135/85 mm Hg and during sleep < 120/70 mm Hg or home BP < 135/ 85mmHg. |
> Masked hypertension
Untreated individuals with office BP <140/90 mm Hg and 24-hour BP. > 130/80 mm Hg and/or BP upon awakening > 135/85 mm Hg and/or BP during sleep > 120/70 mm Hg or home BP > 135/85 mm Hg.
> Masked uncontrolled hypertension
• Individuals treated with office BP < 140/90 mm Hg and 24-h BP 130/80 mm Hg and/or awakening BP 135/85 mm Hg and/or sleep BP 120/70 mm Hg or home BP 135/85 mm Hg.
• Diagnoses require confirmation by repeating outpatient or home monitoring within 3 to 6 months, depending on the individual’s overall cardiovascular risk.
• Ambulatory BP values obtained in the office during the first or last hour of a 24-h recording may also partly reflect the white coat effect (“white coat” window).
• Patients with office BP <140/90 mm Hg, 24-h BP <130/80 mm Hg, awakening BP <135/85 mm Hg but during sleep BP > 120/70 mm Hg should be defined as ’ Isolated nocturnal hypertension’, to be considered a form of masked hypertension.
> Blood pressure variability
BP is a highly dynamic parameter characterized by continuous fluctuations that include both short- and long-term variability. Although short-term BP variability within 24 h can be easily assessed with ABPM, long-term variability requires repeated BP measurements over days, weeks, or months with repeated office, home, or ABPM measurements.
Based on the available evidence, short-term BP variability within 24 h could be considered for risk stratification in population and cohort studies. However, it does not currently represent a parameter for routine use in clinical practice.
| Altered daily BP variation patterns identified by ABPM |
• Inversion (deeper): Night systolic and diastolic blood pressure decrease > 10% of daytime values or the night/day ratio of systolic and diastolic blood pressure < 0.9 and > 0.8 is the pattern of systolic blood pressure and normal daytime diastolic. • Reduced inversion: Nighttime systolic and/or diastolic blood pressure decreases by 1 to 10% of daytime values or night/day systolic and/or diastolic blood pressure ratio <1 and > 0.9. Decreased systolic and/or diastolic diurnal pattern of BP associated with increased cardiovascular risk. • No deeper and ascending: No reduction or increase in nocturnal systolic and/or diastolic blood pressure or the nocturnal/daytime systolic and/or diastolic blood pressure ratio. Associated with increased cardiovascular risk. • Extreme inversion : Marked nocturnal systolic and/or diastolic drop falls > 20% of daytime systolic and/or diastolic values or nocturnal/daytime systolic and/or diastolic ratio < 0.8. Debatable association with cardiovascular risk. • Nocturnal hypertension: Increase in the absolute level of nocturnal systolic and/or diastolic blood pressure (120/70mm Hg). Associated with increased cardiovascular risk - may indicate obstructive sleep apnea. • Morning increase: Excessive increase in systolic and/or diastolic pressure in the morning. • Debatable definitions, thresholds and prognostic impact: The classic definition of non-immersion (nocturnal systolic and/or diastolic drop <10% or night/day ratio > 0.9) can be criticized because it includes "reduced immersion" as a form of "no immersion". Although imprecise, this definition may be clinically justified, as both conditions are associated with increased cardiovascular risk. |
| When to repeat ABPM in clinical practice |
Recommendations on when to repeat ABPM are based on many factors, including clinical judgment and the availability of ABPM. |
| Thresholds for the diagnosis of hypertension based on ABPM |
• 24-h average SBP/DBP 130/80 mm Hg. |
