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.
See also related separate article Hypertension.
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. The monitor takes blood pressures every 20 minutes (less frequently overnight - eg, one-hourly).
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.
- 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.
- 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 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.
- 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.
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.
- 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.
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'.
- 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.
Further reading and references
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 658(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 Nov28(4):571-86. doi: 10.1016/j.ccl.2010.07.006.
Bramlage P, Deutsch C, Kruger R, et al; Validation of the custo screen 400 ambulatory blood pressure-monitoring device according to the European Society of Hypertension International Protocol revision 2010. Vasc Health Risk Manag. 2014 May 1310:303-9. doi: 10.2147/VHRM.S63602. eCollection 2014.
Wexler R; Ambulatory blood pressure monitoring in primary care. South Med J. 2010 May103(5):447-52.
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 1910:139-44. doi: 10.2147/VHRM.S58351. eCollection 2014.
O'Brien E et al; European Society of Hypertension Position Paper on Ambulatory Blood Pressure Monitoring, Journal of Hypertension 2013, 31:1731–1768
Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
Ernst ME, Bergus GR; Ambulatory blood pressure monitoring. South Med J. 2003 Jun96(6):563-8.
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 2777(6):849-53.
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 Jan22(1):81-7.
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 Jan11(1):e1001591. doi: 10.1371/journal.pmed.1001591. Epub 2014 Jan 21.
Mahabala C, Kamath P, Bhaskaran U, et al; Antihypertensive therapy: nocturnal dippers and nondippers. Do we treat them differently? Vasc Health Risk Manag. 20139:125-33. doi: 10.2147/VHRM.S33515. Epub 2013 Mar 24.