Ambulatory Blood Pressure Monitoring

Authored by Dr Laurence Knott, 15 Jul 2014

Reviewed by:
Dr Jacqueline Payne, 15 Jul 2014

Patient professional reference

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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.

Many studies have now confirmed that blood pressure measured over a 24-hour period is superior to clinic blood pressure in predicting future cardiovascular events and target organ damage.[1, 2]

See also related separate article Hypertension.

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).

  • 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.
  • 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]

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.[9]

  • 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]
  • 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.[5]
  • 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.[11]

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.

  1. 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.

  2. Wexler R; Ambulatory blood pressure monitoring in primary care. South Med J. 2010 May103(5):447-52.

  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 1910:139-44. 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 Jun96(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 2777(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 Jan22(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 Jan11(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 differently? Vasc Health Risk Manag. 20139:125-33. doi: 10.2147/VHRM.S33515. Epub 2013 Mar 24.

From a Daily Mail artice, although it has been discussed here previously:Meanwhile scientists are testing whether taking blood pressure pills in the evening rather than the morning may be more...

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