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Ambulatory blood pressure monitoring

Article  in  Australian Family Physician · November 2011

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9 authors, including:

Geoffrey A Head Barry Patrick Mcgrath

Baker Heart and Diabetes Institute Australian Medical Council
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Anastasia Susie Mihailidou Mark R Nelson

Royal North Shore Hospital University of Tasmania
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 clinical

National Heart Foundation

and High Blood Pressure
Research Council of
Australia Ambulatory
Ambulatory blood
pressure monitoring
Blood Pressure Monitoring
Consensus Committee

This article forms part of our ‘Tests and results’ series for 2011 which aims to provide • Suspected nocturnal hypertension or no night time
information about common tests that general practitioners order regularly. It considers areas
such as indications, what to tell the patient, what the test can and cannot tell you, and
reduction in BP (dipping)
interpretation of results. • Hypertension despite appropriate treatment
• Patients with a high risk of future cardiovascular
events (even if clinic BP is normal)
Keywords: ambulatory blood pressure monitoring
• Suspected episodic hypertension.
Ambulatory BP monitoring may also be useful for:
• titrating antihypertensive therapy
Ambulatory blood pressure (ABP) monitoring • borderline hypertension
involves measuring blood pressure (BP) at regular • hypertension detected early in pregnancy
intervals (usually every 20–30 minutes) over a 24 • suspected or confirmed sleep apnoea
hour period while patients undergo normal daily • syncope or other symptoms suggesting orthostatic
activities, including sleep. The portable monitor hypotension, where this cannot be demonstrated in
is worn on a belt connected to a standard cuff on the clinic.
the upper arm (Figure 1) and uses an oscillometric
technique to detect systolic, diastolic and mean When is it not recommended?
BP as well as heart rate.1 When complete, the There are no specific contraindications to ABP monitoring,
device is connected to a computer that prepares however, it is important that this test doesn’t delay
a report of the 24 hour, day time, night time, and commencing drug therapy in patients with severe
sleep and awake (if recorded) average systolic and hypertension (ie. clinic BP grade 3; defined as systolic BP
diastolic BP and heart rate. ≥180 mmHg and/or diastolic BP ≥110 mmHg) as ABP can
be valuable to confirm adequacy of treatment. While not
The accuracy of ABP monitoring has been validated in a a contraindication, ABP monitoring may be inaccurate in
range of patients including young, elderly, pregnant and patients with irregular heart rate and arrhythmias.1
obese subjects (provided the correct size cuff is used).
Ambulatory BP monitoring is safe and is not usually Where does it fit in a diagnostic
associated with complications. Occasionally oedema or approach?
petechiae of the upper arm or bruising under the inflating Ambulatory BP monitoring provides a more reliable
cuff may occur. Modern ABP devices are quiet, lightweight measure of a patient’s BP than isolated clinic measures
and easy to wear, but inflation of the cuff may cause and is not subject to the ‘white-coat effect’, which
some transient discomfort, particularly in people with can overestimate BP, particularly in susceptible
hypertension or when multiple readings are triggered due patients. While clinic measurement of BP is useful
to errors in measurement. Ambulatory BP measurements for screening, and in the management of suspected
during the night may disturb sleep; potentially requiring and true hypertension. Ambulatory BP and home
retesting if there are poor nocturnal BP measurements. BP measurements add considerably to the accurate
diagnosis of hypertension and the provision of optimal
What are the indications? care. Recent recommendations from expert groups such
• Suspected white-coat hypertension (including in as the United Kingdom’s National Institute for Health
pregnancy) and Clinical Excellence strongly advocate wider use of
• Suspected masked hypertension (untreated subject with ABP monitoring in the diagnosis and management of
normal clinic BP and elevated ABP) hypertension.

Reprinted from Australian Family Physician Vol. 40, No. 11, november 2011 877
clinical Ambulatory blood pressure monitoring

threshold 130/80 mmHg)

• Day time (awake) <120/80 mmHg
(hypertension threshold 135/85 mmHg)
• Night time (asleep) <105/65 mmHg
Connecting
Cuff (hypertension threshold 120/75 mmHg).
tube
Ambulatory BP values above ‘normal’ and below
thresholds for hypertension are considered
ABP ‘high normal’. Night time (sleeping) average
device systolic and diastolic BP should both be at least
10% lower than day time (awake) average.1
Blood pressure load (percentage of time that BP
readings exceed hypertension threshold during 24
hours) should be <20%.
Blood pressure variability, maximum systolic
Figure 1. Example of ambulatory monitors (upper left), multiple cuff sizes (lower left) and when BP and morning BP surge should also be taken
fitted to a patient (right)
into account (and targeted by treatment).
Use of these images does not constitute endorsement by the National Heart Foundation of Australia,
nor the High Blood Pressure Council of Australia Treatment targets based on ABP are lower than
the targets for clinic BP readings (eg. for clinic BP
of 140/90, day time ABP equivalent is 136/872)
What should I tell my patient? flowing normally. The monitor defines the maximal Importantly, ABP monitoring can be effectively
Patients should be aware that the device will oscillations as mean arterial BP and then uses used to manage antihypertensive treatment.3 The
automatically inflate the cuff and measure BP an algorithm to calculate systolic and diastolic frequency of ABP assessment can be guided by
periodically over a 24 hour period. They will need BP. The correct cuff size is essential and in very the changes to therapy as routinely performed
to book to have the monitor fitted and, as they large patients, a conical shaped cuff is necessary. using clinic assessments combined with self
cannot get the device wet, they should attend Measure BP in both arms and if the SBP difference measurements. An example of an ABP report is
after bathing. A top with loose sleeves will best is less than 10 mmHg, use the nondominant arm. shown in Figure 2.
accommodate the cuff and a firm waistband will If the SBP difference is greater than 10 mmHg,
help support the monitor. Patients should continue use the arm with the higher pressure. If there are
What won’t the results tell you?
with their normal daily activities, preferably contraindications to measuring BP in one arm (eg. Ambulatory BP monitoring will not provide any
including a work day rather than a rest day. They fistula or previous axillary clearance), the monitor information relating to cardiac arrhythmias and
should take all their usual medications. must be fitted on the other arm. To ensure validity, may be inaccurate in the setting of irregular heart
When the cuff starts to inflate the patient when the ABP monitoring device is fitted, at least rate such as in atrial fibrillation. Ambulatory BP
should stop moving and talking, keep the arm three readings should be recorded simultaneously is not designed to detect postural hypotension
still and relaxed, and breathe normally. They using a calibrated sphygmomanometer as the measurements occur at a fixed interval
should avoid activities that may interfere with the connected to the ABP monitoring device by and devices do not contain inclinometers that
device such as vigorous exercise. A brief diary a Y connector. Average readings for ABP and would be required to record a patient’s position.
is important to record timing of activities, sleep, sphygmomanometer should not differ by more However, diary information can provide positional
taking of medicines, posture and symptoms (eg. than 5 mmHg. Ambulatory BP monitoring devices and event data. Ambulatory BP monitoring can be
dizziness) that may be related to BP. are usually programmed to take readings at set used to assess whether there is high variability
No Medicare rebate is currently available for intervals; 15–30 minutes during the day and of BP which is often associated with orthostatic
ABP monitoring. Costs will vary with provider and every 30–60 minutes at night, to obtain numerous hypotension.4
need to be discussed with the patient. measurements while limiting interference with
activity or sleep. What are the next steps if the
How does the monitor work? test is negative or inconclusive?
Ambulatory BP monitors use cuff oscillometry. What do the results mean? Untreated patients at low risk of cardiovascular
The cuff is inflated until the pressure occludes Measurements obtained from ABP monitoring disease with elevated clinic BP but a normal ABP
flow within the brachial artery. As the pressure is must be interpreted carefully with reference to (ie. day BP is <135/85 mmHg) may have ‘white-
released, blood begins to flow causing fluctuations diary information and the timing of medicines. coat hypertension’. This should be confirmed
(oscillations) in the arterial wall that are detected Reference ‘normal’ ABP values for nonpregnant with a second ABP. People with white-coat
by the monitor. These oscillations increase in adults are2: hypertension are at greater risk of developing
intensity then diminish and cease when blood is • 24 hour average <115/75 mmHg (hypertension true hypertension and glucose intolerance. They

878 Reprinted from Australian Family Physician Vol. 40, No. 11, november 2011
 Ambulatory blood pressure monitoring clinical

Ambulatory blood pressure report

Patient name: Mr J Bond ID: 007 Clinic BP
Scan start date 29/08/2011 Clinic SBP/DBP 140/90 suggests
Scan start time 12:08 Total readings 56 hypertension
Scan end date 30/08/2011 Successful readings 52
Scan end time 13:37 Percent successful 93
OK if >85%
Night
180 Asleep Awake
Grade 1
Blood pressure (mmHg)

160
hypertension
140
threshold
120
100
80
60
1200 1500 1800 2100 0000 0300 0600 0900 1200 Time SBP: Grade 2
hypertension
Summary
≥148 mmHg
Min Mean Max STD BP load (<20%)
Systolic 125 151 183 13.4 94%
Diastolic 71 90 115 11.9 67%
Heart rate 54 70 94 9.5 DBP: Grade 1
Day summary 6:00 to 22:00 hypertension
≥84 mmHg
Min Mean Max STD BP load
Systolic 125 152 176 12.2 91%
Diastolic 73 91 111 10.9 68%
Heart rate 54 71 90 8.7
Night summary 22:00 to 6:00
Min Mean Max STD BP load
Night SBP Systolic 129 146 183 14.7 100%
dipping
abnormal
Diastolic 71 86 115 135 70%
Heart rate 57 69 94 11.1 Night DBP
% Night SBP dip (>10%) 3.9% % Night DBP dip (>10%) 5.5% dipping
Awake summary 7:00 to 1:30 abnormal
Min Mean Max STD BP load
Systolic 132 155 183 11 93%
Diastolic 75 92 115 11 68%
Heart rate 55 73 94 9
Asleep summary 1:30 to 7:00
Min Mean Max STD BP Load
Systolic 125 134 143 5 100%
Diastolic 71 76 85 5 55%
Asleep SBP
Heart rate 54 60 67 5 Asleep DBP
dipping
normal % Night SBP dip (>10%) 14% % Night DBP dip (>10%) 28% dipping
Interpretation: Patient ABP day, night, awake, asleep BP, BP load values are all above normal
hypertension grade 1 threshold (shown in red). While night summary suggests ‘nondipping’
(<10%) this is due to very late sleep onset. The nocturnal dipping based on awake and asleep
values are satisfactory (>10%)
Conclusion: Confirmed grade 1 hypertension
Recommendation: Commence or increase antihypertensive therapy. Assess cardiovascular risk
to determine correct target BP. Reassess after modification
Figure 2. Example of ambulatory blood pressure report. Values in red are above hypertension thresholds based on reference 2

Reprinted from Australian Family Physician Vol. 40, No. 11, november 2011 879
clinical Ambulatory blood pressure monitoring

therefore need ongoing assessment of absolute Servier, BI and Novartis for lectures; Arduino
cardiovascular risk and continued monitoring with A Mangoni has received payment for travel,
clinic and home BP measurements. Repeat ABP accommodation and lectures at international
every 1–2 years. conferences from Pfizer and payment from NAPP
For patients with high cardiovascular risk or Pharmaceuticals for lecturing; Alison Wilson
suspected masked hypertension it is appropriate works for the National Heart Foundation of
to perform an initial ABP and repeat ABP Australia. This work was resourced internally
monitoring in 1–2 years, even if clinic BP remains by the National Heart Foundation using donated
normal. Repeat ABP and/or home BP monitoring in funds.
these patients should be guided by the initial ABP
References
profile and response to treatment.
1. McGrath BP. Ambulatory blood pressure monitoring.
An inconclusive test can occur if there has Med J Aust 2002;176:588–92.
been insufficient valid readings (patient removes 2. Head G, Mihailidou A, Duggan K, et al. Definition
of ambulatory blood pressure targets for diagnosis
or inactivates device) or when there has been
and treatment of hypertension in relation to clinic
sleep disturbances which may obscure the correct blood pressure: prospective cohort study. BMJ
assessment of night time BP. 2010;340:c1104.
3. Staessen JA, Byttebier G, Buntinx F, Celis H,
Authors O’Brien ET, Fagard R. Antihypertensive treat-
National Heart Foundation and High Blood Pressure ment based on conventional or ambulatory blood
Research Council of Australia Ambulatory Blood pressure measurement. A randomized controlled
Pressure Monitoring Consensus Committee: trial. Ambulatory Blood Pressure Monitoring and
Treatment of Hypertension Investigators. JAMA
Geoffrey A Head, Monash University Baker IDI
1997;278:1065–72.
Heart and Diabetes Institute, Melbourne, Victoria, 4. Ejaz AA, Kazory A, Heinig ME. 24-hour blood
[email protected]; Barry P McGrath, pressure monitoring in the evaluation of supine
Department of Medicine, Southern Health, hypertension and orthostatic hypotension. J Clin
Melbourne, Victoria; Anastasia S Mihailidou, Hypertens (Greenwich) 2007;9:952–5.
Department of Cardiology and the Kolling Institute
of Medical Research, Royal North Shore Hospital
and the University of Sydney, New South Wales;
Mark R Nelson, Discipline of General Practice,
School of Medicine, University of Tasmania and
Menzies Research Institute Tasmania; Markus P
Schlaich, Neurovascular Hypertension & Kidney
Disease, Baker IDI Heart and Diabetes Institute,
Melbourne, Victoria; Michael Stowasser University
of Queensland School of Medicine, Princess
Alexandra Hospital, Brisbane, Queensland;
Arduino A Mangoni, Division of Applied Medicine,
University of Aberdeen, United Kingdom; Diane
Cowley, University of Queensland School of
Medicine, Princess Alexandra Hospital, Brisbane,
Queensland; Alison Wilson, Heart Foundation,
Melbourne, Victoria.
Conflict of interest: ICMJE forms completed by all
authors: Geoffrey A Head works for an institution
which has received a NHMRC grant related to this
work. He also has stocks in Telemetry Research;
Barry P McGrath is a paid board member of
Boehringer-Ingelheim and Abbott Pty Ltd;
Anastasia S Mihailidou, Mark R Nelson, Michael
Stowasser and Diane Cowley have declared no
conflict of interest. Markus P Schlaich receives
paid board membership of Abbott Pty Ltd and
institution grants for NHMRC project goals. He
also receives payments from Abbott Pty Ltd,

880 Reprinted from Australian Family Physician Vol. 40, No. 11, november 2011
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