Twenty-four-hour ambulatory blood pressure measurement in clinical practice and research: a critical review of a technique in need of implementation

Abstract

Abstract. O'Brien E (The Conway Institute, University College Dublin, Dublin, Ireland). Twenty-four-hour ambulatory blood pressure measurement in clinical practice and research: a critical review of a technique in need of implementation (Review). J Intern Med 2011; 269: 478-495.This review presents evidence that ambulatory blood pressure measurement (ABPM) should be used more widely in clinical practice and hypertension research. The technique, which should be mandatory in trials of antihypertensive drugs, is not being used in all studies of antihypertensive drug efficacy. ABPM is also being under-used in outcome studies. The failure to implement ABPM in primary care and hypertension research is impeding patient management and scientific advancement. ABPM offers so many advantages in assessing the efficacy of blood pressure (BP)-lowering drugs that it should be mandatory in pharmacological trials. Likewise, the technique provides a means of achieving BP control in clinical practice, which is essential if we are to halt the epidemic of the cardiovascular consequences of hypertension. However, if ABPM is to be implemented for these purposes, certain requirements will need to be fulfilled. These include the availability of accurate, patient-friendly and inexpensive devices; standardization of the presentation and plotting of data with summary statistics for day-to-day practice; provision of comprehensive data analysis for research; an interpretative report to facilitate use in busy clinical practice; a trend report to demonstrate efficacy or otherwise of treatment in clinical practice and online transmission of data to provide immediate real-time data analysis. The reasons why ABPM is not being implemented are reviewed, and proposals are made to make the technique more acceptable.

Assessing Blood Pressure Responses to Noncardiovascular Drugs: The Beneficial Role of Ambulatory Blood Pressure Monitoring

“…17,20 An Example of Information Provided by the Employment of ABPM in a Substudy Since the mechanisms determining BP may differ at different times within the 24-hour cycle, it is not surprising that drugs can vary in their effects in these windows of time. 21,22 The ability of ABPM to detect BP changes that CBPM had failed to identify has been well illustrated in the Heart Outcomes Prevention Evaluation (HOPE) study. [23][24][25][26][27] In the main study, the group receiving ramipril had approximately 35% fewer cardiovascular events, despite an insignificant mean reduction in systolic BP (SBP) of 3 mm Hg and in diastolic BP (DBP) of 2 mm Hg (3 ⁄ 2 mm Hg): the outcome benefit was attributed to angiotensin-converting-enzyme (ACE) inhibition, which was recommended in all high-risk individuals regardless of baseline BP.…”

“…Measurements of SPB and DPB, and also heart rate, can be analyzed to assess potential drug effects during each of these periods. 22 The most important measures of circadian variation are the nocturnal dip and the morning surge. 22,29 Nocturnal hypertension (or a nondipping pattern) is the most important finding associated with increased target organ involvement and increased cardiovascular morbidity and mortality.…”

“…22 The most important measures of circadian variation are the nocturnal dip and the morning surge. 22,29 Nocturnal hypertension (or a nondipping pattern) is the most important finding associated with increased target organ involvement and increased cardiovascular morbidity and mortality. An elevated nocturnal BP or a diminished nocturnal fall in BP is associated with poor cardiovascular outcome in populations 30,31 and also in patients with hypertension.…”

“…The system also yields informative indices associated with outcome, including area under the curve calculations, BP load parameters, trough and peak levels, cusum-derived statistics, and the ambulatory arterial stiffness index, which has been shown to predict cardiovascular mortality in a large cohort of hypertensive individuals, particularly for stroke. 22 Finally, as all hemodynamic changes are influenced by activity, the system is also capable of monitoring the activity status of the patient. Twenty-four-hour actigraphy monitoring is incorporated into a simultaneous 24-hour Holter and ABPM recording to provide statistics that include the duration of actigraphy recording and the mean activity per minute, with an overview plot for display on screen and in reports.…”

Ambulatory Blood Pressure Measurement

“…33 The technique can achieve potential savings of 3% to 14% for cost of care for hypertension and 10% to 23% reduction in treatment days when ABPM was incorporated into the diagnostic process at an annual cost that would be <10% of treatment costs, 34 and it is particularly costeffective for the diagnosis and management of newly diagnosed hypertension. 35 Recently, a detailed cost-benefit analysis was undertaken by NICE and showed that the use of ABPM is the most cost-effective method of confirming a diagnosis of hypertension in a population suspected of having high BP based on a conventional BP screening measurement >140/90 mm Hg and that the technique would result in substantial savings to the UK National Health Service.…”