Make easy to read ABPM

2. Ambulatory Blood Pressure
Monitoring in Children
Fahimeh Asgarian, MD
TUMS

3. Introduction
Recognizing and treating hypertension in the pediatric
population is an important aspect of managing early
manifestations of cardiovascular disease.
Although ABPM has been available and utilized in the
adult population for several decades, it has not been
widely used in pediatric patients until relatively recently.

4. Introduction…
When compared to office BPs, parameters available
through ABPM are more predictive of adverse
cardiovascular and cerebrovascular events in adults
As most children with suspected hypertension are seen by
pediatric nephrologists, familiarity with ABPM is critical for
correct classification and optimal management of elevated
blood pressure.

6. ABPM should be performed for confirmation of HTN:
Children with office BP measurements in the elevated
BP category for 1 year or more
Stage 1 HTN over 3 clinic visits
Suspected WCH or Masked HTN(high risk children)
Patients who have undergone coarctation repair
May be used to assess treatment effectiveness

7. High risk children
• CKD or renal abnormality( MH)
• Solid organ transplant
• Obesity
• T1DM/T2DM
• OSAS(obstructive sleep apnea
syndrome)
• Aortic coarctation (repaired)
• Genetic syndromes associated
with HTN (neurofibromatosis,
Turner syndrome, Williams
syndrome)
• Patient born prematurely
• Secondary HTN

8. Application
Trained personnel should apply the monitor
Correct cuff size should be selected
Right and left arm and a lower extremity BP should be
obtained to rule out coarctation of the aorta

9. Application…
Use non-dominant arm unless there is large difference in
size between the left arm and right arm, then apply to
the arm with the higher BP
Take readings every 15–20 min during the day and every
20–30 min at night

10. Assessment
Minimum of 1 reading per hour, 40–50 for a full day, 65%–
75% of all possible recordings.(US guidelines)
Edit outliers by inspecting for biologic plausibility
(e.g., SBP < 60 or > 220)
Interpret with pediatric ABPM normal data by sex and
height

11. Calculate:
Mean BP
BP load (% of readings above threshold)
Dipping (% decline in BP from wake to sleep)

12. Π

13. Day & Night period
BP threshold
White coat
Night time

14. Reading numbers
BP load
Mean BP White coat
%Dipping

16. ABPM classification office BP ABPM
Normal < 90 percentile mean SBP/DBP<95percentile
or< 120/80 Loads<25%
WCH >=95 percentile mean SBP/DBP< 95percentile
or>130/80 Loads<25%
Pre-HTN >=90 percentile mean SBP/DBP<95percentile
or >120/80 Load>=25%

17. ABPM classification office BP ABPM
Masked HTN < 95th percentile mean SBP/DBP>95th percentile
or < 130/80 Loads>=25%
Ambulatory HTN >95th percentile mean SBP/DBP> 95th percentile
or >130/80 Loads 25-50%
Severe Ambulatory HTN >95th percentile mean SBP/DBP> 95th percentile
or >130/80 Load> 50%

18. Mean BP: Mathematical average of the systolic and
diastolic BP readings captured in each monitoring period.
BP load: Percentage of readings above the 95th
percentile of systolic or diastolic BP based on ambulatory
normative data, which is dependent on age, gender, and
wake/sleep status.
In adults, a high BP load is associated with cardiovascular
(CV) risk.

23. Mean/average SBP/DBP is the main parameter for
identifying HTN.
BP loads:There is some disagreement on the use of BP
loads
‫در‬ ‫و‬ ‫شده‬ ‫کمرنگ‬ ‫االن‬ bp load ‫ارزش‬
‫گذاشته‬ ‫کنار‬ ‫حال‬ ‫در‬ ‫هم‬ ‫بالغین‬ ‫الین‬ ‫گاید‬
‫فاکتوز‬ ‫یه‬ ‫گقتند‬ ‫می‬ ‫قبال‬ .‫هست‬ ‫شدن‬
‫عوارض‬ ‫بینی‬ ‫پیش‬ ‫در‬ ‫مستقل‬
‫کمرنک‬ ‫داره‬ ‫یاالن‬ ‫ول‬ ‫هست‬ ‫کاردیوواسکوال‬
‫همینطور‬ ‫م‬ ‫کودکان‬ ‫در‬ ‫و‬ ‫کیشه‬

24. Nocturnal dipping: Percent dip = [(mean awake BP – mean sleep BP) ÷ mean awake BP] x 100
Normally, the average nocturnal BP is approximately 15% lower than
daytime values, which is referred to as nocturnal dipping.
Failure of the BP to fall at least 10% during sleep is called non-dipping.

25. In adults, non-dipping has been associated with LVH, heart
failure, and other CV complications.
In children, non-dipping is more common in secondary forms of
hypertension and in the obese.
Non-dipping in patients undergoing dialysis may be an
independent predictor of poor cardiovascular outcomes.

26. Abnormally elevated daytime and nocturnal BP levels, and
diminished dipping, have been demonstrated in children
with type 2 diabetes.
These changes may be related to subclinical vascular
damage and renal disease and may be an early marker
for renal deterioration.

27. Pulse pressure
Pulse pressure = Systolic BP - Diastolic BP
PP increases concomitantly with aging and loss of arterial elasticity
Large PP is an independent risk factor for cardiovascular morbidity
and mortality

29. large PP and MAP in childhood predicted increased
carotid IMT and PWV in adulthood, independent of
obesity, diabetes, dyslipidemia, smoking, and other
cardiovascular risk factors

30. White Coat Hypertension
Pediatric WCH may not be a benign condition, as some
children and adolescents have increased LV mass index
and carotid artery intimal-media thickness
Repeat ABPM at one- to two-year intervals in children
with WCH.

31. Masked HTN is associated with an increased LV mass and
obesity
Masked HTN in adults has been associated with an
increased risk of sustained HTN and cardiovascular
morbidity

32. Limitations
Patient acceptance and tolerance of the device
Cost
Lack of algorithms of ABPM for children
Coagulation abnormalities