Ambulatory blood pressure monitoring (ABPM) involves using a portable device to measure blood pressure at regular intervals over 24 hours. ABPM provides important information about blood pressure patterns that office measurements cannot detect, such as nocturnal hypertension. The diagnosis of hypertension is based on ABPM readings showing average blood pressure above 130/80 mmHg for 24 hours or 135/85 mmHg during the day and 120/70 mmHg at night. ABPM can help identify conditions like white coat hypertension and assess treatment effectiveness better than office readings alone. While costly, ABPM provides valuable clinical information and its use should be expanded.

1. Ambulatory blood
pressure monitoring

2. BLOOD PRESSURE MEASUREMENT
 “The measurement of blood pressure is the clinical procedure of greatest
importance that is performed in the sloppiest manner.”
 Kaplan N. M. Amer J Hypertension 1998: 11: 134-6

3.  Rule of half in hypertension

4. Types of BP VARIABILITY DETERMINANTS
AND PROGNOSTIC RELEVANCE

5. Different types
 Office BP monitoring
 Home BP Monitoring
 Ambulatory BP Monitoring

7. ABPM

8.  Automated oscillometric BP apparatus
 Performed on a routine working day
 Cuff to be applied in nondominant arm
 Appropriate cuff- bladder length to encircle 80-100% of arm circumference
 Patients should be told to follow their usual daily activities
 remain still during measurement with the arm relaxed at heart level
 Place monitor on the bed or beneath the pillow at night

9.  Should not take shower or a bath
 Should preferably avoid driving
 Time of drug intake, the time of rising and going to bed, and any symptoms to
be noted
 24-h minimum: 70% of expected number of readings and at least 20 valid
daytime and seven night-time blood pressure measurements

10. ABPM – DIAGNOSTIC THRESHOLDS

11. ABPM recordings

12. Diurnal rhythm of BP
 BP falls to its lowest levels during first few hours of sleep
 Marked surge in morning hours during transition from sleep to wakefulness
 Average difference between awake and sleep SBP and DBP- 10-20%
 Hypertensives also have the same diurnal pattern but it is set at a higher
level

13. Pattern of variation of bp at night
 Nocturnal dipping
 Reduced dipping – less than 10%
 Extreme dipping- more than 20 %
 Non Dipping
 Nocturnal Hypertension

14. Advantages

15. Ambulatory BP in clinical practice
 White-coat hypertension
 False-resistant hypertension in treated patients
 Masked hypertension
 Daytime hypertension
 Nocturnal hypertension (ex. in OSA)
 Assessment of treatment (24-hr BPcontrol)
 Assessing hypertension in children& adolescents
 Assessing hypertension in pregnancy, elderly
 Ambulatory hypotension
 Endocrine hypertension

16. White-coat hypertension
 Untreated patients with elevated office BP ≥ 140/90 mm Hg and
 24-hr ABPM <130/80 mm Hgand
 Awake ABPM <135/85 mm Hg and
 Sleep measurement <120/70 mm Hg or
 Home BP< 135/85 mm Hg
 More common in women

17. Masked hypertension
 Untreated patients with office BP < 140/90 mm Hg and
 24-hr ABPM ≥130/80 mm Hg and
 Awake ABPM ≥135/85 mm Hg and
 Sleep measurement ≥120/70 mm Hg or
 Home BP ≥ 135/85 mm Hg

18. Masked uncontrolled hypertension
 Treated patients with office BP
 <140/90 mm Hg and
 24-hrABPM ≥130/80 mm Hg and
 Awake ABPM ≥ 135/85 mm Hg and
 Sleep measurement ≥ 120/70 mm Hg or
 Home BP ≥ 135/85 mm Hg

19. Resistant Hypertension
 White coat hypertension occur in patients on drug therapy.
 Many patients of suspected resistant hypertension turn out to be white coat
 The latest ACC/AHA guidelines recommend screening of white coat
hypertension in hypertensive patients on three or more medications
 ambulatory readings to be considered before dose escalation

20. Nocturnal hypertension
 ACC/AHA 2017 guidelines
 nocturnal hypertension is defined as a BP more than 120/70 mm Hg
 nocturnal hypertension have association with subclinical end organ damage
 Control of nighttime BP carries more significance
 Patients with once daily morning dosage of antihypertensive medication

21. Pregnancy
 Ambulatory BP is useful in pregnant women,( last trimester )of pregnancy
 ABPM in can also predict the development of preeclampsia or IUGR
 The most significant use of ABPM in pregnancy is to rule out white coat
hypertension,
 the prevalence of which was found to be about 30% in a study by Bellomo
et al.

22. Monitoring drug therapy
 ABPM is indicated - before starting pharmacological therapy.
 ABPM used to monitor therapy in patients already on antihypertensive
drug(s).
 ABPM should be repeated within every 15–20 days to monitor for adequate
effect until the desired BP is achieved.
 Once control has been achieved, it can be repeated annually or biannually.
 Frequency of monitoring with ABPM depends on the degree of hypertension
and treatment response

23. Ambulatory hypotension and autonomic
dysfunction
 It can also be used to identify hypotensive events in young patients and in
patients on antihypertensive medications.
 ABPM may also be used to monitor BP changes in patients with orthostatic
hypotension – indicates autonomic disease
 Patients often have postprandial hypotension,
 inability of the heart rate to compensate for the fall in BP
 reversal of normal circadian rhythm.

24. Underlying systemic abnormalities
 ABPM used in untreated hypertensive patients who present with snoring
 screen for obstructive sleep apnoea- nocturnal hypertension and mild to
moderate hypertension
 Parkinson’s disease, which can present with cardiovascular complications
Supine hypertension, and postural hypotension ,

25. ABPM in infants and children
 Indications are of similar to that of adult

26. Contraindications
 severe clotting disorders,
 severe cardiac rhythm abnormalities such as severe atrial fibrillation,
 latex allergy, which can be found while using particular equipment brands.
 Use of the nondominant arm to apply the monitor, -arterio-venous fistula

27. Limitations of ABPM
Application
Limited availability
Discomfort at night
Reluctance to use repeatedly by
patient
Cost
Function
Imperfect reproducibility
Intermittent measurements in
sedentary Vs ambulatory condition
Inaccurate reading during activity

28. SUMMARY AND
RECOMMENDATIONS
 The diagnosis of hypertension based upon ABPM
 A 24-hour average above 130/80 mmHg
 Daytime (awake) average above 135/85 mmHg
 Nighttime (asleep) average above 120/70 mmHg
 Cardiovascular complications correlate more closely with 24-hour or
daytime ABPM than with the office BP.

29. SUMMARY AND
RECOMMENDATIONS
 ABPM may facilitate achieving blood pressure control and reduce unnecessary
treatment.
 ABPM should always be considered when indicated.
 masked hypertension, white coat hypertension, nocturnal hypertension cannot be
assessed properly without ABPM.
 Self-recorded home BP measurements are an excellent alternative if ABPM is not available
or cost is a concern.

30. CONCLUSION
 Ambulatory monitoring is the gold standard for the prediction of risk related to blood pressure,
 studies have shown that it predicts clinical outcome better than conventional blood-pressure
measurements.
 In spite of the high cost, ABPM should be offered to more and more patients

31. References
 Ambulatory blood pressure monitoring in clinical practiceApaar
Dadlani,a,∗∗ Kushal Madan,b,∗∗∗ and J.P.S. Sawhneyb,∗
 2020 International Society of Hypertension Global Hypertension Practice
Guidelines