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Position statement
Ambulatory blood pressure monitoring
November 2010
National Heart Foundation of Australia and the High Blood Pressure Research
Council of Australia
Position statement: Ambulatory blood pressure monitoring
1
Draft for consultation purposes only
not for citation. Draft: 24 November 2010
[[Preliminary matter]]
[[Publication information to be added]]
[[Suggested citation to be added if published by Heart Foundation/HBPRCA]]
[[Table for editorial/consultation purpose; may not appear in final publication]]
Contents
About this position statement ...................................................................................... 3
Context .................................................................................................................... 3
Measuring ABP ........................................................................................................... 5
Rationale for ABP monitoring in clinical practice ......................................................... 5
ABP reflects actual BP more closely than clinic measurements ............................. 5
ABP is a better predictor of clinical outcomes and end-organ damage................... 6
ABP monitoring can detect absence of nocturnal BP dipping ................................. 6
ABP monitoring is cost-effective.............................................................................. 7
When is ABP monitoring useful? ................................................................................. 7
White-coat effect and suspected white-coat hypertension ...................................... 8
Suspected masked hypertension ............................................................................ 9
Borderline hypertension......................................................................................... 10
Resistant hypertension .......................................................................................... 10
Elderly patients ...................................................................................................... 10
Autonomic failure, orthostatic (postural) hypotension and syncope ...................... 10
Hypertension in pregnancy.................................................................................... 11
Titrating antihypertensive medicines ..................................................................... 11
Patients at high CVD risk....................................................................................... 11
Episodic hypertension ........................................................................................... 11
Suspected sleep apnoea ....................................................................................... 11
Interpreting ABP ........................................................................................................ 13
Normal BP levels in adults compared with clinic BP............................................ 14
Classification of hypertension in adults compared with clinic BP .......................... 14
Treatment targets in adults compared with clinic BP............................................. 15
Factors to consider when interpreting ABP ........................................................... 16
Practical considerations ............................................................................................ 18
Who should perform ABP monitoring? .................................................................. 18
ABP monitoring devices ........................................................................................ 18
Importance of correct cuff size .............................................................................. 18
Initial validation of readings in the clinic ................................................................ 19
Position statement: Ambulatory blood pressure monitoring
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Frequency of measurements................................................................................. 19
Instructions for patients ......................................................................................... 19
How often should ABP monitoring be repeated?................................................... 20
Future research ......................................................................................................... 20
Acknowledgements ................................................................................................... 21
Ambulatory Blood Pressure Monitoring Working Group........................................ 21
Other contributors.................................................................................................. 21
Appendix A. Development process ........................................................................... 22
Consensus process ............................................................................................... 22
Endorsements ....................................................................................................... 22
Appendix B. Classification of BP levels ..................................................................... 23
References ................................................................................................................ 25
About this position statement
This document updates the Heart Foundation s 2002 position statement, Ambulatory
blood pressure monitoring.1 It incorporates revised blood pressure (BP) thresholds
for the diagnosis and management of hypertension.2, 3
This position statement was developed by the Ambulatory Blood Pressure Monitoring
Working Group (a subcommittee of the National Heart Foundation of Australia s
National Blood Pressure and Vascular Disease Advisory Committee) and has been
ratified by the Heart Foundation's Cardiovascular Health Advisory Committee and the
High Blood Pressure Research Council of Australia. The working group considered
the best available evidence from clinical trials and controlled observational studies,
together with clinical expertise (Appendix A).
Context
This position statement supplements current national guidelines for the diagnosis and
management of hypertension in adults.2
Current Australian, international and most national guidelines for the management of
hypertension emphasise that the necessity, choice and intensity of BP-lowering
treatment should be determined by the individual s probability of an event within a
given period (absolute CVD risk),4 based on thorough assessment and consideration
of all risk factors (e.g. age, sex, waist circumference and/or body mass index,
lifestyle, family history, blood lipids, glucose metabolism) and the presence of
associated clinical conditions and/or end-organ damage.2
Position statement: Ambulatory blood pressure monitoring
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Summary of key points
ABP monitoring:
provides BP readings for daytime (awake), night-time (asleep) and 24-hour average, and
provides data to calculate other parameters including BP variability and load.
provides more reliable assessment of actual BP than clinic BP
enables detection of white-coat and masked hypertension
identifies nocturnal non-dippers , who have a worse prognosis
enables better prediction of end-organ damage associated with elevated BP, and risk of
future cardiovascular events, than clinic or occasional BP measurements
provides a reliable guide to therapy
is cost-effective.
ABP monitoring should be arranged, where possible, when any of the following apply:
suspected white-coat effect (including suspected white-coat hypertension). Patients with
white-coat hypertension confirmed by ABP monitoring are at increased risk of
hypertension and end-organ damage, and require continuing BP monitoring.
suspected masked hypertension
borderline hypertension
before commencing an antihypertensive medicine regime
hypertension despite appropriate treatment (including isolated systolic hypertension in the
elderly)
high risk of future cardiovascular events
known or suspected episodic hypertension
suspected sleep apnoea
syncope or other symptoms suggesting orthostatic hypotension, where this cannot be
demonstrated in the clinic
possibility of autonomic failure
hypertension of pregnancy.
Data obtained from ABP monitoring must be interpreted carefully with reference to diary
information and timing of medicines.
Reference normal ABP values for non-pregnant adults are:
24-hour average < 115/75 mmHg
Daytime (awake) < 120/80 mmHg
Night-time (asleep) < 105/65 mmHg.
ABP thresholds for hypertension in adults are:
Average over 24 hours 130/80 mmHg
Daytime (awake) 135/85 mmHg
Night-time (asleep) 120/75 mmHg.
ABP values above normal and below thresholds for hypertension are considered highnormal .
Night-time (sleeping) average systolic and diastolic BP should both be at least 10% lower
than daytime (awake) average.
BP load (percentage time during which BP readings exceed hypertension threshold over 24
hours) should be < 20%.
BP variability, maximum systolic BP and morning BP surge should also be taken into account
(and targeted by treatment).
Treatment targets based on ABP are lower than for clinic BP readings.
Ideally, ABP monitoring should be performed by specialist monitoring centres.
Only appropriately validated devices should be used for ABP monitoring.
Arm circumference should be measured to select the correct cuff size.
ABP readings may not be accurate when taken during exercise, movement or driving, or
when the cardiac rate is irregular.
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Measuring ABP
Ambulatory blood pressure (ABP) monitoring involves the patient wearing a portable
BP measuring device for a specified period (usually 24 hours), during which periodic
BP measurements (usually every 20 30 minutes) are automatically taken via a cuff
worn on the upper arm. The resulting series of BP readings, taken throughout the
person s normal daytime activities and during sleep, provides a robust assessment of
the impact of BP on the person s cardiovascular system (BP load).
ABP monitoring systems provide measures of BP and heart rate during the daytime,
night-time, and while awake and asleep. The data can be used to calculate a range
of parameters associated with CVD risk, including BP variability, heart rate (HR)
variability, BP load and morning BP (see Interpreting ABP).
Rationale for ABP monitoring in clinical practice
Key points
ABP monitoring:
provides BP readings for daytime (awake), night-time (asleep) and 24-hour
average, and provides data to calculate other parameters including BP variability
and load.
provides more reliable assessment of actual BP than clinic BP
enables detection of white-coat and masked hypertension
identifies nocturnal non-dippers , who have a worse prognosis
enables better prediction of end-organ damage associated with elevated BP, and
risk of future cardiovascular events, than clinic or occasional BP measurements
provides a reliable guide to therapy
is cost-effective.
ABP reflects actual BP more closely than clinic measurements
BP measurements taken in the clinic or at home provide limited information about the
individual s actual BP profile (Table 1). Clinic BP readings can be affected by:
measurement errors due to defective instruments, improper techniques or
observer bias
circumstances that exert a pressor effect. This is referred to as the white-coat
effect and can result in white-coat hypertension (isolated clinic hypertension) (see
White-coat effect and suspected white-coat hypertension)
circumstances that mask elevated BP. The converse of white-coat hypertension is
referred to as masked or reverse-white-coat hypertension (see Suspected
masked hypertension).
Occasional (casual) clinic BP measurements only indicate daytime BP status and do
not provide information about the circadian BP pattern, which is influenced by a
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variety of factors (e.g. ambient temperature and humidity, physical activity,
consumption of alcohol, caffeine and food, emotional states such as anxiety and
anger, and sleep-wake routine).
Table 1. Comparison of clinic, home and ambulatory measures of BP
Clinic
Home
Ambulatory
Diagnosis of hypertension
Evaluation of antihypertensive therapy
Prediction of cardiovascular events
White-coat hypertension
Masked hypertension
Presence/absence of nocturnal dipping
Morning hypertension
Short-term day and night BP/HR
variability
Long-term BP variability (if repeated)
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes (limited)
Yes (limited)
No
Yes (limited)
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
BP load
No
No
Yes
Standardised international protocols for
validation exist
Yes
No
Yes
Parameter*
*Parameters measured or clinical conditions that can be detected by properly interpreted ABP
monitoring; Self-measured BP
Table adapted from reference 5
ABP is a better predictor of clinical outcomes and end-organ damage
Prospective studies have shown that ABP is a stronger predictor of clinical outcomes
than conventional clinic BP measurements.6-10
End-organ damage associated with elevated BP, such as left ventricular hypertrophy
(LVH), is more strongly correlated with ABP than with clinic BP measurements.11-14
ABP also correlates more closely with renal and vascular surrogate markers of endorgan damage such as microalbuminuria and carotid artery wall thickness.15
ABP monitoring can detect absence of nocturnal BP dipping
Most studies investigating the significance of night-time hypertension have reported
that night-time (sleeping) BP is more important in predicting clinical outcomes than
daytime (awake) BP,7, 9, 16, 17 particularly in people with hypertension who do not show
normal BP reduction ( dipping ) during sleep. Nocturnal non-dipping is associated
with increased risk of stroke, end-organ damage and cardiovascular events including
death.7, 16, 18, 19
ABP monitoring is the only commonly used practical method to determine the
presence or absence of nocturnal BP dipping (see Interpreting ABP).
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ABP monitoring is cost-effective
ABP monitoring costs more to perform than conventional clinical measurements.i
However, there is consistent evidence that the additional cost is offset by more
reliable diagnosis of hypertension20-22 and that the use of ABP may avoid
unnecessary drug therapy in the follow-up period.23, 24
Rational prescribing of antihypertensive treatment based on accurate BP assessment
may lead to cost savings.23 For example, pharmacological therapy can often be
deferred in patients with white-coat hypertension confirmed by ABP monitoring
(although they require monitoring and lifestyle management of BP). In patients with
hypertension who also show an additional white-coat effect during clinic BP
measurements, confirmation of actual BP profile by ABP monitoring may enable
medication doses to be reduced (see White-coat effect and suspected white-coat
hypertension).
The cost of providing good control of hypertension in an individual can be up to four
times higher using conventional clinic BP measurements.25 The cost benefit ratio is
expected to improve as the cost of managing hypertension rises with increasing rates
of diagnosis and prescribing of new, more expensive antihypertensive agents.
When is ABP monitoring useful?
Key points
ABP monitoring should be arranged, where possible, when any of the following
apply:
suspected white-coat effect (including suspected white-coat hypertension).
Patients with white-coat hypertension confirmed by ABP monitoring are at
increased risk of hypertension and end-organ damage, and require continuing BP
monitoring.
suspected masked hypertension
borderline hypertension
before commencing an antihypertensive medicine regimen
hypertension despite appropriate treatment (including isolated systolic
hypertension in the elderly)
high risk of future cardiovascular events
known or suspected episodic hypertension
suspected sleep apnoea
syncope or other symptoms suggesting orthostatic hypotension, where this cannot
be demonstrated in the clinic
possibility of autonomic failure
hypertension of pregnancy.
i
The costs to the patient are reimbursable by the Department of Veterans Affairs (eligible
patients only) but are not currently reimbursed by Medicare.
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While ABP monitoring is generally recommended for reliable assessment of 24-hour
BP pattern, it is particularly valuable in the following clinical situations.
White-coat effect and suspected white-coat hypertension
In some patients, the BP measurement process itself can induce a higher-thannormal BP (known as the white-coat effect). This effect is particularly noticeable
when BP is measured by a doctor, and much less pronounced when BP is measured
by a nurse or another trained staff member within the clinic.3 Recent studies suggest
that the magnitude of white-coat effect can be reduced by taking clinic BP
measurements using an automated device while the person is alone in a quiet
examining room.26
White-coat hypertension (isolated clinic hypertension) refers to the condition in which
a person meets criteria for hypertension when measured in the clinic but shows
normal BP levels when measured at home or by ABP monitoring.27, 28 It occurs in
approximately 10 20% of the general population.29-31 Factors that make white-coat
hypertension more likely in a person with raised clinic BP include:32
female sex
non-smoker
few recorded clinic BP measurements
borderline hypertension
recent-onset hypertension
absence of evidence of end-organ damage.
When white-coat hypertension is suspected in a person otherwise at low risk of CVD,
ABP monitoring should be performed to provide a more comprehensive and reliable
assessment of the person s BP levels during daily activities (Figure 1). It is preferable
to home BP measurement because it can avoid a self-induced pressor effect.33
White-coat hypertension has been associated with:
higher anxiety scores34
increased (approximately double) risk of hypertension within 8 10 years,
compared with those with normal BP35, 36
increased risk of developing impaired fasting glucose, raised glucose or
diabetes.37
Accordingly, white-coat hypertension confirmed on ABP monitoring warrants careful
assessment, including thorough investigation for end-organ damage and
management of CVD risk factors (including glucose intolerance and lifestyle risk
factors). The diagnosis should be confirmed by repeated ABP monitoring or selfmonitoring using home BP, and repeated every 1 2 years.
White-coat hypertension does not appear to respond to standard antihypertensive
drug therapy consistently,28, 38 but large randomised controlled trials are needed to
investigate this issue.
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Figure 1. Investigation and management of suspected white-coat hypertension
in patients at low risk of CVD
Flow diagram for management of BP in patients with suspected white-coat hypertension, who
are otherwise thought to be at low risk of CVD.
*includes management of lifestyle risk factors, monitoring glucose tolerance (refer to current
hypertension management guidelines)
Suspected masked hypertension
Masked hypertension refers to the situation in which clinic measurements are normal
but ABP measurements are elevated, which occurs up to 10% of the general
population.39 Possible reasons for failure to detect BP elevation on clinic
measurements (particularly in the morning) include evening alcohol consumption and
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the use of short-acting antihypertensive agents,40 Obstructive sleep apnoea is
another important cause of masked hypertension.41
Masked hypertension should be suspected in people with normal clinic BP readings
and any of the following:32, 41, 42
LVH or evidence of other target organ damage
a history of hypertension in both parents
multiple risk factors for cardiovascular disease
obstructive sleep apnoea
occasional high BP readings.
While the full clinical implications of masked hypertension and its appropriate
management are uncertain, this condition has been associated with a worse
prognosis than consistent normotension,39 including increased risk of developing:
hypertension within 10 years36
impaired fasting glucose, raised glucose or diabetes.37
When masked hypertension is suspected, ABP should be performed to provide a
more comprehensive and reliable assessment of the person s BP levels during daily
activities.
Borderline hypertension
ABP monitoring can be useful as a guide to the requirement for antihypertensive drug
treatment in patients with high-normal BP on clinic measurements, especially for
patients with intermediate CVD risk as assessed by an absolute risk calculator.
Resistant hypertension
Resistant hypertension is defined as BP that remains above target despite
appropriate doses of antihypertensive agents from at least three different classes
including a diuretic, good adherence to treatment and appropriate management of
lifestyle risk factors.43 Measurement of ABP is indicated in these patients to assess
BP pattern and assess the degree to which white-coat effect is contributing to
apparent resistance.
Elderly patients
ABP monitoring is useful in the investigation of BP in elderly patients because
orthostatic hypotension is relatively common, and under- and over-treatment carry
particular risks in this group. White-coat hypertension is more common in the elderly,
particular for systolic hypertension in women.44
Autonomic failure, orthostatic (postural) hypotension and syncope
ABP monitoring can be useful to document orthostatic (postural) hypotension or
fluctuating and unstable BP patterns in patients with autonomic failure, which is
relatively common in people with diabetes and the elderly. ABP monitoring is
especially indicated when symptoms such as posture-related syncope or nearsyncope cannot be confirmed in the clinic.
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Hypertension in pregnancy
White-coat hypertension is common in pregnant women and is associated with better
pregnancy outcomes than true hypertension.45 However, the usefulness of ABP
monitoring in pregnancy is unclear due to a lack of clinical studies comparing ABP
monitoring during pregnancy with conventional clinic BP monitoring.46 Nevertheless,
detection of white-coat hypertension by ABP monitoring provides reassurance that
antihypertensive agents can be withdrawn (at least initially), provided that BP is
monitored throughout pregnancy to detect pre-eclampsia, which occurs in a small
subset of women.45
Titrating antihypertensive medicines
Antihypertensive therapy based on ABP monitoring, rather than regular clinic
measurements, may enable better management with more appropriate adjustment of
medication doses required to achieve target BP. ABP may also be a sensitive
indicator of loss of BP control.47
Patients at high CVD risk
Detection of hypertension and treatment to target is critical in those at high CVD risk
identified by existing CVD (e.g. a history of stroke or myocardial infarction), the
presence of end-organ damage (e.g. LVH or microalbuminuria) or associated
conditions that increase CVD risk (e.g. diabetes or chronic kidney disease). ABP
monitoring may be useful in assessing treatment effects and guiding dose titration in
these patients (Figure 2).
Episodic hypertension
Episodic hypertension (e.g. in patients with phaeochromocytoma) may not be
detected with clinic BP measurements. ABP monitoring for at least 24 hours
increases the likelihood of capturing bouts of episodic hypertension that otherwise
might be missed.
Suspected sleep apnoea
Because ABP monitoring permits BP measurements during sleep, it can be useful for
demonstrating nocturnal dipping or lack of nocturnal dipping in patients with
suspected sleep apnoea.41
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Figure 2. ABP monitoring in patients with high CVD risk
Flow diagram for management of BP in patients at high risk of CVD or in whom masked
hypertension is suspected. In these patients it is appropriate to perform ABP monitoring,
even if the clinic BP levels are not elevated.
*existing CVD or as assessed using absolute CVD risk calculator, irrespective of BP (refer to
current hypertension management guidelines)
associated conditions: diabetes, cerebrovascular disease, coronary heart disease, chronic
heart failure, chronic kidney disease, aortic disease, peripheral arterial disease,
hypercholesterolaemia, family history or previous diagnosis of premature CVD or familiar
hypercholesterolaemia (refer to current hypertension management guidelines)
end-organ damage: LVH, microalbuminuria, chronic kidney disease, vascular disease (refer
to current hypertension management guidelines)
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Interpreting ABP
Key points
Data obtained from ABP monitoring must be interpreted carefully with reference to
diary information and timing of medicines.
Reference normal ABP values for non-pregnant adults are:
24-hour average < 115/75 mmHg
Daytime (awake) < 120/80 mmHg
Night-time (asleep) < 105/65 mmHg.
ABP thresholds for hypertension in adults are:
Average over 24 hours
Daytime (awake)
Night-time (asleep)
130/80 mmHg
135/85 mmHg
120/75 mmHg.
ABP values above normal and below thresholds for hypertension are considered
high-normal .
Night-time (sleeping) average systolic and diastolic BP should both be at least
10% lower than daytime (awake) average.
BP load (percentage time during which BP readings exceed hypertension
threshold over 24 hours) should be < 20%.
BP variability, maximum systolic BP and morning BP surge should also be taken
into account (and targeted by treatment).
Treatment targets based on ABP are lower than for clinic BP readings.
ABP readings should be interpreted with reference to patient diary records for sleep,
medicines, posture, activity, symptoms and/or other events (see Instructions for
patients). Actual times for day/night should be used rather than those defined by the
software.
Explanatory notes on the selection of thresholds are provided in Appendix B.
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Normal BP levels in adults compared with clinic BP
Current Australian national guidelines for the diagnosis and management of
hypertension define normal ii BP for adults as clinic BP < 120/80 mmHg.2 This
category corresponds to the following ABP readings (rounded to nearest 5 mmHg):
24-hour average
< 115/75 mmHg
Daytime average < 120/80 mmHg
Night-time average < 105/65 mmHg.
Classification of hypertension in adults compared with clinic BPiii
Current Australian national guidelines for the diagnosis and management of
hypertension define hypertensioniv in adults as clinic BP 140/90 mmHg.2 Equivalent
ABP thresholds for hypertension (rounded to nearest 5 mmHg) are:
24-hour average
130/80 mmHg
Daytime average
135/85 mmHg
Night-time average 120/70 mmHg.
Equivalent ABP thresholds for the classification of hypertension are shown in Table
2. This classification may provide guidance on the appropriate intensity of
antihypertensive therapy. For example, daytime ABP > 168/105 mmHg corresponds
to clinic BP > 180/110 mmHg, and should therefore trigger immediate initiation of
antihypertensive therapy for the management of grade 3 hypertension according to
current guidelines,2 including both pharmacological therapy (commencement of
treatment or an increase in dose) and lifestyle risk factor modification regardless of
other CVD risk factors.
ii
Current guidelines emphasise that BP-related risk is a continuum with no defined lower cutpoint.2
iii
Clinic BP measured by trained staff other than doctors
iv
Current guidelines note that the term hypertension and classification cut-points are used for
practical reasons, on the understanding that individual cardiovascular risk assessment
determines appropriate management in each patient.2
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Table 2. Classification of hypertension in adults
Systolic/diastolic ABP thresholds (not rounded) predicted from clinic BP measured by trained
staff (other than doctors) for diagnosis and grading of hypertension (Source: reference 3).
These equivalents differ slightly from the rounded recommended values shown in the text.
ABP predicted from clinic BP
(mmHg)
Hypertension
Clinic BP
24-hour
Night
Day
Grade 3 (severe)
180/110
163/101
157/93
168/105
Grade 2 (moderate)
160/100
148/93
139/84
152/96
Grade 1 (mild)
140/90
133/84
121/76
136/87
Treatment targets in adults compared with clinic BPv
Treatment targets based on ABP are lower than those based on clinic BP readings.
Like clinic BP treatment targets, ABP targets depend on the individual s absolute risk
of CVD (i.e. targets are lower for patients with or at elevated risk of CVD, including
those with associated conditions or end-organ damage).
ABP treatment targets corresponding with current national guidelines are shown in
Table 3 (see Appendix A for age- and sex-adjusted targets in patients with moderateto-high CVD risk). For practical purposes, the clinic target BP can be simply used as
the target for the mean daytime BP during ABP monitoring (e.g. for a patient with
diabetes, the target for average daytime ABP is less than 130/80 mmHg).3
Table 3. Treatment targets in adults
Systolic/diastolic ABP target values (not rounded) predicted from clinic BP targets (where BP
measured by trained staff other than doctors), based on overall cardiovascular risk
assessment (Source: reference 3) These equivalents differ slightly from the rounded
recommended values shown in the text
ABP equivalents
(mmHg)
Patient group
Clinic BP
24 hour
Uncomplicated hypertension*
< 140/90
< 133/84
< 121/76 < 136/87
People with associated clinical
conditions or end-organ damage
< 130/80
< 125/76
< 112/67 < 128/78
Hypertension plus proteinuria > 1 g/day
< 125/75
< 121/71
< 107/63 < 124/74
Night
Day
*People without any of the following: coronary heart disease, diabetes, chronic kidney
disease, proteinuria (> 300 mg/day), stroke or transient ischaemic attack; People without any
of conditions listed at note [*]
v
Clinic BP measured by trained staff other than doctors
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Factors to consider when interpreting ABP
Age and sex effects
Daytime systolic ABP equivalents for those aged over 65 years are 2 4 mmHg lower
than those for patients aged 25-44 years, and 1 2 mmHg lower than for patients
aged 45 64. Daytime diastolic ABP equivalents do not appear to be affected by age.
Systolic and diastolic ABP equivalents for women are 3 mmHg and 2 mmHg lower,
respectively, than for age-matched men (see Appendix B).
Nocturnal dipping status
Physiologically, BP follows a diurnal pattern, with average night-time (asleep) BP
levels substantially lower than daytime (awake) BP levels. There is wide interindividual variation in the magnitude of the nightly BP dip. Night-time BP predicts
end-organ damage7, 47, 48 and may be a better predictor of clinical outcomes than
daytime BP.9, 17, 19, 49 Night-time readings should be correlated with the patient s diary
to confirm their reliability.
Nocturnal non-dipping is defined as a fall of less than 10% in average night-time
systolic or diastolic BP (or both), compared with daytime averages.50 Non-dipping (or
nocturnal BP increase) suggests marked vascular organ damage or autonomic
dysfunction.13
Extreme dipping (> 20% reduction) may be associated with under-perfusion of the
brain, particularly if antihypertensive treatment results in a greater fall.51
Optimal BP control involves treating to targets for both daytime and night-time BP
(e.g. a nightly dose of an antihypertensive drug may be indicated if non-dipping is
detected).52
Morning BP surge
The risk of stroke, sudden cardiac death or myocardial infarction is highest in the
morning,53 during which there are increases in BP, heart rate, circulating
catecholamines, other hormones and hypercoagulability.54 The magnitude and rate of
morning BP surge is exaggerated in people with hypertension.55
Morning systolic BP measured by ABP monitoring is a strong independent predictor
of stroke and other CVD outcomes.56, 57 Morning BP can also be measured using
home BP measurement.58, 59
In older patients with hypertension, morning BP surge (difference between morning
BP and nadir during sleep) measured by ABP monitoring is strongly correlated with
the risk of stroke, independent of mean BP and nocturnal BP.60
BP and heart rate variability
ABP monitoring provides information on:
short-term BP and HR variability (standard deviation for daytime readings or
night-time readings)
circadian BP and HR variability (day night difference)
long-term BP and HR variability (when ABP monitoring repeated 6-monthly or
yearly).
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BP variability should be taken into account when interpreting BP profiles and
assessing CVD and cerebrovascular risk, given evidence that the goals of treatment
should include reduction of BP variability in addition to reduction of mean BP:
Short-term night-time and daytime BP variability has been correlated with risk of
end-organ damage61 and daytime systolic BP variability has been correlated with
cardiovascular mortality risk.62
Daytime HR variability has been inversely correlated with cardiovascular mortality
risk,62 and the co-occurrence of short-term high BP with low HR variability has
been strongly correlated with cardiovascular mortality risk.62
Long-term (between-visit) clinic systolic BP variability in patients receiving
antihypertensive treatment and maximum daytime ambulatory systolic BP are
63, 64
predictors of stroke risk, independent of mean systolic BP.
Therefore, BP variability may influence the choice of antihypertensive agent.61
BP load
The proportion of time during which BP readings exceed hypertension threshold over
a 24-hour period (i.e. 135/85 mmHg while awake and 120/75 mmHg during sleeping
hours) can be defined as BP load. The measure is closely related to mean BP and
BP variability and is a better predictor of end-organ damage than occasional clinic or
mean ABP readings.65 An estimate of BP load (expressed as percentage time or area
under the BP time curve) is often provided automatically by ABP analysis software.
In a patient with an average 24-hour systolic BP of 120 mmHg, a BP load of
approximately 20% would be expected.65 For an average 24-hour systolic BP of 130
mmHg, BP load would be approximately 50%, while for an average 24-hour systolic
BP of 140 mmHg, BP load would be approximately 85%.
Smoothness Index
Smoothness Index is a measure of optimal 24-hour BP control based on ABP. It is
defined as the ratio between the effect of treatment on average hourly BP for the 24hour period (change in BP [ H]) and the standard deviation (SD) the effect of
treatment on average hourly BP (SD of average H):61, 66
Smoothness Index = average
H
/ SD of average
H
Smoothness Index correlates with the effect of treatment on left ventricular
hypertrophy more closely than the ratio of lowest BP to highest BP (trough : peak
ratio).66
Smoothness Index may indicate the intensity of BP lowering due to a larger
numerator,67 as well as the effectiveness of 24-hour BP control.
Ambulatory Arterial Stiffness Index
Ambulatory Arterial Stiffness Index (AASI) is a measure of arterial wall stiffness,68
based on the concept that in stiffer vessels systolic BP will rise to a greater extent
than diastolic BP as BP changes from lowest (sleeping) levels to highest daytime
levels. AASI is best derived from 24-hour ABP monitoring.
Position statement: Ambulatory blood pressure monitoring
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It is calculated as one minus the regression slope of diastolic over systolic BP.
Normal AASI is typically < 0.5 for younger adults and < 0.7 for older adults.68
AASI is correlated with other measures of arterial stiffness, is a better predictor of
mortality than other risk factors,69 and is associated with subclinical organ damage in
hypertensive patients irrespective of treatment.70 A symmetrical version of AASI has
recently been developed to improve prediction of risk, independent of BP.71
Practical considerations
Key points
Ideally, ABP monitoring should be performed by specialist monitoring centres.
Only appropriately validated devices should be used for ABP monitoring.
Arm circumference should be measured to select the correct cuff size.
ABP readings may not be accurate when taken during exercise, movement or
driving, or when the cardiac rate is irregular.
Who should perform ABP monitoring?
ABP monitoring is a specialised technique that requires staff training, skills and
experience, validated and well-calibrated monitors, the use of correct cuff sizes and
appropriate protocols. . Ideally, it should be performed by experienced specialist
monitoring centres that implement systems for quality control including continual
training and assessment, calibration testing and regular evaluation of equipment.
ABP monitoring devices
ABP monitors use cuff oscillometry, which relies on detection of cuff pressure
oscillations and defines the maximal oscillations as mean arterial BP and then uses
an algorithm to calculate systolic and diastolic BP.72 Since different algorithms are
used by different manufacturers, there is some variation between devices. Mean BP
is the most reliable measurement by oscillometric devices.72 Studies assessing dayto-day variability in ABP profiles have generally reported good reproducibility.
Only devices validated and approved (reaching grade A) by international standards
(British Hypertension Society73 or American Association for the Advancement of
Medical Instrumentation74) should be used for ABP monitoring. Lists of validated
devices can be obtained from the websites of the European Society of Hypertension
(ESH) and British Hypertension Society.75 Since the criteria specified in these
protocols are difficult to fulfil, the Working Group on BP Monitoring of the ESH has
developed a simplified protocol to facilitate validation of devices to be used in clinical
practice.76
Importance of correct cuff size
It is important to chose the correct cuff size, because BP obtained from oscillometric
devices may vary, depending on cuff size and cuff-arm compliance.77 Selection of the
correct cuff is aided by the manufacturer s labelling on the cuff and lines that indicate
if the wrap-round is within the cuff s dimensions, but it is better to measure the arm
Position statement: Ambulatory blood pressure monitoring
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circumference. People with a large upper arm (particularly obese people), may need
conical-shaped cuffs.
Assessing the quality of ABP data
As a guide, a recording is usually considered successful when at least 85% of
readings are suitable for analysis. ABP profiles should be interpreted cautiously, with
reference to activity and sleep patterns.
ABP readings may not be accurate when taken during exercise, movement or
driving, or when the cardiac rate is irregular (e.g. atrial fibrillation). Incorrect readings
can be due to improper cuff fitting (e.g. patients with conical-shaped arms),
movement artefact, tremor, weak or irregular pulse.
The best method for dealing with outlying values is a matter of considerable debate
but, as a general rule, editing should be kept to a minimum,38 or the modified Casadei
method used to eliminate artefactual readings.78 Some devices feature in-built
actigraphy to detect movement, but these still need to be validated.
Initial validation of readings in the clinic
At the time the ABP monitoring device is fitted, at least three readings should be
recorded simultaneously using a mercury column sphygmomanometer connected to
the ABP monitoring device by a Y-connector. Average readings for ABP and
sphygmomanometer should not differ by more than 5 mmHg.
Frequency of measurements
ABP monitoring devices are usually programmed to take readings at set intervals of
20 30 minutes during the day and night in order not to interfere activity or sleep, but
measurements can be made more frequently; some centres use intervals of 15 20
minutes during the day and 30 minutes during the night, while others take readings at
30-minute intervals throughout the 24-hour period.79
Instructions for patients
Patients should be given information and instructions about the procedure in order to
minimise fear and anxiety, especially in nervous individuals. A written set of
instructions to take home is recommended after the initial verbal description (in the
patient s first language, if possible). Patients should be informed which activities may
interfere with the device and instructed to keep a diary to record timing of activities,
sleep, taking of medicines, posture and symptoms (e.g. dizziness) that may be
related to BP. A normal work day should be chosen rather than a rest day, to obtain a
typical BP profile that better predicts end-organ damage.
While modern devices are quiet, lightweight and relatively easy to wear, inflation of
the cuff may cause some minor discomfort, particularly in hypertensive subjects or
when multiple repetitions of the reading are triggered due to errors in measurement.
ABP monitoring is safe and not usually associated with complications, but
occasionally petechiae of the upper arm or bruising under the inflating cuff may
occur, and there may be sleep disturbances.
Position statement: Ambulatory blood pressure monitoring
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Key messages for patients
The monitor will automatically inflate and record BP and HR periodically
throughout the 24-hour period.
Continue with typical daily activities throughout the monitoring period but avoid
vigorous exercise during monitoring.
When the cuff starts inflating, temporarily stop moving or talking for about 1
minute, keep the arm immobilised and relaxed, and try to relax and breathe
normally.
Some monitors give a warning tone prior to measurement.
Do not kink tubing but do retighten connections if a leak occurs.
Occasionally the device may repeat the measurement a moment later at a higher
pressure. This is quite common and does not mean there is a problem.
Keep the device on during sleep and do not switch it off.
During monitoring, do not shower or bathe (sponge baths only) because the cuff
should not be removed.
Make diary entries as requested.
Avoid napping during the day.
Call phone number provided if you have technical difficulties during the monitoring
period.
How often should ABP monitoring be repeated?
When and how often ABP monitoring is repeated depends on clinical judgement,32
and should take into consideration whether the person is at high risk of CVD4 and
whether BP treatment targets have been met (Figure 2).
Repeated ABP monitoring should be considered to guide treatment in people with
masked hypertension, non-dippers and people with markedly increased BP
variability.
Suspected white-coat hypertension should be confirmed by ABP monitoring repeated
several weeks later. ABP monitoring (or home BP monitoring) should be repeated
every 1 2 years in patients at low risk of CVD (Figure 1).
Future research
The potential benefits of normalisation of the circadian BP variability in people with
hypertension, particularly by using chronotherapy aimed at optimising nocturnal BP,
is not known. This issue is being investigated by long-term Ambulatory Blood
Pressure Monitoring and Cardiovascular Events (MAPEC) study.80
There is a need for randomised controlled studies comparing outcomes in patients
with hypertension who are treated on the basis of ABP monitoring versus clinic BP
measurements.
The power of the morning BP surge is a mathematically derived measure of the
morning rate amplitude product. Currently, this parameter cannot readily be
Position statement: Ambulatory blood pressure monitoring
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calculated from data output provided by standard ABP analysis software. Power of
the morning surge may become a useful standard diagnostic measure, because it
has been shown to be almost doubled in people with hypertension or white-coat
hypertension, compared with normotensive people.81
Acknowledgements
Ambulatory Blood Pressure Monitoring Working Group
Professor Geoff Head (Chair)
Dr Andrew Boyden
Ms Diane Cowley
Associate Professor Arduino Mangoni
Professor Barry McGrath
Dr Anastasia Mihailidou
Professor Mark Nelson
Associate Professor Markus Schlaich
Professor Michael Stowasser
Ms Jinty Wilson
The Ambulatory Blood Pressure Monitoring Working Group is a subcommittee of the
National Blood Pressure and Vascular Disease Advisory Committee, National Heart
Foundation of Australia and includes seven members nominated by the High Blood
Pressure Research Council of Australia.
Other contributors
Dr Leah-Anne Ruta, Project officer, Heart Foundation
Ms Jenni Harman, Medical Writer, Meducation
Position statement: Ambulatory blood pressure monitoring
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Appendix A. Development process
This position statement was developed by an ad hoc working group of experts in the
field of ABP monitoring and hypertension research under the auspices of the National
Heart Foundation of Australia and the High Blood Pressure Research Council of
Australia.
Taking as its starting point the Heart Foundation s 2002 position statement,
Ambulatory blood pressure monitoring,1 the working group verified factual statements
and revised the information to incorporate new evidence from reviews, clinical trials
and controlled observational studies, including information from a large Australian
ABP study that suggested new ABP equivalents for hypertension definitions and
treatment targets treatment targets should be adopted.
Consensus process
Each section was allocated to a subgroup of two working group members with
particular expertise in the area. Subgroups reviewed published literature through
database searches, hand-searching, personal knowledge and experience, and
review of other guidelines for ABP monitoring. Drafts were circulated and reviewed
by all working group members and discussed at a series of teleconferences held
between [[month]] 2009 and November 2010 until consensus was reached.
The near final draft was circulated in November 2010 for external consultation by
invited stakeholders including the following:
[[to be added at final draft]].
Endorsements
This position statement has been endorsed by the National Heart Foundation of
Australia and the High Blood Pressure Research Council of Australia.
Position statement: Ambulatory blood pressure monitoring
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Appendix B. Classification of BP levels
The cut-points for normal BP (24-hour average <115/75 mmHg; daytime average
<120/80 mmHg, night-time average <105/65 mmHg) are based on values identified
in a large Australian study (rounded to 5 mmHg).3 These values agree closely with
the findings of international studies (Table 4), which indicate that relative CVD risk
associated with these levels is similar to relative CVD risk associated with clinic BP
readings of <120/80 mg.82
Diastolic BP cut-points in this position statement correspond exactly to those stated
in European Society of Hypertension (ESH) recommendations for BP
measurement.32 Systolic BP cut-points in this position statement are 10 mmHg lower
than cut-points stated in ESH guidelines32 and American Heart Association
guidelines.83
ABP monitoring values adjusted for age and sex are shown in Table 5.
Table 4. Ambulatory and clinic BP equivalents from Australian and
international studies
Blood pressure (mmHg)
Normal
Grade 1 (mild)
hypertension
Clinic BP*
< 120/80
> 140/90
Home BP
< 120/80
> 135/85
24-hour
< 117/76
133/84
Night
< 102/67
121/76
Day
< 120/78
136/87
24-hour
< 117/74
131/79
Night
< 101/65
120/71
Day
< 121/79
138/86
24-hour
< 120/75
130/80
Night
< 115/65
120/70
Day
< 130/80
135/85
Predicted (seated clinic data)
Predicted (International outcome study)
ESH/AHA guidelines for ABP monitoring§
2
*Derived from Australian hypertension management guidelines
ABP predicted from seated clinic BP (n = 5327)3
ABP predicted from International Database of Ambulatory Blood Pressure in relation to
Cardiovascular Outcome (IDACO) study (n = 5682)82
§ European Society for Hypertension and American Heart Association guidelines32, 83
Position statement: Ambulatory blood pressure monitoring
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Table 5. Clinic BP thresholds and ABP equivalents according to age and sex
Clinic BP
threshold
25 45
Men
Women
Age (years)
Age (years)
45 64
> 65
25 45
45 64
> 65
Grade 3
(severe)
hypertension
180/110
176/104 170/105 167/104
171/105
167/103
164/102
Grade 2
(moderate)
hypertension
160/100
158/96
154/96
151/96
154/96
151/95
149/93
Grade 1
(mild)
hypertension
140/90
140/87
138/88
136/87
137/87
135/86
133/85
Target BP one
associated
condition*
130/80
131/79
130/79
128/79
129/78
126/77
125/77
Target BP
proteinuria
125/75
125/75
126/75
125/75
124/75
122/73
121/72
Normal BP
120/80
122/79
122/79
121/79
120/78
118/77
118/77
[[Caption]] Age- and sex-specific systolic/diastolic ABP daytime values predicted from
seated clinic BP levels
*People with any of the following: coronary heart disease, diabetes, chronic kidney disease,
proteinuria (> 300 mg/day), stroke or transient ischaemic attack
People with proteinuria (> 1 g/day)
Position statement: Ambulatory blood pressure monitoring
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Position statement: Ambulatory blood pressure monitoring
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