Ambulatory Blood Pressure Monitoring For Diagnosis Of Hypertension
This page provides information on the listing of a new item for Ambulatory blood pressure monitoring to diagnose hypertension
Page last updated: 18 January 2022
On 1 November 2021, the Australian Government will introduce a new MBS item for diagnosis of hypertension through Ambulatory blood pressure monitoring for people with suspected hypertension .
This change is the outcome of Government agreement to recommendations from the independent Medical Services Advisory Committee .The purpose of the service is to monitor a patients blood pressure continuously over 24 hours via a wearable device to diagnose if they are hypertensive or not. The service includes the fitting of the device, analysis of the data, generation of a report and development of a treatment plan and all consultations associated with the service.
Why The Test Is Performed
ABPM is a valuable tool for diagnosing and managing multiple conditions:
- White coat hypertension: When elevated blood pressure measurements are recorded in the physicians office, but blood pressure readings outside the physicians office are within the normal range. It is estimated that one in three patients with high blood pressures might have white coat hypertension.
- Resistant hypertension: When multiple anti-hypertensive medications fail to adequately control high blood pressure.
- Masked hypertension: When in-office measurements fall within an acceptable range, but the mean blood pressure is actually above the acceptable range.
- Hypotension: Sometimes hypertensive therapy can be associated with low blood pressures. This can be dangerous, particularly in patients with diabetes or with a history of stroke. Ambulatory monitoring can detect asymptomatic drops in blood pressure.
- Diagnosing nocturnal non-dipper status: Healthy individuals systolic blood pressures drop at least 10% while they sleep as compared to systolic blood pressures during the day. Individuals who are non-dippers, whose blood pressure does not drop, are at increased risk of cardiovascular events.
Phenotypes Defined By Clinic And Out
Four phenotypes can be defined by cross-classifying clinic and out-of-clinic hypertension status using ABPM or HBPM . Two phenotypes represent agreement sustained normotension and sustained hypertension , which are phenotypes associated with the lowest and highest CVD risk, respectively . As originally described by Pickering , the term white coat hypertension refers to untreated individuals with elevated clinic blood pressure without elevated daytime blood pressure on ABPM. The term masked hypertension refers to untreated individuals who do not have elevated clinic blood pressure but have elevated daytime blood pressure on ABPM . In addition to those with daytime hypertension, individuals without elevated clinic blood pressure but with 24-hour hypertension and/or nighttime hypertension are also considered to have masked hypertension . HBPM can also be used to define white coat hypertension and masked hypertension .
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How Is The Test Performed
- Taking only 5-10 minutes, our cardiac technician will fit a BP cuff suited to the diameter of your left or right arm and a small BP machine will be worn on a belt on your waist
- The machine is programmed to take your BP at regular intervals of 30 minutes during the day and at 1-hour intervals at night. You will need to keep the monitor on through the night you could put the machine under the pillow or on the bed while you sleep
- At the end of the 24 hours, our cardiac technician will remove the machine and cuff and download the BP readings for analysis
- Your entire BP recording will be reviewed by our doctor and a summarized report of your BP control will be provided and explained to you during your review
Home Blood Pressure Monitoring Research
The Annals of Internal Medicine included a systematic review of home blood pressure monitoring. This study provided data that showed the association between home blood pressure monitoring and the prediction of cardiovascular events or mortality.
Notably, there are fewer studies that link home blood pressure monitoring to cardiovascular outcomes or mortality when compared to ABPM. Due to the lack of evidence linking home blood pressure monitoring to cardiovascular outcome and mortality, the USPSTF only recommends home blood pressure monitoring when ABPM is not available.
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What Are Disadvantages Of 24
You may experience some discomfort due to 24-hour BP monitoring. Pressure due to repeated inflation of the cuff can cause soreness in your upper arm. BP readings during the night may interfere with your sleep. The cuff may also irritate the skin and cause a mild rash on the arm that usually goes away on its own. Some insurance carriers do not reimburse patients for using the ambulatory devices, unless white coat hypertension or masked hypertension is suspected.
How Does The Doctor Use This Test To Manage My Bp
- This confirms that you do not have true hypertension and will not need to be started on long-term anti-hypertensive medications
- Depending on the severity of BP elevation, presence of other cardiovascular risk factors such as diabetes mellitus, high cholesterol, smoking and family history of stroke or heart disease our doctor will guide you through the lifestyle modifications you can make to achieve a good and stable BP control. Medications may be needed and, contrary to popular belief, can be weaned off with good adherence to your doctors advice and follow-up
- This confirms that your BP is sub-optimally controlled despite being on medications and you are at risk of developing long-term complications of hypertension such as heart failure, heart attack, stroke, kidney failure or blindness. By identifying the period of BP spikes during the day or night, our doctor will adjust the type, dose or timings of your medications to achieve good and stable BP control
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Ambulatory Blood Pressure Monitoring In Children And Adolescents: 2022 Update
- This statement presents a succinct review of new evidence, guidance on optimal application of ambulatory blood pressure monitoring in the clinical setting, and an updated classification scheme for the interpretation of ambulatory blood pressure monitoring in children and adolescents.
- ABPM is designed to evaluate BP across many functional dimensions, including position , level of physical activity, sleep, and stress, to provide a more complete view of an individuals BP during normal daily activities.
- This statement provides updated guidance on application and interpretation of ABPM in pediatric patients it specifically addresses: 1) indications for routine performance of ABPM 2) type of ABPM device suitable for use in children 3) standard approach to obtaining ABP studies 4) monitoring criteria and 5) methods for performing ABPM.
Overnight Reduction Or Surge In Blood Pressure
Optimal blood pressure fluctuates over a 24-hour sleep-wake cycle, with values rising in the daytime and falling after midnight. The reduction in early morning blood pressure compared with average daytime pressure is referred to as the night-time dip. Ambulatory blood pressure monitoring may reveal a blunted or abolished overnight dip in blood pressure. This is clinically useful information because non-dipping blood pressure is associated with a higher risk of left ventricle hypertrophy and cardiovascular mortality. By comparing the early morning pressures with average daytime pressures, a ratio can be calculated which is of value in assessing relative risk. Dipping patterns are classified by the percent of drop in pressure, and based on the resulting ratios a person may be clinically classified for treatment as a “non-dipper” , a “dipper”, an “extreme dipper”, or a “reverse dipper”, as detailed in the chart below. Additionally, ambulatory monitoring may reveal an excessive morning blood pressure surge which is associated with increased risk of stroke in elderly people with high blood pressure.
Classification of dipping in blood pressure is based on the American Heart Association’s calculation, using systolic blood pressure as follows:
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Ambulatory Blood Pressure Monitoring Guidelines: What Can Abpm Be Used For
In the medical community ABPM is recognized as a valuable supporting tool of an appropriate pharmacologic treatment management and can have the following uses:
- to measure increased blood pressure readings, which are more reliable and accurate and more strongly correlated to target organ damage or cardiovascular events than one-off measurements
- to detect the effect of white coat hypertension
- to assess resistant hypertension
- to assess masked hypertension
- to assess hypotensive symptoms while on hypertensive medications
- to be used in hypertension or prognostic research
- to assess episodic or autonomic dysfunction.
What Is Ambulatory Blood Pressure Monitoring And How Is It Done
As the name implies, ambulatory blood pressure monitoring is a blood pressure monitoring system that measures the pressure inside your blood circulatory system outside of the clinical setting. Checking your blood pressure when you are ambulant.
Of course, the ambulatory blood pressure monitor will measure your blood pressure when you are active and inactive. For instance, when you are sitting on your sofa watching TV and when you are asleep too.
In short, ambulatory blood pressure monitoring checks your blood pressure regardless of whatever you are doing at fixed intervals. Fixed intervals BP checks could be every 30 minutes or much more frequently.
As long as you have the ambulatory BP monitoring attached to you, it will do its own thing whether you are active or inactive. Readings are certainly more accurate than wrist monitors.
|See also pros and cons of wrist blood pressure monitors|
Ambulatory blood pressure monitoring can be done over a longer time but usually ambulatory blood pressure takes readings over a 24-hour period.
The cuff of the ambulatory monitor is wrapped around your arm and the blood pressure reading device or meter is given to you along side it.
You go about your business during the day and night and at fixed intervals, the blood pressure cuff will inflate and deflate spontaneously to measure your blood pressure at that moment in time.
These readings are recorded digitally over the 24-hour period.
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Downside To Ambulatory Blood Pressure Monitoring
- It is not universally available although this is improving.
- It requires specialist training.
- Bruising where the cuff is located.
- Background noise may lead to interference .
- Poor technique and arrhythmias may cause poor readings.
- There is some evidence that HBPM may be better than ABPM for predicting cardiovascular risk at every level below severe hypertension . However, these findings need to be confirmed by larger trials.
Using An Ambulatory Blood Pressure Monitor
Last Updated October 2020 | This article was created by familydoctor.org editorial staff and reviewed by Peter Rippey, MD, CAQSM
If you have high blood pressure , your doctor may ask you to wear an ambulatory blood pressure monitor. This is a small machine, about the size of a portable radio. You wear it on your belt for 24 hours. The blood pressure cuff can be worn under your clothes and is hidden so others dont see it. The monitor records your blood pressure about every 30 minutes during your day. The information collected can help your doctor see if your blood pressure treatment is working.
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How To Prepare For The Test
- Take a bath before coming for the test as you will be asked to wear the small digital BP machine for 24 hours continuously
- Wear a shirt that can be easily removed so as to facilitate placement of the BP machine and a pair of shorts/pants with belt loops. Bring a belt so that the machine can be worn on a belt on your waist
- Continue taking your regular medications as instructed by our doctor
Overview Of Hbpm Procedures
Home blood pressure was initially measured with the auscultatory technique by an observer . Most currently available HPBM devices are automatic, utilize the oscillometric technique, and are initiated by the patient. Some devices are able to store readings for several weeks, which minimize the need for patients to record the measurements. HBPM devices, which measure blood pressure in the brachial artery, are more reliable than other types of devices such as wrist monitors . HBPM should be performed in a quiet room after 5 minutes of rest in the seated position, with the back and arm supported. A common recommendation for HBPM is that blood pressure be measured by the patient 2 times in the morning and 2 times in the evening. A minimum of 3 consecutive days and a preferred period of 7 consecutive days of HBPM is a reasonable approach for clinical practice . For assessing mean blood pressure, readings obtained on the first day of HBPM are excluded, and all subsequent readings across days are averaged . Figure 1 shows blood pressure readings from HBPM for the same individual in the upper panel who underwent HBPM after ABPM.
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How The Test Is Performed
The diagnostic test begins with fitting a patient with a portable monitor and BP cuff. The patient leaves and returns the next day. Over this period of time, the monitor takes measurements periodically as programmed by the clinician. This generally happens every 15-30 minutes while awake and 30-45 minutes while sleeping.
After the test
When the patient returns, these measurements are transferred to a computer where they can be easily viewed and documented in a report.
Challenges In Using Abpm And Hbpm In Clinical Practice
ABPM is not widely available in primary care settings and is generally only offered in specialized hypertension centers . Insurance companies do not commonly reimburse for indications other than white coat hypertension. Also, the amount of reimbursement for ABPM is low . Some patients may have difficulty wearing ABPM devices at night . There is also lack of formal training or certification for ABPM that may make it difficult for physicians set up these services in their practices.
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Ambulatory Blood Pressure System
Accurate out-of-office blood pressure monitoring is essential for blood pressure evaluation and medical management. ABPM has been available for clinical use for more than 20 years with more than 60 years of available data since it was first described. It is currently accepted as the best ambulatory method to collect blood pressure readings, and its use has exponentially increased as part of the standard of care for hypertensive patients .
Recommendations for use by the 2017 American College of Cardiology guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults. ABPM, ambulatory blood pressure monitoring SBP, systolic blood pressure DBP, diastolic blood pressure. mm Hg, millimeters of mercury CVD, cardiovascular disease.
Diagnosing Hypertension In Primary Care
Hypertension is the most common condition seen in adult primary care practices. To help identify this medical condition, the U.S. Preventative Services Task Force issued a Grade A recommendation stating that out-of-office measurements via ambulatory blood pressure monitor or home blood pressure monitor should be obtained prior to a hypertension diagnosis.1
As a result, ambulatory blood pressure monitoring is now considered to be the reference standard for measuring blood pressure versus in-office and home measurements.
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Path To Improved Health
Not everyone with high blood pressure is asked to wear a monitor. Your doctor may want you to use an ambulatory blood pressure monitor if:
- You have borderline high blood pressure.
- You and your doctor cant keep your blood pressure under control.
- You have blood pressure problems caused by your other medicines.
- You have changed your medicine.
- Youre pregnant and have high blood pressure.
- You have fainting spells.
The monitor may help your doctor find out if youre a person who only has high blood pressure when youre at the doctors office. This is called white-coat hypertension. Its called this because your blood pressure rises when youre nervous or fearful of medical environments. If you have this kind of hypertension, you may not need to take blood pressure medicine.
What Are The Uses Of Ambulatory Blood Pressure Monitoring
- To obtain a twenty-four hour record – more reliable than one-off measurements. Studies have shown that increased blood pressure readings on ABPM are more strongly correlated to end-organ damage than one-off measurements – eg, left ventricular hypertrophy.
- To detect white coat hypertension.
- It has use in hypertension research – eg, reviewing 24-hour profile of antihypertensive medication.
- It may have prognostic use – higher readings on ABPM are associated with increased mortality.
- Response to treatment.
- Hypotensive symptoms whilst on antihypertensive medications.
- It may be more cost-effective in the long term than office blood pressure measurement.
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Recommendation By The Us Preventative Services Task Force
In 2015, the U.S. Preventative Services Task Force published an important systematic review. Within this review, the author discussed the diagnostic and predictive accuracy of different blood pressure methods for cardiovascular events. The systematic review identified nine studies that evaluated the predictive value of 24-hour ABPM on long-term health outcomes. These studies met the following requirements:
- Followed a cohort of patients over time and reported the hazard or risk ratio
- Had to have at least two blood pressure measurement methods at baseline
- Outcomes had to be overall mortality or CVD events
Out of the identified studies, four found that every 10 mmHg increase in ambulatory systolic blood pressure was significantly associated with an increased risk for fatal and nonfatal stroke.8 Additionally, six studies found that every 10 mmHg increase in ambulatory systolic blood pressure was associated with increased risk for fatal and nonfatal cardiovascular events, with hazard ratios ranging from 1.11 to 1.42.8 The systematic review concluded that ambulatory blood pressure monitoring consistently and statistically significantly predicted stroke and other cardiovascular outcomes independently of office blood pressure monitoring.8
What Is Home Blood Pressure Monitoring
Home blood pressure monitoring allows blood pressure to be measured and recorded throughout the day in the patients natural environment. Home blood pressure monitoring is another method used to determine the misclassification of hypertension in the clinic.9 Home blood pressure averages correlate reasonably well with daytime ambulatory averages and therefore is a better predictor of cardiovascular outcomes than office blood pressure.10 This method may be more feasible than ABPM due to its affordability and availability.10
Evidence has demonstrated home monitoring is a stronger predictor of hypertension than office blood pressure monitoring.9 In addition, this evidence also shows that home monitoring is not as strong compared to ambulatory monitoring.9 As a result, home blood pressure monitoring is useful for ruling in hypertension but not as useful for ruling out the condition.9
Although home blood pressure monitoring is preferred over office blood pressure monitoring, there are still some difficulties with this method:
- Relies on proper techniques specifically by the patient
- Measurements are dependent on patient effort and engagement
- Trustworthiness and quality of data
- Data gaps
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