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The Importance of 24-Hour Ambulatory Blood Pressure Monitoring in Patients at Risk of Cardiovascular Events

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Abstract

The accuracy of clinic blood pressure (BP) measurements is limited due to the presence of 24-hour BP variability and white-coat or masked hypertension. In contrast, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Various out-of-office measurements can be obtained using ABPM data, including morning, daytime, night-time and average 24-hour BP. Thus, in clinical practice, ABPM can be used to identify masked hypertension or excessive BP reduction. Furthermore, ABPM data can identify early-morning hypertension and excessive BP variability, both of which correlate with target-organ damage and cardiovascular outcomes. In large outcomes trials, ABPM sub-studies are increasingly performed to help further understand patient outcomes. However, it is evident that control of BP over the full 24-hour period, particularly during the risky early morning period, is not being achieved in general practice. In clinical trials of antihypertensive efficacy, a useful calculation is the smoothness index. This measure assesses the degree of 24-hour BP reduction, as well as its distribution pattern, throughout the 24-hour period. Importantly, the index correlates with hypertension-associated target organ damage, unlike the commonly used trough to peak ratio. Smooth BP control according to this index is achieved with long-acting drugs, such as telmisartan or amlodipine, which provide smooth 24-hour BP control, even during the early morning period. In summary, the use of ABPM is expanding, both in clinical practice and in trials, as it provides a closer correlation to prognosis than clinic BP measures. When choosing an antihypertensive agent for patients with hypertension, it is important to consider reducing BP variability by using longer acting antihypertensives, which may help to prevent cardiovascular morbidity and mortality.

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References

  1. Dawber TR, Kannel WB, Revotskie N, et al. The epidemiology of coronary heart disease: the Framingham enquiry. Proc R Soc Med. 1962;55:265–71.

    PubMed  CAS  Google Scholar 

  2. Pickering T. Ambulatory blood pressure monitoring: an historical perspective. Clin Cardiol 1992;15:II3–II5.

    Google Scholar 

  3. Stanton A, O’Brien E. Noninvasive 24 hour ambulatory blood pressure monitoring: current status. Postgrad Med J. 1993;69:255–67.

    Article  PubMed  CAS  Google Scholar 

  4. Mancia G, Omboni S, Parati G. The importance of blood pressure variability in hypertension. Blood Press Monit. 2000;5(Suppl 1):S9–15.

    Article  PubMed  Google Scholar 

  5. Mancia G, Parati G, Pomidossi G, et al. Alerting reaction and rise in blood pressure during measurement by physician and nurse. Hypertension. 1987;9:209–15.

    Article  PubMed  CAS  Google Scholar 

  6. Mancia G, Bombelli M, Facchetti R, et al. Long-term risk of sustained hypertension in white-coat or masked hypertension. Hypertension. 2009;54:226–32.

    Article  PubMed  CAS  Google Scholar 

  7. Hinman AT, Engel BT, Bickford AF. Portable blood pressure recorder: accuracy and preliminary use in evaluating intradaily variations in pressure. Am Heart J. 1962;63:663–8.

    Google Scholar 

  8. Sokolow M, Werdegar D, Kain HK, et al. Relationship between level of blood pressure measured casually and by portable recorders and severity of complications in essential hypertension. Circulation. 1966;34:279–98.

    Article  PubMed  CAS  Google Scholar 

  9. Parati G. Blood pressure variability: its measurement and significance in hypertension. J Hypertens Suppl. 2005;23:S19–25.

    Article  PubMed  CAS  Google Scholar 

  10. Mancia G, Bombelli M, Facchetti R, et al. Long-term prognostic value of blood pressure variability in the general population: results of the Pressioni Arteriose Monitorate e Loro Associazioni Study. Hypertension. 2007;49:1265–70.

    Article  PubMed  CAS  Google Scholar 

  11. Kikuya M, Hozawa A, Ohokubo T, et al. Prognostic significance of blood pressure and heart rate variabilities: the Ohasama study. Hypertension. 2000;36:901–6.

    Article  PubMed  CAS  Google Scholar 

  12. Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA. 1999;282:539–46.

    Article  PubMed  CAS  Google Scholar 

  13. Omboni S, Parati G, Mancia G. The trough:peak ratio and the smoothness index in the evaluation of control of 24 h blood pressure by treatment in hypertension. Blood Press Monit. 1998;3:201–4.

    PubMed  Google Scholar 

  14. Parati G, Omboni S, Rizzoni D, et al. The smoothness index: a new, reproducible and clinically relevant measure of the homogeneity of the blood pressure reduction with treatment for hypertension. J Hypertens. 1998;16:1685–91.

    Article  PubMed  CAS  Google Scholar 

  15. Parati G, Schumacher H, Bilo G, et al. Evaluating 24-h antihypertensive efficacy by the smoothness index: a meta-analysis of an ambulatory blood pressure monitoring database. J Hypertens. 2010;28:2177–83.

    Article  PubMed  CAS  Google Scholar 

  16. Rizzoni D, Muiesan ML, Salvetti M, et al. The smoothness index, but not the trough-to-peak ratio predicts changes in carotid artery wall thickness during antihypertensive treatment. J Hypertens. 2001;19:703–11.

    Article  PubMed  CAS  Google Scholar 

  17. Campo C, Saavedra J, Segura J, et al. Correlations of smoothness index and trough-to-peak ratio with left ventricular mass index changes induced by lercanidipine in hypertensive patients: a pilot trial. Minerva Med. 2005;96:365–71.

    PubMed  CAS  Google Scholar 

  18. White WB. Ambulatory blood-pressure monitoring in clinical practice. N Engl J Med. 2003;348:2377–8.

    Article  PubMed  Google Scholar 

  19. Longo D, Dorigatti F, Palatini P. Masked hypertension in adults. Blood Press Monit. 2005;10:307–10.

    Article  PubMed  Google Scholar 

  20. Muller JE, Stone PH, Turi ZG, et al. Circadian variation in the frequency of onset of acute myocardial infarction. N Engl J Med. 1985;313:1315–22.

    Article  PubMed  CAS  Google Scholar 

  21. Willich SN, Goldberg RJ, Maclure M, et al. Increased onset of sudden cardiac death in the first three hours after awakening. Am J Cardiol. 1992;70:65–8.

    Article  PubMed  CAS  Google Scholar 

  22. Metoki H, Ohkubo T, Kikuya M, et al. Prognostic significance of night-time, early morning, and daytime blood pressures on the risk of cerebrovascular and cardiovascular mortality: the Ohasama Study. J Hypertens. 2006;24:1841–8.

    Article  PubMed  CAS  Google Scholar 

  23. Kario K, Pickering TG, Umeda Y, et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation. 2003;107:1401–6.

    Article  PubMed  Google Scholar 

  24. Frattola A, Parati G, Cuspidi C, et al. Prognostic value of 24-hour blood pressure variability. J Hypertens. 1993;11:1133–7.

    Article  PubMed  CAS  Google Scholar 

  25. Redon J, Bilo G, Parati G. Home blood pressure control is low during the critical morning hours in patients with hypertension: the SURGE observational study. Fam Pract. 2011;29:421–6.

    Article  PubMed  Google Scholar 

  26. Parati G, Bilo G, Redon J. Morning and smooth 24-hour ambulatory blood pressure control is not achieved in general practice: results from the SURGE observational study. J Hypertens. 2013;616–23.

  27. Shimada K, Fujita T, Ito S, et al. The importance of home blood pressure measurement for preventing stroke and cardiovascular disease in hypertensive patients: a sub-analysis of the Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH) study, a prospective nationwide observational study. Hypertens Res. 2008;31:1903–11.

    Article  PubMed  CAS  Google Scholar 

  28. Obara T, Ohkubo T, Kikuya M, et al. Prevalence of masked uncontrolled and treated white-coat hypertension defined according to the average of morning and evening home blood pressure value: from the Japan Home versus Office Measurement Evaluation Study. Blood Press Monit. 2005;10:311–6.

    Article  PubMed  Google Scholar 

  29. Banegas JR, Segura J, Sobrino J, et al. Effectiveness of blood pressure control outside the medical setting. Hypertension. 2007;49:62–8.

    Article  PubMed  CAS  Google Scholar 

  30. Redon J, Roca-Cusachs A, Mora-Macia J. Uncontrolled early morning blood pressure in medicated patients: the ACAMPA study. Analysis of the Control of Blood Pressure using Abulatory Blood Pressure Monitoring. Blood Press Monit. 2002;7:111–6.

    Article  PubMed  Google Scholar 

  31. Parati G, Bilo G, Redon J. The effects of telmisartan alone or with hydrochlorothiazide on morning and 24-h ambulatory BP control: results from a practice-based study (SURGE 2). Hypertens Res. 2012 [Epub ahead of print].

  32. Conway J, Johnston J, Coats A, et al. The use of ambulatory blood pressure monitoring to improve the accuracy and reduce the numbers of subjects in clinical trials of antihypertensive agents. J Hypertens. 1988;6:111–6.

    Article  PubMed  CAS  Google Scholar 

  33. Conway J, Coats A. Value of ambulatory blood pressure monitoring in clinical pharmacology. J Hypertens Suppl. 1989;7:S29–32.

    Article  PubMed  CAS  Google Scholar 

  34. Dolan E, Stanton AV, Thom S, et al. Ambulatory blood pressure monitoring predicts cardiovascular events in treated hypertensive patients: an Anglo-Scandinavian cardiac outcomes trial substudy. J Hypertens. 2009;27:876–85.

    Article  PubMed  CAS  Google Scholar 

  35. Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366:895–906.

    Article  PubMed  Google Scholar 

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Acknowledgments

The author was fully responsible for all content and editorial decisions, was involved at all stages of manuscript development and has approved the final version of the review that reflects the author’s interpretation and conclusions. Medical writing assistance, supported financially by Boehringer Ingelheim, was provided by Emma Fulkes, PhD, of PAREXEL during the preparation of this review. Boehringer Ingelheim was given the opportunity to check the data used in the manuscript for factual accuracy only. The author has lectured for Boehringer Ingelheim, Novartis, Daichii-Sankyo, Menarini and has participated in advisory board of Daichii-Sankyo.

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  1. Internal Medicine, Hospital Clinico, INCLIVA, University of Valencia, Valencia, Spain

    Josep Redon

  2. CIBER of Obesity and Nutrition C/006, Institute of Health Carlos III, Madrid, Spain

    Josep Redon

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  1. Josep Redon
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Correspondence to Josep Redon.

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Redon, J. The Importance of 24-Hour Ambulatory Blood Pressure Monitoring in Patients at Risk of Cardiovascular Events. High Blood Press Cardiovasc Prev 20, 13–18 (2013). https://doi.org/10.1007/s40292-013-0006-3

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