Guidelines Ambulatory Pressure Monitoring Essay
Guidelines Ambulatory Pressure Monitoring Essay
Question:
Discuss About The Guidelines Ambulatory Pressure Monitoring.
Answer:
Introduction
After analyzing the patient’s situation and gathering relevant cues from the available medical data, I have selected high blood glucose level (BGL) and poor skin turgor as the two most significant abnormal findings for Ms Nancy Huang.
The blood glucose level of Ms Nancy Huang is high and this is abnormal because according to Karlsson (2013), normal blood glucose level in human adults must range in-between 4.0 to 5.4 mmol/litres and in case of Ms Huang it is 24. Di Iorgi et al. (2012) is of the opinion that an abnormal high level of glucose in the blood (hyperglycemia) is associated with glycosuria. This is in case of Ms. Huang. i Iorgi et al. (2012) further argued that in glycosuria the kidneys fail to absorb the extra blood sugar into the blood vessels from the liquid that passes through the renal tubule. This extra level of glucose which cannot be re-absorbed is excreted through urine. This is in accordance of the case study of Ms Huang as her urinalysis test has provided positive results for glycosuria. The main pathophisiology underlying behind high level of blood glucose (hyperglycemia) along with glycosuria is, the body either produces inadequate amount of insulin that fails to absorb the desired glucose present in the blood or development of insulin resistance within the body. Both this abnormal conditions lead to the increase in the blood glucose level and the extra glucose is excreted through urine (Di Iorgi et al. 2012).Guidelines Ambulatory Pressure Monitoring Essay.
Based on the poor skin turgour and frequent excretion or urine, it can be stated that Ms Nacy Huang is suffering from dehydration. According to Hooper et al. (2012), the main pathophysiology of dehydration is negative fluid balance that results from decreased intake along with increased output (renal and gastrointestinal losses). This decrease in the overall body fluid concentration causes reduction in both extracellular and intracellular fluid volumes. Hooper et al. (2012) is of the opinion that one of the vital signs of dehydration is skin turgor. Poor skin turgor means, skin taking longer time to return to the original position after being pinched. It is alternatively defined as the lack of elasticity of skin. Now poor skin turgor is something common among the older adults as their skin’s elasticity is reduced with age however, in case of Ms Huang, this is not normal and thus reflecting lack of adequate fluid content in the body (Shimizu et al. 2012).
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Predict
If hyperglycemia followed by glycosuria and then with subsequent dehydration is not treated effectively on time then fatal outcome may occur. According to Wolfsdorf et al. (2014), if blood
Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient’s BP, which might not reflect patient’s true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP.Guidelines Ambulatory Pressure Monitoring Essay.This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.
This paper aims to provide practical indications to healthcare professionals and manufacturers of ambulatory blood pressure monitoring (ABPM) devices on the characteristics and minimum required contents of a standard ABPM report to be used in the clinical practice. Such indications will help make ABPM reports more easily interpretable and independent from the ABPM device and software used. The first important and unavoidable step of ABPM reporting is a quality assessment: if a recording does not meet the minimum requirements for quality criteria, the reporting physician should advise the patient to repeat the test and should not further proceed to a diagnostic evaluation and interpretation of the recording. A basic clinical report must contain the list of each single reading, the graphical display of individual readings and hourly average values, the mean, minimum and maximum values, and SDs of blood pressure and heart rate values for the 24 h, daytime and night-time, day-night differences, and blood pressure loads. The final medical report should be prepared in a quite logically structured way, considering the following: (i) a judgment on the overall quality of the 24 h recording; (ii) an indication of whether average 24 h, daytime and night-time systolic, and diastolic blood pressure values are within or above the normal limits; and (iii) a description of the 24 h pattern of blood pressure fluctuations. A final general statement on the normotensive or hypertensive status and on the degree of blood pressure control in case of treated patients should also be provided.Guidelines Ambulatory Pressure Monitoring Essay.
Accurate office blood pressure measurement remains crucial in the diagnosis and management of hypertension worldwide, including Latin America (LA). Office blood pressure (OBP) measurement is still the leading technique in LA for screening and diagnosis of hypertension, monitoring of treatment, and long‐term follow‐up. Despite this, due to the increasing awareness of the limitations affecting OBP and to the accumulating evidence on the importance of ambulatory BP monitoring (ABPM), as a complement of OBP in the clinical approach to the hypertensive patient, a progressively greater attention has been paid worldwide to the information on daytime and nighttime BP patterns offered by 24‐h ABPM in the diagnostic, prognostic, and therapeutic management of hypertension. In LA countries, most of the Scientific Societies of Hypertension and/or Cardiology have issued guidelines for hypertension care, and most of them include a special section on ABPM. Also, full guidelines on ABPM are available. However, despite the available evidence on the advantages of ABPM for the diagnosis and management of hypertension in LA, availability of ABPM is often restricted to cities with large population, and access to this technology by lower‐income patients is sometimes limited by its excessive cost. The authors hope that this document might stimulate health authorities in each LA Country, as well as in other countries in the world, to regulate ABPM access and to widen the range of patients able to access the benefits of this technique.
1 INTRODUCTION
Accurate office blood pressure measurement remains crucial in the diagnosis and management of hypertension worldwide, including Latin America (LA).1, 2 Office blood pressure (OBP) measurement is still the leading technique in LA for screening and diagnosis of hypertension, monitoring of treatment, and long‐term follow‐up. Despite this, due to the increasing awareness of the limitations affecting OBP and to the accumulating evidence on the importance of ambulatory BP monitoring (ABPM), as a complement of OBP in the clinical approach to the hypertensive patient, a progressively greater attention has been paid worldwide to the information on daytime and nighttime BP patterns offered by 24‐h ABPM in the diagnostic, prognostic, and therapeutic management of hypertension.
In LA countries, most of the Scientific Societies of Hypertension and/or Cardiology have issued guidelines for hypertension care,3-7 and most of them include a special section on ABPM. Also, full guidelines on ABPM are available.5
However, in LA, the availability of ABPM is often restricted to cities with large population, and access to this technology by lower‐income patients is sometimes limited by its excessive cost.
In the following sections, we will address in detail the available evidence on the advantages of ABPM for the diagnosis and management of hypertension also in LA.
We hope that this document might stimulate health authorities in each LA Country, as well as in other countries in the world, to regulate ABPM access and to widen the range of patients able to access the benefits of this technique. Guidelines Ambulatory Pressure Monitoring Essay.
2 HISTORICAL PERSPECTIVE
The ABPM technique was first described in 1960s by Kain and colleagues, and was initially based on semi‐automated BP measurements.8, 9
First devices were cumbersome8; but progress in technology has made currently available ambulatory monitors smaller, lighter, and minimally noisy, with most of them fully automated and using the oscillometric technique. The use of modern validated ABPM devices thus allows BP to be reliably monitored for 24 hours or longer while patients attend their usual daily activities.10 Nowadays, the large amount of evidence supporting ABPM advantages over the conventional OBP technique for the diagnosis and management of hypertension has highlighted the superiority of the former over the latter approach, which is now acknowledged by all main international guidelines for hypertension management.2, 11-13 Most of the advantages of 24‐h ABPM come from its ability to provide a large number of measurements over the 24 hours and from the possibility to obtain BP measurements in subjects’ daily life, and both during wakefulness and during sleep. This implies, from a practical perspective, that whenever ABPM is not available or is difficult to access, at least part of its advantages can nevertheless be obtained either through the use of home BP self‐monitoring (recently further improved by the current availability of devices with nocturnal BP monitoring function) or through an increase in the number of automated readings which can be obtained by repeating BP measurements both within visits and over repeated visits, and then averaged.14, 15 However, even in developed countries the use of ABPM is at present still recommended in selected cases only, although indications for ABPM are becoming progressively wider, based on the evidence that a larger use of ABPM could contribute to reduce health care cost, prevent cardiovascular events, and be life‐saving.16, 17
3 GENERAL CONSIDERATIONS
3.1 Why is ABPM superior to conventional BP measurement?
OBP measurements are widely available and have an acceptable performance for clinical practice, mainly when obtained through automated and validated oscillometric devices. However, we should be aware that OBP values are characterized by great variability, due both to a random error that affects casual readings and a systematic error in relation to the patient alert reaction, known as “white coat phenomenon.” Furthermore, OBP readings do not provide information about BP during a subject’s usual activities, including nighttime sleep, or over prolonged observation periods. ABPM overcomes all these limitations of OBP and has a stronger association with target organ damage18 and cardiovascular prognosis.19
3.2 Recommendations for ABPM use in clinical practice
3.2.1 Frequency and timing
Outcome‐based approach
Two recent publications analyzed the reliability of the number of ABPM recordings to determine the Ambulatory Arterial Stiffness Index (AASI), the pulse pressure (PP), and the reading‐to‐reading BP variability based on outcome.20, 21Excluding up to 16 readings from recordings reduced the discordance of AASI, but not PP variability over repeated recordings.Guidelines Ambulatory Pressure Monitoring Essay.Taking readings at fixed 1‐ or 2‐hour intervals along the recording significantly affected the concordance of both AASI and PP variability estimates. In terms of outcome (cardiovascular mortality), AASI lost its prognostic significance when the number of randomly excluded readings increased from 8 to 16 or when the interval between readings was 1 hour or longer. While PP variability did not predict cardiovascular mortality, the predictive accuracy of AASI for cardiovascular mortality was affected when the number of readings was lower than 35. Using the Average Real Variability index (ARV) to determine the reading‐to‐reading BP variability, a minimum of 48 readings allowed an accurate assessment of cardiovascular risk.21 There is, however, no published evidence supporting a minimum number of readings based on outcome to determine the blood pressure mean and variability levels derived from ABPM.
Clinical approach
There is no new evidence in this field. The evidence from the pioneering works of Di Rienzo22 and Thijs23, 24 is still the main references supporting the frequency and timing of ABPM. Some evidence on the number of ambulatory BP readings required for reliable assessment of ambulatory BP levels was also provided by the IDACO group.25
3.2.2 Recommended schedule for ABPM
For the reasons exposed above, ABPM must be performed over 24 hours and should include both daytime and nighttime periods.26, 27 One simple and popular method for identifying daytime and nighttime subperiods is to assess the time of awakening and sleeping from diary card entries. Another method is to use a fixed‐narrow time interval approach. According to this approach, nighttime and daytime are defined by removing blood pressure measurement performed during the transitional phases between day and night in the evening and between night and day in the morning.Guidelines Ambulatory Pressure Monitoring Essay.The interval between readings should not be longer than 60 minutes and ideally shorter than 30 minutes.27-29 It is recommended to identify the recording times without measurements, and when their duration is 2 hours or longer, this should be reported as major limitation of an ABPM tracing, requiring repetition of the examination. To avoid losing prognostic accuracy when reporting AASI and ARV or other BPV indices, it is recommended to have at least 35 and 48 readings, respectively.
Currently available ABPM guidelines by the European Society of Hypertension (ESH) Working Group on BP monitoring and cardiovascular variability27-30recommend to consider as acceptable a minimum number of 20 valid daytime (awake) measurements and 7 measurements at night (asleep), based on the requirement to have at least 70% of measurements being obtained at least every 30 min, or more frequently, throughout the entire 24‐h period (Box 1).27
Box 1. Evaluation of ABPM data. modified from Parati et al27 by permission
Definition of daytime and nighttime
Editing and requirements
|
3.2.3 Diagnostic and therapeutic thresholds
We did not find new evidence proposing different cut‐off thresholds for ABPM since the last ESH ABPM position paper was published in 2013.28 We support that it is necessary to move from thresholds based on statistical evidence to outcome‐driven thresholds. Based on a 10‐year cardiovascular risk equivalent to the risk obtained with office blood pressure measurement, suggested thresholds for ABPM were 131/79 mmHg for 24‐hour, 138/86 mmHg for daytime, and 120/71 mmHg for nighttime blood pressure31 substantially supporting the current indications provided by ESH guidelines, that is, 130/80 mmHg for 24 hours, 135/85 mmHg for daytime, and 120/70 mmHg for nighttime32, 33(Table 1). Guidelines Ambulatory Pressure Monitoring Essay.
| Blood pressure | Systolic (mmHg) | Diastolic (mmHg) |
|---|---|---|
| 24‐hour average | ≥130 | ≥ 80 |
| Daytime average | ≥ 135 | ≥85 |
| Nighttime average | ≥ 120 | ≥ 70 |
3.3 Cost‐effectiveness of ABPM
As reported in the 2013 ESH Working Group ABPM guidelines, ABPM may allow health care costs reduction by identifying individuals with white coat hypertension who, when at low cardiovascular risk, may not require pharmacological treatment despite an OBP elevation. ABPM is indeed the most effective technique for identifying white coat hypertension, which may be present in as many as 20% of people who appear to have isolated office BP elevation, and these patients may avoid years of unnecessary and expensive drug treatment, which is often not free from side effects. They may also avoid being penalized unnecessarily because of health insurance or employment‐related issues when erroneously diagnosed as having “hypertension”.34 The cost‐effectiveness of identifying white coat hypertension through ABPM is related to the fact that the cost of care for hypertension is largely dominated by the cost of cardiovascular complications occurring in the long term, and by the cost for drug treatment, rather than by the cost of doctors’ visits and of diagnostic investigations.Guidelines Ambulatory Pressure Monitoring Essay.This is of importance in LA for the limited resources available for health care, which require a long‐term acceptable cost‐effectiveness ratio for any approach proposed for hypertension management.33-35 When assessing the cost‐effectiveness of ABPM,33, 35, 36 in particular in LA where its use is only allowed in large cities and in some countries, the potential of this technique not only to improve the diagnosis and management of hypertension, but also as a means of ensuring implementation of a more effective control of hypertension at community level should be taken into consideration (Box 2).
Box 2. Advantages of ABPM. adapted from Parati et al 27 by permission
- Provides much larger number of readings
- Provides highly reproducible average 24‐h, daytime, and nighttime values
- Identifies white coat and masked hypertension phenomena in untreated and treated individuals
- Provides a profile of BP behavior in the individual’s usual daily environment
- Demonstrated nocturnal hypertension and dipping patterns
- Assesses BP variability over the 24‐h period
- Assesses the 24‐h efficacy of antihypertensive medication
- Detect excessive BP‐lowering during 24h
- Is a much stronger predictor of cardiovascular morbidity and mortality.
ABPM is indeed superior to other BP measurement techniques in demonstrating the efficacy of antihypertensive drugs and the achievement of 24‐h coverage.28, 37
Adjustment of antihypertensive therapy according to ABPM rather than office BP measurements has been shown to result in less antihypertensive medications being prescribed without compromising target organ involvement. It has also been shown that, in patients on treatment with BP‐lowering drugs, ABPM was a better predictor of cardiovascular outcome than office BP.27, 28, 37 Reduction in office BP over time due to a progressive reduction in the white coat effect, especially in elderly patients, who are characterized by a greater BP variability, may be, in fact, erroneously attributed to a BP‐lowering effect of antihypertensive treatment when ABPM is not used to assess treatment efficacy.38 There is a high rate of uncontrolled hypertension in LA due to poor adherence to prescribed treatment.39 It is motivated by social and economic factors in most of these countries.Guidelines Ambulatory Pressure Monitoring Essay.In such a context, it should be acknowledged that ABPM and home blood pressure monitoring (HBPM)40 may help to evaluate the effectiveness of hypertension treatment and may help achieving a better hypertension control.41, 42
It is accepted that ABPM can also identify individuals with normal BP in the office but elevated BP levels in daily life (“masked hypertension”), a condition that has been shown to carry the same adverse prognosis as sustained arterial hypertension, that is, a condition characterized by a BP elevation both in the clinic and in daily life (Figure 1).16, 27, 28
Different blood pressure phenotypes in treated and untreated hypertensives, respectively, defined by comparing office and out‐of‐office BP measurements. Reproduced from Parati et al 96 by permission
A number of studies have analyzed the cost‐benefit aspects of ABPM. Krakoff has shown potential savings of 3‐14% for cost of care for hypertension and 10‐23% reduction in treatment days when ABPM was incorporated into the diagnostic process.43 On an annual basis, the cost of ABPM would be less than 10% of treatment costs. Other cost‐benefit analyses have shown that ABPM is most cost‐effective for the diagnosis and management of newly diagnosed hypertension.
As the cost of ABPM and that of hypertension management differ greatly from country to country and is dependent on the method of health care delivery, the cost‐effectiveness of ABPM may need to be evaluated at a national level.
3.4 Advantages and Limitations of ABPM
As it was described earlier, ABPM has many advantages over other available BP measurement techniques (Table 2). Guidelines Ambulatory Pressure Monitoring Essay.
| OBP | AOBP | ABPM | HBPM | |
|---|---|---|---|---|
| Approx. no. of readings | 2‐3 | 3‐6 | 50‐100 | 10‐30a |
| Operator dependency | Yes | No | No | No |
| Reproducibility | Poor | Better than OBP | Good | Good |
| White coat effect | Yes | No | No | No |
| Patient training | No | No | Limited | Required |
| Patients’ acceptance | Good | Good | Sometimes poor | Usually good |
| Improvement in patient involvement and adherence | No | No | No | Yes |
| Nighttime blood pressure | No | No | Yes | Nob |
| Outcome evidence | +++ | + | +++ | ++ |
| Hypertension diagnosis thresholds (mmHg) | 140/90 | 130‐135/85 | 24 h: 130/80
Day: 135/85 Night: 120/70 |
135/85 |
| Monitoring of treatment | During visits | During visits | Good for 24‐h effects | Good for long‐term monitoring, some insight in 24‐h effects |
| Cost | Low | Low | High | Low |
Note
- ABPM, ambulatory blood pressure monitoring; AOBP, automated office blood pressure; HBPM, home blood pressure monitoring; OBP, office blood pressure. Modified from Parati G et al 40 by permission.
- a With a standard protocol of few days’ monitoring.
- b Nighttime measurements implemented in some models.
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Despite these advantages, also ABPM faces a number of possible difficulties in its application (Box 3).
Box 3. Limitations of ABPM. modified from 27 by permission
- Limited availability
- The provision of a number of intermittent measurements during which the patient is sedentary rather than “ambulatory,” whenever subjects’ behavior is not standardized
- The possibility of inaccurate readings during activity and the inability to detect possibly artifactual measurements
- May cause discomfort, particularly during the night, interfering with sleep patterns and resulting in resistance from some patients to having ABPM repetition during follow‐up
They include its limited availability, the fact that a number of measurements are taken when the patient is “sedentary” rather than “ambulatory,” the possibility of inaccurate readings during activity and the inability to easily identify possibly artifactual measurements, and, finally, the fact that ABPM may cause discomfort, particularly during the night, interfering with sleep patterns and resulting in resistance from some patients to having ABPM repetition during follow‐up.27
4 DEVICES AND SOFTWARE
An accurate device is a fundamental requirement for all BP measurements; if the device used to measure BP is inaccurate, then any discussion on methodological details becomes irrelevant. It is acknowledged that the accuracy of BP‐measuring devices should not be based solely on claims from manufacturers, which can at times be somewhat misleading, but should rather rely on independent validation using an established protocol with the results published in peer‐reviewed journals. The most popular validation protocol is the European Society of Hypertension International Protocol (ESH‐IP),29 and a recent review44 showed that from the publication of the first version of the ESH‐IP in 2002 until June 2010, 48 studies of device accuracy have been reported using the British Hypertension Society (BHS) protocol,45 38 using the AAMI standard, and 104 using the ESH‐IP 2010.30 Thus, it seems that the ESH‐IP succeeded in expanding by 3‐fold to 4‐fold the use of validation procedures worldwide compared with the period before its publication. The availability of the ESH‐IP30, 44 in an online version will further facilitate the validation of ABPM devices.
Since the time when the ESH‐IP29 was first published, there has been an improvement in the performance of the oscillometric devices for BP measurement, but protocol violations and misreporting have been particularly common, suggesting that there is a need for stricter standardization for conducting and reporting a validation study.Guidelines Ambulatory Pressure Monitoring Essay.The revised version of the ESH‐IP30protocol applied tighter validation criteria for the pass level, and the application of these more stringent criteria is expected to double the validation failure rate allowing more accurate devices to enter the market.
The AAMI protocol requires additional testing for ABPM devices in 85 patients in the supine, seated, and standing positions, and stipulates that three devices should be assessed in ambulatory conditions, all of which would be very difficult and costly to perform. The BHS protocol also requires an in‐use (field) assessment of ambulatory monitors45 The International Organization for Standardization (ISO) protocol also requires additional clinical validation in 35 patients in standardized conditions of physical activity (after exercise on a bicycle ergometer or treadmill to increase heart rate by 10‐20%).46 In the attempt to standardize the approach to validation of BP‐measuring devices, an international protocol jointly prepared and approved by ISO, AAMI, and ESH is currently being developed.47. Guidelines Ambulatory Pressure Monitoring Essay.
