小时动态血压检测ABPM
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24h Ambulatory Blood Pressure Measurement (ABPM)
“From research to clinical practice”
Professor BP McGrath Professor of Vascular Medicine Monash University, Melbourne
11:00 AM 3:00 PM 7:00 PM
11:00 PM 3:00 AM 7:00 AM
‘White-coat’ effect in hypertensive patients
Term used to describe phenomenon found in many hypertensive patients whereby clinic BP measurements are consistently greater than the BP values obtained by ABPM or self-BPM, the levels of which are nonetheless increased above normal
• Insufficient duration of action of antihypertensive drugs may be a key factor for high morning BP (Chonan K et al. Clin Exp Hypertens 2002)
Clinical Indications
• Suspected isolated clinic hypertension • Suspected nocturnal hypertension • Suspected masked hypertension • To establish ‘dipper’ status • Resistant hypertension • Hypertension of pregnancy
Assessing prognostic relevance
• Discrepant information from different indices
BMcG 05
BP Variability and CV disease: OhBiblioteka Baidusama
Relative Hazard
*
3
Daytimep=0.01
AMBULATORY BLOOD PRESSURE
PROGNOSTIC SIGNIFICANCE
BMcG 05
EVENTS/100 patient years
CV MORBID EVENT RATE
Verdecchia et al. 1994 6
5
4
3
2
1
0
NT GROUP
HT 'WHITECOAT'
BMcG 05
Kikuya, Imai et al. Hypertension 2000
BMcG 05
CV events according to blood pressure variability
Rate of events (per 100 patient-years)
9 8 7 6 5 4 3 2 1 0
• Willich SN et al. Am J Cardiol 1987 • Kelly-Hayes M et al. Strole 1995 • Elliott W. Stroke 1998
2000’s Circadian variation in haemodynamic, autonomic and hormonal systems synchronize to produce a high risk state
• Shows BP behaviour during usual daily activities
• A stronger predictor of cardiovascular morbidity and mortality than clinic BP
• Can identify patterns: ‘non-dippers’, isolated clinic hypertension, masked hypertension, enhanced BP variability, episodes of hypotension
Low
Medium
High
BPVar (SD) BPVar (ARV)
Mena et al. J Hypertens. 23:505-12
Is 24h control of BP important?
BMcG 05
Yet to be determined the component of
the ABP profile that is the best predictor of prognosis, but…..
‘White-coat’ hypertension (isolated clinic hypertension )
‘ White-coat’ hypertension is a condition in which an individual is hypertensive during repeated clinic BP measurements, but outside the medical environment pressures measured by ABPM or selfBPM techniques are normal
2.85
2 1.81
2.23 1.67
1.00 1
3 Nighttime
2.51
2
1.86 1.71
1.41
1.00 1
0 <11.5 11.5- 13.9- 15.8- 18.8< 139 15.8 18.8
0 <8.1 8.1- 9.9- 11.8- 14.4< 9.9 11.8 14.4
Systolic BP Variability (mmHg)
*
12
10
*
*
8
6
Hypertensive
Normotensive 4
2
0
SBP
DBP
HR
BMcG 05
Head G et al. 2003
BMcG 05
Ambulatory blood pressure measurement (ABPM)
Advantages
• Profile of BP away from medical environment
BMcG 05
24h BP profile analysis
Mean day, night, 24h ABPM Minnesota cosinor method (Halberg et al 1967) Fourier analysis (Chau et al. 1989) Square wave model (Idema et al. 1991) Double logistic analysis (Head et al. 2002)
Day-night differences
• Non-dippers1 - have more end-organ damage • Syst-Eur study2 – 10% increase in N:D ratio gave
hazards ratio for CV events of 1.45 • SAMPLE study3 – night time BP did not improve the
BMcG 05
Recommended levels of normality for ABPM in adults (ESH guidelines 2005)
Optimal* Normal Abnormal
Awake <130/80 <135/85 >140/90
Asleep <115/65 <120/70 >125/75
prediction of LVH regression in addition to daytime ABP. • Ohasama study4 – mean daytime ABP better predictor.
1. Verdecchia et al. Hypertension 1994 2. Staessen et al JAMA 1999 3. Mancia G. et al. Circulation 1997 4. Imai Y et al. Blood Pressure Monitoring 1999
BMcG 05
Masked hypertension (isolated ambulatory hypertension)
This phenomenon refers to patients in whom clinic BP is normal but blood pressure values by ABPM or self-BPM are increased Not uncommon:
HT 'DIPPERS'
HT 'NONDIPPERS'
BMcG 05
Blood pressure variability
1970’s Continuous intra-arterial recordings in humans
1980’s Morning rise in BP associated with higher incidence of sudden cardiac deaths, stroke and myocardial infarction
Potential Indications
• Risk groups- diabetes, renal disease, elderly • Symptom evaluation • Autonomic failure
What is the importance of nocturnal BP?
BMcG 05
BMcG 05
Isolated clinic hypertension
or hypertension in evolution?
160 140 120 100
80 60 40
BMcG 05
Mr. M.L. ABPM profiles 1996, 1998
SLEEP
SBP1 SBP2 DBP1 DBP2
BMcG 05
ABPM: 24h BP profile
Blood Pressure
160 140 120 100
80 60 40 20
0 9:38 AM
BMcG 05
1:06 PM
SLEEP
5:02 PM TIME
9:58 PM
7:33 AM
BMcG 05
24h ABP monitoring
How should the curves be analysed?
There is general consensus that optimal BP control requires a smooth reduction in the 24h ABP profile
Control of morning BP may be the most important goal in the treated hypertensive patient
*Lower optimal values recommended in diabetes mellitus and high-risk patients
BMcG 05
Rate of morning rise in BP, HR Hypertensive (n=51) vs Normotensive (n=63)
• Weber MA Am J Cardiol 2002
Blood pressure variability
Different methods
• SD of the 24h average ABP • A ‘weighted’ 24h ABP SD (to account for
nocturnal BP fall) • Average real variability index (Mena et al 2005)
• 29% Gourlay S et al. J Hum Hypertens 1993, 7:467-72 • 22% PAMELA study Circ 2001, 104:1385-92
BMcG 05
BMcG 05
Ambulatory blood pressure measurement (ABPM)
“From research to clinical practice”
Professor BP McGrath Professor of Vascular Medicine Monash University, Melbourne
11:00 AM 3:00 PM 7:00 PM
11:00 PM 3:00 AM 7:00 AM
‘White-coat’ effect in hypertensive patients
Term used to describe phenomenon found in many hypertensive patients whereby clinic BP measurements are consistently greater than the BP values obtained by ABPM or self-BPM, the levels of which are nonetheless increased above normal
• Insufficient duration of action of antihypertensive drugs may be a key factor for high morning BP (Chonan K et al. Clin Exp Hypertens 2002)
Clinical Indications
• Suspected isolated clinic hypertension • Suspected nocturnal hypertension • Suspected masked hypertension • To establish ‘dipper’ status • Resistant hypertension • Hypertension of pregnancy
Assessing prognostic relevance
• Discrepant information from different indices
BMcG 05
BP Variability and CV disease: OhBiblioteka Baidusama
Relative Hazard
*
3
Daytimep=0.01
AMBULATORY BLOOD PRESSURE
PROGNOSTIC SIGNIFICANCE
BMcG 05
EVENTS/100 patient years
CV MORBID EVENT RATE
Verdecchia et al. 1994 6
5
4
3
2
1
0
NT GROUP
HT 'WHITECOAT'
BMcG 05
Kikuya, Imai et al. Hypertension 2000
BMcG 05
CV events according to blood pressure variability
Rate of events (per 100 patient-years)
9 8 7 6 5 4 3 2 1 0
• Willich SN et al. Am J Cardiol 1987 • Kelly-Hayes M et al. Strole 1995 • Elliott W. Stroke 1998
2000’s Circadian variation in haemodynamic, autonomic and hormonal systems synchronize to produce a high risk state
• Shows BP behaviour during usual daily activities
• A stronger predictor of cardiovascular morbidity and mortality than clinic BP
• Can identify patterns: ‘non-dippers’, isolated clinic hypertension, masked hypertension, enhanced BP variability, episodes of hypotension
Low
Medium
High
BPVar (SD) BPVar (ARV)
Mena et al. J Hypertens. 23:505-12
Is 24h control of BP important?
BMcG 05
Yet to be determined the component of
the ABP profile that is the best predictor of prognosis, but…..
‘White-coat’ hypertension (isolated clinic hypertension )
‘ White-coat’ hypertension is a condition in which an individual is hypertensive during repeated clinic BP measurements, but outside the medical environment pressures measured by ABPM or selfBPM techniques are normal
2.85
2 1.81
2.23 1.67
1.00 1
3 Nighttime
2.51
2
1.86 1.71
1.41
1.00 1
0 <11.5 11.5- 13.9- 15.8- 18.8< 139 15.8 18.8
0 <8.1 8.1- 9.9- 11.8- 14.4< 9.9 11.8 14.4
Systolic BP Variability (mmHg)
*
12
10
*
*
8
6
Hypertensive
Normotensive 4
2
0
SBP
DBP
HR
BMcG 05
Head G et al. 2003
BMcG 05
Ambulatory blood pressure measurement (ABPM)
Advantages
• Profile of BP away from medical environment
BMcG 05
24h BP profile analysis
Mean day, night, 24h ABPM Minnesota cosinor method (Halberg et al 1967) Fourier analysis (Chau et al. 1989) Square wave model (Idema et al. 1991) Double logistic analysis (Head et al. 2002)
Day-night differences
• Non-dippers1 - have more end-organ damage • Syst-Eur study2 – 10% increase in N:D ratio gave
hazards ratio for CV events of 1.45 • SAMPLE study3 – night time BP did not improve the
BMcG 05
Recommended levels of normality for ABPM in adults (ESH guidelines 2005)
Optimal* Normal Abnormal
Awake <130/80 <135/85 >140/90
Asleep <115/65 <120/70 >125/75
prediction of LVH regression in addition to daytime ABP. • Ohasama study4 – mean daytime ABP better predictor.
1. Verdecchia et al. Hypertension 1994 2. Staessen et al JAMA 1999 3. Mancia G. et al. Circulation 1997 4. Imai Y et al. Blood Pressure Monitoring 1999
BMcG 05
Masked hypertension (isolated ambulatory hypertension)
This phenomenon refers to patients in whom clinic BP is normal but blood pressure values by ABPM or self-BPM are increased Not uncommon:
HT 'DIPPERS'
HT 'NONDIPPERS'
BMcG 05
Blood pressure variability
1970’s Continuous intra-arterial recordings in humans
1980’s Morning rise in BP associated with higher incidence of sudden cardiac deaths, stroke and myocardial infarction
Potential Indications
• Risk groups- diabetes, renal disease, elderly • Symptom evaluation • Autonomic failure
What is the importance of nocturnal BP?
BMcG 05
BMcG 05
Isolated clinic hypertension
or hypertension in evolution?
160 140 120 100
80 60 40
BMcG 05
Mr. M.L. ABPM profiles 1996, 1998
SLEEP
SBP1 SBP2 DBP1 DBP2
BMcG 05
ABPM: 24h BP profile
Blood Pressure
160 140 120 100
80 60 40 20
0 9:38 AM
BMcG 05
1:06 PM
SLEEP
5:02 PM TIME
9:58 PM
7:33 AM
BMcG 05
24h ABP monitoring
How should the curves be analysed?
There is general consensus that optimal BP control requires a smooth reduction in the 24h ABP profile
Control of morning BP may be the most important goal in the treated hypertensive patient
*Lower optimal values recommended in diabetes mellitus and high-risk patients
BMcG 05
Rate of morning rise in BP, HR Hypertensive (n=51) vs Normotensive (n=63)
• Weber MA Am J Cardiol 2002
Blood pressure variability
Different methods
• SD of the 24h average ABP • A ‘weighted’ 24h ABP SD (to account for
nocturnal BP fall) • Average real variability index (Mena et al 2005)
• 29% Gourlay S et al. J Hum Hypertens 1993, 7:467-72 • 22% PAMELA study Circ 2001, 104:1385-92
BMcG 05
BMcG 05
Ambulatory blood pressure measurement (ABPM)