Thread by @DrPSVali

🚨Tweetorial Alert
🏁”A primer regarding the basics of Ambulatory Blood Pressure monitoring (ABPM)”
🎯Learning Objectives:
1. When is ABPM indicated
2. How to interpret ABPM data
@NSMCInternship
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Blood Pressure Measurement is a fundamental Procedure tagged with multiple confounders
@NSMCInternship

❓Why precise BP measurement is needed ?
★ overestimation of blood pressure by 5 mm Hg = Inappropriate labeling of 30 million as Hypertensives

★ Under estimation of BP by 5 mm of Hg = Mislabeling of 20 million true hypertensives as normotensives

PMID: 12597757 12493255

Why is ABPM Superior to Office BP Recording ?
In Office BP recording is akin to a snap shot while ABPM offers longitudinal dissection of the BP trend over 24 Hours

ABPM = Better opportunity to profile CV Risk

PMID: 30678763 @NSMCInternship

Who needs ABPM ?
The very purpose of ABPM is to avoid misclassification and to offer prognostic insights with regard to cardiovascular events.

Indications for ABPM 👇
PMID: 16738273 @NSMCInternship

💡One important indication is to assess the difference between True/White Coat/Masked Hypertension
★ White Coat Effect = Treated White coat HTN = In a treated Hypertensive, mean BPs >Threshold in office but below the threshold out of office
PMID: 23682974, 33093691, 11032699

📖To Make ABPM recordings more effective, educate the patient about the ABPM procedure in detail
☀️Cuff to be worn on Non dominant arm
☀️ABPM should be performed on a normal working day
☀️Avoid unusual Physical activity

❓How to interpret ABPM:
There are four essential steps in interpreting ABPM
1. Is the Study data acceptable or Not ?
2. Is the Patient Hypertensive ?
3. At what time of the day, BP is high ?
4. Does the Patient’s BP carry the footprints for adverse CV events ?
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Step 1: Is the Study Acceptable or Not ??
☀️20 Day time recordings
🌙07 Night time recordings
PMID: 30165516
@NSMCInternship

Step 2: Is the Patient Hypertensive based on mean readings?

ACC/AHA 2017 & ESC/ESH Guidelines 2018 suggest a mean ABPM > 125/75-130/80 is consistent with hypertension.👇
PMID: 29146535
PMID: 30165516
@NSMCInternship

Step 3: At what part of the day, BP is high ? Does it ever get low?

Based on BP variability, it can help
To know the timing of Hypertension severity
To assess the hypotensive symptoms
To adjust the timing of hypertensive medications
PMID: 31732802
@NSMCInternship

Step 4: 🔭 Is this Hypertensive Patient more prone for Cardio Vascular Events ?

This is based on
A. Presence or Absence of Nocturnal Dipping
B. Magnitude of Early Morning Surge
PMID: 16738273 @NSMCInternship

🌙 ⬇ Nocturnal Dipping of BP:
Normal dip in BP during Nights: 10-20%
Non Dipper: <10%
Extreme Dipper: >20%
Reverse Dipper: Increase in BP rather decreasing
PMID: 16738273 @NSMCInternship

A nondipper is someone whose BP does not reduce by more than 10% at night.

Extreme Dipper = ⬆ Cognitive impairment in elderly
Reverse Dipper = ⬆ LV Hypertrophy/ Stroke/ Proteinuria
PMID: 26425836
PMID: 8591875
PMID: 34085748
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Morning surge is physiologic, but a change of > 20% = ⬆ risk of Haemorragic Stroke, myocardial infarction, and sudden death
PMID: 14871036
@NSMCInternship

Take Home Message:
1. ABPM = Diagnostic tool + Prognostic tool
2. ABPM = True nature of HTN + characteristics of HTN
3. Nocturnal Dipping & Early morning surge = Well established Prognosticators
@NSMCInternship
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