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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 111-117

Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India


1 Department of Medicine, Hegde Health Complex, Shivamogga, Karnataka, India
2 Department of Neurology, Bharath Neuro Centre, Shivamogga, Karnataka, India
3 Department of Nephrology, Nanjappa Hospital, Shivamogga, Karnataka, India
4 Department of Medicine, Anushri Medical and Diabetes Care Centre, Shivamogga, Karnataka, India

Date of Submission17-Jun-2021
Date of Decision07-Jul-2021
Date of Acceptance20-Jul-2021
Date of Web Publication02-Mar-2022

Correspondence Address:
Dr. Subhashchandra B Hegde
Hegde Health Complex, Park Extension, Shivamogga - 577 201, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_64_21

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  Abstract 


Introduction: High blood pressure (BP) is an important risk factor for cardiovascular diseases. The association of short-term BP variability (BPV) with target organ damage (TOD) is not clearly established. We conducted this observational study to evaluate the degree of concordance between Office BP measurements (OBPM) and ambulatory BP monitoring (ABPM) and to study the association of ABPM parameters on TOD. Materials and Methods: Patients attending clinics of the authors between January 2018 and August 2019 were enrolled. Their BP status was determined by OBPM and ABPM and the degree of concordance analyzed. ABPM parameters between those with TOD and without TOD were compared using appropriate statistical measures. Results: Data from 968 subjects (males 61.5%, mean age 59.39 ± 14.86 years) were analyzed. Masked hypertension (HTN) and white coat HTN were seen in 138 (14.3%) and 50 (5.2%) participants, respectively. There was moderate concordance between ABPM and OBPM readings (Cohen's κ =0.571, 95% confidence interval [CI]: 0.445, 0.595, P < 0.001). There were 530 (54.8%) nondippers and 189 (19.5%) reverse dippers. High morning surge (MS) was seen in 193 patients (19.9%) and TOD was seen in 378 patients (39%). Among all the ABPM parameters which were significantly associated with TOD on univariate analysis, only BPV (P = 0.04, odds ratio [OR]: 1.04, 95% CI: 1.00, 1.08) and systolic BP in active phase (P = 0.01, OR: 1.02, 95% CI: 1.00, 1.04) were found to be predictors of TOD after multiple logistic regression analysis. Dipping status and MS were not associated with TOD. Conclusions: ABPM is a useful tool for diagnosis and accurate categorization of HTN. The analysis of ABPM parameters helps to identify the patients with BPV which has important implications for the prevention of TOD. ABPM is recommended in all individuals with cardiometabolic risk profile or with established TOD even with normal office BP readings.

Keywords: Ambulatory blood pressure monitoring, blood pressure variability, hypertension, target organ damage


How to cite this article:
Hegde SB, Aroor S, Anupama YJ, Hegde SN. Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India. APIK J Int Med 2022;10:111-7

How to cite this URL:
Hegde SB, Aroor S, Anupama YJ, Hegde SN. Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India. APIK J Int Med [serial online] 2022 [cited 2022 May 26];10:111-7. Available from: https://www.ajim.in/text.asp?2022/10/2/111/338903




  Introduction Top


High blood pressure (BP) is an important modifiable risk factor for cardiovascular diseases (CVDs) and accounts for more than 12.8% of deaths globally.[1] An estimated 1.39 billion adult population worldwide have high BP and the prevalence is increasing in low- and middle-income countries.[2] High systolic BP (SBP) is found to be the leading risk factor for disability adjusted life years in adults aged 50 years and above.[3] In India, CVD is a major cause of mortality accounting for nearly one-fourth of all deaths and hypertension (HTN) contributes significantly to both cardiovascular and cerebrovascular deaths.[4] The effects of high BP levels on target organ damage (TOD) and the beneficial effects of antihypertensive therapy has been well established. In an individual, BP is not constant and varies significantly at different times of the day and between days. This BP variability (BPV) may be occurring over short term (like minutes to days) or long term (over days to months). Although the most common method of monitoring BP in an individual is office BP measurement (OBPM), the use of ambulatory BP monitoring (ABPM) which measures BP over 24 h or more is gaining importance in recognition and management of HTN. Studies have recognized that TOD is associated with some circadian changes of BP or BP load during the day rather than isolated BP elevation. ABPM has been shown to be a strong predictor of all-cause and CV mortality than OBPM and many clinical practice guidelines such as National Institute for Health and Care, Joint National Council, and European Society of Cardiology have recommended the use of ABPM in clinical practice.[5],[6],[7],[8] Evidence from many preclinical and clinical studies have clearly shown the role of long-term BPV in cardiovascular complications of HTN.[9],[10] However, studies on short-term BPV and its association with TOD are sparse. In this background, we aimed to analyze the BP patterns by ABPM and to evaluate the degree of concordance between ABPM and OBPM. We also looked at ABPM parameters in the hypertensive and the normotensive participants with the aim of determining the association between these parameters and TOD status of the participants.


  Materials and Methods Top


Study setting and participants

This observational study was conducted in an outpatient clinic of a district headquarters town in Karnataka state, India. Patients visiting clinic of the authors for the regular medical management between January 2018 and August 2019 were enrolled as study participants. These patients included those with diabetes, HTN, cardiovascular, cerebrovascular, airway diseases, and other medical conditions.

Inclusion and exclusion criteria

Participants aged 18 years and above were included in the study. This included patients with high BP on OBPM. Those with normal BP either with some co morbidities or having physical profile or lifestyle which may lead to increased risk for developing HTN were also included. Patients with any hemodynamic instability and those who did not tolerate ABPM were excluded from the study.

Data collection

Patients' details such as age, gender, habits like smoking, tobacco or alcohol consumption were collected. History of diabetes, HTN, presence of other comorbid conditions such as CVD and stroke were elicited. BP, height, and weight were recorded and body mass index (BMI) was calculated. Electrocardiography (ECG) and echocardiography were done in all participants while Carotid Doppler, computed tomography scan, or magnetic resonance imaging brain was done in selected cases based on clinical requirements.

Measurement of blood pressure by OBPM and ambulatory blood pressure monitoring

Office BP was recorded by the physician during the patients' office visits using a BP apparatus by oscillometric method with the patient in the sitting position. An average of three readings taken 5 min apart was considered to be the office BP (OBPM). Patients were explained about the study, ABPM instrument and procedure. Those who were willing to participate were recruited to the study after written informed consent. The physician connected the ABPM machine to the participants and they were allowed to go home. After 24 h, they revisited the clinic and the machine was removed and data were retrieved to generate the ABPM report. ABPM 05 machine (Meditech™, Hungary) which measures BP by oscillometric method was used and the data analyzed using Easy ABPM software.[11] ABPM was recorded on all subjects enrolled in the study. Their medications were not modified during the study. ABPM included BP monitoring for a 24-h period, which was divided into an active (day/awake time) and passive (night/sleep time) period. The measurement interval times were programmed to every 15 min at day time (active period) and every 30 min at night time (passive period). The ABPM report provided the BP data recorded during 24 h, active and passive period. The report also provided the details of percent time elevation (PTE), hyperbaric impact (HBI), diurnal index, and morning surge (MS).

Definition of relevant terms

All subjects with either history of HTN or on antihypertensive medications or SBP >140 mmHg and or diastolic BP (DBP) >90 mmHg on office BP measurements were considered as hypertensives. Study subjects were classified into four categories based on their OBPM and ABPM values as per the European Society of HTN Guidelines.[7] The threshold values for OBPM and ABPM are as follows: SBP 140 mmHg and/or DBP D90 mmHg on OBPM, 24-h SBP S130 and/or DBP D80 mmHg on ABPM recording.

  1. Normotension: Normal OBPM and normal ABPM. This could indicate either a nonhypertensive person or a hypertensive person whose BP is well controlled
  2. Persistent hypertension (PH): Elevated OBPM and elevated ABPM
  3. White-coat hypertension (WCH): Elevated OBPM and normal ABPM
  4. Masked hypertension (MH): Normal OBPM and elevated ABPM.


    • BPV – Which refers to the BP changes that occur within a day (24 h), is characterized by circadian variations in BP and measured by standard deviation (SD) or coefficient of variation of 24-h BP
    • MS – Defined as the morning BP (BP 2-h after rising) minus the sleep BP (the average BP during sleep)[12]
    • Nocturnal dipping – Also known as the diurnal index is defined as the difference between the mean day-time SBP and mean night-time SBP, expressed as a percentage of the day time mean.[12],[13]


These were further categorized into the following category based on their dipping patterns:

  • Dippers – Individuals whose BP dips in the range of 10%–20%[12]
  • Extreme dippers – Those who dip >20%
  • Nondippers – Those who exhibit <10% dip in BP
  • Reverse dippers – on the other hand, those who have an increase in nocturnal BP, instead of a dip
  • PTE is the percentage of time of 24 h during which BP values are considered to be higher than normal[14]
  • Hyperbaric index (HBI) is a measure of the total load exerted on the arterial wall and is calculated as the total area (within one cycle) of any given patient's BP above the threshold.[14]


Obesity was defined as BMI >25 kg/m2 and individuals with BMI 18–25 kg/m2 were considered as normal BMI.[15]

TOD was defined as the presence of any of these organ damages: CVD, cerebrovascular disease, or renal diseases. CVDs could be left ventricular hypertrophy (LVH) or ischemic heart diseases such as angina, or myocardial infarction as determined by ECG/echocardiography. Cerebrovascular diseases were defined as transient ischemic attacks or stroke as determined by clinical examination and radiologic abnormalities. Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate <60 ml/min/1.73 m2 calculated using CKD-epidemiology collaboration equation.[16]

Human rights protection

Study protocol was approved by an independent accredited ethics committee. The subjects were enrolled after written informed consent. They were given sufficient time and information regarding the study protocol. Their apprehensions were suitably addressed and they participated voluntarily without any force by the investigators. They were also given the option to withdraw anytime during the study.

Statistical analysis

Main demographic and clinical data were summarized by calculating the mean (± SD) or median (interquartile range [IQR]) as applicable in case of continuous variables and the absolute (n) and relative (%) frequency in case of categorical variables. The association of ABPM parameters with TOD was assessed by independent t-test in case of continuous variables and Chi-square test in case of categorical variables. P < 0.05 was considered as statistically significant. Parameters which were found to be associated with TOD having P < 0.1 were used as independent variables in a multiple logistic regression to determine significant associations, with TOD as the dependent variable. All statistical analysis was done using SPSS statistical software (SPSS version 16, SPSS Inc., Chicago, IL, USA).


  Results Top


A total of 1064 subjects were enrolled in the study. Data of 968 (90.9%) subjects were considered as evaluable with successful readings (readings having >70% of 24-h ABPM recordings) and were included in the study analysis. Ninety-six subjects were excluded because of incomplete recordings. This cohort of 968 subjects included 656 patients with known HTN on treatment and 312 (32.2%) subjects without history of HTN. After OBPM, 79 subjects were newly detected to be hypertensives.

Subject characteristics

Baseline characteristics of the study participants are shown in [Table 1]. The mean age of the subjects was 59.39 ± 14.86 years with an age range of 18–96 years. There were 595 (61.5%) males and 373 (38.5%) females. More than 80% of the subjects were in the age group of 40–79 years with nearly half of the participants in the age group of 60–79 years. There were 528 (54.54%) subjects with BMI more than 25.
Table 1: Baseline characteristics of study participants (n=968)

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Blood pressure measurements and hypertension categories

Median (IQR) SBP and DBP by OBPM were 140 (132–170) and 90 (80–100) mmHg, respectively. The highest BP reading was 290/190 mmHg and the least was 90/60 mmHg. Mean 24 h SBP and DBP on ABPM were 135.9 (±21.6) and 78.2 (±12.8) mmHg, respectively. Twenty-four-hour mean SBP ranged between 89 and 218 mmHg, while mean DBP ranged between 45 and 130 mmHg, respectively. Based on OBPM readings, 503 people had BP readings >140/90 mmHg. ABPM readings suggested 591 had BP in the HTN range. Cohen's kappa was run to determine the degree of agreement between two methods of BP measurements. There was moderate agreement between the two (Cohen's κ =0.571, 95% confidence interval [CI] 0.445, 0.595, P < 0.001).

Based on OBPM and ABPM values, patients were classified into four categories-PH, normotension, MH, and WCH as described earlier [Figure 1]. Based on BP measured in the clinic, 503 (52%) subjects had BP readings in the HTN range, of whom, only 453 (46.9%) subjects had high BP readings even on ABPM. Hence, WCH was diagnosed in 50 (5.2%) subjects. On the other hand, 591 (61.1%) subjects had high BP on ABPM which was picked up in 453 subjects even on OBPM. Among them, 138 (14.3%) subjects who had high BP readings only on ABPM were (hence) diagnosed to have MH. Thus, 453 (46.9%) subjects had HTN both on OBPM and ABPM which was considered to be PH. Three twenty-seven (33.7%) subjects who had normal BP on both ABPM and OBPM were considered as normotensives [Figure 2].
Figure 1: Hypertension categories by ambulatory blood pressure monitoring

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Figure 2: Relative percentage of blood pressure readings classified as hypertension on OBPM and ambulatory blood pressure monitoring

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Circadian variations and blood pressure variability

The means of ABPM parameters and proportion of circadian variations were analyzed [Table 2]. In all, 232 (24.0%) were dippers while 530 (54.8%) were nondippers, 17 (1.8%) were extreme dippers and reverse dipping was seen in 189 (19.5%) patients. High MS was seen in 20% of patients. Mean diurnal index was 5.2 (±7.21) with the value being highest in WCH and lowest in MH.
Table 2: Ambulatory blood pressure monitoring parameters of participants

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Target organ damage and ambulatory blood pressure monitoring parameters

There were 378 (39.0%) patients with TOD. CVD was seen in 80 (8.3%) patients, cerebrovascular diseases in 222 (22.9%) and CKD in 109 (11.3%) patients. TOD was found in a higher proportion of patients with MH (40.9%) and PH (44.6%) than with normotension (31.4%) or WCH (37.7%) [Figure 3]. When compared with normotension, PH was significantly associated with TOD (odds ratio: 1.76, 95% CI: 1.31, 2.31, P < 0.001). The association of BPV, other ABPM parameters, dipping status, and MS with the presence of TOD was examined [Table 3] and [Table 4]. BPV, SBP in active and passive phase, DBP in passive phase, PTE SBP, and PTE DBP in both active and passive phases and HBI SBP and HBI DBP in both phases were significantly associated with TOD in univariate analysis. Dipping status and MS were not significantly associated with TOD. However, when logistic regression was performed with the above parameters, the only significant predictors of TOD were BPV and SBP in active phase [Table 5]. This association persisted even after adjusting the above-mentioned parameters for age, gender, and diabetes.
Figure 3: Hypertension categories and target organ damage. PH: Persistent hypertension, MH: Masked hypertension, WCH: White coat hypertension

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Table 3: Association of ambulatory blood pressure monitoring parameters with target organ damage

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Table 4: Association of dipping status with target organ damage

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Table 5: Results of multiple logistic regression of ambulatory blood pressure monitoring parameters with target organ damage

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  Discussion Top


In this clinic-based study, we demonstrated that ABPM resulted in identification of at least 10% more hypertensives than OBPM alone. We found MH in 14.3% and WCH in 5.2% participants. The detection of MH and WCH is an important diagnostic utility of ABPM. If only OBPM was considered for diagnosis as is routine in most clinic settings in India, these 19% individuals would have been wrongly diagnosed as either normotensives or hypertensives. Most ABPM parameters were found to be significantly different in patients with TOD than those without, but only BPV and active phase SBP were found to be associated with TOD on logistic regression analysis.

ABPM adds to the HTN management in two distinct areas, MH and WCH. The prevalence of MH is estimated to be 10%–15% of the general population.[17] In other words, one among every six to seven subjects with normal OBPM is likely to be having high BP on ABPM with increased chances of missing the diagnosis of HTN. MH is a clinical entity that is gaining importance in recent times. It is associated with adverse coefficient of variance (CV) outcomes similar to that of persistent HTN. In a recent meta-analysis, with pooled population of 7961 subjects, the overall adjusted hazard ratio was 2.09 (1.55, 2.8, P = 0.001) for MH versus normotension and 2.59 (2.0, 2.35, P = 0.001) for sustained HTN versus normotension.[18] It is also associated with subclinical cardiac, vascular, and renal damage.[19] In our study too, we found all ABPM parameters elevated in MH when compared to normotensive group. This underscores the need for ABPM even in subjects with normal office BP.

The prevalence of WCH is estimated to be 9%–16% in population-based studies.[20] Our study recorded WCH in 5% subjects and the low prevalence could be because this was not a population-based study and the number of HTN patients were higher in the study group. In India-ABPM study, a large clinic-based study involving 27,472 subjects, MH and WCH were found in 19.3% and 12%, respectively.[21] Although our study population was comparable to India-ABPM, the differences in prevalence may be due to the smaller sample size in our study. CV morbidity was found to be lower in WCH than in persistent HTN and is said to be on par with that in normotensives in many previous studies. Several newer studies have however contradicted this view and found greater risk of organ damage even in WCH.[22] However, we did not find significant association of WCH with TOD.

ABPM is a useful tool to detect short-term BPV and diurnal variability which are known to be responsible for several long-term effects of HTN. Short-term BPV by ABPM is generally described with SD or CV of BP values during the 24-h period. Since SD of 24 h BP strongly correlates with the decline in night time BP, this parameter is considered to represent the circadian BP variation. Many cross-sectional studies have described a significant relationship between short-term BPV and TOD. Many studies have reported that BPV by ABPM is predictive of TOD which is independent of BP recordings.[23] Our study too showed a similar association.

Blunted nocturnal dipping is more common and more severe in patients with LVH and ventricular arrhythmia. Nondipper status is also found to be associated with reduced brain matter volume, steeper decline in cognitive function, and silent cerebrovascular disease.[24],[25],[26] Similar association with nondipping has been found in patients with renal dysfunction too. However, we did not find any significant association of dipping status with the presence of TOD. We included only severe forms of TOD and the milder and subclinical forms of TOD were not assessed. This may probably explain the lack of association between dipping status and TOD in the present study.

In addition to nondipping, another important circadian variation in BP is MS. High MS is attributed to neurohumoral alterations including activation of sympathetic nervous system and catecholamines on waking. Several studies have shown the association of MS with cardiovascular events and increased risk of cerebral hemorrhage. Probably due to morning rise in BP, incidences of coronary events and ischemic stroke are higher in the early-morning period.[27],[28],[29] In our study too, we observed significant MS in PH and MH in comparison to normotensives. However, we did not find a significant association of MS with TOD in the present study.

The study has several strengths. Nearly, a thousand patients were enrolled in this study from a single center. Several ABPM parameters not routinely evaluated in other studies such as HBI and PTE were also examined in our study. However, there are a few limitations to this study. We defined TOD based on only a few major markers of organ involvement which would have underestimated the presence of TOD in the study population. Microalbuminuria and urinary albumin excretion rate were not done and if these had been included in the study, they would have been better indicators of the extent of renal damage. The cross-sectional nature of this study would limit the understanding of the impact of ABPM parameters on HTN management and patient outcomes.


  Conclusions Top


In this observational study on the utility of ABPM in a clinic setting, we could demonstrate that diagnosis of MH and WCH is missed in routine office measurements of BP and that ABPM is a useful tool to identify patients at higher risk of TOD. BPV and SBP in the active phase were significantly associated with TOD in the hypertensive population. HTN control as detected by normal OBPM in routine clinic visits may not always indicate adequate control as these patients may have significant BPV on ABPM which puts them at higher risk for TOD. It is important to perform ABPM on all hypertensive patients to recognize the magnitude of diurnal variation. This could help in educating the patients about the need for better control and to modify therapy to suit their needs.

Acknowledgments

We would like to sincerely thank Mrs. Sonali Punja for editing the English language of the manuscript. We are thankful to all the staff of Hegde Health Complex, Shvamogga for their help at various stages of this study and our sincere thanks to all participants who consented to take part in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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