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Papers on ABPM

Overview of ambulatory blood pressure monitoring in childhood and pregnancy
Josep Redon and Empar Lurbe

Despite the fact that the study and applicability of ambulatory blood pressure in children and pregnant women share characteristics which limit the potential development of knowledge for their use, advances produced in the last few years provided the present knowledge regarding the significance and the potential use of ambulatory blood pressure in children and in the pregnant women. In children ambulatory blood pressure monitoring is useful for the diagnosis of mild hypertensives, assessment of refractory hypertension, therapeutic trials with antihypertensive drugs, and clinical investigation when BP is one of the parameters to be taken into account and/or when subtle BP abnormalities are the objective of the study. In pregnant women, the main applicability is to assess the maternal and fetal risk in the hypertensive disorders of pregnancy.

Blood Pressure Monitoring 2001, 6:317–321
Keywords: ambulatory blood pressure monitoring, children, pregnancy,
aHypertension Clinic, Hospital Clinico and bPediatric Nephrology Unit,
Hospital General, University of Valencia, Valencia, Spain.


Superiority of Ambulatory Over Clinic Blood Pressure
Measurement in Predicting Mortality
The Dublin Outcome Study
Eamon Dolan, Alice Stanton, Lut Thijs, Kareem Hinedi, Neil Atkins, Sean McClory, Elly Den Hond, Patricia McCormack, Jan A. Staessen, Eoin O’Brien

Abstract -The purpose of this study was to determine if ambulatory blood pressure measurement predicted total and cardiovascular mortality over and beyond clinic blood pressure measurement and other cardiovascular risk factors; 5292 untreated hypertensive patients referred to a single blood pressure clinic who had clinic and ambulatory blood pressure measurement at baseline were followed up in a prospective study of mortality outcome. Multiple Cox regression was used to model time to total and cause-specific mortality for ambulatory blood pressure measurement while adjusting for clinic blood pressure measurement and other risk factors at baseline.


Blood Pressure Patterns in Normal Pregnancy, Gestational Hypertension, and Preeclampsia
Ramo´n C. Hermida, Diana E. Ayala, Artemio Mojo´n, Jose´ R. Ferna´ndez, Ignacio Alonso, Ine´s Silva, Rafael Ucieda, Manuel Iglesias
Hypertension 2000;36;149-158
Hypertension is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
Copyright © 2000 American Heart Association. All rights reserved. Print ISSN: 0194-911X. Online
ISSN: 1524-4563

ImageAbstract—With the aim to describe the daily pattern of blood pressure during the trimesters of pregnancy in clinically healthy women as well as in pregnant women who developed gestational hypertension or preeclampsia, we analyzed 1494 blood pressure series systematically sampled by ambulatory monitoring for 48 hours every 4 weeks after the first obstetric visit in 124 women with uncomplicated pregnancies, 55 with gestational hypertension, and 23 with a final diagnosis of preeclampsia. The circadian pattern of blood pressure variation for each group and trimester of gestation was established by population multiple-component analysis. A highly statistically significant circadian pattern represented by a linear model that includes components with periods of 24 and 12 hours is demonstrated for systolic and diastolic blood pressure for all groups of pregnant women in all trimesters (P,0.001 in all cases). The differences in circadian rhythm–adjusted mean between complicated and uncomplicated pregnancies are highly statistically significant in all trimesters (always P,0.001). There is also a statistically significant difference in circadian amplitude (extent of daily change) of blood pressure between healthy and complicated pregnancies in all trimesters (always P,0.004). Results further indicate similar circadian characteristics between women who later developed gestational hypertension or preeclampsia in the first trimester of pregnancy. The difference between these 2 groups in circadian mean is statistically significant in the second trimester for systolic (P50.022) but not for diastolic blood pressure (P50.986). In the third trimester, the difference in circadian mean is highly statistically significant for both variables (P,0.001). The differences in blood pressure between healthy and complicated pregnancies can be observed as early as in the first trimester of pregnancy. Those highly significant differences are found when both systolic and diastolic blood pressure for women with a later diagnosis of gestational hypertension or preeclampsia are well within the accepted normal physiological range of blood pressure variability. These differing changes in the circadian pattern of blood pressure with advancing gestational age between healthy and complicated pregnancies offer new end points that may lead to an early identification of hypertensive complications in pregnancy as well as to the establishment of prophylactic intervention.


Ambulatory Pulse Pressure as Predictor of Outcome in Older Patients With Systolic Hypertension
Jan A. Staessen, Lutgarde Thijs, Eoin T. O’Brien, Christopher J. Bulpitt, Peter W. de Leeuw, Robert H. Fagard, Choudomir Nachev, Paolo Palatini, Gianfranco Parati, Jaakko Tuomilehto, John Webster, and Michel E. Safar, for the Syst-Eur Trial Investigators

We enrolled 808 older patients with isolated systolic hypertension (160 to 219/71 95 mm Hg) to investigate whether ambulatory measurement of pulse pressure and mean pressure can refine risk stratification. The patients (60 years) were randomized to nitrendipine (10 to 40 mg/day) with the possible addition of enalapril (5 to 20 mg/day) or hydrochlorothiazide (12.5 to 25 mg/day) or to matching placebos. At baseline, pulse pressure and mean pressure were determined from six conventional blood pressure (BP) readings and from 24-h ambulatory recordings. With adjustment for significant covariables, we computed mutually adjusted relative hazard rates associated with 10 mm Hg increases in pulse pressure or mean pressure. In the placebo group, the 24-h and nighttime pulse pressures consistently predicted total and cardiovascular mortality, all cardiovascular events, stroke, and cardiac events. Daytime pulse pressure predicted cardiovascular mortality, all cardiovascular end points, and stroke. The hazard rates for 10 mm Hg increases in pulse pressure ranged from 1.25 to 1.68. Conventionally measured pulse pressure predicted only cardiovascular mortality with a hazard rate of 1.35. In the active treatment group compared with the placebo patients, the relation between outcome and ambulatory pulse pressure was attenuated to a nonsignificant level. Mean pressure determined from ambulatory or conventional BP measurements was not associated with poorer prognosis. In conclusion, in older patients with isolated systolic hypertension higher pulse pressure estimated by 24-h ambulatory monitoring was a better predictor of adverse outcomes than conventional pulse pressure, whereas conventional and ambulatory mean pressures were not correlated with a worse outcome. Am J Hypertens 2002;15:835–843 © 2002 American Journal of Hypertension, Ltd.


Ambulatory Blood Pressure Level Rather than Dipper/Nondipper Status Predicts Vascular Events in Type 2 Diabetic Subjects
Shigeru NAKANO, Tomohiko ITO, Keisuke FURUYA, Shin-ichi TSUDA, Kazunori KONISHI, Makoto NISHIZAWA, Atsushi NAKAGAWA, Toshikazu KIGOSHI, and Kenzo UCHIDA
From the Division of Endocrinology, the Department of Internal Medicine, Kanazawa Medical University, Ishikawa, Japan.

To clarify which parameter, diurnal pattern of blood pressure (BP) or level of BP variability, has the stronger predictive value for fatal and nonfatal vascular events, vital status after a mean (±SD) follow-up period of 86±46 months was determined in 392 type 2 diabetic subjects without any history of vascular disease, in whom the 24-h BP profile had been monitored between 1988 and 1998. After the exclusion of 28 subjects who died during the follow-up period of causes unrelated to diabetes, 364 subjects were recruited for further analysis. A total of 147 first events, including 50 fatal vascular events and 97 nonfatal vascular events, were recorded during the follow-up period. The rates of various vascular events increased with both reduced nocturnal falls in systolic BP (SBP) and levels of all ambulatory BP parameters. The ambulatory BP parameter showing the largest area under the receiver operating characteristic curve (ROCAUC) for fatal events was the mean 24-h pulse pressure (PP), and that for nonfatal events was the mean nighttime SBP; both exceeded the respective values of nocturnal fall in SBP. Furthermore, when dipper and nondipper diabetic subjects were divided into subgroups based on the 24-h PP (54.3 mmHg) and the nighttime SBP (116.5 mmHg) cut-off points derived from the ROC analyses, Kaplan-Meier plots showed that the diabetic subgroups with high ambulatory BP levels had worse outcomes, independent of dipper/nondipper status. Finally, these parameters were applied to the Cox model with the values of nocturnal fall in SBP and other confounding factors, and results showed that mean 24-h PP and mean nighttime SBP predicted fatal and nonfatal vascular events, respectively, more strongly than nocturnal fall in SBP in type 2 diabetic subjects. These findings therefore suggest that ambulatory BP levels in type 2 diabetic subjects have a higher predictive value for organ damage and death compared with diurnal BP patterns or dipper/nondipper status. (Hypertens Res 2004; 27: 647–656)


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