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Jun 1, 2003 Table of Contents

Editorials
Ambulatory Blood Pressure Monitoring: Technology with a Purpose

MICHAEL E. ERNST, PHARM.D., BCPS

College of Pharmacy and Department of Family Medicine, University of Iowa, Iowa
City, Iowa
GEORGE R. BERGUS, M.D.
Department of Family Medicine, University of Iowa Roy J. and Lucille Carver College
of Medicine, Iowa City, Iowa
Am Fam Physician. 2003 Jun 1;67(11):2262-2271.

Related Article

Hypertension and its sequelae are responsible for many visits to family physicians.
Office-based measurement of blood pressure using aneroid or mercury
sphygmomanometry is central to such visits. In this issue of American Family
Physician, Marchiando and Elston1 review a different, but certainly not new,
approach to measurement of blood pressure. Once regarded solely as a research
instrument, noninvasive 24-hour ambulatory blood pressure monitoring (ABPM) has
emerged as a useful tool for clinicians faced with the challenges of establishing
accurate diagnoses and adjusting antihypertensive therapy. Among its many
indications, ABPM can provide useful information in the evaluation of borderline
hypertension, antihypertensive efficacy, suspected white coat hypertension, and
treatment resistance.2

In addition to multiple automated readings taken during normal daily activities,

ambulatory monitoring enables blood pressure to be measured during sleep and
permits evaluation of circadian patterns in blood pressure. Some evidence indicates

that these readings correlate more closely with surrogate measures of end organ
damage than do office blood pressure (OBP) values.3 Furthermore, recent outcome
studies have strengthened the belief that ABPM is superior to office blood pressure
readings for cardiovascular risk stratification and can be successfully used to direct
therapy.4,5 However, a recent Agency for Healthcare Quality and Research (AHRQ)
Evidence Report points out that the literature in this field is insufficient, and more
research is necessary to determine the most efficacious, practical, and costeffective approach to measuring blood pressure.6

Despite advantages over traditional office measurements, diffusion of ABPM into

routine practice is complicated by unique barriers. Access to the technology is often
limited to academic medical centers, and ambulatory blood pressure measurements
are generally lower than office measurements, even in nor-motensive patients,
making direct correlations between ABPM and OBP difficult. This lack of normative
data has been addressed through analysis of population-based registries, and
Marchiando and Elston1 use a table in their article to summarize current ABPM
thresholds for treatment.

Most hypertension intervention studies have used OBP exclusively for decisions
regarding antihypertensive therapy, and OBP values provide the basis of our current
operational thresholds for defining hypertension. Clinical guidelines emphasize OBP
should remain the standard of measurement on which most medication
interventions should be based, although they acknowledge that ABPM may be
beneficial in certain situations by providing important information not available from
OBP.3,7 While the cost-effectiveness of ABPM has been questioned,6 some evidence
exists that ABPM technology is cost-neutral or saves money.811 At present, thirdparty reimbursement for the test remains highly variable, although Medicare now
reimburses for patients with suspected white coat hypertension.

If made readily available, use of ambulatory monitoring will likely increase. This has
been our experience after establishing an ABPM referral service for primary care
physicians at the University of Iowa. Nearly two years after establishing this service,
we find our physicians make routine and appropriate use of the technology for
selected patients and integrate the results of ABPM into their clinical decisionmaking.

Which patients should receive ABPM? A carte blanche recommendation that ABPM
should be performed on all patients with hypertension is certainly not a judicious

use of resources and should be discouraged. Faced with the possibility of overusing
this convenient technology, it is important to identify patients for whom ABPM is
appropriate. As Marchiando and Elston1 point out, ABPM should supplement but not
substitute office measurements. A series of multiple office or home blood pressure
measurements has been shown to be as reliable as ABPM12,13; unfortunately,
many patients fail to consistently obtain and provide these readings. Twenty-four
hour ABPM is a logical progression. Based on our clinical experience and a review of
the literature, we offer an algorithm (see accompanying figure) for appropriate use
of ABPM that incorporates home and office measurements.14

FIGURE.
Suggested algorithm for appropriate use of ABPM.
*--Major cardiovascular risk factors in patients with hypertension (Joint National
Congress VI) include smoking, dyslipidemia, diabetes, age >60, gender (men and
postmenopausal women), and family history of early cardiovascular disease.
**--The proportion of blood pressures during the monitoring period that are
increased relative to preset thresholds (140/90 mm Hg awake, 120/80 mm Hg
asleep). (CCD = clinical cardiovascular disease; TOD = target organ damage; ABPM
= ambulatory blood pressure monitoring; SBP = systolic blood pressure.)
Hypertension will continue to be a significant problem faced by family physicians.
Sensible and rational use of ABPM technology provides us with a useful tool to
improve outcomes for carefully selected patients.

Michael E. Ernst, Pharm.D., BCPS, is an assistant professor (clinical), College of

Pharmacy and Department of Family Medicine, University of Iowa, Iowa City. He
completed his doctor of pharmacy degree at the University of Iowa, followed by a
specialty pharmacy residency in family medicine. He is a board certified
pharmacotherapy specialist and co-director of the ambulatory blood pressure
monitoring service in the Family Care Center at the University of Iowa Hospitals and
Clinics, Iowa City.

George R. Bergus, M.D., is an associate professor, Department of Family Medicine,

the University of Iowa Roy J. and Lucille Carver College of Medicine. He is a graduate
of the Medical College of Pennsylvania, Philadephia, and completed the family
medicine residency at the University of Rochester, New York. He is board certified in

family practice and has a CAQ in Geriatric Medicine and is codirector of the
ambulatory blood pressure monitoring service in the Family Care Center at the
University of Iowa Hospitals and Clinics.

Address correspondence to Michael E. Ernst, Pharm.D., BCPS., Department of Family

Medicine, 200 Hawkins Dr., 01287-PFP, University of Iowa, Iowa City, IA 52242
(michael-ernst@uiowa.edu). Reprints are not available from the authors.

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