Smad shows high blood pressure. Smad for identifying diseases and prescribing accurate treatment. How is the procedure carried out

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What is this examination - SMAD?

Ambulatory blood pressure monitoring (ABPM) is an outpatient method for measuring blood pressure on an ongoing basis. Ambulatory blood pressure monitoring allows you to record many blood pressure (BP) readings over a 24-hour period, whether the patient is awake or asleep. In most cases, 24-hour monitors take readings every 20-30 minutes during the day and every hour at night with simultaneous measurement of the pulse. Ambulatory blood pressure monitoring gives the doctor information about how blood pressure changes with daily activities and sleep patterns.

What does it show and what diseases does it diagnose?

BP values ​​are recorded by the device for a day of measurements to obtain average values, calculate BP and heart rate variations, BP distribution patterns and other statistics that will help determine the type of hypertension in a patient. Hypertension is a blood pressure measurement in which the systolic (upper) blood pressure is 140 or higher and the diastolic (lower) blood pressure is 90 or higher. For most people, systolic BP drops by about 10-20% during sleep. However, for some people, blood pressure may not drop during sleep and may even rise. 24-hour monitoring can detect abnormal fluctuations that may go unnoticed if blood pressure is only measured in the doctor's office.

When is SMAD used?

• Control episodes of syncope or hypotension.
• Determining how well antihypertensive drugs can control blood pressure, because some of them are not effective enough throughout the day and night.
• Help in preventing the development of acute cardiovascular and cerebrovascular diseases associated with hypertension.

How is the examination carried out?

The patient wears a device the size of a portable radio, which is secured with a belt. During the day, he collects information that will subsequently be transferred to a computer. The cuff attached to the device is put on the arm. The cuff can be worn under clothing, so it will not be visible. It inflates automatically at regular intervals during the day and night. The patient is asked to keep a diary of daily activities to find out what causes pressure changes. After 24 hours, the device and cuff can be removed and returned to the doctor, who will analyze the results and issue a conclusion.

Preparation for the study, contraindications

The procedure does not require special preparation, has no contraindications and side effects. The patient may experience discomfort due to re-inflation of the cuff. This can affect nighttime sleep. The cuff can also irritate the skin and cause a mild rash on the arm that usually goes away on its own.

Traditionally, one-time blood pressure (BP) measurements taken when examining patients do not always reflect its true values, do not give an idea of ​​the daily dynamics, therefore, it is difficult to diagnose arterial hypertension, select antihypertensive drugs, evaluate their effectiveness (especially with a single use) and the adequacy of treatment.

In a fairly significant number of patients during a visit to the doctor, and often in clinical practice, with single measurements, high blood pressure numbers are found, sometimes by 20–40 mm Hg. higher than when measured at home. This is sometimes erroneously interpreted as hypertension, but more often as a "white coat effect". Ambulatory 24-hour blood pressure monitoring (ABPM) in the conditions of normal human activity helps to eliminate this effect, improve the quality of diagnosis and correctly determine the need and tactics of treatment.

In addition, ABPM helps to detect false-negative cases when, with single measurements of blood pressure, normal values ​​are obtained and patients are considered normotensive, although in fact they are hypertensive, tk. when monitoring, they have higher pressure figures throughout the day.

With modern approaches to the treatment of hypertension (AH), it is required to select drugs that can ensure the maintenance of an adequate level of blood pressure for 24 hours. At the same time, the importance of ABPM as a method for assessing the quality of antihypertensive therapy cannot be overestimated.

INDICATIONS FOR BP MONITORING.

Monitoring of blood pressure for a day or more can be used not only to diagnose and control the effectiveness of treatment of arterial hypertension (AH), but also to study the effect on blood pressure of various stressful situations, diet, alcohol intake, smoking, exercise, concomitant drug therapy, etc. .d.

ABPM is the only non-invasive examination method that allows you to:
get information about the level and fluctuations in blood pressure during the day, during wakefulness and sleep;
identify patients with nocturnal hypertension who are at increased risk of target organ damage;
evaluate the adequacy of blood pressure reduction between doses of the next dose of the drug;
control the absence of an excessive decrease in blood pressure at the peak of the drug's action or an insufficient decrease before the next dose, which is especially important when using prolonged antihypertensive drugs designed for a single dose per day;
identify patients with reduced or increased BP variability (insufficient or excessive decrease at night) and decide on the selection and prescription of an antihypertensive drug, taking into account its impact on blood pressure indicators not only during the day, but also at night.

Carrying out SMAD is shown:
Patients suspected of having "office" or "white coat" hypertension and should be considered for treatment;
patients with borderline arterial hypertension, in order to justify the need for drug therapy;
with symptomatic arterial hypertension (renal, endocrine origin, etc.);
with hypertension in pregnant women, nephropathy of pregnant women;
patients with hypertension, resistant according to traditional measurements of blood pressure to treatment with various groups of antihypertensive drugs;
in a number of emergency conditions (hypertensive crises, acute myocardial infarction, acute cerebrovascular accidents, subarachnoid hemorrhages, etc.);
with neurocirculatory dystonia (detection of postural changes in blood pressure associated with the transition from a horizontal to a vertical position of the body and vice versa);
with hypotension, including that resulting from treatment with antihypertensive drugs;
to assess changes in blood pressure during nocturnal angina and respiratory failure;
patients with sleep apnea syndrome;
patients with disorders of carbohydrate and lipid metabolism;
patients with left ventricular myocardial hypertrophy;
during examination before the upcoming major surgery (to assess the risk of hemodynamic disturbances during anesthesia, surgery and in the postoperative period);
in patients with sick sinus syndrome (with stops of the sinus node).

To obtain reliable information when monitoring blood pressure, it is recommended to avoid typical errors that can lead to distortion of measurement results:
use of a device that has not passed clinical verification;
incorrect cuff selection;
displacement of the cuff during monitoring;
lack of a detailed patient diary;
Incorrectly reported sleep and wake times in data analysis;
analysis of BP variability with a large number of unsuccessful measurements;
analysis of nighttime blood pressure values ​​in case of severe sleep disorders caused by the operation of the device, poor tolerance of the procedure;
carrying out monitoring during intensive diagnostic examinations, including taking blood for analysis;
monitoring blood pressure in patients with severe arrhythmias (permanent form of atrial fibrillation, a large number of extrasystoles exceeding 400 per hour or 7-8 per minute, etc.).

TYPES OF PRESSURE MONITORS.

To solve the problems facing the doctor and correctly assess the results of ABPM, it is necessary to know the principles of operation and design of the pressure monitors used.

The operation of all ambulatory blood pressure monitors is based on the detection of restoration of blood flow through the artery after its clamping and subsequent release of pressure in the cuff. The principle of pressure measurement used in some monitors during the injection of air into the cuff gives overestimated results, since in order to overcome the elasticity of the artery wall when it is clamped, it is necessary to create excess pressure that exceeds the pressure in the vessel, especially when it is sclerosed.

To determine the moment of restoration of blood flow through the vessel, various methods can be used: volumetric or electroplethysmography, photoplethysmography (sensors that work in transmitted or reflected light and respond to the appearance of oxyhemoglobin), ultrasonic blood flow detectors, capacitive pulse transducers, isotope clearance sensors, etc. .

Not all of these methods are applicable in the design of wearable devices for monitoring blood pressure. Impedance systems, for example, in which the restoration of blood flow through the artery is controlled by the rheographic method, have not found application in outpatient practice, not only because of the complexity of operation, but also because of the insufficiently small dimensions of the devices.

Ultrasonic sensors based on the Doppler effect have also not been used in ambulatory blood pressure monitoring systems due to low noise immunity and difficulties in positioning the blood flow sensor over the artery.

The first mass-produced ambulatory pressure monitors used an acoustic measurement method based on the detection of Korotkoff sounds using special microphones built into the cuff. Applying the cuff requires precise positioning of the microphone over the artery and maintaining its position for all measurements, which is quite difficult to achieve during the day.

However, this method, although it has become the most widely used and is considered a reference, does not always satisfy users due to the insufficient accuracy of measuring diastolic pressure (BPd), when errors can reach 10–20%. In addition, the mechanism of the origin of Korotkoff's tones and the dependence of their amplitude and frequency characteristics, as well as the moment of appearance and disappearance, on the elastic properties of the arteries remain not fully elucidated.

Monitors built on the acoustic principle of measurement are not sufficiently protected from external noise and interference that occur when the cuff with the microphone located in it rubs against clothing, etc. Therefore, combined systems with simultaneous ECG recording began to be produced, in which noise immunity is ensured by the fact that the microprocessor binds to pressure values ​​only those tones that coincide in time with the R wave of the electrocardiosignal, and the remaining acoustic phenomena are regarded as artifacts.

The disadvantages of pressure monitors with an acoustic measurement principle are not limited to those listed. The sensors built into the cuff are sensitive to mechanical damage, often fail due to breakage of the piezoceramic crystal or broken wires.

The oscillometric method was found to be more suitable for use in ambulatory monitoring systems. Oscillatory systems, such as the ABPM-02 monitor from Meditech (Hungary), have become quite widespread, since they are practically insensitive to noise and allow you to quickly and easily apply a cuff without worrying about its precise positioning. An important advantage of the oscillatory method is the ability to determine the mean pressure (APm), information about which is necessary to understand the course of development of various forms of hypertension, determine the dependence of blood pressure on external factors and therapeutic measures. These monitors are useful for monitoring blood pressure in patients with weak pulses, muffled Korotkoff sounds, or low blood pressure.

In devices based on the oscillatory method, systolic (BPs) and mean (APm) blood pressure are measured. The pressure value in the cuff at the moment of the appearance of the first pulsations during decompression is taken as BPs, and the pressure corresponding to the appearance of oscillations with a maximum amplitude is taken as BPav. Diastolic pressure (BPd) is calculated based on automatic analysis of the amplitude and shape of air pulsations in the cuff according to algorithms that are usually kept secret by developers.

In monitors of other designs, BPm is most often calculated automatically by adding 1/3 of the pulse pressure to the diastolic pressure.

Recently, monitors with a pulse-dynamic method for determining blood pressure have appeared. For example, in the monitors "Dynapulse" of the American company "Pulse Metric", instead of the amplitude one, the so-called "figurative" or contour method of evaluation is used, when during the analysis of each oscillation of air in the cuff, a pulse wave in the artery is constructed, in a patented way, and it is measured BPs and BPd, and BPm is calculated automatically by adding 1/3 systolic 2/3 diastolic.

The display on the computer screen of the pulse waves reconstructed for each contraction and individual analysis of their shape makes it possible to detect irregular (arrhythmic) contractions, which helps in assessing the accuracy of measurements.

By themselves, the values ​​​​of BPs and BPd, determined by any indirect method, are not numbers of pressure inside the artery. Rather, it is the pressure that needs to be created in the cuff to stop blood flow and spread the pulse wave through the artery or change the nature of the tones heard over it. Although these pressure values ​​are directly proportional to the true ones, they are still noticeably higher and have a purely local and conditional value according to the cuff application site, the position of the patient and the type of equipment used. However, these figures should not be neglected, because. they may be important for characterizing the state of the vascular system and circulation in general.

At the same time, the BPmean value is absolute and does not depend on the state of the artery wall, soft tissues and integument of the limb, and the properties of the cuff.

Oscillometric blood pressure monitoring systems are also not without drawbacks. When using them, it is mandatory to ensure, at the time of measurement, the immobility of the limb on which the cuff is applied. Therefore, some companies, in particular Schiller (Switzerland), produce oscillatory pressure monitors, in which a combination of oscillometric and acoustic methods is used to increase noise immunity.

Apparently, when developing blood pressure monitors, it is more expedient to use a combination of oscillatory and electrocardiographic or, in extreme cases, acoustic and electrocardiographic, but it is better than all three methods, as is done in the combined monitors "Kardiotekhnika-4000-AD" by Incart (St. Petersburg), intended for monitoring both ECG and blood pressure. It should be noted that the use of blood pressure monitors, in which the ECG serves only to control the correctness of the selection of pulsations or Korotkoff sounds, is not entirely justified economically, since it requires the purchase of disposable ECG electrodes, which increases the cost of the study. But, due to greater noise immunity, blood pressure measurements with their help can be carried out during physical exertion.

Modern ambulatory blood pressure monitors inflate the cuff automatically to a certain pre-set value. If this value significantly exceeds the systolic blood pressure or does not reach it, then during repeated measurements, the device automatically corrects the pressure created in the cuff.

Measurements, as a rule, are carried out according to a given program during decompression, which occurs according to different algorithms. In some monitors, the rate of pressure release in the cuff is uneven at first the pressure is released slowly, and after determining blood pressure faster, in others the rate is uniform by 2-3 mm Hg. on a pulse beat, thirdly, it is automatically adjusted, depending on the pressure and heart rate, which is preferable, because. systems with a constant uniform reset delay the procedure for measuring blood pressure, especially with a rare pulse, and cause discomfort to the patient. Increasing the decompression rate can lead to measurement errors, more noticeable in bradycardia.

The accuracy of pressure measurement by monitors is usually not controlled by the user, as it is guaranteed by manufacturers in accordance with international requirements and standards.

The safety of patients is ensured by the presence of software or mechanical means in the monitors that automatically turn off the power of the compressor and relieve pressure in the cuff when the maximum allowable pressure values ​​or the time of compression of the limb, controlled by the built-in real-time clock, are exceeded. In addition, monitors can be equipped with a button for manual emergency shutdown of the compressor and pressure relief.

EXAMINATION METHOD.

Before installing the monitor, it is necessary to familiarize the patient with the goals and objectives of the study, as well as with the pressure measurement mode.

The cuff is superimposed on the middle third of the shoulder, preferably over a thin shirt, which is necessary for hygienic reasons, as well as to prevent the occurrence of discomfort or skin irritation with frequent compressions. Applying a cuff over thin tissue does not affect the measurement accuracy in any way. More research by Prof. A. I. Yarotsky, it was shown that under different measurement conditions (imposing a cuff through a layer of cotton wool and a bandage), the pressure value at the appearance of maximum oscillations was always the same.

It is desirable to program the frequency of measurements taking into account the time of sleep and wakefulness of the patient.

According to the recommendations of the working group of the national NBREP program (USA, 1990), the total number of measurements during the day should be at least 50. Most often, blood pressure measurements are performed once every 15 minutes during the daytime and once every 30 minutes at night.

To study the rate of rise in blood pressure in the morning, it is recommended to increase the frequency of measurements up to 1 time in 10 minutes for 1-2 hours after waking up.

When examining patients with blood pressure exceeding 180−190 mm Hg. Art. the number of complaints about unpleasant sensations associated with the operation of the monitor and sleep disturbances is increasing. In such cases, it is desirable to increase the intervals between measurements up to 30 min. day and up to 60 min. at night (recommendations of the Research Institute of Cardiology named after A.L. Myasnikov). This does not lead to statistically significant changes in the main indicators of the daily BP profile and affects mainly the variability indicators.

Typically, patients rarely wake up during the night while the cuff is being inflated. But irritable and easily excitable patients can be advised to take sleeping pills at night.

ASSESSMENT OF THE RESULTS OF MONITORING HELL.

Before proceeding with the evaluation of the results of pressure monitoring, it is necessary to know the principle of operation of the device used and keep in mind that the auscultatory method determines blood pressure quite accurately, but the error in determining blood pressure can reach 10–20%. The oscillatory method allows you to accurately measure all pressure characteristics, although errors in measuring systolic and, especially, diastolic pressure are also not excluded.

The WHO-recommended values ​​of 140/90 mm Hg are usually taken as the upper limit of normal. Some monitors provide lower numbers for night time or have the ability to change the hypertensive thresholds or conditional norm for blood pressure in the range of 120-180 mmHg. and ADd 70−110 mm Hg.

In accordance with international standards, the results of the examination can be considered suitable for further analysis if the device provided at least 80% of satisfactory measurements from those programmed for 24 hours.

It is advisable to evaluate the results in the following order:

1. Visual assessment of trends, cuff pressure oscillations, and reconstructed arterial pulse waves (if available).
2. Evaluation of the maximum, minimum and average values ​​of BPs, BPd, BPmean, BP pulse and heart rate and their dynamics over the observation period according to graphs or digital tables and (if necessary) editing them.
3. Analysis of distribution histograms of the specified parameters.
4. Evaluation of blood pressure variability at different times of the day.
5. Statistical analysis for the entire observation period, day and night fluctuations of parameters, as well as statistical analysis of data for any selected period of time, indicating the maximum, minimum and average values ​​and standard deviation.
6. Evaluation of "body pressure overload" during wakefulness and sleep according to various calculated indicators and indices.
7. Evaluation of the rate and magnitude of the morning rise in blood pressure.

DAILY RHYTHM HELL.

In normotensive patients and in patients with mild or moderate arterial hypertension, there are distinct circadian variations in blood pressure. The maximum values ​​of blood pressure are usually recorded in the daytime, then gradually decrease, reaching a minimum shortly after midnight, and then increase quite sharply in the early morning hours, after waking up. Such dynamics of blood pressure, to some extent, is determined by the activity of the sympathetic nervous system, since it coincides with circadian changes in the concentration of norepinephrine in blood plasma. Therefore, when analyzing ABPM data, it is desirable to specifically note the time when the maximum and minimum blood pressure was recorded for the entire observation period.

Blood pressure levels and their fluctuations during the day, as well as the ratio of daytime and nighttime values, are largely determined by the physical activity of patients. It has been noted that among people with little pronounced daily fluctuations in blood pressure, cardiovascular diseases are common. In our opinion, this observation can rather be explained by the presence of a disease that forces the patient to limit daily physical activity.

Therefore, studying the effect of different levels of physical activity on diurnal fluctuations in BP, detected by ambulatory monitoring, may clarify this issue and assist in making decisions about treatment tactics in these patients.

The absence of a physiological decrease in blood pressure during sleep is associated with an increase in the prevalence of atherosclerotic complications and left ventricular hypertrophy, as well as with dysfunction of the autonomic nervous system.

If, when analyzing trends in 24-hour BP variations, we evaluate the amplitudes and phases of fluctuations, then we can obtain information about the violation of its regulation. It has been noted that diurnal variations in blood pressure in healthy people are usually closely related to variations in heart rate. In patients, for example, with coarctation of the aorta in a typical place, in which both systolic and diastolic pressure in the upper limbs is significantly higher than normal, analysis of BP variations reveals dissociation between the amplitudes of BP and BPd and between the phases of HR and BP. Increased diurnal reactivity of BP and BPd in ​​combination with phase dissociation between BP and HR may reflect impaired baroreflex control of BP in patients with aortic coarctation even after successful surgery.

SPEED OF THE MORNING RISE OF HELL.

In the period from 4 to 10 am, there is a sharp increase in blood pressure from the minimum nighttime values ​​to the daytime level, which coincides, as mentioned above, with the circadian activation of the sympathetic-adrenal system and an increase in the concentration of norepinephrine in the blood plasma. Therefore, when analyzing trends in diurnal fluctuations in blood pressure, it is necessary to pay attention to the early morning hours, since it is at this time that cerebrovascular and coronary complications can occur.

The value of the morning rise in blood pressure is determined by the difference between the maximum and minimum values ​​of blood pressure and blood pressure, and the rate is determined by dividing the difference between these values ​​by the time interval. It has been established that a large value and rate of blood pressure growth in the morning hours are more typical for patients with GB than for healthy individuals.

The dependence of the magnitude and speed of the morning rise in blood pressure on the age of patients was also found: these indicators have the highest values ​​in persons over 60 years of age.

Some researchers have established criteria for diagnosing mild hypertension when 50% or more of pressure values ​​after awakening exceed 140/90, and 50% or more of nighttime measurements exceed 120/80 mmHg. .

HELL VARIABILITY.

Blood pressure, like all physiological parameters, is characterized by fluctuations (variability). Variability in blood pressure during 24-hour monitoring is most often calculated as a standard deviation from the mean value or the coefficient of its variability for a day, day and night. When assessing BP variability, it is necessary to take into account the patient's activity, his mood and other factors, in accordance with the diary.

BP variability is considered elevated if it exceeds normal levels in at least one of the time periods.

In most people, blood pressure fluctuations have a biphasic rhythm, which is characterized by a nightly decrease in blood pressure in both normotonic and hypertensive patients, and its magnitude can vary individually. The severity of the biphasic BP rhythm is assessed by the day-night difference or by the daily index for BPs and BPd.

Presentation of the results of statistical analysis of measurements allows you to calculate some indicators that facilitate the diagnosis of arterial hypertension.

1. "Daily Index" (SI), reflecting the variability of blood pressure, represents the difference between the average values ​​of blood pressure during the day and at night as a percentage. Normal values ​​of the “daily index” are 10–25%, i.e. the average level of nighttime blood pressure should be at least 10% lower than the average daytime. Night pressure reduction by 10-22% is considered optimal. This decrease in BP at night is an integral part of the circadian rhythm and does not depend on the average value of BP during the daytime hours.

Disturbances in the circadian rhythm of blood pressure are more common in patients with impaired carbohydrate tolerance, with type I and type II diabetes mellitus without hypertension and with hypertension, in patients suffering from secondary hypertension (pheochromocytoma, renal hypertension, chronic renal failure), as well as in the elderly.

In some normotonic patients with aggravated heredity for hypertension, disturbances in the circadian rhythm of blood pressure are also observed - insufficient or excessive decrease at night.

Depending on the SI values, the following groups of patients are distinguished:
"Dipper" patients with a normal decrease in blood pressure at night, in which CI is 10−20%;
"Non-dipper" patients with insufficient nocturnal BP reduction, in whom CI is less than 10%;
"Over-dipper" patients with an excessive decrease in blood pressure at night, in which CI exceeds 20%;
"Night-peaker" persons with nocturnal hypertension, whose blood pressure at night exceeds the daytime and CI is negative.

A decrease in the SI value is characteristic of the following pathology:
primary hypertension (including atherosclerotic lesions of the carotid arteries);
syndrome of malignant course of hypertension;
chronic renal failure, renovascular hypertension;
endocrine pathology (Kon's disease, Itsenko-Cushing's disease, pheochromocytoma, diabetes mellitus);
Hypertension of pregnant women, nephropathy of pregnant women (preeclampsia, eclampsia);
congestive heart failure;
condition after kidney or heart transplantation;
damage to target organs in hypertension (kidneys, myocardium).

Circadian rhythm disturbances with insufficient reduction in blood pressure at night also correlate with:
high frequency of stroke;
frequent development of left ventricular myocardial hypertrophy;
abnormal geometry of the left ventricle;
higher incidence of coronary artery disease and mortality from myocardial infarction in non-dipper women;
the frequency and severity of microalbuminuria the earliest marker of kidney damage;
serum creatinine level;
the severity of retinopathy;
sleep apnea syndrome (which is found in 20-50% of patients with GB).

In case of impaired renal function, SI in the vast majority of cases is less than 10%, and in the most severe cases, SI becomes negative. However, the detection of a reduced SI does not unambiguously indicate the presence of one of the listed pathologies, but the frequency of its occurrence is significantly higher than in patients with normal SI.

A decrease in CI can occur with shallow superficial sleep, with drug-induced arterial hypotension.

In patients with an excessive drop in blood pressure at night, ischemic complications are much more likely to occur, which is especially dangerous in concomitant coronary pathology and carotid artery lesions, and requires caution when using long-acting drugs because of the risk of aggravating nocturnal hypotension and, therefore, ischemia.

A decrease in circadian BP variability can be observed in patients with secondary hypertension, dysfunction of the autonomic nervous system, in the elderly, and in patients after heart transplantation.

High BP variability is typical for most AH patients and can be considered as an independent risk factor for target organ damage.

Not only the absolute values ​​of blood pressure, but also the total time during the day when it remains elevated, are important risk factors for cardiovascular complications.

2. Hypertonic (hypotonic) "time index" (HVI), shows in what percentage of the time of the total monitoring duration (or in what percentage of measurements) the blood pressure was above (below) normal, and the conditional limit of the norm for the daytime is 140/90 (average daytime blood pressure = 135/85), and for night 120/80 mmHg (mid-night BP = 115/72), which gives an average value of BP = 130/80 mm Hg for a full day.

According to various data, the GVI in most healthy individuals ranges from 10 to 20% and does not exceed 25%. BBVI for BPmean exceeding 25% is considered unequivocally pathological, which gives grounds for the diagnosis of AH or symptomatic AH. Stable AH is diagnosed when BBVI is at least 50% during the day and at night.

The presence of GVI in a patient receiving antihypertensive therapy above 25% indicates the insufficient effectiveness of the treatment.

In severe arterial hypertension, when during all measurements the BP figures exceed the established limits of the conditional norm, the GVI becomes equal to 100% and ceases to objectively reflect the increase in pressure overload of the target organs.

3. "Area Index" (IP) or hyperbaric (pressure load), shows what kind of hypertonic load acts on the body, i.e. how long during a 24-hour period the patient has elevated blood pressure and how much, on average, it exceeds the upper limit of the normal range (in the graphs, this is the area under the curve above the normal level (in mm Hg * hour) or integral pressure *time Since the area depends not only on the magnitude of the rise in pressure, but also on the duration of the episode, this must be taken into account when analyzing daytime and nighttime episodes and comparatively assessing PI during treatment.

The area index in conjunction with the hypertensive time index makes it possible to judge the effectiveness of antihypertensive therapy, but when evaluating these indicators, it is necessary to pay attention to occasional short-term rises in blood pressure during the day or when waking up and getting up at night and, if necessary, exclude them from the analysis.

In this article, the author tried to summarize the main points that should be paid attention to by doctors who begin to use the technique of 24-hour blood pressure monitoring in their work, or who experience difficulties in evaluating its results. Any comments will be gratefully received.

Ambulatory blood pressure monitoring is a survey that allows you to identify the dynamics of changes in blood pressure (BP) during the day, subject to normal human activity. The technique is used to diagnose hypotension and hypertension. A common name is the abbreviation SMAD.

In people with impaired functioning of the cardiovascular system, blood pressure is unstable. Periods of constant increase or decrease in blood pressure, in which specific clinical signs of a violation appear, are the exception rather than the rule. Usually, pressure jumps during the day, depending on the load, psycho-emotional state, and even the diet of a person.

Reliably diagnosing hypotension or hypertension by a single measurement of blood pressure by a doctor is very difficult. This is due to the patient's individual response to the stressful situation that occurs when visiting the clinic. Moreover, there is even a special term that describes the increase in pressure in the doctor's office - "white coat" hypertension.

Unlike a one-time pressure measurement, ABPM provides more reliable data.

If a person feels uncomfortable in a clinic, blood pressure measurement data by a doctor cannot be considered reliable. The pressure at home, at rest, and the indicators during the examination by a specialist will vary, often quite significantly. ABPM allows you to avoid mistakes and accurately determine the dynamics of changes in blood pressure at rest, during normal household stress and under the influence of other factors.

An alternative to ABPM is a blood pressure diary kept by the patient himself. But such data cannot be considered accurate, since a person may forget to measure pressure or deliberately distort the values ​​in an attempt to deceive the doctor.

Carried out with the help of a special device during the day, daily monitoring of ABPM pressure is the most accurate method of modern diagnostics of blood pressure disorders in patients of any age group.

What defines SMAD?

The SMAD device captures the slightest fluctuations in blood pressure and presents them in the form of a graph. The obtained results of ABPM are deciphered by the doctor, allowing you to accurately diagnose and select the optimal treatment regimen.

The method shows:

• normal or "working" pressure of the patient;
• changes in performance under load;
• BP at night;
• pulse pressure.

In this case, the patient should keep a special diary that will help to accurately decipher the results of ABPM. The diary records all moments of exercise, diet, wake-up time and bedtime. If during the day a person was stressed, this is also recorded in the records, which should then be analyzed by the doctor.

Deciphering SMAD does not take much time, thanks to a large amount of information. The device is very sensitive and captures even the slightest pressure deviations. Monitoring data includes the following information:

• graph of changes in blood pressure during the day;
• average values ​​of systolic, diastolic and pulse pressure;
• values ​​of lower and upper blood pressure during sleep;
• change in performance under load;
• pressure drop at night.

Having figured out what data can be obtained by ABPM monitoring and what it is, you should know when this method is used in cardiology, as well as all its advantages and disadvantages.

ABPM result example

When is an examination scheduled?

ABPM allows you to determine the dynamics of pressure changes in various diseases. Indications for the ABPM monitor:

• determination of the degree of hypertension;
• diagnosing a situational increase in pressure;
• hypotension;
• monitoring pressure in pregnant women.

Watching with ABPM how the pressure changes during the day can be prescribed to patients who have recently suffered a myocardial infarction or stroke. This allows timely adjustment of the treatment regimen.

Indications for ABPM monitoring are diabetes mellitus, gestational disorders, vascular atherosclerosis, heart failure, and renal failure. People with these diseases and disorders are the main risk group for developing hypertension.

During pregnancy, ABPM is used to control the condition of a woman. Poor 24-hour blood pressure in the later stages is an indication for an emergency caesarean section.

For hypertensive patients, ABPM should be carried out to determine the dynamics of disease progression and to select the optimal therapy regimen. Simultaneously with ABPM, in this case, an electrocardiography of the ECG is necessary. ABPM also monitors changes in the heartbeat, so it is prescribed for heart disease.

In addition to ABPM, which determines blood pressure (BP), certain groups of patients may be assigned to measure the level of cholesterol and glucose for an accurate diagnosis.

Preparation for the examination

If the patient has been prescribed ABPM, the doctor will give a detailed briefing before starting these examinations. Preparation for analysis or study of ABPM:

• normalization of the daily routine;
• refusal of clothing that restricts movement;
• cancellation of physical activity;
• bathing refusal.

While wearing the device, do not take a bath or shower, as moisture will cause the device to fail. On the eve of the installation of the device, the patient is allowed to take any sedative drug. Sleeping with the device on your chest is not very comfortable, so it is important to get enough sleep before installing it.

If the patient is taking any medications that may interfere with ABPM data, the physician should be warned. The specialist in this case will give detailed instructions on how to prepare for ABPM, in some cases, drugs are canceled or their dosage is reduced in order to avoid distorting blood pressure values.

How is monitoring carried out?

The most common and accurate research method used in cardiology, according to Holter, is ABPM and an electrocardiogram. Holter examination implies round-the-clock monitoring of ABPM with fixation of the features of the work of the heart at the moments of changes in blood pressure.

The survey algorithm is simple:

• a wide cuff is installed on the shoulder, into which air enters;
• the cuff is attached to the device;
• the device is located on the harness on the chest;
• every half an hour there is a measurement of blood pressure;
• All data is stored in the instrument's memory.

The main work is performed by the device. The ABPM device is a mini-computer or a very smart tonometer that not only measures pressure, but also remembers the values, analyzes them and builds a graph of blood pressure changes. The patient has to follow only a few rules:

• live according to the usual schedule;
• do household chores without looking at the device;
• do not take a shower;
• refuse any drugs (after agreeing this with the doctor);
• Do not bend the tube of the device with your hand with the cuff installed.

The device takes measurements every 30 minutes. The doctor gives the patient a special diary in which any load is recorded during the day. Any changes in the psycho-emotional state and other factors that can provoke a pressure surge are also entered there.

Holter study also includes measurement of heart parameters

How to behave as a patient?

Installation of the device practically does not cause discomfort. A person feels the same as with a normal pressure measurement with a home tonometer. The only negative is the constant squeezing of the arm with a cuff, with a frequency of once every half an hour.

To avoid distorting the data obtained during the survey, you should:

• behave as usual;
• avoid strenuous exercise;
• do not change the diet;
• do not take drugs for hypertension;
• do not be nervous;
• give up tight clothes;
• make sure that the tube of the device is not squeezed.

Stress and psycho-emotional stress can distort the results of the examination. They must be avoided. It is better to minimize contact with others on the day of wearing the device, not get annoyed over trifles and try to stay relaxed.

On the day of pressure monitoring, overtime and night shifts should be avoided. Going to bed should be at the usual time for the patient. It is important not to forget to record this in the diary.

It is necessary to record all events that can affect blood pressure indicators.

Cons of wearing the device

By itself, SMAD is somewhat reminiscent of a small bag over the shoulder, however, it is worn on the neck or on the chest. The device is compact, but can be noticeable to others. You can hide the device under loose clothing.

The main inconvenience when wearing the device is the periodic compression of the artery on the arm at the moment the cuff is inflated with air. The sensations are similar to the operation of a conventional tonometer, but are repeated every half an hour. In this case, the sudden start of the device can take a person by surprise and provoke a small stressful pressure surge. However, this practically does not distort the value, since literally after 2-3 inflations of the cuff, patients get used to the operation of the device.

Another problem is a violation of the sensitivity of the hand at the place where the cuff is worn. This is due to the same compression of the artery. However, some people feel tired in the cuffed arm.

People with particularly sensitive skin may experience irritation or diaper rash after a day of wearing the cuff. This is due to the fact that most often it is made of artificial material that does not allow the skin to breathe. The problem is more related to aesthetic and quickly passes even without treatment.

A serious disadvantage of wearing the device is the need to constantly ensure that the tube connecting the cuff to the tonometer is not squeezed. When going to bed, you will have to choose a body position that will not interfere with the normal flow of air into the cuff. Unfortunately, sleeping with a ABPM device is very uncomfortable.

Contraindications

There are no absolute contraindications to the examination. It may be necessary to reschedule the installation of the device to another date if a person develops a skin rash or aggravates a dermatological disease in the area of ​​​​the cuff, for example, psoriasis.

Installation of the device is not possible in case of fractures, severe bruises, burns and other injuries of the arm on which the cuff is placed. In this case, the study is postponed until the person fully recovers and the skin recovers.

In case of hand injuries or skin damage, the study is transferred

Examination cost

Ambulatory blood pressure monitoring should only be prescribed by a cardiologist. The average cost of this examination depends on the clinic in which the devices are installed, as well as on the type of device.

A study using the Holter method will cost an average of 2300 rubles. In fact, the price range is very large. In different clinics, SMAD costs from 1200 to 3500 rubles. At the same time, the price does not affect the quality of the examination, since all pressure measuring devices work on the same principle, so there is always a place where this procedure is cheaper.

The cost of SMAD also depends on the region. In provincial clinics, the examination costs up to 1500 rubles, in the capital - from 2000.

Can SMAD be fooled?

Hypertension, neurocirculatory dystonia of the hypertensive type and severe heart failure are diseases in which young people may not be drafted into the army. To confirm the diagnosis, daily monitoring of blood pressure is mandatory, as the most optimal way to determine the dynamics of changes in blood pressure.

Young people who do not want to serve often wonder how to cheat SMAD. The suggestions below can be safely posted under the heading of bad advice, but they really help to increase blood pressure and fool the ABPM device.

1. Hold your breath while inserting the cuff. You need to breathe only after it is filled with air.
2. At the time of measuring pressure, you should strain your buttocks and pull your toes towards you. These manipulations are invisible to others, but the body takes them for training, so the pressure rises.
3. Tonic drugs that will help raise the pressure - tincture of lemongrass, ginseng, eleutherococcus. They can be taken 15 drops three times a day for a few days before the installation of ABPM.
4. While wearing the device, lower the cuffed arm below the level of the heart. If a person is lying on a bed, you need to raise your legs high at this time. In this case, normal blood flow is disturbed and pressure rises.
5. In order for the average value of ABPM to exceed 155 per 100 mm Hg. you can take energy drinks, coffee, coffee beans, very strong black tea, or caffeine tablets.
6. Those who want to accurately deceive SMAD should remember one important rule - during sleep, the pressure drops by an average of 20%. If, after all the above methods of raising the pressure, you fall asleep soundly at night, blood pressure will drop, and the average for the examination will not exceed 140 mmHg. Thus, in order to falsely diagnose hypertension, you will have to stay awake during the daily monitoring of pressure.

These methods negatively affect the work of blood vessels and the heart. After activities to deceive SMAD, you will have to intensively rest and recover for at least two weeks.

The technique by which blood pressure is measured and the results obtained for 24 hours is recorded is called daily monitoring. It provides for the registration of indicators at specified time intervals using a special apparatus or a traditional tonometer.

This method of monitoring cardiac activity allows you to determine the average pressure, its values ​​​​at night and during the day, the amplitude of fluctuations and the threat of damage to target organs.

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Benefits of ambulatory blood pressure monitoring

Measurement of pressure in the round-the-clock mode is related to the diagnostic standard and purpose. It has more opportunities to obtain reliable results than a random single measurement. The benefits of ambulatory blood pressure monitoring (ABPM) include:

• shows how the daily load level affects the pressure value;
• reflects the night pressure change;
• helps to diagnose sharp fluctuations - hypertensive and hypotensive crises, fainting;
• in its study, it is possible to make a forecast about the possibility of acute vascular disorders ( , );
• gives a chance to accurately select the optimal time and dosage of antihypertensive drugs or evaluate the effectiveness of taking prescribed medications;
• eliminates the reaction to medical personnel.

The best option is the simultaneous monitoring of blood pressure and ECG ().

This complex allows you to establish the relationship of the main characteristics of the cardiac cycle, which cannot be identified by standard one-time methods.

Indications for carrying out

Used to diagnose the following conditions:

• clinical hypertension (reaction to healthcare workers);
• increased blood pressure during stress overload during working hours;
• border pressure increase;
• nocturnal form of hypertension, apnea;
• symptomatic variants of the disease - a reaction to drugs that increase blood pressure, disorders of the autonomic nervous system, in case of myocardial infarction or ischemia, circulatory failure, inadequate electrical stimulation mode or its poor tolerance;
• variability of indicators in several measurements;
• revealed high blood pressure in the absence of objective data from clinical studies;
• the traditional measurement shows the norm with numerous risk factors, diseases of target organs;
• diagnosis of hypertension in pregnant women with possible preeclampsia.

Also, ABPM can be used in selecting patients for drug treatment, evaluating the effectiveness of therapy, drawing up a scheme with individual selection of the regimen and dose of drugs, before surgery or childbirth, to study the risk of stroke or heart attack.

The technique has no contraindications, but there are a number of pathologies when it must be temporarily abandoned: injuries or pathology of the vessels of the hands, exacerbation of blood diseases, patient refusal, pressure exceeding 195 mm Hg. Art., serious forms.

What should a patient with ABMS do?

In order to obtain reliable blood pressure indicators, the patient must adhere to the following rules during the monitoring period:

• the arm during the measurement period does not need to be bent, it should be in a relaxed state, located along the body;
• the lower level of the cuff is placed 1-2 cm above the elbow bend;
• if the device has started measurements, and at this time the patient is in motion (for example, walking down the street), then you need to stop, lower your hand;
• you can not play sports or perform intense physical work, but otherwise the daily routine should be normal;
• It is not recommended to monitor the registrar's performance.

When performing diagnostics, do not detach parts of the blood pressure monitor, hit it, or expose it to moisture.

Watch the video on 24-hour blood pressure monitoring:

How the complex is carried out

For automatic monitoring, the patient is put on a cuff on the non-working arm (in right-handed people, on the left). Moreover, its location should be in the place of the strongest pulsation of the brachial artery. The pneumocuff is connected by connecting tubes to the pressure recorder. It is a compact monitor that is attached to the subject's belt.

Measurements are taken every 15 minutes during the day and every 30 minutes at night. The received data is loaded into a computer for processing by a special program.

Why keep a diary

In parallel with pressure measurements, the patient must record all events related to activity and health:

• the duration of sleep and its depth, the number of night awakenings;
• the level of psychological stress, stressful situations and their well-being during this period;
• physical activity;
• food intake;
• all medications that are taken;
• the presence of headache, dizziness, fainting, pain in the heart, visual impairment.

Then the doctor compares the data that the monitor gave out with the patient's complaints recorded in the self-control diary. On their basis, it is possible to draw a conclusion about situations that contribute to an increase in pressure, to draw up an optimal scheme for antihypertensive therapy.

Technique for measuring blood pressure and pulse rate

In the event that pressure control is indicated, but there is no special monitoring device, patients are advised to record the results. At the same time, the same entries are made in the diary as with SMAD, but the frequency of measurements per day does not exceed 6-8. In this case, it is imperative to diagnose pressure before bedtime and in the morning before taking medication.

Correct measurements are carried out according to the following principles:

• after eating and taking coffee, tea, an hour or two should pass;
• the hand is completely freed from clothing;
• when measuring, you can not talk;
• a cuff of the right size is required, it must cover at least 80% of the circumference of the upper arm.

The pulse is determined on the radial artery a centimeter above the wrist joint, from the side of the thumb. To count the frequency of beats per minute, use the index, middle and ring fingers of the second hand and a stopwatch.

Apparatus for control

The mechanism of operation of the device is based on the fact that when the blood flow moves through the place of arterial compression, air vibrations occur. If they are registered, then the resulting oscillations can be studied using special algorithms. It is generally accepted that the average level of arterial pressure corresponds to the largest amplitude of the waves, a sharp increase - to systolic, and a decrease - to diastolic blood pressure.

Models of pressure monitoring devices are produced by Russian manufacturers (DMS advanced technologies), as well as foreign firms. The most interesting are recent developments that can simultaneously record blood pressure and ECG. And the Japanese multi-sensor system manufactured by AND can also take into account the temperature regime during measurements, the location of the patient's body, and the intensity of his movements.

There is an increase in pressure at night due to illness, stress, sometimes apnea and panic attacks are added to them if you do not sleep. The causes of sharp jumps in blood pressure during sleep can also be covered in age, in women with menopause. For prevention, long-acting drugs are chosen, which is especially important for the elderly. What pills are needed for nocturnal hypertension? Why does blood pressure rise at night and is normal during the day? What should be normal?

Measurements of pressure without a specific system can hide the true picture on whether the patient has or not. Daily monitoring of pressure indicators can provide valuable information for the attending physician.

What is ambulatory blood pressure monitoring

For a detailed understanding of the characteristics of an increase in pressure in a patient, with further establishment of the causes of this phenomenon, daily monitoring of pressure is performed. The procedure makes it possible to correctly diagnose and prescribe appropriate treatment.

Carrying out daily monitoring of blood pressure is carried out according to the developed method, the difference may be the devices of the hardware system selected for the study. The procedure can take place in conjunction with daily monitoring of the cardiogram.

Elena Malysheva will talk about how to properly conduct daily blood pressure monitoring in the following video:

Who is assigned

• If the patient has a downward pressure trend. Especially if at the same time there are dizziness, bouts of "lightheadedness". Daily observation will make it possible:
  • define the limits
  • the degree of development of hypotension,
  • what are the patterns in pressure change.
• With increased pressure in a patient, the same reasons to monitor this phenomenon throughout the day. The study will clarify:
  • what is the highest blood pressure in the patient,
  • What time of day does this happen?
  • what is the reaction that causes a change in pressure;
  • the effectiveness of the drugs used
  • and other factors influencing pressure increase.

Why is it carried out

Exceeding the level of blood pressure above the value taken as the norm is called hypertension. This condition is fraught with consequences, such as:

• contributes to the appearance
• and other problems.

Many people do not follow changes in pressure and catch on only when dire consequences overtake them. An important task is to study the question:

• Does the patient really have hypertension?
• what factors affect pressure change,
• individual selection of effective hypertension,
• how the body reacts to physical and emotional stress,
• the causes of pre-fainting states and fainting are clarified.

The procedure is repeated if necessary to clarify the diagnosis as prescribed by the doctor. There are no restrictions on the number of such procedures, except for cases that have contraindications.

About daily monitoring of blood pressure in stroke patients and other indications for the procedure, read below.

The following video will tell you about when the doctor prescribes ambulatory blood pressure monitoring:

Indications for holding

• Elderly patients. This is due to the fact that age is one of the factors that contribute to the appearance of a tendency to increase pressure, because:
  • over time, the accumulation of the results of harmful effects occurs,
  • aging of body tissues and other age-related features.
• The version is being checked that the increase in pressure during measurement by a medical officer may be “white coat” hypertension. In other words, the psychological factor of the body's reaction to the presence of a medical worker is triggered. Many people are afraid of doctors since childhood. Therefore, daily monitoring of changes in pressure indicators in the absence of a "white coat" can provide objective information about the issue under study.
• Nocturnal hypertension. Daily monitoring can detect this phenomenon.
• Latent hypertension. Pressure fluctuations that appear in the workplace - the so-called "working day" hypertension.
• Drug therapy when close control is required.
• Determining the rhythm of changing pressure indicators throughout the day. If a violation of the circadian rhythm is detected, then this provides useful information about the patient's condition, and the next task will be to find the causes of this phenomenon, adjusting therapeutic measures.
• Cases where the use of drug therapy is not successful. The pressure does not decrease.
• If the patient's pressure cannot be called high, but such that the doctor has some alertness.
• Significant pressure drops. Low values ​​change to high values ​​when the possibility of complications is created.
• Clarification of the diagnosis when symptoms of insufficiency of the nervous system appear.
• Diagnosis of conditions when low pressure is recorded.
• If the person is young, but has an unfavorable heredity regarding hypertension.
• When observing patients with insulin-dependent diabetes.
• When examining pregnant women, if pressure deviations from the norm are observed.

Contraindications for holding

The procedure is not carried out if:

• If the patient's condition worsens while monitoring pressure indicators, then this type of diagnosis is abandoned. Do not carry out the procedure if the conduction of the heart, arrhythmia or pressure over 200 Hg is impaired. Art.
• If monitoring has already been carried out and undesirable consequences have appeared after the procedure.
• Contraindications will be the following phenomena:
  • thrombocytopenia,
  • injury to the arm on which the cuff is installed,
  • skin diseases at the cuff attachment site,
  • thrombocytopathy.

Is the diagnosis safe?

Measurement of pressure throughout the day does not pose a danger to the patient. He should carry on as usual.

If the patient has symptoms that coincide with contraindications for the use of devices for daily monitoring of blood pressure (BP), then the procedure is not performed.

Preparing for monitoring

In order for the daily monitoring of pressure indicators to be successful, it is necessary to perform preparatory actions. Preparation of technical means:

• It is necessary to check that the recorder is provided with power for the specified time of its operation. Check if the battery is charged, if batteries are used, then it is necessary to analyze whether their charge is enough for 24 hours of uninterrupted operation.
• The registrar is connected to a computer and it is programmed for individual information:
  • patient information,
  • recorder mode:
    • an interval is set at which pressure will be measured for daytime and nighttime;
    • signal programming on the eve of the measurement, if it is decided that it is needed;
    • a setting is entered as to whether the measurement readings will be shown on the display.
• To select a pneumatic cuff that fits the patient, measurements are taken of the circumference of the forearm.

Installation of devices for the procedure:

• The cuff is placed on the forearm of the non-working arm:
  • right-handers on the left hand,
  • lefties on the right hand.
• To ensure that the cuff does not move during monitoring, it is fixed. For this, double-sided discs with a sticky coating are sometimes used.

The patient is explained the rules of conduct during the examination:

• The patient during the next automatic measurement of pressure should make sure that his hand is lowered along the body and the muscles are relaxed.
• It is necessary not to think about the measurement readings and not be interested in them, so as not to affect the result.
• At night, you should sleep as usual, do not focus on the measurement process.
• If a person is in motion, then having heard the signal that the next pressure value will be removed, it is necessary to stop, relax the hand and lower it down. In this position, you should wait until the end of the measurement.
• The patient is told that during the procedure it is necessary to keep a diary. It fixes, indicating the time intervals, what type of activity a person was engaged in, what sensations accompanied the activity, changes in well-being. Such a document is very important, because the patient's diary contains important examples of data from ambulatory BP monitoring.

How is the procedure

In the outpatient clinic, the patient is equipped with devices that will be on him for 24 hours and take pressure measurements.

• A pneumatic cuff is put on the forearm. Its position is fixed to be maintained for the entire duration of the study.
• The main device is fixed on the belt. It weighs about 300 g and does not cause inconvenience to the patient.

After receiving all the instructions, the patient can go home and do his usual activities. Devices on the patient's body will automatically take pressure measurements and keep records of them at specified intervals.

It is important for the patient to responsibly take notes in the diary so that the doctor can get a reliable picture of the relationship between changes in pressure indicators and the possible cause of this phenomenon.

When the test time ends, the device is turned off. You should come to the doctor's appointment to provide the device and a diary for decoding.

During the procedure, you should follow the recommendations:

• It is necessary to observe that there is no pinching of the tube that connects the device and the cuff.
• If there are signs that the device has become faulty, you must return to the doctor, you should not try to fix it yourself.
• The cuff is fixed above the bend of the elbow by two fingers. If her position has shifted, the patient needs to be corrected.
• The patient should not get into places where sources of electromagnetic radiation are located.
• Postpone water procedures for the duration of the study, because the equipment cannot be wetted.
• During the time when the equipment takes measurements, you should relax your hand. The beginning and end of the measurement is signaled by a signal.

We will talk about the interpretation of the results and examples of conclusions on the complex of daily blood pressure monitoring below.

Deciphering the results

The computer program processes the monitoring results automatically. The main indicators of daily observation:

• The circadian rhythm of pressure, in other words, is called the circadian rhythm. Its violation indicates that the cause of this phenomenon should be found.
• Average pressure values ​​are an important indicator for evaluating the results of the study.
• Pressure variability - an assessment of how pressure readings deviate from the circadian rhythm curve.

Average diagnostic cost

The approximate price of the procedure for daily monitoring of blood pressure is on average 700 rubles.

In the video below, responsible parents will find useful information for themselves on how to prepare the baby for the 24-hour blood pressure monitoring procedure: