Ambulatory blood pressure monitoring. Smad: what kind of examination is this, how is it carried out and can it be deceived. About self-measurement of blood pressure

Ambulatory blood pressure monitoring(or abbreviated SMAD) is today the most effective method for detecting disorders in the circulatory system. This procedure, which involves multiple measurements of blood pressure within 24 hours, allows you to identify the slightest failures. Contacting our clinic "Doctor nearby +" on Korovinskoe highway- affordable way make SMAD at an affordable price in Moscow with a minimum investment of time. An individual approach and modern diagnostic equipment allow us to guarantee the accuracy of the results obtained and the delivery of the diagnosis.

Features of BP monitoring (ABPM in CAO)

This method of studying blood pressure is quite simple. A cuff is installed on the patient's arm (middle third of the shoulder), which is connected by a tube to the registrar. The main unit records the parameters obtained during the measurement, and also supplies and bleeds air. Inside the cuff is a highly sensitive sensor that can detect the slightest pulse fluctuations. All data is stored in the device's memory. At the end of the day, the register is transferred to a specialist who can SMAD decode and correctly interpreted to make a diagnosis.

The procedure for monitoring blood pressure ABPM has the following features:

• The number of measurements is determined individually for each patient, taking into account his sleep and wakefulness patterns.
• The minimum number of blood pressure measurements is 50 times. This value is the limit for obtaining an accurate, complete and objective picture.
• Usually during the daytime, blood pressure is checked every 15 minutes, at night - about 1 time per half hour.
• The patient, who has the device installed, can lead a normal life: go to work, eat, walk in the fresh air, play sports.
• During the day, the subject needs to keep a diary, recording in it all physical activity, sleep periods, medications taken, observed symptoms and sensations.

Indications for ABPM in Beskudnikovo

Modern medicine uses daily monitoring of blood pressure ABPM to determine the causes if the patient has such complaints or diseases:

• tendency to faint (including syncope);
• fatigue and general weakness;
• regular headaches and dizziness;
• constant noise (ringing) and stuffy ears;
• decreased vision and the appearance of "flies" in the eyes;
• persistently low or high blood pressure;
• suspected symptomatic or "nocturnal" hypertension;
• cerebrovascular disease;
• neurocirculatory asthenia (NCA);
• disturbances in metabolic processes;
• vegetovascular dystonia (VVD);
• heart failure;
• treatment-resistant arterial hypertension in severe form.

Mandatory ABPM study is for the following categories of patients:

• who have had a stroke or myocardial infarction (to correct the treatment regimen);
• belonging to a high-risk group (presence of insulin-dependent diabetes mellitus, serious kidney disease or overweight);
• entering military schools or for military service (to exclude hypertension);
• having unfavorable heredity (hypertension, acute disorders of cerebral circulation, cerebrovascular disease);
• the elderly (over 60 years old);
• pregnant women with a tendency to disturb blood pressure.

Diseases diagnosed by SMAD in Degunino

Violation of blood pressure can have a different nature of origin and consequences for the body. The data obtained during the diagnostics allows you to make based on the results SMAD conclusion about the presence of such disorders and diseases:

• hypotension or hypertension;
• dysfunction of the autonomic nervous system;
• hypertrophy of the left ventricle of the heart;
• chronic ischemia with angina attacks;
• preinfarction state;
• kidney and adrenal disease (including pheochromocytoma);
• development of atherosclerosis;
• violation of cerebral circulation;
• increased risk of stroke.

Recommendations for preparing for SMAD metro Seligerskaya

Monitoring of blood pressure is carried out in the usual rhythm of everyday life without limiting psycho-emotional and physical stress. Also, for this diagnostic method, there are no restrictions on eating or taking medications (unless otherwise recommended by the attending physician). The procedure has a number of limitations: skin diseases, vascular injuries, acute blood diseases, severe conditions, poor tissue conductivity. Therefore, before carrying out it, it is important to consult with a cardiologist or therapist.

Why is it advantageous to sign up for the SMAD service at the "Doctor Nearby+" clinic in Seligerskaya metro station?

For any disturbing symptoms and conditions, feel free to contact. Registration is by phone. If necessary, leave a request and about metro station 800th anniversary of Moscow On the same day, he will arrive at your home at a convenient time for you, conduct an examination and prescribe the necessary medications. In the service area clinics "Doctor nearby plus" in Moscow and the Moscow region.

To know prices for SMAD You can contact our consultant. Using the phones, you can also make an appointment at a convenient time and clarify the conditions of admission with a specialized doctor.

Ambulatory blood pressure monitoring (ABPM) is a diagnostic procedure. It consists in multiple measurements of indicators during the day. For this purpose, a special device is used. Thanks to this manipulation, it is possible to analyze the dynamics of pressure changes during the day. Some devices also measure the heart rate.

The essence of the procedure

In order to study in detail the features of an increase in pressure and determine the causes of this condition, daily monitoring of blood pressure is prescribed. This study helps to make an accurate diagnosis and choose the best therapy.

The procedure is carried out in accordance with a specific methodology. The difference lies only in the use of hardware system devices that are planned to be used for research. Often, manipulation is combined with daily control of the cardiogram.

Advantages and disadvantages of the technique

Daily measurement of blood pressure has a number of advantages. The key advantage of the procedure is the ability to capture even small fluctuations in the indicator in different categories of patients.

Many people have white coat syndrome. In this case, during a routine examination in a healthy patient without arterial hypertension, pressure increases. Sometimes it can reach very high rates.

After receiving daily monitoring data, when a person is at rest, a specialist can draw a conclusion about the true picture. Usually in such patients, the pressure remains normal throughout the day.

Some people, on the contrary, complain of hypertension, but the doctor fails to detect it at the appointment. In such a situation, this procedure will also come to the rescue. It can be concluded that ABPM plays a key role in the diagnosis of arterial hypertension.

Other advantages of the technique include its accessibility and widespread use. The undoubted advantages are the absence of invasive intervention, low labor intensity and ease of use.

The disadvantages include a slight discomfort for the patient, because he has to wear a cuff on his arm all day, which periodically pumps air. This can create some inconvenience during sleep. However, the high diagnostic value makes this method very common.

Indications

A 24-hour blood pressure monitor is performed in such situations:

Preparation for the procedure

In order for blood pressure monitoring to show an objective picture, it is very important to properly prepare for this procedure.

To do this, you must adhere to the following recommendations:

Instruction is of great importance. This will help the patient to behave correctly during the examination:

1. During each automatic pressure measurement, it is important to ensure that the arm is along the body and the muscles are relaxed.
2. Do not think about indicators or be interested in them. This will help to avoid affecting the result.
3. At night, you need to sleep without focusing on the measurement process, as this may lead to inaccurate results.
4. If a person heard a signal about the next measurement of pressure, he needs to stop, put his hand down and relax. It is in this position that you should wait for the completion of the measurement.
5. Keep a special diary during monitoring. It needs to record all the activities that a person does during the day. It is important to note the time and sensations that accompany certain loads. This document is very important as it includes valuable information about daily blood pressure monitoring.

How to perform the procedure

In an outpatient setting, a person is equipped with special devices that will be fixed on him during the day and record changes in pressure.

To do this, a pneumocuff is attached to the forearm. This element is securely fixed so that it maintains its position throughout the entire procedure. The main device is attached to the belt. It weighs about 300 g and does not cause any discomfort in a person.

After receiving the necessary instructions, the patient can go home and do their usual activities. The device, fixed on the human body, will automatically measure pressure at certain intervals and record the obtained indicators.

The patient should be very careful about fixing the necessary information in the diary. This will allow the specialist to get an objective picture of changes in pressure parameters and establish the probable causes of fluctuations.

After the study is completed, the device must be turned off. After that, you need to come to an appointment with a specialist to give him a device and a diary for decoding.

During the session, you must adhere to the following recommendations:

• It is important to avoid squeezing the tubing that is used to connect the device to the cuff.
• If there are signs of a malfunction of the device, you should return to the doctor. Do not try to fix the device yourself.
• The cuff is attached two fingers above the elbow. If the device has changed its position, the patient should try to correct it.
• A person should not get into the zones of localization of sources of electromagnetic radiation.
• It is important to temporarily abandon water procedures, since the device is forbidden to wet.
• When taking a measurement, it is important to relax your hand. Before the start and end of the measurement, a characteristic signal sounds.

The procedure is often prescribed
children over 7 years old. It is usually combined with monitoring of changes on the electrocardiogram. Indications include high or low blood pressure, heart rhythm disturbances. Also, the procedure is carried out with syncopal conditions, which are loss of consciousness.

The procedure is practically no different from the examination of adult patients. The only difference is that the child needs to be explained in detail or even shown how the 24-hour blood pressure monitor functions and what it is needed for.

Interpretation of results

Diagnostic examination data are processed automatically by a computer. When performing the procedure, pay attention to the following indicators:

1. circadian rhythm of pressure. In medicine, this parameter is called the circadian rhythm. The deviation of this indicator from the norm indicates the need to search for the cause.
2. Average pressure readings. These criteria are also very important for evaluating these procedures.
3. pressure variability. This parameter allows you to assess how strongly the pressure readings deviate from the daily rhythm.

circadian rhythm pressure

Contraindications

In some situations, this procedure is prohibited. Key contraindications to the session include the following:

• Complications during previous monitoring;
• Thrombocytopenia, which implies a decrease in the number of platelets, thrombocytopathy, which is a violation of the qualitative composition of platelets, and other blood pathologies during an exacerbation;
• Pathologies that are accompanied by damage to the vessels of the hands;
• Traumatic injuries of the upper extremities.

Thrombocytopenia Pathologies with damage to the vessels of the hands

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 the 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 SI 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.

One of the most important diagnostic procedures for many diseases is continuous monitoring throughout the day, otherwise -, then ABPM.

When observing the patient, a device for monitoring blood pressure is used.

This is a specially designed instrument that allows you to make a comprehensive analysis.

A smart device for measuring pressure for a day allows doctors to find out:

• whether the patient's blood pressure is always high (or low);
• how, how much the pressure level changes in a particular type of activity;
• whether pressure changes occur during the patient's sleep.

Some devices for measuring pressure for a day have one more function - in addition to measuring pressure, they record the heart rate. A referral for such an examination, when the diagnosis has not yet been established, can be obtained from two specialists - a general practitioner or a cardiologist.

There are a number of symptoms in which pressure monitoring is a vital procedure:

1. frequent headaches,;
2. a noticeable decrease in vision, flashing "flies" before the eyes;
3. frequent laying of the ears, ringing, or noise in them;
4. fast or even rapid fatigue during any work.

The same diagnostic procedure can be prescribed in the complete absence of these symptoms.

An indicator of possible ill health here will be a constant increase in pressure during a medical examination. We are talking about the so-called “white coat” phenomenon, when a patient has a pronounced psychological reaction to any medical actions.

Explicit anxiety at the sight of a doctor leads to quite predictable consequences - an increase in pressure, heart rate. In order to be completely sure that it is precisely the “white coat” phenomenon that is taking place here, doctors prescribe a ABPM procedure, where a 24-hour blood pressure monitor plays a major role.

People who have crossed the threshold of middle age should carefully monitor their state of health, in the presence of alarming symptoms, insist on the implementation of SMAD.

What diseases can be detected by the procedure?

The daily apparatus for measuring pressure allows you to identify:

• (high blood pressure);
• (low pressure).

But these are not all the positive properties of the procedure, for doctors it is an invaluable assistant, acting for the benefit of a particular patient.

Using the apparatus for measuring pressure during the day, the doctor without any problems and very accurately:

• predicts the existing risk of arterial hypertension for each individual patient;
• can determine what complications are possible in the patient in the future or already exist at the moment;
• identify the level of physical activity that is optimal for a particular person;
• can understand how effective those already appointed were.

It is unreasonable to refuse the SMAD offered to you, with its help the doctor will receive a complete picture of the existing errors in your body, and will be able to prescribe the most effective treatment.

How is the procedure carried out?

There are few people who are happy to perceive diagnostic procedures and the treatment itself, often this happens only from the banal lack of correct information. But there is really nothing intimidating about doing SMAD. The patient simply comes to the appointment with the doctor, who will fix a portable device for measuring daily pressure on his body.

Device for measuring daily pressure

The device itself looks like this: a cuff (painfully familiar to us from a standard tonometer), a connecting tube and the main part that writes the read data to the built-in memory). These devices have insignificant differences among themselves, the most common are devices in a case on a harness, which is attached to the belt or thrown over the shoulder.

After that, the patient goes home (to work, service), where he will have to spend the most ordinary day, but at the same time he will have to keep a so-called diary. It will be necessary to record absolutely all your actions for the day on paper, while not forgetting to indicate the exact time.

What events should be recorded in the diary? They certainly record the time of taking the drugs, fix the time of eating, the features of any physical activity: I went to the store, to the kitchen, went up to the fourth floor, etc. Unpleasant symptoms must be noted - headache, dizziness, heart pain, shortness of breath, etc.

If you have been prescribed ABPM, take this procedure seriously as it offers unique chances for improving your health.

How the SMAD device functions, some nuances of the examination

How does the device for continuous monitoring of blood pressure work?

Extremely clearly, the device will measure the pressure of the person being examined once every 15 minutes during the day, once every 30 minutes at night.

However, these intervals depend only on the settings of the device, the intervals between them can be more significant, for example, after 40 minutes in the daytime.

There are no trifles during the examination period, especially when taking medications. If you are already undergoing treatment, taking medication, let your doctor know. You may have to interrupt the course, but only the doctor should decide this. If there is a need to assess the quality of treatment, drugs are taken according to the prescribed schedule, fixing the time of admission on paper. Be sure to note the moment when the patient feels the effect of taking the pills.

In a day, the doctor will remove the device, announcing to the patient at what time the diagnostic results will be ready. At the appointed time, the subject comes to an appointment with a therapist or cardiologist. Having the ABPM data, the specialist will announce the diagnosis to you. If hypertension is diagnosed, additional diagnostic procedures are prescribed to clarify the causes of the disease.

ABPM for the patient is an opportunity to learn about the most important features of your body, you need to undergo an examination in strict accordance with the instructions of the doctor.

What the patient needs to know during the procedure

There is a special rule - when the device for daily monitoring of blood pressure starts to work (the cuff is inflated, in other models - a signal sounds), you need to stop, relax your arm, lowering it down.

This is extremely important for measuring pressure, obtaining an accurate result.

We methodically keep a diary, noting each moderate physical activity (ascent to the 4th floor and above, walking over a distance of more than 1 km). Do not forget to note the time spent driving, high periods, if any.

Taking medications, food, the occurrence of unpleasant symptoms, a detailed description of the latter - all this should be reflected in the diary. All this applies to ordinary daily life. The time of going to bed, the time of awakening should also be noted in the diary. If the dream is interrupted, do not forget to write about it in your diary.

Sometimes the blood pressure monitor does not work correctly, inflating the cuff a second time without any delay.

There is only one explanation - for the first time, the device failed to measure due to the weakening of the cuff, or excessive arm tension.

The cuff should fit snugly around the arm, if not, it should be tightened. When diagnosing blood pressure, you can not do fitness, visit gyms.

There may be some discomfort in the arm due to cuff pressure, sleep disturbances in light sleepers. The arm at the elbow does not fully bend, so hygiene procedures - washing, brushing teeth are somewhat difficult. Taking a shower or bath will also have to be postponed until better times - moisture is harmful to the device.

Despite some inconveniences, the patient must endure them, since the correct diagnosis is the basis of high-quality and effective treatment.

Contraindications for ABPM

It should not be thought that SMAD is shown to absolutely everyone.

There are a number of diseases in which the daily measurement of blood pressure with a device is contraindicated:

• some skin diseases that affect the upper limbs (fungi, lichen, and others);
• upper limb injuries;
• vascular diseases affecting the arteries, veins of the upper extremities (in the acute stage);
• blood diseases, in which the slightest squeezing of the skin is accompanied by bruising (petechial rash, hemorrhagic purpura, severe thrombocytopenia, etc.);
• various mental illnesses of the patient, leading to inability to self-service, aggressiveness, and other serious consequences.

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How is 24-hour blood pressure monitoring performed:

Thus, a sufficiently large number of patients are currently deprived of the opportunity to carefully examine the characteristics of their blood pressure. It is possible that in a few years this problem will simply cease to be relevant, since specialists will have a different, more advanced device for monitoring pressure.

To date, the blood pressure monitor is the best tool for setting errors in the blood pressure field, allowing you to prescribe the correct treatment for the patient.

High blood pressure (BP) is a serious problem requiring treatment. 24-hour blood pressure monitoring is used in case of doubtful indications of the usual measuring method. Since a person in the hospital is affected by many stimuli, BP values ​​can be distorted. Therefore, ABPM helps doctors to obtain accurate data, which reveals the hidden pathologies of the patient.

Method accuracy

ABPM is considered the most accurate method in determining pressure pathologies. It cannot be deceived, because the device captures the slightest fluctuations in parameters. In addition, the study is not carried out alone, Holter diagnostics is often used, which fixes the value of the pulse. With the help of the technique, even a hidden threat is revealed, which the usual measurement of blood pressure is unable to fix.

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Advantages and disadvantages

Daily pressure monitoring, like any method, has good and bad sides. ABPM indicates the possibility of developing cardiovascular pathologies. The test is carried out in the treatment of heart disease and pressure. The positives include:

• registration of indicators over a long time period;
• absence ;
• the possibility of fixing both day and night;
• determination of fluctuations in indicators of a temporary nature;
• accuracy due to the natural environment.

Examples of shortcomings are mainly based on discomfort during the examination, especially when the patient is too nervous. These often include numbness of the limb when wearing the cuff, skin irritation or diaper rash caused by the cuff, as well as the financial side of the service. A daily survey, unlike a one-time measurement, will require an investment.

A single measurement of blood pressure does not always provide true data, which affects the design of treatment methods.

Indications for appointment

Blood pressure monitoring is carried out under the following circumstances:

When not to?

An examination of a person is not carried out in the following situations:

• dermatological lesions of the skin, mainly of the upper limbs;
• pathologies of the circulatory system that cause bruising at the slightest impact on the skin;
• injured upper limbs;
• ailment of vessels and arteries of the upper extremities;
• psychoemotional disorders.

Preparation for the procedure

The procedure is prescribed by the attending physician, who is obliged to explain to the patient how to properly prepare. Preparation for SMAD requires the fulfillment of certain rules in order for the measurement to show reliable information. These include:

• drug withdrawal;
• exclusion of physical activity;
• cancellation of water procedures;
• full sleep at night;
• refusal of squeezing clothing, there should be no extraneous influence on the cuff;
• taking sedatives at night with severe nervousness on the eve of checking blood pressure.

Right before the test:

• the patient should lower his arm down and stop moving when the device starts to automatically inflate the cuff;
• it is important to check the correct position of the tube and cuff during monitoring.

Research progress

The study is carried out using an auscultatory or oscillographic method, however, the use of each of them separately gives inaccurate data. In medicine, it is customary to combine 2 methods so that the ABPM indicators are as accurate as possible. For examination, a cuff is applied to the middle of the upper limb with a tube attached to it, connected to a register that supplies and releases air. The device is equipped with an ultra-sensitive sensor that captures the slightest pressure fluctuations.

Meters are configured individually for each patient, taking into account his regimen, the period allotted for rest and work. Instructions on the number of measurements and their frequency are carried out by the attending physician, who suggests keeping a diary where the results should be recorded. The device takes measurements at least 50 times a day, in the daytime they monitor every 15 minutes, at night - every 30 minutes. When jumping at certain hours, it is required to measure the pressure every 10 minutes.

Holter monitoring

The medical community prefers to simultaneously check the daily pressure and record the pulse rate. Together, these techniques help to trace the dynamics of the development of diseases of the cardiovascular system, to identify hidden ailments. The method was developed by a scientist from America - Holter. Special electrodes are attached to the human sternum to record heart rate data and display them on a special device. The automatic device system works on the principle of electrocardiography, storing the results in the device's memory. At the same time, a cuff is hung on the shoulder, which monitors the pressure. In case of controversial issues on the patient's cardiology, Holter monitoring is extended for several days.

Contraindications apply exclusively to people with mechanical damage to the chest skin (due to the inability to attach the device). Monitoring focusing on Holter is advised to people with such complaints:

Apparatus for measuring

Devices help to make monitoring - tonometers, which fix and store a large amount of information in memory. After the procedure is completed, the 24-hour blood pressure monitoring device outputs data to a PC (personal computer), which processes the data array. The pressure measuring device is sold in pharmacies in different price categories, with different levels of adjustment.