Daily blood pressure monitoring. Ambulatory blood pressure monitoring (manual for physicians)

Ambulatory blood pressure monitoring (ABPM).

Conditions in which the numbers of blood pressure (BP) exceed the generally accepted indicators of the normal value of blood pressure are called hypertensive. Hypertension is known to be widespread among the population, i.e. high blood pressure, and its complications - myocardial infarction, cerebrovascular accident (stroke), heart rhythm disturbances (interruptions, palpitations), creating favorable conditions for the development of atherosclerosis, diabetes mellitus, etc.

Early diagnosis of the initial stages, when a timely change in lifestyle, the rejection of bad habits and, if necessary, the appointment of drug antihypertensive therapy leads to a decrease in deadly complications, prolongs working age, and allows you to feel relatively healthy. Everyone should know their blood pressure, and at any age.

The main methods for measuring blood pressure are auscultatory - the "gold standard" of non-invasive blood pressure measurement and oscillometric, widely used in household blood pressure meters. It is clear that the method of detecting elevated blood pressure continues to be the traditional measurement of blood pressure by a doctor, the so-called "clinical blood pressure", which is essentially a one-time, one-time, not taking into account a variety of physiological conditions that affect the level of pressure. Even with repeated self- or medical measurements of blood pressure, the information received reflects daily figures. Blood pressure during the night period, the sleep period in this situation remains outside the access zone of both the individual and the doctor. The only method that can show the daily profile of blood pressure is ABPM. Conducting ABPM allows you to answer many questions of the diagnostic, treatment-and-prophylactic and scientific plan.

The indications for ABPM, as agreed by the specialists of the European Association of Cardiology, are:

1. White-coat hypertension, when elevated blood pressure is always detected when measured by medical personnel or in a medical institution. If the diagnosis is not specified, it is possible for the patient to prescribe drug therapy, which in this situation, at best, will be unjustified.
2. The question of "hidden, masked" hypertension, hypertension in the workplace or it is called "workday" hypertension. In both indications, the importance of identifying the very fact of an increase in blood pressure and developing the necessary therapeutic and diagnostic measures is understandable.
3. Increased lability of blood pressure, when there are pronounced fluctuations from low to high crisis values, causing a pronounced disturbance of well-being, at the height of blood pressure fluctuations, the risk of complications remains.
4. Patients of the older age group. Age is one of the risk factors for the development of hypertension due to both physiological causes and the accumulation of exposure to bad habits, external influences. It should be noted that the clinical manifestations of hypertension are different in different age periods, the approach to prescribing medications is different.
5. Nocturnal hypertension.
6. Hypertension, which, with regular monitoring by "clinical measurements", remains resistant to the prescribed therapy; for the patient, a situation is created when the implementation of the doctor's recommendations does not lead to stabilization of the condition: complaints persist, blood pressure does not decrease to normal values, etc.
7. When choosing a drug therapy that requires strict control.
8. Patients with type 1 diabetes mellitus (insulin dependent).
9. Diagnosis of hypertension in pregnancy.
10. Diagnosis of hypotensive conditions, especially in the presence of objective and subjective data. If hypotension is detected, dose adjustment of prescribed drugs is possible.
11. If there are complaints indicating insufficiency of the autonomic nervous system. Clarification of the diagnosis allows you to prescribe the necessary therapy.
12. Determination of the circadian rhythm of blood pressure, which in some cases has prognostic value, adjust therapy in time, prescribe additional examinations to identify the causes of circadian rhythm disturbances.

Contraindications for SMAD are:

Absolute - complications during previous monitoring, skin diseases on the shoulder, thrombocytopenia, thrombocytopathy and other blood diseases during the period of exacerbation, trauma of the upper extremities, diseases with damage to the vessels of the upper extremities, patient refusal.

Relative - poor tolerability of the study, severe rhythm and conduction disturbances, blood pressure over 200 mm Hg.

The department of new methods (BP monitoring group) is one of the pioneers in our country in the development and practical application of the methodology. Setting and processing of monitoring data are carried out according to international protocols on devices that have passed mandatory testing for measurement accuracy according to international protocol positions that have received an accuracy class approved for clinical use. Information about ABPM devices can be found at www.dableducation.org.

Specialists conducting research have certificates for this technique and participate in testing devices according to international (European and American) protocols.

Conclusions on the results of ABPM contain a number of indicators with doctor's comments on their clinical and functional assessment and significance.

In addition to the standard study in the ABPM group, studies are conducted on a comparative analysis of several monitorings.

What is smad in cardiology?

ABPM - 24-hour blood pressure monitoring is used to obtain a detailed picture of changes in readings in the case of both high and low blood pressure. SMAD allows:

Take readings of blood pressure during rest, during sleep, and even during physical exertion; Individually select the most effective drugs; Blood pressure readings during moments of short-term ailments, such as dizziness. Exclude white coat syndrome, which is expressed in an increase in blood pressure from stress, when measured in the presence of a doctor.

It is advisable to perform ABPM during pregnancy, especially if there is a risk of preeclampsia in the expectant mother. One of the symptoms of this disease associated with childbearing is an increase in blood pressure.

Daily monitoring of blood pressure in cardiology practice

The accuracy of diagnosis, the adequacy of drug antihypertensive therapy and its safety in arterial hypertension in most cases is determined by the objectivity of measuring blood pressure. Thanks to the discovery of M. S. Korotkov, clinicians have the opportunity to simply, quickly and fairly accurately record the level of blood pressure. But blood pressure is a fairly dynamic indicator, changing depending on the time of day, emotions, physical activity, etc. From this point of view, the traditional three- to four-fold measurement of pressure is a tiny fraction compared to the thousands of readings of this indicator that characterize the 24-hour profile.

The results of measuring blood pressure at a doctor's appointment very often give a distorted idea of ​​its real value due to the anxious reaction of the patient. The phenomenon of "white coat hypertension", the prevalence of which is very high, has been known since the 40s of the XX century. An anticipatory effect with increased blood pressure has been noted both among hypertensive patients and in people who demonstrate normal blood pressure outside the doctor's office. This greatly complicates the identification and comparison of actual blood pressure levels, leads to overdiagnosis of arterial hypertension and errors in assessing the effectiveness of antihypertensive therapy.

Ambulatory blood pressure monitoring (ABPM) opens up additional diagnostic and therapeutic options. One of the main advantages of ABPM is the possibility of recording during sleep, the safety, relative simplicity and high sensitivity of the method, as well as the possibility of multiple repetitions in outpatient, "usual" conditions for patients.

The results of 24-hour monitoring make it possible to reasonably apply the principle of chronotherapy for a differentiated choice of an antihypertensive drug, the frequency and optimal time of its administration, and the determination of drug doses.

Benefits of ambulatory blood pressure monitoring:

1. A large number of measurements during the day.

2. The possibility of recording blood pressure in circumstances as close as possible to normal conditions.

3. Registration of blood pressure during daily activity.

4. Registration of blood pressure during sleep.

5. Ability to assess short-term variability in blood pressure.

6. Ability to assess the circadian rhythm of blood pressure.

7. Diagnosis of "white coat" hypertension.

8. Stronger correlation of mean blood pressure values ​​with target organ damage compared to traditional pressure measurement.

9. ABPM data are of great prognostic value in relation to the development of cardiovascular complications.

10. Regression of lesions of target organs is more closely associated with changes in the average daily values ​​of arterial pressure than with its clinical level.

11. ABPM allows more accurate than "office" blood pressure to determine the degree of reduction in blood pressure in response to treatment, by leveling the effect of "white coat" hypertension.

For the first time, the prognostic value of mean blood pressure values ​​obtained with ABPM and its significant advantage over traditional (one-time) measurements was demonstrated by M. Sokolov et al. (1996). The results of the recent prospective SAMPLE study showed that the regression of left ventricular hypertrophy is more closely associated with changes in mean daily arterial values ​​than in clinical pressure.

At the end of the 1990s, international conferences on ABPM problems were held, the purpose of which was to determine the indications for ABPM and standardize the research procedure.

Recognition of the high clinical value of ABPM is its inclusion in international recommendations for the management of patients with arterial hypertension. The American and Canadian Society of Hypertension, the Brazilian Society of Cardiology, the German League of Hypertension, the Swiss Society of Hypertension have all recommended ABPM for clinical practice. They emphasize the important role of 24-hour blood pressure monitoring and its measurement at home as methods that occupy a significant place in the management of patients with arterial hypertension and provide important additional clinical information.

Indications for ambulatory blood pressure monitoring:

- unusual fluctuations in blood pressure during one or more visits;

- symptoms of hypotension;

- arterial hypertension refractory to treatment.

The emergence of ambulatory blood pressure monitoring has defined a new stage in the diagnosis, treatment and prevention of arterial hypertension. The introduction of ABPM into clinical practice also made it necessary to reconsider the interpretation of the very concept of the "norm" of blood pressure and to expand the understanding of pathological conditions in which the regulation of blood pressure is disturbed.

- Suspicion of "white coat hypertension";

- episodic increase in blood pressure (study of patients with transient hypertension);

- resistance to antihypertensive therapy;

- the need to monitor the effectiveness of antihypertensive drugs;

– diagnosis of hypotension against the background of ongoing therapy;

- Identification of nocturnal hypertension.

– verification of arterial hypertension in pregnant women;

– study of the placebo effect in lowering blood pressure during antihypertensive therapy in placebo-controlled studies.

Additional indications for SMAD include:

- episodic hypertension;

- damage to target organs of unclear etiology;

– diagnosis of the severity of arterial hypertension (according to the level of arterial pressure);

– detection of increased blood pressure variability;

- control over drug correction of circadian rhythm disorders and blood pressure variability.

When conducting ABPM, it should be taken into account that the average value of arterial pressure obtained during monitoring is slightly lower than arterial pressure oriented by the traditional method. Therefore, ABPM results should be considered as not a substitute for traditional clinical blood pressure measurement.

Further research is needed to determine the benefits of ABPM over traditional measurement for predicting morbidity and mortality, promising and other uses of ABPM in clinical practice.

Promising areas of application of SMAD:

– diagnosis of arterial hypertension;

– borderline arterial hypertension;

- arterial hypertension in combination with coronary artery disease, chronic heart failure, cerebrovascular diseases;

- Examination of patients with impaired carbohydrate and lipid metabolism;

- Examination of patients with sleep apnea syndrome;

- suspicion of the symptomatic nature of arterial hypertension;

- suspicion of "hypertension in the workplace";

- examination of young people with a burdened heredity for the occurrence of arterial hypertension.

Diagnostic accuracy:

- forms of arterial hypertension (border / mild);

- patients with left ventricular myocardial hypertrophy;

- cardiopsychoneurosis;

- detection of postural changes in blood pressure associated with the transition from a horizontal to a vertical position of the body and vice versa;

- emergency conditions (hypertensive crisis, acute myocardial infarction, cerebrovascular accident, subarachnoid hemorrhage);

- preparation for a major surgical intervention (to assess the risk of hemodynamic disorders during anesthesia, surgery and in the postoperative period);

- arterial hypertension in pregnant women;

Eliminating underestimation of the importance of arterial hypertension:

- nocturnal rises in blood pressure;

– increased blood pressure variability;

- violation of the circadian rhythm of blood pressure.

Medication control:

- selection of patients for antihypertensive therapy;

- evaluation of the effectiveness and safety of pharmacotherapy;

- assessment of resistance to drug treatment and selection of the optimal treatment regimen for such patients;

- study of the individual daily rhythm of blood pressure in the chronotherapeutic regimen of drug treatment.

Cardiologist N.D. Mikhailiv for INFOMEDNET.RU

Traditionally, one-time measurements of blood pressure (BP) used in 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. Sometimes this is misinterpreted 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;
- assess 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 effect on blood pressure indicators not only during the day, but also at night.

Carrying out SMAD is shown:
Patients who are 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 in 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;
- Wrong choice of cuff;
- displacement of the cuff during monitoring;
- lack of a detailed patient diary;
- incorrectly indicated sleep and wake times when analyzing data;
- 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;
- monitoring during intensive diagnostic examinations, including blood sampling 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 operating in transmitted or reflected light and reacting to the appearance of oxyhemoglobin), ultrasonic blood flow detectors, capacitive pulse transducers, sensors recording isotope clearance, 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 acoustic pressure monitors 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, for example, the ABRM-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 exact 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 using 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 assessment is used, when during the analysis of each oscillation of air in the cuff, a pulse wave in the artery is built, in a patented way, and it is measured BPs and BPd, and BPm is calculated automatically by adding 1/3 systolic 2/3 diastolic.

Displaying on the computer screen 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 in terms of 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 "Cardiotechnika-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 predetermined 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 - 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 apparatus 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 various levels of physical activity on diurnal BP fluctuations 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 magnitude 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 speed 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. The 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.

Disturbances in the circadian rhythm of blood pressure are more common in patients with impaired carbohydrate tolerance, with type I and 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 SI is 10-20%;
- "Non-dipper" - patients with insufficient nighttime blood pressure 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, in whom blood pressure at night exceeds daytime and CI has negative values.

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);
- AH in pregnant women, nephropathy in 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:
- a high frequency of stroke;
- frequent development of left ventricular myocardial hypertrophy;
- abnormal geometry of the left ventricle;
- a 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 SI 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, consequently, 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 higher (lower) than normal, and the conditional limit of the norm for the daytime is considered to be 140/90 (average daytime blood pressure = 135/85), and for night - 120/80 mm Hg. (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 * h) or the 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 doctors should pay attention to when they begin to use the technique of daily monitoring of blood pressure in their work, or who experience difficulties in evaluating its results. Any comments will be gratefully received.

Daily monitoring of blood pressure is carried out throughout the day in the phases of activity (walking, work, physical, mental stress) and rest (sleep, walking in nature, in a lying and sitting position). A small device is around the clock on the human body and automatically measures the performance at regular intervals.

Such diagnostics is of great value for monitoring the effectiveness of treatment, with a complex history, increased risks of complications.

24-hour blood pressure monitoring is carried out to more accurately diagnose problems with pressure in conditions as close as possible to normal human life.

It makes it possible to trace the dynamics, patterns of changes in readings throughout the day, to establish the dependence of pressure surges on various factors. In turn, this makes it possible to make a more accurate diagnosis and prescribe appropriate treatment, refute or confirm suspicions of hypertension / hypotension in an incomprehensible situation, establish factors that affect blood pressure jumps, and track the dynamics of treatment.

For a period of 24-48 hours, a special device weighing about 300-500 grams is attached to the patient's body, capable of recording blood pressure values ​​in various living conditions.

The study is performed on an outpatient basis, and the mechanism will automatically take measurements and record the obtained data in its memory approximately every 15 minutes during the daytime and every 30 minutes at night during sleep (depending on the settings). The patient does not need to record the obtained blood pressure values, but he should, describing in detail his daily routine.

The data obtained can be transferred to a computer and studied in more detail. The doctor will evaluate the following indicators:

• The average value of blood pressure for the entire study period at night and daytime;
• Episodes when the level of blood pressure rose / fell to maximum values;
• Daily index of indicators of diastolic and systolic pressure;
• BP in the morning and after waking up.

Who is it for?

Indications for SMAD are:

1. - some people are afraid of doctors, so they can worry at the reception. This will be displayed during the measurement of pressure: the device will show an increase in blood pressure, although in fact the person is not sick, but simply worried. Daily monitoring will allow you to accurately determine whether a person has problems with pressure or not.
2. Suspicion of .
3. Hidden hypertension or, as it is also called, hypertension of the working day, when pressure surges are observed only in working conditions.
4. The need to monitor the effectiveness of treatment of problems with AD.
5. In the process of treatment, it was revealed that medications do not help to eliminate problems with pressure.
6. To track the rhythm of fluctuations in indicators throughout the day. ABPM allows you to identify the causes and patterns of circadian rhythm disorders.
7. In insulin-dependent diabetes mellitus.
8. For examination of pregnant women in the presence of deviations in blood pressure from the norm.
9. Genetic predisposition to hypertension.
10. Clarification of the diagnosis in cases of the presence of pathologies of the nervous system of a vegetative nature.
11. Large pressure surges (high pressure drops sharply and vice versa).
12. There is a risk of developing complications.
13. To determine the cause of sudden loss of consciousness (one of these may be hypotension).
14. To establish the factors affecting the change in blood pressure.
15. When one-time measurements show borderline values, the symptoms are ambiguous and there is no way to make an accurate diagnosis.

In such situations, daily monitoring of blood pressure provides valuable information that will help to make an accurate diagnosis, suggest the cause of pressure problems and prescribe the most adequate treatment, as well as correct ineffective medical measures.

Method contraindications

Despite its informativeness and research value, SMAD has some contraindications to conduct. These include:

1. Blood pathologies during periods of exacerbation, including thrombocytopenia.
2. Skin diseases and other lesions (wounds, abrasions) in the shoulder area.
3. Diseases accompanied by damage to the vessels in the hands.
4. Injuries of the hands, shoulder joint.
5. During the previous ABPM, there were complications, the patient's condition worsened.
6. Injuries, vascular diseases that may interfere with the procedure (for example, impaired patency of the brachial artery).

Before using the device for SMAD, it is necessary to consult with a therapist.

Advantages and disadvantages of the pressure control method

Today, ABPM is becoming a very popular method of monitoring blood pressure readings and tracking the course of hypertension/hypotension. The advantages of this method include:

• the ability to obtain more accurate, objective readings;
• the results of such a study are independent and more truthful, since the measurement is carried out in conditions close to ordinary life - this makes it possible to exclude the influence of fear of doctors or one-time, random factors on the result of the examination;
• with the help of ABPM, it is possible to detect hidden, not having clearly expressed symptoms, blood pressure disorders;
• makes it possible to prevent the development of the disease with a genetic predisposition;
• very informative in incomprehensible situations (loss of consciousness of unknown etymology, constant weakness, incomprehensible or sleep, short-term systematic jumps in blood pressure, etc.);
• makes it possible to evaluate the effectiveness of the treatment of problems with blood pressure, to correct the ineffective prescription of drugs or their dosage;
• helps to assess the condition of a pregnant woman with blood pressure problems, identify and prevent the development of complications during childbirth, make a decision on the acceptable type of delivery in a particular situation;
• You can measure your blood pressure at home.

The disadvantages of this method include perhaps minor inconveniences during the procedure: you can not take a bath, swim in the river, the sea, visit solariums, baths; care must be taken not to damage the instrument.

A person may experience some discomfort from the constant wearing of the device, especially during sleep. However, compared to the benefits of ABPM, these temporary inconveniences are minor.

Carry out daily monitoring of blood pressure using a device such as a tonometer. Usually, a small lightweight device (up to 500 grams of weight) is used, which is attached to the belt under the clothes, and the cuff is fixed in the shoulder or wrist area. It captures the results and stores them in its memory, and after the procedure is completed, the instrument data is displayed on the computer.

A device for daily monitoring of blood pressure can be purchased at pharmacies or medical service stores, medical equipment.

It is most convenient to take a tonometer with a microcomputer, in which case the measurement results will be automatically stored in the device's memory. Otherwise, you will need to record all the readings yourself.

Today, modern blood pressure monitors have been developed that are worn on the wrist. They are very comfortable, like a watch or a bracelet. However, for people over 50 years of age, such devices are not suitable, since with age the vessels lose their elasticity, and the pressure on the wrist will not be measured accurately.

For a more accurate diagnosis of a person's condition, it is recommended to purchase tonometers that record not only pressure readings, but also pulse. If we talk about specific brands of meters, the following devices enjoy the best reviews:

Some blood pressure monitors can analyze the correct fastening of the cuff, which is also important for obtaining accurate readings.

To get really objective, truthful results, it is very important to choose a high-quality device and an experienced doctor to decipher the values. Cheap low-quality devices can give readings with a large error

Rules and technique for conducting research

Before using the device, it is necessary to read the instructions for it, and carry out all actions according to the prescribed instructions. Otherwise, the tonometer may show inaccurate results or even break down.

To determine the exact indications and the correct procedure, it is recommended to follow these rules:

1. When using a shoulder tonometer, make sure that the lower edges of the cuff are placed one or two fingers above the elbow joint;
2. To obtain more accurate readings during the measurement of blood pressure (the beginning of the measurement can be felt by squeezing the cuff), it is not recommended to move. If it so happened that the movement cannot be stopped, the hand on which the device is attached should be kept free, relaxed and motionless throughout the entire measurement time (the device beeps before starting the measurement);
3. Before going to bed, remove the device (without disconnecting from the cuff) and place it next to the pillow or on the bedside table;
4. Do not pinch the tube that connects the monitor and the cuff. If the monitor compressor is functioning, but the cuff is not inflated, check the condition of the tube and the reliability of the connection;
5. If the conditions for measurement are unsuitable (there is no way to ensure the immobility of the hand), it is better to stop the measurement by pressing the "stop" button, after the set time the device will try again;
6. If it becomes necessary to remove the cuff, it must be disconnected from the monitor;
7. There should be a time indication on the monitor, if it is not there, this may mean that the device has run out of power.

The objectivity of the results also largely depends on the correct preparation and conduct of the procedure.

In order to prepare for ABPM and ensure conditions for obtaining accurate data, several actions should be performed before starting the procedure:

• Since the device will work for a long time, you need to check if the battery is well charged;
• Program the device for the data of a particular patient, set a certain interval through which the pressure will be measured;
• Measure the circumference of the forearm to find the right cuff;
• Install the system: for right-handers, the cuff is attached to the forearm of the left hand, for left-handers - to the right, in order to avoid displacement of the cuff. It is recommended to fix it with double-sided discs or adhesive tape.
• The cuff can be fastened over the sleeve of a thin T-shirt or sweater. Soft tissue will not worsen the results of the study, but will help to avoid such unpleasant phenomena as sweating, skin irritation and itching.

It is very important during the procedure not to think about it, not to analyze the data yourself. Such thoughts can cause excitement and, accordingly, increase pressure.

During sleep, you should also try to relax and not remember the procedure.

How do daily monitoring of pressure and pulse? The procedure is very simple. The main thing is to read the instructions for the device, prepare the device, follow the instructions of the doctor and not worry.

1. Classic way. A cuff is attached to the forearm or wrist, a small device is connected to it (it can be attached to a belt or put in a pocket). The device is installed by a doctor, after which a briefing is carried out, and the patient is sent home. Pressure monitoring takes place on an outpatient basis during the day and at night. The total duration of the procedure is 24-48 hours, during which the patient must wear the device. The number of measurements and their frequency is set by a specialist (usually within 50 times a day - every 15 minutes during the day and 30 minutes at night).
2. Holter monitoring. This method involves fixing two indicators at once: blood pressure and heart rate, which allows you to determine the presence of hidden pathologies and give a more detailed assessment of the state of the cardiovascular system. In addition to a compact tonometer, small electrodes are fixed at certain points in the chest area (they cannot be removed throughout the study), and the data is displayed on a special device. The pulse rate is calculated according to the principle of electrocardiography. The duration of the study is 24-48 hours, but according to the decision of the specialist, the period can be extended several times.

You live your day as usual, without changes. The main thing is to take care of the device and not get hung up on measurements, and also not be afraid of squeezing the cuff.

After the allotted time, you need to return to the appointment with the attending physician, remove the device and provide the diary data. Usually, the results of the study are provided in a few days.

During the day, it is imperative to keep a diary in which all the moments associated with the conduct of SMAD are recorded, namely:

The diary must be filled out as accurately as possible so that the doctor can objectively evaluate the results, make the correct diagnosis and prescribe adequate treatment. If it so happens that you need to remove the device yourself (for example, the end of the procedure fell on the weekend), you should definitely turn off the monitor. It is forbidden to remove the battery from the device, as the results of the study will be lost.

For a child, the method of conducting SMAD does not differ; the procedure is carried out in the same way as in adults. Differences exist only at the stage of deciphering the results.

The indicators taken by the tonometer during the SMAD process are transferred to a personal computer. The results are usually interpreted by comparison with average values ​​taken over 24 hours (eight of which are daytime and eleven are nighttime). After analyzing the data, the doctor makes a conclusion.

The condition of a particular patient is evaluated in comparison with blood pressure indicators, which are considered normal. In a healthy person, the following values ​​\u200b\u200bare considered average:

• daily indicators: 120 (±6) by 70 (±5);
• daily values: 115 (±7) at 73(±6);
• night values: 105 (±7) over 65 (±6).

The normal level of blood pressure during the daytime is considered to be 135 to 83 and nighttime: 120 to 70. If the values ​​​​exceed 140 to 90 during the day and 125 to 75 at night, the pressure is considered high.

High pressure at night or its insufficient decrease (normally, during sleep, blood pressure drops by 10-20%) may indicate the presence of a number of diseases or the risk of their development:

1. Kidney disease in the chronic stage.
2. Sleep problems, including insomnia.
3. Tumors of the adrenal glands.
4. Diabetes.
5. From the side of the cardiovascular system - stroke, hypertension, ischemia, angina pectoris, myocardial infarction, hypertrophy, etc.

The heart rate indicates the state of the heart: if the heart rate reaches 90 or more beats per minute, this may be a tendency to develop tachycardia. If the heart rate is less than 60-50 per minute, this indicates the development of bradycardia.

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Cardiological examination methods are divided into 4 large groups:

Doctor-patient communication

Despite the constant development of medical technology, technology cannot replace a personal conversation between a doctor and a patient. A good cardiologist should carefully ask the patient about his complaints, the history of the development of the disease, the moments of the past and present life of the patient that are important for understanding the disease.

A simple examination of the patient can also provide valuable information to the physician.

But the value of listening and percussion techniques is really decreasing with the development of technology. Among American doctors, the usual stethoscope (listening device) is increasingly being replaced by an ultrasound scanner the size of a mobile phone.

FUNCTIONAL DIAGNOSTICS

ECG (Standard 12-lead Resting Electrocardiography)

The technique, for the development of which Willem Einthoven received the Nobel Prize, has been used by cardiologists for more than 100 years. The first devices were the size of a large machine, the patient sat with his hands and feet in buckets of water.

The pictures on this site are enlarged and moved with the left mouse button!

Modern devices are small consoles for a computer. Unfortunately, the number of wires, clamps and suction cups is not decreasing yet.

What pathology is detected on the ECG with a high degree of probability?

ECG allows you to evaluate the work of the heart by generating and conducting electrical impulses. The following violations are visible on the ECG (if they occurred at the time of recording):

• Rhythm disturbances (arrhythmias - tachyarrhythmias (acceleration of the rhythm), bradyarrhythmias (associated with slowing of the rhythm), atrial fibrillation (atrial fibrillation), extrasystole, and so on
• Disturbances in the nutrition of the heart muscle with blood (ischemic heart disease, the most formidable manifestation of which is myocardial infarction)
• Violation of the conduction of an electrical impulse through the conduction system of the heart (“blockades”), as well as a number of rare and little-known conditions for the average patient.

What pathology does the ECG not detect?

ECG does not reveal:

• Pathology that is not present at the time of recording (10-30 seconds). For example, in the morning you had an arrhythmia attack, you came for an ECG recording - and your heart is working normally. In order to record a rarely manifested pathology, the American Norman Holter developed a daily recording technique (Holter ECG Monitoring).
• Pathology not accompanied by electrical manifestations - small degrees of valvular defects (including mitral valve prolapse)

What pathology is detected on the ECG with an average degree of probability?

• Thickening of the walls of the ventricles and atria
• Expressed stages of valvular defects

Such a pathology is much more accurately determined on Echocardiography, the conclusion of the ECG on these issues may be false or inaccurate.

In what cases does an ECG give false positive results?

False-positive results are when an acute pathology is determined by the ECG, but in fact it is not. This is possible, for example, in menopause in women, when the ECG becomes similar to "acute". The main difference is that such an ECG pattern persists for years, and an acute pathology is called acute because the shape of the teeth can change in a matter of minutes. In addition, an ECG similar to an ischemic pattern can be recorded, for example, in people with autoimmune rheumatic diseases.

If you have a persistently unusual waveform, it's a good idea to carry a copy of the ECG with you, otherwise, if a new ECG is registered, you may be offered urgent hospitalization.

What conclusions of the ECG should not be afraid?

sinus arrhythmia is the normal dependence of the pulse rate on respiratory movements.

Syndrome of early repolarization- a completely harmless feature of the ECG.

Violation of intraventricular and intraatrial conduction- has no clinical picture, restrictions and treatment is not required.

Blockade of the right leg of the bundle of His- this is already a pathology, but again, its clinical significance is very small. In children and adolescents, it may be a variant of the norm.

Migration of the pacemaker through the atria- Restrictions and treatment is not required.

What is required from the patient when recording an ECG?

Just in case (if the clinic does not have disposable wipes), you need to take a couple of wipes with you to wipe the skin moistened for better contact with the electrodes.

Some particularly prominent clinics that do not have the gel may require hairy men to shave their chest hair, but ECG gel (or conventional ultrasound) solves this problem in principle, and chest electrodes stick well on the gel.

To record an ECG, the patient must completely remove clothing from the chest, wrists and ankles (the need to remove thin pantyhose for women is negotiated with the office staff - usually this is not required, a conductive spray is simply sprayed).

Next, the patient lies on the couch, electrodes are applied to him, and recording begins, which lasts from 10 to 30 seconds. During the recording, the patient should lie still without movement, breathing should be shallow so that there is less interference from chest movements.

HOLTER MONITORING (HM)

Norman Holter, having set out to record an ECG in a freely moving person, first developed devices that transmit ECG by radio. A backpack with a transmitter hung on the back of the patient, and a stationary receiver recorded and processed the ECG. More recently, wearable long-term recording devices have been developed, which are now smaller than a pack of cigarettes.

What pathology is revealed by Holter monitoring?

Holter is a "long" (day) ECG, so monitoring reveals the same pathology as an ECG, but much more reliable. These are rhythm and conduction disturbances, coronary heart disease, the so-called "primary electrical heart disease." XM is of particular value for "transient", that is, non-permanent, violations.

What monitor options are there?

Holter monitors differ in the number of recording channels (From two to twelve. A standard ECG is recorded in 12 channels). It is clear that the more channels, the more accurate the data.

For the first Holter monitoring in life, it is better to wear a 12-channel Holter. Ischemic heart disease is also much more reliably determined by a 12-channel Holter. And even the 12-channel gives much more information about arrhythmias (for example, sometimes you can understand from which ventricle the extrasystoles “shoot out”).

However, for example, in repeated studies of a known arrhythmia, three channels are sufficient.

In addition, there are Holter devices with an additional function of daily monitoring of blood pressure (Holter + SMAD). Such devices have all the advantages of SMAD, as well as all the disadvantages (buzzing when air is pumped into the cuff).

Is a holter a guarantee of recording violations?

No. There are cases when during the daily recording, violations do not appear (no attack - no recording). In these cases, many-day (up to 7 days) monitoring is used to “catch” an attack.

For rare (less than once a week) seizures, so-called event recorders (devices that look like wristwatches) are used. They start recording when the button is pressed. The disadvantage of these devices is the recording of only one channel (and the Holter records from 2 to 12 channels), as well as the inability to evaluate the ECG before an attack.

If a dangerous, very rarely manifested pathology is suspected, a miniature apparatus (the so-called loop recorder) can be sewn under the skin, while recording can be carried out for up to several months, and “new” fragments automatically delete old recordings.

How to prepare for Holter monitoring?

The first thing to do is sign up for the procedure. Usually, monitoring is in high demand, the devices are hung on patients, and the queue in state clinics can drag on for up to a month.

For hairy men, it is a good idea to shave off the chest hair at home so that the electrodes fit snugly against the skin. Otherwise, this procedure may have to be carried out in a much less comfortable environment in the clinic. For a three-channel holter, it is enough to shave the left half of the chest, and for a 12-channel holter, it is enough to shave a strip of about 12 cm wide in the middle of the chest and all remaining areas on the left half of the chest.

In the case of a disregard for the clinic's patients, you may need batteries, usually one, less often two finger (or little finger) format, Duracell is better. You may also be required to buy disposable plastic Holter electrodes at Medtekhnika (their number depends on the number of monitor channels).

In some places, the patient may be required to pledge a passport (although this is contrary to law) or some amount of money.

All organizational issues must be discussed when recording for monitoring, so as not to be left "with the nose" (and without research). In a normal clinic, all you need is your presence, all the little things are organized by the clinic.

Patients often ask the question: "Does a mobile phone interfere with recording during Holter monitoring?". No, it does not interfere, the ECG signal is transmitted via shielded wires and radio interference does not significantly affect the signal.

How is the Holter monitoring procedure performed?

At the appointed time, you come to the clinic, and the staff (usually nurses, less often doctors) stick electrodes on you and hang up the device (usually it is placed in a fabric bag on a strap or has a belt clip, like cell phone cases).

You are given a Holter monitoring diary, in which you will record the events of interest to the doctor, and (in good clinics) a certificate for law enforcement agencies with a photo of the device and an explanation that you are wearing a diagnostic medical device, and not a martyr's belt.

In the monitoring diary, you need to record the time of such events (beginning and end):

During the appointment (unless otherwise agreed with the doctor) you need to give yourself physical activity: climbing stairs, brisk walking, etc.

A day after the start of recording, you need to return the monitor to the clinic. This is possible in two ways:

• You come to the clinic in person and the staff removes the device from you.
• If you cannot come to the clinic, you can turn off the device (in most cases this is done by removing the battery), then disconnect the electrodes, after which the device in the package can be delivered to the clinic by your representative. With this option, during the installation of the monitor, you need to ask your sister to show how the device is turned off.

After removing the monitor, the doctor examines the record and draws up a conclusion (usually it takes from one to two hours, although clinics can prescribe a much longer time - up to two days). When removing the monitor, be sure to find out the time when you can pick up the conclusion. In advanced clinics, you can send it by e-mail.

Is there any inconvenience for the patient during Holter monitoring?

Yes, wearing a monitor comes with some minor inconveniences. Firstly, the holter is an electronic device that cannot be filled with water. Accordingly, splashing in the bath or shower with him will not work. You can wash your hands and other parts of the body that do not come into contact with the machine.

The monitor has dimensions and weight, wires are connected to it, electrodes are glued to the patient's body - this can interfere with sleep and active movements to some extent.

In addition, in our turbulent time of terrorist attacks, the appearance in crowded places with wires sticking out from under clothes can lead to serious trouble with law enforcement agencies, so the patient, at his request, can be given a certificate with a photograph of the device and explanations of its safety for others.

What to do with the conclusion?

Holter monitoring, like any technical research method, is done to help the attending physician. Therefore, all medical and further diagnostic appointments after getting acquainted with the results of monitoring should be done by your attending physician - a cardiologist or therapist.

DAILY MONITORING OF ARTERIAL PRESSURE (ABPM)

The development of Holter ECG monitors has led to a parallel development of techniques for long-term recording of blood pressure. Externally, SMAD devices are also small boxes for recording, only a cuff is attached to them with a tube, like a tonometer.

What are the indications for ambulatory blood pressure monitoring?

They are divided into diagnostic and control

Diagnosis - with pronounced fluctuations in blood pressure at a doctor's appointment, to determine the degree of existing hypertension, to assess the daily profile of blood pressure, to identify transient episodes of hyper- and hypotension.

Control - to assess the correctness of the treatment.

How to prepare for ambulatory blood pressure monitoring and how is the procedure?

Everything is almost the same as with Holter monitoring (see above), only men do not need to shave their hairy chest.

Are there any inconveniences when monitoring blood pressure?

Yes. The same as for the Holter (electronic device, it must not come into contact with water).

In addition, you will be accompanied by the buzzing of the pump and the compression of the arm with a cuff, during the day every 15 minutes, at night - every half an hour. Keep this in mind if the monitoring day coincides with important working moments (meetings, etc.).

LOAD TESTS (BIKE ERGOMETRY AND TREADMILL - TREADMILL)

The essence of these techniques is the recording of ECG and blood pressure with gradually increasing dosed physical activity.

This study can shed light on two issues:

• presence or absence of ECG signs of coronary heart disease during exercise
• what is the exercise tolerance in numbers (important for athletes).

How to prepare for stress tests?

Before bicycle ergometry, it is necessary to undergo Holter monitoring and echocardiography procedures. It is recommended to carry out a stress test in the morning, 2 hours after a light breakfast. You need to bring a towel, sportswear and shoes with you to the procedure.

Are there any contraindications for stress testing?

There is. For this, EchoCG and Holter are done before the study. The doctor evaluates the data and gives a conclusion about the possibility (or impossibility) of the study.

RADIATION DIAGNOSIS

ECHO KG - ECHOCARDIOGRAPHY (the old name is ultrasound of the heart)

How the procedure goes, what the patient should do, decoding the results.

Ambulatory blood pressure monitoring is a diagnostic procedure. It provides for repeated measurement of blood pressure throughout the day with the help of a special device.

This allows you to analyze changes in pressure during the day and night: is it always increased (lowered), at what type of activity and how much does it increase (lower), does it change during the night. Some devices measure not only blood pressure, but also heart rate.

The direction for the examination is given by a cardiologist or therapist.

Indications for carrying out

The procedure is prescribed to patients who complain of:

• fast fatigue;
• headaches, dizziness;
• decreased vision, "flies" before the eyes;
• noise or ringing in the ears, stuffy ears.

Also, ABPM can be prescribed to a person who does not have unpleasant symptoms, but when the pressure is measured by a doctor, it is increased. The reason for this may be the “white coat” phenomenon: this is an individual feature that is expressed in a specific psychological reaction to doctors. A person with the "white coat" phenomenon begins to worry excessively during any medical manipulation, so his pressure and heart rate increase. Measuring blood pressure and heart rate using daily monitoring eliminates the influence of this phenomenon on the diagnosis.

The procedure allows you to identify arterial hypertension (hypertension), as well as to preliminarily determine its cause - the underlying disease. It is confirmed in the course of further examinations. Also, using this method, you can diagnose chronic hypotension (arterial hypotension) - low blood pressure.

• predict how dangerous arterial hypertension is for a particular patient;
• determine what complications it can lead to or has already led to;
• understand what level of physical activity is acceptable for a given person;
• determine if pressure medications that have already been prescribed for treatment are effective.

Carrying out the procedure

1. You come to the doctor. It attaches a portable 24-hour blood pressure monitor to your body. It consists of a cuff (the same as that of a conventional tonometer), a connecting tube and the main part of the device, which records the received data into the built-in memory (most often the device itself is placed in a case on a harness that is hung over the shoulder or fixed on the patient's belt) .
2. You live the day according to your usual schedule, but keep a detailed diary. There you write down everything you did during the day with the time.
3. The device measures the pressure every 15 minutes during the day and every 30 minutes at night. Sometimes this interval can be longer (for example, every 40 minutes during the day and every hour at night), depending on the settings.
4. If you have been prescribed any medications, tell your doctor about it. They may be canceled during the examination. If the doctor said that it is not necessary to cancel the appointment (for example, in the case when it is necessary to evaluate the effectiveness of treatment), drink the medicine according to the previous schedule and write down the time of admission in a diary. You can also write down at what point you felt the effect of the medication.
5. A day later, you again come to the doctor. He removes the apparatus and says when to come for the results. Typically, data processing takes no more than one day.

With the results, you go to your treating cardiologist or internist. Based on the ABPM data, he can make a diagnosis, as well as prescribe further diagnostic procedures to clarify the cause of hypertension.

Reminder for the patient

When going through this diagnostic procedure, you will need to remember a few things.

The basic rule is: when the device starts measuring blood pressure (you can recognize this moment by inflating the cuff, and some models emit a signal before starting the measurement), stop, relax your arm and lower it down. Otherwise, the device will not be able to measure the pressure, or the result will be incorrect.

Diary Rules

It happens that the device starts to inflate the cuff again immediately after measuring the pressure. This means that the last time the device failed to measure. Possible reasons for this: you have tightened your arm, or the cuff has loosened. If the arm was relaxed at the time of the first measurement attempt, ask someone to tighten the cuff so that it fits snugly around the arm (you can do this yourself, but it will be inconvenient to tighten it with one hand).

Intense physical activity (fitness, gym) on the day when 24-hour blood pressure monitoring is performed is prohibited.

Contraindications and inconveniences of the procedure

The procedure has no contraindications.

Of the side effects, only discomfort in the arm can be distinguished for 1-2 days after the examination, since the cuff can press.

We will also tell you about the possible inconveniences that you may encounter during the procedure:

• Sleep difficulties. Since the device also measures blood pressure at night, you can wake up from squeezing your arm with a cuff or from a preliminary signal. This is especially true for those who are light sleepers.
• It is impossible to fully bend the arm at the elbow, as the cuff is attached just above the joint. Because of this, it can be inconvenient, for example, to wash your face or brush your teeth.
• You will have to refrain from taking a shower or bath, as the apparatus cannot be wetted.

These are all disadvantages of the procedure. They can be tolerated for the sake of an accurate diagnosis, which can be made after ABPM.

Deciphering the results

Daily blood pressure monitoring provides complete information about changes in systolic and diastolic blood pressure during the day and night.

You will receive a sheet with the result of the examination the next day after the procedure.

It will say there:

1. Blood pressure at different times of the day in the form of a graph.
2. Mean daytime systolic blood pressure.
3. Mean daily diastolic blood pressure.
4. Mean nocturnal systolic blood pressure.
5. Mean nighttime diastolic blood pressure.
6. The degree of nocturnal decrease in systolic and diastolic blood pressure.
7. Variability in systolic and diastolic blood pressure.
8. Mean pulse pressure (difference between systolic and diastolic pressure).

Determining the severity of hypertension by mean pressure

Over 150 at night

Over 100 at night

The degree of nightly decrease in blood pressure should normally be 10-20%. Insufficient pressure reduction at night is an indicator of health problems.

Insufficient pressure relief during sleep

Pulse pressure (difference between upper and lower pressure) should not exceed 53 mm Hg. Art. (ideally 30–40 mmHg). Increased pulse pressure may indicate problems with the thyroid gland, as well as vascular diseases. Patients with high values ​​of pulse pressure have an increased risk of complications of hypertension.

The variability of blood pressure is the degree of its change during the day. Normally, systolic BP variability should be less than 15 mm Hg. Art., diastolic - less than 12 mm Hg. Art. Increased variability indicates low vascular elasticity, which increases the risk of stroke and retinal hemorrhage.

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24 hour blood pressure monitoring

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.

Pros and cons

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;
• lack of white coat fear syndrome;
• 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:

• Stressful situations at work provoke jumps in blood pressure.

detection of primary hypertension;

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.

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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.

Before undergoing a blood pressure diagnosis, you need to stop taking medications.

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.

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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:

pressing pain, projected on the upper left side;

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.

Features in a child

Unlike adults, determining normal BP limits in children is challenging. After all, fluctuations occur against the background of hormonal changes, physical activity, heredity. Doctors have developed special thresholds for possible normal pressure for children, depending on age and somatotype. The implementation of the technique is not fundamentally different from the SMAD of an adult. The only difference will be the threshold of accepted readings. For example, a value of 120/80 is considered normal for a tall child, while for a short child it would be a high number.

SMAD during pregnancy

ABPM in pregnant women is carried out in the 3rd trimester, the result of which will show the presence or absence of pathologies that can affect labor activity. During pregnancy, the body is exposed to increased stress, during which the pressure often rises to the level of 140/90. ABPM for pregnancy is a way to determine whether high blood pressure is the cause of the pathology or a concomitant factor in pregnancy.

Deciphering the results of SMAD

The results of daily monitoring of the arterial level are transferred to a PC, where they are decoded. Most often, decoding takes place according to the method of measuring average values, which are taken over 24 hours (8 night and 11 day). The result shows the blood pressure level of a particular patient, on the basis of which the doctor makes a conclusion. Evaluation is done according to criteria different from ordinary blood pressure. The average accepted values ​​in a healthy patient are summarized in the table:

Final word

SMAD is an indispensable way to diagnose hidden pathologies. Doctors resort to the technique when the usual method of measurement is suspicious. It is often performed among pregnant women (in the last period of gestation), as the pressure rises due to the additional load, which diverts attention from possible problems. The procedure has a preparation algorithm, rules for conducting and calculating results.

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INTERPRETATION OF ABPM RESULTS

Average blood pressure- arithmetic mean values ​​of blood pressure per day, separately for the day and night, are estimated relative to the selected age norms of blood pressure. Then the PBP value is estimated as the difference between BPs and BPd (the norm is 40-55 mm Hg during the day).

Standard deviation- BP variability, most often calculated as a standard deviation from the mean value or the coefficient of its variability for a day, day and night. BP fluctuation limits for children are under development. BP variability is analyzed separately for BPs and for BPd during day/night periods. Exceeding at least one of the four normal indicators is regarded, in conjunction with other altered parameters, as the predominance of the sympathetic link of the autonomic nervous system (ANS).

When assessing BP variability, the patient's activity, sleep quality, as well as other individual factors affecting BP and reflected in the self-observation diary are taken into account.

Daily index (SI) represents the degree of nightly decrease in SBP, BPs and BPd as a percentage, reflects the circadian rhythm of BP. According to the value of SI, several types of changes in BP at night are distinguished:

The optimal degree of nightly decrease in SBP is 10-22% - a group of dippers (literally - "descending reset");

· insufficient degree of nocturnal decrease in SBP - 0-10%, group of non-dippers (no downward discharge). It is noted in the following pathology: primary arterial hypertension, renovascular hypertension, chronic renal failure, vegetative dystonia, endocrine pathology (Itsenko-Cushing's disease, diabetes mellitus);

Reduced SI does not unambiguously indicate the presence of one of the above pathologies, but the frequency of its occurrence in these diseases is much higher;

Excessive degree of nocturnal decrease in SBP - more than 22%, a group of over-dippers (excessive downward discharge), can occur both in patients with vegetative dystonia and in those suffering from essential arterial hypertension;

night peaks, a group of night-peakers, when night SBP exceeds daytime SBP, CI is less than 0, which is observed in severe renal impairment.

Daily heart rate index (circadian index CI) represents the ratio of the average heart rate during the day to the average heart rate at night, i.e. reflects the degree of nightly decrease in heart rate: CI = 1.32 (1.24-1.41) - normal; CI< 1,2 - ригидный пульс, может наблюдаться при выраженной ваготонии и некоторых заболе­ваниях; ЦИ >1.5 - indicates sympathicotonia.

Low QI can be observed with poor sleep quality, frequent awakenings, accompanied by an increase in blood pressure, the wrong choice of the boundaries of the period of wakefulness and night sleep. It is necessary to exclude other causes of heart rate changes - heart rhythm and conduction disturbances, etc.

Temporal index (TI)- the duration of the excess of blood pressure above the upper limit of normal during periods of wakefulness and sleep, expressed as a percentage. Normally, during the day, blood pressure rises with emotional or physical stress. When VI approaches 100%, this indicates a permanently elevated blood pressure. In this case, VI ceases to reflect the dynamics of BP fluctuations, becomes uninformative at constantly high BP values.

Hypertension area index- the value of the excess of blood pressure over the upper limit of the norm during periods of wakefulness and sleep, expressed in mm Hg. Art. at one o'clock. It is defined as the area on the graph, bounded at the top by the curve of blood pressure versus time, and at the bottom by the line of threshold values ​​(upper age norm) of blood pressure. The ratio of the area index to the temporal index> 2-2.5 is typical for the predominance of sympathetic influence, which causes an increase in blood pressure. The ratio of the area index to the temporal index, equal to 1-2, indicates a constantly but moderately elevated blood pressure. In this case, we can assume: symptomatic arterial hypertension, hypothalamic syndrome, shallow or interrupted sleep, measurement error.

Based on the ABPM, analysis and interpretation of the results, three variants of the circadian BP rhythm were identified: sympathicotonic, vagotonic, and mixed, differing in mean BP, pulse BP, BP variability, and time index.

Sympathicotonic type. The sympathicotonic variant is divided into two subtypes - a and b.

a. When analyzing the graphs, a high amplitude of BP oscillations is noted, the location of the curve of average values ​​of systolic BP (BPs) is above the upper limit of normal. During the day, the following are detected: increased mean BP and pulse BP (PAD) with normal values ​​of diastolic BP (BPd); increased variability (more than 12 mm Hg) of blood pressure during the day and (or) at night; normal daily index (SI) if the patient slept well; high temporal index (TI) - more than 39% and the BP area index during the day with a normal BPd temporal index, while the BP area index is 2 or more times greater than the BP temporal index. VI ADd during the day can be more than 26%, and at night it can decrease to 10-15% (but not lower than 10%).

b. If the analysis of the results of ABPM, in addition to changes characteristic of the sympathicotonic type, reveals a persistent increase in blood pressure during the day (mean values ​​​​are above the age norm, high VI, the ratio of the area index to VI is more than 2), then arterial hypertension of the pubertal period can be assumed (when examining teenagers). The diagnosis should be based on the results of a fully performed ABPM, the presence of an appropriate clinical picture, and a family history aggravated by arterial hypertension in the 1-11th generation.

Vagotonic type. When analyzing the graphs, a small amplitude of BP oscillations is noted, the location of the curves of the average values ​​of BPs and BPd is significantly below the upper limits of the norm.

When analyzing the values ​​of blood pressure, the following are revealed: low average values ​​and monotony of blood pressure throughout the entire time of the day; PAD at the lower limit of normal; normal or greater than 22% CI; low values ​​of VI and the area index of BPs and BPd during the day, approaching zero values ​​of VI and the area index of BPs and BPd at night.

Mixed type. The most common type, in which the average value of blood pressure does not exceed the age limits of the norm. When analyzing the tables, signs of both sympathicotonic and vagotonic types are revealed.

Computer analysis of the results of ABPM as an independent diagnostic method significantly increases the productivity of the study, given the large number of calculated indicators. The results of computer analysis are presented in the form of graphs (Fig. 6.13) or are displayed in the form of a table.

Along with this, ABPM is used as a technique that complements 24-hour ECG monitoring (see section 6.8.3).

Rice. 6.13. 24-hour BP monitoring schedule. Significant increase in blood pressure at night and from 12 to 15 hours

ABPM (daily pressure monitoring): indications, how they are carried out, results

Everyone knows that many cardiological diseases have become “younger” in recent years, that is, they occur in young people. Arterial hypertension is no exception. This is due not only to poor ecology and poor quality of nutrition in modern times, but also to an increased level of stressful situations, especially among the working population. But, unfortunately, it is sometimes difficult even for a doctor to recognize and distinguish a situational increase in pressure, for example, during psycho-emotional overload, from true hypertension. Therefore, more and more often in the arsenal of therapists and cardiologists there is such an additional examination method as 24-hour blood pressure monitoring (ABPM), which first of all makes it possible to detect elevated blood pressure in a patient - more than 140/90 mm. rt. Art. (criteria for establishing and diagnosing "hypertension").

The history of the creation of the method goes back to the 60s of the last century, when various attempts were made to register blood pressure throughout the day. At first, devices were used in which the patient independently pumped air into the cuff of the tonometer according to the timer signal. Then attempts were made to measure blood pressure invasively using a catheter in the brachial artery, but the technique was not widely used. In the 70s, a fully automated device was created that independently supplies air to the cuff, and a mini-computer in the device reads the data from successive blood pressure measurements, including at night when the patient is sleeping.

The essence of the method is as follows. A cuff is applied to the patient on the middle and lower third of the shoulder, resembling a conventional apparatus for measuring pressure (tonometer). The cuff is connected to a register that supplies and inflates air, as well as to a sensor that registers blood pressure measurements and stores them in memory. After the examination, the doctor, when removing the device, transfers the results to the computer, after which he can issue a definite conclusion to the patient.

Advantages and disadvantages of the method

The undoubted advantage of the ABPM technique is that monitoring pressure during the day allows you to catch the slightest fluctuations in different categories of patients.

So, for example, in some people there is a “white coat” syndrome, when, during a routine medical examination, for example, in a healthy patient without hypertension, pressure suddenly rises, sometimes to high numbers. After receiving the results of daily monitoring, when the patient is in a calm state, the doctor can get an idea of ​​​​the true state of affairs. As a rule, in such persons, pressure during the day under normal conditions becomes normal.

Some patients, on the contrary, have all the complaints associated with hypertension, but it is not possible to fix high numbers at the doctor's appointment. Then again, the ABPM comes to the aid of the doctor, allowing you to register pressure drops characteristic of hypertension.

Thus, ABPM is often critical in the diagnosis of arterial hypertension.

Other advantages include the wide prevalence and accessibility of the method for the population, non-invasiveness, ease of use and low labor intensity.

Of the shortcomings, we should mention a slight inconvenience for the patient, since during the day you have to stay with a cuff on your arm, periodically pumping air, which can interfere with a good sleep. However, in light of the fact that the diagnostic value of the method is great, these inconveniences can be safely endured.

Indications for the procedure

modern device for SMAD

Daily blood pressure monitoring is indicated in the following cases:

• Primary diagnosis of hypertension.
• Management of treatment in persons with hypertension.
• Obtaining information about the time of day at which the patient's blood pressure often rises in order to correct the doses of drugs received at different times of the day. For example, in patients with high pressure figures at night, it is better to prescribe additional drugs at night, and in the morning and afternoon hours, focus on taking drugs in the morning, immediately after waking up,
• Diagnosis of hypertension in people with a high level of stressful situations during working hours, when hypertension has a psychogenic cause. Tactics of treatment in this case should begin with sedative therapy.
• Sleep apnea syndrome.
• Hypertension in pregnant women, especially with suspected preeclampsia (the study is carried out in a hospital).
• Examination of pregnant women before childbirth in the event that they have hypertension in order to resolve the issue of delivery tactics.
• Examination to confirm professional suitability (train drivers, etc.), as well as for conscripts whose fitness for military service is in doubt.

Contraindications for ABPM

Examination may be contraindicated in the following diseases and conditions of the patient:

1. Dermatological diseases associated with lesions of the skin of the upper limb - lichen, fungus, etc.
2. Blood diseases, for example, severe thrombocytopenia, hemorrhagic purpura, petechial rash, etc., characterized by the appearance of bruises at the slightest pressure on the skin,
3. upper limb injury,
4. Vascular diseases with damage to the arteries and veins of the upper extremities in exacerbation,
5. Mental illness of the patient associated with inability to self-care, aggression and other symptoms.

Preparation for the procedure

Daily pressure monitoring does not require any special preparation. The patient is not only allowed, but even necessary to live in the usual rhythm, without limiting physical or psycho-emotional stress on the day of the study. Of course, you should not go to the gym or drink a lot of alcohol - it is better to exclude it altogether. Also, before the study days, the drugs taken by the patient should be canceled, but this should be done only in agreement with the doctor who prescribed the monitoring. But during an examination conducted to monitor treatment, drugs, on the contrary, should be taken, but the time of taking certain drugs should be recorded in a special diary so that the doctor can see how they affect the level of blood pressure during the day. Again, you need to coordinate the intake of tablets with your doctor.

On the day of the study, food and liquid intake is allowed, since there is no need to "hang" the monitor on an empty stomach. From clothing, preference should be given to a thin long-sleeved T-shirt - for hygienic reasons, because usually the cuff is reusable for all patients.

How is the procedure carried out?

In the morning, at the appointed time, the patient must arrive at the Department of Functional Diagnostics. The examination can be carried out both in the clinic and in the hospital. After a preliminary measurement of pressure by the Korotkoff method using a conventional tonometer, a cuff is put on the patient's shoulder (usually the left for right-handed people, and vice versa), which is connected to a device that pumps air with thin tubes, and also contains a device for storing the information received. . This device is fixed to the belt of the patient's clothing or fits into a special bag that the patient wears over his shoulder. In some cases, electrodes are applied to the patient's chest, recording the cardiogram - in cases of parallel monitoring of the ECG according to the Holter.

The operation of the monitor is already set up in such a way that the device inflates the cuff after a certain amount of time. As a rule, this is once a minute during the daytime, and once an hour at night. At these moments, the patient should pause, freely lower the arm down and wait until the measurement takes place. In addition, the monitor has a button that can be pressed when unpleasant symptoms appear, and an unscheduled blood pressure measurement will occur.

In the daytime, the patient should record in the diary the time of taking medications, the time of eating, the time and nature of physical activity down to the smallest detail - for example, he went to the kitchen, went up to the third floor, etc. It is especially important to note the type of activity at the time of measuring pressure . You should also note unpleasant symptoms - pain in the heart, headaches, shortness of breath, etc.

A day later, the patient visits the functional diagnostics room again in order to remove the monitor, transfer the information to the computer and issue the conclusion of the study protocol.

SMAD in childhood

In children older than seven years, 24-hour blood pressure monitoring is often used, but, as a rule, together with ECG monitoring. Indications are not only hypertension, but also hypotension (low blood pressure), rhythm disturbances, and syncope (loss of consciousness).

Conducting a study is not much different from examining adults, with the only difference being that the child needs to be explained in more detail, and even better, to show how the monitor works and what it is for.

Deciphering the results

The level of blood pressure, as well as some other indicators (body temperature, pulse, respiratory rate) is a value subject to circadian rhythms. The highest level of blood pressure is observed in the morning and afternoon hours, and at night there are low numbers of blood pressure.

Ideally, BP numbers are between 110/70 and 140/90 mm Hg. In children, the pressure may be slightly lower than the figures given. When monitoring, in addition to the average blood pressure figures (systolic blood pressure - SBP and diastolic blood pressure - DBP), circadian rhythm variability is indicated, that is, fluctuations in SBP and DBP up and down from the obtained average daily curve, as well as a daily index, that is, the difference between day and night results BP in percent. Normally, the daily index (SI) is 10-25%. This means that the average "night" BP numbers should be less than "day" by at least 10%. Rhythm variability is considered abnormal if at least one of the measurements gives numbers above or below normal blood pressure values.

example of ABPM results

Depending on the data obtained as a result of the measurements, the doctor issues a conclusion, which indicates the above indicators.

Reliability of the methodology

Again, it is not difficult to achieve elevated blood pressure levels with ABPM, but it is almost impossible to deceive the doctor who performed or received the results. Firstly, this is due to the fact that many conscripts try to increase their blood pressure at night, and, as a rule, young people, even those with hypertension, normalize their blood pressure at night. Secondly, under load, the heart rate increases commensurately with pressure, which in most cases is recorded on ECG monitoring. Therefore, the doctor, seeing sinus tachycardia, coupled with an increase in blood pressure, is likely to think about the reliability of the technique, and prescribe other research methods, possibly even in a hospital.

Some people of military age use nicotine and caffeinated drinks in large quantities, and sometimes even alcohol on the day of the study. Such cocktails of caffeine and continuous loads during the day will certainly affect the heart and blood vessels of a young person, and can lead to cardiovascular pathology in the future. Therefore, it is better not to take risks and conduct this examination as usual. In the end, military service is not as harmful as the possible complications associated with increased blood pressure from caffeine, alcohol and excessive physical exertion, which young people unknowingly resort to in order to "slope" from the army.

There are cases when, on the contrary, the patient wants to “deceive” ABPM in order to hide hypertension and continue responsible work by passing an aptitude test. In this case, it is worth recommending that the subject, at least in general terms, reconsider his lifestyle and exclude addictions, such as malnutrition and excessive consumption of salt, simple carbohydrates, animal fats and excess calories (not to mention alcohol, caffeine and nicotine). And at the same time normalize the level of physical activity, get rid of stress, lack of sleep and uneven loads. Moreover, for a good result, it is worth starting the “perestroika” in advance, at least a few months before the examination. And after it, “fix” a new lifestyle and improve your own health, at the same time slowing down the progression of hypertension.

Interpretation of the results of ambulatory blood pressure monitoring

Men over 50 years of age

Women, under 50 years of age

Women over 50 years of age

For an error-free interpretation of changes in the analysis of the ECG, it is necessary to adhere to the scheme of its decoding given below.

In routine practice and in the absence of special equipment for assessing exercise tolerance and objectifying the functional status of patients with moderate and severe heart and lung diseases, a 6-minute walk test can be used, corresponding to submaximal.

Electrocardiography is a method of graphic recording of changes in the potential difference of the heart that occur during the processes of myocardial excitation.

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Norms for SMAD

Recent years have been marked by an increasing number of large-scale population studies for the development of ABPM standards (Ohasama (Japan), HARVEST and PAMELA, Italy).

Research under the latest program has been conducted since the beginning of the 90s (duration of about 5 years) on the basis of 5 research medical centers. The number of examined normotonic patients was 2400, the age range of the year. The formation of representative subgroups was carried out according to strict criteria of population studies. In addition to the results of monitoring, the clinical characteristics of volunteers, data on the presence of bad habits, social status, psychological portrait on the day of the study, etc. were entered into the data bank.

Here are some preliminary results of the project (G.Sega et al. 1994).

Blood pressure according to the Korotkov method was, when measured in a medical institution, on average 127/82 mm Hg, at home - 119/75 mm Hg, based on the results of monitoring SBP (24) = 118, DBP (24) = 74 . The difference between clinical and monitor, as well as clinical and "home" blood pressure increases progressively with age, reaching 16 and 8 mm Hg for systolic blood pressure. in men and 19 and 14 mm Hg. in women in the older age group (from 55 to 63 years). Blood pressure is higher in men than in women. The bulk of the data is in statistical processing.

The development of DEC standards is currently intensively ongoing in a number of countries around the world and, according to E. O’Brien and J. Staessen (1995):

a) three areas of work are promising - 1) study of the relationship between morbidity and mortality with indicators of recession, 2) establishing the relationship between indicators of recession and traditionally measured values ​​of blood pressure with extrapolation to the recession of prognostic data obtained in traditional population studies, 3) assessment of the boundaries of variations in indicators of recession in populations of apparently healthy people.

b) before the formation of the final standards for the decline, you can use the temporary classification

AVERAGE DECLINES (SBP/DBP) (E.O'Brien and J.Staessen, 1995)

Specialists from the USA (T.Pickering, 1996) and Canada (M.Myers, 1996) propose to focus on somewhat different limit values.

AVERAGE DECLINES (SBP/DBP)

Later, E. O'Brien and J. Staessen summarized the data of studies conducted in a number of countries in Europe and North America and proposed the following due values.

AVERAGE DECLINES (SBP/DBP) (E.O'Brien and J.Staessen, 1998)

At the same time, we present O'Brien's (1991) estimates for the upper limit of the norm for the average daytime values ​​of DECESSION (obtained in a sample of 815 people): years - men 144/88 mm Hg, women 131/83 mm Hg, years - men 143/91 mm Hg, women 132/85 mm Hg, years men 150/98 mm Hg, women 150/94 mm Hg, years - men 155/103 mm Hg, women 177/97 mm Hg

According to a pooled analysis of the results of 24 groups of researchers (4577 normotensive and 1773 patients with mild to moderate forms of AD), L Thijs et al. (1995) estimated the 95th percentile for 24-hour BP values ​​as 133/82 mmHg.

However, 24% of patients with isolated systolic hypertension had SBP(24) below 133 mmHg. and in 30% of patients with diastolic AH, DBP(24) did not exceed 82 mm Hg. Reported percentages were significantly higher in studies focusing on single rather than triple Korotkoff blood pressure measurements.

When evaluating the SAD standards in groups of practically healthy children and adolescents in Spain (E. Lurbe, 1997), upper estimates (95 percentiles, P95) and medians (P50) were obtained for the daily BP profile in three age groups: 6-9 years old

At night, SBP decreased by an average of 12%, and DBP by 22%. The upper limit of the time index (TI) was 39% for SBP and 26% for DBP.

PRESSURE LOAD INDICATORS.

Specialists from the USA (T.Pickering, 1996) and Canada (M.Myers, 1996) suggest focusing on the following values ​​of the time index "TW":

The generally accepted standards for the indices of time (TI) and area (IP) are not currently developed. Here is an estimate of the upper limit of the norm (M + 2σ) for IV systolic - IVAD(D) - and diastolic - IVAD(D) pressure in the daytime based on data from Zachariah et al. (1989).

CIRCULAR RHYTHM HELL

The degree of nocturnal decrease in blood pressure (SNS) from 10 to % is recognized as optimal.

At the same time, reduced SNS, manifestations of stable nocturnal rises in blood pressure, as well as increased SNS, are potentially dangerous as factors for damage to target organs, myocardial and cerebral "catastrophes".

Almost all researchers agree with the lower limit (10%) (about 30 papers at the 16th Congress of the International Society of Hypertension Researchers in Glasgow, 1996). The upper limit of the optimal SNS was estimated relatively recently in% based on the analysis of the frequency of ECG signs of ischemia at night in patients with a combination of hypertension and coronary artery disease (S. Pierdomenico et al., 1995), as well as in the analysis of signs of cerebral circulation disorders (K. et al., 1996).

Based on the SNS data, a classification scheme for patients is used (separately according to the criteria for systolic and diastolic pressure):

1. Normal (optimal) degree of nightly decrease in blood pressure (in the English literature "dippers") - 10%<СНСАД<20 %

2. Insufficient degree of nightly decrease in blood pressure (in the English literature "nondippers") - 0<СНСАД<10 %

3. Increased degree of nocturnal decrease in blood pressure (in the English literature "overdippers") - 20%<СНСАД

4. Sustained increase in nocturnal blood pressure (in the English-language literature "nightpickers") - SNBP<0

A decrease in SNS below the optimal range is observed in a number of patients with primary hypertension (including atherosclerotic lesions of the carotid arteries), it is also characteristic of the syndrome of the malignant course of hypertension, chronic renal failure, renovascular hypertension, Cushing's syndrome, observed after heart and kidney transplantation, with congestive heart failure, eclampsia, diabetic and uremic neuropathy, with widespread atherosclerosis in the elderly. Reduced SNS is characteristic of the black population of the United States.

It should be noted that the degree of nocturnal BP decrease is extremely sensitive to the quality of sleep, day regimen and type of activity during the daytime, and is relatively poorly reproduced during repeated monitoring. Considering these circumstances, most researchers tend to conduct control re-monitoring to confirm deviations in the decline in this trait, detected during a single monitoring.

Standards for indicators of cosinor analysis are in the process of formation. The assessment of these values ​​for "normotics", as well as patients with mild and moderate forms of HA, is given in Table 1 of the APPENDIX.

Acceptable limits for inferring increased variability are under development. Most researchers form them on the basis of average values ​​characteristic of different observation groups. According to P. Verdecchia (1996), these values ​​are for BAP1 (or STD) SBP 11.9 / 9.5 mm Hg. (day Night). At the same time, in the group of hypertensive patients with increased SBP variability, the frequency of cardiovascular complications is higher by % (1372 patients, follow-up time up to 8.5 years).

As temporary standards of variability (VAP1 or STD) for patients with mild and moderate forms of AH in RKNPC, critical values ​​were formed (based on an assessment of the upper limits for normotonics):

for CAD - 15/15 mm Hg. (day Night),

for DBP - 14/12 mm Hg. (day Night).

Patients belong to the group of increased variability if at least one of the four critical values ​​is exceeded.

According to the data obtained in the Department of Arterial Hypertension of the Research Institute of Cardiology, RKNPC, a significant increase in the frequency atherosclerotic changes in the carotid arteries, changes in the microvessels of the fundus, echocardiographic signs of left ventricular hypertrophy (Fig. 7).

A) When focusing on standard values, it is necessary to pay special attention to the daily regimen and the conditions for conducting SMAD. The vast majority of studies are focused on monitoring in the "typical working day" mode. Meanwhile, a comparative study of DECESSIONS (N=12, men, 43+2 years, mild and moderate HA, no therapy at the time of the study) during the working day and a week later in the RCPD hospital showed that the average daily value of SBP decreases in hospital conditions by an average of 9%, and DBP - by 8%. This circumstance must be taken into account not only when trying to transfer the standards obtained on an outpatient basis to the conditions of a clinical hospital, but also when assessing the dynamics of decline during treatment.

B) During daytime sleep, the decrease in blood pressure occurs to the same extent as during nighttime sleep. This is reflected in the form of corresponding "failures" in the DECESSION. On the other hand, episodes of interruption of nocturnal sleep and transition to a vertical position are reflected in the form of peaks in blood pressure and heart rate in the corresponding section of the DECEPTION. How to take these episodes into account when processing the results? Apparently, it is advisable to exclude them from the analysis of the circadian rhythm and the calculation of the SNA. If such episodes are not typical for the patient, then they can be excluded from the calculation of other indicators of the daily profile. If, on the contrary, they are typical, then this kind of correction is not advisable.