Ambulatory blood pressure in heart failure

Ambulatory blood-pressure monitoring (ABPM) is accepted in the evaluation a nd management of hypertension. The use of ABPM in heart failure has receive d considerably less attention. Many patients with advanced heart failure ex perience disabling fatigue, orthostatic dizziness and symptoms of coronary and cerebrovascular insufficiency that may relate to periods of hypotension . These may be exacerbated by vasodilator drug therapy and may be difficult to evaluate by casual clinic recordings. ABPM in heart failure may help in the following: (i) evaluating time-dependent pharmacodynamic drug effects, such as peak and end-of-dose phenomena, tolerance and rebound; (ii) titrat ing ACE inhibitors and other drugs to highest-tolerated doses; and (iii) co rrelating circadian blood-pressure profiles with symptoms, quality of life, severity of heart failure, progression of ventricular and renal dysfunctio n, risks of stroke and myocardial infarction, and life expectancy. Devices for ABPM have been beset by problems of inaccuracy and unreliability. Stand ards for their manufacture and sale (including bench tests of accuracy agai nst sphygmomanometry and intra-arterial recordings, and field tests of reli ability) have been devised independently by several agencies, including the British Hypertension Society (BHS) and US Association for the Advancement of Medical Instrumentation (AAMI). A joint BHS/AAMI set of guidelines is in preparation. These guidelines emphasize the suitability of ABPM devices fo r hypertensive patients and those under general anesthesia, and may not be applicable to ambulant individuals with heart failure and blood pressures a t or below the lower end of the evaluated ranges. Prospective studies of th e accuracy and reliability of ABPM devices, their clinical utility and rese arch potential should be undertaken in patients with heart failure before t heir informal and uncontrolled use in this population becomes widespread.