SomnologieSomnology – Current Sleep Research and Concepts

Reviews

Somnologie 2020 · 24:90–96https://doi.org/10.1007/s11818-020-00250-zPublished online: 12 May 2020© The Author(s) 2020

Svetlana Gorokhova1 · Ingo Fietze2 · Martin Glos2 · Thomas Penzel2,3 ·Migran Buniatyan4 · Oleg Atkov1

1 Russian Medical Academy of Postgraduate Education, Moscow, Russian Federation2 Interdisciplinary Sleep Medicine Center, Charité—UniversitätsmedizinBerlin, Berlin, Germany3 Saratov State University, Saratov, Russian Federation4 Research Clinical Center of the Russian Railways, Moscow, Russian Federation

On the use of actigraphy inclinical evaluation of diurnalblood pressure profile

Ambulatory blood pressuremonitoring

The assessment of diurnal rhythm (pro-file) of blood pressure (BP) by ambula-tory blood pressure monitoring (ABPM)is now an integral part of clinical prac-tice. There are several objective reasonsfor this. Humans have normal circadianvariability of BP rhythm, with a maxi-mum in daytime hours and a minimumin nighttime hours [29, 39]. From theclinical perspective, diurnal BP profile(DBPP) has a prognostic value for riskstratification, because high systolic pres-sure and insufficient BP decrease at nightare themost important risk factors of car-diovascular complications [30, 41]. Sci-entific data emphasize that nighttime BPis a stronger predictor of cardiovascularrisk thandaytimeBP,andthatmoreatten-tion should be paid to BP evaluation dur-ing sleep in some groups of patients [19].It is particularly true for persons withsleep disturbances. According to Eu-ropean Society of Cardiology/EuropeanSociety of Hypertension (ESC/ESH) rec-ommendations on the treatment of ar-terial hypertension published in 2018,suspected lack of nighttime BP decreasein patients with obstructive sleep apnea(OSA) is a specific indication for ABPM[51]. Therefore, theassessmentofdiurnalBP rhythm, BPvalues innighttimehours,nighttime BP decrease, and detection ofnighttime hypertension are indicationsfor ABPM [36, 51]. From the practicalperspective,mostmodernABPMdevices

withautomaticdetectionofnighttimede-crease values, rate of morning increase,anddiurnalBPvariability should supportthe calculation of diurnal BP profile.

ABPM is the main method of mea-surement of diurnal BP profile. It mayseem that it gives the physician compre-hensivedataonindividualDBPPfeatures.However, much attention is now paid tosimultaneous registration of ABPM anddiurnal motor activity (actigraphy) to re-ceive additional information necessaryfor the correct interpretation of ABPMresults and clinically significant decision-making [8, 9, 18]. Actigraphy isnotanewtechnique; firstdeviceswereused instud-ies on human psychology and physiol-ogy in 1950s [42]. However, it remainsrather unknown for many cardiologistsand, therefore, it is insufficiently popular.Thisnecessitates a discussionon someas-pects of its application, particularly forthe assessment of diurnal BP profile.

Actigraphy

Actigraphy is registration of motor ac-tivity by a device implementing a 3D ac-celerometer andposition sensor (actime-ter). Usually, long-time actigraphy is per-formed, with thepatient constantlywear-ing the device fromone day to twoweeks.Theactimeter is fastened to amovingpartof body (wrist, ankle, breast) to enable ac-tivation of the recording of the amplitudeand time of motion (. Fig. 1a). Two-di-mensional sensors register both motionand body position, i.e., lying, standing,

on the right, or on the left side (. Fig. 1b).It should be emphasized that althoughthere are smartphone applications foractigraphy, only validated devices shouldbe used for medical purposes. Com-puter algorithms process the record anddetect periods of relative sleep (no activ-ity) and vigilance (activity). Actigraphswith special analysis of movement pat-tern software additionally estimate vari-ous parameters of objective sleep–wakestructure.

ABPM plus actigraphy

Synchronous monitoring of BP, activity,and body position provides the possibil-ity of performing ABPM and actigraphyin the same time segments. It providesinformation on the state of the cardiovas-cular system in sleep and vigilance, andon the influenceofbodyposition changesand motion on BP and heart rate. Theactigraphy in expert ABPM can there-fore be used for precise, clock-indepen-dent calculation of nighttime and day-time BP, detection of BP changes duringsleep, and finding connections betweenthese changes and motor activity, bodyposition, and breath disturbances dur-ing sleep, and the state of the autonomicnervous system.

Time-independent methods that re-flect current vigilance and sleep are themost reliable for detection of daytimeand nighttime periods and blood pres-sure. It is assumed that aperson isvigilantduring the astronomic day and is at rest

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a

b

Fig. 19 Samples of ac-tograms: a registration ofmotor activity index (ACT,beige bars) and numberof position changes perminute (N., red line);b si-multaneous registrationofmotion amplitude (Am-plitude, upper panel) andbody position (lower panel)

and sleeps during the astronomic night.On the basis of the solar diurnal cycle,time-dependent methods of periodiza-tion were developed with fixed averagedaytimeandnighttimeperiods. Theydif-fer somewhat with respect to the consid-ered time periods, because concurrencewithvigilanceandsleep is important [35].A broad interval with daytime lastingfrom 7AM to 10–11PM and nighttimefrom10–11PMto7AM,oranarrowerin-terval with a daytime period from 10AMto 8PM and nighttime period frommid-night or 1AM to 6AM is taken. Daytimeand nighttime BP and DBPP values arecalculated for these periods.

This general approachdoes not alwaysreflect the reality ofmodern lifestyle. Ob-viously, sleep andnight are not synonyms,and they are not always concurrent. It iswell known that the onset of sleep andits duration vary from night to night andfrom person to person, due to individ-ual behavior, household conditions, andstresses during the day. Theduration andonset of sleep are also influenced byotherfactors, for example seasonal changes oflight day [46]. Additionally, it is knownthat a high proportion of the total popu-lation has sleep disturbances (insomnia,

hypersomnia, sleep apnea, restless legssyndrome, etc.), with impaired fallingasleep, frequent nocturnal arousals, de-creased total sleep duration, and im-paired sleep quality [10, 22, 52]. It shouldbe noted that the impairment of sleepduration and quality is associated witha higher risk of cardiovascular mortality,especially with arterial hypertension [21,26, 37, 50]. Another important aspectis social deprivation of nighttime sleep,which is common in the working pop-ulation and especially in shift workers[22]. . Fig. 2 shows periods of daytimesleep and nighttime activity in a patientworking nightshifts.

To avoid errors in the detection ofsleep periods, diaries are used in whichpatients note the times of falling asleepand arousals [18, 36]. However, thesenotes are not objective in most popu-lations studied [27, 32]. It was foundthat the true time of sleep onset andwake differ from the time in diaries by30min on average and sometimes bymore than90min. . Fig. 3 shows a signif-icantdiscrepancybetween the rest period(8:15PMto7:45AM,probably sleep) reg-isteredbyactigraphyand thenightperiod

of ABPMbased on patient’s diary (11PMto 7AM).

Such cases to some extent explain in-sufficient reproducibility of DBPP values[4, 13]. Eissa et al. [11] note that diariesused for the registration of motor activ-ity are adequate only in 71% of patients,which leads to mistakes in classificationof patients as non-dippers (less than 10%drop in mean BP during sleep) in 32%of cases. For example, 23% of patientswho were considered dippers based ontheir diaries were actually non-dippers.Butkevich et al. [5] showed that due tothe variability of criteria of daytime andnighttime periods, re-classificationof thestatus of patients is inevitable. The dif-ference may be 35–69%.

Muller et al. compared daytime andnighttime BP obtained by simultaneousdiurnal actigraphy and by fixed daytime(7AMto10PM)andnighttime (10PMto7AM) periods [34]. It was found that thevalues of nighttime BP and diurnal indexwere significantly lower in cases of de-tection of night by actigraphy. Therefore,a question arises about the correlation ofnocturnal BP decrease and BP decreaseduring sleep, which is important for theassessment of cardiovascular risk. Her-

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mida et al. [15–17] demonstrated thatBP decrease during sleep confirmed byactigraphy is the most precise prognos-tic risk marker of cardiovascular eventsand renal failure in patients with arterialhypertension. The MAPEC prospectiverandomized blind study, in which 3344patients were observed for over 5 years tofind advantages of chronotherapy of arte-rial hypertension compared to standardtherapy in conditions of outpatient BPcontrol, showed that BP decrease duringsleep, and not in fixed periods of astro-nomical night, was associated with a riskof cardiovascular events [15]. These re-sults should not be ignored.

A meta-analysis by Taylor et al. [47]on heterogeneity of studies on the prog-nostic value of diurnal variability of BPpays much attention to the differences inmethodological approaches to the mea-surement of time of sleep and vigilance.It was noted that the most precise resultsare based on the registration of motoractivity. International recommendationsonoutpatient diurnalBPmonitoring [20]published in 2013 state that diurnal BPprofile anddiurnal index should be basedon BP values measured during sleep andnotintheastronomicalnight, andcurrentactigraphy data should be used. It is ex-pressly stated that the conclusions aboutdiurnal BP profile made on time-depen-dentABPMshouldbe avoided. However,this is not reflected in the position takenby the ESH [35, 36].

The moderate position of the ESH isprobably connected to current technicaland methodological limitations and es-pecially to insufficient software for thecalculation of BP decrease during sleep.Althoughactigraphy is anoption inmod-ern ABPM measurement devices, DBPPvalues are automatically calculated fromstandard nighttime intervals and notsleep periods. This issue can be solvedby manual input of sleep time intervals,as in the case of patients’ diaries.

Sleep disturbances and BPprofiles

The problem of sleep disturbances is welldescribed in reviews [3, 14, 38]. Thereis a high (35–80%) prevalence of arterialhypertension in OSA and OSA is diag-

Abstract · Zusammenfassung

Somnologie 2020 · 24:90–96 https://doi.org/10.1007/s11818-020-00250-z© The Author(s) 2020

S. Gorokhova · I. Fietze · M. Glos · T. Penzel · M. Buniatyan · O. Atkov

On the use of actigraphy in clinical evaluation of diurnal bloodpressure profile

AbstractA disturbed diurnal blood pressure profileis one of the most important risk factors ofcardiovascular diseases. This review analyzesthe use of simultaneous diurnal ambulatoryblood pressure monitoring (ABPM) andmotion activity monitoring (actigraphy) toobtain additional information for correctinterpretation of ABPM results in clinicallysignificant decision-making. The articleconsiders practical aspects of actigraphyin expert ABPM for clock-independentcalculation of the parameters of nighttime

and daytime blood pressure (BP); detectionof BP changes during sleep; connectionwith respiratory disturbances during sleep,motion activity, and body position; andsleep deprivation in shift workers. Originalillustrations of simultaneous ABPM andactigraphy are provided.

KeywordsSleep disturbances · Sleep profile · Ambu-latory blood pressure monitoring · Arterialhypertension · Blood pressure dipping

Einsatz der Aktigraphie zur klinischen Beurteilung destageszeitabhängigen Blutdruckprofils

ZusammenfassungEin gestörtes tageszeitabhängiges Blutdruck-profil ist einer der wichtigsten Risikofaktorenfür Herz-Kreislauf-Erkrankungen. In dervorliegenden Übersichtsarbeit wird dieBedeutung der gleichzeitigen Durchführungdes ambulanten Blutdruckmonitorings(ABPM) und der Messung der Bewegungs-aktivität (Aktigraphie) beschrieben. Durchdie Aktigraphiewerden zusätzliche Informa-tionen für die korrekte Interpretation desABPM gewonnen, die zu klinisch relevantenEntscheidungen beitragen. In diesem Artikelwerden praktische Aspekte der Aktigraphie inder Anwendung durch Experten bei ABPMzur uhrzeitunabhängigen Berechnung der

Parameter des Blutdrucks (BP) am Tag undin der Nacht betrachtet, zur Erkennung vonBP-Veränderungen während des Schlafs, zumZusammenhangmit Atmungsstörungenwäh-rend des Schlafs, zur Bewegungsaktivität undzur Körperposition sowie zum Schlafentzugbei Schichtarbeitern. Originalabbildungender durchgeführten ABPM und Aktigraphieillustrieren exemplarisch die Daten.

SchlüsselwörterSchlafstörungen · Schlafprofil · AmbulantesBlutdruckmonitoring · Arterielle Hypertonie ·Blutdruckabsenkung

nosed in 40% of persons with hyper-tension. Both conditions are mutuallyexacerbating. Similar observations weremade in subjects with short sleep dura-tion. According to prospective studiesand epidemiological data, the probabil-ity of arterial hypertension is 32% higherin persons with short (≤5h) nighttimesleep [7, 24]. The Monitoring Projecton Risk Factors and Chronic Diseasesin the Netherlands (MORGEN) and theProspective Urban Rural Epidemiology(PURE) study that collects data amongresidents of 25 countries demonstratedthat persons with ≤6h of nighttime sleephave a higher total cardiovascular riskand higher risk of coronary heart disease

compared to those who sleep 7–8h [21,50]. In case of simultaneous deteriora-tion of sleep quality, these risk indicatorsincrease to 63 and 79%, respectively. Dis-turbed diurnal BP profile in this categoryof patients is probably an additional con-tribution to the increased risk [23, 28].

Actigraphywith theuse of special ana-lytical programs enables detection of thetime of sleep onset and arousal, dura-tion, effectiveness, and latency of sleep,and arousals and vigilant periods afterthe onset of sleep. The records may lastover aweek (sometimesup to twoweeks),which increases the informative value ofthe study and makes the method an ex-ceptionaldiagnostic tool forpatientswith

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Fig. 29 Registration ofmotor activity (ACT, graybars, upper panel) andnumber of body positionchanges perminute (N., redline, upper panel) as well asambulatory bloodpressuremonitoring (ABPM, lowerpanel) of systolic values(red line),mean values (blueline), and diastolic values(green line) in a nightshiftworker. It is shown thatsleep corresponds to peri-ods from 12:15 to 17:45h.The patient is vigilant dur-ing a standard night periodfor ABPM records (23:00 to07:00h)

Fig. 39 A fragment of therecord of diurnalmotoractivitymonitoring (ACT,gray bars, upper panel) andnumber of body positionchanges perminute (N., redline, upper panel) as wellas ambulatory bloodpres-suremonitoring (ABPM,lower panel) of systolic val-ues (red line),mean values(blue line), anddiastolic val-ues (green line) in patient R,53 years old. A discrepancyis shownbetweenthenightperiod detected by ABPM(23:00 to 07:00h) and sleepperiod (20:15 to 07:45h)detected by actigraphy

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Reviews

Fig. 49 Data sheet ofsimultaneous registrationof body position;motor ac-tivity (Activity); number ofbody position changes perminute (N); systolic,mean,and diastolic ambulatorybloodpressuremonitoring(ABPM) values; pulse pres-sure (PP); heart rate (HR);and double product index(DPI= [SBP× PR] /100)values in patient A, 30 yearsold. The orthostatic hy-potension at 20:13h isshown according to therecordsof activity andbodyposition

sleep disturbances. The gold standard fordiagnostics of sleep disturbances is nowpolysomnographicstudy,whichisexpen-sive and difficult to accomplish in long-term (multiple day) monitoring. Con-sensus papers state that actimetry can beused as an alternative for OSA diagnos-tics, asapre-screening, or ifpolysomnog-raphy is impossible. It is also used todetect circadian sleep disturbances anddyssomnias in people with insomnia, in-cluding when this connected with de-pression, and to detect severe sleep dis-turbances that require treatment [1, 2, 6,33, 44].

The use of actigraphy for this purposeis advisable because of significant mo-tor activity during sleep and decreasedduration ofmotionless periods in insom-nias [45]. Motor activity in persons withOSA is associated with sleep fragmenta-tion with episodes of obstructive apneaor hypopnea [31]. Sleep fragmentationwith motor activity in OSA on the otherhand correlates with a decreased respira-tory function detected by peak rate [31,40].

Thesensitivityofactigraphyfor thede-tection of arousals in patients with OSAis not high (48%comparedwith 98% sen-sitivity for the detection of sleep periodsin general) [25]. However, this method

is highly (>90%) specific. This meansthat although actigraphy per se does notdetect respiratory disturbances, it can in-directly objectify severe OSA and helpsto assess sleep efficiency. The applicationof actimetry with ABPM may improvethe selection of patients for polysomno-graphic study or cardiorespiratorymoni-toring, andobjectify theanalysisofnight-time BP increases [45].

It seems that the detection of restlesslegs syndrome is of a similar importancefor expert evaluation of BP profile. Somestudies revealed that both primary andsecondary syndrome is associated witharterial hypertension, which is found in30% of such patients [49]. It was shownthat restless legs syndrome is more fre-quently detected in patients with insuf-ficient nighttime BP decrease, and thatthey have a more severe form of the syn-drome [12, 43, 48].

Other factors influencing BPprofiles

Actigraphy also helps in revealing otherfactors that influence blood pressure, forexample body position. Clinically signif-icant orthostatic and clinostatic hypo-and hypertension are characterized bya decreased or increased BP after the

transition to a standing or a laying po-sition, respectively. A connection alsowas found between postural or ortho-static BP changes during the day andvarious profiles of nighttime BP decreasein asymptomatic patients without drugtreatment. Postural hypotony and a non-dipping profile deteriorate parameters ofcardiovascular risk [13].

For obvious reasons, postural condi-tions are very hard to detect. Patientsrarely measure BP due to sudden sick-ness on the background of hypo- andhypertension, which is accompanied bydizziness, weakness, and sometimes syn-cope. BP measurement by another per-son is not always possible in such mo-ments, because the episodes are shortand transient. Therefore, special exam-ination is required to find the link be-tween BP and postural changes. Actig-raphy is absolutely indicated in this case,because comparison of the time of thehypo- or hypertension episode and reg-istered standing up enables true episodesto be revealed.

. Fig. 4 shows an example of the shortperiod of orthostatic hypotension.

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Practical aspects

In patients receiving ABPM, actigraphymay help to:1. monitor the activity and its clinical

evolution in an outpatient setting;2. monitor sleep problems, mainly sleep

latency and efficiency.

Research agenda

Studies of patients with ABPM are nec-essary to:1. find out whether actigraphy is an

efficient tool for monitoring ofactivity and sleep in an ambulatorysetting;

2. investigate actigraphic motor activityduring 24h;

3. explore whether and how alteredactigraphic parameters should betreated.

Conclusion

Expert assessment of diurnal BP profilerequires a precise and objective daytimeperiodization to evaluate the individualprofile of BP decrease phases and to findthecausesof insufficientBPdecreasedur-ing sleep. To do this, traditional ABPMshouldbe enhancedwithmethodsofmo-tion activity registration, i.e., actigraphy.Analysis of the data of both measure-mentsmakesitpossible toverifysleepandvigilance periods and detect some sleepdisturbances, periods of motor activity,and changes in body position connectedwith BP changes, which are significantparameters of diurnal profile in patientswith arterial hypertension.

Corresponding address

Dr. Martin GlosInterdisciplinary Sleep Medicine Center,Charité—UniversitätsmedizinBerlinCharitéplatz 1, 10117 Berlin, Germanymartin.glos@charite.de

Funding. Open Access funding provided by ProjektDEAL.

Compliance with ethicalguidelines

Conflict of interest. I. Fietze has received researchgrants fromActelion, Eisai, Heinen& Löwenstein,Jazz Pharmaceuticals, Philips/Respironics, Resmed,Somnodent, UCB, Vanda. M. Glos has received a re-search grant fromPhasya. T. Penzel has receivedresearch grants fromHeinen& Löwenstein, Itamar,Philips/Respironics, Resmed, Somnodentandwaspar-tially supportedbyRussian FederationGovernmentgrantNº 075-15-2019-1885.S. Gorokhova,M. Buni-atyan andO. Atkov declare that theyhave no compet-ing interests. The authors alone are responsible for thecontentandwritingof thepaper. All authorshave readandapproved themanuscript.

For this article, no studieswith humanparticipantsor animalswere performedby anyof the authors. Allstudies performedwere in accordancewith the ethicalstandards indicated in each case.

Open Access. This article is licensedunder a CreativeCommonsAttribution 4.0 International License,whichpermits use, sharing, adaptation, distribution and re-production in anymediumor format, as long as yougive appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons li-cence, and indicate if changesweremade. The imagesor other third partymaterial in this article are includedin the article’s Creative Commons licence, unless in-dicatedotherwise in a credit line to thematerial. Ifmaterial is not included in the article’s Creative Com-mons licence and your intendeduse is not permittedby statutory regulation or exceeds the permitteduse,youwill need toobtain permissiondirectly from thecopyright holder. To viewa copyof this licence, visithttp://creativecommons.org/licenses/by/4.0/.

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Entwicklung kardiovaskuläreMedizin 2019

Schwerpunktheft zu wichtigenPublikationen und Daten desvergangenen Jahres

In dieser Ausgabe bieten wir Ihnen kom-mentierende Reviews zu neuen wichtigen

Publikationenund Daten des vergangenen

Jahres 2019 an.

Ob sich aus den letztjährigen Entwicklun-gen neue Aspekte zu verändertem dia-

gnostischem und/oder therapeutischem

Vorgehen ergeben, erfahren Sie in DerKardiologe 02/2020 in folgenden Beiträgen.

4 Jahresrückblick ischämischeHerzerkrankung

4 Herzklappenerkrankungen20194 Neuigkeiten Elektrophysiologie

4 Elektrische Implantate

4 Update Therapie der Herzinsuffizienz2019

4 Kardiologische Rehabilitation

4 WissenschaftslandschaftDeutschland

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schriften recherchieren und auf alle Inhalteim Volltext zugreifen.

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96 Somnologie 2 · 2020