Transcript ABPM - Cardiotronics

CME Program for Family
Physicians
Ambulatory BP Monitoring
Brian Gore, MD CCFP Dip Epid.
Part II
ABPM
Evolving to newer technologies….
Clinical Indications for
ABPM
Clinical Indications for ABPM
T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002
Suspected WCH or WCE w/o target
organ damage
 Evaluation of treatment resistant HTN
 Hypotension symptoms on
antihypertensive medication

Clinical Indications (cont)
T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002
Intermittent symptoms possibly related
to blood pressure (postural, postprandial)
 Nocturnal hypertension (sleep apnea,
diabetics)
 Autonomic failure: diabetics

What to assess in an ABPM
Evaluation
ABPM readings: quality, #, pattern.
 Periods: total 24 hour, awake, asleep.
 Dipper status: Y,N, Excessive, Reverse
 24-hour pulse pressure.
 White coat HTN or effect.
 Heart rate and rate-pressure product.

Summary Guide to Interpret ABPM
Analyzing the data:
Minimum number acceptable:
14 readings day-time
7 readings night-time
O’Brien, BMJ: 2001
Summary Guide to Interpret ABPM Results
Analyzing the data 1:
ABPM profiles:
- normal day and night periods
- white coat syndrome (includes WCH + WCE)
- borderline hypertension
- nocturnal hypertension
Summary Guide to Interpret ABPM Results
Analyzing the data 2:
ABPM profiles:
- systolic and diastolic hypertension + dipper
- systolic and diastolic hypertension + non-dipper
- isolated systolic hypertension
- isolated diastolic hypertension
- excessive BP variability
What are normal ABPM limits
Are office BP readings comparable
to ABPM values ?
Recommended standards for normal and
abnormal pressures during ABPM.
These pressures are only a guide, and lower pressures may be
abnormal in patients whose total risk factor profile is high and in
whom there is concomitant disease.
Day
Normal
135/85
Abnormal
>140/90
Night
120/70
>125/75
24 hour
130/80
>135/85
Operational Approach for CV Risk Sratification
Verdecchia , V. J Hypertension 2000; 35:844-851
Untreated OHT
White Coat Hypertension
Ambulatory Hypertension
Day-time ABP <135/85
Optimal <130/80
Dipper (>10%)
Normal 24 h PP
< 53 mm Hg
Nondipper
SBP Day to night reduction <10%
Increased 24 hr PP
> 53 mm Hg
LOW RISK
INTERMEDIATE RISK
HIGH RISK
HIGH RISK
ABPM Patterns
O’Brien, BMJ, April, 2000
B. Gore, personal database, 2003
Normal 24 hour ABPM
White Coat Hypertension
White coat hypertension
Prevalence of White Coat
Hypertension
Ranges from 10-30% of hypertensive
population based on review of
clinical trials
Implications of WCE
 Overestimation
of OBP
 Potential for overtreatment
 Nonresponse to Rx
 Potential Rx adverse effects
Stage 1 hypertensive dipper
Stage 2 hypertensive dipper
Hypertensive Dipper (>SHTN)
Isolated Systolic HTN
Hypertensive Non-Dipper
Stage 3 HTN Non-Dipper
Dippers and Non-Dippers
Dipper:
Day/Night
 Non-Dipper: Day/Night

Dipper:
Stroke
 Non-Dipper: Stroke


O’Brien et al, Lancet 1988
>10/5 mmHg
<10/5 mmHg
3%
23%
ABPM Intrigue
Normal 24 hr ABP with morning surge
CV Events that are Coincident with
Morning Blood Pressure ‘Surge’

Myocardial ischemia

Myocardial infarction

Sudden cardiac death

Stroke
Thrombotic
Hemorrhagic
Adapted from: Muller, et al. 1985; Rocco, et al. 1987; Marler, et al. 1989; Willich, et al. 1992.
Case: Gertrude H is a 77 year-old
female
Past History:
Diabetes type 2 for 5 years,
HTN, hyperlipidemia.
OBP: 160/102
FU OBP: 166/98 (2 weeks)
Physical exam: Unremarkable.
BMI: 30.
Meds: Ramipril 10, HCTZ 12.5
mg, Metformin 500 tid, Lipitor 20
qhs.
Significant lab:
CV Risk Ratio: 5.62
MAU 0.06 mcg/ml
HbA1c: .085
24-hr ABPM results:
24 hour abnormal ABP with
marked nocturnal hypertension:
commonly found in patients with
diabetes and loss of glycemic
control or in patients with sleep
apnea.
S+D HTN with Nocturnal Hypertension
Inherent Variability of BP
Blood Pressure Variability and
Target Organ Damage: A Longitudinal
Analysis
n=73
p<0.01
Variability >group average
LVMI (g/m2)
Variability <group average
150
140
130
120
110
100
90
10
< 95
8
11
8
95–108
11
9
109–120
Initial 24-hour MAP (mm Hg)
Adapted from: Frattola, et al. 1993.
8
8
>120
Overtreatment
Autonomic Dysregulation:
Typical patient characteristics:
65 year old female with:
TOD/CCVD: CAD, LVH, CABG,
CVA, Remote MI.
CO-MORBIDITY: DIABETES.
CV-RF: AGE, PM, SMOKER,
HYPERLIPIDEMIA
OBP: 170-180/90
Physical exam: Carotid bruits,
Reduced PP’s, trophic leg changes,
Mild weakness RA.
BMI: 29.
Meds: Metroprolol 100 mg bid,
Cozaar 100 mg qam, Metformin
500 tid, Lipitor 20 qhs, ASA 80 mg
QD.
Lab Investigations:
TC-6.52, HDL-1.05, LDL-5.1
TG: 3.2, CV Risk Ratio:6.21
Proteinuria >3gm/l. HgB A1C:
0.078.
EKG: LVH, Remote inferior MI.
Referred to evaluate 24 hour
control in view of persistently
high OBP
The Dilemma: BP management in
light of ABPM results.
Autonomic Dysfunction
Other ABP Illustrations:
“Trouble Coming”
Stroke Range Hypertension
Isolated SHTN and high risk 24-hr pulse
pressure
Total period: 20 hour 44 min 4/3/2003 10:26 - 4/4/2003 10:26
(51 data)
Mean
Max
Min
SD
DI
PTE
Load
SBP
DBP
MAP
162
214
132
68
95
55
99
135
82
20
13
98
781
9
11
8
5
12
12
66
127
PP
94
127
73
HR
mmHg
mmHg
mmHg
14
mmHg
%
%
mmHg*h/24h
56
67
46
6
Double prod.
/min
/min
/min
/min
9165
13054
6480
1838