Transcript Measurement of Blood Pressure

Blood Pressure
Measurement
2005
How can anything so simple
be so complex?
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Diseases Attributable to
Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy
Hypertension
Chronic kidney failure
Aortic aneurysm
Retinopathy
Peripheral vascular disease
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Adapted from: Arch Intern Med 1996; 156:1926-1935.
Hypertensive
encephalopathy
All
Vascular
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The Challenge In Canada
22% of Canadians 18-70 years of age have hypertension
50% of Canadians >65 years of age have hypertension
Hypertensive patients
who are treated
and BP controlled
Hypertensive patients
who are treated
but BP uncontrolled
21%
22%
Patients who are aware
but remain untreated
and BP uncontrolled
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13%
43%
9%
Diabetic patients
who are treated and
BP controlled
Hypertensive patients
who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
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RECOMMENDED BLOOD PRESSURE
MEASUREMENT TECHNIQUE
2.2.
••The
Thecuff
cuffmust
mustbe
belevel
levelwith
withheart.
heart.
••IfIfarm
circumference
exceeds
arm circumference exceeds 33
33cm,
cm,
aalarge
largecuff
cuff must
mustbe
beused.
used.
••Place
Placestethoscope
stethoscopediaphragm
diaphragmover
over
brachial
artery.
brachial artery.
1.1.
••The
Thepatient
patientshould
should
be
relaxed
be relaxedand
andthe
the
arm
must
be
arm must be
supported.
supported.
••Ensure
Ensureno
notight
tight
clothing
constricts
clothing constricts
the
thearm.
arm.
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3.3.
Stethoscope
Mercury
machine
••The
Thecolumn
columnofof
mercury
mercurymust
mustbe
be
vertical.
vertical.
••Inflate
Inflatetotoocclude
occludethe
the
pulse.
Deflate
at
2
pulse. Deflate at 2toto
33mm/s.
mm/s.Measure
Measure
systolic
(first
systolic (firstsound)
sound)
and
anddiastolic
diastolic
(disappearance)
(disappearance)toto
nearest
nearest 22mm
mmHg.
Hg.
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3
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BP Treatment
Targets
Condition
160/100
Treatment threshold if no risk
factors,TOD or CCD
< 140/90
Treatment target for office BP
measurement
< 135/85
Treatment target for ABP or HBP
measurement
< 130/80
Treatment target for for Type 2
diabetics or non-diabetic
nephropathy
< 125/75
Treatment target for non-diabetic
nephropathy with proteinuria
Automated
BpTRU™ BP Devices
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Benefits of Automated
BpTRU™ BP Devices
– Standardizes BP readings
from one operator to the
next
– Removes many of the errors
associated with manual
readings
– Accurate, reliable and
reproducible readings
– Multiple readings with
averaging
– “Opportunistic screening”
– Accurate, independently
validated device
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– Automatically zeroes with
each inflation
– Performs full system check
every time on powering-up
•
•
•
•
Performs six readings
Discards the first reading
Averages the remainder
Interval between readings
from 1-5 minutes apart
• User can auscultate using
the digital readout when
desired
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180 –
174±3
170 –
Study Results
166±4
158±4
Blood Pressure (mmHg)
160 –
155±5
150 –
146±3
140 –
130 –
120 –
110 –
100 –
90 –
92±2
89±3
80 –
0–
Specialist
90±2
Research
Family
Physician Technician
Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B
88±2
BpTRU
82±2
Ambulatory
BP
Study Conclusions
• The patient’s presence in the doctor’s office or
research unit in itself appears to be partly
responsible for the white coat effect.
• BP readings taken on the initial visit tend to be
higher than other readings.
• The white coat effect can be partly eliminated by
the use of an automated BP recording device
(BpTRU)
• BP readings recorded by the BpTRU device are
similar to readings taken by an experienced
research technician using CHS Guidelines.
Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B
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Overview: Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Self/Home Blood Pressure
Measurement
Hypertension
Hypertension Visit
Visit 11
Hypertensive
Hypertensive
Urgency
Urgency //
Emergency
Emergency
BP
BP Measurement,
Measurement,
History
History and
and Physical
Physical
examination
examination
Hypertension
Hypertension Visit
Visit 22
Target
Target Organ
Organ Damage
Damage
or
Diabetes
or Diabetes
or
Chronic
or Chronic Kidney
Kidney Disease
Disease
or
BP
≥
or BP ≥ 180/110?
180/110?
Yes
Diagnosis
Diagnosis
of
of HTN
HTN
No
BP:
BP: 140-179
140-179 // 90-109
90-109
Clinic
Clinic BPM
BPM
ABPM
ABPM (If
(If available)
available)
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S/H
S/H BPM
BPM (If
(If available)
available)
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25
Diagnostic algorithm for high Blood Pressure including Office,
ABPM and Self/Home Blood Pressure Measurement
Elevated
Elevated Out
Out of
of the
the
Office
BP
Office BP
measurement
measurement
Elevated
Elevated Random
Random
Office
Office BP
BP
Measurement
Measurement
Hypertension
Hypertension Visit
Visit 11
Hypertensive
Hypertensive
Urgency
Urgency //
Emergency
Emergency
BP
BP Measurement,
Measurement,
History
History and
and Physical
Physical examination
examination
Diagnostic tests ordering
at visit 1 or 2
Hypertension Visit 2
within 1 month
Target
Target organ
organ damage
damage
or
or Diabetes
Diabetes
or
or Chronic
Chronic Kidney
Kidney Disease
Disease
or
BP
≥
180/110?
or BP ≥ 180/110?
Yes
Diagnosis
Diagnosis
of
of HTN
HTN
No
BP:
BP: 140-179
140-179 // 90-109
90-109
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26
Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Self/Home Blood Pressure
Measurement
BP:
BP: 140-179
140-179 // 90-109
90-109
24-h
24-h ABPM
ABPM (If
(If available)
available)
Clinic
Clinic BP
BP
S/H
S/H BPM
BPM (If
(If available)
available)
Hypertension visit 3
≥ 160 SBP or
≥ 100 DBP
< 160 / 100
Diagnosis
of HTN
or
ABPM or S/H
BPM if available
Awake
Awake BP
BP
<< 135/85
135/85 or
or
24-hour
24-hour
<< 130/80
130/80
Awake
Awake BP
BP
≥≥ 135
SBP
135 SBP or
or
≥≥ 85
85 DBP
DBP or
or
24-hour
24-hour
≥≥ 130
130 SBP
SBP or
or
≥≥ 80
80 DBP
DBP
Continue to
follow-up
Diagnosis
of HTN
Hypertension visit 4-5
≥ 140 SBP or
≥ 90 DBP
< 140 / 90
Diagnosis
of HTN
<< 135/85
135/85
≥≥ 135/85
135/85
or
Continue to
follow-up
Diagnosis
of HTN
Continue to
follow-up
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27
Threshold for Initiation of Treatment and
Target Values
Condition
Initiation
Target
SBP / DBP mmHg
SBP / DBP mmHg
 140/90
<140/90
SBP >160
<140
 130/80
<130/80
Renal disease
( 130/80)
<130/80
Proteinuria >1 g/day
( 125/75)
<125/75
Diastolic
± systolic hypertension
Isolated systolic hypertension
Diabetes
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28
Home/Self measurement of blood pressure
Beyond diagnosis, Home/Self BP measurement may also be
considered for selected patients for the management of hypertension
Which patients?
• Non adherence
• Hypertension and diabetes
• Office-induced blood pressure elevation
(white coat effect)
If office BP measurement
is elevated and Home BP
is normal
Further assess
using
24-h ambulatory
blood pressure
monitoring
Daytime average BP over 135/85 mm Hg should be considered elevated
15
Suggested Protocol for Home (Self)
Measurement of Blood Pressure
Condition
HOP TO ITT Protocol
• BP 4X/Day for 7 days
• Then 4X/Day2days/week for 7
weeks
• Total 84 readings
• Interval titration if BP
elevated
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BP Treatment Targets
Treatment threshold if no risk factors,
target organ damage or clinical CVD
Treatment target& initiation threshold
for office BP measurements
Treatment target for Ambulatory BP or
Home BP measurement
Treatment target for Type 2 diabetics ±
nephropathy or non-diabetic nephropathy
Treatment target for non-diabetic
nephropathy with proteinuria
Pre-hypertension (JNC-7)
Normal BP
 160/ or/100
< 140/90
< 135/85
< 130/80
< 125/75
120-139/80-89
< 120/70
VALIDATED HOME BP DEVICES: OMRON: HEM-705CP, HEM-711AC, HEM-712C, HEM-773
and LifeSource: (AND) UA-767 CN, UA-767 Plus, UA-779, UA 787
Sunday
Monday Tuesday Wednes- ThursFriday
Saturday
day
day
WEEK 1 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias
Monitor BP 4 times daily, every day for the first week.
AM
/
/
/
/
/
/
/
Noon
/
/
/
/
/
/
/
PM
/
/
/
/
/
/
/
BED
/
/
/
/
/
/
/
Average
/
/
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/
/
/
/
WEEK 2 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias
Monitor BP 4 times daily, two days/week –choosing one weekday and one weekend day.
AM
/
/
/
/
/
/
/
NOON
/
/
/
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/
/
/
PM
/
/
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/
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/
/
BED
/
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Average
/
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/
/
/
WEEK 3 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias
Monitor BP 4 times daily, two days/week –choosing one weekday and one weekend day.
AM
/
/
/
/
/
/
/
NOON
/
/
/
/
/
/
/
PM
/
/
/
/
/
/
/
BED
/
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/
/
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Average
/
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/
/
/
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Validated BP Devices
• BHS
– BHS = British
Hypertension Society
• AAMI
– AAMI = American
Association of Medical
Instruments
• See British Hypertension
Society Website
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• OMRON
–
–
–
–
HEM-705CP
HEM-711AC
HEM-722C
HEM-773
• LifeSource AND
–
–
–
–
UA-767 CN
UA-767 Plus
UA-779
UA-787
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OMRON
• Claims all devices
with exception of
wrist devices are
validated
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OMROM HEM 711 AC
$109.99
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LifeSourceUA-767PC
• For use with a PC and
Monitor Pro software.
• Stores and analyzes
recorded blood pressure
data directly from the UA767PC.
• The software provides
printable summary reports
and graphing capabilities.
• Remotely monitor patients
and their blood pressure
from their homes.
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Validated according to BHS* protocol and
AAMI** approved.
*BHS = British Hypertension Society
**AAMI = American Association of Medical
Instruments
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Life Source UA779CN $99.99
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No charge……? Validity
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When would you order ambulatory
Blood pressure Monitoring?
•
•
•
•
•
•
For Dx mild to mod HTN
For elderly women with ISH
For apparent Rx resistance
For anxiety prone patients
When marked fluctuations in office BP present
For symptoms suggestive of hypotension present
on Rx
• White coat HTN unlikely
– If DM coexists
– If TOD present
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Ambulatory BP Monitoring:
Specific Role in Selected Patients
Which patients?
Those with suspected office-induced BP elevation
Untreated
• Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without
target organ damage
Treated patients
• Blood pressure that is not below target values despite receiving
appropriate chronic antihypertensive therapy
• Symptoms suggestive of hypotension
• Fluctuating office blood pressure readings
24
Ambulatory BP Monitoring
Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
Average daytime ambulatory blood pressure >135/85
mmHg is considered elevated
A drop in nocturnal BP of <10% is associated
with increased risk of CV events
25
Blood Pressure and
Target Organ Damage (TOD)
Current evidence suggests that:
• 24-h blood pressure correlates most closely with TOD
(compared to clinic or casual BP)
• Higher incidence of cardiovascular events when
blood
pressure remains elevated at night (non-dippers)
• Blood pressure variability is an independent
determinant
of TOD
• Highest incidence of cardiovascular events
occurs in AM
Adapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987;
Parati, et al. 1987; Mancia. 1990.
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24-Hour Blood Pressure Profile:
Two Patients with Hypertension
Blood pressure (mm Hg)
Sleep
175
Non-dipper
155
135
Dipper
115
95
75
55
7:00
11:00
15:00
19:00
Time of day
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23:00
3:00
7:00
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Adapted from: Redman, et al. 1976; Mancia, et al. 1983; Kobrin, et al. 1984; Baumgart, et al. 1989; Imai, et al. 1990; Portaluppi, et al. 1991.
24-Hour Blood Pressure Profile:
The Morning Blood Pressure ‘Surge’
Blood pressure (mm Hg)
180
Sleep
Time of awakening
160
140
120
100
80
18:00
22:00
02:00
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Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.
06:00
Time of day
10:00
14:00
18:00
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Circadian Incidence of Cardiovascular
Events: Myocardial Ischemia
n=24
Ischemia (min)
300
250
200
150
100
50
0
01:00
09:00
13:00
Time of day
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Adapted from: Rocco, et al. 1987.
05:00
17:00
21:00
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Recommendations for Follow-up
Diagnosis of hypertension
Non Pharmacological treatment
With or without Pharmacological treatment
Are BP readings below target during 2 consecutive visits?
Yes
Follow-up at 3-6
month intervals
No
Symptoms, Severe
hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes
More frequent
visits
No
Visits every 1
to 2 months
30