Blood Pressure 2

© Continuing Medical Implementation …...bridging the care gap

Blood Pressure Measurement

How can anything so simple

be so complex?


Diseases Attributable to Hypertension

Hypertension

Heart failureStrokeCoronary heart disease

Myocardial infarction

Left ventricular hypertrophy

Aortic aneurysmRetinopathy

Peripheral vascular disease

Hypertensive encephalopathy

Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.

AllVascular


Awareness, Treatment and Control of

High Blood Pressure in Canada

Adapted from: Am J Hypertens 1997; 10:1097-1102.

Patients unaware of their high blood pressure 42%Aware but not treated and not controlled 19%Treated but not controlled 23%Treated and controlled 16%

42%19%

23%

16%


2003

Canadian Hypertension Education Program Recom m endations 34

Office Diagnosis of Hypertension: Sum m aryH igh blood pressure vs H ypertension

Visit 1

Visit 2

Visit 3

Visit 5

Blood pressurem easurem entevery year

-Hypertensiveurgency?

-Target organdam age or BP >160/100?(Visit 3) Hypertension

diagnosisconfirm ed

BP overthreshold for initiation of

treatm ent

Yes

No Validated technique andBP m easurem ent device

Visit 4

History-taking,physical exam ination160

100

140

90

© Continuing Medical Implementation …...bridging the care gap 3

RECO M M ENDED BLO OD PRESSURERECO M M ENDED BLO OD PRESSUREM EASUREM ENT TECHNIQUEM EASUREM ENT TECHNIQUE

2.•The cuff m ust be level with heart.•If arm circum ference exceeds 33 cm ,a large cuff must be used.

•Place stethoscope diaphragm overbrachial artery.

2.2.••The cuff m ust be level with heart.The cuff m ust be level with heart.••If arm circum ference exceeds 33 cm ,If arm circum ference exceeds 33 cm ,a large cuff must be used.a large cuff must be used.

••Place stethoscope diaphragm overPlace stethoscope diaphragm overbrachial artery.brachial artery.

1.•The patient shouldbe relaxed and thearm must besupported.

•Ensure no tightclothing constrictsthe arm .

1.1.••The patient shouldThe patient shouldbe relaxed and thebe relaxed and thearm must bearm must besupported.supported.

••Ensure no tightEnsure no tightclothing constrictsclothing constrictsthe arm .the arm .

3.•The column ofm ercury m ust bevertical.

•Inflate to occlude thepulse. Deflate at 2 to3 m m/s. Measuresystolic (first sound)and diastolic(disappearance) tonearest 2 m m Hg.

3.3.••The column ofThe column ofm ercury m ust bem ercury m ust bevertical.vertical.

••Inflate to occlude theInflate to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to3 m m/s. Measure3 m m/s. Measuresystolic (first sound)systolic (first sound)and diastolicand diastolic(disappearance) to(disappearance) tonearest 2 m m Hg.nearest 2 m m Hg.

StethoscopeStethoscope

M ercuryM ercurym achinem achine


2003


Threshold for Initiation of Treatm ent and Target Values

SBP / DBP m m HgSBP / DBP m m Hg

<130/80(130/80)Renal disease

<125/75

<130/80

<135/85<140

<140/90

Target

SBP >160Isolated systolic hypertension

(135/85)Hom e BP m easurem ent (no diabetes, renal disease or proteinuria)

(125/75)Proteinuria >1 g/day

130/80Diabetes

140/90Diastolic ± systolic hypertension

InitiationCondition

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 diabetic or non-diabetic nephropathy with proteinuria


Automated BpTRU™ BP Devices

http://www.vsmmedtech.com/


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

– 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

180 –170 –160 –150 –140 –130 –120 –110 –100 – 90 – 80 – 0 –

174±3166±4

158±4 155±5146±3

92±289±3 90±2 88±2 82±2

Specialist

FamilyPhysician

ResearchTechnician

BpTRU Ambulatory BP

Blood Pressure

(mmHg)

Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B

Study Results


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


2003


Hypertension anddiabetes

Non adherence

W hich patients?

Further assessusing

am bulatoryblood pressurem onitoring

Norm alHom e BP?

O ffice-induced blood pressure elevation

BP over 135/85 m m Hg should be considered elevated

Hom e (Self) M easurem ent of BP:Specific Role in Selected Patients


2003


Hom e (Self) M easurem ent of BP:Patient Education

AAM I=Association for the Advancem ent of M edical Instrum entation;BHS=British Hypertension Society; IP: International Protocol.

Values over135 / 85 m m Hg

should beconsidered elevated

How to?

Adequate patient training in:-m easuring their BP-interpreting these readings

Regular verifications-accuracy of the device-m easuring techniques

Use devices:-appropriate for the individual (cuff size)-have m et the standards of the AAM I and or the BHS and or IP

Self m easurem ent can help to im prove patient adherence


Validated BP Devices

• BHS– BHS = British Hypertension Society

• AAMI – AAMI = American Association of Medical Instruments

• See British Hypertension Society Website

• OMRON– HEM-705CP– HEM-711AC– HEM-722C– HEM-773

• LifeSource AND – UA-767 CN– UA-767 Plus– UA-779– UA-787

http://www.hyp.ac.uk/bhs/bp_monitors/resources.htm

http://www.hyp.ac.uk/bhs/bp_monitors/resources.htm


OMRON

• Claims all devices with exception of wrist devices are validated


OMROM HEM 711 AC $109.99


LifeSourceUA-767PC

• For use with a PC and Monitor Pro software.

• Stores and analyzes recorded blood pressure data directly from the UA-767PC.

• The software provides printable summary reports and graphing capabilities.

• Remotely monitor patients and their blood pressure from their homes.

Validated according to BHS* protocol and AAMI** approved.*BHS = British Hypertension Society**AAMI = American Association of Medical Instruments


Life Source UA779CN $99.99

http://www.autocontrol.com/


No charge……? Validity


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


2003


Am bulatory BP M onitoring:Specific Role in Selected Patients*

Untreated-M ild (G rade 1) to m oderate (G rade 2) clinic BP elevation and without target organ dam age

Treated patients-Apparent resistance to drug therapy-Sym ptom s suggestive of hypotension-Fluctuating office blood pressure readings

W hich patients?Those with suspected office-induced BP elevation

* W here available


2003


Am bulatory BP M onitoringSpecific Role in Selected Patients

* A drop in nocturnal BP of <10% is associated with increased risk of CV events

How to interpret?M ean daytim e am bulatory blood pressure

>135/85 m m Hg

is considered elevated

Use validated devicesHow to ?


Current evidence suggests that:

Blood Pressure and Target Organ Damage (TOD)

• 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 AMAdapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987;

Parati, et al. 1987; Mancia. 1990.


24-Hour Blood Pressure Profile:

Two Patients with Hypertension

Blood pressure (mm Hg)

7:00 11:00 15:00 19:00 23:00 3:00 7:00

Sleep

Dipper

Non-dipper

Time of day

175

13511595

75

55

155

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’

Time of day

Blood pressure (mm Hg)

18:00 22:00 02:00 06:00 10:00 14:00 18:00

Time of awakeningSleep18

016014012010080

Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.


Ischemia (min)

Adapted from: Rocco, et al. 1987.

01:00 05:00 09:00 13:00 17:00 21:00

300

150

250

200

100

50

0

n=24

Circadian Incidence of Cardiovascular Events: Myocardial Ischemia

Time of day


2003


Recom m endations for Follow -up

Are BP readings below target during 2 consecutive visits?

Non Pharm acological treatm entW ith or without Pharm acological treatm ent

Diagnosis of hypertension

Follow-up at 3-6 m onth intervals

Sym ptom s, Severe hypertension, Intolerance to anti-hypertensive treatm ent or Target Organ Dam age

NoYes

NoYes

M ore frequentvisits

M onthly visits

Blood Pressure 2

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