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Blood Pressure Measurement
How can anything so simple
be so complex?
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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
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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%
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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
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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
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2003
Canadian Hypertension Education Program Recom m endations 39
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
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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
– 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
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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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2003
Canadian Hypertension Education Program Recom m endations 47
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
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2003
Canadian Hypertension Education Program Recom m endations 48
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
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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
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OMRON
• Claims all devices with exception of wrist devices are validated
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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 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
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Life Source UA779CN $99.99
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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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2003
Canadian Hypertension Education Program Recom m endations 49
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
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2003
Canadian Hypertension Education Program Recom m endations 50
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 ?
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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.
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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.
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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.
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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
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2003
Canadian Hypertension Education Program Recom m endations 52
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
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