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Blood Pressure Measurement How can anything so simple be so complex? © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation Adapted from: Arch Intern Med 1996; 156:1926-1935. Hypertensive encephalopathy All Vascular …...bridging the care gap Awareness, Treatment and Control of High Blood Pressure in Canada 16% 42% 23% 19% 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% Adapted from: Am J Hypertens 1997; 10:1097-1102. © Continuing Medical Implementation …...bridging the care gap 3 0 High blood pressure vs Hypertension 0 2 Office Diagnosis of Hypertension: Summary Visit 1 160 100 90 History-taking, physical examination Visit 2 Visit 3 140 - Hypertensive urgency? - Target organ damage or BP >160/100? (Visit 3) Hypertension diagnosis confirmed Visit 4 Visit 5 Blood pressure measurement every year BP over threshold for initiation of treatment No © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations Yes Validated technique and BP measurement device …...bridging the care gap 34 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. © Continuing Medical Implementation 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. …...bridging the care gap 3 © Continuing Medical Implementation …...bridging the care gap 3 0 20 Threshold for Initiation of Treatment and Target Values Condition Initiation Target SBP / DBP mmHg SBP / DBP mmHg 140/90 <140/90 Isolated systolic hypertension SBP >160 <140 Home BP measurement (no diabetes, renal disease or proteinuria) ( 135/85) <135/85 130/80 <130/80 Renal disease ( 130/80) <130/80 Proteinuria >1 g/day ( 125/75) <125/75 Diastolic ± systolic hypertension Diabetes © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations …...bridging the care gap 39 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 © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation – 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 …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap 3 0 20 Home (Self) Measurement of BP: Specific Role in Selected Patients Which patients? Non adherence Hypertension and diabetes Office-induced blood pressure elevation Normal Home BP? Further assess using ambulatory blood pressure monitoring BP over 135/85 mm Hg should be considered elevated © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations …...bridging the care gap 47 3 0 20 Home (Self) Measurement of BP: Patient Education How to? Use devices: - appropriate for the individual (cuff size) - have met the standards of the AAMI and or the BHS and or IP Values over 135 / 85 mm Hg should be considered elevated Adequate patient training in: - measuring their BP - interpreting these readings Regular verifications - accuracy of the device - measuring techniques Self measurement can help to improve patient adherence AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations …...bridging the care gap 48 Validated BP Devices • BHS – BHS = British Hypertension Society • AAMI – AAMI = American Association of Medical Instruments • See British Hypertension Society Website © Continuing Medical Implementation • OMRON – – – – HEM-705CP HEM-711AC HEM-722C HEM-773 • LifeSource AND – – – – UA-767 CN UA-767 Plus UA-779 UA-787 …...bridging the care gap OMRON • Claims all devices with exception of wrist devices are validated © Continuing Medical Implementation …...bridging the care gap OMROM HEM 711 AC $109.99 © Continuing Medical Implementation …...bridging the care gap 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. © Continuing Medical Implementation Validated according to BHS* protocol and AAMI** approved. *BHS = British Hypertension Society **AAMI = American Association of Medical Instruments …...bridging the care gap Life Source UA779CN $99.99 © Continuing Medical Implementation …...bridging the care gap No charge……? Validity © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation …...bridging the care gap 3 0 20 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 - Apparent resistance to drug therapy - Symptoms suggestive of hypotension - Fluctuating office blood pressure readings * Where available © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations …...bridging the care gap 49 3 0 20 Ambulatory BP Monitoring Specific Role in Selected Patients How to ? Use validated devices How to interpret? Mean daytime ambulatory blood pressure >135/85 mm Hg is considered elevated * A drop in nocturnal BP of <10% is associated with increased risk of CV events © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations …...bridging the care gap 50 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. © Continuing Medical Implementation …...bridging the care gap 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 © Continuing Medical Implementation 23:00 3:00 7:00 …...bridging the care gap 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 © Continuing Medical Implementation Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983. 06:00 Time of day 10:00 14:00 18:00 …...bridging the care gap 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 © Continuing Medical Implementation Adapted from: Rocco, et al. 1987. 05:00 17:00 21:00 …...bridging the care gap 3 0 20 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 © Continuing Medical Implementation Canadian Hypertension Education Program Recommendations No Monthly visits …...bridging the care gap 52