Blood Pressure Measurement 2005

1. Blood Pressure Measurement2005 How can anything so simple be so complex? © Continuing Medical Implementation …...bridging the care gap

2. Diseases Attributable to Hypertension Stroke Coronary heart disease Heart failure Cerebral hemorrhage Myocardial infarction Left ventricular hypertrophy Hypertension Chronic kidney failure Aortic aneurysm Hypertensive encephalopathy Retinopathy All Vascular Peripheral vascular disease © Continuing Medical Implementation …...bridging the care gap Adapted from: Arch Intern Med 1996; 156:1926-1935.

3. Hypertensive patients who are treated and BP controlled Hypertensive patients who are treated but BP uncontrolled 13% 9% 21% Diabetic patients who are treated and BP controlled 43% 22% Patients who are aware but remain untreated and BP uncontrolled Hypertensive patients who are unaware Joffres et al. Am J Hyper 2001;14:1099 –1105 The Challenge In Canada 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension © Continuing Medical Implementation …...bridging the care gap

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7. Automated BpTRU™ BP Devices © Continuing Medical Implementation …...bridging the care gap

8. 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 Benefits of Automated BpTRU™ BP Devices © Continuing Medical Implementation …...bridging the care gap

9. Study Results 180 – 170 – 160 – 150 – 140 – 130 – 120 – 110 – 100 – 90 – 80 – 0 – 174±3 166±4 158±4 155±5 146±3 Blood Pressure (mmHg) 92±2 90±2 89±3 88±2 82±2 Ambulatory BP Family Physician BpTRU Specialist Research Technician Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B

10. 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

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15. 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) Further assess using 24-h ambulatory blood pressure monitoring If office BP measurement is elevated and Home BP is normal Daytime average BP over 135/85 mm Hg should be considered elevated

16. Suggested Protocol for Home (Self) Measurement of Blood Pressure HOP TO ITT Protocol • BP 4X/Day for 7 days • Then 4X/Day-2days/week for 7 weeks • Total 84 readings • Interval titration if BP elevated © Continuing Medical Implementation …...bridging the care gap

17. 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 Validated BP Devices © Continuing Medical Implementation …...bridging the care gap

18. OMRON • Claims all devices with exception of wrist devices are validated © Continuing Medical Implementation …...bridging the care gap

19. OMROM HEM 711 AC $109.99 © Continuing Medical Implementation …...bridging the care gap

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

21. Life Source UA779CN $99.99 © Continuing Medical Implementation …...bridging the care gap

22. No charge……? Validity © Continuing Medical Implementation …...bridging the care gap

23. 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

24. Ambulatory BP Monitoring:Specific Role in Selected Patients Which patients? Those with suspectedoffice-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

25. Ambulatory BP MonitoringSpecific 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

26. 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

27. 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 23:00 3:00 7:00 Time of day © Continuing Medical Implementation …...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.

28. 24-Hour Blood Pressure Profile:The Morning Blood Pressure ‘Surge’ Time of awakening Blood pressure (mm Hg) 180 Sleep 160 140 120 100 80 18:00 22:00 02:00 06:00 10:00 14:00 18:00 Time of day © Continuing Medical Implementation …...bridging the care gap Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.

29. Circadian Incidence of Cardiovascular Events: Myocardial Ischemia Ischemia (min) n=24 300 250 200 150 100 50 0 01:00 05:00 09:00 13:00 17:00 21:00 Time of day © Continuing Medical Implementation …...bridging the care gap Adapted from: Rocco, et al. 1987.

30. 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 No Follow-up at 3-6 month intervals Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage Yes No Visits every 1 to 2 months More frequentvisits