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CME Program for Family Physicians Ambulatory BP Monitoring Brian Gore, MD CCFP Dip Epid. Part II ABPM

CME Program for Family Physicians Ambulatory BP Monitoring Brian Gore, MD CCFP Dip Epid. Part II ABPM. Evolving to newer technologies …. Clinical Indications for ABPM. Clinical Indications for ABPM T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002.

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CME Program for Family Physicians Ambulatory BP Monitoring Brian Gore, MD CCFP Dip Epid. Part II ABPM

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  1. CME Program for Family PhysiciansAmbulatory BP MonitoringBrian Gore, MD CCFP Dip Epid.Part IIABPM

  2. Evolving to newer technologies….

  3. Clinical Indications for ABPM

  4. Clinical Indications for ABPMT Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002 • Suspected WCH or WCE w/o target organ damage • Evaluation of treatment resistant HTN • Hypotension symptoms on antihypertensive medication

  5. Clinical Indications (cont)T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002 • Intermittent symptoms possibly related to blood pressure (postural, postprandial) • Nocturnal hypertension (sleep apnea, diabetics) • Autonomic failure: diabetics

  6. What to assess in an ABPM Evaluation • ABPM readings: quality, #, pattern. • Periods: total 24 hour, awake, asleep. • Dipper status: Y,N, Excessive, Reverse • 24-hour pulse pressure. • White coat HTN or effect. • Heart rate and rate-pressure product.

  7. Summary Guide to Interpret ABPMAnalyzing the data:Minimum number acceptable:14 readings day-time 7 readings night-timeO’Brien, BMJ: 2001

  8. Summary Guide to Interpret ABPM Results Analyzing the data 1:ABPM profiles: - normal day and night periods     - white coat syndrome (includes WCH + WCE)     - borderline hypertension      - nocturnal hypertension

  9. Summary Guide to Interpret ABPM Results Analyzing the data 2:ABPM profiles: - systolic and diastolic hypertension + dipper     - systolic and diastolic hypertension + non-dipper - isolated systolic hypertension       - isolated diastolic hypertension      - excessive BP variability

  10. What are normal ABPM limits Are office BP readings comparable to ABPM values ?

  11. Recommended standards for normal and abnormal pressures during ABPM. These pressures are only a guide, and lower pressures may be abnormal in patients whose total risk factor profile is high and in whom there is concomitant disease. Normal Abnormal Day 135/85 >140/90 Night 120/70 >125/75 24 hour 130/80 >135/85

  12. ABPM Patterns O’Brien, BMJ, April, 2000 B. Gore, personal database, 2003

  13. Normal 24 hour ABPM

  14. White Coat Hypertension

  15. White coat hypertension

  16. Prevalence of White Coat Hypertension Ranges from 10-30% of hypertensive population based on review of clinical trials

  17. Implications of WCE • Overestimation of OBP • Potential for overtreatment • Nonresponse to Rx • Potential Rx adverse effects

  18. Stage 1 hypertensive dipper

  19. Stage 2 hypertensive dipper

  20. Hypertensive Dipper (>SHTN)

  21. Isolated Systolic HTN

  22. Hypertensive Non-Dipper

  23. Stage 3 HTN Non-Dipper

  24. Dippers and Non-Dippers • Dipper: Day/Night >10/5 mmHg • Non-Dipper: Day/Night <10/5 mmHg • Dipper: Stroke 3% • Non-Dipper: Stroke 23% • O’Brien et al, Lancet 1988

  25. ABPM Intrigue

  26. Normal 24 hr ABP with morning surge

  27. CV Events that are Coincident with Morning Blood Pressure ‘Surge’ • Myocardial ischemia • Myocardial infarction • Sudden cardiac death • Stroke • Thrombotic • Hemorrhagic Adapted from: Muller, et al. 1985; Rocco, et al. 1987; Marler, et al. 1989; Willich, et al. 1992.

  28. Case: Gertrude H is a 77 year-old female

  29. S+D HTN with Nocturnal Hypertension

  30. Inherent Variability of BP

  31. Blood Pressure Variability and Target Organ Damage: A Longitudinal Analysis n=73 Variability >group average LVMI (g/m2) p<0.01 Variability <group average 150 140 130 120 110 100 10 8 11 8 11 9 8 8 90 < 95 95–108 109–120 >120 Initial 24-hour MAP (mm Hg) Adapted from: Frattola, et al. 1993.

  32. Overtreatment

  33. Autonomic Dysregulation:

  34. Autonomic Dysfunction

  35. Other ABP Illustrations:“Trouble Coming”

  36. Stroke Range Hypertension

  37. Isolated SHTN and high risk 24-hr pulse pressure

  38. Total period: 20 hour 44 min 4/3/2003 10:26 - 4/4/2003 10:26 (51 data) SBP DBP MAP PP HR Double prod. Mean 162 68 99 94 mmHg 56 /min 9165 Max 214 95 135 127 mmHg 67 /min 13054 Min 132 55 82 73 mmHg 46 /min 6480 SD 20 9 12 14 mmHg 6 /min 1838 DI 13 11 12 % PTE 98 8 66 % Load 781 5 127 mmHg*h/24h

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