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2010 Office and Home Blood Pressure Assessment Hypertension Diagnosis and Follow up Overseeing organizations and partners Overseeing organizations Hypertension Canada Canadian Council of Cardiovascular Nurses Canadian Pharmacists Association College of Family Physicians of Canada

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slide1
2010

Office and Home Blood Pressure AssessmentHypertension Diagnosis and Follow up

overseeing organizations and partners
Overseeing organizations and partners

Overseeing organizations

Hypertension Canada

Canadian Council of Cardiovascular Nurses

Canadian Pharmacists Association

College of Family Physicians of Canada

Heart and Stroke Foundation of Canada

Public Health Agency of Canada

Partner organizations

Canadian Cardiovascular Society

Canadian Diabetes Association

Canadian Society of Nephrology

Canadian Stroke Network

Canadian Society of Internal Medicine

Kidney Foundation of Canada

Volunteers (>100)

hypertension canada and the canadian hypertension education program
Hypertension Canada and the Canadian Hypertension Education Program

This slide set is an initiative aimed at enhancing the quality of blood pressure measurement. This venture is the result of a collaborative effort of Hypertension Canada and the Canadian Hypertension Education Program sub-group

Other slide sets and other educational material on hypertension can be downloaded from the following website: http://www.hypertension.ca

slide4
The Canadian Hypertension Education

Program (CHEP)

Overseen by:

Hypertension Canada

The Heart and Stroke Foundation of Canada

The Public Health Agency of Canada

The College of Family Physicians of Canada

The Canadian Council of Cardiovascular Nurses

The Canadian Pharmacy Association.

hypertension canada and the canadian hypertension education program5
Hypertension Canada and the Canadian Hypertension Education Program

Instructions for proper blood pressure measurement are found in the detailed recommendations of the CHEP program (Can J Cardiol 2008;24(6):455-63),

at www.hypertension.ca

blood pressure measurement and hypertension diag n osis
Blood Pressure Measurement and Hypertension Diagnosis

1 in 5 adult Canadians have hypertension

Over 40% of Canadians at aged 56-65 have hypertension

90% of normotensive persons aged 55-65 developed hypertension in the next 20 years in the Framingham study

blood pressure assessment
Blood Pressure Assessment

Blood pressure of all adults should be measured by a trained healthcare professional at all appropriate visits:

To determine cardiovascular risk

To monitor antihypertensive treatment

Blood pressure of adults with high normal blood pressure (130-139/80-89 mmHg) should be assessed annually

life time risk of hypertension in normotensive women and men aged 65 years
Life time Risk of Hypertension in Normotensive Women and men aged 65 years

14

16

18

20

14

16

18

20

0

4

6

8

10

12

0

4

6

8

10

12

2

2

Risk of Hypertension %

Risk of Hypertension %

100

100

Women

Men

80

80

60

60

40

40

20

20

0

0

Years to Follow-up

Years to Follow-up

JAMA 2002:297:1003-10. Framingham data.

modifiable risks for developing hypertension
Modifiable risks for developing hypertension

Obesity

Poor dietary habits

High sodium intake

Sedentary lifestyle

High alcohol consumption

development of hypertension in those with high normal blood pressure
Development of hypertension (%) in those with high normal blood pressure

Framingham cohort Vasan. Lancet 2001;358:1682-86

2010 Canadian Hypertension Education Program Recommendations

new onset hypertension in those with high normal blood pressure
New onset hypertension in those with high normal blood pressure

772 subjects, over weight, mean age 48.5

Not receiving treatment for Hypertension

Average of 3 blood pressures at baseline:

SBP 130-139 and DBP < 89 OR

SBP < 139 and DBP 85-89

Primary endpoint – new onset hypertension

NEJM 2006;354:1685-97

new onset hypertension in people with high normal blood pressure14
New onset hypertension in people with high normal blood pressure

40% of overweight patients with systolic 130-139 or diastolic 85-89 mmHg developed hypertension in 2 years and 63% in 4 years

Annual follow-up of patients with high normal blood pressure is recommended by CHEP.

blood pressure assessment patient preparation and posture
Blood Pressure Assessment:Patient preparation and posture

Standardized Preparation:

Patient

1. No acute anxiety, stress or pain.

2. No caffeine,smoking or nicotine in the preceding 30 minutes.

3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops).

4. Bladder and bowel comfortable.

5. No tight clothing on arm or forearm.

6. Quiet room with comfortabletemperature

7. Rest for at least 5 minutes before measurement

8. Patient should stay silent prior and during the procedure.

blood pressure assessment patient preparation and posture16
Blood Pressure Assessment:Patient preparation and posture

Standardized technique:

Posture

The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart.

His or her feet should touch the floor and legs should not be crossed.

recommended equipment for measuring blood pressure
Recommended Equipment for Measuring Blood Pressure

Use a mercury manometer or a recently calibrated aneroid or a validated automated device.

Aneroid devices should only be used if there is an established calibration check every 12 months.

recommended equipment for measuring blood pressure19
Recommended Equipment for Measuring Blood Pressure
  • Automated oscillometric devices:
  • Use a validated automated device according to BHS, AAMI or IP clinical protocols.
  • For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement.

AAMI=Association for the Advancement of Medical Instrumentation;

BHS=British Hypertension Society; IP: International Protocol.

recommended technique for measuring blood pressure cont
Recommended Technique for Measuring Blood Pressure (cont.)

Select a device with an appropriate size cuff

use an appropriate size cuff
Use an appropriate size cuff

For automated devices, follow the manufacturer’s directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

recommended technique for measuring blood pressure cont22
Recommended Technique for Measuring Blood Pressure (cont.)

Locate the brachial pulse and centre the cuff bladder over it

Positioncuff at the heart level

Arm should be supported

recommended technique for measuring blood pressure cont23
Recommended Technique for Measuring Blood Pressure* (cont.)

To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse

Place stethoscope over the brachial artery

*with manual or semi automated devices

recommended technique for measuring blood pressure cont24
Recommended Technique for Measuring Blood Pressure* (cont.)

Drop pressure by 2 mmHg / beat

Appearance of sound (phase I Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase V Korotkoff) = diastolic pressure

Record measurement

Take at least 2 blood pressure measurements, 1 minute apart

2010 Canadian Hypertension Education Program Recommendations

korotkoff sounds and auscultatory gaps
Korotkoff sounds and auscultatory gaps

Korotkoff sounds

200

No sound

180

Clear sound

Phase 1

160

Muffling

Phase 2

Auscultatory gap

No sound

140

120

Clear sound

Phase 3

100

Muffled sound

Phase 4

80

60

No sound

Phase 5

40

20

0

mmHg

Systolic BP

Phase 3

Phase 4

Diastolic BP

recommended technique for measuring blood pressure
Recommended Technique for Measuring Blood Pressure

Standardized technique:

For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading.

Thereafter, take two measurements on the side where BP is higher.

recommended technique for measuring blood pressure cont27
Recommended Technique for Measuring Blood Pressure* (cont.)

Record the blood pressure to the closest 2 mmHg on the manometer

and whether the patient was supine, sitting or standing.

Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

* For manual blood pressure measurement

recommended technique for measuring blood pressure cont28
Recommended Technique for Measuring Blood Pressure* (cont.)

Avoid digit preference for five (5) or zeros (0) by not rounding up or down.

Record the heart rate.

If the needle on an aneroid device does not zero it is inaccurate however the converse is not true.

* For manual blood pressure measurement

recommended technique for measuring blood pressure cont29
Recommended Technique for Measuring Blood Pressure (cont.)

The seated BP measurement is the standard position to determine diagnostic and therapeutic treatment decisions

The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment.

recommended technique for measuring bp standing bp
Recommended Technique for Measuring BP: Standing BP

Perform in patients

over age 65

with diabetes

if there are symptoms of postural hypotension

Check after 1 to 5 minutes in the standing position and under circumstances when the patients complains of symptoms suggestive of hypotension.

slide31
Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement

Elevated Out of the Office BP measurement

Elevated Random Office BP Measurement

Hypertensive

Urgency / Emergency

BP ≥ 140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110?

Diagnosis

of HTN

Yes

No

BP: 140-179 / 90-109

Hypertension Visit 1

BP Measurement,

History and Physical examination

Diagnostic tests ordering

at visit 1 or 2

Hypertension Visit 2

within 1 month

slide32
Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement

Hypertension Visit 1

BP Measurement,

History and Physical examination

Hypertensive

Urgency / Emergency

Hypertension Visit 2

Target Organ Damage

or Diabetes

or Chronic Kidney Disease

or BP ≥ 180/110?

Diagnosis

of HTN

Yes

No

BP: 140-179 / 90-109

Clinic BPM

ABPM (If available)

HBPM

slide33
Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement

BP: 140-179 / 90-109

Clinic BP

ABPM (If available)

HBPM

Hypertension visit 3

≥ 160 SBP or ≥ 100 DBP

Diagnosis

of HTN

≥ 135 SBP or ≥ DBP 85

Awake BP

< 135/85 and

24-hour

< 130/80

Awake BP

≥ 135 SBP or

≥ 85 DBP

Or 24-hour

≥ 130 SBP or

≥ 80 DBP

< 135/85

< 160 / 100

ABPM or HBPM

or

or

Hypertension visit 4-5

≥ 140 SBP or

≥ 90 DBP

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

Continue to follow-up

Diagnosis

of HTN

Continue to follow-up

< 140 / 90

the concept of masked hypertension
The concept of masked hypertension

135

140

True

hypertensive

Masked HTN

Home or daytime ABPM SBP mmHg

135

True

Normotensive

White Coat HTN

140

Office SBP mmHg

From Pickering, Hypertension 1992

the prognosis of masked hypertension
The prognosis of masked hypertension

Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients).

J Hypertension 2007;25:2193-98

vii home measurement of blood pressure
VII. Home measurement of blood pressure

Home BP measurement should be encouraged to increase patient involvement in care

Which patients?

For the diagnosis of hypertension

Suspected non adherence

White coat hypertension or effect

Masked hypertension

Average BP equal to or over 135/85 mmHg should be considered elevated

benefits of home blood pressure monitoring
Benefits of Home Blood Pressure Monitoring

Rapid confirmation of the diagnosis of hypertension

Better prediction of cardiovascular prognosis

Diagnosis of white coat and masked hypertension

Reduced medication use in white coat effect

Improved adherence to drug therapy

Better blood pressure

not all patients are suited to home measurement
Not all patients are suited to home measurement

Undue anxiety in response to high blood pressure readings

Physical or mental disability prevents accurate technique or recording

Arm not suited to blood pressure cuff (e.g. conical shaped arm)

Irregular pulse or arrhythmias prevent accurate readings

Lack of interest

The vast majority of patients can be trained to measure blood pressure

home measurement of bp use validated bp measurement devices
Home Measurement of BP:Use validated BP measurement devices

This logo* on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement

* Endorsed by the Canadian Hypertension Society

Average BP > 135/85 mmHg should be considered elevated

vii suggested protocol for home measurement of blood pressure for the diagnosis of hypertension
VII. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension

Home blood pressure values should be based on:

duplicate measures,

morning and evening,

for an initial 7-day period.

Singular and first day home BP values should not be considered.

Daytime average BP equal to or over 135/85 mmHg should be considered elevated

home measurement of bp patient education
Home Measurement of BP:Patient Education

How to?

  • Use devices:
  • appropriate for the individual
  • appropriate cuff size
  • marked with this symbol
  • Adequate patient training in:
  • measuring their BP
  • interpreting these readings
  • Regular verification
  • measuring techniques

Values

> 135 / 85 mmHg

should be

considered elevated

Home measurement can help to improve patient adherence

suggested protocol for home measurement of blood pressure
Suggested Protocol for Home Measurement of Blood Pressure

How?

  • Home blood pressure values for assessing white coat hypertension or sustained hypertension should be based on:
  • Duplicate measures,
  • Morning and evening,
  • For an initial 7-day period.
  • Single readings and
  • First day home BP values should not be considered.
  • For patients treated for hypertension
  • Morning measurement should be done before medication taking
vii home measurement of bp patient education
VII. Home Measurement of BP: Patient Education

Assist patients select a model with the correct size of cuff

Measure and record the patients mid arm circumference so they can match it to cuff size

Recommend devices listed at www.hypertension.caor marked with this symbol

Ask patients to carefully follow the instructions with device and to record only those blood pressure readings where they have followed recommended procedure

Advise patients that average readings equal to or over 135/85 mmHg are high

a lower threshold is appropriate for those with diabetes or chronic kidney disease

Values equal to or over

135 / 85 mmHg

should be

considered elevated for those without diabetes or chronic kidney disease

Home measurement can help to improve patient adherence

web based home monitoring
Web based home monitoring

A website to assist patients to monitor and track home blood pressure and support self management including healthy lifestyle change is available at:

www.heartandstroke.ca/BP

slide46
Advice for patients on when to contact a health care professional based on high average home blood pressure readings*

*Patients with diabetes, chronic kidney disease or who are at high risk of cardiovascular events require individualized advice.

*(available at www.hypertension.ca/bpc in the resource section under educational tools for health care professionals in the Brief Hypertension Action Tool or at www.heartandstroke.ca/BP )

home measurement of blood pressure
Home measurement of blood pressure

A poster and instruction sheets can be ordered at: www.hypertension.ca

suggested use of abpm in the management of hypertension
Suggested use of ABPM in the Management of Hypertension

Office BP > 140/90 mmHg

in low risk patients (with no target-organ disease)

Home-monitored blood pressure <135/85mmHg

Home-monitored blood pressure equals or over 135/85mmHg

Perform ABPM

Mean awake BP

Less than 135/85 mmHg

Mean awake BP

equals or over 135/85 mmHg

Follow-up with periodic home-BP measurement and or repeated ABPM every 1-2yr.

Initiate antihypertensive therapy

ABPM: Ambulatory Blood Pressure Monitoring BP: Blood Pressure

Adapted from White W, NEJM 348:24, June 12, 2003

recommendations for follow up
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

More frequentvisits

Visits every

1-2 Months

blood pressure measurement with specific devices
Blood pressure measurement with specific devices

Mercury Blood Pressure Monitor

Aneroid Blood Pressure Monitor

Automated Blood Pressure Monitor

blood pressure measurement with mercury blood pressure monitor
Blood Pressure Measurement with Mercury Blood Pressure Monitor
  • The patient should
    • Be calmly seated for at least 5 minutes
    • Have his or her back supported with a chair back
    • Have their arm bare or have thin clothing on
    • Have their arm supported at the level of the heart.
    • Have their feet on the floor and their legs should not be crossed.
    • Not talk prior and during the procedure.
  • The column of mercury must be vertical, and at the observers eye level

2010 Canadian Hypertension Education Program Recommendations

blood pressure measurement with mercury blood pressure monitor52
Blood Pressure Measurement with Mercury Blood Pressure Monitor
  • Use a cuff with the appropriate size
  • Estimate the systolic beforehand:
    • a) Palpate the brachial artery
    • b) Inflate cuff until pulsation disappears
    • c) Deflate cuff
    • d) Estimate systolic pressure
  • Inflate to 30mmHg above the estimated systolic level needed to occlude the pulse
blood pressure measurement with mercury blood pressure monitor53
Blood Pressure Measurement with Mercury Blood Pressure Monitor
  • Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2mmHg/beat until you hear regular tapping sounds. Measure systolic (first regular sound) to nearest 2mmHg
  • Deflate at a rate of 2 mmHg/heart beat to 10 mmHg below the last heard Korotkoff sound
  • Measure diastolic blood pressure to nearest 2mmHg.
blood pressure measurement with aneroid blood pressure monitor
Blood Pressure Measurement with Aneroid Blood Pressure Monitor
  • The patient should
    • Be calmly seated for at least 5 minutes
    • Have his or her back supported with a chair back
    • Have their arm bare or have thin clothing on
    • Have their arm supported at the level of the heart.
    • Have their feet on the floor and their legs should not be crossed.
    • Not talk prior and during the procedure.
  • The manometer should be easily visible at the observer’s eye level

Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

use of standardized measurement techniques is recommended when assessing blood pressure
Use of standardized measurement techniques is recommended when assessing blood pressure
  • When using automated office oscillometric devices such as the BpTRU, the patient should be seated in a quiet room (no specified period of rest). With the device set to take measures at 1 or 2 minute intervals, the first measurement is taken by a health professional to verify cuff position and validity of the measurement. The patient is left alone after the first measurement while the device automatically takes subsequent readings. The BpTRU automatically discards the first measure and averages the next 5 measures.
blood pressure measurement with aneroid blood pressure monitor56
Blood Pressure Measurement with Aneroid Blood Pressure Monitor
  • Estimate the systolic beforehand:
    • a) Palpate the brachial artery
    • b) Inflate cuff until pulsation disappears
    • c) Deflate cuff
    • d) Estimate systolic pressure when the pulse reappears
  • Inflate to 30mmHg above the estimated systolic level needed to occlude the pulse

Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

blood pressure measurement with aneroid blood pressure monitor57
Blood Pressure Measurement with Aneroid Blood Pressure Monitor
  • Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2mmHg/beat until you hear regular tapping sounds. Measure systolic (first regular sound) to nearest 2mmHg
  • Deflate at a rate of 2mmHg/beat until disappearance. Measure diastolic blood pressure to nearest 2mmHg

Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

blood pressure measurement with aneroid blood pressure monitor58
Blood Pressure Measurement with Aneroid Blood Pressure Monitor

Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

If the needle on an aneroid device does not zero it is inaccurate; however the converse is not true.

assessing the calibration of an aneroid device
Assessing the calibration of an aneroid device

Attach the aneroid device and cuff to a mercury manometer using tubing and if necessary a ‘Y’ or ‘T’ connection (see diagram). Consider putting cotton wool in the T tube to prevent the mercury from oxidizing and becoming contaminated.

Pump the cuff up and assess the pressure of the aneroid at 20 mmHg intervals from 300 mmHg to 60 mmHg.

The aneroid is out of calibration if the readings are 4 or more mmHg different from the mercury device.

Do not use the aneroid device if it reads 4 or more mmHg different from the mercury device at pressures where diagnosis or therapeutic decisions are made.

Note: If the aneroid device does not read ‘0’ when there is no pressure

in the cuff it is out of calibration

attaching an aneroid device to a mercury device for calibration testing
Attaching an aneroid device to a Mercury device for calibration testing

Note: check the mercury column is at zero before testing.

blood pressure measurement with a fully automated home or office automated blood pressure monitor
Blood Pressure Measurement with a Fully Automated Home or Office Automated Blood Pressure Monitor
  • The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure.
  • Ensure no tight clothing constricts the arm
  • Use a cuff with the appropriate size
  • Place the cuff on snuggly with the indicator mark on the cuff over the brachial artery
  • Take at least two blood pressure measurements one minute apart
  • Record measurement as displayed
recommended automated blood pressure monitors for home blood pressure measurement
Recommended automated blood pressure monitors for home blood pressure measurement

Monitors A&D® or LifeSource® Models: 705, 767, 767PAC, 767Plus, 774, 774AC, 779, 787, 787AC

Monitors Omron®  Models: HEM-705 PC, HEM-711, HEM-741CINT

Monitors Microlife® or Thermor® (also sold under different brand names)

Models: BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP 3AC1-2, BP 3AG1, BP 3BTO-1,BP 3BTO-A (2), BP 3BTO-AP, RM 100, BP A100 Plus, BP A 100

slide63

For your patients – ask them to sign up at www.myBPSite.ca for free access to the latest Information & resources on HBP

For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources.