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Hypertension: . Blood Pressure Measurement and the new NICE guideline. Prof Richard McManus BHS Annual Meeting Cambridge 2011. NICE clinical guideline 127. Overview. Blood Pressure Measurement – where are we now? Implications of measurement modalities on diagnosis

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slide1

Hypertension:

Blood Pressure Measurement and the new NICE guideline

Prof Richard McManus

BHS Annual Meeting Cambridge 2011

NICE clinical guideline 127

overview
Overview
  • Blood Pressure Measurement – where are we now?
  • Implications of measurement modalities on diagnosis
  • Systematic Review of methods for diagnosing hypertension
  • Cost effectiveness modelling
  • Guideline recommendations
  • Issues and conclusions
routine measurement is often flawed
Routine measurement is often flawed

Same population with routine and research measurement

even on a single occasion bp drops
Approx 1500 patients

24 practices

6 readings at 1min intervals

12 mmHg systolic drop

Stable after 5th reading

Even on a single occasion BP drops
slide7

Family Practice 1997; 14:130-135

BP takes some time to settle with repeated measurement over weeks/months

bp measurement and diagnosis10
BP measurement and diagnosis
  • Out of office measures:
    • better estimation of “usual blood pressure”
    • better correlated with prognosis
ambulatory vs clinic for prognosis
Ambulatory vs clinic for Prognosis
  • 2 pooled plus 11 individual studies
  • ABPM superior to clinic BP in predicting CVD events
  • Greater risk per mmHg increase in ABPM vs clinic

Hansen J Hyp 2007

slide12

Home vs clinic for prognosis

  • 4 studies
  • 2 biggest did not show convincing additional prognostic benefit from home above office
  • Some evidence from smaller studies of improvement from home (esp DBP) but underpowered
  • Greater risk per mmHg from home

Journal of Hypertension 2004, 22:1099–1104

bp measurement and diagnosis13
BP measurement and diagnosis
  • Out of office measures allow better estimation of “usual blood pressure”
  • Better correlated with prognosis
  • Detection of White Coat (and masked) HT
bp measurement and diagnosis15
BP measurement and diagnosis
  • Out of office measures allow better estimation of “usual blood pressure”
  • Better correlated with prognosis
  • Detection of White Coat (and masked) HT
  • ABPM de facto gold standard for most clinicians
    • What you do when there is uncertainty
how do clinic and out of office measurements compare
How do clinic and out of office measurements compare?
  • Reviewed literature: 2914 studies of which 20 were relevant
  • 7 compared ABPM with clinic monitoring for diagnosis
  • 3 compared HBPM with clinic monitoring for diagnosis
  • Full details: BMJ 2011;342:d3621 doi: 10.1136/bmj.d3621
many people currently potentially misdiagnosed
Many people currently potentially misdiagnosed...

Worse if only studies around diagnostic threshold used:

sensitivity of 86% and

specificity of 46%

what about home monitoring
What about Home Monitoring?

Relative sensitivity and specificity of clinic and home measurement vs ABPM

what threshold abpm
What threshold ABPM ?

Based on Head et al BMJ 2010

  • adjust by 5/5 mmHg at lower threshold (stage 1 hypertension, 140/90 mmHg clinic)
    • ie < 135/85 mm Hg
  • 10/5 mmHg at higher threshold (stage 2 hypertension, 160/100 mmHg clinic)
    • Ie < 150/95 mmHg
how many home measurements
How many Home measurements?

Conclusion = at least 4 days monitoring and discard 1st

is out of office diagnosis cost effective
Is Out of Office Diagnosis cost effective?
  • Modelling to evaluate the most cost-effective method of confirming a diagnosis of hypertension in a population suspected of having hypertension
  • ABPM vs Home vs clinic
  • Further details Lovibond et al, Lancet 2011
markov model
Markov Model
  • Health and personal social services perspective
  • Lifetime horizon
  • Assume all have raised clinic screening
  • People aged 40 and over
markov model25
Markov Model
  • Costs from published sources and NHS
  • Test performance from systematic review
  • Risk calculated using Framingham equation
results
Results
  • ABPM most cost effective for every age group
results27
Results
  • ABPM most cost effective for every age group
  • Robust to wide range of sensitivity analyses
results29
Results
  • ABPM most cost effective for every age group
  • Robust to wide range of sensitivity analyses
  • Sensitive to
    • Assumption of equal test performance
    • Assumption of no effect of Rx below 140/90 mmHg
diagnosing hypertension 1
Diagnosing hypertension (1)

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension

diagnosing hypertension 2
Diagnosing hypertension (2)

When using the following to confirm diagnosis ensure:

ABPM:

  • two measurements per hour during the person’s usual waking hours (Day time mean)

HBPM:

  • two consecutive seated measurements, at least 1 minute apart
  • blood pressure is recorded twice a day and for at least 4 days
  • measurements on the first day are discarded – average value of all remaining is used
care pathway

CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg

Stage 2 hypertension

Care Pathway

If target organ damage present or 10-year cardiovascular risk > 20%

Offer antihypertensive drug treatment

Consider specialist referral

If younger than 40 years

Offer lifestyle interventions

Offer patient education and interventions to support adherence to treatment

Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

abpm issues
ABPM issues
  • Won’t upfront costs be very expensive?
  • Will my (specialist) service be over run?
  • ABPM vs home choice
conclusions
Conclusions
  • Diagnosis of Hypertension is changing
  • Implementation challenging but benefits can be realised in terms of better targeting of treatment and reduced costs
slide36

Hypertension:

Blood Pressure Measurement and the new NICE guideline

Prof Richard McManus

BHS Annual Meeting Cambridge 2011

NICE clinical guideline 127