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Journal Club. Adam Wilcox, PharmD 1/22/14. Patient Case. DB, 70 yo M Overall ABPM summary Avg. BP = 116/62 Daytime = 120/63 Nighttime = 103/58 Systolic load: 9.2% Night dip: 14.2%. First 3 blood pressures (in office) 161/86 158/82 155/87

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journal club

Journal Club

Adam Wilcox, PharmD

1/22/14

patient case
Patient Case
  • DB, 70 yo M
  • Overall ABPM summary
    • Avg. BP = 116/62
    • Daytime = 120/63
    • Nighttime = 103/58
    • Systolic load: 9.2%
    • Night dip: 14.2%
  • First 3 blood pressures (in office)
    • 161/86
    • 158/82
    • 155/87
  • 9/21 (43%) of nighttime readings have SBP <100
  • Medications
    • Lisinopril
    • Beta-blocker
ambulatory bp monitoring
Ambulatory BP Monitoring
  • Monitor blood pressure over a 24 hour period
    • Every 20 minutes while awake
    • Every 30 minutes while sleeping
  • Indications
    • Variable office blood pressure readings
    • Differences between in home and office readings (white coat)
    • Hypertension resistant to multiple medications
what is normal
What is normal?
  • 150/90 or 140/90?
  • 24 hour: <130/80
  • Daytime: <135/85
  • Nighttime: <120/70
  • SBP load: >30% increases cardiovascular risk
  • Nighttime dip: 10-20% is normal
    • Non-dippers: LVH, CHF, microalbuminuria, GFR reduction
question
Question
  • Does nocturnal blood pressure drop have an effect on cardiovascular mortality?
slide6
PICO
  • P: DB, 70yo male
  • I: Extreme dippers(BP decline ≥ 20% of daytime BP)

Non-dippers(BP decline ≥ 0% but < 10% of daytime BP)

Inverted dippers(no nighttime BP decline)

  • C: Dippers(BP decline ≥ 10% but < 20% of daytime BP)
  • O: Cardiovascular mortality
journal article
Journal Article
  • Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.
study basics
Study Basics
  • Objective:
    • To investigate the relationship between nocturnal decline in blood pressure and mortality
  • Type:
    • Prospective trial involving 1542 residents of a rural Japanese community
  • Exclusion:
    • <40 years old, hospitalized individuals, demented patients, people who worked out of town
  • Study population:
    • 565 men(62.5 years) and 977 women(61.2 years)
    • Primarily farmers, retirees, housewives
  • Outcomes:
    • Overall mortality, cardiovascular, non-cardiovascular
methods
Methods
  • Needed at least 8 hours of daytime readings and 4 hours of nighttime readings to be included in the analysis
  • Average duration of monitoring was 22.3 hours
  • Average # of measurements 44.6
  • Average 24 hr, daytime, nighttime, and nocturnal decline were calculated for each person
    • %decline nocBP = (daytime BP – nighttime BP) x 100/daytime BP
    • Classified into groups(extreme, dippers, non-dippers, inverted)
analysis results
Analysis/Results
  • Kaplan-Meier life table, SAS LIFETEST procedure, Cox proportional hazards regression model
  • Mean follow up time 5.1 years(0.1-8.1)
  • Data adjusted for age, sex, smoking status, history of CVD, BP levels, and use of hypertensive medications
analysis results1
Analysis/Results
  • Sharp declines in the inverted dipper group
limitations
Limitations
  • Prospective study
  • All participants came from a small Japanese community
what does this mean to practice
What does this mean to practice?
  • For DB…
    • Avg. BP = 116/62
    • Daytime = 120/63
    • Nighttime = 103/58
    • Systolic load: 9.2%
    • Night dip: 14.2%
    • In office avg. = 158/85
  • For extreme dippers…
    • Prevent the early morning blood pressure surge (stroke, MI)
      • Switch to short-acting
      • Timing of medications
  • For non-dippers/inverted…
      • Move one of your medications to bedtime
are you tired of being on call
Are you tired of being on call?
  • A perfect bracket wins $1 billion
references
References
  • 1. Ernst M. Ambulatory Blood Pressure Monitoring: Recent Evidence and Clinical Pharmacy Applications. Pharmacotherapy 2013;33(1)69-83.
  • 2. Ernst M. Nighttime Blood Pressure Is the Blood Pressure. Pharmacotherapy 2009;29(1)3-6.
  • 3. Kaplan N. Ambulatory Blood Pressure Monitoring and White Coat Hypertension in Adults. UptoDateNov. 2013.
  • 4. Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.