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Journal Club

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

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  1. Journal Club Adam Wilcox, PharmD 1/22/14

  2. 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

  3. 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

  4. 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

  5. Question • Does nocturnal blood pressure drop have an effect on cardiovascular mortality?

  6. 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

  7. 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.

  8. 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

  9. 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)

  10. 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

  11. Analysis/Results • Sharp declines in the inverted dipper group

  12. Limitations • Prospective study • All participants came from a small Japanese community

  13. 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

  14. Are you tired of being on call? • A perfect bracket wins $1 billion

  15. 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.

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