Blood pressure
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This document discusses blood pressure measurement and hypertension. It provides guidelines for proper blood pressure measurement technique and defines thresholds for diagnosing and treating hypertension. It also discusses the use of ambulatory blood pressure monitoring and home blood pressure monitoring to improve diagnosis and management of hypertension. High blood pressure is a major risk factor for heart disease and stroke.
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Blood pressure
- 1. Blood Pressure Measurement How can anything so simple be so complex? © Continuing Medical Implementation …...bridging the care gap
- 2. Diseases Attributable to Hypertension Heart failure Hypertension Stroke Coronary heart disease Myocardial infarction Left ventricular hypertrophy Aortic aneurysm Retinopathy Peripheral vascular disease Cerebral hemorrhage Chronic kidney failure Hypertensive encephalopathy © Continuing Medical Implementation …...bridging the care gap Adapted from: Arch Intern Med 1996; 156:1926-1935. All Vascular
- 3. Awareness, Treatment and Control of High Blood Pressure in Canada 42% 19% 23% 16% Patients unaware of their high blood pressure 42% Aware but not treated and not controlled 19% Treated but not controlled 23% Treated and controlled 16% Adapted from: Am J Hypertens 1997; 10:1097-1102. © Continuing Medical Implementation …...bridging the care gap
- 4. 2003 High blood pressure vs Hypertension Office Diagnosis of Hypertension: Summary Visit 1 Visit 2 Visit 3 160 physical examination 100 Visit 4 Visit 5 Blood pressure measurement every year History-taking, - Hypertensive urgency? - Target organ damage or BP >160/100? (Visit 3) Hypertension diagnosis confirmed BP over threshold for initiation of treatment Yes No Validated technique and BP measurement device 140 90 © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 34
- 5. RECOMMENDED BBLLOOOODD PPRREESSSSUURREE MMEEAASSUURREEMMEENNTT TTEECCHHNNIIQQUUEE 22.. 2. • TThhee ccuuffff mmuusstt bbee lleevveell wwiitthh hheeaarrtt.. • IIff aarrmm cciirrccuummffeerreennccee eexxcceeeeddss 3333 ccmm,, aa llaarrggee ccuuffff mmuusstt bbee uusseedd.. • PPllaaccee sstteetthhoossccooppee ddiiaapphhrraaggmm oovveerr bbrraacchhiiaall aarrtteerryy.. • The cuff must be level with heart. • If arm circumference exceeds 33 cm, a large cuff must be used. • Place stethoscope diaphragm over brachial artery. 11.. 1. • TThhee ppaattiieenntt sshhoouulldd bbee rreellaaxxeedd aanndd tthhee aarrmm mmuusstt bbee ssuuppppoorrtteedd.. • EEnnssuurree nnoo ttiigghhtt ccllootthhiinngg ccoonnssttrriiccttss tthhee aarrmm.. • The patient should be relaxed and the arm must be supported. • Ensure no tight clothing constricts the arm. 33.. 3. • TThhee ccoolluummnn ooff mmeerrccuurryy mmuusstt bbee vveerrttiiccaall.. • IInnffllaattee ttoo oocccclluuddee tthhee ppuullssee.. DDeeffllaattee aatt 22 ttoo 33 mmmm//ss.. MMeeaassuurree ssyyssttoolliicc ((ffiirrsstt ssoouunndd)) aanndd ddiiaassttoolliicc ((ddiissaappppeeaarraannccee)) ttoo nneeaarreesstt 22 mmmm HHgg.. • The column of mercury must be vertical. • Inflate to occlude the pulse. Deflate at 2 to 3 mm/s. Measure systolic (first sound) and diastolic (disappearance) to nearest 2 mm Hg. SStteetthhoossccooppee MMeerrccuurryy mmaacchhiinnee © Continuing Medical Implementation …...bridging the care gap 3
- 6. © Continuing Medical Implementation …...bridging the care gap
- 7. 2003 Threshold for Initiation of Treatment and Target Values Target Condition Initiation SBP / DBP mmHg SBP / DBP mmHg <140/90 <140 <135/85 <130/80 Diastolic ± systolic hypertension ³ 140/90 Isolated systolic hypertension SBP >160 Home BP measurement (³ 135/85) (no diabetes, renal disease or proteinuria) Diabetes ³ 130/80 Renal disease (³ 130/80) <130/80 <125/75 Proteinuria >1 g/day (³ 125/75) © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 39
- 8. BP Treatment Targets Condition 160/100 Treatment threshold if no risk factors,TOD or CCD < 140/90 Treatment target for office BP measurement < 135/85 Treatment target for ABP or HBP measurement < 130/80 Treatment target for for Type 2 diabetics or non-diabetic nephropathy < 125/75 Treatment target for diabetic or non-diabetic nephropathy with proteinuria
- 9. Automated BpTRU™ BP Devices © Continuing Medical Implementation …...bridging the care gap
- 10. Benefits of Automated BpTRU™ BP Devices – Standardizes BP readings from one operator to the next – Removes many of the errors associated with manual readings – Accurate, reliable and reproducible readings – Multiple readings with averaging – “Opportunistic screening” – Accurate, independently validated device – Automatically zeroes with each inflation – Performs full system check every time on powering-up • Performs six readings • Discards the first reading • Averages the remainder • Interval between readings from 1-5 minutes apart • User can auscultate using the digital readout when desired © Continuing Medical Implementation …...bridging the care gap
- 11. 180 – 170 – 160 – 150 – 140 – 130 – 120 – 110 – 100 – 90 – 80 – 0 – 174±3 Study Results 166±4 158±4 155±5 mmHg) 146±3 (Pressure Blood 92±2 89±3 90±2 88±2 82±2 Specialist Family Research Physician Technician BP Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B BpTRU Ambulatory
- 12. Study Conclusions • The patient’s presence in the doctor’s office or research unit in itself appears to be partly responsible for the white coat effect. • BP readings taken on the initial visit tend to be higher than other readings. • The white coat effect can be partly eliminated by the use of an automated BP recording device (BpTRU) • BP readings recorded by the BpTRU device are similar to readings taken by an experienced research technician using CHS Guidelines. Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B © Continuing Medical Implementation …...bridging the care gap
- 13. 2003 Home (Self) Measurement of BP: Specific Role in Selected Patients Which patients? Non adherence Hypertension and diabetes Further assess using ambulatory blood pressure monitoring Normal Home BP? Office-induced blood pressure elevation BP over 135/85 mm Hg should be considered elevated © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 47
- 14. 2003 Home (Self) Measurement of BP: Patient Education How to? Use devices: - appropriate for the individual (cuff size) - have met the standards of the AAMI and or the BHS and or IP Values over 135 / 85 mm Hg considered elevated Adequate patient training in: - measuring their BP - interpreting these readings Regular verifications - accuracy of the device - measuring techniques Self measurement can help to improve patient adherence AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. should be © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 48
- 15. Validated BP Devices • BHS – BHS = British Hypertension Society • AAMI – AAMI = American Association of Medical Instruments • See British Hypertension Society Website • OMRON – HEM-705CP – HEM-711AC – HEM-722C – HEM-773 • LifeSource AND – UA-767 CN – UA-767 Plus – UA-779 – UA-787 © Continuing Medical Implementation …...bridging the care gap
- 16. OMRON • Claims all devices with exception of wrist devices are validated © Continuing Medical Implementation …...bridging the care gap
- 17. OMROM HEM 711 AC $109.99 © Continuing Medical Implementation …...bridging the care gap
- 18. LifeSourceUA-767PC • For use with a PC and Monitor Pro software. • Stores and analyzes recorded blood pressure data directly from the UA- 767PC. • The software provides printable summary reports and graphing capabilities. • Remotely monitor patients and their blood pressure from their homes. Validated according to BHS* protocol and AAMI** approved. *BHS = British Hypertension Society **AAMI = American Association of Medical Instruments © Continuing Medical Implementation …...bridging the care gap
- 19. Life Source UA779CN $99.99 © Continuing Medical Implementation …...bridging the care gap
- 20. No charge……? Validity © Continuing Medical Implementation …...bridging the care gap
- 21. When would you order ambulatory Blood pressure Monitoring? • For Dx mild to mod HTN • For elderly women with ISH • For apparent Rx resistance • For anxiety prone patients • When marked fluctuations in office BP present • For symptoms suggestive of hypotension present on Rx • White coat HTN unlikely – If DM coexists – If TOD present © Continuing Medical Implementation …...bridging the care gap
- 22. 2003 Ambulatory BP Monitoring: Specific Role in Selected Patients* Which patients? Those with suspected office-induced BP elevation Untreated - Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage Treated patients - Apparent resistance to drug therapy - Symptoms suggestive of hypotension - Fluctuating office blood pressure readings * Where available © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 49
- 23. 2003 Ambulatory BP Monitoring Specific Role in Selected Patients Use validated devices How to interpret? How to ? Mean daytime ambulatory blood pressure >135/85 mm Hg is considered elevated * A drop in nocturnal BP of <10% is associated with increased risk of CV events © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 50
- 24. Blood Pressure and Target Organ Damage (TOD) Current evidence suggests that: • 24-h blood pressure correlates most closely with TOD (compared to clinic or casual BP) • Higher incidence of cardiovascular events when blood pressure remains elevated at night (non-dippers) • Blood pressure variability is an independent determinant of TOD • Highest incidence of cardiovascular events occurs in AM Adapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987; Parati, et al. 1987; Mancia. 1990. © Continuing Medical Implementation …...bridging the care gap
- 25. 24-Hour Blood Pressure Profile: Two Patients with Hypertension Blood pressure (mm Hg) Sleep Non-dipper Dipper 175 155 135 115 95 75 55 7:00 11:00 15:00 19:00 23:00 3:00 7:00 Time of day © Continuing Medical Implementation …...bridging the care gap Adapted from: Redman, et al. 1976; Mancia, et al. 1983; Kobrin, et al. 1984; Baumgart, et al. 1989; Imai, et al. 1990; Portaluppi, et al. 1991.
- 26. 24-Hour Blood Pressure Profile: The Morning Blood Pressure ‘Surge’ Time of awakening 180 Sleep 160 140 120 100 80 18:00 22:00 02:00 06:00 10:00 14:00 18:00 Time of day Blood pressure (mm Hg) © Continuing Medical Implementation …...bridging the care gap Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.
- 27. Circadian Incidence of Cardiovascular Events: Myocardial Ischemia Ischemia (min) 01:00 05:00 09:00 13:00 17:00 21:00 300 250 200 150 100 50 0 © Continuing Medical Implementation …...bridging the care gap Adapted from: Rocco, et al. 1987. n=24 Time of day
- 28. 2003 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 frequent visits Monthly visits © Continuing Medical Implementation …...bridging the care gap Canadian Hypertension Education Program Recommendations 52
- 29. TThhiiss ppllaattffoorrmm hhaass bbeeeenn ssttaarrtteedd bbyy PPaarrvveeeenn KKuummaarr CChhaaddhhaa wwiitthh tthhee vviissiioonn tthhaatt nnoobbooddyy sshhoouulldd ssuuffffeerr tthhee wwaayy hhee hhaass ssuuffffeerreedd bbeeccaauussee ooff llaacckk aanndd iimmpprrooppeerr hheeaalltthhccaarree ffaacciilliittiieess iinn IInnddiiaa.. WWee nneeeedd lloottss ooff ffuunnddss mmaannppoowweerr eettcc.. ttoo mmaakkee tthhiiss vviissiioonn aa rreeaalliittyy pplleeaassee ccoonnttaacctt uuss.. JJooiinn uuss aass aa mmeemmbbeerr ffoorr aa nnoobbllee ccaauussee..
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Editor's Notes
- Slide 5 Studies show that a multitude of diseases are attributable to hypertension. They include: • Heart failure • Coronary heart disease • Myocardial infarction • Left ventricular hypertrophy and failure • Aortic aneurysm • Peripheral vascular disease • Retinopathy • Hypertensive encephalopathy • Chronic kidney failure • Cerebral hemorrhage • Stroke With so many diseases linked to hypertension, prompt and effective treatments have the potential to reduce many complications. Dustan HP, et al. Arch Intern Med 1996; 156:1926-1935.
- Slide 6 Despite the advances that have been made in the treatment of hypertension over the last 50 years, it is clear that there is still room for improvement in the management of this condition. Less than 40% of of Canadians with hypertension are treated for their condition. Only 16% those receiving treatment have their blood pressure controlled (BP &lt; 140/90). Joffres MR, et al. Awareness, Treatment, and Control of Hypertension in Canada. Am J Hypertens 1997; 10:1097-1102.
- An aneroid sphygmomanometer found in my partner’s medical bag – the needle was noted to be “off – zero”
- Subsequently, others have studied the BpTRU in both research and clinical settings. This study was presented by Dr. Martin Myers of the U. of Toronto at the CHS meeting last October, and will be published in the American Journal of Hypertension next month. In comparing the BpTRU to a specialist BP, FP BP, research technician and ABP it shows the BpTRU to be as accurate as a research technician.
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- Slide 22 Hypertension increases the risk of target organ damage (i.e. cerebrovascular, cardiovascular and renal events). Several studies have reported a closer relationship between target organ damage and blood pressure when blood pressure was recorded by 24-h ambulatory blood pressure monitoring (ABPM) compared with conventional measurements of blood pressure at the clinic (Mancia 1990; Devereux, et al 1987). A consistent pattern is seen whether target organ damage is assessed by an overall score, left ventricular mass index (LVMI), left ventricular wall thickness, or retinopathy (Sokolow, et al 1966; Devereux, et al 1983; Parati, et al 1987). Sokolow M, Werdegar D, Kain HK, Hinman AT. Relationship between level of blood pressure measured causally and by portable recorders and severity of complications in essential hypertension. Circulation 1966; 34:279-298. Devereux RB, Pickering TG, Harshfield GA et al. Left ventricular hypertrophy in patients with hypertension: importance of blood pressure response to regularly recurring stress. Circulation 1983; 68:470-476. Devereux RB, Pickering TG, Alderman MH, Chiken S, Borer JS, Laragh JH. Left ventricular hypertrophy in hypertension: prevalence and relationship to pathophysiologic variables. Hypertension 1987; 9: (Suppl II):1153-1160. Parati G, Pomidossi G, Albini F, Malaspina D, Mancia G. Relationship of 24-hour blood pressure mean and variability to severity of target-organ damage in hypertension. J Hypertens 1987; 5:93-98. Mancia G. Ambulatory blood pressure monitoring: research and clinical applications. J Hypertens 1990; 8 (Suppl 7): S1-S13.
- Slide 24 Most patients with essential hypertension are ‘dippers’ - patients experience the same circadian pattern as normotensives with a night-time dip in blood pressure (Mancia, et al 1983). The ‘normal’ circadian pattern is lost in some patients with essential hypertension (‘non-dippers’). There appears to be a greater prevalence of this phenomenon in patients with secondary hypertension, renal insufficiency, pre-eclampsia, in elderly hypertensives, and in the accelerated form of malignant hypertension (Redman, et al 1976; Kobrin, et al 1984; Baumgart, et al 1989; Imai, et al 1990; Portaluppi, et al 1991). Redman CWG, Beilin LJ, Bonnar J. Reversed diurnal blood pressure rhythm in hypertensive pregnancies. Clin Sci Mol Med 1976; 51:687-688. Mancia G, Ferrari A, Gregorini L et al. Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Circ Res 1983; 53:96-104. Kobrin I, Oigman W, Kumar A et al. Diurnal variation of blood pressure in elderly patients with essential hypertension. J Am Geriatr Soc 1984; 32:869-879. Baumgart P, Walger P, Gerke M, Dorst K-G, Vetter H, Raum K-H. Nocturnal hypertension in renal failure hemodialysis and after renal transplantation. J Hypertens 1989; 7 (Suppl 6):70-71. Imai Y, Abe K, Munakata M et al. Does ambulatory blood pressure monitoring improve the diagnosis of secondary hypertension? J Hypertens 1990; 8 (Suppl 6):71-78. Portaluppi F, Montanari L, Massari M, Di Chiari V, Capanna M. Loss of nocturnal decline of blood pressure in hypertensives due to chronic renal failure. Am J Hypertens 1991; 4:20-26.
- Slide 27 Blood pressure falls during sleep and rises rapidly just before the time of awakening and arising (Millar-Craig, et al 1978; Mancia, et al 1983). Millar-Craig M, Bishop CN, Raftery EB. Circadian variation of blood pressure. Lancet 1978; I: 795-797. Mancia G, Ferrari A, Gregorini L, et al. Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Circ Res 1983; 53:96-104.
- Slide 29 Epidemiological evidence shows that CHD morbidity and mortality are greatest in the morning waking period (Muller, et al 1985; Thompson, et al 1985; Muller, et al 1987; Rocco, et al 1987; Willich, et al 1987; Mulcahy, et al 1988), between 8 am and 12 noon (Rocco, et al 1987). The peak incidence of cardiovascular events is associated with the BP surge that occurs as people arise and begin their routine daytime activities (Rocco, et al 1987). Muller JE, Stone PH, Turi ZG, et al. Circadian variation in the frequency of onset of acute myocardial infarction. N Engl J Med 1985; 313:1315-1322. Thompson DR, Blandford RL, Sutton TW, Marchant PR. Time of onset of chest pain in acute myocardial infarction. Int J Cardiol 1985; 7:139-146. Muller JE, Ludmer PL, Willich SN, et al. Circadian variation in the frequency of sudden cardiac death. Circulation 1987; 75:131-138. Rocco MB, Barry J, Campbell S, et al. Circadian variation of transient myocardial ischaemia in patients with coronary artery disease. Circulation 1987; 75:395-400. Willich SN, Levy D, Rocco MB, Tofler GH, Stone PH, Muller JE. Circadian variation in the incidence of sudden cardiac death in the Framingham Heart Study population. Am J Cardiol 1987; 60:801-806. Mulcahy D, Keegan J, Cunningham D et al. Circadian variation of total ischaemic burden and its alteration with anti-anginal agents. Lancet 1988; ii:755-759. Willich SN, Goldberg RJ, Maclure M, Perriello L, Muller JE. Increased onset of sudden cardiac death in the first three hours after awakening. Am J Cardiol 1992; 70:65-68.