- 5 in 10 hypertensive patients in Singapore are not optimally controlled. Increased blood pressure variability may impact cardiovascular risk.
- Consultant cardiologist will discuss implications of the SPRINT trial on optimal blood pressure management and the relationship between blood pressure variability and adverse cardiovascular outcomes.
- Joint scientific session will cover optimal blood pressure control in hypertensive patients and implications of blood pressure variability based on recent studies such as the SPRINT trial.
2018 esc esh guidelines for the management of arterial hypertensionVinh Pham Nguyen
This document provides guidelines from the European Society of Cardiology (ESC) and European Society of Hypertension (ESH) for the management of arterial hypertension. It was developed by a task force that reviewed the scientific evidence and medical knowledge available.
The guidelines include updated definitions and classifications of hypertension. They recommend methods for blood pressure measurement in both clinical and daily settings. Guidelines are provided for evaluating hypertension-related organ damage, assessing total cardiovascular risk, and initiating treatment. Lifestyle modifications and drug therapies are discussed as options for lowering blood pressure.
The task force comprised international experts in cardiology and hypertension. They aimed to provide evidence-based recommendations on evaluating and managing hypertensive patients to reduce health risks and improve outcomes
This document summarizes several studies related to sacubitril/valsartan (LCZ696):
- The TRANSITION trial found that initiating sacubitril/valsartan in hospital shortly after stabilization from acute heart failure had similar safety outcomes as initiating post-discharge. About 50% of patients achieved the top dose within 10 weeks.
- The PIONEER-HF trial showed that among patients hospitalized for acute heart failure, sacubitril/valsartan led to a greater reduction in NT-proBNP levels at 8 weeks compared to enalapril, with similar rates of adverse events.
- The landmark PARADIGM-HF trial demonstrated that sacubitril
This document discusses the 2016 ESC Guidelines for the diagnosis and treatment of heart failure. It focuses on the PARADIGM-HF trial which compared the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan (LCZ696) to enalapril in patients with heart failure with reduced ejection fraction. The trial found LCZ696 reduced the risks of cardiovascular death or heart failure hospitalization and all-cause mortality compared to enalapril. LCZ696 was also better tolerated with less cough, hyperkalemia, and renal impairment reported compared to enalapril.
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
The document summarizes guidelines from JNC 8 (2014) on the management of hypertension. It provides 3 key recommendations from JNC 8:
1) Treatment should begin for general population aged ≥60 years with SBP ≥150 mmHg or DBP ≥90 mmHg, and for those <60 years with SBP ≥140 mmHg or DBP ≥90 mmHg.
2) The treatment goal for non-diabetic, non-CKD patients is SBP <150 mmHg and DBP <90 mmHg. Lower goals may apply if no adverse effects.
3) Initial treatment should include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers or thiaz
Hypertension and Diabetic Kidney Disease Progression Hypertension and Diabe...MedicineAndHealthUSA
Hypertension and diabetic kidney disease progression are linked, and reducing proteinuria is key to slowing kidney disease. The document discusses how conditions like hypertension and diabetes that cause kidney damage have increased in the US population. Landmark trials found that lowering blood pressure and proteinuria reduced kidney disease progression and cardiovascular risks. Initial therapy for kidney or diabetes patients should be an ACE inhibitor or ARB to target blood pressure under 130/80 mmHg.
Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning
Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London
2018 esc esh guidelines for the management of arterial hypertensionVinh Pham Nguyen
This document provides guidelines from the European Society of Cardiology (ESC) and European Society of Hypertension (ESH) for the management of arterial hypertension. It was developed by a task force that reviewed the scientific evidence and medical knowledge available.
The guidelines include updated definitions and classifications of hypertension. They recommend methods for blood pressure measurement in both clinical and daily settings. Guidelines are provided for evaluating hypertension-related organ damage, assessing total cardiovascular risk, and initiating treatment. Lifestyle modifications and drug therapies are discussed as options for lowering blood pressure.
The task force comprised international experts in cardiology and hypertension. They aimed to provide evidence-based recommendations on evaluating and managing hypertensive patients to reduce health risks and improve outcomes
This document summarizes several studies related to sacubitril/valsartan (LCZ696):
- The TRANSITION trial found that initiating sacubitril/valsartan in hospital shortly after stabilization from acute heart failure had similar safety outcomes as initiating post-discharge. About 50% of patients achieved the top dose within 10 weeks.
- The PIONEER-HF trial showed that among patients hospitalized for acute heart failure, sacubitril/valsartan led to a greater reduction in NT-proBNP levels at 8 weeks compared to enalapril, with similar rates of adverse events.
- The landmark PARADIGM-HF trial demonstrated that sacubitril
This document discusses the 2016 ESC Guidelines for the diagnosis and treatment of heart failure. It focuses on the PARADIGM-HF trial which compared the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan (LCZ696) to enalapril in patients with heart failure with reduced ejection fraction. The trial found LCZ696 reduced the risks of cardiovascular death or heart failure hospitalization and all-cause mortality compared to enalapril. LCZ696 was also better tolerated with less cough, hyperkalemia, and renal impairment reported compared to enalapril.
The SPRINT trial studied over 9,000 patients at high risk for cardiovascular events to compare intensive blood pressure control (target <120 mm Hg systolic) to standard control (target <140 mm Hg). It found that intensive control significantly reduced rates of fatal and nonfatal heart attacks, heart failure, and death from any cause. However, intensive control also increased some adverse effects like acute kidney injury and hypotension. Overall, the trial demonstrated benefits of very tight blood pressure control for high-risk patients without diabetes.
The document summarizes guidelines from JNC 8 (2014) on the management of hypertension. It provides 3 key recommendations from JNC 8:
1) Treatment should begin for general population aged ≥60 years with SBP ≥150 mmHg or DBP ≥90 mmHg, and for those <60 years with SBP ≥140 mmHg or DBP ≥90 mmHg.
2) The treatment goal for non-diabetic, non-CKD patients is SBP <150 mmHg and DBP <90 mmHg. Lower goals may apply if no adverse effects.
3) Initial treatment should include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers or thiaz
Hypertension and Diabetic Kidney Disease Progression Hypertension and Diabe...MedicineAndHealthUSA
Hypertension and diabetic kidney disease progression are linked, and reducing proteinuria is key to slowing kidney disease. The document discusses how conditions like hypertension and diabetes that cause kidney damage have increased in the US population. Landmark trials found that lowering blood pressure and proteinuria reduced kidney disease progression and cardiovascular risks. Initial therapy for kidney or diabetes patients should be an ACE inhibitor or ARB to target blood pressure under 130/80 mmHg.
Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning
Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London
Nhận viết luận văn Đại học , thạc sĩ - Zalo: 0917.193.864
Tham khảo bảng giá dịch vụ viết bài tại: vietbaocaothuctap.net
Download đề tài: Nghiên cứu ứng dụng một số kỹ thuật lọc máu hiện đại trong cấp cứu điều trị một số bệnh, cho các bạn làm luận văn tham khảo
This document discusses various topics related to dual antiplatelet therapy (DAPT) including the optimal duration of DAPT after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation. It notes that the appropriate DAPT duration remains controversial and may differ between patients based on their individual risks of ischemia and bleeding. The document also discusses balancing anti-ischemic efficacy against bleeding risk when using antithrombotic therapies and considers strategies like individualizing DAPT duration based on patient characteristics. Triple antithrombotic therapy combining DAPT and oral anticoagulants for patients with atrial fibrillation is also reviewed.
Có cần phối hợp đôi trong điều trị rối loạn lipid máu hay không ?
PGS. TS. Nguyễn Văn Trí-Chủ nhiệm Bộ Môn Lão Khoa, ĐHYD TPHCM-Chủ tịch Hội Lão Khoa TPHCM
Statin hoàn toàn không dung nạp với điều trị nên thay thuốc nonstatin
1. ACC/AHA 2013 hay ESC/EAS2011
2. LDL-C thấp và giảm nguy cơ bệnh tim mạch: những bằng chứng mới
3. Cân bằng động sinh tổng hợp và hấp thu cholesterol và cơ chế ức chế kép
4. Bằng chứng lâm sàng với phối hợp thuốc Ezetimibe + Statin
This document provides guidelines for the assessment and management of dyslipidemia from several major organizations. It discusses risk assessment tools for cardiovascular disease from ATP III, ADA, ACC/AHA, and QRISK2. It also compares statin intensity categories between NICE and ACC/AHA guidelines. The document recommends lifestyle modification as first-line treatment and the use of high-intensity statins for primary and secondary prevention of CVD according to the guidelines of NICE, ADA, and ACC/AHA.
The SPRINT trial tested whether treating systolic blood pressure to a lower goal of <120 mm Hg compared to <140 mm Hg would reduce cardiovascular events. Interim results found the intensive treatment reduced cardiovascular complications by 30% and mortality by 25%, leading the trial to stop early. Final results are forthcoming to determine effects on other outcomes like dementia and kidney function.
SGLT-2 inhibitors have shown promising cardiovascular and renal benefits:
1) Trials have found SGLT-2 inhibitors reduce the risk of cardiovascular death in patients with type 2 diabetes and established cardiovascular disease, as well as reducing heart failure hospitalizations in those with diabetes and cardiovascular risk factors.
2) Studies also show SGLT-2 inhibitors improve outcomes for patients with heart failure with reduced ejection fraction, reducing rates of heart failure hospitalization and mortality regardless of diabetes status or background heart failure therapies.
3) SGLT-2 inhibitors were also found to reduce the risk of renal death or progression to end-stage kidney disease in patients with type 2 diabetes and macroalbuminuria.
Ramadan fasting is ritual for all muslims worldwide , where there is abstinace from eating , drinking and smoking from dawn to dusk , daily for one month, frequently , hypertensives asking about their fasting and medications during Ramadan, in the lecture , some focus on the effect of Ramadan on blood pressure , heart rate and other cardiovascular risk factors and lastly general instruction for hypertensives during Ramadan .
This study examined the relationship between blood pressure variability, as measured by 24-hour ambulatory blood pressure monitoring, and cardiovascular outcomes in elderly hypertensive patients. The results showed that increased nighttime systolic blood pressure variability was an independent risk factor for stroke. Specifically, the risk of stroke increased by 80% for every 5 mmHg increase in nighttime systolic blood pressure variability among patients in the placebo group. Daytime blood pressure variability did not predict cardiovascular outcomes. Antihypertensive treatment did not affect blood pressure variability over the course of the study.
Current management of hypertension DR. ANKIT JAIN AIIMSAnkit Jain
This document summarizes current management of hypertension. It begins by stating the high worldwide prevalence of hypertension and its attributable risk for death. It then discusses definitions and classifications of hypertension according to guidelines. Target blood pressure goals for optimal management are outlined, along with evaluating for target organ damage. The importance of lifestyle modifications and pharmacological therapy to reduce cardiovascular events is emphasized.
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Cardiovascular safety of anti-diabetic drugs.Cardiovascular Outcome Trials ...magdy elmasry
Cardiologists and diabetes.Target organs and action mechanism of antidiabetic drugs.Cardiovascular Outcome Trials
( CVOTs ) in Diabetes.Completed and ongoing CVOTs in type 2 diabetes.Diabetes Medications
and
Cardiovascular Impact.Recommendations for management of diabetes
Cardiovascular safety of anti-diabetic drugs.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
The JNC 8 guideline provides evidence-based recommendations for treating hypertension. It focuses on three key questions: 1) what BP thresholds should initiate treatment, 2) what treatment goals are appropriate, and 3) which drug classes are most effective and safe. Major recommendations include treating those over 60 to a goal of <150/90 mmHg, initiating treatment in others at 140/90 mmHg, and using thiazide diuretics, ACE inhibitors, ARBs, or CCBs as initial treatment. The guideline aims to simplify prior recommendations and focus on outcomes from randomized controlled trials.
The DCCT trial showed that intensive diabetes management reduced the risk of eye, kidney, and nerve complications compared to standard management. Intensive therapy aimed for blood glucose levels between 70-120 mg/dl, while standard therapy aimed to avoid symptoms of high or low blood glucose. The risks of intensive therapy were increased hypoglycemia and weight gain. The follow up EDIC study found metabolic memory effects, with long term benefits of early intensive control.
The document discusses updated guidelines for diagnosing and treating hypertension that were released in 2017. Some key points:
- The new guidelines lower the threshold for stage 1 hypertension to 130/80 mm Hg from 140/90 mm Hg. This means nearly half of US adults now have hypertension based on these guidelines.
- Lifetime risk of developing hypertension is approximately 90% for adults aged 55-65 based on data from the Framingham Heart Study.
- Self-monitoring and ambulatory blood pressure monitoring provide benefits over office-based measurements alone for managing hypertension.
- Lifestyle modifications such as weight loss, reduced sodium intake, increased potassium and physical activity are recommended as first-line treatment for many with elevated blood pressure
This document discusses diagnostic challenges and treatment dilemmas related to arterial hypertension. It covers topics such as accurate blood pressure measurement methods, diagnosing hypertension using out-of-office assessments like ambulatory blood pressure monitoring and home monitoring, assessing overall cardiovascular risk, evaluating for secondary causes of hypertension like renovascular disease and hyperaldosteronism, and the role of echocardiography in hypertension management.
Nhận viết luận văn Đại học , thạc sĩ - Zalo: 0917.193.864
Tham khảo bảng giá dịch vụ viết bài tại: vietbaocaothuctap.net
Download đề tài: Nghiên cứu ứng dụng một số kỹ thuật lọc máu hiện đại trong cấp cứu điều trị một số bệnh, cho các bạn làm luận văn tham khảo
This document discusses various topics related to dual antiplatelet therapy (DAPT) including the optimal duration of DAPT after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation. It notes that the appropriate DAPT duration remains controversial and may differ between patients based on their individual risks of ischemia and bleeding. The document also discusses balancing anti-ischemic efficacy against bleeding risk when using antithrombotic therapies and considers strategies like individualizing DAPT duration based on patient characteristics. Triple antithrombotic therapy combining DAPT and oral anticoagulants for patients with atrial fibrillation is also reviewed.
Có cần phối hợp đôi trong điều trị rối loạn lipid máu hay không ?
PGS. TS. Nguyễn Văn Trí-Chủ nhiệm Bộ Môn Lão Khoa, ĐHYD TPHCM-Chủ tịch Hội Lão Khoa TPHCM
Statin hoàn toàn không dung nạp với điều trị nên thay thuốc nonstatin
1. ACC/AHA 2013 hay ESC/EAS2011
2. LDL-C thấp và giảm nguy cơ bệnh tim mạch: những bằng chứng mới
3. Cân bằng động sinh tổng hợp và hấp thu cholesterol và cơ chế ức chế kép
4. Bằng chứng lâm sàng với phối hợp thuốc Ezetimibe + Statin
This document provides guidelines for the assessment and management of dyslipidemia from several major organizations. It discusses risk assessment tools for cardiovascular disease from ATP III, ADA, ACC/AHA, and QRISK2. It also compares statin intensity categories between NICE and ACC/AHA guidelines. The document recommends lifestyle modification as first-line treatment and the use of high-intensity statins for primary and secondary prevention of CVD according to the guidelines of NICE, ADA, and ACC/AHA.
The SPRINT trial tested whether treating systolic blood pressure to a lower goal of <120 mm Hg compared to <140 mm Hg would reduce cardiovascular events. Interim results found the intensive treatment reduced cardiovascular complications by 30% and mortality by 25%, leading the trial to stop early. Final results are forthcoming to determine effects on other outcomes like dementia and kidney function.
SGLT-2 inhibitors have shown promising cardiovascular and renal benefits:
1) Trials have found SGLT-2 inhibitors reduce the risk of cardiovascular death in patients with type 2 diabetes and established cardiovascular disease, as well as reducing heart failure hospitalizations in those with diabetes and cardiovascular risk factors.
2) Studies also show SGLT-2 inhibitors improve outcomes for patients with heart failure with reduced ejection fraction, reducing rates of heart failure hospitalization and mortality regardless of diabetes status or background heart failure therapies.
3) SGLT-2 inhibitors were also found to reduce the risk of renal death or progression to end-stage kidney disease in patients with type 2 diabetes and macroalbuminuria.
Ramadan fasting is ritual for all muslims worldwide , where there is abstinace from eating , drinking and smoking from dawn to dusk , daily for one month, frequently , hypertensives asking about their fasting and medications during Ramadan, in the lecture , some focus on the effect of Ramadan on blood pressure , heart rate and other cardiovascular risk factors and lastly general instruction for hypertensives during Ramadan .
This study examined the relationship between blood pressure variability, as measured by 24-hour ambulatory blood pressure monitoring, and cardiovascular outcomes in elderly hypertensive patients. The results showed that increased nighttime systolic blood pressure variability was an independent risk factor for stroke. Specifically, the risk of stroke increased by 80% for every 5 mmHg increase in nighttime systolic blood pressure variability among patients in the placebo group. Daytime blood pressure variability did not predict cardiovascular outcomes. Antihypertensive treatment did not affect blood pressure variability over the course of the study.
Current management of hypertension DR. ANKIT JAIN AIIMSAnkit Jain
This document summarizes current management of hypertension. It begins by stating the high worldwide prevalence of hypertension and its attributable risk for death. It then discusses definitions and classifications of hypertension according to guidelines. Target blood pressure goals for optimal management are outlined, along with evaluating for target organ damage. The importance of lifestyle modifications and pharmacological therapy to reduce cardiovascular events is emphasized.
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Cardiovascular safety of anti-diabetic drugs.Cardiovascular Outcome Trials ...magdy elmasry
Cardiologists and diabetes.Target organs and action mechanism of antidiabetic drugs.Cardiovascular Outcome Trials
( CVOTs ) in Diabetes.Completed and ongoing CVOTs in type 2 diabetes.Diabetes Medications
and
Cardiovascular Impact.Recommendations for management of diabetes
Cardiovascular safety of anti-diabetic drugs.
Hypertension is common in diabetics, affecting 20-60% of those with diabetes. It is the leading cause of morbidity and mortality worldwide. While only 25% of hypertensive patients have adequate blood pressure control, tight control of both blood pressure and glucose levels can significantly reduce cardiovascular and mortality risks for diabetics. Hypertension and diabetes frequently occur together due to their shared risk factors and pathophysiology, with each condition increasing the risks associated with the other. Proper management of both is important for preventing diabetes and hypertension-related complications.
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
The JNC 8 guideline provides evidence-based recommendations for treating hypertension. It focuses on three key questions: 1) what BP thresholds should initiate treatment, 2) what treatment goals are appropriate, and 3) which drug classes are most effective and safe. Major recommendations include treating those over 60 to a goal of <150/90 mmHg, initiating treatment in others at 140/90 mmHg, and using thiazide diuretics, ACE inhibitors, ARBs, or CCBs as initial treatment. The guideline aims to simplify prior recommendations and focus on outcomes from randomized controlled trials.
The DCCT trial showed that intensive diabetes management reduced the risk of eye, kidney, and nerve complications compared to standard management. Intensive therapy aimed for blood glucose levels between 70-120 mg/dl, while standard therapy aimed to avoid symptoms of high or low blood glucose. The risks of intensive therapy were increased hypoglycemia and weight gain. The follow up EDIC study found metabolic memory effects, with long term benefits of early intensive control.
The document discusses updated guidelines for diagnosing and treating hypertension that were released in 2017. Some key points:
- The new guidelines lower the threshold for stage 1 hypertension to 130/80 mm Hg from 140/90 mm Hg. This means nearly half of US adults now have hypertension based on these guidelines.
- Lifetime risk of developing hypertension is approximately 90% for adults aged 55-65 based on data from the Framingham Heart Study.
- Self-monitoring and ambulatory blood pressure monitoring provide benefits over office-based measurements alone for managing hypertension.
- Lifestyle modifications such as weight loss, reduced sodium intake, increased potassium and physical activity are recommended as first-line treatment for many with elevated blood pressure
This document discusses diagnostic challenges and treatment dilemmas related to arterial hypertension. It covers topics such as accurate blood pressure measurement methods, diagnosing hypertension using out-of-office assessments like ambulatory blood pressure monitoring and home monitoring, assessing overall cardiovascular risk, evaluating for secondary causes of hypertension like renovascular disease and hyperaldosteronism, and the role of echocardiography in hypertension management.
HypertensioN, The Silent Killer, Hypertension is a common disease that is simply defined as persistent elevated arterial blood pressure (BP).
Hypertension (HTN), also known as high blood pressure (BP), affects millions of people. High blood pressure is defined as BP ≥140/90 millimeters of mercury (mmHg). As per JNC 8
Ambulatory blood pressure monitoring (ABPM) provides important information about a patient's blood pressure over 24 hours. It can identify white coat hypertension, masked hypertension, nocturnal hypertension, and determine if a patient's blood pressure demonstrates the normal dipping pattern. ABPM is useful for diagnosing hypertension more accurately and guiding treatment decisions, as it considers factors like blood pressure load and variability that may be missed by office readings alone.
Hypertension is the most common cardiovascular risk factor worldwide, affecting one third of the global population. The current definition of hypertension as a blood pressure over 140/90 mmHg measured during multiple clinic visits is insufficient because blood pressure is a continuously changing variable that can be influenced by daily activities and stress. An updated definition is needed that incorporates measurements from home blood pressure monitoring and ambulatory blood pressure monitoring to better identify true hypertension versus transient high readings and better predict cardiovascular outcomes based on variability.
This document provides guidelines for diagnosing hypertension through diagnostic evaluations. It discusses establishing blood pressure levels, identifying secondary causes, and evaluating cardiovascular risk through measurements, medical history, physical exam, and investigations. Specific guidelines are provided for office and ambulatory blood pressure monitoring, interpreting results, and assessing for target organ damage through tests like ECG, echocardiogram, carotid ultrasound, and lab work.
The 2017 ACC/AHA guidelines provide an updated classification of blood pressure levels and recommendations for diagnosing and treating hypertension. Key points include:
1) The guidelines lower the thresholds for elevated blood pressure and define prehypertension as 120-139/80-89 mmHg and stage 1 hypertension as 140-159/90-99 mmHg.
2) Both higher systolic and diastolic blood pressure are associated with increased risk of cardiovascular disease.
3) Lifestyle modifications like weight loss, reduced sodium intake, and increased physical activity can significantly reduce blood pressure, especially in patients with hypertension.
4) Target blood pressure levels for treatment depend on patient risk factors and comorbidities, but
The document outlines guidelines for the management of arterial hypertension from the 2018 ESC/ESH conference. It discusses definitions of hypertension, recommendations for blood pressure measurement, classifications of hypertension, screening and diagnosis, assessment of hypertension-mediated organ damage, and initiation of blood pressure-lowering treatment. Key points include defining hypertension as a blood pressure over 140/90 mmHg, outlining options for office and out-of-office blood pressure measurement, stratifying cardiovascular risk, and recommending prompt initiation of treatment for grade 2 or 3 hypertension or grade 1 hypertension with high risk or organ damage.
This document provides information on the definition, classification, causes, evaluation, and treatment of hypertension. It defines hypertension as a systolic blood pressure of 130 mm Hg or more or a diastolic blood pressure of 80 mm Hg or more, with a treatment goal of less than 130/80 mm Hg. Hypertension is a major risk factor for cardiovascular disease and is often caused by a combination of genetic and lifestyle/environmental factors. The document outlines guidelines for accurate blood pressure measurement, evaluation of target organ damage, and nonpharmacologic and pharmacologic treatment approaches.
Approach to young hypertensive patientsChandan Kumar
1. The document discusses hypertension in young adults, including definitions of different types of elevated blood pressure (e.g. hypertensive urgency, emergency), risk factors, clinical presentation, causes (primary vs. secondary), evaluation approach, and ambulatory blood pressure monitoring.
2. Most young adults with hypertension have primary/essential hypertension with no identifiable cause, though secondary hypertension can occur in about 10% of cases. Evaluation aims to confirm the diagnosis, assess cardiovascular risk, detect target organ damage, and identify secondary causes.
3. Ambulatory blood pressure monitoring provides blood pressure readings outside the office and can help identify white coat hypertension or masked hypertension, which have implications for risk stratification and treatment.
This document discusses ambulatory blood pressure monitoring (ABPM). It describes how ABPM is used to diagnose conditions like white coat hypertension and nocturnal hypertension. ABPM provides important information about blood pressure over 24 hours that can help guide treatment, especially in elderly patients and those with treatment-resistant hypertension. The document outlines how to perform ABPM, interpret the results, and use ABPM to monitor patients and adjust antihypertensive treatment.
This document discusses guidelines for the treatment of hypertension in Australia. It notes that there are 147 different antihypertensive medications available but only 3 guidelines for treating hypertension with differing recommendations. It also discusses targets for treating hypertension, lifestyle modifications, and the benefits of a DASH diet in reducing blood pressure. The document recommends starting treatment with a single drug such as an ACE inhibitor or calcium channel blocker before progressing to multiple drugs from different classes if blood pressure targets are not reached.
This document provides information about hypertension (high blood pressure) for nurses caring for patients with the long-term condition. It defines hypertension and normal blood pressure levels. Hypertension has no obvious cause for most people and is a growing problem worldwide. Regular exercise and lifestyle factors can both impact and help control blood pressure. The nurse's role is to understand the condition, its effects on the body, and provide education to patients on self-care strategies to sustain their health.
The document summarizes guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It outlines classifications for blood pressure levels, risk factors, treatment goals, lifestyle modifications, and drug therapy recommendations. The guidelines emphasize individualizing treatment based on a patient's specific cardiovascular risks and medical conditions.
The document summarizes the key recommendations from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It introduces new classifications for blood pressure levels, emphasizes the importance of lifestyle modifications and use of thiazide-type diuretics as initial treatment, and recommends treating to lower blood pressure targets to reduce cardiovascular disease risk. It also provides guidance on proper blood pressure measurement techniques, evaluating patient risk factors, and conducting follow-up assessments.
This document summarizes the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It outlines recommendations for classifying and treating hypertension based on blood pressure levels. Key points include classifying blood pressure into normal, prehypertension, and stages 1 and 2 of hypertension, and recommending lifestyle modifications and drug treatments to lower blood pressure to reduce cardiovascular risks. Compelling indications for certain drug classes are noted for conditions like heart disease, diabetes, and chronic kidney disease.
Hypertension is a major public health problem that significantly increases the risk of heart disease, stroke, and kidney disease. While medications can effectively treat hypertension, lifestyle modifications like following the DASH diet, reducing sodium intake, regular exercise, weight management, and limiting alcohol and tobacco use are important first steps to help prevent and control high blood pressure. The guidelines recommend treating hypertension with medications if lifestyle changes do not lower blood pressure enough, with a goal of reducing blood pressure to under 140/90 mmHg to minimize complications.
This document discusses vital signs and provides detailed information about assessing and interpreting blood pressure. It defines blood pressure and its components, describes the equipment used for measurement including sphygmomanometers and stethoscopes, identifies assessment sites on the body, explains Korotkoff sounds heard during measurement, outlines the procedure for taking a reading, and reviews factors that can affect blood pressure values. Abnormal readings and variations like auscultatory gaps are also addressed.
Similar to Optimal Blood Pressure Management Implication of the SPRINT Trial & Blood Pressure Variability (20)
Treating Cholesterol in Asian Patients: Balancing the Risk and Benefitsahvc0858
This document summarizes a presentation on treating cholesterol in Asians given by Dr. Jeremy Chow. It discusses the prevalence of hyperlipidemia in Singapore, challenges with statin usage in Asians including common myths, and new cholesterol targets for high-risk patients. It provides examples of managing different patient cases, including lifestyle modifications, medications such as statins and PCSK9 inhibitors, and balancing risks and benefits of treatment.
Women and Heart Disease-Are You at Risk - By Dr Goh Ping Pingahvc0858
Did you know that heart disease is the leading cause of death globally? On 11 November 2023, Asian Heart & Vascular Centre held Heart to Heart Talk 2023, organized by MediaCorp, official media partner, CNA, at Suntec Convention Centre. We hope to bring awareness and get everyone to recognize the symptoms of common heart and related diseases, and understand the treatments available. Here's the presentation shared by Dr Goh Ping Ping.
Dr Goh Ping Ping is an echocardiologist trained in imaging of the heart.
She is a strong advocate of preventive cardiology and awareness for women's heart health. She manages a broad spectrum of cardiovascular disease including heart attack patients.
For more info, visit www.ahvc.com.sg
Silent Hole, Lethal Flaw - By Dr Cliff Wong Chun Pongahvc0858
Did you know that heart disease is the leading cause of death globally? On 11 November 2023, Asian Heart & Vascular Centre held Heart to Heart Talk 2023, organized by MediaCorp, official media partner, CNA, at Suntec Convention Centre. We hope to bring awareness and get everyone to recognize the symptoms of common heart and related diseases, and understand the treatments available. Here's the presentation shared by Dr Cliff Wong Chun Pong.
Dr Cliff Wong is an echocardiologist trained in imaging of the heart.
He specializes in cardiac imaging (echocardiography and cardiovascular computed tomography). Experienced in managing cardiomyopathy, heart failure, valvular heart diseases and cardio-oncology.
For more info, visit www.ahvc.com.sg
Pulmonary Embolism No. 1 Cause of Preventable Hospital Death Worldwide_What i...ahvc0858
Did you know that heart disease is the leading cause of death globally? On 11 November 2023, Asian Heart & Vascular Centre held Heart to Heart Talk 2023, organized by MediaCorp, official media partner, CNA, at Suntec Convention Centre. We hope to bring awareness and get everyone to recognize the symptoms of common heart and related diseases, and understand the treatments available. Here's the presentation shared by Dr Pipin Kojodjojo.
Dr Pipin Kojodjojo specializes in cardiac electrophysiology and the management of heart rhythm disorders in both adolescents and adults.
He is experienced in managing patients with atrial fibrillation and unexplained blackouts (syncope).
For more info, visit www.ahvc.com.sg
Heart Stent Procedure Demystify - By Dr Tan Chong Hiokahvc0858
Did you know that heart disease is the leading cause of death globally? On 11 November 2023, Asian Heart & Vascular Centre held Heart to Heart Talk 2023, organized by MediaCorp, official media partner, CNA, at Suntec Convention Centre. We hope to bring awareness and get everyone to recognize the symptoms of common heart and related diseases, and understand the treatments available. Here's the presentation shared by Dr Tan Chong Hiok.
Dr Tan is an interventional cardiolgist trained and specialises in stenting of the left main artery and chronic total occlusion.
He is experienced in managing complex cases in patients who have declined or are unsuitable for bypass surgery.
For more info, visit www.ahvc.com.sg
Key changes in the field of cardiac arrhythmias in the past 2 years - Dr Pipi...ahvc0858
Dr Pipin Kojodjojo share more on the topic, key changes in the field of cardiac arrhythmias in the past 2 years.
Visit our website www.ahvc.com.sg for more info.
Heart Disease In Pregnancy During The Pandemicahvc0858
Heart disease in pregnancy during the pandemic
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Exercising During the Pandemic
Presentation by Dr Goh Ping Ping
Cardiologist, Echocardiologist
Clinical Exercise Specialist
Asian Heart & Vascular Centre
www.ahvc.com.sg
COVID 19 and The Heart - Lessons Learnt from this Pandemicahvc0858
COVID 19 and The Heart - Lessons Learnt from this Pandemic
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Cardiac Stress Test vs CT Coronary Angiogram: Which is better?ahvc0858
Cardiac stress tests and CT coronary angiography are effective options for evaluating heart disease, with certain advantages and limitations for each. A cardiac stress test such as a treadmill exercise stress test or stress echocardiogram can detect ischemia by provoking the heart during exercise or pharmacologically, but may have lower sensitivity and specificity than imaging tests. A CT coronary angiogram provides detailed images of the coronary arteries but exposes patients to radiation. The optimal test depends on the individual patient's characteristics, risk factors, and the specific question being answered.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Demystifying Fallopian Tube Blockage- Grading the Differences and Implication...
Optimal Blood Pressure Management Implication of the SPRINT Trial & Blood Pressure Variability
1. Scientific Session 1:
Optimal Blood Pressure
Management
Implication of the SPRINT trial
and BP Variability
Consultant Cardiologist
Asian Heart & Vascular Centre
drgoh.pingping@asianheart.com.sg
Jointly organized by
Dr Goh Ping Ping• 5 in 10 hypertensive patients are not optimally
controlled in Singapore.1,2
• The adverse cardiovascular consequences of
hypertension may depend on increased BP
variability (BPV).3
References:
1. Nieh CC, Ho LM, J Sule, et al. Cross-sectional Study of Hypertension in a Neighborhood in Singapore. Insights Blood Press 2015, 1:1.
2. 2. Seow LSE, Subramaniam M, Abdin E, Vaingankar JA and Chong SA. Hypertension and its associated risks among Singapore elderly
residential population. Journal of Clinical Gerontology and Geriatrics 2015;6(4): 125-132
3. Parati G, Ochoa JE, Lombardi C, Bilo G. Assessment and management of blood-pressure variability. Nat Rev Cardiol. 2013;10:143-55.
2. Optimal Blood Pressure Management
Implication of the SPRINT Trial & Blood
Pressure Variability
3. Hypertension
3
Leading risk factor for death and disability-adjusted life-years lost1
Systolic hypertension is the commonest form of hypertension in individuals
aged 50 years and older2
Systematic review and large meta-analyses of placebo-controlled randomized
clinical trials have shown that treating hypertension reduces risk of:
Stroke by 35 to 40%
Myocardial infarction by 15 to 25%
Heart failure (by up to 64%)35
1. Lim SS et al. Lancet 2012;380:2224-60; 2. Franklin SS et al. Hypertension 2001;37:869-4
3. Chobanian AV et al. JAMA 2003;289:2560-72; 4. Neal B et al. Lancet 2000;356:1955-64;
5. Psaty BM et al. JAMA 1997;277:739-45
4. CONFIDENTIAL & PROPRIETARY—INTERNAL USE ONLY.
STRATEGIES CONTAINED HEREIN ARE NOT NECESSARILY ENDORSED BY PFIZER SENIOR
MANAGEMENT AND ARE SUBJECT TO FURTHER REVIEW BEFORE IMPLEMENTATION.
Framingham Study: 6-year incidence of CHD by SBP and TC levels
Kannel WB et al. Ann Intern Med 1961;55:33-50
4
5. Mdm Wong
52-year-old, executive
Mother has hypertension in old age
Trying to eat less fatty food
Walks 30-40 minutes daily
Comes to see you at the clinic for
upper respiratory tract infection
Clinic BP:
156/93, repeated
Comorbidities
High normal lipids
Not on meds
Had high BP during
pregnancy
6. 6
How to take a proper office BP
(Canadian CHEP Guideline 2016)
Automated office BP equal to or better than manual BP
Upper arm cuff with appropriate bladder size
Lower cuff edge 3 cm above elbow crease, bladder
centred over brachial artery
Arm supported at level of the heart
Quiet room (no rest period specified)
No talking, no crossing of legs
Take readings at 1 min and 2 min intervals
7. better reflects true BP condition than office BP by separating
from medical environment
Use for risk stratification:
Patients with high office BP but normal out-of-office BP
(white-coat hypertension) have lower CV risk than
patients with sustained hypertension
Patients with normal office BP but elevated out-of-office
BP (masked hypertension) is frequently associated with
CV risk factors and has increased risk of CV events
Close association with hypertension induced organ damage,
especially left ventricular hypertrophy
Better prediction of CV morbidity and mortality than office BP
2013 European hypertension guidelines:
ESH/ESC emphasize out-of-office BP measurement
Mancia et al. J Hypertens 2013;31:1281-1357
7
8. Mortality with isolated and/or combined elevated
office, home, and ambulatory BP – PAMELA study
Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA)
Mancia et al. Hypertension 2006;47:846-853
8
Analysis of office, home, and
ambulatory blood pressure in a
population from Monza, Italy
(n=2051) with outcomes of CV and
non-CV death
69 CV and 233 all-cause deaths over
148 months
Increased home and 24-h BP had a
greater risk of CV and all-cause
death than increased office BP
Incidence of CV and all-cause death and elevated BP over an average follow-up of 148 months.
9. Definitions of hypertension
by office and out-of-office blood pressure
Category Systolic
(mmHg)
Diastolic
(mmHg)
Office BP ≥140 and/or ≥90
Ambulatory BP
Daytime (or awake) ≥135 and/or ≥85
Nighttime (or asleep) ≥120 and/or ≥70
24-h ≥130 and/or ≥80
Home BP ≥135 and/or ≥85
9
Mancia et al. J Hypertension 2013;31:1281-1357
10. “white-coat” effect and masked hypertension
National Institute for Health and Clinical Excellence (NICE). Hypertension Clinical Guideline 127:
http://www.nice.org.uk/guidance/cg127
White-coat effect: A discrepancy of more than 20/10 mmHg
between clinic and average daytime ambulatory BP monitoring
(ABPM) or average home BP monitoring (HBPM)
Masked hypertension: The converse of white-coat hypertension.
Normal BP measurements in the office or clinic but episodes of
elevated BP outside of the medical environment
For people identified as having a ‘white-coat effect’ or ‘masked
hypertension’ consider daytime ABPM or HBPM as an adjunct to
clinic BP measurements to monitor response to treatment
10
11. 11
• Usual duration is 24 hours
• Ensure at least two measurements
per hour during the person’s usual
waking hours (for example, between
08:00 and 22:00).
• Use the average value of at least 14
measurements taken during the
person’s usual waking hours to
confirm a diagnosis of hypertension
• Recording is satisfactory if 70% of
values are available
• Diary on events likely to influence
BP
How to Read a 24-hour Ambulatory BP Report
12. 12Confidential & Proprietary – For Internal Use Only – Do Not Disseminate Without Approval
Reference Values for Dipper Status
<= 0% Reverse Dipper
0 to 10% Non-Dipper
10 to 15% Normal Dipper
> 15% Extreme Dipper
Calculation
%Dip = (Average day SBP – Average night SBP) x 100%
Average Day SBP
13. Kaplan-Meier curves reporting the cumulative incidence of cardiovascular events in the 4 categories of dipping pattern. Adjusted risk
of cardiovascular events was increased in reverse dippers (P=0.031) and non dippers (P=0.003) when compared with dippers, whereas
extreme dippers did not differ from dippers (P=0.73). Total mortality did not differ significantly across the dipping categories.
Verdecchia P et al. Hypertension. 2012;60:34-42
BP dipping status predicts cardiovascular events
13
14. How to Monitor Home Blood Pressure
Mancia et al. Hypertension 2006;47:846-853
14
o Two consecutive blood pressure measurements
o at least 1 minute apart
o Patient seated, without crossing legs, quiet environment
o Measure twice daily, ideally in the morning and evening
o at least 4 days, ideally for 7 days
o Discard the measurements taken on the first day and use the average
value of all the remaining measurements
o Store in log book or memory equipped device
o Possible advantage of telemonitoring
15. Item Suggestions Description
Morning
measurement
time
• Sitting BP during 1 hour after
awakening
• After urination
• Before breakfast
• Before taking medicines
• After 1‒2 minutes rest
• Morning interval is defined as the period from awakening
to around 10AM. Despite it is recommended to measure
during 1 hour, the time is not required to be controlled
strictly. Patient compliance is most important
• Keep the consistency of BP measurement: BP increases
before urination and decreases after urination
• Patient compliance: It is easier to measure during 1‒2
minutes after rest rather than 5 minutes. It can improve the
compliance of self-monitoring
• Reduce the variability of BP measurement: Diet
significantly affects BP which increases during eating and
decreases after eating
• BP measurement before taking medicines is helpful to
assess the effect of ‘surge’ on BP. It is also allowed to
measure in 5‒10 minutes after taking medicines
Measurement
frequency
• Measure 1‒3 times every time
• Weekly frequency
- Stable period: At least 3 times per
week
- Drug adjustment period: Perform
home BP monitoring at least 5
times per week
• Keep self-monitoring of BP as long as
possible
• The suggestions derived from Ohasama study. If
subtracting the results of first 3 days from 8-day single BP
measurement at home, the mean results of last 5 days are
highly reproducible
• Mandatory diary can reduce the compliance
15
Hypertension Res 2003;26:771-782
16. Summary
Office BP is recommended for screening and diagnosis of hypertension
Diagnosis of hypertension should be based on at least two BP
measurements per visit and on at least two visits to the office
Out-of-office BP should be considered to confirm the diagnosis of
hypertension, identify the type of hypertension, detect hypertensive
episodes, and maximize prediction of CV risk (e.g. BP variability)
For out-of-office BP measurements, ABPM, or HBPM may be considered
depending on indication, availability, ease, cost of use and, if
appropriate, patient preference
16
17. New evidence for controlling BPV
as part of hypertension management
Blood pressure variability (BPV) and its
management
18. What is BPV?
Normal BP fluctuations occur in response to environmental challenges (eg,
stress or activities)1
Blood pressure variability (BPV) can be observed:
– Over a 24-hour period with ambulatory BP monitoring (ABPM)
showing hour-to-hour variability
– Between clinic visits (visit-to-visit variability) in short and long term
Reducing BP fluctuation in addition to mean BP has recently been
recognized as a potential target for improved management of hypertension
to prevent vascular outcomes, particularly stroke2,3
1. Schillaci et al. Hypertension 2011;58:133-135
2. Rothwell. Lancet 2010;375:938-948.
3. Muntner et al. Hypertension 2011;57:160-166
18
19. BPV differs in extent between individuals
Rothwell PM. Lancet 2010;375:938-948
Patient 1 with lower BPV Patient 2 with higher BPV
Weeks
40
60
80
100
120
140
160
180
200
220
Bloodpressure
(mmHg)
1 2 3
SBP
DBP
40
60
80
100
120
140
160
180
200
220
Bloodpressure
(mmHg)
1 2 3
Weeks
Higher
mean BP
overall
19
20. BPV : how to measure
ABPM can identify patients with morning surge and predicts CV events
better than office BP levels1
HBPM is a good alternative to 24-hour ABPM and variability has been
correlated with target organ damage, CV outcomes, and stroke mortality1,2
The standard deviation (SD) and coefficient of variation (CV) of BP
measurements are commonly used parameters3
Variation independent of the mean (VIM) is a transformation of SD
uncorrelated with mean BP (statistical tool)3
1. Grossman. Diabetes Care 2013;36 Suppl 2:S307-311
2. Parati et al. Blood Press 2013;22:345-354
3. Dolan and O'Brien. Hypertension 2010;56:179-181
BPV indices Formula/derivation
SD SD = √[∑(individual readings – sample mean)2/n]
CV CV = SD/mean
VIM SD/meanx
20
21. MBP surge: what is significant?
MBP surge is defined as the morning BP (average of 2 hours after rising) minus the nighttime
lowest BP (average of 3 BPs)
sleep-trough surge of >55 mmHg is significant
Kario et al. J Cardiovasc Pharmacol 2003;42:S87-S91
*P=0.001
21
22. The rapid rise of BP in the morning is one
of the critical risk variables for CV events
BP profile of untreated
hypertension patients
Mead et al. Br J Cardiol 2008;15:31-34
Incidences of MI and
stroke at different time
intervals
22
Numberofpatientswithevents(MI)n=339
23. Stroke risk and BPV are lower in patients treated with CCBs vs
other antihypertensives despite similar mean BP
Rothwell. Lancet 2010;375:938-948
Randomized trials
with CCBs vs BBs,
ACEIs, or ARBs
comparing
stroke risk and
systolic BPV (SD) Mean SBP
difference (95% CI)
A Stroke risk
Events/patients
CCB Drug B
NORDIL (vs BB/D) 159/5410 196/5471
ASCOT (vs BB) 327/9639 422/9618
ALLHAT (vs ACE) 377/9048 457/9054
Total 1326/43,623 1606/43,774
VALUE (vs ARB) 281/7596 322/7649
INVEST (vs BB) 176/11,267 201/11,309
CAMELOT (vs ACE) 6/663 8/673
0.5 1.5
0.81 (0.66 to 0.01)
0.77 (0.66 to 0.89)
0.82 (0.71 to 0.94)
0.87 (0.74 to 1.03)
0.88 (0.72 to 1.08)
0.76 (0.26 to 2.20)
0.82 (0.76 to 0.88)
Odds ratio (95% CI)
0.5 1.5
B SBP at follow-up
Mean (SD)
Variance ratio (95% CI)
CCB Drug B
NORDIL (vs BB/D) 155.2 (16.3) 151.5 (17.4) 3.70 (3.07 to 4.33)
ASCOT (vs BB) 138.4 (14.8) 140.3 (17.8) -1.90 (-2.36 to -1.44)
Total -0.21 (-0.41 to -0.01)
VALUE (vs ARB) 138.2 (13.8) 140.0 (16.2) -1.80 (-4.92 to 1.32)
INVEST (vs BB) 131.0 (11.0) 131.0 (10.0) 0.00 (-0.27 to 0.27)
CAMELOT (vs ACE) 124.5 (15.5) 123.6 (18.0) 0.60 (–1.20 to 2.40)
ALLHAT (vs ACE) 137.1 (15.0) 138.4 (17.9) -1.30 (-1.78 to -0.82)
0.88 (0.83 to 0.93)
0.69 (0.67 to 0.72)
0.70 (0.67 to 0.73)
0.73 (0.68 to 0.77)
0.83 (0.80 to 0.86)
0.74 (0.64 to 0.86)
0.76 (0.74 to 0.77)
23
24. NICE 2011 guidelines on the
management of BPV
National Institute for Health and Clinical Excellence (NICE). Hypertension Clinical Guideline 127:
http://www.nice.org.uk/guidance/cg127
BPV was most effectively reduced by CCB, closely
followed by thiazide-type diuretics
Those most at risk of increased SBP SD, ie, older
hypertensive people, will already be treated with the
most effective drug classes to suppress SBP SD, ie, a
CCB
(or a thiazide-like diuretic if a CCB is not indicated or
tolerated) as Step 1 therapy
CCBs are one of the antihypertensive
classes of choice for BPV control
24
25. Amlodipine has long half-life
for the control of BPV
1. Kes et al. Curr Med Res Opin 2003;19:226-237
2. Flack et al. Eur Heart J 1996;17(Suppl. A):16-20
Amlodipine is a long-acting CCB that blocks the calcium L-type
channel1
o Slow association and dissociation ensure gradual onset and extended
duration of pharmacodynamic activity
o Long half-life (35‒50 hours), high oral bioavailability, and low renal
clearance (7 mL/min/mg)
It maintains a smooth and sustained dilatation of the systemic
arteriolar resistance vessels1
Amlodipine is a forgiving agent and maintains antihypertensive
effectiveness following missed doses2
25
26. Bedtime administration of amlodipine +
olmesartan improves BPV and morning BP surge
Hoshino A, et al. Clin Exp Hypertens.2010;32:416-422.
MBP surge24-hour SBP and DBP
Hoshino et al. Clin Exp Hypertens 2010;32:416-22.
26
27. BPV in Hypertension Management
Reducing BPV has been recognized as a potential target for improved
management of hypertension to prevent vascular outcomes,
particularly stroke
The differential effects of CCBs compared with other agents like ACEI
and BBs on BPV may account for the disparity in observed efficacy in
reducing the risk of stroke
The most effective approach to preventing cardiovascular event is to
use BP-lowering drugs that reduce both BPV and MBP in addition to
mean BP, and to avoid situations that increase BPV
27
28. CONFIDENTIAL & PROPRIETARY—INTERNAL USE ONLY.
STRATEGIES CONTAINED HEREIN ARE NOT NECESSARILY ENDORSED BY PFIZER SENIOR
MANAGEMENT AND ARE SUBJECT TO FURTHER REVIEW BEFORE IMPLEMENTATION.
SPRINT
(Systolic Blood Pressure Intervention Trial)
Aim:
To assess the most appropriate systolic blood pressure targets to reduce
morbidity and mortality by comparing the benefit of treatment of SBP to a
target of <120 mmHg versus a target of <140 mmHg
Primary hypothesis:
The CVD composite event rate would be lower in the intensive therapy group
compared with the standard therapy group
29. Guidelines for Target Blood Pressure
29
Eighth Joint National Committee (JNC8, 2014)1,3:
<60 years or diabetes/CKD and ≥60 years: 140/90 mmHg
Patients ≥60 years: 150/90 mmHg
American Society of Hypertension/International Society of Hypertension
(2014)2,3:
<80 years: 140/90 mmHg
≥80 years: 150/90 mmHg
1. James PA et al. JAMA. 2014;311:507-20
2. Weber MA et al. J Hypertension. 2014;32:3-15
30. ACCORD: No difference in CV Eventsa in Patients with diabetes with
BP <120 and <140 mmHg
Cushman WC et al. New Engl J Med 2010;362:1575-85
30
n = 4733, type II DM
Intensive arm – target SBP < 120
Standard arm – target SBP < 140
Follow-up = 4.7 years
End-point: fatal MI, non-fatal stroke
or CVD
Mean baseline SBP (all participants)
=139.2±15.8 mmHg
31. SPRINT: Study Design
31
Intensive treatment
Target SBP <120 mmHg
Standard treatment
Target SBP <140 mmHg
• Age ≥50 years
• SBP 130180 mmHg (treated or untreated)
• Additional CV risk (≥1)
Clinical or subclinical CVD (excluding stroke)
CKD (eGFR 20<60 ml/min/1.73 m2)
Framingham Risk Score for 10-year risk ≥15
Age ≥75 years
Wright JT et al. New Engl J Med 2015;373:2103-16
All major antihypertensive classes can be used
Chlorthalidone encouraged as primary thiazide
Amlodipine encouraged as preferred CCB
32. SPRINT:
Enrolment and Follow-up
Ambrosius WT. Clin Trials. 2014;11:532–46
Wright JT et al. New Engl J Med 2015;373:2103-16
32
Intensive
treatment
N=4,678
Standard
treatment
N=4,683
Screened
N=14,692
Randomized
N=9,361
224
111
154
242
134
121
Consent withdrawn
Discontinued intervention
Lost to follow-up
Analyzed (ITT)
4,678 4,683
33. SPRINT: Patient Population
Wright JT et al. New Engl J Med 2015;373:2103-16
*All included in analysis (ITT)
† Increased cardiovascular risk was one of the inclusion criteria
‡ Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 ml per minute per 1.73 m2 of body-surface area.
33
Intensive Treatment
(N = 4678)*
Standard Treatment
(N = 4683)*
Criterion for increased cardiovascular risk — no. (%)†
Age ≥75 yr
Chronic kidney disease‡
Cardiovascular disease
Clinical
Subclinical
Framingham 10-yr cardiovascular disease risk score ≥15%
1317 (28.2)
1330 (28.4)
940 (20.1)
779 (16.7)
247 (5.3)
2870 (61.4)
1319 (28.2)
1316 (28.1)
937 (20.0)
783 (16.7)
246 (5.3)
2867 (61.2)
Female sex — no. (%) 1684 (36.0) 1648 (35.2)
Age — yr
Overall
≥75 yr
67.9 ± 9.4
79.8 ± 3.9
67.9 ± 9.5
79.9 ± 4.1
34. 34
SPRINT: Primary Outcome
Years
Cumulativehazard
243/4678 = 5.2%
319/4683 = 6.8%
ARR 1.6%
NNT = 61
SPRINT was terminated early (after mean follow-up of 3.26 years) on the
recommendation of the DSMB because of a clear benefit of intensive therapy
Wright JT et al. New Engl J Med 2015;373:2103-16
35. CONFIDENTIAL & PROPRIETARY—INTERNAL USE ONLY.
STRATEGIES CONTAINED HEREIN ARE NOT NECESSARILY ENDORSED BY PFIZER SENIOR
MANAGEMENT AND ARE SUBJECT TO FURTHER REVIEW BEFORE IMPLEMENTATION.35
SPRINT: All-cause Mortality
Years
Cumulativehazard
155/4678 = 3.3%
210/4683 = 4.5%
ARR 1.2%
NNT = 90
Wright JT et al. New Engl J Med 2015;373:2103-16
36. CONFIDENTIAL & PROPRIETARY—INTERNAL USE ONLY.
STRATEGIES CONTAINED HEREIN ARE NOT NECESSARILY ENDORSED BY PFIZER SENIOR
MANAGEMENT AND ARE SUBJECT TO FURTHER REVIEW BEFORE IMPLEMENTATION.
Secondary outcomes
Significant reductions with intensive versus standard regimen in:
– Heart failure (HR [95% CI] 0.62 [0.45-0.84], p=0.002)
– Death from CV causes (HR [95% CI] 0.57 [0.38-0.85], p=0.005)
– Primary outcome or death (HR [95% CI] 0.78 [0.67-0.90], p<0.001)
Primary outcome in subgroups of interest
The benefit of intensive therapy was consistent across pre-specified subgroups:
– Age (<75 vs. ≥75 y)
– Previous CVD (yes vs. no)
– SBP (≤132 mmHg vs. >132 but <145 mmHg vs. >145 mmHg)
– Previous CKD (yes vs. no)
Wright JT et al. New Engl J Med 2015;373:2103-16
36
SPRINT: Secondary Outcomes and Subgroups of Interest
37. 37
SPRINT: Summary
Intensive treatment to SBP goal <120 mmHg, compared with a standard goal of <140
mmHg resulted in significantly lower rates of fatal and nonfatal CV events and all cause
mortality (trial prematurely stopped at 3.26 yrs)
30% reduction of composite endpoint including CV death, 25% reduction in mortality
Effect of intensive treatment was consistent across all pre-specified subgroups (age,
gender, race, presence of CVD, SBP tertiles and renal function).
One-third of patients are > 75 years old
• SAEs (hypotension, syncope, electrolyte abnormalities and acute kidney injury/renal
failure) were higher in intensive arm (38.3%) vs standard arm (31.2%); (p=0.14). Notably,
there were no between-group differences in injurious falls or bradycardia
Overall, the authors concluded that the benefit of intensive BP lowering exceeded
potential harm
38. • Office BP and out-of-office BP (ambulatory/home BP) have
complementary roles in management of hypertension
• Reduce both mean BP and BP variability to improve cardiovascular
outcome
• New data suggest that intensive BP lowering is beneficial
38
Summary