Transcript Measurement of Blood Pressure

Blood Pressure
Measurement
How can anything so simple
be so complex?
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Diseases Attributable to
Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy
Hypertension
Chronic kidney failure
Aortic aneurysm
Retinopathy
Peripheral vascular disease
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Adapted from: Arch Intern Med 1996; 156:1926-1935.
Hypertensive
encephalopathy
All
Vascular
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Awareness, Treatment and Control of
High Blood Pressure in Canada
16%
42%
23%
19%
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.
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High blood pressure vs Hypertension
Office Diagnosis of Hypertension: Summary
Visit 1
160
100
90
History-taking,
physical examination
Visit 2
Visit 3
140
- Hypertensive
urgency?
- Target organ
damage or
BP >160/100?
(Visit 3)
Hypertension
diagnosis
confirmed
Visit 4
Visit 5
Blood pressure
measurement
every year
BP over threshold
for initiation of
treatment
No
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Canadian Hypertension Education Program Recommendations
Yes
Validated technique and
BP measurement device
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RECOMMENDED BLOOD PRESSURE
MEASUREMENT TECHNIQUE
2.2.
••The
Thecuff
cuffmust
mustbe
belevel
levelwith
withheart.
heart.
••IfIfarm
circumference
exceeds
arm circumference exceeds 33
33cm,
cm,
aalarge
largecuff
cuff must
mustbe
beused.
used.
••Place
Placestethoscope
stethoscopediaphragm
diaphragmover
over
brachial
artery.
brachial artery.
1.1.
••The
Thepatient
patientshould
should
be
relaxed
be relaxedand
andthe
the
arm
must
be
arm must be
supported.
supported.
••Ensure
Ensureno
notight
tight
clothing
constricts
clothing constricts
the
thearm.
arm.
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3.3.
Stethoscope
Mercury
machine
••The
Thecolumn
columnofof
mercury
mercurymust
mustbe
be
vertical.
vertical.
••Inflate
Inflatetotoocclude
occludethe
the
pulse.
Deflate
at
2
pulse. Deflate at 2toto
33mm/s.
mm/s.Measure
Measure
systolic
(first
systolic (firstsound)
sound)
and
anddiastolic
diastolic
(disappearance)
(disappearance)toto
nearest
nearest 22mm
mmHg.
Hg.
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20 Threshold for Initiation of Treatment and
Target Values
Condition
Initiation
Target
SBP / DBP mmHg
SBP / DBP mmHg
 140/90
<140/90
Isolated systolic hypertension
SBP >160
<140
Home BP measurement
(no diabetes, renal disease or
proteinuria)
( 135/85)
<135/85
 130/80
<130/80
Renal disease
( 130/80)
<130/80
Proteinuria >1 g/day
( 125/75)
<125/75
Diastolic
± systolic hypertension
Diabetes
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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
Automated
BpTRU™ BP Devices
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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
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– 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
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180 –
174±3
170 –
Study Results
166±4
158±4
Blood Pressure (mmHg)
160 –
155±5
150 –
146±3
140 –
130 –
120 –
110 –
100 –
90 –
92±2
89±3
80 –
0–
Specialist
90±2
Research
Family
Physician Technician
Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B
88±2
BpTRU
82±2
Ambulatory
BP
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
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20 Home (Self) Measurement of BP:
Specific Role in Selected Patients
Which patients?
Non adherence
Hypertension and
diabetes
Office-induced blood
pressure elevation
Normal
Home BP?
Further assess
using
ambulatory
blood pressure
monitoring
BP over 135/85 mm Hg should be considered elevated
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3
0
20 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
should be
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.
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Validated BP Devices
• BHS
– BHS = British
Hypertension Society
• AAMI
– AAMI = American
Association of Medical
Instruments
• See British Hypertension
Society Website
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• OMRON
–
–
–
–
HEM-705CP
HEM-711AC
HEM-722C
HEM-773
• LifeSource AND
–
–
–
–
UA-767 CN
UA-767 Plus
UA-779
UA-787
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OMRON
• Claims all devices
with exception of
wrist devices are
validated
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OMROM HEM 711 AC
$109.99
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LifeSourceUA-767PC
• For use with a PC and
Monitor Pro software.
• Stores and analyzes
recorded blood pressure
data directly from the UA767PC.
• The software provides
printable summary reports
and graphing capabilities.
• Remotely monitor patients
and their blood pressure
from their homes.
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Validated according to BHS* protocol and
AAMI** approved.
*BHS = British Hypertension Society
**AAMI = American Association of Medical
Instruments
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Life Source UA779CN $99.99
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No charge……? Validity
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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
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20 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
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3
0
20 Ambulatory BP Monitoring
Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
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
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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.
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24-Hour Blood Pressure Profile:
Two Patients with Hypertension
Blood pressure (mm Hg)
Sleep
175
Non-dipper
155
135
Dipper
115
95
75
55
7:00
11:00
15:00
19:00
Time of day
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23:00
3:00
7:00
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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.
24-Hour Blood Pressure Profile:
The Morning Blood Pressure ‘Surge’
Blood pressure (mm Hg)
180
Sleep
Time of awakening
160
140
120
100
80
18:00
22:00
02:00
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Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.
06:00
Time of day
10:00
14:00
18:00
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Circadian Incidence of Cardiovascular
Events: Myocardial Ischemia
n=24
Ischemia (min)
300
250
200
150
100
50
0
01:00
09:00
13:00
Time of day
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Adapted from: Rocco, et al. 1987.
05:00
17:00
21:00
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0 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
Follow-up at 3-6
month intervals
No
Symptoms, Severe
hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes
More frequent
visits
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No
Monthly visits
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