Transcript Journal Club

Journal Club
ADAM WILCOX, PHARMD
1/22/14
Patient Case
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DB, 70 yo M
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Overall ABPM summary
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First 3 blood pressures (in office)
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161/86
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Avg. BP = 116/62
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158/82
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Daytime = 120/63
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155/87
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Nighttime = 103/58
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Systolic load: 9.2%
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Night dip: 14.2%
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9/21 (43%) of nighttime readings
have SBP <100
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Medications
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Lisinopril
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Beta-blocker
Ambulatory BP Monitoring
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
Monitor blood pressure over a 24 hour period
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Every 20 minutes while awake
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Every 30 minutes while sleeping
Indications
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Variable office blood pressure readings
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Differences between in home and office readings (white coat)
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Hypertension resistant to multiple medications
What is normal?
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150/90 or 140/90?
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24 hour: <130/80
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Daytime: <135/85
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Nighttime: <120/70
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SBP load: >30% increases cardiovascular risk
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Nighttime dip: 10-20% is normal
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Non-dippers: LVH, CHF, microalbuminuria, GFR reduction
Question
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Does nocturnal blood pressure drop have an effect on
cardiovascular mortality?
PICO
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P: DB, 70yo male
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I: Extreme dippers(BP decline ≥ 20% of daytime BP)
Non-dippers(BP decline ≥ 0% but < 10% of daytime BP)
Inverted dippers(no nighttime BP decline)
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C: Dippers(BP decline ≥ 10% but < 20% of daytime BP)
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O: Cardiovascular mortality
Journal Article
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Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in
Blood Pressure and Mortality. American Journal of Hypertension
1997(10)1201-1207.
Study Basics
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Objective:
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
Type:
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
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Prospective trial involving 1542 residents of a rural Japanese community
Exclusion:


To investigate the relationship between nocturnal decline in blood
pressure and mortality
<40 years old, hospitalized individuals, demented patients, people who
worked out of town
Study population:
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565 men(62.5 years) and 977 women(61.2 years)
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Primarily farmers, retirees, housewives
Outcomes:
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Overall mortality, cardiovascular, non-cardiovascular
Methods
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Needed at least 8 hours of daytime readings and 4 hours of
nighttime readings to be included in the analysis
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Average duration of monitoring was 22.3 hours

Average # of measurements 44.6
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Average 24 hr, daytime, nighttime, and nocturnal decline were
calculated for each person
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%decline nocBP = (daytime BP – nighttime BP) x 100/daytime BP
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Classified into groups(extreme, dippers, non-dippers, inverted)
Analysis/Results
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Kaplan-Meier life table, SAS LIFETEST procedure, Cox proportional
hazards regression model
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Mean follow up time 5.1 years(0.1-8.1)

Data adjusted for age, sex, smoking status, history of CVD, BP levels,
and use of hypertensive medications
Analysis/Results

Sharp declines in the inverted
dipper group
Limitations
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Prospective study
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All participants came from a small Japanese community
What does this mean to practice?
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For DB…
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Avg. BP = 116/62

Daytime = 120/63

Nighttime = 103/58
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Systolic load: 9.2%

Night dip: 14.2%

For extreme dippers…


Prevent the early morning blood
pressure surge (stroke, MI)

Switch to short-acting

Timing of medications
For non-dippers/inverted…


In office avg. = 158/85
Move one of your medications to
bedtime
Are you tired of being on call?

A perfect bracket wins $1 billion
References
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1. Ernst M. Ambulatory Blood Pressure Monitoring: Recent Evidence
and Clinical Pharmacy Applications. Pharmacotherapy
2013;33(1)69-83.

2. Ernst M. Nighttime Blood Pressure Is the Blood Pressure.
Pharmacotherapy 2009;29(1)3-6.

3. Kaplan N. Ambulatory Blood Pressure Monitoring and White Coat
Hypertension in Adults. UptoDate Nov. 2013.

4. Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline
in Blood Pressure and Mortality. American Journal of Hypertension
1997(10)1201-1207.