24-uur ambulante bloeddrukmeting versus thuisbloedrukmeting

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1 2017 Dementia 24-uur ambulante bloeddrukmeting versus thuisbloedrukmeting Wat gebruiken in de klinische praktijk? Jan A. Staessen, MD, PhD KU Leuven

2 BPM Key messages to be made BP overrides all other risk factors. CV outcome is closer associated with ambulatory and home BP than with office BP; Both ABPM and HBPM allow stratification for white-coat, masked, and sustained HT and are indispensable for risk stratification. HBPM cannot replace ABPM as the state-of-the-art approach. Only ABPM allows screening for masked HT, nocturnal HT and hypotension. ABPM is cost-effective. Health insurers should facilitate access to ABPM.

3 Dementia 2017 BP is the predominant risk factor Worldwide in all ethnicities and at all ages

4 GBD Global Burden of Disease Diseases and injuries Risk factors High blood pressure DALYs (%) Smoking* Alcohol use IHD LRI Diet in low fruit HAP Low back pain Cerebrovascular disease High BMI Malaria Diarrhoea FPG HIV COPD Road injury PM2.5 Amb Underweight Inactivity Preterm birth Salt complications Diet low in nuts and seeds Tuberculosis Diabetes Lung cancer Deaths (%) Murray CJL et al. Lancet 2012;380:

5 Staessen JA et al. JAMA 1999;282:

6 GBD Conclusions of this section The GBD 2012 confirmed the overriding role of HT as the predominant modifiable CV risk factor. Murray CJL et al. Lancet 2012;380: High BP causes 9.4 million deaths every year more than half of the estimated 17 million deaths per year attributable to CV disease. Murray CJL et al. Lancet 2012;380: CV outcome is closer correlated with ambulatory than office BP. Nighttime BP is the best predictor. Staessen JA et al. JAMA 1999;282: Boggia J et al. Lancet 2007; 370:

7 2017 Dementia White-coat, masked and sustained HT ABPM is essential in risk stratification

8 MH Cross-classification Out-of-office BP (mmhg) Day: 135/85 Night: 120/70 24-h: 130/80 Home: 135/85 Masked HT (15%) Normotension (49%) Sustained HT (25%) White-Coat HT (11%) Office BP: 140/90 mm Hg Automated office BP: 135/85 mm Hg

9 IDACO Populations Denmark Ireland Belgium Venezuela Sweden Russian Federation Poland Czech Republic Italy Japan China 3 continents 12 countries 12,854 subjects Uruguay

10 IDACO Adjusted risk of CV events N of N of Subje c ts E v e n ts 130/80 mm Hg 135/85 mm Hg N of N of Subje c ts E v e n ts NT WCH MH SH HR are adjusted for cohort, sex, age, BMI, cholesterol, smoking and drinking, history of CVD, diabetes, and antihypertensive treatment. P<0.001 Hansen TW et al. J Hypertens 2007; 25:

11 WCH Conclusions of this section CV risk gradually increases from normotension over WCH to MH and sustained HT. Over a prolonged period of follow-up, the risk of WCH remains significantly less than that of sustained HT. The risk associated with MH almost equals that of sustained HT. Hansen TW et al. J Hypertens 2007; 25:

12 2017 Dementia Masked hypertension High risk even in people with office normotension

13 IDACO Risk of fatal combined with non-fatal endpoints by CBP CV events Stroke HT 7 HT CV events (%) Pre-HT NT p< p=0.012 Stroke (%) Pre-HT NT p=0.015 P< Follow-up (years) Follow-up (years) Adjusted for cohort, sex, age, BMI, smoking and drinking, serum cholesterol, CV disease, and DM. HT: 140/90 Pre-HT: /80-89 NT: <120/80 Brguljan Hitij J et al. Am J Hypertens 2014; 27:

14 IDACO HRs (vs. NT) associated with daytime masked HT CV events Stroke No. of subjects No. of events No. of events NT (p=0.0007) Pre-HT (p=0.006) NT with masked HT (p<0.0001) 3.02 (p=0.01) 2.08 (p<0.0001) Pre-HT with masked HT (p<0.0001) Daytime BP 135/ 85 mmhg Brguljan Hitij J et al. Am J Hypertens 2014; 27:

15 IDHOCO International Database of HOme blood pressure in relation to Cardiovascular Outcomes Random population samples with longitudinal follow-up of both fatal and non-fatal cardiovascular outcomes participants from 7 centres. Ohasama, Japan (2777); Finland (Finn-Home: 2075); Dijon, France (1733); Tsurugaya, Japan (836); Didima, Greece (665); Buenos Aires, Argentina (427); Montevideo, Uruguay (400). Asayama K et al. PLOS Medicine 2014;11:e

16 IDHOCO Incidence rates by increasing categories of conventional BP Endpoints per 1000 person-years Deaths Cardiovascular Stroke Cardiac p< p= p< p< Number of the endpoints contributing to the rates is given. p for linear trend across the five categories of conventional BP. 0 Optimal Normal Highnormal Mild HT Severe HT Category of conventional BP Asayama K et al. PLOS Medicine 2014;11:e

17 IDHOCO Risks associated with 10 mm Hg increase in home SBP by 5 categories of conventional BP Category of conventional BP Total mortality Cardiovascular Stroke Cardiac Optimal (<120/<80) 1.21 ( )* 1.28 ( )* 1.26 ( ) 1.25 ( ) Normal ( /80 84) 1.18 ( ) 1.22 ( )* 1.16 ( ) 1.29 ( ) High-normal ( /85 89) 1.01 ( ) 1.24 ( )* 1.33 ( ) 1.03 ( ) Mild hypertension ( /90 99) 1.04 ( ) 1.20 ( ) 1.30 ( ) 1.13 ( ) Severe hypertension ( 160/ 100) 0.95 ( ) 0.95 ( ) 1.00 ( ) 0.89 ( ) HRs were adjusted for cohort as random effect and for sex, age, BMI, smoking, cholesterol, DM, and history of CV as fixed effects. Significance of the HRs: *p<0.05 and p<0.01. Asayama K et al. PLOS Medicine 2014;11:e

18 IDHOCO HR associated with MHT ( 135/ 85 mm Hg) in participants with optimal to high-normal conventional BP Total mortality CV events No. of subjects No. of events No. of events Optimal without MHT Optimal with MHT ( ) ( ) Normal with MHT ( ) ( ) High-normal with MHT ( ) ( ) All with MHT ( ) ( ) Heterogeneity p= Heterogeneity Hazard ratios p=0.68 Hazard ratios Participants with optimal BP without elevated home BP were the reference group. SBP/DBP thresholds for HT on home measurement were 135/ 85 mm Hg. The diamond represents the pooled estimate in all participants with masked hypertension (MHT). Asayama K et al. PLOS Medicine 2014;11:e

19 MH Risk factors for masked HT Risk factor Odds Sensitivity Specificity Misclassified Prehypertension 5.1 ( ) 82% 53% 42% Age 40 y 2.5 ( ) BMI 25 kg/m2 2.0 ( ) Alcohol 1.9 ( ) Diabetes 1.8 ( ) Smoking 1.5 ( ) Brguljan Hitij J et al. Am J Hypertens 2014; 27:

20 MH Conclusions of this section ABPM and HBPM contribute to risk stratification in NT and pre-ht, particularly in the presence of masked HT. ABPM and HBPM help in targeting efforts where they are needed most and in putting pressure on HT.

21 2017 Dementia Persistence of masked HT Is the diagnosis consistent over consecutive visits? Wei FF et al. Am J Hypertens 2015; doi: /ajh/hpv106

22 MH Research question MH has a 15% prevalence in the general population (up to 30% among diabetic patients) and carries risk equal to sustained HT. Does MH persists over consecutive visits, so that patients can be identified reliably? 45 untreated patients (18-70 years) with MH, referred to Ruijin Hospital, Shanghai, for diagnostic ABPM were followed up at 2 and 4 weeks. Office BP was average of three consecutive readings (Omron HEM-7011). Wei FF et al. Am J Hypertens 2015; doi: /ajh/hpv106

23 MH Persistence of MH using daytime BP Baseline 2 weeks 4 weeks NT (9) NT (6) MH (3) MH (45) SH (1) MH (1) NT (7) persistent 32/44 71% MH (35) MH (24) SH (4) Wei FF et al. Am J Hypertens 2015; doi: /ajh/hpv106

24 MH Conclusions of this section Depending on definition of the out-of-office BP (24-h or daytime), MH is persistent in 70% to 80% of untreated Chinese patients referred for ambulatory BP monitoring. Wei FF et al. Am J Hypertens 2015; doi: /ajh/hpv106

25 2017 Dementia Nocturnal hypertension Risk compared with NT and sustained HT

26 IDACO Prevalence of isolated nocturnal HT n = 8711 NT 44% ID-HT 11% IN-HT 7% % 7.2% 9.4% D&N HT 38% 0 Europeans n=5396 Asians n=1877 South Americans n=1438 Li Y et al. J Hypertens 2010;28:

27 IDACO Kaplan-Meier curves Total mortality CV events 30 D&N-HT D&N-HT Incidence (%) p< ID-HT IN-HT NT p< ID-HT IN-HT NT Years of follow-up Li Y et al. J Hypertens 2010;28:

28 IDACO Conclusions of this section Both isolated nocturnal HT and isolated daytime HT predict adverse health outcomes in the general population. Our study supports current guidelines to perform ABPM at the state-ofthe-art method to measure BP, particularly in patients with daytime normotension, but having unexplained target organ damage. Li Y et al. J Hypertens 2010;28:

29 2017 Dementia Ambulatory or home BP? Strategies for diagnosis and management of HT Zhang L et al. Hypertension 2015;65:

30 Ruijin Strategies proposed by guidelines Year Country Strategy 2010 China OBP ABP or HBP 2011 UK OBP and ABP (or HBP) 2012 Japan OBP or HBP ABP 2013 Europe OBP ABP or HBP 2014 Canada OBP and ABP (or HBP) 2015 Taiwan OBP ABP or HBP Zhang L et al. Hypertension 2015;65:

31 Ruijin Characteristics of 831 patients Continous variables Age, y 50.6 BMI, kg/m h BP, mmhg 127/82 Glucose, mmol/l 5.14 Cholesterol, mmol/l 4.98 Creatinine, µmol/l 64.0 Categorical variables % Women, % 49.8 Smoker, % 19.7 Alcohol, % 22.5 Treatment naïve, % 90.0 Off treatment >2 wks 10.0 Zhang L et al. Hypertension 2015;65:

32 Ruijin Reclassification of risk level Initial classification NT (608) office BP HT (223) (831) Home BP NT (442) MH (166) WCH (61) SH (162) Day ABP MH % NT % MH % NT 24 14% SH 44 72% WCH 17 28% SH % WCH 6% Zhang L et al. Hypertension 2015;65:

33 Ruijin Change in risk category Home daytime BP Office + home Office + daytime Normotension 442 (53.2%) 287 (34.5) -155 (-18.6) White-coat HT Masked HT 61 (7.3) 166 (20.0) 26 (3.1) 321 (38.6) -35 (-4.2) +155 (+18.7) risk +190 (+23%) Sustained HT 162 (19.7) 197 (23.7) +35 (+4.2)

34 2017 Strategy of BP monitoring White-coat hypertension (Isolated clinic hypertension) Masked hypertension (Isolated clinic hypertension) Persistently raised office BP Persistently normal office BP Yes Target organ damage? Target organ damage? No Home Low 24-h ABPM High High Start treatment High 24-h ABPM Low Continue to monitor office and home BP Continue to monitor clinic and ambulatory BP Staessen JA et al. Lancet 2003;361:

35 2017 Dementia Cost-effectiveness of diagnostic options Office vs. home vs. ambulatory BP measurement

36 ABPM Cost-effectiveness assumptions Markov model-based probabilistic cost-effectiveness analysis; Hypothetical primary-care population >40 years with screening office BP >140/90 mm Hg and risk profile similar to UK population; Three diagnostic strategies of further BP measurement were compared in terms of lifetime costs, QALYs, and cost-effectiveness: Office BP; Home BP self-monitoring; Ambulatory BP monitoring. Lovibond K et al. Lancet 2011;378:

37 ABPM Cost-effectiveness results Cost saving for all sex-age groups: Men 75 y: 57 ( 105 to 105); Women 40 y: 323 ( 389 to 222); More QALYs above 50 years of age: Women 60 y: (0.001 to 0.015); Men 70 y: (0.012 to 0.035); Findings were robust in a wide range of sensitivity analyses, but sensitive to: HBPM = ABPM; Treatment equally effective irrespective of HT status. Lovibond K et al. Lancet 2011;378:

38 Coverage Out-of-the-office BP measurement Office ABPM HBPM Not covered BE, CH, DK, ES, FR BE, CH, ES, FI, FR, IR, NO, UK Covered IR (free/ ), FI (free/ 60), NO ( 40), UK (free) DK (resistant HT, high variability)

39 ABPM Conclusions of this section ABPM as diagnostic strategy for HT after an initial raised reading in the clinic reduces misdiagnosis and reduces cost. Additional costs for ABPM are counterbalanced by cost savings from better targeted treatment. ABPM is recommended for most patients before the start of antihypertensive drug treatment. Health care providers should therefore facilitate access to ABPM in both primary and specialised care. Lovibond K et al. Lancet 2011;378:

40 BPM Take home messages BP overrides all other risk factors. CV outcome is closer associated with ambulatory and home BP than with office BP; Both ABPM and HBPM allow stratification for white-coat, masked, and sustained HT and are indispensable in risk stratification. HBPM cannot replace ABPM as the state-of-the-art approach. Only ABPM allows screening for masked HT, nocturnal HT and hypotension. ABPM is cost-effective. Health insurers should facilitate access to ABPM.

41 Motie voor de klinische toepassing van 24-uur ambulante bloeddrukmeting