가정혈압의활용 CARDIOVASCULAR CENTER. Wook Bum Pyun M.D., Ph.D. HOME BLOOD PRESSURE MONITORING. Ewha Womans University, school of Medicine

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1 가정혈압의활용 HOME BLOOD PRESSURE MONITORING CARDIOVASCULAR CENTER Wook Bum Pyun M.D., Ph.D. Ewha Womans University, school of Medicine

3 Non-Invasive Blood Pressure Measurement

7 5-20% Resistant to drug treatment European Society of Hypertension (ESH)/European Society of Cardiology (ESC) American Society of Hypertension(ASH)/International Society of hypertension(ish) >140/90 despite treatment with three antihypertensive drugs at optimal doses (50% or more of maximal recommended antihypertensive dose) including a diuretic.

8 Diagnosis of Resistant Hypertension Uncontrolled hypertension Exclude Pseudo resistance Identify Reversible lifestyle factors Discontinue Interfering medication Screening For secondary cause Specific therapy Resistant hypertension Optimize non-pharmacologic and pharmacological treatment regimen

9 Possible causes of pseudo-resistant hypertension Improper blood pressure measurement Heavily calcified or atherosclerotic arteries White coat hypertension Poor patient adherence Inadequate drug doses Inadequate drug combinations

10 Is Useful in the management of patients with Resistance Hypertension? American Journal of Hypertension 28(2) February 2015

11 Changing relationship among clinic, home, and ambulatory blood pressure with increasing age J Am Soc Hypertens 2015;9(7):

12 Home BP Monitoring 42% have white coat hypertension on both ambulatory BP monitoring and home BP monitoring (58% discordance) 44% have masked hypertension on both ambulatory BP monitoring and home BP monitoring (56% discordance)

13 HBPM overestimated systolic BP by 8.8 (95% CI = ) mmhg and diastolic BP by 0.2 (95% CI = 1.0 to 1.4) mmhg. The specificity, sensitivity, and positive and negative predictive values of HBPM in detecting controlled ambulatory BP were 91%, 55%, 89%, and 59%. HBPM presented good agreement with ABPM and can be used as a complementary method in the follow-up of resistant hypertensive patients, particularly in those with controlled ambulatory BPs. American Journal of Hypertension 28(2) February 2015

14 White-coat hypertension; benign? Hypertension. 2014;63:

15 Hypertension. 2014;63:

16 Hypertension. 2014;63:

17 ABPM; standard BP measurement method with more data BUT

19 Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes In CKD or ESRD, ABPM is superior for mortality prediction In 60 yo, HBPM is as good or better than ABPM for mortality prediction In general population additional BP information regardless of measurement type and HBPM and ABPM are higher in prediction of all cause mortality Integrated Blood Pressure Control 2015:

20 HBPM can improve BP control through its indirect effects on patients. HBPM encourages patient-centered care. Self-monitoring of BP reminds patients of the importance of medication adherence and healthy lifestyle factors. Participating in HBPM alone improved BP control.

23 일반적으로가정혈압은진료실혈압보다낮다. 가정혈압으로서고혈압은 135/85 mmhg 이상으로정의한다. 고혈압을진단할때가정혈압은 1 주일에 5 일이상, 아침저녁으로 1~3 회씩측정할것을권장한다. 평가할때는첫날측정치를제외한후평균치를사용한다. 아침에는자고일어나서 1 시간이내에, 소변을본후, 고혈압약을복용하기전에측정한다. 저녁에는잠자리에들기전에측정할것을권장한다. 단, 처음고혈압을진단하기위해서는 1 주일동안매일측정한값을사용하는것을권장한다.

24 Home blood pressure monitoring: Australian Expert Consensus Statement

26 In Cardiovascular events or mortality HBPM and ABPM resulted in similar outcome measurement standard for BP control insufficient data to determine the benefit of using HBPM

27 Guideline for Home Blood Pressure Monitoring

35 HBPM OBPM OBPM Improve BP control and same level of BP control as ABPM Low sensitivity of office BP confirmed to detect optimal BP control defined by HBPM (50%) and ABPM (53.4%) Superior standardization; Night BP and dipping pattern Interfere daily activity and sleep

36 ABPM is Reference Standard For optimal care However, home blood pressure monitoring has better reproducibility. Compared with 24-hour ambulatory blood pressure monitoring, home monitoring is less expensive, much more widely available and provides information about the day-to-day variability of blood pressure.

37 Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension Journal of Hypertension 2015, 33:

38 Home BP monitoring has high specificity, but low sensitivity in the diagnosis of white-coat and masked hypertension, and may therefore behave as a complementary to, but not a replacement of ambulatory BP monitoring. Journal of Hypertension 2015, 33:

39 ABPM Vs. HBPM J Am Soc Hypertens 2016;10(3):

40 There is a lack of strong empiric evidence supporting ABPM or HBPM over the other approach for predicting cardiovascular events or mortality.

41 Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes By comparison, HBPM has some advantages over ABPM. The availability of affordable BP monitoring devices has allowed individuals to measure and record BPs repeatedly throughout their course of treatment. In contrast, ABPM is not directly available to patients, and its high cost presents a barrier to initial and repeated testing. By requiring the individual to wear the cuff and monitor continuously, ABPM does interfere with daily activities and sleep. Although, any advantage in convenience or comfort with HBPM is weighed against the superior standardization of BP measurement and the acquisition of sleep-time BP data by 24-hour ABPM.

42 Blood Pressure Variability; Types and Prognostic Significance Parati G et al. Nature Reviews Cardiology :

43 Wireless HBPM

44 Telemonitoring in the Management of High Blood Pressure Current Pharmaceutical Design, 2015, 21,

45 Telemonitoring Vs. usual care In uncontrolled hypertensive patients To evaluate BP control rate at 6, 12 months At 6 months 71.8% Vs 45.2 (p<0.001) 12 months 71.2% Vs. 52.8% (p=0.005) 18 months 71.8% Vs. 57.1% (p=0.003) Home BP telemonitoring achieved better BP control JAMA 2013;310(1):46-56

46 There is now strong evidence from several randomized controlled trials that using telemetry to communicate home BP measures to healthcare providers (telemonitoring) is associated with highly statistically and clinically significant reductions in BP. However the studies have been of relatively short duration and it is not known if these reductions would be sustained in the long term, nor have any of the studies been at large scale. While there are challenges to implementing telemonitoring at scale there is a need for large implementation trials over relatively prolonged periods to establish the efficacy of such an approach in routine care. Current Pharmaceutical Design, 2015, 21,

48 U.S. Prevention Services Task Force Recommendation Statement

49 U.S. Prevention Services Task Force Recommendation Statement

50 An advantage of 24-hour ambulatory blood pressure monitoring is the detection of nocturnal hypertension or non-dipping blood pressure patterns, which are associated with a worse prognosis. However, newer devices for home blood pressure monitoring may enable nocturnal measurements. At this stage the two methods should be considered as complementary clinical tools.

51 Complementary

52 Do you agree?

53 감사합니다.

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