BLOOD PRESSURE MEASUREMENT HOME BASED OR OFFICE BP MONITORING WHICH, HOW AND WHEN?

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2 BLOOD PRESSURE MEASUREMENT HOME BASED OR OFFICE BP MONITORING WHICH, HOW AND WHEN? DECLARATION OF INTEREST Medical Director and Chairman, Advisory Board dabl Ltd., Dublin, Ireland.

3 BLOOD PRESSURE MEASUREMENT WHY, HOW, WHEN AND WHERE? PROFESSOR MOLECULAR PHARMACOLOGY CONWAY INSTITUE UNIVERSITY COLLEGE DUBLIN CHAIRMAN BLOOD PRESSURE MANAGEMENT IN LOW RESOURCE SETTINGS GENEVA CENTRE FOR INTERNATIONAL HUMANITARIAN COOPERATION FORDHAM UNIVERSITY NEW YORK

4 WHO ~ GLOBAL EPIDEMIC 32 MILLION STROKES & HEART ATTACKS

5 MORTALITY DUE TO LEADING GLOBAL RISK FACTORS Lopez et al. Lancet 2006;367:

6 WHY? BP ~ KING OF PROGNOSTIC MARKERS ESSENTIAL FOR DIAGNOSIS ESSENTIAL FOR BP CONTROL

7 MAJOR CHALLENGES FOR A CHANGING SOCIETY INCREASED LONGEVITY HOPELESS BLOOD PRESSURE CONTROL EPIDEMIC OF STROKE & HEART FAILURE COGNITIVE IMPAIRMENT & DEMENTIA

8 INCREASED LONGEVITY IRISH MALE INFANT years years years

9 BLOOD PRESSURE CONTROL

10 HYPERTENSION HYPERTENSION 1 million UNCONTROLLED 700,000 STROKES 10,000 1 billion p.a. COGNITIVE IMPAIRMENT DEMENTIA CV DISEASE THE MOST SERIOUS & MOST BADLY MANAGED RISK

11 BLOOD PRESSURE CONTROL CARDIOVASCULAR PREVENTION GUIDELINES IN DAILY PRACTICE: A COMPARISON OF EUROASPIRE I, II, AND III SURVEYS IN EIGHT CBPM EUROPEAN ~ SCREENING COUNTRIES ONLY Kotseva K et al. Lancet PATIENTS EUROASPIRE I 1995 EUROASPIRE II 1999 ABPM DATA ~ EUROASPIRE INVALUABLE III AUDIT & RESEARCH 2006 RESOURCE PATIENTS WITH BP > 140/90 mmhg EUROASPIRE I 58.1% EUROASPIRE II 58.3% EUROASPIRE III 60.9%

12 BLOOD PRESSURE CONTROL EUROASPIRE III Blood pressure control is completely inadequate with most patients not achieving targets defined in the guidelines Prescribing antihypertensive drugs is not enough Blood pressure control must be achieved!

13 RULE OF HALVES High Blood Pressure Population

14 RULE OF HALVES High Blood Pressure Population

15 RULE OF HALVES High Blood Pressure Population

16 RULE OF HALVES High Blood Pressure Population

17 RULE OF HALVES High Blood Pressure Population

18 WHY ARE WE DOING SO BADLY

19 FAILURE OF HYPERTENSION MANAGEMENT INACCURATE MEASUREMENT FAILURE TO RECOGNISE NEED FOR CONTROL THERAPEUTIC INERTIA COMPLEXITY OF THE DISEASE

20 CARDIOVASCULAR DISEASE ~ ARTERIAL DISEASE STROKE BRAIN ATTACK HEART ATTACK HEART FAILURE KIDNEY DISEASE RENAL FAILURE HYPERTENSION HIGH BLOOD PRESSURE CONTRIBUTES TO 60 % ALL DEATHS PERIPHERAL ARTERIAL DISEASE PAD

21 EUROPEAN SOCIETY OF HYPERTENSION CENTRES OF EXCELLENCE & ACCREDITED SPECIALISTS

22 HOW?

23 The thing that had been, it is that which shall be; and that which is done is that which shall be done; and there is no new thing under the sun. Ecclesiastes 1.2

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26 REVEREND STEPHEN HALES 1733

27 ETIENNE JULES MAREY

28 SCIPIONE RIVA-ROCCI

29 NICOLAI SERGEIVICH KOROTKOV RUSSIO-JAPANESE WAR

30 THE MOST REMARKABLE FACT ABOUT THE KOROTKOFF SOUND IS THAT IT WAS DISCOVERED William Dock ONE SOMETIMES WISHES THAT NICOLAI KOROTKOFF HAD NOT DESCRIBED THE FOURTH AND FIFTH PHASES Geoffrey Rose

31 THEODORE CALDWELL JANEWAY

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33 CONVENTIONAL BP MEASUREMENT CLINIC SPHYGMO TEMPERATURE HEIGHT HUMIDITY POSITION & TILT NOISE LEVEL OF HG OBSERVER CLOGGED VENT TRAINING MAINTENANCE BIAS STETHOSCOPE DIGIT PREFERENCE SUBJECT INATTENTION INACCURATE IN 0VER ONE-THIRD OF PATIENTS ANXIETY RAPPORT RECENT EXERCISE HEARING & VISION MEAL OR TOBACCO DISTANCE OBESITY ELDERLY CUFF/BLADDER ARRHYTHMIA CUFF CONDITION POSTURE APPLICATION ARM LEVEL BLADDER SIZE ARM SUPPORT BLADDER POSITION RIGHT OR LEFT?

34 WHITE COAT HYPERTENSION 20 25% MASKED HYPERTENSION 10 15% CBPM ~ INCORRECT DIAGNOSIS 30 40%

35 SINCE CBPM IN 1896 CLINICAL SCIENTISTS!

36 Faced with a patient with borderline hypertension, the doctor should be slow to diagnose hypertension until some attempt has been made to categorise the behaviour of blood pressure over time: ambulatory blood pressure measurement is the best way to do this. O Brien E. BMJ 1988:297; The time has surely come where studies of antihypertensive drug efficacy which do not assess blood pressure over 24 h should no longer be acceptable. O Brien E. J Hypertens 1989:7;

37 AMBULATORY BLOOD PRESSURE MEASUREMENT

38 The Charitable Infirmary at Jervis Street Blood Pressure Unit founded 1979

39 SIR GEORGE PICKERING

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41 HARDWARE

42 ACCURACY OF DEVICES

43 SERIES OF VALIDATION PROTOCOLS Stergiou G et al. BP Monit 2010;15:39 48.

44 WEBSITE ~ 2004 BP MEASUREMENT MILLION VISITS ANNUALLY

45 UPPER ARM DEVICES

46 SOFTWARE

47 STANDARDISATION of PRESENTATION

48 NORMAL 24-HOUR PATTERN dabl Ireland

49 COMPUTER-GENERATED INTERPRETATIVE REPORTS

50 COMPUTER-GENERATED REPORTS dabl Ireland The ABPM indicates normal 24-hour systolic & diastolic blood pressure (128 / 78 mmhg daytime, 110 / 62 mmhg night-time).

51 COMPUTER-GENERATED REPORTS EDUCATIONAL ROLE FOR USERS OF ABPM CONSISTENCY IN REPORTING POTENTIAL FOR TREATMENT PROMPTS FINANCIAL SAVINGS

52 CONCISE REPORT & TREND REPORT

53 ABPM REPORTING

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55 STATISTICAL ANALYSIS

56 CLINICAL USE n Mean White-Coat Window SBP DBP HR Daytime SBP DBP HR Night-time SBP DBP HR hour SBP DBP HR RESEARCH

57 ON-LINE HOSTING & ANALYSIS

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59 CLINICAL BENEFITS of ABPM

60 IDENTIFY DECEPTIVE MEASUREMENTS

61 WHITE COAT HYPERTENSION 20-25% hypertensive population 2011 dabl Limited The ABPM shows marked white-coat hypertension (205/100 mmhg) with otherwise normal 24-hour systolic & diastolic blood pressure (128/68 mmhg daytime and 112/54 mmhg night-time). OFFICE HYPERTENSION AMBULATORY NORMOTENSION 156/88 mmhg 128/68 mmhg

62 MASKED HYPERTENSION 10-15% of general population 2011 dabl Limited The ABPM shows mild daytime systolic & diastolic hypertension (147 / 93 mmhg) and normal nighttime systolic & diastolic blood pressure (111 / 66 mmhg). OFFICE NORMOTENSION AMBULATORY HYPERTENSION 124/62 mmhg 147/93 mmhg

63 CONTROL OF HYPERTENSION 2009 dabl Limited OFFICE CONTROL OF BLOOD PRESSURE 134/68 mmhg The ABPM shows mild daytime systolic & diastolic hypertension (147 / 93 mmhg) and normal night-time systolic & diastolic blood pressure (111 / 66 mmhg). AMBULATORY LACK OF BLOOD PRESSURECONTROL 147/93 mmhg

64 ASSESS SEVERITY OF HYPERTENSION

65 MILD HYPERTENSION 2011 dabl Limited The ABPM shows mild daytime systolic & diastolic hypertension (147 / 93 mmhg) and normal night-time systolic & diastolic blood pressure (111 / 66 mmhg).

66 SEVERE HYPERTENSION 2011 dabl Limited The ABPM shows severe 24-hour systolic hypertension (177 mmhg daytime, 161 mmhg night-time) and moderate 24-hour diastolic hypertension (108 mmhg daytime, 94 mmhg night-time).

67 CIRCADIAN PATTERNS in THE ELDERLY

68 ISOLATED SYSTOLIC HYPERTENSION 2011 dabl Limited The ABPM indicates severe 24-hour isolated systolic hypertension (176/68 mmhg daytime and 169/70 mmhg night-time).

69 AUTONOMIC FAILURE 2011 dabl Limited

70 TAILOR TREATMENT to the ABPM PATTERN

71 HYPERTENSIVE - NON DIPPER Shortoprilol 50 mg mane

72 HYPERTENSIVE - NON DIPPER 2011 dabl Limited Longoprolol 20 mg mane

73 ASSESS NOCTURNAL BLOOD PRESSURE

74 DIPPERS AND NON-DIPPERS DIPPERS Day/Night > 10/5 mmhg NON-DIPPERS Day/Night < 10/5 mmhg DIPPERS Stroke 3 % NON-DIPPERS Stroke 23 % O Brien et al. Lancet 1988

75 DIPPING PATTERN 2011 dabl Limited The ABPM shows severe daytime systolic hypertension (181 mmhg), moderate daytime diastolic hypertension (117 mmhg) and normal night-time systolic & diastolic blood pressure (111/68 mmhg).

76 NON-DIPPING PATTERN 2011 dabl Limited The ABPM shows severe 24-hour systolic & diastolic hypertension (210/134 mmhg daytime and 205/130 mmhg night-time).

77 MORNING SURGE 2011 dabl Limited

78 ADJUSTED 5-YEAR RISK OF CARDIOVASCULAR DEATH ACCORDING TO CBPM & ABPM Nighttime 24-hour Daytime Clinic Nighttime 24-hour Daytime Clinic Adjusted for other covariates Dolan et al. Hypertension 2005;46:1-6

79 WHY IS SLEEPING PRESSURE SO PREDICTIVE?

80 NOCTURNAL BLOOD PRESSURE PHENOMENA DIPPING AND NON-DIPPING REVERSE DIPPING EXTREME DIPPING MORNING SURGE NOCTURNAL HYPERTENSION SLEEP APNOEA HAEMODYNAMIC & HORMONAL CHANGES

81 SELF BLOOD PRESSURE PRESSURE MEASUREMENT SBPM

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83 ESH RECOMMENDATIONS FOR SBPM Parati G,Stergiou GS, O Brien E, et al on behalf of the ESH Working Group on Blood Pressure Monitoring. European Society of Hypertension guidelines for blood pressure monitoring at home: J Hypertens 2008, 26: m REST, 30 m NO SMOKING or CAFFEINE, RELAXED SEATED, BACK SUPPORT, ARM ON TABLE, LEGS UNCROSSED INITIAL ASSESSMENT, TREATMENT, FOLLOW-UP 7 DAYS OF MEASUREMENTS 2 MEASUREMENTS, 1-2 MIN INTERVALS, AM & PM DISCARD FIRST DAY MEASUREMENTS AVERAGE 6 DAYS MEASUREMENT DAYTIME ABPM ~ NO NOCTURNAL DATA, NO PATTERNS ABPM and SBPM ~ DIFFERENT DATA ~ COMPLIMENTARY TECHNIQUES

84 SELF BLOOD PRESSURE MEASUREMENT SUPERIOR TO CONVENTIONAL MEASUREMENT SBPM COMPLIMENTARY TO ABPM WHEN ABPM UNAVAILABLE OR INAPPROPRIATE ADHERE TO RECOMMENDATIONS DAYTIME MEAN BP BUT NO NOCTURNAL BP LESS DATA THAN FOR ABPM SBPM AND ABPM ~ DIFFERENT INFORMATION

85 WHEN?

86 NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE) GUIDELINE 2011 Update of clinical guidelines 18 and 34 Hypertension The clinical management of primary hypertension in adults Clinical Guideline 127 Methods, evidence, and recommendations August 2011 Commissioned by the National Institute for Health and Clinical Excellence

87 IF THE CLINIC BLOOD PRESSURE IS 140/90 MMHG OR HIGHER, OFFER AMBULATORY BLOOD PRESSURE MONITORING (ABPM) TO CONFIRM THE DIAGNOSIS OF HYPERTENSION. NICE Final Recommendation 2011

88 Lancet 2011;736:1184-7

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90 WHEN TO DO ABPM Suspected hypertension Suspected white coat hypertension White coat effect Masked Hypertension Resistant hypertension Children and adolescents Elderly patients Suspected nocturnal hypertension Suspected sleep apnoea Hypertension of pregnancy Diabetes Parkinson s disease and other neurological disorders Assessment of drug treatment Evaluation of hypotension Salt sensitivity O Brien E, Parati G, Stergiou G on behalf of ESH. J Hypertens 2012

91 WHERE?

92 WHERE? PRIMARY CARE SPECIALIST CLINICS OTHER OUTLETS

93 MAKE ABPM USER-FRIENDLY ACCESSIBLE TO PATIENTS and SUITABLE FOR ALL

94 Hypertension published online Jan 26 th 2009

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97 ESTABLISH NATIONAL REGISTRIES OF ABPM

98 Lancet 2011;378: Vol 378:2050

99 NATIONAL ABPM REGISTRIES IDACO ARTEMIS OHASAMA - AUSTRALIA

100 SPANISH STUDY ABPM IN PRIMARY CARE TARGET BLOOD PRESSURE CBPM 24% ABPM 52% IRISH STUDY ABPM IN PRIMARY CARE TARGET BLOOD PRESSURE CBPM 12% ABPM 39%

101 CONCLUSIONS WHY? TO HALT THE EPIDEMIC OF CV DISEASE HOW? WITH ABPM STANDARISE METHODOLOGY CENTRAL HOSTING ~ NATIONAL REGISTERIES WHEN? ALL PATIENTS IN ALL CIRCUMSTANCES WITH SUSPECTED HYPERTENSION WHERE? PRIMARY CARE ~ SPECIALIST CLINICS ~ HEALTH CARE PROVIDERS ~ PHARMACIES

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