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.
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
WHO ~ GLOBAL EPIDEMIC 32 MILLION STROKES & HEART ATTACKS
MORTALITY DUE TO LEADING GLOBAL RISK FACTORS Lopez et al. Lancet 2006;367:1747-1757
WHY? BP ~ KING OF PROGNOSTIC MARKERS ESSENTIAL FOR DIAGNOSIS ESSENTIAL FOR BP CONTROL
MAJOR CHALLENGES FOR A CHANGING SOCIETY INCREASED LONGEVITY HOPELESS BLOOD PRESSURE CONTROL EPIDEMIC OF STROKE & HEART FAILURE COGNITIVE IMPAIRMENT & DEMENTIA
INCREASED LONGEVITY IRISH MALE INFANT 1926 57 years 2006 73 years 2010 100 years
BLOOD PRESSURE CONTROL
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
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 2009 2500 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%
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!
RULE OF HALVES High Blood Pressure Population
RULE OF HALVES High Blood Pressure Population
RULE OF HALVES High Blood Pressure Population
RULE OF HALVES High Blood Pressure Population
RULE OF HALVES High Blood Pressure Population
WHY ARE WE DOING SO BADLY
FAILURE OF HYPERTENSION MANAGEMENT INACCURATE MEASUREMENT FAILURE TO RECOGNISE NEED FOR CONTROL THERAPEUTIC INERTIA COMPLEXITY OF THE DISEASE
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
EUROPEAN SOCIETY OF HYPERTENSION CENTRES OF EXCELLENCE & ACCREDITED SPECIALISTS
HOW?
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
REVEREND STEPHEN HALES 1733
ETIENNE JULES MAREY 1830-1904
SCIPIONE RIVA-ROCCI 1863-1939
NICOLAI SERGEIVICH KOROTKOV 1874-1920 RUSSIO-JAPANESE WAR 1904-1905
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
THEODORE CALDWELL JANEWAY 1872-1917
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?
WHITE COAT HYPERTENSION 20 25% MASKED HYPERTENSION 10 15% CBPM ~ INCORRECT DIAGNOSIS 30 40%
SINCE CBPM IN 1896 CLINICAL SCIENTISTS!
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;1211-1212 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;243-247
AMBULATORY BLOOD PRESSURE MEASUREMENT
The Charitable Infirmary at Jervis Street Blood Pressure Unit founded 1979
SIR GEORGE PICKERING
HARDWARE
ACCURACY OF DEVICES
SERIES OF VALIDATION PROTOCOLS 1993-2010 Stergiou G et al. BP Monit 2010;15:39 48.
WEBSITE ~ 2004 BP MEASUREMENT www.dableducational.org 1.5 MILLION VISITS ANNUALLY
UPPER ARM DEVICES
SOFTWARE
STANDARDISATION of PRESENTATION
NORMAL 24-HOUR PATTERN dabl Ireland
COMPUTER-GENERATED INTERPRETATIVE REPORTS
COMPUTER-GENERATED REPORTS dabl Ireland The ABPM indicates normal 24-hour systolic & diastolic blood pressure (128 / 78 mmhg daytime, 110 / 62 mmhg night-time).
COMPUTER-GENERATED REPORTS EDUCATIONAL ROLE FOR USERS OF ABPM CONSISTENCY IN REPORTING POTENTIAL FOR TREATMENT PROMPTS FINANCIAL SAVINGS
CONCISE REPORT & TREND REPORT
ABPM REPORTING
STATISTICAL ANALYSIS
CLINICAL USE n Mean White-Coat Window SBP DBP HR 3 3 3 150 91 63 Daytime SBP DBP HR 21 21 21 148 92 84 Night-time SBP DBP HR 10 10 10 111 66 55 24-hour SBP DBP HR 42 42 42 138 85 72 RESEARCH
ON-LINE HOSTING & ANALYSIS
CLINICAL BENEFITS of ABPM
IDENTIFY DECEPTIVE MEASUREMENTS
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
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
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
ASSESS SEVERITY OF HYPERTENSION
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).
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).
CIRCADIAN PATTERNS in THE ELDERLY
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).
AUTONOMIC FAILURE 2011 dabl Limited
TAILOR TREATMENT to the ABPM PATTERN
HYPERTENSIVE - NON DIPPER Shortoprilol 50 mg mane
HYPERTENSIVE - NON DIPPER 2011 dabl Limited Longoprolol 20 mg mane
ASSESS NOCTURNAL BLOOD PRESSURE
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
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).
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).
MORNING SURGE 2011 dabl Limited
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
WHY IS SLEEPING PRESSURE SO PREDICTIVE?
NOCTURNAL BLOOD PRESSURE PHENOMENA DIPPING AND NON-DIPPING REVERSE DIPPING EXTREME DIPPING MORNING SURGE NOCTURNAL HYPERTENSION SLEEP APNOEA HAEMODYNAMIC & HORMONAL CHANGES
SELF BLOOD PRESSURE PRESSURE MEASUREMENT SBPM
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, 26:1505 1530 5 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
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
WHEN?
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
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
Lancet 2011;736:1184-7
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
WHERE?
WHERE? PRIMARY CARE SPECIALIST CLINICS OTHER OUTLETS
MAKE ABPM USER-FRIENDLY ACCESSIBLE TO PATIENTS and SUITABLE FOR ALL
Hypertension published online Jan 26 th 2009
ESTABLISH NATIONAL REGISTRIES OF ABPM
Lancet 2011;378: Vol 378:2050
NATIONAL ABPM REGISTRIES IDACO ARTEMIS OHASAMA - AUSTRALIA
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%
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