STATE OF THE ART BP ASSESSMENT PROFESSOR MOLECULAR PHARMACOLOGY CONWAY INSTITUE UNIVERSITY COLLEGE DUBLIN CO-CHAIRMAN BLOOD PRESCSURE MANAGEMENT IN LOW RESOURCE SETTINGS CENTRE FOR INTERNATIONAL HUMANITARIAN COOPERATION FORDHAM UNIVERSITY NEW YORK MEDICAL DIRECTOR dabl LIMITED DUBLIN IRELAND
LESSONS FROM CLINICAL PRACTICE
SCIPIONE RIVA-ROCCI 1863-1939 NICOLAI SERGEIVICH KOROTKOV 1910
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 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%
The Charitable Infirmary at Jervis Street Blood Pressure Unit founded 1979
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
MEASUREMENT ACCURACY
SERIES OF VALIDATION PROTOCOLS 1993-2010 Stergiou G et al. BP Monit 2010;15:39 48.
www.dableducational.org
USER-FRIENDLY SOFTWARE
LEVELS OF NORMALITY WINDOWS OF 24-H PROFILE dabl Ireland Owens P, Atkins N, O Brien E. Diagnosis of White Coat Hypertension by Ambulatory Blood Pressure Monitoring. Hypertension 1999;34:267-272
NORMAL 24-HOUR PATTERN dabl Ireland
COMPUTER-GENERATED REPORTS dabl Ireland The ABPM indicates normal 24-hour systolic & diastolic blood pressure (128 / 78 mmhg daytime, 110 / 62 mmhg night-time).
CONCISE REPORT
Hypertension published online Jan 26 th 2009 ABPM TREND REPORT
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
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
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
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
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
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
HYPERTENSIVE - NON DIPPER Shortoprilol 50 mg mane
HYPERTENSIVE - NON DIPPER 2011 dabl Limited Longoprolol 20 mg mane
WHAT DO THE INTERNATIONAL GUIDELINES SAY?
ABPM GUIDELINES 2000-2012 INDICATION BHS 2000 ESH 2003 BRAZIL 2005 AHA 2005 JAPAN 2012 AUST 2012 SUSPECTED WCH Yes Yes Yes Yes Yes Yes WC EFFECT Yes Yes - - Yes Yes SUSPECTED MH Yes Yes Yes Yes Yes Yes DIPPING STATUS Yes Yes - Yes Yes Yes RESISTANT HT Yes Yes - Yes Yes Yes DRUG EFFICACY Yes Yes Yes Yes Yes Yes HYPOTENSION Yes Yes Yes Yes Yes Yes BP VARIABILITY - - - - Yes - SECONDARY HT - - - - Yes - SLEEP APNOEA - - - - - Yes
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE) GUIDELINE 2011
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
GENERAL HYPERTENSION GUIDELINES 2000-2012 INDICATION JNC VII 2003 BHS IV 2004 ESC ESH 2007 LATIN AMER 2009 ITALY 2008 CHEP 2011 SA 2012 TAI- WAN 2012 SUSPECTED HT - - - - - - - - YES NICE 2011 SUSPECTED WCH Yes Yes Yes Yes Yes Yes Yes Yes Yes WC EFFECT - - - - Yes - - - Yes SUSPECTED MH - - - Yes Yes - Yes - No DIPPING STATUS - Yes Yes Yes Yes Yes Yes - No RESISTANT HT Yes Yes Yes Yes Yes Yes Yes Yes - DRUG EFFICACY - Yes Yes Yes Yes Yes Yes - No HYPOTENSION Yes Yes Yes Yes Yes Yes - Yes No BP VARIABILITY - Yes Yes Yes Yes Yes Yes Yes -
NICE OBJECTIVE SAVE MONEY FOR THE NHS Lancet 2011;736:1184-7
PHARMACOLOGICAL TRIALS OF CV DRUGS
THE TIME HAS SURELY COME WHERE STUDIES OF ANTIHYPERTENSIVE DRUG EFFICACY WHICH DO NOT ASSESS BLOOD PRESSURE OVER 24 HOURS SHOULD NO LONGER BE ACCEPTABLE. O Brien E. J Hypertens 1989:7;243-247
Millar Craig et al. BMJ 1979;i:237-238
Millar Craig et al. BMJ 1979;i:237-238
The circadian rhythm of blood pressure raises many questions about the timing of antihypertensive drug dosage and the effects of traditional regimens. Single measurements in outpatient clinics are unlikely to yield useful information on the effects of drugs on this basic cycle. If treatment aims at lowering blood pressure to a "normal level (140/90 mm Hg) clearly it is desirable to lower it to that level throughout the 24-hour cycle. Millar Craig et al. BMJ 1979;i:237-238
Hypertension published online Jan 26 th 2009
VISIT-TO-VISIT BPV IN ASCOT-BPLA 4.5 Hypertension published online Jan 26 th 2009 Average within-visit CV SBP 4.3 4.1 3.9 3.7 3.5 Atenolol Amlodipine Baseline 3 months 1 year 2 year 3 year 4 year 5 year Follow-up
BLOOD PRESSURE VARIABILITY Marked BPV Less BPV
HOPE STUDY New Eng J Med 2002 RAMIPRIL ~ REDUCTION IN CV MORTALITY REDUCTION IN BP ~ 3/2 mmhg ACE INHIBITORS ~ HIGH-RISK PATIENTS ABPM SUB-STUDY ~ 1 YEAR LATER WHOPPING 17/8 mmhg NOCTURNAL FALL 10/4 mmhg REDUCTION IN 24-H ABPM
REAL-TIME ANALYSIS OF ABPM IS ESSENTIAL
ABPM Page (Rejected ABPM)
ABPM Page (Accepted ABPM)
PHARMACOLOGICAL TRIALS OF NON-CV DRUGS
Various Technologies and Means to Measure Blood Pressure in Clinical Trials
SELF-MEASUREMENT OF BLOOD PRESSURE (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 7 DAYS OF MEASUREMENTS 2 MEASUREMENTS, 1-2 MIN INTERVALS, AM & PM DISCARD FIRST DAY MEASUREMENTS AVERAGE 6 DAYS MEASUREMENT APPROXIIMATE EQUIVALENT TO DAYTIME ABPM NO NOCTURNAL DATA, NO PATTERNS ABPM and SBPM ~ DIFFERENT DATA ~ COMPLIMENTARY TECHNIQUES
Drug Information Journal, 2011; 45: 233 239 In my view, a better question regarding ABPM is whether all systemically available drugs intended for chronic use merit a careful assessment of their effects on vital signs by ABPM. Norman Stockbridge. Drug Information Journal, 2011; 45: 5657-8
SINCE CBPM IN 1896 SUPERLATIVE TECHNOLOGY
Hypertension published online Jan 26 th 2009 CARD(X)PLORE DEVICE
ABPM Variability
Hypertension published online Jan 26 th 2009
From the scientific viewpoint, we believe that it is now time to utilize the technique of ABPM to obtain a fuller understanding of the patterns of noncardiovascular drug-induced BP responses than was ever possible with CBPM. J Clin Hypertens 2012
CONCLUSION ~ PLEA PHARMACOLOGICL TRIALS ~ ABPM SCIENCE MUST DIRECT INDUSTRY ACCURATE & EFFICIENT ABPM HARDWARE DUAL OR TREBLE PURPOSE DEVICES STANDARDISED ANALYTICAL SOFTWARE CENTRAL HOSTING & FEED-BACK REAL-TIME MONITORING & ANALYSIS SCIENTIFIC REALITY ~ PROCEDURAL APATHY