blood pressure

© Continuing Medical Implementation …...bridging the care gap

Blood Pressure Measurement

Blood Pressure Measurement

How can anything so simple

be so complex?


Diseases Attributable to Hypertension

Diseases Attributable to Hypertension

Hypertension

Heart failureStroke

Coronary heart disease

Myocardial infarction

Left ventricular hypertrophy

Aortic aneurysm

Retinopathy

Peripheral vascular disease

Hypertensive encephalopathy

Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.

AllVascular


Awareness, Treatment and Control of High Blood Pressure in Canada

Awareness, Treatment and Control of High Blood Pressure in Canada

Adapted from: Am J Hypertens 1997; 10:1097-1102.

Patients unaware of their high blood pressure 42%

Aware but not treated and not controlled 19%

Treated but not controlled 23%

Treated and controlled 16%

42%

19%23%

16%


2003

Canadian Hypertension Education Program Recommendations 34

Office Diagnosis of Hypertension: SummaryHigh blood pressure vs Hypertension

Visit 1

Visit 2

Visit 3

Visit 5

Blood pressuremeasurement

every year

- Hypertensiveurgency?

- Target organdamage or BP >160/100?(Visit 3) Hypertension

diagnosisconfirmed

BP over threshold for initiation of

treatment

Yes

No Validated technique andBP measurement device

Visit 4

History-taking,physical examination160

100

140

90

© Continuing Medical Implementation …...bridging the care gap 3

RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSUREMEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE

2.• The cuff must be level with heart.

• If arm circumference exceeds 33 cm,a large cuff must be used.

• Place stethoscope diaphragm overbrachia l artery.

2.2.•• The cuff must be level with heart.The cuff must be level with heart.

•• If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.

•• Place stethoscope diaphragm overPlace stethoscope diaphragm overbrachia l artery.brachia l artery.

1.• The patient should

be relaxed and thearm must besupported.

• Ensure no tightclothing constrictsthe arm.

1.1.•• The patient shouldThe patient should

be relaxed and thebe relaxed and thearm must bearm must besupported.supported.

•• Ensure no tightEnsure no tightclothing constrictsclothing constrictsthe arm.the arm.

3.• The column of

mercury must bevertical .

• Infla te to occlude thepulse. Deflate at 2 to3 mm/s. Measuresystolic (first sound)and diastolic(disappearance) tonearest 2 mm Hg.

3.3.•• The column ofThe column of

mercury must bemercury must bevertical .vertical .

•• Infla te to occlude theInfla te to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to3 mm/s. Measure3 mm/s. Measuresystolic (first sound)systolic (first sound)and diastolicand diastolic(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.

StethoscopeStethoscope

MercuryMercurymachinemachine


2003


Threshold for Initiation of Treatment and Target Values

SBP / DBP mmHgSBP / DBP mmHg

<130/80(130/80)Renal disease

<125/75

<130/80

<135/85

<140

<140/90

Target

SBP >160Isolated systolic hypertension

(135/85)Home BP measurement (no diabetes, renal disease or proteinuria)

(125/75)Proteinuria >1 g/day

130/80Diabetes

140/90Diastolic ± systolic hypertension

InitiationCondition

BP Treatment Targets

Condition

160/100 Treatment threshold if no risk factors,TOD or CCD

< 140/90 Treatment target for office BP measurement

< 135/85 Treatment target for ABP or HBP measurement

< 130/80 Treatment target for for Type 2 diabetics or non-diabetic nephropathy

< 125/75 Treatment target for diabetic or non-diabetic nephropathy with proteinuria


Automated BpTRU™ BP Devices

Automated BpTRU™ BP Devices


Benefits of Automated BpTRU™ BP DevicesBenefits of Automated BpTRU™ BP Devices

– Standardizes BP readings from one operator to the next

– Removes many of the errors associated with manual readings

– Accurate, reliable and reproducible readings

– Multiple readings with averaging

– “Opportunistic screening”– Accurate, independently

validated device

– Automatically zeroes with each inflation

– Performs full system check every time on powering-up

• Performs six readings

• Discards the first reading

• Averages the remainder

• Interval between readings from 1-5 minutes apart

• User can auscultate using the digital readout when desired

180 –

170 –

160 –

150 –

140 –

130 –

120 –

110 –

100 –

90 –

80 –

0 –

174±3

166±4

158±4155±5

146±3

92±289±3 90±2

88±282±2

Specialist FamilyPhysician

ResearchTechnician

BpTRU Ambulatory BP

Blo

od

Pre

ssu

re (

mm

Hg

)

Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B

Study ResultsStudy Results


Study ConclusionsStudy Conclusions

• The patient’s presence in the doctor’s office or research unit in itself appears to be partly responsible for the white coat effect.

• BP readings taken on the initial visit tend to be higher than other readings.

• The white coat effect can be partly eliminated by the use of an automated BP recording device (BpTRU)

• BP readings recorded by the BpTRU device are similar to readings taken by an experienced research technician using CHS Guidelines.

Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B


2003


Hypertension anddiabetes

Non adherence

Which patients?

Further assessusing

ambulatoryblood pressure

monitoring

Normal

Home BP?Office-induced blood

pressure elevation

BP over 135/85 mm Hg should be considered elevated

Home (Self) Measurement of BP:Specific Role in Selected Patients


2003


Home (Self) Measurement of BP:Patient Education

AAMI=Association for the Advancement of Medical Instrumentation;BHS=British Hypertension Society; IP: International Protocol.

Values over135 / 85 mm Hg

should beconsidered elevated

How to?

Adequate patient training in:- measuring their BP- interpreting these readings

Regular verifications- accuracy of the device- measuring techniques

Use devices:- appropriate for the individual (cuff size)- have met the standards of the AAMI

and or the BHS and or IP

Self measurement can help to improve patient adherence


Validated BP DevicesValidated BP Devices

• BHS– BHS = British

Hypertension Society

• AAMI – AAMI = American

Association of Medical Instruments

• See British Hypertension Society Website

• OMRON– HEM-705CP

– HEM-711AC

– HEM-722C

– HEM-773

• LifeSource AND – UA-767 CN

– UA-767 Plus

– UA-779

– UA-787


OMRONOMRON

• Claims all devices with exception of wrist devices are validated


OMROM HEM 711 AC $109.99

OMROM HEM 711 AC $109.99


LifeSourceUA-767PC LifeSourceUA-767PC

• For use with a PC and Monitor Pro software.

• Stores and analyzes recorded blood pressure data directly from the UA-767PC.

• The software provides printable summary reports and graphing capabilities.

• Remotely monitor patients and their blood pressure from their homes.

Validated according to BHS* protocol and AAMI** approved.*BHS = British Hypertension Society**AAMI = American Association of Medical Instruments


Life Source UA779CN $99.99Life Source UA779CN $99.99


No charge……? ValidityNo charge……? Validity


When would you order ambulatory Blood pressure Monitoring?

When would you order ambulatory Blood pressure Monitoring?

• For Dx mild to mod HTN• For elderly women with ISH• For apparent Rx resistance• For anxiety prone patients• When marked fluctuations in office BP present• For symptoms suggestive of hypotension present on

Rx • White coat HTN unlikely

– If DM coexists– If TOD present


2003


Ambulatory BP Monitoring:Specific Role in Selected Patients*

Untreated- Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and

without target organ damage

Treated patients- Apparent resistance to drug therapy

- Symptoms suggestive of hypotension

- Fluctuating office blood pressure readings

Which patients?Those with suspected office-induced BP elevation

* Where available


2003


Ambulatory BP MonitoringSpecific Role in Selected Patients

* A drop in nocturnal BP of <10% is associated with increased risk of CV events

How to interpret?

Mean daytime ambulatory blood pressure

>135/85 mm Hg

is considered elevated

Use validated devicesHow to ?


Current evidence suggests that:

Blood Pressure and Target Organ Damage (TOD)

Blood Pressure and Target Organ Damage (TOD)

• 24-h blood pressure correlates most closely with TOD (compared to clinic or casual BP)

• Higher incidence of cardiovascular events when blood pressure remains elevated at night (non-dippers)

• Blood pressure variability is an independent determinant of TOD

• Highest incidence of cardiovascular events occurs in AM

Adapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987; Parati, et al. 1987; Mancia. 1990.


24-Hour Blood Pressure Profile: Two Patients with Hypertension 24-Hour Blood Pressure Profile: Two Patients with Hypertension

Blood pressure (mm Hg)

7:00 11:00 15:00 19:00 23:00 3:00 7:00

Sleep

Dipper

Non-dipper

Time of day

175

135

115

95

75

55

155

Adapted from: Redman, et al. 1976; Mancia, et al. 1983; Kobrin, et al. 1984; Baumgart, et al. 1989; Imai, et al. 1990; Portaluppi, et al. 1991.


24-Hour Blood Pressure Profile:The Morning Blood Pressure ‘Surge’

24-Hour Blood Pressure Profile:The Morning Blood Pressure ‘Surge’

Time of day

Blood pressure (mm Hg)

18:00 22:00 02:00 06:00 10:00 14:00 18:00

Time of awakening

Sleep180

160

140

120

100

80

Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.


Ischemia (min)

Adapted from: Rocco, et al. 1987.

01:00 05:00 09:00 13:00 17:00 21:00

300

150

250

200

100

50

0

n=24

Circadian Incidence of Cardiovascular Events: Myocardial Ischemia

Circadian Incidence of Cardiovascular Events: Myocardial Ischemia

Time of day


2003


Recommendations for Follow-up

Are BP readings below target during 2 consecutive visits?

Non Pharmacological treatment

With or without Pharmacological treatment

Diagnosis of hypertension

Follow-up at 3-6 month intervals

Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage

NoYes

NoYes

More frequentvisits

Monthly visits

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This platform has been started byThis platform has been started byParveen Kumar Chadha with the vision that Parveen Kumar Chadha with the vision that nobody should suffer the way he has suffered nobody should suffer the way he has suffered because of lack and improper healthcare because of lack and improper healthcare facilities in India. We need lots of funds facilities in India. We need lots of funds manpower etc. to make this vision a reality manpower etc. to make this vision a reality please contact us. Join us as a member for a please contact us. Join us as a member for a noble cause.noble cause.

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