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High Blood Pressure: problems, solutions and research. Dr Martin Schultz Menzies Research Institute Tasmania University of Tasmania, Hobart, Australia.

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Presentation on theme: "High Blood Pressure: problems, solutions and research. Dr Martin Schultz Menzies Research Institute Tasmania University of Tasmania, Hobart, Australia."— Presentation transcript:

1 High Blood Pressure: problems, solutions and research. Dr Martin Schultz Menzies Research Institute Tasmania University of Tasmania, Hobart, Australia. Martin.Schultz@utas.edu.au Wednesday 23 rd July 2014 Glenorchy School For Seniors

2 Who am I? Postdoctoral research fellow – Menzies Research Institute Tasmania - Heart Foundation fellowship for 2014-2016. Exercise Physiologist Menzies’ blood pressure research group member – led by Associate Professor James Sharman

3 What do we do? Our aim is to improve health outcomes related to high blood pressure.  Clinical research in humans Currently undertaking research projects to: 1)Determine the clinical value of new methods for the detection and management of high blood pressure. e.g. Central BP. 2)Understand the physiology of blood pressure in the human cardiovascular system at rest and during exercise. 3)Establish the role of low stress or ‘moderate’ physical activity blood pressure as a clinical tool.

4 Blood Pressure (BP) – What is it? Two BP values: 1. Systolic (e.g. 120) Maximal pressure exerted within the artery during cardiac contraction (systole) 2. Diastolic (e.g. 80) Minimal pressure during cardiac relaxation (diastole)

5 What are we measuring when assessing BP? 120 mmHg 80 mmHg Systolic BP Diastolic BP Extremes of pulse pressure Estimation of the ‘load’ imposed on the heart and other important organs

6 High blood pressure ‘hypertension’ Continuum of risk related to high BP CV disease risk Blood pressure (mmHg) Hypertension #1 modifiable risk factor for cardiovascular disease

7 Hypertension A major health problem in Tasmania >30% of adult Tasmanians have high blood pressure – the most of any Australian state Many have uncontrolled or undiagnosed high blood pressure Australian survey data 40% of people with high blood pressure are obese, with a further 35% overweight One third of those with unmanaged or uncontrolled blood pressure also have high cholesterol levels Most complete no or very little physical activity Significant action required!

8 BP is normally assessed in the clinic under conditions of rest. How does a Dr normally assess BP? Diagnosis of hypertension Several measures over several visits In conjunction with other risk factors (absolute cardiovascular risk assessment)

9 Associated with stiff arteries: Elderly Classification based on Clinic BP

10 Mancia G, et al Guidelines for the management of arterial hypertension J Hypertens. 2013;31:1281-1357. Clinic BP problems: time and technique! Recommendations Allow patient to sit for 3 – 5 mins No talking, back supported, feet on floor, legs uncrossed, appropriate cuff size, arm at heart level Check BP in both arms; continue on arm with highest reading Take at least 2 BP measures, spaced 1 – 2 mins apart Take additional BPs if first 2 are ‘quite different’ Take after 1 and 3 mins standing (at first visit) in elderly, T2DM or when OH suspected

11 Definition High Clinic BP but normal outside clinic BP Prevalence; o 13% (9 – 16% general population/practice) o 32% (25 – 46% hypertensive patients) 1 More common in; o Older people, females, non smokers, glucose intolerance 2 o People having BP measured by doctor (alarm response) 1. Fagard RH et al, J Hypertens. 2007;25:2193-2198. 2. Mancia G et al, J Hypertens. 2013;31:1281-1357. Problem - White coat hypertension

12 What happens to BP classification? True BP Measured BP Measured BP

13 Problem - Masked hypertension Definition Normal clinic BP with high outside clinic BP (reverse white coat hypertension) Prevalence; o 10 – 19% general population/practice o >50% in patients with exercise hypertension 1 o 29 – 46% patients with T2DM 2 o Up to 50% in patients with treated hypertension 3  Elevated CV risk - 3 x times greater risk compared to people with normal BP 1. Scott J et al, Am J Hypertens. 2008;21:715-721. 2. Franklin SS et al Hypertension. 2013;61(5):964-71. 3. Bobrie G et al, J Hypertens. 2008;26:1715-1725.

14 Masked Hypertension Major problem: Given that those with masked hypertension have normal clinic (rest) BP readings, many individuals who may be at risk simply pass through the clinic without a diagnosis.

15 True BP Measured BP Measured BP What happens to BP classification?

16 Solutions MethodSummary Out of clinic BP1.7 day home BP – 2 readings morning and evening (averaged) 2.24 hour ambulatory BP – 20 mins day, 30 mins night (average day, night and overall) Automated in clinic BPOperator independent, average of repeat measures (15 mins), separate room Menzies BP ClinicOpen for referral of difficult BP cases

17 Solutions MethodSummary Out of clinic BP1.7 day home BP – 2 readings morning and evening (averaged) 2.24 hour ambulatory BP – 20 mins day, 30 mins night (average day, night and overall) Automated in clinic BPOperator independent, average of repeat measures (15 mins), separate room Menzies BP ClinicOpen for referral of difficult BP cases

18 Automated Office BP Automated machine required Quite room, no distractions or personal. 3 measurements taken over 15 minutes (average) Removes ‘white coat effect’ Values more closely reflect that of home/self BP measurements and may be a better representative of BP control. 1 1. Myers et al. Hypertens. 2009 Feb;27(2):280-6.

19 Solutions MethodSummary Out of clinic BP1.7 day home BP – 2 readings morning and evening (averaged) 2.24 hour ambulatory BP – 20 mins day, 30 mins night (average day, night and overall) Automated in clinic BPOperator independent, average of repeat measures (15 mins), separate room Menzies BP ClinicOpen for referral of difficult BP cases Measuring Central BPResearch technique with building clinical efficacy

20 Menzies BP Clinic Overview o Specialist BP clinic (Prof’s Tom Marwick, Matthew Jose, Mark Nelson) – referral from GP o Dedicated clinic co-ordinator - Talia Sleiters o Bulk billed service (within 2 weeks of referral) o Patients with ‘difficult to treat hypertension’ o Comprehensive investigation & risk assessment with plan for return to GP care o Summary letter with any relevant clinical results i.e. 24-hour or 7-day monitoring, pathology tests, ECHO/ECG reports

21 Menzies BP Clinic Data o Clinic, home, 24ABPM, Auto in clinic BP (brachial and central), aortic stiffness, CO, SV o Bloods/urine (DNA, white cells) o Anthropometry o Questionnaires (QOL, PA) o MoCA cognitive and frailty assessment o Retinal photography o Clinical tests (echo, IMT) o Data linkage (hospitalisations, events, mortality) Referrals o Via GP software “Best practice”

22 Patient experience – discharge questionnaire “Friendliness and professionalism of all staff and volunteers” “I got confirmation that my blood pressure was not an immediate risk and that anxiety was a contributing factor in my condition” “The information received put my mind at ease about my blood pressure problem”

23 Solutions MethodSummary Out of clinic BP1.7 day home BP – 2 readings morning and evening (averaged) 2.24 hour ambulatory BP – 20 mins day, 30 mins night (average day, night and overall) Automated in clinic BPOperator independent, average of repeat measures (15 mins), separate room Menzies BP ClinicOpen for referral of difficult BP cases Measuring Central BPResearch technique with building clinical efficacy Predicts CV mortality independent of brachial BP

24 What are we measuring when assessing BP? 120 mmHg 80 mmHg Systolic BP Diastolic BP Extremes of pulse pressure at the upper arm! Central (aortic) BP May better predict adverse CV outcomes

25 Brachial BP 150/ 77 mmHg Brachial BP 150 / 78 mmHg Central BP 139 / 77 mmHg Central BP 131 / 79 mmHg Person A Person B Schultz MG et al. 2012. Eur J Clin Invest, 42(4):393-401. Central BP

26 Major discrepancies in central BP among people with similar brachial BP Overlap in central SBP between brachial BP categories

27 Central BP bedside: non invasive measurement Radial applanation tonometry (valid, 1 reproducible 2 ) 1.Sharman JE et al Hypertension. 2006 Jun;47(6):1203-8. 2.Holland DJ et al. Am J Hypertens. 2008;21(10):1100-6.

28 Cuff central BP from brachial waveform analysis

29 BP GUIDE Study @ Menzies’ = Less use of antihypertensive medication Sharman JE et al. Hypertension. 2013 Dec;62(6):1138-45.

30 Lowering Central BP Lowering BP with medication improves outcomes, but….. Even in populations with normal upper arm (brachial) BP there remains considerable residual risk for CVD. 1 Much of this risk may be due to persistently elevated central BP. 2,3 Despite this….. There has never been a trial to determine the clinical value of targeted central BP lowering. Important study to be undertaken before central BP may be routinely used as a clinical tool. 1.Cushman WC, et al. N Engl J Med.362:1575-1585. 2.Schultz M et al. Eur J Clin Invest. 2012;42(4):393-401. 3.Vlachopoulos C et al. Eur Heart J. 2010;15:1865-71.

31 The LOW CBP Trial @ Menzies Current NHMRC funded multi-centre (Hobart, Canberra, Brisbane) randomised trial over 2 years. 300 patients treated for hypertension who have controlled brachial BP (<140/90 mmHg) but relatively high central SBP. Randomised to receive a medication that selectively lowers central BP or usual care. Findings expected to open the way towards a new and refined target for BP control to lower CVD risk in the broad hypertensive community.

32 Brachial BP 150/80 mmHg Person A Targeting Central BP Central BP 147/81 mmHg Brachial BP 150/80 mmHg Person B Central BP 122/81 mmHg LOWCBP study

33 How can I get involved? Always Talk to your GP first if you are concerned about your BP If you would like to find out if you are eligible to participate in the ‘LOW CBP Trial’ or other Menzies projects, please contact us.

34 Thanks For Listening! Question’s?


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