1. Blood Pressure Assessment and Stroke 2009 Preventing Strokes One At a Time

2. Blood Pressure & Stroke Upon completion, participants will be able to:  Practice according to the Canadian Best Practice Recommendations for Stroke Care as they relate to blood pressure  Discuss the impact of hypertension on stroke risk  Use proper technique when taking a blood pressure  Monitor and interpret blood pressure reading according to Canadian Hypertension Education Program recommendations  Teach patient the why & how of proper blood pressure measurement LEARNING OBJECTIVES

3. Blood Pressure & Stroke  Hypertension Overview  Blood Pressure Targets  Blood Pressure Measurement  Office  Home  Ambulatory Blood Pressure Monitor Content from the following slides is derived from the Canadian Hypertension Education Program Recommendations, 2009 www.hypertension.ca/blood pressurec www.hypertension.ca/blood pressurec Outline

4. Blood Pressure 2.2a Blood Pressure Assessment  All persons at risk for stroke should have their blood pressure measured at each healthcare encounter but no less than once annually.  Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement  Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program.  Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications. CMAJ 2008;179(12 Suppl):E1-E93. Canadian Best Practice Recommendations for Stroke Care, 2008

5. Blood Pressure 2.2b Blood Pressure Management  The Canadian Stroke Strategy recommends target blood pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events.  For prevention of first stroke in the general population the systolic blood pressure treatment goal is a pressure level of less than 140 mm Hg  The diastolic blood pressure treatment goal is a pressure level of less than 90 mm Hg  Blood pressure lowering treatment is recommended for patients who have had a stroke or transient ischemic attack to a target of less than 140/90 mm Hg  In patients who have had a stroke, treatment with an angiotensin-converting enzyme (ACE) inhibitor and diuretic is preferred CMAJ 2008;179(12 Suppl):E1-E93. Canadian Best Practice Recommendations for Stroke Care, 2008

6. 2.2b Cont’d  Blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke in patients with diabetes to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg  Blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke in patients with non diabetic chronic kidney disease to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg  RCTs have not defined the optimal time to initiate BP lowering therapy after stroke or TIA. It is recommended that blood pressure lowering treatment be initiated (or modified) before discharge from hospital.  For recommendations on specific agents and sequence of agents refer to the current CHEP guidelines www.hypertension.ca/chep www.hypertension.ca/chep

7. Modifiable Risks for Developing Hypertension  Obesity  Poor dietary habits  High sodium intake  Sedentary lifestyle  High alcohol consumption 2009 Canadian Hypertension Education Program Recommendations

8. Challenges to Hypertension Management: Public Perceptions  80% of people were unaware of the association between hypertension and CVD  63% believed that hypertension was not a serious condition  38% of people thought they could control high blood pressure without the help of a health professional Can J Cardiol 2005;21:589-93 2009 Canadian Hypertension Education Program Recommendations

9. Question What is the office blood pressure target for a patient with diabetes and/or renal disease? a. < 140/90 b. < 135/85 c. < 160/100 d. < 130/80 e. < 120/80

10. Blood Pressure Targets for the Treatment of Hypertension ConditionTarget Isolated systolic hypertension<140 mmHg Systolic/Diastolic Hypertension Systolic blood pressure Diastolic blood pressure <140 mmHg <90 mmHg Diabetes or Chronic Kidney Disease Systolic Diastolic <130 mmHg <80 mmHg 2009 Canadian Hypertension Education Program Recommendations

11. Question By how many mmHg do you need to lower blood pressure in order to decrease CV risk? a. 2 mmHg b. 5 mmHg c. 10 mmHg d. 15 mmHg e. 20 mmHg

12. Question At what blood pressure does the risk for cardiovascular disease and stroke start to increase? a. > 140/90 b. > 130/80 c. > 110/75 d. < 150/95 e. < 120/85

13. Blood Pressure Measurement  Office (OBPM)  Home (HBPM)  Ambulatory Blood Pressure Monitoring (ABPM) 2009 Canadian Hypertension Education Program Recommendations

14. Resting Blood Pressure Measurement Doing it Right! Recommendations

15. Question How long should a patient rest prior to taking a resting blood pressure measurement? a. 1 minute b. 2 minutes c. 5 minutes d. 10 minutes e. No rest is required

16. Types of Readings  Casual blood pressure - a measurement taken without the required 5 minute rest period  Resting blood pressure - the seated resting blood pressure is used to determine and monitor treatment decisions  Standing blood pressure - is used to test for postural hypotension, which may modify treatment if present 2009 Canadian Hypertension Education Program Recommendations

17. Observer  Positioned comfortably to obtain measurement  Manometer at eye level  Well maintained stethoscope  Clean earpieces 2009 Canadian Hypertension Education Program Recommendations

18. Patient Preparation  No caffeine for 30 – 60 minutes  No smoking for 30 minutes  No exercise for 30 minutes  Bladder/Bowel comfortable  Quiet/temperate, relaxed environment, no talking  Bare arm with no constrictive clothing  Patient should stay silent prior and during the procedure  No acute anxiety, stress or pain 2009 Canadian Hypertension Education Program Recommendations

19. Posture  Calmly seated for 5 minutes  Back well supported  Arm relaxed & supported at heart level  Legs uncrossed, feet flat on the floor 2009 Canadian Hypertension Education Program Recommendations

20. Recommended Equipment for Measuring Blood Pressure Mercury manometerRecently calibrated aneroid Validated automated device 2009 Canadian Hypertension Education Program Recommendations

21. BpTRU  Automated, non invasive monitor that measures blood pressure and pulse in patients using upper arm cuff  Device automatically inflates and deflates the cuff  Uses oscillometric technique  Has 2 operational modes  Manual mode to take one blood pressure measurement  Automatic mode takes 6 measurements, discards the first, and displays the average of the next 5 readings. Product Overview 2009 Canadian Hypertension Education Program Recommendations

22. Cuff Size  Measure arm circumference midpoint b/w shoulder and elbow  Bladder must encircle at least 80% of arm circumference  Lower edge of cuff placed 2-3 cm above elbow crease  Bladder centered over the brachial artery  Tell patient their cuff size 2009 Canadian Hypertension Education Program Recommendations

23. Cuff Position & Dimensions (no standardization between manufacturers)  Locate the brachial pulse and centre the cuff bladder over it  Position cuff at heart level. Circumference of Adult ArmSize of Bladder (cm) 18-26 cm9x18 (Child) > 26-33 cm12x23 (Regular Adult) > 33-41 cm15X33 (Large) > 41 cm18x36 (Extra Large) 2009 Canadian Hypertension Education Program Recommendations

24. Office Technique  On initial visit, blood pressure should be taken in both arms and subsequently it should be measured in the arm with the highest reading. Inform the patient  Duplicate, resting readings, 1 – 2 minutes apart, should be taken at each visit  If readings vary by > 5mmHg, the readings should be repeated until 2 consecutive readings are comparable  Standing blood pressure @ 1 & 3 minutes 2009 Canadian Hypertension Education Program Recommendations

25. Palpation  Determine systolic blood pressure by palpation to decrease pain and exclude possibility of systolic auscultatory gap 1.Palpate the radial pulse 2.Inflate quickly to 60 mmHg and then by increments of 10mmHg until the pulse disappears = estimated palpated systolic pressure 3.Slowly deflate at a rate of 2 mmHg/second until the pulse reappears to confirm your palpated systolic pressure 4.Add 30 mmHg to this number to determine you Maximum Inflation Level (MIL) 2009 Canadian Hypertension Education Program Recommendations

26. Korotkoff Sounds and Auscultatory Gap Systolic blood pressure 200 180 160 140 120 100 80 60 40 20 0 No sound Clear sound Muffled sound No sound Phase 1 Phase 3 Phase 4 Phase 5 MufflingPhase 2 Auscultatory gap No sound mm Hg Korotkoff sounds 2009 Canadian Hypertension Education Program Recommendations

27. Auscultation 1.Palpate, then place stethoscope over brachial artery 2.Inflate cuff pressure to the MIL 3.Deflate cuff pressure by 2 mmHg per second Appearance of 2 regular tapping sounds Korotkoff phase I = systolic pressure 4.Continue to decrease pressure by 2 mmHg per second Disappearance of sound Korotkoff phase V = diastolic pressure 5.If DBP>90 mmHg listen for an additional 30mmHg to rule out Diastolic auscultatory gap 6.Record measurement 2009 Canadian Hypertension Education Program Recommendations

28. The Concept of White Coat vs Masked Hypertension From Pickering et al, Hypertension 2002 Office SBP mmHg Home or ABPM SBP mmHg True Hypertensive True Normotensive White Coat Hypertension Masked Hypertension 135 140 135 140 2009 Canadian Hypertension Education Program Recommendations

29. The Prognosis of Masked hypertension J Hypertension 2007;25:2193-98 Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients). 2009 Canadian Hypertension Education Program Recommendations

30. Question What is the target home blood pressure for a patient without Diabetes Mellitus or Chronic Kidney Disease? a. < 120/80 b. < 125/75 c. < 130/80 d. < 135/85 e. < 140/90

31. OBPM HBPM, ABPM Equivalence A clinic blood pressure of 140/90 mmHg has a similar risk of a: DescriptionBlood Pressure mmHg Home pressure average135 / 85 Daytime average ABP135 / 85 24-hour average ABP130 / 80 2009 Canadian Hypertension Education Program Recommendations

32. Important Role for Home Blood Pressure Measurement  Measuring blood pressure at home has a stronger association with CV prognosis than office based readings  Home measurement can help to:  confirm the diagnosis of hypertension  improve blood pressure control  reduce the need for medications  improve medication adherence in non adherent patients  help to identify white coat and masked hypertension 2009 Canadian Hypertension Education Program Recommendations

33. Home Measurement of Blood Pressure: Use Validated Blood Pressure Measurement Devices This logo* on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement * Endorsed by the Canadian Hypertension Society 2009 Canadian Hypertension Education Program Recommendations

34. Home measurement of blood pressure A poster and instruction sheets can be ordered at the Heart and Stroke Foundation offices or on- line at: http://hypertension.ca/bpc/ wp- content/uploads/2008/03/bil ingualposterorderform.pdf 2009 Canadian Hypertension Education Program Recommendations

35. Patient Instructions  Use a validated monitor  Correct cuff size  Accurate resting technique  Patient technique should be reviewed regularly  Duplicate measurements 1-2 min. apart  7 days after any Rx change or before a doctor’s appointment  AM (before Rx) & PM (2 hrs. after dinner) 2009 Canadian Hypertension Education Program Recommendations

36. Ambulatory Blood Pressure Monitor (ABPM)  Shows blood pressure pattern over a 24 hour period  Measures blood pressure through oscillometric technology which depends on the pulsatility in the brachial artery  Arm must stay motionless during inflation and deflation  Less accurate at extremes of systolic and diastolic blood pressure 36 2009 Canadian Hypertension Education Program Recommendations

37. Diurnal Pattern/Circadian Rhythm  Abnormalities in pattern are associated with increased CV events  Dipping is good  Circadian rhythm of blood pressure is a >10% fall in blood pressure during sleep  A non-dipping pattern is associated with an increase risk of MI, stroke, dementia as blood pressure remains elevated during sleep 2009 Canadian Hypertension Education Program Recommendations

38. Benefits 24 hour ABPM  Provides large number of blood pressure readings outside clinic setting  Helps determine the dynamic changes of blood pressure throughout 24 hour period  Enables physician to adjust treatment appropriately to prevent target organ complications  Rules out ‘White Coat’ hypertension  Used to aid in diagnosis of ‘Masked Hypertension’  Identifies ‘Dippers’ vs. ‘Non-dippers’ 2009 Canadian Hypertension Education Program Recommendations

39. Take Home Message To take accurate blood pressure readings you must ensure: 1.Proper cuff size 2.Validated monitor 3.Accurate resting technique Both in the doctor’s office and at home! 2009 Canadian Hypertension Education Program Recommendations

40. Blood Pressure  www.heartandstroke.ca/BP www.heartandstroke.ca/BP  To monitor home blood pressure and encourage self management of lifestyle  www.hypertension.ca CHEP, 2009 Resources www.hypertension.ca  Health Professional Resources: o Diagnosis of hypertension o Assessment o Treatment o Blood pressure measurement  Patient Resources: www.hypertension.ca/bpcwww.hypertension.ca/bpc o How to take a proper blood pressure o Home blood pressure monitors o Patient education 2009 Canadian Hypertension Education Program Recommendations

41. Canadian Best Practice Recommendations for Stroke Care, updated 2008 www.canadianstrokestrategy.ca