1. Office and Home Blood Pressure Assessment Hypertension Diagnosis and Follow up 2011 Canadian Hypertension Education Program Recommendations

2. Hypertension Canada and the Canadian Hypertension Education Program Instructions for proper blood pressure measurement are found in the detailed recommendations of the CHEP program (Can J Cardiol 2010;26(5):241-248), at www.hypertension.ca www.hypertension.ca

3. Blood Pressure Measurement and Hypertension Diagnosis 1 in 5 adult Canadians have hypertension Over 40% of Canadians at aged 56-65 have hypertension 90% of normotensive persons aged 55-65 developed hypertension in the next 20 years in the Framingham study

4. Blood pressure of all adults should be measured by a trained healthcare professional at all appropriate visits: –To determine cardiovascular risk –To monitor antihypertensive treatment Blood pressure of adults with high normal blood pressure (130-139/80-89 mmHg) should be assessed annually Blood Pressure Assessment

5. Wilkins et al. Health Reports Feb 2010 Prevalence of Hypertension in Canada Mean systolic and diastolic BP by sex and age group, household population aged 20-79 years, March 2007 to February 2009

6. Prevalence of Hypertension in Canada Wilkins et al. Health Reports Feb 2010

7. Life time Risk of Hypertension in Normotensive Women and men aged 65 years Risk of Hypertension % 0 2 4681012 14161820 Years to Follow-up Women Risk of Hypertension % Years to Follow-up 0 2 4681012 14161820 Men JAMA 2002:297:1003-10. Framingham data. 100 80 60 40 20 0 100 80 60 40 20 0

8. Modifiable risks for developing hypertension Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption

9. Development of hypertension (%) in people with high normal blood pressure Framingham cohort Vasan. Lancet 2001;358:1682-86

10. New onset hypertension in people with high normal blood pressure 772 subjects, overweight, mean age 48.5 Not receiving treatment for hypertension Average of 3 blood pressures at baseline: –SBP 130-139 and DBP < 89 OR –SBP < 139 and DBP 85-89 Primary endpoint – new onset hypertension NEJM 2006;354:1685-97

11. New onset hypertension in people with high normal blood pressure NEJM 2006;354:1685-97

12. New onset hypertension in people with high normal blood pressure 40% of overweight patients with systolic 130-139 or diastolic 85-89 mmHg developed hypertension in 2 years and 63% in 4 years Annual follow-up of patients with high normal blood pressure is recommended by CHEP

13. Blood Pressure Assessment: Patient preparation and posture Standardized Preparation: Patient 1.No acute anxiety, stress or pain. 2.No caffeine, smoking or nicotine in the preceding 30 minutes. 3.No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4.Bladder and bowel comfortable. 5.No tight clothing on arm or forearm. 6.Quiet room with comfortable temperature 7.Rest for at least 5 minutes before measurement 8.Patient should stay silent prior and during the procedure.

14. Blood Pressure Assessment: Patient preparation and posture Standardized technique: Posture The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.

15. Blood Pressure Assessment: Patient position X

16. Recommended Equipment for Measuring Blood Pressure Use a mercury manometer or a recently calibrated aneroid or a validated automated device. Aneroid devices should only be used if there is an established calibration check every 12 months.

17. Recommended Equipment for Measuring Blood Pressure Automated oscillometric devices: Use a validated automated device according to BHS, AAMI or IP clinical protocols. For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement. AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol.

18. Recommended Technique for Measuring Blood Pressure (cont.) Select a device with an appropriate size cuff

19. Use an appropriate size cuff Arm circumference (cm)Size of Cuff (cm) From 18 to 269 x 18 (child) From 26 to 3312 x 23 (standard adult model) From 33 to 4115 x 33 (large) More than 4118 x 36 (extra large, obese) For automated devices, follow the manufacturer’s directions. For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

20. Recommended Technique for Measuring Blood Pressure (cont.) Locate the brachial pulse and centre the cuff bladder over it Position cuff at the heart level Arm should be supported

21. Recommended Technique for Measuring Blood Pressure* (cont.) To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse Place stethoscope over the brachial artery *with manual or semi automated devices

22. Recommended Technique for Measuring Blood Pressure* (cont.) Drop pressure by 2 mmHg / beat –Appearance of sound (phase I Korotkoff) = systolic pressure Drop pressure by 2 mmHg / beat –Disappearance of sound (phase V Korotkoff) = diastolic pressure Record measurement Take at least 2 blood pressure measurements, 1 minute apart *with manual or semi automated devices

23. Korotkoff sounds and auscultatory gaps Systolic BP Diastolic BP 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 mmHg Korotkoff sounds Phase 4 Phase 3

24. Recommended Technique for Measuring Blood Pressure Standardized technique: For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading. Thereafter, take two measurements on the side where BP is higher.

25. Recommended Technique for Measuring Blood Pressure* (cont.) Record the blood pressure to the closest 2 mmHg on the manometer and whether the patient was supine, sitting or standing. Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months). * For manual blood pressure measurement

26. Recommended Technique for Measuring Blood Pressure* (cont.) Avoid digit preference for five (5) or zeros (0) by not rounding up or down. Record the heart rate. If the needle on an aneroid device is not zero it is inaccurate; however, the converse is not true. * For manual blood pressure measurement

27. Recommended Technique for Measuring Blood Pressure (cont.) The seated BP measurement is the standard position to determine diagnostic and therapeutic treatment decisions The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment.

28. Recommended Technique for Measuring BP: Standing BP Perform in patients –over age 65 –with diabetes –if there are symptoms of postural hypotension Check after 1 to 5 minutes in the standing position and under circumstances when the patient complains of symptoms suggestive of hypotension

29. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement Elevated Out of the Office BP measurement Elevated Random Office BP Measurement Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 2 within 1 month Yes BP ≥ 140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110? Diagnostic tests ordering at visit 1 or 2 Diagnostic tests ordering at visit 1 or 2 Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN BP: 140-179 / 90-109 No HTN = hypertension

30. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement BP: 140-179 / 90-109 ABPM (If available) Clinic BPM HBPM Yes Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110? Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110? Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN No HBPM = Home Blood Pressure Measurement

31. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement BP: 140-179 / 90-109 ABPM (If available) Clinic BP HBPM Diagnosis of HTN Awake BP ≥ 135 SBP or ≥ 85 DBP Or 24-hour ≥ 130 SBP or ≥ 80 DBP Awake BP ≥ 135 SBP or ≥ 85 DBP Or 24-hour ≥ 130 SBP or ≥ 80 DBP Awake BP < 135/85 and 24-hour < 130/80 Awake BP < 135/85 and 24-hour < 130/80 Continue to follow-up Diagnosis of HTN Hypertension visit 3 ≥ 160 SBP or ≥ 100 DBP ≥ 140 SBP or ≥ 90 DBP < 140 / 90 Diagnosis of HTN Continue to follow-up < 160 / 100 Hypertension visit 4-5 ABPM or HBPM or ≥ 135 SBP or ≥ DBP 85 < 135/85 Diagnosis of HTN Continue to follow-up or

32. The concept of masked hypertension From Pickering, Hypertension 1992 Office SBP mmHg Home or daytime ABPM SBP mmHg True hypertensive True Normotensive White Coat HTN Masked HTN 135 140 135 140

33. The prognosis of masked hypertension Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients). J Hypertension 2007;25:2193-98

34. Threshold for Initiation of Treatment and Target Values ConditionInitiation SBP / DBP mmHg Diastolic ± systolic hypertension  140/90 Isolated systolic hypertension SBP >160 Home BP measurement (no diabetes, renal disease or proteinuria) (  135/85) Diabetes or chronic kidney disease  130/80 Target SBP / DBP mmHg <140/90 <140 <135/85 <130/80

35. VII. Home measurement of blood pressure Home BP measurement should be encouraged to increase patient involvement in care Which patients? –For the diagnosis of hypertension –Suspected non adherence –White coat hypertension or effect –Masked hypertension Average BP equal to or over 135/85 mmHg should be considered elevated

36. Benefits of Home Blood Pressure Monitoring Rapid confirmation of the diagnosis of hypertension Better prediction of cardiovascular prognosis Diagnosis of white coat and masked hypertension Reduced medication use in white coat effect Improved adherence to drug therapy Better blood pressure control

37. Not all patients are suited to home measurement Undue anxiety in response to high blood pressure readings Physical or mental disability prevents accurate technique or recording Arm not suited to blood pressure cuff (e.g. conical shaped arm) Irregular pulse or arrhythmias prevent accurate readings Lack of interest The vast majority of patients can be trained to measure blood pressure

38. Average home BP > 135/85 mmHg should be considered elevated Home Measurement of BP: Use validated BP 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

39. VII. Suggested Protocol for Home Measurement of Blood Pressure for the Diagnosis of Hypertension Home blood pressure values should be based on: –duplicate measures, –morning and evening, –for an initial 7-day period. Singular and first day home BP values should not be considered. Daytime average BP equal to or over 135/85 mmHg should be considered elevated

40. Home Measurement of BP: Patient Education How to? Use devices: –appropriate for the individual –appropriate cuff size –marked with this symbol Adequate patient training in: –measuring their BP –interpreting these readings Regular verification –measuring techniques Home measurement can help to improve patient adherence Values > 135 / 85 mmHg should be considered elevated

41. Suggested Protocol for Home Measurement of Blood Pressure How? Home blood pressure values for assessing white coat hypertension or sustained hypertension should be based on: –Duplicate measures, –Morning and evening, –For an initial 7-day period. Single readings and first day home BP values should not be considered

42. VII. Home Measurement of BP: Patient Education Assist patients to select a model with the correct size of cuff –Measure and record the patients mid arm circumference so they can match it to cuff size Recommend devices listed at www.hypertension.ca or marked with this symbolwww.hypertension.ca Ask patients to carefully follow the instructions with device and to record only those blood pressure readings where they have followed recommended procedure Advise patients that average readings equal to or over 135/85 mmHg are high –a lower threshold is appropriate for those with diabetes or chronic kidney disease Home measurement can help to improve patient adherence Values equal to or over 135 / 85 mmHg should be considered elevated for those without diabetes or chronic kidney disease

43. Web based home monitoring A website to assist patients to monitor and track home blood pressure and support self management including healthy lifestyle change is available at: www.heartandstroke.ca/BP www.heartandstroke.ca/BP

44. Advice for patients on when to contact a health care professional based on high average home blood pressure readings* Systolic BP (mmHg)Diastolic BP reading Less than 130Less than 85Usual follow-up 130-179*85-109*Check reading again using the correct technique. If the readings remain high, discuss with your healthcare provider at your next regularly scheduled appointment 180 – 199*110-119Check reading again using the correct technique. If the readings remain high, schedule an appointment with your doctor to discuss your treatment plan. More than 200*More than 120Check reading again using the correct technique. If the readings remain high, schedule an urgent appointment with your doctor to discuss your treatment plan. *(available at www.hypertension.ca in the resource section under educational tools for health care professionals in the Brief Hypertension Action Tool or at www.heartandstroke.ca/BP)www.hypertension.cawww.heartandstroke.ca/BP *Patients with diabetes, chronic kidney disease or who are at high risk of cardiovascular events require individualized advice.

45. Home measurement of blood pressure A poster and instruction sheets can be ordered at: www.hypertension.ca www.hypertension.ca

46. Suggested use of ABPM in the Management of Hypertension Adapted from White W, NEJM 348:24, June 12, 2003 ABPM: Ambulatory Blood Pressure Monitoring BP: Blood Pressure Office BP > 140/90 mmHg in low risk patients (with no target-organ disease) Home-monitored blood pressure <135/85mmHg Perform ABPM Mean awake BP Less than 135/85 mmHg Follow-up with periodic home- BP measurement and or repeated ABPM every 1-2yr. Mean awake BP equals or over 135/85 mmHg Home-monitored blood pressure equals or over 135/85mmHg Initiate antihypertensive therapy

47. 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 frequent visits Visits every 1-2 Months

48. Blood pressure measurement with specific devices Mercury Blood Pressure Monitor Aneroid Blood Pressure Monitor Automated Blood Pressure Monitor

49. Blood Pressure Measurement with Mercury Blood Pressure Monitor The patient should –Be calmly seated for at least 5 minutes –Have their back supported with a chair back –Have their arm bare or have thin clothing on –Have their arm supported at the level of the heart. –Have their feet on the floor and their legs should not be crossed. –Not talk prior and during the procedure. The column of mercury must be vertical, and at the observers eye level

50. Blood Pressure Measurement with Mercury Blood Pressure Monitor Use a cuff with the appropriate size Estimate the systolic beforehand: –Palpate the brachial artery –Inflate cuff until pulsation disappears –Deflate cuff –Estimate systolic pressure Inflate to 30mmHg above the estimated systolic level needed to occlude the pulse

51. Blood Pressure Measurement with Mercury Blood Pressure Monitor Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2mmHg/beat until you hear regular tapping sounds. Measure systolic (first regular sound) to nearest 2mmHg Deflate at a rate of 2 mmHg/heart beat to 10 mmHg below the last heard Korotkoff sound Measure diastolic blood pressure to nearest 2mmHg.

52. Blood Pressure Measurement with Aneroid Blood Pressure Monitor The patient should –Be calmly seated for at least 5 minutes –Have their back supported with a chair back –Have their arm bare or have thin clothing on –Have their arm supported at the level of the heart –Have their feet on the floor and their legs should not be crossed –Not talk prior and during the procedure. The manometer should be easily visible at the observer’s eye level Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

53. Use of standardized measurement techniques is recommended when assessing blood pressure When using automated office oscillometric devices such as the BpTRU, the patient should be seated in a quiet room (no specified period of rest). With the device set to take measures at 1 or 2 minute intervals, the first measurement is taken by a health professional to verify cuff position and validity of the measurement. The patient is left alone after the first measurement while the device automatically takes subsequent readings. The BpTRU automatically discards the first measure and averages the next 5 measures.

54. Blood Pressure Measurement with Aneroid Blood Pressure Monitor Estimate the systolic beforehand: a)Palpate the brachial artery b)Inflate cuff until pulsation disappears c)Deflate cuff d)Estimate systolic pressure when the pulse reappears Inflate to 30mmHg above the estimated systolic level needed to occlude the pulse Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

55. Blood Pressure Measurement with Aneroid Blood Pressure Monitor Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2mmHg/beat until you hear regular tapping sounds. Measure systolic (first regular sound) to nearest 2mmHg Deflate at a rate of 2mmHg/beat until disappearance. Measure diastolic blood pressure to nearest 2mmHg Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months).

56. Blood Pressure Measurement with Aneroid Blood Pressure Monitor Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months). If the needle on an aneroid device does not zero it is inaccurate; however the converse is not true.

57. Assessing the calibration of an aneroid device Attach the aneroid device and cuff to a mercury manometer using tubing and if necessary a ‘Y’ or ‘T’ connection (see diagram). Consider putting cotton wool in the T tube to prevent the mercury from oxidizing and becoming contaminated. Pump the cuff up and assess the pressure of the aneroid at 20 mmHg intervals from 300 mmHg to 60 mmHg. The aneroid is out of calibration if the readings are 4 or more mmHg different from the mercury device. Do not use the aneroid device if it reads 4 or more mmHg different from the mercury device at pressures where diagnosis or therapeutic decisions are made. Note: If the aneroid device does not read ‘0’ when there is no pressure in the cuff it is out of calibration

58. Attaching an aneroid device to a Mercury device for calibration testing Note: check the mercury column is at zero before testing.

59. Blood Pressure Measurement with a Fully Automated Home or Office Automated Blood Pressure Monitor The patient should be calmly seated for at least 5 minutes, with their back well supported and arm supported at the level of the heart. Their feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure. Ensure no tight clothing constricts the arm Use a cuff with the appropriate size Place the cuff on snuggly with the indicator mark on the cuff over the brachial artery Take at least two blood pressure measurements 1 minute apart Record measurement as displayed

60. Recommended automated blood pressure monitors for home blood pressure measurement Monitors A&D® or LifeSource® Models: 705, 767, 767PAC, 767Plus, 774, 774AC, 779, 787, 787AC Monitors Omron® Models: HEM-705 PC, HEM-711, HEM-741CINT Monitors Microlife® or Thermor® (also sold under different brand names) Models: BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP 3AC1-2, BP 3AG1, BP 3BTO-1,BP 3BTO-A (2), BP 3BTO-AP, RM 100, BP A100 Plus, BP A 100

61. For your patients – ask them to sign up at www.myBPSite.ca for free access to the latest information & resources on high blood pressure www.myBPSite.ca For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources www.htnupdate.ca