Presentation on theme: "HOME AND AMBULATORY BLOOD PRESSURE MONITORING"— Presentation transcript:
1 HOME AND AMBULATORY BLOOD PRESSURE MONITORING Home and ambulatory blood pressure monitoring are tools which are available to us now which we should undoubtedly be making use of. These modalities have really come of age. It has been said, and there is some truth in it, that most of the big outcome hypertension medication trials have been based on office blood pressure measurements. However, there is now ample evidence correlating ABPM and home BPM with cardiovascular outcome, and in fact they are both superior to office BP in predicting outcome
2 Both these modalities are useful because they get us a look at the patient’s blood pressure away from the office/clinic environment and also give us insight in to the 24-hour BP profile. You know that sleeping blood pressures should be the lowest, and the highest blood pressures are usually in the early morning – office/clinic blood pressures give us no information about these things. There is also potentially important information to be obtained with regard to timing of blood pressure medications;- most antihypertensives are supposed to last for 24 hours but many actually don’t. If the meducation is taken at 8am and you are seeing the patient at 11am their BP may be fine (3 hours post-dose) but you may be missing a potentually hazardous “early morning surge”.
3 Uses of ABPM and Home BPM Diagnosis of HypertensionDiagnosis of White Coat HypertensionDiagnosis of Masked HypertensionAssessment of prognostically important asleep and early morning blood pressuresMonitoring efficacy of treatment
4 Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure MeasurementElevated Out of the Office BP measurementElevated Random Office BP MeasurementHypertension Visit 1BP Measurement,History and Physical examinationHypertensiveUrgency / EmergencyDiagnosisof HTNDiagnostic tests orderingat visit 1 or 2YesBP ≥ 140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110?Hypertension Visit 2within 1 monthBP: /No
5 Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure MeasurementBP: /ABPM (If available)Clinic BPMHBPMYesHypertension Visit 2Target Organ Damageor Diabetesor Chronic Kidney Diseaseor BP ≥ 180/110?Hypertension Visit 1BP Measurement,History and Physical examinationHypertensiveUrgency / EmergencyDiagnosisof HTNNo
6 Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure MeasurementBP: /ABPM (If available)Clinic BPHBPM≥ 135 SBP or ≥ DBP 85< 135/85Diagnosisof HTNContinue to follow-uporDiagnosisof HTNHypertension visit 3≥ 160 SBP or ≥ 100 DBP≥ 140 SBP or≥ 90 DBP< 140 / 90Continue to follow-up< 160 / 100Hypertension visit 4-5ABPM or HBPMorDiagnosisof HTNAwake BP≥ 135 SBP or≥ 85 DBPOr 24-hour≥ 130 SBP or≥ 80 DBP< 135/85 and24-hour< 130/80Continue to follow-up
7 “Normal” Values Office BP < 140 / 90 (< 130/80 for DM, CKD, TOD) ABPM awake average < 135/85 (125/75 for DM, CKD, TOD)ABPM asleep average < 120/70Home BPM average < 135/85 (125/75 for DM, CKD, TOD)
8 The concept of masked hypertension 140TruehypertensiveMasked HTNHome or daytime ABPM SBP mmHg135135TrueNormotensiveWhite Coat HTN140Office SBP mmHgFrom Pickering, Hypertension 1992
9 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:
10 Threshold for Initiation of Treatment and Target Values ConditionInitiationSBP / DBP mmHgDiastolic ± systolic hypertension 140/90Isolated systolic hypertensionSBP >160Home BP measurement (no diabetes, renal disease or proteinuria)( 135/85)Diabetes or chronic kidney disease 130/80TargetSBP / DBP mmHg<140/90<140<135/85<130/80The systolic blood pressure target are highlighted to indicate systolic blood pressure control is the major clinical issue currently for most patients
11 Home measurement of blood pressure Home BP measurement should be encouraged to increase patient involvement in careWhich patients?For the diagnosis of hypertensionSuspected non adherenceWhite coat hypertension or effectMasked hypertensionAverage BP equal to or over 135/85 mmHg should be considered elevated
12 Benefits of Home Blood Pressure Monitoring Rapid confirmation of the diagnosis of hypertensionBetter prediction of cardiovascular prognosisDiagnosis of white coat and masked hypertensionReduced medication use in white coat effectImproved adherence to drug therapyBetter blood pressure
13 Not all patients are suited to home measurement Undue anxiety in response to high blood pressure readingsPhysical or mental disability prevents accurate technique or recordingArm not suited to blood pressure cuff (e.g. conical shaped arm)Irregular pulse or arrhythmias prevent accurate readingsLack of interestThe vast majority of patients can be trained to measure blood pressure
14 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
15 Home Measurement of BP: Patient Education How to?Use devices:appropriate for the individualappropriate cuff sizevalidated deviceAdequate patient training in:measuring their BPinterpreting these readingsRegular verificationmeasuring techniquesValues> 135 / 85 mmHgshould beconsidered elevatedHome measurement can help to improve patient adherence
16 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 andFirst day home BP values should not be considered.For patients treated for hypertensionMorning measurement should be done before medication taking
17 Home Measurement of BP: Patient Education Assist patients select a model with the correct size of cuffMeasure and record the patients mid arm circumference so they can match it to cuff sizeRecommend devices validated by British Hypertension SocietyAsk patients to carefully follow the instructions with device and to record only those blood pressure readings where they have followed recommended procedureAdvise patients that average readings equal to or over 135/85 mmHg are higha lower threshold is appropriate for those with diabetes or chronic kidney diseaseValues equal to or over135 / 85 mmHgshould beconsidered elevated for those without diabetes or chronic kidney diseaseHome measurement can help to improve patient adherence
18 Which monitor to recommend to patients? British Hypertension Society maintains an updated list of validated home BP monitors(or Google “British Hypertension Society” and click on “Blood pressure Monitors”)
19 Suggested use of ABPM AND Home BPM in the Management of Hypertension Office BP > 140/90 mmHgin low risk patients (with no target-organ disease)Home-monitored blood pressure <135/85mmHgHome-monitored blood pressure equals or over 135/85mmHgPerform ABPMWhite coat hypertension and ‘non dipping’ is not reproduced in a repeat monitor 30-40% of the timeMean awake BPLess than 135/85 mmHgMean awake BPequals or over 135/85 mmHgFollow-up with periodic home-BP measurement and or repeated ABPM every 1-2yr.Initiate antihypertensive therapyABPM: Ambulatory Blood Pressure Monitoring BP: Blood PressureAdapted from White W, NEJM 348:24, June 12, 2003
20 Special Indications for ABPM Suspect white coat hypertension20% of individuals with office hypertension have normal profile on ABPMThese people do not generally require drug therapy (although their risk is slightly higher than true normotensives)They have a higher risk of progression to establised hypertension and need to be followed long-term (may need eg annual ABPM)
21 (2) Masked Hypertension Office BP < 140/90 (or 130/80 in DM or CKD) with:awake average BP on ABPM >= 135/85 (125/75 in DM or CKD)oror 24 hour average BP on ABPM >= 130/80 (120/70 in DM or CKD)Suspect where target organ damage with normal office blood pressuresUntreated associated with adverse prognosis.
22 (3) Assess Nocturnal Dip and Morning Surge Average asleep blood pressure should be at least 10% lower than average awake blood pressure (“nocturnal dip”)“Non-dipper” status associated with adverse cardiovascular prognosis (common is states of sympathetic overactivity eg diabetes and CKD)Highest blood pressures usually in the early morning (6-10am) – highest risk time for MI and stroke. Exaggerated surge (> 160/100) is a significant risk factor even when average blood pressure adequately controlled. (NB many “24-hour” antihypertensive meds are wearing off at the time of highest risk)Both non-dipping and morning surge can be addressed by apropriately timed adjustment to medsuse drugs know to have long ½ livesevening or bedtime dosing or 1 or more drugs (or even 3am if getting up to PU at that time).
23 (4) Assess Efficacy of Treatment Some treated hypertensives have an office “white coat” effect and appear to be resistant to increasing therapy - these individuals may need serial ABPM to monitor the effect of therapy. Home BP monitoring is also useful in these individuals
24 CONCLUSION:Ambulatory and Home Blood Pressure Monitoring are now an integral (evidence-based) part of hypertension management and should be widely used.