History BP monitoring

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2 History BP monitoring 1733 Rev. Stephen Hales Glass tube in a horse s artery 1834 Hérisson & Gernier First sphygmomanometer 1870 Mohamed First to report increase in arterial pressure was an index of kidney damage 1905 Korotkoff Describes the sounds detected when an arterial vessel is compressed

4 Hypertension Blood Pressure Monitoring Aneroid equipment Inexpensive, lightweight and portable Two person operation/need stethoscope Delicate mechanism, easily damaged Needs calibration with mercury sphygmomanometer

5 Hypertension Blood Pressure Monitoring Mercury sphygmomanometer Standard for BP monitoring No calibration May be bulky Need a second person to use machine May be difficult for hearing impaired or patients with arthritis

6 Hypertension Blood Pressure Monitoring Automatic equipment Contained in one unit Portable with easy-to-read digital display Expensive, fragile Must be calibrated Requires careful cuff placement

7 BP cuff sizes for mercury sphygmomanometer, semi-automatic and ambulatory monitors Indication Bladder width x length (cm) Arm Circumference (cm) Small Adult/Child 12 x 18 <23 Standard Adult 12 x 26 <33 Large. Adult 12 x 40 <50 Adult Thigh Cuff 20 x 42 <53

8 Threshold levels of BP for the diagnosis of Hypertension according to measurement method SBP (mmhg) DBP (mmhg) Office >140 >90 Self/home BP Monitoring >135 >85 Ambulatory BP Monitoring Day >135 >85 Ambulatory BP Monitoring Night >120 >75 Ambulatory 24 hr BP Monitoring >130 >80

9 2013 ESH/ESC Hypertension Guidelines Journal of Hypertension, European Heart Journal, Blood Pressure 2013

10 Office BP Measurement 1. To allow the patients to sit for 3 5 minutes before beginning BP measurements 2. To take at least two BP measurements, in the sitting position, spaced 1 2 min apart, and additional measurements if the first two are quite different. Consider the average BP if deemed appropriate 3. To take repeated measurements of BP to improve accuracy in patients with arrhythmias, such as atrial fibrillation 4. To use a standard bladder (12 13 cm wide and 35 cm long), but have a larger and a smaller bladder available for large (arm circumference >32 cm) and thin arms, respectively

11 Office BP Measurement To measure BP in both arms at first visit to detect possible differences. In this instance, take the arm with the higher value as the reference To measure at first visit BP 1 and 3 min after assumption of the standing position in elderly subjects, diabetic patients, and in other conditions in which orthostatic hypotension may be frequent or suspected To measure, in case of conventional BP measurement, heart rate by pulse palpation (at least 30 s) after the second measurement in the sitting position

12 The measurement of BP

13 A Diagnosis of Hypertension based exclusively Measurement error on Physician Small number of readings readings is no Effects of recent activities longer Expense & Inconvenience acceptable

14 Do we need out-of-office blood pressure in every patient?. Self blood pressure monitoring at home or 24-h ambulatory blood pressure monitoring should be used more frequently in clinical practice, following the indications issued in recent guidelines. Curr Opin Cardiol June;22(4):321-8

16 Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring A joint statement by the American Heart Association, American Society of Hypertension, and the Preventive Cardiovascular Nurses Association Writing Committee Members Thomas G. Pickering, MD, DPhil, FAHA, Chair Nancy Houston Miller, RN, BSN, FAHA Gbenga Ogedegbe, MD, MPH, FAHA Lawrence R. Krakoff, MD, FAHA Nancy T. Artinian, PhD, RN, BC, FAHA David C. Goff, MD, FAHA

17 Current Usage of Home BP Monitoring 1. Growing rapidly: 38% of patients reported using it in 2000,and 55% in In 2000, 35% of patients said that a doctor recommended it; 67% in % of hypertensive patients check their BP 2. regularly.

18 Factors that affect ΗBPΜ Smoking. Caffeine. Cuff size. Pain. Medication use.

19 Impact of errors in technique (McAlister et al, BMJ, 2001;322:908) Factor Systolic BP Diastolic BP Talking 17mm Hg 13mm Hg Exposure to cold 11mm Hg 8mm Hg 8mm Hg 8mm Hg No effect 2-5mm Hg Arm position above heart 8mm Hg/10cm 8mm Hg/10cm Arm position below heart 8mm Hg/10cm 8mm Hg/10cm Arm not supported 2mm Hg 2mm Hg Cuff too small 3 mm Hg 8mm Hg Ingestion of alcohol Supine

20 Procedure for Home BP Measurement No tobacco or caffeine for 30 minutes preceding measurement After 5 minutes rest With arm at heart level; back supported and feet flat on the ground On arm with the highest BP

21 Μέτρηση ΑΠ ανάλογα με τη θέση

22 The measurement of BP

24 Information provided by Home BP Monitoring Home readings tend to be lower than office readings because of the absence of the white coat effect. They are more reproducible because larger numbers of readings can be averaged. It is recommended that an average of at least 12 readings taken morning and evening over several days be used to make clinical decisions. Possibility to measure BP during prolonged periods

25 Information provided by Home BP Monitoring Minimization of placebo effect Improvement of compliance Guidance of treatment (initiation and titration) Identification of patients with WCH or MH.

27 HBPM in White Coat Hypertension WCH is defined as a persistently elevated office BP (>140/90), and a normal BP at other times (<135/85 during the day). Home BP may be useful in its diagnosis, but if it is borderline (between 125/76 and 135/85) 24-ABPM may be indicated. The C.V risk in WCH is relatively low. Patients with WCH may not need drug treatment, but continued home monitoring is advised.

31 Σ.Υ + ΚΑΡΔΙΑΚΑ ΣΥΜΒΑΜΑΤΑ PAMELA STUDY Subjects with ΜΗ had a higher prevalence of cardiovascular and all-cause mortality compared with the subjects with normal office and 24-h blood pressure. Hypertension 2006;47(5):

32 Masked hypertension represents a strong predictor of cardiovascular risk and was present in 16% of subjects without antihypertensive medication and 18% of those with antihypertensive medication.

33 Home BP for Predicting Cardiovascular Risk Five prospective studies have compared home and office BP for predicting cardiovascular outcomes. All 5 found that HBPM is a significant predictor, and 4/5 that it is stronger than office BP.

43 The Need for Home BP Monitoring in Special Populations Elderly: BP variability tends to be high, and white coat hypertension is common. Diabetics: The importance of tight BP control is generally accepted, and home monitoring may help to achieve this. Pregnancy: The early detection of pre-eclampsia might be facilitated by home monitoring of BP. Chronic Kidney Disease: BP may be very variable in such patients, and home monitors have been shown to be accurate in such patients. Children: White coat hypertension occurs in children, and there are some data on normal home BP levels at different ages.

45 24-ABPM Primary indications Suspected white coat hypertension Evaluation of the efficacy of antihypertensive therapy in the case of resistant hypertension evidence of persistent or progressive target organ damage Evaluation of normotensive patients with target organ damage Evaluation of symptoms (especially hypotension) O Brien E. et al., Blood Press Monit 2002

46 24-ABPM Main advantages of ABPM Multiple BP measurements over 24 hours BP evaluations during usual daily activities and sleep Evaluation of the circadian BP pattern Identification of alarm reactions Attenuation of placebo effect Evaluation of antihypertensive effects over 24 hours Possibility of risk stratification O Brien E. et al., Blood Press Monit 2002

47 24-ABPM 24-hour ABPM values are better than cuff BP in predicting: stroke myocardial infarction cardiovascular death treatment-induced regression of LVH Smith D.H. et al., Am J Cardiovasc Drugs 2005

48 Costs and savings for total population of England Costs and savings of using ABPM to confirm diagnosis of hypertension Year Year 1 Change in diagnosis cost ( m) 5.1 Change in treatment cost ( m) 2.5 Net resource impact ( m) 2.6 Year Year Year Year Cost data correct at August This has not been updated for this 2nd edition

49 2013 ESH/ESC Hypertension Guidelines Journal of Hypertension 2013, European Heart Journal 2013, Blood Pressure 2013

50 Office BP Abandonment of the mercury sphygmomanometer Proposed multiple recordings in the office (isolated room)-closer to HBPM/ABPM General no other changes compared to 2007

51 Out-of-office BP HBPM and ABPM are complementary Well-given instructions needed Cut-off values for hypertension

52 Clinical indications for HBPM or ABPM

53 Specific indications for ABPM Importance of nighttime BP Dipping status /low reproducibility Extreme dipping under research BP variability/morning surge/ambulatory stiffness index defined as experimental/no clinical routine use

54 Resistant hypertensionuse of ABPM in 2013 After exclusion of all other confounders ABPM regularly performed in order to exclude spurious resistance and quantify to a better degree BP elevation and subsequent effect of treatment treated hypertensives,12.2% resistant hypertension After ABPM 62.5% true resistant/37.5% white-coat resistance

55 HBPM 3-4 days, preferably 7 days (morning and evening) Exclusion of first day Cheaper/more repeatable/more extended time periods compared to ABPM OD and CV prediction comparable to ABPM/better to office BP according to meta-analyses

56 ΣΥΜΠΕΡΑΣΜΑΤΑ (1) Οι μετρήσεις της πίεσης εκτος ιατρειου είναι χρήσιμες για την αξιολόγηση της πίεσης και τη διάγνωση της υπέρτασης, αλλά κυρίως για τη μακροχρόνια παρακολούθηση της ρύθμισης της πίεσης. Για τη σωστή εκτίμηση της πίεσης εκτος ιατρειου απαραίτητες προϋποθέσεις είναι η εκπαίδευση του αρρώστου στην τεχνική της μέτρησης και ο τακτικός έλεγχος της λειτουργίας του πιεσομέτρου (μια φορά το χρόνο) Οι μετρήσεις εκτος ιατρειου μπορεί να γίνονται από τον ίδιο τον υπερτασικό ή από άλλο άτομο.

57 ΣΥΜΠΕΡΑΣΜΑΤΑ (2) Αξιόπιστες μετρήσεις της πίεσης εκτός ιατρειου μπορούν να γίνουν με υδραργυρικό ή μεταλλικό πιεσόμετρο (σαν ρολόι με περιστρεφόμενη βελόνα) και ακουστικά, εφόσον έχει προηγηθεί σχολαστική εκπαίδευση του αρρώστου στην τεχνική μέτρησης, ή, πιο εύκολα, με αυτόματο ηλεκτρονικό πιεσόμετρο. Οι αλλαγές στη φαρμακευτική θεραπεία (επιπλέον χάπι ή αποφυγή δόσης) με κριτήριο μεμονωμένες μετρήσεις της πίεσης εκτος ιατρειου αποτελούν διαδεδομένη τακτική και πρέπει να αποφεύγονται. αλλά λανθασμένη

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