CME Program for Family Physicians Ambulatory BP Monitoring Brian Gore, MD CCFP Dip Epid. Part II ABPM

Evolving to newer technologies ….

Clinical Indications for ABPM

Clinical Indications for ABPM T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002 Suspected WCH or WCE w/o target organ damage Suspected WCH or WCE w/o target organ damage Evaluation of treatment resistant HTN Evaluation of treatment resistant HTN Hypotension symptoms on antihypertensive medication Hypotension symptoms on antihypertensive medication

Clinical Indications (cont) T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002 Intermittent symptoms possibly related to blood pressure (postural, postprandial) Intermittent symptoms possibly related to blood pressure (postural, postprandial) Nocturnal hypertension (sleep apnea, diabetics) Nocturnal hypertension (sleep apnea, diabetics) Autonomic failure: diabetics Autonomic failure: diabetics

What to assess in an ABPM Evaluation ABPM readings: quality, #, pattern. ABPM readings: quality, #, pattern. Periods: total 24 hour, awake, asleep. Periods: total 24 hour, awake, asleep. Dipper status: Y,N, Excessive, Reverse Dipper status: Y,N, Excessive, Reverse 24-hour pulse pressure. 24-hour pulse pressure. White coat HTN or effect. White coat HTN or effect. Heart rate and rate-pressure product. Heart rate and rate-pressure product.

Summary Guide to Interpret ABPM Results Analyzing the data 1: - Summary Guide to Interpret ABPM Results Analyzing the data 1: ABPM profiles: - normal day and night periods - white coat syndrome (includes WCH + WCE) - borderline hypertension - nocturnal hypertension

Summary Guide to Interpret ABPM Results Analyzing the data 2: Summary Guide to Interpret ABPM Results Analyzing the data 2: ABPM profiles: - systolic and diastolic hypertension + dipper - systolic and diastolic hypertension + non-dipper - isolated systolic hypertension - isolated diastolic hypertension - excessive BP variability

What are normal ABPM limits Are office BP readings comparable to ABPM values ?

Recommended standards for normal and abnormal pressures during ABPM. These pressures are only a guide, and lower pressures may be abnormal in patients whose total risk factor profile is high and in whom there is concomitant disease. NormalAbnormal Day 135/85>140/90 Night 120/70>125/75 24 hour 130/80>135/85

ABPM Patterns O’Brien, BMJ, April, 2000 B. Gore, personal database, 2003 B. Gore, personal database, 2003

Normal 24 hour ABPM

White Coat Hypertension White Coat Hypertension

White coat hypertension White coat hypertension

Prevalence of White Coat Hypertension Ranges from 10-30% of hypertensive population based on review of clinical trials

Implications of WCE  Overestimation of OBP  Potential for overtreatment  Nonresponse to Rx  Potential Rx adverse effects

Stage 1 hypertensive dipper

Stage 2 hypertensive dipper

Hypertensive Dipper (>SHTN)

Isolated Systolic HTN

Hypertensive Non-Dipper

Stage 3 HTN Non-Dipper

Dippers and Non-Dippers Dipper:Day/Night >10/5 mmHg Dipper:Day/Night >10/5 mmHg Non-Dipper: Day/Night <10/5 mmHg Non-Dipper: Day/Night <10/5 mmHg Dipper: Stroke 3% Dipper: Stroke 3% Non-Dipper: Stroke 23% Non-Dipper: Stroke 23% O’Brien et al, Lancet 1988 O’Brien et al, Lancet 1988

ABPM Intrigue ABPM Intrigue

Normal 24 hr ABP with morning surge

CV Events that are Coincident with Morning Blood Pressure ‘Surge’ Myocardial ischemia Myocardial ischemia Myocardial infarction Myocardial infarction Sudden cardiac death Sudden cardiac death Stroke Stroke uThrombotic uHemorrhagic Adapted from: Muller, et al. 1985; Rocco, et al. 1987; Marler, et al. 1989; Willich, et al

Case: Gertrude H is a 77 year-old female Past History: Diabetes type 2 for 5 years, HTN, hyperlipidemia. OBP: 160/102 FU OBP: 166/98 (2 weeks) Physical exam: Unremarkable. BMI: 30. Meds: Ramipril 10, HCTZ 12.5 mg, Metformin 500 tid, Lipitor 20 qhs. Significant lab: CV Risk Ratio: 5.62 MAU 0.06 mcg/ml HbA1c: hr ABPM results: 24 hour abnormal ABP with marked nocturnal hypertension: commonly found in patients with diabetes and loss of glycemic control or in patients with sleep apnea.

S+D HTN with Nocturnal Hypertension

Inherent Variability of BP

Blood Pressure Variability and Target Organ Damage: A Longitudinal Analysis Adapted from: Frattola, et al p< LVMI (g/m 2 ) < 95 95– –120 >120 Initial 24-hour MAP (mm Hg) n=73 Variability <group average Variability >group average

Overtreatment

Autonomic Dysregulation: Typical patient characteristics: 65 year old female with: TOD/CCVD: CAD, LVH, CABG, CVA, Remote MI. CO-MORBIDITY: DIABETES. CV-RF: AGE, PM, SMOKER, HYPERLIPIDEMIA OBP: /90 Physical exam: Carotid bruits, Reduced PP’s, trophic leg changes, Mild weakness RA. BMI: 29. Meds: Metroprolol 100 mg bid, Cozaar 100 mg qam, Metformin 500 tid, Lipitor 20 qhs, ASA 80 mg QD. Lab Investigations: TC-6.52, HDL-1.05, LDL-5.1 TG: 3.2, CV Risk Ratio:6.21 Proteinuria >3gm/l. HgB A1C: EKG: LVH, Remote inferior MI. Referred to evaluate 24 hour control in view of persistently high OBP The Dilemma: BP management in light of ABPM results.

Autonomic Dysfunction Autonomic Dysfunction

Other ABP Illustrations: “Trouble Coming”

Stroke Range Hypertension

Isolated SHTN and high risk 24-hr pulse pressure

Total period: 20 hour 44 min 4/3/ :26 - 4/4/ :26 (51 data) SBPDBP MAP PP HR Double prod. Mean mmHg 56 /min 9165 Max mmHg 67 /min13054 Min mmHg 46 /min 6480 SD mmHg 6 /min 1838 DI % PTE % Load mmHg*h/24h