1. 1 Accurate BP measurement in the diagnosis of hypertension Introduction to AOBP (Automated Office Blood Pressure) Mark Gelfer, MD

2. 2 Disclosures Developer of the BpTRU™ hypertension device Consultant to BpTRU Medical Devices Ltd. until February 2010

3. 3 Objectives At the end of this session you will have an understanding of: the problems with accuracy in BP measurement the need for accuracy in BP measurement the clinical importance of accurate BP measurement the clinical evidence behind AOBP the clinical value of AOBP

4. 4 What’s New for 2010 CHEP recognizes that automated office blood pressure monitors are more frequently being used and provides early guidance on their use Sodium intake recommendations now in line with Health Canada: lower targets recommended with advancing age ARBs = ACEi’s for most indications Combination therapy using first line agents: – Replace multiple pill antihypertensive combinations with single pill combinations – In high risk patients the combination of an ACEi and a DHP CCB is preferred

5. 5 What’s New for 2010 To keep up to date with the latest evidence and resources for the prevention and control of hypertension, go to: www.htnupdate.ca. Have your patients sign up at www.myBPsite.ca to access latest hypertension resources.

6. To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 1500 mg/day Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and sodium in accordance with Canada's Guide to Healthy Eating. Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7 days/week in addition to routine activities of daily living Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) Maintenance of ideal body weight (BMI 18.5-24.9 kg/m 2 ) Waist Circumference Men Women - Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm - South Asian, Chinese <90 cm <80 cm Smoke free environment Lifestyle Recommendations for Prevention and Treatment of Hypertension

7. Meta analysis on different reductions in dietary sodium intake on blood pressure Graham A. MacGregor Hypertension 2003;42:1093-1099

8. Recommendations for daily salt intake 2,300 mg sodium (Na) = 100 mmol sodium (Na) = 5.8 g of salt (NaCl) = 1 level teaspoon of table salt 80% of average sodium intake is in processed foods Only 10% is added at the table or in cooking AgeRecommended Intake 19-501500 51-701300 71 and over1200 Institute of Medicine, 2003

9. VI. Treatment of Hypertension in Patients with Ischemic Heart Disease Caution should be exercised when combining a non DHP-CCB and a beta-blocker If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem) Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure The combination of an ACEi and CCB is preferred 1. Beta-blocker 2. Long-acting CCB Stable angina ACEI are recommended for most patients with established CAD* ARBs are not inferior to ACEI in IHD Short-acting nifedipine *Those at low risk with well controlled risk factors may not benefit from ACEI therapy

10. VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Long-acting Dihydropyridine CCB* Beta-blocker and ACEI or ARB Recent myocardial infarction Heart Failure ? NO YES Long-acting CCB If beta-blocker contraindicated or not effective *Avoid non dihydropyridine CCBs (diltiazem, verapamil)

11. 11 III. Adherence to anti-hypertensive management can be improved by a multi-pronged approach Assess adherence to pharmacological and non- pharmacological therapy at every visit Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth. Simplify medication regimens using long-acting once-daily dosing Utilize fixed-dose combination pills Utilize unit-of-use packaging e.g. blister packaging Replacing multiple pill antihypertensive combinations with single pill combinations!

12. Accurate Measurement of Blood Pressure Automated office blood pressure measurements can be used in the assessment of office blood pressure *. When used under proper conditions, automated office SBP of 135 mmHg or higher or DBP values of 85 mmHg or higher should be considered analogous to mean awake ambulatory SBP of 135 mmHg or higher or DBP of 85 mmHg or higher *. *see notes

13. 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 alone. 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.

14. AOBP Background: Some fully-automated blood pressure measuring devices available for use in the clinic are capable of taking repeated blood pressure measurements when a patient is alone in the examining room. Using repeat measure devices in this manner has been referred to as automated office blood pressure (AOBP) measurement. The 2010 CHEP recommendations now include the use of AOBP as a device for assessment of office blood pressure. Several AOBP devices have been independently validated for clinical accuracy including the BpTRU automatic blood pressure monitor), the Omron office digital blood pressure HEM-907 monitor, and the Microlife Watch BP Office professional device. However, most of the available research in this area has been based on results from the BpTRU device. When used under proper conditions (Table 1), the available evidence suggests that repeat automated office SBP values of 135 mmHg or higher, or DBP values of 85 mmHg or higher, should be considered analogous to mean awake ambulatory SBP reading of 135 mmHg or higher and DBP of 85 mmHg or higher, respectively. Furthermore, it appears that the white coat effect may be reduced or even eliminated when the BpTRU is used properly. It is important to note that to date, only one paper has reported an association between AOBP readings and target organ damage; no data are available that relate AOBP readings to prognosis.