1. © Continuing Medical Implementation …...bridging the care gap Blood Pressure Measurement How can anything so simple be so complex?

2. © Continuing Medical Implementation …...bridging the care gap Diseases Attributable to Hypertension Hypertension Heart failure Stroke Coronary heart disease Myocardial infarction Left ventricular hypertrophy Aortic aneurysm Retinopathy Peripheral vascular disease Hypertensive encephalopathy Chronic kidney failure Cerebral hemorrhage Adapted from: Arch Intern Med 1996; 156:1926-1935. All Vascular

3. © Continuing Medical Implementation …...bridging the care gap Awareness, Treatment and Control of High Blood Pressure in Canada Adapted from: Am J Hypertens 1997; 10:1097-1102. Patients unaware of their high blood pressure42% Aware but not treated and not controlled19% Treated but not controlled23% Treated and controlled16% 42% 19% 23% 16%

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8. BP Treatment Targets Condition 160/100 Treatment threshold if no risk factors,TOD or CCD < 140/90 Treatment target for office BP measurement < 135/85 Treatment target for ABP or HBP measurement < 130/80 Treatment target for for Type 2 diabetics or non-diabetic nephropathy < 125/75 Treatment target for diabetic or non-diabetic nephropathy with proteinuria

9. © Continuing Medical Implementation …...bridging the care gap Automated BpTRU™ BP Devices

10. © Continuing Medical Implementation …...bridging the care gap Benefits of Automated BpTRU™ BP Devices –Standardizes BP readings from one operator to the next –Removes many of the errors associated with manual readings –Accurate, reliable and reproducible readings –Multiple readings with averaging – “Opportunistic screening” –Accurate, independently validated device –Automatically zeroes with each inflation –Performs full system check every time on powering-up Performs six readings Discards the first reading Averages the remainder Interval between readings from 1-5 minutes apart User can auscultate using the digital readout when desired

11. 180 – 170 – 160 – 150 – 140 – 130 – 120 – 110 – 100 – 90 – 80 – 0 – 174±3 166±4 158±4 155±5 146±3 92±2 89±3 90±2 88±2 82±2 Specialist Family Physician Research Technician BpTRU Ambulatory BP Blood Pressure (mmHg) Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B Study Results

12. © Continuing Medical Implementation …...bridging the care gap Study Conclusions The patient’s presence in the doctor’s office or research unit in itself appears to be partly responsible for the white coat effect. BP readings taken on the initial visit tend to be higher than other readings. The white coat effect can be partly eliminated by the use of an automated BP recording device (BpTRU) BP readings recorded by the BpTRU device are similar to readings taken by an experienced research technician using CHS Guidelines. Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B

13. © Continuing Medical Implementation …...bridging the care gap

15. Validated BP Devices BHS –BHS = British Hypertension Society AAMI –AAMI = American Association of Medical Instruments See British Hypertension Society WebsiteBritish Hypertension Society OMRON –HEM-705CP –HEM-711AC –HEM-722C –HEM-773 LifeSource AND –UA-767 CN –UA-767 Plus –UA-779 –UA-787

16. © Continuing Medical Implementation …...bridging the care gap OMRON Claims all devices with exception of wrist devices are validated

17. © Continuing Medical Implementation …...bridging the care gap OMROM HEM 711 AC $109.99

18. © Continuing Medical Implementation …...bridging the care gap LifeSourceUA-767PC For use with a PC and Monitor Pro software. Stores and analyzes recorded blood pressure data directly from the UA- 767PC. The software provides printable summary reports and graphing capabilities. Remotely monitor patients and their blood pressure from their homes. Validated according to BHS* protocol and AAMI** approved. *BHS = British Hypertension Society **AAMI = American Association of Medical Instruments

19. © Continuing Medical Implementation …...bridging the care gap Life Source UA779CN $99.99

20. © Continuing Medical Implementation …...bridging the care gap No charge……? Validity

21. © Continuing Medical Implementation …...bridging the care gap When would you order ambulatory Blood pressure Monitoring? For Dx mild to mod HTN For elderly women with ISH For apparent Rx resistance For anxiety prone patients When marked fluctuations in office BP present For symptoms suggestive of hypotension present on Rx White coat HTN unlikely –If DM coexists –If TOD present

22. © Continuing Medical Implementation …...bridging the care gap

24. Current evidence suggests that: Blood Pressure and Target Organ Damage (TOD) 24-h blood pressure correlates most closely with TOD (compared to clinic or casual BP) Higher incidence of cardiovascular events when blood pressure remains elevated at night (non-dippers) Blood pressure variability is an independent determinant of TOD Highest incidence of cardiovascular events occurs in AM Adapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987; Parati, et al. 1987; Mancia. 1990.

25. © Continuing Medical Implementation …...bridging the care gap 24-Hour Blood Pressure Profile: Two Patients with Hypertension Blood pressure (mm Hg) 7:00 11:00 15:00 19:00 23:00 3:00 7:00 Sleep Dipper Non-dipper Time of day 175 135 115 95 75 55 155 Adapted from: Redman, et al. 1976; Mancia, et al. 1983; Kobrin, et al. 1984; Baumgart, et al. 1989; Imai, et al. 1990; Portaluppi, et al. 1991.

26. © Continuing Medical Implementation …...bridging the care gap 24-Hour Blood Pressure Profile: The Morning Blood Pressure ‘Surge’ Time of day Blood pressure (mm Hg) 18:00 22:00 02:00 06:00 10:00 14:00 18:00 Time of awakening Sleep 180 160 140 120 100 80 Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.

27. © Continuing Medical Implementation …...bridging the care gap Ischemia (min) Adapted from: Rocco, et al. 1987. 01:00 05:00 09:00 13:00 17:00 21:00 300 150 250 200 100 50 0 n=24 Circadian Incidence of Cardiovascular Events: Myocardial Ischemia Time of day

28. © Continuing Medical Implementation …...bridging the care gap