1. © Continuing Medical Implementation …...bridging the care gap Blood Pressure Measurement 2005 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 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension Joffres et al. Am J Hyper 2001;14:1099 –1105 21% 13% 43% 22% Hypertensive patients who are treated but BP uncontrolled Hypertensive patients who are treated and BP controlled Hypertensive patients who are unaware Patients who are aware but remain untreated and BP uncontrolled 9% Diabetic patients who are treated and BP controlled The Challenge In Canada

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

6. 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 non-diabetic nephropathy with proteinuria

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

8. © 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

9. 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

10. © 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

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

15. 15 Non adherence Hypertension and diabetes Office-induced blood pressure elevation (white coat effect) Which patients? Further assess using 24-h ambulatory blood pressure monitoring If office BP measurement is elevated and Home BP is normal Daytime average BP over 135/85 mm Hg should be considered elevated Home/Self measurement of blood pressure Beyond diagnosis, Home/Self BP measurement may also be considered for selected patients for the management of hypertension

16. © Continuing Medical Implementation …...bridging the care gap Suggested Protocol for Home (Self) Measurement of Blood Pressure HOP TO ITT Protocol BP 4X/Day for 7 days Then 4X/Day- 2days/week for 7 weeks Total 84 readings Interval titration if BP elevated

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

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

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

20. © 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

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

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

23. © 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

24. 24 Ambulatory BP Monitoring: Specific Role in Selected Patients Untreated Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage Treated patients Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy Symptoms suggestive of hypotension Fluctuating office blood pressure readings Which patients? Those with suspected office-induced BP elevation

25. 25 Ambulatory BP Monitoring Specific Role in Selected Patients A drop in nocturnal BP of <10% is associated with increased risk of CV events Use validated devices How to interpret? Average daytime ambulatory blood pressure >135/85 mmHg is considered elevated How to ?

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

27. © 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.

28. © 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.

29. © 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

30. 30 Recommendations for Follow-up Are BP readings below target during 2 consecutive visits? Non Pharmacological treatment With or without Pharmacological treatment Diagnosis of hypertension Follow-up at 3-6 month intervals Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage NoYes NoYes More frequent visits Visits every 1 to 2 months