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

2. Evolving to newer technologies ….

4. Clinical Indications for ABPM

5. 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

6. 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

7. 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.

9. 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

10. 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

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

12. 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

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

15. Normal 24 hour ABPM

16. White Coat Hypertension White Coat Hypertension

17. White coat hypertension White coat hypertension

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

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

20. Stage 1 hypertensive dipper

21. Stage 2 hypertensive dipper

22. Hypertensive Dipper (>SHTN)

23. Isolated Systolic HTN

24. Hypertensive Non-Dipper

25. Stage 3 HTN Non-Dipper

26. 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

27. ABPM Intrigue ABPM Intrigue

28. Normal 24 hr ABP with morning surge

29. 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. 1992.

30. 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:.085 24-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.

31. S+D HTN with Nocturnal Hypertension

32. Inherent Variability of BP

33. Blood Pressure Variability and Target Organ Damage: A Longitudinal Analysis Adapted from: Frattola, et al. 1993. p<0.01 150 120 140 130 110 100 90 LVMI (g/m 2 ) < 95 95–108 109–120 >120 Initial 24-hour MAP (mm Hg) n=73 Variability <group average Variability >group average 10 8 11 8 11 9 8 8

34. Overtreatment

35. 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: 170-180/90 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: 0.078. 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.

36. Autonomic Dysfunction Autonomic Dysfunction

37. Other ABP Illustrations: “Trouble Coming”

38. Stroke Range Hypertension

39. Isolated SHTN and high risk 24-hr pulse pressure

40. Total period: 20 hour 44 min 4/3/2003 10:26 - 4/4/2003 10:26 (51 data) SBPDBP MAP PP HR Double prod. Mean162 68 99 94 mmHg 56 /min 9165 Max214 95135127 mmHg 67 /min13054 Min132 55 82 73 mmHg 46 /min 6480 SD 20 9 12 14 mmHg 6 /min 1838 DI 13 11 12 % PTE 98 8 66 % Load781 5127 mmHg*h/24h