Evolving to newer technologies …

CME Program for Family CME Program for Family

PhysiciansPhysicians Ambulatory BP Ambulatory BP

MonitoringMonitoring

Brian Gore, MD CCFP Dip Epid.Brian Gore, MD CCFP Dip Epid.

Part IIPart IIABPMABPM

Evolving to newer technologiesEvolving to newer technologies….….

Clinical Indications for Clinical Indications for ABPMABPM

Clinical Indications for ABPMClinical Indications for ABPMT Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002

Suspected WCH or WCE w/o target Suspected WCH or WCE w/o target organ damageorgan damage

Evaluation of treatment resistant HTNEvaluation of treatment resistant HTN Hypotension symptoms on Hypotension symptoms on

antihypertensive medicationantihypertensive medication

Clinical Indications Clinical Indications (cont)(cont)T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002T Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002

Intermittent symptoms possibly related Intermittent symptoms possibly related to blood pressure (postural, to blood pressure (postural, postprandial)postprandial)

Nocturnal hypertension (sleep apnea, Nocturnal hypertension (sleep apnea, diabetics)diabetics)

Autonomic failure: diabeticsAutonomic failure: diabetics

What to assess in an ABPMWhat to assess in an ABPM EvaluationEvaluation

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, ReverseDipper 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 productHeart rate and rate-pressure product..

Summary Guide to Interpret ABPM Analyzing the data:Analyzing the data:

Minimum number acceptable:

14 readings day-time

7 readings night-time 

O’Brien, BMJ: 2001

Summary Guide to Interpret ABPM Results Summary Guide to Interpret ABPM Results

Analyzing the data 1: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 Summary Guide to Interpret ABPM Results

Analyzing the data 2: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 limitsWhat are normal ABPM limits

Are office BP readings comparable Are office BP readings comparable

to ABPM values ?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.

Normal Abnormal

Day    135/85 >140/90

Night    120/70 >125/75

24 hour    130/80 >135/85

O p era tio n a l A p p ro a ch fo r C V R isk S ra tif ica tio nV e rd e c c h ia , V . J H yp e rte ns io n 2 0 0 0 ; 3 5 :8 4 4 -8 5 1

LO W R I SK

Day- tim e ABP < 135/ 85O ptim al < 130/ 80

W hite Coat Hypertension

INTERMEDIATE RISK

Dipper (> 10% )N orm al 24 h PP

< 53 m m H g

HIGH RISK

N ondipperSBP Day to n ight reduction < 10%

HIGH RISK

I ncreased 24 hr PP> 53 m m H g

Am bulatory Hypertension

Untreated OHT

ABPM PatternsABPM Patterns

O’Brien, BMJ, April, 2000O’Brien, BMJ, April, 2000

B. Gore, personal database, 2003B. Gore, personal database, 2003

Normal 24 hour ABPMNormal 24 hour ABPM

White Coat HypertensionWhite Coat Hypertension

White coat hypertensionWhite coat hypertension

Prevalence of White Coat Prevalence of White Coat HypertensionHypertension

Ranges from 10-30% of hypertensive Ranges from 10-30% of hypertensive population based on review of population based on review of

clinical trialsclinical trials

Implications of WCEImplications of WCE

Overestimation of OBP Overestimation of OBP Potential for overtreatmentPotential for overtreatment Nonresponse to RxNonresponse to Rx Potential Rx adverse Potential Rx adverse

effectseffects

Stage 1 hypertensive dipperStage 1 hypertensive dipper

Stage 2 hypertensive dipperStage 2 hypertensive dipper

Hypertensive Dipper (>SHTN)Hypertensive Dipper (>SHTN)

Isolated Systolic HTNIsolated Systolic HTN

Hypertensive Non-DipperHypertensive Non-Dipper

Stage 3 HTN Non-DipperStage 3 HTN Non-Dipper

Dippers and Non-DippersDippers and Non-Dippers

Dipper:Dipper: Day/Night >10/5 Day/Night >10/5 mmHgmmHg

Non-Dipper: Day/Night <10/5 mmHgNon-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 1988O’Brien et al, Lancet 1988

ABPM IntrigueABPM Intrigue

Normal 24 hr ABP with morning surgeNormal 24 hr ABP with morning surge

CV Events that are Coincident with CV Events that are Coincident with Morning Blood Pressure ‘Surge’Morning Blood Pressure ‘Surge’

Myocardial ischemiaMyocardial ischemia

Myocardial infarctionMyocardial infarction

Sudden cardiac deathSudden cardiac death

StrokeStroke

ThromboticThrombotic HemorrhagicHemorrhagic

Adapted from: Muller, et al. 1985; Rocco, et al. 1987; Marler, et al. 1989; Willich, et al. 1992.

Case: Case: Gertrude H is a 77 year-old Gertrude H is a 77 year-old femalefemale

Past History:Past History:

Diabetes type 2 for 5 years, Diabetes type 2 for 5 years, HTN, hyperlipidemia.HTN, hyperlipidemia.

OBP: 160/102OBP: 160/102

FU OBP: 166/98 (2 weeks)FU OBP: 166/98 (2 weeks)

Physical exam: Physical exam: Unremarkable. Unremarkable.

BMI: 30.BMI: 30.

Meds: Ramipril 10, HCTZ Meds: Ramipril 10, HCTZ 12.5 mg, Metformin 500 tid, 12.5 mg, Metformin 500 tid, Lipitor 20 qhs.Lipitor 20 qhs.

Significant lab:Significant lab:

CV Risk Ratio: 5.62CV Risk Ratio: 5.62

MAU 0.06 mcg/mlMAU 0.06 mcg/ml

HbA1c: .085HbA1c: .085

24-hr ABPM results:24-hr ABPM results:

24 hour abnormal ABP with 24 hour abnormal ABP with marked nocturnal marked nocturnal hypertension: commonly hypertension: commonly found in patients with found in patients with diabetes and loss of diabetes and loss of glycemic control or in glycemic control or in patients with sleep apnea.patients with sleep apnea.

S+D HTN with Nocturnal HypertensionS+D HTN with Nocturnal Hypertension

Inherent Variability of BP

Blood Pressure Variability and Target Organ Damage: A Longitudinal Analysis

Adapted from: Frattola, et al. 1993.

p<0.01150

120

140

130

110

100

90

LVMI (g/m2)

< 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

OvertreatmentOvertreatment

Autonomic Dysregulation:Autonomic Dysregulation:

Typical patient characteristics:Typical patient characteristics:

65 year old female with:65 year old female with:

TOD/CCVD: CAD, LVH, CABG, TOD/CCVD: CAD, LVH, CABG, CVA, Remote MI.CVA, Remote MI.

CO-MORBIDITY: DIABETES. CO-MORBIDITY: DIABETES.

CV-RF: AGE, PM, SMOKER, CV-RF: AGE, PM, SMOKER, HYPERLIPIDEMIAHYPERLIPIDEMIA

OBPOBP: : 170-180/90170-180/90

Physical examPhysical exam: Carotid bruits, : Carotid bruits, Reduced PP’s, trophic leg changes, Reduced PP’s, trophic leg changes, Mild weakness RA. Mild weakness RA.

BMI: 29.BMI: 29.

MedsMeds: : Metroprolol 100 mg bid, Metroprolol 100 mg bid, Cozaar 100 mg qam,Cozaar 100 mg qam, Metformin Metformin 500 tid, Lipitor 20 qhs, ASA 80 mg 500 tid, Lipitor 20 qhs, ASA 80 mg QD.QD.

Lab Investigations:Lab Investigations:

TC-6.52, HDL-1.05, LDL-5.1TC-6.52, HDL-1.05, LDL-5.1

TG: 3.2, CV Risk Ratio:TG: 3.2, CV Risk Ratio:6.216.21

Proteinuria >3gm/l. HgB A1C: Proteinuria >3gm/l. HgB A1C: 0.078.0.078.

EKG: LVH, Remote inferior MI.EKG: LVH, Remote inferior MI.

Referred to evaluate 24 hour Referred to evaluate 24 hour control in view of persistently control in view of persistently high OBPhigh OBP

The Dilemma: BP management in The Dilemma: BP management in light of ABPM resultslight of ABPM results..

Autonomic DysfunctionAutonomic Dysfunction

Other ABP Illustrations:Other ABP Illustrations:“Trouble Coming”“Trouble Coming”

Stroke Range HypertensionStroke Range Hypertension

Isolated SHTN and high risk 24-hr pulse Isolated SHTN and high risk 24-hr pulse pressurepressure

Total period: 20 hour 44 min 4/3/2003 10:26 - 4/4/2003 10:26 (51 data)

SBP DBP MAP PP HR Double prod.

Mean 162 68 99 94 mmHg 56 /min 9165 Max 214 95 135 127 mmHg 67 /min 13054 Min 132 55 82 73 mmHg 46 /min 6480

SD 20 9 12 14 mmHg 6 /min 1838 DI 13 11 12 % PTE 98 8 66 % Load 781 5 127 mmHg*h/24h