Comprehensive Guide to Ambulatory Blood Pressure Monitoring for Family Physicians

1. CME Program for Family PhysiciansAmbulatory BP MonitoringBrian Gore, MD CCFP Dip Epid.Part IIABPM

2. Evolving to newer technologies….

4. Clinical Indications for ABPM

5. Clinical Indications for ABPMT Pickering, Am J Hyperten, 1996, O’Brien, Prague ISH, June 2002 • Suspected WCH or WCE w/o target organ damage • Evaluation of treatment resistant HTN • 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) • Nocturnal hypertension (sleep apnea, diabetics) • Autonomic failure: diabetics

7. What to assess in an ABPM Evaluation • ABPM readings: quality, #, pattern. • Periods: total 24 hour, awake, asleep. • Dipper status: Y,N, Excessive, Reverse • 24-hour pulse pressure. • White coat HTN or effect. • Heart rate and rate-pressure product.

8. Summary Guide to Interpret ABPMAnalyzing the data:Minimum number acceptable:14 readings day-time 7 readings night-timeO’Brien, BMJ: 2001

9. 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: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. Normal Abnormal 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

15. Normal 24 hour ABPM

16. White Coat Hypertension

17. 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 • Non-Dipper: Day/Night <10/5 mmHg • Dipper: Stroke 3% • Non-Dipper: Stroke 23% • O’Brien et al, Lancet 1988

27. ABPM Intrigue

28. Normal 24 hr ABP with morning surge

29. CV Events that are Coincident with Morning Blood Pressure ‘Surge’ • Myocardial ischemia • Myocardial infarction • Sudden cardiac death • Stroke • Thrombotic • Hemorrhagic 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

31. S+D HTN with Nocturnal Hypertension

32. Inherent Variability of BP

33. Blood Pressure Variability and Target Organ Damage: A Longitudinal Analysis n=73 Variability >group average LVMI (g/m2) p<0.01 Variability <group average 150 140 130 120 110 100 10 8 11 8 11 9 8 8 90 < 95 95–108 109–120 >120 Initial 24-hour MAP (mm Hg) Adapted from: Frattola, et al. 1993.

34. Overtreatment

35. Autonomic Dysregulation:

36. 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) 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