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    Optimum Way BP 2023

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    herryapt
    This document discusses the importance of measuring blood pressure outside of the clinic or office setting. It notes that office blood pressure measurements alone are inadequate for diagnosis and management of hypertension due to issues like white coat hypertension. Out of office measurements using ambulatory blood pressure monitoring and home blood pressure monitoring provide more accurate readings over extended periods of time. The document recommends using these out of office methods to properly diagnose hypertension, determine appropriate treatment, and monitor blood pressure control over time.

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    Optimum Way BP 2023

    Uploaded by

    herryapt
    14 views37 pages
    This document discusses the importance of measuring blood pressure outside of the clinic or office setting. It notes that office blood pressure measurements alone are inadequate for diagnosis and management of hypertension due to issues like white coat hypertension. Out of office measurements using ambulatory blood pressure monitoring and home blood pressure monitoring provide more accurate readings over extended periods of time. The document recommends using these out of office methods to properly diagnose hypertension, determine appropriate treatment, and monitor blood pressure control over time.

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    Optimum way BP 2023 (1)

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    This document discusses the importance of measuring blood pressure outside of the clinic or office setting. It notes that office blood pressure measurements alone are inadequate for diagnosis and management of hypertension due to issues like white coat hypertension. Out of office measurements using ambulatory blood pressure monitoring and home blood pressure monitoring provide more accurate readings over extended periods of time. The document recommends using these out of office methods to properly diagnose hypertension, determine appropriate treatment, and monitor blood pressure control over time.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    14 views37 pages

    Optimum Way BP 2023

    Uploaded by

    herryapt
    This document discusses the importance of measuring blood pressure outside of the clinic or office setting. It notes that office blood pressure measurements alone are inadequate for diagnosis and management of hypertension due to issues like white coat hypertension. Out of office measurements using ambulatory blood pressure monitoring and home blood pressure monitoring provide more accurate readings over extended periods of time. The document recommends using these out of office methods to properly diagnose hypertension, determine appropriate treatment, and monitor blood pressure control over time.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 37

    Out of office BP:

    The optimum way in diagnosis and


    management of hypertension

    Eka Harmeiwaty
    National Cardiovascular Center Harapan Kita, Jakarta
    Disclosure

    Nothing to disclosure
    Aim the presentation

    1. To demonstrate the deficiencies of office (clinic) BP measurement despite


    its long term use in clinical practice
    2. To demonstrate the superiority of ‘out of office’ BP (ABPM and HBPM)
    3. To demonstrate that diagnosis and management of hypertension need the
    ‘out of office’ BP measurement
    4. To consider the challenges in clinical practice using of ABPM & HBPM
    Background

    • The treatment of BP is increasingly


    emphasised for more and more people
    • On a population-wide level, a 5-mmHg
    difference in SBP corresponds to an
    estimated 6% absolute and 30% relative
    change in hypertension prevalence

    BMJ cover –September 2010


    History of blood pressure assessment and technology development
    Blood Pressure is measured to

    1. Make a diagnosis of hypertension

    2. Allow titration of anti-hypertensive medication to achieve control

    3. Monitor stability of control over a lifetime


    • The measurement of BP in the office (OBP) is regarded as the
    cornerstone for detecting and managing hypertension. However, OBP has
    major drawbacks, as it is based on few readings which often are
    inadequately standardized and is affected by the white coat and masked
    hypertension phenomena
    • In contemporary clinical practice, BP measurement is often suboptimally
    performed, and this type of unstandardized BP measurement leads to
    errors that can inappropriately alter management decisions in 20–45% of
    cases*

    * Journal of Hypertension37(9):1737-1745, September 2019


    Out Office Blood Pressure Monitoring

    1. Ambulatory Blood Pressure Monitoring (ABPM), is a fully automated


    technique in which BP is recorded over an extended period of time,
    typically 24 hours.

    2. Self-measured BP monitoring at home (referred to here in as self-


    measured BP monitoring) is the measurement of BP by an individual
    outside of an office setting at his/her home (Home Blood Pressure
    Monitoring = HBPM)
    Classification of hypertension based on OBPM and out office blood
    pressure measurement
    24-h blood pressure
    The triad of perfect blood pressure control
    Characteristic of blood pressure information

    Asayama et al.In-office and out-of-office blood pressure measurement. Journal Human Hypertension.2021 https://doi.org/10.1038/s41371-021-00486-8
    Office versus ABPM measurement
    Reproducibility of BP measurement
    Sources of inaccuracy of BP measurement in clinical setting

    1. Patient‐related, such as patient anxiety or pain;


    2. Device‐related, such as poorly‐maintained or calibrated equipment
    3. Procedure‐related, such as suboptimal measurement technique due to
    poor training or staff turnover
    4. Observer‐related, such as a bias towards rounding readings to the
    nearest 10 mm Hg or towards a value of less than 140/90.

    Kallioinen et al. Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review. J Hypertens. 2017;35:421 ‐441
    Major sources of error during blood pressure measurement

    Journal of Hypertension37(9):1737-1745, September 2019


    Why Is Out-of-Office Blood
    Pressure Measurement
    Needed ?
    Adjusted hazard ratios and 95% CIs for the incidence of cardiovascular events
    in sustained hypertensive patients, masked hypertensive patients, and
    patients with isolated clinic hypertension vs true normotensive subjects

    Parati G . Hypertension. Why Is Out-of-Office Blood Pressure Measurement Needed?,Hypertension 2009:54(2):181-187, DOI: (10.1161/HYPERTENSIONAHA.108.122853)
    Estimates for the incidence of a composite cardiovascular end point in white-coat
    hypertension (WCH) and their age-matched (within 5 y) normotensive controls (NT).

    *The analysis was stratified by cardiovascular risk according to the 2013 European guidelines:low risk and high risk
    Huang. Hypertension. Ambulatory Blood Pressure Monitoring to Diagnose and Manage Hypertension. Hypertension 2020;77(2):254-264, DOI:
    (10.1161/HYPERTENSIONAHA.120.14591 )
    Various types of BPV, their determinants, and prognostic
    relevance for cardiovascular and renal outcomes.

    Parati. J of Clinical Hypertension 2018;20(7): 1133-1137, DOI: (10.1111/jch.13304 )


    Clinical indications for using ambulatory blood pressure monitoring

    • Increased BPV on HBPM


    • Presence of advanced target organ damage
    • Suspected masked hypertension
    • Suspected white-coat hypertension
    • Secondary hypertension
    • Monitoring of antihypertensive therapy
    • Treatment-resistant hypertension
    HOW AND WHEN SHOULD ABPM BE MEASURED?

    • Use of an ABPM device that has been validated against accepted


    international standards,
    • Use of the non-dominant arm is recommended to obtain good ABPM
    reading
    • During the day, measures should be taken every 15-30 minutes, while
    measurements every 30-60 min are adequate at night.
    • Overall, at least 70% of readings throughout the 24-hour period should be
    valid, and there should be at least 20 valid daytime and at least 7 valid
    nighttime measurements performing
    • ABPM on a normal workday (rather than the weekend or an unusually
    restful day) will provide data that best reflects a patient's typical BP profile
    Hypertension classifications based on office and ambulatory blood pressure

    J of Clinical Hypertension, Volume: 23, Issue: 3, Pages: 411-421,First published: 14 December 2020, DOI: (10.1111/jch.14128)
    Blood pressure measures determined using ambulatory blood
    pressure monitoring.

    Kario. Circulation. 2013;107:1401-1406.


    Nocturnal blood pressure fall pattern
    difference between daytime mean systolic pressure and nightime mean systolic pressure expressed as a percentage of
    the day value.
    Indications for home-blood pressure monitoring to

    • Uncover white-coat hypertension.


    • Evaluate "masked" hypertension.
    • Improve compliance with long term treatment. It is thought that
    HBPM may increase the involvement of patients in hypertension
    management.
    • Improve conditions where strict blood pressure control is mandatory
    (high-risk patients and pregnancy).
    • Enable a more precise initial diagnosis of hypertension. HBPM
    provides clinically useful information on BP level and profile to
    practising doctors.
    Home Blood Pressure Monitoring

    • Morning and evening blood pressure


    should be measured for at least 5 days
    and ideally 7 days
    • Measurements of the first monitoring
    day are excluded
    • The average of a series of
    measurements taken as described
    should be used for the clinical decisions
    • The users should be informed that BP
    may vary between measurements and
    be instructed not to be alarmed by high
    or low BP measured on a single
    occasion
    Thomas Unger. Hypertension. 2020 International Society of Hypertension Global Hypertension Practice Guidelines, Volume: 75, Issue: 6, Pages: 1334-
    1357, DOI: (10.1161/HYPERTENSIONAHA.120.15026)
    Summary of key home blood pressure monitoring metrics

    Measure Definition
    Morning SBP Average of 2 consecutive values taken each morning over
    several day )at least 3 days)

    Maximum morning SBP Maximum of average of 2 consecutive values taken each


    morning over several day more than 3 days)

    Day by day SBP variability SD of morning values taken over several days
    Morning/evening diffrence Morning SBP minud evening SBP
    Orthostatic morning SBP Standing morning SBP minus sitting morning SBP

    Kario et al. Guidance on home blood pressure monitoring: A statement of the HOPE Asia Network. J Clin Hypertens 2018 Mar; 20(3): 456–461
    Advantages and Limitations of Home Blood Pressure Monitoring

    Advantage Limitations
    • Can take multiple readings over an extended • Some devices have been found to be
    period of time inaccurate
    • Avoids white-coat reaction to BP measurement
    • Cuff placement can affect accuracy
    • Reproducible
    • May induce anxiety and excessive
    • Predicts CV morbidity and mortality better than
    office BP monitoring
    • Can diagnose white-coat and masked hypertension • Risk of treatment change by patients based
    • Allows patients to better understand hypertension on casual home measurements without
    management doctors’ guidance
    • Telemonitoring allows remote monitoring by • Lack of nocturnal recording
    healthcare professionals
    • Not yet reimbursed by insurance
    • Detects increased BP variability
    companies in many countries
    Parati. European Society of Hypertension practice guidelines for home blood pressure monitoring J Hum Hypertens. 2010;24:779–85
    Impact of self-monitoring of BP on clinic dBP according to level of co-intervention
    support at 12 months studies)

    PLoS Med. 2017; 14:e1002389. doi: 10.1371/journal.pmed.1002389


    Am J Hypertens. 2021 Aug; 34(8): 783–794.
    Detection of white coat hypertension or masked hypertension in
    patients not on drug therapy.

    2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High
    Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical PracticeGuidelines.
    Hypertension2017;71(6):HYP.0000000000000065DOI:10.1161/HYP.0000000000000065
    Detection of white coat hypertension or masked
    hypertension in patients on drug therapy.

    2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High
    Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical PracticeGuidelines.
    Hypertension2017;71(6):HYP.0000000000000065DOI:10.1161/HYP.0000000000000065
    Impact of morning home SBP and clinic SBP on
    cardiovascular events (HONEST study)

    J Am Coll Cardiol. 2016;67:1519‐1527.


    Home blood pressure-guided three-step antihypertensive
    strategy for morning hypertension
    CONCLUSION
    • Accurate blood pressure measurement as well as reliable data sources
    are essential in diagnosis and management of hypertension
    • ABPM dan HBPM provide prediction of cardiovascular risk better
    than office BP measurement and should coexist and be used as
    complementary tools, providing different information on a subject’s
    BP status
    • HBPM is an ideal first-line tool for out office blood pressure
    measurement because of its low cost, high availability, and easy
    application

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