Monitoraggio della Pressione Arteriosa come ausilio diagnostico

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1 La SINDROME CARDIO-NEFRO-METABOLICA Con il patrocinio delle sezione Sarde di SID, AMD e SIN JANASDIA ASSOCIAZIONE SCIENTIFICA ONLUS DIABETE SARDEGNA Monitoraggio della Pressione Arteriosa come ausilio diagnostico Marino Ganadu Servizio Nefrologia & Dialisi Ospedale A. Segni OZIERI Responsabile Scientifico Giancarlo Tonolo gtonolo@aslolbia.it 1-2 Ottobre 2010 Hotel Pausania Inn (Tempio)

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3 Come dovrebbe essere misurata la Pressione Arteriosa?

4 Come dovrebbe essere misurata la Pressione Arteriosa? In Ambulatorio Dal Medico? Dall Infermiera? Con uno strumento automatico?

5 Come dovrebbe essere misurata la Pressione Arteriosa? In Ambulatorio Dal Medico? Dall Infermiera? Con uno strumento automatico? NON in Ambulatorio Dal Paziente ( HBPM )? ABPM?

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7 The White Coat Effect in the Real World (Little et al, BMJ 2002; 325: 254) 173 hypertensive patients in 3 general practices in the UK Clinic (MD and RN), self-monitoring, and ABPM White coat effect estimated as difference between other measures of BP and daytime BP:Physician 19/11 mmhg Nurse 1 5/8 mmhg Nurse 2 5/6 mmhg Self-monitoring at home 5/6 mmhg

8 Ambulatory BP and Cardiovascular Disease in the Elderly with Systolic Hypertension: The Syst-Eur Study (N = 808) (per 1000 patient - year) Cardiovascular disease Placebo High risk group- Clinic BP underestimates Active treatment risk Clinic 24-hr Daytime Nighttime Low 130 risk 150 group170 WCH Clinic BP overestimates risk Staessen et al. JAMA 1999; 282:

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11 Masked hypertension: a systematic review. Bobrie G. et al. J Hypertens 2008, 26: Cardiovascular prognosis of masked hypertension. Meta-analysis of the six cohort studies reporting quantitative data for cardiovascular prognosis of MH by comparison to normotensive subjects or subjects with controlled hypertension. HR: 1.92 ( )

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13 Systolic Home BP is similar to ABP in predicting echo-lvh Amb BP 0.4 Home BP Agarwal R, et al. Hypertension 47: 62-68, 2006

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19 CHEP recommendations Increasing evidence of the utility of automated office blood pressure measurement has led to a recommendation to consider automated blood pressure measurement as an option for office blood pressure measurement Canadian Hypertension Education Program

20 EUROPEAN SOCIETY OF HYPERTENSION GUIDELINES FOR THE USE OF HOME BLOOD PRESSURE MONITORING. A SUMMARY REPORT OF THE SECOND INTERNATIONAL CONSENSUS CONFERENCE ON HOME BLOOD PRESSURE MONITORING Short title: Home BP Monitoring Guidelines Gianfranco Parati, George S. Stergiou, Roland Asmar, Grzegorz Bilo, Peter de Leeuw, Yutaka Imai, Kazuomi Kario, Empar Lurbe, Athanasios Manolis, Thomas Mengden, Eoin O Brien, Takayoshi Ohkubo, Paul Padfield, Paolo Palatini, Thomas Pickering, Josep Redon, Miriam Revera, Luis M. Ruilope, Andrew

21 Journal of Hypertension 2008, 26:

22 Ambulatory blood pressure measurement

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25 Ohasama Study Ohkubo T, J Hypertens 2002; 20:

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27 Recommendations for Clinical Use of ABPM: JNC 7 & WHO-ISH JNC 7 WHO-ISH ABPM endorsed Yes Yes Indications: White Coat HTN Yes Yes Labile BP Yes Yes R/O hypotensive episodes Yes Yes Resistant HTN Yes Yes Autonomic dysfunction Yes No

28 Curr Diabetes Rev Mar;6(2): Ambulatory blood pressure and diabetes: targeting nondipping. Cuspidi C, Vaccarella A, Leonetti G, Sala C. Department of Clinical Medicine and Prevention, University of Milano-Bicocca, Milano, Italy. Abstract A reduced fall in nocturnal blood pressure (BP) (i.e. non-dipping) has been related to an increase in target organ damage and cardiovascular (CV) events. Numerous studies have shown that non-dipping is highly prevalent in patients with type 1 and 2 diabetes mellitus. In this paper we reviewed recent literature and our personal data on the prevalence and clinical correlates of abnormal diurnal BP rhythm in diabetic patients; in particular we examined the association of this condition with renal, cardiac, and vascular pre-clinical organ damage as well as CV prognosis. A consistent body of evidence based on crosssectional and longitudinal studies indicates that the lack of the physiologic nocturnal fall in BP may be considered a true clinical trait, a reliable marker of preclinical CV and renal disease and an independent predictor of future CV events. Thus, in the diabetic setting ambulatory BP monitoring (ABPM) should be regarded as a pivotal tool for improving CV risk stratification and therapeutic interventions.

29 Diabetes Res Clin Pract Feb;87(2): Masked hypertension, nocturnal blood pressure and retinopathy in normotensive patients with type 1 diabetes. Rodrigues TC, Canani LH, Viatroski RS, Hoffmann LH, Esteves JF, Gross JL. CONCLUSIONS: In T1D patients with clinic BP<130/80mmHg, masked hypertension and especially masked nocturnal hypertension are present. Normotensive patients with nocturnal BP>120/70mmHg have higher presence of DR, and only will be identified through ABPM.

30 Diabetologia Jun;52(6): Ambulatory blood pressure measurements are related to albumin excretion and are predictive for risk of microalbuminuria in young people with type 1 diabetes. Marcovecchio ML, Dalton RN, Schwarze CP, Prevost AT, Neil HA, Acerini CL, Barrett T, Cooper JD, Edge J, Shield J, Widmer B, Todd JA, Dunger DB. Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.

31 BP Treatment Targets Condition < 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