TEAM-BASED CARE: HOME BLOOD PRESSURE MONITORING IN TODAY S MANAGEMENT OF HYPERTENSION

Transcription

1 TEAM-BASED CARE: HOME BLOOD PRESSURE MONITORING IN TODAY S MANAGEMENT OF HYPERTENSION Donald J. DiPette MD Distinguished Health Science Professor University of South Carolina University of South Carolina School of Medicine-Columbia Department of Medicine 14 th Annual Chronic Disease Symposium Myrtle Beach, S.C. March 12, 2016

2 NHANES: U.S. POPULATION RESULTS PREVALENCE(%) AWARENESS(%) TREATMENT(%) CONTROL(%) JAMA May 2010 ; 303(20)

3 Patient Case 42 year old WM university professor recently relocated and in clinic to establish care Other than stressful job, relocation, and mild GERD, hx is unremarkable FHx: mother has HTN on medications Office BP 136/86 mmhg, taken by nurse PE: BMI 26 otherwise unremarkable

4 Patient Case: continued Specific treatment plan was initiated Patient returns 1 month later No change in history except patient followed the treatment plan Three interval office BPs average /84-88 mmhg Now what?

5 Background: Definition of Hypertension and Its Prevalence High BP or hypertension is defined as persistently elevated BP 140/90 mmhg in otherwise healthy adults. The World Health Report 2002 estimated that more than 1 billion people have high BP and that 7 million people die from high BP annually. It is anticipated that the prevalence of BP will continue to rise as the population ages. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January Available at: Chobanian AV, Bakris GL, Black HR, et al. Hypertension 2003 Dec;42(6): PMID: World Health Organization. The World Health Report 2002 Reducing Risks, Promoting Healthy Life. Available at:

6 Background: Disease Burden of Hypertension Hypertension has been identified as a major risk factor for cardiovascular disease and mortality. Hypertension is also an important modifiable risk factor for several diseases including: Coronary artery disease Stroke Congestive heart failure Chronic kidney disease Peripheral vascular disease Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January Available at: Ezzati M, Oza S, Danaei G, et al. Circulation 2008 Feb 19;117(7): PMID: Chobanian AV, Bakris GL, Black HR, et al. Hypertension 2003 Dec;42(6): PMID:

7 Background: Importance of Blood Pressure Control in the Management of Hypertension Strategies for the management of hypertension involve a combination of antihypertensive medication and lifestyle modifications such as: Smoking cessation Moderation of alcohol consumption Salt restriction and other dietary modifications Regular exercise Weight loss in obese persons Effective BP control has been shown to significantly improve health outcomes and reduce mortality. A decrease of 5 mmhg in systolic BP is estimated to reduce mortality due to stroke and heart disease by 14% and 9% respectively, and all-cause mortality by 7%. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January Available at: Chobanian AV, Bakris GL, Black HR, et al. Hypertension 2003 Dec;42(6): PMID:

8 Blood Pressure Measurement Office (OBPM) Home/Self (HBPM/SMBP) Ambulatory (ABPM) In-patient (IBPM)

9 Background: Aims of using Self Monitoring Blood Pressure (SMBP) in the Management of Hypertension The aims of using SMBP monitoring in hypertension management are: Avoiding undertreatment of hypertension Enhancing patient self-participation in disease management Enhancing adherence to lifestyle and pharmacological interventions Avoiding overtreatment in patients with lower BP outside the clinic than in it. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January Available at:

10 Background: BP Measurement Strategies Measurement in the Health Care Setting For the diagnosis and effective management of hypertension, accurate measurement of BP is crucial. Strategies for BP measurement include measurement in the health care setting and at home. Measurement of BP in the clinic or other health care settings has the following limitations: The need for a period of rest before measurement to obtain reliable readings The possibility that a patient s BP may rise as a result of being in the health care setting (termed white coat hypertension) The possibility that a patient s BP is normal in the clinic, but not outside; (termed masked hypertension) Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January Available at:

11 Types of Readings Casual blood pressure - a measurement taken without the required 5 minute rest period Resting blood pressure - the seated resting blood pressure is used to determine and monitor treatment decisions Standing blood pressure - is used to test for postural hypotension, which may modify treatment if present 2009 Canadian Hypertension Education Program Recommendations

12 Patient Preparation No caffeine for minutes No smoking for 30 minutes No exercise for 30 minutes Bladder/Bowel comfortable Quiet/temperate, relaxed environment, no talking Bare arm with no constrictive clothing Patient should stay silent prior and during the procedure No acute anxiety, stress or pain 2009 Canadian Hypertension Education Program Recommendations

13 Recommended Equipment for Measuring Blood Pressure Mercury manometer Recently calibrated aneroid Validated automated device 2009 Canadian Hypertension Education Program Recommendations

14 Background: SMBP Monitoring Devices Types of SMBP monitoring devices include: Manual devices sphygmomanometers that require manual inflation and auscultation Semiautomated devices manually inflated sphygmomanometers with automated display Automated devices inflation of sphygmomanometers and BP measurement are both automated Many devices are commercially available and have been validated by leading organizations. Patients may require some instruction on device use. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January 2012 Available at: MedlinePlus Web site. Blood pressure monitors for home. Updated June 10, Available at:

15 Validated equipment An up-to-date list of validated monitors can be found at: British Hypertension Society Dabl Education Trust able

16 Support for Home Blood Pressure measurement Measurements taken by patients at home are often lower than readings taken in the office and closer to the average blood pressure recorded by 24 hour ambulatory monitors. Home BP readings predicts risk better than office BP s In a 2005 Gallup poll: o 35% of hypertensive patients now check their blood pressure at least once per week o 86% of patients who had been advised to purchase a blood pressure monitor had done so. o 55% of patients were monitoring their blood pressure an increase of 17 % from AHA-Hypertension 2008

17 Patient Instructions Use a validated monitor Correct cuff size Accurate resting technique Patient technique should be reviewed regularly Duplicate measurements 1-2 min. apart 7 days after any Rx change or before a doctor s appointment AM (before Rx) & PM (2 hrs. after dinner) 2009 Canadian Hypertension Education Program Recommendations

18 Help patients determine their correct cuff size Cuff Name Bladder Width Bladder Length Mid Arm Circumference Child to <22cm Small arm to <27cm Average arm to<33cm Large arm to <41cm Extra Large to <52cm Based on AHA Guidelines

19 Threshold levels of BP for the diagnosis of Hypertension according to measurement method SBP (mmhg) DBP (mmhg) Office >140 >90 Self/home BP Monitoring >135 >85 Ambulatory BP Monitoring Day >135 >85 Ambulatory BP Monitoring Night >120 >75 Ambulatory 24 hr BP Monitoring >130 >80 1 These figures do not necessarily equate with the need for antihypertensive drug treatment to be started and therapy must be based on overall CV risk as well as absolute BP levels. Antihypertensive treatment should however, be initiated in people with sustained office SBP >160mmHg or sustained DBP >100mmHg irrespective of other risk factors. 2 Lower levels of BP to initiate drug therapy may be considered in some instances eg post-stroke, diabetes 3 The highest value of SBP or DBP should be used for classification, whichever method measurement method is used

20 The Concept of White Coat vs Masked Hypertension 140 From Pickering et al, Hypertension 2002 Home or ABPM SBP mmhg 135 Masked Hypertension True Normotensive True Hypertensive White Coat Hypertension Office SBP mmhg 2009 Canadian Hypertension Education Program Recommendations

21 The Prognosis of Masked hypertension 2.5 Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients). J Hypertension 2007;25: Relatve risk of CVD Normotension White Coat Hypertension Masked Hypertension Hypertension 2009 Canadian Hypertension Education Program Recommendations

22 Ambulatory Blood Pressure Monitor (ABPM) Shows blood pressure pattern over a 24 hour period Measures blood pressure through oscillometric technology which depends on the pulsatility in the brachial artery Arm must stay motionless during inflation and deflation Less accurate at extremes of systolic and diastolic blood pressure 2009 Canadian Hypertension Education Program Recommendations 22

23 Diurnal Pattern/Circadian Rhythm Abnormalities in pattern are associated with increased CV events Dipping is good Circadian rhythm of blood pressure is a >10% fall in blood pressure during sleep A non-dipping pattern is associated with an increase risk of MI, stroke, dementia as blood pressure remains elevated during sleep 2009 Canadian Hypertension Education Program Recommendations

24 Benefits of 24 hour ABPM Provides large number of blood pressure readings outside clinic setting Helps determine the dynamic changes of blood pressure throughout 24 hour period Enables physician to adjust treatment appropriately to prevent target organ complications Rules out White Coat hypertension Used to aid in diagnosis of Masked Hypertension Identifies Dippers vs. Non-dippers 2009 Canadian Hypertension Education Program Recommendations

25 Value of Home Blood Pressure Monitoring Five prospective studies have compared home and office BP for predicting cardiovascular outcomes. All 5 found that home BP is a significant predictor, and 4/5 that it is stronger than office BP. Other studies have shown that home BP predicts target organ damage better than office BP. Patients who monitor their home BP may be more likely to take their medications regularly. AHA-Hypertension 2008

26 Conclusions (1 of 2) In the management of hypertension, SMBP alone versus usual care yielded a modest net reduction in in-clinic systolic BP and diastolic BP at 6 months and at 12 months. Adding clinical support to SMBP led to a consistently greater BP reduction when compared to usual care at up to 12 months of followup. The evidence was too limited to determine the superiority of any one form of additional clinical support strategy, as modalities varied widely across studies. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No.45. January Available at:

27 Conclusions (2 of 2) The evidence is weak or insufficient to determine if SMBP monitoring with or without additional support has an impact on other outcomes including: Mortality Quality of life Number of medications used and medication dosage Medication adherence Health care encounters Additional research is needed to determine the effect of SMBP monitoring on BP control beyond 12 months and to determine long-term clinical consequences of SMBP monitoring. Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No.45. January Available at:

28 Patient Case 42 year old WM university professor recently relocated and in clinic to establish care Other than stressful job, relocation, and mild GERD, hx is unremarkable FHx: mother has HTN on medications Office BP 136/86 mmhg, taken by nurse PE: BMI 26 otherwise unremarkable

29 Patient Case: continued Specific treatment plan was initiated Patient returns 1 month later No change in history except patient followed the treatment plan Three interval office BPs average /84-88 mmhg Now what?

30 Patient Case: Outcomes Non-pharmacologic recommendations initiated mainly dietary changes, sodium moderation, and exercise Home BPs recommended which the patient did but only sporadically ABP recommended but patient refused Office BP: without change Awaiting EBM for possible pharmacologic treatment guidance

31 Classification of Blood Pressure for Adults Age 18 years (JNC-7) BP Classification Systolic BP Diastolic BP Normal <120 And <80 Prehypertension Or Stage 1 Hypertension Or Stage 2 Hypertension 160 Or 100 Chobanian AV, et al. JAMA 2003;289:

32 Relative Risk of Morbidity Compared to Non-Hypertensive Population Morbidity ratio (observed/expected) * *Indicates morbidity for non-hypertensive population > Diastolic pressure (mm Hg) Risk of overall morbidity increases with elevation in blood pressure

33 Framingham Heart Study High-normal BP Is Not Benign *CV death, MI, stroke, CHF Adjusted for concomitant CV risk factors Optimal = <120/<80 mmhg Normal = /80 84 mmhg High normal = /84 89 mmhg Vasan RS et al. N Engl J Med. 2001;345:

34 Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption 5 20 mmhg/10 kg weight loss 8 14 mmhg 2 8 mmhg 4 9 mmhg 2 4 mmhg

35 35 Summary Home blood pressures monitoring can: be very helpful in clinical management help in assessment, diagnosis, management, and control enhance self-care and engagement and adherence to therapy at minimal cost

36 36 Thank You! Questions?