Dr Charlotte Hespe (Jennifer Gunn) University of Notre Dame, Australia

Transcription

1 Dr Charlotte Hespe (Jennifer Gunn) University of Notre Dame, Australia

2 1. Why? 2. Current Guidelines 3. Influencers on Blood Pressure in patients with Type 2 Diabetes 4. Device comparison - What are the options? 5. Questionaire results 6. What next?

3 Collaboratives / Imrovement Foundation experience of auditing Diabetes registers and BP measurements

4 at least 80% are either on anti-hypertensive therapy or have untreated hypertension 1 Elevated BP times more prevalent in patients with diabetes 2 35% of men and 46% of women have an elevated blood pressure 2 effective management of blood pressure is extremely important to decrease patient s risk of 2 : stroke retinopathy cardiovascular mortality nephropathy neuropathy Sources: 1. Thomas et al, NHMRC 2004.

5 5 min wait 1-2 min wait 1-2 min wait min wait 2 3 sitting Other arm repeat If > 5mmHg difference 1-2 min wait 4 5 sitting repeat Take average of 4 & 5 PLUS if autonomic neuropathy suspected 1-2 min wait 6 7 lying down 1-2 min wait Standing up Source: NHMRC, 2004

6 Overall good correlation between AU, US, Canada, UK and EU The National Clinical Guideline Centres guideline (UK) was the only guideline to recommend using Ambulatory Blood Pressure Monitoring to confirm diagnosis EU, UK and USA all acknowledged the role that home BP monitoring can play when used as an adjunct to office blood pressures The EU guideline also provided guidelines for using automated office blood pressure measurement Sources: 1. NHMRC, CDA, Canadian Hypertension Education Program, Mancia et al, O Brien et al, Ryden et al, National Clinical Guideline Centre, NCCCC, ADA, Pickering et al, 2005

7 Systolic blood pressure can be is influenced by as much as 20 mmhg by 1 : smoking disease, shock or dehydration food, caffeine or alcohol consumption posture time of day bladder distension changes in temperature and altitude pain emotions Age and ethnicity recent exercise Guidelines recommend avoiding smoking and caffeine 30 minutes prior to BP measurement 2 Sources: 1. Beevers,et al, NHMRC, 2004

8 BP variability sign of disturbed autonomic control of circulation and/or increased arterial stiffness 1 Masked hypertension albuminuria and left ventricle wall thickness 2 Impaired nocturnal BP (e.g. nondipping or reverse dipping) retinopathy, left ventricular hypertrophy, increased GFR, microalbuminuria, retinopathy, and macrovascular complications 4,5 White coat hypertension aortic stiffness and left ventricular hypertrophy 3 Sources: 1. Parati et al, Leitão et al., Salles et al, Felício et al, Leitão et al., 2008.

9 PROS Both portable Mercury - Traditionally regarded as gold standard due to accuracy 1 CONS Both - susceptible to observer error rounding down to closest zero value or recording a higher value 2,3 Mercury - Risk of mercury contamination - banned in Sweden & The Netherlands 4,5 Sources: 1. Pickering et al., Nelson et al, Myers et al., O Brien et al., Myers et al., 2011

10 PROS Traditionally regarded as gold standard due to accuracy 1 CONS susceptible to observer error rounding down or up to closest zero value 2,3 Risk of mercury contamination - banned in Sweden & The Netherlands 4,5 Sources: 1. Pickering et al., Nelson et al, Myers et al., O Brien et al., Myers et al., 2011

11 PROS portable CONS susceptible to observer error - rounding 2,3 can be unreliable especially when handled roughly 1 require regular calibration Sources: 1. Pickering et al., Nelson et al, Myers et al., O Brien et al., Myers et al., 2011

12 PROS portable and easy to use digital display reduces observer error 1 less susceptible to external noise -> more flexible cuff placement 2 CONS large discrepancy between devices different algorithms 2 many devices have not been validated 3, although dabl Educational Trust Limited & British Hypertension Society provide a list of validated devices 4,5 Limitations when measuring an irregular pulse Sources: 1. Nelson et al., Pickering et al., O Brien, dabl Educational Trust Limited, British Hypertension Society, 2012.

13 Using either manual or oscillometric techniques PROS Office measurement by a trained professional is the technique recommended by most guidelines 1 convenient for the physician to undertake 2 CONS Variability in measurement away from patient s natural environment 2 However, measurements can be influenced by the presence of the physician (e.g. the white coat effect) 2 Sources: 1. NHMRC, Conen et al., 2009

14 Patient left alone in a room while multiple blood pressure measurements are automatically taken 1 PROS virtually eliminates the white coat effect as shown by correlation with awake ABPM readings 2 Reduced observer error 2 30 minute AOBP measurement to equally classify normotension, white coat hypertension, masked hypertension, and sustained hypertension 3 Dr can attend to other work? 2 CONS Not all practices have a room available to use for this Additional time required by the patient during the consultation Sources: 1. Quinn et al., Myers et al., Van der Wel et al., 2011

15 now regarded as the gold standard - predicting risk of future cardiovascular events & providing additional prognostic info 1,2 Pros insight into patient s BP over 24 hours in own environment 3 Gives insight into effect of treatment (esp. Phamacology) more cost effective than home or office BP measuring & QOL 4,5 Psychological - patient s anxiety relating to their disease & motivation to improve their BP 6 Cons increased training to interpret and report on results 5 inconvenient to patients - 50% report it was a nuisance or disturbed their sleep 7 Sources: 1. Myers et al., Agarwal et al., O Brien et al., NCGC, O Brien et al., Fravel et al., Van der Wel et al., 2011

16 PROS better at predicting target organ damage and risk of cardiovascular events than Office BP measurements 1 Becoming popular with patients 2 values can be taken over a longer period 3 treatment compliance & improved to BP control 1,2,4 CONS to provide equivalent mean daytime values to ABPM it can be quite intrusive to patient s life 5 many devices available have not been validated 6 prone to observer bias 7 with additional risk that a patient may self-treat against medical advice 8 added cost to patient may prevent uptake, lack of ability to oversee technique and ongoing validation Sources: 1. Parati et al., Padfield, Pickering et al., NCGC, O'Brien, O Brien et al., NCGC, Larkin et al., 2007

17 An internet survey of 400 general practitioners in Central Sydney, NSW was conducted in August 2012 regarding how they currently measure and monitor BP for their patients with Type 2 Diabetes. 74 responses were received and analysed. Questions regarding equipment used, calibration, method and techniques employed for measurement, and BP targets were asked. Questions regarding ABPM and home monitoring Demographic information was requested

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20 Cuff size Rest Posture Arm Position Timing Target BP Device Used Number of measurements taken Calibration Frequency of measurement visits Use of AMBP or home monitoring

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22 How long do they rest prior to measuring BP? 38% 4% 5% 15% Immediate Wait 1-3 minutes 38% Wait 3-5 minutes Wait at least 5 minutes other-15 minutes

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24 2.7% 8.1% 35% Mercury 51% 2.7% Anaeroid Electronic Home monitoring AMBP

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26 86% of the GPs surveyed will advise patients to make use of a home electronic monitor 58.3% of these GPs will also give advise regarding the choice of a machine 40% of these GPs advise them to purchase a validated machine 40% give a protocol regarding use of the monitor 5.4% will use the home monitor measurements instead of clinic measures and 21.6% take them into account when managing BP

27 1. Roll out internet questionnaire to a wider group of GPs covering rural and urban Australia to further validate hypothesis 2. Conduct a pilot study looking at alternate BP measurement protocols in the Primary care setting for monitoring and managing BP in diabetes population ABPM AOBP Home monitoring

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