Blood Pressure

1. Blood Pressure
Measurement
How can anything so simple
be so complex?
© Continuing Medical Implementation …...bridging the care gap

2. Diseases Attributable to
Hypertension
Heart failure
Hypertension
Stroke
Coronary heart disease
Myocardial infarction
Left ventricular
hypertrophy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
Cerebral hemorrhage
Chronic kidney failure
Hypertensive
encephalopathy
© Continuing Medical Implementation …...bridging the care gap
Adapted from: Arch Intern Med 1996; 156:1926-1935.
All
Vascular

3. Awareness, Treatment and Control of
High Blood Pressure in Canada
42%
19%
23%
16%
Patients unaware of their high blood pressure 42%
Aware but not treated and not controlled 19%
Treated but not controlled 23%
Treated and controlled 16%
Adapted from: Am J Hypertens 1997; 10:1097-1102.
© Continuing Medical Implementation …...bridging the care gap

4. 2003
High blood pressure vs Hypertension
Office Diagnosis of Hypertension: Summary
Visit 1
Visit 2
Visit 3
160 physical examination
100
Visit 4
Visit 5
Blood pressure
measurement
every year
History-taking,
- Hypertensive
urgency?
- Target organ
damage or
BP >160/100?
(Visit 3) Hypertension
diagnosis
confirmed
BP over threshold
for initiation of
treatment
Yes
No Validated technique and
BP measurement device
140
90
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 34

5. RECOMMENDED BBLLOOOODD PPRREESSSSUURREE
MMEEAASSUURREEMMEENNTT TTEECCHHNNIIQQUUEE
22..
2.
• TThhee ccuuffff mmuusstt bbee lleevveell wwiitthh hheeaarrtt..
• IIff aarrmm cciirrccuummffeerreennccee eexxcceeeeddss 3333 ccmm,,
aa llaarrggee ccuuffff mmuusstt bbee uusseedd..
• PPllaaccee sstteetthhoossccooppee ddiiaapphhrraaggmm oovveerr
bbrraacchhiiaall aarrtteerryy..
• The cuff must be level with heart.
• If arm circumference exceeds 33 cm,
a large cuff must be used.
• Place stethoscope diaphragm over
brachial artery.
11..
1.
• TThhee ppaattiieenntt sshhoouulldd
bbee rreellaaxxeedd aanndd tthhee
aarrmm mmuusstt bbee
ssuuppppoorrtteedd..
• EEnnssuurree nnoo ttiigghhtt
ccllootthhiinngg ccoonnssttrriiccttss
tthhee aarrmm..
• The patient should
be relaxed and the
arm must be
supported.
• Ensure no tight
clothing constricts
the arm.
33..
3.
• TThhee ccoolluummnn ooff
mmeerrccuurryy mmuusstt bbee
vveerrttiiccaall..
• IInnffllaattee ttoo oocccclluuddee tthhee
ppuullssee.. DDeeffllaattee aatt 22 ttoo
33 mmmm//ss.. MMeeaassuurree
ssyyssttoolliicc ((ffiirrsstt ssoouunndd))
aanndd ddiiaassttoolliicc
((ddiissaappppeeaarraannccee)) ttoo
nneeaarreesstt 22 mmmm HHgg..
• The column of
mercury must be
vertical.
• Inflate to occlude the
pulse. Deflate at 2 to
3 mm/s. Measure
systolic (first sound)
and diastolic
(disappearance) to
nearest 2 mm Hg.
SStteetthhoossccooppee
MMeerrccuurryy
mmaacchhiinnee
© Continuing Medical Implementation …...bridging the care gap 3

6. © Continuing Medical Implementation …...bridging the care gap

7. 2003
Threshold for Initiation of Treatment and
Target Values
Target
Condition Initiation
SBP / DBP mmHg SBP / DBP mmHg
<140/90
<140
<135/85
<130/80
Diastolic ± systolic hypertension ³ 140/90
Isolated systolic hypertension SBP >160
Home BP measurement (³ 135/85)
(no diabetes, renal disease or
proteinuria)
Diabetes ³ 130/80
Renal disease (³ 130/80) <130/80
<125/75
Proteinuria >1 g/day (³ 125/75)
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 39

8. BP Treatment
Targets
Condition
160/100 Treatment threshold if no risk
factors,TOD or CCD
< 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 diabetic or
non-diabetic nephropathy with
proteinuria

9. Automated
BpTRU™ BP Devices
© Continuing Medical Implementation …...bridging the care gap

10. Benefits of Automated
BpTRU™ BP Devices
– Standardizes BP readings
from one operator to the
next
– Removes many of the errors
associated with manual
readings
– Accurate, reliable and
reproducible readings
– Multiple readings with
averaging
– “Opportunistic screening”
– Accurate, independently
validated device
– Automatically zeroes with
each inflation
– Performs full system check
every time on powering-up
• Performs six readings
• Discards the first reading
• Averages the remainder
• Interval between readings
from 1-5 minutes apart
• User can auscultate using
the digital readout when
desired
© Continuing Medical Implementation …...bridging the care gap

11. 180 –
170 –
160 –
150 –
140 –
130 –
120 –
110 –
100 –
90 –
80 –
0 –
174±3
Study Results
166±4
158±4 155±5
mmHg)
146±3
(Pressure Blood 92±2
89±3 90±2 88±2 82±2
Specialist Family
Research
Physician
Technician
BP Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B
BpTRU Ambulatory

12. Study Conclusions
• The patient’s presence in the doctor’s office or
research unit in itself appears to be partly
responsible for the white coat effect.
• BP readings taken on the initial visit tend to be
higher than other readings.
• The white coat effect can be partly eliminated by
the use of an automated BP recording device
(BpTRU)
• BP readings recorded by the BpTRU device are
similar to readings taken by an experienced
research technician using CHS Guidelines.
Myers M, Can. J. Cardiology; 2002; 18 (supp B): 113B
© Continuing Medical Implementation …...bridging the care gap

13. 2003
Home (Self) Measurement of BP:
Specific Role in Selected Patients
Which patients?
Non adherence
Hypertension and
diabetes
Further assess
using
ambulatory
blood pressure
monitoring
Normal
Home BP?
Office-induced blood
pressure elevation
BP over 135/85 mm Hg should be considered elevated
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 47

14. 2003
Home (Self) Measurement of BP:
Patient Education
How to?
Use devices:
- appropriate for the individual (cuff size)
- have met the standards of the AAMI
and or the BHS and or IP
Values over
135 / 85 mm Hg
considered elevated
Adequate patient training in:
- measuring their BP
- interpreting these readings
Regular verifications
- accuracy of the device
- measuring techniques
Self measurement can help to
improve patient adherence
AAMI=Association for the Advancement of Medical Instrumentation;
BHS=British Hypertension Society; IP: International Protocol.
should be
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 48

15. Validated BP Devices
• BHS
– BHS = British
Hypertension Society
• AAMI
– AAMI = American
Association of Medical
Instruments
• See
British Hypertension Society
Website
• OMRON
– HEM-705CP
– HEM-711AC
– HEM-722C
– HEM-773
• LifeSource AND
– UA-767 CN
– UA-767 Plus
– UA-779
– UA-787
© Continuing Medical Implementation …...bridging the care gap

16. OMRON
• Claims all devices
with exception of
wrist devices are
validated
© Continuing Medical Implementation …...bridging the care gap

17. OMROM HEM 711 AC
$109.99
© Continuing Medical Implementation …...bridging the care gap

18. LifeSourceUA-767PC
• For use with a PC and
Monitor Pro software.
• Stores and analyzes
recorded blood pressure
data directly from the UA-
767PC.
• The software provides
printable summary reports
and graphing capabilities.
• Remotely monitor patients
and their blood pressure
from their homes.
Validated according to BHS* protocol and
AAMI** approved.
*BHS = British Hypertension Society
**AAMI = American Association of Medical
Instruments
© Continuing Medical Implementation …...bridging the care gap

19. Life Source UA779CN $99.99
© Continuing Medical Implementation …...bridging the care gap

20. No charge……? Validity
© Continuing Medical Implementation …...bridging the care gap

21. When would you order ambulatory
Blood pressure Monitoring?
• For Dx mild to mod HTN
• For elderly women with ISH
• For apparent Rx resistance
• For anxiety prone patients
• When marked fluctuations in office BP present
• For symptoms suggestive of hypotension present
on Rx
• White coat HTN unlikely
– If DM coexists
– If TOD present
© Continuing Medical Implementation …...bridging the care gap

22. 2003
Ambulatory BP Monitoring:
Specific Role in Selected Patients*
Which patients?
Those with suspected office-induced BP elevation
Untreated
- Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and
without target organ damage
Treated patients
- Apparent resistance to drug therapy
- Symptoms suggestive of hypotension
- Fluctuating office blood pressure readings
* Where available
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 49

23. 2003
Ambulatory BP Monitoring
Specific Role in Selected Patients
Use validated devices
How to interpret?
How to ?
Mean daytime ambulatory blood pressure
>135/85 mm Hg
is considered elevated
* A drop in nocturnal BP of <10% is associated with increased risk of CV events
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 50

24. Blood Pressure and
Target Organ Damage (TOD)
Current evidence suggests that:
• 24-h blood pressure correlates most closely with TOD
(compared to clinic or casual BP)
• Higher incidence of cardiovascular events when
blood
pressure remains elevated at night (non-dippers)
• Blood pressure variability is an independent
determinant
of TOD
• Highest incidence of cardiovascular events
occurs in AM
Adapted from: Sokolow, et al. 1966; Devereux, et al. 1983; Devereux, et al. 1987;
Parati, et al. 1987; Mancia. 1990.
© Continuing Medical Implementation …...bridging the care gap

25. 24-Hour Blood Pressure Profile:
Two Patients with Hypertension
Blood pressure (mm Hg)
Sleep
Non-dipper
Dipper
175
155
135
115
95
75
55
7:00 11:00 15:00 19:00 23:00 3:00 7:00
Time of day
© Continuing Medical Implementation …...bridging the care gap
Adapted from: Redman, et al. 1976; Mancia, et al. 1983; Kobrin, et al. 1984; Baumgart, et al. 1989; Imai, et al. 1990; Portaluppi, et al. 1991.

26. 24-Hour Blood Pressure Profile:
The Morning Blood Pressure ‘Surge’
Time of awakening
180 Sleep
160
140
120
100
80
18:00 22:00 02:00 06:00 10:00 14:00 18:00
Time of day
Blood pressure (mm Hg)
© Continuing Medical Implementation …...bridging the care gap
Adapted from: Millar-Craig, et al. 1978; Mancia, et al. 1983.

27. Circadian Incidence of Cardiovascular
Events: Myocardial Ischemia
Ischemia (min)
01:00 05:00 09:00 13:00 17:00 21:00
300
250
200
150
100
50
0
© Continuing Medical Implementation …...bridging the care gap
Adapted from: Rocco, et al. 1987.
n=24
Time of day

28. 2003
Recommendations for Follow-up
Diagnosis of hypertension
Non Pharmacological treatment
With or without Pharmacological treatment
Are BP readings below target during 2 consecutive visits?
Yes No
Follow-up at 3-6
month intervals
Symptoms, Severe
hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes No
More frequent
visits
Monthly visits
© Continuing Medical Implementation …...bridging the care gap
Canadian Hypertension Education Program Recommendations 52

29. TThhiiss ppllaattffoorrmm hhaass bbeeeenn ssttaarrtteedd bbyy
PPaarrvveeeenn KKuummaarr CChhaaddhhaa wwiitthh tthhee vviissiioonn tthhaatt
nnoobbooddyy sshhoouulldd ssuuffffeerr tthhee wwaayy hhee hhaass ssuuffffeerreedd
bbeeccaauussee ooff llaacckk aanndd iimmpprrooppeerr hheeaalltthhccaarree
ffaacciilliittiieess iinn IInnddiiaa.. WWee nneeeedd lloottss ooff ffuunnddss
mmaannppoowweerr eettcc.. ttoo mmaakkee tthhiiss vviissiioonn aa rreeaalliittyy
pplleeaassee ccoonnttaacctt uuss.. JJooiinn uuss aass aa mmeemmbbeerr ffoorr aa
nnoobbllee ccaauussee..

30. Our views have increased
the mark of the 40,000
Thank you viewers.
Looking for ward for franchise, collaboration,
partners.

31. Contact us:- 011-25464531, 9818569476
E-mail:- nursingnursing@yahoo.in
Saxbee Consultants Details :-www.parveenchadha.com

32. Thank you for your attention