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Nocturnal Hypertension BY AHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine

Nocturnal Hypertension BY AHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine. Systemic Hypertension. The World Health Organization estimates that Hypertension causes 51% of stroke deaths and 45% of coronary heart disease deaths worldwide.

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Nocturnal Hypertension BY AHMAD YOUNES PROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine

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  1. Nocturnal Hypertension BYAHMAD YOUNESPROFESSOR OF THORACIC MEDICINE Mansoura Faculty of Medicine

  2. Systemic Hypertension • The World Health Organization estimates that Hypertension causes51% of stroke deaths and 45% of coronary heart disease deaths worldwide. • Traditionally, blood pressure (BP) is measured in the office or clinic setting. • Twenty-four-hour ambulatory blood pressure monitoring (ABPM)enables the BP to be recorded throughout the day and night away from the medical setting as a person carries out their usual activity. This provides more reliable assessment of BP.

  3. 24--hour ambulatory blood pressure monitoring (ABPM) • Monitors measure about 4 by 3 inches and weigh about 4 lbs. • They can be worn on a belt or in a pouch and are connected to a sphygmomanometer cuff on the upper arm by a plastic tube, • European guidelines recommend 24 h ABPM in certain clinical situations such as suspected white coat hypertension, assessment of nighttime BP ,drug resistance, and hypotensive symptoms.

  4. Different types of blood pressure measurements used in diagnosing hypertension in patients with obstructive sleep apnoea

  5. Office blood pressure • The typical method for blood pressure measurement has long been 1-Manual auscultatory technique with a mercury column or 2-Mechanical aneroid sphygmo- manometer. 3-Automated BP devices • With the benefits that automated BP devices provide with a repeatable standardized technique and removal of observer bias, there has been a shift towards automated devices in clinical practice.

  6. Aneroid Sphygmomanometer • Aneroid sphygmomanometer consists of an aneroid manometer (gauge), complete inflation system, (latex-free inflation bladder, squeeze bulb, and the valve), a zippered carrying case, and operating instructions. • Only use the cuff when the range markings indicated on the cuff show that the proper cuff size is selected, otherwise erroneous readings may result. • Allow space between patient and cuff. Two fingers should fit in this space if the cuff is correctly positioned. • Do not apply cuff to limbs used for IV infusion. • Patient should remain still during measurement to avoid erroneous readings.

  7. Measurement Procedure 1. Patient Position • The patient should sit or lie comfortably. The arm should be fully supported on a flat surface at heart level. (If the arm’s position varies, or is not level with the heart, measurement values obtained will not be consistent with the patient’s true blood pressure.) • When seated, the patient should have their back and arm supported, and their legs should not be crossed. The patient should relax prior to measurement comfortably for five (5) minutes and should refrain from talking or moving during measurement. • Observer should view manometer in a direct line to avoid “Parallax error”.

  8. Measurement Procedure 2. Apply the cuff • Nylon cuffs are specially designed to promote the precisely accurate determination of blood pressure. • Index and range markings ensure use of the correct cuff size. The artery mark indicates proper cuff positioning. • Place the cuff over the bare upper arm with the artery mark positioned directly over the brachial artery. • The bottom edge of the cuff should be positioned approximately (1”)one inch (2-3cm) above the antecubital fold. • Wrap the end of the cuff not containing the bladder around the arm snugly and smoothly and engage adhesive strips. • If the unit is equipped with a calibrated nylon cuff , featuring Index and Range markings, a correct fit may be verified by checking that the Index Line falls between the two Range Lines.

  9. Measurement Procedure 3. Inflate the cuff • Close the valve by turning thumb screw clockwise. • Palpate the radial artery while inflating the cuff. Be sure to inflate cuff quickly by squeezing bulb rapidly. • Inflate cuff 20-30 mmHg above the point at which the radial pulse disappears. 4. Position the Stethoscope • Position the chest piece in the antecubital space below the cuff, distal to the brachium. • Do not place chest piece underneath the cuff, as this impedes accurate measurement. • Use the bell side of a combination stethoscope for clearest detection of the low pitched Korotkoff (pulse) sounds.

  10. Measurement Procedure 5. Deflate the cuff • Open the valve to deflate the cuff gradually at a rate of 2-3 mmHg per second. 6. Measurement • Record the onset of Korotkoff sounds as the systolic pressure, and the disappearance of these sounds as diastolic pressure. • After measurement is completed, open valve fully to release any remaining air in the cuff. • Remove cuff.

  11. Automated Blood Pressure Devices

  12. Omron 10 Series Upper Arm Blood Pressure Monitor • It’s simple to use: just slip the adjustable, pre-formed cuff around your arm and press start. The cuff, which fits a 9-17” circumference, inflates automatically, and provides an accurate reading. • You can test the accuracy, too, since it gives you an average of your last three readings (taken within a 10-minute window). • The monitor can be used by two people, and stores their last 100 readings. • Beyond measuring your blood pressure, the monitor also scans for irregular heart beat.

  13. Omron 7 Series Wrist Blood Pressure Monitor • If you prefer a wrist monitor, look no further than the Omron 7 Series. • Thanks to its slim size and silent inflation, you can discreetly check your blood pressure on the go. • It also features heart zone guidance technology to help ensure your wrist is properly placed at heart level. • The 7 Series automatically averages your last three readings (over a period of ten minutes). It also stores up to 100 readings, allowing you to get a comprehensive picture of your heart health.

  14. Panasonic Portable Upper Arm Blood Pressure Monitor • To operate, you only need to apply the cuff and push the start button. • Its large LCD display makes it really easy to read your results. • The monitor has an automatic memory that captures your last 90 readings so you can quickly track your numbers over time and identify any changes.

  15. LotFancy Blood Pressure Monitor • LotFancy’s blood pressure monitor is FDA-approved and a cinch to operate. It comes with a standard adult-sized cuff that automatically inflates/deflates at the touch of a button. • The monitor’s LCD display is easy to read and shows both systolic and diastolic pressure as well as pulse rate. • LotFancy can average your last three readings for optimal results, while also storing up to 30 readings for four different users. The monitor also detects irregular heartbeats.

  16. Withings Wireless Blood Pressure Monitor • Withings Wireless Blood Pressure Monitor is a great device for gadget lovers. • As the name suggests, it’s wireless. In fact, there’s no display at all. You simply wrap the cuff around your arm and connect it to a companion app that syncs your data automatically. • Indeed, it displays and stores your readings and also enables you to send a detailed report to your doctor. • Since it’s fairly compact, you can test your blood pressure either at home or when you’re on the go.

  17. Finapres NOVA​ • Standard ABPM devices measure blood pressure on set intervals (e.g. each 15- 30 minutes) only. • With Finapres devices short and long term hemodynamic changes will become visible on a beat-to-beat basis. • Finapres devices measure beat-to-beat blood pressure not losing any information between intermittent measurements when using standard ABPM devices. • The dual cuff system makes it possible to switch between fingers on set intervals permitting long continuous measurements. • An optional Remote Control Module provides the possibility to monitor and control a Finapres Nova from a computer outside the patient's room.

  18. Systemic Hypertension • There is marked diurnal variation in the onset time of cardiovascular events, with the peak being exhibited in early morning. • Blood pressure (BP) also exhibits a similar diurnal variation, with a decrease during sleep and a surge in the morning. • OSAHS is considered as the most common cause of secondary systolic hypertension. • 30% of the patients with systemic HT have moderate or severe OSAHS, while between 45% and 68% of OSAHS patients have HT. • Greater than 70% of OSAHS occur in patients with resistant HT.

  19. Systemic Hypertension • CPAP in OSAHS patients with poorly controlled systolic HT provides better systolic control and even leads to recovery of the nocturnal dipper pattern. • ABPM is the reference technique for the diagnosis of HT. • This technique consists of a Holter or automatic monitoring of BP every 15 min during the day and every 30 min at night, according to the recommendations of the European Society of Hypertension and the European Cardiology Society in their 2007 guidelines on the management of HT. • An average daytime or active value of <130/80 mmHg, an average nocturnal value of <120/70 mmHg, and <125/80 mmHg for the 24-h period have been accepted as the normal limits.

  20. Limitations of ABPM • continuous recording is impossible and variations occurring over short periods throughout the night may be missed. • Inflation of the cuff may affect not only the quality of sleep, by causing small arousals, but can also produce changes in the measurement of nocturnal BP. • The discomfort of wearing the cuff for 24-h periods makes it difficult to recruit participants to repeat these measurements over time, with the consequent loss of data. • Arterial catheterization, considered the gold standard, is too invasive to be considered a practical method for the diagnosis of HT.

  21. Morning BP surge • Blood pressure (BP) values vary markedly from day to night and from night to day; a nocturnal BP decrease is followed by a morning BP increase. • A large BP increase in the early morninghas coincided with the fact that morning is a vulnerable period during which more cardiovascular events occur than at later times in the day . • Morning BP surge (MS) has been demonstrated to be animportant prognostic factor of cardiovascular end points in Japanese elderly hypertensive patients4 and in many other population-based cohorts. • Sleep-trough MS (STMS) significantly and independently associated with cardiovascular outcomes. STMS rate could independently help identify subjects with an increased cardiovascular risk. ( J Am Heart Assoc.2017;)

  22. Illustration of parameters describing the sleep-trough morning blood pressure surge (STMS).After identification of nighttime blood pressure (BP) trough and morning BP peak, linear regression analysisbetween BP (y axis) and time (x axis) was conducted. The slope of the BP increase is the STMS rate.

  23. Morning BP surge • The morning period was defined as the interval in the first 2 hours of the daytime, the evening period was defined as the last 2 hours before nighttime, and a preawakening period was defined as the last 2 hours of the nighttime. • Sleep-trough SBP was defined as the lowest nighttime reading. • MS can be described as follows : • STMS, defined as the morning SBP (average of the SBP readings during the morning period) minus the sleep-trough SBP; • preawakening surge, defined as the morning SBP minus the preawakening SBP (average of the SBP readings during the preawakening period); (3) morning-evening SBP difference, defined as the difference between morning and evening SBP (average of the SBP readings during the evening period).

  24. Morning BP surge (4) morning-night SBP difference, defined as the difference between morning and nighttime SBP (average of the SBP readings during the nighttime). SBP night:day ratio was calculated as the ratio of nighttime SBP:daytime SBP (average of the SBP readings during the daytime). • The rate of STMS was derived as the slope of the linear regression of successive SBP measures on time intervals within the time frame of STMS. • Morning hypertension was defined as BP of at least 135/85 mm Hg for ambulatory readings within the first 2 hours of daytime. Nocturnal hypertension was defined by nighttime SBP ≥120 mm Hg or DBP ≥70 mm Hg

  25. What Is New? • Conventional sleep-trough morning BP surge (STMS) focused only on the amplitude rather than the rate of BP increase. • STMS rate is calculated as the slope of linear regression of sequential systolic BP measures on time intervals within the STMS period. • The reproducibility of the STMS rate was better than that of the STMS amplitude. • The STMS rate was also a more sensitive and reliable prognostic factor for long-term mortality than the STMS amplitude. • The prognostic values of the STMS rate were comparable in subjects with or without morning and nocturnal hypertension.

  26. What Are the Clinical Implications? • Because the STMS rate can be easily calculated from the ambulatory BP monitoring data, it has the potential to become a routine parameter in daily practice for subjects receiving ambulatory BP monitoring,in conjunction with other routinely derived parameters, including STMS amplitude.

  27. Nocturnal Hypertension • Isolated nocturnal hypertension (i.e., nighttime BP ≥120/70 mm Hg and day-time <130/80 mm Hg) was associated with a higher risk of total mortality and all cardiovascular events compared with normotension. • Nighttime BP was a better predictor of outcomes than day-time, day-night BP ratio and the dipping status.

  28. Definition of Nocturnal Hypertension • Nocturnal hypertension is defined as systolic BP >120 mmHg and/or diastolic BP >70 mmHg at night. • The variation of BP during the day and night depends on circadian rhythm, and is associated with interaction of the sympathetic nervous system and renin-angiotensin system . • This BP variation consists of : 1- Dipping 2- Extreme dipping 3- Non-dipping and 4- Reverse-dipping.

  29. Circadian Blood Pressure Rhythm • Type of circadian BP rhythm is defined as proportion of the nocturnal average BP fall to daytime average BP value. • If it is <10%, then it is referred to as a non-dipping pattern, if it is 10–20%, it is referred to as dipping pattern . • Nocturnal average BP fall > 20% of daytime average BP values is referred to as extreme dipper pattern. • The increase instead of decrease of average BP values between average nighttime and daytime values is known as reverse dipper pattern. European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). 2013

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