2010

1. 2010 Office and Home Blood Pressure AssessmentHypertension Diagnosis and Follow up

2. Overseeing organizations and partners Overseeing organizations Hypertension Canada Canadian Council of Cardiovascular Nurses Canadian Pharmacists Association College of Family Physicians of Canada Heart and Stroke Foundation of Canada Public Health Agency of Canada Partner organizations Canadian Cardiovascular Society Canadian Diabetes Association Canadian Society of Nephrology Canadian Stroke Network Canadian Society of Internal Medicine Kidney Foundation of Canada Volunteers (>100)

3. Hypertension Canada and the Canadian Hypertension Education Program This slide set is an initiative aimed at enhancing the quality of blood pressure measurement. This venture is the result of a collaborative effort of Hypertension Canada and the Canadian Hypertension Education Program sub-group Other slide sets and other educational material on hypertension can be downloaded from the following website: http://www.hypertension.ca

4. The Canadian Hypertension Education Program (CHEP) Overseen by: Hypertension Canada The Heart and Stroke Foundation of Canada The Public Health Agency of Canada The College of Family Physicians of Canada The Canadian Council of Cardiovascular Nurses The Canadian Pharmacy Association.

5. Hypertension Canada and the Canadian Hypertension Education Program Instructions for proper blood pressure measurement are found in the detailed recommendations of the CHEP program (Can J Cardiol 2008;24(6):455-63), at www.hypertension.ca

6. Blood Pressure Measurement and Hypertension Diagnosis 1 in 5 adult Canadians have hypertension Over 40% of Canadians at aged 56-65 have hypertension 90% of normotensive persons aged 55-65 developed hypertension in the next 20 years in the Framingham study

7. Blood Pressure Assessment Blood pressure of all adults should be measured by a trained healthcare professional at all appropriate visits: To determine cardiovascular risk To monitor antihypertensive treatment Blood pressure of adults with high normal blood pressure (130-139/80-89 mmHg) should be assessed annually

8. The percent of Canadians with hypertension CHHS CMAJ 1992

9. Life time Risk of Hypertension in Normotensive Women and men aged 65 years 14 16 18 20 14 16 18 20 0 4 6 8 10 12 0 4 6 8 10 12 2 2 Risk of Hypertension % Risk of Hypertension % 100 100 Women Men 80 80 60 60 40 40 20 20 0 0 Years to Follow-up Years to Follow-up JAMA 2002:297:1003-10. Framingham data.

10. Modifiable risks for developing hypertension Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption

11. Development of hypertension (%) in those with high normal blood pressure Framingham cohort Vasan. Lancet 2001;358:1682-86 2010 Canadian Hypertension Education Program Recommendations

12. New onset hypertension in those with high normal blood pressure 772 subjects, over weight, mean age 48.5 Not receiving treatment for Hypertension Average of 3 blood pressures at baseline: SBP 130-139 and DBP < 89 OR SBP < 139 and DBP 85-89 Primary endpoint – new onset hypertension NEJM 2006;354:1685-97

13. New onset hypertension in people with high normal blood pressure NEJM 2006;354:1685-97

14. New onset hypertension in people with high normal blood pressure 40% of overweight patients with systolic 130-139 or diastolic 85-89 mmHg developed hypertension in 2 years and 63% in 4 years Annual follow-up of patients with high normal blood pressure is recommended by CHEP.

15. Blood Pressure Assessment:Patient preparation and posture Standardized Preparation: Patient 1. No acute anxiety, stress or pain. 2. No caffeine,smoking or nicotine in the preceding 30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. No tight clothing on arm or forearm. 6. Quiet room with comfortabletemperature 7. Rest for at least 5 minutes before measurement 8. Patient should stay silent prior and during the procedure.

16. Blood Pressure Assessment:Patient preparation and posture Standardized technique: Posture The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.

17. Blood Pressure Assessment:Patient position

18. Recommended Equipment for Measuring Blood Pressure Use a mercury manometer or a recently calibrated aneroid or a validated automated device. Aneroid devices should only be used if there is an established calibration check every 12 months.

19. Recommended Equipment for Measuring Blood Pressure • Automated oscillometric devices: • Use a validated automated device according to BHS, AAMI or IP clinical protocols. • For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement. AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol.

20. Recommended Technique for Measuring Blood Pressure (cont.) Select a device with an appropriate size cuff

21. Use an appropriate size cuff For automated devices, follow the manufacturer’s directions. For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

22. Recommended Technique for Measuring Blood Pressure (cont.) Locate the brachial pulse and centre the cuff bladder over it Positioncuff at the heart level Arm should be supported

23. Recommended Technique for Measuring Blood Pressure* (cont.) To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse Place stethoscope over the brachial artery *with manual or semi automated devices

24. Recommended Technique for Measuring Blood Pressure* (cont.) Drop pressure by 2 mmHg / beat Appearance of sound (phase I Korotkoff) = systolic pressure Drop pressure by 2 mmHg / beat Disappearance of sound (phase V Korotkoff) = diastolic pressure Record measurement Take at least 2 blood pressure measurements, 1 minute apart 2010 Canadian Hypertension Education Program Recommendations

25. Korotkoff sounds and auscultatory gaps Korotkoff sounds 200 No sound 180 Clear sound Phase 1 160 Muffling Phase 2 Auscultatory gap No sound 140 120 Clear sound Phase 3 100 Muffled sound Phase 4 80 60 No sound Phase 5 40 20 0 mmHg Systolic BP Phase 3 Phase 4 Diastolic BP

26. Recommended Technique for Measuring Blood Pressure Standardized technique: For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading. Thereafter, take two measurements on the side where BP is higher.

27. Recommended Technique for Measuring Blood Pressure* (cont.) Record the blood pressure to the closest 2 mmHg on the manometer and whether the patient was supine, sitting or standing. Aneroid devices should not be used unless they are known to be in calibration and are checked regularly (minimally every 12 months). * For manual blood pressure measurement

28. Recommended Technique for Measuring Blood Pressure* (cont.) Avoid digit preference for five (5) or zeros (0) by not rounding up or down. Record the heart rate. If the needle on an aneroid device does not zero it is inaccurate however the converse is not true. * For manual blood pressure measurement

29. Recommended Technique for Measuring Blood Pressure (cont.) The seated BP measurement is the standard position to determine diagnostic and therapeutic treatment decisions The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment.

30. Recommended Technique for Measuring BP: Standing BP Perform in patients over age 65 with diabetes if there are symptoms of postural hypotension Check after 1 to 5 minutes in the standing position and under circumstances when the patients complains of symptoms suggestive of hypotension.

31. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement Elevated Out of the Office BP measurement Elevated Random Office BP Measurement Hypertensive Urgency / Emergency BP ≥ 140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110? Diagnosis of HTN Yes No BP: 140-179 / 90-109 Hypertension Visit 1 BP Measurement, History and Physical examination Diagnostic tests ordering at visit 1 or 2 Hypertension Visit 2 within 1 month

32. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP ≥ 180/110? Diagnosis of HTN Yes No BP: 140-179 / 90-109 Clinic BPM ABPM (If available) HBPM

33. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement BP: 140-179 / 90-109 Clinic BP ABPM (If available) HBPM Hypertension visit 3 ≥ 160 SBP or ≥ 100 DBP Diagnosis of HTN ≥ 135 SBP or ≥ DBP 85 Awake BP < 135/85 and 24-hour < 130/80 Awake BP ≥ 135 SBP or ≥ 85 DBP Or 24-hour ≥ 130 SBP or ≥ 80 DBP < 135/85 < 160 / 100 ABPM or HBPM or or Hypertension visit 4-5 ≥ 140 SBP or ≥ 90 DBP Diagnosis of HTN Continue to follow-up Diagnosis of HTN Continue to follow-up Diagnosis of HTN Continue to follow-up < 140 / 90

34. The concept of masked hypertension 135 140 True hypertensive Masked HTN Home or daytime ABPM SBP mmHg 135 True Normotensive White Coat HTN 140 Office SBP mmHg From Pickering, Hypertension 1992

35. The prognosis of masked hypertension Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients). J Hypertension 2007;25:2193-98

36. Threshold for Initiation of Treatment and Target Values

37. VII. Home measurement of blood pressure Home BP measurement should be encouraged to increase patient involvement in care Which patients? For the diagnosis of hypertension Suspected non adherence White coat hypertension or effect Masked hypertension Average BP equal to or over 135/85 mmHg should be considered elevated

38. Benefits of Home Blood Pressure Monitoring Rapid confirmation of the diagnosis of hypertension Better prediction of cardiovascular prognosis Diagnosis of white coat and masked hypertension Reduced medication use in white coat effect Improved adherence to drug therapy Better blood pressure

39. Not all patients are suited to home measurement Undue anxiety in response to high blood pressure readings Physical or mental disability prevents accurate technique or recording Arm not suited to blood pressure cuff (e.g. conical shaped arm) Irregular pulse or arrhythmias prevent accurate readings Lack of interest The vast majority of patients can be trained to measure blood pressure

40. Home Measurement of BP:Use validated BP measurement devices This logo* on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement * Endorsed by the Canadian Hypertension Society Average BP > 135/85 mmHg should be considered elevated

41. VII. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension Home blood pressure values should be based on: duplicate measures, morning and evening, for an initial 7-day period. Singular and first day home BP values should not be considered. Daytime average BP equal to or over 135/85 mmHg should be considered elevated

42. Home Measurement of BP:Patient Education How to? • Use devices: • appropriate for the individual • appropriate cuff size • marked with this symbol • Adequate patient training in: • measuring their BP • interpreting these readings • Regular verification • measuring techniques Values > 135 / 85 mmHg should be considered elevated Home measurement can help to improve patient adherence

43. Suggested Protocol for Home Measurement of Blood Pressure How? • Home blood pressure values for assessing white coat hypertension or sustained hypertension should be based on: • Duplicate measures, • Morning and evening, • For an initial 7-day period. • Single readings and • First day home BP values should not be considered. • For patients treated for hypertension • Morning measurement should be done before medication taking

44. VII. Home Measurement of BP: Patient Education Assist patients select a model with the correct size of cuff Measure and record the patients mid arm circumference so they can match it to cuff size Recommend devices listed at www.hypertension.caor marked with this symbol Ask patients to carefully follow the instructions with device and to record only those blood pressure readings where they have followed recommended procedure Advise patients that average readings equal to or over 135/85 mmHg are high a lower threshold is appropriate for those with diabetes or chronic kidney disease Values equal to or over 135 / 85 mmHg should be considered elevated for those without diabetes or chronic kidney disease Home measurement can help to improve patient adherence

45. Web based home monitoring A website to assist patients to monitor and track home blood pressure and support self management including healthy lifestyle change is available at: www.heartandstroke.ca/BP

46. Advice for patients on when to contact a health care professional based on high average home blood pressure readings* *Patients with diabetes, chronic kidney disease or who are at high risk of cardiovascular events require individualized advice. *(available at www.hypertension.ca/bpc in the resource section under educational tools for health care professionals in the Brief Hypertension Action Tool or at www.heartandstroke.ca/BP )

47. Home measurement of blood pressure A poster and instruction sheets can be ordered at: www.hypertension.ca

48. Suggested use of ABPM in the Management of Hypertension Office BP > 140/90 mmHg in low risk patients (with no target-organ disease) Home-monitored blood pressure <135/85mmHg Home-monitored blood pressure equals or over 135/85mmHg Perform ABPM Mean awake BP Less than 135/85 mmHg Mean awake BP equals or over 135/85 mmHg Follow-up with periodic home-BP measurement and or repeated ABPM every 1-2yr. Initiate antihypertensive therapy ABPM: Ambulatory Blood Pressure Monitoring BP: Blood Pressure Adapted from White W, NEJM 348:24, June 12, 2003

49. 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 frequentvisits Visits every 1-2 Months

50. Blood pressure measurement with specific devices Mercury Blood Pressure Monitor Aneroid Blood Pressure Monitor Automated Blood Pressure Monitor