Docstoc

Should Ambulatory Blood Pressure Monitoring Echocardiogram and

Document Sample
Should Ambulatory Blood Pressure Monitoring Echocardiogram and Powered By Docstoc
					  Should Ambulatory Blood Pressure
Monitoring, Echocardiogram, and Renin
 Determinations be Part of the Routine
 Evaluation of Hypertensive Patients?

       Thomas Pickering MD, DPhil
     Behavioral Cardiovascular Health and
            Hypertension Program
       Columbia Presbyterian Medical Center
                   New York
  Should Ambulatory Blood Pressure
Monitoring, Echocardiogram, and Renin
 Determinations be Part of the Routine
 Evaluation of Hypertensive Patients?

       Thomas Pickering MD, DPhil
     Behavioral Cardiovascular Health and
            Hypertension Program
       Columbia Presbyterian Medical Center
                   New York
  Should Ambulatory Blood Pressure
Monitoring, Echocardiogram, and Renin
 Determinations be Part of the Routine
  Evaluation of Hypertensive Patients

       Thomas Pickering MD, DPhil
     Behavioral Cardiovascular Health and
            Hypertension Program
       Columbia Presbyterian Medical Center
                   New York
               Rationale-
        One Size Does Not Fit All
1. Level of risk varies greatly in hypertensive
   patients
2. Responsiveness to treatment varies greatly in
   hypertensive patients
               Rationale-
        One Size Does Not Fit All
1. Level of risk varies greatly in hypertensive
   patients
2. Responsiveness to treatment varies greatly in
   hypertensive patients

1. Need tests to improve prediction of risk in
   individual patients, e.g. ABPM,
   Echocardiography, microalbuminuria
               Rationale-
        One Size Does Not Fit All
1. Level of risk varies greatly in hypertensive
   patients
2. Responsiveness to treatment varies greatly in
   hypertensive patients

1. Need tests to improve prediction of risk in
   individual patients, e.g. ABPM,
   Echocardiography, microalbuminuria
2. Need tests to improve prediction of treatment
   response, e.g. renin
      JNC 7 Recommendations for Routine
       Work-up of Hypertensive Patients
 Routine Tests
   • Electrocardiogram
   • Urinalysis
   • Blood glucose, and hematocrit
   • Serum potassium, creatinine, or the corresponding estimated GFR,
     and calcium
   • Lipid profile, after 9- to 12-hour fast, that includes high-density and
     low-density lipoprotein cholesterol, and triglycerides
 Optional tests
   • Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
  unless BP control is not achieved
1. ABPM
2. Echocardiogram
3. Renin
1. ABPM
2. Echocardiogram
3. Renin
  Recommendations for Clinical Use of
     ABPM: JNC 7 & WHO-ISH

                           JNC 7   WHO-ISH
ABPM endorsed              Yes     Yes
Indications:
White Coat HTN             Yes     Yes
Labile BP                  Yes     Yes
R/O hypotensive episodes   Yes     Yes
Resistant HTN              Yes     Yes
Autonomic dysfunction      Yes     No
Ambulatory BP and Cardiovascular Disease
in the Elderly with Systolic Hypertension:
The Syst-Eur Study (N = 808)

                                                             Placebo                            Active treatment
 Cardiovascular disease




                                                      60                                   60

                                                      50                                   50
                          (per 1000 patient - year)




                                                      40                                   40

                                                      30                                   30

                                                      20                                   20
                                                                               Clinic
                                                      10                       24-hr       10
                                                                               Daytime
                                                       0                       Nighttime   0

                                                           110   130   150   170   190          110   130   150   170   190



                                                                                      Staessen et al. JAMA 1999; 282: 539-46.
Ambulatory BP and Cardiovascular Disease
in the Elderly with Systolic Hypertension:
The Syst-Eur Study (N = 808)
                                                                                   High risk group- Clinic
                                                                                   BP underestimates
                                                             Placebo               risk         Active treatment
 Cardiovascular disease




                                                      60                                    60

                                                      50                                    50
                          (per 1000 patient - year)




                                                      40                                    40

                                                      30                                    30

                                                      20                                    20
                                                                               Clinic
                                                      10                       24-hr        10
                                                                               Daytime
                                                       0                       Nighttime    0

                                                           110   130   150   170      190        110   130   150   170    190



                                                                                        Staessen et al. JAMA 1999; 282: 539-46.
Ambulatory BP and Cardiovascular Disease
in the Elderly with Systolic Hypertension:
The Syst-Eur Study (N = 808)
                                                                              High risk group- Clinic
                                                                              BP underestimates
                                                             Placebo          risk         Active treatment
 Cardiovascular disease




                                                      60                                 60

                                                      50                                 50
                          (per 1000 patient - year)




                                                      40                                 40

                                                      30                                 30

                                                      20                                 20
                                                                             Clinic
                                                      10                     24-hr       10
                                                                             Daytime
                                                       0                     Nighttime   0
                                                                 Low risk group- WCH
                                                           110   130              190                                 190
                                                                 Clinic150 overestimates
                                                                        BP 170                110   130   150   170

                                                                 risk
                                                                                    Staessen et al. JAMA 1999; 282: 539-46.
 The White Coat Effect in the Real World
                   (Little et al, BMJ 2002; 325: 254)


• 173 hypertensive patients in 3 general practices in the UK
• Clinic (MD and RN), self-monitoring, and ABPM
• White coat effect estimated as difference between other
measures of BP and daytime BP:-
               Physician                      19/11 mmHg
               Nurse 1                        5/8 mmHg
               Nurse 2                        5/6 mmHg
               Self-monitoring in clinic      10/13 mmHg
               Self-monitoring at home        5/6 mmHg
Clinic
Pressure   White Coat           Sustained
           Hypertension         Hypertension

140/90

           True                 Masked
           Normotension         Hypertension



                          135/85
                                Ambulatory Pressure
Clinic
Pressure   White Coat           Sustained
           Hypertension         Hypertension

140/90

           True                 Masked
           Normotension         Hypertension



                          135/85
                                Ambulatory Pressure
Clinic
Pressure   White Coat           Sustained
           Hypertension         Hypertension

140/90

           True                 Masked
           Normotension         Hypertension



                          135/85
                                Ambulatory Pressure
1. ABPM
2. Echocardiogram
3. Renin
Why Is Echocardiography Useful
  In Hypertensive Patients?

 “No other biological variable (except
advancing age) predicts cardiac risk better
   than left ventricular hypertrophy”.

       (De Simone et al, J Hypertens 12;1129, 1994)
       How Common is LVH in
        Hypertensive Patients?

• ECG LVH in about 5% of ht patients
• Echo LVH in 15-30% of unselected ht patients
• Echo LVH in 20 to 60% of ht patients in referral
centers
Indications for Echocardiography
    in Hypertensive Patients


• Coexistent Heart Disease
• Resistant Hypertension
• Decision to Start Treatment Uncertain
  Echocardiographic LVMI as a Predictor
     of CV Risk (Schillaci et al, Hypertens 2000; 35: 580)
           5
                                                           4.34

           4
CV
Events
                                             2.86
per 100-   3
pt years                        2.24

           2           1.66


               0.85
           1


           0
               1st     2nd       3rd          4th          5th
                                       Quintiles of LVMI
  In-Treatment LV Mass Predicts CV
Events -LIFE Study. (Devereux et al JAMA 2004: 292:2350)
1. ABPM
2. Echocardiogram
3. Renin
     Possible Applications of Renin
              Measurement


1. Better prediction of risk
          Renin as a Risk Factor for MI
                      (Alderman et al, AJH 1997; 10: 1)



Risk of
MI/1000
pt-yrs    35
          30
          25
          20
          15                                                   High
          10                                               Moderate
                                                                      Risk
          5
                                                     Low
                                                                      Status
          0
               Low       Normal         High

                     Renin
    Possible Applications of Renin
             Measurement


1. Better prediction of risk
2. Identification of secondary hypertension
3. Prediction of drug response
   Situations in which Renin
  Measurement May Be Helpful


• Suspected secondary hypertension, e.g.
  hypokalemia (measure off drugs)
• Refractory hypertension (measure on drugs)
• Intolerance to multiple drugs (measure off
  drugs)
     Limited Efficacy of Monotherapy in
    Treating Hypertension (Materson NEJM 1993; 328: 914)
           80                                                         72
           70
                                                          60
Patients   60                           54        55
                             50
Responding 50
%          40
                  31
           30
           20
           10
            0
                Placebo   Captopril   Prazosin   HCTZ   Atenolol   Diltiazem
       JNC 7: New Features and Key Messages
                   (Continued)
 Thiazide-type diuretics should be initial drug therapy for most, either
  alone or combined with other drug classes.

 Certain high-risk conditions are compelling indications for other drug
  classes.

 Most patients will require two or more antihypertensive drugs to
  achieve goal BP.

 If BP is >20/10 mmHg above goal, initiate therapy with two agents,
  one usually should be a thiazide-type diuretic.
 Double-Blind Placebo-Controlled Comparison
   of 5 Classes of Antihypertensive Drugs
                 (Deary et al, J Hypertens 2002; 20:771)


• 34 young (47 years) hypertensives rotated between 5 drugs: A-
ACEI (lisinopril); B- beta blocker( bisoprolol); C- calcium
channel blocker (Amlodipine); D- diuretic (bendrofluazide);
alpha blocker (doxazosin); placebo, for 6 weeks each.
• Best BP responses were to a renin-suppressing drug (A or B).
• No correlations between individual responses to different
drugs, except A with B, and C with D (each r=0.71, p <0.005).
• Response to “best drug” was repeated and highly reproducible
(r=0.79).
• Age and plasma renin activity did not predict BP response.
                 The A/B C/D Rule
ACEI- ARB/Beta blocker Calcium channel blocker/Diuretic

 • Start with A/B or C/D drug: if poor BP response switch to
 other group
 • Younger patients do best with A/B drugs; older patients do
 best with C/D drugs .
 • Beta blockers may be inferior to other drugs for primary
 prevention.
 • In younger patients preferred drug is ARB or ACEI.
 • In older patients preferred drug is Diuretic or CCB.

Brown MJ. Heart 2001; 86:113
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions- ABPM

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without ABPM
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions- ABPM

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without ABPM
• Some type of out-of-office BP monitoring (home or
  ambulatory) is advisable in ALL patients
• ABPM is indicated when there is a discrepancy between
  either successive clinic readings or clinic and home
  readings
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions- Echocardiography

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without echocardiography
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions- Echocardiography

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without echocardiography
• Echocardiography is indicated if any of the following
  occur
   – Coexistent heart disease
   – Refractory hypertension
   – Decision to treat uncertain
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions-Renin measurement

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without renin measurement
Should Ambulatory Blood Pressure Monitoring,
Echocardiogram, and Renin Determinations be Part
of the Routine Evaluation of Hypertensive Patients?
Conclusions-Renin measurement

• Many patients can be evaluated and treated by following
  the basic JNC 7 guidelines without renin measurement
• Renin measurement is indicated in the following situations:
       - Suspected secondary hypertension
       - Refractory hypertension
       - Intolerance to multiple drugs