小时动态血压检测（abpm）

24h Ambulatory Blood Pressure Measurement (ABPM) “From research to clinical practice” Professor BP McGrath Professor of Vascular Medicine Monash University, Melbourne 05 05 ABPM: 24h BP profile SLEEPSLEEP 05 05 05 05 24h ABP monitoring How should the curves be How should the curves be analysedanalysed? ? 05 05 24h BP profile analysis Mean day, night, 24h ABPM Minnesota cosinor method (Halberg et al 1967) Fourier analysis (Chau et al. 1989) Square wave model (Idema et al. 1991) Double logistic analysis (Head et al. 2002) 05 05 Recommended levels of normality for ABPM in adults (ESH guidelines 2005) Optimal*NormalAbnormal Awake140/90 Asleep125/75 *Lower optimal values recommended in diabetes mellitus and high-risk patients*Lower optimal values recommended in diabetes mellitus and high-risk patients 05 05 Rate of morning rise in BP, HR Hypertensive (n=51) vs Normotensive (n=63) mmHg or beats/min per hmmHg or beats/min per h * * * * * * Head G et al. 2003Head G et al. 2003 05 05 Ambulatory blood pressure measurement (ABPM) Advantages Profile of BP away from medical environment Shows BP behaviour during usual daily activities A stronger predictor of cardiovascular morbidity and mortality than clinic BP Can identify patterns: non-dippers, isolated clinic hypertension, masked hypertension, enhanced BP variability, episodes of hypotension 05 05 White-coat hypertension (isolated clinic hypertension ) White-coat hypertension is a condition in which an individual is hypertensive during repeated clinic BP measurements, but outside the medical environment pressures measured by ABPM or self- BPM techniques are normal 05 05 Isolated clinic hypertension or hypertension in evolution? SLEEPSLEEP 05 05 White-coat effect in hypertensive patients Term used to describe phenomenon found in many hypertensive patients whereby clinic BP measurements are consistently greater than the BP values obtained by ABPM or self-BPM, the levels of which are nonetheless increased above normal 05 05 Masked hypertension (isolated ambulatory hypertension) This phenomenon refers to patients in whom clinic BP is normal but blood pressure values by ABPM or self-BPM are increased Not uncommon: 29% Gourlay S et al. J Hum Hypertens 1993, 7:467-72 22% PAMELA study Circ 2001, 104:1385-92 05 05 Ambulatory blood pressure measurement (ABPM) Clinical Indications Suspected isolated clinic hypertension Suspected nocturnal hypertension Suspected masked hypertension To establish dipper status Resistant hypertension Hypertension of pregnancy Potential Indications Risk groups- diabetes, renal disease, elderly Symptom evaluation Autonomic failure 05 05 What is the importance of nocturnal BP? Day-night differences Non-dippers1 - have more end-organ damage Syst-Eur study2 10% increase in N:D ratio gave hazards ratio for CV events of 1.45 SAMPLE study3 night time BP did not improve the prediction of LVH regression in addition to daytime ABP. Ohasama study4 mean daytime ABP better predictor. 1. Verdecchia et al. Hypertension 1994 2. Staessen et al JAMA 1999 3. Mancia G. et al. Circulation 1997 4. Imai Y et al. Blood Pressure Monitoring 1999 05 05 AMBULATORY BLOOD PRESSURE PROGNOSTIC SIGNIFICANCE 05 05 Blood pressure variability 1970s Continuous intra-arterial recordings in humans 1980s Morning rise in BP associated with higher incidence of sudden cardiac deaths, stroke and myocardial infarction Willich SN et al. Am J Cardiol 1987 Kelly-Hayes M et al. Strole 1995 Elliott W. Stroke 1998 2000s Circadian variation in haemodynamic, autonomic and hormonal systems synchronize to produce a high risk state Weber MA Am J Cardiol 2002 05 05 Blood pressure variability Different methods SD of the 24h average ABP A weighted 24h ABP SD (to account for nocturnal BP fall) Average real variability index (Mena et al 2005) Assessing prognostic relevance Discrepant information from different indices 05 05 DaytimeNighttime Systolic BP Variability (mmHg) Relative Hazard * p=0.01 Kikuya, Imai et al. Hypertension 2000 BP Variability and CV disease: BP Variability and CV disease: OhasamaOhasama 05 05 CV events according to blood pressure variability Rate of events (per 100 patient-years)Rate of events (per 100 patient-years) Mena et al. J Hypertens. 23:505-12 05 05 Is 24h control of BP important? Yet to be determined the component of the ABP profile that is the best predictor of prognosis, but There is general consensus that optimal BP control requires a smooth reduction in the 24h ABP profile Control of morning BP may be the most important goal in the treated hypertensive patient Insufficient duration of action of antihypertensive drugs may be a key factor for high morning BP (Chonan K et al. Clin Exp Hypertens 2002) 05 05 Is 24h control of BP important? Important groups Masked hypertension Elderly Diabetes mellitus Cerebrovascular disease Obstructive sleep apnoea (OSA) Hypertension with postural hypotension 05 05 Cardiovascular Disease Overlapping conditions HYPERTENSION DIABETESDIABETES Cerebrovascular Cerebrovascular DisDis Renal diseaseRenal disease HYPERLIPIDAEMIAHYPERLIPIDAEMIA ISCHAEMIC HDISCHAEMIC HD 05 05 Hypertension in Obstructive Sleep Apnoea (OSA) Hypertension and OSA are linked in a stimulus -response fashion This is true even accounting for confounding factors Peppard P et al. New Engl J Med 2000, 342: 1378-84 Hypertension detected in: 42% of OSA patients have clinical hypertension An additional 38% of OSA patients have ABP- detected hypertension Baguet J-F et al. J Hypertens. 2005, 23:521-7 05 05 Type 2 Diabetes Mellitus, arterial stiffness and autonomic dysfunction 45 patients (45-70yrs) and 45 controls matched for age, sex and BMI 24h ABP monitoring (DM2 group) Plasma insulin Autonomic function tests (AN score) Carotid IMT PWV Meyer C et al. Diabetic CareMeyer C et al. Diabetic Care 2004 2004 05 05 24h BP profiles in DM2 05 05 Type 2 Diabetes Mellitus: autonomic dysfunction and arterial stiffness Age, insulin level and AN score were all independently associated with central PWV Lack of fall in night BP may contribute to arterial stiffness Hypothesis: There is interplay between insulin resistance, AN and arterial stiffness in the development of CV disease in DM2. Meyer C et al 2004 05 05 Insulin/Insulin Resistance Autonomic Dysfunction Arterial Stiffness BP and HR Level and Variability “Insulin Mechanism” and Art