BP Patterns And BP variability

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BP variability has nowadays a prognostic value in hypertensives, what about BP variability among the four patterns of BP; normotension, sustained hpertension, whitecoat hypertension and masked hypertension.

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By: pumcsy (84 month(s) ago)

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BP Patterns and Variability: There Is a Prognostic Difference ?:

BP Patterns and Variability: There Is a Prognostic Difference ? By Dr. Abdelsalam Sherif MD cardiology Held at Holiday Inn – Olyea 25 th March 2013

PowerPoint Presentation:

Introduction

Prevalence of Hypertension:

Prevalence of Hypertension

CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS:

CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS BP CLASSIFICATION SBP (MM HG) DBP (MM HG) Normal < 120 <80 Prehypertension 120--139 80--89 Stage 1 hypertension 140—159 90--99 Stage 2 hypertension >160 >100

Proportion of diseases attributable to hypertension:

Proportion of diseases attributable to hypertension Disease % attributable to hypertension Myocardial Infarctions Heart failure A . F. Strokes Renal failure 30 – 40 % Up to 50 % Up to 50 % 30 – 40 % 25 – 30 %

BP Patterns:

BP Patterns

Patters of Blood Pressure:

Patters of Blood Pressure BP can be measured in:- Doctor`s office. Home BP measurement. 24-hour ambulatory BP monitoring. Using both In-office and out of office measurements, the patients can be classified into 4 categories types In-office BP Out of office BP Normal Normal Normal HPN ↑ ↑ White coat HPN ↑ Normal Masked HPN Normal ↑

Prognostic Value Of MH:

Prognostic Value Of MH Target Organ damage Normotension MH HPN LVM 73gm/m2 86gm/m2 90 gm/m2 Atheromatous plaque in carotids 15% 28% 28%

Prognostic Value OF MH:

Prognostic Value OF MH

PowerPoint Presentation:

Copyright ©2005 American College of Cardiology Foundation. Restrictions may apply. Ohkubo, T. et al. J Am Coll Cardiol 2005;46:508-515 Relative hazards (RH) and 95% confidence intervals (CI) of different BP Patterns for cardiovascular disease (CVD) mortality, stroke morbidity, and the composite of CVD mortality/stroke morbidity

BP Variability BPV In Hypertension Status :

BP Variability BPV In Hypertension Status

BP Variability:

BP Variability 1. BP fluctuation is related to many factors as ( physical activity, emotion, diet, salt intake, respiratory cycle and sleep deprivation and others. 2. Higher BP variability is common in patients with older age , history of smoking, DM and prior history of vascular disease. 3. Early studies paved the way to incorporating BPV as an entity that can impact prognosis ( IMT, CV mortality, and CV events; stroke , CHD, HF). 4. Variability in BP is a much stronger determinant of both stroke and CAD outcome than average BP ( ASCOR-BPLA)

Standard deviation (SD) of all 18 systolic blood pressure measurements (SDtotal ) according to blood pressure status in strata of antihypertensive treatment. P value adjusted for age, sex, body mass index, past history of cardiovascular events, diabetes, and hypercholesterolemia.:

Standard deviation (SD) of all 18 systolic blood pressure measurements (SDtotal ) according to blood pressure status in strata of antihypertensive treatment. P value adjusted for age, sex, body mass index, past history of cardiovascular events, diabetes, and hypercholesterolemia.

Hazard ratios for risk of stroke in ASCOT-BPLA patients with mean SBP during follow-up:

Hazard ratios for risk of stroke in ASCOT-BPLA patients with mean SBP during follow-up

Impact Of Treatment On BPV:

Impact Of Treatment On BPV

The amplitude of variations could be influenced by therapy?:

The amplitude of variations could be influenced by therapy?

Average within-visit CV in the two treatment groups during follow-up:

Average within-visit CV in the two treatment groups during follow-up

Stroke risk and coronary risk expressed by decile of within-visit SBP variability:

Stroke risk and coronary risk expressed by decile of within-visit SBP variability Number of patients in each decile of within-visit SD SBP Stroke risk (HR, 95% CI) Coronary risk (HR, 95% CI)

ASCOT-BPLA: summary of all endpoints:

ASCOT-BPLA: summary of all endpoints The area of the blue square is proportional to the amount of statistical information Amlodipine  perindopril better Atenolol  thiazide better 0.50 0.70 1.00 1.45 Primary Non-fatal MI (incl. silent) + fatal CHD Secondary Non-fatal MI (excl. silent) + fatal CHD Total coronary endpoint Total CV events and procedures All-cause mortality Cardiovascular mortality Fatal and non-fatal stroke Fatal and non-fatal heart failure Tertiary Silent MI Unstable angina Chronic stable angina Peripheral arterial disease Life-threatening arrhythmias New-onset diabetes mellitus New-onset renal impairment Post hoc Primary endpoint + coronary revasc procs CV death + MI + stroke 2.00 Unadjusted hazard ratio (95% CI) 0.90 (0.79-1.02) 0.87 (0.76-1.00) 0.87 (0.79-0.96) 0.84 (0.78-0.90) 0.89 (0.81-0.99) 0.76 (0.65-0.90) 0.77 (0.66-0.89) 0.84 (0.66-1.05) 1.27 (0.80-2.00) 0.68 (0.51-0.92) 0.98 (0.81-1.19) 0.65 (0.52-0.81) 1.07 (0.62-1.85) 0.70 (0.63-0.78) 0.85 (0.75-0.97) 0.86 (0.77-0.96) 0.84 (0.76-0.92)

Meta-Analysis of Effects of Antihypertensive Drug Classes on Daytime & Nighttime BP Weiner, Rieckmann, & Pickering, 2005 :

Meta-Analysis of Effects of Antihypertensive Drug Classes on Daytime & Nighttime BP Weiner, Rieckmann, & Pickering, 2005 Change of SBP with Treatment mmHg

Inter-class efficacy comparison:

Petrella R, Michailidis P. Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agent in Blood Pressure Management. Clin Ther 2011;33(9):1190-1203 Inter-class efficacy comparison

PowerPoint Presentation:

ARB Intra-class efficacy comparison - Monotherapy Irbesartan demonstrates higher BP goal attainment vs. other ARBs including losartan, valsartan and candesartan in real-world setting (1 Petrella R, Michailidis P. Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agent in Blood Pressure Management. Clin Ther 2011;33(9):1190-1203

PowerPoint Presentation:

ARB Intra-class efficacy comparison – Combination therapy More patients achieved their target BP on irbesartan-based compared to other ARB-based dual or tri-therapy Petrella R, Michailidis P. Retrospective Analysis of Real-World Efficacy of Angiotensin Receptor Blockers Versus Other Classes of Antihypertensive Agent in Blood Pressure Management. Clin Ther 2011;33(9):1190-1203 The proportions of patients reaching target BP were higher with ARB+HCTZ (35%) than with ARB+CCB (32%) P=0.001 (1)

Home Message:

Home Message Variability in blood pressure is a much stronger determinant of both stroke and coronary disease outcome than average blood pressure. 2 . Variability is telling us about stiffness of blood vessels( large vessels, when they become stiff, are harbingers of future vascular disease). So, we cannot ignore random variation in BP, they are telling us something about the risk of the individual. 3 . Clinicians should give careful consideration to use drugs associated with low variability in blood pressure.

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