Blood Pressure Assessment and Stroke 2009

Blood Pressure Assessment and Stroke

2009

Preventing Strokes One At a Time

Blood Pressure & Stroke

Upon completion, participants will be able to: Practice according to the Canadian Best

Practice Recommendations for Stroke Care as they relate to blood pressure

Discuss the impact of hypertension on stroke risk

Use proper technique when taking a blood pressure

Monitor and interpret blood pressure reading according to Canadian Hypertension Education Program recommendations

Teach patient the why & how of proper blood pressure measurement

LEARNING OBJECTIVES

Blood Pressure & Stroke

Hypertension Overview Blood Pressure Targets Blood Pressure Measurement

Office Home Ambulatory Blood Pressure Monitor

Content from the following slides is derived from the Canadian Hypertension Education Program Recommendations, 2009 www.hypertension.ca/blood pressurec

Outline

http://www.hypertension.ca/bpc

Blood Pressure

2.2a Blood Pressure Assessment All persons at risk for stroke should have their blood

pressure measured at each healthcare encounter but no less than once annually.

Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement

Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program.

Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications.

CMAJ 2008;179(12 Suppl):E1-E93.

Canadian Best Practice Recommendations for Stroke Care, 2008

Blood Pressure

2.2b Blood Pressure Management The Canadian Stroke Strategy recommends target blood

pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events.

For prevention of first stroke in the general population the systolic blood pressure treatment goal is a pressure level of less than 140 mm Hg

The diastolic blood pressure treatment goal is a pressure level of less than 90 mm Hg

Blood pressure lowering treatment is recommended for patients who have had a stroke or transient ischemic attack to a target of less than 140/90 mm Hg

In patients who have had a stroke, treatment with an angiotensin-converting enzyme (ACE) inhibitor and diuretic is preferred

CMAJ 2008;179(12 Suppl):E1-E93.

Canadian Best Practice Recommendations for Stroke Care, 2008

2.2b Cont’d Blood pressure lowering treatment is recommended for the

prevention of first or recurrent stroke in patients with diabetes to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg

Blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke in patients with non diabetic chronic kidney disease to attain systolic blood pressures of less than 130 mm Hg and diastolic blood pressures of lower than 80 mm Hg

RCTs have not defined the optimal time to initiate BP lowering therapy after stroke or TIA. It is recommended that blood pressure lowering treatment be initiated (or modified) before discharge from hospital.

For recommendations on specific agents and sequence of agents refer to the current CHEP guidelines www.hypertension.ca/chep

http://www.hypertension.ca/chep

Modifiable Risks for Developing Hypertension

Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption

2009 Canadian Hypertension Education Program Recommendations

Challenges to Hypertension Management: Public Perceptions

80% of people were unaware of the association between hypertension and CVD

63% believed that hypertension was not a serious condition

38% of people thought they could control high blood pressure without the help of a health professionalCan J Cardiol 2005;21:589-

93


Question

What is the office blood pressure target for a patient with diabetes and/or renal disease?

a. < 140/90b. < 135/85c. < 160/100d. < 130/80e. < 120/80

Blood Pressure Targets for the Treatment of Hypertension

Condition Target

Isolated systolic hypertension <140 mmHg

Systolic/Diastolic Hypertension• Systolic blood pressure • Diastolic blood pressure

<140 mmHg<90 mmHg

Diabetes or Chronic Kidney Disease• Systolic • Diastolic

<130 mmHg<80 mmHg


Question

By how many mmHg do you need to lower blood pressure in order to decrease CV risk?a. 2 mmHgb. 5 mmHgc. 10 mmHgd. 15 mmHge. 20 mmHg

Question

At what blood pressure does the risk for cardiovascular disease and stroke start to increase?

a. > 140/90b. > 130/80c. > 110/75d. < 150/95e. < 120/85

Blood Pressure Measurement

Office (OBPM) Home (HBPM) Ambulatory Blood Pressure

Monitoring (ABPM)


Resting Blood Pressure MeasurementDoing it Right!

Recommendations

Question

How long should a patient rest prior to taking a resting blood pressure measurement?

a. 1 minuteb. 2 minutesc. 5 minutesd. 10 minutese. No rest is required

Types of Readings

Casual blood pressure - a measurement taken without the required 5 minute rest period

Resting blood pressure - the seated resting blood pressure is used to determine and monitor treatment decisions

Standing blood pressure - is used to test for postural hypotension, which may modify treatment if present


Observer

Positioned comfortably to obtain measurement

Manometer at eye level Well maintained stethoscope Clean earpieces


Patient Preparation

No caffeine for 30 – 60 minutes No smoking for 30 minutes No exercise for 30 minutes Bladder/Bowel comfortable Quiet/temperate, relaxed environment, no

talking Bare arm with no constrictive clothing Patient should stay silent prior and during

the procedure No acute anxiety, stress or pain2009 Canadian Hypertension Education Program Recommendations

Posture

Calmly seated for 5 minutes

Back well supported Arm relaxed & supported

at heart level Legs uncrossed, feet flat

on the floor


Recommended Equipment for Measuring Blood Pressure

Mercury manometer Recently calibrated aneroid

Validated automated device


BpTRU

Automated, non invasive monitor that measures blood pressure and pulse in patients using upper arm cuff

Device automatically inflates and deflates the cuff

Uses oscillometric technique Has 2 operational modes

Manual mode to take one blood pressure measurement

Automatic mode takes 6 measurements, discards the first, and displays the average of the next 5 readings.

Product Overview


Cuff Size

Measure arm circumference midpoint b/w shoulder and elbow

Bladder must encircle at least 80% of arm circumference

Lower edge of cuff placed 2-3 cm above elbow crease

Bladder centered over the brachial artery

Tell patient their cuff size2009 Canadian Hypertension Education Program

Recommendations

Cuff Position & Dimensions(no standardization between manufacturers)

Locate the brachial pulse and centre the cuff bladder over it

Position cuff at heart level.

Circumference of Adult Arm

Size of Bladder (cm)

18-26 cm 9x18 (Child)

> 26-33 cm 12x23 (Regular Adult)

> 33-41 cm 15X33 (Large)

> 41 cm 18x36 (Extra Large)2009 Canadian Hypertension Education Program Recommendations

Office Technique

On initial visit, blood pressure should be taken in both arms and subsequently it should be measured in the arm with the highest reading. Inform the patient

Duplicate, resting readings, 1 – 2 minutes apart, should be taken at each visit

If readings vary by > 5mmHg, the readings should be repeated until 2 consecutive readings are comparable

Standing blood pressure @ 1 & 3 minutes


Palpation

Determine systolic blood pressure by palpation to decrease pain and exclude possibility of systolic auscultatory gap1. Palpate the radial pulse2. Inflate quickly to 60 mmHg and then by

increments of 10mmHg until the pulse disappears = estimated palpated systolic pressure

3. Slowly deflate at a rate of 2 mmHg/second until the pulse reappears to confirm your palpated systolic pressure

4. Add 30 mmHg to this number to determine you Maximum Inflation Level (MIL)


Korotkoff Sounds and Auscultatory Gap

Systolic blood pressure

200

180

160

140

120

100

80

60

40

20

0

No sound

Clear sound

Clear sound

Muffled sound

No sound

Phase 1

Phase 3

Phase 4

Phase 5

Muffling Phase 2Auscultatory

gapNo sound

mm Hg

Korotkoff sounds


Auscultation

1. Palpate, then place stethoscope over brachial artery2. Inflate cuff pressure to the MIL3. Deflate cuff pressure by 2 mmHg per second

Appearance of 2 regular tapping sounds Korotkoff phase I = systolic pressure

4. Continue to decrease pressure by 2 mmHg per second

Disappearance of soundKorotkoff phase V = diastolic pressure

5. If DBP>90 mmHg listen for an additional 30mmHg to rule out Diastolic auscultatory gap

6. Record measurement


The Concept of White Coat vs Masked Hypertension

From Pickering et al, Hypertension 2002

Office SBP mmHg

Hom

e o

r A

BPM

SB

P m

mH

g

TrueHypertensive

TrueNormotensiv

e

White Coat Hypertension

MaskedHypertension

135

140

135

140


The Prognosis of Masked hypertension

0

0.5

1

1.5

2

2.5

Normotension White CoatHypertension

MaskedHypertension

Hypertension

Relatve riskof CVD

J Hypertension 2007;25:2193-98

Prevalence of masked hypertension is approximately 10% in the general population (prevalence is higher in diabetic patients).


Question

What is the target home blood pressure for a patient without Diabetes Mellitus or Chronic Kidney Disease?

a. < 120/80b. < 125/75c. < 130/80d. < 135/85e. < 140/90

OBPM HBPM, ABPM Equivalence

A clinic blood pressure of 140/90 mmHg has a similar risk of a:

Description Blood Pressure mmHg

Home pressure average 135 / 85

Daytime average ABP 135 / 85

24-hour average ABP 130 / 80


Important Role for Home Blood Pressure Measurement

Measuring blood pressure at home has a stronger association with CV prognosis than office based readings

Home measurement can help to: confirm the diagnosis of hypertension improve blood pressure control reduce the need for medications improve medication adherence in non adherent

patients help to identify white coat and masked

hypertension2009 Canadian Hypertension Education Program Recommendations

Home Measurement of Blood Pressure:Use Validated Blood Pressure 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


Home measurement of blood pressure

A poster and instruction sheets can be ordered at the Heart and Stroke Foundation offices or on-line at:http://hypertension.ca/bpc/wp-content/uploads/2008/03/bilingualposterorderform.pdf


Patient Instructions

Use a validated monitor Correct cuff size Accurate resting technique Patient technique should be reviewed

regularly Duplicate measurements 1-2 min. apart 7 days after any Rx change or before a

doctor’s appointment AM (before Rx) & PM (2 hrs. after dinner)


Ambulatory Blood Pressure Monitor (ABPM)

Shows blood pressure pattern over a 24 hour period

Measures blood pressure through oscillometric technology which depends on the pulsatility in the brachial artery

Arm must stay motionless during inflation and deflation

Less accurate at extremes of systolic and diastolic blood pressure

36


Diurnal Pattern/Circadian Rhythm Abnormalities in pattern are

associated with increased CV events Dipping is good

Circadian rhythm of blood pressure is a >10% fall in blood pressure during sleep

A non-dipping pattern is associated with an increase risk of MI, stroke, dementia as blood pressure remains elevated during sleep


Benefits 24 hour ABPM

Provides large number of blood pressure readings outside clinic setting

Helps determine the dynamic changes of blood pressure throughout 24 hour period

Enables physician to adjust treatment appropriately to prevent target organ complications

Rules out ‘White Coat’ hypertension Used to aid in diagnosis of ‘Masked Hypertension’ Identifies ‘Dippers’ vs. ‘Non-dippers’2009 Canadian Hypertension Education Program Recommendations

Take Home Message

To take accurate blood pressure readings you must ensure:

1. Proper cuff size

2. Validated monitor

3. Accurate resting technique

Both in the doctor’s office and at home!


Blood Pressure www.heartandstroke.ca/BP

To monitor home blood pressure and encourage self management of lifestyle

www.hypertension.ca CHEP, 2009 Resources Health Professional Resources:

o Diagnosis of hypertensiono Assessmento Treatmento Blood pressure measurement

Patient Resources: www.hypertension.ca/bpc o How to take a proper blood pressureo Home blood pressure monitorso Patient education


Canadian Best Practice Recommendations for Stroke Care, updated 2008

www.canadianstrokestrategy.ca

Blood Pressure Assessment and Stroke 2009

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