小時(shí)動(dòng)態(tài)血壓檢測ABPM課件

24hAmbulatoryBloodPressureMeasurement(ABPM)“Fromresearchtoclinicalpractice”ProfessorBPMcGrathProfessorofVascularMedicineMonashUniversity,Melbourne.BMcG0524hAmbulatoryBloodPressureABPM:24hBPprofileSLEEP.BMcG05ABPM:24hBPprofileSLEEP.BMcGGuilin2002.BMcG05Guilin2002.BMcG0524hABPmonitoringHowshouldthecurvesbeanalysed?.BMcG0524hABPmonitoringHowshouldt24hBPprofileanalysisMeanday,night,24hABPMMinnesotacosinormethod(Halbergetal1967)Fourieranalysis(Chauetal.1989)Squarewavemodel(Idemaetal.1991)Doublelogisticanalysis(Headetal.2002).BMcG0524hBPprofileanalysis.BMcG0RecommendedlevelsofnormalityforABPMinadults(ESHguidelines2005)Optimal*NormalAbnormalAwake<130/80<135/85>140/90Asleep<115/65<120/70>125/75*Loweroptimalvaluesrecommendedindiabetesmellitusandhigh-riskpatients.BMcG05RecommendedlevelsofnormalitRateofmorningriseinBP,HR

Hypertensive(n=51)vsNormotensive(n=63)mmHgorbeats/minperh***HeadGetal.2003.BMcG05RateofmorningriseinBP,HRAmbulatorybloodpressuremeasurement(ABPM)AdvantagesProfileofBPawayfrommedicalenvironmentShowsBPbehaviourduringusualdailyactivitiesAstrongerpredictorofcardiovascularmorbidityandmortalitythanclinicBPCanidentifypatterns:‘non-dippers’,isolatedclinichypertension,maskedhypertension,enhancedBPvariability,episodesofhypotension.BMcG05Ambulatorybloodpressuremeas‘White-coat’hypertension

(isolatedclinichypertension)‘White-coat’hypertensionisaconditioninwhichanindividualishypertensiveduringrepeatedclinicBPmeasurements,butoutsidethemedicalenvironmentpressuresmeasuredbyABPMorself-BPMtechniquesarenormal.BMcG05‘White-coat’hypertension

(isoIsolatedclinichypertension

orhypertensioninevolution?SLEEP.BMcG05Isolatedclinichypertension

o‘White-coat’effect

inhypertensivepatientsTermusedtodescribephenomenonfoundinmanyhypertensivepatientswherebyclinicBPmeasurementsareconsistentlygreaterthantheBPvaluesobtainedbyABPMorself-BPM,thelevelsofwhicharenonethelessincreasedabovenormal.BMcG05‘White-coat’effect

inhypertMaskedhypertension

(isolatedambulatoryhypertension)ThisphenomenonreferstopatientsinwhomclinicBPisnormalbutbloodpressurevaluesbyABPMorself-BPMareincreasedNotuncommon:29%GourlaySetal.JHumHypertens1993,7:467-7222%PAMELAstudyCirc2001,104:1385-92.BMcG05Maskedhypertension

(isolatedAmbulatorybloodpressuremeasurement(ABPM)ClinicalIndications

SuspectedisolatedclinichypertensionSuspectednocturnalhypertensionSuspectedmaskedhypertensionToestablish‘dipper’statusResistanthypertensionHypertensionofpregnancyPotentialIndicationsRiskgroups-diabetes,renaldisease,elderlySymptomevaluationAutonomicfailure.BMcG05AmbulatorybloodpressuremeasWhatistheimportanceofnocturnalBP?Day-nightdifferencesNon-dippers1-havemoreend-organdamageSyst-Eurstudy2–10%increaseinN:DratiogavehazardsratioforCVeventsof1.45SAMPLEstudy3

–nighttimeBPdidnotimprovethepredictionofLVHregressioninadditiontodaytimeABP.Ohasamastudy4–meandaytimeABPbetterpredictor. 1.Verdecchiaetal.Hypertension1994 2.StaessenetalJAMA1999 3.ManciaG.etal.Circulation1997 4.ImaiYetal.BloodPressureMonitoring1999.BMcG05WhatistheimportanceofnoctAMBULATORYBLOODPRESSURE

PROGNOSTICSIGNIFICANCE.BMcG05AMBULATORYBLOODPRESSURE

PROGBloodpressurevariability1970’sContinuousintra-arterialrecordingsinhumans1980’sMorningriseinBPassociatedwithhigherincidenceofsuddencardiacdeaths,strokeandmyocardialinfarctionWillichSNetal.AmJCardiol1987Kelly-HayesMetal.Strole1995ElliottW.Stroke19982000’sCircadianvariationinhaemodynamic,autonomicandhormonalsystemssynchronizetoproduceahighriskstateWeberMAAmJCardiol2002.BMcG05Bloodpressurevariability1970BloodpressurevariabilityDifferentmethodsSDofthe24haverageABPA‘weighted’24hABPSD(toaccountfornocturnalBPfall)Averagerealvariabilityindex(Menaetal2005)AssessingprognosticrelevanceDiscrepantinformationfromdifferentindices.BMcG05BloodpressurevariabilityDiffDaytimeNighttimeSystolicBPVariability(mmHg)RelativeHazard*p=0.01Kikuya,Imaietal.Hypertension2000BPVariabilityandCVdisease:Ohasama.BMcG05DaytimeNighttimeSystolicBPVaCVeventsaccordingto

bloodpressurevariabilityRateofevents(per100patient-years)Menaetal.JHypertens.23:505-12.BMcG05CVeventsaccordingto

bloodIs24hcontrolofBPimportant?Yettobedetermined

thecomponentoftheABPprofilethatisthebestpredictorofprognosis,but…..ThereisgeneralconsensusthatoptimalBPcontrolrequiresasmoothreductioninthe24hABPprofileControlofmorningBPmaybethemostimportantgoalinthetreatedhypertensivepatientInsufficientdurationofactionofantihypertensivedrugsmaybeakeyfactorforhighmorningBP(ChonanKetal.ClinExpHypertens2002).BMcG05Is24hcontrolofBPimportantIs24hcontrolofBPimportant?ImportantgroupsMaskedhypertensionElderlyDiabetesmellitusCerebrovasculardiseaseObstructivesleepapnoea(OSA)Hypertensionwithposturalhypotension.BMcG05Is24hcontrolofBPimportantCardiovascularDisease

OverlappingconditionsHYPERTENSIONDIABETESCerebrovascularDisRenaldiseaseHYPERLIPIDAEMIAISCHAEMICHD.BMcG05CardiovascularDisease

OverlapHypertensionin

ObstructiveSleepApnoea(OSA)HypertensionandOSAarelinkedinastimulus-responsefashionThisistrueevenaccountingforconfoundingfactorsPeppardPetal.NewEnglJMed2000,342:1378-84Hypertensiondetectedin:42%ofOSApatientshaveclinicalhypertensionAnadditional38%ofOSApatientshaveABP-detectedhypertensionBaguetJ-Fetal.JHypertens.2005,23:521-7.BMcG05Hypertensionin

ObstructiveSType2DiabetesMellitus,arterialstiffnessandautonomicdysfunction45patients(45-70yrs)and45controlsmatchedforage,sexandBMI24hABPmonitoring(DM2group)PlasmainsulinAutonomicfunctiontests(ANscore)CarotidIMTPWVMeyerCetal.DiabeticCare2004.BMcG05Type2DiabetesMellitus,arte24hBPprofilesinDM2.BMcG0524hBPprofilesinDM2.BMcG05Type2DiabetesMellitus:autonomicdysfunctionandarterialstiffnessAge,insulinlevelandANscorewereallindependentlyassociatedwithcentralPWVLackoffallinnightBPmaycontributetoarterialstiffnessHypothesis:Thereisinterplaybetweeninsulinresistance,ANandarterialstiffnessinthedevelopmentofCVdiseaseinDM2.MeyerCetal2004.BMcG05Type2DiabetesMellitus:autoInsulin/InsulinResistanceAutonomicDysfunctionArterialStiffnessBPandHRLevelandVariability“InsulinMechanism”andArterialFunction.BMcG05Insu