Current Controversies in Blood Pressure Assessment

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1 Current Controversies in Blood Pressure Assessment 한양의대심장내과신진호

2 Contents 1. 진료실에서자동혈압계를이용해도되는가? 2. 활동혈압과가정혈압측정은필수적인가? 3. 개별환자의위험도평가가꼭필요한가? 4. 아침혈압또는아침고혈압의의의는무엇인가? 5. 아시아인의고혈압의평가는서양인과차이점이있는가? 6. 항혈소판 / 항응고제치료중인환자의적정혈압은얼마인가?

3 SBP correlation Lim YH et al 2014, AJH

4 DBP correlation Lim YH et al 2014, AJH

7 Automated devices for Clinic BP Options for BP measurement [ESH 2013 guideline] Calibration interval [?] 3 mmhg error : 25% difference 5 mmhg : digit preference Authority bias: 5 mmhg error : acceptable for clinical practice Simultaneous measurement Journal of Human Hypertension (2010) 24, 58 63

8 비수은진동법의문제점 N=6000, US NHANES N=450, KOREAN NHANES 유병율의과소평가 10 mmhg 이상의오차의비율 ~ 10% 5 mmhg 이상의오차의비율 ~ 30%

9 Origin of the errors / Resolution Challenge of automated auscultatory device BPM 2012;17:80

10 Potential impact on the clinical practice Current practice guideline : raised target blood pressure Critical importance in stage 2 prehypertension Use of automated device under -3 mmhg errors one of four patients : Neglected out of office BP measurement or auscultation method Irregular pulse : absolutely indicated for auscultation method

11 Issues in non-mercury era (2020~) Auscultation methods : use non-mercury manometer ( 수동모드 ) Deflation speed, scale error

12 활동혈압과가정혈압측정은필수적인가? NICE guideline 2012 : Routine measurement to reduce cost Cost saving To avoid white-coat HTN [drug cost] To avoid complication [QALY, healthcare cost] Masked HTN Risk: SOD, poor CV outcome Predictors

13 Masked Hypertension Job strain [Kim S et al, J Prev Med Pub Health] Male, young, prehtn, smoking, cholesterol Generalized anxiety or stress Cigarette smoking Alcohol Physical activity Family history of hypertension Central obesity Blood Press Monit 2010;15:90 92 Hypertension 2002; 40:

14 언제활동혈압을측정하나? 1. 백의고혈압이의심될때 2. 고혈압약물에반응하지않을때 3. 간헐적인고혈압이있을때 4. 혈압이불안정할때 5. 임신중고혈압의진단시 6. 자율신경장애시혈압측정 7. 위험도평가시정확한혈압측정이필요할때 8. 혈압치료효과를정확하게판정할때

15 측정방법에따른고혈압진단기준 측정방법 수축기혈압 (mmhg) 확장기혈압 (mmhg) 진료실혈압 시간활동혈압하루평균혈압 주간평균혈압 야간평균혈압 가정혈압 기고혈압

16 Pressor effect of 30s breath hold Positive test (test BP > 140/90 mmhg) 226 normotensive (< 120/80 mmhg) Positive (n=25): MHT (n=12) / Negative (n=201): no MHT 43 prehtn (>=120/80 & < 140/90) Positive test (n=28): MHT (n=22) / Negative (n=15) : none BH pressor test and BPM agreed in 93% of cases BH test produced no false negative findings. Blood Press Dec;21(6):372-6

17 Deep breath test for white-coat HTN Deep breath for 30s Uncontrolled HTN(n=240) Control (n=108), DBT (n=106) Difference by DBT: 15/4 mmhg 15% SBP reduction by DBT PPV: 94.5% NPV: 78.4% J Am Board Fam Pract May-Jun;17(3): Blood Press Jan 22:1-6

18 Issues on the protocol Minimum requirements Standard individual education for home BP monitoring Nocturnal BP measurement using home BP device

19 여 56 세, 혈압이높아요 4년전고혈압진단후고혈압약 1년간복용후중단 진료실혈압 136/81 mmhg, 주간혈압 139/86 mmhg, 야간혈압 126/72 mmhg, 체질량지수 : 24.1 kg/m2, 복부둘레 : 86 cm 고혈압의가족력 : 아버지 (+) 공복혈당 : 92 mg/dl, LDL: 135 mg/dl, 소변 ACR: 55 mg/g 심초음파좌심실질량지수 : 95 g/m2 경동맥죽상경화반 (-), 내막중막두께 : 0.9 mm

20 Impacts on the clinical practice TOD: MAU(+) Risk factor: Age, LDL, central obesity, HTN 1. Critical for high risk subjects in prehypertension 2. Decision to start antihypertensive drugs 3. Decision to start statin by counting the number of risk factor

21 개별환자의위험도평가가꼭필요한가? 위험인자 판정기준 무증상 판정기준 나이 남 45 세, 여 55 세 장기손상 조기심혈관질환남 < 55세, 여 < 65세가족력흡연비만또는복부비만 BMI 25 kg/m 2 복부둘레 >90cm/80cm( 남 / 여 ) 이상지질혈증총콜레스테롤 220 mg/dl, LDL-C 150 mg/dl, HDL-C <40mg/dL, 중성지방 200 mg/dl 공복혈당장애 100 공복혈당 < 126 mg/dl 또는내당능장애당뇨병공복혈당 126 mg/dl, 당화혈색소 6.5%, 또는경구당부하2시간혈당 200 mg/dl 뇌뇌졸중, 일과성허혈성발작, 혈관성치매심장좌심실비대, 협심증, 심근경색, 심부전콩팥미세알부민뇨 (30~299 mg/day), 현성단백뇨 ( 300 mg/day), egfr < 60 ml/min/1.73m 2, 만성콩팥병혈관죽상동맥경화반, 대동맥질환, 말초혈관질환 ( 발목-위팔혈압지수 < 0.9), 경동맥내-중막최대두께 1.0 mm, 경동맥대퇴동맥간맥파전달속도 > 10 m/sec 망막 3-4단계고혈압성망막증

22 심혈관위험도와치료방침 위험도 혈압 (mmhg) 2 기고혈압전단계 (130~139/85~89) 1 기고혈압 (140~159/90~9 9) 2 기고혈압 ( 160/100) 위험인자 0 개 생활요법 생활요법 * 또는약물치료 생활요법또는약물치료 ** 당뇨병이외의위험인자 1~2개 생활요법 생활요법 * 또는약물치료 생활요법과약물치료 위험인자 3개이상, 무증상장기손상 생활요법 생활요법과약물치료 생활요법과약물치료 당뇨병, 심혈관질환, 생활요법또는 생활요법과 생활요법과 만성콩팥병, 약물치료 약물치료 약물치료 * 생활요법의기간은수주에서 3 개월이내로실시한다. ** 혈압의높이를고려하여즉시약물치료 를시행할수있다. 설정된목표혈압에따라약물치료를시작할수있다. 10 년간심혈관질환발 생률 :

23 Hypertension in the young Isolated systolic hypertension ABPM Work up for asymptomatic organ damage Work up for secondary hypertension Poor awareness, treatment, and control rate Concept of cumulative risk vs global risk profile JSH 2009 adopted vs JSH 2014 abandoned For young DM : recommended in ADA 2013

24 아침혈압또는아침고혈압의임상적의의 2 year outcome No indication of CBP on or off medication Hypertension 2014;64;989

25 (%) Morning HTN in treated patients N=240 first second third (Hours after arising) blood pressure <140/90mmHg, blood pressure 140/90mmHg and/or 90mmHg Blood press Monit 2002;7:

26 Impact on the clinical practice 외래방문일에고혈압약복용금지의필요성 아침고혈압의메커니즘 : Nondipper, arterial stiffening

27 위험도및 95% 신뢰구간 아시아인에서수축기혈압의뇌졸중위험도 나이군 70세이상 세 60세미만 N = 500, 수축기혈압 (mmhg) Journal of Hypertension 2003, 21:

28 위험도및 95% 신뢰구간 64.0 아시아인에서수축기혈압의허혈성심질환위험도 나이군 70세이상 60-69세 60세미만 N = 500, 수축기혈압 (mmhg) Journal of Hypertension 2003, 21:

29 % 발생비율 위험도및 95% 신뢰구간 4.0 아시아 호주 % 75% 50% 25% 전체뇌졸중 허혈성심질환 기타심혈관질환 0% 수축기혈압 (mmhg) Journal of Hypertension 2003, 21:

30 혈압의분류 혈압분류 수축기혈압 (mmhg) 확장기혈압 (mmhg) 정상혈압 * <120 그리고 <80 고혈압전단계 1기 120~129 또는 80~84 2기 130~139 또는 85~89 고혈압 1기 140~159 또는 90~99 2기 160 또는 100 수축기단독고혈압 140 그리고 <90 * 심혈관질환의발병위험이가장낮은최적혈압

31 2 기전단계고혈압의특징 정상혈압에비해심혈관예후가나쁘다 고혈압으로진행할가능성이높다 가면고혈압의가능성이있다 특정상황에서약물치료가필요하다

32 출혈성경향약제투여시혈압평가 N=4009 Impending risk of ICH: 130/81 mmhg Antiplatelet and/or anticoagulation Stroke 2010;41:1440

33 Clinical implications for Asian Treated hypertension / target BP FEVER study: difference below or above 140/90 mmhg Hypertension in the elderly Threshold for treatment ~ 140/90 in general in Asian cf) JNC VIII, ESH 2013 For frail elderly > 75 years with 140~149 mmhg cf) frail: 6 minute walking 불가능한상태?

34 Take Home Messages 2기전단계고혈압환자의치료기회를놓치지않아야 진료실에서진동법으로혈압을측정할때주의사항 진료실밖혈압측정의비용효과적측면에서가면효과 진료실밖혈압측정의대안 개별위험도평가와약물치료의역치에따른개별적접근 젊은환자의고혈압의임상적중요성 아침고혈압의중요성과임상적용 아시아인고혈압의특징과치료기준에대한관점

고혈압 어떻게 잘 진단하고, 치료할 것인가?

고혈압 어떻게 잘 진단하고, 치료할 것인가? 고혈압의위험도평가 -2013 대한고혈압학회진료지침을중심으로 - (2016 년 2 월개정교육표준슬라이드 ) Sang Jae Rhee, MD., PhD. Wonkwang University Hospital Division of Cardiovascular Medicine 고혈압어떻게잘진단하고, 치료할것인가? 1. 고혈압의역학 2. 혈압측정방법및진단기준 3. 진단과평가