백의효과에영향을주는요인 (Factors Influencing White Coat Effect) 한양의대심장내과신진호
혈압평가에영향을주는요소 고혈압을이상적으로치료의첫걸음 - 혈압에대한정확한평가 측정오차 무작위변동성 (Random variability) 백의효과 (White coat effect) 가면 (Masked) 고혈압
백의효과 의료환경및혈압측정자에의해서유발되는혈압상승현상
White-Coat Effect Actual measurement of the BP may invoke an alerting reaction, a reaction that is only transient in most patients but persistent in some. This reaction may be partially related to the environment but is mostly related to the measurer Kaplan s Clinical Hypertension 8 th Ed.
백의효과의정의 20/10mmHg 이상의혈압차이 수은주혈압계혈압측정시 2SD 임상적인차이를인정할수있는수준 73% of treated HTN(AJH1991;4:844) 진료실혈압 -주간혈압 > 0 > 집단내백의현상의정중값
백의효과 직접측정법 Journal of Hypertension 2003, 21:481 486
백의효과측정법 - 간접법 주간 ( 평균 ) 혈압을기저혈압으로간주 백의효과 = 진료실혈압 -주간혈압
직접측정법과간접측정법간의 상관관계 Journal of Hypertension 2003, 21:481 486
수축기혈압의백의효과 Study Ironson, 1989 Jula, 1999 Khoury, 1992 Modesti, 1994 Myers, 1995b Narkiewicz, 1995 Staessen, 1999 Stergiou, 1998b Thijs, 1996 Zachariah, 1991 Zachariah, 1988 Zawadzka, 1998 N 119 233 131 139 147 411 808 189 477 126 168 410 Difference (SD) from clinic Daytime Nighttime 5-3.8 9 14 11.2 21.9 6.9 21 4 11.5 19 22 23.9 24hr 2.8 17 12 13.1-7 8 13.5mmHg?
근육과피부의교감신경활성도 (Circulation1999;100:222)
근육과피부의교감신경활성도 (Circulation1999;100:222)
80 70 60 P=NS ug/24hr 50 40 30 20 10 0 P=0.01 Norepinephrine Epinephrine 정상반응 (n=32) 과다반응 (n=32) Journal of Hypertension 2003;21:545 553
(88 고혈압, 18 정상 ) 0 20 40 60 80 sec Hypertension1998;31:1021-1029
기립및정신적스트레스에대한 혈압상승과백의효과의상관관계 기립시혈압상승과백의효과 정신적스트레스시혈압상승과백의효과 Hypertension 1998;31:1021-1029
J Hypertens2003;21:545 553
PS+/RR+ PS-/RR /RR- MF Gain PS+/RR+ PS-/RR /RR- MF Gain 백의효과와압수용체반사의민감도 NT N=49 Lying Position 9.32±3.13 3.13 10.96±3.6 9.4±5.6 6 Standing Position 5.53±1.47 5.34±1.58 4.49±2.33 WCNT N=18 8.20±2.17 2.17 9.69±3.15 8.9±5.3 4.72±1.32 4.63±1.37 4.10±2.94 HT N=76 7.39±2.25 8.50±2.7 6.4±2.9 4.61±1.6 1.6 4.78±1.76 3.89±2.78 WCHT vs. NT 0.21 0.19 0.66 <.04 0.08 0.26 WCNT vs. HT 0.22 0.17 0.06 0.64 0.76 0.76 NT vs. HT <.001 <.001 0.002 0.005 0.05 0.03 NT normotensives, WCNT high BP with normal ABP, HT hypertensives, PS+/RR+ and PS-/RR- (ms/mmhg), sequential methods*, MF gain (ms/mmhg), cross-spectral analysis in mid-frequency band * at least three cardiac cycles, Variation threshold: 1mmHg for PS/4ms for RR, only for the values of r 0.95 Clin Auton Res 2004; 14 : 160 166
직장사무실과병원검사실과의혈압차이 (mmhg) 20 18 16 14 12 10 8 6 4 2 0 치료전 치료후 수축기이완기수축기이완기수축기이완기 본태성고혈압환자 (n=25) 정상성인 (n=25) J Hum Hypertens 2000;14:355
진료실에서기기를이용한혈압측정 (mmhg) 180 160 140 120 100 80 60 40 20 0 의사측정기기측정활동혈압모니터 수축기이완기수축기이완기수축기이완기 약물치료중인본태성고혈압환자 (n=25) J Hum Hypertens 1997;11:491
병원환경에서백의효과측정 Day 1 resting level Normotensive Patients 72.5 (11.1) Hypertensive patients 72.8 (13.2) Day 2 waiting room resting level 76.7 (12.1) 76.8 (13.0) Day 2 examination room resting level Day 2 examination room postphysician 74.7 (12.2) 73.4 (11.96) 75.8 (13.7) 73.3 (12.6) Journal of Hypertension 2006, 24:67 74
활동혈압모니터기준상승정도 (mmhg) 28 24 20 16 12 8 4 0-4 측정자요인 의사와간호사 22/14mmHg, 최대 74mmHg 의사측정 간호사측정 최대 5분후 10분후 Hypertension 1987;9:209
활동혈압모니터기준상승정도 (mmhg) 28 24 20 16 12 8 4 0-4 측정자요인 반복측정효과 22/14mmHg, 최대 74mmHg 의사측정 기저치도달 간호사측정 최대 5분후 10분후 Hypertension 1987;9:209
실제진료시백의효과 의사 간호사 1 간호사 2 병원내자기혈압측정가정에서자기혈압측정 19/11 mmhg 5/8 mmhg 5/6 mmhg 10/13 mmhg 5/6 mmhg N = 173, 본태성고혈압환자, 개인의원 3곳 Little et al, BMJ 2002; 325: 254
수축기혈압을기준으로본고혈압 진단의정확성 측정자 예민도 (%) 특이도 (%) LR + LR - 의사간호사자가-병원자가-가정 91.2 83.3 92.7 87.0 25.8 41.2 50.0 59.7 1.2 1.4 1.9 2.2 0.33 0.41 0.15 0.22 Little et al, BMJ, 2002;325:254
혈압측정자와측정방법에따른백의효과 백의효과의정의 : 20/10mmHg of CBP-ABP 80 백의효과의빈도 (%) 60 40 20 0 의사 - 비표준화의사 - 표준화간호사 - 표준화 Myers, et al. Am J Hypertens 1995;8:591-7. Campbell et al. Blood Press Monit 1999;4:71-6.
Journal of Hypertension 2003;21:545 553
진료실혈압과백의효과 본태성고혈압 수축기고혈압 J Hypertens1998;16:23
수축기백의현상 (mmhg) 100 80 60 40 20 0-20 -40-60 N=1581, 정상혈압및고혈압환자 r = -0.22 P <.000 백의현상에영향을주는인자 -80 80 100 120 140 160 180 200 220 주간수축기혈압 (mmhg) Blood Pressure Monitoring 2002;7:271
60 N=1581, 정상혈압및고혈압환자 이완기백의효과 (mmhg) 40 20 0-20 -40-60 백의현상에영향을주는인자 20 40 60 80 100 120 140 주간이완기혈압 (mmhg) r = -0.50 P <.000 Blood Pressure Monitoring 2002;7:271
주간평균혈압과백의효과 본태성고혈압 수축기고혈압 J Hypertens1998;16:23
mmhg 70 60 ** 50 40 30 * 20 10 0 수축기혈압 이완기혈압 대조군 (n=33) 정상반응 - 고혈압 (n=32) 과다반응 - 고혈압 (n=32) 연설의준비와실시에따른혈압상승 Journal of Hypertension 2003;21:545 553
신체활동에대한반응과백의효과 mmhg 5 4 3 2 1 WCE>0 : presence WCE:259/264(451) p = 0.03 p = 0.02 0 백의효과 (-) 백의효과 (+) 이완기혈압 수축기혈압 Blood Press Monit2002;7: 209
혈압의변동성과일상생활 활동회의작업운반도보옷입기합창통화식사대화사무독서제택근무티비시청이완휴식수면 수축기혈압 (mmhg) +20.2 +16.0 +14.0 +12.0 +11.5 +10.7 +9.5 +8.8 +6.7 +5.9 +1.9 +1.6 +0.3 0.0-10.0 이완기혈압 (mmhg) +15.0 +13.0 +9.2 +5.5 +9.5 +6.7 +7.2 +9.6 +6.7 +5.3 +2.2 +3.2 +1.1 0.0-7.6 J Chronic Dis1987;40:671
백의효과 (%) 12 10 맥압백의효과 8 6 4 2 0 * * < 0.05 ** ** < 0.001 ** N=53 N=136 N=313 N=158 N=688 정상비치료군비조절군조절군전체 수축기혈압백의효과 맥압백의효과 AJH 2004; 17:535 539
백의효과 (%) 20 18 16 14 12 10 8 6 4 2 0 백의고혈압에서맥압백의효과 * * < 0.05 ** < 0.001 백의고혈압젊은고혈압고령고혈압당뇨 ** N=28 N=140 N=390 N=88 수축기혈압백의효과 맥압백의효과 AJH 2004; 17:535 539
mmhg 160 120 80 40 0 mmhg 20 15 10 5 0 %16 12 혈압과맥박 * * * * * * * * * 표준편차 변이계수 * * 160 Beats/min. 120 80 40 0 160 Beats/min. 120 80 40 0 16% 12 mmhg 160 120 80 40 0 mmhg 80 60 40 20 0 평균동맥압 * * * * * * * * 맥압 * * * * * * * 주간야간진료실 정상 백의고혈압 본태성고혈압 n=146 n=76 n=344 8 8 4 4 0 수축기혈압확장기혈압맥박 정상백의고혈압본태성고혈압 0 AJH 1999;12:966 972
(%) Nondipper 의비율 50 40 36.6 43.4 37.7 30 20 10 0 정상 (n=146) 백의고혈압 (n=76) 고혈압 (n=344) AJH 1999;12:966 972
Means and correlations among anxiety, expectancy and white coat effect(n=226) Anxiety Expectancy Systolic WCE Diastolic WCE Mean(SD) Anxiety - 0.58** 0.27** 0.26** 20.0(22.6) Expectancy 0.58** - 0.39* 0.26** 1.3(1.5) Systolic WCE 0.29** 0.40** - 0.73** 1.1(14.6) Diastolic WCE 0.27** 0.26** 0.71** - 0.74(9.0) Bivariate correlations are presented above the diagonal; partial correlations adjusted for age and sex are presented below diagonal.**p<0.001 Pickering et al. Blood Pressure Monitoring2005;10:317
Regression models examining the effects of anxiety and expectancy on the systolic and diastolic white coat effect, controlling for age and sex(n=226) Mean awake ABP Age Sex Anxiety Expectancy Systolic WCE B P -0.184 0.334-0.012 0.085 0.352 0.005 0.000 0.843 0.236 0.000 Diastolic WCE B P -0.311 0.031-0.064 0.196 0.188 0.000 0.625 0.326 0.010 0.014 ABP, ambulatory blood pressuure Pickering et al. Blood Pressure Monitoring2005;10:317
Am J Hypertens 2000;13:1135
흡연자에서백의효과 혈압 백의현상 비흡연자흡연자 혈압 진료실혈압 주간혈압 흡연자 비흡연자 AJH 1997;10:483
백의효과와백의고혈압 WCH is a measure of blood pressure level, whereas white coat effect is a measure of change (Pickering( TG 1996) WCE by BP difference and WCH; no significant correlation
백의고혈압 정의 (HTN1999;34:267) 1. Blood pressure >140/90 mmhg when measured in office at least three occasions 2. Normal daytime ambulatory pressure <135/85 mmhg(normal daytime BP except first 1 hr recording) 3. Providing that a minimum difference of 20/10mmHg in manual BP(technically?) 백의고혈압의유병율 10% of general population, 10-15% in referral clinic for ABPM(JAMA1988;259:225, Circ2001;104:1385) 20% in untreated HTN(JAMA1988;259:225, AJH1992;5:64, HTN1999;34:267, JH1993;11;1289, Lancet1996;348:1443) Lancet1996;348:1444
백의고혈압 인위적인구분에불과 정상주간혈압을얼마로정의하느냐에따라서유병율이차이가난다. 재현성? 140/90mmHg 전후로변동하는경우 여성환자를남성이혈압측정할때 고령, 여성, 비흡연자 (n=5716, BPM2004;9:307)
백의고혈압이될가능성 Y = 3.4343 + 0.4603 x 성별 ( 남 =0, 여 =1) + 0.5989 x 현재흡연 (0= 예, 1= 아니오 ) - 0.0482 x 진료실이완기혈압 - 0.0312 x 좌심실질량지수 [g/ht(m 2.7 )] Y = 2.6438 + 0.5128 x 성별 + 0.4543 x 진료실이완기혈압 백의고혈압확률 = Exp(Y)/[1+Exp(Y)] N=1564 WCH = 10.4% Verdecchia P et al. J Hypertens 2001;19:1015
Deep-Breath Test Responses in Patients with and without White-Coat Effect White Coat Effect Present Absent (n=45) (n=28) P Systolic BP(mmHg) 17.8±10.6 10.9±8.1.005 Diastolic BP(mmHg) 6.6±6.9 5.4±5.2 NS WCE > 10% difference of CBP J Am Board Fam Pract 2004;17:184
정상성인 혈압하강군 (n=15) 혈압유지군 (n=15) 혈압상승군 (n=15) Hypertension. 2003;41:244
혈압하강군 (n=25) 고혈압 환자 혈압유지군 (n=22) 혈압상승군 (n=20) Hypertension. 2003;41:244
Deep-Breath Test Operating Characteristics for SBP Drop Likelihood Ratio Cutoff value Sensitivity Specificity Positive Negative >5mmHg 86.7 17.9 1.05 0.7 >10mmHg 80.8 35.7 1.2 0.6 >15mmHg 60.0 71.4 2.3 0.6 >20mmHg 51.1 85.7 3.6 0.6 >25mmHg 28.9 96.4 8.1 0.7 J Am Board Fam Pract 2004;17:184
백의효과에영향을미치는인자 대부분생리학적동반현상, 단순관련요인 백의효과증가 기대심리, 불안감 음주 백의효과감소 흡연, 심호흡 백의고혈압 : 여성, 고령 진료실혈압상승인자 : 과대평가 주간혈압상승인자 : 과소평가
It is clear from evidence trails that current practice of BP measurement is inadequate. Thus, the question is not whether physicians should or should not measure BP in the hypertensive patients; rather, it is how are we to replace the physician measurement with a higher quality BP determination. Am J Hypertens 2004;17:354 360
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