Journal ClubADAM WILCOX, PHARMD

1/22/14

Patient Case

DB, 70 yo M

Overall ABPM summary

Avg. BP = 116/62

Daytime = 120/63

Nighttime = 103/58

Systolic load: 9.2%

Night dip: 14.2%

First 3 blood pressures (in office)

161/86

158/82

155/87

9/21 (43%) of nighttime readings have SBP <100

Medications

Lisinopril

Beta-blocker

Ambulatory BP Monitoring

Monitor blood pressure over a 24 hour period Every 20 minutes while awake

Every 30 minutes while sleeping

Indications Variable office blood pressure readings

Differences between in home and office readings (white coat)

Hypertension resistant to multiple medications

What is normal?

150/90 or 140/90?

24 hour: <130/80

Daytime: <135/85

Nighttime: <120/70

SBP load: >30% increases cardiovascular risk

Nighttime dip: 10-20% is normal Non-dippers: LVH, CHF, microalbuminuria, GFR reduction

Question

Does nocturnal blood pressure drop have an effect on cardiovascular mortality?

PICO

P: DB, 70yo male

I: Extreme dippers(BP decline ≥ 20% of daytime BP)

Non-dippers(BP decline ≥ 0% but < 10% of daytime BP)

Inverted dippers(no nighttime BP decline)

C: Dippers(BP decline ≥ 10% but < 20% of daytime BP)

O: Cardiovascular mortality

Journal Article

Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.

Study Basics Objective:

To investigate the relationship between nocturnal decline in blood pressure and mortality

Type: Prospective trial involving 1542 residents of a rural Japanese community

Exclusion: <40 years old, hospitalized individuals, demented patients, people who

worked out of town

Study population: 565 men(62.5 years) and 977 women(61.2 years)

Primarily farmers, retirees, housewives

Outcomes: Overall mortality, cardiovascular, non-cardiovascular

Methods

Needed at least 8 hours of daytime readings and 4 hours of nighttime readings to be included in the analysis

Average duration of monitoring was 22.3 hours

Average # of measurements 44.6

Average 24 hr, daytime, nighttime, and nocturnal decline were calculated for each person %decline nocBP = (daytime BP – nighttime BP) x 100/daytime BP

Classified into groups(extreme, dippers, non-dippers, inverted)

Analysis/Results

Kaplan-Meier life table, SAS LIFETEST procedure, Cox proportional hazards regression model

Mean follow up time 5.1 years(0.1-8.1)

Data adjusted for age, sex, smoking status, history of CVD, BP levels, and use of hypertensive medications

Analysis/Results

Sharp declines in the inverted dipper group

Limitations

Prospective study

All participants came from a small Japanese community

What does this mean to practice?

For DB…

Avg. BP = 116/62

Daytime = 120/63

Nighttime = 103/58

Systolic load: 9.2%

Night dip: 14.2%

In office avg. = 158/85

For extreme dippers…

Prevent the early morning blood pressure surge (stroke, MI)

Switch to short-acting

Timing of medications

For non-dippers/inverted… Move one of your medications to

bedtime

Are you tired of being on call?

A perfect bracket wins $1 billion

References

1. Ernst M. Ambulatory Blood Pressure Monitoring: Recent Evidence and Clinical Pharmacy Applications. Pharmacotherapy 2013;33(1)69-83.

2. Ernst M. Nighttime Blood Pressure Is the Blood Pressure. Pharmacotherapy 2009;29(1)3-6.

3. Kaplan N. Ambulatory Blood Pressure Monitoring and White Coat Hypertension in Adults. UptoDate Nov. 2013.

4. Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.