Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics

495 Pages·2007·4.037 MB·English

by  Thomas G. Pickering MD, Dphil (auth.), William B. White MD (eds.)

Blood Pressure
Monitoring in
Cardiovascular
Medicine and
Therapeutics
Second Edition

EEDDIITTEEDD BBYY
William B. White,
MMDD
B P M C M
LOOD RESSURE ONITORING IN ARDIOVASCULAR EDICINE
T
AND HERAPEUTICS
C H
LINICAL YPERTENSION
V D
AND ASCULAR ISEASES
W B. W ,
ILLIAM HITE MD
SERIESEDITOR
Blood Pressure Monitoring in Cardiovascular Medicine
and Therapeutics,Second Edition,edited by William B. White,MD,
2007
Hypertension in the Elderly,edited by L. Michael Prisant, MD, 2005
Lower Extremity Arterial Disease, edited by Dennis G. Caralis, MD,
PhD, MPH, and George L. Bakris, MD, 2005
Secondary Hypertension, Clinical Presentation, Diagnosis,
and Treatment, edited by George A. Mansoor, MD, 2004
Pediatric Hypertension, edited by Ronald J. Portman, MD,
Jonathan M. Sorof, MD, and Julie R. Ingelfinger, MD, 2004
B P
LOOD RESSURE
M
ONITORING
C
IN ARDIOVASCULAR
M
EDICINE
T
AND HERAPEUTICS
Second Edition
Edited by
W B. W ,
ILLIAM HITE MD
Section of Hypertension and Clinical Pharmacology,
University of Connecticut School of Medicine,
Farmington, CT
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Foreword
It is about 30 years since the development of the first practical non-
invasive devices for repetitively measuring blood pressures in people
undertaking their usual daily activities.
For those of us involved at the beginning of this technology, this
important new book—comprehensively detailing the current state of
the art—inevitably brings back memories of the early days when moni-
toring devices were large, complicated and uncertain. One of the first
supporters of this science was NASA’s manned space program. I still
vividly recall engineers from a nearby device company borrowing my
laboratory as they labored intently to prepare a blood pressure monitor-
ing instrument, aided by the highly motivated astronaut who was to
wear it during his forthcoming space mission. Remarkably, the proto-
type appeared to work at least as well in orbit as it did on the ground.
The concept of ambulatory blood pressure monitoring has always
been beguiling. It certainly has provided insights into the physiology of
blood pressure, including its diurnal changes. During the last several
years the monitoring equipment has improved in important ways:it has
become far simpler to use,more reliable in its operation and more flex-
ible in gathering data.
From the point of view of the patient, reductions in the size and
weight of the devices have added greatly to their practicality. Despite
this progress, however, not all available automated technologies for
monitoring blood pressure provide acceptable accuracy and repro-
ducibility, and appropriately a major section of this text deals with the
processes for validating and recommending these instruments.
This highly authoritative publication is the Second Edition of a work
first published by Dr William White in 2000. Like its predecessor, it
will become an indispensable source of information and reference in
the field of ambulatory monitoring. Dr White is uniquely qualified for
the task of bringing together and editing the contributions of the
renowned group of experts who have joined him in writing this book.
Not only has his own personal research contributed strongly to the
knowledge that guides this discipline, but for many years he has been
the Editor-in-Chief of Blood Pressure Monitoring, the principal peer-
reviewed publication dealing with this area of clinical science.
v
vi Foreword
There continues to be a notable expansion in the applications of
blood pressure monitoring. Its use in clinical practice has grown signi-
ficantly, particularly as official hypertension guidelines have now
acknowledged its value for the accurate diagnosis of hypertension. This
technology can be valuable in detecting white-coat hypertension,a con-
dition where blood pressure is misleadingly high in the office or clinic,
but normal when measured elsewhere. As well, patients with so-called
masked hypertension, whose blood pressures are atypically low in the
clinical setting, can be identified by this method.
One of the charms of ambulatory blood pressure monitoring is that
it is one of the few medical tests that patients can largely interpret for
themselves. Reviewing blood pressure values obtained over the 24 hour
period allows patients, together with their physicians, to understand
clearly whether or not they are hypertensive. And, if the evidence hap-
pens to point to the existence of hypertension, these informed patients
will often become just as committed as their professional advisors to
achieving effective treatment.
Whole-day monitoring data have also emerged as strong tools for
exploring epidemiology. As the book discusses in detail, these meas-
urements are more powerful in predicting major cardiovascular out-
comes than conventional blood pressure readings. What’s more,certain
periods of the 24 hour pattern—for instance, the night-time readings,
and whether they exhibit the expected physiologic reductions during
sleep—can be of strong prognostic value. Even the rate-of-rise in blood
pressure during the morning arousal period may be linked to the likeli-
hood of major cardiovascular events. Research into the factors that regu-
late blood pressure profiles during the different portions of the day
could ultimately lead to better-directed therapeutic strategies in hyper-
tensive patients at risk.
Ambulatory blood pressure monitoring has become an indispensable
part of studying drugs and potentially other treatments of hypertension.
For a start, by ensuring that only truly hypertensive patients are
included in clinical trials—thereby avoiding the dilutional effects on
data of including patients with white coat hypertension—monitoring
enhances the accuracy of quantifying blood pressure changes.
Importantly, this technique virtually abolishes placebo effects.
Additionally,its reproducibility reduces the number of patients needed
to provide the statistical power for discriminating differences in
achieved blood pressures among comparative treatment groups.
Foreword vii
In many ways this book documents the maturing of ambulatory
monitoring into an integral and vital part of clinical practice and
research in hypertension. But it is far more than just a celebration of the
great progress made in the field during recent years. Dr White brings us
up to date with the insight and knowledge that can only come from one
of the true pioneers and leaders in this work. For those who seek infor-
mation about ambulatory blood pressure monitoring, and certainly for
those who plan to use it, reading this new edition of William White’s
book will be an invaluable experience.
Michael A. Weber, MD
State University of New York
Downstate College of Medicine
Brooklyn, New York
Preface
The second edition of Blood Pressure Monitoring in Cardiovascular
Medicine and Therapeutics is devoted to the topic of circadian variation
in cardiovascular disease,with a special emphasis on the evaluation and
treatment of hypertension. Clinical and device research related to self
and ambulatory monitoring of the blood pressure and heart rate have
led to significant advances in our ability to detect various clinical enti-
ties in patients with hypertension and its vascular complications. This
research is important not only because hypertension is such a common
problem among adults in industrialized countries, but also because the
cardiovascular morbidity and mortality associated with the hyperten-
sive disease process is so great.
Since the first edition of this book in 2000, research efforts in basic
and clinical hypertension have continued to accelerate and work
devoted to the measurement of blood pressure and blood pressure vari-
ability has also remained productive with new evaluations of devices,
novel drug therapies, and outcomes research in cohort and population
studies. During the past 6 years,numerous important research papers in
the field of ambulatory blood pressure monitoring have been published
and annual international consensus conferences have been held at the
European and International Society of Hypertension meetings. Thus,it
remains important and clinically relevant to devote a second edition of
this book that updates research findings involving blood pressure mon-
itoring and cardiovascular therapeutics.
The five chapters in Part I describe the methodology of self and
ambulatory blood pressure monitoring in research and clinical practice.
Dr. Pickering presents a comprehensive assessment of the utility of self
blood pressure measurement for clinical practice by evaluating the
validity of the devices, reviewing the epidemiologic data that are avail-
able,and discussing the potential for this technique in clinical trials and
for the general management of patients. Drs. James and Mansoor
describe the importance of diaries and physical activity recordings in
cardiovascular disease. These techniques are crucial for obtaining mean-
ingful data during ambulatory blood pressure recordings in clinical trials.
Advances in actigraphy research have allowed investigators to pinpoint
changes in physical activity that may directly impact on blood pressure
ix
x Preface
variability. Dr. Krishnan and I have written an overview of ambulatory
monitoring of the blood pressure,including descriptions of device vali-
dation, patterns of blood pressure variation discovered with the advent
of this technique, and usefulness of the methodology in clinical hyper-
tension. Drs. O’Brien and Atkins have written a chapter on the impor-
tance of device validation and their reliability. The importance of device
validation cannot be over-estimated as it eventually can have an effect
on the overall validity of clinical trials using the recorders.
The seven chapters in Part II describe a number of advances in our
understanding of the pathophysiology of the circadian biology of car-
diovascular disorders. Drs. Portaluppi and Smolensky begin with an
overview of the chronobiology of blood pressure regulation in humans.
This chapter lays the groundwork for the rest of this section with its
comprehensive discussion of the progress that has been made in
research involving the chronophysiology of human disease with major
emphases on hypertension, coronary artery disease, and stroke. Drs.
Celis, Staessen, Palatini, Angeli, Schillaci and Verdecchia present a
number of epidemiologic and prognostic studies that examine the
importance of blood pressure and heart rate ability as determinants of
cardiovascular morbidity and mortality. During the past decade, the
field of ambulatory blood pressure monitoring has advanced dramati-
cally owing to the completion and publication of major prospective
studies that relate circadian blood pressure to cardiovascular outcomes.
These studies show convincingly that ambulatory blood pressure values
are independent predictors of cardiovascular morbidity and mortality.
Drs. Sica and Wilson have examined the available data on the role of
neurohormonal activity, salt sensitivity, and the renin–angiotensin sys-
tem on blood pressure variability,especially as it relates to the blunting
of the nocturnal decline in pressure.
Drs. Shea and Muller have reported on the circadian variation of
myocardial infarction and cardiovascular death. These authors remind
us of the need to identify acute causes of sudden death and myocardial
infarction since coronary disease remains the leading cause of death in
so many countries around the globe. Drs. Vagaonescu and Phillips con-
clude this section by providing a review of the data on the relationship
between blood pressure variability and stroke,as well as discussing the
seasonal and daily variations in the incidence of stroke.
The 4 chapters in Part III are all new in this Edition and focus on
ambulatory blood pressure in special populations of patients with
hypertension: Dr. Prisant covers the older patient who has systolic