La pressione arteriosa: può servire qualche strumento in più dello sfigmo?
Topic #NOECM
8 min readJun 5, 2015
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appunti utilizzati nel meeting del 28/4/2015#1 Definizione di Ipertensione
“Prehypertension” e “Isolated Systolic Hipertension” <ISH>: solo a caccia di un mercato sempre più grande? Qualche utile nozione di background in due capitoli del Braunwald (43 & 44) [disponibile nella nostra Biblioteca] da leggere prima del seminario.
Confrontate le due tabelle sopra (errori come quelli della seconda tabella sono molto frequenti). Le linee guida del 2003 non includevano la ISH, ma nel Braunwald si parla diffusamente di questo come “sottotipo emodinamico”. Le soglie poi variano da “paragrafo a paragrafo” del libro, come vedremo nei vari esempi che riproduco.
Ci sono ancora molte criticità conoscitive che rendono difficile stabilire valori soglia ben definiti e il problema non può essere ricondotto solo alla “volontà di ampliare il mercato dell’ipertensione”.
#2 Classificazione della ipertensione arteriosa in pediatria
Dati Normativi in pediatria: Link Dropbox
L’articolo segnalato da Giuseppe Lixia: Link Dropbox
Il case report segnalato da Giuseppe: Link bozza Medium (da qui è possibile accedere alla bibliografia sui dati normativi ABPM e in generale degli apparecchi oscillometrici)
#3 Hemodynamic Subtypes
Primary hypertension falls into three distinctly different hemodynamic subtypes that vary sharply by age.Systolic Hypertension in Teenagers and Young Adults
Typically associated with hypertension in the elderly (see later), isolated systolic hypertension (ISH) also is the main type in young adults (typically 17 to 25 years of age). The key hemodynamic abnormalities are increased cardiac output and a stiff aorta, both presumably reflecting an overactive sympathetic nervous system. The prevalence may reach as high as 25% in young men, but the condition affects only 2% of young women. Several recent studies show that young persons with ISH have elevated central as well as brachial systolic blood pressures, indicating significantly increased hemodynamic burden. Thus ISH in youth may predispose to diastolic hypertension in middle age.Diastolic Hypertension in Middle Age
Hypertension diagnosed in middle age (typically, 30 to 50 years of age) usually has the elevated diastolic pressure pattern, with normal systolic pressure (isolated diastolic hypertension) or elevated systolic pressure (combined systolic-diastolic hypertension). This pattern constitutes classic “essential hypertension.” Isolated diastolic hypertension is more common in men and often associates with middle-age weight gain. Without treatment, isolated diastolic hypertension often progresses to combined systolic-diastolic hypertension. The fundamental hemodynamic fault is an elevated systemic vascular resistance coupled with an inappropriately normal cardiac output. Vasoconstriction at the level of the resistance arterioles results from increased neurohormonal drive and an autoregulatory reaction of vascular smooth muscle to an expanded plasma volume, the latter because of impairment in the kidneys’ ability to excrete sodium.Isolated Systolic Hypertension in Older Adults
After the age of 55 years, ISH (systolic blood pressure > 140 mm Hg and diastolic blood pressure < 90 mm Hg) predominates. In developed countries, systolic pressure rises steadily with age; by contrast, diastolic pressure rises until approximately 55 years of age and then falls progressively thereafter (Fig. A)
The resultant widening of pulse pressure indicates stiffening of the central aorta and a more rapid return of reflected pulse waves from the periphery, augmenting systolic aortic pressure (see Fig. B; also see Figs. e43–1, e43–2, and e43–3). 
(...) ISH may represent an exaggeration of this age-dependent stiffening process, (...) Most cases of ISH arise de novo after 55 years of age (...)A multitude of neurohormonal, renal, and vascular mechanisms interact to various degrees in contributing to these different hemodynamic forms of hypertension.NONINVASIVE MEASUREMENT OF CENTRAL AORTIC PRESSURE BY PULSE TONOMETRY The central aortic pressure waveform is the sum of the pressure wave generated by the left ventricle and reflected waves from the peripheral circulation. When the large conduit arteries are healthy and compliant, the reflected wave merges with the incident wave during diastole, which enhances coronary blood flow. But when the conduit arteries become stiff (as in ISH), pulse wave velocity increases such that the reflected and incident waves merge in systole, thereby augmenting systolic rather than dia- stolic pressure — which increases left ventricular afterload and reduces diastolic coronary flow. Sphymocor (AtCor Medical, Houston) is a commercial device that uses brachial artery blood pressure and a generalized transfer function (proprietary software) to convert the radial waveform — measured by applanation tonography — to a derived central aortic blood pressure waveform. This device has received FDA approval for clinical use in (CPT code 93784). Pulse tonometry provides two principal measures of aortic stiffness that typically are increases in hypertension: pulse wave velocity and augmentation index
(aggiornamento in corso)
(Aggiornamento in corso)
Sito rivenditore italiano BP+ e SphygmoCor
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Altro articolo suggerito a questo link (nuovo link?)
#4 Home monitoring of blood pressure
Home blood pressure monitoring should become a routine part of the clinical management of patients with known or suspected hypertension, the same way in which home blood glucose monitoring is essential to the management of diabetes; two readings should be taken in the morning and at night for at least 4 consecutive days (preferably 7 days); the first day’s readings should be excluded as being falsely elevated, and all other readings be averaged to make clinical decisions; and hypertension should be diagnosed when the average home blood pressure is 135/85 mm Hg or higher.
A validated electronic oscillometric monitor with an arm cuff should be chosen from the Dabl educational website (dableducational.org). Each patient’s monitor needs to be checked in the office for accuracy and cuff size. Patients need to be taught correct measurement technique and how to avoid reporting bias. Wrist monitors are inaccurate and are therefore not recommended. The oscillometric method may not work well in patients with atrial fibrillation or frequent extrasystoles. Some patients become obsessive about taking their blood pressure and should be advised to stop self-measurement altogether.Si legga anche qui: http://www.australianprescriber.com/magazine/38/1/16/9nuovo link?
https://www.nps.org.au/australian-prescriber/articles/home-monitoring-of-blood-pressure
Holter pressorio (24-hour ambulatory blood pressure monitoring) a che cosa può servire?
24 hours ABPM (Ambulatory Blood Pressure Monitoring) provides automated measurements of blood pressure during a 24-hour period while patients are engaged in their usual activities, including sleep. Prospective outcome studies in both treated and untreated patients have shown that ambulatory blood pressure measurement predicts fatal and nonfatal MI and stroke better than standard office measurement does. (fig 43-13). Recommended normal values include an average daytime pressure below 135/85 mm Hg, nighttime pressure below 120/70 mm Hg, and 24-hour pressure below 130/80 mm Hg. Hypertension is diagnosed if the average daytime blood pressure is 135/85 mm Hg or higher or the average 24-hour blood pressure is greater than 130/80 mm Hg. At least two measurements per hour should be taken during the patient’s waking hours, and the average value of at least 14 measurements during that time confirms the diagnosis of hypertension. Whether nocturnal dipping status adds independent prognostic information remains controversial.
White Coat Effect
Automated office blood pressure measurement may be an easier approach to detecting white coat hypertension. With the patient in a quiet room with no medical personnel, six readings are taken in rapid succession with an oscillometric blood pressure monitor. If the average of the last five readings is less than 135/85 mm Hg, the patient is assumed to have normal blood pressure; if the average is 135/85 mm Hg or higher, the patient is assumed to have hypertension.Masked & Nocturnal
Masked Hypertension
Another example of the importance of ambulatory or home monitoring is in patients in whom office readings underestimate out-of-office blood pressure, presumably because of sympathetic overactivity in daily life caused by job or home stress, tobacco abuse, or other adrenergic stimulation that dissipates when they come to the office
Nocturnal Hypertension
Ambulatory monitoring is the only way to detect hypertension during sleep Blood pressure normally dips during sleep and increases sharply when a person awakens and becomes active (see Fig. e43–6). Nocturnal hypertension increases the aggregate hemodynamic load on the cardiovascular system and predicts cardiovascular outcomes better than either daytime ambulatory blood pressure or standard office measurements (see Fig. 43–13). Nocturnal hypertension is particularly common among patients with CKD, presumably because of increased cardiac output (centralization of an expanded plasma volume while supine) and increased systemic vascular resistance (failure of sympathetic vasoconstrictor drive to suppress normally during sleep because of persistent activation of an excitatory reflex in the diseased kidneys). In addition, ambulatory blood pressure monitoring is particularly useful in the diagnosis of baroreflex impairment.
