JOURNAL CLUB

DRPRAVEEN NAGULA

Contents

1Valvular Heart Disease In India

2ESH PRACTICE GUIDELINES for ABPM

3BAT (BAROREFLEX ACTIVATION THERAPY)

4ECG Challenge

5PREVAIL Trial

6Update on PCSK9 Inhibitors

7Abstracts

2

Indian Heart JournalJuly 2014 3

Background

Diseases of the heart valves constitute a major cause of

cardiovascular morbidity and mortality worldwide with rheumatic

heart disease (RHD) being the dominant form of valvular heart

disease (VHD) in developing nations

The current study was undertaken at a tertiary care cardiac center with

the objective of establishing the incidence and patterns of VHD by

Echocardiography (Echo)

4

Among the 136098 first-time Echocardiograms performed

between January 2010 and December 2012 an exclusion

criterion of trivial and functional regurgitant lesionsyielded a

total of 13289 cases of organic valvular heart disease as the

study cohort

5

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Contents

1Valvular Heart Disease In India

2ESH PRACTICE GUIDELINES for ABPM

3BAT (BAROREFLEX ACTIVATION THERAPY)

4ECG Challenge

5PREVAIL Trial

6Update on PCSK9 Inhibitors

7Abstracts

2

Indian Heart JournalJuly 2014 3

Background

Diseases of the heart valves constitute a major cause of

cardiovascular morbidity and mortality worldwide with rheumatic

heart disease (RHD) being the dominant form of valvular heart

disease (VHD) in developing nations

The current study was undertaken at a tertiary care cardiac center with

the objective of establishing the incidence and patterns of VHD by

Echocardiography (Echo)

4

Among the 136098 first-time Echocardiograms performed

between January 2010 and December 2012 an exclusion

criterion of trivial and functional regurgitant lesionsyielded a

total of 13289 cases of organic valvular heart disease as the

study cohort

5

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Indian Heart JournalJuly 2014 3

Background

Diseases of the heart valves constitute a major cause of

cardiovascular morbidity and mortality worldwide with rheumatic

heart disease (RHD) being the dominant form of valvular heart

disease (VHD) in developing nations

The current study was undertaken at a tertiary care cardiac center with

the objective of establishing the incidence and patterns of VHD by

Echocardiography (Echo)

4

Among the 136098 first-time Echocardiograms performed

between January 2010 and December 2012 an exclusion

criterion of trivial and functional regurgitant lesionsyielded a

total of 13289 cases of organic valvular heart disease as the

study cohort

5

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Background

Diseases of the heart valves constitute a major cause of

cardiovascular morbidity and mortality worldwide with rheumatic

heart disease (RHD) being the dominant form of valvular heart

disease (VHD) in developing nations

The current study was undertaken at a tertiary care cardiac center with

the objective of establishing the incidence and patterns of VHD by

Echocardiography (Echo)

4

Among the 136098 first-time Echocardiograms performed

between January 2010 and December 2012 an exclusion

criterion of trivial and functional regurgitant lesionsyielded a

total of 13289 cases of organic valvular heart disease as the

study cohort

5

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Among the 136098 first-time Echocardiograms performed

between January 2010 and December 2012 an exclusion

criterion of trivial and functional regurgitant lesionsyielded a

total of 13289 cases of organic valvular heart disease as the

study cohort

5

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

6

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

In RHD the order of involvement of valves was mitral (602)

followed by aortic tricuspid and pulmonary valves

Mitral stenosis predominantly seen in females was almost

exclusively of rheumatic etiology (974)

The predominant form of isolated MR was rheumatic (411)

followed closely by myxomatous or mitral valve prolapse (408)

Isolated AS more common in males was the third most common

valve lesion seen in 73 of cases Degenerative calcification was

the commonest cause of isolated AS (650) followed by bicuspid

aortic valve (BAV) (339) and RHD (11)7

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Multiple valves were involved in more than a third of all

cases (368) The order of involvement was

MS MR gt MS AR gt MR AR gt AS AR gt MR AS

gt MS AS

Overall 97 of cases had organic tricuspid valve disease

8

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

9

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Age and sex distribution

10

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

11

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Mitral stenosis

12

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Pul HTN among MS pts

13

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

14

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

15

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Most common is MS+MR (AS +MR ndash Euro Heart Survey )

Least combination was that of MS +AS

Multivalvular disease was seen more in Females (121)

Lesion combinations involving MS were common in females

while all AS combinations were in males

MR+AR gt MS + AR - paediatric age groups (reverse in Adults)

In RHDthe combinations were hellip

VALVE LESION

COMBINATION

PROPORTION OF

CASES

MS +MR (466)

MS +AR (265)

MR +AR (233)

AS +AR (24)

MR +AS (09)

MS+AS (03) 16

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Isolated AS

17

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

18

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

19

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Roberts and Virmani et al ndash Tricuspid involvement is 12 - TS -

2 (seen in cases with MS and AS )(necropsy series)

Hauck et al series of TR - RHD and Ebsteins anomaly (41 and

14 ) present study 702 and 154

20

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Conclusion

RHD contributed most to the burden of VHD in the present

study with calcific degeneration myxomatous disease and BAV

being the other major forms of VHD

Multiple valves were affected in more than a third of all cases

21

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

EUROPEAN SOCIETY OF HYPERTENSION PRACTICE GUIDELINES FOR AMBULATORY BLOOD PRESSURE MONITORING

GParati et alJ Hypertension 2014321359-1366

Consensus document 22

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Introduction

Blood Pressure (BP) varies widely through a 24 hr period

Ambulatory blood pressure monitoring (ABPM) involves

measuring BP at regular intervals(usually every 20-30 min)over a

24 hr period while patients undergo normal daily activities

including sleep

Accuracy validated over all ages

23

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

How came the idea of ABPM

Blood pressure is a highly dynamic parameter with continuous

fluctuations having both short term and long term variability

Short term variability within 24 hrs can be readily assessed by

ABPM

Long term variability- BP measurements over daysweeksor

months with repeated measurements of officeHBPMABPM

Short term variability can be considered for risk stratification

Not a parameter for routine use in clinical practice

24

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Advantages of ABPM

25

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Why these guidelines

ESH 2013 ABPM position paper

Evidence from over 600 papers34 international experts in

HTN(Milan2011)

Reference source for ABPM(obviously)

Main conclusions that are directly relevant to clinical practice

are presented and updated

26

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Questions addressed hellip

Which patients should have ABPM

How to apply and interpret ABPM in daily practice

How to introduce an ABPM serivce in routine clinical

practice

27

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Indications

1white coat HTN in untreated patients (most well established

indication)

2identify varying 24 hr BP profiles

3identify masked HTN

4assessment of treatment efficacy

28

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

29

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

30

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Definition of white coat hypertension

31

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Masked HTN Masked uncontrolled HTN

32

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

33

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Fall of Nocturnal

SBPDBP

Ratio of

nightday

SBPDBP

Remarks

DIPPING gt10 lt20 gt08 lt 09 Normal

REDUCED

DIPPING1-10 gt09 lt 10 Increased CV risk

NON DIPPING

RAISINGIncrease in BP ge1 Increased CV risk

EXTREME

DIPPINGgt20 lt08 debatable

NOCTURNAL

HTNgt12070mm Hg

34

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Normal daytime and night time BP with preserved dippingBP increase only in the

white coat windows at the beginning and the end of the ABP recording

Dagnosis ndashWHITE COAT HYPERTENSION

35

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

ABPM in a 45 yr old driver

clinic BP -13888 mm Hg Diagnosis

Masked HypertensionIncreased day time BP particularly during working hours(bus

driver) and increased night time BP with preserved dipping

Clinic BP at13888 mm Hg 36

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Clinic BP at 14686mm Hgdiagnosis

Daytime HYPERTENSION with preserved nocturnal BP dipping

BP constantly elevated during day time(awake) with low night time (asleep) BP37

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Clinic BP at 15288 mm Hgdiagnosis

NON DIPPING HYPERTENSION

Elevated 24 h ambulatory BP with reverse BP dipping at night(BP rising

pattern) in a patient with moderate form of OSA

Bad prognosis 38

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

39

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

40

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

41

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

42

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

43

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

44

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

45

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

46

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

Welch Allyn ABPM 6100 Demonstrationmp4

Wearing a 24 hour blood pressure

monitor[12]mp4

47

What would be an adequate cuff for Blood

pressure monitoring

48

BP cuff sizes in children

49

50

BAROREFLEX ACTIVATION THERAPY

Baroreflex activation therapy

52

53

54

Barostim neo videomp4

55

BP cuff sizes in children

49

50

BAROREFLEX ACTIVATION THERAPY

Baroreflex activation therapy

52

53

54

Barostim neo videomp4

55

50

BAROREFLEX ACTIVATION THERAPY

Baroreflex activation therapy

52

53

54

Barostim neo videomp4

55

BAROREFLEX ACTIVATION THERAPY

Baroreflex activation therapy

52

53

54

Barostim neo videomp4

55

Baroreflex activation therapy

52

53

54

Barostim neo videomp4

55

53

54

Barostim neo videomp4

55

54

Barostim neo videomp4

55

Barostim neo videomp4

55

56

57

58

59

ECG CHALLENGE

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

57

58

59

ECG CHALLENGE

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

58

59

ECG CHALLENGE

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

59

ECG CHALLENGE

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

ECG CHALLENGE

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

61

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

62

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

Supraventricular tachycardia

WPW syndromeLeft lateral pathway

AVRT orthodromic

QRS alternans

63

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

64

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

65

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

66

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

67

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

Acute evolving anterior transmural MI

Post Thrombolysis ndash AIVR

68

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

69

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

70

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

71

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

72

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

73

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

Acute inferior ST segment elevation myocardial

infarction

Second degree AV block(Mobitz type I)

74

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

What is pardeersquos sign

75

ST elevation as a sign of coronary

obstruction

1920

76

77

ST elevation as a sign of coronary

obstruction

1920

76

77

77