IMPPACT: Investigation of Medical Professionals and Patients Achieving Control Together

Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

Impact evaluation of a community-based intervention for prevention of cardiovascular diseases in the slums of Nairobi: the SCALE-UP study

Background

A combination of increasing urbanization, behaviour change, and lack of health services in slums put the urban poor specifically at risk of cardiovascular disease (CVD). This study aimed to evaluate the impact of a community-based CVD prevention intervention on blood pressure (BP) and other CVD risk factors in a slum setting in Nairobi, Kenya.

Design

Prospective intervention study includes awareness campaigns, household visits for screening, and referral and treatment of people with hypertension. The primary outcome was overall change in mean systolic blood pressure (SBP), while secondary outcomes were changes in awareness of hypertension and other CVD risk factors. We evaluated the intervention's impact through consecutive cross-sectional surveys at baseline and after 18 months, comparing outcomes of intervention and control group, through a difference-in-difference method.

Results

We screened 1,531 and 1,233 participants in the intervention and control sites. We observed a significant reduction in mean SBP when comparing before and after measurements in both intervention and control groups, −2.75 mmHg (95% CI −4.33 to −1.18, p=0.001) and −1.67 mmHg (95% CI −3.17 to −0.17, p=0.029), respectively. Among people with hypertension at baseline, SBP was reduced by −14.82 mmHg (95% CI −18.04 to −11.61, p<0.001) in the intervention and −14.05 (95% CI −17.71 to −10.38, p<0.001) at the control site. However, comparing these two groups, we found no difference in changes in mean SBP or hypertension prevalence.

Conclusions

We found significant declines in SBP over time in both intervention and control groups. However, we found no additional effect of a community-based intervention involving awareness campaigns, screening, referral, and treatment. Possible explanations include the beneficial effect of baseline measurements in the control group on behaviour and related BP levels, and the limited success of treatment and suboptimal adherence in the intervention group.

Community Lay Worker Guided Home-Based Monitoring Program for Hypertension Control

Purpose: The purpose of this study was to determine the incidence of hypertension (HTN), compare clinic versus home visit blood pressure (BP) control, and examine the feasibility of home BP monitoring in a vulnerable adult population. Significance: HTN control continues to be an unmet health maintenance challenge across America. This project used a community lay worker (CLW) to guide individuals in a home BP monitoring program for HTN control. Results: Individuals who were educated in monitoring BP at home significantly reduced their systolic BP. Participants validated that this method was effective in meeting their needs for BP control.

Clinical significance of home blood pressure measurements for the prevention and management of high blood pressure

1. Ambulatory blood pressure (ABP) monitoring (M) provides BP information at many points on any particular day during unrestricted routine daily activities, whereas home blood pressure (HBP) monitoring provides a lot of BP information obtained under fixed times and conditions over a long period of time, thus mean values of HBP provide high reproducibility, and thus an overall superiority compared with ABP.  2. HBP is at least equally or better able than ABP to predict hypertensive target organ damage and prognosis of cardiovascular disease.  3. HBPM allows for ongoing disease monitoring by patients, improves adherence to antihypertensive treatment, and can provide health-care providers with timely clinical data and direct and immediate feedback regarding diagnosis and treatment of hypertension.  4. HBPM provides BP information in relation to time; that is, BP in the morning, in the evening and at night during sleep, and it is an essential tool for the diagnosis of white-coat and masked hypertension.  5. HBPM yields minimal alerting affects and no or minimal placebo effect, and can therefore distinguish small, but significant, serial changes in BP. It is thus the most practical method for monitoring BP in the day-to-day management of hypertension. 6. The superiority of HBPM over ABPM and clinic BPM is apparent from almost all practical and clinical research perspectives.

Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review

BACKGROUND

It is recognized that for the reliable assessment of blood pressure (BP) and the accurate diagnosis of hypertension, out-of-office BP measurement with ambulatory (ABPM) or home BP monitoring (HBPM) is often required. The clinical usefulness of ABPM is well established. However, despite the wide use of HBPM, only in the last decade convincing evidence on its usefulness has accumulated.

METHODS

Systematic review of the evidence on applying HBPM in the diagnosis and treatment of hypertension (PubMed, Cochrane Library, 1970-2010).

RESULTS

Sixteen studies in untreated and treated subjects assessed the diagnostic ability of HBPM by taking ABPM as reference. Seven randomized studies compared HBPM vs. office measurements or ABPM for treatment adjustment, whereas many studies compared HBPM with office measurements in assessing the antihypertensive drug effects. Several studies with different design investigated the role of HBPM vs. office measurements in improving patients' compliance with treatment and hypertension control rates. The evidence on the cost-effectiveness of HBPM is limited. The studies reviewed consistently showed moderate diagnostic agreement between HBPM and ABPM, and superiority of HBPM compared to office measurements in diagnosing uncontrolled hypertension, assessing antihypertensive drug effects and improving patients' compliance and hypertension control. Preliminary evidence suggests that HBPM has the potential for cost savings.

CONCLUSIONS

There is conclusive evidence that HBPM is useful for the initial diagnosis and the long-term follow-up of treated hypertension. These data are useful for the optimal application of HBPM, which is widely used in clinical practice. More studies on the cost-effectiveness of HBPM are needed.

Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis

Hypertension remains the most common modifiable cardiovascular risk factor, yet hypertension control rates remain dismal. Home blood pressure (BP) monitoring has the potential to improve hypertension control. The purpose of this review was to quantify both the magnitude and mechanisms of benefit of home BP monitoring on BP reduction. Using a structured review, studies were selected if they reported either changes in BP or percentage of participants achieving a pre-established BP goal between randomized groups using home-based and office-based BP measurements. A random-effects model was used to estimate the magnitude of benefit and relative risk. The search yielded 37 randomized controlled trials with 9446 participants that contributed data for this meta-analysis. Compared with clinic-based measurements (control group), systolic BP improved with home-based BP monitoring (-2.63 mm Hg; 95% CI, -4.24, -1.02); diastolic BP also showed improvement (-1.68 mm Hg; 95% CI, -2.58, -0.79). Reductions in home BP monitoring-based therapy were greater when telemonitoring was used. Home BP monitoring led to more frequent antihypertensive medication reductions (relative risk, 2.02 [95% CI, 1.32 to 3.11]) and was associated with less therapeutic inertia defined as unchanged medication despite elevated BP (relative risk for unchanged medication, 0.82 [95% CI, 0.68 to 0.99]). Compared with clinic BP monitoring alone, home BP monitoring has the potential to overcome therapeutic inertia and lead to a small but significant reduction in systolic and diastolic BP. Hypertension control with home BP monitoring can be enhanced further when accompanied by plans to monitor and treat elevated BP such as through telemonitoring.