Efficacy of a digital therapeutics system in the management of essential hypertension: the HERB-DH1 pivotal trial

A smartwatch sphygmomanometer-based model for predicting short-term new-onset hypertension in individuals with high-normal blood pressure: a cohort study

OBJECTIVES

The objective was to utilize a smartwatch sphygmomanometer to predict new-onset hypertension within a short-term follow-up among individuals with high-normal blood pressure (HNBP).

METHODS

This study consisted of 3180 participants in the training set and 1000 participants in the validation set. Participants underwent both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) using a smartwatch sphygmomanometer. Multivariable Cox regressions were used to analyze cumulative events. A nomogram was constructed to predict new-onset hypertension. Discrimination and calibration were assessed using the C-index and calibration curve, respectively.

RESULTS

Among the 3180 individuals with HNBP in the training set, 693 (21.8%) developed new-onset hypertension within a 6-month period. The nomogram for predicting new-onset hypertension had a C-index of 0.854 (95% CI, 0.843-0.867). The calibration curve demonstrated good agreement between the nomogram's predicted probabilities and actual observations for short-term new-onset hypertension. In the validate dataset, during the 6-month follow-up, the nomogram had a good C-index of 0.917 (95% CI, 0.904-0.930) and a good calibration curve. As the score increased, the risk of new-onset hypertension significantly increased, with an HR of 8.415 (95% CI: 5.153-13.744, p = .000) for the middle-score vs. low-score groups and 86.824 (95% CI: 55.071-136.885, p = .000) for the high-score vs. low-score group.

CONCLUSIONS

This study provides evidence for the use of smartwatch sphygmomanometer to monitor blood pressure in individuals at high risk of developing new-onset hypertension in the near future.

TRIAL REGISTRATION

ChiCTR2200057354.

Sleep blood pressure measured using a home blood pressure monitor was independently associated with cardiovascular disease incidence: the Nagahama study

BACKGROUND

Nocturnal blood pressure (BP) is associated with cardiovascular disease independently of awake BP. However, nocturnal BP measured using an ambulatory monitoring device has limited reproducibility because it is a single-day measurement. We investigated the association between sleep BP measured on multiple days using a timer-equipped home BP monitor and cardiovascular diseases in a general population.

METHODS

The study population comprised 5814 community residents. Participants were required to sleep with wrapping cuffs on their upper arm and BP was measured automatically at 0 : 00, 2 : 00, and 4 : 00. Actigraph was used to determine BP measured during sleep. Participants were also measured home morning and evening BP manually using the same device.

RESULTS

During the 7.3-year mean follow-up period, we observed 117 cases of cardiovascular diseases. The association between sleep BP (per 10 mmHg hazard ratio = 1.31, P  < 0.001) and cardiovascular events remained significant (hazard ratio = 1.22, P  = 0.036) even after adjusting for office BP and confounding factors, such as sleep-disordered breathing. Individuals with sleep-only hypertension ( n  = 1047; hazard ratio = 2.23, P  = 0.005) had a significant cardiovascular risk. Daytime-only hypertension ( n  = 264; hazard ratio = 3.57, P  = 0.001) and combined sleep and daytime hypertension ( n  = 1216; hazard ratio = 3.69, P  < 0.001) was associated with cardiovascular events to the same extent. Sleep BP dipping was not identified as a significant determinant of cardiovascular events.

CONCLUSION

Sleep BP measured using a home BP monitor was independently associated with the incidence of cardiovascular disease in a general population.

User engagement with home blood pressure monitoring: a multinational cohort using real-world data collected with a connected device

OBJECTIVE

Connected blood pressure (BP) monitors provide reliable data when used properly. Our objective was to analyse the engagement of real-world users with self-measurements.

METHODS

We included adult first-time users of a connected BP monitor from July 2019 to March 2021. They were categorized as persistent users if they continued to use the device between 311 and 400 days after inclusion. We defined a criterion to analyse the timing of self-measurements: at least 12 measurements performed within three consecutive days, at least once every 90 days. Persistent users were clustered by state sequence analysis according to the consistency of their BP monitor measurement timing with this criterion during 1 year of follow-up.

RESULTS

Among the 22 177 included users, 11 869 (54%) were persistent during the first year. Their use was consistent with the timing criterion 25% (median) of this time (first and third quartiles: 0%, 50%) and four patterns of use were identified by clustering: 5215 persistent users (44%) only performed occasional sparse measurements, 4054 (34%) complied at the start of follow-up up to eight cumulated months, 1113 (9%) complied at least once during later follow-up up to eight cumulated months, and the remaining 1487 (13%) complied nine or more cumulated months of follow-up.

CONCLUSION

Although connected BP monitors can collect a high volume of data, the real-life timing of self-measurements is far from recommended schedules. We must promote the use of BP monitors as recommended by guidelines and/or learn to analyse more occasional and sparse measurements.

The Impact of Digital Health Solutions on Bridging the Health Care Gap in Rural Areas: A Scoping Review

Digital health tools can improve health care access and outcomes for individuals with limited access to health care, particularly those residing in rural areas. This scoping review examines the existing literature on using digital tools in patients with limited access to health care in rural areas. It assesses their effectiveness in improving health outcomes. The review adopts a comprehensive search strategy to identify relevant studies from electronic databases, and the selected studies are analyzed descriptively. The findings highlight the advantages and barriers of digital health interventions in rural populations. The advantages include increased access to health care practitioners through teleconsultations, improved health care outcomes through remote monitoring, better disease management through mobile health applications and wearable devices, and enhanced access to specialized care and preventive programs. However, limited internet connectivity and a lack of familiarity with digital tools are barriers that must be addressed to ensure equitable access to digital health interventions in rural areas. Overall, digital tools improve health outcomes for individuals with limited health care access in rural areas.

Digital therapeutics in hypertension: How to make sustainable lifestyle changes

Various digital therapeutic products have been validated and approved since 2017. They have demonstrated efficacy and safety as a new therapeutic modality in various disorders or conditions. Hypertension is a common but serious condition that can be prevented or controlled with lifestyle changes and medicines. Although a digital therapeutic in hypertension is validated and approved in Japan, whether digital therapeutics (DTx) can significantly improve sustainable lifestyle changes is still a controversial topic. Most studies did not discuss the long-term gain challenges. In this review, the authors discuss the definition of DTx, and analyze the motivation, engagement and adherence challenges of DTx in hypertension. Some ongoing artificial intelligence (AI)-enabled or cognitive behavioral therapy (CBT)-based digital interventions and behavioral strategies for implementing sustainable lifestyle changes are identified and analyzed. With AI-enabled interventions and behavioral strategies, DTx might be one of the effective approaches to make sustainable lifestyle changes.

A smartphone app-based intervention combined with face-to-face sessions for alcohol dependence at internal medicine clinics: A randomized controlled trial

BACKGROUND

Addressing the limited access to treatments for alcohol dependence, we developed ALM-002, a therapeutic application to be "prescribed" for non-abstinence-oriented treatment in internal medicine settings. Our objective was to preliminarily assess the efficacy and safety of ALM-002.

METHODS

In a multicenter, open-label randomized controlled trial, participants aged ≥20 with alcohol dependence and daily alcohol consumption exceeding 60 g for men and 40 g for women, without severe complications, were randomly assigned to either the intervention group using ALM-002 or the treatment-as-usual control group. Participant in both groups received individual face-to-face sessions by physicians at weeks 0, 4, 8, and 12. The primary endpoint was the change in heavy drinking days (HDDs) from week 0 to week 12. A mixed model for repeated measures was employed.

RESULTS

We enrolled 43 participants: 22 in the intervention group and 21 in the control group. A significant reduction in HDDs every 4 weeks from week 0 to week 12 was observed, with a between-group difference of -6.99 days (95% CI: -12.4 to -1.6 days, standardized mean difference: -0.80).

CONCLUSIONS

These results indicate the potential of ALM-002 as a viable treatment for alcohol dependence. Further studies are needed to evaluate the clinical potential of ALM-002.

Effectiveness of digital health interventions on adherence and control of hypertension: a systematic review and meta-analysis

BACKGROUND

Hypertension, a risk factor for developing cardiovascular disease, is becoming increasingly prevalent worldwide. Digital health is now widely utilized for hypertension management, and numerous studies have assessed its effectiveness.

OBJECTIVE

The review aims to analyse the effectiveness of digital health (i.e., mobile health (mHealth), telehealth, and the combination of mHealth & telehealth) on hypertensive patients, concerning three key areas: clinical outcomes, medication adherence, and adherence to lifestyle changes, as compared to standard care.

METHODS

The review followed the PRISMA framework. Eight electronic databases were scanned for randomized control trials focusing on the effects of mHealth or telehealth on hypertensive patients, published between 2010 and 2023. All processes were conducted by the first two authors independently. A meta-analysis was conducted for quantitative data, while a narrative synthesis was conducted for qualitative data.

RESULTS

In total, 74 studies involving 92 686 participants were identified. The meta-analysis favoured the interventions, revealing a significant decrease in systolic blood pressure and diastolic blood pressure for mHealth, telehealth and mHealth & telehealth groups. Nevertheless, medication adherence showed improvement only in the mHealth group, while blood pressure control showed improvement in both mHealth and mHealth & telehealth groups, and BMI showed improvement only in the mHealth group. Evidence for adherence to physical activity and DASH diet/salt intake remained inconclusive.

CONCLUSION

In general, mHealth and telehealth have demonstrated their merits in improving the clinical outcomes of hypertensive patients.

Temporal trends in adherence to lifestyle recommendations of patients with hypertension in Korea, 2007-2021

Adherence to lifestyle recommendations is crucial in managing hypertension, independent of medical treatment. This study aimed to evaluate the implementation of adherence to lifestyle recommendations and analyze the trends in adherence to lifestyle recommendations among patients with hypertension in Korea from 2007 to 2021 using the Korea National Health and Nutrition Examination Survey (KNHANES). The study included adults aged ≥20 years. Factors such as regular physical activity, smoking and alcohol abstinence, weight and stress management, and adherence to a healthy diet were analyzed. In 2021, A doublefold increase was observed in the proportion of patients with hypertension who adhered to sodium restriction compared to 2007. However, 70% of patients with hypertension consume more sodium than recommended. Moreover, potassium intake has steadily decreased since 2014, with only 23.8% of patients with hypertension meeting the recommended intake. The body mass index (BMI) and waist circumference of patients with hypertension have gradually increased, with fewer patients maintaining an appropriate weight. The neglect of diet and weight control among young patients with hypertension who experience high stress levels poses challenges in modifying their lifestyles. Patients with hypertension in Korea still consume high amounts of sodium, whereas potassium intake is gradually decreasing. Additionally, obesity rates have been increasing, especially among young patients with hypertension. A multidisciplinary approach is necessary for improving the lifestyle habits of hypertensive patients.

The effects of a digital lifestyle intervention in patients with hypertension: Results of a pilot randomized controlled trial

In this pilot study, the authors investigated the preliminary effectiveness of the digital lifestyle intervention, actensio (mementor DE GmbH), in treating arterial hypertension. Adults with arterial hypertension were randomly assigned to an intervention group (actensio + standard care) or a control group (waiting list + standard care) in a 1:1 ratio. Primary and secondary endpoints were assessed at baseline (t0) and 3 months post-randomization (t1). The primary endpoint was average systolic blood pressure, measured at home for 1 week. Secondary endpoints included patient engagement (measured using the "patient activation measure"; PAM-13), average diastolic blood pressure, and heart rate. All endpoints were analyzed using ANCOVA models, following an intention-to-treat approach, while adjusting for baseline values. Missing data were estimated using multiple imputation models. A total of N = 102 participants (f = 59, age = 52.94 ± 9.01) were randomized to either the intervention (IG; N = 52) or the control group (CG; N = 50), of which N = 80 completed the blood pressure diary, and N = 81 the PAM-13 at t1. Between-group comparisons showed an average group difference in systolic blood pressure of -5.06 mm Hg (95% CI = -8.71 to -1.41, p = .013) between the intervention group (M = 137.37 ± 10.13) and the control group (M = 142.35 ± 11.23). Average group difference for patient engagement was 3.35 points with a trend towards statistical significance (95% CI = -018 to 6.89, p = .064), favoring the intervention group (MIG = 79.38 ± 9.44 vs. MCG = 75.45 ± 10.62). There were no group differences in diastolic blood pressure (-1.78 mm Hg; 95% CI = -4.50 to 0.95, p = .402) and heart rate (-0.684; 95% CI = -3.73 to 2.36, p = 0.683). The results of the present pilot study confirm the preliminary effectiveness of the digital lifestyle intervention, actensio, in reducing high blood pressure in patients with hypertension.

National and Regional Trends in the Prevalence of Hypertension in South Korea Amid the Pandemic, 2009-2022: Nationwide Study of Over 3 Million Individuals

BACKGROUND

Understanding the association between hypertension prevalence and socioeconomic and behavioral variables during a pandemic is essential, and this analysis should extend beyond short-term trends.

OBJECTIVE

This study aims to examine long-term trends in the prevalence of participants diagnosed with and receiving treatment for hypertension, using data collected by a nationally representative survey from 2009 to 2022, which includes the COVID-19 pandemic era.

METHODS

A nationwide, population-based, cross-sectional study used data collected from the South Korea Community Health Survey between 2009 and 2022. The study sample comprised 3,208,710 Korean adults over a period of 14 years. We aimed to assess trends in the prevalence of participants diagnosed with and receiving treatment for hypertension in the national population from 2009 to 2022, with a specific focus on the COVID-19 pandemic, using weighted linear regression models.

RESULTS

Among the included 3,072,546 Korean adults, 794,239 (25.85%) were aged 19-39 years, 1,179,388 (38.38%) were aged 40-59 years; 948,097 (30.86%) were aged 60-79 years, and 150,822 (4.91%) were aged 80 years or older. A total of 1,426,379 (46.42%) were men; 761,896 (24.80%) and 712,264 (23.18%) were diagnosed with and received treatment for hypertension, respectively. Although the overall prevalence over the 14-year period increased, the upward trends of patients diagnosed with and receiving treatment for hypertension decreased during the COVID-19 pandemic era compared with the prepandemic era (β difference for trend during vs before the pandemic -.101, 95% CI -0.107 to -0.094 vs -.133, 95% CI -0.140 to -0.127). Notably, the trends in prevalence during the pandemic were less pronounced in subgroups of older adults (≥60 years old) and individuals with higher alcohol consumption (≥5 days/month).

CONCLUSIONS

This nationwide representative study found that the national prevalence of participants diagnosed with and receiving treatment for hypertension increased during the prepandemic era. However, there was a marked decrease in these trends during the prepandemic era, compared with the pandemic era, particularly among specific subgroups at increased risk of negative outcomes. Future studies are needed to evaluate the factors associated with changes in the prevalence of hypertension during the COVID-19 pandemic.

Effectiveness of digital health interventions for telemedicine/telehealth for managing blood pressure in adults: a systematic review and meta-analysis

This systematic review and meta-analysis included randomized controlled trials or observational studies that compare digital health interventions (DHIs) for telemedicine/telehealth versus usual care for managing blood pressure (BP) in adults. We searched PubMed, Cochrane CENTRAL, and IchuShi-Web, and used a random-effects meta-analysis of the weighted mean difference (MD) between the comparison groups to pool data from the included studies. The outcome included the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 117 studies with 68677 participants as eligible. The 3-month intervention period reduced office systolic BP (SBP) compared with usual care in 38 studies (MD: -3.21 mmHg [95% confidence interval: -4.51 to -1.90]), with evidence of heterogeneity. Office SBP across intervention periods demonstrated comparable effects (3-, 6- [54 studies], 12- [43 studies], and >12-month periods [9 studies]). The benefits for office diastolic BP were similar to those for office SBP. Additionally, the interventions significantly reduced the office SBP compared with the control, regardless of the mode of intervention delivery (smartphone apps [38 studies], text messages [35 studies], and websites [34 studies]) or type of facility (medical [74 studies] vs. non-medical [33 studies]). The interventions were more effective in 41 hypertension cohorts compared with 66 non-hypertension cohorts (-4.81 mmHg [-6.33, -3.29] vs. -2.17 mmHg [-3.15, -1.19], P = 0.006 for heterogeneity). In conclusion, DHIs for telemedicine/telehealth improved BP management compared with usual care. The effectiveness with heterogeneity should be considered, as prudent for implementing evidence-based medicine. This meta-analysis considered 117 studies with 68677 participants eligible. The DHIs for telemedicine/telehealth reduced office BP compared with usual care, regardless of intervention duration, intervention delivery mode, facility type, and cohort type. Additionally, the DHIs reduced the risk of uncontrolled BP compared with usual care, regardless of intervention duration, intervention delivery mode, and facility type. BP blood pressure, DHI digital health intervention, MD mean difference, RR risk ratio, SBP systolic blood pressure.

Design and rationale of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study: A cluster randomized controlled trial for hypertension management in primary care

BACKGROUND

Hypertension management in China is suboptimal with high prevalence and low control rate due to various barriers, including lack of self-management awareness of patients and inadequate capacity of physicians. Digital therapeutic interventions including mobile health and computational device algorithms such as clinical decision support systems (CDSS) are scalable with the potential to improve blood pressure (BP) management and strengthen the healthcare system in resource-constrained areas, yet their effectiveness remains to be tested. The aim of this report is to describe the protocol of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study assessing the effect of a multifaceted hypertension management system for supporting patients and physicians on BP lowering in primary care settings.

MATERIALS AND METHODS

The CHESS evaluation study is a parallel-group, cluster-randomized controlled trial conducted in primary care settings in China. Forty-one primary care sites from 3 counties of China are randomly assigned to either the usual care or the intervention group with the implementation of the CHESS system, more than 1,600 patients aged 35 to 80 years with uncontrolled hypertension and access to a smartphone by themselves or relatives are recruited into the study and followed up for 12 months. In the intervention group, participants receive patient-tailored reminders and alerts via messages or intelligent voice calls triggered by uploaded home blood pressure monitoring data and participants' characteristics, while physicians receive guideline-based prescription instructions according to updated individual data from each visit, and administrators receive auto-renewed feedback of hypertension management performance from the data analysis platform. The multiple components of the CHESS system can work synergistically and have undergone rigorous development and pilot evaluation using a theory-informed approach. The primary outcome is the mean change in 24-hour ambulatory systolic BP from baseline to 12 months.

DISCUSSION

The CHESS trial will provide evidence and novel insight into the effectiveness and feasibility of an implementation strategy using a comprehensive digital BP management system for reducing hypertension burden in primary care settings.

TRIAL REGISTRATION

https://www.

CLINICALTRIALS

gov, NCT05605418.

Current status and future prospects of Chinese mobile apps for hypertension management

OBJECTIVE

This study aimed to evaluate the current situation of Chinese mobile apps for hypertension management and explore patients' real requirements for app use, providing a theoretical basis for the future improvement of hypertension apps.

METHODS

We reviewed hypertension management apps from mobile app platforms, and summarized their functional characteristics. In addition, we conducted an online survey among 1000 hypertensive patients, collected valid responses, and analyzed the feedback data.

RESULTS

Forty hypertension management apps were analyzed, with 72.5% offering no more than six functions, indicating limited coverage of advanced and comprehensive functionalities. Among the 934 valid survey responses, patients emphasized four main functions in apps for hypertension management: long-term dynamic blood pressure monitoring, scientific lifestyle management, strict medication management and systematic health knowledge delivering.

CONCLUSION

The existing hypertension management apps mainly serve as "Digital Health" tools with unclear clinical efficacy. The future development of these apps lies in how they transition to "Digital Therapeutics" solutions to better meet patients' needs and provide clear clinical advantages.

Effects of salt intake reduction by urinary sodium to potassium ratio self-monitoring method

Effective and feasible educational methods are needed to control salt intake. We performed a single-center, non-randomized controlled study to investigate the effectiveness and feasibility of self-monitoring using a urinary sodium/potassium (Na/K) ratio-measuring device in patients with difficulty in reducing salt intake. This study included 160 patients with hypertension, chronic kidney disease, or heart disease who were followed up in the outpatient clinic of the Dokkyo Medical University Nikko Medical Center. Urinary Na/K ratio measuring Na/K ratio meter were loaned for 2-6 weeks to the treatment (T) group (n = 80) and not to the patients in the control (C) group (n = 80). In the T group, patients were instructed to measure the urinary Na/K ratio at least three times a day and maintain a Na/K ratio below 2.0. Salt reduction education and home blood pressure measurement guidance continued in both groups. The mean device loan period in the T group was 25.1 days, the mean number of measurements was 3.0 times/day, and the proportion of patients achieving three measurements per day was 48.8% (39/80). Self-monitoring using the urinary Na/K ratio meter successfully reduced salt intake by -1.9 g/day at the second visit (p < 0.001) in the T group. In contrast, no change was observed over time in the C group. Self-monitoring using the urinary Na/K ratio meter successfully reduced salt intake in patients with difficulty reducing salt intake.

Impact of mobile application and outpatient follow-up on renal endpoints and physiological indices in patients with chronic kidney disease: a retrospective cohort study in Southwest China

BACKGROUND

Chronic kidney disease (CKD) is a significant public health concern, and patient self-management is an effective approach to manage the condition. Mobile applications have been used as tools to assist in improving patient self-management, but their effectiveness in long-term outpatient follow-up management of patients with CKD remains to be validated. This study aimed to investigate whether using a mobile application combined with traditional outpatient follow-up can improve health outcomes of patients with CKD .

METHODS

This retrospective cohort study recruited CKD patients with stage 1-5 who were not receiving renal replacement therapy from a CKD management center. Two groups were established: the APP + outpatient follow-up group and the traditional outpatient follow-up group. Baseline data was collected from January 2015 to December 2019, followed by a three-year long-term follow-up until December 2022. Laboratory data, all-cause mortality, and renal replacement treatment were then collected and compared between the two groups.

RESULTS

5326 patients were included in the study, including 2492 in the APP + outpatient group and 2834 in the traditional outpatient group. After IPTW virtualization matching, the final matched the APP + outpatient group consisted of 2489 cases (IQR, 33-55) and 2850 (IQR, 33-55) in the traditional outpatient group. By the end of the study, it was observed that the laboratory data of Phosphorus, Sodium, Triglyceride, Hemoglobin showed significant improvements, Furthermore the APP + outpatient group demonstrated superior results compared to the traditional outpatient group (P < .05). And it was observed that there were 34 deaths (1.4%) in the APP + outpatient group and 46 deaths (1.6%) in the traditional outpatient group(P = .49). After matching for renal replacement therapy outcomes, the two groups were found to be comparable (95% CI [0.72-1.08], P = .23), with no significant difference. However, it was noted that the traditional outpatient group had a lower incidence of using temporary catheters during initial hemodialysis (95% CI [8.4-29.8%], P < .001).

CONCLUSION

The development and application of an app combined with outpatient follow-up management can improve patient health outcomes. However, to ensure optimal preparation for kidney replacement therapy, patients in CKD stages 4-5 may require more frequent traditional outpatient follow-ups, and further develop an information-based decision-making support tool for renal replacement therapy.

Strategies for improving the treatment and control of hypertension in Japan

Despite the significant advancements in the diagnosis and treatment of hypertension, the burden of hypertension remains a major global health care concern. In Japan, estimates show that more than two-thirds of the population have uncontrolled hypertension, regardless of whether they were taking antihypertensive medication. To improve hypertension management, hypertension guidelines have been developed and updated regularly by hypertension societies across various countries and regions. The Japanese Society of Hypertension (JSH) updated the Guidelines for the Management of Hypertension in 2019 (JSH 2019). The JSH 2019 aims to establish a standard management strategy for hypertension and provide evidence to all health care providers. One of its updated main features is its proposal for multidisciplinary team-based care (TBC) involving physicians, pharmacists, nurses, dietitians, and other health care providers. The TBC will help initiate and intensify the management of hypertension, as well as combat clinical inertia, which is expected to contribute to uncontrolled blood pressure and subsequent development of cardiovascular diseases. This is consistent with the recommendations from recent major guidelines on hypertension management. Moreover, to reduce the evidence-practice gap in hypertension management, it is essential to disseminate the essence of the guidelines and provide hypertension education programs for all health care providers and patients. This review summarizes the points of the JSH 2019-based strategy for improving hypertension management and discusses guidelines for its implementation into actual clinical practice.

Digitalomics, digital intervention, and designing future: The next frontier in cardiology

The discipline of cardiology stands at a transformative juncture, primarily influenced by the surge in digital health technologies. These innovations hold the promise to redefine the realms of cardiovascular research and patient care, ushering in an era of individualized and data-driven treatments. This review delves into the heart of this evolution, introducing a comprehensive design for the future of cardiology. Emphasizing the emerging domains of "digitalomics" and "digital intervention", it explores how the integration of patient data, artificial intelligence-enabled diagnostics, and telehealth can lead to more streamlined and personalized cardiovascular health. The "digital-twin" model, a highlight of this approach, encapsulates individual patient characteristics, allowing for targeted treatments. The role of interdisciplinary collaboration in cardiovascular medicine is also underlined, emphasizing the importance of merging traditional cardiology with technological advancements. The convergence of traditional cardiology methods and digital health technologies, facilitated by a transdisciplinary approach, is set to chart a new course in cardiovascular health, emphasizing individualized care and improved clinical outcomes.

Role of Perceived Social Support in Adherence to Antihypertensives and Controlled Hypertension: Findings of a Community Survey from Urban Nepal

Introduction

Social support is considered vital for effective management of chronic conditions, but its role in improving adherence to antihypertensive medication and control of hypertension in urban Nepal is unknown. We examined the role of social support in adherence to antihypertensives and controlled blood pressure to inform future interventions for hypertension management.

Methods

We analyzed cross-sectional data collected at baseline of a cluster randomized trial of hypertension patients (n=1252) in the community between May and November 2022. Multidimensional scale of perceived social support was used to measure social support, adherence to antihypertensives was measured using the Morisky medication adherence scale -8, and individuals with systolic- and diastolic- blood pressure less than 140 and 90 mmHg respectively were considered to have controlled hypertension. Modified Poisson regression models were used to estimate the prevalence ratios and corresponding 95% confidence intervals.

Results

We found that 914 (73%) individuals received moderate to high social support. Participants receiving high social support had a numerically lower proportion of controlled hypertension (51%) however not statistically significant. The proportion of good adherence to antihypertensives did not differ between the social support categories. There was no association in overall, family, friends, and significant other sub-scales of social support with controlled hypertension and adherence to antihypertensives.

Discussion

Further studies to understand the quality and mechanisms through which social support contributes to blood pressure control are needed for the health system to include social support in designing and implementing community-based interventions for hypertension management.

Recent developments in machine learning modeling methods for hypertension treatment

Hypertension is the leading cause of cardiovascular complications. This review focuses on the advancements in medical artificial intelligence (AI) models aimed at individualized treatment for hypertension, with particular emphasis on the approach to time-series big data on blood pressure and the development of interpretable medical AI models. The digitalization of daily blood pressure records and the downsizing of measurement devices enable the accumulation and utilization of time-series data. As mainstream blood pressure data shift from snapshots to time series, the clinical significance of blood pressure variability will be clarified. The time-series blood pressure prediction model demonstrated the capability to forecast blood pressure variabilities with a reasonable degree of accuracy for up to four weeks in advance. In recent years, various explainable AI techniques have been proposed for different purposes of model interpretation. It is essential to select the appropriate technique based on the clinical aspects; for example, actionable path-planning techniques can present individualized intervention plans to efficiently improve outcomes such as hypertension. Despite considerable progress in this field, challenges remain, such as the need for the prospective validation of AI-driven interventions and the development of comprehensive systems that integrate multiple AI methods. Future research should focus on addressing these challenges and refining the AI models to ensure their practical applicability in real-world clinical settings. Furthermore, the implementation of interdisciplinary collaborations among AI experts, clinicians, and healthcare providers are crucial to further optimizing and validate AI-driven solutions for hypertension management.

A Digitally Enabled Combined Lifestyle Intervention for Weight Loss: Pilot Study in a Dutch General Population Cohort

BACKGROUND

Overweight and obesity rates among the general population of the Netherlands keep increasing. Combined lifestyle interventions (CLIs) focused on physical activity, nutrition, sleep, and stress management can be effective in reducing weight and improving health behaviors. Currently available CLIs for weight loss (CLI-WLs) in the Netherlands consist of face-to-face and community-based sessions, which face scalability challenges. A digitally enabled CLI-WL with digital and human components may provide a solution for this challenge; however, the feasibility of such an intervention has not yet been assessed in the Netherlands.

OBJECTIVE

The aim of this study was two-fold: (1) to determine how weight and other secondary cardiometabolic outcomes (lipids and blood pressure) change over time in a Dutch population with overweight or obesity and cardiometabolic risk participating in a pilot digitally enabled CLI-WL and (2) to collect feedback from participants to guide the further development of future iterations of the intervention.

METHODS

Participants followed a 16-week digitally enabled lifestyle coaching program rooted in the Fogg Behavior Model, focused on nutrition, physical activity, and other health behaviors, from January 2020 to December 2021. Participants could access the digital app to register and track health behaviors, weight, and anthropometrics data at any time. We retrospectively analyzed changes in weight, blood pressure, and lipids for remeasured users. Surveys and semistructured interviews were conducted to assess critical positive and improvement points reported by participants and health care professionals.

RESULTS

Of the 420 participants evaluated at baseline, 53 participated in the pilot. Of these, 37 (70%) were classified as overweight and 16 (30%) had obesity. Mean weight loss of 4.2% occurred at a median of 10 months postintervention. The subpopulation with obesity (n=16) showed a 5.6% weight loss on average. Total cholesterol decreased by 10.2% and low-density lipoprotein cholesterol decreased by 12.9% on average. Systolic and diastolic blood pressure decreased by 3.5% and 7.5%, respectively. Participants identified the possibility of setting clear action plans to work toward and the multiple weekly touch points with coaches as two of the most positive and distinctive components of the digitally enabled intervention. Surveys and interviews demonstrated that the digital implementation of a CLI-WL is feasible and well-received by both participants and health care professionals.

CONCLUSIONS

Albeit preliminary, these findings suggest that a behavioral lifestyle program with a digital component can achieve greater weight loss than reported for currently available offline CLI-WLs. Thus, a digitally enabled CLI-WL is feasible and may be a scalable alternative to offline CLI-WL programs. Evidence from future studies in a Dutch population may help elucidate the mechanisms behind the effectiveness of a digitally enabled CLI-WL.

Smart Start - Designing Powerful Clinical Trials Using Pilot Study Data

BACKGROUND: Digital health interventions may be optimized before evaluation in a randomized clinical trial. Although many digital health interventions are deployed in pilot studies, the data collected are rarely used to refine the intervention and the subsequent clinical trials. METHODS: We leverage natural variation in patients eligible for a digital health intervention in a remote patient-monitoring pilot study to design and compare interventions for a subsequent randomized clinical trial. RESULTS: Our approach leverages patient heterogeneity to identify an intervention with twice the estimated effect size of an unoptimized intervention. CONCLUSIONS: Optimizing an intervention and clinical trial based on pilot data may improve efficacy and increase the probability of success. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT04336969.)

A prospective pilot trial of the health data monitoring system without educational content for patients with hypertension

In Japan, a hypertension treatment aid application (CureApp Co., Ltd.) with educational content on hypertension was the first in the world to show significant blood pressure (BP) reduction in hypertensive patients in 2021. Omron Healthcare Corporation and I developed the Health data Monitoring System (HMS) without educational content, which allows patients to check their home BP values periodically and allows physicians to check their home BP data before the hospital visit. As a pilot study, nineteen patients with hypertension used HMS for six months. The percentage of patients achieving their antihypertensive goal increased from 16% to 37%. Mean home systolic BP decreased from 138.1 ± 11.8 mmHg to 130.2 ± 7.8 mmHg. The increase in number of home BP measurements was significantly associated with the amount of homed systolic BP reduction in men. In conclusion, HMS without educational content may be an adjunct to hypertension treatment.

Home systolic blood pressure time in therapeutic range and cardiovascular risk: the practitioner-based nationwide J-HOP study extended

Time in therapeutic range (TTR) for office systolic blood pressure (SBP) is an independent predictor of major cardiovascular events. However, the clinical implications of TTR for home SBP have not yet been investigated. This study determined the association between TTR of home SBP and cardiovascular events in individuals with ≥1 cardiovascular risk factor who were enrolled in The Japan Morning Surge-Home Blood Pressure (J-HOP) study. The therapeutic range for home SBP was defined as home SBP of 100-135 mmHg during the 13-day baseline period of the J-HOP study. Participants were divided into subgroups based on quartiles of TTR for home SBP, and the risk of cardiovascular events was determined in each quartile. During a mean 6.3 years of follow-up in 4070 participants (mean age 65 years), cardiovascular events included stroke in 92, coronary artery disease in 119, heart failure in 41 and aortic dissection in 8. The adjusted hazard ratio (95% confidence interval) for the risk of total cardiovascular events in participants with home SBP TTR in the lowest (100%) versus highest quartile (<15.3%) was 1.74 (1.16-2.61); the corresponding hazard ratio for stroke events was 2.11 (1.06-4.21). A 10% decrease in home SBP TTR was associated with a 4% increase in the risk of total cardiovascular events (p = 0.033) and a 9% increase in the risk of stroke (p = 0.004). The significant association seen between home SBP TTR and the occurrence of cardio- and cerebrovascular events highlights the importance of achieving stable reductions in home SBP and minimizing day-by-day home BP variability.Clinical Trial Registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000000894 (J-HOP study).

Daily self-reported behavioural efficacy records on hypertension digital therapeutics as digital metrics associated with the reduction in morning home blood pressure: post-hoc analysis of HERB-DH1 trial

Digital therapeutics for hypertension, proven effective in the HERB-DH1 trial, enable patients to record and track their daily actions and achievements to improve their lifestyles using an app. However, the association between recording daily behaviours and blood pressure (BP) reduction has not yet been investigated. We conducted a post-hoc analysis to investigate the relationship between them in the HERB-DH1 trial. We defined the counts of daily records of antihypertensive behaviour taken by the patient into the app as daily self-reported behavioural efficacy records (SER). SER was categorised into quartiles, and the trend of changes from baseline to week 12 in morning home systolic blood pressure (SBP), salt intake checklist score, and body weight was assessed. A total of 156 patients with hypertension were included in the analysis. A higher total count of SER was associated with greater SBP reduction (P for trend: 0.049). Patients with a higher SER for salt intake and weight reduction showed reductions in SBP (P for trend: 0.034 and 0.027, respectively). Furthermore, patients with higher salt intake SER exhibited a decrease in the salt intake checklist scores, and patients with greater weight reduction SER experienced a reduction in body weight (P for trend: 0.001 and 0.007, respectively). SER during digital therapeutics is associated with a reduction in morning home SBP in patients with hypertension. Enhancing patients' intrinsic motivation and self-efficacy, as evaluated by the SER, can play an important role in reducing BP by promoting lifestyle improvement. Daily self-reported behavioural efficacy records (SER) defined as the number of patient's app inputs of recall of day-by-day activity of behaviours at the end of the day, is partially affected by self-efficacy and affinity of app, resulting in the effectiveness of digital therapeutics.

Exploring the potential of digital therapeutics: An assessment of progress and promise

Digital therapeutics (DTx), a burgeoning subset of digital health solutions, has garnered considerable attention in recent times. These cutting-edge therapeutic interventions employ diverse technologies, powered by software algorithms, to treat, manage, and prevent a wide array of diseases and disorders. Although DTx shows significant promise as an integral component of medical care, its widespread integration is still in the preliminary stages. This limited adoption can be largely attributed to the scarcity of comprehensive research that delves into DTx's scope, including its technological underpinnings, potential application areas, and challenges-namely, regulatory hurdles and modest physician uptake. This review aims to bridge this knowledge gap by offering an in-depth overview of DTx products' value to both patients and clinicians. It evaluates the current state of maturity of DTx applications driven by digital technologies and investigates the obstacles that developers and regulators encounter in the market introduction phase.

New technologies for the diagnosis, treatment, and monitoring of cardiovascular diseases

Telemedicine enables the remote provision of medical care through information and communication technologies, facilitating data transmission, patient participation, promotion of heart-healthy habits, diagnosis, early detection of acute decompensation, and monitoring and follow-up of cardiovascular diseases. Wearable devices have multiple clinical applications, ranging from arrhythmia detection to remote monitoring of chronic diseases and risk factors. Integrating these technologies safely and effectively into routine clinical practice will require a multidisciplinary approach. Technological advances and data management will increase telemonitoring strategies, which will allow greater accessibility and equity, as well as more efficient and accurate patient care. However, there are still unresolved issues, such as identifying the most appropriate technological infrastructure, integrating these data into medical records, and addressing the digital divide, which can hamper patients' adoption of remote care. This article provides an updated overview of digital tools for a more comprehensive approach to atrial fibrillation, heart failure, risk factors, and treatment adherence.

Mobile health technologies in the prevention and management of hypertension: A scoping review

Introduction

An estimated one billion people globally are currently suffering from hypertension. Prevention and management of hypertension are suboptimal especially in low- and middle-income countries leading to increased complications and deaths. With increased mobile phone coverage globally, this study aims to review mobile health technologies used for the prevention and management of hypertension.

Methods

We conducted a literature search on electronic databases using identified keywords involving "hypertension", "mobile health technology" and their synonyms. Snowballing technique was also used. Papers were screened at two levels by independent reviewers. The targets were studies published in peer-reviewed journals reporting mobile health interventions for hypertension prevention and management. Only primary research studies published in English from January 2017 to April 2024 were included. Google Forms were used to extract the data along with other characteristics, and selected articles were categorised into: mobile application, web-based solutions, and Short Message Service (SMS) and other offline solutions.

Result

The search yielded 184 articles, and 44 studies were included in the review. Most (n = 26) were randomised control trials. Twenty-two studies (22) focused only on mobile applications solutions, 12 on SMS and other offline mHealth, 5 web-based solutions, and 5 combined more than one type of mobile health technology. The United States of America had the majority of studies (n = 17), with 6 studies from other American countries, 11 from Asia and nine from Europe, while only one from Africa. A total of 36 studies reported that mobile health technology significantly improved hypertension care through reduced blood pressure, improved adherence to follow-up visits and medications, and lifestyle changes. SMS and offline mHealth strategies have also demonstrated effectiveness in promoting self-management and reducing racial disparities in hypertension care.

Conclusion

Mobile health technology has the potential to play a significant role in the prevention and management of hypertension. However, there is a need for mobile health solutions for hypertension prevention and management in African countries and other developing countries. Integrating mHealth into primary healthcare delivery would also go a long way in strengthening patient care and reducing the burden on healthcare systems.

2023 update and perspectives

Total 276 manuscripts were published in Hypertension Research in 2022. Here our editorial members picked up the excellent papers, summarized the current topics from the published papers and discussed future perspectives in the sixteen fields. We hope you enjoy our special feature, 2023 update and perspectives in Hypertension Research.

Efficacy of a WeChat-Based Multimodal Digital Transformation Management Model in New-Onset Mild to Moderate Hypertension: Randomized Clinical Trial

BACKGROUND

The advantages of multimodal digitally transformed mobile health management for patients diagnosed with mild to moderate hypertension are not yet established.

OBJECTIVE

We aim to evaluate the therapeutic benefits of a novel WeChat-based multimodal digital transforming management model in mobile health blood pressure (BP) management.

METHODS

This randomized controlled clinical trial included 175 individuals with new-onset mild to moderate hypertension who were admitted to our center between September and October 2022. The patients were randomly assigned to either the multimodal intervention group (n=88) or the usual care group (n=87). The primary composite outcome was home and office BP differences after 6 months. The major secondary outcomes were 6-month quality-of-life scores, including the self-rating anxiety scale, self-rating depression scale, and Pittsburgh Sleep Quality Index.

RESULTS

The mean home BP decreased from 151.74 (SD 8.02)/94.22 (SD 9.32) to 126.19 (SD 8.45)/82.28 (SD 9.26) mm Hg in the multimodal intervention group and from 150.78 (SD 7.87)/91.53 (SD 9.78) to 133.48 (SD 10.86)/84.45 (SD 9.19) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -8.25 mm Hg (95% CI -11.71 to -4.78 mm Hg; P<.001) and -4.85 mm Hg (95% CI -8.41 to -1.30 mm Hg; P=.008), respectively. The mean office BP decreased from 153.64 (SD 8.39)/93.56 (SD 8.45) to 127.81 (SD 8.04)/ 82.16 (SD 8.06) mm Hg in the multimodal intervention group and from 151.48 (SD 7.14)/(91.31 (SD 9.61) to 134.92 (SD 10.11)/85.09 (SD 8.26) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -9.27 mm Hg (95% CI -12.62 to -5.91 mm Hg; P<.001) and -5.18 mm Hg (95% CI -8.47 to -1.89 mm Hg; P=.002), respectively. From baseline to 6 months, home BP control <140/90 mm Hg was achieved in 64 (72.7%) patients in the multimodal intervention group and 46 (52.9%) patients in the usual care group (P=.007). Meanwhile, home BP control <130/80 mm Hg was achieved in 32 (36.4%) patients in the multimodal intervention group and 16 (18.4%) patients in the usual care group (P=.008). After 6 months, there were significant differences in the quality-of-life total and graded scores, including self-rating anxiety scale scores (P=.04), self-rating depression scale scores (P=.03), and Pittsburgh Sleep Quality Index scores (P<.001), in the multimodal intervention group compared with the usual care group.

CONCLUSIONS

The WeChat-based multimodal intervention model improved the BP control rates and lowered the BP levels more than the usual care approach. The multimodal digital transforming management model for hypertension represents an emerging medical practice that utilizes the individual's various risk factor profiles for primary care and personalized therapy decision-making in patients with hypertension.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200063550; https://www.chictr.org.cn/showproj.html?proj=175816.

Home blood pressure-centered approach - from digital health to medical practice: HOPE Asia Network consensus statement 2023

Recent innovations in digital technology have enabled the simultaneous accumulation, and the linking and analysis of time-series big data relating to several factors that influence blood pressure (BP), including biological indicators, physical activity, and environmental information. Various approaches can be used to monitor BP: in the office/clinic; at home; 24-h ambulatory recording; or with wearable and cuffless devices. Of these, home BP monitoring is a reliable and convenient method, and is recommended for hypertension management by current national and international guidelines. This recommendation is based on evidence showing that home BP is an important predictor of cardiovascular, cerebrovascular and kidney disease in patients with hypertension. In addition, lifetime personalized health record (PHR)-based home BP with telemonitoring combined with co-interventions has been shown to lower BP more effectively than the traditional approach based on office BP. Thus, home BP represents a key metric for personalized anticipation medicine, from digital healthcare to digital medicine. This paper summarizes the latest evidence on home BP monitoring and proposes a Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network consensus on a home BP-centered approach to the management of hypertension.

Requirements for design and function of blood pressure measuring devices used for the management of hypertension: Consensus Statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and STRIDE BP

OBJECTIVE

To develop scientific consensus recommendations for the optimal design and functions of different types of blood pressure (BP) measuring devices used in clinical practice for the detection, management, and long-term follow-up of hypertension.

METHODS

A scientific consensus meeting was performed by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability and STRIDE BP (Science and Technology for Regional Innovation and Development in Europe) during the 2022 Scientific Meeting of the ESH in Athens, Greece. Manufacturers were also invited to provide their feedback on BP device design and development. Thirty-one international experts in clinical hypertension and BP monitoring contributed to the development of consensus recommendations on the optimal design of BP devices.

STATEMENT

International consensus was reached on the requirements for the design and features of five types of BP monitors, including office (or clinic) BP monitors, ambulatory BP monitors, home BP monitors, home BP telemonitors, and kiosk BP monitors for public spaces. For each device type "essential" requirements (must have), and "optional" ones (may have) are presented, as well as additional comments on the optimal device design and features.

CONCLUSIONS

These consensus recommendations aim at providing manufacturers of BP devices with the requirements that are considered mandatory, or optional, by clinical experts involved in the detection and management of hypertension. They are also directed to administrative healthcare personnel involved in the provision and purchase of BP devices so that they can recommend the most appropriate ones.

Digital hypertension towards to the anticipation medicine

"Digital Hypertension" is a new research field proposed by the Japanese Society of Hypertension that integrates digital technology into hypertension management and proactively promotes research activities. This novel approach includes the development of new technologies for better BP management, such as sensors for detecting environmental factors that affect BP, information processing, and machine learning. To facilitate "Digital Hypertension," a more sophisticated BP monitoring system capable of measuring an individual's BP more frequently in various situations would be required. With the use of these technologies, hypertension management could shift from the current "dots" management based on office BP readings during clinic visits to a "line" management system based on seamless home BP or individual BP data taken by a wearable BP monitoring device. DTx is the innovation to change hypertension management from "dots" to "line", completely achieved by wearable BP.

Achievement rate of target blood pressure in patients with hypertension treated by hypertension specialists and non-specialists in a real-world setting

Hypertension remains a major global healthcare issue. Considering that most Japanese patients with hypertension are managed by general practitioners, hypertension specialists should be involved in actual clinical practice. We investigated the blood pressure (BP), guidelines recommended for achievement rate of the target BP, and clinical variables of patients with hypertension treated by hypertension specialists and those treated by non-specialists in a real-world setting. Factors associated with the target BP achievement in this population were also investigated. Outpatients with hypertension from 12 medical facilities in Okinawa Prefecture were enrolled (n = 1469 [specialist group, 794; non-specialist group, 675]; mean age, 64.2 years; females, 45.8%). For all patients, BP and rate of the target BP achievement were 129.0 ± 15.5/74.6 ± 10.6 mmHg, and 51.8%, respectively. BP and the rate of target of BP achievement were 128.0 ± 15.1/73.4 ± 10.4 mmHg and 56.7% in the specialist group, and they were 130.1 ± 15.9/76.0 ± 10.8 mmHg and 46.1% in the non-specialist group. The urinary salt excretion and obesity rates were comparable between the specialist and non-specialist groups. Multivariable logistic analyses indicated that hypertension specialists and good medication adherence were positive factors, whereas obesity, chronic kidney disease, diabetes mellitus, and urinary salt excretion were inverse factors associated with target BP achievement in this population. Initiatives for salt reduction, medication adherence, and proper obesity management are crucial to improving BP management in patients with hypertension. Hypertension specialists are expected to play an essential role in them. For all patients, the target blood pressure (BP) achievement rate were 51.8%. Hypertension specialists and good medication adherence were positive factors in achieving target BP; conversely, obesity, diabetes mellitus, chronic kidney disease, and high urinary salt excretion were inverse factors in achieving target BP among patients with hypertension.

Different Home Blood Pressure Thresholds to Predict Perfect 24-Hour Ambulatory Blood Pressure Control in Treated Hypertension Based on an "All-in-One" Device

BACKGROUND

Home blood pressure (BP) is an important component of digital strategies for hypertension management. However, no studies have used the same device to investigate 24-hour BP control status in relation to different home BP control thresholds.

METHODS

Participants in the general practitioner-based, multicenter HI-JAMP study (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days. A validated all-in-one BP monitoring device was used to measure office, home, and ambulatory BP. Baseline data were used to investigate ambulatory BP control status in individuals with well-controlled home BP based on the different guideline thresholds (125/75 mm Hg, 130/80 mm Hg, and 135/85 mm Hg).

RESULTS

Data from 2269 patients were analyzed. For individuals with well-controlled home BP <135/85 mm Hg (59.5% of the total population), the prevalence of uncontrolled 24-hour (≥130/80 mm Hg), daytime (≥135/85 mm Hg), and nighttime ambulatory BP (≥120/70 mm Hg) was 19.9%, 18.5%, and 33.6%, respectively. Corresponding prevalence rates in the 42.7% of participants with well-controlled home BP <130/80 mm Hg were 13.4%, 12.9%, and 26.0%, and when well-controlled home BP was strictly defined as <125/75 mm Hg (23.9% of the population), prevalence of rates of uncontrolled 24-hour, daytime, and nighttime ambulatory BP were 7.0%, 9.0%, and 15.3%, respectively.

CONCLUSIONS

Home BP control status defined using different thresholds could predict 24-hour ambulatory BP control status in treated hypertension. One-third of individuals still had uncontrolled nocturnal hypertension when home BP was controlled to <135/85 mm Hg, but ambulatory BP was quite well controlled when home BP was <125/75 mm Hg.

Digital health, digital medicine, and digital therapeutics in cardiology: current evidence and future perspective in Japan

Ten years passed since Japan set out the Action Plan of Growth Strategy that declared the initiatives of digitalization for medicine, nursing care, and healthcare to achieve the world's most advanced medical care. The initiatives formed the foundation of the Japanese national strategy and have been continuously refined, resulting in the current environment of digital health and digital medicine. Digital health-related terminologies are organized, such as "digital health," "digital medicine," and "digital therapeutics" (DTx), as well as several common digital technologies, including artificial intelligence, machine learning, and mobile health (mHealth). DTx is included in mHealth and is a novel disease treatment option. Also, this article thoroughly describes DTx in Japan and compares it with those in the US and Germany, the leading countries in digital health-related policies, regulations, and their development status. In Japan, two of three DTx applications that have been approved and reimbursed by the Ministry of Health, Labor, and Welfare are explained in detail in relation to cardiovascular medicine. When added to a standard smoking cessation program, the DTx system for nicotine dependence significantly improved the continuous abstinence rate. Moreover, the DTx for hypertension together with the guideline-based hypertension management was effective in patients aged 65 years or younger who were diagnosed with essential hypertension without antihypertensive agents, and it was also found to be cost-effective. DTx in cardiovascular medicine, with consideration on safety, efficacy, and cost-effectiveness, could be widely used not only through basic experiments and clinical studies but also through social implementation.

Telemedicine and Digital Medicine in the Clinical Management of Hypertension and Hypertension-Related Cardiovascular Diseases: A Position Paper of the Italian Society of Arterial Hypertension (SIIA)

High blood pressure is the leading cause of death and disability globally and an important treatable risk factor for cardiovascular, cerebrovascular and chronic kidney diseases. Digital technology, including mobile health solutions and digital therapy, is expanding rapidly in clinical medicine and has the potential to improve the quality of care and effectiveness of drug treatment by making medical interventions timely, tailored to hypertensive patients' needs and by improving treatment adherence. Thus, the systematic application of digital technologies could support diagnosis and awareness of hypertension and its complications, ultimately leading to improved BP control at the population level. The progressive implementation of digital medicine in the national health systems must be accompanied by the supervision and guidance of health authorities and scientific societies to ensure the correct use of these new technologies with consequent maximization of the potential benefits. The role of scientific societies in relation to the rapid adoption of digital technologies, therefore, should encompass the entire spectrum of activities pertaining to their institutional role: information, training, promotion of research, scientific collaboration and advice, evaluation and validation of technological tools, and collaboration with regulatory and health authorities.

Real-World Evidence of a Hospital-Linked Digital Health App for the Control of Hypertension and Diabetes Mellitus in South Korea: Nationwide Multicenter Study

BACKGROUND

Digital health care apps have been widely used for managing chronic conditions such as diabetes mellitus and hypertension, providing promising prospects for enhanced health care delivery, increased patient engagement, and improved self-management. However, the impact of integrating these apps within hospital systems for managing such conditions still lacks conclusive evidence.

OBJECTIVE

We aimed to investigate the real-world effectiveness of using hospital-linked digital health care apps in lowering blood pressure (BP) and blood glucose levels in patients with hypertension and diabetes mellitus.

METHODS

Nationwide multicenter data on demographic characteristics and the use of a digital health care app from 233 hospitals were collected for participants aged 20 to 80 years in South Korea between August 2021 and June 2022. We divided the participants into 2 groups: 1 group consisted of individuals who exclusively used the digital health app (control) and the other group used the hospital-linked digital health app. All the patients participated in a 12-week digital health care intervention. We conducted a comparative analysis to assess the real-world effectiveness of the hospital-linked digital health app. The primary outcome was the differences in the systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG) level, and postprandial glucose (PPG) level between baseline and 12 weeks.

RESULTS

A total of 1029 participants were analyzed for the FBG level, 527 participants were analyzed for the PPG level, and 2029 participants for the SBP and DBP were enrolled. After 12 weeks, a hospital-linked digital health app was found to reduce SBP (-5.4 mm Hg, 95% CI -7.0 to -3.9) and DBP (-2.4 mm Hg, 95% CI -3.4 to -1.4) in participants without hypertension and FBG level in all participants (those without diabetes, -4.4 mg/dL, 95% CI -7.9 to -1.0 and those with diabetes, -3.2 mg/dL, 95% CI -5.4 to -1.0); however, there was no statistically significant difference compared to the control group (using only digital health app). Specifically, participants with diabetes using a hospital-linked digital health app demonstrated a significant decrease in PPG after 12 weeks (-10.9 mg/dL, 95% CI -31.1 to -5.3) compared to those using only a digital health app (P=.006).

CONCLUSIONS

Hospital-linked digital interventions have greatly improved glucose control for diabetes compared with using digital health technology only. These hospital-linked digital health apps have the potential to offer consumers and health care professionals cost-effective support in decreasing glucose levels when used in conjunction with self-monitoring.

Impact of a Novel Digital Therapeutics System on Nonalcoholic Steatohepatitis: The NASH App Clinical Trial

INTRODUCTION

Management of nonalcoholic steatohepatitis (NASH) is a currently unmet clinical need. Digital therapeutics (DTx) is an emerging class of medicine that delivers evidence-based therapeutic interventions. This study was aimed at investigating the efficacy of DTx in patients with NASH.

METHODS

We conducted a multicenter, single-arm, 48-week trial in 19 patients with biopsy-confirmed NASH. All patients received a DTx intervention with a newly developed smartphone application. The primary endpoint was change in the nonalcoholic fatty liver disease activity score (NAS) without worsening of liver fibrosis. The secondary endpoints included improvement of the NAS by ≥2 points without worsening of liver fibrosis, change in the body weight, and regression of fibrosis.

RESULTS

After the 48-week DTx intervention, improvement of the NAS was observed in 68.4% (13/19) of patients. The mean change in the NAS from baseline to the end of the intervention was -2.05 ± 1.96 ( P < 0.001 when compared with the threshold of -0.7). A decrease in the NAS by ≥ 2 points was achieved in 11 (57.9%). The average weight loss at the end of the intervention was 8.3% ( P < 0.001). Reduction of the fibrosis stage was observed in 58.3% when the analysis was limited to patients with stage F2/3 fibrosis. There were no serious adverse events that could be considered as being related to the DTx intervention.

DISCUSSION

DTx for NASH was found to be highly efficacious and well-tolerated. Further evaluation of the DTx intervention for NASH in a phase 3 trial is warranted.

Digital therapeutics in the clinic

Digital therapeutics are emerging as a new form of therapeutic interventions. Unlike conventional therapeutics, digital therapeutics deliver interventions directly to patients using an evidence-based, clinically evaluated software to treat, manage, or prevent diseases. Digital therapeutics manifest in diverse forms such as web-based applications, mobile applications on smart devices, virtual reality, and video games. As its own product category for FDA approval, digital therapeutics can function as stand-alone treatments or in combination with conventional therapeutics to improve adherence and/or efficacy. Here, we review the clinical landscape of digital therapeutics. We summarize FDA-approved products and their clinical use, overview >300 ongoing clinical trials, and discuss challenges for their clinical translation and strategies to overcome the same.

Blood pressure dynamics during home blood pressure monitoring with a digital blood pressure coach—a prospective analysis of individual user data

Introduction

Self-monitoring of blood pressure at home is a better predictor of prognosis and recommended in hypertension guidelines. However, the influence of baseline blood pressure category and measurement schedule on BP values during a period of home blood pressure monitoring (HBPM) are still poorly defined, particularly when used in conjunction with a digital application.

Methods

We analysed temporal BP changes and performed BP classification tracking in users with self-reported hypertension performing HBPM with a digital and interactive blood pressure coach.

Results

Of 3175 users who enrolled in HBPM, 74.1% completed the first measurement period. Overall, mean systolic BP dropped significantly after the first day, but stratification by BP category demonstrated that initial category influenced BP course. BP classification tracking revealed that time to reach final BP category was dependent on baseline category, with users in categories high normal and grade 1 hypertension requiring more days to decrease BP class volatility and to reach their definitive BP class. This was driven by an intense switching between directly neighbouring categories until the middle phase of the HBPM period, while more distant class switching occurred less often and only early on. Overall, &gt;90% of users maintained their category by day 5. Omitting the first day from analysis lead to therapeutically relevant reclassification in 3.8% of users. Users who completed at least two HBPM periods (n = 864) showed a mean SBP/DBP decrease of 2.6/1.6 mmHg, which improved hypertension control from 55.6% to 68.1%.

Conclusion

The optimal length of HBPM period depends on BP category. HBPM with a digital coach is associated with a reduction in average BP and improvement in BP control.