Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies

Enhancing cardiac postoperative care: a smartwatch-integrated remote telemonitoring platform for health screening with ECG analysis

Aims

The integration of smartwatches into postoperative cardiac care transforms patient monitoring, systematically tracking vital signs and delivering real-time data to a centralized platform. This study focuses on developing a platform for seamless integration, assessing reliability, and evaluating the impact on post-cardiac surgery. The goal is to establish a robust foundation for understanding the efficacy and dependability of smartwatch-based telemonitoring, enhancing care for this population.

Methods and results

A total of 108 cardiac surgery patients were divided into telemonitoring (TLM) and control (CTL) groups. The TLM group utilized smartwatches for continuous monitoring of vital parameters (SpO2, HR, BP, ECG) over 30 ± 3 days. Statistical analyses (Pearson, Intraclass Correlation, Bland-Altman, Tost Test) were employed to compare smartwatch measurements with traditional methods. Significant correlations and concordance were observed, particularly in HR and BP measurements. Challenges were noted in SpO2 measurement. The ECG algorithm exhibited substantial agreement with cardiologists (Kappa: 0.794; p > 0.001), highlighting its reliability. The telemonitoring platform played a crucial role in early detection of clinical changes, including prompt Emergency Department (ED) visits, contributing significantly to preventing outcomes that could lead to mortality, such as asymptomatic Atrioventricular block. Positive patient responses affirmed technological efficacy, especially in identifying cardiac arrhythmias like atrial fibrillation.

Conclusion

The integration of smartwatches into remote telemonitoring for postoperative cardiac care demonstrates substantial potential, improving monitoring and early complication detection, thereby enhancing patient outcomes. The FAPO-X Study (Assisted Digital Telemonitoring with Wearables in Patients After Cardiovascular Surgery; NCT05966857) underscores the promising role of telemonitoring in postoperative cardiac care.

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.

Nurse-led digital health program for home blood pressure monitoring in stroke patients: protocol for a pooled analysis of randomized controlled trials

Background

Hypertension is a major risk factor for stroke recurrence in stroke patients. Home blood pressure monitoring, facilitated by digital health technologies and led by nurses, may improve blood pressure control in this high-risk population. However, the evidence is not yet conclusive. This study protocol outlines a pooled analysis of the current literatures to evaluate the effectiveness of nurse-led digital health programs for home blood pressure monitoring in stroke patients.

Methods and analysis

We will conduct a comprehensive search of some major electronic databases (e.g., PubMed, EMBASE, Cochrane Library, and CINAHL) and trial registries for randomized controlled trials evaluating nurse-led digital health programs for home blood pressure monitoring in stroke patients. Two reviewers will independently screen titles and abstracts, review full-text articles, extract data, and assess risk of bias using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2.0). The primary outcome measures will be changes in both systolic and diastolic blood pressure from baseline to the end of the intervention period. Secondary outcomes include adherence to the program, patient satisfaction, and stroke recurrence. Data will be pooled and analyzed using meta-analysis techniques, if appropriate.

Discussion

This study will provide comprehensive evidence on the effectiveness of nurse-led digital health programs for home blood pressure monitoring in stroke patients. The findings could have substantial implications for clinical practice and health policy, potentially informing the development of guidelines and policies related to hypertension management and stroke prevention.

Conclusion

By pooling the results of randomized controlled trials, this study will offer a robust evidence base to inform clinical practice and health policy in the context of stroke patients. Despite potential limitations such as heterogeneity among studies and risk of publication bias, the rigorous methodology and comprehensive approach to data synthesis will ensure the reliability and validity of the findings. The results will be disseminated through a peer-reviewed publication and potentially at relevant conferences.

Registration DOI

https://doi.org/10.17605/OSF.IO/59XQA.

Update of the clinical guideline for hypertension diagnosis and treatment in Iran

BACKGROUND

This article introduces the updated version of the Iranian guideline for the diagnosis and treatment of hypertension in adults. The initial version of the national guideline was developed in 2011 and updated in 2014. Among the reasons necessitating the update of this guideline were the passage of time, the incompleteness of the scopes, the limitation of the target group, and more important is the request of the ministry of health in Iran.

METHOD

The members of the guideline updating group, after reviewing the original version and the new evidence, prepared 10 clinical questions regarding hypertension, and based on the evidence found from the latest scientific documents, provided recommendations or suggestions to answer these questions.

RESULT

According to the updated guideline, the threshold for office prehypertension diagnosis should be considered the systolic blood pressure (SBP) of 130-139 mmHg and/or the diastolic blood pressure (DBP) of 80-89 mmHg, and in adults under 75 years of age without comorbidities, the threshold for office hypertension diagnosis should be SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg. The goal of treatment in adults who lack comorbidities and risk factors is SBP < 140 mmHg and DBP < 90 mmHg. The first-line treatment recommended in people with prehypertension is lifestyle modification, while for those with hypertension, pharmacotherapy along with lifestyle modification. The threshold to start drug therapy is determined at SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg, and the first-line treatment is considered a drug or a combined pill of antihypertensive drugs, including ACEIs, ARBs, thiazide and thiazide-like agents, or CCBs. At the beginning of the pharmacotherapy, the Guideline Updating Group members suggested studying serum electrolytes, creatinine, lipid profile, fasting sugar, urinalysis, and an electrocardiogram. Regarding the visit intervals, monthly visits are suggested at the beginning of the treatment or in case of any change in the type or dosage of the drug until achieving the treatment goal, followed by every 3-to-6-month visits. Moreover, to reduce further complications, it was suggested that healthcare unit employees use telehealth strategies.

CONCLUSIONS

In this guideline, specific recommendations and suggestions have been presented for adults and subgroups like older people or those with cardiovascular disease, diabetes mellitus, chronic kidney disease, and COVID-19.

Telemedicine and patients with heart failure: evidence and unresolved issues

BACKGROUND

Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.

The Role of Telemedicine in Enhancing Chronic Kidney Disease (CKD) Management and Dialysis Care

Telemedicine has emerged as a transformative solution in the realm of healthcare, particularly in addressing the complexities and challenges associated with chronic kidney disease (CKD) and dialysis care. This editorial explores the potential of telemedicine in revolutionizing the management and treatment of kidney diseases, highlighting its role in mitigating the burdens faced by healthcare systems worldwide. With the advent of high-quality audio and visual platforms, telemedicine has facilitated remote healthcare delivery, enabling healthcare professionals to provide exceptional care from a distance. This is particularly relevant in the context of CKD and end-stage kidney disease (ESKD) patients, where the need for continuous care and monitoring is critical. This editorial underscored the escalating incidence of ESKD, driven by prevalent risk factors, such as diabetes, hypertension, and obesity, and the disparities in access to treatments among different populations. The integration of telemedicine in CKD and dialysis care presents a pathway toward a more accessible, efficient, and cost-effective healthcare delivery. It offers numerous benefits, including the convenience of remote monitoring, enhanced patient compliance, reduced healthcare costs, and improved patient satisfaction and quality of life. Telemedicine facilitates a multidisciplinary approach to care, allowing for timely intervention and follow-ups, which are crucial for patients undergoing dialysis. Moreover, the COVID-19 pandemic has accelerated the adoption of telemedicine, showcasing its effectiveness in maintaining continuity of care amid restrictions on patient contact. Despite its promising potential, its implementation of telemedicine faces several challenges, including regulatory hurdles, concerns about the security of medical information, and the adequacy of virtual platforms to capture crucial health indicators. In addition, the financial implications of telemedicine and its long-term sustainability remain areas requiring further investigation. In conclusion, telemedicine holds significant promise in enhancing the care and management of CKD and dialysis patients. It offers a vital solution to overcome the geographical barrier, improve access to care, and alleviate the strain on healthcare systems. However, further research is needed to fully understand its benefits compared to traditional care models and to address the challenges associated with implementation. The expansion of telemedicine in kidney care signifies a step toward a more inclusive, efficient, and patient-centered healthcare future.

Blood pressure outcomes at 18 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

This pragmatic matched cohort study using EHR data extended the follow up to 18 months for BP outcomes comparing individuals prescribed remote patient monitoring (n = 288) and temporally-matched controls (n = 1152) from six primary care practices. After 18 months, the RPM-prescribed cohort had greater BP control < 140/90 mm Hg (RPM cohort: 71.5%, control cohort: 51.9%, p < 0.001) and lower systolic BP (131.6 versus 136.0 mm Hg, p = 0.004) using office and home measurements. BP control at 18 months assessed by office measurements only was also higher in the RPM group (62.2% versus 51.9%, p = 0.004).

Digital Health in Diabetes and Cardiovascular Disease

BACKGROUND

Digital health technologies are rapidly evolving and transforming the care of diabetes and cardiovascular disease (CVD).

PURPOSE OF THE REVIEW

In this review, we discuss emerging approaches incorporating digital health technologies to improve patient outcomes through a more continuous, accessible, proactive, and patient-centered approach. We discuss various mechanisms of potential benefit ranging from early detection to enhanced physiologic monitoring over time to helping shape important management decisions and engaging patients in their care. Furthermore, we discuss the potential for better individualization of management, which is particularly important in diseases with heterogeneous and complex manifestations, such as diabetes and cardiovascular disease. This narrative review explores ways to leverage digital health technology to better extend the reach of clinicians beyond the physical hospital and clinic spaces to address disparities in the diagnosis, treatment, and prevention of diabetes and cardiovascular disease.

CONCLUSION

We are at the early stages of the shift to digital medicine, which holds substantial promise not only to improve patient outcomes but also to lower the costs of care. The review concludes by recognizing the challenges and limitations that need to be addressed for optimal implementation and impact. We present recommendations on how to navigate these challenges as well as goals and opportunities in utilizing digital health technology in the management of diabetes and prevention of adverse cardiovascular outcomes.

Agreement and Reliability of Patient-measured Postvoid Residual Bladder Volumes

OBJECTIVE

To assess the reliability, agreement with provider measurement, and patient preferences regarding patient self-measurement of postvoid residual bladder volume (PVR). PVR measurement in the nonhealthcare setting is a valuable opportunity for remote monitoring of voiding dysfunction patients. We hypothesized that patient self-measurement of PVR using a smart-device portable ultrasound system with artificial intelligence would demonstrate high reliability, strong agreement with provider measurement, and be preferred over provider measurements.

METHODS

Patients were enrolled during outpatient Urology visits. PVRs were measured in triplicate by providers using each of the following: an FDA-cleared (standard) bladder scanner, the portable ultrasound probe using ultrasound images (Butterfly US image mode), and the portable ultrasound probe using abstract images (Butterfly abstract mode). Subjects self-measured PVRs in triplicate using both imaging modes and reported their experiences via questionnaire. Reliability was assessed via intraclass correlation. Agreement between methods was assessed via Bland-Altman analyses using a clinically acceptable difference threshold of 50 mL.

RESULTS

Fifty patients were enrolled. Intraclass correlations ranged from 0.95 to 0.98 for each method. 95% limits of agreement between standard bladder scanner and patient self-measurement were - 71.73 mL and 86.73 mL using Butterfly US image mode and - 93.84 mL and 112.52 mL using Butterfly abstract mode, respectively. Most patients preferred self-measurement over provider measurement (74% vs 26%, respectively).

CONCLUSION

Patient self-measurement of PVR using smart-device integrated portable ultrasound probes is feasible, reliable, and preferred by patients. Limits of agreement between patient self-measurement and standard bladder scanner measurements exceeded our clinically acceptable difference threshold, though the inherent error of ultrasound-based bladder volume measurements should be considered. Longitudinal PVR assessments in nonhealthcare settings may facilitate remote monitoring of voiding dysfunction patients.

Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study

BACKGROUND

Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home.

OBJECTIVE

Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED.

METHODS

Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months.

RESULTS

A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use.

CONCLUSIONS

HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of technology-enabled blood pressure monitoring in primary care: A quasi-experimental trial

INTRODUCTION

Technology to enhance hypertension management is increasingly used in primary care; however, it has not been evaluated in an Asian primary care setting. We aimed to understand the clinical impact and cost-effectiveness of a technology-enabled home blood pressure monitor when deployed in primary care, and patients' perspectives about the technology.

METHODS

A quasi-experimental cohort study was conducted in a polyclinic in Singapore. In total, 120 patients with hypertension were assigned to the telemonitoring intervention group. Patients received a home blood pressure device connected to the clinical care team's dashboard through a mobile gateway. Tele-consultations and nurse-led tele-support were carried out using established clinical protocols. In total, 120 patients assigned to the control group continued to receive usual care in the polyclinic. Clinical outcomes, cost-effectiveness, and patient satisfaction were measured 6 months after recruitment.

RESULTS

In total, 217 patients completed 6 months of follow-up. Telemonitoring intervention patients had significantly increased odds of having controlled blood pressure by a factor of 2.69 (p = 0.01), with the greatest improvement in those whose blood pressure was uncontrolled at baseline (p < 0.05). The incremental cost-effectiveness ratios for all patients was S$23,935.14/quality-adjusted life year (<1 gross domestic product per capita), which was very cost-effective based on World Health Organization cost-effectiveness thresholds. There was greater satisfaction in telemonitoring intervention group relating to the convenience of recording and sharing blood pressure measurements with the health care team, consultation advice received, understanding by the health care team of their condition, and were more motivated to monitor their blood pressure.

DISCUSSION

Telemonitoring with tele-consultation improved blood pressure control and was more cost-effective than usual care. Patients receiving telemonitoring intervention were also more motivated and satisfied with their care.

Blood pressure outcomes at 12 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

Remote patient monitoring (RPM) for hypertension enables automatic transmission of blood pressure (BP) and pulse into the electronic health record (EHR), but its effectiveness in primary care is unknown. This pragmatic matched cohort study using EHR data compared BP outcomes between individuals prescribed RPM and temporally-matched controls from six primary care practices. We retrospectively created a cohort of 288 Medicare-enrolled patients prescribed BP RPM (cases) and 1152 propensity score-matched controls (1:4). Matching was based on age, sex, systolic blood pressure (SBP), marital status, and other characteristics. Outcomes at 3, 6, 9 and 12 months were: controlling high BP (most recent BP < 140/90 mm Hg), antihypertensive medication intensification, and most recent SBP assessed using: all measurements, and office measurements only. At baseline, RPM-prescribed patients and controls had similar ages and systolic BP. BP control diverged at 3 months (RPM: 72.2%, control: 51%, p < 0.001). This difference persisted but decreased over follow-up. After 12 months, the RPM-prescribed cohort had greater BP control (RPM: 71.5%, control: 58.1%, p < 0.001) and lower SBP (132.3 versus 136.5 mm Hg, p = 0.003) using all measurements, but they did not differ using only office measurements (12 month BP control: 60.8% versus 58.1%, p = 0.44; SBP: 135.9 versus 136.5 mm Hg, p = 0.91). At 12 months, the most recent BP measurements were more current for RPM-prescribed patients (median [IQR] 8 [0-109] versus 134 [56-239] days). Net increases in antihypertensive medications by 12 months were similar. Implementation of RPM in primary care could inform hypertension management strategies and increase hypertension control. Registration: ClinicalTrials.gov identifier: NCT05562921.

Economic Evaluation of Blood Pressure Monitoring Techniques in Patients With Hypertension: A Systematic Review

Importance

Blood pressure monitoring is critical to the timely diagnosis and treatment of hypertension. At-home self-monitoring techniques are highly effective in managing high blood pressure; however, evidence regarding the cost-effectiveness of at-home self-monitoring compared with traditional monitoring in clinical settings remains unclear.

Objective

To identify and synthesize published research examining the cost-effectiveness of at-home blood pressure self-monitoring relative to monitoring in a clinical setting among patients with hypertension.

Evidence Review

A systematic literature search of 5 databases (PubMed, MEDLINE, Embase, EconLit, and CINAHL) followed by a backward citation search was conducted in September 2022. Full-text, peer-reviewed articles in English including patients with high blood pressure (systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg) at baseline were included. Data from studies comparing at-home self-monitoring with clinical-setting monitoring alternatives were extracted, and the outcomes of interest included incremental cost-effectiveness and cost-utility ratios. Non-peer-reviewed studies or studies with pregnant women and children were excluded. To ensure accuracy and reliability, 2 authors independently evaluated all articles for eligibility and extracted relevant data from the selected articles.

Findings

Of 1607 articles identified from 5 databases, 16 studies met the inclusion criteria. Most studies were conducted in the US (6 [40%]) and in the UK (6 [40%]), and almost all studies (14 [90%]) used a health care insurance system perspective to determine costs. Nearly half the studies used quality-adjusted life-years gained and cost per 1-mm Hg reduction in blood pressure as outcomes. Overall, at-home blood pressure monitoring (HBPM) was found to be more cost-effective than monitoring in a clinical setting, particularly over a minimum 10-year time horizon. Among studies comparing HBPM alone vs 24-hour ambulatory blood pressure monitoring (ABPM) or HBPM combined with additional support or team-based care, the latter were found to be more cost-effective.

Conclusions and Relevance

In this systematic review, at-home blood pressure self-monitoring, particularly using automatic 24-hour continuous blood pressure measurements or combined with additional support or team-based care, demonstrated the potential to be cost-effective long-term compared with care in the physical clinical setting and could thus be prioritized for patients with hypertension from a cost-effectiveness standpoint.

Digital hypertension management: clinical and cost outcomes of a pilot implementation of the OMRON hypertension management platform

Importance

Home monitoring of blood pressure (BP) in hypertensive patients can improve outcomes, but challenges to both patient compliance and the effective transmission of home BP readings to physicians can limit the extent to which physicians can use this information to improve care. The OMRON Hypertension Management Platform (OMRON HMP) pairs a home BP cuff with a digital product that tracks data, provides reminders to improve patient compliance, and provides a streamlined source of information to physicians.

Objective

The primary objective of the quality improvement (QI) project was to test the hypothesis that use of the OMRON HMP could reduce the number and cost of hypertension related claims, relative to a retrospectively matched cohort of insured members. A secondary objective was to demonstrate improvement in control of BP among patients.

Design

Eligible members were recruited to the QI project between December 1, 2018 and December 30, 2020 and data collected for six months following recruitment. All members received the OMRON HMP intervention.

Setting

Enrollment and data collection were coordinated on-site at selected PCP partner providers in Western Pennsylvania. Eligible members were identified from insurance claims data as those receiving care for primary hypertension from participating primary care physicians and/or cardiologists.

Participants

Eligible members were between the ages of 35 and 85, with a diagnosis of primary hypertension. The retrospective cohort was selected from electronic medical records of Highmark-insured patients with hypertension who received care at Allegheny Health Network (AHN), a subsidiary of Highmark Health. Members were matched on baseline BP and lipid measures, age, smoking status, diabetes status, race and sex.

Intervention

Daily home BP readings were recorded by the OMRON HMP app. Patient data was reviewed by clinical staff on a weekly basis and treatment plans could be adjusted in response to this data.

Results

OMRON HMP users showed a significant increase in the number and cost of hypertension-related claims, contrary to the hypothesis, but did display improvements in control of BP.

Conclusions and Relevance

The use of a digital platform to facilitate at-home BP monitoring appeared to improve BP control but led to increased hypertension-related costs in the short-term.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

Home versus Clinic Blood Pressure Monitoring: Evaluating Applicability in Hypertension Management via Telemedicine

Hypertension is a significant public health concern in Saudi Arabia, affecting 28.6% of the population. Despite the availability of effective treatments, optimal blood pressure control is not always achieved, highlighting the need for effective management strategies. This study aimed to evaluate the applicability of home, compared to clinic, blood pressure measurements for managing hypertension in the Qassim region of Saudi Arabia. The study included 85 adults undergoing antihypertensive treatment. Home blood pressure measurements were obtained during the day and the evening using automated oscillometric sphygmomanometers, whereas clinic measurements were taken during clinic hours. Home blood pressure readings were significantly lower than clinic blood pressure readings, with mean differences of 20.4 mmHg and 4.1 mmHg for systolic and diastolic blood pressures, respectively. There was a positive correlation between the clinic systolic and diastolic blood pressures (r = 0.549, p < 0.001) and a weak correlation between the daytime home and clinic systolic blood pressures (r = 0.218, p < 0.05). This study provides insight into the applicability of home blood pressure monitoring, which may aid in the development of more effective hypertension management strategies, particularly the use of morning home blood pressure monitoring to aid treatment decisions through telehealth medicine.

Determining Optimal Intervals for In-Person Visits during Video-based Telemedicine in Patients with Hypertension: A Cluster Randomized Controlled Trial

BACKGROUND

Introducing telemedicine in outpatient treatment may improve patient satisfaction and convenience. However, the optimal in-person visit interval for video-based telemedicine in patients with hypertension remains unreported in Japan.

OBJECTIVE

We determined the optimal in-person visit interval for video-based telemedicine in patients with hypertension.

METHODS

Design: This was a cluster randomized controlled noninferiority trial. Participants: The target sites were eight clinics in Japan that had a telemedicine system, and the target patients were individuals with essential hypertension. Among patients receiving video-based telemedicine, those who underwent in-person visits at 6-month intervals were included in the intervention group, and those who underwent in-person visits at 3-month intervals were included in the control group. Main Measures: The follow-up period of the participants was 6 months. The primary endpoint of the study was the change in systolic blood pressure, and the secondary endpoints were the rate of treatment continuation after 6 months, patient satisfaction, health economic evaluation, and safety evaluation.

RESULTS

Overall, 64 patients were enrolled. Their mean age was 54.5 ± 10.3 years, and 39 (60.9%) patients were males. For the primary endpoint, the estimated difference in the change in systolic blood pressure between the two groups was 1.18 (90% confidence interval: -3.68 to 6.04). Notably, the criteria for noninferiority were met. Patient satisfaction was higher in the intervention group than in the control group. Furthermore, the indirect costs indicated that lost productivity was significantly less in the intervention group than in the control group. Moreover, the treatment continuation rate did not differ between the intervention and control groups, and there were no adverse events in either group.

CONCLUSIONS

Blood pressure control status and safety did not differ between the intervention and control groups. In-person visits at 6-month intervals may cause a societal cost reduction and improve patient satisfaction during video-based telemedicine.

CLINICALTRIAL

UMIN000040953.

Prospective Cohort Study of Remote Patient Monitoring with and without Care Coordination for Hypertension in Primary Care

BACKGROUND

Out-of-office blood pressure (BP) measurements contribute valuable information for guiding clinical management of hypertension. Measurements from home devices can be directly transmitted to patients' electronic health record for use in remote monitoring programs.

OBJECTIVE

This study aimed to compare in primary care practice care coordinator-assisted implementation of remote patient monitoring (RPM) for hypertension to RPM implementation alone and to usual care.

METHODS

This was a pragmatic observational cohort study. Patients aged 65 to 85 years with Medicare insurance from two populations were included: those with uncontrolled hypertension and a general hypertension group seeing primary care physicians (PCPs) within one health system. Exposures were clinic-level availability of RPM plus care coordination, RPM alone, or usual care. At two clinics (13 PCPs), nurse care coordinators with PCP approval offered RPM to patients with uncontrolled office BP and assisted with initiation. At two clinics (39 PCPs), RPM was at PCPs' discretion. Twenty clinics continued usual care. Main measures were controlling high BP (<140/90 mm Hg), last office systolic blood pressure (SBP), and proportion with antihypertensive medication intensification.

RESULTS

Among the Medicare cohorts with uncontrolled hypertension, 16.7% (39/234) of patients from the care coordination clinics were prescribed RPM versus <1% (4/600) at noncare coordination sites. RPM-enrolled care coordination group patients had higher baseline SBP than the noncare coordination group (148.8 vs. 140.0 mm Hg). After 6 months, in the uncontrolled hypertension cohorts the prevalences of controlling high BP were 32.5% (RPM with care coordination), 30.7 % (RPM alone), and 27.1% (usual care); multivariable adjusted odds ratios (95% confidence interval) were 1.63 (1.12-2.39; p = 0.011) and 1.29 (0.98-1.69; p = 0.068) compared with usual care, respectively.

CONCLUSION

Care coordination facilitated RPM enrollment among poorly controlled hypertension patients and may improve hypertension control in primary care among Medicare patients.

Hypertension management before and under the COVID-19 pandemic: lessons and future directions

Hypertension is a significant risk factor for cardiovascular diseases. The prevalence of hypertension and its complications is increasing yearly, yet it remains inadequately controlled worldwide. It has already been recognized that self-management, including self-measured blood pressure monitoring at home, is more important than office blood pressure monitoring. The practical application of telemedicine using digital technology was already underway. COVID-19 has promoted the popularization of these management systems in primary care, although the COVID-19 pandemic disrupted lifestyle and healthcare access. At the beginning of the pandemic, we were at the mercy of information on whether certain antihypertensive drugs, for example, might pose a risk of infection in the face of unknown infectious diseases. Over the past three years, however, much knowledge has been accumulated. It has been scientifically proven that there is no serious problem in managing hypertension in the same way as before the pandemic. That is to control blood pressure mainly through home blood pressure monitoring and continuing conventional drug therapy while modifying lifestyle. On the other hand, in the New Normal era, it is necessary to accelerate digital hypertension management and the establishment of new social networks and medical systems to prepare for the re-emergence of future pandemics while continuing to protect against infection. This review will summarize the lessons and future directions we learned from the impact of the COVID-19 pandemic on hypertension management. The COVID-19 pandemic has disrupted our daily life, restricted access to healthcare, and altered some of the conventional management of hypertension.

Current situation of telemedicine research for cardiovascular risk in Japan

Hypertension continues to be a principal risk factor for the occurrence of cardiovascular disorders, stroke, and kidney diseases. Although more than 40 million subjects suffer from hypertension in Japan, its optimal control is achieved only a subpopulation of patients, highlighting the need for novel approaches to manage this disorder. Toward the better control of blood pressure, the Japanese Society of Hypertension has developed the Future Plan, in which the application of the state-of-art information and communication technology, including web-based resources, artificial intelligence, and big data analysis, is considered as one of the promising solutions. In fact, the rapid advance of digital health technologies, as well as ongoing coronavirus disease 2019 pandemic, has triggered the structural changes in the healthcare system globally, increasing demand for the remote delivery of the medical services. Nonetheless, it is not entirely clear what evidence exists that support the widespread use of telemedicine in Japan. Here, we summarize the current status of telemedicine research, particularly in the field of hypertension and other cardiovascular risk factors. We note that there have been very few interventional studies in Japan that clearly showed the superiority or noninferiority of telemedicine over standard care, and that the methods of online consultation considerably varied among studies. Clearly, more evidence is necessary for wide implementation of telemedicine in hypertensive patients in Japan, and also those with other cardiovascular risk factors.

Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan

Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.

Role of home blood pressure monitoring in resistant hypertension

The definition of resistant hypertension (RHT) has been updated to include failure to achieve target blood pressure (BP) despite treatment with ≥3 antihypertensive drugs, including diuretics, renin-angiotensin system blockers, and calcium channel blockers, prescribed at the maximum or maximally tolerated doses, or as success in achieving the target blood pressure but requiring ≥4 drugs. RHT is a major clinical problem, as it is associated with higher mortality and morbidity than non-RHT. Therefore, it is crucial to accurately identify RHT patients to effectively manage their disease. Out-of-clinic BP measurement, including home BP monitoring and ambulatory BP monitoring is gaining prominence for the diagnosis and management of RHT. Home BP monitoring is advantageous as it is feasibly repetitive, inexpensive, widely available, and because of its reproducibility over long periods. In addition, home BP monitoring has crucial advantage of allowing safe titration for the maximum or maximally tolerable dose, and for self-monitoring, thereby improving clinical inertia and nonadherence, and allowing true RHT to be more accurately identified.

New perspectives for hypertension management: progress in methodological and technological developments

Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD), accounting for 20% of deaths worldwide. However, 2/3 of people with hypertension are undiagnosed, untreated, or under treated. A multi-pronged approach is needed to improve hypertension management. Elevated blood pressure (BP) in childhood is a predictor of hypertension and CVD in adulthood; therefore, screening and education programmes should start early and continue throughout the lifespan. Home BP monitoring can be used to engage patients and improve BP control rates. Progress in imaging technology allows for the detection of preclinical disease, which may help identify patients who are at greatest risk of CV events. There is a need to optimize the use of current BP control strategies including lifestyle modifications, antihypertensive agents, and devices. Reducing the complexity of pharmacological therapy using single-pill combinations can improve patient adherence and BP control and may reduce physician inertia. Other strategies that can improve patient adherence include education and reassurance to address misconceptions, engaging patients in management decisions, and using digital tools. Strategies to improve physician therapeutic inertia, such as reminders, education, physician-peer visits, and task-sharing may improve BP control rates. Digital health technologies, such as telemonitoring, wearables, and other mobile health platforms, are becoming frequently adopted tools in hypertension management, particularly those that have undergone regulatory approval. Finally, to fight the consequences of hypertension on a global scale, healthcare system approaches to cardiovascular risk factor management are needed. Government policies should promote routine BP screening, salt-, sugar-, and alcohol reduction programmes, encourage physical activity, and target obesity control.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effect of a Multicomponent Intervention Delivered on a Web-Based Platform on Hypertension Control: A Cluster Randomized Clinical Trial

IMPORTANCE

The prevalence of hypertension is high and still increasing across the world, while the control rate remains low in many countries. Emerging technology, such as telemedicine, may offer additional support to change the unsatisfactory situation.

OBJECTIVE

To establish a multicomponent intervention delivered on a web-based telemedicine platform and oriented with the Chinese hypertension management guidelines and to evaluate the effect of the intervention on blood pressure (BP) control for patients with hypertension.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial of a hypertension management program was conducted at 66 community health centers in China from October 1, 2018, to May 31, 2020, with a 12-month follow-up. Patients with hypertension were blinded to randomization and were randomized to either the intervention group or control group. Hypertension was diagnosed at mean systolic BP (SBP) and diastolic BP (DBP) readings higher than 140 and 90 mm Hg or with use of antihypertensive medication. Evaluation of the intervention effect was based on the principle of modified intention to treat.

INTERVENTIONS

Multicomponent intervention was delivered on a web-based platform and consisted of a primary prevention program for cardiovascular disease and standardized management for hypertension.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in BP control rate (SBP and DBP levels <140 and 90 mm Hg, or <130 and 80 mm Hg for patients with diabetes) from baseline to the 12-month follow-up among patients with hypertension in the intervention and control groups.

RESULTS

A total of 4118 patients (mean [SD] age, 61.6 [9.4] years; 2265 women [55.0%]) were included in the analysis, with 2985 in the intervention group and 1133 in the control group. The BP control rate at baseline was 22.8% in the intervention group and 22.5% in the control group. After 12 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (47.4% vs 30.2%; odds ratio, 1.18; 95% CI, 1.13-1.24; P < .001). The intervention effect on SBP level was -10.1 mm Hg (95% CI, -11.7 to -8.5 mm Hg; P < .001) and on DBP level was -1.8 mm Hg (95% CI, -2.8 to -0.8 mm Hg; P < .001).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that a multicomponent intervention delivered on a web-based platform improved BP control rate and lowered BP level more than usual care alone. Such a telemedicine program may provide a new, effective way to treat patients with hypertension in the community and may generate public health benefits across diverse populations.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017791.

Optimizing Hypertension Control Globally: WHF Roadmap

PURPOSE OF REVIEW

Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension.

RECENT FINDINGS

The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.

Wearable blood pressure measurement devices and new approaches in hypertension management: the digital era

Out-of-office blood pressure (BP) measurement is considered an integral component of the diagnostic algorithm and management of hypertension. In the era of digitalization, a great deal of wearable BP measuring devices has been developed. These digital blood pressure monitors allow frequent BP measurements with minimal annoyance to the patient while they do promise radical changes regarding the diagnostic accuracy, as the importance of making an accurate diagnosis of hypertension has become evident. By increasing the number of BP measurements in different conditions, these monitors allow accurate identification of different clinical phenotypes, such as masked hypertension and pathological BP variability, that seem to have a negative impact on cardiovascular prognosis. Frequent measurements of BP and the incorporation of new features in BP variability, both enable well-rounded interpretation of BP data in the context of real-life settings. This article is a review of all different technologies and wearable BP monitoring devices.

An Opportunity to Better Address Hypertension in Women: Self-Measured Blood Pressure Monitoring

More than 56 million women in the United States have hypertension, including almost one in five women of reproductive age. The prevalence of hypertensive disorders of pregnancy is on the rise, putting more women at risk for adverse pregnancy-related outcomes and atherosclerotic cardiovascular disease later in life. Hypertension can be better detected and controlled in women throughout their life course by supporting self-measured blood pressure monitoring. In this study, we present some potential strategies for strengthening our nation's ability to address hypertension in women focusing on pregnancy-related considerations for self-measured blood pressure monitoring.

Effects of telemedicine interventions on essential hypertension: a protocol for a systematic review and meta-analysis

INTRODUCTION

Essential hypertension is a major preventable risk factor for early cardiovascular disease, premature death and disability. It has been reported that telemedicine interventions can provide an innovative solution to essential hypertension to overcome the barriers that exist in traditional treatment or control. Nevertheless, this subject has not been thoroughly investigated. The goal of this study is to systematically evaluate and describe the impact of telemedicine interventions on essential hypertension.

METHODS AND ANALYSIS

To find relevant research, we will conduct a systematic literature search of three databases (PubMed, Embase and Cochrane Library), with no language limitations, in addition to researching grey literature. Two reviewers will extract the data individually, and any disagreements will be resolved by discussion or by a third reviewer. The randomised controlled trials will be chosen based on predetermined inclusion criteria. Primary outcomes will include systolic blood pressure and diastolic blood pressure after the telemedicine intervention. Secondary outcomes will include medication adherence (eg, the Morisky Medication Adherence Questionnaire), quality of life (eg, the MOS item scale of the Health Survey Short Form 36 questionnaire), blood pressure control rate and adverse events (eg, stroke, chronic renal failure, aortic dissection, myocardial infarction and heart failure). The quality of the included studies will be assessed using the Cochrane risk-of-bias method. The data will be analysed using RevMan V.5.3.5 software and STATA V.16.0 software. If heterogeneity testing reveals little or no statistical heterogeneity, a fixed effect model will be used for data synthesis; otherwise, a random effect model would be employed. We will synthesise the available evidence to perform a high-quality meta-analysis.

ETHICS AND DISSEMINATION

This project does not require ethical approval because it will be conducted using publicly available documents. The review's findings will be published in peer-reviewed journals and publications.

PROSPERO REGISTRATION NUMBER

CRD42021293539.

Differentiated effects and determinants of home blood pressure telemonitoring: lessons from a three-year cohort in Anhui Jieshou, China

BACKGROUND

Home blood pressure telemonitoring (HBPT) is witnessing rapid diffusion worldwide. Contemporary studies documented mainly short-term (6-12 month) effects of HBPT with little data about its uptake.

OBJECTIVE

This study aims to explore 3-year use and determinants of HBPT and its interactions with systolic and diastolic blood pressure (SBP/DBP) and blood pressure (BP) control rate.

METHODS

The study used HBPT records from a 3-year cohort of 5658 hypertensive patients in Anhui Jieshou, China and data from a structured household survey of a random sample (n=3005) from the cohort. The data analysis comprised: calculation and presentation, in time-line trajectories, rates of monthly active HBPT and mean SBP/DBP for overall and subgroups of patients with varied start-month SBP/DBP; and multivariable linear, logistics and percentile regression analysis using SBP/DBP, BP control rate and yearly times of HBPT as the dependent variable respectively.

RESULTS

HBPT followed mixed changes in mean monthly SBP/DBP for varied patient groups. The magnitude of changes ranged from -43 to +39 mmHg for SBP and -27 to +15 mmHg for DBP. The monthly rates of active HBPT all manifested a rapid and then slower and slower decline. When controlled for commonly researched confounders, times of HBPT in the last year were found with decreasing correlation coefficients for SBP/DBP (being decreased from 0.10 to -0.35 and from 0.11 to -0.35 respectively) and for BP control rate (from 0.53 to -0.62).

CONCLUSIONS

HBPT had major and "target-converging" effects on SBP/DBP. The magnitude of changes was much greater than have commonly reported. BP, variation in BP and time were the most important determinants of HBPT uptake; while age, education, duration of hypertension, family history and diagnosis of hypertension complications were also linked to the uptake but at apparently weaker strength. There is a clear need for differentiated thinking over application and assessment of HBPT and for identifying and correcting/leveraging potential outdated/new opportunities or beliefs.

Impact of Home Telemonitoring and Management Support on Blood Pressure Control in Nondialysis CKD: A Systematic Review and Meta-Analysis

Background

Hypertension is a major cause of cardiovascular disease, chronic kidney disease (CKD), and death. Several studies have demonstrated the efficacy of home blood pressure telemonitoring (HBPT) for blood pressure (BP) control and outcomes, but the effects of this intervention remain unclear in patients with CKD.

Objective

To determine the impact of HBPT on cardiovascular-related and kidney disease-related outcomes in patients with CKD.

Design

Systematic review and meta-analysis.

Setting

All studies that met our criteria regardless of country of origin.

Participants

Patients with chronic kidney disease included in studies using HBPT for BP assessment and control.

Measurements

Descriptive and quantitative analysis of our primary and secondary outcomes.

Methods

We searched MEDLINE, Embase, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Web of Science, and gray literature from inception for observational and randomized controlled studies in nondialysis (ND) CKD using HBPT for BP control. We selected studies that used HBPT as intervention (with or without a control arm) for BP control in ND-CKD populations. The primary outcome was change in mean systolic BP (SBP) and mean diastolic BP (DBP).

Results

We selected 7 studies from 1669 articles that were initially identified. Overall, pooled estimates in the mean difference (MD) for SBP and DBP were -8.8 mm Hg; 95% confidence interval (CI): -16.2 to -1.4; P = .02 and -2.4 mm Hg; 95% CI: -3.8 to -1.0; P < .001, respectively. For studies comparing intervention with usual care (UC), pooled estimate in MD for SBP was -8.0 mm Hg (P = .02) with no significant reduction for DBP (-2.6 mm Hg; P = .18). In studies without a UC arm, both SBP and DBP were not significantly reduced (P > .05). The pooled estimate in MD for estimated glomerular filtration rate showed a significant improvement (5.4 mL/min/1.73 m2; P < .001).

Limitations

Heterogeneity and few available studies for inclusion limited our ability to identify a robust link between HBPT use and BP and kidney function improvement.

Conclusion

Home blood pressure telemonitoring is associated with mild lowering of BP and moderately improved kidney function in patients with CKD. However, larger studies with improved designs and prolonged interventions are still needed to assess the effects of HBPT on patients' outcomes.

PROSPERO registration ID

CRD42020190705.

Virtual management of hypertension: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension

The coronavirus disease 2019 pandemic caused an unprecedented shift from in person care to delivering healthcare remotely. To limit infectious spread, patients and providers rapidly adopted distant evaluation with online or telephone-based diagnosis and management of hypertension. It is likely that virtual care of chronic diseases including hypertension will continue in some form into the future. The purpose of the International Society of Hypertension's (ISH) position paper is to provide practical guidance on the virtual management of hypertension to improve its diagnosis and blood pressure control based on the currently available evidence and international experts' opinion for nonpregnant adults. Virtual care represents the provision of healthcare services at a distance with communication conducted between healthcare providers, healthcare users and their circle of care. This statement provides consensus guidance on: selecting blood pressure monitoring devices, accurate home blood pressure assessments, delivering patient education virtually, health behavior modification, medication adjustment and long-term virtual monitoring. We further provide recommendations on modalities for the virtual assessment and management of hypertension across the spectrum of resource availability and patient ability.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

.

World Hypertension Day 2021 in Italy: Results of a Nationwide Survey

Introduction

Hypertension is the biggest contributor to the global burden of cardiovascular diseases and related death, but the rates of hypertension awareness, treatment, and control remain largely perfectible.

Methods

During the XVII World Hypertension Day (May 17th, 2021), a nationwide cross-sectional opportunistic study endorsed by the Italian Society of Hypertension was conducted on volunteer adults ≥ 18 years to raise awareness of high blood pressure (BP). A questionnaire on major demographic/clinical features (sex, age, employment, education, BP status awareness, hypertension family/personal history, antihypertensive medications use) and BP measurement habits (≥1 BP measurement in the previous month/week) was administered. Due to the ongoing SARS-CoV-2 pandemic, BP was measured with standard procedures in a subset of participants (24.4%).

Results

A total of 1354 participants (mean age 56.3 ± 15.3 years; 57.3% women; mean BP: 131.2 ± 17.5/81.6 ± 10.5 mmHg; 42.3% self-declared hypertensive; 41.4% on antihypertensive medications) were enrolled; 73.6% declared being aware of their BP status. Among treated individuals with measured BP, 26.9% showed BP levels within the predefined therapeutic goals. Interestingly, BP status awareness rates were the highest among individuals with uncontrolled hypertension (85.1%) and the lowest among those with normal measured BP (54.4%).

Conclusions

This survey provides an updated insight into hypertension awareness and control in a setting of daily clinical practice, emphasizing the centricity of patients in the therapeutic alliance for a successful reduction of cardiovascular risk.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40292-022-00519-4.

Current applications and limitations of European guidelines on blood pressure measurement: implications for clinical practice

Hypertension is the most common cardiovascular (CV) risk factor, strongly and independently associated with an increased risk of major CV outcomes, including myocardial infarction, stroke, congestive heart failure, renal disease and death due to CV causes. Effective control of hypertension is of key importance for reducing the risk of hypertension-related CV complications, as well as for reducing the global burden of CV mortality. However, several studies reported relatively poor rates of control of high blood pressure (BP) in a setting of real-life practice. To improve hypertension management and control, national and international scientific societies proposed several educational and therapeutic interventions, among which the systematic implementation of out-of-office BP measurements represents a key element. Indeed, proper assessment of individual BP profile, including home, clinic and 24-h ambulatory BP levels, may improve awareness of the disease, ensure high level of adherence to prescribed medications in treated hypertensive patients, and thus contribute to ameliorate BP control in treated hypertensive outpatients. In line with these purposes, recent European guidelines have released practical recommendations and clear indications on how, when and how properly measuring BP levels in different clinical settings, with different techniques and different methods. This review aimed at discussing current applications and potential limitations of European guidelines on how to measure BP in office and out-of-office conditions, and their potential implications in the daily clinical management of hypertension.

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

The need for long-term personalized management of frail CVD patients by rehabilitation and telemonitoring: a framework

Due to advances in cardiovascular medicine and preventive cardiology, patients benefit from a better prognosis, even in case of significant disease burden such as acute and chronic coronary syndromes, advanced valvular heart disease and chronic heart failure. These advances have allowed CVD patients to increase their life expectancy, but on the other hand also experience aging-related syndromes such as frailty. Despite being underrecognized, frailty is a critical, common, and co-existent condition among older CVD patients, leading to exercise intolerance and compromised adherence to cardiovascular rehabilitation. Moreover, frail patients need a different approach for CR and are at very high risk for adverse events, but yet are underrepresented in conventional CR. Fortunately, recent advances have been made in technology, allowing remote monitoring, coaching and supervision of CVD patients in secondary prevention programs with promising benefits. Similarly, we hypothesized that such programs should also be implemented to treat frailty in CVD patients. However, considering frail patients' particular needs and challenges, telerehabilitation interventions should thus be appropriately adapted. Our purpose is to provide, for the first time and based on expert opinions, a framework of how such a cardiac telerehabilitation program could be developed and implemented to manage a prevention and rehabilitation program for CVD patients with frailty.

Influence of individualized prevention recommendations after one year on the control of hypertension in 3,868 follow-up participants of the ELITE study

OBJECTIVES

The ELITE study (German acronym for "Nutrition, lifestyle and individual information for prevention of heart attack, stroke and dementia") prospectively collects data on hypertension, cardiovascular risk factors (RF), dietary habits, physical activity, cognitive function, and quality of life in North-West Germany, which will then be improved through targeted individual information. The aim of the study is to improve the health of the participants in the long term and to identify reasons for a lack of implementation of prevention measures.

METHODS

Of 4,602 included subjects, 3,868 could be studied so far at one-year follow-up. Blood pressure (BP) was measured according to the guidelines at admission and blood pressure history, premedication, sports behaviour and BMI were recorded by means of questionnaires and compared with the data collected in the follow-up examination after one year.

RESULTS

The participants were evaluated in 4 groups (G): G1 - normotensive patients (n = 1,558), G2 - controlled hypertensive patients (n = 502), G3 - untreated uncontrolled hypertensive patients (n = 1,080), G4 - treated uncontrolled hypertensive patients (n = 728). In G1 blood pressure (RR) remained unchanged from 126.3/77.8 to 127.8/78.5, in G2 there was a significant (p < 0.001) RR increase from 128.1/77.0 to 134.9/79.8. In G3 and G4 RR decreased significantly (p < 0.001) from 149.9/90.0 to 143.5/86.9 and from 153.1/87.5 to 146.2 84.1 mmHg, respectively. In G3 and G4, RR decreased in 56.1% and 56.3% of subjects and increased in 18% and 21%, respectively. In contrast, RR increase was found more frequently in G1 and G2 (34.3% and 51%, respectively), and RR decrease less frequently (25.4 and 20.7%, respectively). The main reasons for RR decrease were weight loss, more exercise, and more antihypertensives. Frequently, improved compliance and dietary changes were given as reasons. As expected, the opposite often led to RR increase.

CONCLUSION

56% of the hypertensive participants succeeded in lowering their blood pressure, whereas there was a significant increase in blood pressure, especially in those who were well controlled with antihypertensives. This underlines the need to further motivate normotensive patients to maintain their normotension. The results show that the combination of individual written education and lifestyle interventions are an effective tool for the public health sector to combat hypertension. In our participants, lifestyle interventions have a significant impact on BP change. It should be noted critically that there are still too many patients who have not been reached.

The Impact of Synchronous Telehealth Services With a Digital Platform on Day-by-Day Home Blood Pressure Variability in Patients with Cardiovascular Diseases: Retrospective Cohort Study

Background

Hypertension is associated with a large global disease burden with variable control rates across different regions and races. Telehealth has recently emerged as a health care strategy for managing chronic diseases, but there are few reports regarding the effects of synchronous telehealth services on home blood pressure (BP) control and variability.

Objective

The objective of this study is to investigate the effect of synchronous telehealth services with a digital platform on home BP.

Methods

This retrospective study was conducted by the Taiwan ELEctroHEALTH study group at the Telehealth Center of the National Taiwan University Hospital. We analyzed home BP data taken from 2888 patients with cardiovascular disease (CVD) enrolled in our telehealth program between 2009 to 2017. Of the 2888 patients with CVD, 348 (12.05%) patients who received home BP surveillance for ≥56 days were selected for BP analysis. Patients were stratified into three groups: (1) poorly controlled hypertension, (2) well-controlled hypertension, and (3) nonhypertension. The mean, SD, coefficient of variation (CV), and average real variability were calculated.

Results

Telehealth interventions significantly and steadily reduced systolic blood pressure (SBP) in the poorly controlled hypertension group from 144.8.2±9.2 to 133.7±10.2 mmHg after 2 months (P<.001). BP variability reduced in all patients: SBP-SD decreased from 7.8±3.4 to 7.3±3.4 after 2 months (P=.004), and SBP-CV decreased from 6.3±2.5 to 5.9±2.6 after 2 months (P=.004). Event-free survival (admission) analysis stratified by SBP-SD showed longer time to first hospitalization for Q1 patients compared with Q4 patients (P=.02, odds ratio 2.15, 95% CI 1.18-3.89).

Conclusions

Synchronous telehealth intervention may improve home BP control and decrease day-by-day home BP variability in patients with CVD.

Clinician Decisions After Notification of Elevated Blood Pressure Measurements From Patients in a Remote Monitoring Program

IMPORTANCE

Guidelines recommend using telehealth for hypertension management, but insufficient evidence is available to guide strategies for incorporating telehealth data into clinical practice.

OBJECTIVE

To describe how primary care teams responded to elevated remote blood pressure (BP) alerts in the electronic health record (EHR) in a randomized clinical trial of BP telemonitoring conducted in routine practice settings.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study reviewed EHR documentation from May 8, 2018, to August 9, 2019, in a single urban academic family practice site. Primary care teams comprising 28 attending physicians and nurse practitioners, residents, and nurses cared for 162 patients in a text-based clinical trial of remote BP monitoring remote BP monitoring. Data were analyzed from October 21, 2019, to April 30, 2021.

EXPOSURES

Clinicians received a direct message in their EHR inbox when patients submitted at least 3 elevated BP readings.

MAIN OUTCOMES AND MEASURES

Categories and frequencies of clinician action, created via review of EHR-documented clinician responses to EHR alerts by 2 physicians.

RESULTS

Patients in this study (n = 162) were predominantly female (111 [68.5%]) and Black or African American (146 [90.1%]), whereas attending physicians (n = 21) were predominantly female (13 [61.9%]) and non-Hispanic White (19 [90.5%]) with a mean (SD) age of 51.6 (11.1) years. Five hundred fifty-two alerts fell into 12 categories of clinical actions. Clinicians acted on 343 alerts (62.1%). Common remote activities were to reconcile medications and assess adherence (120 of 552 alerts [21.7%]) and verify BP measurement technique (65 of 552 alerts [11.8%]). Clinicians also commonly requested appointments (120 of 552 alerts [21.7%]) and/or saw the patient in a subsequent office visit (114 of 552 alerts [20.7%]). Ninety-six alerts (17.4%) resulted in medication changes; half of these changes were remote (48 of 96 [50.0%]), and the other half were visit-based. For 209 of 552 alerts (37.9%), no changes were made to the care plan, typically without documenting clinical rationale (196 of 209 instances [93.8%]). Exploratory EHR review was used to infer potential clinical rationale for 106 (54.1%) of such cases, but there was insufficient information for the remaining 90 (45.9%).

CONCLUSIONS AND RELEVANCE

These findings suggest that EHR alerts for elevated BP during remote monitoring were effective in prompting a mix of remote and office-based management. It was also common for the plan of care to remain unchanged, possibly suggesting need for more refined alerts and improved clinician support.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Home Blood Pressure and Telemedicine: A Modern Approach for Managing Hypertension During and After COVID-19 Pandemic

Hypertension is the most common cardiovascular risk factor for acute cardiovascular outcomes, including acute coronary disease, stroke, chronic kidney disease and congestive heart failure. Despite the fact that it represents the most prevalent risk factor in the general population, mostly in elderly individuals, its awareness is still relatively low, being about one third of patients living with undiagnosed hypertension and high risk of experiencing acute cardiovascular events. In addition, though recent improvement in pharmacological and non-pharmacological therapeutic options, hypertension is largely uncontrolled, with about 35-40% of treated hypertensive patients achieving the recommended therapeutic targets. Among different modern interventions proposed for improving blood pressure control in treated hypertensive patients, a systematic adoption of home BP monitoring has demonstrated to be one of the most effective. Indeed, it improves patients' awareness of the disease and adherence to prescribed medications and allows tailoring and personalizing BP lowering therapies. Home BP monitoring is particularly suitable for telemedicine and mobile-health solutions. Indeed, in specific conditions, when face-to-face interactions between patients and physicians are not allowed or even suspended, as in case of COVID-19 pandemic, telemedicine may ensure effective management of hypertension, as well as other cardiovascular and non-cardiovascular comorbidities. This review will summarize strengths and limitations of telemedicine in the clinical management of hypertension with a particular focus on the lessons learned during the COVID-19 pandemic.

Telemedicine Readiness Across Medical Conditions in a US National Representative Sample of Older Adults

Telemedicine has provided older adults the ability to seek care remotely during the coronavirus disease (COVID-19) pandemic. However, it is unclear how diverse medical conditions play a role in telemedicine uptake. A total of 3379 participants (≥65 years) were interviewed in 2018 as part of the National Health and Aging Trends Study. We assessed telemedicine readiness across multiple medical conditions. Most chronic medical conditions and mood symptoms were significantly associated with telemedicine unreadiness, for physical or technical reasons or both, while cancer, hypertension, and arthritis were significantly associated with telemedicine readiness. Our findings suggest that multiple medical conditions play a substantial role in telemedicine uptake among older adults in the US. Therefore, comorbidities should be taken into consideration when promoting and adopting telemedicine technologies among older adults.

TOP-10 questions about telemedicine counseling for cardiovascular patients. MONICA experience in 2020

Changes in provision of elective care during coronavirus disease 2019 pandemic require search for new forms of doctor-patient communication. Telemedicine technologies have become widely used for monitoring of patients, especially those with noncommunicable diseases. However, the introduction of telemedicine care is associated with a large number of medical, legal and technical issues. Rational use of telecommunication within the modern clinical guidelines will significantly increase the availability of high-quality healthcare and reduce the hospitalization rate for exacerbation of chronic diseases, as well as improve disease outcomes.

An Updated Meta-Analysis of Remote Blood Pressure Monitoring in Urban-Dwelling Patients with Hypertension

Following the coronavirus disease-2019 pandemic, this study aimed to evaluate the overall effects of remote blood pressure monitoring (RBPM) for urban-dwelling patients with hypertension and high accessibility to healthcare and provide updated quantitative summary data. Of 2721 database-searched articles from RBPM’s inception to November 2020, 32 high-quality studies (48 comparisons) were selected as primary data for synthesis. A meta-analysis was undertaken using a random effects model. Primary outcomes were changes in office systolic blood pressure (SBP) and diastolic blood pressure (DBP) following RBPM. The secondary outcome was the BP control rate. Compared with a usual care group, there was a decrease in SBP and DBP in the RBPM group (standardized mean difference 0.507 (95% confidence interval [CI] 0.339–0.675, p < 0.001; weighted mean difference [WMD] 4.464 mmHg, p < 0.001) and 0.315 (CI 0.209–0.422, p < 0.001; WMD 2.075 mmHg, p < 0.001), respectively). The RBPM group had a higher BP control rate based on a relative ratio (RR) of 1.226 (1.107–1.358, p < 0.001). RBPM effects increased with increases in city size and frequent monitoring, with decreases in intervention duration, and in cities without medically underserved areas. RBPM is effective in reducing BP and in achieving target BP levels for urban-dwelling patients with hypertension.