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

A personal history of research on hypertension From an encounter with hypertension to the development of hypertension practice based on out-of-clinic blood pressure measurements

In the 1970s, many people had severe hypertension and related cardiovascular and cerebrovascular diseases; however, antihypertensive treatments were not available at the time. The author encountered such conditions during the initial exposure to medicine. The author subsequently entered the field of hypertension medicine to prevent such conditions and engaged in hypertension research for more than 50 years. The author's central interest was the physiological and clinical aspects of blood pressure (BP) variability. Out-of-clinic BP measurements were the focus of clinical research. It was anticipated that self-measurement of BP at home (HBP) would improve medical practice surrounding hypertension. To establish evidence-based hypertension medicine, the Ohasama study (an epidemiology based on HBP) was conducted. The study provided firm evidence of the clinical significance of HBP and diagnostic criteria for hypertension and normotension. To establish target HBP levels for antihypertensive therapy, the Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study (a prospective intervention study) was also conducted. Application of HBP measurements expanded to obstetric, clinical pharmacology, pathophysiology, and genetic studies. During these studies, crucial information on the clinical significance of BP variability (such as circadian and day-by-day variation of BP, nocturnal BP, white-coat hypertension, and masked hypertension) was established. Finally, the author described the priority of HBP over clinic-measured BP for the diagnosis of hypertension in the 2014 Japanese Society of Hypertension Guidelines. In this article, the author's history of hypertension research, from the first encounter with hypertension to the construction of guidelines on hypertension, is reviewed.

Intrasession Reliability Analysis for Oscillometric Blood Pressure Method Using a Digital Blood Pressure Monitor in Peruvian Population

Blood Pressure (BP) is one of the most used measured clinical parameters in health promotion and intervention. BP measures can vary due to different parameters, so we aim to study the intrasession test–retest reliability for an oscillometric method using a digital tensiometer in the Peruvian population aged over 15 with and without a diagnosis of hypertension (HT). Data were taken from the Demographic and Family Health Survey conducted in Peru in 2019. Technicians had to follow a standardized protocol on the conditions to carry out a valid and reliable measurement. Relative reliability was excellent in most cases (intraclass correlation coefficient > 0.9); absolute reliability was excellent (standard error of measurement < 5%) and smallest real difference < 10% in most cases. The Bland–Altman plot showed a systematic error of 2.36 for systolic BP in men and 2.16 in women, and 0.823 for diastolic BP in men and 0.71 for diastolic BP in women. Results suggest that the oscillometric method with a digital blood pressure monitor was reliable in absolute and relative terms in this population, so it could be used as a reliable control test to measure changes after an intervention.

Disease-specific nutrition for the elderly and their Caretakers- What was and what could be

INTRODUCTION

Older adults who suffer from chronic illnesses often employ the help of Home Care Aides (HCAs). These HCAs assist their client's nutrition and other activities of daily living. However, many HCAs who care for the elderly are themselves unaware of proper nutrition habits that can improve health outcomes. This project proposal centers on a nutrition-training program that focuses on HCAs and their knowledge of proper nutrition. It will challenge participants to eat better using foods are best suited to the chronic illness that their client suffers from.

APPROACH

The Nutrition Training Package contains materials that can be used in training sessions conducted over two days. Each day consists of interactive activities, discussions and presentations. These materials were adapted from interventions used by the Healthy Aging Program- an intervention previously hosted by EverThrive IL.

OUTCOMES

Although pilot testing is yet to be conducted, the training package is complete and ready for implementation.

CONCLUSION

Based on literature review, the contents of the Nutrition Training Package for Home Care Aides will guide participants through stages of the Model of Change, simultaneously creating the self-efficacy to contribute to elongated, healthier living for the elderly.

Antihypertensive drug effects according to the pretreatment self-measured home blood pressure: the HOMED-BP study

OBJECTIVES

To clarify whether or not the antihypertensive drug effect is proportional to the baseline pretreatment self-measured home blood pressure (HBP) in accordance with the law of initial value (Wilder's law).

DESIGN

A post-hoc analysis of a multicentre clinical trial.

SETTING

Outpatients across Japan with mild-to-moderate essential hypertension.

PARTICIPANTS

Among 3518 randomised participants, 2423 who self-measured HBP during the pretreatment drug-free period (10-28 days after starting fixed-dose antihypertensive monotherapy) with a mean 7.0 years follow-up were eligible.

MAIN OUTCOME MEASURES

We analysed individual HBP readings during pretreatment and monotherapy.

RESULTS

The day-to-day HBP during both the pretreatment period and monotherapy period remains almost the same throughout each period; the results were consistent, regardless of the pretreatment HBP. Following monotherapy, the reduction in the HBP increased by 2.2 mm Hg (95% CI: 1.8 to 2.5 mm Hg) per 10 mm Hg pretreatment HBP increase, up to 11.0 mm Hg (95% CI: 9.9 to 12.0 mm Hg) among patients with an HBP ≥165 mm Hg during pretreatment. Among the 1005 patients receiving low-dose monotherapy (defined daily dose: 0.5 units), the reduction peaked at 8.9-9.1 mm Hg in those with pretreatment HBP 155-164 mm Hg and ≥165 mm Hg (p=0.88).

CONCLUSIONS

According to Wilder's law, the HBP reduction due to fixed-dose monotherapy was proportional to the pretreatment HBP without any regression to the mean phenomenon. With low-dose antihypertensive drugs, however, the HBP reduction peaked in patients with a high pretreatment HBP, indicating the need for such patients to receive a sufficient amount of antihypertensive drug medication at the initial treatment.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (http://www.umin.ac.jp/ctr), Unique identifier: C000000137.

Recent status of self-measured home blood pressure in the Japanese general population: a modern database on self-measured home blood pressure (MDAS)

Despite the clinical usefulness of self-measured home blood pressure (BP), reports on the characteristics of home BP have not been sufficient and have varied due to the measurement conditions in each study. We constructed a database on self-measured home BP, which included five Japanese general populations as subdivided aggregate data that were clustered and meta-analyzed according to sex, age category, and antihypertensive drug treatment at baseline (treated and untreated). The self-measured home BPs were collected after a few minutes of rest in a sitting position: (1) the morning home BP was measured within 1 h of waking, after urination, before breakfast, and before taking antihypertensive medication (if any); and (2) the evening home BP was measured just before going to bed. The pulse rate was simultaneously measured. Eligible data from 2000 onward were obtained. The morning BP was significantly higher in treated participants than in untreated people of the same age category, and the BP difference was more marked in women. Among untreated residents, home systolic/diastolic BPs measured in the morning were higher than those measured in the evening; the differences were 5.7/5.0 mmHg in women (ranges across the cohorts, 5.3-6.8/4.7-5.4 mmHg) and 7.3/7.7 mmHg in men (ranges, 6.4-8.5/7.0-8.7 mmHg). In contrast, the home pulse rate in women and men was 2.4 (range, 1.5-3.7) and 5.6 (range, 4.6-6.6) beats per minute, respectively, higher in the evening than in the morning. We demonstrated the current status of home BP and home pulse rate in relation to sex, age, and antihypertensive treatment status in the Japanese general population. The approach by which fine-clustered aggregate statistics were collected and integrated could address practical issues raised in epidemiological research settings.

The role of patient portals in enhancing self-care in patients with renal conditions

Web-based portals enable patients to access their electronic health records, including test results and clinical documents, from anywhere with Internet access. Some portals also serve as a means of two-way communication between patients and healthcare professionals and provide a platform for the recording of patient-entered data such as home blood pressure readings. Such systems are designed to encourage patient participation in the management of their condition, and ultimately to increase patient empowerment and self-management, which are associated with improved clinical outcomes. As an example of portal use in patients with renal conditions, we discuss the PatientView portal, which is offered free of cost to patients under the care of renal physicians in the UK. We present an account of its various features and briefly describe the user experience. Previous studies examining the impact of this portal on patient care have been very positive; it appears to be popular among users and overall levels of satisfaction with the service are high. As the use of patient portals increases, we discuss barriers to the more widespread use of portals. We offer suggestions on how the care of patients with renal conditions can be enhanced in the future by further developing the existing features, learning from experiences of other patient portals and providing better integration of portal use into the current model of care.

Relationships among clinic, home, and ambulatory blood pressures with small vessel disease of the brain and functional status in older people with hypertension

BACKGROUND

Subcortical small vessel disease, represented as white matter hyperintensity (WMH) on magnetic resonance images (MRI) is associated with functional decline in older people with hypertension. We evaluated the relationships of clinic and out-of-office blood pressures (BP) with WMH and functional status in older persons.

METHODS

Using cross-sectional data from 199 older study participants enrolled in the INFINITY trial, we analyzed the clinic, 24-hour ambulatory, and home BPs and their relationships with WMH burden and mobility and cognitive outcomes.

RESULTS

Volume of WMH was associated with clinic and 24-hour ambulatory systolic BP but not home systolic BP. The mobility measure, supine-to-sit time, had a significant association with 24-hour systolic BP and pulse pressure but not with diastolic BP or values obtained by home BP. Cognitive measures of processing speed (Trails Making Test Part A and the Stroop Word Test) were significantly associated with 24-hour systolic BP, but not clinic and home BPs.

CONCLUSION

These data demonstrate that ambulatory BP measurements in older people are more strongly associated with WMH and certain measures of functional status compared to home BP measurements. Hence, home BP may not be a useful substitute for ambulatory BP for assessing subcortical small vessel disease and its consequences. Further longitudinal analyses comparing clinic and various types of out-of-office BP measures with small vessel brain disease are needed. Clinicaltrials.gov identifier: NCT01650402.

Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m² (95% CI; 3.7-27, p=.01, _adjR² 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m² (95% CI 0.76-3.9, p<.01, _adjR² 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.

Comparison of Optimal Diagnostic Thresholds of Hypertension With Home Blood Pressure Monitoring and 24-Hour Ambulatory Blood Pressure Monitoring

BACKGROUND

Differences between the recently suggested outcome-driven diagnostic threshold of home blood pressure (HBP) measurements and the currently recommended diagnostic threshold of HBP measurements may cause a disagreement between 24-hour ambulatory blood pressure (ABP) and HBP measurements in the diagnosis of hypertension. We evaluated the agreement of various HBP diagnostic thresholds (135/85, 130/85, and 130/80 mm Hg) to ABP measurements, as a reference method.

METHODS

Patients who were confirmed to have high BP (≥140/90 mm Hg) at the outpatient clinic were referred. HBP measurement was performed for 7 days in triplicates every morning and evening. The 24-hour ABP measurement was performed on the 8th day. Using 24-hour ABP measurement as a reference method, we analyzed HBP diagnostic thresholds at 135/85, 130/85, and 130/80 mm Hg.

RESULTS

Among 319 patients, 256 patients (mean age, 51.8 ± 9.7 years; 119 men) with valid HBP measurements and 24-hour ABP measurements were enrolled. The threshold of 130/80 mm Hg showed the highest diagnostic sensitivity (P = 0.001) with diagnostic agreement by Kappa statistics. Using 130/80 mm Hg as a diagnostic threshold of hypertension, the prevalence of masked hypertension was significantly lower than 130/85 and 135/85 mm Hg (7.8, 15.2, and 18.4%, respectively, P = 0.002).

CONCLUSIONS

The present study suggests that lowering the diagnostic thresholds of HBP measurement from 135/85 mm Hg to 130/80 mm Hg may improve diagnostic accuracy for hypertension.

Time to re-evaluate effects of renin-angiotensin system inhibitors on renal and cardiovascular outcomes in diabetic nephropathy

The use of renin-angiotensin system (RAS) inhibitors, such angiotensin converting enzyme inhibitors/angiotensin-II receptor blockers, to slow progression of chronic kidney disease (CKD) in a large group dominated by elderly people in the real world is not supported by available evidence. Large-scale clinical trials had many faults, among them a lack of focus on the elderly. However, it would be difficult to conduct clinical trials of a similar scale in elderly CKD patients. Besides, progression of kidney disease is often slow in elderly persons, and the vast majority of older adults with CKD will die before reaching end stage renal disease. Moreover, since it is not clear that progression of kidney disease, and even of proteinuric diabetic nephropathy, is not inhibited through the use of RAS inhibitors, the most patient-centric goal of therapy for many elderly individuals should be individualized.