Pragmatic Method Using Blood Pressure Diaries to Assess Blood Pressure Control

Evaluating the feasibility of a pharmacist-guided patient-driven intervention to improve blood pressure control in patients with CKD

Background

Methods

Results

Conclusion

Implementation of home blood pressure monitoring among French GPs: A long and winding road

BACKGROUND

To explore the perception of home blood pressure monitoring (HBPM) by general practitioners (GPs) in everyday practice in order to identify facilitators and barriers to its implementation in daily practice.

METHODS

A qualitative study comprising the conduct of six focus groups between October 2016 and February 2017, gathering 41 general practitioners in primary care practice in Lorraine (North Eastern France), with thematic and comprehensive analysis.

RESULTS

The first reasons given by GPs to explain their difficulties with HBPM (Home Blood Pressure Monitoring) implementation were the usual lack of time, material and human resources. However, all of these motives masked other substantial limiting factors including insufficient knowledge regarding HBPM, poor adherence to recommendations on HBPM and fear of losing their medical authority. GPs admitted that HBPM use could enhance patient observance and decrease therapeutic inertia. Despite this observation, most GPs used HBPM only at the time of diagnosis and rarely for follow-up. One explanation for GP reluctance towards HBPM may be, along with guidelines regarding hypertension, HBPM is perceived as being a binding framework and being difficult to implement. This barrier was more predominantly observed among aging GPs than in young GPs and was less frequent when GPs practiced in multidisciplinary health centers because the logistical barrier was no longer present.

DISCUSSION

In order to improve HBPM implementation in everyday practice in France, it is necessary to focus on GP training and patient education. We must also end "medical power" in hypertension management and turn to multidisciplinary care including nurses, pharmacists and patients.

Prevalence and real-world assessment of central aortic blood pressure in adult patients with essential hypertension uncontrolled on single anti-hypertensive agents

OBJECTIVE

To assess the prevalence of high central aortic pressure (CAP) in Indian patients with uncontrolled essential hypertension while on anti-hypertensive monotherapy. Also, to determine correlation between brachial blood pressure (BBP) and CAP, and ascertain if it is impacted by anti-hypertensive drug class and patients' age.

METHODS

In this real-world, observational, prospective study, patients (30-70 years) with uncontrolled BBP (systolic BP [SBP] ≥140 mmHg or diastolic BP [DBP] ≥90 mmHg) were enrolled. Treatment was adjusted at Visit 1 (baseline), based on BBP and at treating physicians' discretion. Primary endpoint was proportion of patients with uncontrolled central aortic SBP (>125 mmHg) at baseline. Secondary endpoints were comparison of BBP and CAP across drugs classes and age groups at baseline and Visit 2 (End-of-study, ∼8 weeks post-baseline), and proportion of patients with uncontrolled central SBP at end-of-study.

RESULTS

Of 2030 patients screened, 1949 patients reported at baseline and 1740 patients completed end-of-study visit. Central SBP was >125 mmHg for 84.3% patients at baseline, and 48% patients at end-of-study. Interestingly, at end-of-study, 6.6% patients still had uncontrolled brachial SBP and controlled central SBP, while 13.6% patients had uncontrolled central SBP and controlled brachial SBP. At both visits, brachial SBP and central SBP showed positive correlation across most drug classes and age groups. At baseline, ACE inhibitors showed better efficacy than other drug classes. At end-of-study, BP control was better with fixed-dose combinations, though free-drug combinations were more frequently prescribed.

CONCLUSION

Measurement of CAP along with BBP can be vital in management of hypertension.

CTRI REGISTRATION NUMBER

CTRI/2015/10/006302.

Accuracy of blood pressure monitoring devices: a critical need for improvement that could resolve discrepancy in hypertension guidelines

Hypertension is the most significant modifiable risk factor for cardiovascular disease and contributes to the highest global burden of disease. Blood pressure (BP) measurement is among the most important of all medical tests, and it is critical for BP monitoring devices to be accurate. Comprehensive new evidence from meta-analyses clearly shows that many BP monitoring devices (including oscillometric machines and "gold standard" mercury auscultation) do not accurately represent the BP within the arteries at the upper arm (brachial) or central aorta. Particular variability in the accuracy of BP devices compared with intra-arterial BP has been demonstrated in the cuff BP range from prehypertension to grade I hypertension (systolic BP 120-159 to diastolic BP 80-99 mmHg). This is within the BP range that is most common among people worldwide and, thus almost certainly, feeding confusion around optimal hypertension guideline thresholds. At the individual level, inaccurate BP devices have major potential consequences for best practice patient management, where underestimation of true BP is a missed opportunity to lower cardiovascular risk (with therapeutics or lifestyle) and overestimation of true BP could lead to overmedication. Each problem leads to increased cost from preventable cardiovascular events and unnecessary medications. Altogether, there is a critical need to improve the accuracy standards of BP monitoring devices. In the meantime, out-of-office BP (24 h of ambulatory BP and/or home BP monitoring) or automated, unobserved in-office BP monitoring that takes the average of multiple readings using validated devices are the best available options to determine BP control.

PURLs: Monitoring home BP readings just got easier

This novel method of identifying patients with uncontrolled hypertension correlates well with ambulatory BP monitoring.

Medication Adherence and Blood Pressure Control Among Hypertensive Patients With Coexisting Long-Term Conditions in Primary Care Settings: A Cross-Sectional Analysis

Hypertension is a typical example of long-term disease posing formidable challenges to health care. One goal of antihypertensive therapy is to achieve optimal blood pressure (BP) control and reduce co-occurring chronic conditions (multimorbidity). This study aimed to assess the influence of multimorbidity on medication adherence, and to explore the association between poor BP control and multimorbidity, with implications for hypertension management.A cross-sectional design with multistage sampling was adopted to recruit Chinese hypertensive patients attending general out-patient clinics from 3 geographic regions in Hong Kong. A modified systemic sampling methodology with 1 patient as a sampling unit was used to recruit consecutive samples in each general out-patient clinic. Data were collected by face-to-face interviews using a standardized protocol. Poor BP control was defined as having systolic BP/diastolic BP ≥130/80 mm Hg for those with diabetes or chronic kidney disease; and ≥140/90 mm Hg for others. Medication adherence was assessed by a validated Chinese version of the Morisky Medication Adherence Scale. A simple unweighted enumeration was adopted to measure the combinations of coexisting long-term conditions. Binary logistic regression analysis was conducted with medication adherence and multimorbidity as outcome variables, respectively, after controlling for effects of patient-level covariates.The prevalence of multimorbidity was 47.4% (95% confidence interval [CI] 45.4%-49.4%) among a total of 2445 hypertensive patients. The proportion of subjects having 0, 1, and ≥2 additional long-term conditions was 52.6%, 29.1%, and 18.3%, respectively. The overall rate of poor adherence to medication was 46.6%, whereas the rate of suboptimal BP control was 48.7%. Albeit the influence of multimorbidity on medication adherence was not found to be statistically significant, patients with poorly controlled BP were more likely to have multimorbidity (adjusted odds ratio 2.07, 95% CI 1.70-2.53, P < 0.001). Diabetes was the most prevalent concomitant long-term condition among hypertensive patients with poor BP control (38.6%, 95% CI 35.8-41.4 vs 19.7%, 95% CI 17.5-21.9 for patients with good BP control, P < 0.001).Multimorbidity was common among hypertensive patients, and was associated with poor BP control. Subjects with coexisting diabetes, heart disease, or chronic kidney disorder should receive more clinical attention to achieve better clinical outcomes.