CME INDIA Presentation by Dr. Bijay Patni, Diabetologist Physician, Kolkata.

Based on a presentation at ICDM, Vadodara-2023

Most with Hypertension in India are not aware and hence not treated.

• Elevated blood pressure that is not managed is a leading contributor to cardiovascular diseases (CVDs), including heart attacks and strokes, making them a leading cause of death and illness worldwide.
• CVDs account for approximately one-third of all fatalities in India. It is estimated that a minimum of one in four adults in India suffers from hypertension, yet only about 12% of them successfully maintain healthy blood pressure levels.
• Despite the substantial impact of hypertension on health and mortality, numerous countries have been sluggish in addressing this issue. Slightly more than half of individuals with hypertension are aware of their condition, and only one out of seven people worldwide successfully manages it.

What is HBPM?

• Home Blood Pressure Monitoring (HBPM) is a dependable, convenient, and cost-effective substitute for Ambulatory Blood Pressure Monitoring (ABPM).
• It employs similar technology to ABPM and empowers patients to self-monitor their blood pressure at their convenience.
• This approach makes it feasible to measure blood pressure under real-life conditions over extended periods.
• WHY?

Must be Considered

• A substantial number of hypertensive patients make multiple errors during self-assessments of their blood pressure, resulting in significant discrepancies compared to readings taken by healthcare professionals. To address this issue:
  • Patients with hypertension should receive education on the correct practices for self-measuring their blood pressure.
  • The competence of patients to conduct independent assessments should be confirmed before any clinical decisions are based on their self-measured readings.

Courtsey: Kario, K., Hoshide, S. & Mogi, M. Topics 2023 in Hypertension Research leading to guidelines in Asia. Hypertens Res 46, 1357–1362 (2023

Recommendation Blues

• Current hypertension guideline documents make strong recommendations for the use of out-of-office BP monitoring techniques, including HBPM and ABPM, for the diagnosis of hypertension and for the monitoring and management of antihypertensive therapy.
• Indian & International hypertension guidelines, scientific statements, and position papers endorse the use of self-measured BP monitoring for the diagnosis and management of high BP.

To ensure the accuracy and reliability of Home Blood Pressure Monitoring (HBPM), it’s crucial to implement the following measures:

1. Patient Education and Training: Provide patients with comprehensive information on hypertension diagnosis and treatment. Educate them on how to select an appropriate HBPM device and how to correctly measure their own blood pressure.
2. Use of Standardized Procedures: Promote the use of standardized procedures for blood pressure measurement to minimize errors and variations.
3. Use of Validated Devices: Encourage the use of validated blood pressure monitoring devices to ensure accurate readings.
4. Pre-Measurement Information: Before taking measurements, patients should be informed about:
   • The importance of accurate BP readings in managing hypertension.
   • The potential risks of modifying antihypertensive therapy without consulting their physician.
   • How to measure their blood pressure correctly (details provided in subsequent slides).
   • The recommended frequency of blood pressure measurements.
5. Variations in BP: Educate patients about the variations in blood pressure that can occur in different activities and environments, including at work, at home, during times of stress, and overnight.

Home Blood Pressure Monitoring (HBPM) is valuable for a range of individuals:

1. Those Diagnosed with High Blood Pressure (Hypertension
2. Individuals Initiating High Blood Pressure Treatment
3. Individuals with Risk Factors.
4. Pregnant Women with Pregnancy-Induced Hypertension
5. Individuals with “White Coat Hypertension”:
6. Individuals with “Masked Hypertension

HBPM is a versatile tool that can benefit various individuals, whether for monitoring an existing condition, assessing treatment effectiveness, identifying masked hypertension, or managing pregnancy-induced hypertension.

Proper preparation and positioning of the individual are crucial for obtaining accurate blood pressure measurements.

Here are the key steps to ensure accuracy:

1. Empty the Bladder: The individual should empty their bladder before taking the blood pressure measurement. A full bladder can affect blood pressure readings.
2. Rest: After emptying the bladder, the individual should rest for at least 5 minutes in a quiet environment. This relaxation period helps stabilize blood pressure.
3. Sitting Position: The individual should sit comfortably in a chair with back support, legs uncrossed, and both feet flat on the floor. The back and arm support help maintain a stable position.
4. Arm and Cuff Placement: A properly sized blood pressure cuff should be placed over a bare midarm without clothing. Ensure that the lower edge of the cuff is positioned just above the antecubital fossa (the bend of the elbow). The center of the cuff bladder, usually marked by the manufacturer, should align with the brachial artery, which is located on the inside of the arm.
5. Arm Position: The cuffed arm should be relaxed and supported on a flat surface, such as a table, so that the cuff is at the level of the heart. This alignment helps to obtain accurate blood pressure measurements.
6. Minimize Distractions: Avoid talking or using electronic devices, like cell phones, during blood pressure measurements. Distractions can affect the accuracy of the reading.
7. Single User Device: Instruct the individual not to share the blood pressure monitoring device with anyone else unless the device is designed to store readings for multiple users.

Following these preparation and positioning guidelines is essential for obtaining reliable and accurate blood pressure measurements at home.

Courtsey: https://www.heart.org/en/news/2022/05/23/monitoring-blood-pressure-at-home-can-be-tricky-heres-how

A recommended schedule for self-measured blood pressure (BP) monitoring

• Frequency and Duration:
  • Take 2 BP measurements at least 1 minute apart in the morning and 2 measurements in the evening (for a total of 4 readings per day).
  • Ideally, perform these measurements for 7 days (resulting in 28 readings in total), with a minimum of 3 days (12 readings) as a viable alternative.
• Averaging Measurements:
  • Calculate the average of all systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings obtained during each monitoring period.
• Avoid “Eyeball Method”:
  • Avoid relying solely on the “eyeball method,” which involves visually scanning the readings to determine the presence of high BP or BP control. Averaging the readings is a more accurate assessment.
• Excluding the First Day’s Readings:
  • Some guidelines suggest excluding the first day’s readings. If you choose to exclude the first day’s readings, the preferred monitoring duration should be 8 days, with a minimum of 4 days.
• Consecutive Monitoring Days:
  • Monitoring should ideally be conducted over consecutive days. However, readings taken on nonconsecutive days may still provide valid data.
• Long-Term Monitoring:
  • Once blood pressure control is achieved and remains stable for several months, monitoring 1 to 3 days every week is likely sufficient for ongoing management.

Barriers to Widespread Use of Self-Measured BP Monitoring

• Lack of patient awareness, training, acceptance
• Measurement errors, patient reliance on single reading
• Perceived inferior to physician-administered clinic-based BPM
• Lack of detailed guidance & recommendations on HBPM in local guidelines.
• Cost is a challenge.
• The implementation of self-measured blood pressure (BP) monitoring may face certain barriers, but these obstacles can be overcome, largely through effective education and the integration of patients, healthcare providers, and healthcare systems.
• Both patients and providers acknowledge that effectively reducing high blood pressure is a collaborative effort. Self-measured BP monitoring for hypertension serves as the essential bridge between the limited care provided in clinics and the actual source of risk and benefit: the patient’s daily life outside the clinic, where self-monitoring becomes indispensable.
• By addressing these barriers and fostering a sense of partnership between patients and healthcare providers, self-measured BP monitoring can play a crucial role in improving hypertension management and overall health outcomes.
• It empowers patients to take an active role in their care and provides healthcare providers with more comprehensive data to make informed decisions and provide personalized treatment.

Use correct size:

Validating your patients for using HBPM

• If patients are using their own monitor, request that they bring it to their next appointment. Verify that the device is a validated model, calibrated according to the manufacturer’s specifications. Confirm that the correct cuff size is being used. Ensure that patients are proficient in operating the machine. Request patients to conduct a measurement during the appointment, adhering to the same guidelines for accuracy as previously described for clinic measurements. Offer guidance on battery life and maintenance of the cuff and machine

CME INDIA Learning Points

Self-measured blood pressure (BP) monitoring is a validated approach recognized as an integral part of the diagnosis and treatment of hypertension. Some important points to note about self-measured BP monitoring include:

Associations with Cardiovascular Risk:

• Higher self-measured BP is associated with an increased cardiovascular risk independently of office BP readings.

Indications for Self-Measured BP Monitoring:

• Diagnosing white-coat hypertension and masked hypertension.
• Identifying the white-coat effect and masked uncontrolled hypertension.
• Evaluating BP response to treatment.
• Confirming the diagnosis of resistant hypertension.
• Detecting morning hypertension.
• Self-measured BP monitoring is considered a practical approach in clinical practice, especially for individuals taking antihypertensive medication, as per the 2017 Hypertension Clinical Practice Guidelines.

Technique and Device Accuracy:

• Use upper arm self-measured BP monitoring devices with appropriately sized cuffs.
• Follow a standardized protocol for BP measurement and monitoring.
• Use validated devices, preferably with the capability to store readings and transfer data electronically to healthcare providers, if available.

Effectiveness on Lowering BP:

• Self-measured BP monitoring, with or without cointerventions, is associated with moderate reductions in systolic and diastolic BP, as well as improved BP control.

Cost and Cost-Effectiveness:

• Self-measured BP monitoring is cost-effective compared to office BP monitoring or usual care, particularly in individuals with high office BP.
• The cost-effectiveness of self-measured BP monitoring for diagnosing and managing masked hypertension in individuals without high office BP is less well-studied.

Barriers to Widespread Use:

• Patient barriers include the need for rigid monitoring protocols, lack of education about the benefits of self-measured BP monitoring, insufficient feedback and recognition from providers, and out-of-pocket costs.
• Provider barriers include concerns about device accuracy, low patient adherence to monitoring schedules, worries about patient anxiety, increased burden on practices and staff, time required for interpreting readings, and lack of reimbursement for devices.
• Healthcare system barriers include inadequate systems for transferring self-measured BP readings to electronic health records and a lack of infrastructure for implementing cointerventions.

CME INDIA Tail Piece

References:

1. Daichi Shimbo, Nancy T. Artinian, Jan N. Basile, Lawrence R. Krakoff, Karen L. Margolis, Michael K. Rakotz, Gregory Wozniak. Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association. https://doi.org/10.1161/CIR.0000000000000803Circulation. 2020;142:e42–e63
2. Nessler, K., Krztoń-Królewiecka, A., Suska, A. et al. The reliability of patient blood pressure self-assessments – a cross-sectional study. BMC Prim. Care 24, 2 (2023). https://doi.org/10.1186/s12875-022-01962-x
3.  Parati G, Stergiou GS, Asmar R, Bilo G, et al.ESH Working Group on Blood Pressure Monitoring. European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens 2010; 24:779–785.
4. Muntner P, Shimbo D, Carey RM, Charleston JB, Gaillard T, Misra S, Myers MG, Ogedegbe G, Schwartz JE, Townsend RR, et al; on behalf of the American Heart Association Council on Hypertension; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; and Council on Quality of Care and Outcomes Research. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73:e35–e66. doi: 10.1161/HYP.0000000000000087
5. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, et al; ESC Scientific Document Group. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–3104. doi: 10.1093/eurheartj/ehy339
6. Chia YC, Buranakitjaroen P, Chen CH, Divinagracia R, Hoshide S, Park S, Shin J, Siddique S, Sison J, Soenarta AA, et al; HOPE Asia Network. Current status of home blood pressure monitoring in Asia: statement from the HOPE Asia Network. J Clin Hypertens (Greenwich). 2017;19:1192–1201. doi: 10.1111/jch.13058
7. Kario, K., Hoshide, S. & Mogi, M. Topics 2023 in Hypertension Research leading to guidelines in Asia. Hypertens Res 46, 1357–1362 (2023). https://doi.org/10.1038/s41440-023-01285-z

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