HOME BP MONITORING FOR HYPERTENSION, 2011

Barry Stults, M.D.

Division of General Internal Medicine

University of Utah Medical Center

“Hypertension: Uncontrolled and Conquering the World”

Lancet Editorial, August 18, 2007

“Hypertension is the most important health problem that clinicians don’t manage well.”

Annals of Internal Medicine Editorial, May 20, 2008

“Hypertension – the neglected disease”

Institute of Medicine, 2010

HTN AS A RISK FACTOR Increases RR by 2.0-4.0 fold for:

• CAD, stroke, HF, PAD • Renal failure, AF, dementia, cognition

Attributable risk for HTN: • Stroke 62% • MI 25% • CKD 56% • Premature death 24% • HF 49%

Aftermath: • Shortens lifespan 5y • $77 billion/y in U.S.

Circulation 2010; 121:e70 J Hum Hypertension 2008; 22:63 Hypertension 2007; 50:1006

BENEFITS OF LOWERING BP

Complication

MI

Stroke

CHF

Death

Average % Reduction

25%

40%

50%

15%

BMJ 2009; 338:b1665 Health Affairs 2007; 26:97 JAMA 2003; 289: 2560

• 10/5 mm Hg at age 65 for 10y:

IMPROVE HTN CONTROL: MEASURE BP ACCURATELY!

“Blood pressure reading does not seem to be done correctly in any clinic…It appears to be so simple that anyone can do it, but they can’t…”

JAMA 2008; 299:2842

• 6 studies with 1600 patients, 1995-2009: Routine clinical practice Research quality BP measurement BP measurement

– Accurate BP measurement BP 10/5 mm Hg! Hypertension 2010; 55:195

VS

BP MEASUREMENT: KEY TECHNIQUES

BP (mm Hg) if not done

Rest ≥ 5 min, quiet 12/6

Seated, back supported 6/8

Cuff at midsternal level 2/inch

Large enough cuff 6-18/4-13

Bladder center over artery 3-5/2-3

Deflate 2 mm Hg/sec SBP/ DBP

No talking during measurement 17/13

If initial BP > goal BP: 1st reading higher

3 readings, 1 min apart • “Alerting response”

Discard 1st, average last 2

Hypertension 2005; 45:142 J Hypertens 2005; 23:697 Can J Card 2008; 24:455

TRADITIONAL HTN RX: CLINICIAN IN OFFICE

Office BP Management (OBPM)

Patient Access

Income

Insurance

Cultural barriers

1 care clinicians

HTN detection

HTN FU

HTN control

Sub-optimal Rx

Therapeutic inertia

Poorly engaged, poorly adherent pts

Infrequent FU

HTN control

Inaccurate BP measurement

Falsely BP (Less often falsely BP)

Over-Dx and Rx of HTN (Less often the reverse)

White-coat HTN: Office BP > Home BP

Inherent BP Variability

HYPERTENSION: EPIDEMIOLOGY BY RACE

Prevalence Awareness Treatment Controlled

White men 34% 74% 64% 44%

White women 31% 78% 70% 43%

Black men 43% 71% 60% 35%

Black women 46% 86% 77% 45%

Hispanic men 28% 60% 46% 30%

Hispanic women 29% 70% 60% 34%

• Hispanics:

• Lowest prevalence of HTN

• Less likely to be aware, treated, or controlled

• Men < 50y, W > 65y less likely to be controlled

J Hypertension 2011, In Press JAMA 2010; 303:2043 Circulation 2011; 123:e18

NEW APPROACH TO HTN RX: TEAM CARE!

Nurse Pharmacist Clinician

Home BP monitoring HTN Rx Algorithms Feedback to pt to Rx

Improve access (telephone rather than office)

Patient empowerment through self-management

Improved adherence to Rx

Reduced therapeutic inertia

HTN Control!

Traditional HTN Rx by 1 Care Clinicians: Too busy Too frazzled Do poorly in RCTs

HBPM: POTENTIAL BENEFITS

Accuracy of BP Estimate

Detect WCH

Average many BP readings

Therapeutic inertia: Pt Adherence to Rx

• clinician Rx ’s • “Self-management”

• Pt. self-titration? • Self-involvement

Accurate HTN Dx

Better CVD Unnecessary prediction BP Rx

HTN control

HBPM: POTENTIAL BENEFITS REALIZED!

Ann Int Med 2011; 154:781 Hypertension 2010; 55:1301 Hypertension 2011; 57:29

Accuracy of BP Estimate by averaging many BP readings

• Need > 10 BP readings to classify pt with SBP = 136-144 as HTN vs No HTN with 80% certainty!

Detect WCH

• 20% of pts with office BP have WCH

Accurate HTN Dx

Better CVD prediction • 8 studies; 17, 688 pts: HBPM > OBPM for CVD prediction

Unnecessary BP Rx • 37 studies: 9446 pts: HBPM

total HTN Rx by 50%

HBPM: POTENTIAL BENEFITS REALIZED!

HTN Control?

Hypertension 2011; 57:29 Ann Med 2010; 42:371 Am J Hypertens 2011; 24:123, 989

Yes: if combined with co-interventions to pharm/non-pharm Rx BP by 4-6/2-3 mm Hg - Correlate with 20-30% CVD events HTN control rates 10-30% - Subgroups with better response to HBPM?

Therapeutic inertia: RCTs of poor HTN control show # of meds prescribed

Patient adherence to Rx • Variable reports • Subgroups with adherence if HBPM?

WHO SHOULD USE HBPM?

AHA, 2008: “Home BP monitoring should become a routine component of BP measurement in the majority of patients with suspected or known hypertension.”

• Role in Dx?

• Role in adjusting Rx? –All or some pts?

• Role in serial monitoring of controlled pts?

Hypertension 2008; 52:10

DIAGNOSIS OF HYPERTENSION

Elevated Office BP: Visits 1, 2

140-179/90-109

• No DM, CKD, or HTN TOD

≥ 180/110, or DM,

CKD, or HTN

TOD

Dx HTN

Home BPM over 7d Serial Office BPM

Visits 3: ≥ 160/100

or

Visits 4,5: ≥ 140/90

Dx HTN

< 125/75 ≥ 135/85 125-134/75-84

WCH Dx HTN

24h ABPM

• Home BPM q 3 mo

• Lifestyle ’s

Option Option

≥ 130/80 < 130/80

Can J Card 2010; 26:241 J Am Soc HTN 2010; 4:56 Hypertension 2008; 52:10

HBPM: ROLE IN RX ADJUSTMENT

Must adjust Rx ( ) in response to pharm/non-pharm Rx • HBPM alone not improve HTN control rates

Which patients benefit from HBPM? • All/most, especially for Dx of WCH/MH?

• Patients with prominent white-coat effect

• Patients with more difficult-to-control HTN

• ? Patients with less adherence/engagement?

Temporary use with loaner HBPM cuffs? • For Dx

• For initial drug titration only, if BP well-controlled

Am J Hypertens 2011; 24:123 Hypertension 2011; 57:21

REQUIREMENTS FOR EFFECTIVE HBPM

• HBPM monitor: validated arm, correct cuff size, accurate

• Precise preparation/measurement technique

– Intensive patient education

• Monitoring protocol: correct for BP variability, predict outcome

• Accurate BP data collection in usable, interpretable format

• Effective communication of BP data to team

• Appropriate interpretation of BP data by team

• Adjustment of Rx by team and communicate to patient

HBPM MONITORS

• Must be validated: AAMI, BHS, and/or IP protocols – Omron (www.omronhealthcare.com) – A&D – Lifesource (www.andmedical.com) – MicroLife (www.microlife.com) – www.hypertension.ca/devices-endorsed-by-

hypertension-canada

• Arm cuffs only (unless massive obesity) • Correct cuff size for mid-arm circumference

– < 33 cm regular cuff – 33-43 cm large adult or self-adjusting – > 43 cm wrist cuff (if wrist < 22 cm)

HBPM MONITORS

• Features cost: $50-$110

– Average last 3 readings $70.00

– 2-use mode $70.00

– Self-adjusting cuff $90.00

– Automatic 3 readings average $100.00

– AM/PM 8 wk averages $100.00

– Software manager $110.00

HBPM: CONFIRM CUFF ACCURACY

• Confirm device accuracy in office and q year – Overestimate BP if very stiff arteries

Some elderly, DM, CKD-dialysis pts

–

inaccurate if irregular pulse (AF, etc)

– No widely accepted technique D1, D2, M1, D3, M2 at 30 sec intervals

? D3 close to/in-between M1, M2

– 7% of validated devices inaccurate with individual patient

Blood Press Monit 2011; 16:168 Hypertension 2008; 52:10

Hypertension 2008; 52:13

HBPM: PRECISE PREPARATION/MEASUREMENT TECHNIQUE

Same careful preparation/technique as required in office:

• Home BP technique video:

– www.hypertension.ca/hypertension-videos

• Home BP technique written instructions:

– www.hypertension.ca/measuring-blood-pressure

– www.hypertension.ca/chep-resources-and-downloads-dp1

– UUMC/VAMC Home BP Measurement handouts

• Check technique in the office!

HBPM MONITORING PROTOCOLS

Designed to correlate with 24h ABPM, CVD outcomes: • Optimal preparation (5 min rest, no talking or TV, etc) • Duplicate/triplicate readings 1 min apart AM PM

– Average 2/2 or last 2/3

• For 3, preferably 7 days – 12-28 readings required

• Discard Day 1, average last 2-6 days – Do not consider isolated readings for decisions

• Communicate mean BP to team – HBPM cuffs that take 3 readings, average them

J Hypertension 2010; 28:226, 259 Hypertension 2011; 57:1081 J Hum Hypertension 2010; 24:779

ACCURATE BP DATA, USABLE RECORDING FORMAT

All BPs to be recorded:

• Some patients leave out higher BPs

Formats:

• Print-outs from memory-equipped devices

• Graphic displays from devices with software

• Manually-entered logbooks: – Vertical orientation www.hypertension.ca/images/stories/dls/2011_Resources_En/My_BP_Log_EN.pdf

– Horizontal orientation to gestalt average BP www.med.umich.edu/1libr/guides/bp%20chart.pdf

• Websites to manage and present home BP readings

WEBSITES TO MANAGE HBPM READINGS

American College of Cardiology: https://apps.peoplechart.com/hypertension American Heart Association: https://www.heart360.org Mayo Clinic: https://healthmanager.mayoclinic.com Healthy Circles LLC: https://www.healthycircles.com (Connect to Microsoft Health Vault)

J Clin Hypertens 2010; 12:389

EFFECTIVE COMMUNICATION OF BP DATA TO TEAM

Bring logbook/BP monitor to clinic: • Frequently not happen

Patient Clinic link to Microsoft Health Vault via web: • ACC, AHA, Mayo Clinic, Health Circles LLC

Standard telephone contact HBPM telemonitoring systems:

• Telephone lines, modem, internet, wireless • Improve HTN control rates in RCTs • High cost, user training

Am J Hypertens 2011; 24:989

APPROPRIATE INTERPRETATION OF BP DATA

• Know goal home BP:

• Confirm proper measurement preparation/technique

• Confirm recommended monitoring protocol

– Mean of 12-28 measurements, bid over 3-7 days

• Confirm medication adherence: self-report, refills

• Other reasons for BP?

– Avoid measurement when think it elevated!

Clinic Goal Home Goal

Most pts < 140/90 < 135/85

DM or CKD < 130/80 < 130/80 (?)

ADJUSTMENT OF HTN RX BY TEAM

Who should adjust HTN Rx? • Clinician Source of therapeutic inertia • Team HTN control rates

– RN/Pharm D using pre-set algorithm

• Patient self-titration HTN control rates – TASMINH2 RCT: safe, effective

Pre-set algorithm Telemonitoring to keep close track

When to adjust HTN Rx? – 2 to 4 wks after medication change

Lancet 2010; 376:163 Am J Hypertens 2011; 24:989 Am J Med 2010; 42:371

HBPM: POTENTIAL FOR GOOD IN TRIALS – REAL WORLD?

Clinicians: • 75% “use” HBPM for HTN pts, BUT…

– 25% use HBPM to aid Dx in borderline HTN – 33% use HBPM to modify HTN Rx – 17% minimally abide by guidelines for implementation

Patients: • 40-60% of U.S. HTN households have cuff, BUT…

– 70% “use” it 25% follow appropriate guidelines for use

– 30-60% communicate BP to clinician – 29% have had cuff accuracy checked – 30% instructed how to correctly use HBPM

J Hypertens 2011; 29:2105 JABFM 2011; 24:370 J Hypertens 2009; 27:275 Can J Card 2010; 26:e152