1 00:00:05,472 --> 00:00:08,242 GOOD MORNING AND WELCOME TO 2 00:00:08,242 --> 00:00:09,209 THE NHLBI WORKSHOP ON BLOOD 3 00:00:09,209 --> 00:00:12,179 PRESSURE ASSESSMENT ACROSS THE 4 00:00:12,179 --> 00:00:13,547 LIFESPAN, TO IMPROVE CLINICAL 5 00:00:13,547 --> 00:00:14,982 RESEARCH AND CLINICAL PRACTICE. 6 00:00:14,982 --> 00:00:18,819 NEXT SLIDE 7 00:00:18,819 --> 00:00:21,455 THE WORKSHOP IS SPONSORED BY THE 8 00:00:21,455 --> 00:00:24,524 DIVISION OF CARDIOVASCULAR 9 00:00:24,524 --> 00:00:25,058 SCIENCES. 10 00:00:25,058 --> 00:00:28,662 IT ORIGINATED IN THE NHLBI 11 00:00:28,662 --> 00:00:30,530 STRATEGIC VISIONING 12 00:00:30,530 --> 00:00:32,533 IMPLEMENTATION GROUP FOCUSED ON 13 00:00:32,533 --> 00:00:34,134 HYPERTENSION, AND IT'S A 14 00:00:34,134 --> 00:00:37,404 FOLLOW-UP TO THE NHLBI WORKSHOP 15 00:00:37,404 --> 00:00:43,677 CONVENED IN 2017. 16 00:00:43,677 --> 00:00:45,579 THE WORKSHOP'S OBJECTIVES 17 00:00:45,579 --> 00:00:47,080 INCLUDE ASSESSMENT OF THE 18 00:00:47,080 --> 00:00:49,716 CURRENT STATE OF KNOWLEDGE AND 19 00:00:49,716 --> 00:00:51,985 IDENTIFICATION OF THE KNOWLEDGE 20 00:00:51,985 --> 00:00:53,954 GAPS, AS WELL AS REVIEW OF THE 21 00:00:53,954 --> 00:00:55,722 ONGOING RESEARCH AND 22 00:00:55,722 --> 00:00:57,357 IDENTIFICATION OF RESEARCH NEEDS 23 00:00:57,357 --> 00:00:58,792 TO IMPROVE BLOOD PRESSURE 24 00:00:58,792 --> 00:01:00,427 ASSESSMENT IN CLINICAL PRACTICE 25 00:01:00,427 --> 00:01:06,533 AND CLINICAL RESEARCH. 26 00:01:06,533 --> 00:01:09,603 THE WORKSHOP IS CHAIRED BY TWO 27 00:01:09,603 --> 00:01:10,704 DISTINGUISHED EXPERTS IN THE 28 00:01:10,704 --> 00:01:12,239 FIELD OF BLOOD PRESSURE 29 00:01:12,239 --> 00:01:14,775 MEASUREMENT AND BEYOND, 30 00:01:14,775 --> 00:01:16,777 DR. MARWAH ABDALLA FROM COLUMBIA 31 00:01:16,777 --> 00:01:18,245 UNIVERSITY AND DR. STEPHEN 32 00:01:18,245 --> 00:01:20,547 JURASCHEK FROM HARVARD 33 00:01:20,547 --> 00:01:21,882 UNIVERSITY, FROM WHOM YOU WILL 34 00:01:21,882 --> 00:01:24,151 HEAR AFTER THE OPENING REMARKS 35 00:01:24,151 --> 00:01:28,422 FROM THE NHLBI LEADERSHIP. 36 00:01:28,422 --> 00:01:34,227 NEXT SLIDE. 37 00:01:34,227 --> 00:01:36,063 I WOULD LIKE TO TAKE THIS 38 00:01:36,063 --> 00:01:39,900 OPPORTUNITY TO SEND THE DCVS 39 00:01:39,900 --> 00:01:41,101 LEADERSHIP -- TO THANK THEM FOR 40 00:01:41,101 --> 00:01:44,604 THEIR SUPPORT OF THE WORKSHOP 41 00:01:44,604 --> 00:01:47,574 AND TO ALSO THANK THE WORKSHOP 42 00:01:47,574 --> 00:01:50,744 PLANNING COMMITTEE, RAVI, 43 00:01:50,744 --> 00:01:54,247 PATRICE, JASMINA AND MICHAEL FOR 44 00:01:54,247 --> 00:01:55,749 THEIR DAILY CONTRIBUTIONS TO THE 45 00:01:55,749 --> 00:01:56,850 WORKSHOP PREPARATION ACTIVITIES. 46 00:01:56,850 --> 00:01:58,618 NOW LET ME TURN IT OVER TO 47 00:01:58,618 --> 00:01:59,786 DR. GOFF, DIRECTOR OF THE NHLBI 48 00:01:59,786 --> 00:02:01,355 DIVISION OF CARDIOVASCULAR 49 00:02:01,355 --> 00:02:04,958 SCIENCES. 50 00:02:04,958 --> 00:02:07,894 >> THANK YOU, DR. EINHORN. 51 00:02:07,894 --> 00:02:10,664 THANK YOU FOR PROVIDING ME WITH 52 00:02:10,664 --> 00:02:14,267 AN OPPORTUNITY TO SHARE A FEW 53 00:02:14,267 --> 00:02:16,536 WORDS WITH THE WORKSHOP 54 00:02:16,536 --> 00:02:17,104 PARTICIPANTS. 55 00:02:17,104 --> 00:02:20,807 I WANT TO START BY THANKING THE 56 00:02:20,807 --> 00:02:22,776 WORKSHOP TEAM, AS DR. EINHORN 57 00:02:22,776 --> 00:02:24,444 HAS ALREADY DONE, AND ESPECIALLY 58 00:02:24,444 --> 00:02:35,222 THE CO-CHAIRS, DR. A ABDALLA AND 59 00:02:35,222 --> 00:02:36,456 APPRECIATE YOUR LEADERSHIP AND 60 00:02:36,456 --> 00:02:37,424 PUTTING TOGETHER THIS 61 00:02:37,424 --> 00:02:39,192 OUTSTANDING WORKSHOP AGENDA AND 62 00:02:39,192 --> 00:02:40,594 SCHEDULE AND PRESENTERS. 63 00:02:40,594 --> 00:02:41,695 REALLY LOOKING FORWARD TO THE 64 00:02:41,695 --> 00:02:42,896 INPUT THAT WE GET FROM YOU FROM 65 00:02:42,896 --> 00:02:44,331 THIS WORKSHOP. 66 00:02:44,331 --> 00:02:47,167 AS DR. EINHORN SAID, 67 00:02:47,167 --> 00:02:49,136 HYPERTENSION IS VERY IMPORTANT 68 00:02:49,136 --> 00:02:52,305 TO THE STRATEGIC VISION AND 69 00:02:52,305 --> 00:02:54,174 IMPLEMENTATION PLAN IN THE 70 00:02:54,174 --> 00:02:55,042 DIVISION OF CARDIOVASCULAR 71 00:02:55,042 --> 00:02:55,375 SCIENCES. 72 00:02:55,375 --> 00:02:59,846 AS YO YOU NO DOUBT KNOW, HIGH BD 73 00:02:59,846 --> 00:03:01,048 PRESSURE IS THE LEADING CAUSE OF 74 00:03:01,048 --> 00:03:02,382 DEATH AND DISABILITY ON THIS 75 00:03:02,382 --> 00:03:03,250 PLANET. 76 00:03:03,250 --> 00:03:05,452 NOW I SOMETIMES SAY, WELL, 77 00:03:05,452 --> 00:03:07,120 THAT'S JUST THIS PLANET, BUT IT 78 00:03:07,120 --> 00:03:08,822 OUGHT TO COUNT FOR SOMETHING. 79 00:03:08,822 --> 00:03:12,559 AND SO IT'S CENTRAL TO OUR 80 00:03:12,559 --> 00:03:15,595 STRATEGIC VISION THAT WE FOCUS 81 00:03:15,595 --> 00:03:18,231 ON WAYS IN WHICH WE CAN 82 00:03:18,231 --> 00:03:21,435 ELIMINATE HYPERTENSION-RELATED 83 00:03:21,435 --> 00:03:23,470 CARDIOVASCULAR DISEASE, AND WE 84 00:03:23,470 --> 00:03:24,571 HOPE ONE DAY ELIMINATE 85 00:03:24,571 --> 00:03:30,377 HYPERTENSION ITSELF. 86 00:03:30,377 --> 00:03:32,012 NOW ALONG THE WAY, IT'S CRITICAL 87 00:03:32,012 --> 00:03:33,747 TO IMPROVE THE CONSISTENCY AND 88 00:03:33,747 --> 00:03:36,716 QUALITY OF BLOOD PRESSURE 89 00:03:36,716 --> 00:03:38,018 MEASUREMENT IN CLINICAL RESEARCH 90 00:03:38,018 --> 00:03:39,786 AND PRACTICE. 91 00:03:39,786 --> 00:03:42,389 I'M OLD ENOUGH TO REMEMBER THE 92 00:03:42,389 --> 00:03:51,798 DAYS OF THE RANDOM 93 00:03:51,798 --> 00:03:54,434 0SFIGHMANOMETER AND MERCURY 94 00:03:54,434 --> 00:03:55,535 MANOMETERS, AND THE EFFORT THAT 95 00:03:55,535 --> 00:03:59,239 HAS GONE INTO STANDARDIZING AND 96 00:03:59,239 --> 00:03:59,773 IMPROVING BLOOD PRESSURE 97 00:03:59,773 --> 00:04:01,108 QUALITY, REALLY DATING OVER THE 98 00:04:01,108 --> 00:04:02,309 DECADES, AND THE CHALLENGE IS 99 00:04:02,309 --> 00:04:03,743 STILL NOT COMPLETELY ADDRESSED. 100 00:04:03,743 --> 00:04:05,278 NEW TECHNOLOGIES WILL HELP US, 101 00:04:05,278 --> 00:04:08,548 BUT ONLY IF USED APPROPRIATELY. 102 00:04:08,548 --> 00:04:10,951 I'M ALSO OLD ENOUGH TO HAVE BEEN 103 00:04:10,951 --> 00:04:11,818 INVOLVED IN THE SPRINT STUDY 104 00:04:11,818 --> 00:04:17,958 BEFORE I CAME TO NHLBI. 105 00:04:17,958 --> 00:04:21,962 AND WHEN SPRINT WAS PUBLISHED, 106 00:04:21,962 --> 00:04:25,599 ONE OF THE COMMENTS THAT WE 107 00:04:25,599 --> 00:04:26,800 FREQUENTLY HEARD WAS THAT, WELL, 108 00:04:26,800 --> 00:04:28,335 WE CAN'T MEASURE BLOOD PRESSURE 109 00:04:28,335 --> 00:04:29,870 IN CLINICAL PRACTICE THE WAY YOU 110 00:04:29,870 --> 00:04:31,071 MEASURED IT IN SPRINT, WE DON'T 111 00:04:31,071 --> 00:04:32,606 HAVE THE TIME, WE DON'T HAVE THE 112 00:04:32,606 --> 00:04:34,708 STAFF, WE DON'T HAVE THE ABILITY 113 00:04:34,708 --> 00:04:39,479 TO DO THAT, AND WE THINK OUR WAY 114 00:04:39,479 --> 00:04:41,248 OF MEASURING BLOOD PRESSURE IN 115 00:04:41,248 --> 00:04:42,449 CLINICAL PRACTICE GIVES US 116 00:04:42,449 --> 00:04:43,216 DIFFERENT RESULTS AND SO WE 117 00:04:43,216 --> 00:04:45,285 THINK WE'RE ALREADY DOING AS 118 00:04:45,285 --> 00:04:47,787 GOOD A JOB OF MANAGING BLOOD 119 00:04:47,787 --> 00:04:48,889 PRESSURE AS YOU WOULD WANT US TO 120 00:04:48,889 --> 00:04:50,223 DO BASED ON SPRINT. 121 00:04:50,223 --> 00:04:53,493 WE JUST DON'T MEASURE BLOOD 122 00:04:53,493 --> 00:04:54,594 PRESSURE AS WELL. 123 00:04:54,594 --> 00:04:56,897 THAT WAS A DISAPPOINTING 124 00:04:56,897 --> 00:04:57,230 COMMENT. 125 00:04:57,230 --> 00:04:58,532 PROBABLY MANY OF YOU HEARD 126 00:04:58,532 --> 00:05:01,468 SOMETHING LIKE THAT AS WELL. 127 00:05:01,468 --> 00:05:03,336 MAYBE I'VE RAISED IT A LITTLE 128 00:05:03,336 --> 00:05:05,205 BIT INARTFULLY, BUT I THINK IT 129 00:05:05,205 --> 00:05:06,606 WAS SOMETHING ALONG THAT LINE. 130 00:05:06,606 --> 00:05:13,947 AND I FIND IT CHALLENGING THAT A 131 00:05:13,947 --> 00:05:15,582 RESPONSE TO REALLY A 132 00:05:15,582 --> 00:05:17,017 GROUNDBREAKING TRIAL THAT SHOWS 133 00:05:17,017 --> 00:05:20,720 THE IMPORTANCE OF CONTROLLING 134 00:05:20,720 --> 00:05:23,924 BLOOD PRESSURE TO LOWER LEVELS 135 00:05:23,924 --> 00:05:25,425 WOULD BE FROM SOME THAT, WELL, 136 00:05:25,425 --> 00:05:27,294 WE JUST CAN'T TAKE THE TIME TO 137 00:05:27,294 --> 00:05:28,495 MEASURE BLOOD PRESSURE WHILE IN 138 00:05:28,495 --> 00:05:30,130 CLINICAL PRACTICE. 139 00:05:30,130 --> 00:05:31,131 WHEN HIGH BLOOD PRESSURE IS THE 140 00:05:31,131 --> 00:05:32,098 LEADING CAUSE OF DEATH AND 141 00:05:32,098 --> 00:05:34,301 DISABILITY ON THE PLANET. 142 00:05:34,301 --> 00:05:35,835 AND THAT SHOULD COUNT FOR 143 00:05:35,835 --> 00:05:38,004 SOMETHING. 144 00:05:38,004 --> 00:05:39,005 SO REALLY LOOKING FORWARD TO 145 00:05:39,005 --> 00:05:40,974 YOUR INPUT, BECAUSE THIS ISSUE 146 00:05:40,974 --> 00:05:42,409 REMAINS CRITICALLY IMPORTANT. 147 00:05:42,409 --> 00:05:44,344 HOW DO WE IMPROVE BLOOD PRESSURE 148 00:05:44,344 --> 00:05:46,880 MEASUREMENT QUALITY AND 149 00:05:46,880 --> 00:05:48,081 CONSISTENCY IN CLINICAL RESEARCH 150 00:05:48,081 --> 00:05:50,183 AND CLINICAL PRACTICE SO THAT WE 151 00:05:50,183 --> 00:05:53,553 CAN CONTINUE TO MAKE PROGRESS ON 152 00:05:53,553 --> 00:05:54,654 HYPERTENSION, DETECTION, 153 00:05:54,654 --> 00:05:56,223 TREATMENT AND CONTROL, AND IN 154 00:05:56,223 --> 00:05:58,925 THE LONG RUN, PREVENTION OF HIGH 155 00:05:58,925 --> 00:06:01,728 BLOOD PRESSURE IN THE FIRST 156 00:06:01,728 --> 00:06:02,295 PLACE. 157 00:06:02,295 --> 00:06:03,630 IT'S CRITICAL TO THE MISSION OF 158 00:06:03,630 --> 00:06:04,030 OUR DIVISION. 159 00:06:04,030 --> 00:06:05,999 I ALSO WANT TO MAKE A PLUG FOR 160 00:06:05,999 --> 00:06:07,634 THE CENTER FOR TRANSLATION 161 00:06:07,634 --> 00:06:09,169 RESEARCH AND IMPLEMENTATION 162 00:06:09,169 --> 00:06:10,737 SCIENCE, A SISTER DIVISION TO 163 00:06:10,737 --> 00:06:12,472 THE DIVISION OF CARDIOVASCULAR 164 00:06:12,472 --> 00:06:18,511 SCIENCES AT NHLBI. 165 00:06:18,511 --> 00:06:19,813 THEY ALSO, WITHIN THEIR 166 00:06:19,813 --> 00:06:21,114 STRATEGIC VISION, ARE HIGHLY, 167 00:06:21,114 --> 00:06:23,283 HIGHLY COMMITTED TO SUPPORTING 168 00:06:23,283 --> 00:06:24,184 IMPLEMENTATION SCIENCE THAT'S 169 00:06:24,184 --> 00:06:27,220 FOCUSED ON IMPROVING CONTROL OF 170 00:06:27,220 --> 00:06:29,089 HIGH BLOOD PRESSURE USING 171 00:06:29,089 --> 00:06:30,257 EVIDENCE-BASED APPROACHES, AS 172 00:06:30,257 --> 00:06:31,558 WELL AS IMPROVING PREVENTION OF 173 00:06:31,558 --> 00:06:33,793 HIGH BLOOD PRESSURE USING 174 00:06:33,793 --> 00:06:34,561 EVIDENCE-BASED APPROACHES. 175 00:06:34,561 --> 00:06:38,732 SO I HOPE THAT THIS WORKSHOP 176 00:06:38,732 --> 00:06:40,734 WILL BE AS EXCITING FOR YOU AS 177 00:06:40,734 --> 00:06:42,335 IT IS FOR US. 178 00:06:42,335 --> 00:06:44,237 I HOPE AT THE END OF IT, YOU'LL 179 00:06:44,237 --> 00:06:47,140 GO AWAY WITH NEW IDEAS FOR NEW 180 00:06:47,140 --> 00:06:49,209 RESEARCH PROJECTS THAT YOU WILL 181 00:06:49,209 --> 00:06:53,146 SUBMIT TO US FOR CONSIDERATION. 182 00:06:53,146 --> 00:06:55,215 AS YOU PROBABLY KNOW, THE VAST 183 00:06:55,215 --> 00:06:58,618 MAJORITY OF THE RESOURCES THAT 184 00:06:58,618 --> 00:07:03,757 WE GET FROM THE TAXPAYERS AND 185 00:07:03,757 --> 00:07:07,260 THE BUDGET GO TO 186 00:07:07,260 --> 00:07:08,228 INVESTIGATOR-INITIATED PEER 187 00:07:08,228 --> 00:07:09,129 REVIEWED DISCOVERY SCIENCE 188 00:07:09,129 --> 00:07:12,732 APPLICATIONS. 189 00:07:12,732 --> 00:07:16,102 AND WE HOPE YOU WILL SUBMIT 190 00:07:16,102 --> 00:07:17,203 APPLICATIONS STIMULATED BY THE 191 00:07:17,203 --> 00:07:18,171 DISCUSSIONS THAT OCCUR DURING 192 00:07:18,171 --> 00:07:22,575 THIS WORKSHOP. 193 00:07:22,575 --> 00:07:23,777 OTHER OUTPUT OF THIS WORKSHOP 194 00:07:23,777 --> 00:07:24,878 WILL INCLUDE AN EXECUTIVE 195 00:07:24,878 --> 00:07:25,945 SUMMARY THAT WILL BE ON OUR 196 00:07:25,945 --> 00:07:27,147 WEBSITE. 197 00:07:27,147 --> 00:07:28,448 IT'S OUR HOPE THAT YOU'LL GET 198 00:07:28,448 --> 00:07:29,349 THAT EXECUTIVE SUMMARY DONE 199 00:07:29,349 --> 00:07:34,854 WITHIN A MONTH OR TWO, SO IT CAN 200 00:07:34,854 --> 00:07:36,356 BE POSTED IN A TIMELY MANNER. 201 00:07:36,356 --> 00:07:37,924 YOU MAY ALSO DECIDE THAT YOU 202 00:07:37,924 --> 00:07:41,194 WANT TO WRITE A WHITE PAPER FOR 203 00:07:41,194 --> 00:07:42,395 CONSIDERATION OF PUBLICATION IN 204 00:07:42,395 --> 00:07:43,430 A PEER-REVIEWED JOURNAL. 205 00:07:43,430 --> 00:07:44,898 IF YOU DECIDE YOU WANT TO DO 206 00:07:44,898 --> 00:07:46,966 THAT, WE WILL SUPPORT THAT. 207 00:07:46,966 --> 00:07:48,201 AND IF YOU DO THAT, WE WOULD 208 00:07:48,201 --> 00:07:49,703 HOPE THAT THAT HAPPENS IN A 209 00:07:49,703 --> 00:07:52,572 TIMELY MANNER TOO IN A MATTER OF 210 00:07:52,572 --> 00:07:54,841 MONTHS, NOT YEARS, SO THAT IT 211 00:07:54,841 --> 00:07:57,811 GETS OUT IN A TIMELY MANNER. 212 00:07:57,811 --> 00:07:59,245 AND THERE MAY ALSO BE FUNDING 213 00:07:59,245 --> 00:08:00,447 OPPORTUNITIES THAT RESULT FROM 214 00:08:00,447 --> 00:08:04,250 YOUR RECOMMENDATIONS. 215 00:08:04,250 --> 00:08:05,251 I'LL JUST SAY THAT DOESN'T 216 00:08:05,251 --> 00:08:06,252 ALWAYS HAPPEN BECAUSE WE HAVE 217 00:08:06,252 --> 00:08:09,556 MORE WORKSHOPS ON AN ANNUAL 218 00:08:09,556 --> 00:08:13,326 BASIS THAN WE CAN SUPPORT 219 00:08:13,326 --> 00:08:13,793 STRATEGIC INITIATIVES. 220 00:08:13,793 --> 00:08:16,863 BUT WE'LL TAKE YOUR INPUT INTO 221 00:08:16,863 --> 00:08:19,265 CONSIDERATION AND THERE MAY BE 222 00:08:19,265 --> 00:08:20,400 STRATEGIC INITIATIVES THAT COME 223 00:08:20,400 --> 00:08:22,435 OUT OF YOUR RECOMMENDATIONS. 224 00:08:22,435 --> 00:08:26,139 SO FOR ALL THOSE REASONS, WE 225 00:08:26,139 --> 00:08:26,906 REALLY APPRECIATE YOU BEING HERE 226 00:08:26,906 --> 00:08:27,240 TODAY. 227 00:08:27,240 --> 00:08:28,675 WE KNOW THERE ARE MANY WAYS YOU 228 00:08:28,675 --> 00:08:30,844 COULD HAVE CHOSEN TO SPEND YOUR 229 00:08:30,844 --> 00:08:31,845 TIME. 230 00:08:31,845 --> 00:08:33,146 WE'RE GRATEFUL THAT YOU CHOSE TO 231 00:08:33,146 --> 00:08:35,448 SPEND SOME TIME WITH US. 232 00:08:35,448 --> 00:08:37,083 AND TO GIVE US THE BENEFIT OF 233 00:08:37,083 --> 00:08:37,784 YOUR INPUT. 234 00:08:37,784 --> 00:08:39,819 SO THANKS SO MUCH. 235 00:08:39,819 --> 00:08:42,222 AND I'LL PASS THE BATON BACK TO 236 00:08:42,222 --> 00:08:52,432 DR. EINHORN. 237 00:08:54,100 --> 00:08:57,103 >> ACTUALLY, IT'S PASSING IT ON 238 00:08:57,103 --> 00:09:01,341 TO DR. JURASCHEK FOR THE NEXT 239 00:09:01,341 --> 00:09:02,475 ITEM ON OUR AGENDA. 240 00:09:02,475 --> 00:09:03,877 >> THANK YOU SO MUCH FOR THAT 241 00:09:03,877 --> 00:09:07,147 VERY INSPIRING INTRODUCTION, 242 00:09:07,147 --> 00:09:09,616 PAUL AND DR. GOFF. 243 00:09:09,616 --> 00:09:15,055 IT'S A REAL HONOR TO CO-CHAIR 244 00:09:15,055 --> 00:09:20,193 THIS WORKSHOP WITH MY ESTEEMED 245 00:09:20,193 --> 00:09:22,162 COLLEAGUE, DR. ABDULLAH. 246 00:09:22,162 --> 00:09:22,929 THE 2017 WORKSHOP WAS SOMETHING 247 00:09:22,929 --> 00:09:24,564 I WAS ABLE TO PARTICIPATE IN AS 248 00:09:24,564 --> 00:09:25,498 AN EARLY STAGE INVESTIGATOR AND 249 00:09:25,498 --> 00:09:30,570 IT WAS REAL REALLY AN INSTRUMENL 250 00:09:30,570 --> 00:09:31,671 DISCUSSION AND LEARNING 251 00:09:31,671 --> 00:09:32,872 OPPORTUNITY FOR ME IN TERMS OF 252 00:09:32,872 --> 00:09:35,175 FRAMING MY RESEARCH, SO I 253 00:09:35,175 --> 00:09:38,878 SINCERELY HOPE THAT THIS EVENT 254 00:09:38,878 --> 00:09:40,213 OVER THE NEXT TWO DAYS HAS THE 255 00:09:40,213 --> 00:09:41,848 SAME KIND OF IMPACT ON ALL OF 256 00:09:41,848 --> 00:09:43,650 OUR LISTENERS AND DISCUSSANTS, 257 00:09:43,650 --> 00:09:45,985 SO I'M REALLY DELIGHTED TO HELP 258 00:09:45,985 --> 00:09:52,025 FACILITATE THIS 2024 UPDATE. 259 00:09:52,025 --> 00:09:53,760 AND SO THESE ARE MY DISCLOSURES. 260 00:09:53,760 --> 00:09:55,728 I AM SUPPORTED BY THE NIH AND 261 00:09:55,728 --> 00:09:57,831 THE AMERICAN HEART ASSOCIATION. 262 00:09:57,831 --> 00:09:59,332 AND I'LL BE FOCUSING ON THE 263 00:09:59,332 --> 00:10:02,969 SUMMARY OF WHAT WAS 264 00:10:02,969 --> 00:10:04,137 ACCOMPLISHED, BIG PICTURE VIEW, 265 00:10:04,137 --> 00:10:05,238 IN 2017 AND ALSO WHERE I THINK 266 00:10:05,238 --> 00:10:07,974 THE STATE OF THE EVIDENCE IS 267 00:10:07,974 --> 00:10:09,309 WITH RESPECT TO SOME OF THE 268 00:10:09,309 --> 00:10:10,176 RECOMMENDATIONS MADE BY THAT 269 00:10:10,176 --> 00:10:11,377 WORKING GROUP. 270 00:10:11,377 --> 00:10:16,216 I'LL NOTE UP FRONT THAT THIS 271 00:10:16,216 --> 00:10:17,717 ISN'T COMPREHENSIVE, AND I 272 00:10:17,717 --> 00:10:19,586 WELCOME EMAILS AND CONTACT FROM 273 00:10:19,586 --> 00:10:21,020 BOTH LISTENERS AND DISCUSSANTS 274 00:10:21,020 --> 00:10:22,856 FROM KEY PAPERS, IF THERE ARE 275 00:10:22,856 --> 00:10:24,624 SOME BLARING OVERSIGHTS. 276 00:10:24,624 --> 00:10:27,227 SO I'D LOVE TO FLESH THIS STATE 277 00:10:27,227 --> 00:10:31,764 OF THE SCIENCE OUT. 278 00:10:31,764 --> 00:10:35,802 SO IN THINKING ABOUT THE 2017 279 00:10:35,802 --> 00:10:38,171 WORKSHOP, THERE'S A REALLY NICE 280 00:10:38,171 --> 00:10:41,774 SUMMARY NICE SUMMARY WHITE PAPER 281 00:10:41,774 --> 00:10:44,978 BY MUNTNER PUBLISHED IN 2019 282 00:10:44,978 --> 00:10:45,879 THAT I HAVE PRESENTED HERE. 283 00:10:45,879 --> 00:10:47,480 WHAT THE WORKSHOP SOUGHT TO 284 00:10:47,480 --> 00:10:49,015 ACCOMPLISH AND I THINK DID QUITE 285 00:10:49,015 --> 00:10:50,450 WELL WAS EVALUATE THE CURRENT 286 00:10:50,450 --> 00:10:51,851 STATE OF KNOWLEDGE ON BLOOD 287 00:10:51,851 --> 00:10:53,586 PRESSURE ASSESSMENT AND CLINICAL 288 00:10:53,586 --> 00:10:54,921 PRACTICE AND RESEARCH FOR 289 00:10:54,921 --> 00:10:56,222 DIAGNOSING HYPERTENSION AND 290 00:10:56,222 --> 00:10:57,590 EVALUATING TREATMENT RESPONSE. 291 00:10:57,590 --> 00:10:58,625 ANOTHER OBJECTIVE WAS TO 292 00:10:58,625 --> 00:10:59,392 IDENTIFY KNOWLEDGE GAPS 293 00:10:59,392 --> 00:11:00,793 PERTAINING TO CURRENT 294 00:11:00,793 --> 00:11:01,928 BROMOPROPANE ASSESSMENT, AND 295 00:11:01,928 --> 00:11:02,729 EVALUATE RESEARCH AND CLINICAL 296 00:11:02,729 --> 00:11:05,064 NEEDS TO IMPROVE BLOOD PRESSURE 297 00:11:05,064 --> 00:11:08,034 MEASUREMENT, AND THEN USE BLOOD 298 00:11:08,034 --> 00:11:09,002 PRESSURE -- EXPLORE WAYS OF 299 00:11:09,002 --> 00:11:10,537 USING BLOOD PRESSURE OBTAINED IN 300 00:11:10,537 --> 00:11:11,471 CLINICAL PRACTICE FOR RESEARCH 301 00:11:11,471 --> 00:11:12,639 AND QUALITY IMPROVEMENT 302 00:11:12,639 --> 00:11:21,414 ACTIVITIES. 303 00:11:21,414 --> 00:11:25,652 SO THIS IS THE KEY FIGURE THAT 304 00:11:25,652 --> 00:11:26,519 RESULTED FROM THE WORKSHOP. 305 00:11:26,519 --> 00:11:30,957 I THINK IT WAS REALLY A GREAT 306 00:11:30,957 --> 00:11:33,092 CRYSTALLIZATION OF THREE PRIMARY 307 00:11:33,092 --> 00:11:35,261 MODALITIES FOR ASSESSING BLOOD 308 00:11:35,261 --> 00:11:37,897 PRESSURES, THEIR DESCRIPTION, 309 00:11:37,897 --> 00:11:39,265 GUIDELINE CONCORDANT PERFORMANCE 310 00:11:39,265 --> 00:11:40,400 STRENGTHS IN TERMS OF EVIDENCE 311 00:11:40,400 --> 00:11:42,035 WITH RESPECT TO THE THREE 312 00:11:42,035 --> 00:11:45,672 MODALITIES: CLINIC, HOME, 313 00:11:45,672 --> 00:11:46,739 SELF-MONITORED AND AMBULATORY, 314 00:11:46,739 --> 00:11:47,840 AND THEN SOME WEAKNESSES WHERE 315 00:11:47,840 --> 00:11:48,975 THERE COULD BE ADDITIONAL 316 00:11:48,975 --> 00:11:49,275 RESEARCH. 317 00:11:49,275 --> 00:11:51,244 AND THE TWO PRIMARY TOPICS OR 318 00:11:51,244 --> 00:11:52,545 QUESTIONS ADDRESSED WERE, ONE, 319 00:11:52,545 --> 00:11:53,479 HOW DIFFERENT MEASUREMENT 320 00:11:53,479 --> 00:11:55,615 METHODS CAN BE INTEGRATED INTO 321 00:11:55,615 --> 00:11:56,583 CLINIC-BASED RESEARCH AND 322 00:11:56,583 --> 00:11:58,351 ROUTINE CLINICAL PRACTICE TO 323 00:11:58,351 --> 00:11:59,886 PERFORM ACCURATE BLOOD PRESSURE 324 00:11:59,886 --> 00:12:01,287 ASSESSMENTS, AND HOW THE QUALITY 325 00:12:01,287 --> 00:12:02,822 OF BLOOD PRESSURE MEASUREMENTS 326 00:12:02,822 --> 00:12:04,090 OBTAINED IN ROUTINE CLINICAL 327 00:12:04,090 --> 00:12:06,225 PRACTICE CAN BE IMPROVED TO 328 00:12:06,225 --> 00:12:07,093 PROVIDE BETTER PATIENT CARE AND 329 00:12:07,093 --> 00:12:08,861 TO BE SUITABLE FOR CLINIC-BASED 330 00:12:08,861 --> 00:12:16,669 RESEARCH. 331 00:12:16,669 --> 00:12:18,805 OTHER KEY CONTRIBUTIONS INCLUDED 332 00:12:18,805 --> 00:12:22,208 A FOCUS ON SPECIAL POPULATIONS, 333 00:12:22,208 --> 00:12:24,143 SO THERE WAS A LOT OF 334 00:12:24,143 --> 00:12:25,244 DISCUSSION, AND I WONDER IF 335 00:12:25,244 --> 00:12:26,446 THERE MIGHT BE A SLIDE RIGHT 336 00:12:26,446 --> 00:12:27,013 BEFORE THIS. 337 00:12:27,013 --> 00:12:28,548 COULD WE JUST GO BACK ONE? 338 00:12:28,548 --> 00:12:35,421 APOLOGIZE. 339 00:12:35,421 --> 00:12:35,688 YES, OKAY. 340 00:12:35,688 --> 00:12:36,522 SO ONE OF THE KEY CONTRIBUTIONS 341 00:12:36,522 --> 00:12:37,624 OF THE WORKING GROUP WAS TO 342 00:12:37,624 --> 00:12:40,493 PROVIDE A CONCISE SEUM REOF 343 00:12:40,493 --> 00:12:42,629 BLOOD PRESSURE MEASUREMENTS, ITS 344 00:12:42,629 --> 00:12:43,396 HISTORY, MODALITIES, BEST 345 00:12:43,396 --> 00:12:45,064 PRACTICE, DETAILED DISCUSSION OF 346 00:12:45,064 --> 00:12:46,699 SOURCES OF BIAS, AND PRACTICES 347 00:12:46,699 --> 00:12:49,402 IN TERMS OF ELECTRONIC RECORD 348 00:12:49,402 --> 00:12:49,736 DOCUMENTATION. 349 00:12:49,736 --> 00:12:51,738 AND THEN THERE WAS A REALLY 350 00:12:51,738 --> 00:12:53,339 CLEAR DELINEATION OF BLOOD 351 00:12:53,339 --> 00:12:55,441 PRESSURE DISCORDANT STATES. 352 00:12:55,441 --> 00:12:56,242 PROBABLY ONE OF THE KEY FIGURES 353 00:12:56,242 --> 00:12:59,612 IN THE WORKING PAPER, BUT REALLY 354 00:12:59,612 --> 00:13:02,115 GREAT DISCUSSION ON HOW TO 355 00:13:02,115 --> 00:13:08,121 HANDLE AN APPROACH, WHITE COAT 356 00:13:08,121 --> 00:13:10,857 HYPERTENSION, SUSTAINED 357 00:13:10,857 --> 00:13:11,324 HYPERTENSION. 358 00:13:11,324 --> 00:13:12,925 THERE WAS ALSO A DISCUSSION OF 359 00:13:12,925 --> 00:13:14,127 SPECIAL POPULATIONS SO OLDER 360 00:13:14,127 --> 00:13:15,995 ADULTS, SOME SPECIAL CONDITION, 361 00:13:15,995 --> 00:13:17,764 ORTHOSTATIC HYPOTENSION, 362 00:13:17,764 --> 00:13:19,399 OBESITY, ATRIAL FIBRILLATION AND 363 00:13:19,399 --> 00:13:19,932 PREGNANCY. 364 00:13:19,932 --> 00:13:22,135 THEN A DISCUSSION OF CLINIC AND 365 00:13:22,135 --> 00:13:23,436 RESEARCH BLOOD PRESSURE 366 00:13:23,436 --> 00:13:24,637 MEASUREMENT, HOW THEY COMPARED 367 00:13:24,637 --> 00:13:27,707 AND SOME DISCUSSION AROUND 368 00:13:27,707 --> 00:13:28,908 MINIMAL STANDARDS FOR PERFORMING 369 00:13:28,908 --> 00:13:30,143 RESEARCH WITH THESE DIFFERENT 370 00:13:30,143 --> 00:13:31,244 TYPES OF MEASUREMENTS. 371 00:13:31,244 --> 00:13:33,413 SO YOU CAN SEE COVERED A LOT OF 372 00:13:33,413 --> 00:13:34,814 GROUND, BUT THERE'S CERTAINLY 373 00:13:34,814 --> 00:13:36,015 SOME AREAS THAT ARE NOT PRESENT 374 00:13:36,015 --> 00:13:38,685 THAT WE HOPE TO ADDRESSED TO AND 375 00:13:38,685 --> 00:13:48,861 TOMORROW. 376 00:14:01,240 --> 00:14:11,484 SORRY, NEXT SLIDE? 377 00:14:15,788 --> 00:14:19,325 WELL, I'LL KEEP TALKING. 378 00:14:19,325 --> 00:14:21,394 AND SO -- 379 00:14:21,394 --> 00:14:22,829 >> HOLD ON ONE SECOND. 380 00:14:22,829 --> 00:14:23,496 MY COMPUTER FROZE. 381 00:14:23,496 --> 00:14:24,130 I'M SORRY ABOUT THAT. 382 00:14:24,130 --> 00:14:25,231 >> NO PROBLEM AT ALL. 383 00:14:25,231 --> 00:14:33,206 NO PROBLEM AT ALL. 384 00:14:33,206 --> 00:14:35,441 SO ANOTHER MAJOR, I THINK, 385 00:14:35,441 --> 00:14:36,375 CONTRIBUTION THAT WILL BE COMING 386 00:14:36,375 --> 00:14:38,377 UP FROM THE WORKING GROUP WAS A 387 00:14:38,377 --> 00:14:39,879 DETAILED LIST OF RECOMMENDATIONS 388 00:14:39,879 --> 00:14:42,749 TO FILL GAPS IN EVIDENCE. 389 00:14:42,749 --> 00:14:45,051 AND SO I'LL WALK EVERYONE 390 00:14:45,051 --> 00:14:46,018 THROUGH POINT BY POINT WHAT 391 00:14:46,018 --> 00:14:48,421 THOSE RECOMMENDATIONS WERE, AND 392 00:14:48,421 --> 00:14:50,056 WHERE I THINK THERE MIGHT BE 393 00:14:50,056 --> 00:14:51,357 SOME POTENTIAL GAPS THAT COULD 394 00:14:51,357 --> 00:14:52,592 BE ADDRESSED WITH THE COMING 395 00:14:52,592 --> 00:14:54,761 WORKING GROUP. 396 00:14:54,761 --> 00:14:55,328 MOVING FORWARD. 397 00:14:55,328 --> 00:14:57,630 AND SO THE FIRST -- IF WE GO 398 00:14:57,630 --> 00:15:04,270 BACK ONE SLIDE, RECOMMENDATION A 399 00:15:04,270 --> 00:15:05,471 WAS TO DETERMINE THE VARIATION 400 00:15:05,471 --> 00:15:06,372 IN BLOOD PRESSURE MEASUREMENT 401 00:15:06,372 --> 00:15:08,074 APPROACHES BEING USED IN ROUTINE 402 00:15:08,074 --> 00:15:08,975 CLINICAL PRACTICE ACROSS THE 403 00:15:08,975 --> 00:15:10,143 UNITED STATES AND IN CLINICAL 404 00:15:10,143 --> 00:15:11,277 RESEARCH PROTOCOLS. 405 00:15:11,277 --> 00:15:13,913 AND SO IF WE GO TO THE NEXT 406 00:15:13,913 --> 00:15:18,718 SLIDE, WE'LL SEE THAT THERE IS 407 00:15:18,718 --> 00:15:20,386 IS -- THIS IS AN OLDER STUDY 408 00:15:20,386 --> 00:15:21,854 PUBLISHED IN 2014 LOOKING AT 409 00:15:21,854 --> 00:15:23,189 DIFFERENT APPROACHES USED, 410 00:15:23,189 --> 00:15:24,524 THEY'RE ALL STANDARDIZED 411 00:15:24,524 --> 00:15:25,258 ASSESSMENTS OF BLOOD PRESSURE 412 00:15:25,258 --> 00:15:27,026 BUT USED IN CLINICAL TRIALS ON 413 00:15:27,026 --> 00:15:27,794 HYPERTENSION TREATMENT. 414 00:15:27,794 --> 00:15:29,562 AND I THINK THAT THIS IS AN AREA 415 00:15:29,562 --> 00:15:31,063 WHERE THERE COULD BE A FAIR 416 00:15:31,063 --> 00:15:33,499 AMOUNT MORE DONE TO CHARACTERIZE 417 00:15:33,499 --> 00:15:40,807 PRACTICES IN THE UNITED STATES. 418 00:15:40,807 --> 00:15:42,441 ONE, I THINK, IMPORTANT 419 00:15:42,441 --> 00:15:45,077 CONTRIBUTION THAT HAS COME UP 420 00:15:45,077 --> 00:15:46,846 SINCE THE LAST WORKSHOP WAS THE 421 00:15:46,846 --> 00:15:48,915 STATEMENT ON THIS STANDARDIZED 422 00:15:48,915 --> 00:15:49,882 CLINICAL BLOOD PRESSURE 423 00:15:49,882 --> 00:15:50,883 MEASUREMENT, A CALL TO ACTION, 424 00:15:50,883 --> 00:15:53,085 AND THIS WORKING GROUP OF 425 00:15:53,085 --> 00:15:54,253 INTERNATIONAL COLLEAGUES PUT 426 00:15:54,253 --> 00:15:55,688 TOGETHER A NUMBER OF VERY 427 00:15:55,688 --> 00:15:57,990 CONCISE EVIDENCE-BASED GUIDELINE 428 00:15:57,990 --> 00:16:00,193 CONCORDANT APPROACHES TO MEASURE 429 00:16:00,193 --> 00:16:02,028 BLOOD PRESSURE AND THEN ALSO TO 430 00:16:02,028 --> 00:16:03,229 PERFORM STANDARDIZED ASSESSMENTS 431 00:16:03,229 --> 00:16:05,865 IN CLINIC AND HAS A VERY NICE 432 00:16:05,865 --> 00:16:08,234 SUMMARY OF WHERE SOME ADDITIONAL 433 00:16:08,234 --> 00:16:18,744 RESEARCH COULD BE BENEFICIAL. 434 00:16:19,378 --> 00:16:20,313 WHERE THERE HAS BEEN REALLY GOOD 435 00:16:20,313 --> 00:16:22,915 OR A LOT OF WORK RECENTLY ON 436 00:16:22,915 --> 00:16:25,351 CHARACTERIZING PRACTICE IN THE 437 00:16:25,351 --> 00:16:28,187 UNITED STATES HAS BEEN AROUND 438 00:16:28,187 --> 00:16:29,155 CUFFS. 439 00:16:29,155 --> 00:16:32,859 SO THIS IS A NICE PAIM BASED ON 440 00:16:32,859 --> 00:16:38,364 NHANES THAT LOOKED AT ARM 441 00:16:38,364 --> 00:16:41,934 CIRCUMFERENCE, HOW THERE'S 442 00:16:41,934 --> 00:16:42,668 GROWING CONCERNS OR GROWING 443 00:16:42,668 --> 00:16:43,970 NEEDS FOR LARGER CUFF SIZES IN 444 00:16:43,970 --> 00:16:45,671 THE U.S. POPULATION, SO AGAIN, 445 00:16:45,671 --> 00:16:47,540 SOME CHARACTERIZATION OF NEEDS 446 00:16:47,540 --> 00:16:51,911 IN THE U.S. 447 00:16:51,911 --> 00:16:55,748 AND THEN THIS COMMUNICATION 448 00:16:55,748 --> 00:16:57,917 LOOKED AT CUFF SIZES FROM HOME 449 00:16:57,917 --> 00:17:00,386 DEVICES THAT ARE LISTED ON THE 450 00:17:00,386 --> 00:17:01,554 AMERICAN MEDICAL ASSOCIATION'S 451 00:17:01,554 --> 00:17:03,389 VALIDATED BLOOD PRESSURE DEVICE 452 00:17:03,389 --> 00:17:05,458 LISTING AND GIVES YOU A SENSE OF 453 00:17:05,458 --> 00:17:06,792 OKAY, MAYBE THIS ISN'T WHAT'S 454 00:17:06,792 --> 00:17:08,527 BEING USED BUT THIS IS WHAT'S 455 00:17:08,527 --> 00:17:12,531 RECOMMENDED FOR USE IN CLINICAL 456 00:17:12,531 --> 00:17:13,799 PRACTICE OR AT LEAST VALIDATED. 457 00:17:13,799 --> 00:17:16,536 YOU CAN SEE WHERE THERE'S A LOT 458 00:17:16,536 --> 00:17:17,737 OF GOOD COVERAGE IN TERMS OF 459 00:17:17,737 --> 00:17:19,705 CUFF SIZES BUT THEN MAYBE WHERE 460 00:17:19,705 --> 00:17:20,506 THERE'S SOME GAPS IN TERMS OF 461 00:17:20,506 --> 00:17:27,013 THE SMALLER AND LARGER RANGE. 462 00:17:27,013 --> 00:17:30,416 THEN IN THIS RECENT RESEARCH 463 00:17:30,416 --> 00:17:31,517 LETTER, THESE AUTHORS LOOKED AT 464 00:17:31,517 --> 00:17:32,652 WHAT'S SELLING MOST IN THE 465 00:17:32,652 --> 00:17:33,920 UNITED STATES ON AMAZON, AND 466 00:17:33,920 --> 00:17:36,656 THEY LOOKED AT CUFF RANGES AS 467 00:17:36,656 --> 00:17:37,156 WELL. 468 00:17:37,156 --> 00:17:38,958 SO IT DOESN'T QUITE GET AT THE 469 00:17:38,958 --> 00:17:40,593 QUESTION OF WHAT PRACTICES ARE 470 00:17:40,593 --> 00:17:42,695 IN PLACE, BUT I THINK WE HAVE AT 471 00:17:42,695 --> 00:17:44,397 LEAST MORE CLARIFICATION AROUND 472 00:17:44,397 --> 00:17:47,800 WHAT WOULD BE IDEAL IN CLINICAL 473 00:17:47,800 --> 00:17:49,235 PRACTICE AND IN TERMS OF HOME 474 00:17:49,235 --> 00:17:50,269 MONITORING, SOME OF WHAT'S 475 00:17:50,269 --> 00:17:51,404 AVAILABLE TO CONSUMERS AND WHAT 476 00:17:51,404 --> 00:17:57,209 PEOPLE ARE PURCHASING. 477 00:17:57,209 --> 00:17:58,844 SO SOME MORE WORK TO DO ON POINT 478 00:17:58,844 --> 00:17:59,979 A, BUT I THINK THERE HAS BEEN 479 00:17:59,979 --> 00:18:02,581 SOME PROGRESS. 480 00:18:02,581 --> 00:18:03,783 IN TERMS OF RECOMMENDATION B, 481 00:18:03,783 --> 00:18:04,984 IDENTIFY THE ASPECTS OF THE 482 00:18:04,984 --> 00:18:06,018 BLOOD PRESSURE MEASUREMENT 483 00:18:06,018 --> 00:18:07,420 PROTOCOL, FOR EXAMPLE, PRESENCE 484 00:18:07,420 --> 00:18:09,021 OF AN OBSERVER, DURATION OF WAIT 485 00:18:09,021 --> 00:18:11,223 TIME, THAT HAVE THE MOST 486 00:18:11,223 --> 00:18:12,625 SUBSTANTIAL IMPACT ON THE 487 00:18:12,625 --> 00:18:14,260 ACCURACY AND PRECISION OF 488 00:18:14,260 --> 00:18:15,461 CLINICAL BLOOD PRESSURE. 489 00:18:15,461 --> 00:18:16,662 THIS RESEARCH CAN GUIDE THE 490 00:18:16,662 --> 00:18:17,863 DEVELOPMENT OF SIMPLIFIED 491 00:18:17,863 --> 00:18:19,098 BROMOPROPANE MEASUREMENT 492 00:18:19,098 --> 00:18:20,599 PROTOCOLS FOR IMPLEMENTATION IN 493 00:18:20,599 --> 00:18:21,767 ROUTINE CLINICAL PRACTICE. 494 00:18:21,767 --> 00:18:22,568 SO CERTAINLY THERE'S ALWAYS MORE 495 00:18:22,568 --> 00:18:23,803 WORK TO DO IN THIS REGARD BUT I 496 00:18:23,803 --> 00:18:25,338 DO THINK THERE'S BEEN SOME 497 00:18:25,338 --> 00:18:26,839 REALLY GREAT STUDIES I'D LOVE TO 498 00:18:26,839 --> 00:18:28,474 JUST SHARE WITH THE GROUP THAT I 499 00:18:28,474 --> 00:18:29,475 CAME ACROSS IN MY REVIEW. 500 00:18:29,475 --> 00:18:38,551 SO IN THE FIRST SLIDE, REGARDING 501 00:18:38,551 --> 00:18:40,953 THE OBSERVER BEING IN 502 00:18:40,953 --> 00:18:42,054 ATTENDANCE, THIS WAS A MAJOR 503 00:18:42,054 --> 00:18:43,155 QUESTION THAT WAS RAISED DURING 504 00:18:43,155 --> 00:18:44,023 THE SPRINT TRIAL. 505 00:18:44,023 --> 00:18:46,525 I THINK DR. GOFF ALLUDED TO IT. 506 00:18:46,525 --> 00:18:47,727 THERE HAS BEEN SINCE A LOT OF 507 00:18:47,727 --> 00:18:49,395 IMPORTANT WORK AROUND THIS AREA. 508 00:18:49,395 --> 00:18:50,863 IT STILL CONTINUES TO BE AN AREA 509 00:18:50,863 --> 00:18:53,966 OF A LOT OF DEBATE AND A LOT OF 510 00:18:53,966 --> 00:18:55,601 STRONG FEELINGS AND PE 511 00:18:55,601 --> 00:18:56,802 PERSPECTIVES, BUT I THINK THERE 512 00:18:56,802 --> 00:18:58,704 HAS BEEN SOME COMPELLING 513 00:18:58,704 --> 00:19:00,306 EVIDENCE I'D LIKE TO JUST SHARE. 514 00:19:00,306 --> 00:19:02,174 SO ONE IS THIS SYSTEMATIC REVIEW 515 00:19:02,174 --> 00:19:03,275 LOOKING AT BLOOD PRESSURE 516 00:19:03,275 --> 00:19:09,181 COMPARED TO A WAIT TIME ABP M&A 517 00:19:09,181 --> 00:19:10,282 OBP, AND YOU CAN SEE HERE 518 00:19:10,282 --> 00:19:12,785 THERE'S REALLY NO -- SEEMS TO BE 519 00:19:12,785 --> 00:19:15,855 NO RELATIONSHIP BY ATTENDANT 520 00:19:15,855 --> 00:19:17,156 STATUS AND DIFFERENCE COMPARED 521 00:19:17,156 --> 00:19:18,257 TO ABPM. 522 00:19:18,257 --> 00:19:19,892 AND THEN THE JOHNSON STUDY 523 00:19:19,892 --> 00:19:22,261 PUBLISHED IN HYPERTENSION 2018, 524 00:19:22,261 --> 00:19:25,531 SO RIGHT AFTER THE WORKSHOP, 525 00:19:25,531 --> 00:19:27,166 LOOKED AT PRACTICES IN THE 526 00:19:27,166 --> 00:19:28,467 CLINICS THAT WERE INVOLVED IN 527 00:19:28,467 --> 00:19:29,769 SPRINT WITH RESPECT TO BLOOD 528 00:19:29,769 --> 00:19:31,437 PRESSURE MEASUREMENTS AND ALSO 529 00:19:31,437 --> 00:19:32,138 CARDIOVASCULAR DISEASE RISK AND 530 00:19:32,138 --> 00:19:35,908 THERE WAS NO REAL IMPACT ON -- 531 00:19:35,908 --> 00:19:37,443 FROM ATTENDANCE ON THE BENEFIT 532 00:19:37,443 --> 00:19:38,577 FROM MORE INTENSIVE BLOOD 533 00:19:38,577 --> 00:19:39,845 PRESSURE TREATMENT. 534 00:19:39,845 --> 00:19:41,714 SO VERY REASSURING THAT WE 535 00:19:41,714 --> 00:19:42,682 SHOULDN'T -- MAYBE THIS 536 00:19:42,682 --> 00:19:46,118 SHOULDN'T BE AN ITEM OF MAJOR 537 00:19:46,118 --> 00:19:49,889 CONCERN. 538 00:19:49,889 --> 00:19:51,424 THERE'S BEEN SOME GOOD EVIDENCE 539 00:19:51,424 --> 00:19:52,858 AROUND CLOTHING, THOUGH I THINK 540 00:19:52,858 --> 00:19:53,826 MORE WORK COULD BE DONE. 541 00:19:53,826 --> 00:19:55,361 THIS IS A NICE META-ANALYSIS 542 00:19:55,361 --> 00:19:59,098 THAT LOOKED AT DIFFERENT CALIBER 543 00:19:59,098 --> 00:19:59,999 CLOTHING AMOUNTS OVER SKIN ON 544 00:19:59,999 --> 00:20:02,802 THE ARM. 545 00:20:02,802 --> 00:20:04,537 AND SHOWED IF IT WAS VERY THIN, 546 00:20:04,537 --> 00:20:05,971 THERE DIDN'T SEEM TO BE A MAJOR 547 00:20:05,971 --> 00:20:10,209 EFFECT ON BIAS, BUT THERE WAS 548 00:20:10,209 --> 00:20:13,512 MAYBE SOME HINT OF IT WHEN THE 549 00:20:13,512 --> 00:20:14,947 CLOTHING WAS THICKER. 550 00:20:14,947 --> 00:20:16,816 HOWEVER, THIS WAS A VERY SMALL 551 00:20:16,816 --> 00:20:18,717 AMOUNT, 1-MILLIMETER OF MERCURY, 552 00:20:18,717 --> 00:20:19,652 NOT SIGNIFICANT, SO EVEN IF 553 00:20:19,652 --> 00:20:20,953 THERE IS SOMETHING THERE, IT 554 00:20:20,953 --> 00:20:22,721 MIGHT NOT BE ALL THAT CLINICALLY 555 00:20:22,721 --> 00:20:23,255 MEANINGFUL. 556 00:20:23,255 --> 00:20:24,457 I DO THINK THAT THERE'S MORE 557 00:20:24,457 --> 00:20:26,425 WORK TO BE DONE AROUND PRECISION 558 00:20:26,425 --> 00:20:27,526 OF MEASUREMENT. 559 00:20:27,526 --> 00:20:29,061 THIS FOCUSES ON BIAS, BUT IN 560 00:20:29,061 --> 00:20:30,963 SOME SENSE, HAVING MORE VARIABLE 561 00:20:30,963 --> 00:20:32,465 BLOOD PRESSURES COULD BE 562 00:20:32,465 --> 00:20:35,067 CONCERNING IN TERMS OF 563 00:20:35,067 --> 00:20:36,435 IDENTIFICATION OF EXTREMES IN 564 00:20:36,435 --> 00:20:42,608 BLOOD PRESSURE, LOW OR HIGH. 565 00:20:42,608 --> 00:20:44,143 WITH REGARDS TO THE WAIT TIME 566 00:20:44,143 --> 00:20:45,010 BEFORE BLOOD PRESSURE 567 00:20:45,010 --> 00:20:46,245 ASSESSMENTS IN CLINIC, THIS HAS 568 00:20:46,245 --> 00:20:48,214 BEEN A GREAT LAST COUPLE OF 569 00:20:48,214 --> 00:20:49,548 YEARS. 570 00:20:49,548 --> 00:20:52,351 WE HAD TWO VERY NICE TRIALS. 571 00:20:52,351 --> 00:20:53,919 ONE IN 618 ADULTS IN THE CONTEXT 572 00:20:53,919 --> 00:20:56,288 OF A CLINIC PRACTICE THAT SHOWED 573 00:20:56,288 --> 00:20:58,691 THAT IF YOU WERE TO HAVE NO REST 574 00:20:58,691 --> 00:21:01,760 PERIOD PRIOR TO AN AOBP VERSUS 575 00:21:01,760 --> 00:21:02,761 FIVE MINUTES OF REST, YOU CAN 576 00:21:02,761 --> 00:21:06,031 SEE OVER HERE THE MEAN REALLY 577 00:21:06,031 --> 00:21:09,969 COMPARED TO A WAIT TIME ABPM, 578 00:21:09,969 --> 00:21:12,505 MINIMAL EFFECT FROM NO REST 579 00:21:12,505 --> 00:21:14,006 PERIOD, SUGGESTING THAT WE CAN 580 00:21:14,006 --> 00:21:16,308 SHORTEN THE REST TIME. 581 00:21:16,308 --> 00:21:17,710 AND THEN IN THIS REALLY NICE 582 00:21:17,710 --> 00:21:19,278 TRIAL CONDUCTED IN BALTIMORE, 583 00:21:19,278 --> 00:21:22,414 WHERE THEY LOOKED AT ZERO, 2 OR 584 00:21:22,414 --> 00:21:24,717 5-MINUTE REST, VERY SIMILAR 585 00:21:24,717 --> 00:21:26,485 FINDINGS, THAT SHORTER REST 586 00:21:26,485 --> 00:21:27,686 TIMES, MAYBE EVEN NO REST IS 587 00:21:27,686 --> 00:21:29,688 REASONABLE FOR SCREENING FOR 588 00:21:29,688 --> 00:21:31,824 BLOOD PRESSURE, BUT POTENTIALLY 589 00:21:31,824 --> 00:21:33,259 THERE MIGHT BE MORE OF A ROLE OF 590 00:21:33,259 --> 00:21:35,127 A REST PERIOD AMONG INDIVIDUALS 591 00:21:35,127 --> 00:21:36,362 WITH HIGHER BASELINE BLOOD 592 00:21:36,362 --> 00:21:38,063 PRESSURE SO INDIVIDUALS WHO ARE 593 00:21:38,063 --> 00:21:38,831 HYPERTENSIVE. 594 00:21:38,831 --> 00:21:39,598 OBVIOUSLY SOMETHING CHALLENGING 595 00:21:39,598 --> 00:21:41,033 TO KNOW AT THE TIME OF 596 00:21:41,033 --> 00:21:44,837 SCREENING, BUT CERTAINLY 597 00:21:44,837 --> 00:21:46,038 CONSISTENT THAT SHORTER REST 598 00:21:46,038 --> 00:21:47,907 MIGHT BE OKAY IN THE CLINIC 599 00:21:47,907 --> 00:21:55,681 PRACTICE. 600 00:21:55,681 --> 00:21:57,449 THIS IS SOME OF OUR OWN WORK ON 601 00:21:57,449 --> 00:21:59,084 INTERVAL FROM A 602 00:21:59,084 --> 00:21:59,985 PSEUDORANDOMMIZED DESIGN OF A 603 00:21:59,985 --> 00:22:01,487 HUNDRED PATIENTS AND WE LOOKED 604 00:22:01,487 --> 00:22:04,423 AT 30 VERSUS 62ND INTERVALS 605 00:22:04,423 --> 00:22:05,424 BETWEEN REPEATED MEASUREMENTS 606 00:22:05,424 --> 00:22:06,625 AND FOUND REALLY NO DIFFERENCE 607 00:22:06,625 --> 00:22:08,260 WITH RESPECT TO -- OR COMPARED 608 00:22:08,260 --> 00:22:11,197 TO ABPM OR WHEN YOU LOOKED AT 609 00:22:11,197 --> 00:22:13,232 SORT OF THE DECREMENT OF BLOOD 610 00:22:13,232 --> 00:22:14,833 PRESSURE COMPARED TO THE FIRST 611 00:22:14,833 --> 00:22:17,236 MEASUREMENT, SUGGESTING THAT 612 00:22:17,236 --> 00:22:20,940 MAYBE 30 SECONDS INTERVAL MAY BE 613 00:22:20,940 --> 00:22:23,776 OKAY AS OPPOSED TO 60 SECONDS. 614 00:22:23,776 --> 00:22:29,915 AND THEN IN THE NEXT SLIDE, A 615 00:22:29,915 --> 00:22:30,883 FOLLOW-UP QUALITY IMPROVEMENT 616 00:22:30,883 --> 00:22:32,851 PROJECT, ABOUT 200 PATIENTS 617 00:22:32,851 --> 00:22:35,054 REFERRED FOR ABPM, WE NOTED NO 618 00:22:35,054 --> 00:22:37,890 DIFFERENCE BETWEEN A 619 00:22:37,890 --> 00:22:39,992 FIVE-MINUTE, 62ND, 62ND, SO FIVE 620 00:22:39,992 --> 00:22:42,261 MINUTE DELAY, 62ND INTERVAL 621 00:22:42,261 --> 00:22:45,297 PROTOCOL VERSUS A 3 MINUTE, 30, 622 00:22:45,297 --> 00:22:47,199 30 PROTOCOL, SUGGESTING THAT THE 623 00:22:47,199 --> 00:22:49,168 COMBINATION OF THE TWO IN THE 624 00:22:49,168 --> 00:22:50,369 SETTING OF CLINIC PRACTICE, A 625 00:22:50,369 --> 00:22:52,638 REAL WORLD SETTING, DIDN'T SEEM 626 00:22:52,638 --> 00:22:54,640 TO INFLUENCE BLOOD PRESSURE 627 00:22:54,640 --> 00:22:56,609 ACCURACY OR PRECISION, WHICH IS 628 00:22:56,609 --> 00:22:59,345 ALSO QUITE REASSURING. 629 00:22:59,345 --> 00:23:01,747 IN THE NEXT SLIDE, THERE'S 630 00:23:01,747 --> 00:23:04,049 ANOTHER REALLY EXCELLENT STUDY 631 00:23:04,049 --> 00:23:06,118 ON CUFF SIZE THAT'S RECENTLY 632 00:23:06,118 --> 00:23:13,993 CONCLUDED CALLED CUFFSZ. 633 00:23:13,993 --> 00:23:15,961 IN THIS CROSSOVER RANDOMIZED 634 00:23:15,961 --> 00:23:17,896 STUDY OF 195 COMMUNITY DWELLING 635 00:23:17,896 --> 00:23:19,265 ADULTS, YOU CAN SEE THEY LOOKED 636 00:23:19,265 --> 00:23:20,899 AT A SIZE TOO LARGE, PROPERLY 637 00:23:20,899 --> 00:23:22,868 SIZED CUFF, A SIZE TOO SMALL AND 638 00:23:22,868 --> 00:23:25,271 A SIZE TWO SIZES SMALL, AND WHAT 639 00:23:25,271 --> 00:23:28,207 THEY FOUND IS THAT -- CONFIRMED 640 00:23:28,207 --> 00:23:29,208 WHAT HAS BEEN THOUGHT THAT THIS 641 00:23:29,208 --> 00:23:31,043 CUFF SIZE REALLY DOES SEEM TO 642 00:23:31,043 --> 00:23:32,278 MATTER, AND IF YOU'RE TOO LARGE, 643 00:23:32,278 --> 00:23:34,880 YOU'LL HAVE A LOWER BLOOD 644 00:23:34,880 --> 00:23:36,081 PRESSURE, ABOUT 4 MILLIMETERS OF 645 00:23:36,081 --> 00:23:37,950 MERCURY, IF YOU'RE TOO SMALL, 646 00:23:37,950 --> 00:23:39,251 INCREASE OF ABOUT 5 MILLIMETERS 647 00:23:39,251 --> 00:23:40,753 OF MERCURY, AND IF YOU'RE TWO 648 00:23:40,753 --> 00:23:42,421 SIZES OFF, THE BIAS COULD BE AS 649 00:23:42,421 --> 00:23:44,490 GREAT AS 20 MILLIMETERS OF 650 00:23:44,490 --> 00:23:44,757 MERCURY. 651 00:23:44,757 --> 00:23:45,791 SUGGESTING THAT THIS IS A 652 00:23:45,791 --> 00:23:47,092 FEATURE THAT DOES SEEM TO BE 653 00:23:47,092 --> 00:23:49,328 REALLY IMPORTANT. 654 00:23:49,328 --> 00:23:53,265 THERE WAS ANOTHER GREAT TRIAL 655 00:23:53,265 --> 00:23:55,334 PERFORMED ON ARM SUPPORT, A 656 00:23:55,334 --> 00:23:57,403 CROSSOVER STUDY OF 133 ADULTS 657 00:23:57,403 --> 00:23:59,505 THAT ALSO RECENTLY CAME OUT 658 00:23:59,505 --> 00:24:01,807 CALLED THE ARMS TRIAL. 659 00:24:01,807 --> 00:24:03,742 AND IN THIS STUDY, THEY LOOKED 660 00:24:03,742 --> 00:24:04,743 AT TWO DIFFERENT -- I'M SORRY, 661 00:24:04,743 --> 00:24:06,278 THIS IS ON THE NEXT SLIDE. 662 00:24:06,278 --> 00:24:06,945 I APOLOGIZE. 663 00:24:06,945 --> 00:24:10,649 THEY LOOK AT TWO DIFFERENT 664 00:24:10,649 --> 00:24:12,084 POSITIONS, ONE IS RESTING THE 665 00:24:12,084 --> 00:24:13,819 ARM IN THE LAP, THE OTHER ON THE 666 00:24:13,819 --> 00:24:16,855 SIDE VERSUS RESTED ON A DESK OR 667 00:24:16,855 --> 00:24:18,657 TABLE NEARBY AT HEART LEVEL. 668 00:24:18,657 --> 00:24:20,592 AND WHAT THEY FOUND IS THAT ARM 669 00:24:20,592 --> 00:24:22,661 POSITION ALSO IMPACTS BLOOD 670 00:24:22,661 --> 00:24:24,496 PRESSURE, AND HERE YOU CAN SEE 671 00:24:24,496 --> 00:24:26,298 IF IT'S IN THE LEFT, INCREASE OF 672 00:24:26,298 --> 00:24:27,132 ABOUT 4 MILLIMETERS OF MERCURY, 673 00:24:27,132 --> 00:24:28,801 AT THE SIDE, ABOUT 6 1/2 674 00:24:28,801 --> 00:24:30,669 MILLIMETERS OF MERCURY FOR 675 00:24:30,669 --> 00:24:31,337 SYSTOLIC BLOOD PRESSURE, 676 00:24:31,337 --> 00:24:32,204 SUGGESTING THAT ARM POSITION IS 677 00:24:32,204 --> 00:24:33,405 SOMETHING THAT SHOULD BE ON THE 678 00:24:33,405 --> 00:24:39,778 CHECKLIST. 679 00:24:39,778 --> 00:24:42,147 THEN ANOTHER TRIAL THAT'S STILL 680 00:24:42,147 --> 00:24:43,449 I BELIEVE UNDER REVIEW, SO THESE 681 00:24:43,449 --> 00:24:44,483 ARE RESULTS FROM THE ABSTRACT, 682 00:24:44,483 --> 00:24:49,688 THEY LOOKED AT -- IT'S CALLED 683 00:24:49,688 --> 00:24:50,789 DECIBELS, SAME GROUP IN 684 00:24:50,789 --> 00:24:51,790 BALTIMORE, REALLY EXCELLENT 685 00:24:51,790 --> 00:24:52,891 NAMING OF TRIALS, I HAVE TO SAY. 686 00:24:52,891 --> 00:24:54,727 THEY LOOKED AT, IN ADDITION TO 687 00:24:54,727 --> 00:24:57,596 THE GREAT DESIGNS, THEY LOOKED 688 00:24:57,596 --> 00:24:59,231 AT PUBLIC LOUD SETTING, A PUBLIC 689 00:24:59,231 --> 00:25:01,633 QUIET SETTING -- OR PUBLIC QUIET 690 00:25:01,633 --> 00:25:03,836 SETTING AND THEN A PRIVATE QUIET 691 00:25:03,836 --> 00:25:05,070 SETTING, SO KIND OF TWO 692 00:25:05,070 --> 00:25:07,339 DIFFERENT FACTORS, AND WHAT THEY 693 00:25:07,339 --> 00:25:10,843 OBSERVED IS THAT THERE MAY BE 694 00:25:10,843 --> 00:25:14,113 SOME IMPACT OF SOUND AND 695 00:25:14,113 --> 00:25:18,817 SETTING, PARTICULARLY ON 696 00:25:18,817 --> 00:25:19,752 DIASTOLIC BLOOD PRESSURE. 697 00:25:19,752 --> 00:25:21,120 SETTING MAY BE IMPORTANT WITH 698 00:25:21,120 --> 00:25:22,454 REGARDS TO SYSTOLIC AND 699 00:25:22,454 --> 00:25:23,188 DIASTOLIC BLOOD PRESSURE BUT THE 700 00:25:23,188 --> 00:25:25,624 MAGNITUDES ARE RELATIVELY SMALL, 701 00:25:25,624 --> 00:25:27,292 1 TO 2 MILLIMETERS OF MERCURY, 702 00:25:27,292 --> 00:25:28,327 AND CERTAINLY WE'RE LOOKING 703 00:25:28,327 --> 00:25:30,629 FORWARD TO THE PUBLICATION OF 704 00:25:30,629 --> 00:25:32,531 THIS TRIAL, HOPEFULLY IN COMING 705 00:25:32,531 --> 00:25:41,573 DAYS. 706 00:25:41,573 --> 00:25:43,008 SO WHAT ABOUT RECOMMENDATION C? 707 00:25:43,008 --> 00:25:48,013 SO TO EVALUATE THE EFFECTS OF 708 00:25:48,013 --> 00:25:48,914 INTERVENTIONS TO IMPROVE BLOOD 709 00:25:48,914 --> 00:25:50,549 PRESSURE MEASUREMENTS IN ROUTINE 710 00:25:50,549 --> 00:25:51,884 CLINICAL PRACTICE, FOR EXAMPLE, 711 00:25:51,884 --> 00:25:54,186 USE OF AUTOMATED DEVICES THAT 712 00:25:54,186 --> 00:25:56,155 OBTAIN AN AVERAGE MULTIPLE 713 00:25:56,155 --> 00:25:57,456 READINGS ON THE ACCURACY AND 714 00:25:57,456 --> 00:25:58,357 PRECISION OF CLINIC BLOOD 715 00:25:58,357 --> 00:26:00,292 PRESSURE MEASUREMENTS AND BLOOD 716 00:26:00,292 --> 00:26:09,601 PRESSURE CONTROL RATES. 717 00:26:09,601 --> 00:26:11,670 SO THERE'S A GREAT STUDY, I WANT 718 00:26:11,670 --> 00:26:13,872 TO HIGHLIGHT HERE THAT WAS 719 00:26:13,872 --> 00:26:16,608 CONDUCTED IN 11 CLINICS IN THE 720 00:26:16,608 --> 00:26:19,344 MIDWEST, AND WHAT THIS STUDY 721 00:26:19,344 --> 00:26:20,646 SHOWED, THEY LOOKED AT THE 722 00:26:20,646 --> 00:26:21,980 IMPLEMENTATION OF AUTOMATED 723 00:26:21,980 --> 00:26:24,383 STANDARDIZED BLOOD PRESSURE 724 00:26:24,383 --> 00:26:25,150 ASSESSMENTS IN THE CLINIC 725 00:26:25,150 --> 00:26:28,520 SETTING, AND YOU CAN SEE ON THE 726 00:26:28,520 --> 00:26:32,257 LEFT SIDE, PANEL A, KIND OF THE 727 00:26:32,257 --> 00:26:33,258 MANUAL AUSCULTATION, AND THEN 728 00:26:33,258 --> 00:26:35,194 THE DISTRIBUTION OF BLOOD 729 00:26:35,194 --> 00:26:37,629 PRESSURES FROM AFTER AUTOMATED 730 00:26:37,629 --> 00:26:38,497 ASSESSMENTS WERE IMPLEMENTED. 731 00:26:38,497 --> 00:26:40,799 YOU CAN SEE A LOT OF END DIGIT 732 00:26:40,799 --> 00:26:42,634 PREFERENCE PRIOR TO AUTOMATION, 733 00:26:42,634 --> 00:26:44,837 AND THEN A MUCH MORE SMOOTH 734 00:26:44,837 --> 00:26:47,439 DISTRIBUTION AFTER AUTOMATION, 735 00:26:47,439 --> 00:26:48,774 SUGGESTING THAT THERE MAY BE 736 00:26:48,774 --> 00:26:51,510 THAT HUMAN DESIRE TO ROUND 737 00:26:51,510 --> 00:26:54,880 NUMBERS OR JUST THE INABILITY TO 738 00:26:54,880 --> 00:26:57,182 DIFFERENTIATE BETWEEN MAYBE 739 00:26:57,182 --> 00:26:57,850 TWO MILLIMETERS OF MERCURY FROM 740 00:26:57,850 --> 00:27:02,120 SOME OF OUR ANDROID DEVICES. 741 00:27:02,120 --> 00:27:03,555 IN ADDITION, THEY SHOWED WHAT 742 00:27:03,555 --> 00:27:05,190 THE MEAN BLOOD PRESSURE WAS, AND 743 00:27:05,190 --> 00:27:06,825 I THINK AGAIN, THIS ALLUDES TO 744 00:27:06,825 --> 00:27:09,127 SOME OF THE CRITIQUES DR. GOFF 745 00:27:09,127 --> 00:27:11,430 WAS OPENING WITH, BUT YOU CAN 746 00:27:11,430 --> 00:27:13,165 SEE THAT AFTER AUTOMATION WAS 747 00:27:13,165 --> 00:27:14,032 IMPLEMENTED, THE MEAN BLOOD 748 00:27:14,032 --> 00:27:16,568 PRESSURE WAS HIGHER, AND THE 749 00:27:16,568 --> 00:27:20,706 AUTHORS COP CLEU CONCLUDED THATE 750 00:27:20,706 --> 00:27:21,907 FOLKS, WHEN THEY'RE LISTENING, 751 00:27:21,907 --> 00:27:23,775 THERE'S A BIAS TOWARDS LOOKING 752 00:27:23,775 --> 00:27:24,977 FOR MORE FAVORABLE MEASUREMENTS 753 00:27:24,977 --> 00:27:27,179 OR MAYBE DISCARDING UNFAVORABLE 754 00:27:27,179 --> 00:27:29,147 MEASUREMENTS, SO IN SOME SENSE, 755 00:27:29,147 --> 00:27:31,650 IT'S UNCLEAR THAT AUTOMATION 756 00:27:31,650 --> 00:27:32,985 WOULD ACTUALLY RESULT IN A LOWER 757 00:27:32,985 --> 00:27:33,519 MEAN BLOOD PRESSURE. 758 00:27:33,519 --> 00:27:35,587 IT MIGHT ACTUALLY JUST RESULT IN 759 00:27:35,587 --> 00:27:36,221 A MORE ACCURATE BLOOD PRESSURE 760 00:27:36,221 --> 00:27:40,626 THAT COULD BE HIGHER. 761 00:27:40,626 --> 00:27:42,261 SO REALLY IMPORTANT STUDY. 762 00:27:42,261 --> 00:27:44,663 I THINK THIS IS ALSO REALLY AN 763 00:27:44,663 --> 00:27:49,167 IMPORTANT STUDY THAT USED DATA 764 00:27:49,167 --> 00:27:52,337 FROM THE ERIC COHORT, LOOKED AT 765 00:27:52,337 --> 00:27:53,972 THE FIRST MEASUREMENT VERSUS THE 766 00:27:53,972 --> 00:27:55,474 AVERAGE AND SECOND AND THIRD 767 00:27:55,474 --> 00:27:56,041 MEASUREMENT IN ERIC. 768 00:27:56,041 --> 00:27:58,343 I BRING THIS UP BECAUSE I THINK 769 00:27:58,343 --> 00:27:59,444 IT WELL ILLUSTRATES THE 770 00:27:59,444 --> 00:28:00,546 IMPORTANCE OF MULTIPLE 771 00:28:00,546 --> 00:28:01,179 MEASUREMENTS IN THE CLINIC. 772 00:28:01,179 --> 00:28:08,387 SO YOU CAN SEE THIS LOWER LINE 773 00:28:08,387 --> 00:28:10,589 HERE, CONSISTENT WITH RESPECT TO 774 00:28:10,589 --> 00:28:14,293 CVD RISK, AND THE HIGHEST 775 00:28:14,293 --> 00:28:14,927 CONSISTENT HIGH BLOOD PRESSURE, 776 00:28:14,927 --> 00:28:17,362 THE FIRST MEASUREMENT 777 00:28:17,362 --> 00:28:18,363 CORRESPONDED WITH THE AVERAGE OF 778 00:28:18,363 --> 00:28:19,031 THE SECOND AND THIRD. 779 00:28:19,031 --> 00:28:20,232 BUT THEN YOU SEE IN THE MIDDLE 780 00:28:20,232 --> 00:28:24,836 THE MISSED HYPERTENSIVE GROUP. 781 00:28:24,836 --> 00:28:27,005 YOU CAN SEE WITH REGARDS TO 782 00:28:27,005 --> 00:28:28,073 CARDIOVASCULAR RISK, MISSING 783 00:28:28,073 --> 00:28:31,577 HYPERTENSION IS PR PRETTY 784 00:28:31,577 --> 00:28:34,112 PROBLEMATIC AND LONG TERM ALIGNS 785 00:28:34,112 --> 00:28:35,847 MORE WITH THOSE WITH CONSISTENT 786 00:28:35,847 --> 00:28:36,548 HYPERTENSION, SUGGESTING THE 787 00:28:36,548 --> 00:28:37,382 IMPORTANCE OF DOING MORE THAN 788 00:28:37,382 --> 00:28:38,717 ONE MEASUREMENT IN CLINIC TO 789 00:28:38,717 --> 00:28:39,918 REALLY CLASSIFY PEOPLE'S RISK 790 00:28:39,918 --> 00:28:45,591 APPROPRIATELY. 791 00:28:45,591 --> 00:28:46,792 SO THIS IS AN AREA, 792 00:28:46,792 --> 00:28:47,993 RECOMMENDATION D, THAT I THOUGHT 793 00:28:47,993 --> 00:28:49,127 HAD SOME GAPS. 794 00:28:49,127 --> 00:28:52,497 SO EVALUATE HEAD TO HEAD 795 00:28:52,497 --> 00:28:54,466 COMPARATIVE DATA ON THE 796 00:28:54,466 --> 00:28:55,033 ASSOCIATION OF STANDARDIZED 797 00:28:55,033 --> 00:28:56,969 CLINIC VERSUS OUT OF CLINIC BLP 798 00:28:56,969 --> 00:28:59,037 WITH CVD OUTCOMES AND MORTALITY. 799 00:28:59,037 --> 00:29:00,606 IN THE NEXT SLIDE, I HAVE A 800 00:29:00,606 --> 00:29:02,908 PAPER THAT I THINK IS ONE OF THE 801 00:29:02,908 --> 00:29:04,743 MOST COMPREHENSIVE COHORT 802 00:29:04,743 --> 00:29:07,379 STUDIES THAT LOOK AT DIFFERENT 803 00:29:07,379 --> 00:29:08,180 MODALITIES OF BLOOD PRESSURE 804 00:29:08,180 --> 00:29:09,448 MEASUREMENT WITH RESPECT TO 805 00:29:09,448 --> 00:29:09,781 OUTCOMES. 806 00:29:09,781 --> 00:29:10,983 THERE ARE SOME OTHER COHORTS OUT 807 00:29:10,983 --> 00:29:11,183 THERE. 808 00:29:11,183 --> 00:29:15,020 I THINK THIS IS AN AREA WHERE 809 00:29:15,020 --> 00:29:16,655 THERE COULD BE A LOT MORE AND I 810 00:29:16,655 --> 00:29:18,957 KNOW NHLBI HAS SPONSORED SEVERAL 811 00:29:18,957 --> 00:29:23,562 COHORT STUDIES THAT WILL LOOK AT 812 00:29:23,562 --> 00:29:24,229 MULTI-MODALITY BLOOD PRESSURE 813 00:29:24,229 --> 00:29:25,297 ASSESSMENTS BUT WILL TAKE SOME 814 00:29:25,297 --> 00:29:26,732 TIME TO ACCRUE EVENTS, SO 815 00:29:26,732 --> 00:29:27,733 CERTAINLY AN AREA THAT I THINK 816 00:29:27,733 --> 00:29:29,034 WE COULD BENEFIT MUCH MORE FROM 817 00:29:29,034 --> 00:29:31,436 IN TERMS OF LEARNING HOW THESE 818 00:29:31,436 --> 00:29:32,304 DEVICES RELATE TO CLINICAL 819 00:29:32,304 --> 00:29:37,876 OUTCOMES. 820 00:29:37,876 --> 00:29:40,278 ITEM E, EVALUATE THE IMPACT OF 821 00:29:40,278 --> 00:29:45,017 SYSTEMATIC AND RANDOM ERRORS ON 822 00:29:45,017 --> 00:29:46,318 THE DIAGNOSIS AND MANAGEMENT OF 823 00:29:46,318 --> 00:29:48,620 HYPERTENSION AND IDENTIFY 824 00:29:48,620 --> 00:29:51,023 APPROACHES TO DELINEATE REAL 825 00:29:51,023 --> 00:29:52,224 CHANGES IN BLOOD PRESSURE FROM 826 00:29:52,224 --> 00:29:53,325 RANDOM ERROR FOLLOWING TREATMENT 827 00:29:53,325 --> 00:29:53,659 INITIATION. 828 00:29:53,659 --> 00:29:55,494 SO I THINK THERE'S BEEN SOME 829 00:29:55,494 --> 00:29:56,361 IMPORTANT WORK IN THIS AREA. 830 00:29:56,361 --> 00:30:02,167 ON THE NEXT SLIDE, I INCLUDE DRT 831 00:30:02,167 --> 00:30:03,702 DEMONSTRATED THAT THERE'S 832 00:30:03,702 --> 00:30:05,337 GREATER GAINS FROM HAVING 833 00:30:05,337 --> 00:30:07,406 MEASUREMENTS OVER MULTIPLE 834 00:30:07,406 --> 00:30:09,074 VISITS THAN HAVING REPEAT 835 00:30:09,074 --> 00:30:10,175 MEASURES WITHIN VISIT. 836 00:30:10,175 --> 00:30:12,110 BOTH ARE IMPORTANT FOR IMPROVING 837 00:30:12,110 --> 00:30:12,678 PRECISION. 838 00:30:12,678 --> 00:30:16,481 AND SO YOU CAN SEE, IF YOU COULD 839 00:30:16,481 --> 00:30:19,551 JUST CLICK TWICE THROUGH THE 840 00:30:19,551 --> 00:30:20,452 ANIMATION, BUT YOU CAN SEE THERE 841 00:30:20,452 --> 00:30:23,588 ARE GREATER REDUCTIONS, THIS IS 842 00:30:23,588 --> 00:30:24,589 DISPLAYING THE STANDARD ERRORS. 843 00:30:24,589 --> 00:30:26,024 THE STANDARD ERRORS GO DOWN MORE 844 00:30:26,024 --> 00:30:27,759 WHEN YOU GO FROM ONE VISIT TO 845 00:30:27,759 --> 00:30:29,594 THE SECOND VISIT, HAVING TWO 846 00:30:29,594 --> 00:30:31,396 VISITS, VERSUS MULTIPLE 847 00:30:31,396 --> 00:30:34,199 MEASUREMENTS PURVIS IT. 848 00:30:34,199 --> 00:30:35,100 PER VISIT. 849 00:30:35,100 --> 00:30:36,301 THIS SPEAKS TO THE IDEA THAT 850 00:30:36,301 --> 00:30:37,235 THERE'S GREATER VARIABILITY IN 851 00:30:37,235 --> 00:30:38,503 BLOOD PRESSURE BETWEEN VISIT 852 00:30:38,503 --> 00:30:39,805 VERSUS WITHIN VISITS, BUT BOTH 853 00:30:39,805 --> 00:30:40,472 ARE REALLY IMPORTANT. 854 00:30:40,472 --> 00:30:42,641 ON THE NEXT SLIDE, THERE WAS A 855 00:30:42,641 --> 00:30:44,376 REALLY NICE NHANES PAPER THAT 856 00:30:44,376 --> 00:30:49,748 WAS PUBLISHED SHOWING THAT -- 857 00:30:49,748 --> 00:30:51,817 YOU CAN JUST CLICK TWO MORE 858 00:30:51,817 --> 00:30:52,384 TIMES. 859 00:30:52,384 --> 00:30:52,951 I'M SORRY. 860 00:30:52,951 --> 00:31:01,893 PERFECT. 861 00:31:01,893 --> 00:31:04,096 SO HERE IN THIS NHANES STUDY, 862 00:31:04,096 --> 00:31:05,397 THEY EVALUATE THE IMPACT OF BIAS 863 00:31:05,397 --> 00:31:06,398 ON THE PREVALENCE OF 864 00:31:06,398 --> 00:31:07,466 HYPERTENSION OR HIGH BLOOD 865 00:31:07,466 --> 00:31:08,366 PRESSURE IN THE U.S. POPULATION. 866 00:31:08,366 --> 00:31:10,202 I THINK IT NICELY ILLUSTRATES 867 00:31:10,202 --> 00:31:11,403 HOW EVEN SMALL AMOUNTS OF BIAS 868 00:31:11,403 --> 00:31:14,473 HAVE REALLY SIGNIFICANT 869 00:31:14,473 --> 00:31:16,875 IMPORTANT IMPLICATIONS FOR 870 00:31:16,875 --> 00:31:18,977 POPULATION ESTIMATES OF BLOOD 871 00:31:18,977 --> 00:31:21,146 PRESSURE. 872 00:31:21,146 --> 00:31:22,914 AND SO YOU CAN KIND OF SEE THAT 873 00:31:22,914 --> 00:31:26,418 ILLUSTRATED HERE, THAT THERE'S 874 00:31:26,418 --> 00:31:27,619 TREMENDOUS VARIATION DEPENDING 875 00:31:27,619 --> 00:31:29,588 ON HOW ACCURATE THE BLOOD 876 00:31:29,588 --> 00:31:30,689 PRESSURE MEASUREMENT IS. 877 00:31:30,689 --> 00:31:37,329 THAT HAS IMPLICATIONS FOR 878 00:31:37,329 --> 00:31:38,663 MEASURES FOR CLINICAL PRACTICE. 879 00:31:38,663 --> 00:31:40,398 THIS IS A REALLY INTERESTING, I 880 00:31:40,398 --> 00:31:41,967 THINK, THOUGHT-PROVOKING PAPER 881 00:31:41,967 --> 00:31:43,001 THAT CAME OUT OF CONNECTICUT 882 00:31:43,001 --> 00:31:47,205 THAT LOOKED AT CLINICS, CLINIC 883 00:31:47,205 --> 00:31:50,809 VISITS AND THESE DYADS OF AT 884 00:31:50,809 --> 00:31:52,110 LEAST TWO VISITS WITHIN 90 DAYS 885 00:31:52,110 --> 00:31:53,745 AND THEY SHOWED THE SUBSTANTIAL 886 00:31:53,745 --> 00:31:55,380 VARIATION FROM VISIT TO VISIT 887 00:31:55,380 --> 00:31:56,381 OBSERVED IN THE CLINIC SETTING 888 00:31:56,381 --> 00:31:57,883 AND I THINK THIS HIGHLIGHT THE 889 00:31:57,883 --> 00:32:00,318 CHALLENGE, THEY SAID IN SOME 890 00:32:00,318 --> 00:32:02,821 SENSE, YOU ALMOST CAN'T EVEN USE 891 00:32:02,821 --> 00:32:04,589 OR USE A CLINIC MEASUREMENT TO 892 00:32:04,589 --> 00:32:07,225 ASSESS RESPONSE TO THERAPY, IT 893 00:32:07,225 --> 00:32:08,860 KIND OF A CONCERNING CONCLUSION 894 00:32:08,860 --> 00:32:10,695 BUT CERTAINLY SPRINT WOULD SAY 895 00:32:10,695 --> 00:32:12,297 OTHERWISE, BUT IN SOME SENSE IN 896 00:32:12,297 --> 00:32:14,432 THE REAL WORLD SETTING, THIS IS 897 00:32:14,432 --> 00:32:16,968 SOMETHING TO REALLY THINK ABOUT. 898 00:32:16,968 --> 00:32:19,237 THE AMOUNT OF VARIATION THAT CAN 899 00:32:19,237 --> 00:32:22,107 HAPPEN BETWEEN CLINIC VISITS 900 00:32:22,107 --> 00:32:23,108 REALLY PRESENTS A LOT OF 901 00:32:23,108 --> 00:32:24,509 CHALLENGES IN TERMS OF 902 00:32:24,509 --> 00:32:26,478 EVALUATING TREATMENT RESPONSE. 903 00:32:26,478 --> 00:32:27,913 AS ILLUSTRATED BY THE 904 00:32:27,913 --> 00:32:28,747 DISTRIBUTION OF DIFFERENCES 905 00:32:28,747 --> 00:32:30,315 BETWEEN THESE TWO VISITS WITHIN 906 00:32:30,315 --> 00:32:36,454 90 DAYS. 907 00:32:36,454 --> 00:32:37,756 SO RECOMMENDATION F, ASSESS THE 908 00:32:37,756 --> 00:32:38,857 ASSOCIATIONS BETWEEN ROUTINE 909 00:32:38,857 --> 00:32:40,358 CLINIC AND RESEARCH BLP 910 00:32:40,358 --> 00:32:41,793 MEASUREMENTS, DETERMINE IN WHAT 911 00:32:41,793 --> 00:32:42,994 CIRCUMSTANCES MEASUREMENTS CAN 912 00:32:42,994 --> 00:32:44,196 BE ACCEPTABLE TO BE USED IN 913 00:32:44,196 --> 00:32:45,397 RESEARCH. 914 00:32:45,397 --> 00:32:48,900 AND I HIGHLIGHTED IN NEXT SLIDE 915 00:32:48,900 --> 00:32:52,838 A PAPER FROM SPRINT THAT 916 00:32:52,838 --> 00:32:55,473 COMPARED OUTPATIENT BLOOD 917 00:32:55,473 --> 00:32:56,007 PRESSURES TO SPRINT BLOOD 918 00:32:56,007 --> 00:32:56,708 PRESSURE, SO THESE ARE FOLKS 919 00:32:56,708 --> 00:32:59,945 THAT WERE IN SPRINT AND ALSO HAD 920 00:32:59,945 --> 00:33:01,780 CLINICAL MEASUREMENTS PERFORMED, 921 00:33:01,780 --> 00:33:02,614 ELECTRONIC RECORDS, AT THE SAME 922 00:33:02,614 --> 00:33:03,849 TIME, AND WHAT THEY NOTED WAS 923 00:33:03,849 --> 00:33:05,750 THAT THERE WAS SUBSTANTIAL 924 00:33:05,750 --> 00:33:06,718 HETEROGENEITY BETWEEN BLOOD 925 00:33:06,718 --> 00:33:08,053 PRESSURES RECORDED IN THE 926 00:33:08,053 --> 00:33:09,454 ELECTRONIC RECORD IN TRIALS, 927 00:33:09,454 --> 00:33:10,555 SIGNIFICANT VARIABILITY OVER 928 00:33:10,555 --> 00:33:11,890 TIME BETWEEN AND WITHIN THE 929 00:33:11,890 --> 00:33:14,392 PARTICIPANTS AND ACROSS CLINIC 930 00:33:14,392 --> 00:33:14,793 SITES. 931 00:33:14,793 --> 00:33:16,561 AND THERE WAS REALLY NO EASY WAY 932 00:33:16,561 --> 00:33:20,966 TO CORRECT FOR THESE DIFFERE 933 00:33:20,966 --> 00:33:21,266 DIFFERENCES. 934 00:33:21,266 --> 00:33:23,134 SO AGAIN IT'S RESEARCH 935 00:33:23,134 --> 00:33:24,102 HIGHLIGHTING THE PROBLEM. 936 00:33:24,102 --> 00:33:26,071 WE STILL WANT SOLUTIONS BUT 937 00:33:26,071 --> 00:33:27,839 CERTAINLY RECOGNIZING THAT 938 00:33:27,839 --> 00:33:29,708 SUBSTITUTING CLINIC ASSESSMENTS 939 00:33:29,708 --> 00:33:32,344 MAY NOT BE AT A POINT WHERE THAT 940 00:33:32,344 --> 00:33:34,479 WORKS QUITE WELL. 941 00:33:34,479 --> 00:33:38,116 OR AT LEAST RELIABLY. 942 00:33:38,116 --> 00:33:39,517 RECOMMENDATION G, DETERMINE THE 943 00:33:39,517 --> 00:33:40,852 OPTIMAL QUALITY METRIC FOR BLOOD 944 00:33:40,852 --> 00:33:42,287 PRESSURE CONTROL USING AVERAGE 945 00:33:42,287 --> 00:33:43,688 BLOOD PRESSURE AT AN INDIVIDUAL 946 00:33:43,688 --> 00:33:46,725 VISIT OR ACROSS SEVERAL VISITS, 947 00:33:46,725 --> 00:33:47,859 THE LAST AVAILABLE READING FROM 948 00:33:47,859 --> 00:33:48,927 THE ELECTRONIC MEDICAL RECORD. 949 00:33:48,927 --> 00:33:53,098 I THINK THIS IS AN AREA OF GAP. 950 00:33:53,098 --> 00:33:54,499 I THINK I FOUND THIS REALLY -- 951 00:33:54,499 --> 00:33:57,903 THIS PAPER THAT SPEAKS TO 952 00:33:57,903 --> 00:33:59,537 PROGRESS IN THIS AREA. 953 00:33:59,537 --> 00:34:01,539 THE PCORNET HAS BEEN WORKING A 954 00:34:01,539 --> 00:34:05,110 LOT ON CLINIC LEVEL MEASURES AND 955 00:34:05,110 --> 00:34:06,511 HERE THEY IDENTIFIED NINE 956 00:34:06,511 --> 00:34:08,847 DIFFERENT CONTROL METRICS THAT 957 00:34:08,847 --> 00:34:10,715 ARE BASED ON EVIDENCE FOR 958 00:34:10,715 --> 00:34:11,449 QUALITY. 959 00:34:11,449 --> 00:34:12,350 I STILL THINK THERE'S 960 00:34:12,350 --> 00:34:14,619 SUBSTANTIAL WORK TO BE DONE IN 961 00:34:14,619 --> 00:34:16,388 TERMS OF EVALUATING THESE 962 00:34:16,388 --> 00:34:17,055 METRICS' PERFORMANCE WITH 963 00:34:17,055 --> 00:34:18,256 RESPECT TO OUTCOMES BUT 964 00:34:18,256 --> 00:34:20,659 CERTAINLY HAVING CLEAR 965 00:34:20,659 --> 00:34:24,362 DEFINITIONS BEING FOLLOWED IN A 966 00:34:24,362 --> 00:34:26,331 LARGE NETWORK, I THINK IS A 967 00:34:26,331 --> 00:34:27,766 SIGNIFICANT STEP FORWARD AND 968 00:34:27,766 --> 00:34:28,533 CERTAINLY WE'LL HAVE MUCH TO 969 00:34:28,533 --> 00:34:33,772 LEARN IN THE FUTURE. 970 00:34:33,772 --> 00:34:35,206 RECOMMENDATION H WAS TO EVALUATE 971 00:34:35,206 --> 00:34:37,709 THE ROLE OF ABPM IN HOME BLOOD 972 00:34:37,709 --> 00:34:38,610 PRESSURE MONITORING IN THE 973 00:34:38,610 --> 00:34:39,811 DIAGNOSIS AND TREATMENT OF 974 00:34:39,811 --> 00:34:40,145 HYPERTENSION. 975 00:34:40,145 --> 00:34:41,680 I THINK THAT THIS IS STILL AN 976 00:34:41,680 --> 00:34:45,150 AREA WHERE THERE'S BEEN A LOT OF 977 00:34:45,150 --> 00:34:46,618 WORK DONE, A LOT OF EXCITING 978 00:34:46,618 --> 00:34:47,986 WORK BUT ALSO SOME GAPS. 979 00:34:47,986 --> 00:34:49,321 IN THE NEXT SLIDE, THERE WERE A 980 00:34:49,321 --> 00:34:50,588 NUMBER OF SUBPOINTS RELATED TO 981 00:34:50,588 --> 00:34:50,956 THIS AREA. 982 00:34:50,956 --> 00:34:52,691 SO YOU COULD SEE THE EXCITEMENT 983 00:34:52,691 --> 00:34:55,760 OF THE WORKING GROUP AROUND HOME 984 00:34:55,760 --> 00:34:57,095 MONITORING. 985 00:34:57,095 --> 00:34:58,630 I PUT IN RED AREAS WHERE I THINK 986 00:34:58,630 --> 00:34:59,831 THERE'S A LITTLE BIT MORE WORK 987 00:34:59,831 --> 00:35:04,836 TO BE DONE. 988 00:35:04,836 --> 00:35:08,340 SO ABPM, PLUS OR MINUS SLEEP 989 00:35:08,340 --> 00:35:12,544 VERSUS HBPM AND CARDIOVASCULAR 990 00:35:12,544 --> 00:35:14,579 RISK, I THINK THERE'S A ROLE FOR 991 00:35:14,579 --> 00:35:16,081 SOME MORE OBSERVATIONAL EVIDENCE 992 00:35:16,081 --> 00:35:17,882 HERE. 993 00:35:17,882 --> 00:35:20,819 UNATTENDED AOBP AND AT HOME 994 00:35:20,819 --> 00:35:23,021 SCREENING TOOLS BEFORE ABPM. 995 00:35:23,021 --> 00:35:23,989 I THINK THERE'S BEEN SOME WORK 996 00:35:23,989 --> 00:35:25,190 THERE I'LL GET INTO. 997 00:35:25,190 --> 00:35:26,858 NUMBER THREE WAS THE EFFECT OF 998 00:35:26,858 --> 00:35:28,727 INITIATING INTENSIFYING INTO 999 00:35:28,727 --> 00:35:30,795 HYPERTENSIVE MEDICATION AMONG 1000 00:35:30,795 --> 00:35:33,531 ADULTS WITH WHITE COAT 1001 00:35:33,531 --> 00:35:36,267 HYPERTENSION AND MASKED 1002 00:35:36,267 --> 00:35:36,701 HYPERTENSION. 1003 00:35:36,701 --> 00:35:38,870 FIVE, WAYS TO REDUCE BARRIERS TO 1004 00:35:38,870 --> 00:35:40,872 ABPM AND HOME BLOOD PRESSURE 1005 00:35:40,872 --> 00:35:42,507 MONITORING IN CLINICAL PRACTICE. 1006 00:35:42,507 --> 00:35:43,708 SIX, OPTIMAL PROTOCOL FOR HOME 1007 00:35:43,708 --> 00:35:45,143 TO DIAGNOSE AND MANAGE 1008 00:35:45,143 --> 00:35:46,111 HYPERTENSION, TIME OF DAY, 1009 00:35:46,111 --> 00:35:47,979 NUMBER OF MEASUREMENTS, 1010 00:35:47,979 --> 00:35:50,048 DURATION, AND THEN THE SEVENTH 1011 00:35:50,048 --> 00:35:52,684 POINT, QUANTIFYING THE BURDEN OF 1012 00:35:52,684 --> 00:35:55,420 24-HOUR ABPM ON SLEEP AND DAILY 1013 00:35:55,420 --> 00:35:57,355 ACTIVITY DIST DISTURBANCES. 1014 00:35:57,355 --> 00:35:59,057 SO GOING THROUGH SOME OF THESE 1015 00:35:59,057 --> 00:36:00,692 SUBPOINTS ON THE NECTS SLIDE, I 1016 00:36:00,692 --> 00:36:05,897 NEXT SLIDE, IWANT TO HIGHLIGHT G 1017 00:36:05,897 --> 00:36:07,399 THE DETECTION OF HYPERTENSION 1018 00:36:07,399 --> 00:36:08,933 STUDY, A REALLY IMPORTANT STUDY 1019 00:36:08,933 --> 00:36:09,868 WITH A TREMENDOUS AMOUNT OF 1020 00:36:09,868 --> 00:36:10,969 MEASUREMENTS. 1021 00:36:10,969 --> 00:36:13,505 SO THREE WEEKS OF HOME, TWO 1022 00:36:13,505 --> 00:36:16,674 24-HOUR ABPM READINGS, 1023 00:36:16,674 --> 00:36:17,742 ECHOCARDIOGRAM, AND OFFICE 1024 00:36:17,742 --> 00:36:20,512 MEASURED OVER THREE VISITS. 1025 00:36:20,512 --> 00:36:23,681 WHAT THEY CONCLUDED WITH REALLY 1026 00:36:23,681 --> 00:36:26,017 ROBUST ANALYTIC APPROACHES IS 1027 00:36:26,017 --> 00:36:27,085 THAT HOME HAS THE POTENTIAL AT 1028 00:36:27,085 --> 00:36:29,354 LEAST IN THIS COHORT TO BE MORE 1029 00:36:29,354 --> 00:36:30,588 RELIABLE, AND SEEMED MORE 1030 00:36:30,588 --> 00:36:34,392 STRONGLY CORRELATED WITH LEFT 1031 00:36:34,392 --> 00:36:37,562 VENTRICULAR MASS INDEX, A 1032 00:36:37,562 --> 00:36:38,997 CLINICAL MARKER OF POTENTIALLY 1033 00:36:38,997 --> 00:36:40,432 THE DOWNSTREAM EFFECTS OF HIGH 1034 00:36:40,432 --> 00:36:40,799 BLOOD PRESSURE. 1035 00:36:40,799 --> 00:36:44,469 SO CERTAINLY REALLY FASCINATING 1036 00:36:44,469 --> 00:36:46,004 FINDINGS THAT I THINK HAVE 1037 00:36:46,004 --> 00:36:47,405 CONTRIBUTED A LOT TO OUR 1038 00:36:47,405 --> 00:36:48,540 UNDERSTANDING OF THESE DIFFERENT 1039 00:36:48,540 --> 00:36:50,909 MODALITIES. 1040 00:36:50,909 --> 00:36:51,910 IN THE NEXT SLIDE, I PRESENT 1041 00:36:51,910 --> 00:36:54,879 SOME OF OUR OWN WORK AROUND 1042 00:36:54,879 --> 00:36:56,714 MEASUREMENTS BEFORE ABPM. 1043 00:36:56,714 --> 00:36:58,716 SO THIS IS A QUALITY IMPROVEMENT 1044 00:36:58,716 --> 00:37:02,754 PROJECT OF 100 ADULTS WHERE WE 1045 00:37:02,754 --> 00:37:05,457 LOOKED AT ANG LPN MEASURED BLOOD 1046 00:37:05,457 --> 00:37:13,498 PRESSURE BEFORE AVPM, AOBP, 1047 00:37:13,498 --> 00:37:14,232 AUTOMATED BLOOD PRESSURE 1048 00:37:14,232 --> 00:37:16,334 ASSESSMENT AFTER THE ABPM, AND 1049 00:37:16,334 --> 00:37:19,404 THEN COMPARED THEIR PERFORMANCE, 1050 00:37:19,404 --> 00:37:21,039 AND IF YOU CLICK THROUGH, YOU 1051 00:37:21,039 --> 00:37:23,108 CAN SEE THAT THE SINGLE 1052 00:37:23,108 --> 00:37:24,342 MEASUREMENTS AND EVEN THE 1053 00:37:24,342 --> 00:37:25,643 AVERAGE THAT WERE PERFORMED 1054 00:37:25,643 --> 00:37:29,481 MANUALLY HAD SOME OF THE BIGGER 1055 00:37:29,481 --> 00:37:31,349 DIFFERENCES WITH A WAIT TIME 1056 00:37:31,349 --> 00:37:33,318 ABPM. 1057 00:37:33,318 --> 00:37:36,721 BUT THEN INTERESTINGLY, A SINGLE 1058 00:37:36,721 --> 00:37:38,356 FIRST AOBP MEASUREMENT, SO NOT 1059 00:37:38,356 --> 00:37:40,792 REALLY AUTOMATED, IT'S JUST THE 1060 00:37:40,792 --> 00:37:42,527 FIRST MEASUREMENT STILL SIMILAR 1061 00:37:42,527 --> 00:37:44,062 KIND OF BIAS OBSERVED WITH 1062 00:37:44,062 --> 00:37:45,930 RESPECT TO SYSTOLIC BLOOD 1063 00:37:45,930 --> 00:37:47,132 PRESSURE AROUND 4, BUT THEN WHEN 1064 00:37:47,132 --> 00:37:50,235 WE WENT TO THE SECOND AND THIRD, 1065 00:37:50,235 --> 00:37:51,836 THERE WERE SOME IMPROVEMENTS AND 1066 00:37:51,836 --> 00:37:53,304 THE AVERAGE SEEMED TO MINIMIZE 1067 00:37:53,304 --> 00:38:00,178 BIAS THE MOST. 1068 00:38:00,178 --> 00:38:01,613 I HIGHLIGHT THIS WORK IN 1069 00:38:01,613 --> 00:38:02,247 PROGRESS. 1070 00:38:02,247 --> 00:38:04,015 WE NOW HAVE 50 FOLKS BUT I'LL 1071 00:38:04,015 --> 00:38:05,016 JUST POINT OUT HERE, THIS IS 1072 00:38:05,016 --> 00:38:06,317 LOOKING AT CHANGES OVER TIME 1073 00:38:06,317 --> 00:38:08,920 WITH HOME, AND OFFICE, AND THIS 1074 00:38:08,920 --> 00:38:10,121 WAS A QUALITY IMPROVEMENT 1075 00:38:10,121 --> 00:38:11,356 PROJECT AS WELL THAT WE'VE BEEN 1076 00:38:11,356 --> 00:38:13,124 WORKING ON, AND IT TURNS OUT 1077 00:38:13,124 --> 00:38:15,293 THAT THE AOBP CHANGE HAS REALLY 1078 00:38:15,293 --> 00:38:18,830 NOT BEEN AS PRONOUNCED AS THE 1079 00:38:18,830 --> 00:38:20,799 HOME AND WE'RE HOPING TO SHARE 1080 00:38:20,799 --> 00:38:22,867 THIS SOON, BUT I DO THINK MORE 1081 00:38:22,867 --> 00:38:25,503 WORK SHOULD BE DONE AROUND THIS 1082 00:38:25,503 --> 00:38:26,704 CORRELATION OF CHANGES OVER TIME 1083 00:38:26,704 --> 00:38:27,672 WITH THE DIFFERENT BLOOD 1084 00:38:27,672 --> 00:38:32,277 PRESSURE MODALITIES. 1085 00:38:32,277 --> 00:38:34,279 IN TERMS OF TREATMENT OF MASKED 1086 00:38:34,279 --> 00:38:35,346 HYPERTENSION, I'LL CALL THIS 1087 00:38:35,346 --> 00:38:37,549 PAPER TO EVERYONE'S ATTENTION, 1088 00:38:37,549 --> 00:38:39,884 THIS WAS A RECENT STUDY TRIAL 1089 00:38:39,884 --> 00:38:42,620 LOOKING AT FOLKS WHO HAD ABPM IN 1090 00:38:42,620 --> 00:38:44,722 ADDITION TO AN OFFICE 1091 00:38:44,722 --> 00:38:45,790 ASSESSMENT, THEY WERE IDENTIFIED 1092 00:38:45,790 --> 00:38:47,692 AS HAVING MASKED HYPERTENSION, 1093 00:38:47,692 --> 00:38:49,427 AND LOOKING AT END ORGAN DAMAGE, 1094 00:38:49,427 --> 00:38:51,996 SO STILL NOT QUITE AT THE CBD 1095 00:38:51,996 --> 00:38:53,264 EVENT LEVEL, BUT CERTAINLY 1096 00:38:53,264 --> 00:38:54,365 DEMONSTRATING THAT MORE 1097 00:38:54,365 --> 00:38:56,568 AGGRESSIVE OR MORE -- TREATMENT 1098 00:38:56,568 --> 00:38:57,802 OF MASKED HYPERTENSION SEEMED TO 1099 00:38:57,802 --> 00:38:59,237 HAVE HEALTH BENEFITS, SO THIS IS 1100 00:38:59,237 --> 00:39:01,139 ONE OF THE FEW TRIALS OF ITS 1101 00:39:01,139 --> 00:39:02,207 KIND. 1102 00:39:02,207 --> 00:39:03,308 THERE WAS NOT I GUESS A CONTROL 1103 00:39:03,308 --> 00:39:04,309 GROUP THAT LOOKED AT JUST 1104 00:39:04,309 --> 00:39:07,712 TREATING TO A LOWER GOAL, SO IT 1105 00:39:07,712 --> 00:39:09,447 COULD VERY WELL BE THAT A LOT OF 1106 00:39:09,447 --> 00:39:10,915 THOSE FOLKS MIGHT BE CAPTURED 1107 00:39:10,915 --> 00:39:12,083 JUST BY TREATING TO A LOWER 1108 00:39:12,083 --> 00:39:13,618 OFFICE, BUT NONETHELESS, THIS 1109 00:39:13,618 --> 00:39:15,019 CONCEPT OF MASKED CERTAINLY 1110 00:39:15,019 --> 00:39:20,425 PROBED IN THIS TRIAL. 1111 00:39:20,425 --> 00:39:26,531 THEN I TALK ABOUT KR CHRONOTHER, 1112 00:39:26,531 --> 00:39:28,766 WE HAVE THE BED MED AND BED 1113 00:39:28,766 --> 00:39:29,300 MED-FRAIL TRIALS. 1114 00:39:29,300 --> 00:39:30,468 THESE WERE RECENTLY REPORTED 1115 00:39:30,468 --> 00:39:31,502 LOOKING AT THE TIMING OF 1116 00:39:31,502 --> 00:39:33,905 MEDICATIONS AND THE PRINCIPAL 1117 00:39:33,905 --> 00:39:34,806 INVESTIGATOR CONCLUDED REALLY NO 1118 00:39:34,806 --> 00:39:36,674 DIFFERENCE IN TERMS OF TIMING 1119 00:39:36,674 --> 00:39:39,210 AND PEOPLE SHOULD REALLY FOCUS 1120 00:39:39,210 --> 00:39:40,845 ON TAKING THEIR MEDS AT A TIME 1121 00:39:40,845 --> 00:39:42,046 WHEN THEY'RE MOST LIKELY TO 1122 00:39:42,046 --> 00:39:43,147 ADHERE TO THEIR REGIMEN. 1123 00:39:43,147 --> 00:39:44,682 SO I THINK THAT THAT'S SOME VERY 1124 00:39:44,682 --> 00:39:46,985 IMPORTANT TRIALS THAT CAME OUT 1125 00:39:46,985 --> 00:39:48,753 IN FRAIL AND OLDER POPULATIONS. 1126 00:39:48,753 --> 00:39:52,023 THEN IN THE NEXT SLIDE, I HAVE 1127 00:39:52,023 --> 00:39:54,692 LISTED HERE THE DATA FROM THE 1128 00:39:54,692 --> 00:39:56,427 TIME STUDY ALSO RECENTLY 1129 00:39:56,427 --> 00:39:57,962 PRESENTED VERY LARGE PRAGMATIC 1130 00:39:57,962 --> 00:39:59,497 STUDY THAT SHOWED THAT TIMING 1131 00:39:59,497 --> 00:40:02,433 ALSO DIDN'T SEEM TO IMPACT 1132 00:40:02,433 --> 00:40:06,037 OUTCOMES AS WELL, SUGGESTING 1133 00:40:06,037 --> 00:40:07,305 THAT REALLY CHRONOTHERAPY 1134 00:40:07,305 --> 00:40:08,940 SHOULDN'T BE A MAJOR FOCUS, WE 1135 00:40:08,940 --> 00:40:11,342 SHOULD FOCUS ON LONGER ACTING 1136 00:40:11,342 --> 00:40:12,677 AGENTS BUT NOT NECESSARILY THE 1137 00:40:12,677 --> 00:40:13,745 TIMING OF THOSE ADMINISTRATIONS. 1138 00:40:13,745 --> 00:40:16,614 I WILL SAY THAT NEITHER OF THESE 1139 00:40:16,614 --> 00:40:17,849 STUDIES TARGETED FOLKS WITH 1140 00:40:17,849 --> 00:40:18,750 NOCTURNAL HYPERTENSION, THAT 1141 00:40:18,750 --> 00:40:20,585 MIGHT BE A SUBSET THAT STILL 1142 00:40:20,585 --> 00:40:22,020 SOME WORK COULD BE DONE, BUT 1143 00:40:22,020 --> 00:40:24,989 CERTAINLY IN THE GENERAL 1144 00:40:24,989 --> 00:40:26,958 POPULATION, NOTE MUCH EVIDENCE 1145 00:40:26,958 --> 00:40:32,330 NOT MUCH EVIDENCEFOR TIMING THE. 1146 00:40:32,330 --> 00:40:33,865 THIS IS AGAIN A QUALITY 1147 00:40:33,865 --> 00:40:34,966 IMPROVEMENT PROJECT THAT OUR 1148 00:40:34,966 --> 00:40:37,468 GROUP DID FOCUSED ON DEVICE 1149 00:40:37,468 --> 00:40:38,102 CONCORDANCE. 1150 00:40:38,102 --> 00:40:40,038 WE FOUND THAT EVEN IN CLINIC AT 1151 00:40:40,038 --> 00:40:41,673 THE EXACT SAME TIME, THE HOME 1152 00:40:41,673 --> 00:40:42,874 DEVICE AND THE OFFICE DEVICE, 1153 00:40:42,874 --> 00:40:44,742 EVEN IF IT'S THE SAME BRAND, 1154 00:40:44,742 --> 00:40:47,245 COULD DIFFER IN ABOUT 20% OF 1155 00:40:47,245 --> 00:40:47,912 DEVICES. 1156 00:40:47,912 --> 00:40:49,647 SO CERTAINLY SOMETHING TO THINK 1157 00:40:49,647 --> 00:40:51,883 ABOUT IN TRYING TO INTERPRET 1158 00:40:51,883 --> 00:40:52,417 DEVICES AT HOME. 1159 00:40:52,417 --> 00:40:53,551 THERE MIGHT BE SOME PATIENTS 1160 00:40:53,551 --> 00:40:55,386 WITH DOCTORS THAT CONTRIBUTE TO 1161 00:40:55,386 --> 00:40:57,021 DISCORDANCE THAT WE DON'T FULLY 1162 00:40:57,021 --> 00:40:57,989 UNDERSTAND. 1163 00:40:57,989 --> 00:40:59,691 AND I THINK MORE WORK SHOULD BE 1164 00:40:59,691 --> 00:41:02,060 DONE HERE, BUT CERTAINLY 1165 00:41:02,060 --> 00:41:03,161 SURPRISING RESULT FOR US AND I 1166 00:41:03,161 --> 00:41:04,262 THINK IMPORTANT FOR THE QUESTION 1167 00:41:04,262 --> 00:41:08,966 RAISED BY THE WORKSHOP. 1168 00:41:08,966 --> 00:41:11,703 THIS IS ANOTHER REALLY IMPORTANT 1169 00:41:11,703 --> 00:41:14,105 STUDY THAT WAS ON HOW TO PERFORM 1170 00:41:14,105 --> 00:41:16,307 HOME, AND IN THIS GROUP ALSO 1171 00:41:16,307 --> 00:41:18,276 FROM THE IMPROVING DETECTION OF 1172 00:41:18,276 --> 00:41:19,377 HYPERTENSION, THEY LOOKED AT 1173 00:41:19,377 --> 00:41:20,812 NUMBER OF DAYS OF HOME 1174 00:41:20,812 --> 00:41:23,982 MONITORING AND LOOKED AT THE 1175 00:41:23,982 --> 00:41:26,150 ENTIRE MONITORED PERIOD AND THEN 1176 00:41:26,150 --> 00:41:28,386 SORT OF JUST THE SUBSET OF DAYS, 1177 00:41:28,386 --> 00:41:32,657 AND FOUND THAT REALLY IF YOU 1178 00:41:32,657 --> 00:41:33,958 LOOKED AT THE PERCENTAGE WITH A 1179 00:41:33,958 --> 00:41:35,393 DISCORDANCE OF ABOUT 1180 00:41:35,393 --> 00:41:36,594 10 MILLIMETERS OF MERCURY, YOU 1181 00:41:36,594 --> 00:41:38,062 KNOW, OBVIOUSLY HAVING MORE 1182 00:41:38,062 --> 00:41:39,697 DAYS, THERE'S LESS DISCORDANCE, 1183 00:41:39,697 --> 00:41:42,867 BUT YOU CAN SEE THE DROPOFF WAS 1184 00:41:42,867 --> 00:41:47,605 KIND OF GRA ACTUAL GRADUAL AND T 1185 00:41:47,605 --> 00:41:49,574 REALLY CROSS THE 85% POINT UNTIL 1186 00:41:49,574 --> 00:41:51,242 YOU GOT DOWN TO THE ONE TO TWO 1187 00:41:51,242 --> 00:41:52,877 DAY RANGE, SO THEY CONCLUDED 1188 00:41:52,877 --> 00:41:54,212 THAT THREE DAYS DOES A PRETTY 1189 00:41:54,212 --> 00:41:55,613 GOOD JOB FOR HOME MONITORING, 1190 00:41:55,613 --> 00:41:57,515 WHICH I THINK IS A REALLY 1191 00:41:57,515 --> 00:41:58,916 IMPORTANT FINDING. 1192 00:41:58,916 --> 00:42:01,018 THERE'S A PAPER THAT LOOKS AT 1193 00:42:01,018 --> 00:42:03,454 THRESHOLDS, AND I THOUGHT THIS 1194 00:42:03,454 --> 00:42:05,189 WAS ALSO A VERY SOPHISTICATED 1195 00:42:05,189 --> 00:42:06,157 STUDY FROM THE IMPROVING 1196 00:42:06,157 --> 00:42:07,859 DETECTION OF HYPERTENSION COHORT 1197 00:42:07,859 --> 00:42:08,393 AS WELL. 1198 00:42:08,393 --> 00:42:10,361 AND THEY LOOKED AT THRESHOLDS, 1199 00:42:10,361 --> 00:42:11,896 RIGHT, AND THE IDEA WAS, WELL, 1200 00:42:11,896 --> 00:42:15,099 MAYBE IF WE USE A BROADER 1201 00:42:15,099 --> 00:42:16,734 THRESHOLD, MORE EXPANSIVE 1202 00:42:16,734 --> 00:42:19,804 THRESHOLD OR EXTREME THRESHOLDS 1203 00:42:19,804 --> 00:42:21,239 OTHER SHORTER DAYS, WE MIGHT NOT 1204 00:42:21,239 --> 00:42:22,673 NEED TO DO ADDITIONAL DAYS OF 1205 00:42:22,673 --> 00:42:23,007 MONITORING. 1206 00:42:23,007 --> 00:42:24,942 I PUT THE CITATION HERE FOR 1207 00:42:24,942 --> 00:42:26,878 FOLKS TO READ, BUT THEY POINTED 1208 00:42:26,878 --> 00:42:30,481 OUT THAT IF YOU -- DEPENDING 1209 00:42:30,481 --> 00:42:32,450 ON -- WHERE YOU PUT THOSE 1210 00:42:32,450 --> 00:42:33,885 BOUNDS, WE MIGHT BE ABLE TO DO 1211 00:42:33,885 --> 00:42:35,653 MUCH BETTER OR SIMPLIFY THE 1212 00:42:35,653 --> 00:42:36,621 MONITORING REGIMEN TO FEWER THAN 1213 00:42:36,621 --> 00:42:37,221 THREE DAYS. 1214 00:42:37,221 --> 00:42:38,923 SO ALSO EXCITING EVIDENCE THERE 1215 00:42:38,923 --> 00:42:43,027 AS WELL. 1216 00:42:43,027 --> 00:42:44,562 THE NEXT SLIDE FOCUSES ON THE 1217 00:42:44,562 --> 00:42:50,401 ROLE OF SLEEP AND ABPM. 1218 00:42:50,401 --> 00:42:52,136 I THINK PART OF THE CHARGE WAS 1219 00:42:52,136 --> 00:42:53,771 RELATED TO CHARACTERIZING THE 1220 00:42:53,771 --> 00:42:55,440 IMPACTS OF ABPM ON SLEEP AND 1221 00:42:55,440 --> 00:42:58,810 THIS IS A REALLY NICE PAPER FROM 1222 00:42:58,810 --> 00:43:00,945 MYCO-CHAIR, DR. ABDALLA, THAT 1223 00:43:00,945 --> 00:43:03,881 SHOWS THAT SLEEP DURATION, 1224 00:43:03,881 --> 00:43:07,585 LENGTH OF SLEEP DURATION IS 1225 00:43:07,585 --> 00:43:10,688 RELATED TO DIPPING PATTERNS 1226 00:43:10,688 --> 00:43:11,022 OVERNIGHT. 1227 00:43:11,022 --> 00:43:12,890 AND THEN IN THE NEXT SLIDE, I 1228 00:43:12,890 --> 00:43:15,493 THINK THIS IS A REALLY IMPORTANT 1229 00:43:15,493 --> 00:43:18,563 CONTRIBUTION AROUND ACTIVITY AND 1230 00:43:18,563 --> 00:43:20,098 BLOOD PRESSURE. 1231 00:43:20,098 --> 00:43:23,501 AND IN THIS PARTICULAR COHORT, 1232 00:43:23,501 --> 00:43:27,238 FOLKS WORE A REALLY HIGHLY 1233 00:43:27,238 --> 00:43:31,843 SENSITIVE ACCELEROMETER OR 1234 00:43:31,843 --> 00:43:33,044 ACTOGRAM AND WERE ABLE TO 1235 00:43:33,044 --> 00:43:35,012 DEMONSTRATE THAT BEING ACTIVE 1236 00:43:35,012 --> 00:43:36,781 WAS RELATED TO A 15% INCREASE IN 1237 00:43:36,781 --> 00:43:38,216 BLOOD PRESSURE ASSESSMENTS ON 1238 00:43:38,216 --> 00:43:38,549 ABPM. 1239 00:43:38,549 --> 00:43:40,618 THAT'S IMPORTANT, I THINK, KIND 1240 00:43:40,618 --> 00:43:43,588 OF CONTEXTUAL DATA THAT I THINK 1241 00:43:43,588 --> 00:43:46,023 COULD BE INFORMATIVE FOR 1242 00:43:46,023 --> 00:43:47,458 SUBSEQUENT GENERATIONS OF 1243 00:43:47,458 --> 00:43:48,960 DEVICES AND DEVICE DEVELOPMENT, 1244 00:43:48,960 --> 00:43:51,162 WHEN WE THINK ABOUT CAPTURING 1245 00:43:51,162 --> 00:43:52,597 CONTEXTS BETTER TO INTERPRET 1246 00:43:52,597 --> 00:43:54,999 BLOOD PRESSURE. 1247 00:43:54,999 --> 00:43:56,467 ITEM NUMBER H WAS TO EVALUATE 1248 00:43:56,467 --> 00:43:57,768 THE ROLE OF BLOOD PRESSURE IN 1249 00:43:57,768 --> 00:44:02,373 PUBLIC LOCATIONS FOR SCREENING. 1250 00:44:02,373 --> 00:44:03,975 TO GUIDE ANTIHYPERTENSIVE 1251 00:44:03,975 --> 00:44:04,275 MEDICATION. 1252 00:44:04,275 --> 00:44:06,444 I HAVE A REALLY NICE, IN THE 1253 00:44:06,444 --> 00:44:11,015 NEXT SLIDE, A TRIAL BY DR. GREEN 1254 00:44:11,015 --> 00:44:11,449 OF 510 PARTICIPANTS. 1255 00:44:11,449 --> 00:44:13,150 THEY LOOKED AT KIOSKS, THEY 1256 00:44:13,150 --> 00:44:14,118 LOOKED AT HOME, THEY LOOKED AT 1257 00:44:14,118 --> 00:44:22,260 THE CLINIC AND ABMM BPM AND FOUD 1258 00:44:22,260 --> 00:44:26,197 THAT WHILE CLINIC MIGHT 1259 00:44:26,197 --> 00:44:28,299 UNDERESTIMATE ABPM, KIE OS BEING 1260 00:44:28,299 --> 00:44:31,602 SEEMED TO OVERESTIMATE ABPM BY 1261 00:44:31,602 --> 00:44:33,571 ABOUT 10, A CLINIC UNDERESTIMATE 1262 00:44:33,571 --> 00:44:35,573 BY ABOUT 5 MERCURY SYSTOLIC AND 1263 00:44:35,573 --> 00:44:37,008 SO PROVIDING SOME DATA AROUND 1264 00:44:37,008 --> 00:44:38,976 HOW THESE PERFORM AND HOW WE 1265 00:44:38,976 --> 00:44:40,044 NEED TO THINK ABOUT THESE 1266 00:44:40,044 --> 00:44:42,046 MEASUREMENTS WHEN THEY COME FROM 1267 00:44:42,046 --> 00:44:43,247 DIFFERENT SOURCES. 1268 00:44:43,247 --> 00:44:45,983 ITEMS J WAS THE VALIDITY OF 1269 00:44:45,983 --> 00:44:46,984 NOVEL APPROACHES. 1270 00:44:46,984 --> 00:44:48,319 WE HAVE SOME SESSIONS DEDICATED 1271 00:44:48,319 --> 00:44:50,288 TO THIS SO I'LL JUST GIVE AN 1272 00:44:50,288 --> 00:44:50,821 OVERARCHING VIEW. 1273 00:44:50,821 --> 00:44:52,056 I THINK THERE'S MORE WORK TO BE 1274 00:44:52,056 --> 00:44:53,491 DONE HERE, BUT IN TERMS OF 1275 00:44:53,491 --> 00:44:56,894 CUFFLESS VALIDATION, CUFFLESS 1276 00:44:56,894 --> 00:44:57,562 DEVICES, IN THE NEXT SLIDE, 1277 00:44:57,562 --> 00:44:59,430 THERE HAVE BEEN A NUMBER OF 1278 00:44:59,430 --> 00:45:01,832 VALIDATION PROTOCOLS THAT HAVE 1279 00:45:01,832 --> 00:45:04,468 BEEN PUBLISHED. 1280 00:45:04,468 --> 00:45:06,103 I THINK THAT'S A HUGE ADVANCE IN 1281 00:45:06,103 --> 00:45:09,874 THE FIELD, SO THE IEEE PROTOCOL, 1282 00:45:09,874 --> 00:45:13,010 THE ISO-3 WHICH LOOKS AT 1283 00:45:13,010 --> 00:45:14,712 CONTINUOUS DEVICES WITH AN 1284 00:45:14,712 --> 00:45:15,913 ARTERIAL LINE REFERENCE AND THEN 1285 00:45:15,913 --> 00:45:17,982 THE ESH GUIDELINE, WHICH IS A 1286 00:45:17,982 --> 00:45:19,550 CLINICAL VALIDATION 1287 00:45:19,550 --> 00:45:20,751 RECOMMENDATION, AND I LIST HERE 1288 00:45:20,751 --> 00:45:21,619 THE SIX TESTS THAT THEY 1289 00:45:21,619 --> 00:45:23,054 RECOMMEND THAT ARE ALL VERY 1290 00:45:23,054 --> 00:45:24,689 CLINICALLY FOCUSED. 1291 00:45:24,689 --> 00:45:27,225 AND IN ADDITION TO THAT ONGOING 1292 00:45:27,225 --> 00:45:29,293 IS THE ISO-7 WORKING GROUP WHERE 1293 00:45:29,293 --> 00:45:31,529 THEY HAVE A DRAFTED PROTOCOL, 1294 00:45:31,529 --> 00:45:32,330 OBVIOUSLY A LOT OF APPROVALS 1295 00:45:32,330 --> 00:45:33,497 THAT NEED TO HAPPEN FOR THIS, 1296 00:45:33,497 --> 00:45:35,800 BUT WE SHOULD BE HAVING SOME 1297 00:45:35,800 --> 00:45:36,901 PROCEDURES TO INTERPRET SOME OF 1298 00:45:36,901 --> 00:45:40,071 THESE DEVICES MOVING FORWARD. 1299 00:45:40,071 --> 00:45:41,906 IN THE NEXT SLIDE, NEXT TWO 1300 00:45:41,906 --> 00:45:44,008 SLIDES, I JUST HIGHLIGHT TWO 1301 00:45:44,008 --> 00:45:46,777 STUDIES THAT I THINK ARE REALLY 1302 00:45:46,777 --> 00:45:48,012 PIVOTAL FOR THINKING ABOUT 1303 00:45:48,012 --> 00:45:50,181 CUFFLESS DEVICES. 1304 00:45:50,181 --> 00:45:54,051 ONE IS A STUDY THAT LOOK AT 1305 00:45:54,051 --> 00:45:54,919 41 PARTICIPANTS AND SHOWED 1306 00:45:54,919 --> 00:45:57,455 REALLY GOOD CONCORDANCE WITH ONE 1307 00:45:57,455 --> 00:45:58,222 CUFFLESS DEVICE DURING THE DAY, 1308 00:45:58,222 --> 00:45:59,857 BUT AT NIGHTTIME, SOME 1309 00:45:59,857 --> 00:46:00,758 DISCORDANCE IN TERMS OF 1310 00:46:00,758 --> 00:46:01,959 NOCTURNAL DIPPING, SO AN AREA 1311 00:46:01,959 --> 00:46:02,627 JUST TO THINK ABOUT. 1312 00:46:02,627 --> 00:46:05,029 AND THEY HAD THREE FOLKS WHO ARE 1313 00:46:05,029 --> 00:46:06,864 STARTED ON ANTIHYPERTENSIVES 1314 00:46:06,864 --> 00:46:08,566 THAT WERE NOT TRACKED VERY WELL 1315 00:46:08,566 --> 00:46:10,001 BY THE CUFFLESS DEVICE, 1316 00:46:10,001 --> 00:46:11,636 SUGGESTING THE IMPORTANCE OF 1317 00:46:11,636 --> 00:46:12,737 RECALIBRATION FOR SOME OF THESE 1318 00:46:12,737 --> 00:46:13,938 DEVICES. 1319 00:46:13,938 --> 00:46:17,775 AND THEN IN THE AURA STUDY 1320 00:46:17,775 --> 00:46:19,110 CONDUCTED BY MICROSOFT, THEY 1321 00:46:19,110 --> 00:46:20,678 LOOKED AT A NUMBER OF NOVEL 1322 00:46:20,678 --> 00:46:22,313 TECHNOLOGIES WITH RESPECT TO 1323 00:46:22,313 --> 00:46:24,148 DIFFERENT BODY POSITIONS, OFFICE 1324 00:46:24,148 --> 00:46:29,887 AND ABPM, AND THIS IS THE NEXT 1325 00:46:29,887 --> 00:46:30,521 SLIDE. 1326 00:46:30,521 --> 00:46:32,590 THEY FOUND ESSENTIALLY NO VALUE 1327 00:46:32,590 --> 00:46:35,660 IN MEASURING RESTING BLOOD 1328 00:46:35,660 --> 00:46:36,327 PRESSURE, 24-HOUR AMBULATORY 1329 00:46:36,327 --> 00:46:36,894 BLOOD PRESSURE. 1330 00:46:36,894 --> 00:46:38,763 SO IMPORTANT STUDIES, I THINK, 1331 00:46:38,763 --> 00:46:43,234 FOR OUR REFERENCE. 1332 00:46:43,234 --> 00:46:44,568 RECOMMENDATION K WAS TO ASSESS 1333 00:46:44,568 --> 00:46:47,204 THE VALUE OF USING ORTHOSTATIC 1334 00:46:47,204 --> 00:46:54,712 HYPOTENSION AS A PART OF -- TO 1335 00:46:54,712 --> 00:46:56,113 GUIDE ANTIHYPERTENSIVE THERAPY. 1336 00:46:56,113 --> 00:46:57,314 I JUST HIGHLIGHT A STATEMENT 1337 00:46:57,314 --> 00:46:59,350 FROM THE AMERICAN HEART 1338 00:46:59,350 --> 00:47:00,251 ASSOCIATION, CERTAINLY I THINK 1339 00:47:00,251 --> 00:47:02,787 WAS INFORMATIVE FOR THE 1340 00:47:02,787 --> 00:47:03,387 CONDITION. 1341 00:47:03,387 --> 00:47:04,455 ON THE NEXT SLIDE WE JUST 1342 00:47:04,455 --> 00:47:06,424 HIGHLIGHT A COUPLE AREAS OF 1343 00:47:06,424 --> 00:47:07,758 MEASUREMENT ERROR TO BE 1344 00:47:07,758 --> 00:47:10,194 CONSIDERED WHEN DIAGNOSING. 1345 00:47:10,194 --> 00:47:11,328 OH AND HYPERTENSION, SO ONE IS 1346 00:47:11,328 --> 00:47:12,797 JUST THE MEASUREMENT AT BOTH 1347 00:47:12,797 --> 00:47:13,898 TIME POINTS AND THE NEXT SLIDE 1348 00:47:13,898 --> 00:47:15,132 IS ALSO THE DEGREE OF 1349 00:47:15,132 --> 00:47:15,433 VARIABILITY. 1350 00:47:15,433 --> 00:47:17,968 YOU COULD HAVE A FIXED AMOUNT OF 1351 00:47:17,968 --> 00:47:20,071 PERCENTAGE OF VARIABILITY BUT IF 1352 00:47:20,071 --> 00:47:21,172 YOU'RE AT A HIGHER RESTING BLOOD 1353 00:47:21,172 --> 00:47:22,173 PRESSURE, THAT'S GOING TO 1354 00:47:22,173 --> 00:47:24,208 MANIFEST AS A GREATER CHANGE IN 1355 00:47:24,208 --> 00:47:26,210 BLOOD PRESSURE WHICH WOULD 1356 00:47:26,210 --> 00:47:27,378 QUALIFY FOR OH. 1357 00:47:27,378 --> 00:47:28,245 SO SOMETHING TO BE THINKING 1358 00:47:28,245 --> 00:47:29,547 ABOUT WHEN WE'RE TRYING TO SORT 1359 00:47:29,547 --> 00:47:31,415 OUT IF SOMEONE HAS OH OR NOT. 1360 00:47:31,415 --> 00:47:33,084 THEN IN THE NEXT SLIDE, WE 1361 00:47:33,084 --> 00:47:36,153 SUMMARIZE IN A STATEMENT HOW 1362 00:47:36,153 --> 00:47:38,322 TO JUST APPROACH -- A FRAMEWORK 1363 00:47:38,322 --> 00:47:39,357 FOR APPROACHING SOME OF THE 1364 00:47:39,357 --> 00:47:42,426 DIFFERENT OH CONDITIONS, SO LIKE 1365 00:47:42,426 --> 00:47:43,828 CLASSIC AUTONOMIC DYSFUNCTION 1366 00:47:43,828 --> 00:47:45,396 VERSUS SOME OF THE PHYSIOLOGY 1367 00:47:45,396 --> 00:47:46,497 RELATED TO OH. 1368 00:47:46,497 --> 00:47:49,900 AND THEN THOSE TWO KIND OF 1369 00:47:49,900 --> 00:47:52,770 PSEUDOMEASUREMENT CONDITIONS, 1370 00:47:52,770 --> 00:47:54,171 THRESHOLD EFFECTS OF MEASUREMENT 1371 00:47:54,171 --> 00:47:55,406 ERROR TO THINK ABOUT. 1372 00:47:55,406 --> 00:47:58,242 IN THE NEXT SLIDE, I HAVE HERE 1373 00:47:58,242 --> 00:48:01,312 SOME WORK THAT WE DID ON 1374 00:48:01,312 --> 00:48:03,347 INDIVIDUAL LEVEL META-ANALYSIS 1375 00:48:03,347 --> 00:48:05,716 ON THE EFFECTS OF INTENSIVE 1376 00:48:05,716 --> 00:48:07,251 THERAPY ON THE OCCURRENCE OF OH, 1377 00:48:07,251 --> 00:48:08,919 SHOWING THAT CONTRARY TO 1378 00:48:08,919 --> 00:48:10,221 EXPECTATION MORE AGGRESSIVE 1379 00:48:10,221 --> 00:48:11,355 THERAPY SEEMED TO REDUCE THE 1380 00:48:11,355 --> 00:48:12,656 FREQUENCY OF OH. 1381 00:48:12,656 --> 00:48:15,226 IN THE NEXT SLIDE, A SUBGROUP 1382 00:48:15,226 --> 00:48:16,894 ANALYSIS, WE LOOKED AT STANDING 1383 00:48:16,894 --> 00:48:19,497 BLOOD PRESSURE LESS THAN 110 AND 1384 00:48:19,497 --> 00:48:21,065 THEN PRERANDOMMIZATION OH AND 1385 00:48:21,065 --> 00:48:22,700 REALLY THE FOLKS WITH THE LOWER 1386 00:48:22,700 --> 00:48:24,769 BLOOD PRESSURES IN THE STANDING 1387 00:48:24,769 --> 00:48:26,170 POSITION OR GREATER DROPS DID 1388 00:48:26,170 --> 00:48:27,438 NOT SEEM TO BE 1389 00:48:27,438 --> 00:48:28,873 DISPROPORTIONATELY AT HIGHER 1390 00:48:28,873 --> 00:48:30,841 RISK FROM FREETMENT OF HAVING 1391 00:48:30,841 --> 00:48:31,809 OH, SUGGESTING THAT SCREENING 1392 00:48:31,809 --> 00:48:32,643 FOR THESE CONDITIONS BEFORE 1393 00:48:32,643 --> 00:48:33,944 TREATMENT WITH RESPECT TO OH 1394 00:48:33,944 --> 00:48:34,979 MIGHT NOT BE RELEVANT. 1395 00:48:34,979 --> 00:48:37,047 IN THE NEXT SLIDE, WE LOOK AT 1396 00:48:37,047 --> 00:48:39,250 OUTCOMES FROM THE TRIALS, AND 1397 00:48:39,250 --> 00:48:40,518 CONCLUDED THAT AMONG INDIVIDUALS 1398 00:48:40,518 --> 00:48:47,491 WITH OH, MORE INTENSIVE THERAPY 1399 00:48:47,491 --> 00:48:49,794 SEEMED TO REDUCE RISK OF 1400 00:48:49,794 --> 00:48:50,461 CARDIOVASCULAR DISEASE OR ALL 1401 00:48:50,461 --> 00:49:00,771 CAUSE MORTALITY. 1402 00:49:00,771 --> 00:49:05,709 HERE WAS THE STUDY I WAS JUST 1403 00:49:05,709 --> 00:49:06,911 REFERRING TO WITH THE LOWER RISK 1404 00:49:06,911 --> 00:49:08,279 OF CARDIOVASCULAR DISEASE OR ALL 1405 00:49:08,279 --> 00:49:13,784 CAUSE MORTALITY. 1406 00:49:13,784 --> 00:49:17,521 L, EVALUATE PROGNOSTIC IMPACT OF 1407 00:49:17,521 --> 00:49:19,623 DIFFERENT ORTHOSTATIC 1408 00:49:19,623 --> 00:49:20,591 HYPOTENSION DEFINITIONS WITH AN 1409 00:49:20,591 --> 00:49:22,259 EMPHASIS ON POSITION. 1410 00:49:22,259 --> 00:49:23,894 THIS IS SOME WORK ON BODY 1411 00:49:23,894 --> 00:49:25,262 POSITION, AND HERE WE SHOW THERE 1412 00:49:25,262 --> 00:49:27,097 ARE DIFFERENT PHYSIOLOGIC 1413 00:49:27,097 --> 00:49:28,732 RESPONSE FROM GOING FROM A 1414 00:49:28,732 --> 00:49:30,868 SEATED TO STANDING POSITION 1415 00:49:30,868 --> 00:49:31,936 VERSUS SUPINE TO STANDING, 1416 00:49:31,936 --> 00:49:34,371 POPULATION OF OLDER ADULTS AT 1417 00:49:34,371 --> 00:49:36,574 RISK FOR FALLING, AND THEN THE 1418 00:49:36,574 --> 00:49:38,242 SUPINE PROTOCOL SEEMING TO 1419 00:49:38,242 --> 00:49:39,343 DIFFERENTIATE OR DISCRIMINATE 1420 00:49:39,343 --> 00:49:41,345 RISK OF FALLING BETTER THAN A 1421 00:49:41,345 --> 00:49:42,580 SEATED PROTOCOL. 1422 00:49:42,580 --> 00:49:44,081 THE NEXT SLIDE, USING THE SAME 1423 00:49:44,081 --> 00:49:45,282 POPULATION, WE LOOKED AT TIMING 1424 00:49:45,282 --> 00:49:48,385 OF MEASUREMENT AND CONCLUDED 1425 00:49:48,385 --> 00:49:50,454 THAT EARLIER OH ASSESSMENTS WERE 1426 00:49:50,454 --> 00:49:54,325 MORE SENSITIVE FOR OH AND 1427 00:49:54,325 --> 00:49:56,060 STRONGLY RELATED TO PEOPLE BEING 1428 00:49:56,060 --> 00:49:57,294 SYMPTOMATIC WHEN THEY STOOD UP, 1429 00:49:57,294 --> 00:49:59,296 BUT THE LONGER TERM, MORE 1430 00:49:59,296 --> 00:50:02,366 SUSTAINED OH SEEMED TO BE MORE 1431 00:50:02,366 --> 00:50:03,667 SPECIFIC FOR FALL RISK, SO 1432 00:50:03,667 --> 00:50:04,768 OBVIOUSLY MORE WORK TO BE DONE 1433 00:50:04,768 --> 00:50:06,770 THERE. 1434 00:50:06,770 --> 00:50:09,740 ITEM M, APPS EVALUATING APPS FOR 1435 00:50:09,740 --> 00:50:12,243 SIMPLIFYING AND ORGANIZING 1436 00:50:12,243 --> 00:50:14,144 INCOMING DATA FROM OUT OF OFFICE 1437 00:50:14,144 --> 00:50:15,346 BLOOD PRESSURE MEASUREMENTS. 1438 00:50:15,346 --> 00:50:16,113 I HIGHLIGHT ONE TRIAL. 1439 00:50:16,113 --> 00:50:17,548 I THINK THERE'S A LOT OF WORK TO 1440 00:50:17,548 --> 00:50:19,116 BE DONE HERE, BUT THIS IS AN 1441 00:50:19,116 --> 00:50:23,387 INTERESTING TRIAL LOOKING AT AN 1442 00:50:23,387 --> 00:50:26,323 APP-ENABLED BLOOD PRESSURE 1443 00:50:26,323 --> 00:50:30,661 MEASUREMENT MODALITY AND KIND OF 1444 00:50:30,661 --> 00:50:33,597 QUANTIFYING THE AMUSE BP STUDY, 1445 00:50:33,597 --> 00:50:35,466 QUANTIFYING ITS RELIABILITY AND 1446 00:50:35,466 --> 00:50:37,601 NEGATIVE PREDICTIVE VALUE WITH 1447 00:50:37,601 --> 00:50:42,072 RESPECT TO ABPM. 1448 00:50:42,072 --> 00:50:43,507 IN THE NEXT SLIDE, 1449 00:50:43,507 --> 00:50:45,175 RECOMMENDATION N, EVALUATE 1450 00:50:45,175 --> 00:50:46,010 APPROACHES TO MEASURING BLOOD 1451 00:50:46,010 --> 00:50:51,515 PRESSURE IN MORBIDLY OBESE 1452 00:50:51,515 --> 00:50:51,982 ADULTS. 1453 00:50:51,982 --> 00:50:53,183 WE HAVE A SESSION DEDICATED TO 1454 00:50:53,183 --> 00:50:54,652 THIS LATER ON BECAUSE THIS IS 1455 00:50:54,652 --> 00:50:56,186 SUCH AN IMPORTANT ISSUE, AND IN 1456 00:50:56,186 --> 00:50:57,688 THE NEXT SLIDE, I JUST 1457 00:50:57,688 --> 00:50:59,156 HIGHLIGHT -- THIS IS SEEN IN 1458 00:50:59,156 --> 00:51:00,157 PREVIOUS WORK -- HOW THERE'S 1459 00:51:00,157 --> 00:51:02,793 JUST REALLY EVEN FOR REFERENCE 1460 00:51:02,793 --> 00:51:05,496 STANDARDS AN I INADEQUATE AMOUNT 1461 00:51:05,496 --> 00:51:07,865 OF DEVICES -- OR BECAUSE OF 1462 00:51:07,865 --> 00:51:10,601 LARGER ARMS, THERE'S REALLY NOT 1463 00:51:10,601 --> 00:51:13,203 EVEN A MEANS TO HAVE A REFERENCE 1464 00:51:13,203 --> 00:51:15,906 STANDARD FOR VALIDATING DEVICES 1465 00:51:15,906 --> 00:51:17,975 FOR MANY INDIVIDUALS AS THE ARM 1466 00:51:17,975 --> 00:51:19,510 CIRCUMFERENCE GETS HIGHER, 1467 00:51:19,510 --> 00:51:21,245 SUGGESTING THAT THIS IS A REALLY 1468 00:51:21,245 --> 00:51:23,380 IMPORTANT AREA AS OBESITY HAS 1469 00:51:23,380 --> 00:51:27,318 BECOME SO PREVALENT WORLDWIDE. 1470 00:51:27,318 --> 00:51:30,688 THERE WAS A REALLY USEFUL 1471 00:51:30,688 --> 00:51:34,491 STATEMENT LED BY PAUL PALANTINI 1472 00:51:34,491 --> 00:51:35,926 RECOMMENDING APPROACHES FOR 1473 00:51:35,926 --> 00:51:38,996 FOLKS WITH LARGER ARM 1474 00:51:38,996 --> 00:51:40,230 CIRCUMFERENCES AND DESCRIBING 1475 00:51:40,230 --> 00:51:41,665 SOME OF THE CONTOUR AND SORT OF 1476 00:51:41,665 --> 00:51:43,400 SLANTS TO BE CONCERNED ABOUT, 1477 00:51:43,400 --> 00:51:46,370 AND A CALL FOR CUFFS THAT 1478 00:51:46,370 --> 00:51:50,874 ACTUALLY COULD ADDRESS A 1479 00:51:50,874 --> 00:51:52,743 NON-CYLINDRICAL ARM SHAPE, SO I 1480 00:51:52,743 --> 00:51:53,611 THINK THIS IS AN IMPORTANT 1481 00:51:53,611 --> 00:51:54,545 DISCUSSION THAT WAS ADVANCED 1482 00:51:54,545 --> 00:51:54,812 THERE. 1483 00:51:54,812 --> 00:51:58,415 SO IN CONCLUSION ON THE NEXT 1484 00:51:58,415 --> 00:52:02,019 SLIDE, THE 2017 WORKING GROUP 1485 00:52:02,019 --> 00:52:05,689 LED A REALLY MEANINGFUL 1486 00:52:05,689 --> 00:52:07,124 DISTILLATE OF KEY CHALLENGES 1487 00:52:07,124 --> 00:52:08,092 FACING BLOOD PRESSURE ASSESSMENT 1488 00:52:08,092 --> 00:52:09,193 IN CLINICAL PRACTICE AND 1489 00:52:09,193 --> 00:52:09,660 RESEARCH. 1490 00:52:09,660 --> 00:52:11,629 THERE WERE A NUMBER OF STUDY, I 1491 00:52:11,629 --> 00:52:13,163 TRIED TO GO THROUGH AS MANY AS I 1492 00:52:13,163 --> 00:52:17,334 COULD THAT HAVE DIRECTLY 1493 00:52:17,334 --> 00:52:18,135 RESPONDED TO AND INFORMED 1494 00:52:18,135 --> 00:52:19,236 QUESTIONS RAISED BY THE WORKING 1495 00:52:19,236 --> 00:52:20,871 GROUP, BUT THERE ARE A LOT OF 1496 00:52:20,871 --> 00:52:22,006 ONGOING GAPS WHICH WILL BE THE 1497 00:52:22,006 --> 00:52:23,340 FOCUS OF THE PRESENT WORKSHOPS. 1498 00:52:23,340 --> 00:52:25,609 SO THANK YOU SO MUCH FOR YOUR 1499 00:52:25,609 --> 00:52:25,809 TIME. 1500 00:52:25,809 --> 00:52:27,311 THIS LAST SLIDE IS JUST A THANK 1501 00:52:27,311 --> 00:52:32,149 YOU TO OUR PARTICIPANTS, 1502 00:52:32,149 --> 00:52:33,017 DISCUSSANTS AND THANK YOU TO THE 1503 00:52:33,017 --> 00:52:35,519 NHLBI FOR SUPPORTING THIS 1504 00:52:35,519 --> 00:52:36,086 DISCUSSION. 1505 00:52:36,086 --> 00:52:39,823 >> WELL, THE NEXT ITEM ON THE 1506 00:52:39,823 --> 00:52:42,026 AGENDA IS THE CHARGE TO THE 1507 00:52:42,026 --> 00:52:49,600 GROUP FROM THE CHAIRS WORKSHOP. 1508 00:52:49,600 --> 00:52:50,467 MARWAH AND STEPHEN? 1509 00:52:50,467 --> 00:52:52,369 >> THANK YOU SO MUCH AGAIN FOR 1510 00:52:52,369 --> 00:52:57,941 THE OPPORTUNITY TO DISCUSS OUR 1511 00:52:57,941 --> 00:53:02,312 CHARGE TO THE GROUP. 1512 00:53:02,312 --> 00:53:04,782 SO AS WE ALL ARE HERE BECAUSE 1513 00:53:04,782 --> 00:53:05,315 ACCURATE BLOOD PRESSURE 1514 00:53:05,315 --> 00:53:06,417 MEASUREMENT REMAINS A 1515 00:53:06,417 --> 00:53:08,285 CORNERSTONE OF EFFECTIVE 1516 00:53:08,285 --> 00:53:10,754 CLINICAL CARE AND A CRITICAL 1517 00:53:10,754 --> 00:53:12,823 FOCUS FOR RESEARCH AND DESPITE 1518 00:53:12,823 --> 00:53:14,992 MANY ADVANCES IN TECHNOLOGY AND 1519 00:53:14,992 --> 00:53:15,993 METHODOLOGY, GAPS PERSIST THAT 1520 00:53:15,993 --> 00:53:18,095 AFFECTS PATIENTS, CLINICIANS AND 1521 00:53:18,095 --> 00:53:19,196 REACH SERS, AND AS YOU JUST 1522 00:53:19,196 --> 00:53:20,464 HEARD FROM STEPHEN SINCE THE 1523 00:53:20,464 --> 00:53:21,932 2017 WORKSHOP, THERE'S STILL A 1524 00:53:21,932 --> 00:53:23,834 NEED TO EVALUATE PROGRESS AND 1525 00:53:23,834 --> 00:53:25,803 DISCUSS FURTHER RESEARCH 1526 00:53:25,803 --> 00:53:26,236 DIRECTIONS INCLUDING 1527 00:53:26,236 --> 00:53:27,237 TECHNOLOGICAL DEVELOPMENTS AND 1528 00:53:27,237 --> 00:53:28,605 PLOOP ASSESSMENTS PARTICULARLY 1529 00:53:28,605 --> 00:53:30,441 IN SPECIAL POPULATIONS. 1530 00:53:30,441 --> 00:53:32,976 THERE'S BEEN BOTH AN INTEREST IN 1531 00:53:32,976 --> 00:53:35,045 PROGRESS IN THE USE OF 24 HOUR 1532 00:53:35,045 --> 00:53:36,513 BLOOD PRESSURE MONITORING BUT 1533 00:53:36,513 --> 00:53:39,483 THE ESTABLISHED METHODOLOGIES 1534 00:53:39,483 --> 00:53:42,119 ARE RATHER INCONCLUSIVE AND NEW 1535 00:53:42,119 --> 00:53:42,920 EMERGING APPROACHES THAT WE'LL 1536 00:53:42,920 --> 00:53:44,888 HEAR ABOUT LATER INCLUDING 1537 00:53:44,888 --> 00:53:48,392 CONTINUOUS AND CUFFLESS. 1538 00:53:48,392 --> 00:53:50,627 SO WE'VE STARTED THE WORKSHOP 1539 00:53:50,627 --> 00:53:52,496 REALLY WITH AN EMPHASIS ON THE 1540 00:53:52,496 --> 00:53:53,897 LIFESPAN, WHICH WILL BE THE NEXT 1541 00:53:53,897 --> 00:53:54,264 SESSION. 1542 00:53:54,264 --> 00:53:55,799 BLOOD PRESSURE ASSESSMENT ACROSS 1543 00:53:55,799 --> 00:53:56,800 THE LIFESPAN INCLUDING IN 1544 00:53:56,800 --> 00:53:58,869 PREGNANT WOMEN AND CHILDREN 1545 00:53:58,869 --> 00:54:00,404 REPRESENT CRITICAL GAPS. 1546 00:54:00,404 --> 00:54:02,172 IN PARTICULAR, BLOOD PRESSURE 1547 00:54:02,172 --> 00:54:04,074 ASSESSMENT IN PREGNANCY HAS 1548 00:54:04,074 --> 00:54:06,710 GAINED ATTENTION IN LIGHT OF THE 1549 00:54:06,710 --> 00:54:08,078 REPORTED CHAP CLINICAL TRIAL AND 1550 00:54:08,078 --> 00:54:11,248 WE KNOW THAT THE LAST AAP 1551 00:54:11,248 --> 00:54:12,649 CLINICAL PRACTICE GUIDELINE FOR 1552 00:54:12,649 --> 00:54:14,384 SCREENING AND MANAGEMENT OF HIGH 1553 00:54:14,384 --> 00:54:15,953 BLOOD PRESSURE IN CHILDREN AND 1554 00:54:15,953 --> 00:54:18,455 ADOLESCENT WAS PUBLISHED IN 1555 00:54:18,455 --> 00:54:18,922 2017. 1556 00:54:18,922 --> 00:54:20,457 SO WE'VE CONVENED A SERIES OF 1557 00:54:20,457 --> 00:54:22,092 EXPERTS TO EXPRESS CURRENT 1558 00:54:22,092 --> 00:54:24,661 CHALLENGES AND EXPLORE 1559 00:54:24,661 --> 00:54:27,397 INNOVATIVE SOLUTIONS IN ORDER TO 1560 00:54:27,397 --> 00:54:28,599 ADVANCE THE FIELD OF BLOOD 1561 00:54:28,599 --> 00:54:29,900 PRESSURE ASSESSMENT. 1562 00:54:29,900 --> 00:54:31,735 SO OUR CHARGE FOR TODAY IS BOTH 1563 00:54:31,735 --> 00:54:34,571 AMBITIOUS AND ESSENTIAL, TO 1564 00:54:34,571 --> 00:54:36,340 IDENTIFY PERSISTENT GAPS AND 1565 00:54:36,340 --> 00:54:38,909 CHALLENGES IN BLOOD PRESSURE 1566 00:54:38,909 --> 00:54:41,378 ASSESSMENT, DEFINE PRACTICAL AND 1567 00:54:41,378 --> 00:54:42,412 TRANSFORMATIVE SOLUTIONS THAT 1568 00:54:42,412 --> 00:54:44,781 CAN SHAPE CURRENT AND FUTURE 1569 00:54:44,781 --> 00:54:45,415 RESEARCH AGENDAS, BUT REALLY 1570 00:54:45,415 --> 00:54:48,252 THAT CAN INSPIRE SYSTEM-WIDE 1571 00:54:48,252 --> 00:54:49,853 CHANGE THAT ULTIMATELY I THINK 1572 00:54:49,853 --> 00:54:52,122 THIS IS THE BROAD MISSION, CAN 1573 00:54:52,122 --> 00:54:53,557 IMPACT CLINICAL GUIDELINES, 1574 00:54:53,557 --> 00:54:55,359 HEALTH POLICY TO IMPROVE BLOOD 1575 00:54:55,359 --> 00:54:56,994 PRESSURE EQUITABLY AND TO DO SO, 1576 00:54:56,994 --> 00:54:58,195 WE'VE OUTLINED SEVERAL 1577 00:54:58,195 --> 00:54:59,396 OBJECTIVES. 1578 00:54:59,396 --> 00:55:01,865 THE FIRST OBJECTIVE IS TO ASSESS 1579 00:55:01,865 --> 00:55:02,666 THE CURRENT STATE OF KNOWLEDGE 1580 00:55:02,666 --> 00:55:04,134 ON BLOOD PRESSURE ASSESSMENT IN 1581 00:55:04,134 --> 00:55:07,437 CLINICAL PRACTICE AND CLINICAL 1582 00:55:07,437 --> 00:55:11,475 RESEARCH. 1583 00:55:11,475 --> 00:55:14,945 OBJECTIVE NUMBER TWO IS TO 1584 00:55:14,945 --> 00:55:15,712 IDENTIFY KNOWLEDGE GAPS 1585 00:55:15,712 --> 00:55:16,380 PERTAINING TO CURRENT BLOOD 1586 00:55:16,380 --> 00:55:17,881 PRESSURE ASSESSMENT METHODS AND 1587 00:55:17,881 --> 00:55:19,049 IDENTIFY OBSTACLES THAT NIH MAY 1588 00:55:19,049 --> 00:55:20,117 BE ABLE TO IMPACT. 1589 00:55:20,117 --> 00:55:21,518 FOR THE REST OF THE OBJECTIVES, 1590 00:55:21,518 --> 00:55:23,187 I'M GOING TO ASK STEPHEN TO 1591 00:55:23,187 --> 00:55:26,123 PRESENT. 1592 00:55:26,123 --> 00:55:28,058 >> THE THIRD OBJECTIVE IS TO 1593 00:55:28,058 --> 00:55:29,259 REVIEW ONGOING RESEARCH AND 1594 00:55:29,259 --> 00:55:30,294 IDENTIFY RESEARCH NEEDS TO 1595 00:55:30,294 --> 00:55:30,794 IMPROVE BLOOD PRESSURE 1596 00:55:30,794 --> 00:55:31,828 ASSESSMENT IN CLINICAL PRACTICE 1597 00:55:31,828 --> 00:55:39,136 AND CLINICAL RESEARCH. 1598 00:55:39,136 --> 00:55:41,572 THEN TO COMPLEMENT AND EXPAND ON 1599 00:55:41,572 --> 00:55:43,574 THE 2023 WORKSHOP ON 1600 00:55:43,574 --> 00:55:44,241 TRANSFORMING HYPERTENSION 1601 00:55:44,241 --> 00:55:45,542 DIAGNOSIS AND MANAGEMENT IN THE 1602 00:55:45,542 --> 00:55:47,244 ERA OF ARTIFICIAL INTELLIGENCE. 1603 00:55:47,244 --> 00:55:50,214 SO WE HAVE A TECHNOLOGY TIE-IN 1604 00:55:50,214 --> 00:55:55,986 TO MAKE THINGS CONTEMPORARY. 1605 00:55:55,986 --> 00:56:00,624 AND SO THE WORKSHOP IS ORGANIZED 1606 00:56:00,624 --> 00:56:01,658 INTO FIVE SESSIONS THAT ARE, I 1607 00:56:01,658 --> 00:56:03,927 THINK, REALLY DENSE, HAVE SOME 1608 00:56:03,927 --> 00:56:06,597 AMAZING SPEAKERS, BUT WILL COVER 1609 00:56:06,597 --> 00:56:07,497 A LOT OF GROUND. 1610 00:56:07,497 --> 00:56:09,333 SO SESSION ONE FOCUSES ON 1611 00:56:09,333 --> 00:56:12,469 SPECIAL POPULATIONS ACROSS THE 1612 00:56:12,469 --> 00:56:13,904 LIFESPAN. 1613 00:56:13,904 --> 00:56:15,205 ADDRESSING SOME -- I WOULD SAY 1614 00:56:15,205 --> 00:56:17,207 SOME IMPORTANT GAPS FROM THE 1615 00:56:17,207 --> 00:56:18,809 2017 WORK GROUP. 1616 00:56:18,809 --> 00:56:20,010 SESSION TWO IS LOOKING AT BLOOD 1617 00:56:20,010 --> 00:56:24,014 PRESSURE CONTROL ACROSS CLINICAL 1618 00:56:24,014 --> 00:56:24,982 CONDITIONS, AND PARTICULARLY 1619 00:56:24,982 --> 00:56:28,485 SOME CONDITIONS WHERE CONTROL 1620 00:56:28,485 --> 00:56:30,420 SOMETIMES IS MORE OF A CONCERN 1621 00:56:30,420 --> 00:56:31,622 OR MORE CHALLENGING TO 1622 00:56:31,622 --> 00:56:34,124 ASCERTAIN. 1623 00:56:34,124 --> 00:56:35,325 SESSION THREE, LOOKING AT CUFF 1624 00:56:35,325 --> 00:56:37,127 TO CUFFLESS DEVICES, NEW 1625 00:56:37,127 --> 00:56:38,028 FRONTIERS IN BLOOD PRESSURE 1626 00:56:38,028 --> 00:56:40,097 ASSESSMENT AND MONITORING. 1627 00:56:40,097 --> 00:56:43,500 SO A SPECIAL FOCUS ON WHERE 1628 00:56:43,500 --> 00:56:45,302 WE'RE AT IN TERMS OF 1629 00:56:45,302 --> 00:56:45,969 TECHNOLOGIES, WHERE WE ARE IN 1630 00:56:45,969 --> 00:56:48,138 TERMS OF VALIDATION, AND WHAT 1631 00:56:48,138 --> 00:56:50,340 NEEDS TO BE DONE. 1632 00:56:50,340 --> 00:56:51,908 SESSION FOUR, INTEGRATING 1633 00:56:51,908 --> 00:56:53,243 TECHNOLOGIES FROM RESEARCH TO 1634 00:56:53,243 --> 00:56:53,744 PRACTICE. 1635 00:56:53,744 --> 00:56:55,412 SO HOW DO WE -- WE HAVE ALL 1636 00:56:55,412 --> 00:56:57,447 THESE TECHNOLOGIES BUT HOW DO WE 1637 00:56:57,447 --> 00:57:00,083 REALLY GET THEM FRP THE RYE 1638 00:57:00,083 --> 00:57:02,586 SEARCH INTO THE CLINIC SPACE. 1639 00:57:02,586 --> 00:57:04,254 AND SESSION FIVE, IMPLEMENTATION 1640 00:57:04,254 --> 00:57:05,589 OF INNOVATIVE TOOLS TO ENSURE 1641 00:57:05,589 --> 00:57:07,057 EQUITY ACROSS THE LIFESPAN, 1642 00:57:07,057 --> 00:57:08,458 WHICH I THINK IS A REALLY 1643 00:57:08,458 --> 00:57:09,793 CRITICAL PIECE, YOU KNOW, OFTEN 1644 00:57:09,793 --> 00:57:12,095 WITH TECHNOLOGIES, IT CREATES 1645 00:57:12,095 --> 00:57:16,333 MORE DISPARITY AND SO THE IDEA 1646 00:57:16,333 --> 00:57:19,136 IS WE WANT TO MAKE SURE THERE'S 1647 00:57:19,136 --> 00:57:19,903 ACCESS. 1648 00:57:19,903 --> 00:57:20,771 AND EQUITY IN TERMS OF HOW 1649 00:57:20,771 --> 00:57:25,275 THEY'RE IMPLEMENTED. 1650 00:57:25,275 --> 00:57:26,877 WE ALSO HAVE THREE BREAKOUT 1651 00:57:26,877 --> 00:57:30,681 SESSIONS THAT WILL INVOLVE THE 1652 00:57:30,681 --> 00:57:32,983 DISCUSSANTS TO TACKLE THE 1653 00:57:32,983 --> 00:57:33,984 FOLLOWING THEMES. 1654 00:57:33,984 --> 00:57:35,018 ONE, PRACTICAL USE AND 1655 00:57:35,018 --> 00:57:36,119 VALIDATION OF EMERGING BLOOD 1656 00:57:36,119 --> 00:57:36,920 PRESSURE DEVICES. 1657 00:57:36,920 --> 00:57:40,590 SO KIND OF AN EXTENSION OF THE 1658 00:57:40,590 --> 00:57:42,159 PRIOR SESSION REALLY DIVING IN 1659 00:57:42,159 --> 00:57:43,927 TO WHAT NEED TO BE DONE AROUND 1660 00:57:43,927 --> 00:57:45,329 THESE DEVICES IN TERMS OF HOW WE 1661 00:57:45,329 --> 00:57:47,531 THINK ABOUT THEM, AND ASSURE 1662 00:57:47,531 --> 00:57:48,565 THEIR ACCURACY. 1663 00:57:48,565 --> 00:57:49,900 THE SECOND SESSION FOCUSING ON 1664 00:57:49,900 --> 00:57:52,069 ACCESS AND EQUITY IN BLOOD 1665 00:57:52,069 --> 00:57:53,403 PRESSURE MEASUREMENT ASSESSMENTS 1666 00:57:53,403 --> 00:57:55,105 AND MONITORING, WHICH IS REALLY 1667 00:57:55,105 --> 00:57:59,242 A THEME THROUGHOUT THE ENTIRE 1668 00:57:59,242 --> 00:58:00,243 WORKSHOP, AND THEN THREE, 1669 00:58:00,243 --> 00:58:02,045 LOOKING AT RELIABLE BLOOD 1670 00:58:02,045 --> 00:58:04,247 PRESSURE MEASUREMENTS, BASED 1671 00:58:04,247 --> 00:58:05,749 ON -- WITH A FOCUS ON SORT OF 1672 00:58:05,749 --> 00:58:06,783 OUR TRADITIONAL APPROACHES TO 1673 00:58:06,783 --> 00:58:11,855 BLOOD PRESSURE. 1674 00:58:11,855 --> 00:58:14,358 SO OUR KIND OF CHARGE AND ASK OF 1675 00:58:14,358 --> 00:58:15,125 PARTICIPANTS IS CONTRIBUTE YOUR 1676 00:58:15,125 --> 00:58:18,528 COMMENTS AND QUESTIONS. 1677 00:58:18,528 --> 00:58:22,065 THERE'S NO BAD COMMENTS OR 1678 00:58:22,065 --> 00:58:22,666 QUESTIONS. 1679 00:58:22,666 --> 00:58:25,168 TO SOME EXTENT, AS LONG AS 1680 00:58:25,168 --> 00:58:26,236 YOU'RE RESPECTFUL OF OTHERS, BUT 1681 00:58:26,236 --> 00:58:27,704 WE REALLY WOULD LOVE TO HEAR 1682 00:58:27,704 --> 00:58:29,806 YOUR IDEAS AND THOUGHTS AND ANY 1683 00:58:29,806 --> 00:58:32,109 AREAS THAT WE SHOULD BE 1684 00:58:32,109 --> 00:58:35,445 CONSIDERING AS WE TRY TO TACKLE 1685 00:58:35,445 --> 00:58:37,080 THIS REALLY IMPORTANT ISSUE. 1686 00:58:37,080 --> 00:58:38,682 FEEL FREE TO ENGAGE THE SPEAKERS 1687 00:58:38,682 --> 00:58:40,584 AS MUCH AS YOU CAN DURING THEIR 1688 00:58:40,584 --> 00:58:42,953 TALKS, AND IF -- SOMETIMES 1689 00:58:42,953 --> 00:58:46,890 THERE'S NOT ADEQUATE TIME TO 1690 00:58:46,890 --> 00:58:47,758 ADDRESS EVERYTHING AND MANY 1691 00:58:47,758 --> 00:58:49,192 TIMES THERE MIGHT BE IMPORTANT 1692 00:58:49,192 --> 00:58:50,026 QUESTIONS THAT MAY BE DIFFICULT 1693 00:58:50,026 --> 00:58:53,397 TO CONVEY IN THE CHAT OR MIGHT 1694 00:58:53,397 --> 00:58:54,731 REQUIRE MORE DISCUSSION, SO WE 1695 00:58:54,731 --> 00:58:55,499 REALLY ENCOURAGE YOU TO REACH 1696 00:58:55,499 --> 00:58:59,603 OUT TO THE ORGANIZERS OF THE 1697 00:58:59,603 --> 00:59:02,105 EVENT IF WE RUN OUT OF TIME OUR 1698 00:59:02,105 --> 00:59:04,141 FEEL LIKE YOUR COMMENT WASN'T 1699 00:59:04,141 --> 00:59:06,209 ADEQUATELY DEVELOPED. 1700 00:59:06,209 --> 00:59:07,444 WE REALLY LOVE THAT OPPORTUNITY 1701 00:59:07,444 --> 00:59:10,714 TO ENGAGE IN SOME SENSE WITH THE 1702 00:59:10,714 --> 00:59:12,849 CHARGE TO DEVELOP A SUMMARY 1703 00:59:12,849 --> 00:59:13,950 LATER, SOME OF THE COMMENT COULD 1704 00:59:13,950 --> 00:59:15,385 BE REALLY INFORMATIVE FOR SOME 1705 00:59:15,385 --> 00:59:22,893 OF THAT LATER THOUGHT WORK. 1706 00:59:22,893 --> 00:59:24,628 OUR ASK OF THE PRESENTERS BE TO 1707 00:59:24,628 --> 00:59:27,030 ENGAGE YOUR COLLEAGUES AND 1708 00:59:27,030 --> 00:59:27,798 PARTICIPANTS THROUGHOUT THE 1709 00:59:27,798 --> 00:59:29,199 SESSIONS. 1710 00:59:29,199 --> 00:59:30,734 MAKE NOTE OF ANY GAPS OR NEW 1711 00:59:30,734 --> 00:59:33,437 IDEAS THAT ARE DEVELOPED AND 1712 00:59:33,437 --> 00:59:35,839 PRESENTED DURING THE SESSIONS 1713 00:59:35,839 --> 00:59:37,240 AND CONTRIBUTE THEM AND BRING 1714 00:59:37,240 --> 00:59:39,276 THEM UP IN THE WORKING GROUP 1715 00:59:39,276 --> 00:59:41,144 BREAKOUT SESSIONS. 1716 00:59:41,144 --> 00:59:43,447 DEVELOP TOPICS THAT ARE IN THE 1717 00:59:43,447 --> 00:59:45,315 SMALL GROUP SESSIONS, SO IF 1718 00:59:45,315 --> 00:59:47,050 LET'S SAY THERE'S SOMETHING THAT 1719 00:59:47,050 --> 00:59:48,652 WE FELT LIKE SHOULD HAVE BEEN 1720 00:59:48,652 --> 00:59:51,254 COVERED MORE FULLY OR MIGHT 1721 00:59:51,254 --> 00:59:53,890 WARRANT MORE DISCUSSION, REALLY 1722 00:59:53,890 --> 00:59:55,759 ENGAGE YOUR COLLEAGUES TO 1723 00:59:55,759 --> 00:59:58,762 DEVELOP THAT FURTHER. 1724 00:59:58,762 --> 01:00:00,397 THEN AS WAS MENTIONED, WE'LL 1725 01:00:00,397 --> 01:00:03,033 WORK TOGETHER, VERY COMMITTED TO 1726 01:00:03,033 --> 01:00:04,000 SUMMARIZING THE EXECUTIVE 1727 01:00:04,000 --> 01:00:07,370 SUMMARY AND SUMMARIZING THE 1728 01:00:07,370 --> 01:00:10,207 CONTENT IN A WAY THAT CAN BE 1729 01:00:10,207 --> 01:00:12,342 DISSEMINATED MORE BROADLY FOR 1730 01:00:12,342 --> 01:00:13,009 PRACTITIONERS AND RESEARCHERS 1731 01:00:13,009 --> 01:00:20,650 THROUGHOUT THE WORLD. 1732 01:00:20,650 --> 01:00:21,751 SO THANK YOU, AGAIN, FOR 1733 01:00:21,751 --> 01:00:25,422 EVERYONE ATTENDING TODAY. 1734 01:00:25,422 --> 01:00:26,289 SH THIS 1735 01:00:26,289 --> 01:00:27,057 REMARKABLE SUPPORT AND INTEREST 1736 01:00:27,057 --> 01:00:31,561 IN THIS WORKSHOP. 1737 01:00:31,561 --> 01:00:33,597 >> SO NOW WE ARE MOVING TO 1738 01:00:33,597 --> 01:00:36,533 SESSION 1, AND THE MODERATORS OF 1739 01:00:36,533 --> 01:00:45,542 THE SESSION ARE PAUL DRAWZ AND 1740 01:00:45,542 --> 01:00:46,009 ANDREW SOUTH. 1741 01:00:46,009 --> 01:00:46,977 PLEASE TAKE IT OVER. 1742 01:00:46,977 --> 01:00:47,410 >> THANK YOU. 1743 01:00:47,410 --> 01:00:50,013 PAUL DRAWZ, I'M A NEPHROLOGY 1744 01:00:50,013 --> 01:00:51,081 HYPERTENSION RESEARCHER AT THE 1745 01:00:51,081 --> 01:00:55,785 UNIVERSITY OF MINNESOTA. 1746 01:00:55,785 --> 01:01:01,691 >> [INAUDIBLE] 1747 01:01:01,691 --> 01:01:04,127 >> SO THIS SESSION IS ENTITLED 1748 01:01:04,127 --> 01:01:05,128 BLOOD PRESSURE ASSESSMENT IN 1749 01:01:05,128 --> 01:01:06,429 SPECIAL POPULATIONS ACROSS THE 1750 01:01:06,429 --> 01:01:08,198 LIFESPAN. 1751 01:01:08,198 --> 01:01:10,534 OUR FIRST SPEAKER IS DR. JOSEPH 1752 01:01:10,534 --> 01:01:11,635 FLYNN, PROFESSOR OF PEDIATRICS 1753 01:01:11,635 --> 01:01:12,769 AT THE UNIVERSITY OF WASHINGTON, 1754 01:01:12,769 --> 01:01:14,704 A MEMBER OF THE DIVISION OF 1755 01:01:14,704 --> 01:01:16,506 NEPHROLOGY AT SEATTLE CHILDREN'S 1756 01:01:16,506 --> 01:01:18,375 HOSPITAL, AND INTERNATIONALLY 1757 01:01:18,375 --> 01:01:19,910 RECOGNIZED EXPERT IN THE 1758 01:01:19,910 --> 01:01:21,645 TREATMENT OF HYPERTENSION IN 1759 01:01:21,645 --> 01:01:22,746 CHILDREN, AND HE WILL BE 1760 01:01:22,746 --> 01:01:25,348 PRESENTING ON CHALLENGES IN 1761 01:01:25,348 --> 01:01:26,116 PEDIATRIC BLOOD PRESSURE 1762 01:01:26,116 --> 01:01:26,883 MEASUREMENT. 1763 01:01:26,883 --> 01:01:33,023 DR. FLYNN. 1764 01:01:33,023 --> 01:01:34,224 >> THANK YOU FOR THAT 1765 01:01:34,224 --> 01:01:34,824 INTRODUCTION AND THANK YOU TO 1766 01:01:34,824 --> 01:01:36,927 THE ORGANIZERS FOR ASKING ME TO 1767 01:01:36,927 --> 01:01:37,894 TALK. 1768 01:01:37,894 --> 01:01:41,064 AND ACTUALLY THANK YOU FOR 1769 01:01:41,064 --> 01:01:45,001 INCLUDING CHILDREN IN THIS 1770 01:01:45,001 --> 01:01:45,735 ITERATION OF THE WORKSHOP. 1771 01:01:45,735 --> 01:01:48,204 WE HAD TALKED ABOUT HOW CHILDREN 1772 01:01:48,204 --> 01:01:54,144 HAD BEEN LEFT OUT OF THE 2017 1773 01:01:54,144 --> 01:01:57,514 WORKSHOP AND I'M GLAD THAT WE'RE 1774 01:01:57,514 --> 01:02:00,784 GETTING OUR OWN CHANCE TO BE AT 1775 01:02:00,784 --> 01:02:10,961 THE TABLE. 1776 01:02:18,702 --> 01:02:24,207 DISCLOSURES, AND THEN NEXT 1777 01:02:24,207 --> 01:02:24,741 SLIDE, PLEASE. 1778 01:02:24,741 --> 01:02:26,376 SO THESE ARE SOME OF THE THINGS 1779 01:02:26,376 --> 01:02:33,149 I'M GOING TO TALK ABOUT TODAY. 1780 01:02:33,149 --> 01:02:34,784 LISTENING TO STEVE'S TALK, I 1781 01:02:34,784 --> 01:02:36,086 REALLY THOUGHT THAT PROBABLY 1782 01:02:36,086 --> 01:02:37,187 ALMOST -- WELL, NOT ALL OF THE 1783 01:02:37,187 --> 01:02:39,456 THINGS HE HAD HIGHLIGHTED COULD 1784 01:02:39,456 --> 01:02:42,559 BE SORT OF ISSUES IN PEDIATRIC 1785 01:02:42,559 --> 01:02:43,760 BLOOD PRESSURE MEASUREMENT, BUT 1786 01:02:43,760 --> 01:02:46,529 MANY OF THEM, I THINK WE SHARE 1787 01:02:46,529 --> 01:02:50,333 MANY OF THE SAME CHALLENGES THAT 1788 01:02:50,333 --> 01:02:53,703 ARE SEEN IN ADULT BLOOM 1789 01:02:53,703 --> 01:02:58,074 MEASUREMENT IN BOTH RESEARCH AND 1790 01:02:58,074 --> 01:03:04,080 CLINICAL SETTINGS. 1791 01:03:04,080 --> 01:03:08,652 LY SAY TI WILL SAY THAT I HAVE N 1792 01:03:08,652 --> 01:03:10,854 REALLY TO FOCUS ON CLINIC BLOOD 1793 01:03:10,854 --> 01:03:13,790 PRESSURE MEASUREMENT AND NOT GO 1794 01:03:13,790 --> 01:03:16,826 INTO ISSUES RELATED TO 1795 01:03:16,826 --> 01:03:18,495 AMBULATORY BLOOD PRESSURE 1796 01:03:18,495 --> 01:03:19,529 MEASUREMENT OR HOME BLOOD 1797 01:03:19,529 --> 01:03:22,832 PRESSURE MEASUREMENT. 1798 01:03:22,832 --> 01:03:27,203 I HAD A VERY SHORT TIME ALLOTTED 1799 01:03:27,203 --> 01:03:29,906 TO ME AND I THINK EACH OF THOSE 1800 01:03:29,906 --> 01:03:33,309 THINGS ARE IMPORTANT, BUT FOR 1801 01:03:33,309 --> 01:03:36,680 TODAY, WE'LL TALK MOSTLY ABOUT 1802 01:03:36,680 --> 01:03:40,950 CLINIC MEASUREMENT, AND IF 1803 01:03:40,950 --> 01:03:43,987 PEOPLE HAVE QUESTIONS 1804 01:03:43,987 --> 01:03:46,389 SPECIFICALLY ABOUT AMBULATORY OR 1805 01:03:46,389 --> 01:03:48,024 HOME BLOOD PRESSURE MEASUREMENT, 1806 01:03:48,024 --> 01:03:51,928 THAT CERTAINLY CAN BE DISCUSSED 1807 01:03:51,928 --> 01:03:53,496 IN THE Q & A OR THE PANEL 1808 01:03:53,496 --> 01:04:02,338 DISCUSSION. 1809 01:04:02,338 --> 01:04:03,206 SO I'M GOING TO START OFF WITH 1810 01:04:03,206 --> 01:04:04,841 JUST TALKING ABOUT OUR ONE BIG 1811 01:04:04,841 --> 01:04:06,676 CHALLENGE IN PEDIATRICS, AND 1812 01:04:06,676 --> 01:04:08,111 THAT'S RELATED TO THE SIZE OF 1813 01:04:08,111 --> 01:04:11,381 OUR PATIENT. 1814 01:04:11,381 --> 01:04:11,748 S. 1815 01:04:11,748 --> 01:04:12,816 CHILDREN COME IN MANY DIFFERENT 1816 01:04:12,816 --> 01:04:15,085 SIZES AND THEY GROW, AND THIS 1817 01:04:15,085 --> 01:04:18,455 HAS IMPLICATIONS FOR HOW BLOOD 1818 01:04:18,455 --> 01:04:25,261 PRESSURE IS MEASURED AND HOW 1819 01:04:25,261 --> 01:04:30,133 EASY OR DIFFICULT IT MAY BE TO 1820 01:04:30,133 --> 01:04:31,034 GET ACCURATE BLOOD PRESSURE 1821 01:04:31,034 --> 01:04:31,468 MEASUREMENTS. 1822 01:04:31,468 --> 01:04:36,606 IT'S A BIG DEAL. 1823 01:04:36,606 --> 01:04:39,876 THEN UNFORTUNATELY, MANY 1824 01:04:39,876 --> 01:04:40,510 CHILDREN OVERGROW. 1825 01:04:40,510 --> 01:04:48,585 THIS IS SOME DATA FROM THE CDC 1826 01:04:48,585 --> 01:04:50,019 THAT PLOTS THE FREQUENCY OF 1827 01:04:50,019 --> 01:04:55,058 OBESITY IN CHILDREN, AND YOU CAN 1828 01:04:55,058 --> 01:04:59,295 SEE THAT OVER TIME, THE RATES OF 1829 01:04:59,295 --> 01:05:02,298 OBESITY HAVE INCREASED MARKEDLY 1830 01:05:02,298 --> 01:05:02,665 IN CHILDREN. 1831 01:05:02,665 --> 01:05:04,834 THEY SEEM TO BE PLATEAUING A 1832 01:05:04,834 --> 01:05:11,374 LITTLE BIT MORE RECENTLY, BUT 1833 01:05:11,374 --> 01:05:14,677 THIS AS IN ADULTS WILL HAVE 1834 01:05:14,677 --> 01:05:15,779 IMPLICATIONS FOR OBTAINING 1835 01:05:15,779 --> 01:05:16,346 ACCURATE BLOOD PRESSURE 1836 01:05:16,346 --> 01:05:23,953 MEASUREMENT. 1837 01:05:23,953 --> 01:05:26,256 SO JUST STARTING WITH THE CUFFS, 1838 01:05:26,256 --> 01:05:28,992 AS YOU CAN SEE IN THE CARTOON ON 1839 01:05:28,992 --> 01:05:31,127 THE LEFT, WE ARE AS INTERESTED 1840 01:05:31,127 --> 01:05:35,732 IN HAVING APPROPRIATELY SIZED 1841 01:05:35,732 --> 01:05:38,835 CUFFS IN CHILDREN FOR ACCURATE 1842 01:05:38,835 --> 01:05:42,405 BLOOD PRESSURE MEASUREMENT TO 1843 01:05:42,405 --> 01:05:49,979 ENSURE APPROPRIATE COMPRESSION 1844 01:05:49,979 --> 01:05:51,414 IN THE BRACHIAL ARTERY SO THAT 1845 01:05:51,414 --> 01:05:53,183 IS THE SAME ISSUE FOR US IN 1846 01:05:53,183 --> 01:05:55,485 PEDIATRICS AS IT IS IN ADULTS, 1847 01:05:55,485 --> 01:05:56,786 AND THAT MEANS AS YOU CAN SEE ON 1848 01:05:56,786 --> 01:05:58,755 THE RIGHT THAT YOU NEED AN EVEN 1849 01:05:58,755 --> 01:06:00,723 LARGER VARIETY OF CUFF SIZES AND 1850 01:06:00,723 --> 01:06:02,759 THOSE THERE ARE REALLY JUST THE 1851 01:06:02,759 --> 01:06:06,796 CHILD AND INFANT SIZE, BUT IN MY 1852 01:06:06,796 --> 01:06:11,267 CLINIC, I MAY HAVE A 6 MONTH OLD 1853 01:06:11,267 --> 01:06:13,403 IN ONE ROOM AND A 20-YEAR-OLD IN 1854 01:06:13,403 --> 01:06:15,071 THE NEXT ROOM, AND THEY'RE GOING 1855 01:06:15,071 --> 01:06:20,777 TO HAVE VERY DIFFERENT ARM 1856 01:06:20,777 --> 01:06:23,813 SIZES, WE NEED VERY DIFFERENT 1857 01:06:23,813 --> 01:06:25,782 SIZED CUPS AVAILABLE AND THIS 1858 01:06:25,782 --> 01:06:26,683 BECOMES AN ISSUE PARTICULARLY IN 1859 01:06:26,683 --> 01:06:28,251 THE PRIMARY CARE SETTING, WHERE 1860 01:06:28,251 --> 01:06:30,353 THEY MAY NOT HAVE THE WIDE 1861 01:06:30,353 --> 01:06:31,654 VARIETY OF CUFF SIZES AVAILABLE 1862 01:06:31,654 --> 01:06:40,296 THAT ARE NEEDED. 1863 01:06:40,296 --> 01:06:42,265 AS IS TRUE AND STEVE SHOWED SOME 1864 01:06:42,265 --> 01:06:46,536 DATA, I THINK, ON THIS POINT AS 1865 01:06:46,536 --> 01:06:48,605 WELL, THAT THERE ARE NO 1866 01:06:48,605 --> 01:06:51,541 STANDARDIZATION OF CUFF SIZES. 1867 01:06:51,541 --> 01:06:58,915 THIS SLIDE IS OLD, FROM 25 YEARS 1868 01:06:58,915 --> 01:07:01,050 AGO NOW, BUT I GUARANTEE YOU THE 1869 01:07:01,050 --> 01:07:03,119 SAME ISSUE IS STILL OUT THERE, 1870 01:07:03,119 --> 01:07:04,988 WHERE ONE MANUFACTURER'S CHILD 1871 01:07:04,988 --> 01:07:08,358 CUFF MAY BE A SMALL ADULT CUFF 1872 01:07:08,358 --> 01:07:14,063 BY THE NEXT MANUFACTURER. 1873 01:07:14,063 --> 01:07:15,765 SO FOR PEOPLE WHO ARE NOT 1874 01:07:15,765 --> 01:07:18,534 CAREFUL ABOUT HOW THEY CHOOSE 1875 01:07:18,534 --> 01:07:20,803 THEIR CUFF, IT QUITE EASY TO 1876 01:07:20,803 --> 01:07:23,740 CHOOSE THE WRONG SIZE CUFF IF 1877 01:07:23,740 --> 01:07:27,677 YOU JUST LOOK AT THE NAME OF THE 1878 01:07:27,677 --> 01:07:32,282 CUFF OR THE NAME THAT'S ON THE 1879 01:07:32,282 --> 01:07:36,319 CUFF. 1880 01:07:36,319 --> 01:07:39,155 SO THIS LEADS TO A LOT OF 1881 01:07:39,155 --> 01:07:43,059 VARIABILITY IN WHICH CUFF IS 1882 01:07:43,059 --> 01:07:43,626 CHOSEN. 1883 01:07:43,626 --> 01:07:46,462 THIS WAS A VERY INTERESTING 1884 01:07:46,462 --> 01:07:48,765 STUDY, AGAIN IT'S SORT OF OLD, 1885 01:07:48,765 --> 01:07:54,070 BURRBUT RELEVANT WHERE THIS WAST 1886 01:07:54,070 --> 01:07:56,606 OF A SURVEY COMPLETED BY 1887 01:07:56,606 --> 01:07:58,341 PEDIATRIC NURSES, PEDIATRIC 1888 01:07:58,341 --> 01:08:03,046 RESIDENTS, AND PEDIATRIC FACULTY 1889 01:08:03,046 --> 01:08:04,347 PHYSICIANS, AND ONE WOULD THINK 1890 01:08:04,347 --> 01:08:07,150 THAT THEY WOULD BE CHOOSING THE 1891 01:08:07,150 --> 01:08:09,886 SAME SIZE CUFF FOR EACH CHILD 1892 01:08:09,886 --> 01:08:11,688 BUT YOU DON'T REALLY NEED TO 1893 01:08:11,688 --> 01:08:14,023 LOOK AT THE NUMBERS THERE. 1894 01:08:14,023 --> 01:08:15,458 BUT TO KNOW THAT THERE WAS QUITE 1895 01:08:15,458 --> 01:08:18,294 A LOT OF VARIABILITY IN WHICH 1896 01:08:18,294 --> 01:08:20,029 CUFF WAS CHOSEN. 1897 01:08:20,029 --> 01:08:27,136 SO THIS BECOMES A CONCERN IN THE 1898 01:08:27,136 --> 01:08:31,507 CLINIC. 1899 01:08:31,507 --> 01:08:34,978 AND WITH THE CHILDHOOD OBESITY 1900 01:08:34,978 --> 01:08:36,946 EPIDEMIC, ALL THOSE BIG CUFFS 1901 01:08:36,946 --> 01:08:40,650 THAT STEVE TALKED ABOUT, GUESS 1902 01:08:40,650 --> 01:08:42,051 WHAT, WE NEED THEM IN PEDIATRICS 1903 01:08:42,051 --> 01:08:43,486 AS WELL. 1904 01:08:43,486 --> 01:08:47,090 AND THIS SLIDE COMES FROM 1905 01:08:47,090 --> 01:08:48,291 NHANES -- ADVANCE ONE MORE, 1906 01:08:48,291 --> 01:08:54,330 PLEASE. 1907 01:08:54,330 --> 01:08:58,001 AND SO JUST TO SHOW YOU THAT 1908 01:08:58,001 --> 01:09:02,372 WHEN YOU LOOK AT SORT OF EVEN 1909 01:09:02,372 --> 01:09:04,140 THE ADOLESCENT AGE GROUP, WHICH 1910 01:09:04,140 --> 01:09:06,075 I'VE HIGHLIGHTED THERE IN THE 1911 01:09:06,075 --> 01:09:11,547 RED BOX, THE NUMBER OF 1912 01:09:11,547 --> 01:09:16,586 ADOLESCENTS WHO REQUIRED EXTRA 1913 01:09:16,586 --> 01:09:18,654 LARGE OR -- LARGE OR EXTRA LARGE 1914 01:09:18,654 --> 01:09:22,258 ADULT CUFFS WAS SUBSTANTIAL. 1915 01:09:22,258 --> 01:09:26,729 13% FOR THE BAUM BRAND CUFFS AND 1916 01:09:26,729 --> 01:09:29,532 22% FOR THE WELCH ALLYN CUFFS 1917 01:09:29,532 --> 01:09:32,935 AND EVEN 4% OF EXTRA LARGE CUFFS 1918 01:09:32,935 --> 01:09:38,174 FOR THE -- IN THE WELL 1919 01:09:38,174 --> 01:09:38,941 CHALLENGED. 1920 01:09:38,941 --> 01:09:41,110 SO THE OBESITY EPIDEMIC IS A 1921 01:09:41,110 --> 01:09:42,445 PROBLEM. 1922 01:09:42,445 --> 01:09:44,614 ONE INTERESTING POINT AND I'D BE 1923 01:09:44,614 --> 01:09:46,249 INTERESTED TO HEAR STEVE AND 1924 01:09:46,249 --> 01:09:47,984 OTHERS WOULD SAY ABOUT THIS, IS 1925 01:09:47,984 --> 01:09:50,386 THAT THERE HAS BEEN SOME 1926 01:09:50,386 --> 01:09:53,423 INTEREST IN LOOKING AT CONICAL 1927 01:09:53,423 --> 01:09:57,026 CUFFS IN PEDIATRICS FOR CHILDREN 1928 01:09:57,026 --> 01:09:59,662 WITH OBESITY, BUT A RECENT PAPER 1929 01:09:59,662 --> 01:10:04,033 THAT WAS PUBLISHED DEMONSTRATED 1930 01:10:04,033 --> 01:10:06,969 THAT THE ACCURACY OF CONICAL 1931 01:10:06,969 --> 01:10:10,006 CUFFS IN ADOLESCENTS WAS NO 1932 01:10:10,006 --> 01:10:13,709 BETTER THAN STANDARD SIZE CUFFS. 1933 01:10:13,709 --> 01:10:15,711 SO IT'S UNCLEAR WHETHER WE NEED 1934 01:10:15,711 --> 01:10:19,315 TO HAVE CONICAL SIZE CUFFS IN 1935 01:10:19,315 --> 01:10:20,583 CHILDREN, THIS BECOMES, OFTEN, 1936 01:10:20,583 --> 01:10:22,452 AN AREA WHICH WE WOULD WANT TO 1937 01:10:22,452 --> 01:10:32,929 DO MORE WORK IN EVENTUALLY. 1938 01:10:33,262 --> 01:10:34,063 AND THEN WHAT HAPPENS IN 1939 01:10:34,063 --> 01:10:34,597 PRACTICE? 1940 01:10:34,597 --> 01:10:35,798 I'M NOT GOING TO GO INTO DETAIL 1941 01:10:35,798 --> 01:10:39,635 FOR EITHER OF THESE PAPERS, BUT 1942 01:10:39,635 --> 01:10:41,037 THESE ARE ALL SORT OF QUALITY 1943 01:10:41,037 --> 01:10:42,538 IMPROVEMENT STUDIES WHERE THEY 1944 01:10:42,538 --> 01:10:45,241 LOOKED AT LIKE WHAT HAPPENS IN 1945 01:10:45,241 --> 01:10:48,144 THE OFFICE WHEN CHILDREN GO TO 1946 01:10:48,144 --> 01:10:51,214 HAVE THEIR ARM -- OR HAVE THEIR 1947 01:10:51,214 --> 01:10:53,583 BLOOD PRESSURE MEASURED, AND SO 1948 01:10:53,583 --> 01:10:55,618 MY HYPERTENSION CLINIC, THE 1949 01:10:55,618 --> 01:10:58,020 FIRST STEP MY MEDICAL ASSISTANT 1950 01:10:58,020 --> 01:10:59,922 DOES IS THEY GET OUT A TAPE 1951 01:10:59,922 --> 01:11:01,858 MEASURE TO MEASURE THE ARM 1952 01:11:01,858 --> 01:11:02,592 CIRCUMFERENCE TO MAKE SURE 1953 01:11:02,592 --> 01:11:04,293 THEY'RE CHOOSING THE RIGHT SIZE 1954 01:11:04,293 --> 01:11:06,362 CUFF, BUT IF YOU LOOK ADD WHAT'S 1955 01:11:06,362 --> 01:11:08,664 HAPPENING IN PRACTICE, THAT'S 1956 01:11:08,664 --> 01:11:10,066 NOT HAPPENING. 1957 01:11:10,066 --> 01:11:15,171 AND THEN WE HAVE PROBABLY ABOUT 1958 01:11:15,171 --> 01:11:17,073 EIGHT DIFFERENT SIZE CUFFS FOR 1959 01:11:17,073 --> 01:11:19,709 OUR DEVICES, BUT WHEN YOU LOOK 1960 01:11:19,709 --> 01:11:21,677 AT WHAT HAPPENS IN PRACTICE, 1961 01:11:21,677 --> 01:11:24,480 MANY OFFICES DO NOT HAVE ALL 1962 01:11:24,480 --> 01:11:27,316 CUFF SIZES AVAILABLE. 1963 01:11:27,316 --> 01:11:29,952 AND THEN IN EPIC, WE'VE PUT DOWN 1964 01:11:29,952 --> 01:11:31,487 WHAT SIZE CUFF WE USED TO 1965 01:11:31,487 --> 01:11:32,789 MEASURE THE BLOOD PRESSURE, BUT 1966 01:11:32,789 --> 01:11:35,658 THIS IS NOT HAPPENING IN 1967 01:11:35,658 --> 01:11:36,392 PRACTICE EITHER. 1968 01:11:36,392 --> 01:11:39,996 AND SO ALL OF THESE THINGS SHOW 1969 01:11:39,996 --> 01:11:42,732 THAT THERE ARE CHALLENGES JUST 1970 01:11:42,732 --> 01:11:45,134 BEGINNING WITH CHOOSING THE 1971 01:11:45,134 --> 01:11:48,437 RIGHT SIZE CUFF TO OBTAIN 1972 01:11:48,437 --> 01:11:49,172 ACCURATE BLOOD PRESSURE 1973 01:11:49,172 --> 01:11:57,680 MEASUREMENT IN CHILDREN. 1974 01:11:57,680 --> 01:12:00,850 NOW WHAT ABOUT GETTING TO THE 1975 01:12:00,850 --> 01:12:05,888 ACTUAL DEVICES? 1976 01:12:05,888 --> 01:12:07,423 SO THERE ARE VALIDATION 1977 01:12:07,423 --> 01:12:08,591 PROTOCOLS OUT THERE, WHICH YOU 1978 01:12:08,591 --> 01:12:11,661 ALL ARE FAMILIAR WITH. 1979 01:12:11,661 --> 01:12:13,496 AND TAMMY BRADY IS GOING TO BE 1980 01:12:13,496 --> 01:12:16,465 TALKING MORE ABOUT THEM IN 1981 01:12:16,465 --> 01:12:20,203 DETAIL. 1982 01:12:20,203 --> 01:12:21,571 I JUST BRING YOUR ATTENTION TO 1983 01:12:21,571 --> 01:12:24,640 THE AAMI/ESH/ISO COLLABORATION 1984 01:12:24,640 --> 01:12:25,708 STATEMENT WHICH WAS PUBLISHED A 1985 01:12:25,708 --> 01:12:27,009 FEW YEARS AGO WHICH ACTUALLY 1986 01:12:27,009 --> 01:12:28,544 CALLED OUT THAT IF THE DEVICE IS 1987 01:12:28,544 --> 01:12:33,349 GOING TO BE USED IN BOTH ADULTS 1988 01:12:33,349 --> 01:12:40,756 AND CHIRP, YOU CHILDREN U YOUT 1989 01:12:40,756 --> 01:12:41,724 LEAST 35 SUBJECTS BETWEEN THE 1990 01:12:41,724 --> 01:12:42,825 AGES OF 3 AND 12 IN YOUR 1991 01:12:42,825 --> 01:12:44,527 POPULATION, AND THAT YOU NEED 1992 01:12:44,527 --> 01:12:49,665 TO -- AND THAT IN THAT AGE 1993 01:12:49,665 --> 01:12:55,705 GROUP, THE STANDARDS IN TERMS OF 1994 01:12:55,705 --> 01:12:56,806 DIFFERENT COMPARED TO THE 1995 01:12:56,806 --> 01:12:58,307 REFERENCE DEVICE ARE THE SAME AS 1996 01:12:58,307 --> 01:13:02,144 IN ADULTS. 1997 01:13:02,144 --> 01:13:04,413 SO I THINK PROBABLY TAMMY WILL 1998 01:13:04,413 --> 01:13:06,148 GO INTO THIS MORE, BUT AT LEAST 1999 01:13:06,148 --> 01:13:10,653 WE KNOW THAT THERE ARE DEVICE 2000 01:13:10,653 --> 01:13:17,560 VALIDATION PROTOCOLS THAT CALL 2001 01:13:17,560 --> 01:13:19,061 OUT THE NEED TO HAVE A 2002 01:13:19,061 --> 01:13:19,795 SUFFICIENT NUMBER OF CHILDREN IN 2003 01:13:19,795 --> 01:13:23,966 THE POPULATION WHEN THE DEVICE 2004 01:13:23,966 --> 01:13:34,477 IS BEING UTILIZED IN CHILDREN. 2005 01:13:34,877 --> 01:13:41,684 AND THEN THIS WAS ANOTHER TABLE, 2006 01:13:41,684 --> 01:13:42,985 THIS IS A TABLE FROM THAT SAME 2007 01:13:42,985 --> 01:13:45,721 PAPER WHERE THEY TALK ABOUT WHAT 2008 01:13:45,721 --> 01:13:50,860 SIZE CUFFS NEED TO BE AVAILABLE 2009 01:13:50,860 --> 01:13:52,728 FOR OBTAINING ACCURATE 2010 01:13:52,728 --> 01:13:55,665 VALIDATION STUDIES, AND AGAIN, I 2011 01:13:55,665 --> 01:13:56,866 WON'T DWELL ON THIS BECAUSE I'M 2012 01:13:56,866 --> 01:13:59,936 SURE THATTA ME WILL COVER IT. 2013 01:13:59,936 --> 01:14:01,337 -- I'M SURE THAT 2014 01:14:01,337 --> 01:14:02,571 TAMMY WILL COVER IT. 2015 01:14:02,571 --> 01:14:04,307 AND YOU KNOW, THERE ARE A LOT OF 2016 01:14:04,307 --> 01:14:05,508 VALIDATION STUDIES OUT THERE. 2017 01:14:05,508 --> 01:14:09,445 I DON'T NORMALLY LOOK AT THESE 2018 01:14:09,445 --> 01:14:11,147 GRAPHS IN PUBMED WHEN YOU SEE -- 2019 01:14:11,147 --> 01:14:12,581 WHEN YOU DO A SEARCH, BUT I 2020 01:14:12,581 --> 01:14:15,084 THOUGHT IT WAS INTERESTING TO 2021 01:14:15,084 --> 01:14:18,120 SEE THAT JUST OVER THE LAST 2022 01:14:18,120 --> 01:14:24,226 WHATEVER, FROM 1996 TO 2024, 2023 01:14:24,226 --> 01:14:30,700 THERE ARE 493 STUDIES THAT WERE 2024 01:14:30,700 --> 01:14:31,901 PUBLISHED IN BLOOD PRESSURE 2025 01:14:31,901 --> 01:14:33,536 MONITORING, WHICH IS THE JOURNAL 2026 01:14:33,536 --> 01:14:38,341 IN WHICH MOST OF THESE STUDIES 2027 01:14:38,341 --> 01:14:39,875 ARE PUBLISHED, FOCUS ON DEVICE 2028 01:14:39,875 --> 01:14:46,415 VALIDATION. 2029 01:14:46,415 --> 01:14:47,950 BUT ONLY 40 OF THEM INCLUDED 2030 01:14:47,950 --> 01:14:48,617 CHILDREN. 2031 01:14:48,617 --> 01:14:54,924 SO VERY FEW DEVICE STUDIES ARE 2032 01:14:54,924 --> 01:14:56,258 INCLUDING CHILDREN, AND 2033 01:14:56,258 --> 01:14:57,426 CONSEQUENTLY IT'S NO STRETCH OF 2034 01:14:57,426 --> 01:15:02,031 THE IMAGINATION TO THEN REALIZE 2035 01:15:02,031 --> 01:15:06,369 THAT THAT MEANS THAT NOT MANY 2036 01:15:06,369 --> 01:15:07,336 DEVICES ARE ACTUALLY VALIDATED 2037 01:15:07,336 --> 01:15:10,239 IN CHILDREN. 2038 01:15:10,239 --> 01:15:16,245 AND WHEN YOU GO TO THE DIFFERENT 2039 01:15:16,245 --> 01:15:18,848 ORGANIZATIONS THAT LOOK AT WHICH 2040 01:15:18,848 --> 01:15:20,716 DEVICES HAVE PEDIATRIC 2041 01:15:20,716 --> 01:15:22,017 VALIDATION, THERE ARE NOT VERY 2042 01:15:22,017 --> 01:15:22,351 MANY. 2043 01:15:22,351 --> 01:15:26,689 SO YOU CAN SEE THAT ON THE 2044 01:15:26,689 --> 01:15:28,391 STRIDEBP WEBSITE, THERE WERE 13 2045 01:15:28,391 --> 01:15:31,660 OFFICE DEVICES VALIDATED IN 2046 01:15:31,660 --> 01:15:33,829 CHILDREN, ONLY THREE DEVICES FOR 2047 01:15:33,829 --> 01:15:36,999 HOME, AND THREE FOR AMBULATORY 2048 01:15:36,999 --> 01:15:39,969 BLOOD PRESSURE, AND ON THE 2049 01:15:39,969 --> 01:15:41,837 VALIDATEBP.ORG WEBSITE, ONLY ONE 2050 01:15:41,837 --> 01:15:45,307 DEVICE HAD PEDIATRIC VALIDATION. 2051 01:15:45,307 --> 01:15:47,610 AND SO THIS BECOMES PART OF THE 2052 01:15:47,610 --> 01:15:50,112 PROBLEM THEN FOR US WHEN WE DO 2053 01:15:50,112 --> 01:15:52,715 RESEARCH IN CHILDREN, AND LOOK 2054 01:15:52,715 --> 01:15:55,351 AT BLOOD PRESSURE MEASUREMENT 2055 01:15:55,351 --> 01:15:58,521 WHERE THE FIRST QUESTION IS, 2056 01:15:58,521 --> 01:16:00,389 WELL, WAS THE DEVICE VALIDATED, 2057 01:16:00,389 --> 01:16:01,891 AND OFTEN THEY'RE NOT. 2058 01:16:01,891 --> 01:16:03,392 AND ONE COMMENT HERE ABOUT HOME 2059 01:16:03,392 --> 01:16:05,728 BLOOD PRESSURE MONITORING IS 2060 01:16:05,728 --> 01:16:07,897 THAT THIS IS ONE OF THE REASONS 2061 01:16:07,897 --> 01:16:09,298 WHY HOME BLOOD PRESSURE 2062 01:16:09,298 --> 01:16:13,035 MONITORING DID NOT GET ENDORSED 2063 01:16:13,035 --> 01:16:14,570 IN THE AMERICAN ACADEMY OF 2064 01:16:14,570 --> 01:16:21,210 PEDIATRICS CPG BECAUSE OF SO FEW 2065 01:16:21,210 --> 01:16:22,077 DEVICES BEING AVAILABLE FOR 2066 01:16:22,077 --> 01:16:24,380 HOME. 2067 01:16:24,380 --> 01:16:27,683 THERE'S REALLY ONLY ONE, AND WE 2068 01:16:27,683 --> 01:16:31,153 AT SEATTLE CHILDREN'S HOSPITAL 2069 01:16:31,153 --> 01:16:33,022 ARE FORTUNATE ENOUGH TO BE ABLE 2070 01:16:33,022 --> 01:16:34,423 TO JUST GIVE THEM TO PARENTS, 2071 01:16:34,423 --> 01:16:35,090 BECAUSE PARENTS WOULD NEVER BE 2072 01:16:35,090 --> 01:16:38,594 ABLE TO FIND THEM ON THEIR OWN. 2073 01:16:38,594 --> 01:16:42,298 BUT THIS IS, OF COURSE, NOT THE 2074 01:16:42,298 --> 01:16:52,741 TYPICAL PRACTICE SETTING. 2075 01:16:59,548 --> 01:17:01,317 AND THEN THE PRACTICE OF 2076 01:17:01,317 --> 01:17:02,218 STANDARDIZED BLOOD PRESSURE 2077 01:17:02,218 --> 01:17:04,386 MEASUREMENT HAS BEEN DISCUSSED, 2078 01:17:04,386 --> 01:17:05,921 AND GUESS WHAT, THIS IS WHAT WE 2079 01:17:05,921 --> 01:17:07,556 WANT TO BE DOING IN CHILDREN AS 2080 01:17:07,556 --> 01:17:08,424 WELL. 2081 01:17:08,424 --> 01:17:11,927 AND WHEN WE HAVE DONE OUR 2082 01:17:11,927 --> 01:17:16,065 RESEARCH STUDIES IN CHILDREN 2083 01:17:16,065 --> 01:17:19,568 MOST RECENTLY, THE SHIP AHOY 2084 01:17:19,568 --> 01:17:20,769 PROJECT WHICH SOME OF YOU MAY BE 2085 01:17:20,769 --> 01:17:22,071 FAMILIAR WITH AND THE ONGOING 2086 01:17:22,071 --> 01:17:25,674 CHRONIC KIDNEY DISEASE IN 2087 01:17:25,674 --> 01:17:30,146 CHILDREN STUDY, WE ARE 2088 01:17:30,146 --> 01:17:33,315 PRACTICING STANDARDIZED BLOOD 2089 01:17:33,315 --> 01:17:35,284 PRESSURE MEASUREMENT TECHNIQUE 2090 01:17:35,284 --> 01:17:40,055 IN CHILDREN AND IN THE CPG, WE 2091 01:17:40,055 --> 01:17:42,591 HAVE THE WHOLE SECTION DEVOTED 2092 01:17:42,591 --> 01:17:47,796 TO POSITIONING THE PATIENT, AND 2093 01:17:47,796 --> 01:17:49,832 OBTAIN THE CORRECT MEASUREMENT, 2094 01:17:49,832 --> 01:17:52,902 AND WE ACTUALLY -- BECAUSE THERE 2095 01:17:52,902 --> 01:17:56,939 ARE NO COMMERCIALLY AVAILABLE 2096 01:17:56,939 --> 01:17:58,807 VIDEOS ON THE INTERNET -- LET ME 2097 01:17:58,807 --> 01:18:01,810 REPEAT THAT -- THERE ARE ZERO 2098 01:18:01,810 --> 01:18:06,215 VIDEOS ON THE INTERNET THAT 2099 01:18:06,215 --> 01:18:06,749 DEMONSTRATE CORRECT BLOOD 2100 01:18:06,749 --> 01:18:09,618 PRESSURE MEASUREMENT IN 2101 01:18:09,618 --> 01:18:13,889 CHILDREN, WE HAD TO MAKE ONE FOR 2102 01:18:13,889 --> 01:18:17,526 THE AAP AND WE NOW SORT OF HOUSE 2103 01:18:17,526 --> 01:18:18,627 THAT ON THE INTERNATIONAL 2104 01:18:18,627 --> 01:18:21,363 PEDIATRIC HYPERTENSION 2105 01:18:21,363 --> 01:18:24,066 ASSOCIATION WEBSITE. 2106 01:18:24,066 --> 01:18:25,734 BUT POSITIONING THE CHILD AND 2107 01:18:25,734 --> 01:18:28,037 DOING ALL OF THE SAME STEPS IS 2108 01:18:28,037 --> 01:18:32,575 IMPORTANT. 2109 01:18:32,575 --> 01:18:33,709 AND GUESS WHAT? 2110 01:18:33,709 --> 01:18:34,743 PATIENT POSITIONING IN CHILDREN 2111 01:18:34,743 --> 01:18:38,881 IS A LITTLE MORE COMPLICATED. 2112 01:18:38,881 --> 01:18:42,718 REMEMBER THAT SLIDE I SHOWED YOU 2113 01:18:42,718 --> 01:18:45,020 OF CHILDREN OF DIFFERENT SIZES. 2114 01:18:45,020 --> 01:18:47,623 WELL, WE HAVE TO TAKE THESE 2115 01:18:47,623 --> 01:18:48,290 THINGS INTO ACCOUNT IN OUR 2116 01:18:48,290 --> 01:18:51,460 CLINICS. 2117 01:18:51,460 --> 01:18:55,197 SO THIS IS A PHOTOGRAPH OF WHERE 2118 01:18:55,197 --> 01:18:57,132 I PRACTICE, THIS IS ONE OF MY 2119 01:18:57,132 --> 01:18:58,567 OUTREACH CLINICS, WHERE WE 2120 01:18:58,567 --> 01:19:01,503 ACTUALLY HAVE THESE SMALL CHAIRS 2121 01:19:01,503 --> 01:19:03,772 IN WHICH WE HAVE TO -- IF WE'RE 2122 01:19:03,772 --> 01:19:05,341 GOING TO HAVE THE CHILD 2123 01:19:05,341 --> 01:19:07,109 CORRECTLY POSITIONED, THEY NEED 2124 01:19:07,109 --> 01:19:08,744 TO BE IN THESE SMALL CHAIRS. 2125 01:19:08,744 --> 01:19:11,580 THIS IS VERY HARD ON MY BACK. 2126 01:19:11,580 --> 01:19:15,384 BUT WE DO TO MAKE SURE THE 2127 01:19:15,384 --> 01:19:16,819 POSITIONING OF THE CHILD IS 2128 01:19:16,819 --> 01:19:20,522 CORRECT. 2129 01:19:20,522 --> 01:19:24,393 SOMETIMES WE'LL PUT FOOT SUPPORT 2130 01:19:24,393 --> 01:19:26,328 UNDER THEM ON A STANDARD BENCH, 2131 01:19:26,328 --> 01:19:32,034 WHICH CAN HELP. 2132 01:19:32,034 --> 01:19:34,770 BUT THIS IS SORT OF A LITTLE 2133 01:19:34,770 --> 01:19:36,305 FUNNY COUPLE OF PICTURES, BUT 2134 01:19:36,305 --> 01:19:41,343 VERY IMPORTANT ISSUE IS THAT 2135 01:19:41,343 --> 01:19:42,544 PATIENT POSITIONING NEEDS TO BE 2136 01:19:42,544 --> 01:19:44,046 CORRECT IN PEDIATRICS JUST AS IN 2137 01:19:44,046 --> 01:19:50,185 ADULTS. 2138 01:19:50,185 --> 01:19:51,620 THEN HOW ARE WE GOING TO MEASURE 2139 01:19:51,620 --> 01:19:53,355 THE BLOOD PRESSURE? 2140 01:19:53,355 --> 01:19:55,090 SO ONE ISSUE THAT WE HAVE IN 2141 01:19:55,090 --> 01:19:57,493 CHILDREN IS THAT BECAUSE 2142 01:19:57,493 --> 01:19:59,895 CHILDREN GROW AND BECAUSE BLOOD 2143 01:19:59,895 --> 01:20:01,430 PRESSURE CHANGES AS CHILDREN 2144 01:20:01,430 --> 01:20:04,600 GROW, WE HAVE NORMATIVE DATA 2145 01:20:04,600 --> 01:20:06,969 THAT GIVE US THE NORMAL VALUES 2146 01:20:06,969 --> 01:20:09,171 AT DIFFERENT AGES AND HEIGHTS IN 2147 01:20:09,171 --> 01:20:10,372 CHILDREN. 2148 01:20:10,372 --> 01:20:13,175 AND THOSE DATA ARE BASED UPON US 2149 01:20:13,175 --> 01:20:20,082 UPONAUSCULTATORY BLOOD PRESSURE 2150 01:20:20,082 --> 01:20:20,849 MEASUREMENT. 2151 01:20:20,849 --> 01:20:21,950 HOWEVER WE KNOW THAT THIS MAY 2152 01:20:21,950 --> 01:20:23,585 NOT BE WHAT'S DONE IN PRACTICE. 2153 01:20:23,585 --> 01:20:25,120 AND WE ACKNOWLEDGE THAT IN THE 2154 01:20:25,120 --> 01:20:25,988 CLINICAL PRACTICE GUIDELINE, 2155 01:20:25,988 --> 01:20:31,760 WHERE WE SAID THAT, YES, OKAY, 2156 01:20:31,760 --> 01:20:35,497 USE THE OSCILLOMETRIC DEVICE TO 2157 01:20:35,497 --> 01:20:36,432 OBTAIN THE FIRST BLOOD PRESSURE 2158 01:20:36,432 --> 01:20:37,866 OR TO ON TAKE THE SCREENING 2159 01:20:37,866 --> 01:20:40,836 BLOOD PRESSURE, BUT THAT BECAUSE 2160 01:20:40,836 --> 01:20:45,507 THE NORMAL VALUES ARE DERIVED 2161 01:20:45,507 --> 01:20:49,778 FROM AUSCULTATORY BLOOD PRESSURE 2162 01:20:49,778 --> 01:20:51,013 MEASUREMENT, THEN YOU NEED TO 2163 01:20:51,013 --> 01:20:53,849 REPEAT THEM BY AUSCULTATION TO 2164 01:20:53,849 --> 01:20:54,183 CONFIRM. 2165 01:20:54,183 --> 01:20:55,617 THIS IS A PROBLEM, THOUGH, 2166 01:20:55,617 --> 01:20:57,219 BECAUSE MANY PEDIATRIC OFFICES 2167 01:20:57,219 --> 01:21:01,190 MAY NOT HAVE MANUAL DEVICES. 2168 01:21:01,190 --> 01:21:04,126 IT DOES REQUIRE TRAINING. 2169 01:21:04,126 --> 01:21:10,899 I CAN DO THIS IN MY HYPERTENSION 2170 01:21:10,899 --> 01:21:11,133 CLINIC. 2171 01:21:11,133 --> 01:21:12,968 WE HAVE A QUIZ WE GIVE TO OUR 2172 01:21:12,968 --> 01:21:13,969 MEDICAL ASSISTANTS TO MAKE SURE 2173 01:21:13,969 --> 01:21:15,838 THEY'RE DOING IT ACCURATELY, BUT 2174 01:21:15,838 --> 01:21:17,806 IT DEFINITELY HAS AN IMPACT ON 2175 01:21:17,806 --> 01:21:19,541 PATIENT FLOW, AND I THINK THAT 2176 01:21:19,541 --> 01:21:24,580 THAT'S PROBABLY BEEN MENTIONED 2177 01:21:24,580 --> 01:21:31,153 BY STEVE EARLIER AS WELL. 2178 01:21:31,153 --> 01:21:34,523 OF COURSE EVEN PEDIATRIC 2179 01:21:34,523 --> 01:21:35,924 NEPHROLOGISTS USE OSLO METRIC 2180 01:21:35,924 --> 01:21:36,592 DEVICES. 2181 01:21:36,592 --> 01:21:41,630 THIS IS A STUDY THAT WE DID MANY 2182 01:21:41,630 --> 01:21:42,831 YEARS AGO NOW THAT SHOWED THAT 2183 01:21:42,831 --> 01:21:48,737 MOST PEDIATRIC NEPHROLOGISTS USE 2184 01:21:48,737 --> 01:21:50,672 OSCILLOMETRIC DEVICES FOR BLOOD 2185 01:21:50,672 --> 01:21:53,876 PRESSURE MEASUREMENT, FEWER USE 2186 01:21:53,876 --> 01:21:55,410 ENEROID OR MERCURY DEVICES. 2187 01:21:55,410 --> 01:21:56,712 ACTUALLY MANY OF THEM WERE STILL 2188 01:21:56,712 --> 01:21:57,713 USING MERCURY AT THE TIME. 2189 01:21:57,713 --> 01:22:02,050 I DON'T KNOW THAT ANYONE IS 2190 01:22:02,050 --> 01:22:10,793 ANYMORE. 2191 01:22:10,793 --> 01:22:13,228 WE KNOW THIS IS A PROBLEM 2192 01:22:13,228 --> 01:22:14,296 BECAUSE OSCILLOMETRIC DEVICES 2193 01:22:14,296 --> 01:22:16,064 MAY LEAD TO INACCURATE 2194 01:22:16,064 --> 01:22:17,032 MEASUREMENTS, WHICH CAN THEN 2195 01:22:17,032 --> 01:22:18,801 LEAD TO MISCLASSIFICATION. 2196 01:22:18,801 --> 01:22:21,637 THIS WAS A PAPER WE PUBLISHED A 2197 01:22:21,637 --> 01:22:23,138 NUMBER OF YEARS AGO FROM THE 2198 01:22:23,138 --> 01:22:24,373 CHRONIC KIDNEY DISEASE IN 2199 01:22:24,373 --> 01:22:27,576 CHILDREN STUDY WHERE WE COMPARED 2200 01:22:27,576 --> 01:22:30,279 BLOOD PRESSURES MEASURED USING 2201 01:22:30,279 --> 01:22:32,381 AN OSCILLOMETRIC DEVICE TO THE 2202 01:22:32,381 --> 01:22:33,482 US A CULT TRI BLOOD PRESSURE, 2203 01:22:33,482 --> 01:22:34,550 AND YOU CAN SEE THERE WAS QUITE 2204 01:22:34,550 --> 01:22:43,725 A BIT OF SCATTER, AND THE 2205 01:22:43,725 --> 01:22:44,493 BLAND-ALTMAN PLOTS DIDN'T LOOK 2206 01:22:44,493 --> 01:22:44,927 VERY GOOD. 2207 01:22:44,927 --> 01:22:47,129 AND THIS IS A STUDY DONE BY 2208 01:22:47,129 --> 01:22:52,067 TAMMY'S GROUP WHERE THEY LOOKED 2209 01:22:52,067 --> 01:22:53,268 AT THE -- AGAINST THE TRIAGE 2210 01:22:53,268 --> 01:22:54,870 BLOOD PRESSURE COMPARED TO THE 2211 01:22:54,870 --> 01:22:57,272 MANUAL BLOOD PRESSURE BY THE 2212 01:22:57,272 --> 01:23:00,309 GOOD DR. BRADY HERSELF, AND 2213 01:23:00,309 --> 01:23:02,644 THERE WAS QUITE A BIT OF SCATTER 2214 01:23:02,644 --> 01:23:05,147 THERE AS WELL, AND SO -- AND 2215 01:23:05,147 --> 01:23:07,249 THAT DEGREE OF SCATTER IS 2216 01:23:07,249 --> 01:23:09,818 SIGNIFICANT, AND WE SHOWED IN 2217 01:23:09,818 --> 01:23:11,720 THE STUDY FROM THE CHRONIC 2218 01:23:11,720 --> 01:23:18,060 KIDNEY DISEASE IN CHILDREN 2219 01:23:18,060 --> 01:23:19,795 COHORT THAT DID LEAD TO 2220 01:23:19,795 --> 01:23:20,896 MISCLASSIFICATION OF CHILDREN 2221 01:23:20,896 --> 01:23:23,866 BECAUSE OF THE INACCURACIES FROM 2222 01:23:23,866 --> 01:23:30,305 THE OSCILLOMETRIC TECHNIQUE. 2223 01:23:30,305 --> 01:23:32,608 SO JUST TO SUM IT UP, THERE IS A 2224 01:23:32,608 --> 01:23:34,376 NUMBER OF FACTORS THAT CAN 2225 01:23:34,376 --> 01:23:35,577 AFFECT ACCURACY OF BLOOD 2226 01:23:35,577 --> 01:23:37,779 PRESSURE MEASUREMENT IN 2227 01:23:37,779 --> 01:23:38,247 CHILDREN. 2228 01:23:38,247 --> 01:23:41,483 WE HAVE A PATIENT POPULATION 2229 01:23:41,483 --> 01:23:43,785 WITH VARIABILITY IN ARM SIZE, 2230 01:23:43,785 --> 01:23:47,489 THERE ARE FEW VALIDATED DEVICES, 2231 01:23:47,489 --> 01:23:54,663 THERE ARE EDUCATION GAPS 2232 01:23:54,663 --> 01:23:56,798 REGARDING TECHNIQUE AND 2233 01:23:56,798 --> 01:23:58,000 PREFERRED METHOD OF BLOOD 2234 01:23:58,000 --> 01:23:58,534 PRESSURE MANAGEMENT. 2235 01:23:58,534 --> 01:23:59,968 AND WE NEED TO ADDRESS THESE 2236 01:23:59,968 --> 01:24:01,837 PROBLEMS, AND I'VE LISTED THERE 2237 01:24:01,837 --> 01:24:03,472 SOME STRATEGIES WHICH COULD BE 2238 01:24:03,472 --> 01:24:06,642 USED TO ADDRESS THE PROBLEMS 2239 01:24:06,642 --> 01:24:08,510 INCLUDING MORE PEDIATRIC 2240 01:24:08,510 --> 01:24:13,415 VALIDATION STUDIES, PERHAPS 2241 01:24:13,415 --> 01:24:22,391 STAND DAITISTANDARDIZATION IN C, 2242 01:24:22,391 --> 01:24:23,692 MORE EDUCATIONAL EFFORTS AND 2243 01:24:23,692 --> 01:24:25,027 QUALITY IMPROVEMENT EFFORTS AND 2244 01:24:25,027 --> 01:24:27,629 THEN PATIENT EDUCATION AND 2245 01:24:27,629 --> 01:24:28,463 EMPOWERMENT, WHICH IS SOMETHING 2246 01:24:28,463 --> 01:24:29,932 THAT WAS RAISED IN THAT ARMS 2247 01:24:29,932 --> 01:24:31,266 STUDY RECENTLY WHERE, YOU KNOW, 2248 01:24:31,266 --> 01:24:34,770 I HEARD AN INTERVIEW WITH 2249 01:24:34,770 --> 01:24:37,272 DR. BRADY ON SCIENCE FRIDAY, AND 2250 01:24:37,272 --> 01:24:39,241 THEY WERE TALKING ABOUT HOW 2251 01:24:39,241 --> 01:24:42,077 PATIENTS SHOULD BE ASKING THAT 2252 01:24:42,077 --> 01:24:43,512 THEIR BLOOD PRESSURE BE MEASURED 2253 01:24:43,512 --> 01:24:46,481 USING THE CORRECT SIZE DEVICE. 2254 01:24:46,481 --> 01:24:49,751 SO I DON'T KNOW THAT CHILDREN 2255 01:24:49,751 --> 01:24:51,820 CAN ACTUALLY DO THAT, BUT I WILL 2256 01:24:51,820 --> 01:24:57,092 TELL YOU THAT MANY TIMES, 2257 01:24:57,092 --> 01:24:58,293 PARENTS WILL COMMENT TO US THAT, 2258 01:24:58,293 --> 01:25:02,664 WOW, THIS IS THE FIRST TIME THAT 2259 01:25:02,664 --> 01:25:04,232 SOMEONE HAS ACTUALLY MEASURED MY 2260 01:25:04,232 --> 01:25:05,968 CHILD'S ARM AND USED THAT SIZE 2261 01:25:05,968 --> 01:25:09,705 CUFF ON MY CHILD. 2262 01:25:09,705 --> 01:25:11,239 AND SO WE HAVE A LOT OF WORK TO 2263 01:25:11,239 --> 01:25:12,908 DO IN PEDIATRICS, AND AGAIN, I 2264 01:25:12,908 --> 01:25:16,044 THANK YOU FOR THE OPPORTUNITY TO 2265 01:25:16,044 --> 01:25:17,145 TALK ABOUT SOME OF THE 2266 01:25:17,145 --> 01:25:27,356 CHALLENGES. 2267 01:25:32,828 --> 01:25:34,429 >> THANK YOU VERY MUCH, 2268 01:25:34,429 --> 01:25:36,631 DR. FLYNN, AS ALWAYS, EVEN -- 2269 01:25:36,631 --> 01:25:38,233 YOU GIVE A LOT OF THE VARIATION 2270 01:25:38,233 --> 01:25:39,368 OF THAT TALK, I ALWAYS LEARN 2271 01:25:39,368 --> 01:25:41,203 SOMETHING NEW AND YOU ALWAYS 2272 01:25:41,203 --> 01:25:42,637 MAKE ME RE-THINK WHAT I WAS 2273 01:25:42,637 --> 01:25:44,172 TAUGHT AND WHAT I TAKE FOR 2274 01:25:44,172 --> 01:25:44,406 GRANTED. 2275 01:25:44,406 --> 01:25:45,607 SO THANK YOU VERY MUCH. 2276 01:25:45,607 --> 01:25:46,808 GIVEN THE TIME, WE'RE GOING TO 2277 01:25:46,808 --> 01:25:49,111 MOVE RIGHT ALONG AND WE'LL DO 2278 01:25:49,111 --> 01:25:52,047 QUESTIONS DURING THE PANEL 2279 01:25:52,047 --> 01:25:53,482 DISCUSSION. 2280 01:25:53,482 --> 01:25:56,218 AND NEXT UP, WE HAVE DR. KARA 2281 01:25:56,218 --> 01:25:57,786 HOPPE FROM UNIVERSITY OF 2282 01:25:57,786 --> 01:25:59,187 WISCONSIN AT MADISON HERE TO 2283 01:25:59,187 --> 01:26:01,923 TALK TO US ABOUT PREGNANCY IN 2284 01:26:01,923 --> 01:26:03,759 THE FOURTH TRIMESTER. 2285 01:26:03,759 --> 01:26:05,861 DR. HOPPE IS A MATERNAL FETAL 2286 01:26:05,861 --> 01:26:06,928 MEDICINE SPECIALIST WHOSE 2287 01:26:06,928 --> 01:26:08,597 RESEARCH FOCUSES ON HYPERTENSION 2288 01:26:08,597 --> 01:26:09,464 DURING PREGNANCY AND, VERY 2289 01:26:09,464 --> 01:26:13,168 IMPORTIMPORTANTLY, THE POSTPARTM 2290 01:26:13,168 --> 01:26:14,369 PERIOD, INCLUDING DEVELOPING 2291 01:26:14,369 --> 01:26:16,671 INTERVENTIONS TO IMPROVE 2292 01:26:16,671 --> 01:26:17,639 HEALTHCARE DELIVERY IN PATIENT 2293 01:26:17,639 --> 01:26:19,074 OUTCOMES IN THIS VERY MUCH 2294 01:26:19,074 --> 01:26:22,611 OVERLOOKED POPULATION. 2295 01:26:22,611 --> 01:26:25,180 >> THANK YOU SO MUCH TO THE 2296 01:26:25,180 --> 01:26:26,081 ORGANIZERS, MODERATORS, AND 2297 01:26:26,081 --> 01:26:26,948 INCLUDING PREGNANT PEOPLE IN 2298 01:26:26,948 --> 01:26:30,352 THIS WORKSHOP. 2299 01:26:30,352 --> 01:26:31,787 I WASN'T PLANNING ON SAYING THIS 2300 01:26:31,787 --> 01:26:33,655 BUT JUST REFLECTING ON 2301 01:26:33,655 --> 01:26:35,290 DR. FLYNN'S PRESENTATION WHICH 2302 01:26:35,290 --> 01:26:37,492 WAS PHENOMENAL, I JUST WANTED TO 2303 01:26:37,492 --> 01:26:39,027 SAY AS A PARENT, I JUST RECENTLY 2304 01:26:39,027 --> 01:26:40,529 HAD TWO OF MY CHILDREN, ONE IS 2305 01:26:40,529 --> 01:26:42,297 10, ONE IS 13 AT THEIR STANDARD 2306 01:26:42,297 --> 01:26:43,799 PEDIATRIC VISIT AND MY 2307 01:26:43,799 --> 01:26:45,033 13-YEAR-OLD, VERY ACTIVE, PRETTY 2308 01:26:45,033 --> 01:26:48,303 MUSCULAR AND NEAR ADULT HA-SIZED 2309 01:26:48,303 --> 01:26:49,938 YOUNG LADY HAD HER BPs 2310 01:26:49,938 --> 01:26:51,373 REPORTED AS ELEVATED, AND WHEN I 2311 01:26:51,373 --> 01:26:52,774 ASKED ABOUT IT, THEY WERE 2312 01:26:52,774 --> 01:26:53,842 DISREGARDED AND THEN IT TOOK ME 2313 01:26:53,842 --> 01:26:55,210 AS A PHYSICIAN SCIENTIST WHO 2314 01:26:55,210 --> 01:26:57,045 CARES ABOUT HYPERTENSION TO SAY, 2315 01:26:57,045 --> 01:26:59,915 YOU KNOW, HER BLOOD PRESSURE IS 2316 01:26:59,915 --> 01:27:01,550 ELEVATED, I ASKED TO RECHECK IT, 2317 01:27:01,550 --> 01:27:02,984 THEY DIDN'T RECHECK IT, AND THEN 2318 01:27:02,984 --> 01:27:04,686 SHE WENT BACK FOR A FOLLOW-UP, 2319 01:27:04,686 --> 01:27:05,720 BLOOD PRESSURE WAS STILL 2320 01:27:05,720 --> 01:27:06,822 ELEVATED, SO THEY SAID, WELL, 2321 01:27:06,822 --> 01:27:08,356 WE'LL PUT IT IN HER CHART, YOU 2322 01:27:08,356 --> 01:27:09,558 KNOW, TO THINK ABOUT. 2323 01:27:09,558 --> 01:27:10,592 AND I WENT HOME AND I THOUGHT 2324 01:27:10,592 --> 01:27:13,295 ABOUT IT, I MEASURED HER ARM, I 2325 01:27:13,295 --> 01:27:14,496 RECHECKED IT WITH PROPER 2326 01:27:14,496 --> 01:27:15,697 TECHNIQUE, AND HER BLOOD 2327 01:27:15,697 --> 01:27:18,433 PRESSURES WERE COMPLETELY 2328 01:27:18,433 --> 01:27:20,635 NORMAL, SO I MYCHARTED THE 2329 01:27:20,635 --> 01:27:21,403 PHYSICIAN AND SHE SAID NOTE 2330 01:27:21,403 --> 01:27:23,138 TAKEN, I THINK WE NEED MORE 2331 01:27:23,138 --> 01:27:24,139 EDUCATION IN OUR CLINIC. 2332 01:27:24,139 --> 01:27:27,109 AND JUST TO NOTE, THEY HAD ONE 2333 01:27:27,109 --> 01:27:28,643 BP DEVICE, THEY DID NOT MEASURE 2334 01:27:28,643 --> 01:27:30,278 HER ARM AND THE KIDS' LEGS WERE 2335 01:27:30,278 --> 01:27:31,480 HANGING FROM ADULT CHAIRS. 2336 01:27:31,480 --> 01:27:32,814 SO I JUST WANT TO VALIDATE 2337 01:27:32,814 --> 01:27:34,249 EVERYTHING THAT DR. FLYNN JUST 2338 01:27:34,249 --> 01:27:36,985 SAID AS A PARENT. 2339 01:27:36,985 --> 01:27:44,226 SO ANYWAYS, WHEN WE TALK ABOUT 2340 01:27:44,226 --> 01:27:46,428 PREGNANCY, I JUST COMMENTED HERE 2341 01:27:46,428 --> 01:27:48,930 REGARDING THE OBJECTIVES OF THE 2342 01:27:48,930 --> 01:27:49,564 MEETING. 2343 01:27:49,564 --> 01:27:50,665 MY GOAL HERE IS TO JUST TALK 2344 01:27:50,665 --> 01:27:51,566 ABOUT THE CURRENT STATE OF 2345 01:27:51,566 --> 01:27:52,434 KNOWLEDGE ON BLOOD PRESSURE 2346 01:27:52,434 --> 01:27:53,969 ASSESSMENT IN PREGNANT AND 2347 01:27:53,969 --> 01:27:55,804 POSTPARTUM PERSONS, KNOWLEDGE 2348 01:27:55,804 --> 01:27:56,905 GAPS PERTAINING TO CURRENT BLOOD 2349 01:27:56,905 --> 01:27:58,240 PRESSURE ASSESSMENT METHODS IN 2350 01:27:58,240 --> 01:28:00,108 THE PREGNANT AND POSTPARTUM 2351 01:28:00,108 --> 01:28:03,812 PATIENTS, AND THEN ONGOING 2352 01:28:03,812 --> 01:28:05,113 RESEARCH AND IDENTIFY RESEARCH 2353 01:28:05,113 --> 01:28:06,982 NEEDS TO IMPROVE THOSE BLOOD 2354 01:28:06,982 --> 01:28:08,216 PRESSURE ASSESSMENTS AGAIN IN 2355 01:28:08,216 --> 01:28:10,519 OUR PREGNANT AND POSTPARTUM 2356 01:28:10,519 --> 01:28:11,686 PERSONS. 2357 01:28:11,686 --> 01:28:16,525 I HAVE SOME DISCLOSURES. 2358 01:28:16,525 --> 01:28:18,827 JUST A REALLY BRIEF BACKGROUND. 2359 01:28:18,827 --> 01:28:20,028 I FEEL LIKE THERE'S SO MUCH TO 2360 01:28:20,028 --> 01:28:22,130 COVER REGARDING PREGNANT AND 2361 01:28:22,130 --> 01:28:24,833 POSTPARTUM PEOPLE. 2362 01:28:24,833 --> 01:28:26,835 SO I JUST KIND OF KEPT IT AS 2363 01:28:26,835 --> 01:28:28,036 BROAD STROKES BUT IN JERNTION WE 2364 01:28:28,036 --> 01:28:30,205 HAVE INCREASING RATES OF 2365 01:28:30,205 --> 01:28:30,872 HYPERTENSION DISORDERS OF 2366 01:28:30,872 --> 01:28:32,641 PREGNANCY ACROSS THE U.S. 2367 01:28:32,641 --> 01:28:33,975 WE HAVE INCREASING RATES OF 2368 01:28:33,975 --> 01:28:36,244 MATERNAL MORTALITY, ESPECIALLY 2369 01:28:36,244 --> 01:28:39,648 RELATED TO CARDIOVASCULAR 2370 01:28:39,648 --> 01:28:41,383 DISORDERS, AND HYPERTENSION IS A 2371 01:28:41,383 --> 01:28:44,452 LARGE CONTRIBUTOR TO THAT. 2372 01:28:44,452 --> 01:28:45,053 ADDITIONALLY, PEOPLE WHO HAVE 2373 01:28:45,053 --> 01:28:46,888 THESE CONDITIONS HAVE INCREASED 2374 01:28:46,888 --> 01:28:50,592 RISK OF LONG TERM CARDIOVASCULAR 2375 01:28:50,592 --> 01:28:51,493 DISORDERS AND MORTALITY. 2376 01:28:51,493 --> 01:28:52,194 GUIDELINES REGARDING BLOOD 2377 01:28:52,194 --> 01:28:53,361 PRESSURE ASSESSMENT AND CONTROL 2378 01:28:53,361 --> 01:28:58,166 IN PREGNANCY ARE PRIMARILY BASED 2379 01:28:58,166 --> 01:28:59,701 ON EXPERT OPINION AND NOT 2380 01:28:59,701 --> 01:29:01,102 CONSISTENT WITH NON-PREGNANT 2381 01:29:01,102 --> 01:29:03,071 ADULTS. 2382 01:29:03,071 --> 01:29:03,838 POSTPARTUM BLOOD PRESSURE 2383 01:29:03,838 --> 01:29:05,840 MONITORING USING REMOTE PATIENT 2384 01:29:05,840 --> 01:29:07,776 MONITORING OR SELF-MONITOR BLOOD 2385 01:29:07,776 --> 01:29:09,878 PRESSURE HAS INCREASING EVIDENCE 2386 01:29:09,878 --> 01:29:12,380 REGARDING THE SUPPORT OF USE OF 2387 01:29:12,380 --> 01:29:14,482 THIS, BUT IT'S LIMITED AND 2388 01:29:14,482 --> 01:29:14,916 SCALABILITY HAS BEEN 2389 01:29:14,916 --> 01:29:15,450 PARTICULARLY CHALLENGING. 2390 01:29:15,450 --> 01:29:17,852 WE HAVE LACK OF VALIDATED 2391 01:29:17,852 --> 01:29:19,387 DEVICES AND APPROPRIATE CUFF 2392 01:29:19,387 --> 01:29:21,256 SIZES FOR OUR PREGNANT AND 2393 01:29:21,256 --> 01:29:22,457 POSTPARTUM PEOPLE AND WE HAVE 2394 01:29:22,457 --> 01:29:24,326 LACK OF ACCESS TO BLOOD PRESSURE 2395 01:29:24,326 --> 01:29:25,327 DEVICES IN GENERAL. 2396 01:29:25,327 --> 01:29:29,364 SO EVEN IF WE HAD GOOD DEVICES, 2397 01:29:29,364 --> 01:29:30,665 GOOD RECOMMENDATIONS, PEOPLE 2398 01:29:30,665 --> 01:29:31,866 REALLY CAN'T ACCESS THE BLOOD 2399 01:29:31,866 --> 01:29:32,701 PRESSURE DEVICES THEY NEED. 2400 01:29:32,701 --> 01:29:34,336 THEN SPECIFICALLY TO ADDRESS HOW 2401 01:29:34,336 --> 01:29:35,870 IS HYPERTENSION CARE IN THIS 2402 01:29:35,870 --> 01:29:37,105 AREA DIFFERENT THAN IN 2403 01:29:37,105 --> 01:29:38,740 NON-PREGNANT ADULTS? 2404 01:29:38,740 --> 01:29:41,009 IN GENERAL WHEN WE'RE TALKING 2405 01:29:41,009 --> 01:29:43,211 ABOUT -- IT CONSIDERED AN AREA 2406 01:29:43,211 --> 01:29:44,779 WHERE THIS CAN BE AN ACUTE 2407 01:29:44,779 --> 01:29:46,815 CONDITION AND A VERY DIFFERENT 2408 01:29:46,815 --> 01:29:48,450 SITUATION THAN OUR GENERAL ADULT 2409 01:29:48,450 --> 01:29:50,018 POPULATION OR PEOPLE WITH 2410 01:29:50,018 --> 01:29:53,288 CHRONIC HYPERTENSION. 2411 01:29:53,288 --> 01:29:54,489 ADDITIONALLY, IN COMPARISON TO 2412 01:29:54,489 --> 01:29:55,690 ADULT HYPERTENSION RESEARCH, 2413 01:29:55,690 --> 01:29:57,359 THERE'S VERY FEW PREGNANCY 2414 01:29:57,359 --> 01:30:06,001 TRIALS AVAILABLE. 2415 01:30:06,001 --> 01:30:07,202 IN PREPARING FOR THIS TALK, I 2416 01:30:07,202 --> 01:30:09,604 FOUND THIS INSIGHTFUL PAPER JUST 2417 01:30:09,604 --> 01:30:10,605 TALKING ABOUT THE INTERSECTION 2418 01:30:10,605 --> 01:30:13,008 OF CARDIOVASCULAR HEALTH AND 2419 01:30:13,008 --> 01:30:14,276 MATERNAL HEALTH WITH A PORTFOLIO 2420 01:30:14,276 --> 01:30:15,410 ANALYSIS OF FEDERAL GRANT 2421 01:30:15,410 --> 01:30:19,481 FUNDING FROM 2016 TO '21. 2422 01:30:19,481 --> 01:30:23,518 KIND OF ASTOUNDINGLY, IT APPEARS 2423 01:30:23,518 --> 01:30:24,953 THAT OVERALL MATERNAL HEALTH 2424 01:30:24,953 --> 01:30:26,888 GRANTS REMAINED UNCHANGED AND 2425 01:30:26,888 --> 01:30:30,091 ONLY MADE UP OF 1.5% OF TOTAL 2426 01:30:30,091 --> 01:30:32,927 DHHS GRANT FUNDING. 2427 01:30:32,927 --> 01:30:35,897 MATERNAL CARDIOVASCULAR HEALTH 2428 01:30:35,897 --> 01:30:39,301 SPECIFIC FUNDING HAD 2429 01:30:39,301 --> 01:30:39,968 APPROXIMATELY 755 GRANTS AND YOU 2430 01:30:39,968 --> 01:30:43,338 CAN SEE THE TOTALS THERE. 2431 01:30:43,338 --> 01:30:46,975 INSTITUTE FUNDING PRIORITIES FOR 2432 01:30:46,975 --> 01:30:50,245 NON-NIH, DHHS AGENCIES INCLUDED 2433 01:30:50,245 --> 01:30:52,781 MOSTLY GENERAL MATERNAL HEALTH 2434 01:30:52,781 --> 01:30:54,749 RELATED TO CARDIOVASCULAR 2435 01:30:54,749 --> 01:30:57,819 HEALTH, AND THEN MOST COMMON 2436 01:30:57,819 --> 01:30:59,120 METHODOLOGY WAS CLINICALLY 2437 01:30:59,120 --> 01:31:08,129 APPLIED RESEARCH IN THE -- 2438 01:31:08,129 --> 01:31:09,564 HYPERTENSION, DISORDERS OF 2439 01:31:09,564 --> 01:31:11,433 PREGNANCY, MATERNAL MORTALITY, 2440 01:31:11,433 --> 01:31:12,968 THE MOST COMMON AREAS WITH 2441 01:31:12,968 --> 01:31:14,469 METHODOLOGY SPANNING A LARGER 2442 01:31:14,469 --> 01:31:15,770 SPECTRUM OF BASIC CLINICAL 2443 01:31:15,770 --> 01:31:16,371 TRIALS OR TRANSLATIONAL 2444 01:31:16,371 --> 01:31:16,805 RESEARCH. 2445 01:31:16,805 --> 01:31:20,075 REGARDING WHERE IS THE FUNDING 2446 01:31:20,075 --> 01:31:23,044 PREPARTUM, IT 78.5% POSTPARTUM, 2447 01:31:23,044 --> 01:31:26,247 50%, AND THEN THE PREPREGNANCY 2448 01:31:26,247 --> 01:31:27,115 PERIPARTUM PERIODS AROUND 10%. 2449 01:31:27,115 --> 01:31:29,217 SO IN GENERAL, FEDERAL FUNDING 2450 01:31:29,217 --> 01:31:33,655 FOR MATERNAL HEALTH SPECIFICALLY 2451 01:31:33,655 --> 01:31:34,756 AROUND CARDIOVASCULAR HEALTH 2452 01:31:34,756 --> 01:31:36,324 INCREASE AT THE SAME RATE AS 2453 01:31:36,324 --> 01:31:37,625 FUNDING FOR OTHER RESEARCH BUT 2454 01:31:37,625 --> 01:31:39,594 ONLY REPRESENTED ABOUT 1.5% OF 2455 01:31:39,594 --> 01:31:44,199 OVERALL FUNDING. 2456 01:31:44,199 --> 01:31:47,936 WHEN I PULLED ON NIH REPORTER 2457 01:31:47,936 --> 01:31:50,004 FUNDING FOR HYPERTENSION VERSUS 2458 01:31:50,004 --> 01:31:50,872 PREGNANCY AND KIND OF THE 2459 01:31:50,872 --> 01:31:53,408 INSTITUTES THAT ARE FUNDING, YOU 2460 01:31:53,408 --> 01:31:54,743 CAN SEE THERE IS AN INCREASE IN 2461 01:31:54,743 --> 01:31:56,478 GENERAL OF HYPERTENSION FUNDED 2462 01:31:56,478 --> 01:31:57,679 RESEARCH AS WELL AS PREGNANCY 2463 01:31:57,679 --> 01:31:59,614 RELATED RESEARCH, I COULDN'T GET 2464 01:31:59,614 --> 01:32:02,183 INTO THE DEPTHS OF THE 2465 01:32:02,183 --> 01:32:05,487 HYPERTENSION IN PREGNANCY AREAS, 2466 01:32:05,487 --> 01:32:06,888 BUT I JUST FIND IT PROMISING 2467 01:32:06,888 --> 01:32:08,656 THAT THOSE FUNDING LEVELS ARE 2468 01:32:08,656 --> 01:32:12,694 GOING UP. 2469 01:32:12,694 --> 01:32:14,329 SO PREGNANCY IS A GREAT TIME OF 2470 01:32:14,329 --> 01:32:15,530 CHANGE, AND THERE'S A LOT TO 2471 01:32:15,530 --> 01:32:17,732 TALK ABOUT REGARDING HOW DO WE 2472 01:32:17,732 --> 01:32:18,767 DIAGNOSE ALL THESE DIFFERENT 2473 01:32:18,767 --> 01:32:20,301 TYPES OF HYPERTENSION DISORDERS 2474 01:32:20,301 --> 01:32:21,903 AND IT'S PROBABLY REALLY OUTSIDE 2475 01:32:21,903 --> 01:32:23,304 THE SCOPE OF THE TALK TODAY, BUT 2476 01:32:23,304 --> 01:32:26,841 WE DO HAVE INCREASING RATES OF 2477 01:32:26,841 --> 01:32:28,276 PEOPLE WHO COME INTO PREGNANCY 2478 01:32:28,276 --> 01:32:29,477 WITH KNOWN CHRONIC HYPERTENSION 2479 01:32:29,477 --> 01:32:35,717 AND THERE IS A A KA NUN DUMB TT 2480 01:32:35,717 --> 01:32:37,252 THE DIAGNOSTIC BLOOD PRESSURE 2481 01:32:37,252 --> 01:32:39,120 THRESHOLD FOR HYPERTENSION IN 2482 01:32:39,120 --> 01:32:41,222 PREGNANCY HAS NOT CHANGED, IT 2483 01:32:41,222 --> 01:32:42,090 REMAINS 140 GREATER THAN OR 2484 01:32:42,090 --> 01:32:44,292 EQUAL TO 140 OVER 90. 2485 01:32:44,292 --> 01:32:45,894 SO IF THEY HAD STAGE ONE 2486 01:32:45,894 --> 01:32:49,664 HYPERTENSION BASED ON -- WE 2487 01:32:49,664 --> 01:32:51,099 DON'T KNOW WHAT TO DO WITH THOSE 2488 01:32:51,099 --> 01:32:52,434 PATIENTS AND WE HAVE NOT CHANGED 2489 01:32:52,434 --> 01:32:54,502 THE GUIDELINES TO REFLECT 2490 01:32:54,502 --> 01:32:56,104 CHRONIC HYPERTENSION WITH THOSE 2491 01:32:56,104 --> 01:32:57,238 BLOOD PRESSURE THRESHOLDS NOW 2492 01:32:57,238 --> 01:32:58,606 THAT THEY'RE PREGNANT. 2493 01:32:58,606 --> 01:33:00,575 AND THEN WE HAVE IN GENERAL ANY 2494 01:33:00,575 --> 01:33:04,045 OF THESE OTHER TYPES OF 2495 01:33:04,045 --> 01:33:06,581 DISORDERS, AND THEY'RE ALL 2496 01:33:06,581 --> 01:33:08,216 DIAGNOSED AT THE BLOOD PRESSURE 2497 01:33:08,216 --> 01:33:12,387 THRESHOLD OF 140 OVER 90, AND 2498 01:33:12,387 --> 01:33:13,922 THEN THAT ALL KIND OF DETAIL OUT 2499 01:33:13,922 --> 01:33:15,590 WHAT TYPE OF HYPERTENSION 2500 01:33:15,590 --> 01:33:18,793 DISORDER THEY'RE GOING TO HAVE. 2501 01:33:18,793 --> 01:33:20,295 THE OTHER THING I JUST WANT TO 2502 01:33:20,295 --> 01:33:22,931 COMMENT REGARDING BLOOD PRESSURE 2503 01:33:22,931 --> 01:33:23,364 DEVICES. 2504 01:33:23,364 --> 01:33:24,899 WE HAVE A LOT OF OVERWEIGHT 2505 01:33:24,899 --> 01:33:26,234 PREGNANT PEOPLE AND OFTENTIMES 2506 01:33:26,234 --> 01:33:28,436 WE'RE STRUGGLING TO FIND AN ARM 2507 01:33:28,436 --> 01:33:30,839 CUFF THAT ACTUALLY FITS 2508 01:33:30,839 --> 01:33:33,675 PROPERLY. 2509 01:33:33,675 --> 01:33:34,809 AND ADDITIONALLY THERE'S A LOT 2510 01:33:34,809 --> 01:33:36,644 OF PROBLEMS WITH AVAILABILITY 2511 01:33:36,644 --> 01:33:37,612 WITH VALIDATED BLOOD PRESSURE 2512 01:33:37,612 --> 01:33:38,780 DEVICES IN OUR PREGNANT 2513 01:33:38,780 --> 01:33:48,957 PATIENTS. 2514 01:33:49,290 --> 01:33:50,325 SO WHEN CONSIDERING PHYSIOLOGIC 2515 01:33:50,325 --> 01:33:51,759 CHANGES IN PREGNANCY, WE START 2516 01:33:51,759 --> 01:33:53,728 TO SEE CHANGES AS EARLY AS THE 2517 01:33:53,728 --> 01:33:54,696 FIRST TRIMESTER. 2518 01:33:54,696 --> 01:33:56,231 SPECIFIC CHANGES INCLUDE AN 2519 01:33:56,231 --> 01:33:57,899 INCREASED HEART RATE, BLOOD 2520 01:33:57,899 --> 01:33:59,100 VOLUME CARDIAC OUTPUT, AS WELL 2521 01:33:59,100 --> 01:34:00,969 AS STROKE VOLUME. 2522 01:34:00,969 --> 01:34:03,605 THERE'S ALSO INCREASED RENAL AND 2523 01:34:03,605 --> 01:34:05,573 UTERINE BLOOD FLOW, THERE'S 2524 01:34:05,573 --> 01:34:07,876 INREESED TOTAL BODY WATER, BLOOD 2525 01:34:07,876 --> 01:34:09,944 VOLUME AND CAPILLARY HYDROSTATIC 2526 01:34:09,944 --> 01:34:11,279 PRESSURE AS WELL AS DECREASES IN 2527 01:34:11,279 --> 01:34:12,280 PERIPHERAL RESISTANCE TO 2528 01:34:12,280 --> 01:34:13,648 ACCOMMODATE THE DEVELOPING FETUS 2529 01:34:13,648 --> 01:34:16,851 IN THE UTERINE CAVITY. 2530 01:34:16,851 --> 01:34:18,052 AS PREGNANCY PROGRESSES WE CAN 2531 01:34:18,052 --> 01:34:19,754 START TO SEE ANATOMIC 2532 01:34:19,754 --> 01:34:22,423 COMPRESSION OF THE INFERIOR VENA 2533 01:34:22,423 --> 01:34:26,594 CAVA AGAIN DUAL TO THAT UTERINE 2534 01:34:26,594 --> 01:34:27,262 SIZE. 2535 01:34:27,262 --> 01:34:29,831 THESE CLASSIC CHANGES CAN ALSO 2536 01:34:29,831 --> 01:34:32,634 BE DEVELOPED FURTHER WHEN A 2537 01:34:32,634 --> 01:34:33,735 PERSON DEVELOPS PRE-ECLAMPSIA IN 2538 01:34:33,735 --> 01:34:35,703 CERTAIN CASES YOU'LL SEE 2539 01:34:35,703 --> 01:34:37,605 ACTUALLY THE HEART RATE REDUCES 2540 01:34:37,605 --> 01:34:41,976 QUITE A BIT, THE PERIPHERAL 2541 01:34:41,976 --> 01:34:44,178 RESISTANCE WITH IN A NORMAL 2542 01:34:44,178 --> 01:34:48,149 PREGNANCY FOAS DO GOES DOWN, ITO 2543 01:34:48,149 --> 01:34:48,783 UP QUITE A BIT. 2544 01:34:48,783 --> 01:34:50,351 I WAS JUST IN A BLOOD PRESSURE 2545 01:34:50,351 --> 01:34:51,219 VALIDATION WORKSHOP EARLIER THIS 2546 01:34:51,219 --> 01:34:52,654 WEEK AND KNOWING SPECIFICALLY 2547 01:34:52,654 --> 01:34:54,722 THAT THOSE PARTICULAR PARAMETERS 2548 01:34:54,722 --> 01:34:59,794 MAY ALTER THE CALCULATIONS 2549 01:34:59,794 --> 01:35:01,296 PROVIDED IN THE OSCILLATORY 2550 01:35:01,296 --> 01:35:04,365 BLOOD PRESSURE MACHINES SO 2551 01:35:04,365 --> 01:35:05,700 THERE'S A LOT OF WORK THAT NEEDS 2552 01:35:05,700 --> 01:35:07,569 TO BE DONE AND CONSIDERED WHEN 2553 01:35:07,569 --> 01:35:08,570 THINKING ABOUT THE PHYSIOLOGICAL 2554 01:35:08,570 --> 01:35:09,537 CHANGES IN THIS SPECIAL 2555 01:35:09,537 --> 01:35:11,573 POPULATION AND HOW ACCURATE OUR 2556 01:35:11,573 --> 01:35:13,074 BLOOD PRESSURE READINGS MIGHT BE 2557 01:35:13,074 --> 01:35:14,275 AS WELL AS HOW ARE WE CARING FOR 2558 01:35:14,275 --> 01:35:15,276 THEM IN THE PREGNANCY REGARDING 2559 01:35:15,276 --> 01:35:16,811 THESE CHANGES. 2560 01:35:16,811 --> 01:35:18,012 THE FIGURE ON THE RIGHT, I JUST 2561 01:35:18,012 --> 01:35:20,448 PUT HERE AS A HISTORICAL FIGURE 2562 01:35:20,448 --> 01:35:21,950 BECAUSE THIS IS ONE OFTEN FOUND 2563 01:35:21,950 --> 01:35:24,953 IN OUR TEXTBOOKS AND IT'S FROM 2564 01:35:24,953 --> 01:35:26,888 THE 80s WHERE THEY INCLUDED 69 2565 01:35:26,888 --> 01:35:28,456 PREGNANT PERSONS AND THEN THEY 2566 01:35:28,456 --> 01:35:30,625 HAVE SEQUENTIAL EVALUATIONS OF 2567 01:35:30,625 --> 01:35:33,061 THEIR BLOPs THROUGH THEIR 2568 01:35:33,061 --> 01:35:34,462 PREGNANCY AND THEN AGAIN ONE 2569 01:35:34,462 --> 01:35:36,464 TIME FOR SIX WEEKS POSTPARTUM. 2570 01:35:36,464 --> 01:35:39,000 WHAT IT SHOWS IS THAT THE 2571 01:35:39,000 --> 01:35:42,704 AVERAGE BLOOD PRESSURE ARE LOWER 2572 01:35:42,704 --> 01:35:44,272 DURING PREGNANCY AND -- AROUND 2573 01:35:44,272 --> 01:35:45,673 THE 28TH WEEK OR SO BUT THEN 2574 01:35:45,673 --> 01:35:47,075 THEY PICK UP AND BLOOD PRESSURES 2575 01:35:47,075 --> 01:35:48,109 WILL REACH THEIR BASELINE 2576 01:35:48,109 --> 01:35:49,110 TOWARDS THE END OF THE 2577 01:35:49,110 --> 01:35:49,877 PREGNANCY. 2578 01:35:49,877 --> 01:35:51,279 AND SO WHEN I STARTED IN THIS 2579 01:35:51,279 --> 01:35:52,814 FIELD, THAT REALLY WAS LIKE ONE 2580 01:35:52,814 --> 01:35:54,282 OF THE ONLY FIGURES OUT THERE, 2581 01:35:54,282 --> 01:35:58,219 AND THERE'S BEEN A LOT OF WORK 2582 01:35:58,219 --> 01:35:59,554 AND MORE WORK THAT'S COMING OUT 2583 01:35:59,554 --> 01:36:01,422 TO TRY TO REALLY UNDERSTAND HOW 2584 01:36:01,422 --> 01:36:03,124 DO THESE BLOOD PRESSURES CHANGE 2585 01:36:03,124 --> 01:36:05,193 AND HOW CAN OUR RECOMMENDATIONS 2586 01:36:05,193 --> 01:36:06,628 PERHAPS BE ALTERED TO PROVIDE 2587 01:36:06,628 --> 01:36:16,204 BETTER CARE. 2588 01:36:16,204 --> 01:36:17,739 SO THE KNOWLEDGE ABOUT BLOOD 2589 01:36:17,739 --> 01:36:19,374 PRESSURE PROFILES, HOW THEY 2590 01:36:19,374 --> 01:36:20,942 BEHAVE IN PREGNANCY THROUGH 2591 01:36:20,942 --> 01:36:22,043 POSTPARTUM I WOULD SAY IS ONE OF 2592 01:36:22,043 --> 01:36:27,982 OUR LARGE E. GAPS ANDEST GAPS AI 2593 01:36:27,982 --> 01:36:29,017 MENTIONED HYPERTENSION DISORDERS 2594 01:36:29,017 --> 01:36:31,486 ARE GOING UP, MORBIDITY AND 2595 01:36:31,486 --> 01:36:33,588 MORTALITY IS GOING UP IT'S LIKE 2596 01:36:33,588 --> 01:36:35,356 WHERE ARE WE MISSING THE BOAT. 2597 01:36:35,356 --> 01:36:37,659 SO I MADE RECOMMENDATION, YOU 2598 01:36:37,659 --> 01:36:38,226 KNOW, HISTORICALLY SPECIFIC 2599 01:36:38,226 --> 01:36:39,761 RECOMMENDATIONS FOR WELL MAYBE 2600 01:36:39,761 --> 01:36:40,662 PEOPLE COULD STAY IN THE 2601 01:36:40,662 --> 01:36:42,397 HOSPITAL LONGER POSTPARTUM OR 2602 01:36:42,397 --> 01:36:44,132 THAT THE CLASSIC AND STILL THE 2603 01:36:44,132 --> 01:36:46,100 STANDARD IS PEOPLE SHOULD COME 2604 01:36:46,100 --> 01:36:47,201 BACK AFTER BIRTH TO HAVE THEIR 2605 01:36:47,201 --> 01:36:48,436 BLOOD PRESSURES ASSESSED. 2606 01:36:48,436 --> 01:36:50,304 BUT WHEN WE ACTUALLY CAN START 2607 01:36:50,304 --> 01:36:52,173 LOOKING AT THESE BLOOD PRESSURE 2608 01:36:52,173 --> 01:36:54,275 PROFILES AND UNDERSTAND, I KNOW 2609 01:36:54,275 --> 01:36:55,476 THE FIGURES ARE SMALL BUT THESE 2610 01:36:55,476 --> 01:36:59,447 ARE ONES THAT MY GRE GROUP HAS 2611 01:36:59,447 --> 01:36:59,981 PUBLISHED. 2612 01:36:59,981 --> 01:37:01,082 THE ONE ON THE LEFT IS ALL 2613 01:37:01,082 --> 01:37:03,251 HYPERTENSION IN PREGNANCY 2614 01:37:03,251 --> 01:37:04,919 PATIENTS SPECIFICALLY EXCLUDING 2615 01:37:04,919 --> 01:37:05,386 CHRONIC HYPERTENSION. 2616 01:37:05,386 --> 01:37:09,624 YOU CAN SEE THAT CLASSIC STORY 2617 01:37:09,624 --> 01:37:11,392 OF BLOOD PRESSURE -- EARLY IN 2618 01:37:11,392 --> 01:37:12,593 THE PREGNANCY, HOWEVER THEY RISE 2619 01:37:12,593 --> 01:37:14,362 AND THEY REACH THEIR PEAK AT 2620 01:37:14,362 --> 01:37:15,396 DELIVERY, BUT THEN THEY HAVE A 2621 01:37:15,396 --> 01:37:18,099 PERIOD OF TIME OVER THE FIRST 2622 01:37:18,099 --> 01:37:19,300 4 TO 7 DAYS POSTPARTUM WHERE 2623 01:37:19,300 --> 01:37:20,768 THEY WILL GO DOWN AND THEN PEAK 2624 01:37:20,768 --> 01:37:21,436 AGAIN. 2625 01:37:21,436 --> 01:37:22,870 AND I THINK THAT'S IMPORTANT 2626 01:37:22,870 --> 01:37:24,405 BECAUSE IF WE'RE NOT SEEING 2627 01:37:24,405 --> 01:37:28,142 PATIENTS OR ASSESSING THEIR -- 2628 01:37:28,142 --> 01:37:29,243 EVERY DAY WE'RE GOING TO MISS 2629 01:37:29,243 --> 01:37:31,212 THE TIMES WHEN THOSE BLOOD 2630 01:37:31,212 --> 01:37:34,048 PRESSURES SPIKE AND THERE MIGHT 2631 01:37:34,048 --> 01:37:36,818 BE MORE MORBIDITY. 2632 01:37:36,818 --> 01:37:37,785 THE FIGURE ON THE RIGHT IS 2633 01:37:37,785 --> 01:37:39,120 SIMILAR, IT'S JUST PULLING APART 2634 01:37:39,120 --> 01:37:40,088 THE DIFFERENT TYPES OF 2635 01:37:40,088 --> 01:37:43,257 HYPERTENSION DISORDERS AND 2636 01:37:43,257 --> 01:37:44,892 INCLUDING -- WE HAD CLOSE TO 900 2637 01:37:44,892 --> 01:37:46,561 PEOPLE IN THESE STUDIES, AND YOU 2638 01:37:46,561 --> 01:37:48,096 CAN SEE FOR THE CHRONIC 2639 01:37:48,096 --> 01:37:49,897 HYPERTENSIVE PATIENTS IN THE 2640 01:37:49,897 --> 01:37:51,766 SYSTOLIC AND DIASTOLIC BLOOD 2641 01:37:51,766 --> 01:37:55,470 PRESSURE PROFILES THAT THEY 2642 01:37:55,470 --> 01:37:59,774 RECOVER THEIR TO AT OR BELOW 2643 01:37:59,774 --> 01:38:00,975 THEIR PRECONCEPTION BLOOD 2644 01:38:00,975 --> 01:38:02,944 PRESSURES, OF OUR, IN THE FOLKS 2645 01:38:02,944 --> 01:38:05,146 WHO HAD A HYPERTENSION RELATED 2646 01:38:05,146 --> 01:38:08,349 DISORDER IN THEIR PREGNANCY, NOT 2647 01:38:08,349 --> 01:38:12,954 CHRONIC, THE, THEY'RE NOT RECOVG 2648 01:38:12,954 --> 01:38:14,922 THEIR DIASTOLIC BLOOD PRESSURE 2649 01:38:14,922 --> 01:38:15,590 SPECIFICALLY, SO THIS MIGHT 2650 01:38:15,590 --> 01:38:17,125 PROVIDE SOME INSIGHT INTO 2651 01:38:17,125 --> 01:38:19,961 NECESSARY CARE BEYOND EVEN THE . 2652 01:38:19,961 --> 01:38:22,964 SO WHAT DO WE KNOW CURRENT 2653 01:38:22,964 --> 01:38:23,598 STATE? 2654 01:38:23,598 --> 01:38:24,932 I POINT OUT HERE SEVERE 2655 01:38:24,932 --> 01:38:26,467 HYPERTENSION SHOULD BE TREATED. 2656 01:38:26,467 --> 01:38:28,803 SO OUR SEVERE HYPERTENSION 2657 01:38:28,803 --> 01:38:32,206 THRESHOLD IS 160/110 MILLIMETERS 2658 01:38:32,206 --> 01:38:33,407 OF MERCURY AND THAT'S SORT OF 2659 01:38:33,407 --> 01:38:34,842 OUR THRESHOLD WHERE EVERYBODY 2660 01:38:34,842 --> 01:38:37,178 SHOULD BE TREATED. 2661 01:38:37,178 --> 01:38:40,148 BEFORE THE CHAP TRIAL, MANY 2662 01:38:40,148 --> 01:38:41,349 PEOPLE WITH CHRONIC HYPERTENSION 2663 01:38:41,349 --> 01:38:43,851 WERE TAKEN OFF THEIR MEDICATIONS 2664 01:38:43,851 --> 01:38:48,689 AND WERE NOT TREATED UNTIL 2665 01:38:48,689 --> 01:38:49,423 160/110. 2666 01:38:49,423 --> 01:38:50,992 SO THAT LEADS TO THE CHAP TRIAL 2667 01:38:50,992 --> 01:38:55,930 AND WE LOOKED AT A COMPOSITE OUT 2668 01:38:55,930 --> 01:38:59,867 COME OF PRETERM BIRTH LESS THAN 2669 01:38:59,867 --> 01:39:03,738 35 WEEKS, PREECLAMPSIA WITH 2670 01:39:03,738 --> 01:39:05,907 SEVERE FEATURES, ABRUPTION AND 2671 01:39:05,907 --> 01:39:08,643 FETAL DEMISE WHILE NOT AFFECTING 2672 01:39:08,643 --> 01:39:09,210 SGA. 2673 01:39:09,210 --> 01:39:11,412 WHAT WE FOUND IS THAT THAT 2674 01:39:11,412 --> 01:39:13,381 COMPOSITE OUTCOME AS WELL AS THE 2675 01:39:13,381 --> 01:39:16,984 INDIVIDUAL COMPONENTS OF THAT 2676 01:39:16,984 --> 01:39:20,421 COMPOSITE WERE ALREADY REDUCED 2677 01:39:20,421 --> 01:39:23,391 AND WE DID NOT AFFECT THE FETAL 2678 01:39:23,391 --> 01:39:28,162 SIZE, SO SGA LESS THAN A THE 2679 01:39:28,162 --> 01:39:29,497 FIFTH OR TENTH WAS NOT 2680 01:39:29,497 --> 01:39:31,399 SIGNIFICANT. 2681 01:39:31,399 --> 01:39:38,706 ADDITIONALLY WE FOUND THE 2682 01:39:38,706 --> 01:39:39,807 REDUCTION IN THE COMPOSITE 2683 01:39:39,807 --> 01:39:41,876 OUTCOME WAS EVEN BETTER, THE 2684 01:39:41,876 --> 01:39:44,111 PROBLEM IS THAT THIS WAS 2685 01:39:44,111 --> 01:39:44,545 SPECIFICALLY CHRONIC 2686 01:39:44,545 --> 01:39:45,313 HYPERTENSIVE PATIENTS SO THESE 2687 01:39:45,313 --> 01:39:46,714 RESULTS REALLY ARE NOT ABLE TO 2688 01:39:46,714 --> 01:39:49,717 BE GENERALIZED TO OTHER 2689 01:39:49,717 --> 01:39:50,284 HYPERTENSION DISORDERS OF 2690 01:39:50,284 --> 01:39:53,221 PREGNANCY AND WE STILL DON'T 2691 01:39:53,221 --> 01:39:57,391 KNOW WHAT -- AND CURRENTLY WE 2692 01:39:57,391 --> 01:39:59,460 REALLY DON'T PROVIDE 2693 01:39:59,460 --> 01:40:00,261 ANTIHYPERTENSIVE TREATMENT UNTIL 2694 01:40:00,261 --> 01:40:03,164 THEY REACH THAT SEVERE RANGE. 2695 01:40:03,164 --> 01:40:05,600 THE CHIP TRIAL WAS HI HISTORICAY 2696 01:40:05,600 --> 01:40:08,035 ALSO ANOTHER TRIAL LOOKING AT 2697 01:40:08,035 --> 01:40:10,204 TIGHTER BLOOD PRESSURE CONTROL. 2698 01:40:10,204 --> 01:40:12,440 SPECIFICALLY TIGHTER DIASTOLIC 2699 01:40:12,440 --> 01:40:13,474 BLOOD PRESSURE CONTROL VERSUS 2700 01:40:13,474 --> 01:40:18,279 LESS TIGHT AND IN THAT TRIAL 2701 01:40:18,279 --> 01:40:20,281 THEY FOUND ADDITIONALLY THAT 2702 01:40:20,281 --> 01:40:20,948 TIGHTER BLOOD PRESSURE CONTROL 2703 01:40:20,948 --> 01:40:22,149 IS ASSOCIATED WITH LOWER RISKS 2704 01:40:22,149 --> 01:40:28,656 OF SEVERE HYPERTENSION WITHOUT 2705 01:40:28,656 --> 01:40:30,291 INCREASING RISK TO THE FETUS OR 2706 01:40:30,291 --> 01:40:30,625 NEWBORN. 2707 01:40:30,625 --> 01:40:31,592 THERE ARE A LOT OF BLOOD 2708 01:40:31,592 --> 01:40:33,027 PRESSURE SPIKES HAPPENING IN 2709 01:40:33,027 --> 01:40:36,230 THOSE POSTPARTUM DAYS 4 TO 2710 01:40:36,230 --> 01:40:37,865 7 THAT ARE BEFORE THE SCHEDULED 2711 01:40:37,865 --> 01:40:46,173 CLINIC OUTPATIENT FOLLOWUPS. 2712 01:40:46,173 --> 01:40:47,174 UNDERESTIMATING THE AMOUNT OF 2713 01:40:47,174 --> 01:40:49,277 PEOPLE PROBABLY THAT STILL HAVE 2714 01:40:49,277 --> 01:40:50,811 PERSISTENT HYPERTENSION THROUGH 2715 01:40:50,811 --> 01:40:53,514 THAT 6 WEEK POSTPARTUM PERIOD. 2716 01:40:53,514 --> 01:40:58,319 NOW REMOTE PATIENT MONITORING ON 2717 01:40:58,319 --> 01:41:00,254 THE UP AND COMING, BUT WE HAVE 2718 01:41:00,254 --> 01:41:02,890 SHOWN THAT IT CAN REDUCE 2719 01:41:02,890 --> 01:41:11,666 HOSPITAL RO READMISSIONS. 2720 01:41:11,666 --> 01:41:13,401 WE'VE ALSO SHOWN SIMILAR 2721 01:41:13,401 --> 01:41:15,069 STRATEGIES CAN REDUCE RACIAL 2722 01:41:15,069 --> 01:41:16,504 DISPARITIES IN POST HYPERTENSION 2723 01:41:16,504 --> 01:41:18,739 CARE ATTENDANCE OR ABILITY TO AT 2724 01:41:18,739 --> 01:41:21,208 LEAST ACQUIRE BLOOD PRESSURES. 2725 01:41:21,208 --> 01:41:24,512 SO THESE STRATEGIES ARE 2726 01:41:24,512 --> 01:41:25,713 UNDERSTUDIED SMALL STUDIES, AND 2727 01:41:25,713 --> 01:41:26,914 WE NEED MORE INFORMATION BUT 2728 01:41:26,914 --> 01:41:29,817 THERE'S PROMISING HOPE FOR THEM. 2729 01:41:29,817 --> 01:41:32,653 AND THEN JUST A COMMENT ABOUT 2730 01:41:32,653 --> 01:41:33,154 24-HOUR AMBULATORY BLOOD 2731 01:41:33,154 --> 01:41:35,523 PRESSURE TESTING. 2732 01:41:35,523 --> 01:41:40,161 THAT IT COULD BE HELPFUL IN 2733 01:41:40,161 --> 01:41:41,562 DEFINING -- AGAIN MANY PREGNANT 2734 01:41:41,562 --> 01:41:43,097 PERSONS COME TO PREGNANCY 2735 01:41:43,097 --> 01:41:44,799 THINKING THEY MAY OR MAY NOT 2736 01:41:44,799 --> 01:41:46,167 HAVE HYPERTENSION OR THEY HAVE 2737 01:41:46,167 --> 01:41:47,601 WHITE COAT BUT NOBODY IS 2738 01:41:47,601 --> 01:41:49,136 THINKING ABOUT VERIFYING THIS 2739 01:41:49,136 --> 01:41:51,038 AND THERE'S POTENTIAL RISKS OF 2740 01:41:51,038 --> 01:41:52,473 OVERTREATING OR UNDERTREATING IN 2741 01:41:52,473 --> 01:41:53,874 THE PREGNANCY IF WE DON'T REALLY 2742 01:41:53,874 --> 01:41:59,347 KNOW WHAT PEOPLE HAVE. 2743 01:41:59,347 --> 01:42:01,048 JUST A COMMENT ABOUT 2744 01:42:01,048 --> 01:42:01,649 SELF-MEASURED BLOOD PRESSURE 2745 01:42:01,649 --> 01:42:01,949 MONITORING. 2746 01:42:01,949 --> 01:42:04,318 I THINK MOST PEOPLE ON THIS CALL 2747 01:42:04,318 --> 01:42:05,987 ARE PROBABLY VERY WELL AWARE OF 2748 01:42:05,987 --> 01:42:07,321 THAT BUT REFERRING TO BLOOD 2749 01:42:07,321 --> 01:42:08,956 PRESSURE MEASUREMENTS OIB TAINED 2750 01:42:08,956 --> 01:42:10,091 BY THE PATIENT OUTSIDE OF THE 2751 01:42:10,091 --> 01:42:11,525 CLINICAL SETTING OFTEN AT HOME. 2752 01:42:11,525 --> 01:42:13,628 THIS STRATEGY IS MOST COMMONLY 2753 01:42:13,628 --> 01:42:15,029 USED IN NON-PREGNANT PEOPLE. 2754 01:42:15,029 --> 01:42:16,731 THERE'S MANY RESOURCES DEVELOPED 2755 01:42:16,731 --> 01:42:17,598 FOR IMPLEMENTATION AND USE AS 2756 01:42:17,598 --> 01:42:19,133 WELL AS FOLLOW-UP. 2757 01:42:19,133 --> 01:42:21,535 ON THE OTHER SIDE, REMOTE 2758 01:42:21,535 --> 01:42:23,337 PATIENT MONITORING IS WHAT WE'RE 2759 01:42:23,337 --> 01:42:24,538 CALLING THE HOME SURVEILLANCE, 2760 01:42:24,538 --> 01:42:26,607 WHICH INCORPORATES A DIGITAL 2761 01:42:26,607 --> 01:42:30,644 HEALTH SOLUTION THAT CAPTURES 2762 01:42:30,644 --> 01:42:32,113 AND -- OUTSIDE THE TRADITIONAL 2763 01:42:32,113 --> 01:42:33,214 HEALTHCARE ENVIRONMENT. 2764 01:42:33,214 --> 01:42:35,850 THIS IS WHAT WE'RE TENDING TO 2765 01:42:35,850 --> 01:42:37,251 OFFER AND DO IN THE PREGNANCY 2766 01:42:37,251 --> 01:42:38,319 AND POSTPARTUM SPACE. 2767 01:42:38,319 --> 01:42:39,854 MORE RESOURCES ARE COMING, BUT 2768 01:42:39,854 --> 01:42:41,389 THERE IS NO STANDARDIZED CARE 2769 01:42:41,389 --> 01:42:41,956 MODEL. 2770 01:42:41,956 --> 01:42:43,157 IT'S COSTLY. 2771 01:42:43,157 --> 01:42:45,493 AND OUR EVIDENCE IS CURRENTLY 2772 01:42:45,493 --> 01:42:45,793 LACKING. 2773 01:42:45,793 --> 01:42:48,429 WE DID JUST PUBLISH A 2774 01:42:48,429 --> 01:42:50,331 MULTICENTER PAPER TO REALLY TALK 2775 01:42:50,331 --> 01:42:51,432 ABOUT OUR DIFFERENCES AND 2776 01:42:51,432 --> 01:42:52,967 EXPERIENCES ACROSS THE COUNTRY 2777 01:42:52,967 --> 01:42:55,036 USING THESE STRATEGIES. 2778 01:42:55,036 --> 01:42:57,138 AND THERE'S DEFINITELY 2779 01:42:57,138 --> 01:42:58,139 DIFFERENCES IN THE THRESHOLDS 2780 01:42:58,139 --> 01:43:00,441 PEOPLE ARE INTERVENING ON BEHALF 2781 01:43:00,441 --> 01:43:04,078 OF BLOOD PRESSURES, HOW THEY'RE 2782 01:43:04,078 --> 01:43:05,279 UTILIZING THIS STRATEGY, AND 2783 01:43:05,279 --> 01:43:09,116 AGAIN, MOST OF NEM A THEM ARE IN 2784 01:43:09,116 --> 01:43:10,818 ACADEMIC CENTERS SO NOT 2785 01:43:10,818 --> 01:43:12,019 NECESSARILY ABLE TO DISSEMINATE 2786 01:43:12,019 --> 01:43:13,354 BROADLY IN OTHER SPACES. 2787 01:43:13,354 --> 01:43:14,221 SO A LOT OF WORK NEEDS TO BE 2788 01:43:14,221 --> 01:43:19,193 DONE IN THIS SPACE. 2789 01:43:19,193 --> 01:43:25,866 I WANTED TO JUST THROW OUT MANY 2790 01:43:25,866 --> 01:43:26,534 NATIONWIDE STRATEGIES ARE 2791 01:43:26,534 --> 01:43:29,170 WORKING TO IMPROVE HYPERTENSION 2792 01:43:29,170 --> 01:43:30,404 CARE AND DELIVERY AS WELL AS 2793 01:43:30,404 --> 01:43:31,806 OUTCOMES IN THE PREGNANT AND 2794 01:43:31,806 --> 01:43:32,706 POSTPARTUM PERIOD. 2795 01:43:32,706 --> 01:43:34,341 SO FOR EXAMPLE, THE MILLION 2796 01:43:34,341 --> 01:43:35,810 HEARTS HYPERTENSION AND 2797 01:43:35,810 --> 01:43:37,311 PREGNANCY CHANGE PACKAGE, WHICH 2798 01:43:37,311 --> 01:43:41,148 HAS BEEN REALLY -- IN WHICH YOU 2799 01:43:41,148 --> 01:43:42,917 CAN CHANGE CARE PROCESSES 2800 01:43:42,917 --> 01:43:44,051 RELATED TO HYPERTENSION AND 2801 01:43:44,051 --> 01:43:44,418 PREGNANCY. 2802 01:43:44,418 --> 01:43:46,987 IT WAS AUTHORED BY CDC AND SEVEN 2803 01:43:46,987 --> 01:43:50,291 ORGANIZATIONS DEDICATED TO 2804 01:43:50,291 --> 01:43:52,526 IMPROVING MATERNAL HEALTH, THE 2805 01:43:52,526 --> 01:43:55,696 BULK MADE UP OF TABLES LIKE YOU 2806 01:43:55,696 --> 01:43:58,432 CAN SEE ON THIS SLIDE, WITH 2807 01:43:58,432 --> 01:44:00,000 CONCEPTS WHICH ARE BROAD NOTIONS 2808 01:44:00,000 --> 01:44:02,636 FOR CHANGE AND WAYS TO HAVE 2809 01:44:02,636 --> 01:44:03,604 DIFFERENT SPECIFIC CHANGE IDEAS 2810 01:44:03,604 --> 01:44:05,372 WHICH ARE ACTIONABLE 2811 01:44:05,372 --> 01:44:07,708 IMPLEMENTATION STRATEGIES, AND 2812 01:44:07,708 --> 01:44:12,179 THEN EACH CHANGE AIR, THERE ARE 2813 01:44:12,179 --> 01:44:15,149 TESTED TOOLS AND RESOURCES FROM 2814 01:44:15,149 --> 01:44:17,118 CLINICIANS IN THE FOLD AS WELL 2815 01:44:17,118 --> 01:44:20,321 AS NATIONAL ORGANIZATIONS THAT 2816 01:44:20,321 --> 01:44:23,924 CAN HELP NEXT SLIDE. 2817 01:44:23,924 --> 01:44:25,292 SO IN GENERAL, WHAT'S NEEDED? 2818 01:44:25,292 --> 01:44:27,495 SO WE NEED A LOT IN THIS SPACE. 2819 01:44:27,495 --> 01:44:29,029 TREATMENT THRESHOLDS FOR 2820 01:44:29,029 --> 01:44:31,565 NON-CHRONIC HYPERTENSION DURING 2821 01:44:31,565 --> 01:44:36,203 PREGNANCY, AND ALL TYPES, 2822 01:44:36,203 --> 01:44:38,272 POSTPARTUM. 2823 01:44:38,272 --> 01:44:43,077 WE HAVE LIMITED RECOMMENDATIONS 2824 01:44:43,077 --> 01:44:46,714 AND EVIDENCE IN EVEN 2825 01:44:46,714 --> 01:44:47,548 HYPERTENSIVE MEDICATIONS. 2826 01:44:47,548 --> 01:44:50,684 WE'RE USING VERY UNDERSTUDIED IN 2827 01:44:50,684 --> 01:44:53,187 GENERAL, WE HAVE SOME OTHER 2828 01:44:53,187 --> 01:44:55,489 OPTIONS BULL THE PRIMARY FIRST 2829 01:44:55,489 --> 01:44:57,091 LINE AGENTS USED IN NON-PREGNANT 2830 01:44:57,091 --> 01:45:01,662 ADULTS THAT LIKELY WORK BETTER 2831 01:45:01,662 --> 01:45:03,330 OR SOMEWHAT ABLE TO BE USED IN 2832 01:45:03,330 --> 01:45:04,865 PREGNANCY BUT MANY COULD BE, SO 2833 01:45:04,865 --> 01:45:06,300 AGAIN JUST A CALLOUT THAT WE 2834 01:45:06,300 --> 01:45:09,036 REALLY COULD USE SOME UPDATES NP 2835 01:45:09,036 --> 01:45:10,504 STUDYING THE MEDICATION TYPES WE 2836 01:45:10,504 --> 01:45:13,674 HAVE. 2837 01:45:13,674 --> 01:45:15,109 AND THAT MAYBE WE COULD USE MORE 2838 01:45:15,109 --> 01:45:16,243 EFFECTIVELY. 2839 01:45:16,243 --> 01:45:17,645 DEVICE COVERAGE, DEVICE 2840 01:45:17,645 --> 01:45:17,945 VALIDATION. 2841 01:45:17,945 --> 01:45:21,515 WE REALLY NEED TO ENDORSE AND 2842 01:45:21,515 --> 01:45:23,584 REIMBURSE -- HAVE ENDORSEMENT 2843 01:45:23,584 --> 01:45:26,020 AND REIMBURSEMENT CARE MODELS 2844 01:45:26,020 --> 01:45:28,756 FOR SMBP AND/OR RPM FOR 2845 01:45:28,756 --> 01:45:30,357 PREGNANCY AND POSTPARTUM 2846 01:45:30,357 --> 01:45:30,591 PERIODS. 2847 01:45:30,591 --> 01:45:31,926 WE NEED STANDARD RECOMMENDATIONS 2848 01:45:31,926 --> 01:45:33,627 FOR THESE AS WELL AND REALLY 2849 01:45:33,627 --> 01:45:37,231 NEED TO OPTIMIZE -- SO WE'RE 2850 01:45:37,231 --> 01:45:40,034 TALKING ABOUT CHRONIC 2851 01:45:40,034 --> 01:45:41,769 HYPERTENSION FOR TWO DAYS BUT 2852 01:45:41,769 --> 01:45:44,071 WHEN SOMEONE HAS HYPERTENSION IN 2853 01:45:44,071 --> 01:45:45,372 THEIR PREGNANCY THEY'RE AT RISK 2854 01:45:45,372 --> 01:45:46,640 LONG TERM, SO REALLY CLOSING 2855 01:45:46,640 --> 01:45:48,008 THAT GAP, SO THAT TRANSITION 2856 01:45:48,008 --> 01:45:48,742 THAT WILL CARE IS REALLY 2857 01:45:48,742 --> 01:45:51,545 IMPORTANT. 2858 01:45:51,545 --> 01:45:53,480 PRIORITY, AGAIN, KEEPING 2859 01:45:53,480 --> 01:45:56,317 BIRTHING AND POSTPARTUM PEOPLE 2860 01:45:56,317 --> 01:45:57,618 SAFE. 2861 01:45:57,618 --> 01:46:00,154 IT'S GOING TO TAKE ALL LEVELS OF 2862 01:46:00,154 --> 01:46:01,822 THINGS IN THIS DIAGRAM, AN I 2863 01:46:01,822 --> 01:46:04,024 JUST PUT THIS HERE AS AN EXAMPLE 2864 01:46:04,024 --> 01:46:05,993 OF INDIVIDUAL LEVEL FACTORS, 2865 01:46:05,993 --> 01:46:07,194 HEALTHCARE PROFESSIONAL FACTORS, 2866 01:46:07,194 --> 01:46:08,362 HEALTH SYSTEM FACTORS AND 2867 01:46:08,362 --> 01:46:09,230 COMMUNITY FACTORS. 2868 01:46:09,230 --> 01:46:10,531 IT'S REALLY GOING TO TAKE A 2869 01:46:10,531 --> 01:46:14,535 VILLAGE TO MAKE AN IMPACT. 2870 01:46:14,535 --> 01:46:16,604 AND THEN THIS WAS MY SUMMARY 2871 01:46:16,604 --> 01:46:19,873 SLIDE HERE, KEY GAPS ON THE 2872 01:46:19,873 --> 01:46:20,608 LEFT. 2873 01:46:20,608 --> 01:46:22,643 SO THIS MIGHT SOUND TERRIBLE, 2874 01:46:22,643 --> 01:46:25,412 BUT OUR CURRENT STATE OF 2875 01:46:25,412 --> 01:46:27,147 KNOWLEDGE IS POOR, POUR 2876 01:46:27,147 --> 01:46:28,882 KNOWLEDGE GAP IS EXTENSIVE, AND 2877 01:46:28,882 --> 01:46:30,818 THERE IS A NEED FOR DEFINING 2878 01:46:30,818 --> 01:46:33,754 STANDARDS OF CARE MODELS TO 2879 01:46:33,754 --> 01:46:35,956 IMPROVE HYPERTENSION CARE AND 2880 01:46:35,956 --> 01:46:38,292 REDUCE MATERNAL MORBIDITY AND 2881 01:46:38,292 --> 01:46:38,559 MORTALITY. 2882 01:46:38,559 --> 01:46:42,796 MANY FEATURE OPPORTUNITIES TO 2883 01:46:42,796 --> 01:46:44,431 IDENTIFY PRIORITIES, CREATE 2884 01:46:44,431 --> 01:46:45,032 COLLABORATIVE ENVIRONMENTS AND 2885 01:46:45,032 --> 01:46:46,667 SUPPORT TRIALS TO CREATE 2886 01:46:46,667 --> 01:46:48,202 EVIDENCE TO ADVANCE HYPERTENSION 2887 01:46:48,202 --> 01:46:51,372 CARE DURING THESE REPRODUCTIVE 2888 01:46:51,372 --> 01:46:54,308 YEARS, FOCUSED ACROSS THE ENTIRE 2889 01:46:54,308 --> 01:46:56,477 RESEARCH SPECTRUM, SO TRAINEES, 2890 01:46:56,477 --> 01:46:58,345 BASIC SCIENCE, CLINICAL 2891 01:46:58,345 --> 01:46:59,713 TRANSLATIONAL TRIALS AND 2892 01:46:59,713 --> 01:47:00,781 IMPLEMENTATION TRIALS, AND THEN 2893 01:47:00,781 --> 01:47:03,851 THE IDEA OF AI, I JUST WANT TO 2894 01:47:03,851 --> 01:47:05,419 SAY, HAS LARGE POTENTIAL. 2895 01:47:05,419 --> 01:47:08,188 SO WHEN WE BROUGHT UP A.I. HERE, 2896 01:47:08,188 --> 01:47:10,457 IT'S PROBABLY TALKING MORE ABOUT 2897 01:47:10,457 --> 01:47:12,660 BP DEVICES AND THINGS, BUT IN 2898 01:47:12,660 --> 01:47:17,965 THE CONCEPT OF CARE MODELS, THE 2899 01:47:17,965 --> 01:47:19,933 ABILITY TO TELL A PATIENT YOUR 2900 01:47:19,933 --> 01:47:21,669 BP LOOKS GOOD, YOU NEED TO GO 2901 01:47:21,669 --> 01:47:24,171 IN, YOU NEED PROMPT OR EFFECTIVE 2902 01:47:24,171 --> 01:47:27,241 TREATMENT, AGAIN CALLING -- 2903 01:47:27,241 --> 01:47:28,208 POSTPARTUM PERIOD IS MUCH 2904 01:47:28,208 --> 01:47:29,576 DIFFERENT THAN CHRONIC 2905 01:47:29,576 --> 01:47:30,077 HYPERTENSION. 2906 01:47:30,077 --> 01:47:31,879 SO I'M EXCITED ABOUT ALL THIS, 2907 01:47:31,879 --> 01:47:33,547 AND THANK YOU FOR THE 2908 01:47:33,547 --> 01:47:36,050 OPPORTUNITY. 2909 01:47:36,050 --> 01:47:45,959 THAT'S ALL I HAVE. 2910 01:47:45,959 --> 01:47:47,728 >> ALL RIGHT, THANK YOU FOR 2911 01:47:47,728 --> 01:47:51,565 THAT, DR. HOPPE. 2912 01:47:51,565 --> 01:47:55,402 OUR NEXT SPEAKER IS DR. LEWIS 2913 01:47:55,402 --> 01:47:57,071 LIPSITZ, PROFESSOR OF MEDICINE 2914 01:47:57,071 --> 01:47:58,706 AT HARVARD MEDICAL SCHOOL, 2915 01:47:58,706 --> 01:48:00,240 DIRECTOR OF MARCUS INSTITUTE FOR 2916 01:48:00,240 --> 01:48:02,376 AGING RESEARCH AT HEBREW 2917 01:48:02,376 --> 01:48:04,011 SENIORLIFE AND CHIEF DIVISION OF 2918 01:48:04,011 --> 01:48:05,646 GERONTOLOGY AT BETH ISRAEL 2919 01:48:05,646 --> 01:48:08,982 DEACONESS MEDICAL CENTER AND 2920 01:48:08,982 --> 01:48:09,616 EDITOR-IN-CHIEF OF THE JOURNAL 2921 01:48:09,616 --> 01:48:12,353 OF GERONTOLOGY MEDICAL SCIENCES 2922 01:48:12,353 --> 01:48:14,321 RESEARCH, FOCUSES ON THE 2923 01:48:14,321 --> 01:48:15,923 MECHANISMS AND MANAGEMENT OF 2924 01:48:15,923 --> 01:48:17,424 COGNITIVE AND MOBILITY DISORDERS 2925 01:48:17,424 --> 01:48:18,525 AND THEIR INTERACTIONS IN OLDER 2926 01:48:18,525 --> 01:48:18,959 ADULTS. 2927 01:48:18,959 --> 01:48:20,427 HE'LL BE PRESENTING ON BLOOD 2928 01:48:20,427 --> 01:48:22,663 PRESSURE MONITORING IN OLDER 2929 01:48:22,663 --> 01:48:25,933 ADULTS, MANAGING COGNITIVE 2930 01:48:25,933 --> 01:48:27,134 DECLINE AND BP VARIABILITY. 2931 01:48:27,134 --> 01:48:28,135 >> THANK YOU VERY MUCH. 2932 01:48:28,135 --> 01:48:29,603 I APPRECIATE THE ORGANIZERS OF 2933 01:48:29,603 --> 01:48:31,238 THIS WORKSHOP INVITING ME AND 2934 01:48:31,238 --> 01:48:33,607 ASKING ME TO SPEAK ABOUT BLOOD 2935 01:48:33,607 --> 01:48:35,776 PRESSURE MONITORING IN OLDER 2936 01:48:35,776 --> 01:48:36,744 ADULTS, PARTICULARLY WITH 2937 01:48:36,744 --> 01:48:38,379 COGNITIVE DECLINE IN BLOOD 2938 01:48:38,379 --> 01:48:48,021 PRESSURE VARIABILITY. 2939 01:48:48,021 --> 01:48:49,590 SO THIS SLIDE ILLUSTRATES THE 2940 01:48:49,590 --> 01:48:52,126 PREMISE UNDERLYING MY COMMENTS 2941 01:48:52,126 --> 01:48:54,728 THIS AFTERNOON, AND REALLY THE 2942 01:48:54,728 --> 01:48:55,929 MAIN POINTS THAT I'D LIKE TO 2943 01:48:55,929 --> 01:48:56,130 MAKE. 2944 01:48:56,130 --> 01:48:57,431 I THINK EVERYONE KNOWS THAT 2945 01:48:57,431 --> 01:49:00,167 AGING IS ASSOCIATED WITH BLOOD 2946 01:49:00,167 --> 01:49:01,135 PRESSURE ELEVATION. 2947 01:49:01,135 --> 01:49:02,503 THIS IS COMMON KNOWLEDGE. 2948 01:49:02,503 --> 01:49:04,471 BUT AGING ALSO IMPAIRS BLOOD 2949 01:49:04,471 --> 01:49:07,441 PRESSURE REGULATION. 2950 01:49:07,441 --> 01:49:09,410 SO DOES BLOOD PRESSURE ELEVATION 2951 01:49:09,410 --> 01:49:10,177 IMPAIR BLOOD PRESSURE 2952 01:49:10,177 --> 01:49:11,879 REGULATION, SO THAT WHAT WE SEE 2953 01:49:11,879 --> 01:49:16,583 IN MANY OLDER ADULTS IS 2954 01:49:16,583 --> 01:49:17,651 INCREASED BLOOD PRESSURE 2955 01:49:17,651 --> 01:49:18,318 VARIABILITY, PARTICULARLY HEE 2956 01:49:18,318 --> 01:49:20,120 POTENTIAL IN RESPONSE TO MANY 2957 01:49:20,120 --> 01:49:21,422 COMMON ACTIVITIES. 2958 01:49:21,422 --> 01:49:23,490 THERE'S NOT MUCH THAT WE CAN DO 2959 01:49:23,490 --> 01:49:25,025 AT THE MOMENT ABOUT AGING OTHER 2960 01:49:25,025 --> 01:49:26,860 THAN MAINTAINING OUR HEALTH. 2961 01:49:26,860 --> 01:49:29,163 AND I THINK WE ALL WANT TO AGE. 2962 01:49:29,163 --> 01:49:31,031 BUT THERE'S A LOT WE CAN DO 2963 01:49:31,031 --> 01:49:32,332 ABOUT BLOOD PRESSURE ELEVATION, 2964 01:49:32,332 --> 01:49:34,234 AN BY ELIMINATING HYPERTENSION, 2965 01:49:34,234 --> 01:49:37,438 WE CAN IMPROVE BLOOD PRESSURE 2966 01:49:37,438 --> 01:49:38,172 REGULATION, REDUCE BLOOD 2967 01:49:38,172 --> 01:49:40,140 PRESSURE VARIABILITY, AND 2968 01:49:40,140 --> 01:49:43,677 PREVENT SOME OF THE ADVERSE 2969 01:49:43,677 --> 01:49:45,012 CONSEQUENCES THAT ARE RELATED TO 2970 01:49:45,012 --> 01:49:48,615 HYPOTENSION. 2971 01:49:48,615 --> 01:49:50,184 SO THE BOTTOM LINE HERE I WANT 2972 01:49:50,184 --> 01:49:51,318 TO GET ACROSS TO YOU IS THAT 2973 01:49:51,318 --> 01:49:53,921 AGING IS CHARACTERIZED BY AN 2974 01:49:53,921 --> 01:49:54,488 INCREASE IN BLOOD PRESSURE 2975 01:49:54,488 --> 01:49:55,989 VARIABILITY. 2976 01:49:55,989 --> 01:49:58,258 SO MANY TIMES, IT'S NOT THE 2977 01:49:58,258 --> 01:50:00,227 MEASUREMENT, PER SE, THAT IS THE 2978 01:50:00,227 --> 01:50:02,763 PROBLEM, BUT THE UNDERLYING 2979 01:50:02,763 --> 01:50:03,464 PHYSIOLOGY OF AGING. 2980 01:50:03,464 --> 01:50:07,501 SO LET'S GO TO THE NEXT SLIDE. 2981 01:50:07,501 --> 01:50:08,902 HERE IS JUST A VERY QUICK 2982 01:50:08,902 --> 01:50:10,471 SUMMARY OF THE EFFECTS OF AGING 2983 01:50:10,471 --> 01:50:14,341 ON BLOOD PRESSURE REGULATION. 2984 01:50:14,341 --> 01:50:15,309 ON THE LEFT IS THE BLOOD 2985 01:50:15,309 --> 01:50:16,310 PRESSURE EQUATION WHICH YOU ALL 2986 01:50:16,310 --> 01:50:17,711 KNOW IS THE PRODUCT OF HEART 2987 01:50:17,711 --> 01:50:19,947 RATE TIMES VASCULAR RESISTANCE 2988 01:50:19,947 --> 01:50:21,148 TIMES STROKE VOLUME. 2989 01:50:21,148 --> 01:50:24,485 BUT AGING AFFECTS EACH OF THESE 2990 01:50:24,485 --> 01:50:29,389 PARAMETERS, AGING DECREASES 2991 01:50:29,389 --> 01:50:32,359 BAROREFLEX SENSITIVITY BY 2992 01:50:32,359 --> 01:50:36,363 DECREASING HEART RATE RESPONSE 2993 01:50:36,363 --> 01:50:38,332 TO HYPOTENSION AND DECREASING 2994 01:50:38,332 --> 01:50:40,200 VASCULAR RESISTANCE RESPONSES. 2995 01:50:40,200 --> 01:50:44,404 IT ALSO INCREASES RENAL, SALT 2996 01:50:44,404 --> 01:50:48,475 AND WATER EXCRETION AND IMPAIRS 2997 01:50:48,475 --> 01:50:50,310 DIASTOLIC VENTRICULAR FILLING. 2998 01:50:50,310 --> 01:50:53,180 SO IF SOMEONE HAS HYPERTENSION 2999 01:50:53,180 --> 01:50:54,781 IN ADDITION TO AGE, THERE ARE 3000 01:50:54,781 --> 01:50:57,284 FURTHER IMPAIRMENTS IN EACH OF 3001 01:50:57,284 --> 01:50:59,019 THESE PHYSIOLOGIC MECHANISMS. 3002 01:50:59,019 --> 01:51:00,153 HIGHER BLOOD PRESSURE IS 3003 01:51:00,153 --> 01:51:01,822 REQUIRED FOR CEREBRAL PRO 3004 01:51:01,822 --> 01:51:02,055 FUSION. 3005 01:51:02,055 --> 01:51:04,992 BLOOD PRESSURE REDUCES 3006 01:51:04,992 --> 01:51:11,665 BAROREFLEX SENSITIVITY EVEN 3007 01:51:11,665 --> 01:51:12,933 ABOVE -- SO AS A RESULT OF THESE 3008 01:51:12,933 --> 01:51:14,234 PHYSIOLOGIC CHANGES, WE SEE A 3009 01:51:14,234 --> 01:51:15,469 LOT OF BLOOD PRESSURE 3010 01:51:15,469 --> 01:51:20,140 VARIABILITY IN OLDER AGE. 3011 01:51:20,140 --> 01:51:21,308 THAT'S ILLUSTRATED HERE IN THIS 3012 01:51:21,308 --> 01:51:22,609 STUDY THAT WE DID A NUMBER OF 3013 01:51:22,609 --> 01:51:25,245 YEARS AGO IN WHICH WE MEASURED 3014 01:51:25,245 --> 01:51:25,946 SYSTOLIC BLOOD PRESSURE BETWEEN 3015 01:51:25,946 --> 01:51:29,149 THE HOURS OF 7:00 A.M. AND 3016 01:51:29,149 --> 01:51:31,985 1:00 P.M. SHOWN ON THE X AXIS IN 3017 01:51:31,985 --> 01:51:33,353 RESPONSE TO A STAND DIED SERIES 3018 01:51:33,353 --> 01:51:34,888 OF ACTIVITY SHOWN ACROSS THE 3019 01:51:34,888 --> 01:51:35,222 TOP. 3020 01:51:35,222 --> 01:51:40,427 WE LOOKED AT A GROUP OF HOLDER 3021 01:51:40,427 --> 01:51:42,062 INDIVIDUALSS WHO A GROUP OF 3022 01:51:42,062 --> 01:51:43,497 YOUNGER INDIVIDUALS WHO WERE 3023 01:51:43,497 --> 01:51:45,566 HEALTHY VOLUNTEERED THAT CAME 3024 01:51:45,566 --> 01:51:48,235 INTO THE LAN AND HAD EXACTLY THE 3025 01:51:48,235 --> 01:51:49,670 SAME CIRCUMSTANCES AS THE OLDER 3026 01:51:49,670 --> 01:51:50,437 FOLKS. 3027 01:51:50,437 --> 01:51:52,506 THE FIRST THING YOU CAN SEE IS 3028 01:51:52,506 --> 01:51:54,308 THE OLDER COHORT STARTED WITH 3029 01:51:54,308 --> 01:51:55,242 MUCH HIGHER BLOOD PRESSURES 3030 01:51:55,242 --> 01:51:56,176 FIRST THING IN THE MORNING. 3031 01:51:56,176 --> 01:51:58,245 THEY WERE RELATIVELY 3032 01:51:58,245 --> 01:51:58,979 HYPERTENSIVE, PARTICULARLY 3033 01:51:58,979 --> 01:52:00,080 COMPARED TO THE YOUNG. 3034 01:52:00,080 --> 01:52:02,916 AND AS YOU CAN SEE, THEY HAVE A 3035 01:52:02,916 --> 01:52:04,184 TREMENDOUS BLOOD PRESSURE 3036 01:52:04,184 --> 01:52:05,619 VARIABILITY IN RESPONSE TO 3037 01:52:05,619 --> 01:52:06,920 COMMON DAILY ACTIVITIES. 3038 01:52:06,920 --> 01:52:09,323 AND THESE ARE FIRST -- THEY'RE 3039 01:52:09,323 --> 01:52:10,090 SUPINE IN THE MORNING WHEN THEY 3040 01:52:10,090 --> 01:52:12,492 WAKE UP FROM BED. 3041 01:52:12,492 --> 01:52:14,127 THEY THEN STAND UP TO DO THEIR 3042 01:52:14,127 --> 01:52:14,895 MORNING HYGIENE, THEY THEN SIT 3043 01:52:14,895 --> 01:52:17,364 DOWN FOR A MORNING MEAL, 3044 01:52:17,364 --> 01:52:18,665 BREAKFAST, SIT THERE FOR AN 3045 01:52:18,665 --> 01:52:20,867 HOUR, THEN STAND AND AMBULATE. 3046 01:52:20,867 --> 01:52:23,437 LATER WE GAVE THEM A 3047 01:52:23,437 --> 01:52:25,973 NITROGLYCERIN TABLET WHICH IS 3048 01:52:25,973 --> 01:52:30,877 SOMETHING MANY OF OUR OLDER 3049 01:52:30,877 --> 01:52:33,347 PATIENTS TAKE FOR HEART DISEASE, 3050 01:52:33,347 --> 01:52:35,215 THEN THEY HAD THEM STAND AND 3051 01:52:35,215 --> 01:52:36,750 AMBULATE AND LATER TAKE THEIR 3052 01:52:36,750 --> 01:52:39,152 USUAL MEDICATIONS AND EAT LUNCH. 3053 01:52:39,152 --> 01:52:41,388 NOTE THERE ARE MARKED 3054 01:52:41,388 --> 01:52:43,924 HYPOTENSIVE RESPONSES TO 3055 01:52:43,924 --> 01:52:44,891 STANDING FIRST THING IN THE 3056 01:52:44,891 --> 01:52:48,195 MORNING, AFTER BREAKFAST, AFTER 3057 01:52:48,195 --> 01:52:50,330 STANDING AGAIN AFTER 3058 01:52:50,330 --> 01:52:51,298 NITROGLYCERIN, AFTER MEDICATIONS 3059 01:52:51,298 --> 01:52:52,933 AND LUNCH. 3060 01:52:52,933 --> 01:52:54,901 THE YOUNG CERTAINLY HAVE SOME 3061 01:52:54,901 --> 01:53:00,173 BLOOD PRESSURE VARIABILITY BUT 3062 01:53:00,173 --> 01:53:05,278 NO, EATING BREAKFAST, STANDING 3063 01:53:05,278 --> 01:53:10,617 UP, TAKING EXTRA -- AND ALL 3064 01:53:10,617 --> 01:53:12,653 REDUCE PRELOAD RETURN, VENOUS 3065 01:53:12,653 --> 01:53:13,520 RETURN TO THE HEART, SO WHAT 3066 01:53:13,520 --> 01:53:15,822 WOULD A NORMAL PERSON DO TO 3067 01:53:15,822 --> 01:53:19,293 COMPENSATE FOR THAT? 3068 01:53:19,293 --> 01:53:20,794 THIS IS A VERY SIMILAR SETUP 3069 01:53:20,794 --> 01:53:23,864 WITH TIME ON THE X AXIS HERE, 3070 01:53:23,864 --> 01:53:25,766 SIMILAR ACTIVITIES, BUT NOW 3071 01:53:25,766 --> 01:53:27,434 WE'RE LOOKING AT THE HEART RATE 3072 01:53:27,434 --> 01:53:30,871 IN RESPONSE TO THESE ABILITIES, 3073 01:53:30,871 --> 01:53:32,472 INCREASING THEIR HEART RATE IN 3074 01:53:32,472 --> 01:53:37,778 RESPONSE TO STANDING, WHILE THE 3075 01:53:37,778 --> 01:53:39,212 OLD INDIVIDUALS HAVE A BLUNTED 3076 01:53:39,212 --> 01:53:42,049 RESPONSE. 3077 01:53:42,049 --> 01:53:43,316 AND LARGELY BECAUSE OF THIS 3078 01:53:43,316 --> 01:53:44,785 IMPAIRED HEART RATE RESPONSE, 3079 01:53:44,785 --> 01:53:47,854 IMPAIRED BAROREFLEX SENSITIVITY, 3080 01:53:47,854 --> 01:53:50,390 THE OLDER PATIENTS HAVE A 3081 01:53:50,390 --> 01:53:50,924 DRAMATIC BLOOD PRESSURE 3082 01:53:50,924 --> 01:53:52,025 VARIABILITY. 3083 01:53:52,025 --> 01:53:54,528 SO AGING IS ASSOCIATED NOT JUST 3084 01:53:54,528 --> 01:53:57,764 WITH HYPERTENSION AND 3085 01:53:57,764 --> 01:54:01,368 HYPOTENSION BUT AN INCREASING 3086 01:54:01,368 --> 01:54:01,668 VARIABILITY. 3087 01:54:01,668 --> 01:54:02,969 SO WHAT ARE THE CONSEQUENCES OF 3088 01:54:02,969 --> 01:54:04,404 THIS? 3089 01:54:04,404 --> 01:54:05,806 WELL, FIRST OF ALL, LET ME JUST 3090 01:54:05,806 --> 01:54:08,141 POINT OUT THIS PARADOX THAT THE 3091 01:54:08,141 --> 01:54:09,943 HIGHER THE BLOOD PRESSURE, THE 3092 01:54:09,943 --> 01:54:11,478 FARTHER IT FALLS, AND STEPHEN 3093 01:54:11,478 --> 01:54:14,114 RELATED TO THIS EARLIER, AND 3094 01:54:14,114 --> 01:54:16,216 THIS JUST SHOWS THIS DIASTOLIC 3095 01:54:16,216 --> 01:54:17,884 BLOOD PRESSURE CHANGE AFTER A 3096 01:54:17,884 --> 01:54:20,954 MEAL IN 60 MINUTES AS A FUNCTION 3097 01:54:20,954 --> 01:54:22,289 OF THE BASAL SYSTOLIC BLOOD 3098 01:54:22,289 --> 01:54:23,690 PRESSURE AT OTHER TIMES, AND YOU 3099 01:54:23,690 --> 01:54:26,593 CAN SEE THAT THERE IS A LINEAR 3100 01:54:26,593 --> 01:54:28,095 RELATIONSHIP SUCH THAT THOSE 3101 01:54:28,095 --> 01:54:29,663 WERE HIGHER BLOOD PRESSURES HAVE 3102 01:54:29,663 --> 01:54:31,531 THE GREATER DECLINES IN BLOOD 3103 01:54:31,531 --> 01:54:32,232 PRESSURE AFTER EATING. 3104 01:54:32,232 --> 01:54:34,701 AND THIS IS ALSO TRUE AFTER 3105 01:54:34,701 --> 01:54:41,308 STANDING UP. 3106 01:54:41,308 --> 01:54:42,175 SO ONE OF THE CONSEQUENCES IS 3107 01:54:42,175 --> 01:54:44,044 THAT THE BRAIN MAY NOT GET 3108 01:54:44,044 --> 01:54:45,879 ENOUGH CEREBRAL BLOOD FLOW TO 3109 01:54:45,879 --> 01:54:48,381 NOURISH NEURONS DURING THESE 3110 01:54:48,381 --> 01:54:48,849 HYPOTENSIVE EPISODES. 3111 01:54:48,849 --> 01:54:50,684 AND THIS HAS NOW BEEN FAIRLY 3112 01:54:50,684 --> 01:54:54,054 WELL DEMONSTRATED, PARTICULARLY 3113 01:54:54,054 --> 01:54:55,489 IN WATERSHED AREAS OF THE BRAIN, 3114 01:54:55,489 --> 01:54:57,090 AND THOSE ARE AREAS SURROUNDING 3115 01:54:57,090 --> 01:54:59,693 THE VENTRICLES WHERE THESE VERY 3116 01:54:59,693 --> 01:55:01,661 SMALL PERFORATOR VESSELS BECOME 3117 01:55:01,661 --> 01:55:03,497 SMALLER AND SMALLER AND SMALLER, 3118 01:55:03,497 --> 01:55:04,931 AND HERE THEY OFTEN BREAK DOWN 3119 01:55:04,931 --> 01:55:06,666 OR DIE OUT IF THERE IS NOT 3120 01:55:06,666 --> 01:55:08,702 ENOUGH PERFUSION OF THOSE AREAS. 3121 01:55:08,702 --> 01:55:11,538 AND THIS IS SHOWN ON CT SCANS 3122 01:55:11,538 --> 01:55:13,974 AND MRI SCANS OF THE BRAIN AS 3123 01:55:13,974 --> 01:55:16,176 WHITE MATTER HYPERINTENSITIES 3124 01:55:16,176 --> 01:55:17,077 SURROUNDING THE VENTRICLES. 3125 01:55:17,077 --> 01:55:19,246 AND HERE IT IS IN WHITE AND HERE 3126 01:55:19,246 --> 01:55:22,883 IT IS HIGHLIGHTED IN RED. 3127 01:55:22,883 --> 01:55:25,485 THESE WHITE MATTER 3128 01:55:25,485 --> 01:55:26,353 HYPERINTENSITIES ARE VERY 3129 01:55:26,353 --> 01:55:27,654 IMPORTANT CAUSES OF MOBILITY 3130 01:55:27,654 --> 01:55:28,655 IMPAIRMENTS AND COGNITIVE 3131 01:55:28,655 --> 01:55:34,694 IMPAIRMENTS. 3132 01:55:34,694 --> 01:55:35,295 ANOTHER EFFECT OF HYPERTENSION 3133 01:55:35,295 --> 01:55:37,364 IS IMPAIRMENTS IN CEREBRAL AUTO 3134 01:55:37,364 --> 01:55:37,664 REGULATION. 3135 01:55:37,664 --> 01:55:40,801 SO IF WE'RE GOING TO HAVE 3136 01:55:40,801 --> 01:55:41,401 HYPOTENSIVE EVENTS, WE MAY NOT 3137 01:55:41,401 --> 01:55:45,639 BE ABLE TO AUTO DIAGNOSEREGULATR 3138 01:55:45,639 --> 01:55:48,241 BLOOD FLOW TO THE BRAIN 3139 01:55:48,241 --> 01:55:48,775 PROPERLY. 3140 01:55:48,775 --> 01:55:51,111 THIS IS A CLASSIC AUTOREGULATION 3141 01:55:51,111 --> 01:55:52,813 CURVE WHICH SHOWS DIFFERENT 3142 01:55:52,813 --> 01:55:54,047 CEREBRAL PRO FUSION PRESSURES ON 3143 01:55:54,047 --> 01:55:55,515 THE X AXIS, THAT IS BLOOD 3144 01:55:55,515 --> 01:55:56,716 PRESSURE, AND CEREBRAL BLOOD 3145 01:55:56,716 --> 01:55:57,918 FLOW ON THE Y AXIS. 3146 01:55:57,918 --> 01:55:59,853 THE SOLID LINE IS THE NORMAL 3147 01:55:59,853 --> 01:56:02,355 CURVE AND YOU CAN SEE THAT 3148 01:56:02,355 --> 01:56:04,658 THERE'S A PERIOD IN WHICH THERE 3149 01:56:04,658 --> 01:56:10,430 IS NO DMAING CERE CHANGE IN CERD 3150 01:56:10,430 --> 01:56:12,199 FLOW OR CHANGES IN CEREBRAL 3151 01:56:12,199 --> 01:56:13,500 BLOOD PRESSURE UNTIL YOU GET TO 3152 01:56:13,500 --> 01:56:14,534 MUCH HIGHER VALUES OF BLOOD 3153 01:56:14,534 --> 01:56:17,838 PRESSURE OR MUCH LOWER VALUES 3154 01:56:17,838 --> 01:56:20,140 WHEN CEREBRAL BLOOD FLOW FALLS 3155 01:56:20,140 --> 01:56:20,574 OFF. 3156 01:56:20,574 --> 01:56:22,476 SO IF ONE WERE TO GO FROM SUPINE 3157 01:56:22,476 --> 01:56:24,010 TO A STANDING POSITION DURING 3158 01:56:24,010 --> 01:56:25,312 THIS PLATEAU OF THE 3159 01:56:25,312 --> 01:56:26,079 AUTOREGULATION CURVE, YOU 3160 01:56:26,079 --> 01:56:27,480 WOULDN'T SEE MUCH OF A CHANGE IN 3161 01:56:27,480 --> 01:56:28,815 CEREBRAL BLOOD FLOW AND, 3162 01:56:28,815 --> 01:56:31,418 THEREFORE, NO IMPACT ON 3163 01:56:31,418 --> 01:56:33,453 COGNITION OR WHITE MATTER. 3164 01:56:33,453 --> 01:56:34,554 HOWEVER, HYPERTENSION SHIFTS 3165 01:56:34,554 --> 01:56:38,158 THIS CURVE TO THE RIGHT. 3166 01:56:38,158 --> 01:56:40,360 SO NOW IF YOU GO FROM SUE BIEN 3167 01:56:40,360 --> 01:56:42,963 BLOOD PRSUPINEBLOOD PRESSURE TOR 3168 01:56:42,963 --> 01:56:44,698 STANDING BLOOD PRESSURE, YOU 3169 01:56:44,698 --> 01:56:50,670 MIGHT FALL BELOW THIS CURVE, 3170 01:56:50,670 --> 01:56:51,238 THEREBY THREATENING CEREBRAL 3171 01:56:51,238 --> 01:56:52,105 BLOOD FLOW. 3172 01:56:52,105 --> 01:56:53,406 THE GOOD NEWS IS THAT THE 3173 01:56:53,406 --> 01:56:54,741 TREATMENT OF HYPERTENSION CAN 3174 01:56:54,741 --> 01:56:56,643 RESTORE THIS AUTOREGULATION 3175 01:56:56,643 --> 01:56:57,978 CURVE BACK TOWARD NORMAL. 3176 01:56:57,978 --> 01:57:02,349 AGAIN, PRESERVING THE BRAIN, 3177 01:57:02,349 --> 01:57:03,183 BLOOD FLOW AND COGNITIVE 3178 01:57:03,183 --> 01:57:10,657 FUNCTION. 3179 01:57:10,657 --> 01:57:11,858 WE'VE ALSO SHOWN YEARS AGO THAT 3180 01:57:11,858 --> 01:57:13,693 WE CAN IMPROVE CEREBRAL BLOOD 3181 01:57:13,693 --> 01:57:15,896 FLOW BY THE TREATMENT OF 3182 01:57:15,896 --> 01:57:16,396 HYPERTENSION. 3183 01:57:16,396 --> 01:57:17,464 HERE WE TOOK A GROUP OF PATIENTS 3184 01:57:17,464 --> 01:57:19,833 WHO WERE INITIALLY HYPERTENSIVE 3185 01:57:19,833 --> 01:57:21,434 WITH SYSTOLIC PRESSURES ABOVE 3186 01:57:21,434 --> 01:57:23,703 160 AND WE MEASURED CEREBRAL 3187 01:57:23,703 --> 01:57:25,372 BLOOD FLOW WITH A DOPPLER 3188 01:57:25,372 --> 01:57:27,340 TECHNIQUE AND YOU CAN SEE IN THE 3189 01:57:27,340 --> 01:57:29,042 SOLID LINE THAT IT DROPS A BIT 3190 01:57:29,042 --> 01:57:29,809 WHEN PEOPLE STAND UP. 3191 01:57:29,809 --> 01:57:30,677 WE THEN TREATED THESE PEOPLE 3192 01:57:30,677 --> 01:57:32,646 WITH AN ACE INHIBITOR REGIMEN 3193 01:57:32,646 --> 01:57:34,381 FOR SIX MONTHS, AND WE THOUGHT 3194 01:57:34,381 --> 01:57:37,450 THAT, MY GOSH, THIS 3195 01:57:37,450 --> 01:57:38,618 ANTIHYPERTENSIVE MAY REDUCE 3196 01:57:38,618 --> 01:57:39,786 CEREBRAL BLOOD FLOW, BUT, IN 3197 01:57:39,786 --> 01:57:42,889 FACT THE OPPOSITE OCCURRED, IT 3198 01:57:42,889 --> 01:57:43,757 INCREASED CEREBRAL BLOOD FLOW. 3199 01:57:43,757 --> 01:57:45,392 SO THE TREATMENT OF HYPERTENSION 3200 01:57:45,392 --> 01:57:47,127 IN OLDER ADULTS, THESE ARE 3201 01:57:47,127 --> 01:57:52,799 PEOPLE OVER AGE 75, ACTUALLY 3202 01:57:52,799 --> 01:57:57,370 IMPROVED CEREBRAL BLOOD FLOW. 3203 01:57:57,370 --> 01:57:58,571 THERE ARE NOW SEVERAL STUDIES 3204 01:57:58,571 --> 01:58:01,741 THAT SHOW THAT ANTIHYPERTENSIVE 3205 01:58:01,741 --> 01:58:03,043 TREATMENT MAY ACTUALLY REDUCE 3206 01:58:03,043 --> 01:58:06,413 THE RISK OF DEMENTIA. 3207 01:58:06,413 --> 01:58:07,948 KEEP IN MIND THAT THESE STUDIES 3208 01:58:07,948 --> 01:58:10,016 WERE DONE WITH A NUMBER OF 3209 01:58:10,016 --> 01:58:11,751 DIFFERENT TECHNIQUES OF 3210 01:58:11,751 --> 01:58:12,953 MEASURING BLOOD PRESSURE, YET IN 3211 01:58:12,953 --> 01:58:14,387 AGGREGATE, THEY ALL HAVE SIMILAR 3212 01:58:14,387 --> 01:58:16,656 RESULTS THAT THE TREATMENT OF 3213 01:58:16,656 --> 01:58:18,224 HYPERTENSION MIGHT ACTUALLY 3214 01:58:18,224 --> 01:58:20,260 REDUCE THE RISK OF DEMENTIA. 3215 01:58:20,260 --> 01:58:22,128 THIS IS JUST ONE OF THOSE 3216 01:58:22,128 --> 01:58:24,164 STUDIES CALLED THE COSMIC STUDY, 3217 01:58:24,164 --> 01:58:25,966 IT'S A META-ANALYSIS OF 17 3218 01:58:25,966 --> 01:58:27,334 STUDIES FROM 15 DIFFERENT 3219 01:58:27,334 --> 01:58:29,936 COUNTRIES REPRESENTING OVER 3220 01:58:29,936 --> 01:58:31,237 34,000 COMMUNITY DWELLING OLDER 3221 01:58:31,237 --> 01:58:33,974 ACULTS OF MEAN AGE 72.5, AND 3222 01:58:33,974 --> 01:58:36,343 THEY WERE STUDIED FOR FOLLOW-UP 3223 01:58:36,343 --> 01:58:37,777 OF ABOUT 4.3 YEARS. 3224 01:58:37,777 --> 01:58:39,212 AND I'LL JUST POINT OUT HERE 3225 01:58:39,212 --> 01:58:42,816 THAT THOSE WITH TREATED 3226 01:58:42,816 --> 01:58:45,719 HYPERTENSION HAD NO DIFFERENCE 3227 01:58:45,719 --> 01:58:48,788 THAN THOSE WHO WERE HEALTHY 3228 01:58:48,788 --> 01:58:51,858 CONTROLS IN THE RISK OF ALL 3229 01:58:51,858 --> 01:58:52,826 CAUSE DEMENTIA. 3230 01:58:52,826 --> 01:58:55,061 IN A FULLY ADJUSTED ANALYSIS, 3231 01:58:55,061 --> 01:58:55,996 THERE WAS NO SIGNIFICANT 3232 01:58:55,996 --> 01:58:57,397 DIFFERENCE BETWEEN TREATED 3233 01:58:57,397 --> 01:58:58,164 HYPERTENSIVES AND HEALTHY 3234 01:58:58,164 --> 01:58:59,032 CONTROLS. 3235 01:58:59,032 --> 01:59:02,402 YET UNTREATED HYPERTENSIVES 3236 01:59:02,402 --> 01:59:04,804 COMPARED TO HEALTHY CONTROLS OR 3237 01:59:04,804 --> 01:59:06,339 THOSE WERE TREATED HYPERTENSION 3238 01:59:06,339 --> 01:59:11,011 HAD A INCREASE IN THEIR RISK OF 3239 01:59:11,011 --> 01:59:12,879 DEMENTIA. 3240 01:59:12,879 --> 01:59:13,980 SO THIS JUST ILLUSTRATES THAT 3241 01:59:13,980 --> 01:59:15,615 THE TREATMENT OF HYPERTENSION, 3242 01:59:15,615 --> 01:59:17,217 REGARDLESS OF HOW THAT'S DEFINED 3243 01:59:17,217 --> 01:59:18,885 OR MEASURED, MIGHT ACTUALLY 3244 01:59:18,885 --> 01:59:20,820 IMPROVE COGNITION AND PREVENT 3245 01:59:20,820 --> 01:59:25,091 DEMENTIA. 3246 01:59:25,091 --> 01:59:26,826 THE SPRINT-MIND STUDY HAD 3247 01:59:26,826 --> 01:59:27,227 SIMILAR RESULTS. 3248 01:59:27,227 --> 01:59:31,731 THIS WAS REFERRED TO EARLIER, 3249 01:59:31,731 --> 01:59:33,600 AND HERE A SYSTOLIC BLOOD 3250 01:59:33,600 --> 01:59:37,170 PRESSURE REDUCTION TO 120 3251 01:59:37,170 --> 01:59:38,171 REPRESENTING INTENSIVE TREATMENT 3252 01:59:38,171 --> 01:59:39,606 VERSUS STANDARD TREATMENT TO 140 3253 01:59:39,606 --> 01:59:41,508 OR BELOW REDUCE THE INCIDENCE OF 3254 01:59:41,508 --> 01:59:43,143 MILD COGNITIVE IMPAIRMENT BY 3255 01:59:43,143 --> 01:59:45,445 19%. 3256 01:59:45,445 --> 01:59:47,213 IT DID NOT SIGNIFICANTLY REDUCE 3257 01:59:47,213 --> 01:59:49,082 DEMENTIA, BUT THE COMBINED END 3258 01:59:49,082 --> 01:59:50,450 POINT OF MILD COGNITIVE 3259 01:59:50,450 --> 01:59:51,985 IMPAIRMENT AND DEMENTIA WAS 3260 01:59:51,985 --> 01:59:56,589 SIGNIFICANTLY REDUCED BY 15%. 3261 01:59:56,589 --> 01:59:58,091 SO THE TREATMENT OF BLOOD 3262 01:59:58,091 --> 01:59:59,426 PRESSURE DID NOT HARM COGNITION 3263 01:59:59,426 --> 02:00:00,593 AND GENERALLY WHAT'S GOOD FOR 3264 02:00:00,593 --> 02:00:08,234 THE HEART IS GOOD FOR THE BRAIN. 3265 02:00:08,234 --> 02:00:09,836 HERE IS A LARGE META-ANALYSIS OF 3266 02:00:09,836 --> 02:00:11,471 THE VARIOUS ANTIHYPERTENSIVE 3267 02:00:11,471 --> 02:00:12,839 TRIALS FOR THEIR EFFECT ON 3268 02:00:12,839 --> 02:00:14,107 DEMENTIA DEFINED IN A NUMBER OF 3269 02:00:14,107 --> 02:00:15,875 DIFFERENT WAYS THROUGH SPECIFIC 3270 02:00:15,875 --> 02:00:19,679 CRITERIA OR CLINICAL DIAGNOSES 3271 02:00:19,679 --> 02:00:21,614 OR DEMENTIA WITH MILD COGNITIVE 3272 02:00:21,614 --> 02:00:21,981 IMPAIRMENT. 3273 02:00:21,981 --> 02:00:26,019 AND IN AGGREGATE, THE ODDS RATIO 3274 02:00:26,019 --> 02:00:28,855 WAS .93, WHICH SHOWED ABOUT A 7% 3275 02:00:28,855 --> 02:00:30,824 REDUCTION IN THE RISK OF 3276 02:00:30,824 --> 02:00:31,591 DEMENTIA. 3277 02:00:31,591 --> 02:00:38,698 SMALL, BUT SIGNIFICANT. 3278 02:00:38,698 --> 02:00:41,067 NOT ONLY DOES THE INTENSIVE 3279 02:00:41,067 --> 02:00:43,703 TREATMENT OF HYPERTENSION REDUCE 3280 02:00:43,703 --> 02:00:46,639 THE RISK OF DEMENTIA IN OLDER 3281 02:00:46,639 --> 02:00:48,141 ADULTS BUT IT ALSO REDUCES THE 3282 02:00:48,141 --> 02:00:50,777 PROGRESSION OF WHITE MATTER 3283 02:00:50,777 --> 02:00:51,611 HYPERINTENSITIES, SUGGESTING 3284 02:00:51,611 --> 02:00:52,612 THAT IN FACT IT MAY HAVE AN 3285 02:00:52,612 --> 02:00:56,316 IMPORTANT IMPACT ON CEREBRAL 3286 02:00:56,316 --> 02:00:57,183 BLOOD FLOW. 3287 02:00:57,183 --> 02:00:59,152 HERE YOU CAN SEE AT 18 MONTHS OR 3288 02:00:59,152 --> 02:01:01,855 36 MONTHS SHOWN ON THE X AXIS, 3289 02:01:01,855 --> 02:01:03,923 THE INTENSIVE TREATMENT SHOWN IN 3290 02:01:03,923 --> 02:01:07,093 RED REDUCES THE CHANGE IN WHITE 3291 02:01:07,093 --> 02:01:08,928 MATTER HYPERINTENSITIES AT BOTH 3292 02:01:08,928 --> 02:01:10,363 TIME POINTS COMPARED TO STANDARD 3293 02:01:10,363 --> 02:01:18,138 TREATMENT. 3294 02:01:18,138 --> 02:01:19,539 SO THE KEY POINTS I'D LIKE TO 3295 02:01:19,539 --> 02:01:22,609 MAKE IS THAT OLDER ADULTS, 3296 02:01:22,609 --> 02:01:24,110 ESPECIALLY THOSE WITH 3297 02:01:24,110 --> 02:01:25,578 HYPERTENSION, HAVE INCREASED 3298 02:01:25,578 --> 02:01:27,614 BLOOD PRESSURE VARIABILITY THAT 3299 02:01:27,614 --> 02:01:29,816 PLACES THEM AT RISK OF 3300 02:01:29,816 --> 02:01:31,117 HYPOTENSION DURING COMMON DAILY 3301 02:01:31,117 --> 02:01:31,651 ACTIVITIES. 3302 02:01:31,651 --> 02:01:32,852 REMEMBER THE HIGHER YOU ARE, THE 3303 02:01:32,852 --> 02:01:35,488 FARTHER YOU FALL. 3304 02:01:35,488 --> 02:01:36,789 THIS, OF COURSE, CREATES ALL 3305 02:01:36,789 --> 02:01:39,325 KINDS OF ISSUES ABOUT WHAT THE 3306 02:01:39,325 --> 02:01:41,127 THRESHOLD FOR HYPERTENSION WOULD 3307 02:01:41,127 --> 02:01:42,996 BE, WHAT THE THRESHOLD FOR 3308 02:01:42,996 --> 02:01:45,431 HYPOTENSION WOULD BE, BUT IN 3309 02:01:45,431 --> 02:01:47,033 GENERAL, HYPERTENSIVE 3310 02:01:47,033 --> 02:01:48,868 INDIVIDUALS, REGARDLESS OF HOW 3311 02:01:48,868 --> 02:01:52,172 IT'S DEFINED, ARE AT RISK OF 3312 02:01:52,172 --> 02:01:53,239 HYPOTENSIVE EVENTS THROUGHOUT 3313 02:01:53,239 --> 02:01:56,342 THE DAY. 3314 02:01:56,342 --> 02:01:58,578 ORTHOSTATIC AND POST PRANDIAL 3315 02:01:58,578 --> 02:01:59,279 HYPOTENSION ARE PARTICULARLY 3316 02:01:59,279 --> 02:02:00,680 COMMON IN OLDER PEOPLE AND 3317 02:02:00,680 --> 02:02:02,081 THEY'RE OFTEN OVERLOOKED IN THE 3318 02:02:02,081 --> 02:02:02,749 CLINICAL PRACTICE. 3319 02:02:02,749 --> 02:02:04,450 REMEMBER THEY THREATEN CEREBRAL 3320 02:02:04,450 --> 02:02:06,986 PERFUSION AND MAY RESULT IN 3321 02:02:06,986 --> 02:02:08,188 CEREBRAL MICROVASCULAR DISEASE 3322 02:02:08,188 --> 02:02:09,722 AND COGNITIVE IMPAIRMENT. 3323 02:02:09,722 --> 02:02:11,324 THE TREATMENT OF HYPERTENSION 3324 02:02:11,324 --> 02:02:14,294 MAY IMPROVE BLOOD PRESSURE 3325 02:02:14,294 --> 02:02:15,261 REGULATORY MECHANISMS AND 3326 02:02:15,261 --> 02:02:18,231 PREVENT HYPOTENSION AND ITS 3327 02:02:18,231 --> 02:02:19,499 CONSEQUENCES, AND, THEREFORE, 3328 02:02:19,499 --> 02:02:21,067 BLOOD PRESSURE MONITORING DURING 3329 02:02:21,067 --> 02:02:26,105 ACTIVITIES OF DAILY LIVING, 3330 02:02:26,105 --> 02:02:28,174 WHETHER IT BE BY HOME BASED 3331 02:02:28,174 --> 02:02:30,476 METHOD USING A DIARY OR 3332 02:02:30,476 --> 02:02:31,878 AMBULATORY MEASUREMENTS SHOULD 3333 02:02:31,878 --> 02:02:35,148 BE DONE IN ALL OF OUR OLDER 3334 02:02:35,148 --> 02:02:36,449 PATIENTS, ESPECIALLY AFTER 3335 02:02:36,449 --> 02:02:37,650 MEALS, POSTURE CHANGE AND 3336 02:02:37,650 --> 02:02:39,619 MEDICATION ADMINISTRATION. 3337 02:02:39,619 --> 02:02:41,588 AND THIS CAN HELP DETECT THE 3338 02:02:41,588 --> 02:02:45,191 CIRCUMSTANCES, TIMING AND DEGREE 3339 02:02:45,191 --> 02:02:47,627 OF VARIABILITY OF BLOOD PRESSURE 3340 02:02:47,627 --> 02:02:48,895 AND ITS RESPONSE TO TREATMENT. 3341 02:02:48,895 --> 02:02:50,296 NOW MANY OF THE MONITORING 3342 02:02:50,296 --> 02:02:52,498 DEVICES WE USE, PARTICULARLY 3343 02:02:52,498 --> 02:02:55,134 AMBULATORY MONITORING, ARE NOT 3344 02:02:55,134 --> 02:03:00,807 SPECIFIC ENOUGH TO LOOK AT THE 3345 02:03:00,807 --> 02:03:02,108 POSTURAL CHANGE RESPONSE OR 3346 02:03:02,108 --> 02:03:03,009 MEDICATION ADMINISTRATION, SO 3347 02:03:03,009 --> 02:03:04,310 IT'S VERY IMPORTANT THAT WE'RE 3348 02:03:04,310 --> 02:03:06,446 ABLE TO LOOK IN RESPONSE TO 3349 02:03:06,446 --> 02:03:08,314 THESE PARTICULAR ACTIVITIES. 3350 02:03:08,314 --> 02:03:11,818 AND AVERAGING MEASURES OVER TIME 3351 02:03:11,818 --> 02:03:14,887 ALSO DOES NOT ENABLE YOU TO PICK 3352 02:03:14,887 --> 02:03:16,623 OUT THE CHANGES THAT OCCUR 3353 02:03:16,623 --> 02:03:18,358 DURING THESE COMMON ACTIVITIES. 3354 02:03:18,358 --> 02:03:19,559 SO I THINK IT'S VERY IMPORTANT 3355 02:03:19,559 --> 02:03:25,865 TO KEEP THIS IN MIND. 3356 02:03:25,865 --> 02:03:27,533 SO THE KEY KNOWLEDGE GAPS ARE 3357 02:03:27,533 --> 02:03:28,735 SHOWN IN THE LEFT COLUMN HERE 3358 02:03:28,735 --> 02:03:31,070 AND OUR FUTURE OPPORTUNITIES, 3359 02:03:31,070 --> 02:03:32,772 SOME OF THE FUTURE OPPORTUNITIES 3360 02:03:32,772 --> 02:03:34,307 WE HAVE ON THE RIGHT. 3361 02:03:34,307 --> 02:03:36,876 THE FIRST GAP IS HOW TO MEASURE 3362 02:03:36,876 --> 02:03:39,012 BLOOD PRESSURE CONTINUOUSLY IN 3363 02:03:39,012 --> 02:03:42,382 RESPONSE TO SPECIFIC DAILY 3364 02:03:42,382 --> 02:03:43,483 ACTIVITIES. 3365 02:03:43,483 --> 02:03:44,784 AND THEN AT WHAT STAGE OF 3366 02:03:44,784 --> 02:03:46,085 COGNITIVE IMPAIRMENT OR FRAILTY 3367 02:03:46,085 --> 02:03:46,919 DOES BLOOD PRESSURE TREATMENT 3368 02:03:46,919 --> 02:03:50,923 SLOW OR IMPROVE COGNITIVE 3369 02:03:50,923 --> 02:03:51,424 DECLINE? 3370 02:03:51,424 --> 02:03:52,525 PROBABLY THE TREATMENT OF 3371 02:03:52,525 --> 02:03:54,060 HYPERTENSION IN PEOPLE ALREADY 3372 02:03:54,060 --> 02:03:55,762 IMPAIRED WITH ADVANCED DEMENTIA 3373 02:03:55,762 --> 02:03:59,399 IS NOT GOING TO IMPROVE THEIR 3374 02:03:59,399 --> 02:04:02,902 COGNITION OR CEREBRAL BLOOD FLOW 3375 02:04:02,902 --> 02:04:05,505 OR MICROVASCULAR DISEASE, BUT 3376 02:04:05,505 --> 02:04:08,675 CERTAINLY EARLY STAGE DEMENTIA 3377 02:04:08,675 --> 02:04:10,643 OR PREDEMENTIA PERIODS ARE KEY 3378 02:04:10,643 --> 02:04:12,278 TREATMENT OPPORTUNITIES. 3379 02:04:12,278 --> 02:04:14,347 AND WE DON'T KNOW WHY 3380 02:04:14,347 --> 02:04:15,114 ANTIHYPERTENSIVE MEDICATIONS CAN 3381 02:04:15,114 --> 02:04:16,649 IMPROVE BLOOD PRESSURE 3382 02:04:16,649 --> 02:04:18,084 REGULATION, PREVENT HYPOTENSION 3383 02:04:18,084 --> 02:04:19,185 AND PRESERVE CEREBRAL BLOOD 3384 02:04:19,185 --> 02:04:23,523 FLOW. 3385 02:04:23,523 --> 02:04:25,058 SO THERE ARE MANY FUTURE 3386 02:04:25,058 --> 02:04:25,758 OPPORTUNITIES WHICH WE WILL BE 3387 02:04:25,758 --> 02:04:26,693 DISCUSSING DURING THIS WORKSHOP. 3388 02:04:26,693 --> 02:04:29,829 WE NEED TO DEVELOP RELIABLE, 3389 02:04:29,829 --> 02:04:30,897 CONTINUOUS A AMBULATORY BLOOD 3390 02:04:30,897 --> 02:04:32,031 PRESSURE MONITORS THAT HAVE THE 3391 02:04:32,031 --> 02:04:33,900 ABILITY TO PROMPT PATIENTS FOR 3392 02:04:33,900 --> 02:04:36,302 SYMPTOMS AND TIME MEASUREMENTS 3393 02:04:36,302 --> 02:04:37,470 AT SPECIFIC TIMES WE'RE 3394 02:04:37,470 --> 02:04:37,804 INTERESTED IN. 3395 02:04:37,804 --> 02:04:39,472 I USUALLY GIVE MY PATIENTS A 3396 02:04:39,472 --> 02:04:41,307 DIARY TO TAKE HOME AFTER 3397 02:04:41,307 --> 02:04:43,176 INSTRUCTING THEM ON BLOOD 3398 02:04:43,176 --> 02:04:44,644 PRESSURE MEASUREMENT TECHNIQUE 3399 02:04:44,644 --> 02:04:45,912 AND ASK THEM TO FILL OUT THAT 3400 02:04:45,912 --> 02:04:48,214 DIARY AT SPECIFIC TIMES OF DAY 3401 02:04:48,214 --> 02:04:50,717 AND IN RESPONSE TO SPECIFIC 3402 02:04:50,717 --> 02:04:51,017 ACTIVITIES. 3403 02:04:51,017 --> 02:04:52,418 WE ALSO NEED TO TEST THE EFFECT 3404 02:04:52,418 --> 02:04:54,087 OF DIFFERENT MEDICATIONS ON 3405 02:04:54,087 --> 02:04:55,521 CEREBRAL BLOOD FLOW, AS WELL AS 3406 02:04:55,521 --> 02:04:58,024 BRAIN STRUCTURE AND FUNCTION. 3407 02:04:58,024 --> 02:04:59,559 AND ULTIMATELY CONDUCT 3408 02:04:59,559 --> 02:05:01,094 RANDOMIZED CONTROL TRIALS OF 3409 02:05:01,094 --> 02:05:03,496 BLOOD PRESSURE MANAGEMENT ON 3410 02:05:03,496 --> 02:05:04,564 PATIENTS WITH AND WITHOUT 3411 02:05:04,564 --> 02:05:08,601 DIFFERENT STAIMT STAGES OF COGNE 3412 02:05:08,601 --> 02:05:10,136 IMPAIRMENT USING BROMOPROPANE 3413 02:05:10,136 --> 02:05:11,204 VARIABILITY, CEREBRAL BLOOD 3414 02:05:11,204 --> 02:05:12,872 FLOW, MR IMAGING AND BIOMARKERS 3415 02:05:12,872 --> 02:05:13,740 AS OUTCOMES. 3416 02:05:13,740 --> 02:05:14,941 SO THANK YOU VERY MUCH FOR YOUR 3417 02:05:14,941 --> 02:05:15,308 ATTENTION. 3418 02:05:15,308 --> 02:05:21,614 I WILL STOP THERE. 3419 02:05:21,614 --> 02:05:24,984 >> THANK YOU FOR THAT WONDERFUL 3420 02:05:24,984 --> 02:05:25,985 PRESENTATION AND THANKS TO THE 3421 02:05:25,985 --> 02:05:28,388 WHOLE PANEL FOR THREE GREAT 3422 02:05:28,388 --> 02:05:31,090 TALKS. 3423 02:05:31,090 --> 02:05:32,091 WE HAVE ABOUT 15 MINUTES HERE 3424 02:05:32,091 --> 02:05:36,229 FOR QUESTIONS. 3425 02:05:36,229 --> 02:05:37,563 LEW, I HAVE A QUESTION FOR YOU. 3426 02:05:37,563 --> 02:05:38,965 AS YOU THINK ABOUT VARIABILITY 3427 02:05:38,965 --> 02:05:41,801 IN THE ELDERLY POPULATION, DO 3428 02:05:41,801 --> 02:05:44,203 YOU RECOMMEND EVEN MORE 3429 02:05:44,203 --> 02:05:45,738 MEASUREMENTS BEFORE DIAGNOSING 3430 02:05:45,738 --> 02:05:47,673 HYPERTENSION OR DECIDING TO 3431 02:05:47,673 --> 02:05:48,641 INTENSIFY IN THAT POPULATION 3432 02:05:48,641 --> 02:05:51,310 BECAUSE OF THAT VARIABILITY? 3433 02:05:51,310 --> 02:06:00,186 >> I DO RECOMMEND MEASUREMENTS, 3434 02:06:00,186 --> 02:06:01,254 MORE IS AN INTERESTING ISSUE, 3435 02:06:01,254 --> 02:06:02,321 BUT AT SPECIFIC TIMES. 3436 02:06:02,321 --> 02:06:05,591 AS YOU SAW IN THE GRAPHS THAT I 3437 02:06:05,591 --> 02:06:07,794 SHOWED, MANY MEAN OF OUR OLDER 3438 02:06:07,794 --> 02:06:10,496 PATIENTS WAKE UP HYPERTENSIVE IN 3439 02:06:10,496 --> 02:06:10,963 THE MORNING. 3440 02:06:10,963 --> 02:06:12,932 THEY HAVE A REVERSAL OF THE 3441 02:06:12,932 --> 02:06:15,301 NOCTURNAL DIPPING OF THE 3442 02:06:15,301 --> 02:06:16,402 CIRCADIAN RHYTHM, THEY WAKE UP 3443 02:06:16,402 --> 02:06:18,070 QUITE HYPERTENSIVE AND ALL THAT 3444 02:06:18,070 --> 02:06:19,772 IT TAKES TO REDUCE THEIR BLOOD 3445 02:06:19,772 --> 02:06:21,207 PRESSURE IS A MEAL AND AFTER 3446 02:06:21,207 --> 02:06:23,075 BREAKFAST, MANY OF THEM ARE 3447 02:06:23,075 --> 02:06:24,444 RELATIVELY HYPERTENSIVE. 3448 02:06:24,444 --> 02:06:26,345 SO IF THAT'S THE CASE MAYBE I'LL 3449 02:06:26,345 --> 02:06:27,647 JUST TREAT THEM WITH A MEAL. 3450 02:06:27,647 --> 02:06:29,382 SOME OF THEM ARE HYPERTENSIVE 3451 02:06:29,382 --> 02:06:33,085 OVERNIGHT BECAUSE THEY HAVE 3452 02:06:33,085 --> 02:06:34,086 SLEEP APNEA OR OTHER PROBLEMS. 3453 02:06:34,086 --> 02:06:36,722 SO I MIGHT TREAT THEM AT 3454 02:06:36,722 --> 02:06:37,890 BEDTIME. 3455 02:06:37,890 --> 02:06:39,292 SO I NEED ENOUGH MEASUREMENTS TO 3456 02:06:39,292 --> 02:06:41,828 BE ABLE TO DEFINE WHEN THEY ARE 3457 02:06:41,828 --> 02:06:42,595 HYPERTENSIVE, WHEN THEY ARE NOT 3458 02:06:42,595 --> 02:06:44,864 SO I CAN ADJUST THEIR TREATMENT 3459 02:06:44,864 --> 02:06:45,198 ACCORDINGLY. 3460 02:06:45,198 --> 02:06:47,166 AND I DON'T NEED IT EVERY DAY, I 3461 02:06:47,166 --> 02:06:49,869 USUALLY ASK MY PATIENTS TO TAKE 3462 02:06:49,869 --> 02:06:50,670 THEIR BLOOD PRESSURES UNDER 3463 02:06:50,670 --> 02:06:52,171 THOSE CIRCUMSTANCES MONDAY, 3464 02:06:52,171 --> 02:06:52,972 WEDNESDAY, FRIDAY FOR THREE 3465 02:06:52,972 --> 02:06:54,073 WEEKS AND THEN BRING THE RESULTS 3466 02:06:54,073 --> 02:06:55,541 TO ME AND THEN I CAN EVALUATE IT 3467 02:06:55,541 --> 02:06:56,776 IN THE OFFICE AND MAKE A 3468 02:06:56,776 --> 02:06:57,577 DECISION. 3469 02:06:57,577 --> 02:07:06,953 >> GREAT, THANK YOU. 3470 02:07:06,953 --> 02:07:08,488 SO QUESTION, THERE'S ALSO BEEN A 3471 02:07:08,488 --> 02:07:09,922 LOT OF DISCUSSION REGARDING 3472 02:07:09,922 --> 02:07:11,891 NON-ADHERENCE IN ROUTINE CARE TO 3473 02:07:11,891 --> 02:07:12,992 GUIDELINE RECOMMENDATIONS FOR 3474 02:07:12,992 --> 02:07:16,229 BLOOD PRESSURE MEASUREMENT 3475 02:07:16,229 --> 02:07:17,563 TECHNIQUES. 3476 02:07:17,563 --> 02:07:21,033 I'M WONDERING, KARA AND JOE, 3477 02:07:21,033 --> 02:07:22,101 MAYBE IF YOU COULD COMMENT ON 3478 02:07:22,101 --> 02:07:23,102 THE SPECIFIC CHALLENGES. 3479 02:07:23,102 --> 02:07:25,238 I THINK, JOE, YOU MENTIONED 3480 02:07:25,238 --> 02:07:26,539 CHAIRS, CUFF SIZE. 3481 02:07:26,539 --> 02:07:28,407 IN YOUR SPECIFIC POPULATIONS FOR 3482 02:07:28,407 --> 02:07:29,909 WHAT YOU SEE IN ROUTINE CARE 3483 02:07:29,909 --> 02:07:31,010 COMPARED TO WHAT YOU MIGHT SEE 3484 02:07:31,010 --> 02:07:34,447 IN YOUR OWN CLINIC. 3485 02:07:34,447 --> 02:07:37,250 >> I THINK ONE THING TO JUST 3486 02:07:37,250 --> 02:07:40,086 SPEAK ABOUT IN THE PREGNANT AND 3487 02:07:40,086 --> 02:07:40,753 POSTPARTUM PATIENTS IS -- AND 3488 02:07:40,753 --> 02:07:42,922 THIS IS NOT TO BE DISRESPECTFUL, 3489 02:07:42,922 --> 02:07:43,923 BUT WE'RE NOT A CHRONIC CARE 3490 02:07:43,923 --> 02:07:44,991 MANAGEMENT OR PRIMARY CARE 3491 02:07:44,991 --> 02:07:46,759 CLINIC MOST OF THE TIME, AND SO 3492 02:07:46,759 --> 02:07:48,327 THE STAFF AND THE PROVIDERS ARE 3493 02:07:48,327 --> 02:07:50,062 NOT THINKING ABOUT BLOOD 3494 02:07:50,062 --> 02:07:52,798 PRESSURE TECHNIQUE AND SO I'VE 3495 02:07:52,798 --> 02:07:54,767 PERSONALLY TRIED TO DO A LOT AT 3496 02:07:54,767 --> 02:07:56,102 MY INSTITUTION OF LIKE PEOPLE 3497 02:07:56,102 --> 02:07:57,570 JUST NEED TO BE SITTING PROPERLY 3498 02:07:57,570 --> 02:07:59,639 AND FOLLOWING PROPER MY JEAN, AS 3499 02:07:59,639 --> 02:08:03,342 PROPER HYGIENE, ASWELL AS THEREN 3500 02:08:03,342 --> 02:08:04,944 OF HAVING PEOPLE DO OUT OF 3501 02:08:04,944 --> 02:08:06,479 CLINIC MONITORING BUT THERE'S NO 3502 02:08:06,479 --> 02:08:07,813 INSTRUCTIONS OR TEACHING OR 3503 02:08:07,813 --> 02:08:08,814 INVESTMENT, YOU KNOW, OR THE 3504 02:08:08,814 --> 02:08:10,416 PEOPLE THAT ARE DOING THEM DON'T 3505 02:08:10,416 --> 02:08:12,051 EVEN KNOW HOW TO TEACH IT, SO 3506 02:08:12,051 --> 02:08:13,052 THERE'S REALLY A LACK OF 3507 02:08:13,052 --> 02:08:14,420 EDUCATION, I THINK, ON ALL 3508 02:08:14,420 --> 02:08:15,555 LEVELS THERE. 3509 02:08:15,555 --> 02:08:17,657 ANOTHER ISSUE IS, LIKE, IF WE 3510 02:08:17,657 --> 02:08:19,091 HAVE ANTEPARTUM PATIENTS IN THE 3511 02:08:19,091 --> 02:08:20,393 HOSPITAL, THEY'RE IN BEDS, SO 3512 02:08:20,393 --> 02:08:21,761 PEOPLE ARE NOT GETTING THEM OUT 3513 02:08:21,761 --> 02:08:23,496 OF BED TO MEASURE THEIR BLOOD 3514 02:08:23,496 --> 02:08:24,597 PRESSURES, AND SO I WOULD JUST 3515 02:08:24,597 --> 02:08:26,666 SAY, LIKE, BROAD STROKES ACROSS 3516 02:08:26,666 --> 02:08:28,634 THE PREGNANT POPULATION IS A LOT 3517 02:08:28,634 --> 02:08:31,170 OF EDUCATION IS NEEDED NOT ONLY 3518 02:08:31,170 --> 02:08:33,139 FROM OUTPATIENT BUT INPATIENT 3519 02:08:33,139 --> 02:08:35,675 AND STANDARDIZATION OF JUST 3520 02:08:35,675 --> 02:08:38,978 SIMPLY TAKING A BLOOD PRESSURE. 3521 02:08:38,978 --> 02:08:40,279 THEN ANOTHER THING IS WE HAVE A 3522 02:08:40,279 --> 02:08:42,114 LOT OF OBESE PATIENTS AND THE 3523 02:08:42,114 --> 02:08:43,883 EXTRA LARGE CUFFS ARE TOO LONG 3524 02:08:43,883 --> 02:08:45,051 FOR THEIR ARMS. 3525 02:08:45,051 --> 02:08:46,686 THERE'S LACK OF DEVICES THAT FIT 3526 02:08:46,686 --> 02:08:50,990 WELL TOO. 3527 02:08:50,990 --> 02:08:52,558 SO THOSE ARE JUST SOME IMMEDIATE 3528 02:08:52,558 --> 02:08:53,192 COMMENTS I HAVE. 3529 02:08:53,192 --> 02:08:59,565 >> AND YOU KNOW, FOR CHILDREN, 3530 02:08:59,565 --> 02:09:03,169 LACK OF ADHERENCE TO TECHNIQUE 3531 02:09:03,169 --> 02:09:06,772 TO BE EITHER IN THE OFFICE OR AT 3532 02:09:06,772 --> 02:09:13,346 HOME, AND SO WE ARE PRETTY, OF 3533 02:09:13,346 --> 02:09:14,981 COURSE, COMPULSIVE IN OUR 3534 02:09:14,981 --> 02:09:16,115 HYPERTENSION CLINIC TO MAKE SURE 3535 02:09:16,115 --> 02:09:24,590 WE'RE DOING THINGS RIGHT. 3536 02:09:24,590 --> 02:09:26,993 THERE HAVE BEEN SORT OF LARGE 3537 02:09:26,993 --> 02:09:29,295 QUALITY IMPROVEMENT EFFORTS TO 3538 02:09:29,295 --> 02:09:33,132 LOOK AT THIS IN GENERAL 3539 02:09:33,132 --> 02:09:39,705 PEDIATRIC PRACTICES, AND THERE'S 3540 02:09:39,705 --> 02:09:41,874 CLEARLY SOME POOR ADHERENCE TO 3541 02:09:41,874 --> 02:09:44,410 THAT, TO ALL OF THE STEPS, AND 3542 02:09:44,410 --> 02:09:49,315 SO SOME THINGS THAT POTENTIALLY 3543 02:09:49,315 --> 02:09:50,082 COULD OVERCOME THAT. 3544 02:09:50,082 --> 02:09:53,786 I WAS INTERESTED TO HEAR ABOUT 3545 02:09:53,786 --> 02:09:55,688 THAT YOU DIDN'T NEED TO WAIT AS 3546 02:09:55,688 --> 02:09:57,857 LONG BEFORE DOING THE 3547 02:09:57,857 --> 02:09:59,492 MEASUREMENT OR WAIT AS LONG IN 3548 02:09:59,492 --> 02:10:00,993 BETWEEN, I THINK WE NEED TO LOOK 3549 02:10:00,993 --> 02:10:04,630 AT THAT IN CHILDREN, IT NOT 3550 02:10:04,630 --> 02:10:10,636 REALLY BEEN STUDIED TO MY 3551 02:10:10,636 --> 02:10:13,806 KNOWLEDGE, AND JUST PRODUCING 3552 02:10:13,806 --> 02:10:17,209 MORE EDUCATIONAL MATERIALS AND 3553 02:10:17,209 --> 02:10:22,014 GETTING THE WORD OUT THERE FOR 3554 02:10:22,014 --> 02:10:25,718 GENERAL PEDIATRICIANS. 3555 02:10:25,718 --> 02:10:27,553 WE DO SPEND A LOT OF TIME WITH 3556 02:10:27,553 --> 02:10:28,788 OUR PATIENTS, SO OUR NURSES HAVE 3557 02:10:28,788 --> 02:10:34,560 A STRUCTURED WAY OF TEACHING THE 3558 02:10:34,560 --> 02:10:36,929 PATIENTS HOW TO MEASURE THEIR 3559 02:10:36,929 --> 02:10:39,465 BLOOD PRESSURE, AND THAT 3560 02:10:39,465 --> 02:10:43,536 INCLUDES A HANDOUT AND A REVIEW 3561 02:10:43,536 --> 02:10:46,038 OF HOW THE DEVICE WORKS AND SO 3562 02:10:46,038 --> 02:10:48,708 FORTH. 3563 02:10:48,708 --> 02:10:51,677 AND WE'LL OFTEN SORT OF 3564 02:10:51,677 --> 02:10:52,878 REINFORCE THAT WHEN PATIENTS 3565 02:10:52,878 --> 02:10:54,947 COME BACK FOR CLINIC VISITS, 3566 02:10:54,947 --> 02:10:58,284 ESPECIALLY WHEN I'M SEEING A BIG 3567 02:10:58,284 --> 02:11:00,319 DISCREPANCY BETWEEN THE HOME 3568 02:11:00,319 --> 02:11:01,787 BLOOD PRESSURE READINGS AND THE 3569 02:11:01,787 --> 02:11:04,724 OFFICE BLOOD PRESSURE READINGS. 3570 02:11:04,724 --> 02:11:06,058 LIKE DID YOU ACTUALLY SIT DOWN 3571 02:11:06,058 --> 02:11:07,560 AND REST FOR A WHILE BEFORE YOU 3572 02:11:07,560 --> 02:11:10,963 DID THAT BLOOD PRESSURE THERE, 3573 02:11:10,963 --> 02:11:11,464 JOSE? 3574 02:11:11,464 --> 02:11:13,966 YOU KNOW, THE ANSWER WILL OFTEN 3575 02:11:13,966 --> 02:11:17,236 BE NO, AND YOU DO SOME EDUCATION 3576 02:11:17,236 --> 02:11:24,910 IN THAT SETTING. 3577 02:11:24,910 --> 02:11:26,512 >> I'M REALLY INTERESTED TO SEE 3578 02:11:26,512 --> 02:11:27,980 WHERE WE'RE GOING TO GO AND I 3579 02:11:27,980 --> 02:11:29,181 THINK ALL THREE OF YOU TOUCHED 3580 02:11:29,181 --> 02:11:31,817 ON THE FACT THAT THERE'S A BIG 3581 02:11:31,817 --> 02:11:37,923 IMPLEMENTATION GAP, AND I LOVED 3582 02:11:37,923 --> 02:11:40,326 THAT AHA HYPERTENSION SIGN TIFNG 3583 02:11:40,326 --> 02:11:41,727 SESSIONS IN NOVEMBER IN CHICAGO, 3584 02:11:41,727 --> 02:11:43,729 THIS CAME UP CONSTANTLY, MAYBE 3585 02:11:43,729 --> 02:11:45,698 I'M BIASED, IS THAT WE HAVE ALL 3586 02:11:45,698 --> 02:11:47,233 THESE GUIDELINES, WE KNOW WHAT 3587 02:11:47,233 --> 02:11:51,604 TO DO, WE KNOW WHAT BLOOD 3588 02:11:51,604 --> 02:11:52,605 PRESSURE IS THE TARGET, WE KNOW 3589 02:11:52,605 --> 02:11:53,906 WHAT MEDS, BUT THEY'RE STILL NOT 3590 02:11:53,906 --> 02:11:55,141 BEING IMPLEMENTED ACROSS THE 3591 02:11:55,141 --> 02:11:56,642 BOARD, NOT EVEN JUST IN PRIMARY 3592 02:11:56,642 --> 02:11:58,144 CARE BUT FOR THOSE OF YOU WHO DO 3593 02:11:58,144 --> 02:12:00,179 THIS WORK FOR A LIVING AND I AM 3594 02:12:00,179 --> 02:12:02,148 A POSTER CHILD FOR THAT, I FAIL 3595 02:12:02,148 --> 02:12:03,482 TO DO STUFF PER GUIDELINES ALL 3596 02:12:03,482 --> 02:12:04,383 THE TIME. 3597 02:12:04,383 --> 02:12:05,251 OFTENTIMES IT'S NOT BECAUSE I 3598 02:12:05,251 --> 02:12:06,385 DON'T BELIEVE IN THEM, BUT 3599 02:12:06,385 --> 02:12:08,287 BECAUSE I'M HUMAN AND I FORGET 3600 02:12:08,287 --> 02:12:10,055 AND WE GET BUSY IN CLINIC. 3601 02:12:10,055 --> 02:12:11,924 SO I'M CURIOUS FOR YOU ALL, HOW 3602 02:12:11,924 --> 02:12:13,893 DO WE REALLY TRANSFORM THE FIELD 3603 02:12:13,893 --> 02:12:16,495 BY DOING WHAT YOU ALLUDED TO, 3604 02:12:16,495 --> 02:12:18,564 JOSEPH, OF EMPOWERING, NOT JUST 3605 02:12:18,564 --> 02:12:20,633 OUR PATIENTS OR FAMILIES LIKE 3606 02:12:20,633 --> 02:12:23,135 KARA DID WITH HER KIDS, BUT 3607 02:12:23,135 --> 02:12:24,870 PROVIDERS TOO, AT ALL LEVELS, 3608 02:12:24,870 --> 02:12:27,373 NOT JUST THE PHYSICIANS AND THE 3609 02:12:27,373 --> 02:12:29,041 PAs, AND THE NURSE 3610 02:12:29,041 --> 02:12:30,442 PRACTITIONERS, BUT THE MAs, 3611 02:12:30,442 --> 02:12:34,180 THE NURSES, TO REALLY DO THESE 3612 02:12:34,180 --> 02:12:36,348 THINGS BUT IN A SUSTAINABLE WAY, 3613 02:12:36,348 --> 02:12:38,083 THE WAY WE CONCEPTUALIZE IT IS 3614 02:12:38,083 --> 02:12:39,518 WE HAVE TO CHANGE THE SYSTEM, WE 3615 02:12:39,518 --> 02:12:40,853 HAVE TO CHANGE THE CULTURE AND 3616 02:12:40,853 --> 02:12:41,353 WE HAVE TO EDUCATE. 3617 02:12:41,353 --> 02:12:43,222 SO WE HAVE TO MAKE IT STUPIDLY 3618 02:12:43,222 --> 02:12:47,693 EASY FOR PEOPLE TO DO THESE 3619 02:12:47,693 --> 02:12:48,727 THINGS, WHICH REALLY REQUIRES 3620 02:12:48,727 --> 02:12:50,563 THEIR BUY-IN TO GET THAT 3621 02:12:50,563 --> 02:12:52,097 INTERNAL MOTIVATION THAT THEY'RE 3622 02:12:52,097 --> 02:12:53,465 INVESTED IN REMEMBERING TO DO 3623 02:12:53,465 --> 02:12:55,000 THINGS AND THEN MAKING IT A 3624 02:12:55,000 --> 02:12:56,669 REALLY EASY SYSTEM WHERE IT'S 3625 02:12:56,669 --> 02:12:57,436 AUTOMATIC, THEY DON'T EVEN HAVE 3626 02:12:57,436 --> 02:12:58,237 TO THINK ABOUT IT. 3627 02:12:58,237 --> 02:12:59,538 AND I DON'T HAVE A SOLUTION. 3628 02:12:59,538 --> 02:13:01,040 SO I'M CURIOUS FOR YOU ALL. 3629 02:13:01,040 --> 02:13:02,374 NOT AN EASY ASK. 3630 02:13:02,374 --> 02:13:09,515 WHAT DO YOU THINK WE SHOULD DO? 3631 02:13:09,515 --> 02:13:11,483 >> I MIGHT JUST MAKE A COMMENT. 3632 02:13:11,483 --> 02:13:12,685 IT HARD ENOUGH TO EVEN GET 3633 02:13:12,685 --> 02:13:13,886 PEOPLE TO PAY ATTENTION TO BLOOD 3634 02:13:13,886 --> 02:13:15,120 PRESSURE, LET ALONE MEASURE IT 3635 02:13:15,120 --> 02:13:15,554 CORRECTLY. 3636 02:13:15,554 --> 02:13:18,190 SO I'M KIND OF HAPPY IF THEY 3637 02:13:18,190 --> 02:13:19,325 MEASURE IT, EVEN IF IT'S NOT 3638 02:13:19,325 --> 02:13:20,426 EXACTLY RIGHT. 3639 02:13:20,426 --> 02:13:21,961 AND MAYBE THAT SOUNDS A LITTLE 3640 02:13:21,961 --> 02:13:26,999 BIT OFF TOPIC, BUT I THINK WE 3641 02:13:26,999 --> 02:13:28,801 OFTEN ERR ON THE SIDE OF TRYING 3642 02:13:28,801 --> 02:13:31,337 TO MAKE SURE THEY DON'T HAVE 3643 02:13:31,337 --> 02:13:31,937 HYPERTENSION THAN DIAGNOSING 3644 02:13:31,937 --> 02:13:33,873 THAT THEY DO. 3645 02:13:33,873 --> 02:13:35,641 THEY COME IN TO THE OFFICE, 3646 02:13:35,641 --> 02:13:39,011 WE'RE WEARING OUR WHITE COAT, 3647 02:13:39,011 --> 02:13:39,712 IT'S HIGH BLOOD PRESSURE. 3648 02:13:39,712 --> 02:13:40,980 IT'S NOT JUST THE WHITE COAT. 3649 02:13:40,980 --> 02:13:42,514 THERE ARE OTHER TIMES OF DAY, 3650 02:13:42,514 --> 02:13:43,282 OTHER CIRCUMSTANCES IN THEIR 3651 02:13:43,282 --> 02:13:47,820 LIVES WHEN THEY'RE STRESSED, AND 3652 02:13:47,820 --> 02:13:49,455 SO IF THEIR PRESSURE IS HIGH 3653 02:13:49,455 --> 02:13:50,756 WHEN THEY'RE STRESSED, I WANT TO 3654 02:13:50,756 --> 02:13:52,625 KNOW IT. 3655 02:13:52,625 --> 02:13:54,260 CERTAINLY POSITION, TIMING, ALL 3656 02:13:54,260 --> 02:13:55,394 OF THAT ARE IMPORTANT, NO 3657 02:13:55,394 --> 02:13:56,795 QUESTION ABOUT THAT, BUT I THINK 3658 02:13:56,795 --> 02:13:58,497 WE KEEP TAKING THE PRESSURE OVER 3659 02:13:58,497 --> 02:13:59,798 AND OVER AGAIN UNTIL WE FIND A 3660 02:13:59,798 --> 02:14:01,567 VALUE WE LIKE, WHICH IS USUALLY 3661 02:14:01,567 --> 02:14:07,606 A VALUE THAT'S NORMATTENTIVE. 3662 02:14:07,606 --> 02:14:09,008 SO WE'VE WORKED SO HARD TO 3663 02:14:09,008 --> 02:14:10,542 ELIMINATE THE FINDING THE 3664 02:14:10,542 --> 02:14:12,611 HYPERTENSION, AND I WOULD KIND 3665 02:14:12,611 --> 02:14:14,713 OF THINK EVEN THOUGH I'M A 3666 02:14:14,713 --> 02:14:16,115 GERIATRICIAN AND I DON'T WANT TO 3667 02:14:16,115 --> 02:14:17,883 TREAT EVERYBODY TOO MUCH, I 3668 02:14:17,883 --> 02:14:20,920 THINK WE SHOULDN'T BE SO WORRIED 3669 02:14:20,920 --> 02:14:24,690 ABOUT SOMEBODY WHO COMES IN -- I 3670 02:14:24,690 --> 02:14:27,393 THINK WE SHOULD TREAT THEM AND 3671 02:14:27,393 --> 02:14:30,796 NOT WORRY AS MUCH ABOUT IF WE'RE 3672 02:14:30,796 --> 02:14:31,664 EXACTLY RIGHT ACCORDING TO 3673 02:14:31,664 --> 02:14:31,997 GUIDELINES. 3674 02:14:31,997 --> 02:14:36,835 JUST A THOUGHT. 3675 02:14:36,835 --> 02:14:38,470 >> SOME OF MY STRATEGIES ARE 3676 02:14:38,470 --> 02:14:39,438 REALLY ABOUT LIKE -- I THINK 3677 02:14:39,438 --> 02:14:42,174 THERE NEEDS -- IN MY DREAM 3678 02:14:42,174 --> 02:14:44,944 WORLD, IT WOULD BE LIKE WORKING 3679 02:14:44,944 --> 02:14:46,779 WITH HIGH LEVEL IMPACTFUL 3680 02:14:46,779 --> 02:14:48,447 ORGANIZATIONS THAT MAYBE DO 3681 02:14:48,447 --> 02:14:49,748 CMEs AND TEACHING AND OTHER 3682 02:14:49,748 --> 02:14:51,050 THINGS, AND THEN SOME SORT OF 3683 02:14:51,050 --> 02:14:52,484 LIKE INCENTIVE FOR THIS. 3684 02:14:52,484 --> 02:14:53,686 I THINK PREGNANCY IS ONE THING, 3685 02:14:53,686 --> 02:14:55,654 BUT I THINK ALSO THE POSTPARTUM 3686 02:14:55,654 --> 02:14:56,922 AND TRANSITION TO LONG-TERM 3687 02:14:56,922 --> 02:14:58,958 CARE, I MEAN, IF WE CAN REALLY 3688 02:14:58,958 --> 02:15:00,392 HELP PEOPLE UNDERSTAND, THIS IS 3689 02:15:00,392 --> 02:15:03,228 WHY OUR PEOPLE IN THE U.S. ARE 3690 02:15:03,228 --> 02:15:04,229 DYING, YOU KNOW, AND IF YOU CAN 3691 02:15:04,229 --> 02:15:06,098 MAKE AN IMPACT, IF WE CAN MAKE 3692 02:15:06,098 --> 02:15:08,267 IT PERSONAL AND MAKE IT REALLY 3693 02:15:08,267 --> 02:15:09,501 FEEL LIKE YOU'RE REALLY MAKING 3694 02:15:09,501 --> 02:15:11,036 AN IMPACT, MAYBE THERE'S A WAY, 3695 02:15:11,036 --> 02:15:14,673 BUT I DON'T KNOW, EASY TOOLS 3696 02:15:14,673 --> 02:15:16,842 OR -- I DON'T REALLY HAVE A 3697 02:15:16,842 --> 02:15:17,109 SOLUTION. 3698 02:15:17,109 --> 02:15:19,011 BUT I THINK THAT'S A START, IS 3699 02:15:19,011 --> 02:15:20,446 LIKE REALLY MAKING IT PERSONAL 3700 02:15:20,446 --> 02:15:22,548 SOMEHOW. 3701 02:15:22,548 --> 02:15:25,284 THAT'S NOT REALLY RESEARCH, BUT, 3702 02:15:25,284 --> 02:15:26,719 LAKE -- OR ALSO WAYS FOR PEOPLE 3703 02:15:26,719 --> 02:15:27,920 WHO DON'T HAVE TIME TO DO 3704 02:15:27,920 --> 02:15:30,456 RESEARCH TO GET THE FEEDBACK OF 3705 02:15:30,456 --> 02:15:32,091 LIKE WHAT THEY'RE DOING IS 3706 02:15:32,091 --> 02:15:33,192 INFORMING RESEARCH, SO COULD 3707 02:15:33,192 --> 02:15:36,695 THERE BE SOME WAY THAT WE COULD, 3708 02:15:36,695 --> 02:15:37,896 LIKE, INCLUDE PEOPLE IN STANDARD 3709 02:15:37,896 --> 02:15:40,432 CLINICAL CARE SETTINGS TO 3710 02:15:40,432 --> 02:15:42,835 PROVIDE DATA THAT KNOWS THEY'RE 3711 02:15:42,835 --> 02:15:43,836 REALLY MAKING A CHANGE OR 3712 02:15:43,836 --> 02:15:44,703 SOMETHING LIKE THAT? 3713 02:15:44,703 --> 02:15:47,006 SO ANYWAYS, BUY-IN AND REWARDS, 3714 02:15:47,006 --> 02:15:57,216 MAYBE THAT'S THE WAY TO SUCCESS. 3715 02:15:57,216 --> 02:16:01,887 >> QUESTIONS FROM THE AUDIENCE? 3716 02:16:01,887 --> 02:16:04,690 >> THIS IS DICK DART UP IN 3717 02:16:04,690 --> 02:16:04,990 MARSHFIELD. 3718 02:16:04,990 --> 02:16:07,059 I'M A CLINICIAN, MANY YEARS IN 3719 02:16:07,059 --> 02:16:07,593 CLINIC PRACTICE. 3720 02:16:07,593 --> 02:16:09,561 I THINK ALL THE COMMENTS MADE 3721 02:16:09,561 --> 02:16:10,796 ARE VERY TYPICAL. 3722 02:16:10,796 --> 02:16:12,431 I'M IN A PRIVATE PRACTICE, IT'S 3723 02:16:12,431 --> 02:16:16,035 A LARGE GROUP PRACTICE. 3724 02:16:16,035 --> 02:16:17,036 BUT I'VE BEEN TREATED TO THE 3725 02:16:17,036 --> 02:16:19,104 SAME THING WHERE I GO IN AND GET 3726 02:16:19,104 --> 02:16:20,506 SOMEBODY TO TAKE MY BLOOD 3727 02:16:20,506 --> 02:16:21,507 PRESSURE, THEY'LL PUT THE WRONG 3728 02:16:21,507 --> 02:16:22,708 SIZE CUFF ON, THEY'RE TALKING TO 3729 02:16:22,708 --> 02:16:24,143 ME AND THEY WANT TO RUN THROUGH 3730 02:16:24,143 --> 02:16:28,414 THINGS, AND I THINK WHAT 3731 02:16:28,414 --> 02:16:29,314 DR. SOUTH POINTED OUT, IT'S ON 3732 02:16:29,314 --> 02:16:30,616 THE WALL, WHAT YOU SHOULD DO, 3733 02:16:30,616 --> 02:16:31,817 AND I'M LIKE, WHAT DO YOU 3734 02:16:31,817 --> 02:16:33,886 HAVE -- I TELL THEM, I SAID, I'D 3735 02:16:33,886 --> 02:16:35,120 REALLY LIKE YOU TO DO THIS 3736 02:16:35,120 --> 02:16:37,389 RIGHT, NOT BECAUSE I WORRY ABOUT 3737 02:16:37,389 --> 02:16:37,723 HYPERTENSION. 3738 02:16:37,723 --> 02:16:38,824 I HAVE A LITTLE BIT OF BLOOD 3739 02:16:38,824 --> 02:16:40,459 PRESSURE BUT IT'S WELL 3740 02:16:40,459 --> 02:16:43,929 CONTROLLED, BUT I THINK IT'S THE 3741 02:16:43,929 --> 02:16:45,330 ISSUE OF WE OUGHT TO BE MORE 3742 02:16:45,330 --> 02:16:46,999 CONCERNED ABOUT OUTCOMES VERSUS 3743 02:16:46,999 --> 02:16:49,168 THE INCOMES, MEANING THE MONEY 3744 02:16:49,168 --> 02:16:51,470 YOU MAKE FOR DOING SOMETHING 3745 02:16:51,470 --> 02:16:52,471 VERSUS THE OUTCOMES WE'RE 3746 02:16:52,471 --> 02:16:53,572 GETTING IN TERMS OF ACTUALLY 3747 02:16:53,572 --> 02:16:54,773 MAKING PEOPLE HEALTHY, OR 3748 02:16:54,773 --> 02:16:55,974 KEEPING THEM HEALTHY. 3749 02:16:55,974 --> 02:16:57,509 AND I THINK THAT'S A VERY 3750 02:16:57,509 --> 02:16:58,677 DIFFICULT THING TO GET ACROSS 3751 02:16:58,677 --> 02:17:01,246 AND GET TO PEOPLE TO GET IN THE 3752 02:17:01,246 --> 02:17:02,748 HABIT OF DOING, MEASURING BLOOD 3753 02:17:02,748 --> 02:17:07,419 PRESSURE CORRECTLY. 3754 02:17:07,419 --> 02:17:08,954 >> YEAH, IF I COULD JUST 3755 02:17:08,954 --> 02:17:10,489 COMMENT, THERE'S A QUESTION FROM 3756 02:17:10,489 --> 02:17:15,961 TAMMY IN THE CHAT ALSO ABOUT 3757 02:17:15,961 --> 02:17:20,332 WHAT SHOULD WE DO TO IMPROVE 3758 02:17:20,332 --> 02:17:22,634 CARDIOVASCULAR HEALTH IN YOUTH. 3759 02:17:22,634 --> 02:17:28,173 I THINK IT DOES BEGIN WITH 3760 02:17:28,173 --> 02:17:29,875 SIMPLIFYING THE RECOGNITION OF 3761 02:17:29,875 --> 02:17:31,844 HYPERTENSION, PROVIDING PEOPLE 3762 02:17:31,844 --> 02:17:34,179 WITH TOOLS FOR DETECTING IT, AND 3763 02:17:34,179 --> 02:17:38,550 THEN WE HAVE THE BIG QUESTION IN 3764 02:17:38,550 --> 02:17:41,520 PEDIATRICS OF NOT REALLY KNOWING 3765 02:17:41,520 --> 02:17:45,224 THE BEST MODE OF TREATMENT. 3766 02:17:45,224 --> 02:17:47,726 AND SO FIGURING THAT OUT. 3767 02:17:47,726 --> 02:17:50,929 THAT'S NOT THE FOCUS OF THIS 3768 02:17:50,929 --> 02:17:58,036 WORKSHOP, BUT UNDERSTANDING 3769 02:17:58,036 --> 02:18:04,042 WHETHER INTERVENING WITH 3770 02:18:04,042 --> 02:18:05,144 MEDICATION CHANGE VERSUS 3771 02:18:05,144 --> 02:18:06,278 LIFESTYLE CHANGE IS GOING TO BE 3772 02:18:06,278 --> 02:18:07,679 MORE BENEFICIAL FOR YOUTH AND 3773 02:18:07,679 --> 02:18:10,449 THEN PREVENTION OF FUTURE 3774 02:18:10,449 --> 02:18:11,850 CARDIOVASCULAR DISEASE IS A HUGE 3775 02:18:11,850 --> 02:18:12,751 RESEARCH GAP THAT WE HAVE IN 3776 02:18:12,751 --> 02:18:13,318 PEDIATRICS. 3777 02:18:13,318 --> 02:18:14,620 BUT GETTING BACK TO THE BLOOD 3778 02:18:14,620 --> 02:18:15,921 PRESSURE MEASUREMENT, I LIKE THE 3779 02:18:15,921 --> 02:18:17,689 IDEA OF CMEs. 3780 02:18:17,689 --> 02:18:20,592 WE DO WORK WITH THE AMERICAN 3781 02:18:20,592 --> 02:18:21,860 ACADEMY OF PEDIATRICS, AND 3782 02:18:21,860 --> 02:18:25,731 TYPICALLY THERE ARE WORKSHOPS AT 3783 02:18:25,731 --> 02:18:28,133 THEIR ANNUAL CONFERENCE, AND I'M 3784 02:18:28,133 --> 02:18:33,906 IN THE MIDDLE OF PREPARING A 3785 02:18:33,906 --> 02:18:34,473 PERSPECTIVES FOR THE JOURNAL 3786 02:18:34,473 --> 02:18:39,311 THAT MAY HAVE SOME -- CALLING 3787 02:18:39,311 --> 02:18:40,679 ATTENTION TO THE ISSUE OF BLOOD 3788 02:18:40,679 --> 02:18:43,448 PRESSURE MEASUREMENT. 3789 02:18:43,448 --> 02:18:44,983 I THINK THESE ARE THE THINGS 3790 02:18:44,983 --> 02:18:47,853 THAT WE ALL NEED TO DO NO MATTER 3791 02:18:47,853 --> 02:18:50,589 WHAT SEGMENT OF THE AGE RANGE 3792 02:18:50,589 --> 02:18:58,130 WHEWE'RE SORT OF ADDRESSING. 3793 02:18:58,130 --> 02:18:59,798 >> I THINK ANOTHER ASPECT IS 3794 02:18:59,798 --> 02:19:00,465 REALLY PUTTING IT IN THE PLACE 3795 02:19:00,465 --> 02:19:02,701 OF COMMUNITY AND PEOPLE 3796 02:19:02,701 --> 02:19:04,203 THEMSELVES, SO IF, FOR EXAMPLE, 3797 02:19:04,203 --> 02:19:05,604 LIKE -- AGAIN, I GO BACK TO 3798 02:19:05,604 --> 02:19:06,772 PREGNANCY BUT IT COULD BE 3799 02:19:06,772 --> 02:19:07,940 APPLICABLE TO A LOT OF PLACES, 3800 02:19:07,940 --> 02:19:09,474 LIKE HERE'S A FORM, HERE'S AN 3801 02:19:09,474 --> 02:19:12,010 ALERT IN YOUR EMR, LIKE I HAD A 3802 02:19:12,010 --> 02:19:13,345 PREGNANCY-RELATED HYPERTENSION 3803 02:19:13,345 --> 02:19:15,414 ISSUE, IT THEN FLAGS TO THEIR 3804 02:19:15,414 --> 02:19:17,950 PCP, LIKE THEY NEED XYZ EVERY 3805 02:19:17,950 --> 02:19:19,017 SINGLE YEAR RATHER THAN, LIKE, 3806 02:19:19,017 --> 02:19:21,954 THEY DON'T GET ANY CARE UNTIL 3807 02:19:21,954 --> 02:19:23,422 FOUR YEARS LATER WHEN THEY HAVE 3808 02:19:23,422 --> 02:19:27,025 THE NEXT PREGNANCY OR THEY HIT 3809 02:19:27,025 --> 02:19:28,560 MENOPAUSE OR THEY'RE GERIATRIC 3810 02:19:28,560 --> 02:19:29,428 OR SOMETHING. 3811 02:19:29,428 --> 02:19:32,631 SO LETTING PEOPLE UNDERSTAND AND 3812 02:19:32,631 --> 02:19:34,399 KNOW WHAT REALLY HAPPENED TO 3813 02:19:34,399 --> 02:19:38,971 THEM, AND THEN THAT THEY MAY 3814 02:19:38,971 --> 02:19:41,206 FEEL GREAT BUT HYPERTENSION CAN 3815 02:19:41,206 --> 02:19:43,709 BE ASYMPTOMATIC SOME OF THE 3816 02:19:43,709 --> 02:19:44,142 TIME. 3817 02:19:44,142 --> 02:19:45,611 I THINK AGAIN INTERVENTIONS OR 3818 02:19:45,611 --> 02:19:47,613 TRIALS WHERE WE FOCUS ON THE 3819 02:19:47,613 --> 02:19:50,349 PERSON THEMSELVES AND LIKE SELF 3820 02:19:50,349 --> 02:19:52,651 STRATEGIES, AND ALSO COMMUNITY 3821 02:19:52,651 --> 02:19:54,052 PARTNERS, HOW CAN COMMUNITY 3822 02:19:54,052 --> 02:19:56,255 PARTNERS HELP? 3823 02:19:56,255 --> 02:19:56,388 SH 3824 02:19:56,388 --> 02:20:00,859 >SH>> SO THANK YOU AGAIN TO OUR 3825 02:20:00,859 --> 02:20:02,261 PANELISTS HERE FOR THREE GREAT 3826 02:20:02,261 --> 02:20:03,729 TALKS TO GET THESE DISCUSSIONS 3827 02:20:03,729 --> 02:20:04,830 STARTED. 3828 02:20:04,830 --> 02:20:07,332 I DO WANT TO NOTE THAT IF YOU 3829 02:20:07,332 --> 02:20:09,434 HAVE A QUESTION AND YOU ARE NOT 3830 02:20:09,434 --> 02:20:11,870 A DISCUSSANT OR A MODERATOR, 3831 02:20:11,870 --> 02:20:16,475 YOU'LL NEED TO PUT THAT IN THE 3832 02:20:16,475 --> 02:20:17,910 CHAT AND WE'LL TRY TO GET TO 3833 02:20:17,910 --> 02:20:20,012 THOSE FOR THE FUTURE 3834 02:20:20,012 --> 02:20:22,414 DISCUSSIONS. 3835 02:20:22,414 --> 02:20:24,149 AND SO I BELIEVE WE HAVE A 3836 02:20:24,149 --> 02:20:25,484 10-MINUTE BREAK AND WE'LL BE 3837 02:20:25,484 --> 02:20:28,020 COMING BACK AT 12:30, BUT I'M 3838 02:20:28,020 --> 02:20:29,221 NOT ONE OF THE ORGANIZERS SO 3839 02:20:29,221 --> 02:20:31,957 I'LL TURN THAT OVER TO THE NHLBI 3840 02:20:31,957 --> 02:20:34,059 CREW FOR THAT. 3841 02:20:34,059 --> 02:20:35,761 >> THIS IS CORRECT. 3842 02:20:35,761 --> 02:20:39,031 SO LET US PROMPTLY RETURN AT 3843 02:20:39,031 --> 02:20:45,504 12:30 -- I'M SORRY, 1:30 OR 3844 02:20:45,504 --> 02:20:46,838 WHATEVER TIMING, 12:30, 1:30, 3845 02:20:46,838 --> 02:20:50,976 BUT IN ABOUT 8 MINUTES, AND 3846 02:20:50,976 --> 02:20:52,044 THAT'S TO SESSION NUMBER 2. 3847 02:20:52,044 --> 02:20:52,511 THANK YOU. 3848 02:20:52,511 --> 02:21:02,754 SEE YOU THEN. 3849 02:21:41,393 --> 02:21:43,428 THANK YOU. 3850 02:21:43,428 --> 02:21:45,430 I APPRECIATE THE INVITATION TO 3851 02:21:45,430 --> 02:21:48,500 SPEAK TO YOU ALL ABOUT THIS 3852 02:21:48,500 --> 02:21:48,834 MATTER. 3853 02:21:48,834 --> 02:21:50,836 CAN I HAVE THE NEXT SLIDE, 3854 02:21:50,836 --> 02:21:53,305 PLEASE. 3855 02:21:53,305 --> 02:21:57,676 NEXT ONE. 3856 02:21:57,676 --> 02:21:59,211 THESE ARE MY DISCLOSURES. 3857 02:21:59,211 --> 02:22:04,316 WE ONLY HAVE TIME FOR A VERY 3858 02:22:04,316 --> 02:22:07,452 BRIEF OVERVIEW OF THESE 3859 02:22:07,452 --> 02:22:09,688 AUTONOAUTO NOM 3860 02:22:09,988 --> 02:22:11,256 AUTONOMIC DISORDERS SO I'LL 3861 02:22:11,256 --> 02:22:14,926 HIGHLIGHT THE GAPS THAT NEED 3862 02:22:14,926 --> 02:22:16,261 IMPROVEMENT AS WE GO ALONG AND 3863 02:22:16,261 --> 02:22:18,296 THOSE ARE IN RED. 3864 02:22:18,296 --> 02:22:27,506 THE DISTRIBUTION OF ORTHOSTATIC 3865 02:22:27,506 --> 02:22:28,573 BLOOD PRESSURE CHANGES AND WE 3866 02:22:28,573 --> 02:22:30,742 FOCUS ON THE EXTREME ON THE 3867 02:22:30,742 --> 02:22:31,476 LEFT. 3868 02:22:31,476 --> 02:22:34,479 PATIENTS THAT HAVE A SIGNIFICANT 3869 02:22:34,479 --> 02:22:41,887 DROP IN BLOOD PRESSURE ON 3870 02:22:41,887 --> 02:22:46,658 STANDING AND THE PATIENTS ARE 3871 02:22:46,658 --> 02:22:51,029 SYMPTOMATIC AND CAN ONLY WALK 3872 02:22:51,029 --> 02:22:52,464 FOR A FEW SECONDS AND IMPACTS 3873 02:22:52,464 --> 02:22:53,932 QUALITY OF LIFE AND ASSOCIATED 3874 02:22:53,932 --> 02:22:56,101 WITH SIGNIFICANT RISK OF FALLS 3875 02:22:56,101 --> 02:22:59,237 AND DISABILITY IN THE ELDERLY 3876 02:22:59,237 --> 02:23:00,338 AND ALSO AN INDEPENDENT RISK 3877 02:23:00,338 --> 02:23:05,610 FACTOR FOR INCREASED MORTALITY. 3878 02:23:05,610 --> 02:23:09,080 STUDIES HAVE SHOWN ALSO THE 3879 02:23:09,080 --> 02:23:12,784 OTHER EXTREME ORTHOSTATIC 3880 02:23:12,784 --> 02:23:14,853 HYPERTENSION IS ASSOCIATE WITH 3881 02:23:14,853 --> 02:23:16,455 INCREASED RISK OF CARDIOVASCULAR 3882 02:23:16,455 --> 02:23:19,090 AND RENAL DISEASE AND ALSO AN 3883 02:23:19,090 --> 02:23:20,358 INDEPENDENT RISK FACTOR FOR 3884 02:23:20,358 --> 02:23:21,259 INCREASED MORTALITY. 3885 02:23:21,259 --> 02:23:23,295 THE DIFFERENCE BEING OF COURSE 3886 02:23:23,295 --> 02:23:28,300 THAT THESE PATIENTS ARE USUALLY 3887 02:23:28,300 --> 02:23:28,733 NOT SYMPTOMATIC. 3888 02:23:28,733 --> 02:23:31,102 THEY'RE ASYMPTOMATIC WITH THE 3889 02:23:31,102 --> 02:23:33,171 EXCEPTION OF YOUNGER PATIENTS WE 3890 02:23:33,171 --> 02:23:36,808 FOLLOW IN THE AUTONOMIC CENTER 3891 02:23:36,808 --> 02:23:46,284 WITH HYPERSYMPTOMS. 3892 02:23:46,284 --> 02:23:50,622 THE IMPAIRED AUTONOMIC REFLEXES 3893 02:23:50,622 --> 02:23:58,196 YOU ALMOST NEVER ARE ORTHOSTATIC 3894 02:23:58,196 --> 02:23:59,598 HYPERTENSION THAT CAN BE BY 3895 02:23:59,598 --> 02:24:01,766 AGING. 3896 02:24:01,766 --> 02:24:03,435 BUT OF COURSE THOSE PATIENTS 3897 02:24:03,435 --> 02:24:06,671 HAVE A SIGNIFICANT TROP IN BLOOD 3898 02:24:06,671 --> 02:24:08,874 PRESSURE WITH VERY LITTLE OR NO 3899 02:24:08,874 --> 02:24:11,042 INCREASE IN HEART RATE AND 3900 02:24:11,042 --> 02:24:20,185 THAT'S WHAT WE CALL NEUROGENIC 3901 02:24:20,185 --> 02:24:23,588 ORTHOSTATIC HYPERTENSION AND 3902 02:24:23,588 --> 02:24:28,093 CAN'T COMPENSATE FOR THE DROP IN 3903 02:24:28,093 --> 02:24:29,094 BLOOD PRESSURE AND SOME HAVE 3904 02:24:29,094 --> 02:24:30,462 SEEN A SIGNIFICANT INCREASE IN 3905 02:24:30,462 --> 02:24:33,365 HEART RATE AND THIS IS VERY 3906 02:24:33,365 --> 02:24:35,834 IMPORTANT TO MEASURE THAT NOT 3907 02:24:35,834 --> 02:24:37,602 ONLY THE BLOOD PRESSURE BUT 3908 02:24:37,602 --> 02:24:43,742 HEART RATE BECAUSE IT TELLS US 3909 02:24:43,742 --> 02:24:45,210 THERE'S AGGREGATING FACTORS THAT 3910 02:24:45,210 --> 02:24:48,547 NEED TO BE CORRECTED AND THAT 3911 02:24:48,547 --> 02:24:52,250 ALONE CAN IMPROVE ORTHOSTATIC 3912 02:24:52,250 --> 02:24:53,885 HYPERTENSION. 3913 02:24:53,885 --> 02:24:59,724 ON THE RIGHT SIDE IS THE 3914 02:24:59,724 --> 02:25:06,665 PATHOPHYSIOLOGY AND IN THE OLDER 3915 02:25:06,665 --> 02:25:09,234 HYPERTENSIVE SHOWING AORTIC 3916 02:25:09,234 --> 02:25:13,405 STIFFNESS AND IN THE YOUNGER 3917 02:25:13,405 --> 02:25:20,078 PATIENTS WITH HYPER MINERGIC SIN 3918 02:25:20,078 --> 02:25:21,146 SOME VERY HAVE HEART RATE AND 3919 02:25:21,146 --> 02:25:24,215 IT'S IMPORTANT TO MEASURE THE 3920 02:25:24,215 --> 02:25:24,449 VITALS. 3921 02:25:24,449 --> 02:25:25,684 IT'S RARELY DONE UNFORTUNATELY 3922 02:25:25,684 --> 02:25:31,056 AND ONE OF THE THINGS WE NEED TO 3923 02:25:31,056 --> 02:25:40,231 IMPROVE ON AND STUDY ORTHOSTATIC 3924 02:25:40,231 --> 02:25:40,832 HYPERTENSION. 3925 02:25:40,832 --> 02:25:42,767 SO ORTHOSTATIC HYPERTENSION IS 3926 02:25:42,767 --> 02:25:46,805 DEFINED AS A DROP IN SYSTOLIC 3927 02:25:46,805 --> 02:25:47,606 BLOOD PRESSURE 20 OR MORE WITHIN 3928 02:25:47,606 --> 02:25:54,546 THREE MINUTES OF STANDING. 3929 02:25:54,546 --> 02:25:55,947 THE DEFINITION HAS BEEN AROUND 3930 02:25:55,947 --> 02:25:57,849 FOR A WHILE AND TIME TESTED AND 3931 02:25:57,849 --> 02:26:03,922 PREDICTIVE OF ADVERSE OUTCOME IN 3932 02:26:03,922 --> 02:26:09,728 CLINICAL EPIDEMIOLOGICAL 3933 02:26:09,728 --> 02:26:10,061 STUDIES. 3934 02:26:10,061 --> 02:26:14,199 THE DEFINITION OF ORTHOSTATIC 3935 02:26:14,199 --> 02:26:16,368 HYPERTENSION IS MORE RECENT AND 3936 02:26:16,368 --> 02:26:18,870 WE PROPOSED A SUSTAINED INCREASE 3937 02:26:18,870 --> 02:26:25,043 IN SYSTOLIC BLOOD PRESSURE OF 20 3938 02:26:25,043 --> 02:26:29,014 MERCURY WITH SYSTOLIC BLOOD 3939 02:26:29,014 --> 02:26:34,119 PRESSURE GREATER THAN 140. 3940 02:26:34,119 --> 02:26:37,489 WE CAN ARGUE WHETHER IT PREDICTS 3941 02:26:37,489 --> 02:26:38,957 ADVERSE OUTCOME BUT THAT'S 3942 02:26:38,957 --> 02:26:39,858 SOMETHING THAT PROBABLY NEEDS 3943 02:26:39,858 --> 02:26:46,965 SOME REFINING OVER TIME. 3944 02:26:46,965 --> 02:26:52,437 HOW DO WE MAKE THE DIAGNOSIS? 3945 02:26:52,437 --> 02:26:53,171 WITH ORTHOSTATIC HYPERTENSION 3946 02:26:53,171 --> 02:26:54,706 MOST PATIENTS COME TO US AND 3947 02:26:54,706 --> 02:26:58,276 YOU'LL BE SURPRISED HOW LONG IT 3948 02:26:58,276 --> 02:27:04,149 TAKES PHYSICIANS TO RECOGNIZE 3949 02:27:04,149 --> 02:27:07,018 THE SYSTEMS AND MEASURE 3950 02:27:07,018 --> 02:27:08,787 ORTHOSTATIC VITALS BUT IT'S 3951 02:27:08,787 --> 02:27:09,921 USUALLY PRETTY EVIDENT 3952 02:27:09,921 --> 02:27:14,225 TYPICALLY. 3953 02:27:14,225 --> 02:27:21,232 ON THE OTHER HAND, THE 3954 02:27:21,232 --> 02:27:22,467 ORTHOSTATIC HYPERTENSION UNLESS 3955 02:27:22,467 --> 02:27:25,070 YOU ROUTINELY MEASURE VITALS 3956 02:27:25,070 --> 02:27:27,405 LIKE WE DO IN OUR CENTERS BUT 3957 02:27:27,405 --> 02:27:28,673 ALMOST NOBODY DOES THAT IS 3958 02:27:28,673 --> 02:27:31,042 BASICALLY A FINDING FROM 3959 02:27:31,042 --> 02:27:32,077 CLINICAL TRIALS. 3960 02:27:32,077 --> 02:27:38,450 THESE WERE CLINICAL TRIALS THAT 3961 02:27:38,450 --> 02:27:39,617 WERE DESIGN TO STUDY ORTHOSTATIC 3962 02:27:39,617 --> 02:27:41,653 HYPERTENSION AND NOW OF COURSE 3963 02:27:41,653 --> 02:27:44,622 YOU REALIZE YOU ALSO HAVE THE 3964 02:27:44,622 --> 02:27:45,657 PROBLEM OF ORTHOSTATIC 3965 02:27:45,657 --> 02:27:46,224 HYPERTENSION WHICH IS AS 3966 02:27:46,224 --> 02:27:46,524 IMPORTANT. 3967 02:27:46,524 --> 02:27:50,462 SO IT'S BEEN A FINDING IN 3968 02:27:50,462 --> 02:27:56,367 CLINICAL TRAILS. 3969 02:27:56,367 --> 02:27:59,571 IN TERMS OF DIAGNOSIS, WE CAN 3970 02:27:59,571 --> 02:28:01,706 MAKE SOME REFINEMENTS FOR 3971 02:28:01,706 --> 02:28:04,242 EXAMPLE WHAT IS THE OPTIMAL 3972 02:28:04,242 --> 02:28:08,780 DURATION TO DIAGNOSIS OR STUDY 3973 02:28:08,780 --> 02:28:09,114 HYPERTENSION. 3974 02:28:09,114 --> 02:28:13,918 THERE'S A FEW PATIENTS THAT HAVE 3975 02:28:13,918 --> 02:28:14,853 TRADE ORTHOSTATIC HYPERTENSION 3976 02:28:14,853 --> 02:28:16,554 AND IT'S HARD TO ARGUE TO CHANGE 3977 02:28:16,554 --> 02:28:19,391 THE WHOLE CLINICAL SETTING JUST 3978 02:28:19,391 --> 02:28:20,458 TO DIAGNOSIS THE FEW PATIENTS 3979 02:28:20,458 --> 02:28:28,633 BUT IN PATIENTS WITH CLASSICAL 3980 02:28:28,633 --> 02:28:30,068 SYMPTOMS AND RELIEF ON LYING 3981 02:28:30,068 --> 02:28:32,570 DOWN AND MEASURE THE VITALS AND 3982 02:28:32,570 --> 02:28:38,710 AUTHOR COMPLETELY NORMAL WE DO 3983 02:28:38,710 --> 02:28:43,715 SOMETIMES ORDER LONGERER -- 3984 02:28:43,715 --> 02:28:47,986 LONGER TESTS AND IT'S MEASURE TO 3985 02:28:47,986 --> 02:28:51,456 MEASURE ORTHOSTATIC VITALS BUT 3986 02:28:51,456 --> 02:28:52,724 IT'S ALMOST NEVER DONE EVEN IN 3987 02:28:52,724 --> 02:28:55,960 PATIENTS THAT NEED IT. 3988 02:28:55,960 --> 02:28:59,631 WE HAVE TO FIGHT IN OUR CLINIC 3989 02:28:59,631 --> 02:29:04,702 TO IMPLEMENT THE MEASUREMENT OF 3990 02:29:04,702 --> 02:29:09,641 ORTHOSTATIC VITALS. 3991 02:29:09,641 --> 02:29:14,179 SO SO TO ME THE BEST RETURN ON 3992 02:29:14,179 --> 02:29:17,382 INVESTMENT WOULD BE TO DEFINE 3993 02:29:17,382 --> 02:29:21,219 CRITERIA FROM SEATED TO STANDING 3994 02:29:21,219 --> 02:29:21,719 BLOOD PRESSURE. 3995 02:29:21,719 --> 02:29:23,822 BECAUSE THAT WILL FACILITATE 3996 02:29:23,822 --> 02:29:30,195 ENORMOUSLY THE DIAGNOSIS IN 3997 02:29:30,195 --> 02:29:32,030 CLINIC AND RESEARCH TRIALS. 3998 02:29:32,030 --> 02:29:33,965 IT WILL BE ADDING JUST ONE 3999 02:29:33,965 --> 02:29:35,300 MEASUREMENT OR TWO OR THREE, 4000 02:29:35,300 --> 02:29:38,603 WHATEVER STANDING. 4001 02:29:38,603 --> 02:29:40,104 OPPOSED TO HAVING THE PATIENT 4002 02:29:40,104 --> 02:29:41,639 LIE DOWN FOR 15 MINUTES IS 4003 02:29:41,639 --> 02:29:43,374 ALMOST IMPOSSIBLE TO DO. 4004 02:29:43,374 --> 02:29:46,477 FOR MY MONEY, THIS WOULD BE THE 4005 02:29:46,477 --> 02:29:50,215 BEST IMPROVEMENT WE CAN MAKE TO 4006 02:29:50,215 --> 02:29:57,755 DEFINE CRITERIA, DIAGNOSE THE 4007 02:29:57,755 --> 02:29:58,990 CRITERIA USING SEATED TO 4008 02:29:58,990 --> 02:30:00,191 STANDING RATHER LYING IT 4009 02:30:00,191 --> 02:30:00,558 STANDING. 4010 02:30:00,558 --> 02:30:03,094 WHO SHOULD BE SCREENED? 4011 02:30:03,094 --> 02:30:09,400 AGAIN, WE FIND IT'S VERY HARD TO 4012 02:30:09,400 --> 02:30:12,837 IMPLEMENT MEASURE IN ORTHOSTATIC 4013 02:30:12,837 --> 02:30:14,973 VITALS AND A PATIENT WITH 4014 02:30:14,973 --> 02:30:18,943 SYMPTOMS AND LIGHT HEADEDNESS IS 4015 02:30:18,943 --> 02:30:21,746 THE TYPICAL ONE BUT YOU'D BE 4016 02:30:21,746 --> 02:30:23,781 SURPRISED HOW TENSION DOESN'T 4017 02:30:23,781 --> 02:30:26,851 DESCRIBE THE SYMPTOMS AS LIGHT 4018 02:30:26,851 --> 02:30:28,720 HEADEDNESS BUT FATIGUE OR PAIN 4019 02:30:28,720 --> 02:30:31,823 IN THE BACK OF THE NECK. 4020 02:30:31,823 --> 02:30:34,859 ANY SYMPTOMS THAT WORSENS AND 4021 02:30:34,859 --> 02:30:38,296 IMPROVES BY SITTING OR LYING 4022 02:30:38,296 --> 02:30:43,101 DOWN WE NEED TO MEASURE 4023 02:30:43,101 --> 02:30:44,936 ORTHOSTATIC MEASUREMENTS AND 4024 02:30:44,936 --> 02:30:46,371 THERE'S STUDIES SHOWING PATIENTS 4025 02:30:46,371 --> 02:30:56,915 WHO GO TO THE E.R. FOR SYNCHOPE 4026 02:31:04,656 --> 02:31:06,424 AND IT CAN IMPROVE QUALITY OF 4027 02:31:06,424 --> 02:31:16,167 LIFE. 4028 02:31:16,167 --> 02:31:18,469 IT'S A QUESTION WHO SHOULD BE 4029 02:31:18,469 --> 02:31:19,404 SCREENED BECAUSE THERE'S NO 4030 02:31:19,404 --> 02:31:21,239 SYMPTOMS OR QUALITY OF LIFE TO 4031 02:31:21,239 --> 02:31:24,709 IMPROVE SO WHAT IS THE VALUE OF 4032 02:31:24,709 --> 02:31:26,077 FINDING THIS AND IS IT 4033 02:31:26,077 --> 02:31:27,779 ACTIONABLE FOR SOMETHING WE NEED 4034 02:31:27,779 --> 02:31:29,147 TO DO DIFFERENTLY? 4035 02:31:29,147 --> 02:31:33,384 IN YOUNG PATIENTS THERE'S SOME 4036 02:31:33,384 --> 02:31:35,253 EVIDENCE BY OTHERS THAT IT DOES 4037 02:31:35,253 --> 02:31:38,222 PREDICT THE FUTURE DEVELOPMENT 4038 02:31:38,222 --> 02:31:38,923 OF HYPERTENSION. 4039 02:31:38,923 --> 02:31:47,065 SO THAT MIGHT BE ANOTHER VALUE. 4040 02:31:47,065 --> 02:31:49,200 WHAT WE DO? 4041 02:31:49,200 --> 02:31:52,303 SHOULD WE TO MORE INTENSIVE 4042 02:31:52,303 --> 02:31:53,504 BLOOD PRESSURE CONTROL. 4043 02:31:53,504 --> 02:31:57,909 THE STUDIES SHOW YOU EVEN IN 4044 02:31:57,909 --> 02:32:03,348 REGULAR HYPERTENSION WITHOUT 4045 02:32:03,348 --> 02:32:04,415 ST 4046 02:32:04,415 --> 02:32:06,284 STUDYING HYPERTENSION YOU SHOULD 4047 02:32:06,284 --> 02:32:10,388 DO MORE AND COULD IT BE WE NEED 4048 02:32:10,388 --> 02:32:13,057 TO USE BLOOD PRESSURE OUTCOME AS 4049 02:32:13,057 --> 02:32:14,359 OPPOSED TO SEAT AND THE BLOOD 4050 02:32:14,359 --> 02:32:16,861 PRESSURE WILL BE HIGHER ARE ALL 4051 02:32:16,861 --> 02:32:27,372 QUESTIONS WE NEED TO RESOLVE. 4052 02:32:28,139 --> 02:32:33,711 THE DIFFERENCE BETWEEN BOTH 4053 02:32:33,711 --> 02:32:36,481 EXTREMES IS ORTHOSTATIC 4054 02:32:36,481 --> 02:32:37,181 HYPERTENSION IS A NATURAL 4055 02:32:37,181 --> 02:32:39,350 FINDING AND WHAT DO WE DO WITH 4056 02:32:39,350 --> 02:32:39,651 THE FINDING? 4057 02:32:39,651 --> 02:32:41,085 BUT THERE'S RESEARCH WE NEED TO 4058 02:32:41,085 --> 02:32:50,995 DO TO DEFINE THESE THINGS. 4059 02:32:50,995 --> 02:32:53,865 IN TERMS OF MANAGEMENT GAPS AND 4060 02:32:53,865 --> 02:32:56,701 I APOLOGIZE THIS SHOULD HAVE 4061 02:32:56,701 --> 02:32:58,202 BEEN ON THE LEFT BUT THAT'S 4062 02:32:58,202 --> 02:33:00,138 OKAY. 4063 02:33:00,138 --> 02:33:02,140 THE CHALLENGE YOU CAN UNDERSTAND 4064 02:33:02,140 --> 02:33:06,878 THERE'S A CHALLENGE IN TREATING 4065 02:33:06,878 --> 02:33:07,678 ORTHOSTATIC HYPERTENSION IN 4066 02:33:07,678 --> 02:33:09,247 PATIENTS WITH HYPERTENSION WHICH 4067 02:33:09,247 --> 02:33:14,452 ARE THE MOST COMMON CLINICAL 4068 02:33:14,452 --> 02:33:14,686 FINDING. 4069 02:33:14,686 --> 02:33:16,454 MOST PATIENTS WITH ORTHOSTATIC 4070 02:33:16,454 --> 02:33:17,455 HYPERTENSION WILL HAVE SOME 4071 02:33:17,455 --> 02:33:21,359 HYPERTENSION SOMETIMES VERY 4072 02:33:21,359 --> 02:33:21,592 SEVERE. 4073 02:33:21,592 --> 02:33:25,897 SO WHAT MEDICINES CAN WE USE TO 4074 02:33:25,897 --> 02:33:26,531 TREAT ORTHOSTATIC HYPERTENSION 4075 02:33:26,531 --> 02:33:36,974 WITHOUT WORSENING SUPINE 4076 02:33:38,276 --> 02:33:39,777 HYPERTENSION AND THE WORSE WILL 4077 02:33:39,777 --> 02:33:44,682 WORSEN IT MORE THAN IMPROVE 4078 02:33:44,682 --> 02:33:46,217 STANDING BLOOD PRESSURE. 4079 02:33:46,217 --> 02:33:50,021 AND THOSE ARE THE ONLY TWO FDA 4080 02:33:50,021 --> 02:33:51,322 APPROVED DRUGS. 4081 02:33:51,322 --> 02:33:54,892 THEY BOTH HAVE A WARNING FOR 4082 02:33:54,892 --> 02:33:56,727 SUPINE HYPERTENSION. 4083 02:33:56,727 --> 02:33:58,463 WE NEED TO DEVELOP OTHER 4084 02:33:58,463 --> 02:33:59,063 MEDICATIONS THAT WILL DO A 4085 02:33:59,063 --> 02:34:04,335 BETTER JOB. 4086 02:34:04,335 --> 02:34:05,269 DIAGNOSTIC MEANS ARE PROBABLY 4087 02:34:05,269 --> 02:34:09,040 THE BEST AND THE STUDIES WE HAVE 4088 02:34:09,040 --> 02:34:11,242 DONE RECENTLY ARE LESS EFFECTIVE 4089 02:34:11,242 --> 02:34:12,210 IN PATIENTS WITH HYPERTENSION 4090 02:34:12,210 --> 02:34:14,679 WHICH IS WHERE THEY'LL BE MOSTLY 4091 02:34:14,679 --> 02:34:16,247 NEEDED. 4092 02:34:16,247 --> 02:34:21,919 THERE'S NEW STUDIES THEN WITH 4093 02:34:21,919 --> 02:34:23,955 INHIBITORS LIKE TAMOXIFEN THAT 4094 02:34:23,955 --> 02:34:29,627 PLAY BE -- MAY BE HELPFUL AND 4095 02:34:29,627 --> 02:34:30,261 IMPROVE STANDING BLOOD PRESSURE. 4096 02:34:30,261 --> 02:34:36,100 NEXT SLIDE. 4097 02:34:36,100 --> 02:34:41,272 HOW CAN WE TREAT HYPERTENSION 4098 02:34:41,272 --> 02:34:42,473 WITHOUT WORSENING ORTHOSTATIC 4099 02:34:42,473 --> 02:34:44,609 HYPERTENSION? 4100 02:34:44,609 --> 02:34:46,711 IN THE MAJORITY OF THE 4101 02:34:46,711 --> 02:34:47,545 HYPERTENSIVE THERE'S EVIDENCE 4102 02:34:47,545 --> 02:34:50,481 YOU SHOULD NOT STOP AT THE 4103 02:34:50,481 --> 02:34:52,116 HYPERTENSION WHICH IS A COMMON 4104 02:34:52,116 --> 02:34:53,651 MISTAKE AND DO INTENSE BLOOD 4105 02:34:53,651 --> 02:34:59,657 PRESSURE CONTROL WITHOUT 4106 02:34:59,657 --> 02:35:01,959 TRIGGERING ORTHOSTATIC 4107 02:35:01,959 --> 02:35:03,661 HYPERTENSION AND SOME 4108 02:35:03,661 --> 02:35:05,997 HYPERTENSION SHOULD BE REFERRED 4109 02:35:05,997 --> 02:35:07,598 MORE THAN OTHERS AND THERE'S A 4110 02:35:07,598 --> 02:35:14,472 LIST WE PUBLISHED WITH STEVEN IN 4111 02:35:14,472 --> 02:35:18,943 AN AMERICAN HEART GUIDANCE 4112 02:35:18,943 --> 02:35:20,678 DOCUMENT BUT THERE'S SOME 4113 02:35:20,678 --> 02:35:28,586 RATIONALE FOR IT BUT IT WILL BE 4114 02:35:28,586 --> 02:35:30,054 GOOD TO HAVE SOMEBODY BASED. 4115 02:35:30,054 --> 02:35:32,223 IT'S IMPORTANT TO REALIZE IN 4116 02:35:32,223 --> 02:35:36,394 THOSE STUDIES PATIENTS WITH 4117 02:35:36,394 --> 02:35:36,894 SIGNIFICANT ORTHOSTATIC 4118 02:35:36,894 --> 02:35:41,332 HYPERTENSION WERE EXCLUDED FROM 4119 02:35:41,332 --> 02:35:43,267 THOSE STUDIES. 4120 02:35:43,267 --> 02:35:46,470 SOME HAVE SEVERE ORTHOSTATIC 4121 02:35:46,470 --> 02:35:48,573 HYPERTENSION AND HYPERTENSION. 4122 02:35:48,573 --> 02:35:53,044 AND THE INTERESTING THING IS THE 4123 02:35:53,044 --> 02:35:58,449 SUPINE NOCTURNAL HYPERTENSION 4124 02:35:58,449 --> 02:36:00,718 INDUCES DAYTIME ORTHOSTATIC 4125 02:36:00,718 --> 02:36:06,857 HYPERTENSION BECAUSE THE SUPINE 4126 02:36:06,857 --> 02:36:14,565 BLOOD PRESSURE INDUCES THE 4127 02:36:14,565 --> 02:36:15,900 ORTHOSTATIC HYPERTENSION AS A 4128 02:36:15,900 --> 02:36:19,370 RESULT DURING THE DAY IT'S 4129 02:36:19,370 --> 02:36:19,570 WORSE. 4130 02:36:19,570 --> 02:36:25,876 AND THIS DEFINES YEARS OF WORK 4131 02:36:25,876 --> 02:36:29,647 AND WE HAVE TRIED TO REDUCE 4132 02:36:29,647 --> 02:36:30,481 NOCTURNAL HYPERTENSION AND A LOT 4133 02:36:30,481 --> 02:36:35,653 OF THEM DO THAT BUT NONE REDUCE 4134 02:36:35,653 --> 02:36:46,163 BLOOD PRESSURE AND THESE ARE 4135 02:37:05,650 --> 02:37:07,151 LONG-TERM EFFICACY. 4136 02:37:07,151 --> 02:37:10,087 LET ME STOP BECAUSE OF TIME 4137 02:37:10,087 --> 02:37:11,656 CONSTRAINTS AND BE HAPPY TO 4138 02:37:11,656 --> 02:37:12,523 ANSWER QUESTIONS IN THE PANEL 4139 02:37:12,523 --> 02:37:14,458 SECTION. 4140 02:37:14,458 --> 02:37:16,327 THANK YOU. 4141 02:37:16,327 --> 02:37:23,634 >> THANK YOU FOR A FANTASTIC 4142 02:37:23,634 --> 02:37:24,407 PRESENTATION. 4143 02:37:24,407 --> 02:37:27,771 WE CAN GO TO THE NEXT -- OKAY, 4144 02:37:27,771 --> 02:37:28,238 THANK YOU. 4145 02:37:28,238 --> 02:37:31,942 SO NEXT WE HAVE DR. DART, WHO 4146 02:37:31,942 --> 02:37:34,011 WILL BE SPEAKING ON THE 4147 02:37:34,011 --> 02:37:35,279 MEASUREMENTS OF BLOOD PRESSURE 4148 02:37:35,279 --> 02:37:36,714 IN THE OBESE AND WEIGHT LOSS, 4149 02:37:36,714 --> 02:37:38,549 THE CLINICAL CHALLENGE. 4150 02:37:38,549 --> 02:37:40,084 SO WITHOUT FURTHER ADO, I'LL 4151 02:37:40,084 --> 02:37:42,353 TURN THINGS OVER TO DR. DART. 4152 02:37:42,353 --> 02:37:44,655 >> THANKS, PAUL. 4153 02:37:44,655 --> 02:37:45,422 AND THANK YOU. 4154 02:37:45,422 --> 02:37:47,758 I'M DICK DART, I'M AT THE CENTER 4155 02:37:47,758 --> 02:37:50,728 FOR PRECISION MEDICINE, 4156 02:37:50,728 --> 02:37:51,595 MARSHFIELD CLINIC RESEARCH 4157 02:37:51,595 --> 02:37:56,734 INSTITUTE AND MARSHFIELD CLINIC 4158 02:37:56,734 --> 02:37:58,235 HEALTH SYSTEM. 4159 02:37:58,235 --> 02:38:03,140 THESE ARE MY DISCLOSURES. 4160 02:38:03,140 --> 02:38:07,077 I'M CHAIR OF THE ISO LARGE ARM 4161 02:38:07,077 --> 02:38:09,179 DEFINITION TASK FORCE AND MOTION 4162 02:38:09,179 --> 02:38:10,280 ARTIFACT SUBCOMMITTEE AND ALSO A 4163 02:38:10,280 --> 02:38:12,049 MEMBER OF THE AMA VALIDATED 4164 02:38:12,049 --> 02:38:13,484 DEVICE LISTING INDEPENDENT 4165 02:38:13,484 --> 02:38:14,418 REVIEW COMMITTEE BUT I HAVE NO 4166 02:38:14,418 --> 02:38:19,323 OTHER CONFLICTS. 4167 02:38:19,323 --> 02:38:24,128 IT WAS VON WRECKLING HAW 16 THAT 4168 02:38:24,128 --> 02:38:25,829 OWE HAD MADE AN ERROR IN THE 4169 02:38:25,829 --> 02:38:27,598 SIZE OF CUFF HE HAD FOR HIS 4170 02:38:27,598 --> 02:38:30,000 BLOOD PRESSURE DEVICE THAT IT 4171 02:38:30,000 --> 02:38:31,068 READ BLOOD PRESSURES TOO HIGH, 4172 02:38:31,068 --> 02:38:32,603 IT WAS ACTUALLY RICHARD DAY IN 4173 02:38:32,603 --> 02:38:34,772 THE JOURN JOURNAL OF PEDIATRICSN 4174 02:38:34,772 --> 02:38:35,973 1939 WHO IND IND KATEED THAT ONE 4175 02:38:35,973 --> 02:38:37,675 SHOULD SELECT A CUFF FROM 4176 02:38:37,675 --> 02:38:38,676 THEWITZ GIVEN READINGS ON THE 4177 02:38:38,676 --> 02:38:40,611 FLAT PART OF THE CURVE AND FOR 4178 02:38:40,611 --> 02:38:41,378 PRACTICAL PURPOSES THIS MEANS 4179 02:38:41,378 --> 02:38:43,213 THE USE OF A CUFF WHICH IS AS 4180 02:38:43,213 --> 02:38:47,685 WIDE AS WILL FIT THE ARM WITHOUT 4181 02:38:47,685 --> 02:38:49,520 IMPINGING ON THE ELBOW AND 4182 02:38:49,520 --> 02:38:51,055 AXILLA, AND THOSE LAST TWO 4183 02:38:51,055 --> 02:38:53,657 POINTS ARE GOING TO BE ONES THAT 4184 02:38:53,657 --> 02:38:55,159 I'M EMPHASIZING AS WE GO ON. 4185 02:38:55,159 --> 02:38:57,461 SO THE PROBLEM WITH THE LARGE OR 4186 02:38:57,461 --> 02:38:59,229 OBESE ARM, THERE IS NO 4187 02:38:59,229 --> 02:39:00,330 UNIVERSALLY ACCEPTED DEFINITION 4188 02:39:00,330 --> 02:39:02,232 FOR LARGE ARMS, NOT REALLY. 4189 02:39:02,232 --> 02:39:04,201 THERE ARE DEFINITION PROPOSAL, 4190 02:39:04,201 --> 02:39:05,636 SOME OF WHICH I'LL BE 4191 02:39:05,636 --> 02:39:07,237 DISCUSSING, THE MANUSCRIPT WAS 4192 02:39:07,237 --> 02:39:09,673 ALSO IN PROGRESS AND THAT IS 4193 02:39:09,673 --> 02:39:10,641 NOTED BELOW. 4194 02:39:10,641 --> 02:39:14,812 DOES THE LARGE ARM INCLUDE 4195 02:39:14,812 --> 02:39:24,788 CHILDREN AND ADOLESCENTS, AS DRP 4196 02:39:24,788 --> 02:39:29,960 AND GROW OUT BUT BY THE TIME 4197 02:39:29,960 --> 02:39:38,969 THEY GET TO US THEY'VE GROWN UP 4198 02:39:38,969 --> 02:39:41,271 AND -- HAVE COMMENTED RECENTLY. 4199 02:39:41,271 --> 02:39:44,541 AMONGST MANY ARTICLES, STEPHEN 4200 02:39:44,541 --> 02:39:45,609 JURASCHEK COMMENTED ON ONE OF 4201 02:39:45,609 --> 02:39:47,778 THE MANY EXAMINING EXISTING CUFF 4202 02:39:47,778 --> 02:39:50,414 SYSTEMS AND THE ERRORS IN THE 4203 02:39:50,414 --> 02:39:50,948 AMERICAN HEART ASSOCIATION 4204 02:39:50,948 --> 02:39:52,249 GUIDELINES EXIST OVER A WIDE 4205 02:39:52,249 --> 02:39:53,650 RANGE OF ARMS AND SIZES AND 4206 02:39:53,650 --> 02:39:55,519 NOTING THE NEED FOR A PROPER 4207 02:39:55,519 --> 02:39:57,755 CUFF IN SYSTEMS AND VALIDATION 4208 02:39:57,755 --> 02:40:00,190 STUDIES. 4209 02:40:00,190 --> 02:40:03,761 SO THE UNIVERSAL STANDARDS FOR 4210 02:40:03,761 --> 02:40:04,561 BLOOD PRESSURE VALIDATIONS 4211 02:40:04,561 --> 02:40:06,697 REALLY AT THIS POINT HAVE USED 4212 02:40:06,697 --> 02:40:09,867 42 CENTIMETERS OR LARGER FOR ARM 4213 02:40:09,867 --> 02:40:10,968 CIRCUMFERENCE AS ONE DEFINITION. 4214 02:40:10,968 --> 02:40:13,370 HOWEVER, WE ARE PROPOSING A MUCH 4215 02:40:13,370 --> 02:40:16,940 MORE DEFINED CONSIDERATION WITH 4216 02:40:16,940 --> 02:40:18,475 MID UPPER ARM CIRCUMFERENCE 4217 02:40:18,475 --> 02:40:19,877 WHICH VARIES OVER A WIDE RANGE 4218 02:40:19,877 --> 02:40:22,579 AND IS NOT LIMITED TO AN UPPER 4219 02:40:22,579 --> 02:40:23,447 SIZE THOUGH IT GENERALLY IS 4220 02:40:23,447 --> 02:40:25,649 GOING TO BE UP AT LEAST 4221 02:40:25,649 --> 02:40:27,384 SOMEWHERE AROUND 50 TO 55 TO BE 4222 02:40:27,384 --> 02:40:29,353 TRULY LARGE. 4223 02:40:29,353 --> 02:40:37,561 THE INNER ARM, THE PHYSICAL 4224 02:40:37,561 --> 02:40:39,163 STATURE COMES INTO PLAY WITH 4225 02:40:39,163 --> 02:40:41,665 SOME OF THE RECENT STUFF THAT 4226 02:40:41,665 --> 02:40:42,432 PALLATINI AND COLLEAGUES HAVE 4227 02:40:42,432 --> 02:40:43,634 DONE. 4228 02:40:43,634 --> 02:40:44,935 ADDITIONALLY THERE'S BEEN 4229 02:40:44,935 --> 02:40:47,304 REFINEMENT VERSUS THE 4230 02:40:47,304 --> 02:40:54,111 CYLINDRICAL SHAPE OF THE ARM AND 4231 02:40:54,111 --> 02:40:55,979 ARMS IN GENERAL BUT PARTICULARLY 4232 02:40:55,979 --> 02:41:01,652 APPLIED TO LARGE ARMS. 4233 02:41:01,652 --> 02:41:07,324 NOW ONE OF THE THINGS IS THE 4234 02:41:07,324 --> 02:41:09,693 BLADDER WIDTH WAS AT LEAST COT 4235 02:41:09,693 --> 02:41:13,964 FIED IN '76 AND '78 TAKING 4236 02:41:13,964 --> 02:41:15,532 MOSTLY AUSCULTATORY DATA AND 4237 02:41:15,532 --> 02:41:17,534 USING A SWEET SPOT OF ABOUT 40% 4238 02:41:17,534 --> 02:41:23,440 OF THE ARM CIRCUMFERENCE, WOULD 4239 02:41:23,440 --> 02:41:24,842 THE -- BLOOD PRESSURE READINGS. 4240 02:41:24,842 --> 02:41:27,444 MORE RECENTLY THEY TOOK THIS A 4241 02:41:27,444 --> 02:41:30,180 BIT FURTHER AND USING RADIAL ART 4242 02:41:30,180 --> 02:41:32,583 REA BLOOD PRESSURES TO COMPARE 4243 02:41:32,583 --> 02:41:34,117 THE ARM CIRCUMFERENCE WIDTH 4244 02:41:34,117 --> 02:41:35,586 RATIO AND IT CAME OUT FAIRLY 4245 02:41:35,586 --> 02:41:41,158 CLOSE TO THIS 40%, AND THAT WAS 4246 02:41:41,158 --> 02:41:45,229 SUPPORTED BY ALPERT, IT WOULD 4247 02:41:45,229 --> 02:41:46,697 HAVE BEEN NICER TO AS HE NOTES 4248 02:41:46,697 --> 02:41:48,131 TO USE BRACHIAL ARTERY STUDIES 4249 02:41:48,131 --> 02:41:50,801 BUT THAT IS NOT REASONABLE IN A 4250 02:41:50,801 --> 02:41:51,802 CLINICAL SETTING. 4251 02:41:51,802 --> 02:41:53,770 THE CRITICAL ISSUE IS REALLY THE 4252 02:41:53,770 --> 02:41:56,473 SWEET SPOT FOR MOST ACCURATE 4253 02:41:56,473 --> 02:41:58,308 BLOOD PRESSURE LIES BETWEEN 37% 4254 02:41:58,308 --> 02:42:08,685 AND 50% OF BLOOD WITH ARMS -- 4255 02:42:08,685 --> 02:42:11,088 HOWEVER, BWACR IS NOT THE SOLE 4256 02:42:11,088 --> 02:42:12,823 PARAMETER REQUIRED BY CUFFS TO 4257 02:42:12,823 --> 02:42:13,590 OBTAIN ACCURATE BLOOD PRESSURE 4258 02:42:13,590 --> 02:42:14,324 MEASUREMENT. 4259 02:42:14,324 --> 02:42:15,559 AND THIS VERY BRIEFLY IS A SLIDE 4260 02:42:15,559 --> 02:42:18,562 THAT SHOWS THAT THE INNER ARM 4261 02:42:18,562 --> 02:42:27,004 LENGTH OR THE ARM CIRCUMFERENCE, 4262 02:42:27,004 --> 02:42:29,072 SHOWS A VIRTUAL LINEAR CONDITION 4263 02:42:29,072 --> 02:42:30,807 BETWEEN INNER ARM LENGTH, UPPER 4264 02:42:30,807 --> 02:42:33,410 ARM LENGTH, AND MID ARM 4265 02:42:33,410 --> 02:42:34,611 CIRCUMFERENCE, BELOW WHICH ANY 4266 02:42:34,611 --> 02:42:37,881 CUFF THAT WOULD BE IN THIS AREA 4267 02:42:37,881 --> 02:42:40,050 WILL NOT BE ABLE TO BE USED FOR 4268 02:42:40,050 --> 02:42:41,118 AN AUSCULTATORY REFERENCE, IT 4269 02:42:41,118 --> 02:42:43,654 GOING TO COME OVER THE TIP OF 4270 02:42:43,654 --> 02:42:45,389 THE ANTECUBITAL FOSSA AND LIKELY 4271 02:42:45,389 --> 02:42:49,326 NOT FIT UP INTO THE ACTS -- 4272 02:42:49,326 --> 02:42:51,628 WITHOUT PRESSING UP INTO THE 4273 02:42:51,628 --> 02:42:54,131 AXILLA. 4274 02:42:54,131 --> 02:42:58,335 SO THE NEXT COMPONENT IS THE 4275 02:42:58,335 --> 02:42:59,236 TRONCO-CONICAL SHAPE OF THE 4276 02:42:59,236 --> 02:43:01,905 UPPER ARM. 4277 02:43:01,905 --> 02:43:11,148 THEY DESIGNED A TRAP TRAPEZOIDL 4278 02:43:11,148 --> 02:43:15,953 CUFF, AND THEY SHOWED THEM TO BE 4279 02:43:15,953 --> 02:43:17,921 MORE ACCURATE IN LARGE ARMS THAN 4280 02:43:17,921 --> 02:43:18,889 THE CYLINDRICAL CUFFS. 4281 02:43:18,889 --> 02:43:20,857 HOWEVER IT WAS MAXWELL AND MORE 4282 02:43:20,857 --> 02:43:24,428 RECENTLY PALATINI AND COLLEAGUES 4283 02:43:24,428 --> 02:43:29,232 WHO MEASURED NUMEROUS STUDIES, 4284 02:43:29,232 --> 02:43:38,809 YET -- REMAINS TO BE ELUSIVE 4285 02:43:38,809 --> 02:43:39,476 THOUGH A SIGNIFICANT STEP 4286 02:43:39,476 --> 02:43:41,345 FORWARD AS WAS NOTED BY TAMMY 4287 02:43:41,345 --> 02:43:44,614 BRADY AND SANDRA TAYLOR, THE 4288 02:43:44,614 --> 02:43:46,216 RECENT STUDY MENTIONED BY 4289 02:43:46,216 --> 02:43:49,286 DR. FLYNN EARLIER DONE IN 4290 02:43:49,286 --> 02:43:50,921 PEDIATRICS, THERE WERE ONLY 4291 02:43:50,921 --> 02:43:54,424 SEVEN CHILDREN IN WHICH THE 4292 02:43:54,424 --> 02:43:56,994 TRUNK OF -- THE CUFF WAS USED 4293 02:43:56,994 --> 02:43:59,396 AND THEY DIDN'T FIND A 4294 02:43:59,396 --> 02:43:59,696 DIFFERENCE. 4295 02:43:59,696 --> 02:44:01,832 THAT HAS NOT BEEN PROVEN WITH 4296 02:44:01,832 --> 02:44:05,068 THE CASE WITH -- THEY'VE USED 4297 02:44:05,068 --> 02:44:06,370 PAPER THIN SENSORS UNDER THE 4298 02:44:06,370 --> 02:44:10,440 SPECIAL CUFFS TO ASSESS FOR EVEN 4299 02:44:10,440 --> 02:44:16,013 PRESSURE DISTRIBUTION AND IT 4300 02:44:16,013 --> 02:44:17,748 SUGGESTS THIS MIGHT SERVE AS A 4301 02:44:17,748 --> 02:44:20,617 VALIDATION CUFF YET THRAWS A 4302 02:44:20,617 --> 02:44:22,119 GOOD BIT MORE WORK TO BE DONE ON 4303 02:44:22,119 --> 02:44:22,319 THIS. 4304 02:44:22,319 --> 02:44:23,820 AND THIS IS WHY IT MAKES IT A 4305 02:44:23,820 --> 02:44:24,821 LITTLE EASIER TO UNDERSTAND. 4306 02:44:24,821 --> 02:44:27,024 IF YOU THINK OF AN ARM AS 4307 02:44:27,024 --> 02:44:28,258 CYLINDRICAL AND A CUP FITS 4308 02:44:28,258 --> 02:44:31,795 AROUND IT, THAT'S GOING TO BE 4309 02:44:31,795 --> 02:44:33,530 FAIRLY LARGER, THAT CUFF BEGINS 4310 02:44:33,530 --> 02:44:35,732 TO GET A LITTLE BIT MORE 4311 02:44:35,732 --> 02:44:37,567 EXPANDED AT THE UPPER END BUT BY 4312 02:44:37,567 --> 02:44:42,372 THE TIME YOU GET TO THE VERY -- 4313 02:44:42,372 --> 02:44:46,043 JUST CLEARLY PHYSICALLY CANNOT 4314 02:44:46,043 --> 02:44:46,710 SATISFACTORILY ENCASE THIS KIND 4315 02:44:46,710 --> 02:44:49,679 OF AN ARM AND THAT IS ONE OF THE 4316 02:44:49,679 --> 02:44:52,182 REASONS WHY WE'RE PROSING A 4317 02:44:52,182 --> 02:44:59,723 TRUNK OF CONICAL COMPONENT. 4318 02:44:59,723 --> 02:45:00,791 SO THIS TURNS US TO THE PROBLEM 4319 02:45:00,791 --> 02:45:02,592 OF OBESITY AND OVERWEIGHT. 4320 02:45:02,592 --> 02:45:07,898 THAT WAS ALLUDED TO BY DR. FL 4321 02:45:07,898 --> 02:45:09,966 DR. FLYNN, IT'S BEEN INCREASING 4322 02:45:09,966 --> 02:45:13,370 FOR DECADE, THERE'S CONCOMITANT 4323 02:45:13,370 --> 02:45:14,571 CO-MORBID, THERE'S TYPE 4324 02:45:14,571 --> 02:45:15,772 2 DIABETES, CARDIAC AND RENAL 4325 02:45:15,772 --> 02:45:17,774 DISEASE AND THE EFFECT OF 4326 02:45:17,774 --> 02:45:22,446 OBESITY AS A CAUSAL FACTOR IN 4327 02:45:22,446 --> 02:45:23,513 HIGH BLOOT, I WILL MENTION THAT 4328 02:45:23,513 --> 02:45:24,815 THE REFERENCE I LOOKED AT, WHICH 4329 02:45:24,815 --> 02:45:28,785 IS BY HALL, ET AL., IN 2024, IS 4330 02:45:28,785 --> 02:45:30,954 AN OUTSTANDING REVIEW OF THE 4331 02:45:30,954 --> 02:45:34,991 COMPLEX INTERACTIONS OF OBESITY 4332 02:45:34,991 --> 02:45:36,326 IN HYPERTENSION AND REMAINING 4333 02:45:36,326 --> 02:45:36,626 DISEASES. 4334 02:45:36,626 --> 02:45:39,463 IT HAS AN IMPACT ON THE CUFF 4335 02:45:39,463 --> 02:45:40,797 SIZE REQUIREMENTS AND THE 4336 02:45:40,797 --> 02:45:41,465 EFFECTIVE WEIGHT LOSS ON BLOOD 4337 02:45:41,465 --> 02:45:42,365 PRESSURE WILL BE SOMETHING ELSE 4338 02:45:42,365 --> 02:45:52,876 THAT WE WILL BRIEFLY TOUCH ON. 4339 02:46:01,451 --> 02:46:02,586 THIS IS BEGINNING TO SHOW UP 4340 02:46:02,586 --> 02:46:04,187 MORE AND MORE BOTH IN CHILDREN 4341 02:46:04,187 --> 02:46:10,660 AS DR. FLYNN POINTED OUT 4342 02:46:10,660 --> 02:46:18,635 REFAMILY SIZING BETTHEY'REGOING, 4343 02:46:18,635 --> 02:46:22,772 KIDS THAT ARE 1 16 TO 4344 02:46:22,772 --> 02:46:23,840 19-YEAR-OLDS, THESE ARE BIG 4345 02:46:23,840 --> 02:46:24,841 CUFFS SO THIS IS AFFECTING 4346 02:46:24,841 --> 02:46:26,276 CHILDREN AS MUCH AS IT IS 4347 02:46:26,276 --> 02:46:28,211 ADULTS. 4348 02:46:28,211 --> 02:46:29,846 IN REGARDS TO ADULTS, THE ADULT 4349 02:46:29,846 --> 02:46:31,481 LARGE AND EXTRA LARGE CUFFS, YOU 4350 02:46:31,481 --> 02:46:33,517 CAN SEE THAT THE NUMBERS ARE 4351 02:46:33,517 --> 02:46:35,919 MUCH LARGER WITH ADULT CUFFS BUT 4352 02:46:35,919 --> 02:46:38,722 THEY DROP A LITTLE BIT TO 4353 02:46:38,722 --> 02:46:40,290 97 MILLION OR ABOUT 8 MILLION 4354 02:46:40,290 --> 02:46:43,126 WITH THE VERY LARGE CUFFS AND 4355 02:46:43,126 --> 02:46:49,132 ALTHOUGH THE SLANT ANGLE GETS 4356 02:46:49,132 --> 02:46:51,635 MORE -- DECREASED MORE AS ARMS 4357 02:46:51,635 --> 02:46:53,370 GET LARGER, THERE IS A SPLAY IN 4358 02:46:53,370 --> 02:46:54,704 THESE ARMS IN TERMS OF THEIR 4359 02:46:54,704 --> 02:46:56,506 ABILITY TO HAVE ACCURATE BLOOD 4360 02:46:56,506 --> 02:46:58,341 PRESSURE POSSIBLY BECAUSE OF THE 4361 02:46:58,341 --> 02:46:59,643 INNER ARM LENGTH ON SOME OF 4362 02:46:59,643 --> 02:47:01,344 THESE PATIENTS, THESE SUBJECTS 4363 02:47:01,344 --> 02:47:04,080 BEING SOMEWHAT LARGER THAN IN 4364 02:47:04,080 --> 02:47:05,482 OTHER -- THAN SOME OTHER ONES SO 4365 02:47:05,482 --> 02:47:12,122 THAT YOU GET THIS LARGE SPLAY. 4366 02:47:12,122 --> 02:47:15,192 SO THE MODEL FOR THE LARGE ARM 4367 02:47:15,192 --> 02:47:16,593 CUFF/BLADDER SYSTEM, WE DON'T 4368 02:47:16,593 --> 02:47:17,694 REALLY HAVE ONE YET AND THERE'S 4369 02:47:17,694 --> 02:47:22,966 LIMITATIONS TO THE SPECIAL 4370 02:47:22,966 --> 02:47:23,934 TRONCOCONICAL CUFF BECAUSE 4371 02:47:23,934 --> 02:47:25,969 THERE'S BEEN SMALL NUMBERS OF 4372 02:47:25,969 --> 02:47:28,171 SUBJECTS THAT HAVE BEEN STUDIED 4373 02:47:28,171 --> 02:47:32,776 IN THE EXTRA LARGE ARM GROUPS. 4374 02:47:32,776 --> 02:47:35,912 THE RESULTS ARE LIKELY GOING TO 4375 02:47:35,912 --> 02:47:38,548 BE VALID, IT'S NOT BY CHANCE BY 4376 02:47:38,548 --> 02:47:40,183 WHAT THEY GET. 4377 02:47:40,183 --> 02:47:41,518 NOTABLY THEY ECK! 4378 02:47:41,518 --> 02:47:43,753 CLEUDED PATIENTS WHO HAD LESS 4379 02:47:43,753 --> 02:47:44,721 THAN 20 CENTIMETER INTERARM 4380 02:47:44,721 --> 02:47:47,591 LENGTH AND THE USE OF A CUFF OF 4381 02:47:47,591 --> 02:47:49,459 APPROPRIATE LENGTH WAS NOT 4382 02:47:49,459 --> 02:47:50,760 POSSIBLE WITH THESE SMALLER ARMS 4383 02:47:50,760 --> 02:47:54,364 AND THIS RESULTED IN ABOUT 5.5% 4384 02:47:54,364 --> 02:47:56,199 OF THEIR EXTRA LARGE POPULATION 4385 02:47:56,199 --> 02:47:59,436 THAT WAS STUDIED THAT HAD THIS 4386 02:47:59,436 --> 02:47:59,903 DISTANCE LESS THAN 4387 02:47:59,903 --> 02:48:00,470 20 CENTIMETERS. 4388 02:48:00,470 --> 02:48:02,739 IN THE REAL WORLD, PAOLO 4389 02:48:02,739 --> 02:48:04,040 SUGGESTED THERE ARE GOING TO BE 4390 02:48:04,040 --> 02:48:07,644 MANY MORE SUCH ARMS IF OLDER 4391 02:48:07,644 --> 02:48:08,845 ADULTS AND SHORTER PEOPLE ARE 4392 02:48:08,845 --> 02:48:10,046 CONSIDERED AND IN LARGER 4393 02:48:10,046 --> 02:48:10,847 POPULATIONS BUT THEY PROPOSE 4394 02:48:10,847 --> 02:48:13,750 THIS CUFF SYSTEM MIGHT BE USED 4395 02:48:13,750 --> 02:48:19,322 AS A REFERENCE CUFF, AGAIN, IF 4396 02:48:19,322 --> 02:48:22,359 THEY ARE NOT IN THIS ANTECUBITAL 4397 02:48:22,359 --> 02:48:25,428 FOSSA AXILLA RATIO OF LESS THAN 4398 02:48:25,428 --> 02:48:32,202 20 CENTIMETERS. 4399 02:48:32,202 --> 02:48:35,739 SO OBESITY AND HIGH BLOOD 4400 02:48:35,739 --> 02:48:37,140 PRESSURE IN WEIGHT LOSS IS A 4401 02:48:37,140 --> 02:48:38,742 VERY COMPLICATED THING BUT IS 4402 02:48:38,742 --> 02:48:41,044 PART AND PARCEL TO THE ISSUE 4403 02:48:41,044 --> 02:48:42,679 WE'RE DEALING WITH THIS IN 4404 02:48:42,679 --> 02:48:43,313 POPULATION. 4405 02:48:43,313 --> 02:48:45,882 WE ARE TRYING TO FIND CUFFS THAT 4406 02:48:45,882 --> 02:48:47,717 GIVE US ACCURATE BLOOD PRESSURE 4407 02:48:47,717 --> 02:48:47,984 READINGS. 4408 02:48:47,984 --> 02:48:56,693 THESE ARE ASSOCIATED AS I'VE -- 4409 02:48:56,693 --> 02:48:58,028 THE EXACT CAUSE AND EFFECT OF 4410 02:48:58,028 --> 02:48:59,429 OBESITY AND HIGH BLOOD PRESSURE 4411 02:48:59,429 --> 02:49:00,964 IS NOT TOTALLY KNOWN BUT IT'S 4412 02:49:00,964 --> 02:49:01,531 MULTIFACTOR YA. 4413 02:49:01,531 --> 02:49:03,900 IN THIS NICE REVIEW, THIS 4414 02:49:03,900 --> 02:49:05,201 INCLUDES SUCH THINGS AS VISCERAL 4415 02:49:05,201 --> 02:49:07,737 ADIPOSE TISSUE, SEUB CUTANEOUS 4416 02:49:07,737 --> 02:49:10,140 ADIPOSE TISSUE, ECOLOGICAL, 4417 02:49:10,140 --> 02:49:12,542 METABOLIC, GUT MICROBIOME, 4418 02:49:12,542 --> 02:49:13,276 INFLAMMATORY COMPONENTS, SALT 4419 02:49:13,276 --> 02:49:15,245 AND OTHER FACTORS ASSOCIATED BUT 4420 02:49:15,245 --> 02:49:19,349 NOT YET FULLY CLARIFIED. 4421 02:49:19,349 --> 02:49:21,318 SO IF WE GET AN APPROACH TO 4422 02:49:21,318 --> 02:49:22,952 WEIGHT LOSS, THIS IS GOING TO 4423 02:49:22,952 --> 02:49:23,620 IMPACT THINGS. 4424 02:49:23,620 --> 02:49:24,621 A COUPLE POINTS IS THAT THERE 4425 02:49:24,621 --> 02:49:26,356 ARE MEDICATIONS, THEY CAN BE 4426 02:49:26,356 --> 02:49:27,757 EFFECTIVE, BUT THEY HAVE A LOT 4427 02:49:27,757 --> 02:49:29,459 OF SIDE EFFECTS AND THERE'S NOT 4428 02:49:29,459 --> 02:49:31,227 VERY MUCH IN THE WAY OF LONG 4429 02:49:31,227 --> 02:49:32,028 TERM USE. 4430 02:49:32,028 --> 02:49:35,498 IN FACT -- THERE ARE SURGICAL 4431 02:49:35,498 --> 02:49:36,466 INTERVENTIONS, MANY OF THEM ARE 4432 02:49:36,466 --> 02:49:37,901 VERY EFFECTIVE. 4433 02:49:37,901 --> 02:49:38,868 HOWEVER, IF YOU CONSUME THE 4434 02:49:38,868 --> 02:49:41,004 WRONG KINDS OF FOOD SUCH AS LOTS 4435 02:49:41,004 --> 02:49:43,139 OF MALTED MILKS, ET CETERA, YOU 4436 02:49:43,139 --> 02:49:43,907 CAN GET AROUND THEM. 4437 02:49:43,907 --> 02:49:45,475 WE ALL KNOW THAT EXERCISE IS 4438 02:49:45,475 --> 02:49:47,477 VERY EFFECTIVE, AT LEAST IN SOME 4439 02:49:47,477 --> 02:49:49,212 ASPECTS OF BOTH IMPROVING 4440 02:49:49,212 --> 02:49:50,513 CARDIOVASCULAR HEALTH BUT ALSO 4441 02:49:50,513 --> 02:49:51,381 REDUCING WEIGHT, AND WE KNOW 4442 02:49:51,381 --> 02:49:53,116 THAT THE DASH DIET IS ASSOCIATED 4443 02:49:53,116 --> 02:49:56,119 WITH AT LEAST AN 8-MILLIMETER OF 4444 02:49:56,119 --> 02:49:58,221 MERCURY SYSTOLIC DROP. 4445 02:49:58,221 --> 02:50:00,957 MEDITERRANEAN IS 2 MILLIMETERS 4446 02:50:00,957 --> 02:50:03,626 SYSTOLIC DROP BUT AS STEPHEN 4447 02:50:03,626 --> 02:50:07,831 JURASCHEK AND HIS GROUP SHOWED, 4448 02:50:07,831 --> 02:50:09,366 DASH PLUS LOW SODIUM INTAKE IN 4449 02:50:09,366 --> 02:50:14,404 SOME POPULATION OF GREATER THAN 4450 02:50:14,404 --> 02:50:17,107 150 THEY GOT AT LEAST A 10 DROP 4451 02:50:17,107 --> 02:50:18,208 OF MERCURY WHICH IS REALLY QUITE 4452 02:50:18,208 --> 02:50:19,743 REMARKABLE BUT THE PROBLEMS ARE 4453 02:50:19,743 --> 02:50:23,880 THAT IS THE SUSTAINABILITY. 4454 02:50:23,880 --> 02:50:24,681 SO CONCLUSION. 4455 02:50:24,681 --> 02:50:25,949 THE BLOOD PRESSURE MEASUREMENT 4456 02:50:25,949 --> 02:50:27,250 IN THE OBESE AND LARGE ARM 4457 02:50:27,250 --> 02:50:28,251 POPULATION LACKS PROPER CUFFS 4458 02:50:28,251 --> 02:50:30,720 OVER A WIDE RANGE OF ARM SIZES, 4459 02:50:30,720 --> 02:50:33,790 INNER ARM LENGTHS, SHAPES, SLANT 4460 02:50:33,790 --> 02:50:37,093 ANGLE, AND INCLUDES THE YOUNG TO 4461 02:50:37,093 --> 02:50:38,495 ADULTS. 4462 02:50:38,495 --> 02:50:40,964 ADULT AND CHILDHOOD OVERWEIGHT 4463 02:50:40,964 --> 02:50:42,599 AND OBESE POPULATIONS HAVE 4464 02:50:42,599 --> 02:50:43,166 INCREASED WORLDWIDE. 4465 02:50:43,166 --> 02:50:45,301 THE HIGH BLOOD PRESSURE, 4466 02:50:45,301 --> 02:50:46,403 METABOLIC SYNDROME AND CO-MORBID 4467 02:50:46,403 --> 02:50:47,170 DISEASES ASSOCIATED WITH THESE 4468 02:50:47,170 --> 02:50:47,971 ARE INCREASING. 4469 02:50:47,971 --> 02:50:50,340 WEIGHT LOSS IS EFFECTIVE IN 4470 02:50:50,340 --> 02:50:51,741 LOWERING BLOOD PRESSURE BUT IS 4471 02:50:51,741 --> 02:50:52,609 DIFFICULT TO ACHIEVE AND 4472 02:50:52,609 --> 02:50:53,410 MAINTAIN. 4473 02:50:53,410 --> 02:50:55,478 DASH COMBINED WITH A LOW SODIUM 4474 02:50:55,478 --> 02:50:57,847 DIET IS VERY LIKELY TO BE QUITE 4475 02:50:57,847 --> 02:51:00,150 EFFECTIVE. 4476 02:51:00,150 --> 02:51:01,785 SO WHAT DO I SEE? 4477 02:51:01,785 --> 02:51:03,286 WELL, THERE ARE STILL THE LONG 4478 02:51:03,286 --> 02:51:08,291 PROBLEM THAT'S BEEN DISCUSSED 4479 02:51:08,291 --> 02:51:11,594 EARLIER IN THIS SYMPOSIUM, 4480 02:51:11,594 --> 02:51:13,129 ERRORS IN BLOOD PRESSURE MESH. 4481 02:51:13,129 --> 02:51:14,931 , WE REALLY NEED TOIM PROVE A 4482 02:51:14,931 --> 02:51:16,266 LOT MORE IN TEACHING BLOOD 4483 02:51:16,266 --> 02:51:18,101 PRESSURE MEASUREMENT FOR HOME, 4484 02:51:18,101 --> 02:51:19,102 IN THE CLINIC, IN THE HOSPITAL. 4485 02:51:19,102 --> 02:51:20,904 I THINK IT'S ANOTHER ISSUE 4486 02:51:20,904 --> 02:51:21,538 THAT'S VERY MUCH OVERLOOKED IN 4487 02:51:21,538 --> 02:51:22,772 TERMS OF JUST SPEED AND 4488 02:51:22,772 --> 02:51:24,841 EXPEDITIOUS GETTING THINGS DONE, 4489 02:51:24,841 --> 02:51:26,810 IS THE DIRECT BLOOD PRESSURE 4490 02:51:26,810 --> 02:51:28,111 CUFF FOR USE IN BLOOD PRESSURE 4491 02:51:28,111 --> 02:51:29,212 MEASUREMENTS OF LARGE ARMS. 4492 02:51:29,212 --> 02:51:31,514 AND THAT WE OUGHT TO HAVE PROPER 4493 02:51:31,514 --> 02:51:36,319 APPLICATION APPROPRIATENESS IN 4494 02:51:36,319 --> 02:51:38,788 IF YOU CAN USE AN ACCOMMODATING 4495 02:51:38,788 --> 02:51:40,657 UPPER ARM CUFF OR WRIST OR LEG 4496 02:51:40,657 --> 02:51:41,524 DEVICE AND THAT WILL BE 4497 02:51:41,524 --> 02:51:42,792 DISCUSSED MORE LATER, BUT THE 4498 02:51:42,792 --> 02:51:44,127 USE OF THE DIETS PARTICULARLY 4499 02:51:44,127 --> 02:51:45,962 NEEDS TO BE MUCH MORE EMPHASIZED 4500 02:51:45,962 --> 02:51:47,764 AND IN MY CLINICAL EXPERIENCE, 4501 02:51:47,764 --> 02:51:50,033 AT LEAST, MUCH BETTER ACCESS TO 4502 02:51:50,033 --> 02:51:51,534 DIETITIAN AND COUNSELING AND 4503 02:51:51,534 --> 02:51:53,937 HEALTHY DIET WILL BE SOMETHING 4504 02:51:53,937 --> 02:51:56,873 THAT SHOULD IMPROVE THIS 4505 02:51:56,873 --> 02:52:02,212 CONSIDERABLY. 4506 02:52:02,212 --> 02:52:04,314 AND THANK YOU, AND THAT 4507 02:52:04,314 --> 02:52:08,017 COMPLETES. 4508 02:52:08,017 --> 02:52:10,453 THAT COMPLETES MY DISCUSSION. 4509 02:52:10,453 --> 02:52:12,155 >> THANK YOU, DICK. 4510 02:52:12,155 --> 02:52:16,259 WONDERFUL PRESENTATION. 4511 02:52:16,259 --> 02:52:20,263 >> THESE ARE MY REFERENCES. 4512 02:52:20,263 --> 02:52:21,197 THANK YOU. 4513 02:52:21,197 --> 02:52:23,266 >> PEOPLE CAN PUT COMMENTS IN 4514 02:52:23,266 --> 02:52:25,401 THE CHAT BOX AND I WILL TURN 4515 02:52:25,401 --> 02:52:28,104 THINGS OVER TO DR. BEV GREEN FOR 4516 02:52:28,104 --> 02:52:33,243 THE NEXT INTRODUCTION. 4517 02:52:33,243 --> 02:52:35,912 >> I NEED TO TURN ON MY VIDEO. 4518 02:52:35,912 --> 02:52:43,353 SOMEBODY NEEDS TO DO THAT. 4519 02:52:43,353 --> 02:52:46,256 >> OKAY, HI. 4520 02:52:46,256 --> 02:52:48,992 OUR NEXT TALK IS ON OPTIMIZING 4521 02:52:48,992 --> 02:52:50,527 BLOOD PRESSURE ASSESSMENT IN 4522 02:52:50,527 --> 02:52:53,263 CHRONIC KIDNEY DISEASE BY 4523 02:52:53,263 --> 02:52:55,632 JORDANA COHEN, WHO IS AN 4524 02:52:55,632 --> 02:52:58,801 ASSOCIATE INVESTIGATOR AND A 4525 02:52:58,801 --> 02:53:00,970 NEPHROLOGIST AT THE UNIVERSITY 4526 02:53:00,970 --> 02:53:05,909 OF PENNSYLVANIA. 4527 02:53:05,909 --> 02:53:07,377 GM AHEAD. 4528 02:53:07,377 --> 02:53:08,811 >> THANK YOU SO MUCH FOR THE 4529 02:53:08,811 --> 02:53:09,646 INTRODUCTION. 4530 02:53:09,646 --> 02:53:10,647 AS MENTIONED I'LL BE TALKING TO 4531 02:53:10,647 --> 02:53:11,848 YOU ABOUT OPTIMIZING BLOOD 4532 02:53:11,848 --> 02:53:12,749 PRESSURE PRESSURE ASSESSMENT IN 4533 02:53:12,749 --> 02:53:18,721 CHRONIC KIDNEY DISEASE. 4534 02:53:18,721 --> 02:53:22,325 SO MY ONLY DISCLOSURE IS THAT I 4535 02:53:22,325 --> 02:53:23,760 GET ROYALTIES FROM UP TO DATE 4536 02:53:23,760 --> 02:53:25,562 FOR DOING CARTS OR EDUCATION 4537 02:53:25,562 --> 02:53:26,429 BASICALLY IN THE AREA OF BLOOD 4538 02:53:26,429 --> 02:53:33,670 PRESSURE MEASUREMENT. 4539 02:53:33,670 --> 02:53:34,771 WE KNOW THAT IN PATIENTS WITH 4540 02:53:34,771 --> 02:53:36,205 CHRONIC KIDNEY DISEASE THERE ARE 4541 02:53:36,205 --> 02:53:37,206 A LOT OF THINGS THAT LEAD TO 4542 02:53:37,206 --> 02:53:39,142 HIGH BLOOD PRESSURE THAT WE SORT 4543 02:53:39,142 --> 02:53:40,543 OF EXPECT AS TRADITIONAL RISK 4544 02:53:40,543 --> 02:53:42,078 FACTORS THAT HAVE BEEN TALKED 4545 02:53:42,078 --> 02:53:43,580 ABOUT AT LENGTH TODAY SUCH AS 4546 02:53:43,580 --> 02:53:44,914 AGING, AND THEN THERE ARE 4547 02:53:44,914 --> 02:53:46,649 SPECIFIC RISK FACTORS TO KIDNEY 4548 02:53:46,649 --> 02:53:47,951 DISEASE THAT MAKE HYPERTENSION 4549 02:53:47,951 --> 02:53:49,252 ESSENTIALLY UBIQUITOUS IN ALMOST 4550 02:53:49,252 --> 02:53:51,220 ALL PATIENTS WHO HAVE CHRONIC 4551 02:53:51,220 --> 02:53:54,724 KIDNEY DISEASE WITH MORE COMMON 4552 02:53:54,724 --> 02:53:55,491 HIGHER PREVALENCE OF 4553 02:53:55,491 --> 02:53:56,793 HYPERTENSION AS KIDNEY FUNCTION 4554 02:53:56,793 --> 02:53:57,660 WORSENS. 4555 02:53:57,660 --> 02:54:01,364 THIS INCLUDES THAT MOST PEOPLE 4556 02:54:01,364 --> 02:54:02,599 WL ADVANCING CHRONIC KIDNEY 4557 02:54:02,599 --> 02:54:04,901 DISEASE DEVELOP VOLUME OVERLOAD, 4558 02:54:04,901 --> 02:54:06,970 ACCELERATED ARTERIAL STIFFNESS 4559 02:54:06,970 --> 02:54:09,372 AND HAVE EXCESS ACTIVITY OF THE 4560 02:54:09,372 --> 02:54:12,642 SYMPATHETIC NERVOUS SYSTEM, 4561 02:54:12,642 --> 02:54:13,276 ANGIOTENSIN SYSTEM, AS WELL AS 4562 02:54:13,276 --> 02:54:14,444 OTHER FACTORS WE SEE IN SEVERAL 4563 02:54:14,444 --> 02:54:15,244 OF THE OTHER POPULATIONS THAT 4564 02:54:15,244 --> 02:54:17,780 WE'VE SPOKEN ABOUT TODAY SUCH AS 4565 02:54:17,780 --> 02:54:22,018 ENDOTHELIAL DYSFUNCTION. 4566 02:54:22,018 --> 02:54:23,553 ESA ARE AN ADDITIONAL FACTOR IN 4567 02:54:23,553 --> 02:54:24,854 OUR PATIENTS WHO HAVE MORE 4568 02:54:24,854 --> 02:54:26,389 ADVANCED KIDNEY DISEASE AND ARE 4569 02:54:26,389 --> 02:54:29,092 ON DIALYSIS THAT ALSO CAN 4570 02:54:29,092 --> 02:54:36,099 INCREASE BLOOD PRESSURE. 4571 02:54:36,099 --> 02:54:38,167 SO BLOOD PRESSURE TREATMENT 4572 02:54:38,167 --> 02:54:39,268 THRESHOLD RECOMMENDATIONS TEND 4573 02:54:39,268 --> 02:54:40,603 TO DIFFER ACROSS DIFFERENT 4574 02:54:40,603 --> 02:54:41,671 POPULATIONS IF YOU LOOK ACROSS 4575 02:54:41,671 --> 02:54:43,339 GUIDELINES. 4576 02:54:43,339 --> 02:54:45,141 THE 2017ACCHA GUIDELINE AS 4577 02:54:45,141 --> 02:54:47,210 EVERYBODY HERE IS WELL AWARE 4578 02:54:47,210 --> 02:54:48,211 RECOMMENDED DIAGNOSTIC 4579 02:54:48,211 --> 02:54:49,412 THRESHOLDS FOR HYPERTENSION OF 4580 02:54:49,412 --> 02:54:52,181 GREATER THAN OR EQUAL TO 130 4581 02:54:52,181 --> 02:54:53,583 OVER 80 IN HIGHER RISK ADULTS 4582 02:54:53,583 --> 02:54:54,684 AND A TREATMENT THRESHOLD THAT 4583 02:54:54,684 --> 02:54:57,587 SHOULD BE LESS THAN 130/80 IN 4584 02:54:57,587 --> 02:55:02,625 ALL ADULTS REGARDLESS OF -- ONCE 4585 02:55:02,625 --> 02:55:03,826 THEY HAVE A DIAGNOSIS OF 4586 02:55:03,826 --> 02:55:11,167 HYPERTENSION. 4587 02:55:11,167 --> 02:55:12,001 THERE SHOULD BE SOMETHING ON 4588 02:55:12,001 --> 02:55:12,769 THAT PRIOR SLIDE. 4589 02:55:12,769 --> 02:55:17,273 I GUESS IT GOT CUT OUT 4590 02:55:17,273 --> 02:55:19,342 UNFORTUNATELY. 4591 02:55:19,342 --> 02:55:20,677 SO THE BLOOD PRESSURE TREATMENT 4592 02:55:20,677 --> 02:55:21,744 THRESHOLD SHOULD BE LESS THAN 4593 02:55:21,744 --> 02:55:24,380 120, THIS IS BASED OFF OF 4594 02:55:24,380 --> 02:55:25,248 SIMILAR EVIDENCE AS WHAT THE 4595 02:55:25,248 --> 02:55:26,549 RECOMMENDATIONS WERE FOR THE 4596 02:55:26,549 --> 02:55:29,185 TWEP 17 ACCHA GUIDELINE BUT I 4597 02:55:29,185 --> 02:55:31,354 THINK IT'S SPECIFICALLY 4598 02:55:31,354 --> 02:55:33,556 RECOMMENDED FOR A FEW REASONS 4599 02:55:33,556 --> 02:55:34,857 THAT I'LL TALK ABOUT ON MY NEXT 4600 02:55:34,857 --> 02:55:44,967 SLIDE. 4601 02:55:45,635 --> 02:55:47,637 SO THERE'S A LOT OF RATIONALE 4602 02:55:47,637 --> 02:55:49,172 FOR WHY I THINK THERE COULD BE 4603 02:55:49,172 --> 02:55:52,442 THIS DISCREPANCY. 4604 02:55:52,442 --> 02:55:54,077 KDIGO RECOMMENDS THIS MORE 4605 02:55:54,077 --> 02:55:56,179 STRINGENT BLOOD PRESSURE, FIRST 4606 02:55:56,179 --> 02:55:57,714 OF ALL HINGING ON REQUIRING 4607 02:55:57,714 --> 02:55:59,449 STANDARDIZED OFFICE BLOOD 4608 02:55:59,449 --> 02:55:59,982 PRESSURE. 4609 02:55:59,982 --> 02:56:00,783 OTHER RECOMMENDATIONS ALSO 4610 02:56:00,783 --> 02:56:02,518 RECOMMEND THIS, BUT THEY TRY TO 4611 02:56:02,518 --> 02:56:07,390 BE EVEN MORE STRINGENT ABOUT IT. 4612 02:56:07,390 --> 02:56:10,259 ADDITIONALLY, THERE'S THIS 4613 02:56:10,259 --> 02:56:11,427 DISPROPORTIONATE CARDIOVASCULAR 4614 02:56:11,427 --> 02:56:13,296 RISK IN PATIENTS WITH CHRONIC 4615 02:56:13,296 --> 02:56:15,498 KIDNEY DISEASE WHERE OUR 4616 02:56:15,498 --> 02:56:18,334 PATIENTS TEND TO ALL 4617 02:56:18,334 --> 02:56:20,636 UBIQUITOUSLY BE AT ELEVATED RISK 4618 02:56:20,636 --> 02:56:22,371 FOR CARDIOVASCULAR RISK FACTOR 4619 02:56:22,371 --> 02:56:25,775 AND SO BECAUSE THE MEAN GOAL OF 4620 02:56:25,775 --> 02:56:26,743 LOWERING BLOOD PRESSURE IS THAT 4621 02:56:26,743 --> 02:56:28,077 REDUCTION IN CARDIOVASCULAR 4622 02:56:28,077 --> 02:56:29,345 RISK, NOT REALLY A KIDNEY PRO 4623 02:56:29,345 --> 02:56:29,846 TECH. 4624 02:56:29,846 --> 02:56:31,047 IF ANYTHING SOMETIMES WE'LL SEE 4625 02:56:31,047 --> 02:56:35,151 MORE OF THIS THERAPEUTIC 4626 02:56:35,151 --> 02:56:35,852 HYPERCREATININEIA AS PATIENTS 4627 02:56:35,852 --> 02:56:37,820 HAVE THE RISE IN CREATININE BUT 4628 02:56:37,820 --> 02:56:39,689 LOWERING OF CARDIOVASCULAR RISK, 4629 02:56:39,689 --> 02:56:42,925 AND SO THIS REALLY MAY BE 4630 02:56:42,925 --> 02:56:44,560 DISTINCTIVELY WHY KDIGO PUSHED 4631 02:56:44,560 --> 02:56:45,728 SO MUCH FOR THAT LOWER BLOOD 4632 02:56:45,728 --> 02:56:46,729 PRESSURE GOAL. 4633 02:56:46,729 --> 02:56:47,463 ADDITIONALLY, PATIENTS WITH 4634 02:56:47,463 --> 02:56:49,499 CHRONIC KIDNEY DISEASE ARE OFTEN 4635 02:56:49,499 --> 02:56:51,667 EXCLUDED FROM BLOOD PRESSURE 4636 02:56:51,667 --> 02:56:53,302 TRIALS AND I'LL TALK A BIT ABOUT 4637 02:56:53,302 --> 02:56:56,038 THE IMPLICATIONS OF THIS IN 4638 02:56:56,038 --> 02:56:57,273 PEOPLE WITH MORE ADVANCED KIDNEY 4639 02:56:57,273 --> 02:56:58,508 TEASE WHO REALLY AREN'T INCLUDED 4640 02:56:58,508 --> 02:57:04,914 IN THAT KDIGO RECOMMENDATION. 4641 02:57:04,914 --> 02:57:06,215 WE REALLY DON'T HAVE ANY 4642 02:57:06,215 --> 02:57:09,452 GUIDANCE IN WHAT THEIR GOAL FOR 4643 02:57:09,452 --> 02:57:11,354 BLOOD PRESSURE WOULD BE EVEN 4644 02:57:11,354 --> 02:57:12,622 THOUGH THEY'RE AT GREATER RISK 4645 02:57:12,622 --> 02:57:13,956 OF DEVELOPING CARDIOVASCULAR 4646 02:57:13,956 --> 02:57:14,657 EVENTS. 4647 02:57:14,657 --> 02:57:15,691 THEN THERE'S ALSO THE QUESTION 4648 02:57:15,691 --> 02:57:19,262 OF WHETHER IT'S THE ACHIEVED 4649 02:57:19,262 --> 02:57:21,664 VERSUS ASSIGNED BLOOD PRESSURE 4650 02:57:21,664 --> 02:57:23,099 GOALS AND THE GUIDELINES 4651 02:57:23,099 --> 02:57:26,269 BASICALLY WERE MORE STRINGENT IN 4652 02:57:26,269 --> 02:57:27,603 SAYING SPRINT ASSIGNED PEOPLE TO 4653 02:57:27,603 --> 02:57:28,671 A BLOOD PRESSURE GOAL OF LESS 4654 02:57:28,671 --> 02:57:29,872 THAN 120 AND THAT'S WHAT WE 4655 02:57:29,872 --> 02:57:30,540 SHOULD BE RECOMMENDING TO ARE 4656 02:57:30,540 --> 02:57:32,275 OUR PATIENTS, UNDERSTANDING 4657 02:57:32,275 --> 02:57:33,075 THERE COULD BE A SLIGHT LEHIGHER 4658 02:57:33,075 --> 02:57:35,444 RISK OF ADVERSE EVENTS, THAT'S 4659 02:57:35,444 --> 02:57:38,114 SUPER SEEDED BY THEIR EXCESS 4660 02:57:38,114 --> 02:57:42,485 CARDIOVASCULAR RISK. 4661 02:57:42,485 --> 02:57:44,887 AND SO THERE ARE SOME REALLY 4662 02:57:44,887 --> 02:57:45,555 IMPORTANT DISTINCTIONS 4663 02:57:45,555 --> 02:57:46,756 PARTICULARLY IN BLOOD PRESSURE 4664 02:57:46,756 --> 02:57:48,157 ASSESSMENT, WHICH WAS WHAT I WAS 4665 02:57:48,157 --> 02:57:49,358 TASKED WITH DISCUSSING IN PEOPLE 4666 02:57:49,358 --> 02:57:50,893 WHO HAVE CHRONIC KIDNEY DISEASE 4667 02:57:50,893 --> 02:57:52,528 COMPARED TO NON-CHRONIC KIDNEY 4668 02:57:52,528 --> 02:57:53,629 DISEASE POPULATIONS. 4669 02:57:53,629 --> 02:57:55,698 FIRST AND FOREMOST, AS HAS COME 4670 02:57:55,698 --> 02:57:58,835 UP PREVIOUSLY WHEN TALKING ABOUT 4671 02:57:58,835 --> 02:57:59,869 PREGNANT PATIENTS, THERE ARE 4672 02:57:59,869 --> 02:58:01,137 PARTICULAR CHALLENGES WITH BLOOD 4673 02:58:01,137 --> 02:58:03,806 PRESSURE MEASUREMENT ACCURACY 4674 02:58:03,806 --> 02:58:04,774 AND DEVICE VALIDATION IN 4675 02:58:04,774 --> 02:58:06,309 PATIENTS WITH CHRONIC KIDNEY 4676 02:58:06,309 --> 02:58:06,642 DISEASE. 4677 02:58:06,642 --> 02:58:09,278 THERE ARE NO GUIDELINES THAT 4678 02:58:09,278 --> 02:58:10,012 RECOMMEND DISTINCTIVE BLOOD 4679 02:58:10,012 --> 02:58:15,618 PRESSURE VALIDATION, HOWEVER 4680 02:58:15,618 --> 02:58:17,920 THESE PATIENTS ARE MUCH, MUCH 4681 02:58:17,920 --> 02:58:19,789 MORE SUSCEPTIBLE TO HAVING 4682 02:58:19,789 --> 02:58:20,790 BROADER OSCILLOMETRIC WAVEFORMS 4683 02:58:20,790 --> 02:58:23,025 WHICH CAN BE DIFFERENTIALLY 4684 02:58:23,025 --> 02:58:23,793 INTERPRETED BY THESE DEVICES AND 4685 02:58:23,793 --> 02:58:25,228 MAY RESULT IN DIFFERENT 4686 02:58:25,228 --> 02:58:26,195 VALIDATION, MEANING THAT IN A 4687 02:58:26,195 --> 02:58:27,797 COUPLE OF STUDIES THAT HAVE 4688 02:58:27,797 --> 02:58:29,031 TRIED TO VALIDATE BLOOD PRESSURE 4689 02:58:29,031 --> 02:58:30,132 DEVICES IN CHRONIC KIDNEY 4690 02:58:30,132 --> 02:58:32,535 DISEASE POPULATIONS AND DIALYSIS 4691 02:58:32,535 --> 02:58:34,704 POPULATIONS, WHICH HAVE BEEN 4692 02:58:34,704 --> 02:58:36,572 VALIDATED IN NON-CKD 4693 02:58:36,572 --> 02:58:38,007 POPULATIONS, THEY FOUND THAT THE 4694 02:58:38,007 --> 02:58:39,675 DEVICES OFTEN ARE NOT ACCURATE. 4695 02:58:39,675 --> 02:58:41,277 AND IT'S NOT CLEAR IF THIS COULD 4696 02:58:41,277 --> 02:58:42,912 BE RELATED TO SOME ISSUES WITH 4697 02:58:42,912 --> 02:58:45,781 ACTUALLY BEING ABLE TO PERFORM 4698 02:58:45,781 --> 02:58:48,184 THE VALIDATION PROTOCOLS 4699 02:58:48,184 --> 02:58:49,452 PERFECTLY IN THOSE POPULATIONS 4700 02:58:49,452 --> 02:58:51,120 OR IF IT'S REALLY THE FACT THAT 4701 02:58:51,120 --> 02:58:52,455 THEY HAD DIFFERENT BLOOD VESSEL 4702 02:58:52,455 --> 02:58:53,856 CHARACTERISTICS THAT ARE KNOWN 4703 02:58:53,856 --> 02:58:55,691 TO IMPACT THAT OSCILLOMETRIC 4704 02:58:55,691 --> 02:59:00,296 WAVE ENVELOPE THAT'S USED TO 4705 02:59:00,296 --> 02:59:02,365 EXTRAPOLATE BLOOD PRESSURE FROM 4706 02:59:02,365 --> 02:59:03,699 THESE AUTOMATED DEVICES. 4707 02:59:03,699 --> 02:59:06,535 OUR PATIENT ALSO HAVE A HIGHER 4708 02:59:06,535 --> 02:59:08,604 BURDEN OF ARRHYTHMIAS THAN MOST 4709 02:59:08,604 --> 02:59:09,906 PATIENTS IN THE GENERAL 4710 02:59:09,906 --> 02:59:11,240 POPULATION AND THIS COULD 4711 02:59:11,240 --> 02:59:13,409 CONTRIBUTE TO DIFFICULTIES WITH 4712 02:59:13,409 --> 02:59:14,277 GETTING ACCURATE BLOOD PRESSURE 4713 02:59:14,277 --> 02:59:15,278 MORE SO THAN IN THE GENERAL 4714 02:59:15,278 --> 02:59:17,179 POPULATION AND THEY ALSO HAVE A 4715 02:59:17,179 --> 02:59:19,849 LOT MORE INTERSTITIAL EDEMA 4716 02:59:19,849 --> 02:59:21,317 BROADLY WHICH CAN CREATE ISSUES 4717 02:59:21,317 --> 02:59:23,252 WITH BLOOD PRESSURE ACCURACY AND 4718 02:59:23,252 --> 02:59:24,453 THE POSSIBILITY TO GET AN 4719 02:59:24,453 --> 02:59:25,688 ACCURATE BLOOD PRESSURE. 4720 02:59:25,688 --> 02:59:26,455 ADDITIONALLY OUR PATIENTS IN 4721 02:59:26,455 --> 02:59:30,493 GENERAL WHEN WE FRID TRY TO ASSN 4722 02:59:30,493 --> 02:59:32,228 THEM TO SELF-MONITORING OF BLOOD 4723 02:59:32,228 --> 02:59:33,763 PRESSURE HAVE MUCH MORE 4724 02:59:33,763 --> 02:59:35,398 DIFFICULTY BROADLY WITH 4725 02:59:35,398 --> 02:59:37,700 SELF-EFFICACY AND UPTAKE OF 4726 02:59:37,700 --> 02:59:38,935 INTERVENTIONS FOR MANY REASONS 4727 02:59:38,935 --> 02:59:40,336 IN PART DUE TO THE FACT THAT 4728 02:59:40,336 --> 02:59:42,204 THESE PATIENTS ARE OFTEN CH 4729 02:59:42,204 --> 02:59:43,272 LOWER SOCIOECONOMIC STATUSES AND 4730 02:59:43,272 --> 02:59:45,474 OFTEN HAVE LOWER HEALTH 4731 02:59:45,474 --> 02:59:47,677 LITERACY, SO THESE ARE REALLY 4732 02:59:47,677 --> 02:59:50,279 DISTINCTIVE CHALLENGES, MORE SO 4733 02:59:50,279 --> 02:59:52,515 THAN ANY OTHER POPULATIONS. 4734 02:59:52,515 --> 02:59:53,816 ADDITIONALLY CHRONIC KIDNEY 4735 02:59:53,816 --> 02:59:58,955 DISEASE IS A RISK FACTOR FOR 4736 02:59:58,955 --> 03:00:00,923 MASKED HYPERTENSION. 4737 03:00:00,923 --> 03:00:01,924 ABOUT A QUARTER OF OUR PATIENTS 4738 03:00:01,924 --> 03:00:03,826 OFTEN ARE FOUND TO HAVE MASKED 4739 03:00:03,826 --> 03:00:04,894 HYPERTENSION BEFORE STARTING 4740 03:00:04,894 --> 03:00:06,562 DIALYSIS AND WE DON'T HAVE ANY 4741 03:00:06,562 --> 03:00:08,531 DATA ON OUT OF OFFICE TREATMENT 4742 03:00:08,531 --> 03:00:10,599 TARGETS IN PEOPLE WHO HAVE A 4743 03:00:10,599 --> 03:00:11,367 NORMAL OFFICE BLOOD PRESSURE IN 4744 03:00:11,367 --> 03:00:13,769 ALL THESE RANDOMIZED CONTROL 4745 03:00:13,769 --> 03:00:16,505 TRIALS USING OFFICE OUT MATED 4746 03:00:16,505 --> 03:00:18,474 BLOOD PRESSURES BUT HAVE AN 4747 03:00:18,474 --> 03:00:19,342 ELEVATED BLOOD PRESSURE THE REST 4748 03:00:19,342 --> 03:00:25,481 OF THE TIME. 4749 03:00:25,481 --> 03:00:29,518 THEN HEMODIALYSIS OPENS AN 4750 03:00:29,518 --> 03:00:30,619 ENTIRELY NEW CAN OF WORMS. 4751 03:00:30,619 --> 03:00:31,754 THEY HAVE UNFORTUNATELY EVEN 4752 03:00:31,754 --> 03:00:33,055 GREATER CHALLENGES IN GETTING 4753 03:00:33,055 --> 03:00:34,357 ACCURATE BLOOD PRESSURE 4754 03:00:34,357 --> 03:00:37,393 MEASUREMENTS. 4755 03:00:37,393 --> 03:00:38,828 PERIDIALYSIS BLOOD PRESSURE, 4756 03:00:38,828 --> 03:00:40,363 MEANING THOSE THAT ARE PERFORMED 4757 03:00:40,363 --> 03:00:42,031 BEFORE, DURING AND AFTER 4758 03:00:42,031 --> 03:00:43,232 DIALYSIS, HAVE BEEN THE CLASSIC 4759 03:00:43,232 --> 03:00:47,036 TARGETS FOR VOLUME MANAGEMENT 4760 03:00:47,036 --> 03:00:47,937 AND ANTIHYPERTENSIVE THERAPY. 4761 03:00:47,937 --> 03:00:49,572 AS A DIALYSIS PROVIDER I CAN'T 4762 03:00:49,572 --> 03:00:50,773 TELL YOU HOW MANY PHONE CALLS I 4763 03:00:50,773 --> 03:00:52,742 GET ON A REGULAR BASIS ASKING 4764 03:00:52,742 --> 03:00:53,976 FOR TITRATIONS AND DRY WEIGHTS 4765 03:00:53,976 --> 03:00:54,744 AND BLOOD PRESSURE MEDICATIONS 4766 03:00:54,744 --> 03:00:56,479 BASED OFF OF THESE READINGS AND 4767 03:00:56,479 --> 03:00:58,547 THERE IS A LARGE VOLUME OF THESE 4768 03:00:58,547 --> 03:00:58,881 READINGS. 4769 03:00:58,881 --> 03:01:00,216 AND THEY'RE OFTEN TAKEN WHILE 4770 03:01:00,216 --> 03:01:03,386 THE PATIENT IS SUPINE, OVER 4771 03:01:03,386 --> 03:01:04,920 CLOTHING, GETTING STUCK WITH A 4772 03:01:04,920 --> 03:01:05,788 NEEDLE AND IN PAIN OR FEARING 4773 03:01:05,788 --> 03:01:08,324 THE PAIN THAT'S ABOUT TO HAPPEN, 4774 03:01:08,324 --> 03:01:09,825 WITH A LOT OF SUBSTANTIAL 4775 03:01:09,825 --> 03:01:11,460 AMBIENT NOISE IN THESE DIALYSIS 4776 03:01:11,460 --> 03:01:12,795 UNITS WITH ALARMS CONSTANTLY 4777 03:01:12,795 --> 03:01:13,863 GOING OFF SIMILAR TO WHAT YOU 4778 03:01:13,863 --> 03:01:16,265 WOULD GET IN AN INTENSIVE CARE 4779 03:01:16,265 --> 03:01:16,732 UNIT. 4780 03:01:16,732 --> 03:01:18,200 OFTEN POOR ANATOMICAL PLACEMENT 4781 03:01:18,200 --> 03:01:19,135 BECAUSE MANY OF OUR PATIENTS 4782 03:01:19,135 --> 03:01:21,203 HAVE HAD MULTIPLE ARTERIAL 4783 03:01:21,203 --> 03:01:22,538 VENOUS FISH TEU LAS AND NO 4784 03:01:22,538 --> 03:01:24,040 LONGER HAVE A LIMB TO OBTAIN A 4785 03:01:24,040 --> 03:01:25,041 BLOOD PRESSURE FROM AND YOU'RE 4786 03:01:25,041 --> 03:01:29,178 GETTING AN ARTERIAL BRACHIAL 4787 03:01:29,178 --> 03:01:30,846 INDEX AND MANY OF THEM HAVE 4788 03:01:30,846 --> 03:01:31,914 VOLUME OVERLOAD THAT'S OFTEN 4789 03:01:31,914 --> 03:01:34,316 MUCH MORE COMPLICATED AND OFTEN 4790 03:01:34,316 --> 03:01:35,418 WORSE THAN IN THE PREDIALYSIS 4791 03:01:35,418 --> 03:01:36,085 POPULATION. 4792 03:01:36,085 --> 03:01:37,386 THERE'S ALSO AGAIN A LOT OF 4793 03:01:37,386 --> 03:01:39,288 CONFOUNDING FROM COMORBIDITIES, 4794 03:01:39,288 --> 03:01:40,689 FOR EXAMPLE, MANY PATIENTS ARE 4795 03:01:40,689 --> 03:01:43,192 PRELOAD DEPENDENT, WE SEE A HIGH 4796 03:01:43,192 --> 03:01:46,362 PORTION OF INDIVIDUALS WITH PAIR 4797 03:01:46,362 --> 03:01:49,965 -- WHEREYOUR BLOOD PRESSURE CA, 4798 03:01:49,965 --> 03:01:53,803 VERY QUICKLY PLUMMET AS SOON AS 4799 03:01:53,803 --> 03:01:57,640 THERE'S FLUID REMOVAL ON 4800 03:01:57,640 --> 03:01:58,441 DIALYSIS. 4801 03:01:58,441 --> 03:01:59,608 THEN THEIR PATIENTS ALSO SPEND 4802 03:01:59,608 --> 03:02:01,911 MOST OF THE TIME OUTSIDE THE 4803 03:02:01,911 --> 03:02:03,345 DIALYSIS SETTING, THERE'S 4804 03:02:03,345 --> 03:02:04,747 GROWING EVIDENCE SAYING THESE 4805 03:02:04,747 --> 03:02:13,155 PATIENTS HAVE EVEN MORE MAS MASD 4806 03:02:13,155 --> 03:02:14,490 THAN WHAT'S SEEN IN THE 4807 03:02:14,490 --> 03:02:15,458 PREDIALYSIS CHRONIC KIDNEY 4808 03:02:15,458 --> 03:02:16,892 DISEASE POPULATION. 4809 03:02:16,892 --> 03:02:18,761 SO IT'S NOT SURPRISING THAT WE 4810 03:02:18,761 --> 03:02:22,465 HAVE DATA, MOST OF US ALL OF 4811 03:02:22,465 --> 03:02:26,969 WHICH HAVE BEEN -- WHICH THAT 4812 03:02:26,969 --> 03:02:31,240 SHOWS A VERY BIG -- AND 4813 03:02:31,240 --> 03:02:31,774 NON-DIALYSIS UNIT BLOOD 4814 03:02:31,774 --> 03:02:34,944 PRESSURES IN PATIENTS WHO ARE 4815 03:02:34,944 --> 03:02:36,479 HEMODIALYSIS PATIENTS, SO THIS 4816 03:02:36,479 --> 03:02:39,081 DATA, FOR EXAMPLE, CRICK SHOWS 4817 03:02:39,081 --> 03:02:41,484 THAT THE PERIDIALYSIS BLOOD 4818 03:02:41,484 --> 03:02:42,718 PRESSURES IN THE UPPER LEFT 4819 03:02:42,718 --> 03:02:44,687 REALLY HAVE THIS U-SHAPED 4820 03:02:44,687 --> 03:02:46,422 ASSOCIATION WITH MORTALITY AND 4821 03:02:46,422 --> 03:02:48,257 THE LOWEST RISK IS SEEN AT BLOOD 4822 03:02:48,257 --> 03:02:52,795 PRESSURES AROUND 150, EVEN UNTO 4823 03:02:52,795 --> 03:02:54,830 160, WHEREAS PATIENTS' BLOOD 4824 03:02:54,830 --> 03:02:55,631 PRESSURES OUTSIDE OF THE 4825 03:02:55,631 --> 03:02:56,632 DIALYSIS UNIT FOLLOW MORE WHAT 4826 03:02:56,632 --> 03:02:59,268 WE'RE USED TO SEEING, WHERE 4827 03:02:59,268 --> 03:03:02,705 BLOOD PRESSURES MEASURED OUT ARE 4828 03:03:02,705 --> 03:03:03,672 ASSOCIATED WITH LOWER MORTALITY 4829 03:03:03,672 --> 03:03:08,210 AND THOSE THAT ARE HIGHER ARE 4830 03:03:08,210 --> 03:03:12,948 ASSOCIATED HIGHER IN 4831 03:03:12,948 --> 03:03:13,816 CARDIOVASCULAR EVENTS. 4832 03:03:13,816 --> 03:03:15,351 WE DON'T HAVE A GOLD STANDARD ON 4833 03:03:15,351 --> 03:03:18,287 HOW TO OBTAIN BLOOD PRESSURES 4834 03:03:18,287 --> 03:03:25,194 FROM THESE PATIENTS, WE DO FEEL 4835 03:03:25,194 --> 03:03:28,164 THAT -- EVEN THESE PATIENTS WHO 4836 03:03:28,164 --> 03:03:30,132 OFTEN NO LONGER URINATE OR 4837 03:03:30,132 --> 03:03:31,433 URINATE A VERY SMALL AMOUNT 4838 03:03:31,433 --> 03:03:33,068 WHERE THEIR BLOOD PRESSURE CAN 4839 03:03:33,068 --> 03:03:35,171 VARY A GREAT DEAL OVER THE 4840 03:03:35,171 --> 03:03:36,372 44 HOUR PERIOD BETWEEN DIALYSIS 4841 03:03:36,372 --> 03:03:38,007 SESSIONS AND THAT'S HISTORICALLY 4842 03:03:38,007 --> 03:03:40,109 WHAT'S BEEN DONE TO COLLECT 4843 03:03:40,109 --> 03:03:41,010 THEIR OUT OF DIALYSIS BLOOD 4844 03:03:41,010 --> 03:03:43,412 PRESSURES BUT IT'S VERY POORLY 4845 03:03:43,412 --> 03:03:45,481 TOLERATED TO DO IT FOR THAT LONG 4846 03:03:45,481 --> 03:03:48,450 AND WITH PATIENTS WITH SO MUCH 4847 03:03:48,450 --> 03:03:50,553 CO-MORBIDITY BURDEN AND OTHER 4848 03:03:50,553 --> 03:03:52,521 DEED BURDEN, THIS IS AN EXAMPLE 4849 03:03:52,521 --> 03:03:55,491 OF A SEMI QUALITATIVE MIXED 4850 03:03:55,491 --> 03:03:57,459 EFFECT -- OR MIXED METHODS STUDY 4851 03:03:57,459 --> 03:04:01,063 THAT WE HAD -- THESE PATIENTS 4852 03:04:01,063 --> 03:04:03,632 REALLY, REALLY LOVE DOING HOME 4853 03:04:03,632 --> 03:04:04,800 BLOOD PRESSURE MONITORING, FELT 4854 03:04:04,800 --> 03:04:05,968 EMPOWERED BY IT AND WERE ABLE TO 4855 03:04:05,968 --> 03:04:08,037 DO IT BUT IT'S REALLY 4856 03:04:08,037 --> 03:04:08,771 UNDERUTILIZED. 4857 03:04:08,771 --> 03:04:09,872 DIALYSIS PROVIDERS WHEN GIVEN 4858 03:04:09,872 --> 03:04:11,840 HOME PRESSURES REALLY DON'T KNOW 4859 03:04:11,840 --> 03:04:13,275 WHAT TO DO WITH THEM AND HAVE 4860 03:04:13,275 --> 03:04:14,710 NOT BEEN ACTING ON THEM 4861 03:04:14,710 --> 03:04:17,246 HISTORICALLY. 4862 03:04:17,246 --> 03:04:18,781 AND SO IN SUMMARY, WE REALLY 4863 03:04:18,781 --> 03:04:20,449 DON'T HAVE SUFFICIENT EVIDENCE 4864 03:04:20,449 --> 03:04:21,250 TO GUIDE BLOOD PRESSURE TARGETS 4865 03:04:21,250 --> 03:04:24,086 IN THESE PATIENTS. 4866 03:04:24,086 --> 03:04:24,853 PERIDIALYSIS BLOOD PRESSURE IS 4867 03:04:24,853 --> 03:04:26,922 THE CLASSIC TARGET OF VOLUME 4868 03:04:26,922 --> 03:04:28,324 MANAGEMENT IN ANTIHYPERTENSIVE 4869 03:04:28,324 --> 03:04:29,458 THERAPY BUT IT'S REALLY 4870 03:04:29,458 --> 03:04:34,363 SUBOPTIMAL BASED ON 4871 03:04:34,363 --> 03:04:37,533 EPIDEMIOLOGIC DATA. 4872 03:04:37,533 --> 03:04:41,337 OBVIOUSLY -- ARE BETTER TO 4873 03:04:41,337 --> 03:04:42,871 TARGET WHEN INDIVIDUALIZING 4874 03:04:42,871 --> 03:04:43,839 TREATMENT STRATEGIES BUT THERE'S 4875 03:04:43,839 --> 03:04:45,507 VERY LITTLE DATA IN THIS AREA. 4876 03:04:45,507 --> 03:04:47,343 CURRENTLY A CO-INVESTIGATOR ON A 4877 03:04:47,343 --> 03:04:49,211 MULTICENTER TRIAL THAT'S JUST 4878 03:04:49,211 --> 03:04:50,412 STARTING TO SCRATCH THE SURFACE 4879 03:04:50,412 --> 03:04:52,047 OF UNDERSTANDING THE SAFETY OF 4880 03:04:52,047 --> 03:04:54,583 DOING THIS, AND THE FEASIBILITY 4881 03:04:54,583 --> 03:04:56,885 AND WHETHER PATIENTS CAN UPTAKE 4882 03:04:56,885 --> 03:04:58,153 THIS, BUT THERE'S A LOT MORE 4883 03:04:58,153 --> 03:05:03,626 WORK THAT NEEDS TO BE DONE. 4884 03:05:03,626 --> 03:05:07,363 SO TO CONCLUDE I THINK THERE ARE 4885 03:05:07,363 --> 03:05:08,030 SEVERAL KNOWLEDGE GAPS IN THIS 4886 03:05:08,030 --> 03:05:08,564 SPACE. 4887 03:05:08,564 --> 03:05:12,301 IN TERMS OF GAPS WE REALLY DON'T 4888 03:05:12,301 --> 03:05:14,003 KNOW WHETHER SEPARATE BLOOD 4889 03:05:14,003 --> 03:05:15,771 PRESSURE DEVICE VALIDATION IS 4890 03:05:15,771 --> 03:05:17,740 REQUIRED, WHAT THE OPTIMAL BLOOD 4891 03:05:17,740 --> 03:05:18,774 PRESSURE TREATMENT TARGETS 4892 03:05:18,774 --> 03:05:20,609 SETTING AN APPROACH SHOULD BE IN 4893 03:05:20,609 --> 03:05:21,810 DIALYSIS PATIENTS IN PARTICULAR. 4894 03:05:21,810 --> 03:05:24,113 THE APPROPRIATENESS AND 4895 03:05:24,113 --> 03:05:26,982 IDENTIFICATION OF OUT OF OFFICE 4896 03:05:26,982 --> 03:05:32,621 BECAUSE OF THIS MARKEDLY 4897 03:05:32,621 --> 03:05:33,522 HIGHER -- SELF-EFFICACY AND 4898 03:05:33,522 --> 03:05:35,024 OTHER ISSUES AND APPROACHES TO 4899 03:05:35,024 --> 03:05:35,924 IMPROVING IMPLEMENTATION OF 4900 03:05:35,924 --> 03:05:39,228 OFFICE AND HOME BLOOD PRESSURE 4901 03:05:39,228 --> 03:05:41,096 MEASUREMENTS FOCUSING ON THE 4902 03:05:41,096 --> 03:05:42,731 DISTINCTIVE NEEDS OF THOSE 4903 03:05:42,731 --> 03:05:49,638 PATIENTS WITH ISSUES IN MIND. 4904 03:05:49,638 --> 03:05:52,708 I THINK MY LAST SLIDE IS SKIPPED 4905 03:05:52,708 --> 03:05:53,942 BUT I HAD A FUTURE 4906 03:05:53,942 --> 03:05:54,476 OPPORTUNITIES, THANK YOU. 4907 03:05:54,476 --> 03:05:55,911 SO I THINK SPECIFICALLY THE 4908 03:05:55,911 --> 03:05:57,880 FUTURE OPPORTUNITIES ARE IN 4909 03:05:57,880 --> 03:05:58,647 DEVELOPING TRIALS AND 4910 03:05:58,647 --> 03:05:59,782 OBSERVATIONAL STUDIES THAT I'LL 4911 03:05:59,782 --> 03:06:01,750 FOCUS ON THESE MAIN GAPS, 4912 03:06:01,750 --> 03:06:03,919 PLAYERLY BROADENING THE 4913 03:06:03,919 --> 03:06:06,355 INCLUSION OF CHRONIC KIDNEY 4914 03:06:06,355 --> 03:06:07,389 DISEASE PATIENTS IN TRIALS 4915 03:06:07,389 --> 03:06:11,060 BECAUSE OF THEIR EX- -- WE REDI 4916 03:06:11,060 --> 03:06:12,928 DON'T KNOW HOW TO TREAT THESE 4917 03:06:12,928 --> 03:06:14,330 PATIENTS, ESPECIALLY THOSE WITH 4918 03:06:14,330 --> 03:06:15,331 MORE CHRONIC KIDNEY DISEASE OR 4919 03:06:15,331 --> 03:06:17,299 AT LEAST DEVELOPING TRIALS THAT 4920 03:06:17,299 --> 03:06:21,470 WILL FOCUS ON THEM TO FILL IN 4921 03:06:21,470 --> 03:06:22,438 THOSE GAPS. 4922 03:06:22,438 --> 03:06:22,938 SO THANK YOU VERY MUCH. 4923 03:06:22,938 --> 03:06:25,841 >> THANK YOU, JORDY, FOR AN 4924 03:06:25,841 --> 03:06:27,609 EXCELLENT TALK. 4925 03:06:27,609 --> 03:06:29,044 I HAVE A LOT OF QUESTIONS, I 4926 03:06:29,044 --> 03:06:30,913 HOPE OUR AUDIENCE DOES TOO. 4927 03:06:30,913 --> 03:06:35,584 PUT THEM IN THE CHAT, PLEASE. 4928 03:06:35,584 --> 03:06:38,220 AND OUR NEXT SPEAKER IS ADAM 4929 03:06:38,220 --> 03:06:40,522 BRESS, WHO IS A DOCTOR OF 4930 03:06:40,522 --> 03:06:42,057 PHARMACOLOGY AT THE UNIVERSITY 4931 03:06:42,057 --> 03:06:45,227 OF UTAH AND A 4932 03:06:45,227 --> 03:06:46,261 PHARMACOEPIDEMIOLOGIST. 4933 03:06:46,261 --> 03:06:47,429 AND HE'S GOING TO SPEAK ABOUT 4934 03:06:47,429 --> 03:06:49,298 BLOOD PRESSURE AS A CRITICAL 4935 03:06:49,298 --> 03:06:51,066 VITAL SIGN, TRANSITIONING FROM 4936 03:06:51,066 --> 03:06:52,534 HOSPITAL TO HOME SETTINGS. 4937 03:06:52,534 --> 03:06:56,038 THANK YOU. 4938 03:06:56,038 --> 03:06:57,639 >> THANKS SO MUCH, DR. GREEN. 4939 03:06:57,639 --> 03:06:59,174 IT'S REALLY A PLEASURE AND AN 4940 03:06:59,174 --> 03:07:01,043 HONOR TO BE HERE TODAY WITH SUCH 4941 03:07:01,043 --> 03:07:02,144 ESTEEMED LEADERS, EXPERTS AND 4942 03:07:02,144 --> 03:07:02,678 FRIENDS. 4943 03:07:02,678 --> 03:07:04,980 I'VE ALREADY LEARNED QUITE A 4944 03:07:04,980 --> 03:07:05,414 BIT. 4945 03:07:05,414 --> 03:07:07,082 SO MY TALK IS ON BLOOD PRESSURE 4946 03:07:07,082 --> 03:07:10,352 AS IT RELATES TO THE HOSPITAL TO 4947 03:07:10,352 --> 03:07:13,389 HOME TRANSITION. 4948 03:07:13,389 --> 03:07:14,923 AS WE'VE HEARD FROM DR. GOFF AND 4949 03:07:14,923 --> 03:07:19,328 ALL THE OTHER TALKS, WE KNOW 4950 03:07:19,328 --> 03:07:20,229 THAT HIGH BLOOD PRESSURE IS THE 4951 03:07:20,229 --> 03:07:21,663 LEADING CAUSE OF CARDIOVASCULAR 4952 03:07:21,663 --> 03:07:24,366 DISEASE AND IS ALSO AN EMERGING 4953 03:07:24,366 --> 03:07:26,101 CAUSE AND RISK FACTOR FOR 4954 03:07:26,101 --> 03:07:28,637 COGNITIVE DECLINE AND DEMENTIA, 4955 03:07:28,637 --> 03:07:31,273 AND THE CONTEXT FOR MY TALK IS 4956 03:07:31,273 --> 03:07:32,341 DESPITE THE WIDESPREAD 4957 03:07:32,341 --> 03:07:33,976 AVAILABILITY OF SAFE, 4958 03:07:33,976 --> 03:07:35,544 INEXPENSIVE, EFFECTIVE 4959 03:07:35,544 --> 03:07:38,580 ANTIHYPERTENSIVE MEDICATIONS, 4960 03:07:38,580 --> 03:07:39,348 BLOOD PRESSURE CONTROL RATES 4961 03:07:39,348 --> 03:07:41,116 COULD BE HIGHER, PARTICULARLY IN 4962 03:07:41,116 --> 03:07:42,751 GROUPS THAT DON'T HAVE A REGULAR 4963 03:07:42,751 --> 03:07:43,852 HEALTHCARE PROVIDER OR USUAL 4964 03:07:43,852 --> 03:07:48,690 SOURCE OF CARE. 4965 03:07:48,690 --> 03:07:49,992 THE ADDITIONAL CONTEXT IS THERE 4966 03:07:49,992 --> 03:07:53,462 ARE ABOUT 36 MILLION 4967 03:07:53,462 --> 03:07:54,329 HOSPITALIZATION EVENTS IN THE 4968 03:07:54,329 --> 03:07:59,635 UNITED STATES EACH YEAR. 4969 03:07:59,635 --> 03:08:00,803 IN WHICH MANY BLOOD PRESSURE 4970 03:08:00,803 --> 03:08:03,872 VALUES AND READINGS ARE TAKEN 4971 03:08:03,872 --> 03:08:08,911 AND PERHAPS UTILIZED FOR CARE. 4972 03:08:08,911 --> 03:08:12,448 AND THESE BLOOD PRESSURE 4973 03:08:12,448 --> 03:08:15,184 READINGS COULD BE ELEVATED FOR 4974 03:08:15,184 --> 03:08:17,052 NUMEROUS REASONS, FOR UNDERLYING 4975 03:08:17,052 --> 03:08:18,020 HYPERTENSION ITSELF, COULD BE 4976 03:08:18,020 --> 03:08:20,022 BECAUSE OF INACCURATE 4977 03:08:20,022 --> 03:08:22,191 MEASUREMENT, COULD BE FROM AN 4978 03:08:22,191 --> 03:08:23,325 ATROAGENIC CAUSE SUCH AS 4979 03:08:23,325 --> 03:08:25,828 MEDICATIONS, IT ALSO COBBLE 4980 03:08:25,828 --> 03:08:26,929 SERRATED BECAUSE OF THE STRESS 4981 03:08:26,929 --> 03:08:29,364 FROM THE ACUTE ILLNESS OR 4982 03:08:29,364 --> 03:08:31,099 PHYSIOLOGICAL PROCESS OR PERHAPS 4983 03:08:31,099 --> 03:08:31,867 SLEEP DEPRIVATION. 4984 03:08:31,867 --> 03:08:35,137 SO WITH ALL THAT, MY TALK IS 4985 03:08:35,137 --> 03:08:36,572 GOING TO TALK ABOUT WHAT'S THE 4986 03:08:36,572 --> 03:08:38,106 STATE OF THE EVIDENCE, PERHAPS 4987 03:08:38,106 --> 03:08:40,976 THE GUIDANCE FOR WHAT TO DO WITH 4988 03:08:40,976 --> 03:08:42,277 ALL THESE BLOOD PRESSURE 4989 03:08:42,277 --> 03:08:44,880 READINGS IN THE HOSPITAL? 4990 03:08:44,880 --> 03:08:47,216 AND WHILE THERE IS A LOT OF 4991 03:08:47,216 --> 03:08:48,550 EVIDENCE, A LOT OF REALLY GOOD 4992 03:08:48,550 --> 03:08:50,085 EVIDENCE, A LOT OF RANDOMIZED 4993 03:08:50,085 --> 03:08:52,821 EVIDENCE AND GUIDELINES FOR THE 4994 03:08:52,821 --> 03:08:53,989 MANAGEMENT OF HYPERTENSION IN 4995 03:08:53,989 --> 03:08:56,792 THE OUTPATIENT SETTING, THERE'S 4996 03:08:56,792 --> 03:08:58,193 VERY LITTLE HIGH QUALITY 4997 03:08:58,193 --> 03:09:00,395 EVIDENCE, BEST PRACTICES, FOR 4998 03:09:00,395 --> 03:09:03,131 HOW TO MANAGE BLOOD PRESSURE IN 4999 03:09:03,131 --> 03:09:07,269 THE INPATIENT SETTING. 5000 03:09:07,269 --> 03:09:08,504 WE DON'T REALLY HAVE GOOD 5001 03:09:08,504 --> 03:09:11,773 EVIDENCE TO TELL US SHOULD WE BE 5002 03:09:11,773 --> 03:09:12,407 TREATING HIGH BLOOD PRESSURE 5003 03:09:12,407 --> 03:09:13,775 WITH MEDICATIONS DURING THE 5004 03:09:13,775 --> 03:09:16,612 HOSPITAL AND WHAT TO DO AT 5005 03:09:16,612 --> 03:09:19,147 DISCHARGE IN THE ABSENCE OF 5006 03:09:19,147 --> 03:09:20,015 HYPERTENSION EMERGENCY, WHERE 5007 03:09:20,015 --> 03:09:22,251 THERE'S SIGNS AND SYMPTOMS OF 5008 03:09:22,251 --> 03:09:25,387 NEW OR WORSENING TARGET ORGAN 5009 03:09:25,387 --> 03:09:25,621 DAMAGE. 5010 03:09:25,621 --> 03:09:27,456 BUT IN THE CONTEXT OF 5011 03:09:27,456 --> 03:09:28,891 ASYMPTOMATIC HYPERTENSION, 5012 03:09:28,891 --> 03:09:32,060 THERE'S VERY LIMITED EVIDENCE ON 5013 03:09:32,060 --> 03:09:34,029 WHAT TO DO. 5014 03:09:34,029 --> 03:09:36,231 SO THE NEXT SLIDE, SO I HAD THE 5015 03:09:36,231 --> 03:09:39,401 HONOR OF LEADING AN ESTEEMED 5016 03:09:39,401 --> 03:09:43,438 GROUP ALONG WITH MYCOCHAIR TO 5017 03:09:43,438 --> 03:09:45,440 REVIEW THE LITERATURE AND 5018 03:09:45,440 --> 03:09:47,309 INCREASE SOME FRAME WORKS AND 5019 03:09:47,309 --> 03:09:49,912 PERHAPS HIGHLIGHT SOME BEST 5020 03:09:49,912 --> 03:09:51,346 PRACTICES AND EVIDENCE GAPS FOR 5021 03:09:51,346 --> 03:09:54,349 THE MANAGEMENT, ELEVATED BLOOD 5022 03:09:54,349 --> 03:09:56,852 PRESSURE IN ACUTE CARE SETTINGS 5023 03:09:56,852 --> 03:10:02,658 AND IT WAS PUBLISHED, INCLUDED A 5024 03:10:02,658 --> 03:10:04,393 DIVERSE GROUP OF CLINICIANS AND 5025 03:10:04,393 --> 03:10:06,161 SCIENTISTS FROM HOSPITAL 5026 03:10:06,161 --> 03:10:08,564 MEDICINE, CARDIOLOGY, 5027 03:10:08,564 --> 03:10:09,298 NEPHROLOGY, EMERGENCY MEDICINE 5028 03:10:09,298 --> 03:10:15,137 AND OTHERS. 5029 03:10:15,137 --> 03:10:16,338 I DO THINK THERE'S TWO POINTS OF 5030 03:10:16,338 --> 03:10:20,842 VIEW ON THIS. 5031 03:10:20,842 --> 03:10:22,678 ONE POINT OF VIEW IS THERE IS A 5032 03:10:22,678 --> 03:10:23,412 CASE TO BE MADE THAT THE 5033 03:10:23,412 --> 03:10:24,813 HOSPITALIZATION MAY BE A GOOD 5034 03:10:24,813 --> 03:10:28,116 TIME TO HELP IMPROVE THE 5035 03:10:28,116 --> 03:10:31,720 OUTPATIENT MANAGEMENT OF HIGH 5036 03:10:31,720 --> 03:10:32,354 BLOOD PRESSURE. 5037 03:10:32,354 --> 03:10:33,889 ONE ARGUMENT IS IDENTIFY 5038 03:10:33,889 --> 03:10:34,756 INDIVIDUALS WITH UNDIAGNOSED 5039 03:10:34,756 --> 03:10:35,757 ESSENTIAL HYPERTENSION. 5040 03:10:35,757 --> 03:10:37,659 AND FOR THE REASONS I MENTIONED 5041 03:10:37,659 --> 03:10:40,395 BEFORE, THIS MAY BE CHALLENGING. 5042 03:10:40,395 --> 03:10:42,030 IT ALSO MAY PROVIDE AN 5043 03:10:42,030 --> 03:10:45,200 OPPORTUNITY TO OPTIMIZE POOR 5044 03:10:45,200 --> 03:10:47,002 QUALITY REGIMENS, PARTICULARLY 5045 03:10:47,002 --> 03:10:48,637 PATIENTS WHO DON'T HAVE REGULAR 5046 03:10:48,637 --> 03:10:50,339 ACCESS TO CARE AND THERE'S MORE 5047 03:10:50,339 --> 03:10:55,811 OP THIS LATER. 5048 03:10:55,811 --> 03:10:59,281 SO THE COMMITTEE DID THINK A LOT 5049 03:10:59,281 --> 03:11:01,783 ABOUT THE CAUSES OF ELEVATED 5050 03:11:01,783 --> 03:11:02,851 BLOOD PRESSURE IN THE ACUTE CARE 5051 03:11:02,851 --> 03:11:04,152 SETTING AND WE ORGANIZE THEM 5052 03:11:04,152 --> 03:11:06,254 INTO PATIENT FACTORS AND 5053 03:11:06,254 --> 03:11:10,292 HOSPITAL ENVIRONMENTAL FACTORS. 5054 03:11:10,292 --> 03:11:11,159 AND THERE'S TWO HEMISPHERES ON 5055 03:11:11,159 --> 03:11:14,630 THIS FIGURE THAT WAS INCLUDED IN 5056 03:11:14,630 --> 03:11:17,666 THE REPORT, AND THE PATIENT 5057 03:11:17,666 --> 03:11:19,067 FACTORS IN THE NORTHERN 5058 03:11:19,067 --> 03:11:23,605 HEMISPHERE IN THE GREEN AND THE 5059 03:11:23,605 --> 03:11:24,339 HOSPITAL ENVIRONMENTAL -- SOME 5060 03:11:24,339 --> 03:11:25,907 THAT ARE A LITTLE BIT OF BOTH, 5061 03:11:25,907 --> 03:11:31,813 SO THE CLINICAL CONDITION 5062 03:11:31,813 --> 03:11:33,348 OVERLOAD, UNCONTROLLED CHRONIC 5063 03:11:33,348 --> 03:11:34,383 HYPERTENSION. 5064 03:11:34,383 --> 03:11:41,323 COULD BE BIOLOGICAL RESPONSES TO 5065 03:11:41,323 --> 03:11:44,726 PLA MA CORTISOL AND CAT CHOLINE 5066 03:11:44,726 --> 03:11:52,067 LEVELS, COULD BE -- A BIG ONE 5067 03:11:52,067 --> 03:12:01,043 SUCH AS FAILURE TO START A HOME 5068 03:12:01,043 --> 03:12:01,610 ANTIHYPERTENSIVE MEDICATION. 5069 03:12:01,610 --> 03:12:05,981 OF COURSE A BIG ONE, 5070 03:12:05,981 --> 03:12:09,918 INAPPROPRIATE PPE MEASURING, OR 5071 03:12:09,918 --> 03:12:11,453 INBOUND A DEVICE THAT HASN'T 5072 03:12:11,453 --> 03:12:14,956 BEEN CAL GRATED OR VALIDATED, SO 5073 03:12:14,956 --> 03:12:21,329 THIS IS A FRAMEWORK WHY -- SO 5074 03:12:21,329 --> 03:12:23,065 NOW I WANT TO TRANSITION TO A 5075 03:12:23,065 --> 03:12:26,802 LITTLE BIT OF THE 70 -- HOW 5076 03:12:26,802 --> 03:12:28,003 OFTEN ANTIHYPERTENSIVE 5077 03:12:28,003 --> 03:12:28,870 MEDICATIONS HAVE PERHAPS 5078 03:12:28,870 --> 03:12:29,204 CHANGED. 5079 03:12:29,204 --> 03:12:30,839 AND I WANT TO FIRST FOCUS ON 5080 03:12:30,839 --> 03:12:31,540 DISCHARGE. 5081 03:12:31,540 --> 03:12:33,275 THIS IS DATA FROM TIM ANDERSON. 5082 03:12:33,275 --> 03:12:35,377 HE LOOKED AT VETERAN DATA FROM 5083 03:12:35,377 --> 03:12:38,213 THE VHA, VETERAN 65 YEARS OR 5084 03:12:38,213 --> 03:12:40,282 OLDER WITH A DIAGNOSIS OF 5085 03:12:40,282 --> 03:12:41,483 HYPERTENSION, WHO WERE 5086 03:12:41,483 --> 03:12:42,918 HOSPITALIZED FOR KNOWLEDGE 5087 03:12:42,918 --> 03:12:44,686 CARDIAC REASONS. 5088 03:12:44,686 --> 03:12:47,089 WHAT YOU'RE SEEING HERE IS THE 5089 03:12:47,089 --> 03:12:51,493 RATE OF INTENSIFICATION AT 5090 03:12:51,493 --> 03:12:54,629 DISCHARGE BASED ON THE INPATIENT 5091 03:12:54,629 --> 03:12:56,531 BLOOD PRESSURE LEVELS, NOT 5092 03:12:56,531 --> 03:13:01,203 ELEVATED, MODERATELY ELEVATED, 5093 03:13:01,203 --> 03:13:02,904 AND THEY ALSO LOOKED AT THEIR 5094 03:13:02,904 --> 03:13:06,408 OUTPATIENT MEASURES BEFORE 5095 03:13:06,408 --> 03:13:08,510 HOSPITALIZED, AND WHO THINGS YOU 5096 03:13:08,510 --> 03:13:10,712 DO HERE, ONE IS THE PROBABILITY 5097 03:13:10,712 --> 03:13:12,347 OF INTENSIFICATION WAS STRONGLY 5098 03:13:12,347 --> 03:13:14,316 ASSOCIATED WITH THE INPATIENT 5099 03:13:14,316 --> 03:13:15,617 READINGS, WHICH MAKES SENSE, BUT 5100 03:13:15,617 --> 03:13:17,285 IF YOU LOOK AT THE SEVERELY 5101 03:13:17,285 --> 03:13:20,122 ELEVATED GROUP, HOW WELL THEY 5102 03:13:20,122 --> 03:13:25,727 WERE CONTROLLED AS AN OUTPATIENT 5103 03:13:25,727 --> 03:13:27,496 WASN'T STRONGLY ASSOCIATED WITH 5104 03:13:27,496 --> 03:13:28,730 INTENSIFICATION AT DISCHARGE. 5105 03:13:28,730 --> 03:13:30,565 ANOTHER ELEGANT ASPECT OF TIM'S 5106 03:13:30,565 --> 03:13:32,334 PAPER IS HE LOOKED AT THE 5107 03:13:32,334 --> 03:13:34,436 INTENSIFICATION RATES BY GROUPS 5108 03:13:34,436 --> 03:13:37,172 OF PATIENTS THAT MAY HAVE A 5109 03:13:37,172 --> 03:13:39,374 LOWER LIKELIHOOD OF BENEFIT ON 5110 03:13:39,374 --> 03:13:41,243 THE LEFT, CATEGORIES OF LIFE 5111 03:13:41,243 --> 03:13:43,879 EXPECTANCY WITH OR WITHOUT 5112 03:13:43,879 --> 03:13:45,647 DEMENTIA, METASTATIC FLIG MAN 5113 03:13:45,647 --> 03:13:48,150 SEE, AND WE CAN ARGUE ABOUT WHAT 5114 03:13:48,150 --> 03:13:56,057 THE DETERMINATIONS OF LOW 5115 03:13:56,057 --> 03:13:59,227 LOWER -- -- CONDITIONS LIKE 5116 03:13:59,227 --> 03:14:01,363 RENAL DISEASE, WHAT YOU SEE IS A 5117 03:14:01,363 --> 03:14:02,731 SIMILAR INTENSIFICATION RATE. 5118 03:14:02,731 --> 03:14:04,833 SO TIM IN THIS PAPER MADE A 5119 03:14:04,833 --> 03:14:06,168 POINT THAT AMONGST PEOPLE WHO 5120 03:14:06,168 --> 03:14:08,703 MAY BE LESS LIKELY TO BEN FID, 5121 03:14:08,703 --> 03:14:10,238 ARE STILL GETTING INTENSIFIED AT 5122 03:14:10,238 --> 03:14:18,079 THE SAME RATE AND WHO HAVE HIGH 5123 03:14:18,079 --> 03:14:22,517 RISK OF ASCVD HAVE THE SAME 5124 03:14:22,517 --> 03:14:23,485 INTENSIFICATION RATES. 5125 03:14:23,485 --> 03:14:24,820 NOW TIM TOOK THIS ONE STEP 5126 03:14:24,820 --> 03:14:26,822 FURTHER AND LOOKED AT OUTCOMES, 5127 03:14:26,822 --> 03:14:27,622 AGAIN IN AN OBSERVATIONAL 5128 03:14:27,622 --> 03:14:29,424 DESIGN, THIS WAS A PROPENSITY 5129 03:14:29,424 --> 03:14:33,195 MATCHED ANALYSIS AND HE COMPARED 5130 03:14:33,195 --> 03:14:34,496 HOSPITAL READMISSION, SERIOUS 5131 03:14:34,496 --> 03:14:37,332 ADVERSE EVENTS, CARDIOVASCULAR 5132 03:14:37,332 --> 03:14:38,767 DISEASE EVENTS BETWEEN THESE 5133 03:14:38,767 --> 03:14:41,536 PATIENTS, MATCHED PATIENTS WHO 5134 03:14:41,536 --> 03:14:46,341 WERE INTENSIFIED. 5135 03:14:46,341 --> 03:14:47,676 THE SURPRISING FINDING HERE IS 5136 03:14:47,676 --> 03:14:49,845 THAT AMONG PATIENTS THAT HAD 5137 03:14:49,845 --> 03:14:51,279 THEIR ANTIHYPERTENSIVE 5138 03:14:51,279 --> 03:14:53,615 MEDICATION REGIMEN INTENSIFIED 5139 03:14:53,615 --> 03:14:56,218 AT DISK CHARGE, HAD A HIGHER 5140 03:14:56,218 --> 03:14:58,787 RATE OF ADVERSE EVENTS: 5141 03:14:58,787 --> 03:15:01,523 READMISSION, SERIOUS ADVERSE 5142 03:15:01,523 --> 03:15:01,823 EVENTS. 5143 03:15:01,823 --> 03:15:05,327 SO THIS IS SOME OF THE DATA WHEN 5144 03:15:05,327 --> 03:15:07,062 PEOPLE MAKE THE ARGUMENT THAT 5145 03:15:07,062 --> 03:15:09,998 MAYBE IT'S BETTER TO NOT TUNE 5146 03:15:09,998 --> 03:15:17,572 UP, CHANGE OR INTENSIFY 5147 03:15:17,572 --> 03:15:28,316 ANTIHYPERTENSIVE, A. WHAT ARE E 5148 03:15:28,516 --> 03:15:29,618 OF THE STEPS TO CONSIDER AT 5149 03:15:29,618 --> 03:15:30,051 DISCHARGE? 5150 03:15:30,051 --> 03:15:33,889 WE ORGANIZED THIS BASICALLY INTO 5151 03:15:33,889 --> 03:15:34,956 TWO, CAREFUL REVIEW AND 5152 03:15:34,956 --> 03:15:36,224 POTENTIAL ADJUSTMENT, CAREFUL 5153 03:15:36,224 --> 03:15:37,759 ADJUSTMENT OF THE 5154 03:15:37,759 --> 03:15:38,894 ANTIHYPERTENSIVE MEDICATION 5155 03:15:38,894 --> 03:15:39,127 REGIMEN. 5156 03:15:39,127 --> 03:15:41,429 AGAIN THERE'S NOT GOOD EVIDENCE 5157 03:15:41,429 --> 03:15:42,931 AROUND IS IT WHAT THE RISK 5158 03:15:42,931 --> 03:15:45,567 BENEFIT OF DOING THIS IS. 5159 03:15:45,567 --> 03:15:47,435 THERE'S THE ANALYSIS FROM TIM, 5160 03:15:47,435 --> 03:15:48,770 WHICH SHOWS THERE MIGHT -- IT 5161 03:15:48,770 --> 03:15:51,273 MAY NOT BE IDEAL, BUT WE'RE NOT 5162 03:15:51,273 --> 03:15:58,179 SURE IN WHICH PATIENTS. 5163 03:15:58,179 --> 03:15:59,581 TO HELP WITH THINKING THROUGH 5164 03:15:59,581 --> 03:16:00,382 THE TRANSITION FROM HOSPITAL TO 5165 03:16:00,382 --> 03:16:01,917 HOME, WE CREATED THIS FIGURE. 5166 03:16:01,917 --> 03:16:05,620 WE CALL IT AIM AS AN ALGORITHM, 5167 03:16:05,620 --> 03:16:07,088 A FOR ARRANGE, COMPREHENSIVE 5168 03:16:07,088 --> 03:16:08,189 FOLLOW-UP CARE WITHIN TWO WEEKS 5169 03:16:08,189 --> 03:16:08,723 OF DISCHARGE. 5170 03:16:08,723 --> 03:16:10,959 FOR ASSESSMENT AND CORE 5171 03:16:10,959 --> 03:16:11,927 FORMATION OF THE DIAGNOSIS IF IT 5172 03:16:11,927 --> 03:16:15,096 HAPPENS TO BE A NEW DIAGNOSIS. 5173 03:16:15,096 --> 03:16:16,498 AS WELL AS MANAGEMENT OF 5174 03:16:16,498 --> 03:16:20,268 MEDICATIONS AND SO FORTH. 5175 03:16:20,268 --> 03:16:22,170 INFORM, I FOR INFORM PATIENTS 5176 03:16:22,170 --> 03:16:23,305 ABOUT THE IMPORTANCE OF 5177 03:16:23,305 --> 03:16:24,406 BROMOPROPANE AND STEPS TO TAKE 5178 03:16:24,406 --> 03:16:26,708 AT HOME AND INCLUDING NON-FARM 5179 03:16:26,708 --> 03:16:28,710 CLA JIK INTERVENTIONS AND THEN 5180 03:16:28,710 --> 03:16:30,612 MONITOR. 5181 03:16:30,612 --> 03:16:33,415 OF COURSE TRYING TO FACILITATE 5182 03:16:33,415 --> 03:16:34,049 PATIENTS GETTING INTO PROGRAMS 5183 03:16:34,049 --> 03:16:35,984 WITH TEAM-BASED CARE. 5184 03:16:35,984 --> 03:16:36,985 I APPRECIATE THESE AREN'T 5185 03:16:36,985 --> 03:16:38,820 AVAILABLE AS MUCH AS WE'D LIKE, 5186 03:16:38,820 --> 03:16:41,122 BUT TO REALLY TRY TO HELP 5187 03:16:41,122 --> 03:16:43,124 PATIENTS GET INTO CENTERS LIKE 5188 03:16:43,124 --> 03:16:47,595 THAT. 5189 03:16:47,595 --> 03:16:49,564 WE ALSO TALK ABOUT MEDICATION 5190 03:16:49,564 --> 03:16:57,872 COUNSELING AT DISCHARGE. 5191 03:16:57,872 --> 03:16:59,307 1 IN 7 PATIENTS EXPRESS 5192 03:16:59,307 --> 03:17:01,609 CONFUSION ABOUT THEIR MEDICATION 5193 03:17:01,609 --> 03:17:02,410 AT DISCHARGE. 5194 03:17:02,410 --> 03:17:07,649 SO HIGHLIGHTING THE IMPORTANCE 5195 03:17:07,649 --> 03:17:10,318 OF CLEAR COMMUNICATION, DURING 5196 03:17:10,318 --> 03:17:20,795 EMISSION AND OCCUPATION. 5197 03:17:27,102 --> 03:17:29,871 ANOTHER AREA AGAIN IS THINKING 5198 03:17:29,871 --> 03:17:31,706 ABOUT THE PHARMACEUTICAL CARE OR 5199 03:17:31,706 --> 03:17:33,508 THE ANTIHYPERTENSIVE MEDICATION 5200 03:17:33,508 --> 03:17:36,177 REGIMEN AT DISCHARGE. 5201 03:17:36,177 --> 03:17:38,546 AGAIN, ASSESSING THE WHOLE 5202 03:17:38,546 --> 03:17:39,581 MEDICATION REGIMEN, NOT JUST THE 5203 03:17:39,581 --> 03:17:40,415 ANTIHYPERTENSIVE MEDICATIONS 5204 03:17:40,415 --> 03:17:41,850 LOOKING FOR DRUG-DRUG 5205 03:17:41,850 --> 03:17:43,618 INTERACTIONS. 5206 03:17:43,618 --> 03:17:46,154 TRYING TO ASSESS THE QUALITY OF 5207 03:17:46,154 --> 03:17:47,589 THE ANTIHYPERTENSIVE MEDICATION 5208 03:17:47,589 --> 03:17:49,090 REGIMEN, I'LL SHARE SOME DATA ON 5209 03:17:49,090 --> 03:17:51,226 THIS IN A MINUTE, OF COURSE NEW 5210 03:17:51,226 --> 03:17:52,427 MEDICATION INITIATION SHOULD 5211 03:17:52,427 --> 03:17:55,163 ALIGN WITH THE 2017 -- THE MOST 5212 03:17:55,163 --> 03:17:59,100 RECENT U.S. GUIDELINES, SINGLE 5213 03:17:59,100 --> 03:18:01,202 PILL COMBINATIONS, HOME 5214 03:18:01,202 --> 03:18:06,674 MONITORING AND TEAM-BASED CARE. 5215 03:18:06,674 --> 03:18:10,078 IN TERMS OF GAPS IN QUALITY OF 5216 03:18:10,078 --> 03:18:11,179 PHARMACEUTICAL CARE IN 5217 03:18:11,179 --> 03:18:12,280 HYPERTENSION, I JUST WANT TO 5218 03:18:12,280 --> 03:18:13,148 POINT OUT A FEW. 5219 03:18:13,148 --> 03:18:17,352 THIS IS DATA FROM OUR GROUP LED 5220 03:18:17,352 --> 03:18:19,320 BY KATIE DARINGTON SHOWING NEW 5221 03:18:19,320 --> 03:18:21,056 TREATMENT OF HYPERTENSION BASED 5222 03:18:21,056 --> 03:18:22,390 ON BLOOD PRESSURE LEVEL, AND WE 5223 03:18:22,390 --> 03:18:25,260 FOUND THAT ABOUT 60% OF VETERANS 5224 03:18:25,260 --> 03:18:27,762 WITH A PRE-TREATMENT OF GREATER 5225 03:18:27,762 --> 03:18:30,031 THAN 160, WEAR STARTING ON ONLY 5226 03:18:30,031 --> 03:18:30,765 SINGLE AGENT. 5227 03:18:30,765 --> 03:18:32,734 SO THIS IS A SIGNIFICANT GAP IN 5228 03:18:32,734 --> 03:18:34,302 CARE, WE KNOW THAT MOST PATIENTS 5229 03:18:34,302 --> 03:18:36,571 WITH HYPERTENSION NEED TWO OR 5230 03:18:36,571 --> 03:18:39,107 THREE AND THEN INITIAL 5231 03:18:39,107 --> 03:18:40,008 COMBINATION THERAPY IS A LITTLE 5232 03:18:40,008 --> 03:18:44,412 MORE EFFECTIVE THAN USUAL CARE 5233 03:18:44,412 --> 03:18:45,413 OR STEP CARE. 5234 03:18:45,413 --> 03:18:47,282 ANOTHER QUALITY GAP THAT WE'VE 5235 03:18:47,282 --> 03:18:49,350 LOOKED AT IS BETA BLOCK EARLY 5236 03:18:49,350 --> 03:18:51,119 THERAPY AMONG PEOPLE WITHOUT 5237 03:18:51,119 --> 03:18:57,258 COMPELLING INDICATIONS, SUCH AS 5238 03:18:57,258 --> 03:18:58,226 CORONARY DISEASE, HEART FAILURE 5239 03:18:58,226 --> 03:18:59,894 WITH REDUCED EJECTION FRACTION 5240 03:18:59,894 --> 03:19:02,097 OR ATRIAL FIBRILLATION. 5241 03:19:02,097 --> 03:19:04,399 THIS IS SHOWING THE PREVALENCE 5242 03:19:04,399 --> 03:19:07,469 OF BETA BLOCKER USE AMONG 5243 03:19:07,469 --> 03:19:13,174 VETERANS WITHOUT COMPELLING 5244 03:19:13,174 --> 03:19:19,080 INDICATIONS. 5245 03:19:19,080 --> 03:19:19,681 RESISTANT HYPERTENSION. 5246 03:19:19,681 --> 03:19:25,386 THIS WAS DATA LANGFORD LED IN 5247 03:19:25,386 --> 03:19:26,354 THE JACKSON HEART STUDY LOOKING 5248 03:19:26,354 --> 03:19:29,290 AT THE PREVALENCE OF THE 5249 03:19:29,290 --> 03:19:39,567 LONG-ACTING MORE PR AND THE FOUH 5250 03:19:39,567 --> 03:19:44,172 LINE, FOUND THAT ONLY ABOUT 7% 5251 03:19:44,172 --> 03:19:48,343 OF PATIENTS IN THE JACKSON HEART 5252 03:19:48,343 --> 03:19:53,047 STUDY WITH RESISTANCE -- AND 5253 03:19:53,047 --> 03:19:59,587 ONLY 17% WERE TAKING SPYRO OR -- 5254 03:19:59,587 --> 03:20:09,330 CAN BE EVALUATED AND TAKEN CARE 5255 03:20:09,330 --> 03:20:10,665 FOUND THAT ABOUT 20% OF PATIENTS 5256 03:20:10,665 --> 03:20:12,433 WITH HYPERTENSION WERE TAKING AT 5257 03:20:12,433 --> 03:20:14,068 LEAST ONE DRUG THAT COULD 5258 03:20:14,068 --> 03:20:14,702 INCREASE BLOOD PRESSURE. 5259 03:20:14,702 --> 03:20:18,072 IT USUALLY ANTI-DEPRESSANTS OR 5260 03:20:18,072 --> 03:20:19,941 NSAIDs. 5261 03:20:19,941 --> 03:20:20,909 ANTI-DEPRESSANTS ARE PROBABLY A 5262 03:20:20,909 --> 03:20:23,478 LITTLE MORE TRICKY TO MODIFY BY 5263 03:20:23,478 --> 03:20:24,245 NSAIDs ARE SOMETHING WE CAN 5264 03:20:24,245 --> 03:20:31,553 HELP WITH. 5265 03:20:31,553 --> 03:20:34,122 ADHERENCE. 5266 03:20:34,122 --> 03:20:35,924 CRITICAL TO STUDY MORE 5267 03:20:35,924 --> 03:20:36,891 INTERVENTIONS THAT CAN ACTUALLY 5268 03:20:36,891 --> 03:20:38,092 HELP PATIENTS WITH ADHERENCE, 5269 03:20:38,092 --> 03:20:40,061 THIS IS ANOTHER PAPER FROM TIM'S 5270 03:20:40,061 --> 03:20:43,231 GROUP LOOKING AT AT HOSPITAL 5271 03:20:43,231 --> 03:20:45,366 DISCHARGE WHAT THE PERSISTENCE 5272 03:20:45,366 --> 03:20:49,404 RATES ARE OF NEW MEDICATIONS OR 5273 03:20:49,404 --> 03:20:50,104 DOSE INCREASES, AND JUST LIKE 5274 03:20:50,104 --> 03:20:52,407 ALL THE OTHER ANALYSIS, IT'S 5275 03:20:52,407 --> 03:20:58,846 VERY LOW AT ONE YEAR, ABOUT 50%. 5276 03:20:58,846 --> 03:21:00,348 IN THE INTEREST OF TIME I'LL 5277 03:21:00,348 --> 03:21:01,549 SKIP THROUGH THESE NEXT COUPLE 5278 03:21:01,549 --> 03:21:06,988 SLIDES AND JUST GO RIG RIGHT TOY 5279 03:21:06,988 --> 03:21:09,257 GAPS AND FUTURE DIRECTIONS. 5280 03:21:09,257 --> 03:21:10,124 ABOUT TWO MORE. 5281 03:21:10,124 --> 03:21:11,893 I JUST WAS TALKING A LITTLE BIT 5282 03:21:11,893 --> 03:21:14,829 ABOUT FBCs AND TEAM-BASED 5283 03:21:14,829 --> 03:21:17,065 CARE. 5284 03:21:17,065 --> 03:21:18,600 SO WE'LL GO BACK ONE SLIDE. 5285 03:21:18,600 --> 03:21:24,739 THE KEY KNOWLEDGE GAPS ARE 5286 03:21:24,739 --> 03:21:26,374 ADDRESSING THE IMPACT OF 5287 03:21:26,374 --> 03:21:29,344 INACCURATE BLOOD PRESSURE 5288 03:21:29,344 --> 03:21:29,978 MEASUREMENT. 5289 03:21:29,978 --> 03:21:33,414 SHOULD WE BE MODIFYING 5290 03:21:33,414 --> 03:21:35,583 MEDICATIONS AND THE 5291 03:21:35,583 --> 03:21:36,851 ANTIHYPERTENSIVE MEDICATIONS IN 5292 03:21:36,851 --> 03:21:41,089 THE HOSPITAL OR NOT IN THE 5293 03:21:41,089 --> 03:21:45,126 ABSENCE OF NEW OR WORSENING 5294 03:21:45,126 --> 03:21:46,361 TARGET ORGAN DAMAGE, AND THEN 5295 03:21:46,361 --> 03:21:48,796 WHAT ARE THE BP GOALS FOR 5296 03:21:48,796 --> 03:21:49,597 INPATIENTS? 5297 03:21:49,597 --> 03:21:55,236 THOSE ARE THREE KNOWLEDGE GAPS 5298 03:21:55,236 --> 03:21:56,871 AND THEN HOME MONITORING, 5299 03:21:56,871 --> 03:21:58,906 EVALUATING APPROACHES TO ENSURE 5300 03:21:58,906 --> 03:22:00,975 PATIENTS ARE DISCHARGED WITH 5301 03:22:00,975 --> 03:22:02,010 VALIDATED HOME BEEPING MONITORS 5302 03:22:02,010 --> 03:22:03,945 AND TRAINING. 5303 03:22:03,945 --> 03:22:05,546 WHAT LEVEL OF PHARMACEUTICAL 5304 03:22:05,546 --> 03:22:09,217 CARE SHOULD BE PROVIDED AT 5305 03:22:09,217 --> 03:22:09,484 DISCHARGE? 5306 03:22:09,484 --> 03:22:19,527 WHAT PROVIDES A FAVORABLE RI RIK 5307 03:22:19,527 --> 03:22:20,495 BENEFIT PROFILE? 5308 03:22:20,495 --> 03:22:21,763 AND THEN THERAPY ESCALATION 5309 03:22:21,763 --> 03:22:22,196 THRESHOLDS. 5310 03:22:22,196 --> 03:22:23,531 SO WITH THAT, THANK YOU VERY 5311 03:22:23,531 --> 03:22:23,731 MUCH. 5312 03:22:23,731 --> 03:22:25,667 >> THANK YOU, ADAM. 5313 03:22:25,667 --> 03:22:26,434 FANTASTIC PRESENTATION AS 5314 03:22:26,434 --> 03:22:32,206 ALWAYS. 5315 03:22:32,206 --> 03:22:36,144 FOR THE DISCUSSION, MAYBE ALL OF 5316 03:22:36,144 --> 03:22:36,911 THE SPEAKERS FROM THE SESSION 5317 03:22:36,911 --> 03:22:47,355 CAN TURN ON THEIR CAMERAS? 5318 03:22:51,459 --> 03:22:52,694 PLEASE, IF PEOPLE HAVE QUESTIONS 5319 03:22:52,694 --> 03:22:54,128 OR COMMENTS, PLEASE PUT THEM IN 5320 03:22:54,128 --> 03:22:55,430 THE CHAT. 5321 03:22:55,430 --> 03:22:56,664 WOULD YOU LIKE TO GET US 5322 03:22:56,664 --> 03:22:56,898 STARTED? 5323 03:22:56,898 --> 03:22:58,299 >> I HAVE A COUPLE THINGS. 5324 03:22:58,299 --> 03:23:02,804 ONE WAS ABOUT MEASURING BLOOD 5325 03:23:02,804 --> 03:23:06,007 PRESSURE, WE GOT SOME QUESTIONS 5326 03:23:06,007 --> 03:23:07,642 ON THAT IN PEOPLE THAT ARE 5327 03:23:07,642 --> 03:23:08,409 OVERWEIGHT. 5328 03:23:08,409 --> 03:23:10,378 THERE WAS ONE QUESTION ABOUT 5329 03:23:10,378 --> 03:23:19,087 USING THE FOREARM, ALSO WRIST 5330 03:23:19,087 --> 03:23:20,154 MONITORS BEING USEFUL FOR PEOPLE 5331 03:23:20,154 --> 03:23:21,689 THAT ARE OTHERWISE HARD TO FIT 5332 03:23:21,689 --> 03:23:26,094 IN UPPER ARM MONITORS. 5333 03:23:26,094 --> 03:23:27,762 >> SURE. 5334 03:23:27,762 --> 03:23:30,365 THANKS, BEV. 5335 03:23:30,365 --> 03:23:32,900 THE DEFAULT IN MOST OF THE 5336 03:23:32,900 --> 03:23:35,203 GUIDELINES IS TO PUT A STANDARD 5337 03:23:35,203 --> 03:23:37,305 UPPER ARM CUFF, WHATEVER THAT 5338 03:23:37,305 --> 03:23:39,073 MAY BE, 14 CENTIMETERS OR SO ON 5339 03:23:39,073 --> 03:23:40,375 A FOREARM. 5340 03:23:40,375 --> 03:23:42,810 I KNOW OF NO -- AND THEN MEASURE 5341 03:23:42,810 --> 03:23:45,313 THE RADIAL PULSE, RADIAL 5342 03:23:45,313 --> 03:23:46,748 PRESSURE BY EITHER AUSCULTATION 5343 03:23:46,748 --> 03:23:51,018 OR PALPATION. 5344 03:23:51,018 --> 03:23:53,221 MOST OF THE GUIDELINES HAVE 5345 03:23:53,221 --> 03:23:57,291 EITHER BEEN TENUOUS OR AT LEAST 5346 03:23:57,291 --> 03:24:00,128 CAREFUL THAT THE USE OF PRESENT 5347 03:24:00,128 --> 03:24:02,363 WRIST DEVICES, ET CETERA, NEED 5348 03:24:02,363 --> 03:24:02,797 FURTHER EVALUATION. 5349 03:24:02,797 --> 03:24:04,332 SO I DON'T WANT TO DIP INTO THAT 5350 03:24:04,332 --> 03:24:05,266 BECAUSE I KNOW THAT'S COMING UP 5351 03:24:05,266 --> 03:24:08,369 AS A FULL DISCUSSION. 5352 03:24:08,369 --> 03:24:09,103 BUT I THINK THAT ONE OF THE 5353 03:24:09,103 --> 03:24:11,939 CONCERNS I HAVE ABOUT THIS IS 5354 03:24:11,939 --> 03:24:13,708 THAT THE FOREARMS IN SOME PEOPLE 5355 03:24:13,708 --> 03:24:16,344 ARE REMARKABLY LARGE, THEY'RE 5356 03:24:16,344 --> 03:24:26,854 ALSO TRUNCOCONAL IN WRISTS, SO 5357 03:24:28,389 --> 03:24:29,757 I'M NOT SURE HOW ACCURATE THAT 5358 03:24:29,757 --> 03:24:30,291 IS. 5359 03:24:30,291 --> 03:24:31,492 I DON'T OTHERWISE HAVE A GOOD 5360 03:24:31,492 --> 03:24:32,493 ANSWER FOR THIS. 5361 03:24:32,493 --> 03:24:34,395 I'M SIMPLY REFLECTING WHAT IS 5362 03:24:34,395 --> 03:24:36,364 PRINCE BLI MY KNOWLEDGE OF 5363 03:24:36,364 --> 03:24:38,199 WHAT'S IN THE LITERATURE, AND 5364 03:24:38,199 --> 03:24:40,601 THE FACT IS WE ALREADY KNOW 5365 03:24:40,601 --> 03:24:43,938 THESE CUFFS AND CUFF DEVICES FOR 5366 03:24:43,938 --> 03:24:48,009 ARMS AND FOREARMS AND FINGERS 5367 03:24:48,009 --> 03:24:51,045 ARE OUT THERE. 5368 03:24:51,045 --> 03:24:52,447 I THINK THAT'S THE BEST ANSWER I 5369 03:24:52,447 --> 03:24:55,383 CAN GIVE. 5370 03:24:55,383 --> 03:24:58,219 >> WE'VE HAD SOME COMMENTS ABOUT 5371 03:24:58,219 --> 03:24:59,954 CHILDREN WITH LARGE ARMS AS 5372 03:24:59,954 --> 03:25:03,424 WELL-BEING VERY, VERY DIFFICULT 5373 03:25:03,424 --> 03:25:06,994 AND NEEDING MORE RESEARCH. 5374 03:25:06,994 --> 03:25:10,631 ANYBODY ELSE WANT TO CHIME IN? 5375 03:25:10,631 --> 03:25:11,432 GO AHEAD. 5376 03:25:11,432 --> 03:25:13,167 >> ANOTHER QUESTION ABOUT 5377 03:25:13,167 --> 03:25:19,073 OBESITY, WHICH IS MAJOR WEIGHT 5378 03:25:19,073 --> 03:25:19,874 LOSS, IS BLOOD PRESSURE 5379 03:25:19,874 --> 03:25:23,611 MEASUREMENT A CHALLENGE WITH 5380 03:25:23,611 --> 03:25:26,614 EXCESS SKIN TISSUE OR ARE WE 5381 03:25:26,614 --> 03:25:28,850 GOING TO BE SEEING THIS AS A 5382 03:25:28,850 --> 03:25:31,586 PROBLEM COMING UP, GIVEN THE 5383 03:25:31,586 --> 03:25:35,389 INCREASE IN GLP1 USE AND PEOPLE 5384 03:25:35,389 --> 03:25:36,057 LOSING SUBSTANTIAL WEIGHT? 5385 03:25:36,057 --> 03:25:37,558 >> THAT'S A GREAT QUESTION AND I 5386 03:25:37,558 --> 03:25:39,327 DON'T KNOW THE -- I HAVE NOT 5387 03:25:39,327 --> 03:25:41,796 SEEN ANYTHING THAT HAS REALLY 5388 03:25:41,796 --> 03:25:42,430 ADDRESSED THIS. 5389 03:25:42,430 --> 03:25:49,537 MUCH OF THE LITERATURE I'VE 5390 03:25:49,537 --> 03:25:50,938 SEEN -- USE OF CLOTHING, WHETHER 5391 03:25:50,938 --> 03:25:51,973 THAT IMPACTS ON IT. 5392 03:25:51,973 --> 03:25:53,307 THE REAL ISSUE, I THINK, PAUL 5393 03:25:53,307 --> 03:25:54,609 AND THE BEST ANSWER I CAN GIVE 5394 03:25:54,609 --> 03:25:59,814 IS WHETHER A CUFF IS ADEQUATE TO 5395 03:25:59,814 --> 03:26:01,916 THE BLADDER WIDTH TO THE ARM 5396 03:26:01,916 --> 03:26:02,984 CIRCUMFERENCE, NUMBER ONE. 5397 03:26:02,984 --> 03:26:04,652 NUMBER TWO IS THAT IT HAS 5398 03:26:04,652 --> 03:26:06,320 COMPRESSIBILITY THAT IS 5399 03:26:06,320 --> 03:26:07,755 SYMMETRICAL TO THE ARM. 5400 03:26:07,755 --> 03:26:09,490 BEYOND THAT, I DON'T THINK THAT 5401 03:26:09,490 --> 03:26:10,691 THERE'S ANYTHING -- I'M NOT 5402 03:26:10,691 --> 03:26:11,692 SEEING ANYTHING. 5403 03:26:11,692 --> 03:26:13,194 MAYBE SOMEBODY ELSE ON THE PANEL 5404 03:26:13,194 --> 03:26:14,695 HAS OR OTHERS IN THE AUDIENCE, 5405 03:26:14,695 --> 03:26:16,430 BUT I'M NOT SEEING ANYTHING THAT 5406 03:26:16,430 --> 03:26:20,201 SAYS WHAT DO YOU DO WHEN THE ARM 5407 03:26:20,201 --> 03:26:27,542 GETS MUCH, MUCH SMALLER? 5408 03:26:27,542 --> 03:26:31,746 >> I THINK FOR DR. BIAGGIONI, 5409 03:26:31,746 --> 03:26:34,348 HOPE I DID THAT RIGHT -- WHAT'S 5410 03:26:34,348 --> 03:26:36,217 THE SINGLE MOST IMPORTANT 5411 03:26:36,217 --> 03:26:37,985 THING -- I'M A FAMILY PHYSICIAN, 5412 03:26:37,985 --> 03:26:41,155 AND I KNOW THAT FAMILY 5413 03:26:41,155 --> 03:26:45,293 PHYSICIANS OFTEN DON'T INTENSIFY 5414 03:26:45,293 --> 03:26:47,528 MEDICATIONS IN PEOPLE WHO ARE 7E 5415 03:26:47,528 --> 03:26:48,396 AFRAID THEY'RE GOING TO FALL. 5416 03:26:48,396 --> 03:26:53,367 OF COURSE THEY SHOULD BE DOING 5417 03:26:53,367 --> 03:26:56,437 THE PASTORAL BP BEFORE THEY MAKE 5418 03:26:56,437 --> 03:26:57,638 THAT ASSUMPTION AND ALSO ASK 5419 03:26:57,638 --> 03:26:58,906 THEM ABOUT THE SYMPTOMS, BUT 5420 03:26:58,906 --> 03:26:59,774 WHAT IS THE MOST IMPORTANT THING 5421 03:26:59,774 --> 03:27:02,176 YOU MIGHT TELL THEM ONCE THEY'VE 5422 03:27:02,176 --> 03:27:07,548 DONE THOSE ASSESSMENTS OR NOT 5423 03:27:07,548 --> 03:27:09,250 HOW TO BE GENERICALLY WORRIED 5424 03:27:09,250 --> 03:27:11,886 ABOUT LOWERING OLDER PEOPLE'S 5425 03:27:11,886 --> 03:27:13,287 BLOOD PRESSURE WHO MIGHT GET A 5426 03:27:13,287 --> 03:27:13,521 BENEFIT? 5427 03:27:13,521 --> 03:27:14,889 >> THANKS SO MUCH FOR THE 5428 03:27:14,889 --> 03:27:15,222 QUESTION. 5429 03:27:15,222 --> 03:27:17,191 I'M NOT GOING TO -- I MEAN, IT 5430 03:27:17,191 --> 03:27:25,066 CAN GET COMPLICATED BASED ON 5431 03:27:25,066 --> 03:27:25,766 HYPOTENSION NEEDS. 5432 03:27:25,766 --> 03:27:26,968 BUT IN MOST PATIENTS EVEN IF 5433 03:27:26,968 --> 03:27:32,340 THEY HAVE MILD ORTHOSTATIC 5434 03:27:32,340 --> 03:27:33,874 HYPOTENSION, THEIR HYPERTENSION 5435 03:27:33,874 --> 03:27:42,416 NEEDS TO BE TREAT TREATED LIKE 5436 03:27:42,416 --> 03:27:45,286 EVERYBODY ELSE. 5437 03:27:45,286 --> 03:27:45,953 WE SEE FOR EXAMPLE PHYSICIANS 5438 03:27:45,953 --> 03:27:49,090 ARE USING A LOT OF CARVEDILOL 5439 03:27:49,090 --> 03:27:53,527 AND OF COURSE THAT'S AN ALMA 5440 03:27:53,527 --> 03:27:53,761 BLOCKER. 5441 03:27:53,761 --> 03:28:00,001 AND IF YOU HAVE POSTURAL -- 5442 03:28:00,001 --> 03:28:02,036 OTHER TYPE OF BETA-BLOCKERS. 5443 03:28:02,036 --> 03:28:03,738 EXAMPLES LIKE THAT. 5444 03:28:03,738 --> 03:28:05,806 AND A LOT OF PATIENTS AT THAT 5445 03:28:05,806 --> 03:28:15,683 AGE MAY BE ON -- SO IDENTIFYING 5446 03:28:15,683 --> 03:28:16,917 FACTORS THAT CAN AGGRAVATE 5447 03:28:16,917 --> 03:28:18,352 HYPOTENSION THAT HAVE NOTHING TO 5448 03:28:18,352 --> 03:28:21,522 DO WITH GOOD TREATMENT FOR 5449 03:28:21,522 --> 03:28:23,991 HYPERTENSION, THAT WOULD BE THE 5450 03:28:23,991 --> 03:28:24,291 FIRST STEP. 5451 03:28:24,291 --> 03:28:25,760 BUT IN MOST PATIENTS, YOU CAN DO 5452 03:28:25,760 --> 03:28:33,367 BOTH. 5453 03:28:33,367 --> 03:28:35,670 LEW'S COMMENT ALREADY ON THIS 5454 03:28:35,670 --> 03:28:38,039 QUESTION SAYING THAT THERE'S 5455 03:28:38,039 --> 03:28:39,807 EVIDENCE THAT THE SLOW GRADUAL 5456 03:28:39,807 --> 03:28:41,776 TREATMENT OF AN OLDER ADULT 5457 03:28:41,776 --> 03:28:43,544 MIGHT ACTUALLY ROW DUES RATHER 5458 03:28:43,544 --> 03:28:47,515 THAN WORSEN IT, AND I THINK 5459 03:28:47,515 --> 03:28:48,182 THAT'S CORRECT. 5460 03:28:48,182 --> 03:28:50,051 HE'S DONE A VERY NICE STUDY 5461 03:28:50,051 --> 03:28:55,122 SHOWING THAT UNCONTROLLED 5462 03:28:55,122 --> 03:28:56,791 FORTIFYING HYPOTENSION, PERHAPS 5463 03:28:56,791 --> 03:28:58,526 MAKE A MECHANISM THAT I 5464 03:28:58,526 --> 03:29:02,229 MENTIONED WITH NOCTURNAL 5465 03:29:02,229 --> 03:29:04,365 DIURESIS -- IT CAN BE A 5466 03:29:04,365 --> 03:29:06,033 COMPLICATED ISSUE BUT IF YOU 5467 03:29:06,033 --> 03:29:07,868 REMOVE AGGRAVATING FACTORS AND 5468 03:29:07,868 --> 03:29:10,805 YOU FOCUS ON THE TREATMENT OF 5469 03:29:10,805 --> 03:29:11,539 HYPERTENSION, IN GENERAL, THAT 5470 03:29:11,539 --> 03:29:15,042 IS THE BEST FOR THE PATIENT. 5471 03:29:15,042 --> 03:29:15,476 >> THANK YOU. 5472 03:29:15,476 --> 03:29:16,877 YOU WANT TO HAVE ANOTHER ONE, 5473 03:29:16,877 --> 03:29:17,078 PAUL? 5474 03:29:17,078 --> 03:29:20,047 >> I'M GOING TO ASK ADAM A 5475 03:29:20,047 --> 03:29:20,948 QUESTION, BECAUSE SOMETHING HE 5476 03:29:20,948 --> 03:29:22,750 SAID AT THE END OF HIS TALK 5477 03:29:22,750 --> 03:29:25,019 PIQUED MY INTEREST, AND THIS IS 5478 03:29:25,019 --> 03:29:29,724 FOCUSED ON WHAT TO DO FOR BLOOD 5479 03:29:29,724 --> 03:29:30,491 PRESSURE MEASUREMENT POST 5480 03:29:30,491 --> 03:29:31,692 DISCHARGE. 5481 03:29:31,692 --> 03:29:34,061 YOU MENTIONED BLOOD PRESSURE 5482 03:29:34,061 --> 03:29:34,428 HOME MONITORING. 5483 03:29:34,428 --> 03:29:41,035 DO YOU THINK THAT SHOULD BE -- 5484 03:29:41,035 --> 03:29:42,903 DO YOU THINK THAT IS THE BEST 5485 03:29:42,903 --> 03:29:44,271 APPROACH POST DISCHARGE? 5486 03:29:44,271 --> 03:29:46,006 I'VE READ SOME DATA THAT SOME 5487 03:29:46,006 --> 03:29:49,410 SEVERE HYPERTENSION, I GUESS, 5488 03:29:49,410 --> 03:29:51,178 RETURNS TO NORMAL POST 5489 03:29:51,178 --> 03:29:52,546 DISCHARGE. 5490 03:29:52,546 --> 03:29:53,514 BUT I'M NOT SURE WHAT YOUR 5491 03:29:53,514 --> 03:29:54,515 THOUGHTS ARE ABOUT BLOOD 5492 03:29:54,515 --> 03:29:56,917 PRESSURE MEASUREMENT, BOTH I 5493 03:29:56,917 --> 03:30:00,888 GUESS, YOU KNOW, FOR THOSE WITH 5494 03:30:00,888 --> 03:30:01,555 SEVERE HYPERTENSION IN THE 5495 03:30:01,555 --> 03:30:03,090 HOSPITAL BUT THEN ALSO POST 5496 03:30:03,090 --> 03:30:05,192 DISCHARGE, WHETHER THERE SHOULD 5497 03:30:05,192 --> 03:30:06,727 BE PROGRAMS OR HOW THAT BEST 5498 03:30:06,727 --> 03:30:07,094 SHOULD BE DONE. 5499 03:30:07,094 --> 03:30:08,729 >> I THINK IT'S A GREAT 5500 03:30:08,729 --> 03:30:11,165 QUESTION, PAUL, AND I GUESS 5501 03:30:11,165 --> 03:30:15,469 BASED ON MY UNDERSTANDING OF THE 5502 03:30:15,469 --> 03:30:16,470 LITERATURE, I THINK IT AN OPEN 5503 03:30:16,470 --> 03:30:17,671 QUESTION AND I THINK IT AN AREA 5504 03:30:17,671 --> 03:30:23,410 THAT COULD HELP REVEAL 5505 03:30:23,410 --> 03:30:24,178 THE DEGREE TO WHICH THE BLOOD 5506 03:30:24,178 --> 03:30:27,248 PRESSURES ARE ELEVATED IN THE 5507 03:30:27,248 --> 03:30:28,449 HOSPITAL AS A RESULT OF THE 5508 03:30:28,449 --> 03:30:29,550 ACUTE PHYSIOLOGICAL PROCESS OR 5509 03:30:29,550 --> 03:30:39,326 THE STRESSORS IN CONFIRMING IF 5510 03:30:39,326 --> 03:30:40,427 BLOOD PRESSURES GO DOWN AT HOME 5511 03:30:40,427 --> 03:30:43,164 WITHOUT ANY INTERVENTION, 5512 03:30:43,164 --> 03:30:44,865 THE DEGREE TO WHICH KIND OF THAT 5513 03:30:44,865 --> 03:30:50,137 IS CONTRIBUTING AND COULD HELP 5514 03:30:50,137 --> 03:30:52,339 CONFIRM THE HYPOTHESIS THAT ON 5515 03:30:52,339 --> 03:30:55,409 AVERAGE, IN GENERAL, WE SHOULD 5516 03:30:55,409 --> 03:30:59,180 BE VERY CONSERVATIVE WITH 5517 03:30:59,180 --> 03:31:00,681 INTENSIFYING OR INITIATING 5518 03:31:00,681 --> 03:31:02,583 MEDICATIONS IN THE HOSPITAL. 5519 03:31:02,583 --> 03:31:03,784 I THINK IT'S A REALLY 5520 03:31:03,784 --> 03:31:04,919 INTERESTING QUESTION. 5521 03:31:04,919 --> 03:31:06,887 I THINK WE WOULD LEARN A LOT 5522 03:31:06,887 --> 03:31:08,756 FROM LIKE AN IMPLEMENTATION 5523 03:31:08,756 --> 03:31:15,029 STUDY OR AN ACTUAL STUDY THAT 5524 03:31:15,029 --> 03:31:18,199 UTILIZED HOME READINGS AFTER 5525 03:31:18,199 --> 03:31:19,900 HOSPITALIZATIONS TO KIND OF SEE 5526 03:31:19,900 --> 03:31:25,773 MORE OF WHAT HAPPENS. 5527 03:31:25,773 --> 03:31:29,376 >> I MIGHT ADD IT WOULD BE 5528 03:31:29,376 --> 03:31:30,878 GREAT -- IN MY PERFECT WORLD 5529 03:31:30,878 --> 03:31:35,616 THERE WOULD BE AN RPM PROGRAM 5530 03:31:35,616 --> 03:31:43,324 WITH PHARMACISTS AND REVIEW 5531 03:31:43,324 --> 03:31:44,692 MY -- ALMOST KIND OF LIKE 5532 03:31:44,692 --> 03:31:47,695 POSTPARTUM HYPERTENSION. 5533 03:31:47,695 --> 03:31:48,629 >> THANK YOU. 5534 03:31:48,629 --> 03:31:51,599 THERE'S A COMMENT IN THE CHAT 5535 03:31:51,599 --> 03:31:52,666 FOR JORDY OR A QUESTION. 5536 03:31:52,666 --> 03:31:59,506 DO YOU THINK THERE'S ENOUGH 5537 03:31:59,506 --> 03:32:01,375 EVIDENCE TO SUGGEST SOME DEVICES 5538 03:32:01,375 --> 03:32:04,678 WORK DIFFERENTLY IN -- 5539 03:32:04,678 --> 03:32:05,713 WARRANTING THEM BECOMING A 5540 03:32:05,713 --> 03:32:06,380 SPECIAL POPULATION? 5541 03:32:06,380 --> 03:32:13,354 I'M GOING TO ADD ON TO MY -- SO 5542 03:32:13,354 --> 03:32:17,224 YOU CAN COMMENT -- VERSUS MORE 5543 03:32:17,224 --> 03:32:18,325 ADVANCED KIDNEY DISEASE, IF YOU 5544 03:32:18,325 --> 03:32:19,059 DON'T MIND? 5545 03:32:19,059 --> 03:32:24,231 >> SO THEN TAMMY ADDED ANOTHER 5546 03:32:24,231 --> 03:32:25,733 QUESTION TOO THAT I'M HAPPY TO 5547 03:32:25,733 --> 03:32:25,966 ANSWER. 5548 03:32:25,966 --> 03:32:29,003 I THINK IT'S WORSE AS KIDNEY 5549 03:32:29,003 --> 03:32:34,241 DISEASE WORSENS, YOU WORK -- 5550 03:32:34,241 --> 03:32:35,376 HIGHER BLOOD PRESSURES ON 5551 03:32:35,376 --> 03:32:36,010 AVERAGE IN THE POPULATION WHICH 5552 03:32:36,010 --> 03:32:39,613 ARE REALLY THE FACTORS THAT 5553 03:32:39,613 --> 03:32:42,516 LIKELY CONFOUND THE WAY THAT THE 5554 03:32:42,516 --> 03:32:43,984 DEVICE IS ABLE TO CALCULATE THE 5555 03:32:43,984 --> 03:32:44,318 READINGS. 5556 03:32:44,318 --> 03:32:45,519 I THINK WE DON'T HAVE ENOUGH 5557 03:32:45,519 --> 03:32:46,754 EVIDENCE TO EVEN KNOW WHETHER 5558 03:32:46,754 --> 03:32:48,422 THEY HAVE TO BE SPECIAL 5559 03:32:48,422 --> 03:32:51,058 POPULATION TO TAMMY'S QUESTION. 5560 03:32:51,058 --> 03:32:55,996 THE STUDIES THAT HAVE IDENTIFIED 5561 03:32:55,996 --> 03:32:57,731 THAT DEVICES ARE NOT VALID IN 5562 03:32:57,731 --> 03:32:59,867 PATIENTS WITH CKD HAVE ISSUES 5563 03:32:59,867 --> 03:33:01,835 AND HAVE VIOLATIONS TO PROTOCOLS 5564 03:33:01,835 --> 03:33:03,737 AND SO I'VE NOT SEEN ONE TO MY 5565 03:33:03,737 --> 03:33:04,738 KNOWLEDGE THAT HAS NOT VIOLATED 5566 03:33:04,738 --> 03:33:06,640 A PROTOCOL OR THAT HAS PROVIDED 5567 03:33:06,640 --> 03:33:08,342 ENOUGH INFORMATION IN THEIR 5568 03:33:08,342 --> 03:33:12,579 PUBLICATION TO KNOW AND THEY 5569 03:33:12,579 --> 03:33:17,051 DIDN'T -- SO IT NOT 100% CLEAR 5570 03:33:17,051 --> 03:33:20,087 BUT PART OF IT IS THAT CKD 5571 03:33:20,087 --> 03:33:21,588 PATIENTS TEND TO RUN 5572 03:33:21,588 --> 03:33:23,691 HYPERTENSIVE AND THE MORE 5573 03:33:23,691 --> 03:33:26,193 HYPERTENSIVE, THE LESS ACCURATE 5574 03:33:26,193 --> 03:33:29,530 A LOT OF THESE GUYS, WHERE NO 5575 03:33:29,530 --> 03:33:31,198 MATTER WHAT YOU DO, YOU'RE GOING 5576 03:33:31,198 --> 03:33:33,434 TO STRUGGLE TO END UP SEEING 5577 03:33:33,434 --> 03:33:34,034 SUBSTANTIAL VALIDITY WITH THE 5578 03:33:34,034 --> 03:33:34,601 DEVICES. 5579 03:33:34,601 --> 03:33:37,204 I DON'T MEAN TO BE ANILIST IN 5580 03:33:37,204 --> 03:33:39,707 THAT REGARD, I HOPE I'M WRONG 5581 03:33:39,707 --> 03:33:41,041 BUT THERE UNFORTUNATELY ISN'T 5582 03:33:41,041 --> 03:33:41,809 SUFFICIENT EVIDENCE TO SAY FOR 5583 03:33:41,809 --> 03:33:42,009 SURE. 5584 03:33:42,009 --> 03:33:43,677 IN TERMS OF TAMMY'S OTHER 5585 03:33:43,677 --> 03:33:46,280 QUESTION OF WHETHER THERE IS 5586 03:33:46,280 --> 03:33:47,815 POTENTIALLY A POPULATION WITH 5587 03:33:47,815 --> 03:33:52,619 CKD AND MILD PO MODERATE -- YES, 5588 03:33:52,619 --> 03:33:54,221 I THINK IT VERY SIMILAR TO WHAT 5589 03:33:54,221 --> 03:33:55,089 WE END UP SEEING WITH THE 5590 03:33:55,089 --> 03:33:56,423 REDUCTION OF HYPERFILTRATION 5591 03:33:56,423 --> 03:34:02,196 JUST WITH USING IRBs THAT IN 5592 03:34:02,196 --> 03:34:03,364 PEOPLE WHO PARTICULARLY HAVE 5593 03:34:03,364 --> 03:34:08,936 SECONDARY FSGS MEANING YOU WOULD 5594 03:34:08,936 --> 03:34:16,010 SEE RENAL BENEFIT FROM BLOOD 5595 03:34:16,010 --> 03:34:16,577 PRESSURE LOWERING IN THOSE 5596 03:34:16,577 --> 03:34:17,511 PATIENTS. 5597 03:34:17,511 --> 03:34:20,414 ADDITIONALLY WE DEFINITELY SEE 5598 03:34:20,414 --> 03:34:21,815 THAT, THERE HAS NOT BEEN A LARGE 5599 03:34:21,815 --> 03:34:22,983 SCALE TRIAL THAT HAS LOOKED AT 5600 03:34:22,983 --> 03:34:24,385 THAT. 5601 03:34:24,385 --> 03:34:26,387 BUT WE GENERALLY AS A GROUP OF 5602 03:34:26,387 --> 03:34:28,155 NEUROLOGISTS TEND TO AGREE THERE 5603 03:34:28,155 --> 03:34:29,390 IS KIDNEY BENEFIT IN CERTAIN 5604 03:34:29,390 --> 03:34:30,290 PATIENTS WITH BLOOD PRESSURE 5605 03:34:30,290 --> 03:34:31,892 LOWERING AND THEN IN EVERYBODY 5606 03:34:31,892 --> 03:34:34,361 ELSE THERE IS DEFINITELY 5607 03:34:34,361 --> 03:34:37,231 CARDIOVASCULAR BENEFIT WHETHER 5608 03:34:37,231 --> 03:34:38,198 OR NOT -- 5609 03:34:38,198 --> 03:34:40,401 >> SO A FOLLOW-UP TO THAT. 5610 03:34:40,401 --> 03:34:43,237 I THINK ONE OF THE ADVERSE EVENT 5611 03:34:43,237 --> 03:34:45,039 WE'VE SEEN IN SOME OF THE 5612 03:34:45,039 --> 03:34:46,573 INTENSIFIED MEDICATION TRIALS 5613 03:34:46,573 --> 03:34:51,945 GOING DOWN TO 120 SYSTOLIC IS 5614 03:34:51,945 --> 03:34:53,580 ACUTE RENAL ISSUES, AND YOU SAID 5615 03:34:53,580 --> 03:34:54,314 SOME VERY INTERESTING THINGS TO 5616 03:34:54,314 --> 03:34:57,251 ME ABOUT IT, ABOUT WHETHER WE 5617 03:34:57,251 --> 03:34:58,352 SHOULD BE CONCERNED ABOUT THAT 5618 03:34:58,352 --> 03:35:00,387 OR NOT AS WE GO TO THESE LOWER 5619 03:35:00,387 --> 03:35:00,621 TARGETS. 5620 03:35:00,621 --> 03:35:02,156 >> THERE WERE SEVERAL REALLY 5621 03:35:02,156 --> 03:35:04,124 ELEGANT STUDIES DONE POST HOC IN 5622 03:35:04,124 --> 03:35:05,959 SPRINT IN PARTICULAR WHERE THEY 5623 03:35:05,959 --> 03:35:08,028 LOOKED AT TUBULAR BIOMARKERS IN 5624 03:35:08,028 --> 03:35:11,632 PATIENTS WHO HAD INTENSIVE BLOOD 5625 03:35:11,632 --> 03:35:13,133 PRESSURE LOWERING, AND BASICALLY 5626 03:35:13,133 --> 03:35:13,901 THE CONCLUSION WAS THAT MOST OF 5627 03:35:13,901 --> 03:35:16,303 IT IS HEMODYNAMIC. 5628 03:35:16,303 --> 03:35:17,938 MOST OF IT IS WHAT I WAS 5629 03:35:17,938 --> 03:35:19,773 STARTING TO ALLUDE TO IN THE 5630 03:35:19,773 --> 03:35:21,175 TALK WHERE WHEN YOUR BLOOD 5631 03:35:21,175 --> 03:35:22,709 PRESSURES ARE HIGHER, YOU'RE 5632 03:35:22,709 --> 03:35:30,117 PUPERFUSING YOUR KIDNEYS MORE, R 5633 03:35:30,117 --> 03:35:34,521 YOU MAY TEND TO SEE -- ANY LONG 5634 03:35:34,521 --> 03:35:37,391 TERM RISK, IT DOESN'T RELATE TO 5635 03:35:37,391 --> 03:35:39,927 PROGRESSION OF CHRONIC KIDNEY 5636 03:35:39,927 --> 03:35:40,461 DISEASE. 5637 03:35:40,461 --> 03:35:43,097 AT LEAST NOT IN THE STUDIES I'VE 5638 03:35:43,097 --> 03:35:45,666 LOOKED AT REALLY CLOSELY -- 5639 03:35:45,666 --> 03:35:47,101 TRULY CAUSES LASTING KIDNEY 5640 03:35:47,101 --> 03:35:48,635 HARM, ONLY THAT IT DOESN'T 5641 03:35:48,635 --> 03:35:51,872 NECESSARILY BENEFIT THE KIDNEYS. 5642 03:35:51,872 --> 03:36:02,116 >> THANK YOU. 5643 03:36:02,883 --> 03:36:09,590 >> ACTUALLY -- DID DO -- IN 5644 03:36:09,590 --> 03:36:11,625 DIABETIC PATIENTS I FORGOT ABOUT 5645 03:36:11,625 --> 03:36:14,128 THAT ONE BUT IT SMALL AND VERY 5646 03:36:14,128 --> 03:36:15,762 NEGLIGIBLE RELATIVE TO THE A 5647 03:36:15,762 --> 03:36:17,531 CARDIOVASCULAR BENEFIT. 5648 03:36:17,531 --> 03:36:18,599 >> DO YOU HAVE ANOTHER QUESTION, 5649 03:36:18,599 --> 03:36:18,799 PAUL? 5650 03:36:18,799 --> 03:36:20,033 >> PLEASE, GO AHEAD. 5651 03:36:20,033 --> 03:36:22,803 >> ONE OF THE THINGS I HEAR THE 5652 03:36:22,803 --> 03:36:23,570 NEPHROLOGISTS TALK ABOUT 5653 03:36:23,570 --> 03:36:26,406 SOMETIMES IS PSEUDOHYPERTENSION, 5654 03:36:26,406 --> 03:36:28,408 AND IT'S SOMETHING WE NEED TO BE 5655 03:36:28,408 --> 03:36:31,311 CAUTIOUS ABOUT WHEN WE MEASURE 5656 03:36:31,311 --> 03:36:31,678 BLOOD PRESSURE. 5657 03:36:31,678 --> 03:36:34,448 COULD YOU TALK ABOUT THAT A 5658 03:36:34,448 --> 03:36:35,983 LITTLE? 5659 03:36:35,983 --> 03:36:39,386 JORDY, I'M ADDRESSING THAT TO 5660 03:36:39,386 --> 03:36:40,521 YOU. 5661 03:36:40,521 --> 03:36:42,756 >> I'M NOT SURE IN WHICH REGARD 5662 03:36:42,756 --> 03:36:45,492 BUT I THINK OF 5663 03:36:45,492 --> 03:36:47,828 PSEUDOHYPERTENSION ACROSS THE 5664 03:36:47,828 --> 03:36:48,829 BOARD IN SO MANY SITUATIONS HAVE 5665 03:36:48,829 --> 03:36:50,364 BEEN TALKED ABOUT, MOST OF OUR 5666 03:36:50,364 --> 03:36:51,765 PATIENTS JUST END UP IN THE 5667 03:36:51,765 --> 03:36:55,102 CLINIC MORE OFTEN AND HAVE -- 5668 03:36:55,102 --> 03:36:56,870 BUT I THINK THAT VOLUME CAN 5669 03:36:56,870 --> 03:36:57,905 DEFINITELY CONFOUND BLOOD 5670 03:36:57,905 --> 03:36:59,173 PRESSURE BUT MOST OF IT ENDS UP 5671 03:36:59,173 --> 03:37:02,342 BEING A LOT OF ARTIFACT. 5672 03:37:02,342 --> 03:37:03,944 I DO THINK THAT OUT OF OFFICE 5673 03:37:03,944 --> 03:37:05,145 BLOOD PRESSURE MONITORING CAN 5674 03:37:05,145 --> 03:37:06,246 HELP TO OVERCOME THAT, BUT 5675 03:37:06,246 --> 03:37:07,381 UNFORTUNATELY WE'RE LACKING IN 5676 03:37:07,381 --> 03:37:10,117 GREAT DATA SHOWING THAT BESIDES 5677 03:37:10,117 --> 03:37:12,085 REALLY GOOD QUALITY DATA FROM 5678 03:37:12,085 --> 03:37:16,623 THE CRICK STUDY THAT PAUL HELP 5679 03:37:16,623 --> 03:37:17,958 TODAY LEAD WHICH SHOWS THAT WE 5680 03:37:17,958 --> 03:37:20,594 HAVE VERY SUBSTANTIAL LINKAGE OF 5681 03:37:20,594 --> 03:37:22,396 THE AMBULATORY BLOOD PRESSURE 5682 03:37:22,396 --> 03:37:24,164 MONITORING IN CKD PATIENTS WITH 5683 03:37:24,164 --> 03:37:26,033 ADVERSE OUTCOMES, THAT'S 5684 03:37:26,033 --> 03:37:27,434 STRONGER THAN WHAT WE WOULD SEE 5685 03:37:27,434 --> 03:37:28,936 WITH CLINIC BLOOD PRESSURE 5686 03:37:28,936 --> 03:37:29,269 MEASUREMENTS. 5687 03:37:29,269 --> 03:37:31,805 >> AND HOW ABOUT SEVERE 5688 03:37:31,805 --> 03:37:32,573 ATHEROSCLEROSIS, WOULD THAT 5689 03:37:32,573 --> 03:37:33,774 AFFECT THE BLOOD PRESSURE 5690 03:37:33,774 --> 03:37:34,408 READINGS? 5691 03:37:34,408 --> 03:37:35,475 ANYBODY COMMENT ON THAT? 5692 03:37:35,475 --> 03:37:40,948 >> IT CAN INS LOW METRIC 5693 03:37:40,948 --> 03:37:43,584 DEVICES, SIMILAR TO WIDE BLOOD 5694 03:37:43,584 --> 03:37:46,520 PRESSURE, IT MAKES THE ENVELOPE 5695 03:37:46,520 --> 03:37:47,754 MORE ASYMMETRIC SO THESE DEVICES 5696 03:37:47,754 --> 03:37:49,089 HAVE TO BE DEVELOPED IN A WAY 5697 03:37:49,089 --> 03:37:52,626 THAT CAN HANDLE THOSE CHANGES IN 5698 03:37:52,626 --> 03:37:54,695 THE CHARACTERISTICS OF THE 5699 03:37:54,695 --> 03:37:54,995 WAVEFORMS. 5700 03:37:54,995 --> 03:37:56,763 SOME DEVICES HAVE BEEN DEVELOPED 5701 03:37:56,763 --> 03:37:58,298 TO TRY TO ADDRESS THAT AND MANY 5702 03:37:58,298 --> 03:38:00,334 HAVEN'T AND THAT'S PART OF WHY 5703 03:38:00,334 --> 03:38:02,636 THE VALIDATION PROCESS IS SO 5704 03:38:02,636 --> 03:38:03,937 IMPORTANT IN A BROAD RANGE OF 5705 03:38:03,937 --> 03:38:04,238 INDIVIDUALS. 5706 03:38:04,238 --> 03:38:06,840 >> I THINK THE OTHER COMMENT TO 5707 03:38:06,840 --> 03:38:07,941 THAT, JUROR TEE, IS THAT IN 5708 03:38:07,941 --> 03:38:11,778 TERMS OF OUR WORK WITH THE -- 5709 03:38:11,778 --> 03:38:14,948 THAT WHICH IS SUBMITTED, IT IS 5710 03:38:14,948 --> 03:38:16,516 NOT OFTEN VERY CHARACTERISTIC OF 5711 03:38:16,516 --> 03:38:17,985 THE ACTUAL UNDERLYING VASCULAR 5712 03:38:17,985 --> 03:38:19,519 PATHOLOGY THAT MIGHT BE PRESENT. 5713 03:38:19,519 --> 03:38:23,657 SO THAT THE THING -- YOUR 5714 03:38:23,657 --> 03:38:24,958 QUESTION IS IT DIFFICULT TO KNOW 5715 03:38:24,958 --> 03:38:27,127 FOR SURE WHEN YOU GET A DEVICE 5716 03:38:27,127 --> 03:38:28,662 WHETHER OR NOT THERE HAVE BEEN 5717 03:38:28,662 --> 03:38:31,231 PATIENTS WHO HAVE SUBSTANTIAL 5718 03:38:31,231 --> 03:38:32,232 ATHEROSCLEROSIS THAT MIGHT, IN 5719 03:38:32,232 --> 03:38:38,038 FACT, TEST OUT THE DEVICES' 5720 03:38:38,038 --> 03:38:48,215 ALGORITHMS. 5721 03:38:48,215 --> 03:38:51,685 >> PLEASE KEEP THE QUESTIONS 5722 03:38:51,685 --> 03:38:52,552 COMING IN THE CHAT BOX. 5723 03:38:52,552 --> 03:38:55,322 YOU MENTIONED SOMETHING ABOUT A 5724 03:38:55,322 --> 03:39:00,727 LOT OF THE DATA ON ORTHOSTATIC 5725 03:39:00,727 --> 03:39:02,029 HYPOTENSION COMES FROM THE 5726 03:39:02,029 --> 03:39:02,496 1990s AND BEFORE. 5727 03:39:02,496 --> 03:39:03,897 DID I UNDERSTAND THAT CORRECTLY? 5728 03:39:03,897 --> 03:39:06,166 AND CAN YOU TALK ABOUT WHAT THE 5729 03:39:06,166 --> 03:39:07,701 MORE NEED FOR RECENT DATA? 5730 03:39:07,701 --> 03:39:11,638 >> YOU KNOW, WE CONTINUE TO WORK 5731 03:39:11,638 --> 03:39:14,775 ON STUDYING HYPERTENSION AND 5732 03:39:14,775 --> 03:39:15,876 THERE'S A LOT OF STUDIES 5733 03:39:15,876 --> 03:39:17,978 RECENTLY MOSTLY SHOWING THAT 5734 03:39:17,978 --> 03:39:23,383 PRECISE LEA, YOU CAN EVEN TO 5735 03:39:23,383 --> 03:39:25,052 TIGHT BLOOD PRESSURE CONTROL 5736 03:39:25,052 --> 03:39:27,321 WITHOUT NECESSARILY TRIGGERING 5737 03:39:27,321 --> 03:39:29,523 OR WORSENING ORTHOSTATIC 5738 03:39:29,523 --> 03:39:30,424 HYPOTENSION. 5739 03:39:30,424 --> 03:39:31,792 THERE'S A LOT OF NEW DATA THAT 5740 03:39:31,792 --> 03:39:33,760 ARE VERY GOOD FOR THAT. 5741 03:39:33,760 --> 03:39:38,332 NOW, AGAIN, I ONLY EMPHASIZE THE 5742 03:39:38,332 --> 03:39:42,903 FACT THAT IN THOSE STUDIES, WE 5743 03:39:42,903 --> 03:39:47,507 EXCLUDED PATIENTS WITH SEVERE 5744 03:39:47,507 --> 03:39:48,375 ORTHOSTATIC HYPOTENSION. 5745 03:39:48,375 --> 03:39:49,476 SO YOU NEED TO BE CAREFUL ABOUT 5746 03:39:49,476 --> 03:39:50,544 THAT AND THAT'S SOMETHING THAT 5747 03:39:50,544 --> 03:39:52,212 NEEDS TO BE CONSIDERED, BUT THE 5748 03:39:52,212 --> 03:39:55,115 RESEARCH WITH ORTHOSTATIC 5749 03:39:55,115 --> 03:39:55,782 HYPOTENSION HAS BEEN GOING ON 5750 03:39:55,782 --> 03:39:58,518 FOR MANY, MANY YEARS AND WE'RE 5751 03:39:58,518 --> 03:39:59,820 STILL LEARNING. 5752 03:39:59,820 --> 03:40:01,254 THE ORTHOSTATIC HYPERTENSION IS 5753 03:40:01,254 --> 03:40:03,957 A LITTLE BIT MORE RECENT. 5754 03:40:03,957 --> 03:40:06,460 AND IN PART BECAUSE THE STUDIES 5755 03:40:06,460 --> 03:40:08,295 THAT WERE DONE FOR ORTHO IS THAT 5756 03:40:08,295 --> 03:40:11,465 TICK HYPOTENSION, YOU KNOW, LET 5757 03:40:11,465 --> 03:40:12,232 US REALIZE THAT WE ALSO HAVE 5758 03:40:12,232 --> 03:40:14,368 THIS PROBLEM WITH ORTHO IS THAT 5759 03:40:14,368 --> 03:40:15,902 TICK HYPERTENSION THAT WE KNOW 5760 03:40:15,902 --> 03:40:19,873 WE DIDN'T RECOGNIZE BEFORE, AND 5761 03:40:19,873 --> 03:40:27,948 CAN BE AS MUCH OF A RISK FACTOR 5762 03:40:27,948 --> 03:40:31,118 AS MUCH AS IT IS -- 5763 03:40:31,118 --> 03:40:33,053 >> GIVEN A QUICK FOLLOW-UP, 5764 03:40:33,053 --> 03:40:43,597 THANK YOU FOR THE ANSWER, GIVEN 5765 03:40:44,531 --> 03:40:46,099 IT'S NOT REALLY MEASURED, ALMOST 5766 03:40:46,099 --> 03:40:47,701 NEVER DOB, I THINK WHAT YOU 5767 03:40:47,701 --> 03:40:50,137 SAID, WHAT WOULD BE THE FIRST 5768 03:40:50,137 --> 03:40:52,105 STEP, IF WE CAN'T GET EVERYONE, 5769 03:40:52,105 --> 03:40:55,075 HOW WOULD YOU TACKLE 5770 03:40:55,075 --> 03:40:55,442 IMPLEMENTATION? 5771 03:40:55,442 --> 03:40:57,477 >> IN ORDER TO START A 5772 03:40:57,477 --> 03:40:59,012 POTENTIAL -- IT MORE IMMEDIATE 5773 03:40:59,012 --> 03:40:59,946 BECAUSE YOU CAN INTERVENE, 5774 03:40:59,946 --> 03:41:01,281 IMPROVE QUALITY OF LIFE AND 5775 03:41:01,281 --> 03:41:04,117 PREVENT FALLS. 5776 03:41:04,117 --> 03:41:05,485 STUDYING HYPERTENSION, I THINK 5777 03:41:05,485 --> 03:41:08,355 WE NEED TO LEARN MORE ON WHAT DO 5778 03:41:08,355 --> 03:41:11,958 WE GAIN BY DETECTING IT? 5779 03:41:11,958 --> 03:41:14,561 I'M NOT CONVINCED THAT WE 5780 03:41:14,561 --> 03:41:16,329 SHOULD -- I MEAN, IDEALLY 5781 03:41:16,329 --> 03:41:19,566 MEASURE ORTHOSTATIC VITALS WHEN 5782 03:41:19,566 --> 03:41:20,901 YOU FIRST DIAGNOSE A PATIENT, 5783 03:41:20,901 --> 03:41:22,736 NOT IN EVERY SINGLE VISIT, BUT 5784 03:41:22,736 --> 03:41:24,938 YOU KNOW, ONCE A YEAR PERHAPS, I 5785 03:41:24,938 --> 03:41:26,540 THINK THAT WILL BE HELPFUL, BUT 5786 03:41:26,540 --> 03:41:29,810 I HAVE NO BASIS TO TELL YOU THAT 5787 03:41:29,810 --> 03:41:31,344 THAT RECOMMENDATION WILL LEAD TO 5788 03:41:31,344 --> 03:41:34,748 IMPROVEMENT IN QUALITY OF CARE. 5789 03:41:34,748 --> 03:41:37,350 THAT IS WHAT IS MISSING. 5790 03:41:37,350 --> 03:41:40,320 BUT IF WE ARE ABLE TO DETERMINE 5791 03:41:40,320 --> 03:41:45,192 IF IDENTIFYING ORTHOSTATIC 5792 03:41:45,192 --> 03:41:45,692 HYPERTENSION WILL MAKE A 5793 03:41:45,692 --> 03:41:47,961 DIFFERENCE IN THE TYPE OF 5794 03:41:47,961 --> 03:41:49,029 MEDICATIONS, THE 5795 03:41:49,029 --> 03:41:51,097 ANTIHYPERTENSIVE WE USE, IF IT 5796 03:41:51,097 --> 03:41:52,399 MAKES A DIFFERENCE WHETHER THE 5797 03:41:52,399 --> 03:41:54,167 OUTCOME IS STANDING BLOOD 5798 03:41:54,167 --> 03:41:56,770 PRESSURE RATHER THAN SEATED 5799 03:41:56,770 --> 03:41:58,238 BLOOD PRESSURE, IF OUR INTENSIVE 5800 03:41:58,238 --> 03:41:58,872 BLOOD PRESSURE CONTROLS TO 5801 03:41:58,872 --> 03:42:00,474 TARGET STANDING RATHER THAN 5802 03:42:00,474 --> 03:42:01,808 SEATED, THOSE ARE THE TYPE OF 5803 03:42:01,808 --> 03:42:06,847 RESEARCH WE NEED TO MAKE IT 5804 03:42:06,847 --> 03:42:09,649 USEFUL TO TAKE OURSELF TO 5805 03:42:09,649 --> 03:42:11,485 MEASURE UPRIGHT BLOOD PRESSURES. 5806 03:42:11,485 --> 03:42:12,719 >> THERE'S A FOLLOW-UP QUESTION 5807 03:42:12,719 --> 03:42:14,120 IN THE CHAT BOX ABOUT HOW MUCH 5808 03:42:14,120 --> 03:42:18,592 DO WE KNOW ABOUT SEX DIFFERENCES 5809 03:42:18,592 --> 03:42:21,228 IN ORTHOSTATIC HYPO AND 5810 03:42:21,228 --> 03:42:21,561 HYPERTENSION? 5811 03:42:21,561 --> 03:42:23,029 >> I DON'T KNOW THAT THERE'S 5812 03:42:23,029 --> 03:42:25,131 MUCH DIFFERENCE. 5813 03:42:25,131 --> 03:42:28,401 I THINK FOR ONCE FEMALES ARE AS 5814 03:42:28,401 --> 03:42:34,207 BAD AS MALES FOR THE FIRST TIME, 5815 03:42:34,207 --> 03:42:35,408 AND THE ONLY DIFFERENCE, 5816 03:42:35,408 --> 03:42:39,679 PERHAPS, IS IN THE YOUNG 5817 03:42:39,679 --> 03:42:41,314 PATIENTS WITH HYPERADRENERGIC 5818 03:42:41,314 --> 03:42:42,182 SYNDROMES, THAT UNFORTUNATELY 5819 03:42:42,182 --> 03:42:44,584 TENDS TO BE MORE COMMON IN 5820 03:42:44,584 --> 03:42:45,418 WOMEN. 5821 03:42:45,418 --> 03:42:49,055 BUT IN TERMS OF THE REGULAR 5822 03:42:49,055 --> 03:42:50,924 HYPERTENSIVE PATIENTS, WHICH, 5823 03:42:50,924 --> 03:42:53,760 YOU KNOW, TEND TO BE OLDER, WE 5824 03:42:53,760 --> 03:42:56,129 DON'T SEE ANY SEX DIFFERENCE IN 5825 03:42:56,129 --> 03:42:58,865 TERMS OF THE PREVALENCE OR THE 5826 03:42:58,865 --> 03:43:01,268 SEVERITY OF ORTHOSTATIC 5827 03:43:01,268 --> 03:43:05,071 HYPOTEPTION OR HYPERTENSION. 5828 03:43:05,071 --> 03:43:06,039 HYPOTENSION OR HYPERTENSION. 5829 03:43:06,039 --> 03:43:06,907 >> THANKS. 5830 03:43:06,907 --> 03:43:07,741 OBVIOUSLY SEX DIFFERENCES ARE 5831 03:43:07,741 --> 03:43:08,975 IMPORTANT SO IT'S GOOD TO KNOW. 5832 03:43:08,975 --> 03:43:19,219 >> OF COURSE. 5833 03:43:22,088 --> 03:43:23,390 >> ANY OTHER QUESTIONS BEFORE WE 5834 03:43:23,390 --> 03:43:24,491 WRAP UP THE SESSION? 5835 03:43:24,491 --> 03:43:26,426 I THINK WE HAVE A SHORT BREAK 5836 03:43:26,426 --> 03:43:32,132 COMING UP. 5837 03:43:32,132 --> 03:43:33,867 >> DO THE PANELISTS HAVE ANY 5838 03:43:33,867 --> 03:43:41,341 QUESTIONS FOR EACH OTHER? 5839 03:43:41,341 --> 03:43:42,208 NO? 5840 03:43:42,208 --> 03:43:44,244 WELL I THINK THIS WAS REALLY AN 5841 03:43:44,244 --> 03:43:45,245 EXCELLENT SESSION. 5842 03:43:45,245 --> 03:43:46,980 THERE ARE A LOT OF NEW THINGS 5843 03:43:46,980 --> 03:43:48,949 THAT I'VE LEARNED AND IMPORTANT 5844 03:43:48,949 --> 03:43:51,618 THINGS FOR US TO WORK ON TO KNOW 5845 03:43:51,618 --> 03:43:53,086 MORE ABOUT IN EACH OF THESE 5846 03:43:53,086 --> 03:43:53,520 AREAS. 5847 03:43:53,520 --> 03:43:54,754 SO THANK YOU. 5848 03:43:54,754 --> 03:43:58,091 >> YES, THANKS, EVERYONE, FOR 5849 03:43:58,091 --> 03:43:59,526 FANTASTIC PRESENTATIONS. 5850 03:43:59,526 --> 03:44:03,997 I'LL TURN THINGS BACK TO PAOLO 5851 03:44:03,997 --> 03:44:06,800 TO TELL US WHAT'S NEXT. 5852 03:44:06,800 --> 03:44:12,606 >> SO THIS SESSION IS -- WELL, 5853 03:44:12,606 --> 03:44:14,674 WE HAVE A LITTLE BIT LONGER 5854 03:44:14,674 --> 03:44:17,177 BREAK, SO EVERYONE CAN GET SOME 5855 03:44:17,177 --> 03:44:18,578 REFRESHMENT OVER THAT TIME. 5856 03:44:18,578 --> 03:44:21,548 SO LET US RECONVENE, AND I 5857 03:44:21,548 --> 03:44:24,751 WANTED TO THANK FOR TWO 5858 03:44:24,751 --> 03:44:25,885 EXCELLENT SESSIONS THAT WE JUST 5859 03:44:25,885 --> 03:44:29,889 HAD, AND LET US CONVENE AT 5860 03:44:29,889 --> 03:44:33,393 3:15 OR 2:15, 3:15 EASTERN TIME. 5861 03:44:33,393 --> 03:44:34,761 FOR THE SESSION NUMBER THREE. 5862 03:44:34,761 --> 03:44:36,506 THANK YOU. 5863 03:44:36,506 --> 03:44:46,983 >> WELCOME TO SESSION 3. 5864 03:44:46,983 --> 03:44:48,652 KATE KIRLEY AND KIMBERLY CROWLEY 5865 03:44:48,652 --> 03:44:50,020 PLEASE TAKE OVER FROM ME. 5866 03:44:50,020 --> 03:44:50,654 THANK YOU. 5867 03:44:50,654 --> 03:44:52,222 >> WELCOME TO SESSION 3, FROM 5868 03:44:52,222 --> 03:44:53,957 CUFF TO CUFFLESS AND EVERYTHING 5869 03:44:53,957 --> 03:44:56,226 IN BETWEEN, NEW FRONTIERS IN BP 5870 03:44:56,226 --> 03:44:57,994 MONITORING AND ASSESSMENT. 5871 03:44:57,994 --> 03:44:59,730 I'M KATE KIRLEY, ONE OF THE 5872 03:44:59,730 --> 03:45:00,797 MODERATORS, I'M A FAMILY 5873 03:45:00,797 --> 03:45:06,770 PHYSICIAN AND I WORK FOR THE 5874 03:45:06,770 --> 03:45:08,138 AMERICAN MEDICAL ASSOCIATION. 5875 03:45:08,138 --> 03:45:11,141 KIMBERLY? 5876 03:45:11,141 --> 03:45:14,811 >> I'M A BIOMEDICAL ENGINEER AND 5877 03:45:14,811 --> 03:45:15,579 TEAM LEAD AT THE CENTER FOR 5878 03:45:15,579 --> 03:45:17,681 DEVICES AND RADIOLOGICAL HEALTH 5879 03:45:17,681 --> 03:45:25,088 AT THE FDA. 5880 03:45:25,088 --> 03:45:28,892 OUR FIRST PRESENTER TODAY IS DR. 5881 03:45:28,892 --> 03:45:32,262 SHE'S A CARDIOLOGIST, CLINICAL 5882 03:45:32,262 --> 03:45:34,030 RESEARCHER AND AN ASSOCIATE 5883 03:45:34,030 --> 03:45:36,633 PROFESSOR OF MEDICINE AT 5884 03:45:36,633 --> 03:45:38,301 COLUMBIA UNIVERSITY, AS WELL AS 5885 03:45:38,301 --> 03:45:40,470 ALSO A CO-CHAIR FOR THIS 5886 03:45:40,470 --> 03:45:40,737 WORKSHOP. 5887 03:45:40,737 --> 03:45:44,174 SHE WILL BE SPEAKING ABOUT THE 5888 03:45:44,174 --> 03:45:46,476 CONTEXTUAL GAPS AND CHALLENGES 5889 03:45:46,476 --> 03:45:48,445 IN BLOOD PRESSURE MEASUREMENT, 5890 03:45:48,445 --> 03:45:49,880 IN THE OFFICE AND OUT OF OFFICE 5891 03:45:49,880 --> 03:45:55,018 BROMOPROPANE MONITORING. 5892 03:45:55,018 --> 03:46:03,193 >> THANK YOU SO MUCH. 5893 03:46:03,193 --> 03:46:05,061 I HAVE NO DISCLOSURES. 5894 03:46:05,061 --> 03:46:06,596 I AM SUPPORTED BY THE NHLBI. 5895 03:46:06,596 --> 03:46:07,464 THANK YOU. 5896 03:46:07,464 --> 03:46:08,999 AS WE ALL KNOW FOR SOME 5897 03:46:08,999 --> 03:46:09,599 INDIVIDUALS, BLOOD PRESSURE IN 5898 03:46:09,599 --> 03:46:11,168 THE OFFICE SETTING IS NOT 5899 03:46:11,168 --> 03:46:12,702 REFLECTIVE OF THEIR USUAL BLOOD 5900 03:46:12,702 --> 03:46:13,804 PRESSURE OUTSIDE OF THE OFFICE 5901 03:46:13,804 --> 03:46:14,771 SETTING. 5902 03:46:14,771 --> 03:46:18,708 AS SUCH THE 2017 ACCHA 5903 03:46:18,708 --> 03:46:21,044 GUIDELINES HAVE OUT OF OFFICE 5904 03:46:21,044 --> 03:46:28,018 BROMOPROPANE MEASUREMENTS VIA 5905 03:46:28,018 --> 03:46:30,587 OUT OF OFFICE OR IN HOME 5906 03:46:30,587 --> 03:46:31,688 BROMOPROPANE MONITORING. 5907 03:46:31,688 --> 03:46:33,857 WE HAVE FOUR BLOOD PRESSURE 5908 03:46:33,857 --> 03:46:34,157 PHENOTYPES. 5909 03:46:34,157 --> 03:46:36,827 TWO OF THESE REPRESENT A 5910 03:46:36,827 --> 03:46:37,294 MISMATCH, WHITE COAT 5911 03:46:37,294 --> 03:46:38,795 HYPERTENSION AND THE SECOND IS 5912 03:46:38,795 --> 03:46:40,964 MASKED HYPERTENSION DEFINED AS 5913 03:46:40,964 --> 03:46:41,631 NON-ELEVATED OFFICE BLOOD 5914 03:46:41,631 --> 03:46:42,732 PRESSURE WITH ELEVATED OUT OF 5915 03:46:42,732 --> 03:46:44,100 OFFICE BLOOD PRESSURE, WHICH HAS 5916 03:46:44,100 --> 03:46:46,002 BEEN ASSOCIATED WITH TARGET 5917 03:46:46,002 --> 03:46:47,904 ORGAN DAMAGE AND CARDIOVASCULAR 5918 03:46:47,904 --> 03:46:58,181 DISEASE EVENTS. 5919 03:46:58,415 --> 03:47:04,154 NEXT SLIDE. 5920 03:47:04,154 --> 03:47:04,921 AMBULATORY BLOOD PRESSURE IS 5921 03:47:04,921 --> 03:47:06,990 USUALLY MEASURED IN THE 5922 03:47:06,990 --> 03:47:07,657 NATURALISTIC ENVIRONMENT 5923 03:47:07,657 --> 03:47:10,293 TYPICALLY OVER A 24 HOUR PERIOD 5924 03:47:10,293 --> 03:47:11,795 WHICH CAN IDENTIFY THESE 5925 03:47:11,795 --> 03:47:13,997 PHENOTYPES AS WELL AS MEASURE 5926 03:47:13,997 --> 03:47:14,865 SLEEP IN THE 24 HOUR PATTERN OF 5927 03:47:14,865 --> 03:47:16,433 BLOOD PRESSURE. 5928 03:47:16,433 --> 03:47:17,300 AMBULATORY BLOOD PRESSURE HAS A 5929 03:47:17,300 --> 03:47:18,602 STRONGER ASSOCIATION WITH 5930 03:47:18,602 --> 03:47:19,703 CARDIOVASCULAR DISEASE THAN 5931 03:47:19,703 --> 03:47:23,206 OFFICE BLOOD PRESSURE. 5932 03:47:23,206 --> 03:47:24,174 HOWEVER WE KNOW THAT THERE ARE 5933 03:47:24,174 --> 03:47:28,211 SEVERAL LIMITATIONS OF ABPM, 5934 03:47:28,211 --> 03:47:30,513 INCLUDING POOR PATIENT 5935 03:47:30,513 --> 03:47:31,514 TOLERABILITY, THE DEVICE ITSELF 5936 03:47:31,514 --> 03:47:34,017 IS EXPENSIVE, USUALLY PLACED AT 5937 03:47:34,017 --> 03:47:35,819 SPECIALIZED CENTERS WITH 5938 03:47:35,819 --> 03:47:37,354 EXPERTISE, THE DEVICE ISN'T 5939 03:47:37,354 --> 03:47:41,291 READILY AVAILABLE, DEVITAL CMS 5940 03:47:41,291 --> 03:47:42,359 REIMBURSEMENT. 5941 03:47:42,359 --> 03:47:44,427 DATA FROM OUR GROUP SHOWS FROM 5942 03:47:44,427 --> 03:47:46,396 2007 TO 2010, ONLY 0.1% OF 5943 03:47:46,396 --> 03:47:48,698 MEDICARE BENEFICIARIES ACTUALLY 5944 03:47:48,698 --> 03:47:54,371 HAD ABPM CLAIMS. 5945 03:47:54,371 --> 03:48:00,977 IN CONTRAST, HOME MEASURED BLOOD 5946 03:48:00,977 --> 03:48:03,013 PRESSURE MAY BE A MORE PRAGMATIC 5947 03:48:03,013 --> 03:48:04,981 APPROACH IN CLINICAL PRACTICE. 5948 03:48:04,981 --> 03:48:08,084 OBVIOUSLY WE KNOW TO DO IT 5949 03:48:08,084 --> 03:48:08,652 PROPERLY REQUIRES A CERTAIN 5950 03:48:08,652 --> 03:48:10,754 AMOUNT OF TRAINING, GUIDELINES 5951 03:48:10,754 --> 03:48:12,389 OBVIOUSLY SUGGEST INDIVIDUALS 5952 03:48:12,389 --> 03:48:13,823 PERFORM TWO READINGS IN THE 5953 03:48:13,823 --> 03:48:15,325 MORNING AND TWO AT NIGHT FOR AT 5954 03:48:15,325 --> 03:48:17,093 LEAST SEVEN DAYS ALTHOUGH THERE 5955 03:48:17,093 --> 03:48:18,495 ARE SOME DATA FROM OUR GROUP 5956 03:48:18,495 --> 03:48:20,230 SHOWING EVEN THREE DAYS OF 5957 03:48:20,230 --> 03:48:21,131 READINGS ARE ACCEPTABLE AND 5958 03:48:21,131 --> 03:48:22,432 OBVIOUSLY ENSURING A VALIDATED 5959 03:48:22,432 --> 03:48:24,734 DEVICE. 5960 03:48:24,734 --> 03:48:26,569 THERE'S SOME DATA SHOWING THAT 5961 03:48:26,569 --> 03:48:27,070 ALSO HOME BLOOD PRESSURE 5962 03:48:27,070 --> 03:48:29,539 MONITORING MAY BE MORE RELIABLE 5963 03:48:29,539 --> 03:48:30,840 THAN OFFICE BLOOD PRESSURE AND 5964 03:48:30,840 --> 03:48:32,342 MORE STRONGLY CORRELATED WITH 5965 03:48:32,342 --> 03:48:33,043 END ORGAN DAMAGE. 5966 03:48:33,043 --> 03:48:34,544 HERE'S DATA FROM OUR GROUP USING 5967 03:48:34,544 --> 03:48:36,947 THE IMPROVING THE DETECTION OF 5968 03:48:36,947 --> 03:48:39,549 HYPERTENSION STUDY, NEW YORK 5969 03:48:39,549 --> 03:48:42,185 CITY ADULTS WITHOUT A HIS TRIF 5970 03:48:42,185 --> 03:48:42,752 HYPERTENSION, OFFICE BLOOD 5971 03:48:42,752 --> 03:48:44,120 PRESSURE ASSESSMENT, AMBULATORY 5972 03:48:44,120 --> 03:48:45,221 BLOOD PRESSURE MOB TORING AND 5973 03:48:45,221 --> 03:48:46,990 TWO WEEKS OF HOME BLOOD PRESSURE 5974 03:48:46,990 --> 03:48:48,325 MONITORING. 5975 03:48:48,325 --> 03:48:50,160 IT WAS CONDUCTED ON THREE VISIT 5976 03:48:50,160 --> 03:48:51,895 WITH THREE READINGS PURVIS IT. 5977 03:48:51,895 --> 03:48:54,631 BLOOD PRESSURE WAS MEASURED BY 5978 03:48:54,631 --> 03:48:57,000 ABPM EVERY 30 MINUTES OVER A 24 5979 03:48:57,000 --> 03:48:58,268 HOUR PERIOD AND BLOOD PRESSURE 5980 03:48:58,268 --> 03:48:58,835 WAS MEASURED BY HOME BLOOD 5981 03:48:58,835 --> 03:48:59,869 PRESSURE MONITORING USING A 5982 03:48:59,869 --> 03:49:01,638 PROTOCOL OF TWO READINGS IN THE 5983 03:49:01,638 --> 03:49:03,440 MORNING AND TWO EVENING READINGS 5984 03:49:03,440 --> 03:49:09,946 OVER A WEEK. 5985 03:49:09,946 --> 03:49:12,015 -- AS A MEASURE OF TARGET ORGAN 5986 03:49:12,015 --> 03:49:12,782 DAMAGE. 5987 03:49:12,782 --> 03:49:15,151 THE FIRST TABLE ABOVE WAS 5988 03:49:15,151 --> 03:49:17,253 HIGHEST FOR HOME BLOOD PRESSURE 5989 03:49:17,253 --> 03:49:17,487 AS .94. 5990 03:49:17,487 --> 03:49:19,556 IN THE TABLE BELOW IT SHOWS 5991 03:49:19,556 --> 03:49:23,360 THREE SEPARATE MODELS WE 5992 03:49:23,360 --> 03:49:24,894 EXAMINE, MODEL ONE IS AN 5993 03:49:24,894 --> 03:49:25,895 UNADJUSTED MODEL, TWO IS 5994 03:49:25,895 --> 03:49:28,865 ADJUSTING FOR DEMOGRAPHICS, 5995 03:49:28,865 --> 03:49:30,900 DIABETES STA TURKS AND MODEL 5996 03:49:30,900 --> 03:49:32,235 THREE IS FULLY ADJUSTED 5997 03:49:32,235 --> 03:49:34,437 INCLUDING THE COVARIATES IN 5998 03:49:34,437 --> 03:49:35,638 MODEL TWO AS WELL AS THE OTHER 5999 03:49:35,638 --> 03:49:42,112 BLOOD PRESSURE MEASURES. 6000 03:49:42,112 --> 03:49:43,313 A 10-MILLIMETER HIGHER SYSTOLIC 6001 03:49:43,313 --> 03:49:44,914 AND DIASTOLIC HOME BLOOD 6002 03:49:44,914 --> 03:49:46,349 PRESSURE WERE ASSOCIATED WITH 6003 03:49:46,349 --> 03:49:49,853 NEARLY 5-GRAM PER METER SQUARED 6004 03:49:49,853 --> 03:49:50,387 HIGHER. 6005 03:49:50,387 --> 03:49:52,989 AFTER ADJUSTMENT FOR HOME BLOOD 6006 03:49:52,989 --> 03:49:54,024 PRESSURE, NEITHER OFFICE BLOOD 6007 03:49:54,024 --> 03:49:54,958 PRESSURE NOR AMBULATORY BLOOD 6008 03:49:54,958 --> 03:49:56,526 PRESSURE WAS ACTUALLY ASSOCIATED 6009 03:49:56,526 --> 03:49:58,061 WITH LEFT VENTRICULAR MASS INDEX 6010 03:49:58,061 --> 03:49:59,796 IN THE STUDY. 6011 03:49:59,796 --> 03:50:00,363 THIS MAY SUGGEST WHEN BLOOD 6012 03:50:00,363 --> 03:50:01,431 PRESSURE IS ASSESSED USING 6013 03:50:01,431 --> 03:50:02,399 GUIDELINE RECOMMENDED 6014 03:50:02,399 --> 03:50:03,400 APPROACHES, HOME BLOOD PRESSURE 6015 03:50:03,400 --> 03:50:04,434 MONITORING MAY ACTUALLY BE 6016 03:50:04,434 --> 03:50:07,303 SUPERIOR TO OFFICE IN A WEEK 6017 03:50:07,303 --> 03:50:09,506 ABPM AND MAY BE EVEN THAT ABPM 6018 03:50:09,506 --> 03:50:11,674 MAY NOT BE NEEDED WHEN YOU 6019 03:50:11,674 --> 03:50:13,009 CONDUCT OFFICE AND HOME PRESSURE 6020 03:50:13,009 --> 03:50:15,412 MONITORING. 6021 03:50:15,412 --> 03:50:19,215 HOWEVER AS WE KNOW, THERE ARE 6022 03:50:19,215 --> 03:50:21,117 CERTAIN LIMITATIONS OF HOME 6023 03:50:21,117 --> 03:50:22,519 BLOOD PRESSURE MONITORING. 6024 03:50:22,519 --> 03:50:25,155 UNLIKE ABPM, MOST DEVICES CANNOT 6025 03:50:25,155 --> 03:50:25,755 MEASURE BLOOD PRESSURE DURING 6026 03:50:25,755 --> 03:50:27,223 SLEEP, ALTHOUGH THERE ARE NOW 6027 03:50:27,223 --> 03:50:28,425 SOME NOCTURNAL HOME BLOOD 6028 03:50:28,425 --> 03:50:29,192 PRESSURE DEVICES BUT THOSE ARE 6029 03:50:29,192 --> 03:50:30,660 NOT WIDELY AVAILABLE. 6030 03:50:30,660 --> 03:50:34,030 WE KNOW THAT HOME BLOOD PRESSURE 6031 03:50:34,030 --> 03:50:36,833 MONITORING IS BEST WITH 6032 03:50:36,833 --> 03:50:37,834 COINTERVENTIONS, AUTOMATIC 6033 03:50:37,834 --> 03:50:38,935 RECORDINGS AND TELEHEALTH 6034 03:50:38,935 --> 03:50:41,871 INTEGRATIONS IS NOT AVAILABLE IN 6035 03:50:41,871 --> 03:50:43,373 EVERY SINGLE MEDICAL CENTER AND 6036 03:50:43,373 --> 03:50:45,375 SPACE, AND OBVIOUSLY LONG-TERM 6037 03:50:45,375 --> 03:50:47,544 PATIENT ADHERENCE IS CHALLENGING 6038 03:50:47,544 --> 03:50:58,088 AND REIMBURSEMENT RATES ARE LOW. 6039 03:51:06,196 --> 03:51:08,765 SO WHICH IS SUPERIOR, ABPM OR 6040 03:51:08,765 --> 03:51:09,966 HOME BLOOD PRESSURE MONITORING? 6041 03:51:09,966 --> 03:51:12,268 THAT'S ONE OF THE BIGGEST 6042 03:51:12,268 --> 03:51:13,036 UNANSWERED QUESTIONS. 6043 03:51:13,036 --> 03:51:16,840 WHICH DEVICE IS MORE ASSOCIATED 6044 03:51:16,840 --> 03:51:20,443 WITH CVD EVENTS OR MORTALITY. 6045 03:51:20,443 --> 03:51:22,979 WE IDENTIFIED ONLY NINE ARTICLES 6046 03:51:22,979 --> 03:51:24,280 THAT EXAMINED WHETHER BLOOD 6047 03:51:24,280 --> 03:51:29,552 PRESSURE FROM ABMPM OR -- WE 6048 03:51:29,552 --> 03:51:31,387 FOUND WHEN AMBULATORY BLOOD 6049 03:51:31,387 --> 03:51:32,622 PRESSURE WAS ADJUSTED FOR HOME 6050 03:51:32,622 --> 03:51:33,690 BLOOD PRESSURE, SI STOLG BLOOD 6051 03:51:33,690 --> 03:51:35,125 PRESSURE WAS ASSOCIATED WITH THE 6052 03:51:35,125 --> 03:51:36,793 OUTCOMES OF INTEREST IN TWO OF 6053 03:51:36,793 --> 03:51:38,394 FOUR COHORTS AND TWO OF THREE 6054 03:51:38,394 --> 03:51:39,596 FOR DIASTOLIC BLOOD PRESSURE. 6055 03:51:39,596 --> 03:51:40,697 WHEN HOME BLOOD PRESSURE WAS 6056 03:51:40,697 --> 03:51:42,532 ADJUSTED FOR AMBULATORY BLOOD 6057 03:51:42,532 --> 03:51:44,267 PRESSURE, SYSTOLIC BLOOD 6058 03:51:44,267 --> 03:51:45,034 PRESSURE AND HOME BLOOD PRESSURE 6059 03:51:45,034 --> 03:51:46,035 MONITORING WAS ASSOCIATED WITH 6060 03:51:46,035 --> 03:51:49,439 OUTCOMES IN ZERO OF THREE 6061 03:51:49,439 --> 03:51:51,307 COHORTS AND ONLY ONE OF TWO FOR 6062 03:51:51,307 --> 03:51:51,941 DIASTOLIC BLOOD PRESSURE. 6063 03:51:51,941 --> 03:51:53,576 SO CLEARLY THIS REMAINS AN 6064 03:51:53,576 --> 03:51:54,444 UNANSWERED QUESTION GIVEN THE 6065 03:51:54,444 --> 03:51:56,012 SMALL NUMBER OF STUDIES IN THE 6066 03:51:56,012 --> 03:51:56,813 LITERATURE. 6067 03:51:56,813 --> 03:51:58,915 NONETHELESS, THE 2017 GUIDELINES 6068 03:51:58,915 --> 03:52:00,817 DO SUGGEST THE FOLLOWING 6069 03:52:00,817 --> 03:52:02,051 ALGORITHM, FOR INDIVIDUALS WHO 6070 03:52:02,051 --> 03:52:04,420 RUN TREATED THE USE OF DAY TIME 6071 03:52:04,420 --> 03:52:05,622 ABPM IS PREFERRED WITH HOME 6072 03:52:05,622 --> 03:52:07,323 BLOOD PRESSURE MONITORING AS AN 6073 03:52:07,323 --> 03:52:08,591 ALTERNATIVE WHEREAS FOR TREATED 6074 03:52:08,591 --> 03:52:09,492 ADULTS, HOME BLOOD PRESSURE 6075 03:52:09,492 --> 03:52:12,195 MONITORING IS PREFERRED WITH AN 6076 03:52:12,195 --> 03:52:15,398 ALTERNATIVE DAY TIME ABPM. 6077 03:52:15,398 --> 03:52:18,001 BESIDES A LACK OF DATA ON 6078 03:52:18,001 --> 03:52:19,135 OUTCOMES, VALUES OBTAINED VERSUS 6079 03:52:19,135 --> 03:52:24,340 HOME VERSUS -- DON'T ALWAYS 6080 03:52:24,340 --> 03:52:25,441 AGREE. 6081 03:52:25,441 --> 03:52:27,644 USING DATA FROM THE STUDY. 6082 03:52:27,644 --> 03:52:33,550 IN OUR SAMPLE THE MAJORITY, 61%, 6083 03:52:33,550 --> 03:52:35,285 HAD MASKED HYPERTENSION ONLY 6084 03:52:35,285 --> 03:52:38,922 DETECTED ON ABPM. 6085 03:52:38,922 --> 03:52:40,456 APPROXIMATELY 30% HAD MASKED 6086 03:52:40,456 --> 03:52:42,091 HYPERTENSION DETECTED ON BOTH 6087 03:52:42,091 --> 03:52:43,493 ABPM AND HOME BLOOD PRESSURE 6088 03:52:43,493 --> 03:52:46,596 MONITORING. 6089 03:52:46,596 --> 03:52:48,231 FLEURN WHILE A SMALL MINORITY, 6090 03:52:48,231 --> 03:52:49,732 9%, HAD MASKED HYPERTENSION THAT 6091 03:52:49,732 --> 03:52:51,067 WAS DETECTED ONLY ON HOME BLOOD 6092 03:52:51,067 --> 03:52:53,136 PRESSURE MONITORING BUT NOT ON 6093 03:52:53,136 --> 03:52:53,703 AMBULATORY BLOOD PRESSURE 6094 03:52:53,703 --> 03:52:54,003 MONITORING. 6095 03:52:54,003 --> 03:52:55,538 SO I THINK THESE FINDINGS 6096 03:52:55,538 --> 03:52:57,006 SUGGEST THAT IF YOU ONLY USE 6097 03:52:57,006 --> 03:52:57,941 HOME BLOOD PRESSURE MONITORING, 6098 03:52:57,941 --> 03:52:59,375 YOU MAY MISCLASSIFY MANY IF NOT 6099 03:52:59,375 --> 03:53:01,778 THE MAJORITY OF INDIVIDUALS WITH 6100 03:53:01,778 --> 03:53:02,478 MASKED HYPERTENSION AS YOU'RE 6101 03:53:02,478 --> 03:53:04,113 GOING TO MISS APPROXIMATELY 60% 6102 03:53:04,113 --> 03:53:06,716 OF THOSE WHO ARE DETECTED ON 6103 03:53:06,716 --> 03:53:07,050 ABPM. 6104 03:53:07,050 --> 03:53:09,018 SO AS I MENTIONED EARLIER, 6105 03:53:09,018 --> 03:53:10,019 MASKED HYPERTENSION IS 6106 03:53:10,019 --> 03:53:12,288 ASSOCIATED WITH CVD EVENTS AND 6107 03:53:12,288 --> 03:53:13,156 MISSED IN THE OFFICE SETTING SO 6108 03:53:13,156 --> 03:53:15,024 USE OF HOME BLOOD PRESSURE ALONE 6109 03:53:15,024 --> 03:53:18,094 MAY ALSO FAIL TO DETECT THIS 6110 03:53:18,094 --> 03:53:18,995 PHENOTYPE. 6111 03:53:18,995 --> 03:53:20,597 BECAUSE MASKED HYPERTENSION IS 6112 03:53:20,597 --> 03:53:22,565 MISSED IN THE OFFICE ANOTHER 6113 03:53:22,565 --> 03:53:24,300 CRITICAL RESEARCH PRIORITY IS 6114 03:53:24,300 --> 03:53:25,868 HOW BEST TO SCREEN FOR MASKED 6115 03:53:25,868 --> 03:53:27,170 HYPERTENSION. 6116 03:53:27,170 --> 03:53:28,538 WE CAN'T SCREEN EVERYONE IN THE 6117 03:53:28,538 --> 03:53:32,575 U.S. WITH ELEVATED BP, I'VE 6118 03:53:32,575 --> 03:53:33,509 ALREADY DISCUSSED SOME OF THE 6119 03:53:33,509 --> 03:53:36,012 LIMITATIONS OF BOTH DEVICES AND 6120 03:53:36,012 --> 03:53:38,314 WIDESPREAD IMPLEMENTATION 6121 03:53:38,314 --> 03:53:38,915 BARRIERS SO REALLY IS THERE A 6122 03:53:38,915 --> 03:53:40,049 BETTER APPROACH TO MEASURE 6123 03:53:40,049 --> 03:53:40,650 OFFICE BLOOD PRESSURE WITHOUT 6124 03:53:40,650 --> 03:53:43,219 THE NEED TO CONDUCT ABPM WHICH 6125 03:53:43,219 --> 03:53:44,320 WOULD POTENTIALLY BE A PARADIGM 6126 03:53:44,320 --> 03:53:45,388 SHIFT IN HYPERTENSION DIAGNOSIS 6127 03:53:45,388 --> 03:53:49,125 AND MANAGEMENT. 6128 03:53:49,125 --> 03:53:52,862 SO WHAT IS THIS NEW PARADIGM? 6129 03:53:52,862 --> 03:53:55,665 WHAT'S PROPOSED HAS BEEN THE USE 6130 03:53:55,665 --> 03:53:58,001 OF UNATTENDED OFFICE BLOOD 6131 03:53:58,001 --> 03:54:00,803 PRESSURE MEASUREMENT WITHOUT A 6132 03:54:00,803 --> 03:54:01,437 CLINICIAN PRESENT IN THE OFFICE 6133 03:54:01,437 --> 03:54:01,938 TO MEASURE OFFICE BLOOD 6134 03:54:01,938 --> 03:54:05,508 PRESSURE. 6135 03:54:05,508 --> 03:54:06,609 SO UNATTENDED BROMOPROPANE 6136 03:54:06,609 --> 03:54:08,645 MEASUREMENT SHOULD IDEALLY USE 6137 03:54:08,645 --> 03:54:09,212 STANDARDIZED PROTOCOL WITH A 6138 03:54:09,212 --> 03:54:10,346 WAIT PERIOD FOLLOWED BY 6139 03:54:10,346 --> 03:54:11,547 AUTOMATED OFFICE BLOOD PRESSURE 6140 03:54:11,547 --> 03:54:12,315 MEASUREMENTS WITHOUT THE 6141 03:54:12,315 --> 03:54:13,950 CLINICIAN PRESENT IN THE ROOM IN 6142 03:54:13,950 --> 03:54:14,851 ORDER TO ELIMINATE THE WHITE 6143 03:54:14,851 --> 03:54:16,252 COAT EFFECT AND, THEREFORE, 6144 03:54:16,252 --> 03:54:17,220 WHITE COAT HYPERTENSION FOR SOME 6145 03:54:17,220 --> 03:54:18,254 INDIVIDUALS. 6146 03:54:18,254 --> 03:54:22,058 HOWEVER WHEN YOU LOCK AT THE LOE 6147 03:54:22,058 --> 03:54:23,593 DATA, THERE'S SCARCITY OF HIGH 6148 03:54:23,593 --> 03:54:25,061 QUALITY DATA WITH SOME SHOWING 6149 03:54:25,061 --> 03:54:26,062 NO DIFFERENCE BETWEEN UNATTENDED 6150 03:54:26,062 --> 03:54:27,297 AND ATTENDED OFFICE BLOOD 6151 03:54:27,297 --> 03:54:30,733 PRESSURE AND UNATTENDED OFFICE 6152 03:54:30,733 --> 03:54:31,901 BROMOPROPANE IS LOWER THAN 6153 03:54:31,901 --> 03:54:33,202 ATTENDED BROMOPROPANE. 6154 03:54:33,202 --> 03:54:34,871 YOU LOOK AT THE STUDIES THEY 6155 03:54:34,871 --> 03:54:36,539 WERE OFTEN NOT PERFORMED ON THE 6156 03:54:36,539 --> 03:54:36,939 SAME PARTICIPANT. 6157 03:54:36,939 --> 03:54:38,241 AN EXAMPLE OF THAT WOULD BE THE 6158 03:54:38,241 --> 03:54:42,712 SPRIPT TSPRINT TRIAL WHICH DID M 6159 03:54:42,712 --> 03:54:43,279 UNATTENDED BROMOPROPANE 6160 03:54:43,279 --> 03:54:44,247 MEASUREMENTS BUT WERE NOT DONE 6161 03:54:44,247 --> 03:54:45,348 IN THE SAME PARTICIPANTS AND 6162 03:54:45,348 --> 03:54:48,418 THERE WERE DIFFERENTS ACROSS 6163 03:54:48,418 --> 03:54:49,285 SITES. 6164 03:54:49,285 --> 03:54:54,557 ALSO SPRINT WAS NOT A PRIORI 6165 03:54:54,557 --> 03:54:55,058 DESIGNED. 6166 03:54:55,058 --> 03:54:57,160 SO A RECENT SYSTEMATIC ANALYSIS 6167 03:54:57,160 --> 03:54:59,462 OF 12 STUDIES, THE DIFFERENCE 6168 03:54:59,462 --> 03:55:02,198 BETWEEN UNATTENDED AND ATTENDED 6169 03:55:02,198 --> 03:55:06,903 BMP MEASUREMENTS WAS MINUS 6170 03:55:06,903 --> 03:55:08,871 3.66 AND 1.67 MILLIMETERS OF 6171 03:55:08,871 --> 03:55:09,539 MERCURY RESPECTIVELY. 6172 03:55:09,539 --> 03:55:11,507 WHEN YOU CLOSELY EXAMINE THESE 6173 03:55:11,507 --> 03:55:13,209 STUDIES AND THESE META-ANALYSES, 6174 03:55:13,209 --> 03:55:14,143 IN ADDITION TO THE FACT THAT 6175 03:55:14,143 --> 03:55:15,144 MEASUREMENTS WERE NOT PERFORMED 6176 03:55:15,144 --> 03:55:19,182 WITHIN THE SAME PARTICIPANTS, SO 6177 03:55:19,182 --> 03:55:21,351 WITHIN INDIVIDUAL IN DIFFERENCES 6178 03:55:21,351 --> 03:55:23,353 CANNOT BE DETERMINED. 6179 03:55:23,353 --> 03:55:25,054 THE FEW DID COMPARE ATTENDED -- 6180 03:55:25,054 --> 03:55:26,856 MANY OF THESE STUDIES DID NOT 6181 03:55:26,856 --> 03:55:27,657 RANDOMIZE THE ORDER OF BLOOD 6182 03:55:27,657 --> 03:55:35,932 PRESSURE ME MEASUREMENTS. 6183 03:55:35,932 --> 03:55:37,166 ORDER EFFECTS AND REGRESSION TO 6184 03:55:37,166 --> 03:55:38,568 THE MEAN CANNOT BE EXCLUDED AND 6185 03:55:38,568 --> 03:55:40,002 FURTHER WITHIN THE SAME 6186 03:55:40,002 --> 03:55:42,071 RANDOMIZED STUDIES, MOST DID NOT 6187 03:55:42,071 --> 03:55:44,907 COMPARE OFFICE BLOOD PRESSURE TO 6188 03:55:44,907 --> 03:55:48,511 AWAKE BLOOD PRESSURE ON ABPM. 6189 03:55:48,511 --> 03:55:50,580 FURTHER THERE STILL REMAINS A 6190 03:55:50,580 --> 03:55:51,681 CRITICAL RESEARCH GAP AS TO 6191 03:55:51,681 --> 03:55:53,349 WHETHER ATTENDED OR UNATTENDED 6192 03:55:53,349 --> 03:55:54,984 OFFICE BLOOD PRESSURE IS CLOSER 6193 03:55:54,984 --> 03:55:58,721 TO AWAKE BLOOD PRESSURE ABPM. 6194 03:55:58,721 --> 03:56:00,123 SO WHAT ARE THE CLINICAL 6195 03:56:00,123 --> 03:56:01,324 IMPLICATIONS OF UNATTENDED 6196 03:56:01,324 --> 03:56:01,657 BROMOPROPANE? 6197 03:56:01,657 --> 03:56:03,226 SO FOR THE PURPOSE OF THIS 6198 03:56:03,226 --> 03:56:04,727 SLIDE, I'M GOING TO WALK YOU 6199 03:56:04,727 --> 03:56:08,197 THROUGH, LET'S ASSUME YOU'RE 6200 03:56:08,197 --> 03:56:14,036 OMNI SHENT, SENT, YOU KNOW THEY 6201 03:56:14,036 --> 03:56:15,972 ABPM IS REALLY THE TRUTH AND IT 6202 03:56:15,972 --> 03:56:16,973 CORRECTLY REFLECTS AN 6203 03:56:16,973 --> 03:56:17,640 INDIVIDUAL'S BLOOD PRESSURE. 6204 03:56:17,640 --> 03:56:19,008 SO LET GO THROUGH THE FIRST 6205 03:56:19,008 --> 03:56:19,609 SCENARIO. 6206 03:56:19,609 --> 03:56:21,911 IF ATTENDED OFFICE BLOOD 6207 03:56:21,911 --> 03:56:22,779 PRESSURE WHEN PERFORMED USING 6208 03:56:22,779 --> 03:56:24,981 PROPER TECHNIQUE IS ACTUALLY 6209 03:56:24,981 --> 03:56:26,949 SIMILAR TO AWAKE BLOOD PRESSURE 6210 03:56:26,949 --> 03:56:28,684 ON ABPM THEN THERE'S NO NEED TO 6211 03:56:28,684 --> 03:56:29,886 CHANGE OUR CLINICAL PRACTICE. 6212 03:56:29,886 --> 03:56:31,521 FOR SCENARIO TWO, IF UNATTENDED 6213 03:56:31,521 --> 03:56:32,522 OFFICE BLOOD PRESSURE IS 6214 03:56:32,522 --> 03:56:33,723 ACTUALLY CLOSER TO AWAKE BLOOD 6215 03:56:33,723 --> 03:56:36,793 PRESSURE IN ABPM WHEN COMPARED 6216 03:56:36,793 --> 03:56:37,326 TO ATTENDED OFFICE BLOOD 6217 03:56:37,326 --> 03:56:38,661 PRESSURE THEN WE REALLY SHOULD 6218 03:56:38,661 --> 03:56:39,729 BE USING UNATTENDED OFFICE BLOOD 6219 03:56:39,729 --> 03:56:41,063 PRESSURE. 6220 03:56:41,063 --> 03:56:42,465 OUR CLINICAL WORKFLOW WOULD HAVE 6221 03:56:42,465 --> 03:56:44,100 TO CHANGE, OUR PATIENTS WOULD 6222 03:56:44,100 --> 03:56:47,103 NEED TO BE INSTRUCTED ON HOW TO 6223 03:56:47,103 --> 03:56:50,373 SELF-MEASURE BROMOPROPANE DURINE 6224 03:56:50,373 --> 03:56:50,606 VISITS. 6225 03:56:50,606 --> 03:56:52,141 WE NEED TO FIND TIME IN AN 6226 03:56:52,141 --> 03:56:53,876 OFFICE SPACE TO HAVE PEOPLE 6227 03:56:53,876 --> 03:56:54,444 SITTING ALONE. 6228 03:56:54,444 --> 03:56:56,913 IN THEORY THE PRESENCE OF WHITE 6229 03:56:56,913 --> 03:56:59,015 COAT HYPERTENSION AND MASKED 6230 03:56:59,015 --> 03:57:01,117 HYPERTENSION WOULD BE LOWER AND 6231 03:57:01,117 --> 03:57:03,319 WOULD NOT BE OVERTREATED OR 6232 03:57:03,319 --> 03:57:05,054 UNDERTREATED RESPECTIVELY. 6233 03:57:05,054 --> 03:57:06,255 A THIRD EXAMPLE, WE'RE IMAGINING 6234 03:57:06,255 --> 03:57:08,224 YOU STILL KNOW THE TRUTH, THE 6235 03:57:08,224 --> 03:57:10,726 PATIENT HAS HIGHER -- YOU ALSO 6236 03:57:10,726 --> 03:57:14,063 KNOW THE TRUTH THEIR ATTENDED 6237 03:57:14,063 --> 03:57:15,331 OFFICE BLOOD PRESSURE IF YOU 6238 03:57:15,331 --> 03:57:17,366 CHECK IT WAS ALSO HIGH AND IT'S 6239 03:57:17,366 --> 03:57:19,502 ACTUALLY CLOSER IN VALUE TO THE 6240 03:57:19,502 --> 03:57:20,503 AWAKE BLOOD PRESSURE, MEANING 6241 03:57:20,503 --> 03:57:22,905 THAT THIS PERSON YOU ACTUALLY 6242 03:57:22,905 --> 03:57:23,806 KNOW TRULY HAS A DIAGNOSIS OF 6243 03:57:23,806 --> 03:57:24,774 SUSTAINED HYPERTENSION. 6244 03:57:24,774 --> 03:57:26,642 INSTEAD YOU HAD THIS PATIENT 6245 03:57:26,642 --> 03:57:28,044 PERFORM UNATTENDED OFFICE BLOOD 6246 03:57:28,044 --> 03:57:28,611 PRESSURE AND FOR WHATEVER 6247 03:57:28,611 --> 03:57:30,112 REASON, THEY'RE UNATTENDED 6248 03:57:30,112 --> 03:57:30,713 OFFICE BLOOD PRESSURE MAY BE 6249 03:57:30,713 --> 03:57:32,882 BECAUSE OF POOR TECHNIQUE OR 6250 03:57:32,882 --> 03:57:39,789 OTHERWISE IS M STA MISTAKENLY NT 6251 03:57:39,789 --> 03:57:41,090 HIGH, THEY WOULD NOT MEET THE 6252 03:57:41,090 --> 03:57:41,824 THRESHOLD FOR SUSTAINED 6253 03:57:41,824 --> 03:57:42,191 HYPERTENSION. 6254 03:57:42,191 --> 03:57:44,794 IN THIS CASE, THE LIKELIHOOD OF 6255 03:57:44,794 --> 03:57:45,728 MASKED HYPERTENSION THEN WOULD 6256 03:57:45,728 --> 03:57:46,028 INCREASE. 6257 03:57:46,028 --> 03:57:48,364 IN THIS THIRD SCENARIO, 6258 03:57:48,364 --> 03:57:49,866 INDIVIDUALS WITH SUSTAINED 6259 03:57:49,866 --> 03:57:51,300 HYPERTENSION WOULD NOW BE 6260 03:57:51,300 --> 03:57:53,069 CONVERTED TO HAVING MASKED 6261 03:57:53,069 --> 03:57:53,603 HYPERTENSION. 6262 03:57:53,603 --> 03:57:54,904 THIS DIAGNOSIS WOULD THEN BE 6263 03:57:54,904 --> 03:57:56,772 MISSED IN THE OFFICE IF YOU JUST 6264 03:57:56,772 --> 03:57:58,441 USE UNATTENDED OFFICE BLOOD 6265 03:57:58,441 --> 03:57:58,774 PRESSURE ONLY. 6266 03:57:58,774 --> 03:58:03,045 IIN EFFECT, THE PATIENT WOULD 6267 03:58:03,045 --> 03:58:05,882 OTHERWISE BE DIAGNOSED AS HAVING 6268 03:58:05,882 --> 03:58:07,083 SUSTAINED HYPERTENSION IF YOU 6269 03:58:07,083 --> 03:58:11,454 HAD CONDUCTED ABPM AND TREATMENT 6270 03:58:11,454 --> 03:58:12,889 MAY HAVE BEEN INITIATED. 6271 03:58:12,889 --> 03:58:14,757 THERE ARE NOT MANY STUDIES THAT 6272 03:58:14,757 --> 03:58:16,058 LOOKED AT WHAT HAPPENS TO THE 6273 03:58:16,058 --> 03:58:16,859 PREVALENCE OF MASKED 6274 03:58:16,859 --> 03:58:20,496 HYPERTENSION IN THESE SCENARIOS. 6275 03:58:20,496 --> 03:58:21,998 SO WHAT ABOUT SLEEP BLOOD 6276 03:58:21,998 --> 03:58:22,365 PRESSURE? 6277 03:58:22,365 --> 03:58:23,799 THE SOLE RELIANCE ON OFFICE 6278 03:58:23,799 --> 03:58:25,001 BLOOD PRESSURE I THINK IGNORES 6279 03:58:25,001 --> 03:58:27,370 THE IMPACT OF HIGH SLEEP BLOOD 6280 03:58:27,370 --> 03:58:28,538 PRESSURE AND CARDIOVASCULAR 6281 03:58:28,538 --> 03:58:29,539 OUTCOMES, PARTICULARLY IN BLACK 6282 03:58:29,539 --> 03:58:30,072 ADULTS. 6283 03:58:30,072 --> 03:58:31,741 WE FOUND THAT THE PREVALENCE OF 6284 03:58:31,741 --> 03:58:33,476 MASKED NIGHTTIME HYPERTENSION 6285 03:58:33,476 --> 03:58:34,243 AMONG INDIVIDUALS WITHOUT A 6286 03:58:34,243 --> 03:58:35,545 HISTORY OF HYPERTENSION WAS 6287 03:58:35,545 --> 03:58:36,646 PARTICULARLY HIGH IN BLACK 6288 03:58:36,646 --> 03:58:38,314 ADULTS IN THE JACKSON HEART 6289 03:58:38,314 --> 03:58:39,382 STUDY, THAT'S A FIGURE ON THE 6290 03:58:39,382 --> 03:58:41,150 LEFT SIDE. 6291 03:58:41,150 --> 03:58:44,320 AND WITH OVER 40% HAVING HIGH 6292 03:58:44,320 --> 03:58:45,421 NIGHTTIME BLOOD PRESSURE VERSUS 6293 03:58:45,421 --> 03:58:47,256 22% HAVE HIGH DAY TIME BLOOD 6294 03:58:47,256 --> 03:58:48,491 PRESSURE, SO THESE INDIVIDUALS 6295 03:58:48,491 --> 03:58:52,228 WERE BEING SEEN I SEATED IN THED 6296 03:58:52,228 --> 03:58:53,195 JUST HAD AN OFFICE BLOOD 6297 03:58:53,195 --> 03:58:54,063 PRESSURE, THEY WOULD NOT HAVE 6298 03:58:54,063 --> 03:58:56,399 BEEN DIAGNOSED AT ALL OBVIOUSLY. 6299 03:58:56,399 --> 03:58:58,768 WE ALSO SHOWED THAT NOCTURNAL 6300 03:58:58,768 --> 03:59:04,240 HYPERTENSION DEFINED AS SLEEP -- 6301 03:59:04,240 --> 03:59:07,009 IS ALSO ASSOCIATED WITH HIGH 6302 03:59:07,009 --> 03:59:07,610 CARDIOVASCULAR DISEASE EVENTS. 6303 03:59:07,610 --> 03:59:09,078 THERE'S A TABLE ON THE RIGHT 6304 03:59:09,078 --> 03:59:12,348 SIDE IN THE TABLE -- MODEL FOUR, 6305 03:59:12,348 --> 03:59:16,752 FULLY ADJUSTED MODEL, THAT HAS A 6306 03:59:16,752 --> 03:59:18,621 RATIO FOR CVD EVENTS ASSOCIATED 6307 03:59:18,621 --> 03:59:20,690 WITH HIGH SLEEP BLOOD PRESSURE 6308 03:59:20,690 --> 03:59:21,991 WAS 2.07 IN THE FULLY ADJUSTED 6309 03:59:21,991 --> 03:59:26,829 MODEL. 6310 03:59:26,829 --> 03:59:28,464 SO HIGH NIGHTTIME BLOOD PRESSURE 6311 03:59:28,464 --> 03:59:30,967 HAS ALSO BEEN ASSOCIATED WITH 6312 03:59:30,967 --> 03:59:33,869 HIGH SLEEP BLOOD PRESSURE -- I 6313 03:59:33,869 --> 03:59:34,904 PRESENT ONE FROM 13 6314 03:59:34,904 --> 03:59:37,340 POPULATION-BASED STUDIES OVER 6315 03:59:37,340 --> 03:59:38,541 11,000 INDIVIDUALS FROM EUROPE, 6316 03:59:38,541 --> 03:59:40,343 ASIA AND SOUTH AMERICA. 6317 03:59:40,343 --> 03:59:41,744 MEDIAN AGE WAS 54, ALMOST HALF 6318 03:59:41,744 --> 03:59:43,479 WERE WOMEN AND THE STUDY HAD 6319 03:59:43,479 --> 03:59:45,114 13.8 YEARS OF FOLLOW-UP DATA. 6320 03:59:45,114 --> 03:59:47,149 WHAT THEY FOUND FOR EACH 6321 03:59:47,149 --> 03:59:48,217 20-MILLIMETER OR HIGHER 6322 03:59:48,217 --> 03:59:49,518 NIGHTTIME SYSTOLIC BLOOD 6323 03:59:49,518 --> 03:59:50,753 PRESSURE WAS ASSOCIATED WITH ALL 6324 03:59:50,753 --> 03:59:52,188 CAUSE MORTALITY IN THE 6325 03:59:52,188 --> 03:59:54,690 MULTIVARIABLE ADJUSTED HAZARD 6326 03:59:54,690 --> 03:59:55,057 RATIO WAS 1.23. 6327 03:59:55,057 --> 03:59:56,859 IN THE SAME STUDY THEY ALSO 6328 03:59:56,859 --> 03:59:59,095 LOOKED AT CBD EVENTS WHICH WAS 6329 03:59:59,095 --> 04:00:01,063 DEFINED AS CARDIOVASCULAR 6330 04:00:01,063 --> 04:00:02,698 MORTALITY COMBINED WITH 6331 04:00:02,698 --> 04:00:04,467 NON-FATAL CORONARY EVENTS, HEART 6332 04:00:04,467 --> 04:00:05,901 FAILURE OR STROKE, HAVING A 6333 04:00:05,901 --> 04:00:07,637 SIMILAR ASSOCIATION EACH 6334 04:00:07,637 --> 04:00:08,838 20-MILLIMETER OF MERCURY HIGHER 6335 04:00:08,838 --> 04:00:10,640 NIGHTTIME SYSTOLIC BLOOD 6336 04:00:10,640 --> 04:00:11,707 PRESSURE ASSOCIATED WITH 6337 04:00:11,707 --> 04:00:12,375 CARDIOVASCULAR DISEASE EVENT. 6338 04:00:12,375 --> 04:00:16,979 THERE ARE THE MULTIVARIABLE 6339 04:00:16,979 --> 04:00:18,781 ADJUSTED RATIO WAS 1.16 AND 6340 04:00:18,781 --> 04:00:19,915 WHICH DID NOT CHANGE WITH 6341 04:00:19,915 --> 04:00:22,518 FURTHER ADJUSTED FOR 24 HOUR 6342 04:00:22,518 --> 04:00:22,885 BLOOD PRESSURE. 6343 04:00:22,885 --> 04:00:27,256 SO ANOTHER GAP AND ONE OF THE 6344 04:00:27,256 --> 04:00:28,257 MAIN CHALLENGES WAS BLOOD 6345 04:00:28,257 --> 04:00:30,092 PRESSURE THRESHOLDS IN THE CHASE 6346 04:00:30,092 --> 04:00:31,293 TO UNDERSTAND WHAT MODALITY 6347 04:00:31,293 --> 04:00:32,194 PROVIDES THE BEST ESTIMATE OF 6348 04:00:32,194 --> 04:00:32,795 TRUE BLOOD PRESSURE. 6349 04:00:32,795 --> 04:00:35,698 TO QUOTE THE 2017AAC GUIDELINES, 6350 04:00:35,698 --> 04:00:36,799 THE PRECISE RELATIONSHIPS 6351 04:00:36,799 --> 04:00:38,768 BETWEEN OFFICE READINGS, 6352 04:00:38,768 --> 04:00:42,038 AMBULATORY HOME READINGS IS 6353 04:00:42,038 --> 04:00:42,505 UNSETTLED. 6354 04:00:42,505 --> 04:00:44,006 THERE'S GENERAL AGREEMENT 6355 04:00:44,006 --> 04:00:45,741 THEY'RE OFTEN HIGHER THAN 6356 04:00:45,741 --> 04:00:46,742 AMBULATORY HOME BLOOD PRESSURE 6357 04:00:46,742 --> 04:00:47,643 AND HERE I HIGHLIGHT FROM THE 6358 04:00:47,643 --> 04:00:48,611 GUIDELINES THE EXAMPLE THAT THEY 6359 04:00:48,611 --> 04:00:52,515 PROVIDE WITH THE DIFFERENCES IN 6360 04:00:52,515 --> 04:00:54,617 BLOOD PRESSURE THRESHOLDS FROM 6361 04:00:54,617 --> 04:00:57,620 HOME, BLOOD PRESSURE DAY TIME 6362 04:00:57,620 --> 04:01:01,357 SLEEP AND 24 HOUR -- 120 OVER 6363 04:01:01,357 --> 04:01:04,927 80, 130 OVER 80 AND 140 OVER 90. 6364 04:01:04,927 --> 04:01:05,961 ONLY FOR AN OFFICE BLOOD 6365 04:01:05,961 --> 04:01:08,497 PRESSURE THRESHOLD OF 120 OVER 6366 04:01:08,497 --> 04:01:09,365 80 AND 130 OVER 80 DO YOU HAVE 6367 04:01:09,365 --> 04:01:10,900 THE SAME THRESHOLD FOR HOME 6368 04:01:10,900 --> 04:01:12,635 BLOOD PRESSURE AND DAY TIME 6369 04:01:12,635 --> 04:01:14,070 ABPM, WHEREAS THAT'S NOT TRUE AT 6370 04:01:14,070 --> 04:01:17,573 A THRESHOLD OF 140/90 AND THIS 6371 04:01:17,573 --> 04:01:19,141 DISCREPANCY ACTUALLY INCREASES 6372 04:01:19,141 --> 04:01:19,775 WITH HIGHER BLOOD PRESSURES. 6373 04:01:19,775 --> 04:01:21,110 OBVIOUSLY NIGHTTIME BLOOD 6374 04:01:21,110 --> 04:01:22,978 PRESSURE AND 24 HOUR ABPM ON THE 6375 04:01:22,978 --> 04:01:25,314 CHART SHOWS THEY HAVE THEIR OWN 6376 04:01:25,314 --> 04:01:25,815 SEPARATE BLOOD PRESSURE 6377 04:01:25,815 --> 04:01:27,049 THRESHOLDS WHICH ON A PRACTICAL 6378 04:01:27,049 --> 04:01:28,117 LEVEL LEADS TO A LOT OF 6379 04:01:28,117 --> 04:01:29,218 CONFUSION FOR PATIENTS AND 6380 04:01:29,218 --> 04:01:30,386 CLINICIANS ALIKE WHEN YOU'RE 6381 04:01:30,386 --> 04:01:31,420 TRYING TO COMPARE OFFICE AND OUT 6382 04:01:31,420 --> 04:01:36,659 OF OFFICE BLOOD PRESSURE. 6383 04:01:36,659 --> 04:01:37,860 SO OBVIOUSLY THE NEXT GAP TO 6384 04:01:37,860 --> 04:01:39,662 CONSIDER THIS IS WHERE -- WITH 6385 04:01:39,662 --> 04:01:41,697 THE INTRODUCTION OF CONTINUOUS 6386 04:01:41,697 --> 04:01:42,598 BLOOD PRESSURE MONITORING, WHAT 6387 04:01:42,598 --> 04:01:44,033 DOES THIS MEAN IN THE CONTEXT OF 6388 04:01:44,033 --> 04:01:45,267 ESTABLISHING BLOOD PRESSURE 6389 04:01:45,267 --> 04:01:45,601 THRESHOLDS? 6390 04:01:45,601 --> 04:01:47,103 WILL THE SAME THRESHOLDS APPLY 6391 04:01:47,103 --> 04:01:50,940 OR SHOULD THEY EVEN? 6392 04:01:50,940 --> 04:01:55,244 SO IN SUMMARY, I PROVIDE SOME 6393 04:01:55,244 --> 04:01:56,245 KEY KNOWLEDGE GAPS AND FUTURE 6394 04:01:56,245 --> 04:01:57,179 OPPORTUNITIES. 6395 04:01:57,179 --> 04:01:59,215 SOME KEY GAPS INCLUDE DEFINING 6396 04:01:59,215 --> 04:02:00,149 UNIFORM BLOOD PRESSURE 6397 04:02:00,149 --> 04:02:01,884 THRESHOLDS ACROSS OFFICE AND OUT 6398 04:02:01,884 --> 04:02:02,518 OF OFFICE BLOOD PRESSURE 6399 04:02:02,518 --> 04:02:05,588 MEASUREMENTS AND OBVIOUSLY NEW 6400 04:02:05,588 --> 04:02:06,889 DEVICES. 6401 04:02:06,889 --> 04:02:08,324 CAN WE IMPROVE UPON OFFICE BLOOD 6402 04:02:08,324 --> 04:02:09,458 PRESSURE MEASUREMENT? 6403 04:02:09,458 --> 04:02:10,392 IT'S A SELF MEASURED BLOOD 6404 04:02:10,392 --> 04:02:11,761 PRESSURE BUT JUST IN A DIFFERENT 6405 04:02:11,761 --> 04:02:12,428 ENVIRONMENTAL CONTEXT. 6406 04:02:12,428 --> 04:02:14,163 I HAVE NOT SPOKEN TO 6407 04:02:14,163 --> 04:02:15,064 IMPLEMENTATION BARRIERS AT 6408 04:02:15,064 --> 04:02:17,700 LENGTH BUT OBVIOUSLY THE IMPACT 6409 04:02:17,700 --> 04:02:19,001 OF STRUCTURE LEVEL FACTORS IS A 6410 04:02:19,001 --> 04:02:19,902 KEY GAP. 6411 04:02:19,902 --> 04:02:20,469 WHAT ARE SOME FUTURE 6412 04:02:20,469 --> 04:02:21,003 OPPORTUNITIES? 6413 04:02:21,003 --> 04:02:23,272 I THINK CAN WE TOTALLY DISRUPT 6414 04:02:23,272 --> 04:02:24,273 THE CONCEPT OF OFFICE BLOOD 6415 04:02:24,273 --> 04:02:26,375 PRESSURE AND ONLY RELY ON OUT OF 6416 04:02:26,375 --> 04:02:28,344 OFFICE BLOOD PRESSURE? 6417 04:02:28,344 --> 04:02:30,412 DO WE THINK UNATTENDED OFFICE 6418 04:02:30,412 --> 04:02:31,514 BLOOD PRESSURE MAY ACTUALLY BE A 6419 04:02:31,514 --> 04:02:32,848 GATEWAY FOR IMPROVING PATIENT 6420 04:02:32,848 --> 04:02:36,585 EDUCATION AND ENGAGEMENT IN SELF 6421 04:02:36,585 --> 04:02:37,887 HELP BLOOM INSTRUMENT AND 6422 04:02:37,887 --> 04:02:39,455 THINKING ABOUT THE ENVIRONMENTAL 6423 04:02:39,455 --> 04:02:40,222 CONTEXT FOR WHICH WE START TO 6424 04:02:40,222 --> 04:02:41,624 ENGAGE INDIVIDUALS FOR SELF 6425 04:02:41,624 --> 04:02:43,292 BLOOD PRESSURE MESH M. 6426 04:02:43,292 --> 04:02:44,560 SECOND FUTURE OPPORTUNITIES, I 6427 04:02:44,560 --> 04:02:45,961 KNOW THERE ARE MANY PEOPLE WHO 6428 04:02:45,961 --> 04:02:51,567 WILL SPEAK WITH B. ABOUT THIS , 6429 04:02:51,567 --> 04:02:54,403 AND LASTLY CAN WE RELIABLY 6430 04:02:54,403 --> 04:02:55,437 ASSESS NOCTURNAL BLOOD PRESSURE 6431 04:02:55,437 --> 04:02:59,909 FOR MORE THAN A 24 TO 48 HOUR 6432 04:02:59,909 --> 04:03:00,142 PERIOD. 6433 04:03:00,142 --> 04:03:01,610 CAN YOU MEASURE BLOOD PRESSURE 6434 04:03:01,610 --> 04:03:02,311 WITHOUT DISTURBING SLEEP. 6435 04:03:02,311 --> 04:03:09,218 THANK YOU SO MUCH. 6436 04:03:09,218 --> 04:03:11,086 >> THANK YOU SO MUCH, 6437 04:03:11,086 --> 04:03:11,487 DR. ABDALLA. 6438 04:03:11,487 --> 04:03:13,689 NEXT UP I BELIEVE WE HAVE 6439 04:03:13,689 --> 04:03:18,894 DR. RICHARD CARAMAKRISHNA MUKKAO 6440 04:03:18,894 --> 04:03:19,562 US ABOUT CUFFLESS BLOOD PRESSURE 6441 04:03:19,562 --> 04:03:19,995 MEASUREMENT. 6442 04:03:19,995 --> 04:03:21,997 TAKE IT AWAY. 6443 04:03:21,997 --> 04:03:23,499 >> NEXT SLIDE, PLEASE. 6444 04:03:23,499 --> 04:03:25,000 GOOD AFTERNOON, THANK YOU TO THE 6445 04:03:25,000 --> 04:03:26,402 CHAIRS AND ORGANIZERS FOR THE 6446 04:03:26,402 --> 04:03:27,603 INVITATION TO PARTICIPATE IN 6447 04:03:27,603 --> 04:03:29,772 THIS IMPORTANT WORKSHOP. 6448 04:03:29,772 --> 04:03:31,507 I'VE STUDIED CUFFLESS BLOOD 6449 04:03:31,507 --> 04:03:32,374 PRESSURE MEASUREMENT FOR MORE 6450 04:03:32,374 --> 04:03:35,177 THAN A DECADE NOW, AND I'M GOING 6451 04:03:35,177 --> 04:03:36,912 TO TELL YOU WHERE WE ACTUALLY 6452 04:03:36,912 --> 04:03:37,980 STAND AT PRESENT WITH THIS 6453 04:03:37,980 --> 04:03:40,115 TECHNOLOGY. 6454 04:03:40,115 --> 04:03:41,550 AND BEFORE I BEGIN, I SHOULD 6455 04:03:41,550 --> 04:03:44,186 MENTION THAT I HAVE NIH FUNDING, 6456 04:03:44,186 --> 04:03:46,155 AND PATENTS ON CUFFLESS BLOOD 6457 04:03:46,155 --> 04:03:48,257 PRESSURE TECHNOLOGY THAT IS 6458 04:03:48,257 --> 04:03:49,325 DIFFERENT FROM THE METHODS THAT 6459 04:03:49,325 --> 04:03:55,898 I'LL FOCUS ON TODAY. 6460 04:03:55,898 --> 04:03:57,900 SO HERE ARE THE CONVENTIONAL 6461 04:03:57,900 --> 04:03:59,768 METHODS FROM NONINVASIVE 6462 04:03:59,768 --> 04:04:01,337 MEASUREMENT OF BLOOD PRESSURE. 6463 04:04:01,337 --> 04:04:06,175 AMONGST THESE METHODS, 6464 04:04:06,175 --> 04:04:07,610 OSCILLOMETRY IN THE FORM OF 6465 04:04:07,610 --> 04:04:09,411 AUTOMATIC ARM CUFF DEVICES HAS 6466 04:04:09,411 --> 04:04:12,014 EMERGED AS THE MOST WIDELY USED 6467 04:04:12,014 --> 04:04:13,215 METHOD BY SIGNIFICANT EXTENT. 6468 04:04:13,215 --> 04:04:15,718 THIS IS 50-YEAR-OLD TECHNOLOGY. 6469 04:04:15,718 --> 04:04:17,887 IT'S EASIEST TO USE, IT'S 6470 04:04:17,887 --> 04:04:19,455 INEXPENSIVE, AND CLOSEST IN 6471 04:04:19,455 --> 04:04:22,825 ACCURACY TO THE STANDARD MANUAL 6472 04:04:22,825 --> 04:04:23,692 AUSCULTATORY METHOD. 6473 04:04:23,692 --> 04:04:25,661 HOWEVER, AS WITH ALL 6474 04:04:25,661 --> 04:04:27,730 CONVENTIONAL METHODS, OS LOM 6475 04:04:27,730 --> 04:04:30,499 TREE REQUIRES AN INFLATABLE CUFF 6476 04:04:30,499 --> 04:04:32,735 AND IS NOT READILY AVAILABLE AND 6477 04:04:32,735 --> 04:04:38,908 CUMBERSOME TO USE. 6478 04:04:38,908 --> 04:04:41,076 SO MANY WANT TO ELIMINATE THE 6479 04:04:41,076 --> 04:04:41,610 CUFF FROM BLOOD PRESSURE 6480 04:04:41,610 --> 04:04:43,245 MEASUREMENT AND CUFFLESS BLOOD 6481 04:04:43,245 --> 04:04:44,079 PRESSURE MEASUREMENT HAS NOW 6482 04:04:44,079 --> 04:04:45,948 BECOME A FIELD. 6483 04:04:45,948 --> 04:04:47,316 STUDIES ARE INCREASINGLY 6484 04:04:47,316 --> 04:04:48,717 APPEARING IN THE LITERATURE AS 6485 04:04:48,717 --> 04:04:51,253 SHOWN IN THE UPPER LEFT, AND 6486 04:04:51,253 --> 04:04:54,590 SEVERAL WEARABLE DEVICES ARE NOW 6487 04:04:54,590 --> 04:04:55,958 CLEARED BY THE FDA AS WELL AS 6488 04:04:55,958 --> 04:04:57,593 THE EUROPEAN COMMISSION AS SHOWN 6489 04:04:57,593 --> 04:04:59,895 ON THE RIGHT. 6490 04:04:59,895 --> 04:05:02,731 A COMPREHENSIVE REVIEW OF THE 6491 04:05:02,731 --> 04:05:04,400 FLURRY OF ACTIVITY CAN BE FOUND 6492 04:05:04,400 --> 04:05:08,137 IN THE LOWER LEFT. 6493 04:05:08,137 --> 04:05:12,808 SO MOST OF THE STUDIES AND 6494 04:05:12,808 --> 04:05:14,576 LIKELY ALL OF THE REGULATORY 6495 04:05:14,576 --> 04:05:16,879 CLEARED DEVICES EMPLOY PULSE 6496 04:05:16,879 --> 04:05:19,748 WAVE ANALYSIS WITH OR WITHOUT 6497 04:05:19,748 --> 04:05:21,116 PULSE ARRIVAL TIME. 6498 04:05:21,116 --> 04:05:23,752 SO PULSE WAVE ANALYSIS METHODS 6499 04:05:23,752 --> 04:05:32,494 TYPICALLY MEASURE A 6500 04:05:32,494 --> 04:05:34,263 PHOTOPLETHYSMOGRAPHY OR PPG 6501 04:05:34,263 --> 04:05:36,131 WAVEFORM WHICH INDICATES SMALL 6502 04:05:36,131 --> 04:05:40,235 VESSEL BLOOD VOLUME OSCILLATIONS 6503 04:05:40,235 --> 04:05:41,603 WHICH INDICATES THAT PERIPHERAL 6504 04:05:41,603 --> 04:05:43,072 ARTERY FORCES. 6505 04:05:43,072 --> 04:05:48,110 SO NEITHER WAVTHIS THEN WILL EXS 6506 04:05:48,110 --> 04:05:49,545 FROM THE WAVEFORM AND MAP OR CAL 6507 04:05:49,545 --> 04:05:51,280 GREAT THESE FEATURES TO BLOOD 6508 04:05:51,280 --> 04:05:53,282 PRESSURE VALUES USING MACHINE 6509 04:05:53,282 --> 04:05:55,084 LEARNING. 6510 04:05:55,084 --> 04:05:57,886 PULSE WAVE ANALYSIS WITH PULSE 6511 04:05:57,886 --> 04:06:02,157 ARRIVAL TIME METHODS ALSO RECORD 6512 04:06:02,157 --> 04:06:05,894 AN ECG WAVEFORM TO EXTRACT PULSE 6513 04:06:05,894 --> 04:06:07,329 ARRIVAL TIME AS THE TIME DELAY 6514 04:06:07,329 --> 04:06:11,066 BETWEEN THE ECG AND HEMODYNAMIC 6515 04:06:11,066 --> 04:06:11,734 WAVEFORMS, AND POSSIBLY OTHER 6516 04:06:11,734 --> 04:06:14,136 FEATURES. 6517 04:06:14,136 --> 04:06:16,538 AND AS SHOWN IN THE GOLD BOX, 6518 04:06:16,538 --> 04:06:19,375 THESE METHODS REQUIRE PERIODIC 6519 04:06:19,375 --> 04:06:22,378 MEASUREMENT WITH AN ARM CUFF 6520 04:06:22,378 --> 04:06:25,214 DEVICE AS PART OF THE 6521 04:06:25,214 --> 04:06:26,315 CALIBRATION PROCEDURE OR USE 6522 04:06:26,315 --> 04:06:28,617 ONLY DEMOGRAPHIC INFORMATION 6523 04:06:28,617 --> 04:06:32,021 SUCH AS AGE, BIOLOGICAL SEX, AND 6524 04:06:32,021 --> 04:06:33,989 BMI FOR LESS RELIABLE 6525 04:06:33,989 --> 04:06:34,990 CALIBRATION. 6526 04:06:34,990 --> 04:06:36,959 AND, THEREFORE, AND THE MOST 6527 04:06:36,959 --> 04:06:38,761 IMPORTANT THING TO UNDERSTAND, 6528 04:06:38,761 --> 04:06:40,829 IS THAT THE SOLE PURPOSE OF 6529 04:06:40,829 --> 04:06:43,565 THESE DEVICES IS TO MEASURE 6530 04:06:43,565 --> 04:06:45,000 BLOOD PRESSURE CHANGES IN A 6531 04:06:45,000 --> 04:06:47,870 PERSON RELATIVE TO THE 6532 04:06:47,870 --> 04:06:48,537 CALIBRATION RATHER THAN 6533 04:06:48,537 --> 04:06:49,772 MEASURING THE ABSOLUTE BLOOD 6534 04:06:49,772 --> 04:06:54,977 PRESSURE LEVEL. 6535 04:06:54,977 --> 04:06:56,078 SO I THINK IT'S IMPORTANT TO 6536 04:06:56,078 --> 04:06:58,213 NOTE THAT THESE METHODS ARE NOT 6537 04:06:58,213 --> 04:07:00,616 SUPPORTED BY GENERALLY ACCEPTED 6538 04:07:00,616 --> 04:07:02,151 PHYSIOLOGICAL PRINCIPLES. 6539 04:07:02,151 --> 04:07:06,021 SO AS JUST ONE EXAMPLE, A BASIC 6540 04:07:06,021 --> 04:07:08,323 PHYSIOLOGICAL MODEL TO THE LEFT 6541 04:07:08,323 --> 04:07:11,360 INDICATES THAT PPG CHANGES ARE 6542 04:07:11,360 --> 04:07:15,030 EQUAL TO THE PRODUCT OF SMALL 6543 04:07:15,030 --> 04:07:15,597 VESSEL COMPLIANCE AND BLOOD 6544 04:07:15,597 --> 04:07:17,533 PRESSURE CHANGES. 6545 04:07:17,533 --> 04:07:20,369 SMALL VESSEL COMPLIANCE IS 6546 04:07:20,369 --> 04:07:22,337 MODULATED BY SMOOTH MUSCLE 6547 04:07:22,337 --> 04:07:24,139 CONTRACTION AND CAN, THEREFORE, 6548 04:07:24,139 --> 04:07:25,874 VARY INDEPENDENTLY OF BLOOD 6549 04:07:25,874 --> 04:07:26,708 PRESSURE. 6550 04:07:26,708 --> 04:07:28,310 SO IF YOU LOOK TO THE RIGHT, 6551 04:07:28,310 --> 04:07:32,047 THERE ARE DATA SHOWING THAT AS A 6552 04:07:32,047 --> 04:07:34,116 CONSEQUENCE, CHANGES IN BLOOD 6553 04:07:34,116 --> 04:07:36,518 PRESSURE INDUCED BY VARIOUS 6554 04:07:36,518 --> 04:07:38,620 INTERVENTIONS HAVE LITERAL 6555 04:07:38,620 --> 04:07:39,822 RELATIONSHIP WITH THE INDUCED 6556 04:07:39,822 --> 04:07:41,890 CHANGE IN PPG AMPLITUDE. 6557 04:07:41,890 --> 04:07:44,893 SO YOU CAN SEE THAT MENTAL 6558 04:07:44,893 --> 04:07:47,729 ARITHMETIC WHICH IS PRIMARILY A 6559 04:07:47,729 --> 04:07:49,598 CARDIAC INTERVENTION INCREASES 6560 04:07:49,598 --> 04:07:53,669 BOTH BLOOD PRESSURE AND THE PPG 6561 04:07:53,669 --> 04:07:55,437 AMPLITUDE, WHEREAS COLD PRESSOR, 6562 04:07:55,437 --> 04:07:57,406 WHICH IS A VASCULAR 6563 04:07:57,406 --> 04:07:58,907 INTERVENTION, INCREASES BLOOD 6564 04:07:58,907 --> 04:08:01,210 PRESSURE BY A SIMILAR AMOUNT BUT 6565 04:08:01,210 --> 04:08:05,080 DECREASES THE PPG AMPLITUDE VIA 6566 04:08:05,080 --> 04:08:06,715 A REDUCTION IN SMALL VESSEL 6567 04:08:06,715 --> 04:08:13,622 COMPLIANCE. 6568 04:08:13,622 --> 04:08:15,390 SO EVEN SO, NUMEROUS STUDIES 6569 04:08:15,390 --> 04:08:16,625 CLAIM THAT PULSE WAVE ANALYSIS 6570 04:08:16,625 --> 04:08:19,695 METHODS ARE ACCURATE. 6571 04:08:19,695 --> 04:08:20,596 HOWEVER, MANY OF THE STUDIES ARE 6572 04:08:20,596 --> 04:08:25,734 ACTUALLY PROBLEMATIC. 6573 04:08:25,734 --> 04:08:27,836 SO FIRSTLY, RESULTS IN PUBLISHED 6574 04:08:27,836 --> 04:08:29,138 PAPERS ARE OFTEN PRESENTED 6575 04:08:29,138 --> 04:08:29,438 INCORRECTLY. 6576 04:08:29,438 --> 04:08:32,107 SO WE PERFORMED COMPUTER STUDIES 6577 04:08:32,107 --> 04:08:33,408 TO SIMULATE CUFFLESS BLOOD 6578 04:08:33,408 --> 04:08:37,513 PRESSURE MEASUREMENTS WITH ZERO 6579 04:08:37,513 --> 04:08:39,481 CORRELATION TO REFERENCE CUFF 6580 04:08:39,481 --> 04:08:40,482 BLOOD PRESSURE MEASUREMENTS AND 6581 04:08:40,482 --> 04:08:42,217 THEN PRESENTED THE RESULTS LIKE 6582 04:08:42,217 --> 04:08:44,219 IN MANY PAPERS. 6583 04:08:44,219 --> 04:08:46,622 THAT'S WHAT'S SHOWN IN GREY. 6584 04:08:46,622 --> 04:08:48,157 THE RESULTS SHOW IMPRESSIVE 6585 04:08:48,157 --> 04:08:50,759 CORRELATION OF A CUFF CALIBRATED 6586 04:08:50,759 --> 04:08:53,095 METHOD WITH CUFF BLOOD PRESSURE. 6587 04:08:53,095 --> 04:08:54,663 HOWEVER, WHEN THE DATA ARE 6588 04:08:54,663 --> 04:08:56,732 PRESENTED CORRECTLY, AS THE 6589 04:08:56,732 --> 04:08:58,200 CHANGE IN THE CUFFLESS BLOOD 6590 04:08:58,200 --> 04:09:00,836 PRESSURE RELATIVE TO THE 6591 04:09:00,836 --> 04:09:02,371 CALIBRATION VERSUS THE CHANGE IN 6592 04:09:02,371 --> 04:09:04,139 CUFF BLOOD PRESSURE RELATIVE TO 6593 04:09:04,139 --> 04:09:06,008 THE CALIBRATION, WE SEE THE TRUE 6594 04:09:06,008 --> 04:09:08,243 LACK OF CORRELATION IN THE LOWER 6595 04:09:08,243 --> 04:09:13,782 LEFT. 6596 04:09:13,782 --> 04:09:18,787 STEKDLY SECONDLY THE TESTING PRL 6597 04:09:18,787 --> 04:09:20,189 EMPLOYED IN MANY STUDIES OFTEN 6598 04:09:20,189 --> 04:09:21,056 DO NOT INCLUDE BLOOD PRESSURE 6599 04:09:21,056 --> 04:09:21,823 CHANGES AND BLOOD PRESSURE 6600 04:09:21,823 --> 04:09:24,259 CHANGES AGAIN ARE WHAT PULSE 6601 04:09:24,259 --> 04:09:24,927 WAVE ANALYSIS MEASURE. 6602 04:09:24,927 --> 04:09:26,795 AND MOST NOTABLY, A NUMBER OF 6603 04:09:26,795 --> 04:09:34,069 STUDIES HAVE EMPLOYED THE 6604 04:09:34,069 --> 04:09:34,603 AAMI/ESH/ISO STANDARD FOR 6605 04:09:34,603 --> 04:09:38,574 TESTING CUFF DEVICES TO ASSESS 6606 04:09:38,574 --> 04:09:39,675 PULSE WAVE ANALYSIS METHODS. 6607 04:09:39,675 --> 04:09:40,876 HOWEVER, THIS STANDARD IS NOT 6608 04:09:40,876 --> 04:09:42,077 APPLICABLE TO PULSE WAVE 6609 04:09:42,077 --> 04:09:43,445 ANALYSIS METHODS BECAUSE IT DOES 6610 04:09:43,445 --> 04:09:45,113 NOT INCLUDE THE NECESSARY BLOOD 6611 04:09:45,113 --> 04:09:49,218 PRESSURE CHANGES. 6612 04:09:49,218 --> 04:09:51,620 STUDIES OF CUFF CALIBRATED PULSE 6613 04:09:51,620 --> 04:09:52,988 WAVE ANALYSIS METHODS WITHOUT 6614 04:09:52,988 --> 04:09:53,855 ANY BLOOD PRESSURE CHANGES CAN 6615 04:09:53,855 --> 04:09:57,459 BE SIMPLY DISMISSED. 6616 04:09:57,459 --> 04:09:59,194 THIRDLY, AND PERHAPS MOST 6617 04:09:59,194 --> 04:10:01,129 IMPORTANTLY, MANY STUDIES DO NOT 6618 04:10:01,129 --> 04:10:03,398 INCLUDE COMPARISONS TO FAIR 6619 04:10:03,398 --> 04:10:05,601 BASELINE MODELS AS SHOWN IN THE 6620 04:10:05,601 --> 04:10:09,304 LOWER RIGHT. 6621 04:10:09,304 --> 04:10:11,440 SO PULSE WAVE ANALYSIS METHODS 6622 04:10:11,440 --> 04:10:12,441 AGAIN COMPUTE BLOOD PRESSURE 6623 04:10:12,441 --> 04:10:15,577 FROM A HEMODYNAMIC WAVEFORM 6624 04:10:15,577 --> 04:10:18,213 MEASUREMENT AND A NON-WAVEFORM 6625 04:10:18,213 --> 04:10:19,114 INFORMATION SUCH AS THE CUFF 6626 04:10:19,114 --> 04:10:21,617 BLOOD PRESSURE FOR CALIBRATION, 6627 04:10:21,617 --> 04:10:24,353 AGE, SEX, AND BMI. 6628 04:10:24,353 --> 04:10:26,788 IT IS WELL-KNOWN THAT THIS OTHER 6629 04:10:26,788 --> 04:10:29,358 INFORMATION, THE OTHER 6630 04:10:29,358 --> 04:10:29,992 NON-WAVEFORM INFORMATION 6631 04:10:29,992 --> 04:10:31,960 CORRELATES WITH THE BLOOD 6632 04:10:31,960 --> 04:10:32,761 PRESSURE FOR MEASUREMENT. 6633 04:10:32,761 --> 04:10:35,030 SO THE METHODS MUST, THEREFORE, 6634 04:10:35,030 --> 04:10:38,267 BE COMPARED TO BASELINE MODELS 6635 04:10:38,267 --> 04:10:40,035 IN WHICH BLOOD PRESSURE IS 6636 04:10:40,035 --> 04:10:42,004 COMPUTED ONLY FROM THE 6637 04:10:42,004 --> 04:10:42,738 NON-WAVEFORM INFORMATION TO 6638 04:10:42,738 --> 04:10:44,773 DETERMINE IF THE METHOD IS WORTH 6639 04:10:44,773 --> 04:10:47,075 USING OR NOT. 6640 04:10:47,075 --> 04:10:50,045 A PULSE WAVE ANALYSIS DEVICE IS 6641 04:10:50,045 --> 04:10:52,447 SUPERFLUOUS IF THE WAVEFORM THAT 6642 04:10:52,447 --> 04:10:54,416 IT MEASURING DOES NOT OFFER ANY 6643 04:10:54,416 --> 04:10:55,317 VALUE TO BLOOD PRESSURE 6644 04:10:55,317 --> 04:11:00,489 MEASUREMENT ACCURACY. 6645 04:11:00,489 --> 04:11:02,691 SO SOME STUDIES OF PULSE WAVE 6646 04:11:02,691 --> 04:11:05,627 ANALYSIS DEVICES WITH COMPANY 6647 04:11:05,627 --> 04:11:07,462 INVOLVEMENT APPEAR TO BE 6648 04:11:07,462 --> 04:11:08,530 PROPERLY DONE AND SHOW 6649 04:11:08,530 --> 04:11:12,034 REMARKABLE RESULTS. 6650 04:11:12,034 --> 04:11:13,568 SO TO THE LEFT ARE RESULTS FROM 6651 04:11:13,568 --> 04:11:16,538 ONE STUDY OF A DEMOGRAPHIC 6652 04:11:16,538 --> 04:11:20,275 CALIBRATED RISK TONOMETRY DEVICE 6653 04:11:20,275 --> 04:11:21,443 AGAINST INVASIVE BLOOD PRESSURE. 6654 04:11:21,443 --> 04:11:23,378 YOU CAN SEE THE CORRELATION IS 6655 04:11:23,378 --> 04:11:26,648 STRONG, ESPECIALLY CONSIDERING 6656 04:11:26,648 --> 04:11:27,949 THE DEMOGRAPHIC CALIBRATION WAS 6657 04:11:27,949 --> 04:11:28,517 EMPLOYED. 6658 04:11:28,517 --> 04:11:30,752 TO THE RIGHT ARE RESULTS FROM 6659 04:11:30,752 --> 04:11:33,355 ANOTHER STUDY OF A CUFF 6660 04:11:33,355 --> 04:11:38,293 CALIBRATED WRIST PPG DEVICE 6661 04:11:38,293 --> 04:11:39,861 AGAINST 24 HOUR ABPM. 6662 04:11:39,861 --> 04:11:45,133 THE R SCAR SQUARED VALUES ARE .O 6663 04:11:45,133 --> 04:11:45,300 .99. 6664 04:11:45,300 --> 04:11:48,236 I'M TALKING R SQUARED, NOT R. 6665 04:11:48,236 --> 04:11:49,638 NOTE THAT CUFF BLOOD PRESSURE 6666 04:11:49,638 --> 04:11:51,740 MEASUREMENTS HAVE SIGNIFICANT 6667 04:11:51,740 --> 04:11:53,275 ERROR IN PLOTTING THE 6668 04:11:53,275 --> 04:11:55,243 MEASUREMENTS OF ONE CUFF DEVICE 6669 04:11:55,243 --> 04:11:58,447 VERSUS ANOTHER CUFF DEVICE WOULD 6670 04:11:58,447 --> 04:12:07,356 NOT YIELD THIS R SQUARED LEVEL. 6671 04:12:07,356 --> 04:12:09,324 SO AS STEPHEN MENTIONED, A 6672 04:12:09,324 --> 04:12:10,625 MICROSOFT RESEARCH TEAM RECENTLY 6673 04:12:10,625 --> 04:12:13,195 PUBLISHED A COMPREHENSIVE STUDY 6674 04:12:13,195 --> 04:12:14,663 TO DETERMINE IF PULSE WAVE 6675 04:12:14,663 --> 04:12:18,133 ANALYSIS METHODS CAN ACTUALLY 6676 04:12:18,133 --> 04:12:19,334 TRACK BLOOD PRESSURE CHANGES. 6677 04:12:19,334 --> 04:12:22,771 THEY DESIGNED A PRACTICAL YET 6678 04:12:22,771 --> 04:12:25,307 INFORMATIVE STUDY AND INCLUDED 6679 04:12:25,307 --> 04:12:26,274 OVER A THOUSAND DIVERSE 6680 04:12:26,274 --> 04:12:27,275 SUBJECTS. 6681 04:12:27,275 --> 04:12:28,810 THEY BUILT WRIST DEVICES TO 6682 04:12:28,810 --> 04:12:32,914 MEASURE PPG, TO NO, MA'AM TREE, 6683 04:12:32,914 --> 04:12:35,650 AND ECG WAVEFORMS, AND THEY THEN 6684 04:12:35,650 --> 04:12:37,018 EXPLORED AN ARRAY OF MACHINE 6685 04:12:37,018 --> 04:12:39,054 LEARNING ALGORITHMS TO DEVELOP 6686 04:12:39,054 --> 04:12:41,156 MODELS FOR COMPUTING BLOOD 6687 04:12:41,156 --> 04:12:43,191 PRESSURE FROM WAVEFORM FEATURES 6688 04:12:43,191 --> 04:12:45,794 AND NON-WAVEFORM INFORMATION 6689 04:12:45,794 --> 04:12:47,996 SUCH AS THE CUFF BLOOD PRESSURE 6690 04:12:47,996 --> 04:12:52,234 MEASUREMENT FOR CALIBRATION AND 6691 04:12:52,234 --> 04:12:54,035 THE TIME OF DAY, YES, THE TIME 6692 04:12:54,035 --> 04:12:56,204 OF DAY TO HELP WITH DIE URGE 6693 04:12:56,204 --> 04:13:00,175 BLOOD PRESSURE CHANGES. 6694 04:13:00,175 --> 04:13:01,610 CRUCIALLY, THEY CREATED FAIR 6695 04:13:01,610 --> 04:13:03,612 BASELINE MODELS TO COMPUTE BLOOD 6696 04:13:03,612 --> 04:13:05,914 PRESSURE FROM THE NON-WAVEFORM 6697 04:13:05,914 --> 04:13:07,249 INFORMATION ALONE AS SHOWN ON 6698 04:13:07,249 --> 04:13:10,085 THE LOWER LEFT. 6699 04:13:10,085 --> 04:13:12,921 AND THEY FOUND THAT THE WAVEFORM 6700 04:13:12,921 --> 04:13:16,458 FEATURE MODELS WERE ONLY ABLE TO 6701 04:13:16,458 --> 04:13:17,759 YIELD SLIGHTLY LOWER BLOOD 6702 04:13:17,759 --> 04:13:19,528 PRESSURE ERRORS AGAINST 6703 04:13:19,528 --> 04:13:21,129 REFERENCE CUFF DEVICES THAN THE 6704 04:13:21,129 --> 04:13:23,932 BASELINE MODELS AS SHOWN ON THE 6705 04:13:23,932 --> 04:13:25,801 LOWER RIGHT. 6706 04:13:25,801 --> 04:13:27,436 THEIR RESULTS, THEREFORE, 6707 04:13:27,436 --> 04:13:29,004 INDICATE THAT PULSE WAVE 6708 04:13:29,004 --> 04:13:32,307 ANALYSIS METHODS OFFER 6709 04:13:32,307 --> 04:13:33,275 ESSENTIALLY NO VALUE IN BLOOD 6710 04:13:33,275 --> 04:13:41,917 PRESSURE MONITORING. 6711 04:13:41,917 --> 04:13:43,852 SO THE MICROSOFT RESEARCH 6712 04:13:43,852 --> 04:13:46,888 PROJECT SHOULD BE REGARDED AS AN 6713 04:13:46,888 --> 04:13:48,089 AUTHORITATIVE STUDY OF PULSE 6714 04:13:48,089 --> 04:13:50,392 WAVE ANALYSIS METHODS FOR THE 6715 04:13:50,392 --> 04:13:52,227 FOLLOWING REASONS. 6716 04:13:52,227 --> 04:13:54,396 AN ELITE RESEARCH TEAM PERFORMED 6717 04:13:54,396 --> 04:13:57,999 AN UNBIASED STUDY OF CUFFLESS 6718 04:13:57,999 --> 04:13:59,468 BLOOD PRESSURE WITHOUT FINANCIAL 6719 04:13:59,468 --> 04:14:01,970 OR PUBLISHING CONCERNS. 6720 04:14:01,970 --> 04:14:03,839 THE STUDY COST MILLIONS OF 6721 04:14:03,839 --> 04:14:04,639 DOLLARS. 6722 04:14:04,639 --> 04:14:07,375 THE STUDY CONSTITUTED AN 6723 04:14:07,375 --> 04:14:09,177 EXHAUSTIVE ASSESSMENT OF WRIST 6724 04:14:09,177 --> 04:14:13,315 PULSE WAVE ANALYSIS METHODS WITH 6725 04:14:13,315 --> 04:14:15,283 HIGH SIMILARITY TO THE 6726 04:14:15,283 --> 04:14:17,486 REGULATORY CLEARED WRIST DEVICES 6727 04:14:17,486 --> 04:14:18,787 THAT I SHOWED EARLIER. 6728 04:14:18,787 --> 04:14:21,156 THE TEAM FOUND THAT THESE 6729 04:14:21,156 --> 04:14:24,292 METHODS OFFERED NO VALUE IN 6730 04:14:24,292 --> 04:14:25,160 MEASURING BLOOD PRESSURE OVER 6731 04:14:25,160 --> 04:14:27,896 FAIR BASELINE MODELS. 6732 04:14:27,896 --> 04:14:30,298 THIS MEANS THAT THEY DID NOT 6733 04:14:30,298 --> 04:14:33,535 WORK AT ALL, ZERO. 6734 04:14:33,535 --> 04:14:34,870 THE TEAM IS OFFERING THEIR DATA 6735 04:14:34,870 --> 04:14:37,038 FOR FREE TO THE PUBLIC. 6736 04:14:37,038 --> 04:14:40,542 AND THE TEAM EVIDENTLY QUIT 6737 04:14:40,542 --> 04:14:41,743 CUFFLESS BLOOD PRESSURE RESEARCH 6738 04:14:41,743 --> 04:14:46,648 FOLLOWING THEIR STUDY. 6739 04:14:46,648 --> 04:14:48,950 A FEW STUDIES OF THE LATEST FDA 6740 04:14:48,950 --> 04:14:52,287 CLEARED PULSE WAVE ANALYSIS 6741 04:14:52,287 --> 04:14:52,954 DEVICES HAVE SHOWN THAT THEY 6742 04:14:52,954 --> 04:14:54,689 PERFORM SIMILARLY TO BASELINE 6743 04:14:54,689 --> 04:14:56,658 MODELS. 6744 04:14:56,658 --> 04:15:00,195 TO THE LEFT ARE RESULTS OF A 6745 04:15:00,195 --> 04:15:01,897 CALIBRATED GARMENT DEVICE 6746 04:15:01,897 --> 04:15:04,432 SHOWING THAT IT YIELDED A 6747 04:15:04,432 --> 04:15:07,536 SYSTOLIC BLOOD PRESSURE ERROR OF 6748 04:15:07,536 --> 04:15:11,172 8.7 MILL ME TUR MERCURY AGAINST 6749 04:15:11,172 --> 04:15:12,807 CUFF BLOOD PRESSURE, WHEREAS A 6750 04:15:12,807 --> 04:15:14,709 BASELINE MODEL THAT COMPUTED 6751 04:15:14,709 --> 04:15:16,845 BLOOD PRESSURE FROM ONLY 6752 04:15:16,845 --> 04:15:18,647 DEMOGRAPHIC INFORMATION PRODUCED 6753 04:15:18,647 --> 04:15:26,388 A SLIGHT LEHIGHER ELY HIGHER ERF 6754 04:15:26,388 --> 04:15:27,355 9.4-MILLIMETER OF MERCURY. 6755 04:15:27,355 --> 04:15:30,859 TO THE RIGHT ARE A DEMOGRAPHIC 6756 04:15:30,859 --> 04:15:32,260 CALIBRATED TOE NO, MA'AM TREE 6757 04:15:32,260 --> 04:15:33,128 DEVICE AGAINST INVASIVE BLOOD 6758 04:15:33,128 --> 04:15:35,163 PRESSURE IN INFANTS. 6759 04:15:35,163 --> 04:15:36,598 ALTHOUGH RESULTS FROM BASELINE 6760 04:15:36,598 --> 04:15:39,834 MODELS WERE NOT PROVIDED, THE 6761 04:15:39,834 --> 04:15:41,036 CORRELATION PLOTS INDICATE THAT 6762 04:15:41,036 --> 04:15:44,172 BODY WEIGHT ALONE COULD HAVE 6763 04:15:44,172 --> 04:15:45,540 ESTIMATED THE BLOOD PRESSURE 6764 04:15:45,540 --> 04:15:51,179 FAIRLY WELL HERE. 6765 04:15:51,179 --> 04:15:52,914 BECAUSE OF THE LACK OF 6766 04:15:52,914 --> 04:15:54,683 CONVINCING VALIDATION DATA, THE 6767 04:15:54,683 --> 04:15:58,887 EUROPEAN SOCIETY OF HYPERTENSION 6768 04:15:58,887 --> 04:15:59,521 RECOMMENDS THAT CUFFLESS BLOOD 6769 04:15:59,521 --> 04:16:00,221 PRESSURE MEASUREMENT DEVICES 6770 04:16:00,221 --> 04:16:01,723 SHOULD NOT BE USED IN CLINICAL 6771 04:16:01,723 --> 04:16:06,995 PRACTICE. 6772 04:16:06,995 --> 04:16:09,564 SO I WOULD LIKE TO AT LEAST 6773 04:16:09,564 --> 04:16:12,534 MENTION THAT CONCEPTS FOR 6774 04:16:12,534 --> 04:16:13,468 CUFFLESS AND CALIBRATION-FREE, 6775 04:16:13,468 --> 04:16:14,903 THAT IS TRULY CUFFLESS BLOOD 6776 04:16:14,903 --> 04:16:18,707 PRESSURE MONITORING, HAVE BEEN 6777 04:16:18,707 --> 04:16:20,675 PROPOSED, AND NONE OF THESE FAR 6778 04:16:20,675 --> 04:16:23,211 LESS INVESTIGATED METHODS WOULD 6779 04:16:23,211 --> 04:16:25,547 BE AS CONVENIENT AS PULSE WAVE 6780 04:16:25,547 --> 04:16:28,917 ANALYSIS DEVICES AFTER CUFF 6781 04:16:28,917 --> 04:16:31,219 CALIBRATION, BUT THEY OR OTHER 6782 04:16:31,219 --> 04:16:32,654 FUTURE METHODS MIGHT EVENTUALLY 6783 04:16:32,654 --> 04:16:35,190 BE SHOWN TO YIELD SUFFICIENT 6784 04:16:35,190 --> 04:16:36,658 BLOOD PRESSURE ACCURACY WITHOUT 6785 04:16:36,658 --> 04:16:42,430 USING A CUFF. 6786 04:16:42,430 --> 04:16:46,701 SO IN SUMMARY, THE FIELD OF 6787 04:16:46,701 --> 04:16:47,836 CUFFLESS BLOOD PRESSURE CAN ONLY 6788 04:16:47,836 --> 04:16:50,639 BE UNDERSTOOD BY TAKING A DEEP 6789 04:16:50,639 --> 04:16:51,506 DIVE. 6790 04:16:51,506 --> 04:16:54,876 POPULAR CUFFLESS DEVICES HAVE 6791 04:16:54,876 --> 04:16:56,411 NOT BEEN PROVEN TO OFFER 6792 04:16:56,411 --> 04:16:57,712 SIGNIFICANT VALUE IN BLOOD 6793 04:16:57,712 --> 04:16:59,681 PRESSURE MEASUREMENT ACCURACY UP 6794 04:16:59,681 --> 04:17:01,650 TO NOW. 6795 04:17:01,650 --> 04:17:04,719 SO IF YOU HAVE ANY DOUBTS, 6796 04:17:04,719 --> 04:17:06,388 CONSIDER THIS: BLOOD PRESSURE 6797 04:17:06,388 --> 04:17:10,892 IS BY FAR THE MOST IMPORTANT 6798 04:17:10,892 --> 04:17:12,527 PHYSIOLOGICAL VARIABLE FOR A 6799 04:17:12,527 --> 04:17:14,229 CONSUMER DEVICE TO BE ABLE TO 6800 04:17:14,229 --> 04:17:14,462 MONITOR. 6801 04:17:14,462 --> 04:17:16,831 IF PULSE WAVE ANALYSIS METHODS 6802 04:17:16,831 --> 04:17:18,233 REALLY WORKED, THEN WHY DON'T 6803 04:17:18,233 --> 04:17:21,302 THE LEADING COMPANIES IN THE 6804 04:17:21,302 --> 04:17:22,504 WORLD WITH ELITE MACHINE 6805 04:17:22,504 --> 04:17:24,806 LEARNING TEAMS AND VAST 6806 04:17:24,806 --> 04:17:26,041 RESOURCES OFFER CUFFLESS BLOOD 6807 04:17:26,041 --> 04:17:29,611 PRESSURE MONITORING? 6808 04:17:29,611 --> 04:17:31,479 FUTURE TECHNOLOGY DEVELOPMENT 6809 04:17:31,479 --> 04:17:33,548 WORK IS WORTHWHILE AND NEEDED TO 6810 04:17:33,548 --> 04:17:35,016 REALIZE THE DREAM OF CUFFLESS 6811 04:17:35,016 --> 04:17:37,385 BLOOD PRESSURE MEASUREMENT. 6812 04:17:37,385 --> 04:17:47,562 THANK YOU. 6813 04:17:48,296 --> 04:17:50,031 >> 6814 04:17:50,031 --> 04:17:51,566 >> THANK YOU, DR. MUKKAMALA. 6815 04:17:51,566 --> 04:17:53,535 OUR NEXT PRESENTER IS DR. TAMMY 6816 04:17:53,535 --> 04:17:56,671 BRADY, WHO IS A PROFESSOR OF 6817 04:17:56,671 --> 04:17:58,907 PEDIATRICS AND EPIDEMIOLOGY AND 6818 04:17:58,907 --> 04:18:01,276 MEDICAL DIRECTOR OF PEDIATRIC 6819 04:18:01,276 --> 04:18:03,244 HYPERTENSION PROGRAM AT JOHNS 6820 04:18:03,244 --> 04:18:03,678 HOPKINS UNIVERSITY. 6821 04:18:03,678 --> 04:18:05,280 SHE WILL BE TALKING ABOUT THE 6822 04:18:05,280 --> 04:18:08,550 BEST PRACTICES FOR BLOOD 6823 04:18:08,550 --> 04:18:10,552 PRESSURE VOL DAITION. 6824 04:18:10,552 --> 04:18:10,852 VALIDATION. 6825 04:18:10,852 --> 04:18:12,787 >> THANK YOU VERY MUCH, 6826 04:18:12,787 --> 04:18:13,054 KIMBERLY. 6827 04:18:13,054 --> 04:18:14,255 IT'S MY PLEASURE TO BE HERE. 6828 04:18:14,255 --> 04:18:16,558 THANK YOU VERY MUCH TO THE 6829 04:18:16,558 --> 04:18:18,493 ORGANIZERS FOR INVITING ME. 6830 04:18:18,493 --> 04:18:19,260 AND TODAY I'M GOING TO BE 6831 04:18:19,260 --> 04:18:20,128 TALKING TO YOU ABOUT SOMETHING 6832 04:18:20,128 --> 04:18:22,063 THAT I'M VERY PASSIONATE ABOUT, 6833 04:18:22,063 --> 04:18:24,399 SO IN ADDITION TO BEING 6834 04:18:24,399 --> 04:18:25,500 PASSIONATE ABOUT BLOOD PRESSURE 6835 04:18:25,500 --> 04:18:28,236 MEASUREMENT, I'M PASSIONATE 6836 04:18:28,236 --> 04:18:31,272 ABOUT DEVICE VALIDATION. 6837 04:18:31,272 --> 04:18:35,176 I'M ABOUT TO FINISH OUT MY THIRD 6838 04:18:35,176 --> 04:18:36,177 TERM AS CO-CHAIR OF THE 6839 04:18:36,177 --> 04:18:37,245 ASSOCIATION FOR THE ADVANCEMENT 6840 04:18:37,245 --> 04:18:42,517 OF MEDICAL INSTRUMENTATION 6841 04:18:42,517 --> 04:18:44,219 COMMITTEE WHICH HELPED DEVELOP 6842 04:18:44,219 --> 04:18:44,919 VALIDATION PROTOCOLS. 6843 04:18:44,919 --> 04:18:50,959 I'M ALSO CO-CHAIR OF THE AMA -- 6844 04:18:50,959 --> 04:18:54,295 ALONG WITH DR. JORDY COHEN. 6845 04:18:54,295 --> 04:18:55,630 SO THERE ARE A NUMBER OF 6846 04:18:55,630 --> 04:18:56,831 VALIDATION PROTOCOLS THAT HAVE 6847 04:18:56,831 --> 04:18:58,366 BEEN AVAILABLE ACROSS THE LAST 6848 04:18:58,366 --> 04:18:59,467 SEVERAL DECADES. 6849 04:18:59,467 --> 04:19:01,169 YOU CAN SEE THAT THIS IS 6850 04:19:01,169 --> 04:19:02,270 AVAILABILITY OF VALIDATION 6851 04:19:02,270 --> 04:19:04,205 PROTOCOLS FOR DEVICE 6852 04:19:04,205 --> 04:19:05,807 MANUFACTURERS TO TEST IF THEIR 6853 04:19:05,807 --> 04:19:07,242 DEVICE IS CLINICALLY ACCURATE. 6854 04:19:07,242 --> 04:19:08,543 IT'S BEEN AVAILABLE SINCE THE 6855 04:19:08,543 --> 04:19:08,943 80s. 6856 04:19:08,943 --> 04:19:10,812 THERE HAVE BEEN A VARIETY OF 6857 04:19:10,812 --> 04:19:12,480 DIFFERENT ORGANIZATIONS, SOME 6858 04:19:12,480 --> 04:19:14,315 PROFESSIONAL ORGANIZATIONS, 6859 04:19:14,315 --> 04:19:15,183 PROFESSIONAL SOCIETIES THAT HAVE 6860 04:19:15,183 --> 04:19:19,254 COME UP WITH DIFFERENT PROTOCOLS 6861 04:19:19,254 --> 04:19:22,056 AND PARTICULARLY WITH -- THERE 6862 04:19:22,056 --> 04:19:23,358 HAS BEEN MULTIPLE ITERATIONS OF 6863 04:19:23,358 --> 04:19:25,560 PROTOCOLS TO IMPROVE ON THEM. 6864 04:19:25,560 --> 04:19:28,263 THE MOST RECENT ITERATION WAS 6865 04:19:28,263 --> 04:19:30,665 PUBLISHED IN 2018, AND THIS HAS 6866 04:19:30,665 --> 04:19:32,767 BEEN LARGELY THOUGHT OF AS THE 6867 04:19:32,767 --> 04:19:33,201 UNIVERSAL STANDARD. 6868 04:19:33,201 --> 04:19:34,769 THIS IS CURRENTLY BEING UPDATED 6869 04:19:34,769 --> 04:19:36,971 AS WE SPEAK AND A NEWER VERSION 6870 04:19:36,971 --> 04:19:38,740 WILL LIKELY BE OUT IN THE NEXT 6871 04:19:38,740 --> 04:19:42,911 YEAR OR SO. 6872 04:19:42,911 --> 04:19:47,749 SO I'M GOING TO BEGIN THE 6873 04:19:47,749 --> 04:19:48,817 TASK -- THESE DOCUMENTS ARE 6874 04:19:48,817 --> 04:19:50,685 QUITE DENSE BUT I'M GOING TO DO 6875 04:19:50,685 --> 04:19:51,953 MY BEST TO GO THROUGH WHAT SOME 6876 04:19:51,953 --> 04:19:54,355 OF THE KEY CONCEPTS ARE. 6877 04:19:54,355 --> 04:19:56,558 SO MOST OF US THINK ABOUT 6878 04:19:56,558 --> 04:19:57,926 VALIDATION STANDARDS ARE 6879 04:19:57,926 --> 04:19:59,894 THINKING ABOUT CUFF DEVICES THAT 6880 04:19:59,894 --> 04:20:02,964 PROVIDE BLOOD PRESSURE 6881 04:20:02,964 --> 04:20:03,398 MEASUREMENTS. 6882 04:20:03,398 --> 04:20:10,839 THE DASH 2 STANDARD. 6883 04:20:10,839 --> 04:20:12,307 SO THERE ARE SEVERAL OTHER 6884 04:20:12,307 --> 04:20:15,176 STANDARDS THAT WE WORK ON. 6885 04:20:15,176 --> 04:20:17,779 THERE IS THE DASH 3 STANDARD 6886 04:20:17,779 --> 04:20:20,582 WHICH ADDRESSES BLOOD PRESSURE 6887 04:20:20,582 --> 04:20:22,350 DEVICES THAT PROVIDE CONTINUOUS 6888 04:20:22,350 --> 04:20:23,117 CUFFLESS MEASUREMENT. 6889 04:20:23,117 --> 04:20:24,419 I WILL GO TO THAT IN A LITTLE 6890 04:20:24,419 --> 04:20:25,520 BIT LATER ON. 6891 04:20:25,520 --> 04:20:26,588 THERE IS THE DASH 4 STANDARD 6892 04:20:26,588 --> 04:20:27,889 WHICH IS IN PROGRESS. 6893 04:20:27,889 --> 04:20:30,191 WHICH IS INTENDED FOR USE FOR 6894 04:20:30,191 --> 04:20:36,297 DEVICES IN PATIENT TRANSPORT. 6895 04:20:36,297 --> 04:20:38,166 THERE IS THE DASH 5 STANDARD, 6896 04:20:38,166 --> 04:20:41,102 WHICH ALLOWS US TO TEST 6897 04:20:41,102 --> 04:20:42,437 REPEATABILITY AND 6898 04:20:42,437 --> 04:20:43,805 REPRODUCIBILITY OF SIMULATORS 6899 04:20:43,805 --> 04:20:48,076 USED FOR TESTING OF AUTOMATED 6900 04:20:48,076 --> 04:20:50,311 NONINVASIVE SPHIG KNOW MAN 6901 04:20:50,311 --> 04:20:52,180 METERS, THEN THERE'S THE DASH 6902 04:20:52,180 --> 04:20:53,147 7 STANDARD WHICH IS IN 6903 04:20:53,147 --> 04:20:54,048 PRODUCTION OR IN PROGRESS WHICH 6904 04:20:54,048 --> 04:20:56,951 WILL HELP US TEST THE 6905 04:20:56,951 --> 04:20:57,418 INTERMITTENT CUFFLESS 6906 04:20:57,418 --> 04:20:58,486 MEASUREMENT DESPISES. 6907 04:20:58,486 --> 04:21:02,924 THIS HAS BEEN GOING ON FOR OVER 6908 04:21:02,924 --> 04:21:03,591 A YEAR, IT'S BEEN A VERY ACTIVE 6909 04:21:03,591 --> 04:21:04,893 GROUP AND IT IS HOPEFUL THAT WE 6910 04:21:04,893 --> 04:21:06,194 WILL HAVE AT LEAST A DRAFT 6911 04:21:06,194 --> 04:21:07,695 STANDARD OF THIS BY THE END OF 6912 04:21:07,695 --> 04:21:17,939 FEBRUARY 2025. 6913 04:21:19,474 --> 04:21:21,142 SO WE'RE GOING TO TALK FIRST 6914 04:21:21,142 --> 04:21:30,852 ABOUT THE DASH 2 STANDARD. 6915 04:21:30,852 --> 04:21:32,353 I JUST WANTED TO GIVE SOME 6916 04:21:32,353 --> 04:21:33,154 DEFINITIONS TO SET THE STAGE. 6917 04:21:33,154 --> 04:21:41,562 SO IN DOING VALIDATION TESTING, 6918 04:21:41,562 --> 04:21:42,864 THAT NEEDS TO BE TESTED AGAINST 6919 04:21:42,864 --> 04:21:43,831 A REFERENCE STANDARD. 6920 04:21:43,831 --> 04:21:45,133 IN THE VALIDATION PROTOCOLS 6921 04:21:45,133 --> 04:21:46,901 THERE ARE TWO POTENTIAL 6922 04:21:46,901 --> 04:21:48,069 REFERENCE STANDARDS FOR USE. 6923 04:21:48,069 --> 04:21:50,772 AN INVASIVE ONE USING ARTERIAL 6924 04:21:50,772 --> 04:21:52,006 LINE BLOOD PRESSURES OR 6925 04:21:52,006 --> 04:21:54,375 NONINVASIVE ONE WHICH IS AN US A 6926 04:21:54,375 --> 04:21:55,877 CULL TRI MEASUREMENT THAT IS 6927 04:21:55,877 --> 04:21:58,713 EITHER OBTAINED FROM THE MERCURY 6928 04:21:58,713 --> 04:22:03,484 DEVICE OR ANEROID DEVICE WITH A 6929 04:22:03,484 --> 04:22:04,686 SPECIFIC AMOUNT OF ACCURACY. 6930 04:22:04,686 --> 04:22:06,421 THESE ARE USING A TWO-PIECE 6931 04:22:06,421 --> 04:22:07,956 CUFF, IT HAS A BLADDER THAT 6932 04:22:07,956 --> 04:22:09,290 MEETS VERY SPECIFIC DIMENSIONS 6933 04:22:09,290 --> 04:22:12,560 WHICH YOU CAN SEE ON THE SLIDE. 6934 04:22:12,560 --> 04:22:14,796 THIS TESTING IS TYPICALLY DONE 6935 04:22:14,796 --> 04:22:16,464 IN EITHER A GENERAL POPULATION 6936 04:22:16,464 --> 04:22:18,533 OR IT WILL ALSO BE DONE IN A 6937 04:22:18,533 --> 04:22:19,734 SPECIAL POPULATION. 6938 04:22:19,734 --> 04:22:22,403 SO A SPECIAL POPULATION IS ONE 6939 04:22:22,403 --> 04:22:26,641 WHO THERE IS EITHER A -- OR 6940 04:22:26,641 --> 04:22:27,542 CLINICAL EVIDENCE THAT THE 6941 04:22:27,542 --> 04:22:28,543 DEVICE WILL ACT DIFFERENTLY IN 6942 04:22:28,543 --> 04:22:30,678 THAT POPULATION. 6943 04:22:30,678 --> 04:22:36,784 AND ADULT POPULATION IS 6944 04:22:36,784 --> 04:22:38,319 ALL-COMERS OVER -- OF AGE WHO 6945 04:22:38,319 --> 04:22:40,388 ARE EITHER UNTREATED OR TREATED 6946 04:22:40,388 --> 04:22:45,093 AS HYPERTENSIVE, SO FOR A 6947 04:22:45,093 --> 04:22:47,395 GENERAL POPULATION STUDY, LIKE I 6948 04:22:47,395 --> 04:22:50,331 SAID YOU CAN EITHER HAVE AN US A 6949 04:22:50,331 --> 04:22:53,701 CULL TA TRI REFERENCE OR HAVE 8N 6950 04:22:53,701 --> 04:22:54,769 HAVE INVASIVE REFERENCE IN WHICH 6951 04:22:54,769 --> 04:22:56,204 WOULD YOU HAVE AT LEAST 15 6952 04:22:56,204 --> 04:22:56,971 SUBJECTS ENROLLED. 6953 04:22:56,971 --> 04:23:00,041 THE POPULATION THAT YOU'RE 6954 04:23:00,041 --> 04:23:03,811 STUDYING NEEDS TO BE AT LEAST 12 6955 04:23:03,811 --> 04:23:07,882 YEARS OF AGE, AT LEAST 30% MALE 6956 04:23:07,882 --> 04:23:10,818 SEX AND 30% FEMALE SEX, AND MEET 6957 04:23:10,818 --> 04:23:11,419 SPECIFIC BROMOPROPANE 6958 04:23:11,419 --> 04:23:12,854 DISTRIBUTION WHICH YOU CAN SEE 6959 04:23:12,854 --> 04:23:13,454 DELINEATED IN THE TABLE TO THE 6960 04:23:13,454 --> 04:23:13,654 RIGHT. 6961 04:23:13,654 --> 04:23:14,956 THIS IS SO THAT WE CAN DETERMINE 6962 04:23:14,956 --> 04:23:17,125 WHETHER OR NOT THE DEVICE 6963 04:23:17,125 --> 04:23:18,693 PERFORMS SUFFICIENTLY WELL 6964 04:23:18,693 --> 04:23:19,994 ACROSS A WIDE RANGE OF BLOOD 6965 04:23:19,994 --> 04:23:21,796 PRESSURE VALUES. 6966 04:23:21,796 --> 04:23:24,966 IN ADDITION TO FULFILLING THESE 6967 04:23:24,966 --> 04:23:27,168 REQUIREMENTS, EACH OF THE CUFFS 6968 04:23:27,168 --> 04:23:28,403 THAT COME WITH THE DEVICE NEED 6969 04:23:28,403 --> 04:23:30,938 TO BE TESTED, AND NEED TO HAVE 6970 04:23:30,938 --> 04:23:32,907 SPECIFIC NUMBER OF INDIVIDUALS 6971 04:23:32,907 --> 04:23:34,709 TESTED USING THOSE CUFFS, AND 6972 04:23:34,709 --> 04:23:36,144 THEN THE ENTIRE CUFF RANGE, YOU 6973 04:23:36,144 --> 04:23:38,012 NEED TO MAKE SURE THE CUFF RANGE 6974 04:23:38,012 --> 04:23:40,381 IS TESTING, AND I'LL SHOW YOU 6975 04:23:40,381 --> 04:23:45,753 WHAT I MEAN IN THE NEXT SLIDES. 6976 04:23:45,753 --> 04:23:48,256 SO WHEN WE THINK ABOUT A DEVICE, 6977 04:23:48,256 --> 04:23:49,924 THE CUFF IS INTEGRAL TO THE 6978 04:23:49,924 --> 04:23:51,559 DEVICE, AND MANY DEVICES COME -- 6979 04:23:51,559 --> 04:23:53,194 WILL COME WITH SEVERAL DIFFERENT 6980 04:23:53,194 --> 04:23:56,597 COSTS. 6981 04:23:56,597 --> 04:23:58,433 SO THIS FIGURE IS SOMETHING THAT 6982 04:23:58,433 --> 04:23:59,500 WAS SHOWN EARLIER TODAY, AND 6983 04:23:59,500 --> 04:24:01,569 THIS IS LOOKING AT ALL OF THE 6984 04:24:01,569 --> 04:24:04,105 DEVICES THAT WERE AVAILABLE ON 6985 04:24:04,105 --> 04:24:07,442 THE AMA -- WEBSITE SO YOU CAN 6986 04:24:07,442 --> 04:24:09,310 SEE ON THE LEFT THE VARIOUS 6987 04:24:09,310 --> 04:24:11,179 DEVICES, TO THE RIGHT WHAT 6988 04:24:11,179 --> 04:24:12,513 YOU'LL SEE WHAT CUFFS ARE 6989 04:24:12,513 --> 04:24:13,214 AVAILABLE WITH EACH DEVICE AND 6990 04:24:13,214 --> 04:24:14,849 THEN YOU CAN SEE USING THE 6991 04:24:14,849 --> 04:24:19,720 REFERENCE ALONG THE TOP WHAT 6992 04:24:19,720 --> 04:24:20,354 THE -- RANGE IS APPROPRIATE FOR 6993 04:24:20,354 --> 04:24:21,589 EACH ONE OF THOSE CUFFS. 6994 04:24:21,589 --> 04:24:24,725 SO TO GO THROUGH WHAT I WAS 6995 04:24:24,725 --> 04:24:28,062 DESCRIBING EARLIER, IN TERMS OF 6996 04:24:28,062 --> 04:24:32,600 THE NUMBER OF TESTS -- 6997 04:24:32,600 --> 04:24:33,367 [INAUDIBLE]. 6998 04:24:33,367 --> 04:24:34,802 SO I'M GOING TO USE THIS EXAMPLE 6999 04:24:34,802 --> 04:24:35,770 HERE. 7000 04:24:35,770 --> 04:24:38,239 AND YOU CAN SEE THAT THIS DEVICE 7001 04:24:38,239 --> 04:24:39,607 COMES WITH THREE DIFFERENT 7002 04:24:39,607 --> 04:24:40,108 CUFFS. 7003 04:24:40,108 --> 04:24:47,215 AND THAT THE CUFFS HAVE A NICE 7004 04:24:47,215 --> 04:24:49,617 DISTRIBUTION OF 14 TO 7005 04:24:49,617 --> 04:24:50,284 40 CENTIMETERS AND THEY ACHIEVED 7006 04:24:50,284 --> 04:24:51,152 THAT DISTRIBUTION USING THREE 7007 04:24:51,152 --> 04:24:58,626 DIFFERENT CUFFS. 7008 04:24:58,626 --> 04:25:00,895 NOW THIS DEVICE COMES WITH FOUR 7009 04:25:00,895 --> 04:25:03,731 DIFFERENT CUFFS AND THESE FOUR 7010 04:25:03,731 --> 04:25:04,932 DIFFERENT CUFFS ACCOMMODATE A 7011 04:25:04,932 --> 04:25:09,470 DIFFERENT GROUP OR DIFFERENT -- 7012 04:25:09,470 --> 04:25:12,907 SIZE DISTRIBUTION, ANYWHERE 7013 04:25:12,907 --> 04:25:15,977 BETWEEN 20 AND 55 CENTIMETERS. 7014 04:25:15,977 --> 04:25:18,479 SO WHEN MANUFACTURERS ARE 7015 04:25:18,479 --> 04:25:19,347 TESTING EITHER ONE OF THOSE 7016 04:25:19,347 --> 04:25:20,615 CUFFS, THEY HAVE TO FIGURE OUT 7017 04:25:20,615 --> 04:25:21,949 HOW MANY INDIVIDUALS NEED TO BE 7018 04:25:21,949 --> 04:25:22,483 TESTED PER CUFF. 7019 04:25:22,483 --> 04:25:23,584 SO ON THIS SLIDE YOU'LL SEE ON 7020 04:25:23,584 --> 04:25:26,387 THE TOP THERE ARE THREE GREENISH 7021 04:25:26,387 --> 04:25:27,021 RECTANGLES AND THAT'S SUPPOSED 7022 04:25:27,021 --> 04:25:29,557 TO REFER TO THE DEVICE THAT'S 7023 04:25:29,557 --> 04:25:31,592 DELINEATED IN RED, AND THEN THE 7024 04:25:31,592 --> 04:25:34,228 FOUR BLUISH RECTANGLES ARE THE 7025 04:25:34,228 --> 04:25:34,762 DEVICE [INAUDIBLE]. 7026 04:25:34,762 --> 04:25:40,334 SO WHEN YOU HAVE A CUFF THAT IS 7027 04:25:40,334 --> 04:25:41,536 12 CENTIMETERS OR LESS, THERE'S 7028 04:25:41,536 --> 04:25:42,603 A VERY SPECIFIC FORMULA THAT YOU 7029 04:25:42,603 --> 04:25:43,938 USE TO DETERMINE HOW MANY PEOPLE 7030 04:25:43,938 --> 04:25:46,340 NEED TO BE TESTED IN THE CUFF 7031 04:25:46,340 --> 04:25:47,608 AND WHEN YOU HAVE LARGER CUFFS 7032 04:25:47,608 --> 04:25:49,143 LIKE YOU SEE WITH THE YELLOW 7033 04:25:49,143 --> 04:25:50,444 STAR, YOU WILL HAVE A DIFFERENT 7034 04:25:50,444 --> 04:25:51,679 FORMULA TO DETERMINE HOW MANY 7035 04:25:51,679 --> 04:25:53,614 INDIVIDUALS NEED TO BE TESTED. 7036 04:25:53,614 --> 04:25:56,484 SO THIS WILL TELL YOU HOW MANY 7037 04:25:56,484 --> 04:25:58,319 PER CUFF, BUT YOU NEED TO ALSO 7038 04:25:58,319 --> 04:26:00,688 LIKE I SAID EARLIER MAKE SURE 7039 04:26:00,688 --> 04:26:02,290 THAT THERE ARE -- THAT EACH ONE 7040 04:26:02,290 --> 04:26:08,262 OF THE CUFFS IS TESTED ACROSS 7041 04:26:08,262 --> 04:26:10,565 THAT --. 7042 04:26:10,565 --> 04:26:12,099 SO USING THOSE FORMULAS, YOU 7043 04:26:12,099 --> 04:26:14,335 WILL SEE THAT THE FIRST CUFF 7044 04:26:14,335 --> 04:26:16,671 FAMILY, THERE ARE 12 AND 15 7045 04:26:16,671 --> 04:26:17,538 INDIVIDUALS THAT NEED TO BE 7046 04:26:17,538 --> 04:26:19,006 TESTED IN EACH OF THE CUFFS, AND 7047 04:26:19,006 --> 04:26:20,274 THEN YOU CAN SEE IN THE CUFF 7048 04:26:20,274 --> 04:26:23,110 FAMILY WHERE THERE ARE -- FOR 7049 04:26:23,110 --> 04:26:25,313 THE LARGER CUFF, THERE'S A MUCH 7050 04:26:25,313 --> 04:26:25,880 LARGER NUMBER OF INDIVIDUALS 7051 04:26:25,880 --> 04:26:33,588 THAT NEED TO BE TESTED. 7052 04:26:33,588 --> 04:26:37,658 SO IN ADDITION, EACH -- FOR THE 7053 04:26:37,658 --> 04:26:39,260 CUFFS THAT ARE THE SMALLER SIZE, 7054 04:26:39,260 --> 04:26:40,795 12 CENTIMETERS OR LESS, IT'S NOT 7055 04:26:40,795 --> 04:26:42,496 JUST ENOUGH TO HAVE 12 PEOPLE, 7056 04:26:42,496 --> 04:26:44,332 PER SE, IN THAT FIRST CUFF THAT 7057 04:26:44,332 --> 04:26:46,534 YOU SEE ON THE UPPER LEFT, BUT 7058 04:26:46,534 --> 04:26:48,069 HALF OF THE -- 40% OF THE 7059 04:26:48,069 --> 04:26:49,704 SUBJECTS NEED TO BE TESTED 7060 04:26:49,704 --> 04:26:51,672 WITHIN THE UPPER HALF OF THE 7061 04:26:51,672 --> 04:26:53,407 SPECIFIED RANGE AND HALF OF 7062 04:26:53,407 --> 04:26:54,709 THEM -- 40% OF THEM NEED TO BE 7063 04:26:54,709 --> 04:26:57,111 TESTED IN THE OTHER HALF. 7064 04:26:57,111 --> 04:26:58,579 AND SO AS AN EXAMPLE, YOU CAN 7065 04:26:58,579 --> 04:27:02,583 SEE THE FIRST CUFF, FIVE OF THEM 7066 04:27:02,583 --> 04:27:04,785 HAVE TO BE TESTED -- AND FIVE OF 7067 04:27:04,785 --> 04:27:06,187 THEM TESTED IN THE UPPER HALF. 7068 04:27:06,187 --> 04:27:08,155 THE LARGE E. CUFFS, THE ONES 7069 04:27:08,155 --> 04:27:09,290 16 CENTIMETERS OR GREATER, 7070 04:27:09,290 --> 04:27:10,424 THERE'S EVEN GREATER 7071 04:27:10,424 --> 04:27:12,326 REQUIREMENTS. 7072 04:27:12,326 --> 04:27:14,695 AT LEAST 20% OF THE SUBJECTS 7073 04:27:14,695 --> 04:27:15,896 WERE ALLOCATED TO THE CUFF TO BE 7074 04:27:15,896 --> 04:27:17,865 TESTED SO 30 IN THIS EXAMPLE 7075 04:27:17,865 --> 04:27:20,167 NEED TO BE IN EACH ONE OF THE 7076 04:27:20,167 --> 04:27:21,235 QUARTILES OF THE ARM 7077 04:27:21,235 --> 04:27:22,236 CIRCUMFERENCE THAT IS 7078 04:27:22,236 --> 04:27:23,671 ACCOMMODATED BY THAT CUFF. 7079 04:27:23,671 --> 04:27:25,206 AND THEN AT LEAST 10% OF THE 7080 04:27:25,206 --> 04:27:27,808 SUBJECTS NEED TO BE IN THE 7081 04:27:27,808 --> 04:27:31,512 UPPER -- AND THE LOWER QUARTILE 7082 04:27:31,512 --> 04:27:36,684 RANGE. 7083 04:27:36,684 --> 04:27:37,985 SO ONCE YOU'VE GOTTEN YOUR 7084 04:27:37,985 --> 04:27:39,754 PATIENT POPULATION, YOUR STUDY 7085 04:27:39,754 --> 04:27:41,956 POPULATION, THEN YOU'RE MOVING 7086 04:27:41,956 --> 04:27:43,557 ON TO THE ACTUAL TESTING. 7087 04:27:43,557 --> 04:27:47,161 SO THE TESTING THAT OCCURS IS 7088 04:27:47,161 --> 04:27:47,928 EXACTLY THE PATIENT PREPARATION 7089 04:27:47,928 --> 04:27:49,864 AND THE ACTUAL MEASUREMENT 7090 04:27:49,864 --> 04:27:50,564 PROCEDURE IS THE SAME AS OUR 7091 04:27:50,564 --> 04:27:53,000 USUAL CLINICAL PRACTICE 7092 04:27:53,000 --> 04:27:53,434 GUIDELINES. 7093 04:27:53,434 --> 04:27:55,836 IN OUR CURRENT AAMI PROTOCOL, WE 7094 04:27:55,836 --> 04:27:58,039 USE WHAT'S CALLED THE SAME ARM 7095 04:27:58,039 --> 04:27:58,572 SEQUENTIAL METHOD. 7096 04:27:58,572 --> 04:28:00,207 WHAT THAT MEANS IS THE CUFF 7097 04:28:00,207 --> 04:28:02,376 IS -- THE REFERENCE CUFF IS PUT 7098 04:28:02,376 --> 04:28:04,712 ON ONE OF THE ARMS, WE HAVE TWO 7099 04:28:04,712 --> 04:28:05,846 INDEPENDENT OBSERVERS, THEY USE 7100 04:28:05,846 --> 04:28:08,349 A DOUBLE-HEADED STETHOSCOPE, 7101 04:28:08,349 --> 04:28:10,751 THEY SIMULTANEOUSLY WILL 7102 04:28:10,751 --> 04:28:16,691 DETERMINE WHAT THE K1 AND THE KH 7103 04:28:16,691 --> 04:28:18,259 THE SYSTOLIC AND DIASTOLIC 7104 04:28:18,259 --> 04:28:18,592 PRESSURE. 7105 04:28:18,592 --> 04:28:19,927 THEN ONCE THEY GET THEIR 7106 04:28:19,927 --> 04:28:21,128 REFERENCE MEASUREMENTS, THE CUFF 7107 04:28:21,128 --> 04:28:23,264 IS REMOVED, THE DEVICE ALONG 7108 04:28:23,264 --> 04:28:27,034 WITH THE DEVICE CUFF IS PUT ON 7109 04:28:27,034 --> 04:28:31,172 THE DEVICE IN THE TEST. 7110 04:28:31,172 --> 04:28:33,541 -- THAT DIFFER IN MORE THAN 7111 04:28:33,541 --> 04:28:34,108 4 MILLIMETERS OF MERCURY IS 7112 04:28:34,108 --> 04:28:35,409 EXCLUDED AND YOU NEED ULTIMATELY 7113 04:28:35,409 --> 04:28:38,579 AT THE END OF THE DAY AT 7114 04:28:38,579 --> 04:28:44,685 LEAST -- AND YOUR ANALYSIS. 7115 04:28:44,685 --> 04:28:47,321 SO THIS IS JUST TABLES NOTATING 7116 04:28:47,321 --> 04:28:48,489 THE ALTERNATING OF THE REFERENCE 7117 04:28:48,489 --> 04:28:50,224 AND THE TEST DEVICE AND SO 7118 04:28:50,224 --> 04:28:56,364 FORTH. 7119 04:28:56,364 --> 04:28:58,232 SO AGAIN, AT THE END, YOU WILL 7120 04:28:58,232 --> 04:29:03,037 HAVE AT LEAST 255 PAIRED 7121 04:29:03,037 --> 04:29:04,638 MEASUREMENTS. 7122 04:29:04,638 --> 04:29:05,206 TO DETERMINE WHETHER OR NOT 7123 04:29:05,206 --> 04:29:06,073 THOSE MEASUREMENTS INDICATE A 7124 04:29:06,073 --> 04:29:07,708 DEVICE THAT IS ACCURATE PER THE 7125 04:29:07,708 --> 04:29:10,010 VALIDATION PROTOCOL, THERE ARE 7126 04:29:10,010 --> 04:29:12,146 TWO CR CRITERION, THE FIRST DEAS 7127 04:29:12,146 --> 04:29:13,647 WITH INDIVIDUAL READINGS AND THE 7128 04:29:13,647 --> 04:29:16,984 SECOND CRITERION DEALS WITH 7129 04:29:16,984 --> 04:29:21,322 INDIVIDUAL SUBJECTS. 7130 04:29:21,322 --> 04:29:25,059 YOU LOOK AT THE MEAN BLOOD 7131 04:29:25,059 --> 04:29:27,561 PRESSURE DIFFERENCE AND OVERALL 7132 04:29:27,561 --> 04:29:28,662 THAT NEEDS TO HAVE A DIFFERENCE 7133 04:29:28,662 --> 04:29:31,198 OF LESS THAN OR EQUAL TO 7134 04:29:31,198 --> 04:29:32,500 5 MILLIMETERS OF MERCURY WITH NO 7135 04:29:32,500 --> 04:29:34,101 MORE THAN 8 MILLIMETERS OF 7136 04:29:34,101 --> 04:29:36,370 MERCURY AS A STANDARD DEVIATION. 7137 04:29:36,370 --> 04:29:40,408 THEN FOR CRITERIA 2, YOU TAKE 8E 7138 04:29:40,408 --> 04:29:41,609 DIFFERENCES AND THEN YOU 7139 04:29:41,609 --> 04:29:42,610 DETERMINE WHAT THAT AVERAGE 7140 04:29:42,610 --> 04:29:44,078 DIFFERENCE IS, AND THEN ON THE 7141 04:29:44,078 --> 04:29:45,413 TABLE I'LL SHOW YOU ON THE NEXT 7142 04:29:45,413 --> 04:29:47,181 SLIDE EU ABLE TO DETERMINE WHAT 7143 04:29:47,181 --> 04:29:48,816 THE ALLOWABLE STANDARD DEVIATION 7144 04:29:48,816 --> 04:29:55,122 IS AND THAT WILL ALLOW TO YOU 7145 04:29:55,122 --> 04:29:56,190 KNOW WHETHER OR NOT THE DEVICE 7146 04:29:56,190 --> 04:29:56,857 CAN PASS. 7147 04:29:56,857 --> 04:29:58,058 IN THIS EXAMPLE WHEN THEY'RE 7148 04:29:58,058 --> 04:30:00,795 DOING THAT CRITERIA TWO, THEY 7149 04:30:00,795 --> 04:30:02,963 CAME UP WITH A BLOOD PRESSURE 7150 04:30:02,963 --> 04:30:04,498 DIFFERENCE OF 2 MILLIMETERS OF 7151 04:30:04,498 --> 04:30:06,767 MERCURY, WHICH ALLOWED THEM TO 7152 04:30:06,767 --> 04:30:09,303 HAVE NO MORE THAN 5.49 STANDARD 7153 04:30:09,303 --> 04:30:10,838 DEVIATION SO THAT WOULD BE USED 7154 04:30:10,838 --> 04:30:11,839 TO INTERPRET WHAT THE RESULTS 7155 04:30:11,839 --> 04:30:20,114 WERE. 7156 04:30:20,114 --> 04:30:24,718 SO THAT'S OVERALL HOW YOU CAN 7157 04:30:24,718 --> 04:30:26,353 CONDUCT VALIDATION TESTING FOR A 7158 04:30:26,353 --> 04:30:33,027 DEVICE USING THIS REFERENCE -- 7159 04:30:33,027 --> 04:30:35,996 SUCH AS EXERCISE -- OR ABPM 7160 04:30:35,996 --> 04:30:36,864 THERE ARE SEPARATE REQUIREMENTS 7161 04:30:36,864 --> 04:30:38,799 AND CERTAINLY I DID NOT REVIEW 7162 04:30:38,799 --> 04:30:41,535 WHAT NEEDS TO HAPPEN FOR 7163 04:30:41,535 --> 04:30:46,707 INVASIVE REFERENCE STUDY. 7164 04:30:46,707 --> 04:30:48,542 SO ONE OF THE THINGS I'M VERY 7165 04:30:48,542 --> 04:30:50,277 INTERESTED IN AS A PEDIATRIC 7166 04:30:50,277 --> 04:30:51,145 PATHOLOGIST IS SOME OF THESE 7167 04:30:51,145 --> 04:30:53,013 SPECIAL POPULATIONS. 7168 04:30:53,013 --> 04:30:56,016 THEY INCLUDE -- DEVICES ARE 7169 04:30:56,016 --> 04:30:56,684 LIKELY TO PERFORM DIFFERENTLY, 7170 04:30:56,684 --> 04:30:59,386 SO THEY HAVE BEEN DESIGNATED AS 7171 04:30:59,386 --> 04:31:01,155 A SPECIAL POPULATION, MEANING 7172 04:31:01,155 --> 04:31:02,223 THERE'S ADDITIONAL TESTING THAT 7173 04:31:02,223 --> 04:31:03,524 FLEEDZ TO BE DONE IN THESE 7174 04:31:03,524 --> 04:31:04,525 POPULATIONS TO MAKE SURE THAT 7175 04:31:04,525 --> 04:31:08,762 THEY'RE ACCURATE. 7176 04:31:08,762 --> 04:31:09,530 SO WHAT THIS MEANS IS THAT IF 7177 04:31:09,530 --> 04:31:12,266 YOU WANT TO HAVE A DEVICE THAT 7178 04:31:12,266 --> 04:31:21,742 IS TESTED OR DESIGNATED FOR 7179 04:31:21,742 --> 04:31:23,611 INFANTS, THEN YOU CAN SEE THAT 7180 04:31:23,611 --> 04:31:24,945 THESE ARE THE DIFFERENCES IN 7181 04:31:24,945 --> 04:31:26,480 TERMS OF TESTING REQUIREMENTS 7182 04:31:26,480 --> 04:31:28,949 FOR EACH OF THESE SPECIAL 7183 04:31:28,949 --> 04:31:29,250 POPULATIONS. 7184 04:31:29,250 --> 04:31:30,918 FOR INFANTS WHO ARE ANYWHERE 7185 04:31:30,918 --> 04:31:38,125 FROM BIRTH UP TO 3 YEARS OF AGE, 7186 04:31:38,125 --> 04:31:41,762 [INAUDIBLE] NEED 18 SUNTS. 7187 04:31:41,762 --> 04:31:42,129 18 SUBJECTS. 7188 04:31:42,129 --> 04:31:43,831 YOU CAN SEE THERE ARE VERY 7189 04:31:43,831 --> 04:31:44,999 SPECIFIC REQUIREMENTS REGARDING 7190 04:31:44,999 --> 04:31:47,101 EIGHT AND WAGE. 7191 04:31:47,101 --> 04:31:48,903 THERE'S NO -- DISTRIBUTION 7192 04:31:48,903 --> 04:31:51,472 REQUIREMENTS AND THERE IS SOME 7193 04:31:51,472 --> 04:31:53,007 SIMPLY TIS ANALYSIS THAT IS DONE 7194 04:31:53,007 --> 04:31:55,109 AND THERE IS -- CRITERIA. 7195 04:31:55,109 --> 04:31:57,077 FOR CHILDREN WHO ARE 3 TO 12 7196 04:31:57,077 --> 04:31:59,780 YEARS OF AGE YOU CAN USE 7197 04:31:59,780 --> 04:32:00,781 INVASIVE OR US A CULL TA TRI 7198 04:32:00,781 --> 04:32:01,515 METHODS. 7199 04:32:01,515 --> 04:32:03,050 YOU CAN DO TESTING IN 85 KIDS OR 7200 04:32:03,050 --> 04:32:04,785 YOU CAN DO A GENERAL POPULATION 7201 04:32:04,785 --> 04:32:08,722 STUDY IN WHICH THE -- GENERAL 7202 04:32:08,722 --> 04:32:09,790 POPULATION PARTICIPANTS ABOVE 12 7203 04:32:09,790 --> 04:32:11,358 YEARS OF AGE AND 35 CHILDREN FOR 7204 04:32:11,358 --> 04:32:15,062 A TOTAL OF 85 POPULATION, OR YOU 7205 04:32:15,062 --> 04:32:19,199 CAN DO 35 -- A STUDY IN 35 7206 04:32:19,199 --> 04:32:22,269 CHILDREN AS A SPECIAL POPULATION 7207 04:32:22,269 --> 04:32:23,571 AFTER 85 PARTICIPANTS HAVE 7208 04:32:23,571 --> 04:32:25,306 COMPLETED AND PASSED A GENERAL 7209 04:32:25,306 --> 04:32:26,740 POPULATION STUDY. 7210 04:32:26,740 --> 04:32:30,778 AND THEN FOR PREGNANT WOMEN, THE 7211 04:32:30,778 --> 04:32:32,313 REQUIREMENTS IN THE -- STANDARD 7212 04:32:32,313 --> 04:32:35,783 ARE THAT YOU CAN DO TESTING, 7213 04:32:35,783 --> 04:32:37,985 INVASIVE OR -- IN PREGNANT WOMEN 7214 04:32:37,985 --> 04:32:40,921 OR IN -- AS A SPECIAL POPULATION 7215 04:32:40,921 --> 04:32:41,789 AFTER 85% GENERAL POPULATION 7216 04:32:41,789 --> 04:32:43,757 STUDY HAS BEEN COMPLETED. 7217 04:32:43,757 --> 04:32:45,092 NOTABLY PREGNANT WOMEN IN THE 7218 04:32:45,092 --> 04:32:47,061 SECOND OR THIRD TRIMESTER, A 7219 04:32:47,061 --> 04:32:49,330 THIRD OF EACH OF THE WOMEN WHO 7220 04:32:49,330 --> 04:32:50,731 ARE INCLUDED IN WHICHEVER STUDY 7221 04:32:50,731 --> 04:32:52,733 YOU DO NEED TO HAVE VARIOUS 7222 04:32:52,733 --> 04:32:54,635 BLOOD PRESSURE REQUIREMENTS, 7223 04:32:54,635 --> 04:32:58,606 REQUIREMENTS OF HAVING EITHER 7224 04:32:58,606 --> 04:33:02,776 PROTEINURIA -- SO THAT WAS THE 7225 04:33:02,776 --> 04:33:03,410 DASH 2 STANDARD. 7226 04:33:03,410 --> 04:33:06,447 I'M GOING TO GO BRIEFLY OVER THE 7227 04:33:06,447 --> 04:33:08,849 OTHER STANDARDS. 7228 04:33:08,849 --> 04:33:12,786 SO UNTIL 2022, THERE HAVE BEEN 7229 04:33:12,786 --> 04:33:15,122 NO STANDARDS FOR AAMI STANDARDS 7230 04:33:15,122 --> 04:33:16,724 FOR CUFFLESS DEVICES SO MANY 7231 04:33:16,724 --> 04:33:18,225 MANUFACTURERS USED DASH 7232 04:33:18,225 --> 04:33:19,560 2 STANDARD FOR THIS, AND AS WE 7233 04:33:19,560 --> 04:33:21,528 JUST HEARD THAT THAT WAS NOT 7234 04:33:21,528 --> 04:33:25,099 NECESSARILY APPROPRIATE. 7235 04:33:25,099 --> 04:33:27,067 SO WHAT CUFFLESS DEVICES DO THAT 7236 04:33:27,067 --> 04:33:28,702 GIVE CONTINUOUS MEASUREMENTS, 7237 04:33:28,702 --> 04:33:30,037 THIS IS IMPORTANT TO THINK ABOUT 7238 04:33:30,037 --> 04:33:33,207 IN TERMS OF THE MORE -- LIKE THE 7239 04:33:33,207 --> 04:33:34,508 WATCHES AND THE RINGS THAT WE'VE 7240 04:33:34,508 --> 04:33:37,544 BEEN HEARING ABOUT THAT ARE 7241 04:33:37,544 --> 04:33:40,481 COMING AWAY, THESE DEVICES -- 7242 04:33:40,481 --> 04:33:42,616 GIVE YOU AN OUTPUT FREQUENTLY, 7243 04:33:42,616 --> 04:33:45,119 SO ONE OR MORE OUTPUT EVERY 7244 04:33:45,119 --> 04:33:46,186 30 SECONDS. 7245 04:33:46,186 --> 04:33:46,920 THIS BECAUSE OF THE FREQUENCY OF 7246 04:33:46,920 --> 04:33:50,124 THE OUTPUT REQUIRES AN INVASIVE 7247 04:33:50,124 --> 04:33:50,724 REFERENCE. 7248 04:33:50,724 --> 04:33:52,726 THESE DEVICES CAN PROVIDE EITHER 7249 04:33:52,726 --> 04:33:53,861 TREND DATA, WHICH I THINK OF AS 7250 04:33:53,861 --> 04:33:54,828 DELTA BLOOD PRESSURE SO THE 7251 04:33:54,828 --> 04:33:57,031 CHANGE IN BLOOD PRESSURE, OR IT 7252 04:33:57,031 --> 04:34:02,469 GIVES YOU AN APP MEANT TO BE 7253 04:34:02,469 --> 04:34:03,003 ESTIMATED BLOOD PRESSURE. 7254 04:34:03,003 --> 04:34:05,539 THIS IS TIMENTED TO BE TYPE B OR 7255 04:34:05,539 --> 04:34:05,873 TYPE A. 7256 04:34:05,873 --> 04:34:08,275 UP WITH OF THE THINGS IN THE 7257 04:34:08,275 --> 04:34:09,476 STANDARD THAT'S IMPORTANT FOR 7258 04:34:09,476 --> 04:34:10,678 ALL OF US TO KNOW IS THAT USERS 7259 04:34:10,678 --> 04:34:14,181 OF THESE CONTINUOUS AUTOMATED 7260 04:34:14,181 --> 04:34:16,050 COMPLEX DEVICES COULD BE MISLED 7261 04:34:16,050 --> 04:34:18,652 TO THINK THE VALUES DISPLAYING 7262 04:34:18,652 --> 04:34:21,321 ON THE SCREEN ARE ABSOLUTELY 7263 04:34:21,321 --> 04:34:24,658 ACCURATE WHEN IN REALITY THEY 7264 04:34:24,658 --> 04:34:29,463 ARE NOT. 7265 04:34:29,463 --> 04:34:35,369 SO FOR THE TYPE A -- AND GIVE 7266 04:34:35,369 --> 04:34:36,570 YOU BLOOD PRESSURE CHANGES, 7267 04:34:36,570 --> 04:34:38,539 WHEREAS THE ONES THAT PROVIDE 7268 04:34:38,539 --> 04:34:45,946 TREND DATA -- ONLY REQUIRE THE 7269 04:34:45,946 --> 04:34:47,581 LAST TWO OF THOSE PERFORMANCE 7270 04:34:47,581 --> 04:34:48,982 ASSESSMENTS. 7271 04:34:48,982 --> 04:34:52,619 SO I'LL BRIEF GO THROUGH THIS, 7272 04:34:52,619 --> 04:34:54,588 SO AGAIN, AN INVASIVE REFERENCE, 7273 04:34:54,588 --> 04:34:56,690 SIMILAR SEX DISTRIBUTION. 7274 04:34:56,690 --> 04:34:58,792 THERE IS A REQUIREMENT FOR AN 7275 04:34:58,792 --> 04:35:00,761 AGE DISTRIBUTION TO RECOGNIZE 7276 04:35:00,761 --> 04:35:01,995 THAT AS WITH OLDER INDIVIDUALS, 7277 04:35:01,995 --> 04:35:04,598 THERE'S MORE ARTERIAL STIFFNESS 7278 04:35:04,598 --> 04:35:07,501 AND DEVICES MAY ACT DIFFERENTLY 7279 04:35:07,501 --> 04:35:08,736 SO THERE IS AN -- REQUIREMENT 7280 04:35:08,736 --> 04:35:10,904 AND THERE IS A DIFFERENT BLOOD 7281 04:35:10,904 --> 04:35:12,039 PRESSURE DISTRIBUTION AS MANY OF 7282 04:35:12,039 --> 04:35:13,474 THESE DEVICES ARE INTENDED TO BE 7283 04:35:13,474 --> 04:35:15,409 USED IN ICUs OR IN OPERATING 7284 04:35:15,409 --> 04:35:17,144 ROOMS WHERE THERE HAS TO BE 7285 04:35:17,144 --> 04:35:18,612 BIGGER SWINGS IN BLOOD PRESSURE 7286 04:35:18,612 --> 04:35:19,079 SO THE BLOOD PRESSURE 7287 04:35:19,079 --> 04:35:22,716 DISTRIBUTION IS DIFFERENT TO 7288 04:35:22,716 --> 04:35:23,584 AFFECT THAT. 7289 04:35:23,584 --> 04:35:25,686 THERE'S NO REQUIRED AGE 7290 04:35:25,686 --> 04:35:26,787 DISTRIBUTION WHEN BEING TESTED 7291 04:35:26,787 --> 04:35:32,559 IN CHILDREN UNDER 12. 7292 04:35:32,559 --> 04:35:34,728 UNDER -- THERE IS AN AGE WEIGHT 7293 04:35:34,728 --> 04:35:36,163 DISTRIBUTION THAT NEEDS TO BE 7294 04:35:36,163 --> 04:35:39,666 FULFILLED. 7295 04:35:39,666 --> 04:35:41,535 LET'S GO PAST THAT ONE TO THE 7296 04:35:41,535 --> 04:35:51,712 NEXT ONE. 7297 04:35:54,815 --> 04:35:59,553 SO THE ONE THING I DO WANT TO 7298 04:35:59,553 --> 04:36:00,988 HIGHLIGHT FOR THE CONTINUOUS 7299 04:36:00,988 --> 04:36:02,289 BLOOD PRESSURE DEVICES, THE 7300 04:36:02,289 --> 04:36:06,994 STANDARD REQUIRES THE PAIRED 7301 04:36:06,994 --> 04:36:13,100 VALUES BE LESS THAN 7302 04:36:13,100 --> 04:36:16,737 6 MILLIMETERS OF MERCURY. 7303 04:36:16,737 --> 04:36:18,038 SO THAT WAS REALLY FOCUSING ON 7304 04:36:18,038 --> 04:36:19,406 THE ACCURACY OF BLOOD PRESSURE, 7305 04:36:19,406 --> 04:36:21,475 IN TERMS OF STABILITY AND BLOOD 7306 04:36:21,475 --> 04:36:23,644 PRESSURE CHANGES, THERE'S 7307 04:36:23,644 --> 04:36:26,280 ADDITIONAL TESTING. 7308 04:36:26,280 --> 04:36:27,481 WHAT THE STANDARDS GOES THROUGH 7309 04:36:27,481 --> 04:36:29,016 IS THAT THESE DEVICES NEED TO 7310 04:36:29,016 --> 04:36:30,851 HAVE SPECIFIC THINGS THAT TELL 7311 04:36:30,851 --> 04:36:34,588 YOU HOW THEY PERFORM IMMEDIATELY 7312 04:36:34,588 --> 04:36:37,157 POST CALIBRATION IN DIFFERENT 7313 04:36:37,157 --> 04:36:38,425 DEVICE POSITIONS AFTER INDUCING 7314 04:36:38,425 --> 04:36:40,727 THE BLOOD PRESSURE CHANGE AND 7315 04:36:40,727 --> 04:36:42,996 BEFORE THOSE DEVICES GET RECAL 7316 04:36:42,996 --> 04:36:44,198 RECALIBRATED SO ALL THOSE THINGS 7317 04:36:44,198 --> 04:36:45,866 GET HANDLED IN THE STANDARD. 7318 04:36:45,866 --> 04:36:48,035 SO WHAT ABOUT HOW WE TEST 7319 04:36:48,035 --> 04:36:49,903 DEVICES THAT GIVE YOU 7320 04:36:49,903 --> 04:36:51,505 INTERMITTENT CUFFLESS BLOOD 7321 04:36:51,505 --> 04:36:52,105 PRESSURE MEASUREMENTS? 7322 04:36:52,105 --> 04:36:55,142 SO THIS IS IN PROGRESS. 7323 04:36:55,142 --> 04:36:56,243 THESE DEVICES ARE DIFFERENT THAN 7324 04:36:56,243 --> 04:36:58,011 THE CONTINUOUS ONES BECAUSE 7325 04:36:58,011 --> 04:37:00,447 THESE GIVE YOU AN OUTPUT LESS 7326 04:37:00,447 --> 04:37:02,950 FREQUENTLY SO MORE THAN EVERY 7327 04:37:02,950 --> 04:37:03,650 30 SECONDS. 7328 04:37:03,650 --> 04:37:05,452 OR UPON WHEN THE USER ACTUATES 7329 04:37:05,452 --> 04:37:11,358 IT, PUSHES A BUTTON. 7330 04:37:11,358 --> 04:37:12,359 SO AS WE'RE DEVELOPING THIS 7331 04:37:12,359 --> 04:37:15,195 STANDARD, WE ARE THINKING ABOUT 7332 04:37:15,195 --> 04:37:16,029 AND WE'RE DEVELOPING THE 7333 04:37:16,029 --> 04:37:17,898 STANDARD TO ADDRESS SIX 7334 04:37:17,898 --> 04:37:20,801 POTENTIAL AND/OR EXISTING 7335 04:37:20,801 --> 04:37:21,435 DEVICES ON THE MARKET. 7336 04:37:21,435 --> 04:37:24,271 SO MANY OF THESE DEVICES AS WAS 7337 04:37:24,271 --> 04:37:26,773 JUST DESCRIBED IN THE EARLIER 7338 04:37:26,773 --> 04:37:30,077 PRESENTATION REQUIRE SOME SORT 7339 04:37:30,077 --> 04:37:33,780 OF INITIALIZATION AND -- MANY 7340 04:37:33,780 --> 04:37:36,483 REQUIRE DEMOGRAPHICS OR 7341 04:37:36,483 --> 04:37:37,751 ANTHROPOMETRICS, AND MANY NOW 7342 04:37:37,751 --> 04:37:44,291 REQUIRE INITIALIZATION I WITH A 7343 04:37:44,291 --> 04:37:45,726 CUFF, PUT IT INTO THE DEVICE AND 7344 04:37:45,726 --> 04:37:47,794 ALL THAT INFORMATION IS USED 7345 04:37:47,794 --> 04:37:49,463 ALONG WITH OTHER METHODS LIKE 7346 04:37:49,463 --> 04:37:55,369 PULSE WAVE ANALYSIS AND -- WITH 7347 04:37:55,369 --> 04:37:55,936 OUTPUT. 7348 04:37:55,936 --> 04:37:57,137 SO THE SIX DIFFERENT TYPES ARE 7349 04:37:57,137 --> 04:38:00,974 THE ONES THAT DON'T REQUIRE ANY 7350 04:38:00,974 --> 04:38:02,509 INITIALIZATION OF PERSONAL 7351 04:38:02,509 --> 04:38:03,110 INFORMATION, CONSIDERED TO BE 7352 04:38:03,110 --> 04:38:06,246 PLUG AND PLAY D DEVICES, AND YOU 7353 04:38:06,246 --> 04:38:08,181 CAN SEE HERE THE ONES THAT 7354 04:38:08,181 --> 04:38:11,818 REQUIRE CUFF BLOOD PRESSURE. 7355 04:38:11,818 --> 04:38:13,253 THOSE DO NOT REQUIRE PERSONAL 7356 04:38:13,253 --> 04:38:15,188 INFORMATION AND NEITHER PROVIDES 7357 04:38:15,188 --> 04:38:16,089 YOU WITH ABSOLUTE BLOOD PRESSURE 7358 04:38:16,089 --> 04:38:17,324 IN MILLIMETERS MILL METERS OF 7359 04:38:17,324 --> 04:38:18,492 MERCURY OR ATTRACTS BLOOD 7360 04:38:18,492 --> 04:38:19,793 PRESSURE AS DESCRIBED EARLIER 7361 04:38:19,793 --> 04:38:20,627 PROVIDING MORE OF A CHANGE IN 7362 04:38:20,627 --> 04:38:25,465 BLOOD PRESSURE. 7363 04:38:25,465 --> 04:38:26,133 SO AS WE HAVE BEEN DEVELOPING 7364 04:38:26,133 --> 04:38:27,234 THE STANDARDS, THERE ARE THINGS 7365 04:38:27,234 --> 04:38:28,735 THAT WE'VE BEEN THINKING ABOUT, 7366 04:38:28,735 --> 04:38:33,273 SOME OF THEM ARE HIGHLIGHTED 7367 04:38:33,273 --> 04:38:34,708 HERE WHICH IS THE ESH 7368 04:38:34,708 --> 04:38:35,676 RECOMMENDATIONS AND THINGS THAT 7369 04:38:35,676 --> 04:38:37,744 WE MIGHT CONSIDER FOR VALIDATION 7370 04:38:37,744 --> 04:38:39,613 OF CUFFLESS INTERMITTENT 7371 04:38:39,613 --> 04:38:40,514 DEVICES. 7372 04:38:40,514 --> 04:38:43,116 SO THINGS THAT ARE BEING 7373 04:38:43,116 --> 04:38:43,784 CONSIDERED, THINKING ABOUT HOW 7374 04:38:43,784 --> 04:38:46,620 DO WE TEST STATIC, ABSOLUTE 7375 04:38:46,620 --> 04:38:48,689 BROMOPROPANE ACCURACY, HOW DO WE 7376 04:38:48,689 --> 04:38:51,058 TEST FOR HYDROSTATIC PRESSURE 7377 04:38:51,058 --> 04:38:54,728 EFFECT ROBUSTNESS, WEAKNESS OR 7378 04:38:54,728 --> 04:38:56,496 EFFECTIVENESS OF BLOOD PRESSURE 7379 04:38:56,496 --> 04:38:57,898 DECREASING AND IS IT ACTIVE ARE 7380 04:38:57,898 --> 04:39:00,067 THE BLOOD PRESSURE DOES 7381 04:39:00,067 --> 04:39:00,334 DECREASE? 7382 04:39:00,334 --> 04:39:01,335 WE'RE THINKING ABOUT HOW DO WE 7383 04:39:01,335 --> 04:39:03,737 TEST IT WHEN WE'RE AWAKE AND 7384 04:39:03,737 --> 04:39:05,906 ASLEEP, BROMOPROPANE CHANGE AND 7385 04:39:05,906 --> 04:39:08,208 ACCURACY POSITION WHEN BLOOD 7386 04:39:08,208 --> 04:39:09,643 PRESSURE -- EXERCISE -- THAT'S A 7387 04:39:09,643 --> 04:39:11,745 THING WE'D WANT TO TR TO HELP -- 7388 04:39:11,745 --> 04:39:14,548 BLOOD PRESSURE AND ACTIVE 7389 04:39:14,548 --> 04:39:15,582 INCREASING BLOOD PRESSURE AND 7390 04:39:15,582 --> 04:39:17,985 SEEING HOW THE DEVICE IS 7391 04:39:17,985 --> 04:39:21,488 ACCURATE OVER TIME THE FURTHER 7392 04:39:21,488 --> 04:39:23,256 IT GETS AWAY FROM THE INITIAL 7393 04:39:23,256 --> 04:39:26,393 CUFF CALIBRATION. 7394 04:39:26,393 --> 04:39:28,996 SO THERE ARE MANY, MANY, MANY 7395 04:39:28,996 --> 04:39:30,097 BLOOD PRESSURE MEASURING DEVICES 7396 04:39:30,097 --> 04:39:31,631 ON THE MARKET, HOWEVER, MANY 7397 04:39:31,631 --> 04:39:36,136 PEOPLE DON'T RECOGNIZE THAT 7398 04:39:36,136 --> 04:39:37,804 ABOUT 20% OF THEM HAVE EVER BEEN 7399 04:39:37,804 --> 04:39:39,539 SUBJECTED TO VALIDATION TESTING. 7400 04:39:39,539 --> 04:39:41,875 SO YOU CAN PUT YOUR DEVICE ON 7401 04:39:41,875 --> 04:39:47,314 THE MARKET EVEN IF IT HASN'T 7402 04:39:47,314 --> 04:39:50,484 UNDERGONE -- VIOLATIONS IN -- SO 7403 04:39:50,484 --> 04:39:52,252 I GET PEOPLE ASKING ME ALL THE 7404 04:39:52,252 --> 04:39:54,955 TIME, WHAT ABOUT AN FDA-APPROVED 7405 04:39:54,955 --> 04:39:55,489 DEVICE? 7406 04:39:55,489 --> 04:39:58,125 THE ONE THING I WANT TO BE ABOUT 7407 04:39:58,125 --> 04:40:00,527 IS THAT THE FDA DOES NOT APPROVE 7408 04:40:00,527 --> 04:40:01,395 BLOOD PRESSURE DEVICES, THEY 7409 04:40:01,395 --> 04:40:03,363 CLEAR THEM. 7410 04:40:03,363 --> 04:40:06,967 SO APPROVAL GENERALLY ONLY 7411 04:40:06,967 --> 04:40:08,835 APPLIES TO HIGH RISK MEDICAL 7412 04:40:08,835 --> 04:40:09,603 DEVICES AND BLOOD PRESSURE 7413 04:40:09,603 --> 04:40:11,138 DEVICES ARE NOT SUFFICIENTLY 7414 04:40:11,138 --> 04:40:11,671 HIGH RISK. 7415 04:40:11,671 --> 04:40:18,879 SO THEY GET CLEARED THROUGH THE 7416 04:40:18,879 --> 04:40:19,112 PATHWAY. 7417 04:40:19,112 --> 04:40:20,881 SO A CLEARED DEVICE IS ONE THAT 7418 04:40:20,881 --> 04:40:23,817 IS AT LEAST A SAFE AND EFFECTIVE 7419 04:40:23,817 --> 04:40:26,319 SUBSTANTIALLY EQUIVALENT TO A 7420 04:40:26,319 --> 04:40:29,823 LEGALLY MARKETED DEVICE -- NOT 7421 04:40:29,823 --> 04:40:30,457 NECESSARILY CLINICAL TESTING OF 7422 04:40:30,457 --> 04:40:32,559 THE NEW DEVICE. 7423 04:40:32,559 --> 04:40:33,994 THE NEW DEVICE DOES NOT 7424 04:40:33,994 --> 04:40:36,329 NECESSARILY NEED TO BE TESTED IF 7425 04:40:36,329 --> 04:40:37,664 IT WAS DEEMED TO BE 7426 04:40:37,664 --> 04:40:40,434 SUBSTANTIALLY APPROPRIATE. 7427 04:40:40,434 --> 04:40:42,035 I THINK WE'RE GOING TO SKIP THIS 7428 04:40:42,035 --> 04:40:44,104 ONE AND THE NEXT ONE. 7429 04:40:44,104 --> 04:40:44,404 KEEP GOING. 7430 04:40:44,404 --> 04:40:47,107 AND THEN ONE MORE. 7431 04:40:47,107 --> 04:40:50,477 SO AGAIN, DEVICES CAN BE CLEARED 7432 04:40:50,477 --> 04:40:52,712 WITHOUT THEY THEMSELVES 7433 04:40:52,712 --> 04:40:54,114 UNDERGOING SEPARATE VALIDATION 7434 04:40:54,114 --> 04:40:55,749 TESTING IF THE MANUFACTURER 7435 04:40:55,749 --> 04:41:02,089 CLAIMS SUBSTANTIAL EQUIVALENT TO 7436 04:41:02,089 --> 04:41:04,724 THE MARKETED DEVICE. 7437 04:41:04,724 --> 04:41:12,599 LET'S SKIP TO THE SUMMARY SLIDE. 7438 04:41:12,599 --> 04:41:14,034 SO IN SUMMARY, THERE ARE 7439 04:41:14,034 --> 04:41:15,001 MULTIPLE VALIDATION PROTOCOLS 7440 04:41:15,001 --> 04:41:16,436 AVAILABLE FOR TESTING NUMEROUS 7441 04:41:16,436 --> 04:41:18,305 DEVICES INTENDED TO MEASURE 7442 04:41:18,305 --> 04:41:19,039 BLOOD PRESSURE, THEY'RE VERY 7443 04:41:19,039 --> 04:41:20,540 COMPLEX, AND THEY'RE SPECIFIC TO 7444 04:41:20,540 --> 04:41:24,978 MAKE SURE THAT THEY'RE ACCURATE 7445 04:41:24,978 --> 04:41:28,482 ACROSS THE -- POPULATION, VERY 7446 04:41:28,482 --> 04:41:30,550 FEW DEVICES FOR SALE HAVE EVER 7447 04:41:30,550 --> 04:41:32,185 BEEN TESTED FOR ACCURACY AND 7448 04:41:32,185 --> 04:41:34,488 DEVICES CAN RECEIVE FDA 7449 04:41:34,488 --> 04:41:36,990 CLEARANCE IF THEY'RE 7450 04:41:36,990 --> 04:41:38,458 SUBSTANTIALLY EQUIVALENT. 7451 04:41:38,458 --> 04:41:39,826 TECHNOLOGY IS EVOLVING QUICKLY, 7452 04:41:39,826 --> 04:41:41,728 NEW TECH INNOVATIONS REQUIRE 7453 04:41:41,728 --> 04:41:43,630 INNOVATIVE APPROACHES BY 7454 04:41:43,630 --> 04:41:44,831 REGULATORS, PROFESSIONAL 7455 04:41:44,831 --> 04:41:46,566 SOCIETIES, CLINICIANS, AND HOW 7456 04:41:46,566 --> 04:41:49,102 WE CAN INTEGRATE THEM INTO 7457 04:41:49,102 --> 04:41:55,976 CLINICAL CARE SO ONE THING -- TO 7458 04:41:55,976 --> 04:41:57,944 COLLABORATE MORE CLOSELY. 7459 04:41:57,944 --> 04:41:59,246 AND ONE THING WE CONSTANTLY HAVE 7460 04:41:59,246 --> 04:42:00,413 TO THINK ABOUT WHEN WE'RE 7461 04:42:00,413 --> 04:42:01,882 TALKING ABOUT VALIDATION 7462 04:42:01,882 --> 04:42:02,849 STANDARDS IS THAT THAT REALLY 7463 04:42:02,849 --> 04:42:05,285 PERTAINS TO ACCURACY AND 7464 04:42:05,285 --> 04:42:06,186 STANDARD DIED RESEARCH SETTING, 7465 04:42:06,186 --> 04:42:07,821 IT DOESN'T ADDRESS HOW THE 7466 04:42:07,821 --> 04:42:10,090 DEVICE IS PERFORMING, OPTIMAL 7467 04:42:10,090 --> 04:42:10,991 SETTINGS. 7468 04:42:10,991 --> 04:42:11,958 SO WHAT'S MISSING WHEN YOU HAVE 7469 04:42:11,958 --> 04:42:13,927 A VALIDATED DEVICE YOU DON'T 7470 04:42:13,927 --> 04:42:15,896 HAVE A PERFORMANCE IN THE REAL 7471 04:42:15,896 --> 04:42:18,765 WORLD WITH TYPICAL USE. 7472 04:42:18,765 --> 04:42:21,168 ONE THING I FOUND PARTICULARLY 7473 04:42:21,168 --> 04:42:22,269 INTERESTING IS AS WE WERE 7474 04:42:22,269 --> 04:42:23,737 TALKING ABOUT SOME OF THE 7475 04:42:23,737 --> 04:42:25,305 LIMITATIONS TO THESE DEVICE, 7476 04:42:25,305 --> 04:42:26,406 PARTICULARLY HOW THEY DON'T 7477 04:42:26,406 --> 04:42:27,607 REALLY PERFORM WELL DURING 7478 04:42:27,607 --> 04:42:29,342 SLEEP, AND THINKING ABOUT WHAT 7479 04:42:29,342 --> 04:42:31,678 YOU NEED TO DO TO TEST THEM 7480 04:42:31,678 --> 04:42:32,913 DURING, ONE THING TO HIGHLIGHT 7481 04:42:32,913 --> 04:42:42,689 ISHIGHLIGHT -- HOW CAN WE IMPROE 7482 04:42:42,689 --> 04:42:44,024 AND INCREASE THE CONSISTENCY 7483 04:42:44,024 --> 04:42:44,991 BETWEEN THE PROTOCOLS? 7484 04:42:44,991 --> 04:42:47,727 I THINK MY LAST SLIDE IS NEXT. 7485 04:42:47,727 --> 04:42:49,362 AND SO WITH THOSE ADDITIONAL 7486 04:42:49,362 --> 04:42:50,897 TESTING REQUIREMENTS FOR SPECIAL 7487 04:42:50,897 --> 04:42:52,199 POPULATIONS, ONE OF THE 7488 04:42:52,199 --> 04:42:53,733 DOWNSTREAM EFFECTS IS THAT THESE 7489 04:42:53,733 --> 04:42:56,469 POPULATIONS TEND TO NOT HAVE AS 7490 04:42:56,469 --> 04:42:58,338 MANY DEVICES AVAILABLE FOR USE, 7491 04:42:58,338 --> 04:43:01,541 AND WITH CHILDREN AND -- WE NEED 7492 04:43:01,541 --> 04:43:03,810 TO THINK ABOUT THAT, ARE THERE 7493 04:43:03,810 --> 04:43:05,245 INNOVATIVE WAYS THAT YOU CAN 7494 04:43:05,245 --> 04:43:08,315 TEST AND MAKE SURE THEY'RE 7495 04:43:08,315 --> 04:43:12,052 ACCURATE WITHIN THESE 7496 04:43:12,052 --> 04:43:12,686 POPULATIONS. 7497 04:43:12,686 --> 04:43:13,687 THANK YOU VERY MUCH FOR YOUR 7498 04:43:13,687 --> 04:43:14,287 ATTENTION. 7499 04:43:14,287 --> 04:43:16,022 >> THANK YOU SO MUCH, DR. BRADY. 7500 04:43:16,022 --> 04:43:18,858 WE'LL HAND IT OVER TO ALMOST 7501 04:43:18,858 --> 04:43:20,827 HILARY WALL FROM CDC'S MILLION 7502 04:43:20,827 --> 04:43:21,061 HEARTS. 7503 04:43:21,061 --> 04:43:23,330 >> THANKS A BUNCH, KATE. 7504 04:43:23,330 --> 04:43:24,764 IF WE CAN GO TO THE NEXT SLIDE. 7505 04:43:24,764 --> 04:43:25,732 GREAT. 7506 04:43:25,732 --> 04:43:28,068 SO HILARY WALL, I'M HERE TO TALK 7507 04:43:28,068 --> 04:43:32,906 TO YOU ABOUT USING BIG DATA FOR 7508 04:43:32,906 --> 04:43:35,408 HYPERTENSION CLINICAL 7509 04:43:35,408 --> 04:43:35,875 DECISION-MAKING. 7510 04:43:35,875 --> 04:43:37,444 I AM GOING TO MENTION SOME SORT 7511 04:43:37,444 --> 04:43:39,646 OF TRADE NAMES NOT FOR 7512 04:43:39,646 --> 04:43:41,314 ENDORSEMENT, JUST USING THEM FOR 7513 04:43:41,314 --> 04:43:44,818 IDENTIFICATION AND EXAMPLES. 7514 04:43:44,818 --> 04:43:46,253 SO AGAIN, I WAS ASKED TO GEF A 7515 04:43:46,253 --> 04:43:49,956 TALK ABOUT USING BIG DATA FOR 7516 04:43:49,956 --> 04:43:51,625 HYPERTENSION CLINICAL 7517 04:43:51,625 --> 04:43:52,592 DECISION-MAKING AND SOME OF THE 7518 04:43:52,592 --> 04:43:53,393 CHALLENGES AND OPPORTUNITIES 7519 04:43:53,393 --> 04:43:54,894 THAT THERE ARE IN THAT FIELD. 7520 04:43:54,894 --> 04:43:59,499 I'M NOT A CLINICIAN, I AM AN 7521 04:43:59,499 --> 04:44:00,267 EPIDEMIOLOGIST BY TRAINING SO 7522 04:44:00,267 --> 04:44:01,468 THAT'S REALLY THE LENS THROUGH 7523 04:44:01,468 --> 04:44:03,236 WHICH I'M LOOKING THROUGH, BUT I 7524 04:44:03,236 --> 04:44:04,871 ALSO WORK WITH A LOT OF 7525 04:44:04,871 --> 04:44:06,006 CLINICIANS, ESPECIALLY COMMUNITY 7526 04:44:06,006 --> 04:44:07,841 HEALTH CENTERS, AS THEY DIG DEEP 7527 04:44:07,841 --> 04:44:08,942 INTO THEIR ELECTRONIC HEALTH 7528 04:44:08,942 --> 04:44:10,010 RECORD DATA FOR QUALITY 7529 04:44:10,010 --> 04:44:11,778 IMPROVEMENT PURPOSES IN 7530 04:44:11,778 --> 04:44:13,413 PARTICULAR AND IMPACTS THAT 7531 04:44:13,413 --> 04:44:14,547 MIGHT HAVE ON CLINICAL QUALITY 7532 04:44:14,547 --> 04:44:15,215 MEASURES. 7533 04:44:15,215 --> 04:44:16,516 SO I'M GOING TO HIT SORT OF A 7534 04:44:16,516 --> 04:44:19,019 WHOLE BUNCH OF TOPICS HERE 7535 04:44:19,019 --> 04:44:19,219 TODAY. 7536 04:44:19,219 --> 04:44:21,221 BUT I'M GOING TO START A LITTLE 7537 04:44:21,221 --> 04:44:23,523 BIT WITH PUBLIC HEALTH 7538 04:44:23,523 --> 04:44:24,090 SURVEILLANCE BECAUSE THAT'S 7539 04:44:24,090 --> 04:44:25,825 WHERE I COME FROM AND OUR WORK 7540 04:44:25,825 --> 04:44:26,926 USING ELECTRONIC HEALTH RECORD 7541 04:44:26,926 --> 04:44:29,029 DATA FOR PUBLIC HEALTH 7542 04:44:29,029 --> 04:44:30,196 SURVEILLANCE HAS ACTUALLY 7543 04:44:30,196 --> 04:44:32,065 PROVIDED US AN OPPORTUNITY TO 7544 04:44:32,065 --> 04:44:33,066 SORT OF LOOK UNDER THE HOOD AND 7545 04:44:33,066 --> 04:44:34,801 SEE HOW THE SAUSAGE IS MADE WITH 7546 04:44:34,801 --> 04:44:39,839 REGARD TO ELECTRONIC HEALTH 7547 04:44:39,839 --> 04:44:42,475 RECORD DATA AND ALL OF THEIR 7548 04:44:42,475 --> 04:44:44,010 SORT OF BEAUTIFUL MESSINESS THAT 7549 04:44:44,010 --> 04:44:46,012 THEY BRING. 7550 04:44:46,012 --> 04:44:46,780 JUST IN CASE YOU WEREN'T AWARE, 7551 04:44:46,780 --> 04:44:48,048 IN THE UNITED STATES THE 7552 04:44:48,048 --> 04:44:48,948 NATIONAL HEALTH AND NUTRITION 7553 04:44:48,948 --> 04:44:49,816 EXAMINATION SURVEY IS 7554 04:44:49,816 --> 04:44:51,251 ESSENTIALLY OUR ONLY 7555 04:44:51,251 --> 04:44:52,552 SURVEILLANCE DATA SOURCE FOR 7556 04:44:52,552 --> 04:44:53,687 HYPERTENSION PREVALENCE AND 7557 04:44:53,687 --> 04:44:54,220 BLOOD PRESSURE CONTROL. 7558 04:44:54,220 --> 04:44:56,056 THERE ARE OTHER DATA SOURCES 7559 04:44:56,056 --> 04:44:58,792 THAT GET AT SORT OF -- BUT THIS 7560 04:44:58,792 --> 04:45:00,860 IS REALLY OUR ONLY DATA SOURCE 7561 04:45:00,860 --> 04:45:02,662 THAT GIVES US HYPERTENSION AND 7562 04:45:02,662 --> 04:45:04,898 BLOOD PRESSURE CONTROL. 7563 04:45:04,898 --> 04:45:06,466 HOWEVER, IT'S CONSIDERED A GOLD 7564 04:45:06,466 --> 04:45:07,734 STANDARD BUT HOWEVER, THERE'S 7565 04:45:07,734 --> 04:45:09,002 CHALLENGES WITH IT JUST LIKE ANY 7566 04:45:09,002 --> 04:45:09,969 DATA SOURCE, RIGHT? 7567 04:45:09,969 --> 04:45:12,339 IT'S VERY EXPENSIVE TO MAINTAIN, 7568 04:45:12,339 --> 04:45:14,140 IT'S NOT VERY TIMELY, YOU'RE NOT 7569 04:45:14,140 --> 04:45:16,976 GETTING REALTIME DATA FROM IT IN 7570 04:45:16,976 --> 04:45:19,312 ANY WAY, SHAPE OR FORM AND IF 7571 04:45:19,312 --> 04:45:21,014 YOU'RE A STATE OR LOCAL HEALTH 7572 04:45:21,014 --> 04:45:22,015 DEPARTMENT, YOU'RE REALLY NOT 7573 04:45:22,015 --> 04:45:28,455 ABLE TO GET -- FROM NHANES. 7574 04:45:28,455 --> 04:45:30,790 WHAT WE FOUND OUT WHEN COVID-19 7575 04:45:30,790 --> 04:45:32,325 HIT, WHEN THE COUNTRY SHUT DOWN, 7576 04:45:32,325 --> 04:45:34,260 NHANES DATA COLLECTION SHUT DOWN 7577 04:45:34,260 --> 04:45:36,296 AND FRANKLY HAS BEEN DISRUPTED 7578 04:45:36,296 --> 04:45:38,131 IN DIFFERENT WAYS SORT OF 7579 04:45:38,131 --> 04:45:39,132 INCONSISTENTLY OVER THE LAST 7580 04:45:39,132 --> 04:45:42,068 FIVE YEARS, AND IT ONLY NEXT 7581 04:45:42,068 --> 04:45:43,937 YEAR WHEN THEIR DATA COLLECTION 7582 04:45:43,937 --> 04:45:45,472 CYCLES ABOUT BEGIN AGAIN. 7583 04:45:45,472 --> 04:45:47,674 SO FOR FIVE YEARS, WE'VE HAD NOT 7584 04:45:47,674 --> 04:45:49,809 GREAT ESTIMATES FOR BLOOD 7585 04:45:49,809 --> 04:45:50,210 PRESSURE CONTROL. 7586 04:45:50,210 --> 04:45:56,883 AND THAT'S A PROBLEM. 7587 04:45:56,883 --> 04:45:58,518 BUT THE CHALLENGE, WHEN YOU HAVE 7588 04:45:58,518 --> 04:46:00,286 SOMETHING CALLED A GOLD 7589 04:46:00,286 --> 04:46:00,954 STANDARD, PEOPLE AREN'T VERY 7590 04:46:00,954 --> 04:46:02,355 QUICK TO LOOK FOR AN 7591 04:46:02,355 --> 04:46:08,395 ALTERNATIVE. 7592 04:46:08,395 --> 04:46:14,167 SO THEY'RE NOT QUICK TO THINK 7593 04:46:14,167 --> 04:46:15,969 OUTSIDE OF THE BOX AND HOW ELSE 7594 04:46:15,969 --> 04:46:19,672 WE MIGHT GET TO THOSE INDICATORS 7595 04:46:19,672 --> 04:46:20,874 THAT I MENTIONED. 7596 04:46:20,874 --> 04:46:22,709 WHEN I HEARD ABOUT MEANINGFUL 7597 04:46:22,709 --> 04:46:24,511 USE, YES, I WAS HAPPY WAS GOING 7598 04:46:24,511 --> 04:46:27,046 TO IMPROVE EFFICIENCY AND 7599 04:46:27,046 --> 04:46:28,581 PATIENT OUTCOMES POTENTIALLY, 7600 04:46:28,581 --> 04:46:29,682 BUT I JUST WAS SALIVATING OVER 7601 04:46:29,682 --> 04:46:31,251 THE HUGE VOLUME OF DATA THAT WE 7602 04:46:31,251 --> 04:46:33,486 WOULD BE SITTING ON TOP. 7603 04:46:33,486 --> 04:46:34,421 AND YES IT WAS GOING TO BE MESSY 7604 04:46:34,421 --> 04:46:35,755 AND WE NEEDED TO FIGURE OUT 7605 04:46:35,755 --> 04:46:39,793 METHODS FOR IT, BUT THIS WAS A 7606 04:46:39,793 --> 04:46:40,994 HUGE OPPORTUNITY IN MY MIND, SO 7607 04:46:40,994 --> 04:46:42,429 I STARTED SQUAWKING TO ANYONE 7608 04:46:42,429 --> 04:46:44,063 WHO HAD DOLLARS AND 7609 04:46:44,063 --> 04:46:46,232 DECISION-MAKING CAPABILITY AT 7610 04:46:46,232 --> 04:46:48,101 CDC, AND EVENTUALLY WE DID GET 7611 04:46:48,101 --> 04:46:51,538 TO THE POINT WHERE WE WERE USING 7612 04:46:51,538 --> 04:46:53,173 EHR DATA FOR SURVEILLANCE. 7613 04:46:53,173 --> 04:46:54,707 I CERTAINLY WAS NOT THE ONLY 7614 04:46:54,707 --> 04:46:56,543 PERSON WHO WAS THINKING ABOUT 7615 04:46:56,543 --> 04:46:58,077 ELECTRONIC HEALTH RECORD DATA 7616 04:46:58,077 --> 04:46:59,312 FOR SURVEILLANCE AND OTHER 7617 04:46:59,312 --> 04:46:59,779 PURPOSES. 7618 04:46:59,779 --> 04:47:03,249 YOU CAN SEE ON THE LEFT 7619 04:47:03,249 --> 04:47:04,350 ESPECIALLY PUBLIC HEALTH 7620 04:47:04,350 --> 04:47:06,352 JURISDICTIONS THAT CAN'T BENEFIT 7621 04:47:06,352 --> 04:47:09,489 FROM NHANES WE'RE THINKING -- 7622 04:47:09,489 --> 04:47:11,691 WHAT CAN I DO AT THE STATE LEVEL 7623 04:47:11,691 --> 04:47:14,327 IN MARWAH ABDALLA, TO REALLY USE 7624 04:47:14,327 --> 04:47:14,961 ELECTRONIC HEALTH RECORD DATA TO 7625 04:47:14,961 --> 04:47:15,995 ANSWER QUESTIONS THAT I HAVE 7626 04:47:15,995 --> 04:47:18,832 ABOUT SERIOUS HEALTH CONDITIONS. 7627 04:47:18,832 --> 04:47:20,233 HRSA HAS BEEN COLLECTING THEIR 7628 04:47:20,233 --> 04:47:22,869 EUN FOM DATA SYSTEM FOR YEARS 7629 04:47:22,869 --> 04:47:23,870 FROM COMMUNITY HEALTH CENTERS. 7630 04:47:23,870 --> 04:47:26,072 IT'S REALLY A PROGRAMMATIC 7631 04:47:26,072 --> 04:47:28,575 DATABASE BUT EVEN THAT HAS BEEN 7632 04:47:28,575 --> 04:47:29,876 COLLECTING ROUTINELY CLINICAL 7633 04:47:29,876 --> 04:47:31,644 QUALITY MEASURES DATA. 7634 04:47:31,644 --> 04:47:32,312 IT'S ALLOWED OUR NATION TO 7635 04:47:32,312 --> 04:47:33,413 REALLY LOOK AT HOW WE'RE DOING 7636 04:47:33,413 --> 04:47:34,714 FROM A SAFETY NET PROVIDER 7637 04:47:34,714 --> 04:47:38,117 PERSPECTIVE AND THAT'S BEEN 7638 04:47:38,117 --> 04:47:39,118 MORPHING AND CHANGING OVER TIME 7639 04:47:39,118 --> 04:47:41,421 AS WELL, I'LL TALK A LITTLE BIT 7640 04:47:41,421 --> 04:47:42,922 ABOUT THAT. 7641 04:47:42,922 --> 04:47:43,490 WE ALSO HAVE HEALTH CENTER 7642 04:47:43,490 --> 04:47:45,058 CONTROLLED NETWORKS AND HEALTH 7643 04:47:45,058 --> 04:47:46,025 INFORMATION EXCHANGES THAT 7644 04:47:46,025 --> 04:47:49,395 REALLY A AGGREGATE DATA THAT THN 7645 04:47:49,395 --> 04:47:55,101 CAN BE USED FOR DIFFERENT 7646 04:47:55,101 --> 04:47:59,372 PURPOSES, AND WE HAVE RESEARCH 7647 04:47:59,372 --> 04:48:01,241 PER FOR -- HELPED INFORM WHAT WE 7648 04:48:01,241 --> 04:48:03,743 CALL OUR MULTISTATE EHR BASED 7649 04:48:03,743 --> 04:48:06,713 NETWORK FOR DISEASE SURVEILLANCE 7650 04:48:06,713 --> 04:48:07,780 OR MENDS. 7651 04:48:07,780 --> 04:48:09,215 AGAIN, THE LESSONS WE'VE LEARNED 7652 04:48:09,215 --> 04:48:11,551 BY BEING EPIDEMIOLOGISTS AND 7653 04:48:11,551 --> 04:48:13,052 DIGGING INTO THE VERY MICRO 7654 04:48:13,052 --> 04:48:15,889 LEVEL DETAILS OF THIS PARTICULAR 7655 04:48:15,889 --> 04:48:20,293 SURVEILLANCE SYSTEM CAN 7656 04:48:20,293 --> 04:48:24,330 ABSOLUTELY BE APPLIED TO 7657 04:48:24,330 --> 04:48:24,998 CLINICAL DECISION-MAKING. 7658 04:48:24,998 --> 04:48:26,733 BUT LET'S LOOK AT WHAT ARE SOME 7659 04:48:26,733 --> 04:48:29,469 TOOLS FOR CLINICAL 7660 04:48:29,469 --> 04:48:30,036 DECISION-MAKING? 7661 04:48:30,036 --> 04:48:31,404 FIRST QUALITY IMPROVEMENT RUN 7662 04:48:31,404 --> 04:48:31,671 CLARTS. 7663 04:48:31,671 --> 04:48:33,873 IF YCHARTS. 7664 04:48:33,873 --> 04:48:35,842 IF YOU'RE DOING CONTINUOUS 7665 04:48:35,842 --> 04:48:36,509 QUALITY IMPROVEMENT, THIS IS ONE 7666 04:48:36,509 --> 04:48:37,810 WAY YOU CAN MONITOR YOUR 7667 04:48:37,810 --> 04:48:38,478 PROGRESS THERE. 7668 04:48:38,478 --> 04:48:40,847 USUALLY USING A LONGITUDAL 7669 04:48:40,847 --> 04:48:42,015 PERFORMANCE MEASURE, A CLINICAL 7670 04:48:42,015 --> 04:48:43,650 QUALITY MEASURE TO REALLY SEE 7671 04:48:43,650 --> 04:48:45,184 HOW QUALITY IMPROVEMENT CHANGES 7672 04:48:45,184 --> 04:48:47,053 HAVE IMPACTED THE PERFORMANCE ON 7673 04:48:47,053 --> 04:48:48,054 SOMETHING LIKE BLOOD PRESSURE 7674 04:48:48,054 --> 04:48:50,323 CONTROL. 7675 04:48:50,323 --> 04:48:52,625 YOU CAN ALSO BE USING CLINICAL 7676 04:48:52,625 --> 04:48:54,494 QUALITY MEASURE DASHBOARDS OR 7677 04:48:54,494 --> 04:48:55,094 JUST DASHBOARDS IN GENERAL AND 7678 04:48:55,094 --> 04:48:56,529 THANKS TO THE AMA FOLKS WHO LET 7679 04:48:56,529 --> 04:48:57,897 ME USE THIS PARTICULAR SLIDE. 7680 04:48:57,897 --> 04:48:59,666 HERE YOU CAN SEE WE'VE GOT OUR 7681 04:48:59,666 --> 04:49:01,067 OUT COME MEASURE OF INTEREST, 7682 04:49:01,067 --> 04:49:03,303 AND THEN ALSO SOME PROCESS 7683 04:49:03,303 --> 04:49:05,405 MEASURES THAT ARE RELATED. 7684 04:49:05,405 --> 04:49:06,706 AND THEN HERE, WE'VE GOT -- YOU 7685 04:49:06,706 --> 04:49:08,908 DIG DOWN ONE MORE LAYER, WHAT 7686 04:49:08,908 --> 04:49:10,443 PATIENTS ARE FALLING OUT OF THE 7687 04:49:10,443 --> 04:49:12,111 NUMERATOR ON OUR PERFORMANCE 7688 04:49:12,111 --> 04:49:14,080 MEASURES, WE CAN LOOK AT 7689 04:49:14,080 --> 04:49:15,715 REGISTRY TO FIGURE OUT WHO MIGHT 7690 04:49:15,715 --> 04:49:17,684 NEED ADDITIONAL CLINICAL 7691 04:49:17,684 --> 04:49:21,321 ATTENTION, AND THEN OUR NEXT 7692 04:49:21,321 --> 04:49:23,923 SLIDE, WE CAN LOOK AT EITHER 7693 04:49:23,923 --> 04:49:26,693 PRE-VISIT OR AT THE POINT OF 7694 04:49:26,693 --> 04:49:27,794 CARE, WHAT'S GOING ON WITH THAT 7695 04:49:27,794 --> 04:49:28,861 INDIVIDUAL PATIENT AND HOPEFULLY 7696 04:49:28,861 --> 04:49:31,130 SOME OF THEIR LONGITUDAL DATA ON 7697 04:49:31,130 --> 04:49:34,567 BLOOD PRESSURE. 7698 04:49:34,567 --> 04:49:39,405 BUT SO ANY OF THOSE CLINICAL 7699 04:49:39,405 --> 04:49:40,473 DECISION-MAKING TOOLS I JUST 7700 04:49:40,473 --> 04:49:42,141 SHOWED YOU AND MANY OTHERS, YOUR 7701 04:49:42,141 --> 04:49:43,910 LITTLE TRIGGERS THAT GO OFF IN 7702 04:49:43,910 --> 04:49:44,877 YOUR ELECTRONIC HEALTH RECORD, 7703 04:49:44,877 --> 04:49:47,180 THEY REALLY ALL RELY ON WHAT IT 7704 04:49:47,180 --> 04:49:51,584 IS THAT TRIGGERS HYPERTENSION OR 7705 04:49:51,584 --> 04:49:52,518 BLOOD PRESSURE CONTROL IN OUR 7706 04:49:52,518 --> 04:49:54,887 FAVORITE TOOL OF OUR CHOOSING. 7707 04:49:54,887 --> 04:49:58,591 AND I CAN HEAR YOU ALL SAYING IT 7708 04:49:58,591 --> 04:49:59,058 ICD10 CODES, HILARY. 7709 04:49:59,058 --> 04:49:59,659 OBVIOUSLY. 7710 04:49:59,659 --> 04:50:01,894 AND IF YOU SAID THAT TO ME, I 7711 04:50:01,894 --> 04:50:03,863 WOULD SAY WELL, YES, YOU'RE 7712 04:50:03,863 --> 04:50:05,999 PARTIALLY RIGHT, ICD10 CODES 7713 04:50:05,999 --> 04:50:07,734 CERTAINLY CAN BE USED TO TRIGGER 7714 04:50:07,734 --> 04:50:10,737 HYPERTENSION AND USED TO SORT OF 7715 04:50:10,737 --> 04:50:12,038 BUILD BLOOD PRESSURE CONTROL 7716 04:50:12,038 --> 04:50:13,039 MEASURES BUT I WOULD SAY YOU'RE 7717 04:50:13,039 --> 04:50:18,745 ONLY PARTIALLY RIGHT. 7718 04:50:18,745 --> 04:50:20,279 WHAT WE -- WHAT I AND MANY 7719 04:50:20,279 --> 04:50:20,947 RESEARCHERS IN THE FIELD HAVE 7720 04:50:20,947 --> 04:50:22,348 COME TO UNDERSTAND IS THAT WHEN 7721 04:50:22,348 --> 04:50:24,317 YOU REALLY DIG INTO ELECTRONIC 7722 04:50:24,317 --> 04:50:26,419 HEALTH RECORD DATA RELATED TO 7723 04:50:26,419 --> 04:50:28,054 HYPERTENSION, YOU START SEEING 7724 04:50:28,054 --> 04:50:29,589 NON-TRIVIAL NUMBERS OF PATIENTS 7725 04:50:29,589 --> 04:50:30,690 WHO HAVE NOT BEEN GIVEN A 7726 04:50:30,690 --> 04:50:31,891 DIAGNOSIS CODE, HAVE NOT BEEN 7727 04:50:31,891 --> 04:50:36,629 GIVEN AN ICD10 CODE, BUT THEY 7728 04:50:36,629 --> 04:50:41,234 HAVE MULTIPLE ELEVATED BLOOD 7729 04:50:41,234 --> 04:50:42,502 PRESSURE READ READINGS SO WE 7730 04:50:42,502 --> 04:50:44,504 SORT OF -- THIS IS POTENTIALLY 7731 04:50:44,504 --> 04:50:46,506 UNDIAGNOSED HYPERTENSION IN 7732 04:50:46,506 --> 04:50:47,106 ELECTRONIC HEALTH RECORDS, AND 7733 04:50:47,106 --> 04:50:48,274 MILLION HEARTS MY PROGRAM HAS 7734 04:50:48,274 --> 04:50:50,576 REALLY DONE THIS HIDING IN PLAIN 7735 04:50:50,576 --> 04:50:52,211 SIGHT, BECAUSE IF WE JUST START 7736 04:50:52,211 --> 04:50:52,879 TO LOOK FOR FOLKS, YOU'RE GOING 7737 04:50:52,879 --> 04:50:54,347 TO START FINDING OTHER PATIENTS 7738 04:50:54,347 --> 04:50:56,883 THAT POTENTIALLY HAVE 7739 04:50:56,883 --> 04:50:57,216 HYPERTENSION. 7740 04:50:57,216 --> 04:51:00,720 AND YOU CAN SEE HERE MIKE 7741 04:51:00,720 --> 04:51:02,355 RAYCOTS HAS PUBLISHED ON THIS, 7742 04:51:02,355 --> 04:51:04,123 WE'VE PUBLISHED ON WORK WE'VE 7743 04:51:04,123 --> 04:51:06,325 DONE SPECIFICALLY WITH COMMUNITY 7744 04:51:06,325 --> 04:51:07,894 HEALTH CENTERS TO REALLY DIG 7745 04:51:07,894 --> 04:51:09,495 INTO THE MICRO LEVEL DETAILS. 7746 04:51:09,495 --> 04:51:13,933 KAESER HAS PUBLISHED ON THIS IN 7747 04:51:13,933 --> 04:51:18,638 BOTH PREGNANT AS WELL AS NON 7748 04:51:18,638 --> 04:51:20,473 NON-PREGNANT AS WELL AS WITH 7749 04:51:20,473 --> 04:51:21,207 HYPERTENSION. 7750 04:51:21,207 --> 04:51:22,775 WHAT THIS IS REALLY COMING DOWN 7751 04:51:22,775 --> 04:51:28,614 TO IS DEVELOPING A HYPERTENSION 7752 04:51:28,614 --> 04:51:29,582 PHENOTYPE, USING ELECTRONIC 7753 04:51:29,582 --> 04:51:30,783 HEALTH RECORD DATA. 7754 04:51:30,783 --> 04:51:34,353 SO YES, OF COURSE ICD10 CODES 7755 04:51:34,353 --> 04:51:39,292 AND ICD10 ESSENTIAL HYPERTENSION 7756 04:51:39,292 --> 04:51:40,827 THAT'S WHAT'S USED MOST COMMONLY 7757 04:51:40,827 --> 04:51:43,563 IN OUR CLINICAL QUALITY MEASURES 7758 04:51:43,563 --> 04:51:45,765 AND -- BUT MIGHT YOU FOR YOUR 7759 04:51:45,765 --> 04:51:47,633 PRURPSES, FOR YOUR HEALTHCARE 7760 04:51:47,633 --> 04:51:49,368 SETTINGS PURPOSES, MIGHT YOU 7761 04:51:49,368 --> 04:51:51,671 WANT TO EXPAND THE ICD10 CODES 7762 04:51:51,671 --> 04:51:53,339 THAT YOU'RE LOOKING AT? 7763 04:51:53,339 --> 04:51:55,675 WE HEARD JORDY TALK ABOUT 7764 04:51:55,675 --> 04:51:56,342 HYPERTENSIVE CKD. 7765 04:51:56,342 --> 04:51:58,244 MIGHT WE WANT TO LOOK AT THAT IN 7766 04:51:58,244 --> 04:51:59,212 SOME OF OUR TOOLS? 7767 04:51:59,212 --> 04:52:01,414 DO YOU KNOW WHAT ICD10 CODES ARE 7768 04:52:01,414 --> 04:52:03,382 ACTUALLY BEING USED TO BUILD THE 7769 04:52:03,382 --> 04:52:06,119 DATA VISH SAYINGS THAT YOU'RE 7770 04:52:06,119 --> 04:52:07,253 SEEING? 7771 04:52:07,253 --> 04:52:08,654 MANY ON THE CALL ARE 7772 04:52:08,654 --> 04:52:09,222 HYPERTENSION RESEARCHERS SO 7773 04:52:09,222 --> 04:52:10,957 YOU'RE VERY INVOLVED IN YOUR 7774 04:52:10,957 --> 04:52:15,261 DATA, BUT EVERY DAY CLINICIAN 7775 04:52:15,261 --> 04:52:17,663 MIGHT NOT BE AS INVOLVED IN THE 7776 04:52:17,663 --> 04:52:19,866 NUTS AND BOLTS OF THEIR DATA 7777 04:52:19,866 --> 04:52:20,733 VISUALIZATIONS AND THEIR 7778 04:52:20,733 --> 04:52:22,201 CLINICAL DECISION-MAKING TOOLS. 7779 04:52:22,201 --> 04:52:23,636 SO THESE ARE JUST SOME 7780 04:52:23,636 --> 04:52:25,271 CONSIDERATIONS FROM AN ICD10 7781 04:52:25,271 --> 04:52:25,605 PERSPECTIVE. 7782 04:52:25,605 --> 04:52:27,473 BUT I WOULD ALSO ENCOURAGE FOLKS 7783 04:52:27,473 --> 04:52:29,008 TO THINK ABOUT LOOKING FOR 7784 04:52:29,008 --> 04:52:31,110 PATIENTS THAT ARE ON AN 7785 04:52:31,110 --> 04:52:32,078 ANTIHYPERTENSIVE MEDICATION, AND 7786 04:52:32,078 --> 04:52:34,247 I HEAR YOU, THEY'RE USED FOR OFF 7787 04:52:34,247 --> 04:52:34,981 LABEL REASONS. 7788 04:52:34,981 --> 04:52:38,818 WE LOOKED AT THAT IN THAT MEN'S 7789 04:52:38,818 --> 04:52:40,787 SURVEILLANCE -- THAT MENDS 7790 04:52:40,787 --> 04:52:41,687 SURVEILLANCE SYSTEM I TALKED 7791 04:52:41,687 --> 04:52:43,523 ABOUT AND IT ACTUALLY HAPPENED 7792 04:52:43,523 --> 04:52:46,292 MUCH LESS FREQUENTLY THAN I 7793 04:52:46,292 --> 04:52:46,592 ANTICIPATED. 7794 04:52:46,592 --> 04:52:47,426 I WOULD ABSOLUTELY CONSIDER 7795 04:52:47,426 --> 04:52:49,061 USING TWO OR MORE ELEVATED BLOOD 7796 04:52:49,061 --> 04:52:49,629 PRESSURE VALUES. 7797 04:52:49,629 --> 04:52:51,631 BUT YOU HAVE TO SYRINGE ABOUT 7798 04:52:51,631 --> 04:52:53,299 WHAT THRESHOLD DO YOU USE? 7799 04:52:53,299 --> 04:52:57,937 JUST AT 130/80 OR 140/90? 7800 04:52:57,937 --> 04:52:59,472 YOU MIGHT WANT TO START LOOKING 7801 04:52:59,472 --> 04:53:01,140 AT HIGHER BLOOD PRESSURE VALUES 7802 04:53:01,140 --> 04:53:03,409 BECAUSE YOU HAVE MORE CONFIDENCE 7803 04:53:03,409 --> 04:53:05,278 THAT THOSE PEOPLE LIKELY HAVE 7804 04:53:05,278 --> 04:53:05,711 HYPERTENSION. 7805 04:53:05,711 --> 04:53:07,580 ARE YOU THEKING ABOUT USING IT 7806 04:53:07,580 --> 04:53:11,918 SELF MEASURED BLOOD MONITORING 7807 04:53:11,918 --> 04:53:13,452 VALUES, ABOP IF IT'S AVAILABLE 7808 04:53:13,452 --> 04:53:14,854 TO YOU AND THEN ALSO SOME 7809 04:53:14,854 --> 04:53:17,056 HEALTHCARE SETTINGS USED TO BE 7810 04:53:17,056 --> 04:53:18,724 MORE PERTINENT, BUT THEY TAKE 7811 04:53:18,724 --> 04:53:19,258 INTO CONSIDERATION WHETHER 7812 04:53:19,258 --> 04:53:20,493 HYPERTENSION IS WRITTEN IN THE 7813 04:53:20,493 --> 04:53:22,328 CLINICAL NOTES. 7814 04:53:22,328 --> 04:53:23,429 SO ALL OF THESE SORT OF DATA 7815 04:53:23,429 --> 04:53:27,667 ELEMENTS COULD BE USED TO 7816 04:53:27,667 --> 04:53:29,769 BUILD -- LOOK LIKE FROM AN 7817 04:53:29,769 --> 04:53:31,070 ELECTRONIC HEALTH RECORD 7818 04:53:31,070 --> 04:53:31,370 PERSPECTIVE. 7819 04:53:31,370 --> 04:53:33,272 YOU CAN DO THE SAME THING WITH 7820 04:53:33,272 --> 04:53:34,273 BLOOD PRESSURE CONTROL, LOTS OF 7821 04:53:34,273 --> 04:53:35,474 DIFFERENT CONSIDERATIONS. 7822 04:53:35,474 --> 04:53:37,243 ARE YOU USING OFFICE BLOOD 7823 04:53:37,243 --> 04:53:39,111 PRESSURE VALUES, WHICH ONE, IF 7824 04:53:39,111 --> 04:53:40,613 THERE ARE MULTIPLE VALUES IN ONE 7825 04:53:40,613 --> 04:53:42,114 DAY, YOU NEED TO MAKE A DECISION 7826 04:53:42,114 --> 04:53:43,649 ABOUT HOW YOU'RE HANDLING THOSE. 7827 04:53:43,649 --> 04:53:45,384 ARE YOU DROPPING THE FIRST ONE, 7828 04:53:45,384 --> 04:53:47,353 ARE YOU AVERAGING THEM ALL, ARE 7829 04:53:47,353 --> 04:53:48,955 YOU TAKING THE LOWEST SYSTOLIC 7830 04:53:48,955 --> 04:53:52,558 AND THE LOWEST DIE STOL FROM TWO 7831 04:53:52,558 --> 04:53:55,761 DIFFERENT MEASURES -- CMS WANTS 7832 04:53:55,761 --> 04:53:57,396 65 AND Q F-18. 7833 04:53:57,396 --> 04:53:59,599 SO THERE'S LOTS OF DIFFERENT 7834 04:53:59,599 --> 04:54:00,967 DISSECTION POINTS IN THERE AND 7835 04:54:00,967 --> 04:54:02,235 DO YOU TOE WHAT DECISION POINTS 7836 04:54:02,235 --> 04:54:03,569 HAVE BEEN MADE WHEN YOU'RE 7837 04:54:03,569 --> 04:54:04,971 LOOKING AT THINGS LIKE A BLOOD 7838 04:54:04,971 --> 04:54:06,973 PRESSURE CONTROL REPORT, SMBP, 7839 04:54:06,973 --> 04:54:09,075 SAME THING, HOW ARE YOU HANDLING 7840 04:54:09,075 --> 04:54:11,210 THOSE VALUES, WHAT IF A PATIENT 7841 04:54:11,210 --> 04:54:12,945 BRINGS IN THEIR VALUES WRITTEN 7842 04:54:12,945 --> 04:54:14,013 DOWN ON PAPER, ARE YOU USING 7843 04:54:14,013 --> 04:54:15,514 THOSE THE SAME WAY YOU MIGHT IF 7844 04:54:15,514 --> 04:54:17,149 THEY WERE TRANSMITTED 7845 04:54:17,149 --> 04:54:17,516 ELECTRONICALLY? 7846 04:54:17,516 --> 04:54:20,219 HOW ARE YOU HANDLING SMBP OR RPM 7847 04:54:20,219 --> 04:54:23,055 IN THE PREGNANCY AND POSTPARTUM 7848 04:54:23,055 --> 04:54:24,123 POPULATION? 7849 04:54:24,123 --> 04:54:25,758 AOBP, SAME KINDS OF THINGS, THEN 7850 04:54:25,758 --> 04:54:27,493 FUTURE TECHNOLOGIES, THESE ARE 7851 04:54:27,493 --> 04:54:29,028 THINGS THAT AS PEOPLE ARE 7852 04:54:29,028 --> 04:54:29,929 DEVELOPING FUTURE TECHNOLOGIES, 7853 04:54:29,929 --> 04:54:34,567 I WISH THAT WHEN THEY GOT TO THE 7854 04:54:34,567 --> 04:54:35,768 FDA CLEARANCE POINT, THEY WOULD 7855 04:54:35,768 --> 04:54:36,936 START SAYING OKAY, LET'S ASSUME 7856 04:54:36,936 --> 04:54:38,304 I'M GOING TO GET FDA CLEARANCE, 7857 04:54:38,304 --> 04:54:40,439 WHAT DO WE NEED TO DO TO REALLY 7858 04:54:40,439 --> 04:54:41,507 IMPLEMENT THIS BROADLY IN THE 7859 04:54:41,507 --> 04:54:42,842 CLINICAL SETTINGS IN THE UNITED 7860 04:54:42,842 --> 04:54:43,075 STATES? 7861 04:54:43,075 --> 04:54:45,511 THESE ARE THE THINGS, THESE ARE 7862 04:54:45,511 --> 04:54:48,114 CONSIDERATIONS THAT I WISH 7863 04:54:48,114 --> 04:54:49,215 DEVICE MANUFACTURERS WOULD KEEP 7864 04:54:49,215 --> 04:54:50,249 IN MIND. 7865 04:54:50,249 --> 04:54:52,051 SO A LOT OF THIS, A LOT OF THE 7866 04:54:52,051 --> 04:54:54,120 CHALLENGES AND LIKE HOW YOU 7867 04:54:54,120 --> 04:54:55,187 FIGURE OUT WHETHER OR NOT THINGS 7868 04:54:55,187 --> 04:54:56,289 HAVE BEEN DONE, THESE ARE 7869 04:54:56,289 --> 04:54:57,556 MAPPING ISSUES. 7870 04:54:57,556 --> 04:54:58,991 AND THIS GETS LIKE REALLY SORT 7871 04:54:58,991 --> 04:55:01,394 OF INFORMATICS-HEAVY, BUT IT'S 7872 04:55:01,394 --> 04:55:03,496 ALSO NOT VERY WELL EXPLORED IN 7873 04:55:03,496 --> 04:55:04,931 THE PUBLISHED LITERATURE. 7874 04:55:04,931 --> 04:55:06,332 THIS IS ONE EXAMPLE THAT WE 7875 04:55:06,332 --> 04:55:08,534 LOOKED AT THOSE SORT OF 7876 04:55:08,534 --> 04:55:12,171 MEANINGFUL USE THE MEDICARE EHR 7877 04:55:12,171 --> 04:55:13,372 INCENTIVE PROGRAM DATA FROM 7878 04:55:13,372 --> 04:55:14,674 PHYSICIANS ONLY WHO REPORTED ON 7879 04:55:14,674 --> 04:55:16,709 IN Q F-18 WHICH IS CONTROLLING 7880 04:55:16,709 --> 04:55:17,143 HIGH BLOOD PRESSURE. 7881 04:55:17,143 --> 04:55:19,445 THE BOTTOM TWO, IF YOU LOOK AT 7882 04:55:19,445 --> 04:55:21,547 2014, THE DATA ON THE RIGHT, THE 7883 04:55:21,547 --> 04:55:23,182 BOTTOM TWO PIECES OF THE COLUMN 7884 04:55:23,182 --> 04:55:24,817 ARE JUST LIKE HOW THEY 7885 04:55:24,817 --> 04:55:25,618 PERFORMED. 7886 04:55:25,618 --> 04:55:28,821 THE TOP TWO PIECES ARE WHAT I 7887 04:55:28,821 --> 04:55:30,556 WANT TO POINT OUT. 7888 04:55:30,556 --> 04:55:32,191 4.4% OF PHYSICIANS REPORTED THEY 7889 04:55:32,191 --> 04:55:34,727 HAD ZERO PATIENTS WITH BLOOD 7890 04:55:34,727 --> 04:55:36,729 PRESSURE CONTROL, NO ONE HAD 7891 04:55:36,729 --> 04:55:38,798 THEIR BLOOD PRESSURE OVER 140/90 7892 04:55:38,798 --> 04:55:40,166 AND THEN ANOTHER 12% REPORTED 7893 04:55:40,166 --> 04:55:42,435 THAT THEY HAD ZERO PATIENCE WITH 7894 04:55:42,435 --> 04:55:48,874 HYPERTENSPATIENTS WITHHYPERTENS. 7895 04:55:48,874 --> 04:55:50,176 THAT SEEMED REALLY STRANGE TO US 7896 04:55:50,176 --> 04:55:51,877 THAT YOU HAD THIS BIG PORTION OF 7897 04:55:51,877 --> 04:55:57,116 PHYSICIANS CLAIMING THINGS ON 7898 04:55:57,116 --> 04:55:58,884 THE OPPOSITE ENDS OF THE 7899 04:55:58,884 --> 04:55:59,885 SPECTRUM, SO I THINK WHAT WE 7900 04:55:59,885 --> 04:56:01,187 DECIDED WAS THIS WAS REALLY A 7901 04:56:01,187 --> 04:56:02,154 MAPPING ISSUE AND THOSE 7902 04:56:02,154 --> 04:56:03,622 CLINICIANS NEEDED TO WORK WITH 7903 04:56:03,622 --> 04:56:04,423 THEIR ELECTRONIC HEALTH RECORD 7904 04:56:04,423 --> 04:56:05,925 PROVIDERS TO FIX WHATEVER ISSUE 7905 04:56:05,925 --> 04:56:06,726 THEY HAD. 7906 04:56:06,726 --> 04:56:08,561 THEY WEREN'T -- WHEREVER THEY 7907 04:56:08,561 --> 04:56:09,228 WERE ENTERING BLOOD PRESSURE 7908 04:56:09,228 --> 04:56:14,767 INTO THEIR INTERFACE OR EHR 7909 04:56:14,767 --> 04:56:16,268 INTERFACE TO WHERE IT WAS BEING 7910 04:56:16,268 --> 04:56:18,404 REPORTED OUT. 7911 04:56:18,404 --> 04:56:19,705 SO YOU ALL ARE LIKELY FAMILIAR 7912 04:56:19,705 --> 04:56:22,641 WITH THE FIVE RIGHTS OF CLINICAL 7913 04:56:22,641 --> 04:56:24,076 DECISION SUPPORT, YOU'VE GOT THE 7914 04:56:24,076 --> 04:56:25,511 RIGHT PERSON TO THE RIGHT PERSON 7915 04:56:25,511 --> 04:56:26,312 IN THE RIGHT FORMAT THROUGH THE 7916 04:56:26,312 --> 04:56:27,413 RIGHT CHANNEL AT THE RIGHT TIME. 7917 04:56:27,413 --> 04:56:29,515 AND I THINK WHEN IT COMES TO THE 7918 04:56:29,515 --> 04:56:30,149 RIGHT INFORMATION, SOME OF THAT 7919 04:56:30,149 --> 04:56:31,951 HAS TO DO WITH DATA VALIDATION, 7920 04:56:31,951 --> 04:56:35,788 AND I'M NOT GOING TO DIVE DEEPLY 7921 04:56:35,788 --> 04:56:36,889 INTO THIS BECAUSE WE HAVE A 7922 04:56:36,889 --> 04:56:37,990 PUBLICATION I INCLUDED ON THE 7923 04:56:37,990 --> 04:56:41,927 SLIDE WHERE WE REALLY DUG VERY, 7924 04:56:41,927 --> 04:56:44,397 VERY DEPLY AND WENT DOWN A 7925 04:56:44,397 --> 04:56:48,000 VALIDATION RABBIT HOLE FOR THAT 7926 04:56:48,000 --> 04:56:49,535 SYSTEM I TALKED ABOUT, YOU 7927 04:56:49,535 --> 04:56:51,303 REALLY HAVE AN OPPORTUNITY TO 7928 04:56:51,303 --> 04:56:52,972 PICK APART DATA ELEMENTS ANDLY 7929 04:56:52,972 --> 04:56:54,173 DISCOVER SOME VERY INTERESTING 7930 04:56:54,173 --> 04:56:54,807 THINGS. 7931 04:56:54,807 --> 04:56:56,876 SO NOT EVERYTHING IN THIS 7932 04:56:56,876 --> 04:56:58,477 PUBLICATION IS DIRECTLY 7933 04:56:58,477 --> 04:56:59,645 APPLICABLE TO A CLINICAL SETTING 7934 04:56:59,645 --> 04:57:01,013 BUT I THINK MANY OF THE CONCEPTS 7935 04:57:01,013 --> 04:57:03,249 CAN BE APPLIED FROM A VALIDATION 7936 04:57:03,249 --> 04:57:08,054 STANDPOINT. 7937 04:57:08,054 --> 04:57:10,122 SO I SORT OF WAS OUTLINING 7938 04:57:10,122 --> 04:57:10,689 CHALLENGES THERE. 7939 04:57:10,689 --> 04:57:12,792 SOME OF THE OPPORTUNITIES WE 7940 04:57:12,792 --> 04:57:14,894 HAVE, THE CLINICAL QUALITY ME 7941 04:57:14,894 --> 04:57:16,429 MEASURES THAT SORT OF ARE AN 7942 04:57:16,429 --> 04:57:18,130 INDICATOR OF CLINICAL 7943 04:57:18,130 --> 04:57:18,664 DECISION-MAKING, THERE ARE 7944 04:57:18,664 --> 04:57:19,432 OPPORTUNITIES THERE, THEY ONLY 7945 04:57:19,432 --> 04:57:20,833 LOOK AT ESSENTIAL HYPERTENSION, 7946 04:57:20,833 --> 04:57:23,269 MAYBE THAT'S OKAY, THEY EXCLUDE 7947 04:57:23,269 --> 04:57:24,670 PREGNANT INDIVIDUALS SO IF WE'RE 7948 04:57:24,670 --> 04:57:28,974 TRYING TO LOOK AT WHAT BLOOD 7949 04:57:28,974 --> 04:57:30,976 PRESSURE CONTROL, BLOOD PRESSURE 7950 04:57:30,976 --> 04:57:33,412 MANAGEMENT LOOKS LIKE IN 7951 04:57:33,412 --> 04:57:34,713 PREGNANT POPULATION, WE DON'T 7952 04:57:34,713 --> 04:57:35,681 HAVE THOSE MEASURES. 7953 04:57:35,681 --> 04:57:39,318 THEY ARE BEING DEVELOPED, THEY 7954 04:57:39,318 --> 04:57:41,654 HAVE M LINE INNOVATION AND EARLY 7955 04:57:41,654 --> 04:57:46,325 NEXT YEAR WE'LL LOOK AT -- IN 7956 04:57:46,325 --> 04:57:49,128 BOTH THE PREGNANT AND IMMEDIATE 7957 04:57:49,128 --> 04:57:49,528 POSTPARTUM PERIOD. 7958 04:57:49,528 --> 04:57:50,262 AGAIN AS FUTURE TECHNOLOGIES 7959 04:57:50,262 --> 04:57:52,231 COME TO LIGHT, WE NEED, THE 7960 04:57:52,231 --> 04:57:54,033 BROADER WE, NEED TO BE THICKING 7961 04:57:54,033 --> 04:57:55,868 ABOUT HOW DO WE INCORPORATE 7962 04:57:55,868 --> 04:57:57,570 THESE VALIDATED ACCEPTABLE BLOOD 7963 04:57:57,570 --> 04:57:58,971 PRESSURE TECHNOLOGIES INTO 7964 04:57:58,971 --> 04:58:00,072 MEASURES OF BLOOD PRESSURE 7965 04:58:00,072 --> 04:58:02,007 CONTROL. 7966 04:58:02,007 --> 04:58:03,109 IF WE'RE NOT THINKING ABOUT IT 7967 04:58:03,109 --> 04:58:04,743 NOW OR WHEN THESE TECHNOLOGIES 7968 04:58:04,743 --> 04:58:05,544 FIRST SORT OF COME TO LIGHT, 7969 04:58:05,544 --> 04:58:06,879 IT'S LIKE WE HAVE TO WAIT YEARS 7970 04:58:06,879 --> 04:58:08,414 AND YEARS FOR THEM TO ACTUALLY 7971 04:58:08,414 --> 04:58:11,150 GET INTO PRACTICE. 7972 04:58:11,150 --> 04:58:12,518 SMBP, MANY OF YOU KNOW THOSE 7973 04:58:12,518 --> 04:58:15,788 VALUES HAVE BEEN EVOLVING OVER 7974 04:58:15,788 --> 04:58:17,156 TIME HOW THEY'RE BEING DIGESTED 7975 04:58:17,156 --> 04:58:18,791 BY THE CLINICAL QUALITY 7976 04:58:18,791 --> 04:58:19,125 MEASURES. 7977 04:58:19,125 --> 04:58:19,992 RIGHT NOW THEY DON'T SAY YOU 7978 04:58:19,992 --> 04:58:21,193 HAVE TO USE AN AVERAGE BLOOD 7979 04:58:21,193 --> 04:58:22,628 PRESSURE SO THAT'S PROBLEMATIC, 7980 04:58:22,628 --> 04:58:25,164 BUT AT LEAST THERE'S AN ESSENCE 7981 04:58:25,164 --> 04:58:27,900 OF SMBP IN THOSE VALUES. 7982 04:58:27,900 --> 04:58:30,402 THE PREVENT CALCULATOR, THIS IS 7983 04:58:30,402 --> 04:58:31,537 OUT. 7984 04:58:31,537 --> 04:58:32,872 WE THINK LIKELY IT'S GOING TO BE 7985 04:58:32,872 --> 04:58:35,274 INVOLVED IN FUTURE HYPERTENSION 7986 04:58:35,274 --> 04:58:35,941 GUIDELINES. 7987 04:58:35,941 --> 04:58:38,144 WE KNOW RIGHT NOW THERE ARE EHR 7988 04:58:38,144 --> 04:58:41,347 INSTALLATIONS THAT CAN'T DO AN 7989 04:58:41,347 --> 04:58:42,848 ASCBD RISK CALCULATION AND IT'S 7990 04:58:42,848 --> 04:58:44,783 BEEN YEARS SINCE THAT WAS THE 7991 04:58:44,783 --> 04:58:45,951 RECOMMENDATION IN THE GUIDELINE. 7992 04:58:45,951 --> 04:58:47,620 SO NOW IS THE TIME TO BE 7993 04:58:47,620 --> 04:58:50,656 THINKING ABOUT HOW DO WE 7994 04:58:50,656 --> 04:58:52,258 INCORPORATE IT INTO AN 7995 04:58:52,258 --> 04:58:53,359 ELECTRONIC HEALTH RECORD SO THAT 7996 04:58:53,359 --> 04:58:54,994 IT READY TO GO WHEN NEW 7997 04:58:54,994 --> 04:58:55,861 GUIDELINES COME OUT. 7998 04:58:55,861 --> 04:58:58,330 I'M GOING TO SKIP AHEAD A LITTLE 7999 04:58:58,330 --> 04:59:00,099 BIT JUST FOR THE SAKE OF TIME. 8000 04:59:00,099 --> 04:59:04,170 SO I AM A HUGE SMBP FAN AND I 8001 04:59:04,170 --> 04:59:15,314 HEARD DR. INJURE CHECK JURASCHEF 8002 04:59:16,048 --> 04:59:17,383 US HAVE BEEN WORKING TO CLOSE 8003 04:59:17,383 --> 04:59:18,350 THOSE GAPS OVER THE LAST NUMBER 8004 04:59:18,350 --> 04:59:18,751 OF YEARS. 8005 04:59:18,751 --> 04:59:20,085 THERE ARE A FEW THINGS THAT HAVE 8006 04:59:20,085 --> 04:59:21,453 HAPPENED IN THE PAST TWO OR SO 8007 04:59:21,453 --> 04:59:22,521 YEARS I WANT TO MAKE SURE 8008 04:59:22,521 --> 04:59:23,322 EVERYONE KNOWS ABOUT. 8009 04:59:23,322 --> 04:59:24,823 ONE OF THE BIGGEST BARRIERS THAT 8010 04:59:24,823 --> 04:59:28,727 I'VE HEARD FROM CLINICIANS IS 8011 04:59:28,727 --> 04:59:30,563 THAT THERE'S NO PLACE TO CAPTURE 8012 04:59:30,563 --> 04:59:32,097 AN AVERAGE BLOOD PRESSURE IN THE 8013 04:59:32,097 --> 04:59:33,299 EHR. 8014 04:59:33,299 --> 04:59:34,900 WELL, THERE'S SOMETHING CALLED 8015 04:59:34,900 --> 04:59:37,403 THE US CHORDAE TA FOR 8016 04:59:37,403 --> 04:59:39,471 INTEROPERABILITY THAT WILL BE 8017 04:59:39,471 --> 04:59:40,806 MANDATORY IN CERTIFIED 8018 04:59:40,806 --> 04:59:42,174 ELECTRONIC HEALTH RECORD 8019 04:59:42,174 --> 04:59:42,441 PRODUCTS. 8020 04:59:42,441 --> 04:59:46,278 AND MANY OF US ON THIS CALL AND 8021 04:59:46,278 --> 04:59:47,713 MANY OTHER FOLKS CONCERNED ABOUT 8022 04:59:47,713 --> 04:59:48,280 HYPERTENSION, BLOOD PRESSURE 8023 04:59:48,280 --> 04:59:49,548 CONTROL, WE SORT OF ADVOCATED 8024 04:59:49,548 --> 04:59:52,017 WITH A LOWER CASE A AND PUT 8025 04:59:52,017 --> 04:59:53,986 COMMENTS IN, PUBLIC COMMENTS IN 8026 04:59:53,986 --> 04:59:57,323 SUPPORTING THE USE OF AVERAGE 8027 04:59:57,323 --> 04:59:57,923 BLOOD PRESSURE IN ELECTRONIC 8028 04:59:57,923 --> 04:59:58,757 HEALTH RECORDS, SO SOON IN 8029 04:59:58,757 --> 05:00:01,260 COMING YEARS, THAT WILL BE A 8030 05:00:01,260 --> 05:00:03,362 MANDATORY FIELD THAT ELECTRONIC 8031 05:00:03,362 --> 05:00:03,963 HEALTH RECORDS WILL HAVE TO BE 8032 05:00:03,963 --> 05:00:10,903 ABLE TO CAPTURE, AND CARDX IS A 8033 05:00:10,903 --> 05:00:12,871 STANDARDS EFFORT THAT I 8034 05:00:12,871 --> 05:00:14,206 ENCOURAGE TO YOU CHECK OUT. 8035 05:00:14,206 --> 05:00:16,141 I THINK THIS WILL REALLY HELP 8036 05:00:16,141 --> 05:00:18,344 STREAMLINE DATA TRANSMISSION FOR 8037 05:00:18,344 --> 05:00:19,345 SMBP AS WELL. 8038 05:00:19,345 --> 05:00:20,045 I'M GOING TO END IT THERE 8039 05:00:20,045 --> 05:00:21,247 BECAUSE I KNOW WE'RE OVER TIME, 8040 05:00:21,247 --> 05:00:22,481 BUT I'LL PASS IT OVER TO YOU, 8041 05:00:22,481 --> 05:00:22,681 KATE. 8042 05:00:22,681 --> 05:00:24,083 THANK YOU. 8043 05:00:24,083 --> 05:00:25,718 >> THANK YOU, HILARY. 8044 05:00:25,718 --> 05:00:27,119 WE'LL HAVE ALL OUR SPEAKERS COME 8045 05:00:27,119 --> 05:00:29,788 BACK ON CAMERA HERE AND I JUST 8046 05:00:29,788 --> 05:00:31,457 WANT TO KICK OFF OUR DISCUSSION 8047 05:00:31,457 --> 05:00:32,958 SECTION BY THANKING ALL OF OUR 8048 05:00:32,958 --> 05:00:33,225 SPEAKERS. 8049 05:00:33,225 --> 05:00:35,494 THESE WERE WONDERFUL, WONDERFUL 8050 05:00:35,494 --> 05:00:36,295 PRESENTATIONS, REALLY I THINK 8051 05:00:36,295 --> 05:00:39,598 THE WHOLE DAY HAS BEEN 8052 05:00:39,598 --> 05:00:40,332 FANTASTIC. 8053 05:00:40,332 --> 05:00:44,003 AS WE GET INTO QUESTIONI QUESTIM 8054 05:00:44,003 --> 05:00:45,204 REFLECTING THAT COMING FROM THE 8055 05:00:45,204 --> 05:00:46,038 IMPLEMENTATION SIDE OF THINGS 8056 05:00:46,038 --> 05:00:47,573 AND WORKING WITH PHYSICIANS AND 8057 05:00:47,573 --> 05:00:48,107 CARE TEAMS. 8058 05:00:48,107 --> 05:00:49,208 I SEE THAT MANY OF THE ISSUES 8059 05:00:49,208 --> 05:00:52,978 THAT WE'VE DISCUSSED TODAY ARE 8060 05:00:52,978 --> 05:00:53,746 REALLY NOT TOP OF MIND TO THEM. 8061 05:00:53,746 --> 05:00:55,481 THEY REALLY DO NOT HAVE A LOT OF 8062 05:00:55,481 --> 05:00:56,949 AWARENESS INTO SOME OF THE 8063 05:00:56,949 --> 05:00:59,385 QUESTIONS THAT WE'RE THINKING 8064 05:00:59,385 --> 05:01:00,586 ABOUT, TRYING TO SUR FAR, TRYING 8065 05:01:00,586 --> 05:01:01,987 TO ANSWER WITH FURTHER RESEARCH. 8066 05:01:01,987 --> 05:01:04,089 SO I HOPE THIS GROUP IN ADDITION 8067 05:01:04,089 --> 05:01:05,257 TO REALLY IDENTIFYING RESEARCH 8068 05:01:05,257 --> 05:01:07,860 GAPS, I HOPE WE CAN ALSO 8069 05:01:07,860 --> 05:01:09,728 IDENTIFY WHAT IS SETTLED AND 8070 05:01:09,728 --> 05:01:12,164 REALLY KIND OF SURFACE SET AND 8071 05:01:12,164 --> 05:01:13,599 OUTLINE THAT AND MAKE IT VERY 8072 05:01:13,599 --> 05:01:14,900 CLEAR TO CLINICIANS AND CARE 8073 05:01:14,900 --> 05:01:16,535 TEAMS WHAT BEST PRACTICES ARE 8074 05:01:16,535 --> 05:01:17,736 AND WORK TOWARDS GETTING THOSE 8075 05:01:17,736 --> 05:01:19,271 THINGS ALL INCORPORATED INTO 8076 05:01:19,271 --> 05:01:23,242 GUIDELINES AND THEN SOME OF US 8077 05:01:23,242 --> 05:01:23,842 HERE ON THIS CALL CAN REALLY 8078 05:01:23,842 --> 05:01:24,977 TAKE THAT AND WORK ON THE 8079 05:01:24,977 --> 05:01:27,613 IMPLEMENTATION SIDE OF THINGS. 8080 05:01:27,613 --> 05:01:29,715 BUT I KNOW PART OF OUR CHARGE 8081 05:01:29,715 --> 05:01:30,749 TODAY IS REALLY TALKING ABOUT 8082 05:01:30,749 --> 05:01:31,417 THOSE RESEARCH GAPS. 8083 05:01:31,417 --> 05:01:32,718 SO MY FIRST QUESTION REALLY TO 8084 05:01:32,718 --> 05:01:34,887 ALL THE SPEAKERS, YOU ALL 8085 05:01:34,887 --> 05:01:36,422 IDENTIFIED MAJOR GAPS AND 8086 05:01:36,422 --> 05:01:36,755 OPPORTUNITIES. 8087 05:01:36,755 --> 05:01:40,693 BUT IF WE HAD TO PUSH YOU ON 8088 05:01:40,693 --> 05:01:42,394 THAT SINGLE SORT OF LOW HANGING 8089 05:01:42,394 --> 05:01:43,595 FRUIT OR THAT SINGLE HIGHEST 8090 05:01:43,595 --> 05:01:47,766 PRIORITY FOR US TO SOLVE WITH 8091 05:01:47,766 --> 05:01:48,634 FURTHER INVESTIGATION THAT WOULD 8092 05:01:48,634 --> 05:01:49,835 REALLY ADVANCE THIS FIELD, WHAT 8093 05:01:49,835 --> 05:01:50,436 WOULD IT BE? 8094 05:01:50,436 --> 05:01:52,304 MAYBE WE CAN GO IN ORDER OF OUR 8095 05:01:52,304 --> 05:01:55,541 SPEAKERS, STARTING WITH YOU, 8096 05:01:55,541 --> 05:01:55,774 MARWAH. 8097 05:01:55,774 --> 05:01:58,677 >> I'M GOING TO SAY WE SHOULD BE 8098 05:01:58,677 --> 05:01:59,445 IMPLEMENTING THINGS WE ALREADY 8099 05:01:59,445 --> 05:02:01,747 KNOW WORK. 8100 05:02:01,747 --> 05:02:04,016 SO FOCUSING ON THE WORK THATTA 8101 05:02:04,016 --> 05:02:09,355 THATTAMMY AND OTHERS HAVE DONE S 8102 05:02:09,355 --> 05:02:10,956 PROPER TECHNIQUE AND EDUCATION 8103 05:02:10,956 --> 05:02:12,024 AND IT IS BARRIERS WITHIN OUR 8104 05:02:12,024 --> 05:02:13,425 OWN COMMUNITIES AS CLINICIANS 8105 05:02:13,425 --> 05:02:16,995 BROADLY DEFINED WHETHER IT'S 8106 05:02:16,995 --> 05:02:19,131 COMMUNITY HEALTH WORKERS, ALL 8107 05:02:19,131 --> 05:02:20,499 THE WAY TO PHYSICIANS AND OTHER 8108 05:02:20,499 --> 05:02:21,934 TYPES OF PROFESSIONALS. 8109 05:02:21,934 --> 05:02:24,069 I WORRY THAT ACTUALLY WITH MORE 8110 05:02:24,069 --> 05:02:27,005 INFORMATION, MORE NEW DEVICES, 8111 05:02:27,005 --> 05:02:28,440 MORE CONTINUOUS THRESHOLDS, ALL 8112 05:02:28,440 --> 05:02:30,142 THE THINGS THAT I BROUGHT UP, 8113 05:02:30,142 --> 05:02:32,978 WE'RE GOING TO DO WORSE BECAUSE 8114 05:02:32,978 --> 05:02:34,613 WE HAVEN'T GOTTEN THE BASICS 8115 05:02:34,613 --> 05:02:36,482 CORRECT. 8116 05:02:36,482 --> 05:02:38,384 AND THAT'S GOING TO CAUSE MORE 8117 05:02:38,384 --> 05:02:39,385 PROBLEMS IN THE FUTURE RATHER 8118 05:02:39,385 --> 05:02:41,787 THAN SOLVING THEM. 8119 05:02:41,787 --> 05:02:43,088 >> KEEP IT SIMPLE. 8120 05:02:43,088 --> 05:02:46,425 I THINK THERE'S A LOT OF VALUE 8121 05:02:46,425 --> 05:02:46,625 THERE. 8122 05:02:46,625 --> 05:02:47,092 RAMA, WHAT ABOUT YOU? 8123 05:02:47,092 --> 05:02:49,094 >> WELL, I TALKED ABOUT CUFFLESS 8124 05:02:49,094 --> 05:02:50,696 BLOOD PRESSURE TECHNOLOGY AND 8125 05:02:50,696 --> 05:02:52,531 WHERE IT STANDS AT PRESENT, BUT 8126 05:02:52,531 --> 05:02:56,769 I'LL TRY TO ANSWER YOUR QUESTION 8127 05:02:56,769 --> 05:02:58,203 MORE BROADLY THAN MY TALK. 8128 05:02:58,203 --> 05:02:59,972 THE UNFORTUNATE THING IS IN 8129 05:02:59,972 --> 05:03:01,039 CUFFLESS BLOOD PRESSURE 8130 05:03:01,039 --> 05:03:01,607 MEASUREMENT, THERE IS NO LOW 8131 05:03:01,607 --> 05:03:03,308 HANGING FRUIT. 8132 05:03:03,308 --> 05:03:04,743 DEVELOPING ACCURATE CUFFLESS 8133 05:03:04,743 --> 05:03:06,512 BLOOD PRESSURE DEVICES, IT'S A 8134 05:03:06,512 --> 05:03:09,014 SUPER HARD TECHNICAL PROBLEM, 8135 05:03:09,014 --> 05:03:11,483 AND SINCE THE REGULATORY CLEARED 8136 05:03:11,483 --> 05:03:13,218 CUFFLESS DEVICES ONLY MEASURE 8137 05:03:13,218 --> 05:03:16,688 BLOOD PRESSURE CHANGES, THEIR 8138 05:03:16,688 --> 05:03:17,389 VALIDATION REQUIRES INDUCING 8139 05:03:17,389 --> 05:03:17,990 BLOOD PRESSURE CHANGES. 8140 05:03:17,990 --> 05:03:19,858 AND THIS MAKES VALIDATION A HARD 8141 05:03:19,858 --> 05:03:21,260 PROBLEM AS WELL. 8142 05:03:21,260 --> 05:03:23,729 AND SO I WOULD SAY, FOR THE 8143 05:03:23,729 --> 05:03:25,164 ATTENDEES OF THIS WORKSHOP THAT 8144 05:03:25,164 --> 05:03:29,101 PROBABLY THE SINGLE HIGH 8145 05:03:29,101 --> 05:03:30,636 PRIORITY ITEM TO ADDRESS WOULD 8146 05:03:30,636 --> 05:03:31,570 BE TO DEVELOP A VALIDATION 8147 05:03:31,570 --> 05:03:34,306 STANDARD FOR CUFFLESS DEVICES 8148 05:03:34,306 --> 05:03:37,976 WITH CONSENSUS FROM MULTIPLE 8149 05:03:37,976 --> 05:03:40,212 GROUPS, AND I THINK THAT SOME OF 8150 05:03:40,212 --> 05:03:42,414 THE PEOPLE SHOULD HAVE THE 8151 05:03:42,414 --> 05:03:43,982 TECHNICAL KNOWLEDGE AND BE 8152 05:03:43,982 --> 05:03:45,350 IMPARTIAL, LIKE NEED TO HAVE 8153 05:03:45,350 --> 05:03:47,653 BOTH OF THOSE. 8154 05:03:47,653 --> 05:03:50,923 AND A VALIDATION ST STANDARD, IT 8155 05:03:50,923 --> 05:03:52,524 WOULD BE IMPORTANT FOR TWO 8156 05:03:52,524 --> 05:03:52,758 REASONS. 8157 05:03:52,758 --> 05:03:54,226 ONE REASON IS TO PREVENT 8158 05:03:54,226 --> 05:03:55,194 INADEQUATE DEVICES FROM BEING 8159 05:03:55,194 --> 05:03:57,463 USED IN PATIENT CARE, AND THE 8160 05:03:57,463 --> 05:03:58,096 OTHER REASON, I THINK IT'S JUST 8161 05:03:58,096 --> 05:03:59,765 AS IMPORTANT, IS TO FOSTER THE 8162 05:03:59,765 --> 05:04:01,366 DEVELOPMENT OF NEW TECHNOLOGY 8163 05:04:01,366 --> 05:04:03,669 THAT COULD SUCCESSFULLY PASS THE 8164 05:04:03,669 --> 05:04:06,939 VALIDATION STANDARD. 8165 05:04:06,939 --> 05:04:10,776 >> THAT SEEMS LIKE A GOOD TEE-UP 8166 05:04:10,776 --> 05:04:11,243 FOR TAMMY. 8167 05:04:11,243 --> 05:04:12,878 >> SO I THINK -- WELL, ACTUALLY 8168 05:04:12,878 --> 05:04:14,446 I LIKE WHAT MARWAH WAS SAYING, I 8169 05:04:14,446 --> 05:04:16,715 THINK WE CAN DO A BETTER JOB OF 8170 05:04:16,715 --> 05:04:17,316 USING THE TOOLS THAT WE HAVE, 8171 05:04:17,316 --> 05:04:22,754 BUT I ALSO THINK I WOULD LOVE TO 8172 05:04:22,754 --> 05:04:23,856 MAKE IT EASIER FOR PATIENTS TO 8173 05:04:23,856 --> 05:04:26,225 PROVIDE US WITH HOME OR OUT OF 8174 05:04:26,225 --> 05:04:26,792 OFFICE BLOOD PRESSURE 8175 05:04:26,792 --> 05:04:27,860 MEASUREMENTS THAT ARE ACCURATE. 8176 05:04:27,860 --> 05:04:29,394 IT IS SUCH AN AMAZING TOOL, 8177 05:04:29,394 --> 05:04:30,662 THAT'S WHERE MOST OF OUR 8178 05:04:30,662 --> 05:04:31,330 PATIENTS ARE SPENDING THEIR 8179 05:04:31,330 --> 05:04:32,297 TIME, BUT ESPECIALLY IN 8180 05:04:32,297 --> 05:04:33,832 CHILDREN, IT'S REALLY HARD TO 8181 05:04:33,832 --> 05:04:36,401 GET GOOD OUT OF OFFICE BLOOD 8182 05:04:36,401 --> 05:04:36,668 PRESSURE. 8183 05:04:36,668 --> 05:04:37,936 WE DON'T HAVE ENOUGH DEVICES, 8184 05:04:37,936 --> 05:04:39,137 THE KIDS DON'T REALLY ENJOY 8185 05:04:39,137 --> 05:04:40,839 WEARING THEM, IT'S HARD FOR 8186 05:04:40,839 --> 05:04:42,174 FAMILIES TO HAVE TO -- IF WE'RE 8187 05:04:42,174 --> 05:04:43,242 DOING AN AMBULATORY BLOOD 8188 05:04:43,242 --> 05:04:45,310 PRESSURE MONITORING TEST, THEY 8189 05:04:45,310 --> 05:04:46,912 HAVE TO COME TO THE CLINIC TO 8190 05:04:46,912 --> 05:04:47,679 GET THE DEVICE, THEY HAVE TO 8191 05:04:47,679 --> 05:04:49,848 RETURN IT, THEY HAVE TO TAKE OFF 8192 05:04:49,848 --> 05:04:51,550 TIME, AND WE JUST DON'T MAKE IT 8193 05:04:51,550 --> 05:04:52,518 EASY FOR PATIENTS AND SO I THINK 8194 05:04:52,518 --> 05:04:55,821 A LOT OF OUR PATIENTS ARE NOT 8195 05:04:55,821 --> 05:04:57,422 GETTING OPTIMAL CARE. 8196 05:04:57,422 --> 05:04:58,590 SO I THINK IF WE COULD COME UP 8197 05:04:58,590 --> 05:05:00,125 WITH WAYS TO MAKE IT EASIER TO 8198 05:05:00,125 --> 05:05:01,326 GET OUT OF OFFICE BLOOD PRESSURE 8199 05:05:01,326 --> 05:05:06,465 MEASUREMENTS FOR ALL PATIENTS, 8200 05:05:06,465 --> 05:05:08,100 AND MAKE SURE WE ADDRESS SOME OF 8201 05:05:08,100 --> 05:05:09,167 THOSE DISPARITIES FOR THAT, I 8202 05:05:09,167 --> 05:05:10,168 THINK THAT WOULD BE REALLY 8203 05:05:10,168 --> 05:05:11,537 GREAT, THAT WOULD BE WHERE I 8204 05:05:11,537 --> 05:05:15,641 THINK THE PRIORITY SHOULD BE. 8205 05:05:15,641 --> 05:05:18,243 >> I TOTALLY AGREE WE NEED TO 8206 05:05:18,243 --> 05:05:18,844 MAKE IT EASIER AND ONE OF THE 8207 05:05:18,844 --> 05:05:20,546 WAYS WE CAN MAKE IT EASIER IS BY 8208 05:05:20,546 --> 05:05:23,148 FOCUSING ON INTEROPERABILITY AND 8209 05:05:23,148 --> 05:05:23,749 STANDARDS, BECAUSE RIGHT NOW, 8210 05:05:23,749 --> 05:05:26,418 ALL OF OUR TECHNICAL HEL I.T. 8211 05:05:26,418 --> 05:05:28,954 TOOLS, THEY ALL SPEAK A 8212 05:05:28,954 --> 05:05:29,888 DIFFERENT LANGUAGE, A 8213 05:05:29,888 --> 05:05:30,756 PROPRIETARY LANGUAGE, AND SO 8214 05:05:30,756 --> 05:05:32,958 WHEN YOU TRY TO TRANSMIT FROM 8215 05:05:32,958 --> 05:05:34,459 ONE DIRECTION OR THE OTHER, YOU 8216 05:05:34,459 --> 05:05:37,162 HAVE TO, LIKE, TRANSLATE BETWEEN 8217 05:05:37,162 --> 05:05:38,564 EVERY UNIQUE SYSTEM. 8218 05:05:38,564 --> 05:05:40,232 AND THAT POSES ITS OWN SET OF 8219 05:05:40,232 --> 05:05:40,632 CHALLENGES. 8220 05:05:40,632 --> 05:05:42,234 SO THERE ARE -- I TRIED TO -- I 8221 05:05:42,234 --> 05:05:43,569 WAS ENDING BUT THERE ARE 8222 05:05:43,569 --> 05:05:44,970 STANDARDS THAT EXIST AND MORE 8223 05:05:44,970 --> 05:05:46,438 STANDARDS NEED TO BE BUILT, BUT 8224 05:05:46,438 --> 05:05:48,206 I THINK FOCUSING ON 8225 05:05:48,206 --> 05:05:48,974 INTEROPERABILITY HELPS US NOW 8226 05:05:48,974 --> 05:05:50,842 FOR THE TOOLS THAT WE HAVE, AND 8227 05:05:50,842 --> 05:05:52,311 HELPS US AS WE THINK FORWARD 8228 05:05:52,311 --> 05:05:55,514 LIKE WHAT TOOLS ARE COMING. 8229 05:05:55,514 --> 05:05:57,683 >> ONE COMMENT ON THAT BEFORE -- 8230 05:05:57,683 --> 05:05:59,017 I KNOW KIMBERLY WANTS TO ASK A 8231 05:05:59,017 --> 05:05:59,284 QUESTION. 8232 05:05:59,284 --> 05:06:00,586 I AGREE WITH YOU ON THE 8233 05:06:00,586 --> 05:06:01,353 STANDARDS, HILARY, BUT I ALSO 8234 05:06:01,353 --> 05:06:03,322 HAVE CONCERNS ABOUT THE PACE AT 8235 05:06:03,322 --> 05:06:04,489 WHICH THIS WORKS. 8236 05:06:04,489 --> 05:06:07,225 YOU'VE MENTIONED THE U.S. CDI 8237 05:06:07,225 --> 05:06:08,860 VERSION 4 THAT WILL INCLUDE 8238 05:06:08,860 --> 05:06:10,162 AMBULATORY -- OR AVERAGE BLOOD 8239 05:06:10,162 --> 05:06:10,996 PRESSURE. 8240 05:06:10,996 --> 05:06:13,065 I'M NOT SURE WE KNOW THE 8241 05:06:13,065 --> 05:06:14,166 IMPLEMENTATION DATA OF THAT YET. 8242 05:06:14,166 --> 05:06:17,102 I THINK IT'S GOING TO BE 2027 OR 8243 05:06:17,102 --> 05:06:17,302 2028. 8244 05:06:17,302 --> 05:06:19,605 >> WE DON'T KNOW FOR SURE, BUT I 8245 05:06:19,605 --> 05:06:21,239 THINK WE CAN PRESSURE -- I THINK 8246 05:06:21,239 --> 05:06:23,375 IF EVERYONE IS PRESSURING EHR 8247 05:06:23,375 --> 05:06:25,344 VENDORS TO PRECERTIFY ON THOSE 8248 05:06:25,344 --> 05:06:27,379 DATA ELEMENTS, I THINK WE MIGHT 8249 05:06:27,379 --> 05:06:30,882 BE ABLE TO MAKE SOME HEADWAY. 8250 05:06:30,882 --> 05:06:32,184 >> THANK YOU SO MUCH. 8251 05:06:32,184 --> 05:06:33,719 I THINK MY QUESTION ACTUALLY 8252 05:06:33,719 --> 05:06:35,887 FOLLOWS THAT PRETTY WELL. 8253 05:06:35,887 --> 05:06:38,957 YOU KNOW, RAMA TOUCHED ON THE 8254 05:06:38,957 --> 05:06:40,559 FACT THAT CUFFLESS BLOOD 8255 05:06:40,559 --> 05:06:43,929 PRESSURE DEVICES MAY NOT BE, YOU 8256 05:06:43,929 --> 05:06:44,896 KNOW, CLINICALLY READY. 8257 05:06:44,896 --> 05:06:47,099 ONCE THEY ARE CLINICALLY READY, 8258 05:06:47,099 --> 05:06:49,701 HOW DO WE SEE THESE DEVICES 8259 05:06:49,701 --> 05:06:53,705 BEING INCORPORATED INTO CLINICAL 8260 05:06:53,705 --> 05:06:54,606 DECISION-MAKING AS A FIRST STEP, 8261 05:06:54,606 --> 05:06:57,275 YOU KNOW, HAVING THESE DEVICES 8262 05:06:57,275 --> 05:06:59,044 CONNECT TO EHRs? 8263 05:06:59,044 --> 05:07:00,779 WHAT'S THE FIRST STEP IN 8264 05:07:00,779 --> 05:07:02,514 INCORPORATING THOSE INTO THE 8265 05:07:02,514 --> 05:07:07,119 CLINICAL DECISION-MAKING? 8266 05:07:07,119 --> 05:07:08,387 >> THERE ARE MANY FIRST STEPS 8267 05:07:08,387 --> 05:07:10,922 THAT HAVE TO HAPPEN ALL AT THE 8268 05:07:10,922 --> 05:07:13,558 SAME TIME, I THINK. 8269 05:07:13,558 --> 05:07:15,661 >> WELL, AS A CLINICIAN, I HAVE 8270 05:07:15,661 --> 05:07:16,995 TO SAY, I'M A LITTLE WORRIED 8271 05:07:16,995 --> 05:07:18,530 ABOUT ONCE WE GET ALL THAT 8272 05:07:18,530 --> 05:07:19,398 INFORMATION FROM PATIENTS, IT 8273 05:07:19,398 --> 05:07:24,269 GOING TO BE A MASSIVE AMOUNT OF 8274 05:07:24,269 --> 05:07:26,238 DATA, AND I DON'T KNOW -- YOU 8275 05:07:26,238 --> 05:07:28,473 KNOW, I THINK THAT'S GOING TO BE 8276 05:07:28,473 --> 05:07:29,274 CHALLENGING TO FIGURE OUT WHAT 8277 05:07:29,274 --> 05:07:30,042 TO DO WITH IT. 8278 05:07:30,042 --> 05:07:31,443 AND I ALSO THINK THINGS THAT ARE 8279 05:07:31,443 --> 05:07:34,312 GOING TO BE CHALLENGING, YOU 8280 05:07:34,312 --> 05:07:36,748 KNOW, JUST AS A STEP BACK, WHEN 8281 05:07:36,748 --> 05:07:38,283 I GET HOME BLOOD PRESSURE 8282 05:07:38,283 --> 05:07:39,051 MEASUREMENTS, SOMETIMES I'M NOT 8283 05:07:39,051 --> 05:07:40,686 SURE WHAT TO DO WITH THEM 8284 05:07:40,686 --> 05:07:42,087 BECAUSE DO THEY GET A VALIDATED 8285 05:07:42,087 --> 05:07:43,155 DEVICE, IS THE CUFF THE RIGHT 8286 05:07:43,155 --> 05:07:45,190 SIZE, I CAN'T TELL YOU HOW MANY 8287 05:07:45,190 --> 05:07:47,392 KIDS ARE SENT TO THE ED FOR 8288 05:07:47,392 --> 05:07:48,794 HYPERTENSIVE CRISIS BECAUSE THEY 8289 05:07:48,794 --> 05:07:51,263 USED A SMALL CUFF, IS IT THE 8290 05:07:51,263 --> 05:07:52,264 RIGHT SIZE CUFF, DID THEY ADHERE 8291 05:07:52,264 --> 05:07:53,065 TO ALL OF THE DIFFERENT STEPS 8292 05:07:53,065 --> 05:07:56,101 THAT YOU NEED FOR VARIOUS 8293 05:07:56,101 --> 05:07:57,569 ACCURACY, AND I'VE BEEN SPENDING 8294 05:07:57,569 --> 05:08:00,639 THE LAST COUPLE YEARS OF MY 8295 05:08:00,639 --> 05:08:02,274 CAREER WORKING ON ACCURACY, AND 8296 05:08:02,274 --> 05:08:04,342 SO WHEN WE HAVE NOW THESE 8297 05:08:04,342 --> 05:08:05,544 CUFFLESS DEVICES WHERE I THINK 8298 05:08:05,544 --> 05:08:07,179 THAT THERE'S EVEN MORE CHANCE 8299 05:08:07,179 --> 05:08:10,315 FOR ERROR WITH WHAT I'M SEEING, 8300 05:08:10,315 --> 05:08:11,616 IT GOING TO BE CHALLENGING, NOT 8301 05:08:11,616 --> 05:08:13,051 ONLY AM I GOING TO HAVE A LOT OF 8302 05:08:13,051 --> 05:08:14,519 NUMBERS TO LOOK AT, BUT I'M 8303 05:08:14,519 --> 05:08:17,823 GOING TO NEED TO THINK ABOUT ALL 8304 05:08:17,823 --> 05:08:18,490 THESE DIFFERENT THINGS THAT 8305 05:08:18,490 --> 05:08:24,629 MIGHT HAVE LED TO SOME ERROR. 8306 05:08:24,629 --> 05:08:27,099 SO I THINK WE -- I THINK AS A 8307 05:08:27,099 --> 05:08:28,200 CLINICIAN, I DON'T KEEP UP WITH 8308 05:08:28,200 --> 05:08:29,968 THE TECH IN THE SAME WAY THAT 8309 05:08:29,968 --> 05:08:32,003 SOME REALLY TECH-MINDED PEOPLE 8310 05:08:32,003 --> 05:08:33,872 DO, AND SO I'M GOING TO NEED 8311 05:08:33,872 --> 05:08:35,507 SOME HELP AS THESE THINGS BECOME 8312 05:08:35,507 --> 05:08:37,576 MORE AVAILABLE TO FIGURE OUT HOW 8313 05:08:37,576 --> 05:08:40,512 TO INTERPRET THIS INFORMATION 8314 05:08:40,512 --> 05:08:41,480 WHEN PATIENTS ARE SENDING THEM 8315 05:08:41,480 --> 05:08:42,948 TO ME. 8316 05:08:42,948 --> 05:08:45,751 >> I'D ALSO ADD THE PATIENT 8317 05:08:45,751 --> 05:08:47,452 PERSPECTIVE, SO IN THE SLEEP 8318 05:08:47,452 --> 05:08:52,624 WORLD, THERE'S TERMINOLOGY OF 8319 05:08:52,624 --> 05:08:53,492 ORTHOSOMNIA, PERSONAL SLEEP 8320 05:08:53,492 --> 05:08:55,026 TRACKING, FITBIT DEVICES, 8321 05:08:55,026 --> 05:08:56,228 WEARABLE DEVICES AND THERE ARE 8322 05:08:56,228 --> 05:08:57,329 PEOPLE WHO ARE NOW GETTING 8323 05:08:57,329 --> 05:08:59,097 OBSESSED WITH THE CONTINUOUS 8324 05:08:59,097 --> 05:09:01,333 INFORMATION, AND IT ACTUALLY 8325 05:09:01,333 --> 05:09:02,200 CAUSING WORSE SLEEP AND SLEEP 8326 05:09:02,200 --> 05:09:02,534 QUALITY. 8327 05:09:02,534 --> 05:09:06,338 THIS IS NOW A NEW PHENOMENON, 8328 05:09:06,338 --> 05:09:08,073 AND WHAT WE STARTED WITH, LET'S 8329 05:09:08,073 --> 05:09:09,708 MAKE IT BETTER, BETTER, I'M 8330 05:09:09,708 --> 05:09:11,109 CONCERNED FROM THE PATIENT 8331 05:09:11,109 --> 05:09:12,077 PERSPECTIVE, NOT JUST THE 8332 05:09:12,077 --> 05:09:12,711 CLINICIAN AND MANAGEMENT, THINK 8333 05:09:12,711 --> 05:09:14,479 ABOUT ALL THE EHR ALARMS THAT 8334 05:09:14,479 --> 05:09:16,414 ARE GOING TO GO OFF ONCE THIS IS 8335 05:09:16,414 --> 05:09:17,382 NOW INCORPORATED. 8336 05:09:17,382 --> 05:09:19,050 BUT ALSO FOR OUR PATIENTS, IF 8337 05:09:19,050 --> 05:09:20,252 THEY'RE CONTINUOUSLY LOOKING AT 8338 05:09:20,252 --> 05:09:23,054 THEIR SMARTPHONES, YOU KNOW, FOR 8339 05:09:23,054 --> 05:09:24,022 THEIR BLOOD PRESSURE OUTPUT, 8340 05:09:24,022 --> 05:09:25,624 JUST THE WAY THAT NOW CONTINUOUS 8341 05:09:25,624 --> 05:09:27,626 GLUCOSE MONITORS ARE DOING, 8342 05:09:27,626 --> 05:09:28,560 PEOPLE ARE NOW GETTING OBSESSED 8343 05:09:28,560 --> 05:09:30,529 WITH CONCEPT OF CONTINUOUS 8344 05:09:30,529 --> 05:09:31,630 GLUCOSE MONITOR, WHAT IS THAT 8345 05:09:31,630 --> 05:09:33,031 GOING TO LOOK LIKE FOR BLOOD 8346 05:09:33,031 --> 05:09:33,799 PRESSURE IN PEOPLE WHO ARE 8347 05:09:33,799 --> 05:09:35,000 POTENTIALLY GOING TO GET MORE 8348 05:09:35,000 --> 05:09:35,967 AND MORE OBSESSED? 8349 05:09:35,967 --> 05:09:38,136 I THINK SOME PEOPLE, SOME 8350 05:09:38,136 --> 05:09:40,739 CLINICIANS WILL ALSO LIKE TO 8351 05:09:40,739 --> 05:09:42,741 TURN OFF FOR ABPM DEVICES WOULD 8352 05:09:42,741 --> 05:09:44,209 LIKE TO HIDE AND MASK THE 8353 05:09:44,209 --> 05:09:46,077 NUMBERS THROUGHOUT THE 24 HOUR 8354 05:09:46,077 --> 05:09:46,945 PERIOD SO WE'RE NOT ALWAYS 8355 05:09:46,945 --> 05:09:48,980 GETTING THIS BURDEN OF ALERTS 8356 05:09:48,980 --> 05:09:50,749 AND, YOU KNOW, MESSAGES THROUGH 8357 05:09:50,749 --> 05:09:52,484 THE EHR, LIKE HEY, MY BLOOD 8358 05:09:52,484 --> 05:09:54,319 PRESSURE THIS MINUTE WAS THIS, 8359 05:09:54,319 --> 05:09:54,986 WHAT DO I DO? 8360 05:09:54,986 --> 05:09:56,288 AND THERE MAY BE NOTHING TO DO, 8361 05:09:56,288 --> 05:09:57,622 RIGHT? 8362 05:09:57,622 --> 05:09:58,990 SO THAT'S MY OTHER CONCERN ON 8363 05:09:58,990 --> 05:10:01,526 THE OTHER SIDE OF WHAT WILL ALL 8364 05:10:01,526 --> 05:10:06,231 THIS DATA DO FOR PATIENTS. 8365 05:10:06,231 --> 05:10:07,766 >> WE NEED TO BE SMART WITH ALL 8366 05:10:07,766 --> 05:10:09,334 THIS DATA, THERE'S NO QUESTION. 8367 05:10:09,334 --> 05:10:10,635 I SAW A COUPLE QUESTIONS COMING 8368 05:10:10,635 --> 05:10:13,705 IN TO THE Q & A AND THE CHAT 8369 05:10:13,705 --> 05:10:16,708 THAT WERE RELATED TO KIND OF THE 8370 05:10:16,708 --> 05:10:17,809 FUNDAMENTAL DIFFERENCES 8371 05:10:17,809 --> 05:10:19,778 POTENTIALLY BETWEEN ABPM AND 8372 05:10:19,778 --> 05:10:21,413 HOME BLOOD PRESSURE MONITORING. 8373 05:10:21,413 --> 05:10:25,417 I THINK MARWAH MAYBE YOUR TALK 8374 05:10:25,417 --> 05:10:27,586 MIGHT HAVE PROMPTED SOME OF 8375 05:10:27,586 --> 05:10:28,486 THESE QUESTIONS, SO THE IDEA 8376 05:10:28,486 --> 05:10:31,089 THAT ARE THEY FUNDAMENTALLY 8377 05:10:31,089 --> 05:10:31,690 MEASURING DIFFERENT THINGS AND 8378 05:10:31,690 --> 05:10:32,691 HOW DO WE KIND OF APPROACH THAT. 8379 05:10:32,691 --> 05:10:35,760 I THINK, TAMMY, YOU EVEN POSED A 8380 05:10:35,760 --> 05:10:37,596 QUESTION RELATED TO IN CHILDREN, 8381 05:10:37,596 --> 05:10:41,867 SEEING DIFFERENCES WITH ABPM 8382 05:10:41,867 --> 05:10:43,201 BECAUSE OF THE ACTIVITY THAT MAY 8383 05:10:43,201 --> 05:10:44,236 BE ASSOCIATED WITH KIDS WHILE 8384 05:10:44,236 --> 05:10:46,738 THEY'RE RECEIVING ABPM AND ALSO 8385 05:10:46,738 --> 05:10:49,241 SOME EARLIER DATA WE SAW TODAY 8386 05:10:49,241 --> 05:10:51,843 ABOUT ACTIVE ADULTS MAYBE HAVING 8387 05:10:51,843 --> 05:10:53,945 DIFFERENCES IN THEIR ABPM, SO 8388 05:10:53,945 --> 05:10:55,747 ANY COMMENTS YOU HAVE THERE 8389 05:10:55,747 --> 05:10:57,082 ABOUT SORT OF THOSE FUNDAMENTAL 8390 05:10:57,082 --> 05:10:59,918 DIFFERENCES BETWEEN ABPM AND 8391 05:10:59,918 --> 05:11:02,187 BLOOD PRESSURE MONITORING? 8392 05:11:02,187 --> 05:11:05,957 >> I THINK THEY'RE MEASURING 8393 05:11:05,957 --> 05:11:08,293 DIFFERENT THINGS. 8394 05:11:08,293 --> 05:11:10,362 AS A CLINICIAN, I TRY TO THINK 8395 05:11:10,362 --> 05:11:11,696 WHICH PATIENT WOULD BENEFIT IN 8396 05:11:11,696 --> 05:11:13,365 ADDITION TO WHAT THE GUIDELINES 8397 05:11:13,365 --> 05:11:14,399 SAY, BUT WHICH BENEFIT, DO I 8398 05:11:14,399 --> 05:11:16,801 JUST NEED A 24 HOUR, LIKE, 8399 05:11:16,801 --> 05:11:17,435 SNAPSHOT ON? 8400 05:11:17,435 --> 05:11:19,704 AND THAT I ACTUALLY WANTED TO 8401 05:11:19,704 --> 05:11:21,573 KNOW, IS THERE SOMETHING IN 8402 05:11:21,573 --> 05:11:23,441 THEIR HOME ENVIRONMENTS? 8403 05:11:23,441 --> 05:11:27,812 I KNOW -- IS THERE SOMETHING IN 8404 05:11:27,812 --> 05:11:29,347 THEIR HOME ENVIRONMENT THAT MAY 8405 05:11:29,347 --> 05:11:31,249 BE CAUSING THEIR HOME BLOOD 8406 05:11:31,249 --> 05:11:32,817 PRESSURE TO BE ELEVATED, MAYBE 8407 05:11:32,817 --> 05:11:34,052 IT'S INTERACTIONS, WHATEVER IT 8408 05:11:34,052 --> 05:11:35,620 IS, AS OPPOSED TO SORT OF HOME 8409 05:11:35,620 --> 05:11:36,955 BLOOD PRESSURE WHERE I'M TRYING 8410 05:11:36,955 --> 05:11:38,757 TO GET A LONGER TERM PERSPECTIVE 8411 05:11:38,757 --> 05:11:40,292 OF WHAT IT GOING TO DO AND 8412 05:11:40,292 --> 05:11:41,726 REALLY TRYING TO ADVISE PEOPLE 8413 05:11:41,726 --> 05:11:45,864 ON HOW TO MODIFY MAYBE LIFESTYLE 8414 05:11:45,864 --> 05:11:47,198 MODIFICATIONS AND INTERVENTIONS 8415 05:11:47,198 --> 05:11:48,066 BECAUSE THAT'S, I THINK, MORE OF 8416 05:11:48,066 --> 05:11:49,434 A DIALOGUE BETWEEN THE PATIENT 8417 05:11:49,434 --> 05:11:55,140 AND THEIR OWN INFORMATION. 8418 05:11:55,140 --> 05:11:56,875 SO I THINK IT'S JUST HOME BLOOD 8419 05:11:56,875 --> 05:11:58,510 PRESSURE JUST IN A DIFFERENT 8420 05:11:58,510 --> 05:11:58,977 ENVIRONMENTAL CONTEXT. 8421 05:11:58,977 --> 05:12:02,213 AND I ACTUALLY THINK IF THE DATA 8422 05:12:02,213 --> 05:12:05,684 TRULY HIGH QUALITY DATA THAT I 8423 05:12:05,684 --> 05:12:07,118 MENTIONED WITH WITHIN PERSON 8424 05:12:07,118 --> 05:12:08,653 RANDOMIZATION DOES SHOW 8425 05:12:08,653 --> 05:12:10,322 POTENTIALLY MAYBE BETTER THAN 8426 05:12:10,322 --> 05:12:11,589 UNATTENDED, THAT'S REALLY AN 8427 05:12:11,589 --> 05:12:13,325 OPPORTUNITY FOR NEW PATIENT 8428 05:12:13,325 --> 05:12:15,193 ENGAGEMENT AND SAYING LET ME 8429 05:12:15,193 --> 05:12:17,529 TEACH YOU THE PROPER TECHNIQUE 8430 05:12:17,529 --> 05:12:18,663 WHILE YOU'RE WITH ME IN THE 8431 05:12:18,663 --> 05:12:19,397 OFFICE. 8432 05:12:19,397 --> 05:12:21,399 THAT ADDRESSES SOME OF THE 8433 05:12:21,399 --> 05:12:23,234 BARRIERS, IT'S LIKE I'M GOING TO 8434 05:12:23,234 --> 05:12:24,135 TAKE THE TIME TO SHOW YOU HOW TO 8435 05:12:24,135 --> 05:12:25,537 DO THIS RIGHT WHILE YOU'RE HERE 8436 05:12:25,537 --> 05:12:27,405 IN THE OFFICE, YOU'RE GOING TO 8437 05:12:27,405 --> 05:12:28,907 PRACTICE BY YOURSELF. 8438 05:12:28,907 --> 05:12:30,542 YOU CAN ASK QUESTIONS, AND I 8439 05:12:30,542 --> 05:12:34,612 WANT YOU TO CONTINUE THIS IN AN 8440 05:12:34,612 --> 05:12:36,748 OUTSIDE ENVIRONMENT AND THIS IS 8441 05:12:36,748 --> 05:12:37,949 HOW I'M GOING TO USE YOUR DATA 8442 05:12:37,949 --> 05:12:38,616 ACROSS THESE DIFFERENT 8443 05:12:38,616 --> 05:12:39,150 ENVIRONMENTAL CONTEXTS. 8444 05:12:39,150 --> 05:12:41,853 I THINK WHEN YOU PRESENT IT THAT 8445 05:12:41,853 --> 05:12:42,854 WAY, YOU REALLY CAN HAVE AN 8446 05:12:42,854 --> 05:12:46,124 OPPORTUNITY TO USE OFFICE -- 8447 05:12:46,124 --> 05:12:46,891 HOME BLOOD PRESSURE AND OFFICE 8448 05:12:46,891 --> 05:12:48,226 BLOOD PRESSURE IN A WAY THAT'S 8449 05:12:48,226 --> 05:12:49,828 POTENTIALLY THE SAME AND I THINK 8450 05:12:49,828 --> 05:12:52,530 THAT'S WHAT DR. TOWNSEND WAS 8451 05:12:52,530 --> 05:12:55,500 THINKING IN TERMS OF SOME OF THE 8452 05:12:55,500 --> 05:13:04,509 QUESTIONS HE POSED. 8453 05:13:04,509 --> 05:13:09,247 >> I WAS JUST GOING TO ADD ON 8454 05:13:09,247 --> 05:13:11,549 THAT TO MARWAH'S POINT, I 8455 05:13:11,549 --> 05:13:12,751 ACTUALLY MAKE A BIG PRODUCTION 8456 05:13:12,751 --> 05:13:14,586 ABOUT WHAT I'M DOING WHEN 8457 05:13:14,586 --> 05:13:15,453 MEASURING BLOOD PRESSURE BECAUSE 8458 05:13:15,453 --> 05:13:17,756 AS SOON AS I WALK INTO THE ROOM, 8459 05:13:17,756 --> 05:13:18,957 I SAY WE'RE GOING TO MOVE YOU 8460 05:13:18,957 --> 05:13:20,525 OVER HERE SO YOU'RE POSITIONED 8461 05:13:20,525 --> 05:13:23,728 IN THE RIGHT SPOT SO YOUR ARM IS 8462 05:13:23,728 --> 05:13:24,496 POSITIONED WELL, I MEASURE THEIR 8463 05:13:24,496 --> 05:13:26,765 ARM, TALK ABOUT THE CUFF. 8464 05:13:26,765 --> 05:13:28,333 SO I MAKE SURE THAT -- AGAIN I 8465 05:13:28,333 --> 05:13:31,336 MAKE A BIG SHOW OF IT, NOT -- 8466 05:13:31,336 --> 05:13:34,139 BUT FOR EDUCATION, THIS IS WHY 8467 05:13:34,139 --> 05:13:34,773 I'M DOING THESE THINGS, I WANT 8468 05:13:34,773 --> 05:13:36,574 YOU TO REMEMBER THIS NEXT TIME 8469 05:13:36,574 --> 05:13:38,043 YOU'RE AT YOUR PRIME RYE CARE 8470 05:13:38,043 --> 05:13:39,411 DOCTOR SO YOU CAN MAKE SURE YOU 8471 05:13:39,411 --> 05:13:41,513 REMEMBER TO REMIND THEM TO DO IT 8472 05:13:41,513 --> 05:13:42,714 THIS WAY MOVING FORWARD, SO I 8473 05:13:42,714 --> 05:13:48,353 THINK THAT'S SUPER IMPORTANT. 8474 05:13:48,353 --> 05:13:49,454 >> THERE'S ANOTHER QUESTION IN 8475 05:13:49,454 --> 05:13:52,490 THE CHAT SIMILAR TO THIS ABPM 8476 05:13:52,490 --> 05:13:54,259 CONVERSATION. 8477 05:13:54,259 --> 05:13:56,995 WHEN WE'RE COMPARING CUFFLESS 8478 05:13:56,995 --> 05:14:02,667 DEVICES TO ABPM TO ESTIMATE THAT 8479 05:14:02,667 --> 05:14:07,305 ASLEEP BLOOD PRESSURE, 8480 05:14:07,305 --> 05:14:08,740 POTENTIALLY THERE'S THE 8481 05:14:08,740 --> 05:14:09,407 DIFFERENCE IN THE CUFFLESS BLOOD 8482 05:14:09,407 --> 05:14:13,344 PRESSURE VERSUS THE ABPM OUTPUT 8483 05:14:13,344 --> 05:14:16,548 DUE TO JUST THE ABPM MAKING THE 8484 05:14:16,548 --> 05:14:18,149 USER AWARE THAT THEY ARE GETTING 8485 05:14:18,149 --> 05:14:20,652 THEIR MEASUREMENT TAKEN, AND SO 8486 05:14:20,652 --> 05:14:23,154 HOW DO WE FACTOR THAT IN TO THE 8487 05:14:23,154 --> 05:14:26,891 VALIDATION OF THESE CUFFLESS 8488 05:14:26,891 --> 05:14:28,193 DEVICES? 8489 05:14:28,193 --> 05:14:30,728 ACTUALLY I WON'T EVEN PROVIDE 8490 05:14:30,728 --> 05:14:32,597 ANY EXAMPLES, JUST SEE WHAT THE 8491 05:14:32,597 --> 05:14:37,235 GROUP HAS TO SAY ABOUT THAT. 8492 05:14:37,235 --> 05:14:38,970 >> I WOULD SAY THAT YOU COULD 8493 05:14:38,970 --> 05:14:40,972 COMPARE THEM AT THE SAME TIME. 8494 05:14:40,972 --> 05:14:43,908 YOU KNOW, WHEN THE CUFF IS 8495 05:14:43,908 --> 05:14:45,443 INFLATING, A PATIENT DOESN'T 8496 05:14:45,443 --> 05:14:46,344 HAVE INTERARM DIFFERENCE, YOU 8497 05:14:46,344 --> 05:14:49,581 COULD TEST THAT AND BOTH UNDER 8498 05:14:49,581 --> 05:14:50,682 THE PERTURBATION OF THE CUFF 8499 05:14:50,682 --> 05:14:52,750 INFLATION, BUT IF YOU LOOK AT -- 8500 05:14:52,750 --> 05:14:58,056 YOU KNOW, STEPHEN HAD SHOWED 8501 05:14:58,056 --> 05:14:58,957 SOME DATA OF A COMMERCIAL DEVICE 8502 05:14:58,957 --> 05:15:01,459 BEING TESTED INDEPENDENTLY UNDER 8503 05:15:01,459 --> 05:15:05,263 ABPM, A CUFFLESS DEVICE, AND THE 8504 05:15:05,263 --> 05:15:06,598 ABPM DEVICE SHOWED THE NIGHTTIME 8505 05:15:06,598 --> 05:15:08,433 DIP, BUT THE CUFFLESS DEVICE 8506 05:15:08,433 --> 05:15:09,367 DIDN'T. 8507 05:15:09,367 --> 05:15:10,001 SO YOU KNOW, YOU THINK IT WOULD 8508 05:15:10,001 --> 05:15:12,937 BE THE OTHER WAY AROUND, IF THE 8509 05:15:12,937 --> 05:15:17,308 CUFF DEVICE WAS CAUSING THE -- 8510 05:15:17,308 --> 05:15:18,409 PERTURBING THE PATIENT, AND I 8511 05:15:18,409 --> 05:15:20,178 JUST WANT TO ALSO ADD, ONE OF 8512 05:15:20,178 --> 05:15:22,013 THE KEY POINTS OF WHAT I WAS 8513 05:15:22,013 --> 05:15:23,648 TRYING TO SAY IS THAT, IF YOU 8514 05:15:23,648 --> 05:15:25,783 SEE CUFFLESS DEVICES DETECTING 8515 05:15:25,783 --> 05:15:27,152 THE NIGHTTIME DIP IN THE FUTURE, 8516 05:15:27,152 --> 05:15:30,321 THAT COULD BE JUST BECAUSE THE 8517 05:15:30,321 --> 05:15:32,390 CUFFLESS DEVICE TAKES THE TIME 8518 05:15:32,390 --> 05:15:35,226 OF DAY, SO IF IT'S LIKE 8519 05:15:35,226 --> 05:15:36,961 1:00 A.M., 2:00 A.M., 3:00 A.M., 8520 05:15:36,961 --> 05:15:39,330 MAYBE IT TAKES THE ACCELEROMETER 8521 05:15:39,330 --> 05:15:40,131 AND SEES YOU'RE NOT MOVING AND 8522 05:15:40,131 --> 05:15:41,866 JUST TAKES A BLOOD PRESSURE 15% 8523 05:15:41,866 --> 05:15:43,835 LOWER THAN DAY TIME. 8524 05:15:43,835 --> 05:15:45,870 AND SO THOSE ARE THE THINGS 8525 05:15:45,870 --> 05:15:46,571 WE'VE GOT TO WORRY ABOUT WITH 8526 05:15:46,571 --> 05:15:47,772 THE CUFFLESS DEVICE. 8527 05:15:47,772 --> 05:15:50,542 IT'S TAKING THE WAVEFORM 8528 05:15:50,542 --> 05:15:52,110 MEASUREMENT FROM A WEARABLE AND 8529 05:15:52,110 --> 05:15:55,947 IT TAKING LIKE DEMOGRAPHICS AND 8530 05:15:55,947 --> 05:15:56,714 CUFF CALIBRATION. 8531 05:15:56,714 --> 05:15:58,650 YOU HAVE TO THINK ABOUT DID THE 8532 05:15:58,650 --> 05:16:01,819 WAVEFORM HELP IN THE MEASUREMENT 8533 05:16:01,819 --> 05:16:03,354 OR NOT BECAUSE IF IT DIDN'T, WHY 8534 05:16:03,354 --> 05:16:04,222 WOULD YOU WEAR IT? 8535 05:16:04,222 --> 05:16:06,824 YOU COULD JUST HAVE THE CUFF, 8536 05:16:06,824 --> 05:16:07,825 DEMOGRAPHICS, PUT IN YOUR 8537 05:16:07,825 --> 05:16:09,360 SMARTPHONE AND GET SOME 8538 05:16:09,360 --> 05:16:09,928 CALCULATION OUT. 8539 05:16:09,928 --> 05:16:13,164 THAT'S WHAT I MEAN, THERE'S NO 8540 05:16:13,164 --> 05:16:14,832 EVIDENT TO DATE THAT THERE'S NO 8541 05:16:14,832 --> 05:16:17,335 WAVEFORM PROVIDING ANY ADDED 8542 05:16:17,335 --> 05:16:17,535 VALUE. 8543 05:16:17,535 --> 05:16:20,905 >> ONE THING TO ADD ON TO THAT, 8544 05:16:20,905 --> 05:16:22,540 FOR ME, WHEN I'VE BEEN IN A LOT 8545 05:16:22,540 --> 05:16:23,841 OF THESE HYPERTENSION MEETINGS 8546 05:16:23,841 --> 05:16:25,710 AND I'VE SEEN THAT DATA THAT'S 8547 05:16:25,710 --> 05:16:27,245 BEING DISPLAYED AND THERE'S BEEN 8548 05:16:27,245 --> 05:16:30,281 A LOT OF CONVERSATION ABOUT HOW 8549 05:16:30,281 --> 05:16:31,816 TO TEST THESE DEVICES WHILE 8550 05:16:31,816 --> 05:16:32,917 WE'RE SLEEPING. 8551 05:16:32,917 --> 05:16:36,120 YOU KNOW, AMBULATORY BLOORP 8552 05:16:36,120 --> 05:16:38,890 MONITORS ARE NEVER TESTED DURING 8553 05:16:38,890 --> 05:16:40,758 SLEEP, THEY'RE NEVER TESTED 8554 05:16:40,758 --> 05:16:43,094 WHILE SUPINE SO WE'RE COMPARING 8555 05:16:43,094 --> 05:16:44,362 A DEVICE WHERE WE DON'T EVEN 8556 05:16:44,362 --> 05:16:46,331 KNOW HOW IT PERFORMS IN THAT 8557 05:16:46,331 --> 05:16:47,432 POSITION AND THAT CONDITION, AND 8558 05:16:47,432 --> 05:16:48,866 WE'RE ASSUMING IT'S THE 8559 05:16:48,866 --> 05:16:49,601 REFERENCE STANDARD BUT WE DON'T 8560 05:16:49,601 --> 05:16:52,904 KNOW IF IT PERFORMS THE WAY THEY 8561 05:16:52,904 --> 05:16:54,405 EXPECT TO PERFORM. 8562 05:16:54,405 --> 05:16:56,374 SO I THINK TO ME, IT'S 8563 05:16:56,374 --> 05:16:59,010 CHALLENGING WHEN I WAS SAYING 8564 05:16:59,010 --> 05:17:01,613 THE VALIDATION PROTOCOLS ALIGN A 8565 05:17:01,613 --> 05:17:02,480 LITTLE BIT BETTER, THIS MAKES WE 8566 05:17:02,480 --> 05:17:06,851 WANT TO REVISIT WHILE WE DO 8567 05:17:06,851 --> 05:17:09,387 AMBULATORY BLOOD PRESSURE 8568 05:17:09,387 --> 05:17:11,022 MONITORING TESTING -- MOVING 8569 05:17:11,022 --> 05:17:11,256 FORWARD. 8570 05:17:11,256 --> 05:17:12,890 >> I THINK WE MAY BE AT OUR 8571 05:17:12,890 --> 05:17:13,324 TIME. 8572 05:17:13,324 --> 05:17:16,261 I'M NOT SURE, PAULA, IF WE 8573 05:17:16,261 --> 05:17:17,228 SHOULD HAND IT BACK TO YOU OR 8574 05:17:17,228 --> 05:17:20,665 ANYTHING ELSE RIGHT NOW? 8575 05:17:20,665 --> 05:17:25,536 >> I WOULD LIKE TO INVITE THE 8576 05:17:25,536 --> 05:17:26,638 MEETING CHAIRS FOR SOME CLOSING 8577 05:17:26,638 --> 05:17:30,942 COMMENTS FOR DAY ONE. 8578 05:17:30,942 --> 05:17:33,011 >> FROM MY PERSPECTIVE, IT'S 8579 05:17:33,011 --> 05:17:34,612 BEEN A FABULOUS CONVERSATION. 8580 05:17:34,612 --> 05:17:35,280 I KNOW THERE'S MANY MORE THINGS 8581 05:17:35,280 --> 05:17:36,080 WE CAN DISCUSS. 8582 05:17:36,080 --> 05:17:37,482 I WANTED TO FIRST SAY THANK YOU 8583 05:17:37,482 --> 05:17:39,450 TO ALL THE SPEAKERS. 8584 05:17:39,450 --> 05:17:41,986 IT'S BEEN A GREAT DAY ONE. 8585 05:17:41,986 --> 05:17:44,055 PLEASE KEEP THE ENGAGEMENT UP 8586 05:17:44,055 --> 05:17:45,023 AND WE'RE GOING TO TRY AND 8587 05:17:45,023 --> 05:17:46,858 COLLECT ALL THESE QUESTIONS AS 8588 05:17:46,858 --> 05:17:47,625 WELL SO THAT WE CAN USE THEM 8589 05:17:47,625 --> 05:17:49,260 MOVING FORWARD FOR DAY TWO. 8590 05:17:49,260 --> 05:17:50,561 AND SOME OF THE BREAKOUT 8591 05:17:50,561 --> 05:17:52,964 SESSIONS. 8592 05:17:52,964 --> 05:17:55,633 STEPHEN, I KNOW YOU'RE -- 8593 05:17:55,633 --> 05:17:57,568 >> THIS EXCEEDED EXPECTATIONS. 8594 05:17:57,568 --> 05:17:59,704 I CAME IN WITH REALLY A LOT OF 8595 05:17:59,704 --> 05:18:00,838 EXCITEMENT FOR TODAY, THE TALKS 8596 05:18:00,838 --> 05:18:02,140 HAVE BEEN FABULOUS, THE QIS HAVE 8597 05:18:02,140 --> 05:18:04,609 BEEN REALLY WONDERFUL AND 8598 05:18:04,609 --> 05:18:05,009 THOUGHT-PROVOKING. 8599 05:18:05,009 --> 05:18:08,246 I FEEL LIKE WE DON'T HAVE ENOUGH 8600 05:18:08,246 --> 05:18:09,781 TIME, AND I KIND OF DID EXPECT 8601 05:18:09,781 --> 05:18:10,848 THAT. 8602 05:18:10,848 --> 05:18:11,616 SO I'M REALLY EXCITED TO 8603 05:18:11,616 --> 05:18:12,383 CONTINUE WITH THE SAME LEVEL OF 8604 05:18:12,383 --> 05:18:13,718 PASSION AND ENGAGEMENT TOMORROW, 8605 05:18:13,718 --> 05:18:15,787 AND THANK YOU ALL FOR JOINING 8606 05:18:15,787 --> 05:18:17,422 TODAY AND AGAIN, PAULA, FOR ALL 8607 05:18:17,422 --> 05:18:18,423 YOUR LEADERSHIP IN ORGANIZING 8608 05:18:18,423 --> 05:18:19,290 THIS. 8609 05:18:19,290 --> 05:18:22,427 >> THANK YOU ALL FOR A GREAT DAY 8610 05:18:22,427 --> 05:18:26,364 TODAY, AND SEE YOU TOMORROW AT 8611 05:18:26,364 --> 05:18:27,932 11:00 A.M. 8612 05:18:27,932 --> 05:18:29,567 BYE-BYE. 8613 05:18:29,567 --> 05:18:39,567 >> TAKE CARE.