GOOD MORNING AND WELCOME TO
THE NHLBI WORKSHOP ON BLOOD
PRESSURE ASSESSMENT ACROSS THE
LIFESPAN, TO IMPROVE CLINICAL
RESEARCH AND CLINICAL PRACTICE.
NEXT SLIDE
THE WORKSHOP IS SPONSORED BY THE
DIVISION OF CARDIOVASCULAR
SCIENCES.
IT ORIGINATED IN THE NHLBI
STRATEGIC VISIONING
IMPLEMENTATION GROUP FOCUSED ON
HYPERTENSION, AND IT'S A
FOLLOW-UP TO THE NHLBI WORKSHOP
CONVENED IN 2017.
THE WORKSHOP'S OBJECTIVES
INCLUDE ASSESSMENT OF THE
CURRENT STATE OF KNOWLEDGE AND
IDENTIFICATION OF THE KNOWLEDGE
GAPS, AS WELL AS REVIEW OF THE
ONGOING RESEARCH AND
IDENTIFICATION OF RESEARCH NEEDS
TO IMPROVE BLOOD PRESSURE
ASSESSMENT IN CLINICAL PRACTICE
AND CLINICAL RESEARCH.
THE WORKSHOP IS CHAIRED BY TWO
DISTINGUISHED EXPERTS IN THE
FIELD OF BLOOD PRESSURE
MEASUREMENT AND BEYOND,
DR. MARWAH ABDALLA FROM COLUMBIA
UNIVERSITY AND DR. STEPHEN
JURASCHEK FROM HARVARD
UNIVERSITY, FROM WHOM YOU WILL
HEAR AFTER THE OPENING REMARKS
FROM THE NHLBI LEADERSHIP.
NEXT SLIDE.
I WOULD LIKE TO TAKE THIS
OPPORTUNITY TO SEND THE DCVS
LEADERSHIP -- TO THANK THEM FOR
THEIR SUPPORT OF THE WORKSHOP
AND TO ALSO THANK THE WORKSHOP
PLANNING COMMITTEE, RAVI,
PATRICE, JASMINA AND MICHAEL FOR
THEIR DAILY CONTRIBUTIONS TO THE
WORKSHOP PREPARATION ACTIVITIES.
NOW LET ME TURN IT OVER TO
DR. GOFF, DIRECTOR OF THE NHLBI
DIVISION OF CARDIOVASCULAR
SCIENCES.
>> THANK YOU, DR. EINHORN.
THANK YOU FOR PROVIDING ME WITH
AN OPPORTUNITY TO SHARE A FEW
WORDS WITH THE WORKSHOP
PARTICIPANTS.
I WANT TO START BY THANKING THE
WORKSHOP TEAM, AS DR. EINHORN
HAS ALREADY DONE, AND ESPECIALLY
THE CO-CHAIRS, DR. A ABDALLA AND
APPRECIATE YOUR LEADERSHIP AND
PUTTING TOGETHER THIS
OUTSTANDING WORKSHOP AGENDA AND
SCHEDULE AND PRESENTERS.
REALLY LOOKING FORWARD TO THE
INPUT THAT WE GET FROM YOU FROM
THIS WORKSHOP.
AS DR. EINHORN SAID,
HYPERTENSION IS VERY IMPORTANT
TO THE STRATEGIC VISION AND
IMPLEMENTATION PLAN IN THE
DIVISION OF CARDIOVASCULAR
SCIENCES.
AS YO YOU NO DOUBT KNOW, HIGH BD
PRESSURE IS THE LEADING CAUSE OF
DEATH AND DISABILITY ON THIS
PLANET.
NOW I SOMETIMES SAY, WELL,
THAT'S JUST THIS PLANET, BUT IT
OUGHT TO COUNT FOR SOMETHING.
AND SO IT'S CENTRAL TO OUR
STRATEGIC VISION THAT WE FOCUS
ON WAYS IN WHICH WE CAN
ELIMINATE HYPERTENSION-RELATED
CARDIOVASCULAR DISEASE, AND WE
HOPE ONE DAY ELIMINATE
HYPERTENSION ITSELF.
NOW ALONG THE WAY, IT'S CRITICAL
TO IMPROVE THE CONSISTENCY AND
QUALITY OF BLOOD PRESSURE
MEASUREMENT IN CLINICAL RESEARCH
AND PRACTICE.
I'M OLD ENOUGH TO REMEMBER THE
DAYS OF THE RANDOM
0SFIGHMANOMETER AND MERCURY
MANOMETERS, AND THE EFFORT THAT
HAS GONE INTO STANDARDIZING AND
IMPROVING BLOOD PRESSURE
QUALITY, REALLY DATING OVER THE
DECADES, AND THE CHALLENGE IS
STILL NOT COMPLETELY ADDRESSED.
NEW TECHNOLOGIES WILL HELP US,
BUT ONLY IF USED APPROPRIATELY.
I'M ALSO OLD ENOUGH TO HAVE BEEN
INVOLVED IN THE SPRINT STUDY
BEFORE I CAME TO NHLBI.
AND WHEN SPRINT WAS PUBLISHED,
ONE OF THE COMMENTS THAT WE
FREQUENTLY HEARD WAS THAT, WELL,
WE CAN'T MEASURE BLOOD PRESSURE
IN CLINICAL PRACTICE THE WAY YOU
MEASURED IT IN SPRINT, WE DON'T
HAVE THE TIME, WE DON'T HAVE THE
STAFF, WE DON'T HAVE THE ABILITY
TO DO THAT, AND WE THINK OUR WAY
OF MEASURING BLOOD PRESSURE IN
CLINICAL PRACTICE GIVES US
DIFFERENT RESULTS AND SO WE
THINK WE'RE ALREADY DOING AS
GOOD A JOB OF MANAGING BLOOD
PRESSURE AS YOU WOULD WANT US TO
DO BASED ON SPRINT.
WE JUST DON'T MEASURE BLOOD
PRESSURE AS WELL.
THAT WAS A DISAPPOINTING
COMMENT.
PROBABLY MANY OF YOU HEARD
SOMETHING LIKE THAT AS WELL.
MAYBE I'VE RAISED IT A LITTLE
BIT INARTFULLY, BUT I THINK IT
WAS SOMETHING ALONG THAT LINE.
AND I FIND IT CHALLENGING THAT A
RESPONSE TO REALLY A
GROUNDBREAKING TRIAL THAT SHOWS
THE IMPORTANCE OF CONTROLLING
BLOOD PRESSURE TO LOWER LEVELS
WOULD BE FROM SOME THAT, WELL,
WE JUST CAN'T TAKE THE TIME TO
MEASURE BLOOD PRESSURE WHILE IN
CLINICAL PRACTICE.
WHEN HIGH BLOOD PRESSURE IS THE
LEADING CAUSE OF DEATH AND
DISABILITY ON THE PLANET.
AND THAT SHOULD COUNT FOR
SOMETHING.
SO REALLY LOOKING FORWARD TO
YOUR INPUT, BECAUSE THIS ISSUE
REMAINS CRITICALLY IMPORTANT.
HOW DO WE IMPROVE BLOOD PRESSURE
MEASUREMENT QUALITY AND
CONSISTENCY IN CLINICAL RESEARCH
AND CLINICAL PRACTICE SO THAT WE
CAN CONTINUE TO MAKE PROGRESS ON
HYPERTENSION, DETECTION,
TREATMENT AND CONTROL, AND IN
THE LONG RUN, PREVENTION OF HIGH
BLOOD PRESSURE IN THE FIRST
PLACE.
IT'S CRITICAL TO THE MISSION OF
OUR DIVISION.
I ALSO WANT TO MAKE A PLUG FOR
THE CENTER FOR TRANSLATION
RESEARCH AND IMPLEMENTATION
SCIENCE, A SISTER DIVISION TO
THE DIVISION OF CARDIOVASCULAR
SCIENCES AT NHLBI.
THEY ALSO, WITHIN THEIR
STRATEGIC VISION, ARE HIGHLY,
HIGHLY COMMITTED TO SUPPORTING
IMPLEMENTATION SCIENCE THAT'S
FOCUSED ON IMPROVING CONTROL OF
HIGH BLOOD PRESSURE USING
EVIDENCE-BASED APPROACHES, AS
WELL AS IMPROVING PREVENTION OF
HIGH BLOOD PRESSURE USING
EVIDENCE-BASED APPROACHES.
SO I HOPE THAT THIS WORKSHOP
WILL BE AS EXCITING FOR YOU AS
IT IS FOR US.
I HOPE AT THE END OF IT, YOU'LL
GO AWAY WITH NEW IDEAS FOR NEW
RESEARCH PROJECTS THAT YOU WILL
SUBMIT TO US FOR CONSIDERATION.
AS YOU PROBABLY KNOW, THE VAST
MAJORITY OF THE RESOURCES THAT
WE GET FROM THE TAXPAYERS AND
THE BUDGET GO TO
INVESTIGATOR-INITIATED PEER
REVIEWED DISCOVERY SCIENCE
APPLICATIONS.
AND WE HOPE YOU WILL SUBMIT
APPLICATIONS STIMULATED BY THE
DISCUSSIONS THAT OCCUR DURING
THIS WORKSHOP.
OTHER OUTPUT OF THIS WORKSHOP
WILL INCLUDE AN EXECUTIVE
SUMMARY THAT WILL BE ON OUR
WEBSITE.
IT'S OUR HOPE THAT YOU'LL GET
THAT EXECUTIVE SUMMARY DONE
WITHIN A MONTH OR TWO, SO IT CAN
BE POSTED IN A TIMELY MANNER.
YOU MAY ALSO DECIDE THAT YOU
WANT TO WRITE A WHITE PAPER FOR
CONSIDERATION OF PUBLICATION IN
A PEER-REVIEWED JOURNAL.
IF YOU DECIDE YOU WANT TO DO
THAT, WE WILL SUPPORT THAT.
AND IF YOU DO THAT, WE WOULD
HOPE THAT THAT HAPPENS IN A
TIMELY MANNER TOO IN A MATTER OF
MONTHS, NOT YEARS, SO THAT IT
GETS OUT IN A TIMELY MANNER.
AND THERE MAY ALSO BE FUNDING
OPPORTUNITIES THAT RESULT FROM
YOUR RECOMMENDATIONS.
I'LL JUST SAY THAT DOESN'T
ALWAYS HAPPEN BECAUSE WE HAVE
MORE WORKSHOPS ON AN ANNUAL
BASIS THAN WE CAN SUPPORT
STRATEGIC INITIATIVES.
BUT WE'LL TAKE YOUR INPUT INTO
CONSIDERATION AND THERE MAY BE
STRATEGIC INITIATIVES THAT COME
OUT OF YOUR RECOMMENDATIONS.
SO FOR ALL THOSE REASONS, WE
REALLY APPRECIATE YOU BEING HERE
TODAY.
WE KNOW THERE ARE MANY WAYS YOU
COULD HAVE CHOSEN TO SPEND YOUR
TIME.
WE'RE GRATEFUL THAT YOU CHOSE TO
SPEND SOME TIME WITH US.
AND TO GIVE US THE BENEFIT OF
YOUR INPUT.
SO THANKS SO MUCH.
AND I'LL PASS THE BATON BACK TO
DR. EINHORN.
>> ACTUALLY, IT'S PASSING IT ON
TO DR. JURASCHEK FOR THE NEXT
ITEM ON OUR AGENDA.
>> THANK YOU SO MUCH FOR THAT
VERY INSPIRING INTRODUCTION,
PAUL AND DR. GOFF.
IT'S A REAL HONOR TO CO-CHAIR
THIS WORKSHOP WITH MY ESTEEMED
COLLEAGUE, DR. ABDULLAH.
THE 2017 WORKSHOP WAS SOMETHING
I WAS ABLE TO PARTICIPATE IN AS
AN EARLY STAGE INVESTIGATOR AND
IT WAS REAL REALLY AN INSTRUMENL
DISCUSSION AND LEARNING
OPPORTUNITY FOR ME IN TERMS OF
FRAMING MY RESEARCH, SO I
SINCERELY HOPE THAT THIS EVENT
OVER THE NEXT TWO DAYS HAS THE
SAME KIND OF IMPACT ON ALL OF
OUR LISTENERS AND DISCUSSANTS,
SO I'M REALLY DELIGHTED TO HELP
FACILITATE THIS 2024 UPDATE.
AND SO THESE ARE MY DISCLOSURES.
I AM SUPPORTED BY THE NIH AND
THE AMERICAN HEART ASSOCIATION.
AND I'LL BE FOCUSING ON THE
SUMMARY OF WHAT WAS
ACCOMPLISHED, BIG PICTURE VIEW,
IN 2017 AND ALSO WHERE I THINK
THE STATE OF THE EVIDENCE IS
WITH RESPECT TO SOME OF THE
RECOMMENDATIONS MADE BY THAT
WORKING GROUP.
I'LL NOTE UP FRONT THAT THIS
ISN'T COMPREHENSIVE, AND I
WELCOME EMAILS AND CONTACT FROM
BOTH LISTENERS AND DISCUSSANTS
FROM KEY PAPERS, IF THERE ARE
SOME BLARING OVERSIGHTS.
SO I'D LOVE TO FLESH THIS STATE
OF THE SCIENCE OUT.
SO IN THINKING ABOUT THE 2017
WORKSHOP, THERE'S A REALLY NICE
SUMMARY NICE SUMMARY WHITE PAPER
BY MUNTNER PUBLISHED IN 2019
THAT I HAVE PRESENTED HERE.
WHAT THE WORKSHOP SOUGHT TO
ACCOMPLISH AND I THINK DID QUITE
WELL WAS EVALUATE THE CURRENT
STATE OF KNOWLEDGE ON BLOOD
PRESSURE ASSESSMENT AND CLINICAL
PRACTICE AND RESEARCH FOR
DIAGNOSING HYPERTENSION AND
EVALUATING TREATMENT RESPONSE.
ANOTHER OBJECTIVE WAS TO
IDENTIFY KNOWLEDGE GAPS
PERTAINING TO CURRENT
BROMOPROPANE ASSESSMENT, AND
EVALUATE RESEARCH AND CLINICAL
NEEDS TO IMPROVE BLOOD PRESSURE
MEASUREMENT, AND THEN USE BLOOD
PRESSURE -- EXPLORE WAYS OF
USING BLOOD PRESSURE OBTAINED IN
CLINICAL PRACTICE FOR RESEARCH
AND QUALITY IMPROVEMENT
ACTIVITIES.
SO THIS IS THE KEY FIGURE THAT
RESULTED FROM THE WORKSHOP.
I THINK IT WAS REALLY A GREAT
CRYSTALLIZATION OF THREE PRIMARY
MODALITIES FOR ASSESSING BLOOD
PRESSURES, THEIR DESCRIPTION,
GUIDELINE CONCORDANT PERFORMANCE
STRENGTHS IN TERMS OF EVIDENCE
WITH RESPECT TO THE THREE
MODALITIES: CLINIC, HOME,
SELF-MONITORED AND AMBULATORY,
AND THEN SOME WEAKNESSES WHERE
THERE COULD BE ADDITIONAL
RESEARCH.
AND THE TWO PRIMARY TOPICS OR
QUESTIONS ADDRESSED WERE, ONE,
HOW DIFFERENT MEASUREMENT
METHODS CAN BE INTEGRATED INTO
CLINIC-BASED RESEARCH AND
ROUTINE CLINICAL PRACTICE TO
PERFORM ACCURATE BLOOD PRESSURE
ASSESSMENTS, AND HOW THE QUALITY
OF BLOOD PRESSURE MEASUREMENTS
OBTAINED IN ROUTINE CLINICAL
PRACTICE CAN BE IMPROVED TO
PROVIDE BETTER PATIENT CARE AND
TO BE SUITABLE FOR CLINIC-BASED
RESEARCH.
OTHER KEY CONTRIBUTIONS INCLUDED
A FOCUS ON SPECIAL POPULATIONS,
SO THERE WAS A LOT OF
DISCUSSION, AND I WONDER IF
THERE MIGHT BE A SLIDE RIGHT
BEFORE THIS.
COULD WE JUST GO BACK ONE?
APOLOGIZE.
YES, OKAY.
SO ONE OF THE KEY CONTRIBUTIONS
OF THE WORKING GROUP WAS TO
PROVIDE A CONCISE SEUM REOF
BLOOD PRESSURE MEASUREMENTS, ITS
HISTORY, MODALITIES, BEST
PRACTICE, DETAILED DISCUSSION OF
SOURCES OF BIAS, AND PRACTICES
IN TERMS OF ELECTRONIC RECORD
DOCUMENTATION.
AND THEN THERE WAS A REALLY
CLEAR DELINEATION OF BLOOD
PRESSURE DISCORDANT STATES.
PROBABLY ONE OF THE KEY FIGURES
IN THE WORKING PAPER, BUT REALLY
GREAT DISCUSSION ON HOW TO
HANDLE AN APPROACH, WHITE COAT
HYPERTENSION, SUSTAINED
HYPERTENSION.
THERE WAS ALSO A DISCUSSION OF
SPECIAL POPULATIONS SO OLDER
ADULTS, SOME SPECIAL CONDITION,
ORTHOSTATIC HYPOTENSION,
OBESITY, ATRIAL FIBRILLATION AND
PREGNANCY.
THEN A DISCUSSION OF CLINIC AND
RESEARCH BLOOD PRESSURE
MEASUREMENT, HOW THEY COMPARED
AND SOME DISCUSSION AROUND
MINIMAL STANDARDS FOR PERFORMING
RESEARCH WITH THESE DIFFERENT
TYPES OF MEASUREMENTS.
SO YOU CAN SEE COVERED A LOT OF
GROUND, BUT THERE'S CERTAINLY
SOME AREAS THAT ARE NOT PRESENT
THAT WE HOPE TO ADDRESSED TO AND
TOMORROW.
SORRY, NEXT SLIDE?
WELL, I'LL KEEP TALKING.
AND SO --
>> HOLD ON ONE SECOND.
MY COMPUTER FROZE.
I'M SORRY ABOUT THAT.
>> NO PROBLEM AT ALL.
NO PROBLEM AT ALL.
SO ANOTHER MAJOR, I THINK,
CONTRIBUTION THAT WILL BE COMING
UP FROM THE WORKING GROUP WAS A
DETAILED LIST OF RECOMMENDATIONS
TO FILL GAPS IN EVIDENCE.
AND SO I'LL WALK EVERYONE
THROUGH POINT BY POINT WHAT
THOSE RECOMMENDATIONS WERE, AND
WHERE I THINK THERE MIGHT BE
SOME POTENTIAL GAPS THAT COULD
BE ADDRESSED WITH THE COMING
WORKING GROUP.
MOVING FORWARD.
AND SO THE FIRST -- IF WE GO
BACK ONE SLIDE, RECOMMENDATION A
WAS TO DETERMINE THE VARIATION
IN BLOOD PRESSURE MEASUREMENT
APPROACHES BEING USED IN ROUTINE
CLINICAL PRACTICE ACROSS THE
UNITED STATES AND IN CLINICAL
RESEARCH PROTOCOLS.
AND SO IF WE GO TO THE NEXT
SLIDE, WE'LL SEE THAT THERE IS
IS -- THIS IS AN OLDER STUDY
PUBLISHED IN 2014 LOOKING AT
DIFFERENT APPROACHES USED,
THEY'RE ALL STANDARDIZED
ASSESSMENTS OF BLOOD PRESSURE
BUT USED IN CLINICAL TRIALS ON
HYPERTENSION TREATMENT.
AND I THINK THAT THIS IS AN AREA
WHERE THERE COULD BE A FAIR
AMOUNT MORE DONE TO CHARACTERIZE
PRACTICES IN THE UNITED STATES.
ONE, I THINK, IMPORTANT
CONTRIBUTION THAT HAS COME UP
SINCE THE LAST WORKSHOP WAS THE
STATEMENT ON THIS STANDARDIZED
CLINICAL BLOOD PRESSURE
MEASUREMENT, A CALL TO ACTION,
AND THIS WORKING GROUP OF
INTERNATIONAL COLLEAGUES PUT
TOGETHER A NUMBER OF VERY
CONCISE EVIDENCE-BASED GUIDELINE
CONCORDANT APPROACHES TO MEASURE
BLOOD PRESSURE AND THEN ALSO TO
PERFORM STANDARDIZED ASSESSMENTS
IN CLINIC AND HAS A VERY NICE
SUMMARY OF WHERE SOME ADDITIONAL
RESEARCH COULD BE BENEFICIAL.
WHERE THERE HAS BEEN REALLY GOOD
OR A LOT OF WORK RECENTLY ON
CHARACTERIZING PRACTICE IN THE
UNITED STATES HAS BEEN AROUND
CUFFS.
SO THIS IS A NICE PAIM BASED ON
NHANES THAT LOOKED AT ARM
CIRCUMFERENCE, HOW THERE'S
GROWING CONCERNS OR GROWING
NEEDS FOR LARGER CUFF SIZES IN
THE U.S. POPULATION, SO AGAIN,
SOME CHARACTERIZATION OF NEEDS
IN THE U.S.
AND THEN THIS COMMUNICATION
LOOKED AT CUFF SIZES FROM HOME
DEVICES THAT ARE LISTED ON THE
AMERICAN MEDICAL ASSOCIATION'S
VALIDATED BLOOD PRESSURE DEVICE
LISTING AND GIVES YOU A SENSE OF
OKAY, MAYBE THIS ISN'T WHAT'S
BEING USED BUT THIS IS WHAT'S
RECOMMENDED FOR USE IN CLINICAL
PRACTICE OR AT LEAST VALIDATED.
YOU CAN SEE WHERE THERE'S A LOT
OF GOOD COVERAGE IN TERMS OF
CUFF SIZES BUT THEN MAYBE WHERE
THERE'S SOME GAPS IN TERMS OF
THE SMALLER AND LARGER RANGE.
THEN IN THIS RECENT RESEARCH
LETTER, THESE AUTHORS LOOKED AT
WHAT'S SELLING MOST IN THE
UNITED STATES ON AMAZON, AND
THEY LOOKED AT CUFF RANGES AS
WELL.
SO IT DOESN'T QUITE GET AT THE
QUESTION OF WHAT PRACTICES ARE
IN PLACE, BUT I THINK WE HAVE AT
LEAST MORE CLARIFICATION AROUND
WHAT WOULD BE IDEAL IN CLINICAL
PRACTICE AND IN TERMS OF HOME
MONITORING, SOME OF WHAT'S
AVAILABLE TO CONSUMERS AND WHAT
PEOPLE ARE PURCHASING.
SO SOME MORE WORK TO DO ON POINT
A, BUT I THINK THERE HAS BEEN
SOME PROGRESS.
IN TERMS OF RECOMMENDATION B,
IDENTIFY THE ASPECTS OF THE
BLOOD PRESSURE MEASUREMENT
PROTOCOL, FOR EXAMPLE, PRESENCE
OF AN OBSERVER, DURATION OF WAIT
TIME, THAT HAVE THE MOST
SUBSTANTIAL IMPACT ON THE
ACCURACY AND PRECISION OF
CLINICAL BLOOD PRESSURE.
THIS RESEARCH CAN GUIDE THE
DEVELOPMENT OF SIMPLIFIED
BROMOPROPANE MEASUREMENT
PROTOCOLS FOR IMPLEMENTATION IN
ROUTINE CLINICAL PRACTICE.
SO CERTAINLY THERE'S ALWAYS MORE
WORK TO DO IN THIS REGARD BUT I
DO THINK THERE'S BEEN SOME
REALLY GREAT STUDIES I'D LOVE TO
JUST SHARE WITH THE GROUP THAT I
CAME ACROSS IN MY REVIEW.
SO IN THE FIRST SLIDE, REGARDING
THE OBSERVER BEING IN
ATTENDANCE, THIS WAS A MAJOR
QUESTION THAT WAS RAISED DURING
THE SPRINT TRIAL.
I THINK DR. GOFF ALLUDED TO IT.
THERE HAS BEEN SINCE A LOT OF
IMPORTANT WORK AROUND THIS AREA.
IT STILL CONTINUES TO BE AN AREA
OF A LOT OF DEBATE AND A LOT OF
STRONG FEELINGS AND PE
PERSPECTIVES, BUT I THINK THERE
HAS BEEN SOME COMPELLING
EVIDENCE I'D LIKE TO JUST SHARE.
SO ONE IS THIS SYSTEMATIC REVIEW
LOOKING AT BLOOD PRESSURE
COMPARED TO A WAIT TIME ABP M&A
OBP, AND YOU CAN SEE HERE
THERE'S REALLY NO -- SEEMS TO BE
NO RELATIONSHIP BY ATTENDANT
STATUS AND DIFFERENCE COMPARED
TO ABPM.
AND THEN THE JOHNSON STUDY
PUBLISHED IN HYPERTENSION 2018,
SO RIGHT AFTER THE WORKSHOP,
LOOKED AT PRACTICES IN THE
CLINICS THAT WERE INVOLVED IN
SPRINT WITH RESPECT TO BLOOD
PRESSURE MEASUREMENTS AND ALSO
CARDIOVASCULAR DISEASE RISK AND
THERE WAS NO REAL IMPACT ON --
FROM ATTENDANCE ON THE BENEFIT
FROM MORE INTENSIVE BLOOD
PRESSURE TREATMENT.
SO VERY REASSURING THAT WE
SHOULDN'T -- MAYBE THIS
SHOULDN'T BE AN ITEM OF MAJOR
CONCERN.
THERE'S BEEN SOME GOOD EVIDENCE
AROUND CLOTHING, THOUGH I THINK
MORE WORK COULD BE DONE.
THIS IS A NICE META-ANALYSIS
THAT LOOKED AT DIFFERENT CALIBER
CLOTHING AMOUNTS OVER SKIN ON
THE ARM.
AND SHOWED IF IT WAS VERY THIN,
THERE DIDN'T SEEM TO BE A MAJOR
EFFECT ON BIAS, BUT THERE WAS
MAYBE SOME HINT OF IT WHEN THE
CLOTHING WAS THICKER.
HOWEVER, THIS WAS A VERY SMALL
AMOUNT, 1-MILLIMETER OF MERCURY,
NOT SIGNIFICANT, SO EVEN IF
THERE IS SOMETHING THERE, IT
MIGHT NOT BE ALL THAT CLINICALLY
MEANINGFUL.
I DO THINK THAT THERE'S MORE
WORK TO BE DONE AROUND PRECISION
OF MEASUREMENT.
THIS FOCUSES ON BIAS, BUT IN
SOME SENSE, HAVING MORE VARIABLE
BLOOD PRESSURES COULD BE
CONCERNING IN TERMS OF
IDENTIFICATION OF EXTREMES IN
BLOOD PRESSURE, LOW OR HIGH.
WITH REGARDS TO THE WAIT TIME
BEFORE BLOOD PRESSURE
ASSESSMENTS IN CLINIC, THIS HAS
BEEN A GREAT LAST COUPLE OF
YEARS.
WE HAD TWO VERY NICE TRIALS.
ONE IN 618 ADULTS IN THE CONTEXT
OF A CLINIC PRACTICE THAT SHOWED
THAT IF YOU WERE TO HAVE NO REST
PERIOD PRIOR TO AN AOBP VERSUS
FIVE MINUTES OF REST, YOU CAN
SEE OVER HERE THE MEAN REALLY
COMPARED TO A WAIT TIME ABPM,
MINIMAL EFFECT FROM NO REST
PERIOD, SUGGESTING THAT WE CAN
SHORTEN THE REST TIME.
AND THEN IN THIS REALLY NICE
TRIAL CONDUCTED IN BALTIMORE,
WHERE THEY LOOKED AT ZERO, 2 OR
5-MINUTE REST, VERY SIMILAR
FINDINGS, THAT SHORTER REST
TIMES, MAYBE EVEN NO REST IS
REASONABLE FOR SCREENING FOR
BLOOD PRESSURE, BUT POTENTIALLY
THERE MIGHT BE MORE OF A ROLE OF
A REST PERIOD AMONG INDIVIDUALS
WITH HIGHER BASELINE BLOOD
PRESSURE SO INDIVIDUALS WHO ARE
HYPERTENSIVE.
OBVIOUSLY SOMETHING CHALLENGING
TO KNOW AT THE TIME OF
SCREENING, BUT CERTAINLY
CONSISTENT THAT SHORTER REST
MIGHT BE OKAY IN THE CLINIC
PRACTICE.
THIS IS SOME OF OUR OWN WORK ON
INTERVAL FROM A
PSEUDORANDOMMIZED DESIGN OF A
HUNDRED PATIENTS AND WE LOOKED
AT 30 VERSUS 62ND INTERVALS
BETWEEN REPEATED MEASUREMENTS
AND FOUND REALLY NO DIFFERENCE
WITH RESPECT TO -- OR COMPARED
TO ABPM OR WHEN YOU LOOKED AT
SORT OF THE DECREMENT OF BLOOD
PRESSURE COMPARED TO THE FIRST
MEASUREMENT, SUGGESTING THAT
MAYBE 30 SECONDS INTERVAL MAY BE
OKAY AS OPPOSED TO 60 SECONDS.
AND THEN IN THE NEXT SLIDE, A
FOLLOW-UP QUALITY IMPROVEMENT
PROJECT, ABOUT 200 PATIENTS
REFERRED FOR ABPM, WE NOTED NO
DIFFERENCE BETWEEN A
FIVE-MINUTE, 62ND, 62ND, SO FIVE
MINUTE DELAY, 62ND INTERVAL
PROTOCOL VERSUS A 3 MINUTE, 30,
30 PROTOCOL, SUGGESTING THAT THE
COMBINATION OF THE TWO IN THE
SETTING OF CLINIC PRACTICE, A
REAL WORLD SETTING, DIDN'T SEEM
TO INFLUENCE BLOOD PRESSURE
ACCURACY OR PRECISION, WHICH IS
ALSO QUITE REASSURING.
IN THE NEXT SLIDE, THERE'S
ANOTHER REALLY EXCELLENT STUDY
ON CUFF SIZE THAT'S RECENTLY
CONCLUDED CALLED CUFFSZ.
IN THIS CROSSOVER RANDOMIZED
STUDY OF 195 COMMUNITY DWELLING
ADULTS, YOU CAN SEE THEY LOOKED
AT A SIZE TOO LARGE, PROPERLY
SIZED CUFF, A SIZE TOO SMALL AND
A SIZE TWO SIZES SMALL, AND WHAT
THEY FOUND IS THAT -- CONFIRMED
WHAT HAS BEEN THOUGHT THAT THIS
CUFF SIZE REALLY DOES SEEM TO
MATTER, AND IF YOU'RE TOO LARGE,
YOU'LL HAVE A LOWER BLOOD
PRESSURE, ABOUT 4 MILLIMETERS OF
MERCURY, IF YOU'RE TOO SMALL,
INCREASE OF ABOUT 5 MILLIMETERS
OF MERCURY, AND IF YOU'RE TWO
SIZES OFF, THE BIAS COULD BE AS
GREAT AS 20 MILLIMETERS OF
MERCURY.
SUGGESTING THAT THIS IS A
FEATURE THAT DOES SEEM TO BE
REALLY IMPORTANT.
THERE WAS ANOTHER GREAT TRIAL
PERFORMED ON ARM SUPPORT, A
CROSSOVER STUDY OF 133 ADULTS
THAT ALSO RECENTLY CAME OUT
CALLED THE ARMS TRIAL.
AND IN THIS STUDY, THEY LOOKED
AT TWO DIFFERENT -- I'M SORRY,
THIS IS ON THE NEXT SLIDE.
I APOLOGIZE.
THEY LOOK AT TWO DIFFERENT
POSITIONS, ONE IS RESTING THE
ARM IN THE LAP, THE OTHER ON THE
SIDE VERSUS RESTED ON A DESK OR
TABLE NEARBY AT HEART LEVEL.
AND WHAT THEY FOUND IS THAT ARM
POSITION ALSO IMPACTS BLOOD
PRESSURE, AND HERE YOU CAN SEE
IF IT'S IN THE LEFT, INCREASE OF
ABOUT 4 MILLIMETERS OF MERCURY,
AT THE SIDE, ABOUT 6 1/2
MILLIMETERS OF MERCURY FOR
SYSTOLIC BLOOD PRESSURE,
SUGGESTING THAT ARM POSITION IS
SOMETHING THAT SHOULD BE ON THE
CHECKLIST.
THEN ANOTHER TRIAL THAT'S STILL
I BELIEVE UNDER REVIEW, SO THESE
ARE RESULTS FROM THE ABSTRACT,
THEY LOOKED AT -- IT'S CALLED
DECIBELS, SAME GROUP IN
BALTIMORE, REALLY EXCELLENT
NAMING OF TRIALS, I HAVE TO SAY.
THEY LOOKED AT, IN ADDITION TO
THE GREAT DESIGNS, THEY LOOKED
AT PUBLIC LOUD SETTING, A PUBLIC
QUIET SETTING -- OR PUBLIC QUIET
SETTING AND THEN A PRIVATE QUIET
SETTING, SO KIND OF TWO
DIFFERENT FACTORS, AND WHAT THEY
OBSERVED IS THAT THERE MAY BE
SOME IMPACT OF SOUND AND
SETTING, PARTICULARLY ON
DIASTOLIC BLOOD PRESSURE.
SETTING MAY BE IMPORTANT WITH
REGARDS TO SYSTOLIC AND
DIASTOLIC BLOOD PRESSURE BUT THE
MAGNITUDES ARE RELATIVELY SMALL,
1 TO 2 MILLIMETERS OF MERCURY,
AND CERTAINLY WE'RE LOOKING
FORWARD TO THE PUBLICATION OF
THIS TRIAL, HOPEFULLY IN COMING
DAYS.
SO WHAT ABOUT RECOMMENDATION C?
SO TO EVALUATE THE EFFECTS OF
INTERVENTIONS TO IMPROVE BLOOD
PRESSURE MEASUREMENTS IN ROUTINE
CLINICAL PRACTICE, FOR EXAMPLE,
USE OF AUTOMATED DEVICES THAT
OBTAIN AN AVERAGE MULTIPLE
READINGS ON THE ACCURACY AND
PRECISION OF CLINIC BLOOD
PRESSURE MEASUREMENTS AND BLOOD
PRESSURE CONTROL RATES.
SO THERE'S A GREAT STUDY, I WANT
TO HIGHLIGHT HERE THAT WAS
CONDUCTED IN 11 CLINICS IN THE
MIDWEST, AND WHAT THIS STUDY
SHOWED, THEY LOOKED AT THE
IMPLEMENTATION OF AUTOMATED
STANDARDIZED BLOOD PRESSURE
ASSESSMENTS IN THE CLINIC
SETTING, AND YOU CAN SEE ON THE
LEFT SIDE, PANEL A, KIND OF THE
MANUAL AUSCULTATION, AND THEN
THE DISTRIBUTION OF BLOOD
PRESSURES FROM AFTER AUTOMATED
ASSESSMENTS WERE IMPLEMENTED.
YOU CAN SEE A LOT OF END DIGIT
PREFERENCE PRIOR TO AUTOMATION,
AND THEN A MUCH MORE SMOOTH
DISTRIBUTION AFTER AUTOMATION,
SUGGESTING THAT THERE MAY BE
THAT HUMAN DESIRE TO ROUND
NUMBERS OR JUST THE INABILITY TO
DIFFERENTIATE BETWEEN MAYBE
TWO MILLIMETERS OF MERCURY FROM
SOME OF OUR ANDROID DEVICES.
IN ADDITION, THEY SHOWED WHAT
THE MEAN BLOOD PRESSURE WAS, AND
I THINK AGAIN, THIS ALLUDES TO
SOME OF THE CRITIQUES DR. GOFF
WAS OPENING WITH, BUT YOU CAN
SEE THAT AFTER AUTOMATION WAS
IMPLEMENTED, THE MEAN BLOOD
PRESSURE WAS HIGHER, AND THE
AUTHORS COP CLEU CONCLUDED THATE
FOLKS, WHEN THEY'RE LISTENING,
THERE'S A BIAS TOWARDS LOOKING
FOR MORE FAVORABLE MEASUREMENTS
OR MAYBE DISCARDING UNFAVORABLE
MEASUREMENTS, SO IN SOME SENSE,
IT'S UNCLEAR THAT AUTOMATION
WOULD ACTUALLY RESULT IN A LOWER
MEAN BLOOD PRESSURE.
IT MIGHT ACTUALLY JUST RESULT IN
A MORE ACCURATE BLOOD PRESSURE
THAT COULD BE HIGHER.
SO REALLY IMPORTANT STUDY.
I THINK THIS IS ALSO REALLY AN
IMPORTANT STUDY THAT USED DATA
FROM THE ERIC COHORT, LOOKED AT
THE FIRST MEASUREMENT VERSUS THE
AVERAGE AND SECOND AND THIRD
MEASUREMENT IN ERIC.
I BRING THIS UP BECAUSE I THINK
IT WELL ILLUSTRATES THE
IMPORTANCE OF MULTIPLE
MEASUREMENTS IN THE CLINIC.
SO YOU CAN SEE THIS LOWER LINE
HERE, CONSISTENT WITH RESPECT TO
CVD RISK, AND THE HIGHEST
CONSISTENT HIGH BLOOD PRESSURE,
THE FIRST MEASUREMENT
CORRESPONDED WITH THE AVERAGE OF
THE SECOND AND THIRD.
BUT THEN YOU SEE IN THE MIDDLE
THE MISSED HYPERTENSIVE GROUP.
YOU CAN SEE WITH REGARDS TO
CARDIOVASCULAR RISK, MISSING
HYPERTENSION IS PR PRETTY
PROBLEMATIC AND LONG TERM ALIGNS
MORE WITH THOSE WITH CONSISTENT
HYPERTENSION, SUGGESTING THE
IMPORTANCE OF DOING MORE THAN
ONE MEASUREMENT IN CLINIC TO
REALLY CLASSIFY PEOPLE'S RISK
APPROPRIATELY.
SO THIS IS AN AREA,
RECOMMENDATION D, THAT I THOUGHT
HAD SOME GAPS.
SO EVALUATE HEAD TO HEAD
COMPARATIVE DATA ON THE
ASSOCIATION OF STANDARDIZED
CLINIC VERSUS OUT OF CLINIC BLP
WITH CVD OUTCOMES AND MORTALITY.
IN THE NEXT SLIDE, I HAVE A
PAPER THAT I THINK IS ONE OF THE
MOST COMPREHENSIVE COHORT
STUDIES THAT LOOK AT DIFFERENT
MODALITIES OF BLOOD PRESSURE
MEASUREMENT WITH RESPECT TO
OUTCOMES.
THERE ARE SOME OTHER COHORTS OUT
THERE.
I THINK THIS IS AN AREA WHERE
THERE COULD BE A LOT MORE AND I
KNOW NHLBI HAS SPONSORED SEVERAL
COHORT STUDIES THAT WILL LOOK AT
MULTI-MODALITY BLOOD PRESSURE
ASSESSMENTS BUT WILL TAKE SOME
TIME TO ACCRUE EVENTS, SO
CERTAINLY AN AREA THAT I THINK
WE COULD BENEFIT MUCH MORE FROM
IN TERMS OF LEARNING HOW THESE
DEVICES RELATE TO CLINICAL
OUTCOMES.
ITEM E, EVALUATE THE IMPACT OF
SYSTEMATIC AND RANDOM ERRORS ON
THE DIAGNOSIS AND MANAGEMENT OF
HYPERTENSION AND IDENTIFY
APPROACHES TO DELINEATE REAL
CHANGES IN BLOOD PRESSURE FROM
RANDOM ERROR FOLLOWING TREATMENT
INITIATION.
SO I THINK THERE'S BEEN SOME
IMPORTANT WORK IN THIS AREA.
ON THE NEXT SLIDE, I INCLUDE DRT
DEMONSTRATED THAT THERE'S
GREATER GAINS FROM HAVING
MEASUREMENTS OVER MULTIPLE
VISITS THAN HAVING REPEAT
MEASURES WITHIN VISIT.
BOTH ARE IMPORTANT FOR IMPROVING
PRECISION.
AND SO YOU CAN SEE, IF YOU COULD
JUST CLICK TWICE THROUGH THE
ANIMATION, BUT YOU CAN SEE THERE
ARE GREATER REDUCTIONS, THIS IS
DISPLAYING THE STANDARD ERRORS.
THE STANDARD ERRORS GO DOWN MORE
WHEN YOU GO FROM ONE VISIT TO
THE SECOND VISIT, HAVING TWO
VISITS, VERSUS MULTIPLE
MEASUREMENTS PURVIS IT.
PER VISIT.
THIS SPEAKS TO THE IDEA THAT
THERE'S GREATER VARIABILITY IN
BLOOD PRESSURE BETWEEN VISIT
VERSUS WITHIN VISITS, BUT BOTH
ARE REALLY IMPORTANT.
ON THE NEXT SLIDE, THERE WAS A
REALLY NICE NHANES PAPER THAT
WAS PUBLISHED SHOWING THAT --
YOU CAN JUST CLICK TWO MORE
TIMES.
I'M SORRY.
PERFECT.
SO HERE IN THIS NHANES STUDY,
THEY EVALUATE THE IMPACT OF BIAS
ON THE PREVALENCE OF
HYPERTENSION OR HIGH BLOOD
PRESSURE IN THE U.S. POPULATION.
I THINK IT NICELY ILLUSTRATES
HOW EVEN SMALL AMOUNTS OF BIAS
HAVE REALLY SIGNIFICANT
IMPORTANT IMPLICATIONS FOR
POPULATION ESTIMATES OF BLOOD
PRESSURE.
AND SO YOU CAN KIND OF SEE THAT
ILLUSTRATED HERE, THAT THERE'S
TREMENDOUS VARIATION DEPENDING
ON HOW ACCURATE THE BLOOD
PRESSURE MEASUREMENT IS.
THAT HAS IMPLICATIONS FOR
MEASURES FOR CLINICAL PRACTICE.
THIS IS A REALLY INTERESTING, I
THINK, THOUGHT-PROVOKING PAPER
THAT CAME OUT OF CONNECTICUT
THAT LOOKED AT CLINICS, CLINIC
VISITS AND THESE DYADS OF AT
LEAST TWO VISITS WITHIN 90 DAYS
AND THEY SHOWED THE SUBSTANTIAL
VARIATION FROM VISIT TO VISIT
OBSERVED IN THE CLINIC SETTING
AND I THINK THIS HIGHLIGHT THE
CHALLENGE, THEY SAID IN SOME
SENSE, YOU ALMOST CAN'T EVEN USE
OR USE A CLINIC MEASUREMENT TO
ASSESS RESPONSE TO THERAPY, IT
KIND OF A CONCERNING CONCLUSION
BUT CERTAINLY SPRINT WOULD SAY
OTHERWISE, BUT IN SOME SENSE IN
THE REAL WORLD SETTING, THIS IS
SOMETHING TO REALLY THINK ABOUT.
THE AMOUNT OF VARIATION THAT CAN
HAPPEN BETWEEN CLINIC VISITS
REALLY PRESENTS A LOT OF
CHALLENGES IN TERMS OF
EVALUATING TREATMENT RESPONSE.
AS ILLUSTRATED BY THE
DISTRIBUTION OF DIFFERENCES
BETWEEN THESE TWO VISITS WITHIN
90 DAYS.
SO RECOMMENDATION F, ASSESS THE
ASSOCIATIONS BETWEEN ROUTINE
CLINIC AND RESEARCH BLP
MEASUREMENTS, DETERMINE IN WHAT
CIRCUMSTANCES MEASUREMENTS CAN
BE ACCEPTABLE TO BE USED IN
RESEARCH.
AND I HIGHLIGHTED IN NEXT SLIDE
A PAPER FROM SPRINT THAT
COMPARED OUTPATIENT BLOOD
PRESSURES TO SPRINT BLOOD
PRESSURE, SO THESE ARE FOLKS
THAT WERE IN SPRINT AND ALSO HAD
CLINICAL MEASUREMENTS PERFORMED,
ELECTRONIC RECORDS, AT THE SAME
TIME, AND WHAT THEY NOTED WAS
THAT THERE WAS SUBSTANTIAL
HETEROGENEITY BETWEEN BLOOD
PRESSURES RECORDED IN THE
ELECTRONIC RECORD IN TRIALS,
SIGNIFICANT VARIABILITY OVER
TIME BETWEEN AND WITHIN THE
PARTICIPANTS AND ACROSS CLINIC
SITES.
AND THERE WAS REALLY NO EASY WAY
TO CORRECT FOR THESE DIFFERE
DIFFERENCES.
SO AGAIN IT'S RESEARCH
HIGHLIGHTING THE PROBLEM.
WE STILL WANT SOLUTIONS BUT
CERTAINLY RECOGNIZING THAT
SUBSTITUTING CLINIC ASSESSMENTS
MAY NOT BE AT A POINT WHERE THAT
WORKS QUITE WELL.
OR AT LEAST RELIABLY.
RECOMMENDATION G, DETERMINE THE
OPTIMAL QUALITY METRIC FOR BLOOD
PRESSURE CONTROL USING AVERAGE
BLOOD PRESSURE AT AN INDIVIDUAL
VISIT OR ACROSS SEVERAL VISITS,
THE LAST AVAILABLE READING FROM
THE ELECTRONIC MEDICAL RECORD.
I THINK THIS IS AN AREA OF GAP.
I THINK I FOUND THIS REALLY --
THIS PAPER THAT SPEAKS TO
PROGRESS IN THIS AREA.
THE PCORNET HAS BEEN WORKING A
LOT ON CLINIC LEVEL MEASURES AND
HERE THEY IDENTIFIED NINE
DIFFERENT CONTROL METRICS THAT
ARE BASED ON EVIDENCE FOR
QUALITY.
I STILL THINK THERE'S
SUBSTANTIAL WORK TO BE DONE IN
TERMS OF EVALUATING THESE
METRICS' PERFORMANCE WITH
RESPECT TO OUTCOMES BUT
CERTAINLY HAVING CLEAR
DEFINITIONS BEING FOLLOWED IN A
LARGE NETWORK, I THINK IS A
SIGNIFICANT STEP FORWARD AND
CERTAINLY WE'LL HAVE MUCH TO
LEARN IN THE FUTURE.
RECOMMENDATION H WAS TO EVALUATE
THE ROLE OF ABPM IN HOME BLOOD
PRESSURE MONITORING IN THE
DIAGNOSIS AND TREATMENT OF
HYPERTENSION.
I THINK THAT THIS IS STILL AN
AREA WHERE THERE'S BEEN A LOT OF
WORK DONE, A LOT OF EXCITING
WORK BUT ALSO SOME GAPS.
IN THE NEXT SLIDE, THERE WERE A
NUMBER OF SUBPOINTS RELATED TO
THIS AREA.
SO YOU COULD SEE THE EXCITEMENT
OF THE WORKING GROUP AROUND HOME
MONITORING.
I PUT IN RED AREAS WHERE I THINK
THERE'S A LITTLE BIT MORE WORK
TO BE DONE.
SO ABPM, PLUS OR MINUS SLEEP
VERSUS HBPM AND CARDIOVASCULAR
RISK, I THINK THERE'S A ROLE FOR
SOME MORE OBSERVATIONAL EVIDENCE
HERE.
UNATTENDED AOBP AND AT HOME
SCREENING TOOLS BEFORE ABPM.
I THINK THERE'S BEEN SOME WORK
THERE I'LL GET INTO.
NUMBER THREE WAS THE EFFECT OF
INITIATING INTENSIFYING INTO
HYPERTENSIVE MEDICATION AMONG
ADULTS WITH WHITE COAT
HYPERTENSION AND MASKED
HYPERTENSION.
FIVE, WAYS TO REDUCE BARRIERS TO
ABPM AND HOME BLOOD PRESSURE
MONITORING IN CLINICAL PRACTICE.
SIX, OPTIMAL PROTOCOL FOR HOME
TO DIAGNOSE AND MANAGE
HYPERTENSION, TIME OF DAY,
NUMBER OF MEASUREMENTS,
DURATION, AND THEN THE SEVENTH
POINT, QUANTIFYING THE BURDEN OF
24-HOUR ABPM ON SLEEP AND DAILY
ACTIVITY DIST DISTURBANCES.
SO GOING THROUGH SOME OF THESE
SUBPOINTS ON THE NECTS SLIDE, I
NEXT SLIDE, IWANT TO HIGHLIGHT G
THE DETECTION OF HYPERTENSION
STUDY, A REALLY IMPORTANT STUDY
WITH A TREMENDOUS AMOUNT OF
MEASUREMENTS.
SO THREE WEEKS OF HOME, TWO
24-HOUR ABPM READINGS,
ECHOCARDIOGRAM, AND OFFICE
MEASURED OVER THREE VISITS.
WHAT THEY CONCLUDED WITH REALLY
ROBUST ANALYTIC APPROACHES IS
THAT HOME HAS THE POTENTIAL AT
LEAST IN THIS COHORT TO BE MORE
RELIABLE, AND SEEMED MORE
STRONGLY CORRELATED WITH LEFT
VENTRICULAR MASS INDEX, A
CLINICAL MARKER OF POTENTIALLY
THE DOWNSTREAM EFFECTS OF HIGH
BLOOD PRESSURE.
SO CERTAINLY REALLY FASCINATING
FINDINGS THAT I THINK HAVE
CONTRIBUTED A LOT TO OUR
UNDERSTANDING OF THESE DIFFERENT
MODALITIES.
IN THE NEXT SLIDE, I PRESENT
SOME OF OUR OWN WORK AROUND
MEASUREMENTS BEFORE ABPM.
SO THIS IS A QUALITY IMPROVEMENT
PROJECT OF 100 ADULTS WHERE WE
LOOKED AT ANG LPN MEASURED BLOOD
PRESSURE BEFORE AVPM, AOBP,
AUTOMATED BLOOD PRESSURE
ASSESSMENT AFTER THE ABPM, AND
THEN COMPARED THEIR PERFORMANCE,
AND IF YOU CLICK THROUGH, YOU
CAN SEE THAT THE SINGLE
MEASUREMENTS AND EVEN THE
AVERAGE THAT WERE PERFORMED
MANUALLY HAD SOME OF THE BIGGER
DIFFERENCES WITH A WAIT TIME
ABPM.
BUT THEN INTERESTINGLY, A SINGLE
FIRST AOBP MEASUREMENT, SO NOT
REALLY AUTOMATED, IT'S JUST THE
FIRST MEASUREMENT STILL SIMILAR
KIND OF BIAS OBSERVED WITH
RESPECT TO SYSTOLIC BLOOD
PRESSURE AROUND 4, BUT THEN WHEN
WE WENT TO THE SECOND AND THIRD,
THERE WERE SOME IMPROVEMENTS AND
THE AVERAGE SEEMED TO MINIMIZE
BIAS THE MOST.
I HIGHLIGHT THIS WORK IN
PROGRESS.
WE NOW HAVE 50 FOLKS BUT I'LL
JUST POINT OUT HERE, THIS IS
LOOKING AT CHANGES OVER TIME
WITH HOME, AND OFFICE, AND THIS
WAS A QUALITY IMPROVEMENT
PROJECT AS WELL THAT WE'VE BEEN
WORKING ON, AND IT TURNS OUT
THAT THE AOBP CHANGE HAS REALLY
NOT BEEN AS PRONOUNCED AS THE
HOME AND WE'RE HOPING TO SHARE
THIS SOON, BUT I DO THINK MORE
WORK SHOULD BE DONE AROUND THIS
CORRELATION OF CHANGES OVER TIME
WITH THE DIFFERENT BLOOD
PRESSURE MODALITIES.
IN TERMS OF TREATMENT OF MASKED
HYPERTENSION, I'LL CALL THIS
PAPER TO EVERYONE'S ATTENTION,
THIS WAS A RECENT STUDY TRIAL
LOOKING AT FOLKS WHO HAD ABPM IN
ADDITION TO AN OFFICE
ASSESSMENT, THEY WERE IDENTIFIED
AS HAVING MASKED HYPERTENSION,
AND LOOKING AT END ORGAN DAMAGE,
SO STILL NOT QUITE AT THE CBD
EVENT LEVEL, BUT CERTAINLY
DEMONSTRATING THAT MORE
AGGRESSIVE OR MORE -- TREATMENT
OF MASKED HYPERTENSION SEEMED TO
HAVE HEALTH BENEFITS, SO THIS IS
ONE OF THE FEW TRIALS OF ITS
KIND.
THERE WAS NOT I GUESS A CONTROL
GROUP THAT LOOKED AT JUST
TREATING TO A LOWER GOAL, SO IT
COULD VERY WELL BE THAT A LOT OF
THOSE FOLKS MIGHT BE CAPTURED
JUST BY TREATING TO A LOWER
OFFICE, BUT NONETHELESS, THIS
CONCEPT OF MASKED CERTAINLY
PROBED IN THIS TRIAL.
THEN I TALK ABOUT KR CHRONOTHER,
WE HAVE THE BED MED AND BED
MED-FRAIL TRIALS.
THESE WERE RECENTLY REPORTED
LOOKING AT THE TIMING OF
MEDICATIONS AND THE PRINCIPAL
INVESTIGATOR CONCLUDED REALLY NO
DIFFERENCE IN TERMS OF TIMING
AND PEOPLE SHOULD REALLY FOCUS
ON TAKING THEIR MEDS AT A TIME
WHEN THEY'RE MOST LIKELY TO
ADHERE TO THEIR REGIMEN.
SO I THINK THAT THAT'S SOME VERY
IMPORTANT TRIALS THAT CAME OUT
IN FRAIL AND OLDER POPULATIONS.
THEN IN THE NEXT SLIDE, I HAVE
LISTED HERE THE DATA FROM THE
TIME STUDY ALSO RECENTLY
PRESENTED VERY LARGE PRAGMATIC
STUDY THAT SHOWED THAT TIMING
ALSO DIDN'T SEEM TO IMPACT
OUTCOMES AS WELL, SUGGESTING
THAT REALLY CHRONOTHERAPY
SHOULDN'T BE A MAJOR FOCUS, WE
SHOULD FOCUS ON LONGER ACTING
AGENTS BUT NOT NECESSARILY THE
TIMING OF THOSE ADMINISTRATIONS.
I WILL SAY THAT NEITHER OF THESE
STUDIES TARGETED FOLKS WITH
NOCTURNAL HYPERTENSION, THAT
MIGHT BE A SUBSET THAT STILL
SOME WORK COULD BE DONE, BUT
CERTAINLY IN THE GENERAL
POPULATION, NOTE MUCH EVIDENCE
NOT MUCH EVIDENCEFOR TIMING THE.
THIS IS AGAIN A QUALITY
IMPROVEMENT PROJECT THAT OUR
GROUP DID FOCUSED ON DEVICE
CONCORDANCE.
WE FOUND THAT EVEN IN CLINIC AT
THE EXACT SAME TIME, THE HOME
DEVICE AND THE OFFICE DEVICE,
EVEN IF IT'S THE SAME BRAND,
COULD DIFFER IN ABOUT 20% OF
DEVICES.
SO CERTAINLY SOMETHING TO THINK
ABOUT IN TRYING TO INTERPRET
DEVICES AT HOME.
THERE MIGHT BE SOME PATIENTS
WITH DOCTORS THAT CONTRIBUTE TO
DISCORDANCE THAT WE DON'T FULLY
UNDERSTAND.
AND I THINK MORE WORK SHOULD BE
DONE HERE, BUT CERTAINLY
SURPRISING RESULT FOR US AND I
THINK IMPORTANT FOR THE QUESTION
RAISED BY THE WORKSHOP.
THIS IS ANOTHER REALLY IMPORTANT
STUDY THAT WAS ON HOW TO PERFORM
HOME, AND IN THIS GROUP ALSO
FROM THE IMPROVING DETECTION OF
HYPERTENSION, THEY LOOKED AT
NUMBER OF DAYS OF HOME
MONITORING AND LOOKED AT THE
ENTIRE MONITORED PERIOD AND THEN
SORT OF JUST THE SUBSET OF DAYS,
AND FOUND THAT REALLY IF YOU
LOOKED AT THE PERCENTAGE WITH A
DISCORDANCE OF ABOUT
10 MILLIMETERS OF MERCURY, YOU
KNOW, OBVIOUSLY HAVING MORE
DAYS, THERE'S LESS DISCORDANCE,
BUT YOU CAN SEE THE DROPOFF WAS
KIND OF GRA ACTUAL GRADUAL AND T
REALLY CROSS THE 85% POINT UNTIL
YOU GOT DOWN TO THE ONE TO TWO
DAY RANGE, SO THEY CONCLUDED
THAT THREE DAYS DOES A PRETTY
GOOD JOB FOR HOME MONITORING,
WHICH I THINK IS A REALLY
IMPORTANT FINDING.
THERE'S A PAPER THAT LOOKS AT
THRESHOLDS, AND I THOUGHT THIS
WAS ALSO A VERY SOPHISTICATED
STUDY FROM THE IMPROVING
DETECTION OF HYPERTENSION COHORT
AS WELL.
AND THEY LOOKED AT THRESHOLDS,
RIGHT, AND THE IDEA WAS, WELL,
MAYBE IF WE USE A BROADER
THRESHOLD, MORE EXPANSIVE
THRESHOLD OR EXTREME THRESHOLDS
OTHER SHORTER DAYS, WE MIGHT NOT
NEED TO DO ADDITIONAL DAYS OF
MONITORING.
I PUT THE CITATION HERE FOR
FOLKS TO READ, BUT THEY POINTED
OUT THAT IF YOU -- DEPENDING
ON -- WHERE YOU PUT THOSE
BOUNDS, WE MIGHT BE ABLE TO DO
MUCH BETTER OR SIMPLIFY THE
MONITORING REGIMEN TO FEWER THAN
THREE DAYS.
SO ALSO EXCITING EVIDENCE THERE
AS WELL.
THE NEXT SLIDE FOCUSES ON THE
ROLE OF SLEEP AND ABPM.
I THINK PART OF THE CHARGE WAS
RELATED TO CHARACTERIZING THE
IMPACTS OF ABPM ON SLEEP AND
THIS IS A REALLY NICE PAPER FROM
MYCO-CHAIR, DR. ABDALLA, THAT
SHOWS THAT SLEEP DURATION,
LENGTH OF SLEEP DURATION IS
RELATED TO DIPPING PATTERNS
OVERNIGHT.
AND THEN IN THE NEXT SLIDE, I
THINK THIS IS A REALLY IMPORTANT
CONTRIBUTION AROUND ACTIVITY AND
BLOOD PRESSURE.
AND IN THIS PARTICULAR COHORT,
FOLKS WORE A REALLY HIGHLY
SENSITIVE ACCELEROMETER OR
ACTOGRAM AND WERE ABLE TO
DEMONSTRATE THAT BEING ACTIVE
WAS RELATED TO A 15% INCREASE IN
BLOOD PRESSURE ASSESSMENTS ON
ABPM.
THAT'S IMPORTANT, I THINK, KIND
OF CONTEXTUAL DATA THAT I THINK
COULD BE INFORMATIVE FOR
SUBSEQUENT GENERATIONS OF
DEVICES AND DEVICE DEVELOPMENT,
WHEN WE THINK ABOUT CAPTURING
CONTEXTS BETTER TO INTERPRET
BLOOD PRESSURE.
ITEM NUMBER H WAS TO EVALUATE
THE ROLE OF BLOOD PRESSURE IN
PUBLIC LOCATIONS FOR SCREENING.
TO GUIDE ANTIHYPERTENSIVE
MEDICATION.
I HAVE A REALLY NICE, IN THE
NEXT SLIDE, A TRIAL BY DR. GREEN
OF 510 PARTICIPANTS.
THEY LOOKED AT KIOSKS, THEY
LOOKED AT HOME, THEY LOOKED AT
THE CLINIC AND ABMM BPM AND FOUD
THAT WHILE CLINIC MIGHT
UNDERESTIMATE ABPM, KIE OS BEING
SEEMED TO OVERESTIMATE ABPM BY
ABOUT 10, A CLINIC UNDERESTIMATE
BY ABOUT 5 MERCURY SYSTOLIC AND
SO PROVIDING SOME DATA AROUND
HOW THESE PERFORM AND HOW WE
NEED TO THINK ABOUT THESE
MEASUREMENTS WHEN THEY COME FROM
DIFFERENT SOURCES.
ITEMS J WAS THE VALIDITY OF
NOVEL APPROACHES.
WE HAVE SOME SESSIONS DEDICATED
TO THIS SO I'LL JUST GIVE AN
OVERARCHING VIEW.
I THINK THERE'S MORE WORK TO BE
DONE HERE, BUT IN TERMS OF
CUFFLESS VALIDATION, CUFFLESS
DEVICES, IN THE NEXT SLIDE,
THERE HAVE BEEN A NUMBER OF
VALIDATION PROTOCOLS THAT HAVE
BEEN PUBLISHED.
I THINK THAT'S A HUGE ADVANCE IN
THE FIELD, SO THE IEEE PROTOCOL,
THE ISO-3 WHICH LOOKS AT
CONTINUOUS DEVICES WITH AN
ARTERIAL LINE REFERENCE AND THEN
THE ESH GUIDELINE, WHICH IS A
CLINICAL VALIDATION
RECOMMENDATION, AND I LIST HERE
THE SIX TESTS THAT THEY
RECOMMEND THAT ARE ALL VERY
CLINICALLY FOCUSED.
AND IN ADDITION TO THAT ONGOING
IS THE ISO-7 WORKING GROUP WHERE
THEY HAVE A DRAFTED PROTOCOL,
OBVIOUSLY A LOT OF APPROVALS
THAT NEED TO HAPPEN FOR THIS,
BUT WE SHOULD BE HAVING SOME
PROCEDURES TO INTERPRET SOME OF
THESE DEVICES MOVING FORWARD.
IN THE NEXT SLIDE, NEXT TWO
SLIDES, I JUST HIGHLIGHT TWO
STUDIES THAT I THINK ARE REALLY
PIVOTAL FOR THINKING ABOUT
CUFFLESS DEVICES.
ONE IS A STUDY THAT LOOK AT
41 PARTICIPANTS AND SHOWED
REALLY GOOD CONCORDANCE WITH ONE
CUFFLESS DEVICE DURING THE DAY,
BUT AT NIGHTTIME, SOME
DISCORDANCE IN TERMS OF
NOCTURNAL DIPPING, SO AN AREA
JUST TO THINK ABOUT.
AND THEY HAD THREE FOLKS WHO ARE
STARTED ON ANTIHYPERTENSIVES
THAT WERE NOT TRACKED VERY WELL
BY THE CUFFLESS DEVICE,
SUGGESTING THE IMPORTANCE OF
RECALIBRATION FOR SOME OF THESE
DEVICES.
AND THEN IN THE AURA STUDY
CONDUCTED BY MICROSOFT, THEY
LOOKED AT A NUMBER OF NOVEL
TECHNOLOGIES WITH RESPECT TO
DIFFERENT BODY POSITIONS, OFFICE
AND ABPM, AND THIS IS THE NEXT
SLIDE.
THEY FOUND ESSENTIALLY NO VALUE
IN MEASURING RESTING BLOOD
PRESSURE, 24-HOUR AMBULATORY
BLOOD PRESSURE.
SO IMPORTANT STUDIES, I THINK,
FOR OUR REFERENCE.
RECOMMENDATION K WAS TO ASSESS
THE VALUE OF USING ORTHOSTATIC
HYPOTENSION AS A PART OF -- TO
GUIDE ANTIHYPERTENSIVE THERAPY.
I JUST HIGHLIGHT A STATEMENT
FROM THE AMERICAN HEART
ASSOCIATION, CERTAINLY I THINK
WAS INFORMATIVE FOR THE
CONDITION.
ON THE NEXT SLIDE WE JUST
HIGHLIGHT A COUPLE AREAS OF
MEASUREMENT ERROR TO BE
CONSIDERED WHEN DIAGNOSING.
OH AND HYPERTENSION, SO ONE IS
JUST THE MEASUREMENT AT BOTH
TIME POINTS AND THE NEXT SLIDE
IS ALSO THE DEGREE OF
VARIABILITY.
YOU COULD HAVE A FIXED AMOUNT OF
PERCENTAGE OF VARIABILITY BUT IF
YOU'RE AT A HIGHER RESTING BLOOD
PRESSURE, THAT'S GOING TO
MANIFEST AS A GREATER CHANGE IN
BLOOD PRESSURE WHICH WOULD
QUALIFY FOR OH.
SO SOMETHING TO BE THINKING
ABOUT WHEN WE'RE TRYING TO SORT
OUT IF SOMEONE HAS OH OR NOT.
THEN IN THE NEXT SLIDE, WE
SUMMARIZE IN A STATEMENT HOW
TO JUST APPROACH -- A FRAMEWORK
FOR APPROACHING SOME OF THE
DIFFERENT OH CONDITIONS, SO LIKE
CLASSIC AUTONOMIC DYSFUNCTION
VERSUS SOME OF THE PHYSIOLOGY
RELATED TO OH.
AND THEN THOSE TWO KIND OF
PSEUDOMEASUREMENT CONDITIONS,
THRESHOLD EFFECTS OF MEASUREMENT
ERROR TO THINK ABOUT.
IN THE NEXT SLIDE, I HAVE HERE
SOME WORK THAT WE DID ON
INDIVIDUAL LEVEL META-ANALYSIS
ON THE EFFECTS OF INTENSIVE
THERAPY ON THE OCCURRENCE OF OH,
SHOWING THAT CONTRARY TO
EXPECTATION MORE AGGRESSIVE
THERAPY SEEMED TO REDUCE THE
FREQUENCY OF OH.
IN THE NEXT SLIDE, A SUBGROUP
ANALYSIS, WE LOOKED AT STANDING
BLOOD PRESSURE LESS THAN 110 AND
THEN PRERANDOMMIZATION OH AND
REALLY THE FOLKS WITH THE LOWER
BLOOD PRESSURES IN THE STANDING
POSITION OR GREATER DROPS DID
NOT SEEM TO BE
DISPROPORTIONATELY AT HIGHER
RISK FROM FREETMENT OF HAVING
OH, SUGGESTING THAT SCREENING
FOR THESE CONDITIONS BEFORE
TREATMENT WITH RESPECT TO OH
MIGHT NOT BE RELEVANT.
IN THE NEXT SLIDE, WE LOOK AT
OUTCOMES FROM THE TRIALS, AND
CONCLUDED THAT AMONG INDIVIDUALS
WITH OH, MORE INTENSIVE THERAPY
SEEMED TO REDUCE RISK OF
CARDIOVASCULAR DISEASE OR ALL
CAUSE MORTALITY.
HERE WAS THE STUDY I WAS JUST
REFERRING TO WITH THE LOWER RISK
OF CARDIOVASCULAR DISEASE OR ALL
CAUSE MORTALITY.
L, EVALUATE PROGNOSTIC IMPACT OF
DIFFERENT ORTHOSTATIC
HYPOTENSION DEFINITIONS WITH AN
EMPHASIS ON POSITION.
THIS IS SOME WORK ON BODY
POSITION, AND HERE WE SHOW THERE
ARE DIFFERENT PHYSIOLOGIC
RESPONSE FROM GOING FROM A
SEATED TO STANDING POSITION
VERSUS SUPINE TO STANDING,
POPULATION OF OLDER ADULTS AT
RISK FOR FALLING, AND THEN THE
SUPINE PROTOCOL SEEMING TO
DIFFERENTIATE OR DISCRIMINATE
RISK OF FALLING BETTER THAN A
SEATED PROTOCOL.
THE NEXT SLIDE, USING THE SAME
POPULATION, WE LOOKED AT TIMING
OF MEASUREMENT AND CONCLUDED
THAT EARLIER OH ASSESSMENTS WERE
MORE SENSITIVE FOR OH AND
STRONGLY RELATED TO PEOPLE BEING
SYMPTOMATIC WHEN THEY STOOD UP,
BUT THE LONGER TERM, MORE
SUSTAINED OH SEEMED TO BE MORE
SPECIFIC FOR FALL RISK, SO
OBVIOUSLY MORE WORK TO BE DONE
THERE.
ITEM M, APPS EVALUATING APPS FOR
SIMPLIFYING AND ORGANIZING
INCOMING DATA FROM OUT OF OFFICE
BLOOD PRESSURE MEASUREMENTS.
I HIGHLIGHT ONE TRIAL.
I THINK THERE'S A LOT OF WORK TO
BE DONE HERE, BUT THIS IS AN
INTERESTING TRIAL LOOKING AT AN
APP-ENABLED BLOOD PRESSURE
MEASUREMENT MODALITY AND KIND OF
QUANTIFYING THE AMUSE BP STUDY,
QUANTIFYING ITS RELIABILITY AND
NEGATIVE PREDICTIVE VALUE WITH
RESPECT TO ABPM.
IN THE NEXT SLIDE,
RECOMMENDATION N, EVALUATE
APPROACHES TO MEASURING BLOOD
PRESSURE IN MORBIDLY OBESE
ADULTS.
WE HAVE A SESSION DEDICATED TO
THIS LATER ON BECAUSE THIS IS
SUCH AN IMPORTANT ISSUE, AND IN
THE NEXT SLIDE, I JUST
HIGHLIGHT -- THIS IS SEEN IN
PREVIOUS WORK -- HOW THERE'S
JUST REALLY EVEN FOR REFERENCE
STANDARDS AN I INADEQUATE AMOUNT
OF DEVICES -- OR BECAUSE OF
LARGER ARMS, THERE'S REALLY NOT
EVEN A MEANS TO HAVE A REFERENCE
STANDARD FOR VALIDATING DEVICES
FOR MANY INDIVIDUALS AS THE ARM
CIRCUMFERENCE GETS HIGHER,
SUGGESTING THAT THIS IS A REALLY
IMPORTANT AREA AS OBESITY HAS
BECOME SO PREVALENT WORLDWIDE.
THERE WAS A REALLY USEFUL
STATEMENT LED BY PAUL PALANTINI
RECOMMENDING APPROACHES FOR
FOLKS WITH LARGER ARM
CIRCUMFERENCES AND DESCRIBING
SOME OF THE CONTOUR AND SORT OF
SLANTS TO BE CONCERNED ABOUT,
AND A CALL FOR CUFFS THAT
ACTUALLY COULD ADDRESS A
NON-CYLINDRICAL ARM SHAPE, SO I
THINK THIS IS AN IMPORTANT
DISCUSSION THAT WAS ADVANCED
THERE.
SO IN CONCLUSION ON THE NEXT
SLIDE, THE 2017 WORKING GROUP
LED A REALLY MEANINGFUL
DISTILLATE OF KEY CHALLENGES
FACING BLOOD PRESSURE ASSESSMENT
IN CLINICAL PRACTICE AND
RESEARCH.
THERE WERE A NUMBER OF STUDY, I
TRIED TO GO THROUGH AS MANY AS I
COULD THAT HAVE DIRECTLY
RESPONDED TO AND INFORMED
QUESTIONS RAISED BY THE WORKING
GROUP, BUT THERE ARE A LOT OF
ONGOING GAPS WHICH WILL BE THE
FOCUS OF THE PRESENT WORKSHOPS.
SO THANK YOU SO MUCH FOR YOUR
TIME.
THIS LAST SLIDE IS JUST A THANK
YOU TO OUR PARTICIPANTS,
DISCUSSANTS AND THANK YOU TO THE
NHLBI FOR SUPPORTING THIS
DISCUSSION.
>> WELL, THE NEXT ITEM ON THE
AGENDA IS THE CHARGE TO THE
GROUP FROM THE CHAIRS WORKSHOP.
MARWAH AND STEPHEN?
>> THANK YOU SO MUCH AGAIN FOR
THE OPPORTUNITY TO DISCUSS OUR
CHARGE TO THE GROUP.
SO AS WE ALL ARE HERE BECAUSE
ACCURATE BLOOD PRESSURE
MEASUREMENT REMAINS A
CORNERSTONE OF EFFECTIVE
CLINICAL CARE AND A CRITICAL
FOCUS FOR RESEARCH AND DESPITE
MANY ADVANCES IN TECHNOLOGY AND
METHODOLOGY, GAPS PERSIST THAT
AFFECTS PATIENTS, CLINICIANS AND
REACH SERS, AND AS YOU JUST
HEARD FROM STEPHEN SINCE THE
2017 WORKSHOP, THERE'S STILL A
NEED TO EVALUATE PROGRESS AND
DISCUSS FURTHER RESEARCH
DIRECTIONS INCLUDING
TECHNOLOGICAL DEVELOPMENTS AND
PLOOP ASSESSMENTS PARTICULARLY
IN SPECIAL POPULATIONS.
THERE'S BEEN BOTH AN INTEREST IN
PROGRESS IN THE USE OF 24 HOUR
BLOOD PRESSURE MONITORING BUT
THE ESTABLISHED METHODOLOGIES
ARE RATHER INCONCLUSIVE AND NEW
EMERGING APPROACHES THAT WE'LL
HEAR ABOUT LATER INCLUDING
CONTINUOUS AND CUFFLESS.
SO WE'VE STARTED THE WORKSHOP
REALLY WITH AN EMPHASIS ON THE
LIFESPAN, WHICH WILL BE THE NEXT
SESSION.
BLOOD PRESSURE ASSESSMENT ACROSS
THE LIFESPAN INCLUDING IN
PREGNANT WOMEN AND CHILDREN
REPRESENT CRITICAL GAPS.
IN PARTICULAR, BLOOD PRESSURE
ASSESSMENT IN PREGNANCY HAS
GAINED ATTENTION IN LIGHT OF THE
REPORTED CHAP CLINICAL TRIAL AND
WE KNOW THAT THE LAST AAP
CLINICAL PRACTICE GUIDELINE FOR
SCREENING AND MANAGEMENT OF HIGH
BLOOD PRESSURE IN CHILDREN AND
ADOLESCENT WAS PUBLISHED IN
2017.
SO WE'VE CONVENED A SERIES OF
EXPERTS TO EXPRESS CURRENT
CHALLENGES AND EXPLORE
INNOVATIVE SOLUTIONS IN ORDER TO
ADVANCE THE FIELD OF BLOOD
PRESSURE ASSESSMENT.
SO OUR CHARGE FOR TODAY IS BOTH
AMBITIOUS AND ESSENTIAL, TO
IDENTIFY PERSISTENT GAPS AND
CHALLENGES IN BLOOD PRESSURE
ASSESSMENT, DEFINE PRACTICAL AND
TRANSFORMATIVE SOLUTIONS THAT
CAN SHAPE CURRENT AND FUTURE
RESEARCH AGENDAS, BUT REALLY
THAT CAN INSPIRE SYSTEM-WIDE
CHANGE THAT ULTIMATELY I THINK
THIS IS THE BROAD MISSION, CAN
IMPACT CLINICAL GUIDELINES,
HEALTH POLICY TO IMPROVE BLOOD
PRESSURE EQUITABLY AND TO DO SO,
WE'VE OUTLINED SEVERAL
OBJECTIVES.
THE FIRST OBJECTIVE IS TO ASSESS
THE CURRENT STATE OF KNOWLEDGE
ON BLOOD PRESSURE ASSESSMENT IN
CLINICAL PRACTICE AND CLINICAL
RESEARCH.
OBJECTIVE NUMBER TWO IS TO
IDENTIFY KNOWLEDGE GAPS
PERTAINING TO CURRENT BLOOD
PRESSURE ASSESSMENT METHODS AND
IDENTIFY OBSTACLES THAT NIH MAY
BE ABLE TO IMPACT.
FOR THE REST OF THE OBJECTIVES,
I'M GOING TO ASK STEPHEN TO
PRESENT.
>> THE THIRD OBJECTIVE IS TO
REVIEW ONGOING RESEARCH AND
IDENTIFY RESEARCH NEEDS TO
IMPROVE BLOOD PRESSURE
ASSESSMENT IN CLINICAL PRACTICE
AND CLINICAL RESEARCH.
THEN TO COMPLEMENT AND EXPAND ON
THE 2023 WORKSHOP ON
TRANSFORMING HYPERTENSION
DIAGNOSIS AND MANAGEMENT IN THE
ERA OF ARTIFICIAL INTELLIGENCE.
SO WE HAVE A TECHNOLOGY TIE-IN
TO MAKE THINGS CONTEMPORARY.
AND SO THE WORKSHOP IS ORGANIZED
INTO FIVE SESSIONS THAT ARE, I
THINK, REALLY DENSE, HAVE SOME
AMAZING SPEAKERS, BUT WILL COVER
A LOT OF GROUND.
SO SESSION ONE FOCUSES ON
SPECIAL POPULATIONS ACROSS THE
LIFESPAN.
ADDRESSING SOME -- I WOULD SAY
SOME IMPORTANT GAPS FROM THE
2017 WORK GROUP.
SESSION TWO IS LOOKING AT BLOOD
PRESSURE CONTROL ACROSS CLINICAL
CONDITIONS, AND PARTICULARLY
SOME CONDITIONS WHERE CONTROL
SOMETIMES IS MORE OF A CONCERN
OR MORE CHALLENGING TO
ASCERTAIN.
SESSION THREE, LOOKING AT CUFF
TO CUFFLESS DEVICES, NEW
FRONTIERS IN BLOOD PRESSURE
ASSESSMENT AND MONITORING.
SO A SPECIAL FOCUS ON WHERE
WE'RE AT IN TERMS OF
TECHNOLOGIES, WHERE WE ARE IN
TERMS OF VALIDATION, AND WHAT
NEEDS TO BE DONE.
SESSION FOUR, INTEGRATING
TECHNOLOGIES FROM RESEARCH TO
PRACTICE.
SO HOW DO WE -- WE HAVE ALL
THESE TECHNOLOGIES BUT HOW DO WE
REALLY GET THEM FRP THE RYE
SEARCH INTO THE CLINIC SPACE.
AND SESSION FIVE, IMPLEMENTATION
OF INNOVATIVE TOOLS TO ENSURE
EQUITY ACROSS THE LIFESPAN,
WHICH I THINK IS A REALLY
CRITICAL PIECE, YOU KNOW, OFTEN
WITH TECHNOLOGIES, IT CREATES
MORE DISPARITY AND SO THE IDEA
IS WE WANT TO MAKE SURE THERE'S
ACCESS.
AND EQUITY IN TERMS OF HOW
THEY'RE IMPLEMENTED.
WE ALSO HAVE THREE BREAKOUT
SESSIONS THAT WILL INVOLVE THE
DISCUSSANTS TO TACKLE THE
FOLLOWING THEMES.
ONE, PRACTICAL USE AND
VALIDATION OF EMERGING BLOOD
PRESSURE DEVICES.
SO KIND OF AN EXTENSION OF THE
PRIOR SESSION REALLY DIVING IN
TO WHAT NEED TO BE DONE AROUND
THESE DEVICES IN TERMS OF HOW WE
THINK ABOUT THEM, AND ASSURE
THEIR ACCURACY.
THE SECOND SESSION FOCUSING ON
ACCESS AND EQUITY IN BLOOD
PRESSURE MEASUREMENT ASSESSMENTS
AND MONITORING, WHICH IS REALLY
A THEME THROUGHOUT THE ENTIRE
WORKSHOP, AND THEN THREE,
LOOKING AT RELIABLE BLOOD
PRESSURE MEASUREMENTS, BASED
ON -- WITH A FOCUS ON SORT OF
OUR TRADITIONAL APPROACHES TO
BLOOD PRESSURE.
SO OUR KIND OF CHARGE AND ASK OF
PARTICIPANTS IS CONTRIBUTE YOUR
COMMENTS AND QUESTIONS.
THERE'S NO BAD COMMENTS OR
QUESTIONS.
TO SOME EXTENT, AS LONG AS
YOU'RE RESPECTFUL OF OTHERS, BUT
WE REALLY WOULD LOVE TO HEAR
YOUR IDEAS AND THOUGHTS AND ANY
AREAS THAT WE SHOULD BE
CONSIDERING AS WE TRY TO TACKLE
THIS REALLY IMPORTANT ISSUE.
FEEL FREE TO ENGAGE THE SPEAKERS
AS MUCH AS YOU CAN DURING THEIR
TALKS, AND IF -- SOMETIMES
THERE'S NOT ADEQUATE TIME TO
ADDRESS EVERYTHING AND MANY
TIMES THERE MIGHT BE IMPORTANT
QUESTIONS THAT MAY BE DIFFICULT
TO CONVEY IN THE CHAT OR MIGHT
REQUIRE MORE DISCUSSION, SO WE
REALLY ENCOURAGE YOU TO REACH
OUT TO THE ORGANIZERS OF THE
EVENT IF WE RUN OUT OF TIME OUR
FEEL LIKE YOUR COMMENT WASN'T
ADEQUATELY DEVELOPED.
WE REALLY LOVE THAT OPPORTUNITY
TO ENGAGE IN SOME SENSE WITH THE
CHARGE TO DEVELOP A SUMMARY
LATER, SOME OF THE COMMENT COULD
BE REALLY INFORMATIVE FOR SOME
OF THAT LATER THOUGHT WORK.
OUR ASK OF THE PRESENTERS BE TO
ENGAGE YOUR COLLEAGUES AND
PARTICIPANTS THROUGHOUT THE
SESSIONS.
MAKE NOTE OF ANY GAPS OR NEW
IDEAS THAT ARE DEVELOPED AND
PRESENTED DURING THE SESSIONS
AND CONTRIBUTE THEM AND BRING
THEM UP IN THE WORKING GROUP
BREAKOUT SESSIONS.
DEVELOP TOPICS THAT ARE IN THE
SMALL GROUP SESSIONS, SO IF
LET'S SAY THERE'S SOMETHING THAT
WE FELT LIKE SHOULD HAVE BEEN
COVERED MORE FULLY OR MIGHT
WARRANT MORE DISCUSSION, REALLY
ENGAGE YOUR COLLEAGUES TO
DEVELOP THAT FURTHER.
THEN AS WAS MENTIONED, WE'LL
WORK TOGETHER, VERY COMMITTED TO
SUMMARIZING THE EXECUTIVE
SUMMARY AND SUMMARIZING THE
CONTENT IN A WAY THAT CAN BE
DISSEMINATED MORE BROADLY FOR
PRACTITIONERS AND RESEARCHERS
THROUGHOUT THE WORLD.
SO THANK YOU, AGAIN, FOR
EVERYONE ATTENDING TODAY.
SH THIS
REMARKABLE SUPPORT AND INTEREST
IN THIS WORKSHOP.
>> SO NOW WE ARE MOVING TO
SESSION 1, AND THE MODERATORS OF
THE SESSION ARE PAUL DRAWZ AND
ANDREW SOUTH.
PLEASE TAKE IT OVER.
>> THANK YOU.
PAUL DRAWZ, I'M A NEPHROLOGY
HYPERTENSION RESEARCHER AT THE
UNIVERSITY OF MINNESOTA.
>> [INAUDIBLE]
>> SO THIS SESSION IS ENTITLED
BLOOD PRESSURE ASSESSMENT IN
SPECIAL POPULATIONS ACROSS THE
LIFESPAN.
OUR FIRST SPEAKER IS DR. JOSEPH
FLYNN, PROFESSOR OF PEDIATRICS
AT THE UNIVERSITY OF WASHINGTON,
A MEMBER OF THE DIVISION OF
NEPHROLOGY AT SEATTLE CHILDREN'S
HOSPITAL, AND INTERNATIONALLY
RECOGNIZED EXPERT IN THE
TREATMENT OF HYPERTENSION IN
CHILDREN, AND HE WILL BE
PRESENTING ON CHALLENGES IN
PEDIATRIC BLOOD PRESSURE
MEASUREMENT.
DR. FLYNN.
>> THANK YOU FOR THAT
INTRODUCTION AND THANK YOU TO
THE ORGANIZERS FOR ASKING ME TO
TALK.
AND ACTUALLY THANK YOU FOR
INCLUDING CHILDREN IN THIS
ITERATION OF THE WORKSHOP.
WE HAD TALKED ABOUT HOW CHILDREN
HAD BEEN LEFT OUT OF THE 2017
WORKSHOP AND I'M GLAD THAT WE'RE
GETTING OUR OWN CHANCE TO BE AT
THE TABLE.
DISCLOSURES, AND THEN NEXT
SLIDE, PLEASE.
SO THESE ARE SOME OF THE THINGS
I'M GOING TO TALK ABOUT TODAY.
LISTENING TO STEVE'S TALK, I
REALLY THOUGHT THAT PROBABLY
ALMOST -- WELL, NOT ALL OF THE
THINGS HE HAD HIGHLIGHTED COULD
BE SORT OF ISSUES IN PEDIATRIC
BLOOD PRESSURE MEASUREMENT, BUT
MANY OF THEM, I THINK WE SHARE
MANY OF THE SAME CHALLENGES THAT
ARE SEEN IN ADULT BLOOM
MEASUREMENT IN BOTH RESEARCH AND
CLINICAL SETTINGS.
LY SAY TI WILL SAY THAT I HAVE N
REALLY TO FOCUS ON CLINIC BLOOD
PRESSURE MEASUREMENT AND NOT GO
INTO ISSUES RELATED TO
AMBULATORY BLOOD PRESSURE
MEASUREMENT OR HOME BLOOD
PRESSURE MEASUREMENT.
I HAD A VERY SHORT TIME ALLOTTED
TO ME AND I THINK EACH OF THOSE
THINGS ARE IMPORTANT, BUT FOR
TODAY, WE'LL TALK MOSTLY ABOUT
CLINIC MEASUREMENT, AND IF
PEOPLE HAVE QUESTIONS
SPECIFICALLY ABOUT AMBULATORY OR
HOME BLOOD PRESSURE MEASUREMENT,
THAT CERTAINLY CAN BE DISCUSSED
IN THE Q & A OR THE PANEL
DISCUSSION.
SO I'M GOING TO START OFF WITH
JUST TALKING ABOUT OUR ONE BIG
CHALLENGE IN PEDIATRICS, AND
THAT'S RELATED TO THE SIZE OF
OUR PATIENT.
S.
CHILDREN COME IN MANY DIFFERENT
SIZES AND THEY GROW, AND THIS
HAS IMPLICATIONS FOR HOW BLOOD
PRESSURE IS MEASURED AND HOW
EASY OR DIFFICULT IT MAY BE TO
GET ACCURATE BLOOD PRESSURE
MEASUREMENTS.
IT'S A BIG DEAL.
THEN UNFORTUNATELY, MANY
CHILDREN OVERGROW.
THIS IS SOME DATA FROM THE CDC
THAT PLOTS THE FREQUENCY OF
OBESITY IN CHILDREN, AND YOU CAN
SEE THAT OVER TIME, THE RATES OF
OBESITY HAVE INCREASED MARKEDLY
IN CHILDREN.
THEY SEEM TO BE PLATEAUING A
LITTLE BIT MORE RECENTLY, BUT
THIS AS IN ADULTS WILL HAVE
IMPLICATIONS FOR OBTAINING
ACCURATE BLOOD PRESSURE
MEASUREMENT.
SO JUST STARTING WITH THE CUFFS,
AS YOU CAN SEE IN THE CARTOON ON
THE LEFT, WE ARE AS INTERESTED
IN HAVING APPROPRIATELY SIZED
CUFFS IN CHILDREN FOR ACCURATE
BLOOD PRESSURE MEASUREMENT TO
ENSURE APPROPRIATE COMPRESSION
IN THE BRACHIAL ARTERY SO THAT
IS THE SAME ISSUE FOR US IN
PEDIATRICS AS IT IS IN ADULTS,
AND THAT MEANS AS YOU CAN SEE ON
THE RIGHT THAT YOU NEED AN EVEN
LARGER VARIETY OF CUFF SIZES AND
THOSE THERE ARE REALLY JUST THE
CHILD AND INFANT SIZE, BUT IN MY
CLINIC, I MAY HAVE A 6 MONTH OLD
IN ONE ROOM AND A 20-YEAR-OLD IN
THE NEXT ROOM, AND THEY'RE GOING
TO HAVE VERY DIFFERENT ARM
SIZES, WE NEED VERY DIFFERENT
SIZED CUPS AVAILABLE AND THIS
BECOMES AN ISSUE PARTICULARLY IN
THE PRIMARY CARE SETTING, WHERE
THEY MAY NOT HAVE THE WIDE
VARIETY OF CUFF SIZES AVAILABLE
THAT ARE NEEDED.
AS IS TRUE AND STEVE SHOWED SOME
DATA, I THINK, ON THIS POINT AS
WELL, THAT THERE ARE NO
STANDARDIZATION OF CUFF SIZES.
THIS SLIDE IS OLD, FROM 25 YEARS
AGO NOW, BUT I GUARANTEE YOU THE
SAME ISSUE IS STILL OUT THERE,
WHERE ONE MANUFACTURER'S CHILD
CUFF MAY BE A SMALL ADULT CUFF
BY THE NEXT MANUFACTURER.
SO FOR PEOPLE WHO ARE NOT
CAREFUL ABOUT HOW THEY CHOOSE
THEIR CUFF, IT QUITE EASY TO
CHOOSE THE WRONG SIZE CUFF IF
YOU JUST LOOK AT THE NAME OF THE
CUFF OR THE NAME THAT'S ON THE
CUFF.
SO THIS LEADS TO A LOT OF
VARIABILITY IN WHICH CUFF IS
CHOSEN.
THIS WAS A VERY INTERESTING
STUDY, AGAIN IT'S SORT OF OLD,
BURRBUT RELEVANT WHERE THIS WAST
OF A SURVEY COMPLETED BY
PEDIATRIC NURSES, PEDIATRIC
RESIDENTS, AND PEDIATRIC FACULTY
PHYSICIANS, AND ONE WOULD THINK
THAT THEY WOULD BE CHOOSING THE
SAME SIZE CUFF FOR EACH CHILD
BUT YOU DON'T REALLY NEED TO
LOOK AT THE NUMBERS THERE.
BUT TO KNOW THAT THERE WAS QUITE
A LOT OF VARIABILITY IN WHICH
CUFF WAS CHOSEN.
SO THIS BECOMES A CONCERN IN THE
CLINIC.
AND WITH THE CHILDHOOD OBESITY
EPIDEMIC, ALL THOSE BIG CUFFS
THAT STEVE TALKED ABOUT, GUESS
WHAT, WE NEED THEM IN PEDIATRICS
AS WELL.
AND THIS SLIDE COMES FROM
NHANES -- ADVANCE ONE MORE,
PLEASE.
AND SO JUST TO SHOW YOU THAT
WHEN YOU LOOK AT SORT OF EVEN
THE ADOLESCENT AGE GROUP, WHICH
I'VE HIGHLIGHTED THERE IN THE
RED BOX, THE NUMBER OF
ADOLESCENTS WHO REQUIRED EXTRA
LARGE OR -- LARGE OR EXTRA LARGE
ADULT CUFFS WAS SUBSTANTIAL.
13% FOR THE BAUM BRAND CUFFS AND
22% FOR THE WELCH ALLYN CUFFS
AND EVEN 4% OF EXTRA LARGE CUFFS
FOR THE -- IN THE WELL
CHALLENGED.
SO THE OBESITY EPIDEMIC IS A
PROBLEM.
ONE INTERESTING POINT AND I'D BE
INTERESTED TO HEAR STEVE AND
OTHERS WOULD SAY ABOUT THIS, IS
THAT THERE HAS BEEN SOME
INTEREST IN LOOKING AT CONICAL
CUFFS IN PEDIATRICS FOR CHILDREN
WITH OBESITY, BUT A RECENT PAPER
THAT WAS PUBLISHED DEMONSTRATED
THAT THE ACCURACY OF CONICAL
CUFFS IN ADOLESCENTS WAS NO
BETTER THAN STANDARD SIZE CUFFS.
SO IT'S UNCLEAR WHETHER WE NEED
TO HAVE CONICAL SIZE CUFFS IN
CHILDREN, THIS BECOMES, OFTEN,
AN AREA WHICH WE WOULD WANT TO
DO MORE WORK IN EVENTUALLY.
AND THEN WHAT HAPPENS IN
PRACTICE?
I'M NOT GOING TO GO INTO DETAIL
FOR EITHER OF THESE PAPERS, BUT
THESE ARE ALL SORT OF QUALITY
IMPROVEMENT STUDIES WHERE THEY
LOOKED AT LIKE WHAT HAPPENS IN
THE OFFICE WHEN CHILDREN GO TO
HAVE THEIR ARM -- OR HAVE THEIR
BLOOD PRESSURE MEASURED, AND SO
MY HYPERTENSION CLINIC, THE
FIRST STEP MY MEDICAL ASSISTANT
DOES IS THEY GET OUT A TAPE
MEASURE TO MEASURE THE ARM
CIRCUMFERENCE TO MAKE SURE
THEY'RE CHOOSING THE RIGHT SIZE
CUFF, BUT IF YOU LOOK ADD WHAT'S
HAPPENING IN PRACTICE, THAT'S
NOT HAPPENING.
AND THEN WE HAVE PROBABLY ABOUT
EIGHT DIFFERENT SIZE CUFFS FOR
OUR DEVICES, BUT WHEN YOU LOOK
AT WHAT HAPPENS IN PRACTICE,
MANY OFFICES DO NOT HAVE ALL
CUFF SIZES AVAILABLE.
AND THEN IN EPIC, WE'VE PUT DOWN
WHAT SIZE CUFF WE USED TO
MEASURE THE BLOOD PRESSURE, BUT
THIS IS NOT HAPPENING IN
PRACTICE EITHER.
AND SO ALL OF THESE THINGS SHOW
THAT THERE ARE CHALLENGES JUST
BEGINNING WITH CHOOSING THE
RIGHT SIZE CUFF TO OBTAIN
ACCURATE BLOOD PRESSURE
MEASUREMENT IN CHILDREN.
NOW WHAT ABOUT GETTING TO THE
ACTUAL DEVICES?
SO THERE ARE VALIDATION
PROTOCOLS OUT THERE, WHICH YOU
ALL ARE FAMILIAR WITH.
AND TAMMY BRADY IS GOING TO BE
TALKING MORE ABOUT THEM IN
DETAIL.
I JUST BRING YOUR ATTENTION TO
THE AAMI/ESH/ISO COLLABORATION
STATEMENT WHICH WAS PUBLISHED A
FEW YEARS AGO WHICH ACTUALLY
CALLED OUT THAT IF THE DEVICE IS
GOING TO BE USED IN BOTH ADULTS
AND CHIRP, YOU CHILDREN U YOUT
LEAST 35 SUBJECTS BETWEEN THE
AGES OF 3 AND 12 IN YOUR
POPULATION, AND THAT YOU NEED
TO -- AND THAT IN THAT AGE
GROUP, THE STANDARDS IN TERMS OF
DIFFERENT COMPARED TO THE
REFERENCE DEVICE ARE THE SAME AS
IN ADULTS.
SO I THINK PROBABLY TAMMY WILL
GO INTO THIS MORE, BUT AT LEAST
WE KNOW THAT THERE ARE DEVICE
VALIDATION PROTOCOLS THAT CALL
OUT THE NEED TO HAVE A
SUFFICIENT NUMBER OF CHILDREN IN
THE POPULATION WHEN THE DEVICE
IS BEING UTILIZED IN CHILDREN.
AND THEN THIS WAS ANOTHER TABLE,
THIS IS A TABLE FROM THAT SAME
PAPER WHERE THEY TALK ABOUT WHAT
SIZE CUFFS NEED TO BE AVAILABLE
FOR OBTAINING ACCURATE
VALIDATION STUDIES, AND AGAIN, I
WON'T DWELL ON THIS BECAUSE I'M
SURE THATTA ME WILL COVER IT.
-- I'M SURE THAT
TAMMY WILL COVER IT.
AND YOU KNOW, THERE ARE A LOT OF
VALIDATION STUDIES OUT THERE.
I DON'T NORMALLY LOOK AT THESE
GRAPHS IN PUBMED WHEN YOU SEE --
WHEN YOU DO A SEARCH, BUT I
THOUGHT IT WAS INTERESTING TO
SEE THAT JUST OVER THE LAST
WHATEVER, FROM 1996 TO 2024,
THERE ARE 493 STUDIES THAT WERE
PUBLISHED IN BLOOD PRESSURE
MONITORING, WHICH IS THE JOURNAL
IN WHICH MOST OF THESE STUDIES
ARE PUBLISHED, FOCUS ON DEVICE
VALIDATION.
BUT ONLY 40 OF THEM INCLUDED
CHILDREN.
SO VERY FEW DEVICE STUDIES ARE
INCLUDING CHILDREN, AND
CONSEQUENTLY IT'S NO STRETCH OF
THE IMAGINATION TO THEN REALIZE
THAT THAT MEANS THAT NOT MANY
DEVICES ARE ACTUALLY VALIDATED
IN CHILDREN.
AND WHEN YOU GO TO THE DIFFERENT
ORGANIZATIONS THAT LOOK AT WHICH
DEVICES HAVE PEDIATRIC
VALIDATION, THERE ARE NOT VERY
MANY.
SO YOU CAN SEE THAT ON THE
STRIDEBP WEBSITE, THERE WERE 13
OFFICE DEVICES VALIDATED IN
CHILDREN, ONLY THREE DEVICES FOR
HOME, AND THREE FOR AMBULATORY
BLOOD PRESSURE, AND ON THE
VALIDATEBP.ORG WEBSITE, ONLY ONE
DEVICE HAD PEDIATRIC VALIDATION.
AND SO THIS BECOMES PART OF THE
PROBLEM THEN FOR US WHEN WE DO
RESEARCH IN CHILDREN, AND LOOK
AT BLOOD PRESSURE MEASUREMENT
WHERE THE FIRST QUESTION IS,
WELL, WAS THE DEVICE VALIDATED,
AND OFTEN THEY'RE NOT.
AND ONE COMMENT HERE ABOUT HOME
BLOOD PRESSURE MONITORING IS
THAT THIS IS ONE OF THE REASONS
WHY HOME BLOOD PRESSURE
MONITORING DID NOT GET ENDORSED
IN THE AMERICAN ACADEMY OF
PEDIATRICS CPG BECAUSE OF SO FEW
DEVICES BEING AVAILABLE FOR
HOME.
THERE'S REALLY ONLY ONE, AND WE
AT SEATTLE CHILDREN'S HOSPITAL
ARE FORTUNATE ENOUGH TO BE ABLE
TO JUST GIVE THEM TO PARENTS,
BECAUSE PARENTS WOULD NEVER BE
ABLE TO FIND THEM ON THEIR OWN.
BUT THIS IS, OF COURSE, NOT THE
TYPICAL PRACTICE SETTING.
AND THEN THE PRACTICE OF
STANDARDIZED BLOOD PRESSURE
MEASUREMENT HAS BEEN DISCUSSED,
AND GUESS WHAT, THIS IS WHAT WE
WANT TO BE DOING IN CHILDREN AS
WELL.
AND WHEN WE HAVE DONE OUR
RESEARCH STUDIES IN CHILDREN
MOST RECENTLY, THE SHIP AHOY
PROJECT WHICH SOME OF YOU MAY BE
FAMILIAR WITH AND THE ONGOING
CHRONIC KIDNEY DISEASE IN
CHILDREN STUDY, WE ARE
PRACTICING STANDARDIZED BLOOD
PRESSURE MEASUREMENT TECHNIQUE
IN CHILDREN AND IN THE CPG, WE
HAVE THE WHOLE SECTION DEVOTED
TO POSITIONING THE PATIENT, AND
OBTAIN THE CORRECT MEASUREMENT,
AND WE ACTUALLY -- BECAUSE THERE
ARE NO COMMERCIALLY AVAILABLE
VIDEOS ON THE INTERNET -- LET ME
REPEAT THAT -- THERE ARE ZERO
VIDEOS ON THE INTERNET THAT
DEMONSTRATE CORRECT BLOOD
PRESSURE MEASUREMENT IN
CHILDREN, WE HAD TO MAKE ONE FOR
THE AAP AND WE NOW SORT OF HOUSE
THAT ON THE INTERNATIONAL
PEDIATRIC HYPERTENSION
ASSOCIATION WEBSITE.
BUT POSITIONING THE CHILD AND
DOING ALL OF THE SAME STEPS IS
IMPORTANT.
AND GUESS WHAT?
PATIENT POSITIONING IN CHILDREN
IS A LITTLE MORE COMPLICATED.
REMEMBER THAT SLIDE I SHOWED YOU
OF CHILDREN OF DIFFERENT SIZES.
WELL, WE HAVE TO TAKE THESE
THINGS INTO ACCOUNT IN OUR
CLINICS.
SO THIS IS A PHOTOGRAPH OF WHERE
I PRACTICE, THIS IS ONE OF MY
OUTREACH CLINICS, WHERE WE
ACTUALLY HAVE THESE SMALL CHAIRS
IN WHICH WE HAVE TO -- IF WE'RE
GOING TO HAVE THE CHILD
CORRECTLY POSITIONED, THEY NEED
TO BE IN THESE SMALL CHAIRS.
THIS IS VERY HARD ON MY BACK.
BUT WE DO TO MAKE SURE THE
POSITIONING OF THE CHILD IS
CORRECT.
SOMETIMES WE'LL PUT FOOT SUPPORT
UNDER THEM ON A STANDARD BENCH,
WHICH CAN HELP.
BUT THIS IS SORT OF A LITTLE
FUNNY COUPLE OF PICTURES, BUT
VERY IMPORTANT ISSUE IS THAT
PATIENT POSITIONING NEEDS TO BE
CORRECT IN PEDIATRICS JUST AS IN
ADULTS.
THEN HOW ARE WE GOING TO MEASURE
THE BLOOD PRESSURE?
SO ONE ISSUE THAT WE HAVE IN
CHILDREN IS THAT BECAUSE
CHILDREN GROW AND BECAUSE BLOOD
PRESSURE CHANGES AS CHILDREN
GROW, WE HAVE NORMATIVE DATA
THAT GIVE US THE NORMAL VALUES
AT DIFFERENT AGES AND HEIGHTS IN
CHILDREN.
AND THOSE DATA ARE BASED UPON US
UPONAUSCULTATORY BLOOD PRESSURE
MEASUREMENT.
HOWEVER WE KNOW THAT THIS MAY
NOT BE WHAT'S DONE IN PRACTICE.
AND WE ACKNOWLEDGE THAT IN THE
CLINICAL PRACTICE GUIDELINE,
WHERE WE SAID THAT, YES, OKAY,
USE THE OSCILLOMETRIC DEVICE TO
OBTAIN THE FIRST BLOOD PRESSURE
OR TO ON TAKE THE SCREENING
BLOOD PRESSURE, BUT THAT BECAUSE
THE NORMAL VALUES ARE DERIVED
FROM AUSCULTATORY BLOOD PRESSURE
MEASUREMENT, THEN YOU NEED TO
REPEAT THEM BY AUSCULTATION TO
CONFIRM.
THIS IS A PROBLEM, THOUGH,
BECAUSE MANY PEDIATRIC OFFICES
MAY NOT HAVE MANUAL DEVICES.
IT DOES REQUIRE TRAINING.
I CAN DO THIS IN MY HYPERTENSION
CLINIC.
WE HAVE A QUIZ WE GIVE TO OUR
MEDICAL ASSISTANTS TO MAKE SURE
THEY'RE DOING IT ACCURATELY, BUT
IT DEFINITELY HAS AN IMPACT ON
PATIENT FLOW, AND I THINK THAT
THAT'S PROBABLY BEEN MENTIONED
BY STEVE EARLIER AS WELL.
OF COURSE EVEN PEDIATRIC
NEPHROLOGISTS USE OSLO METRIC
DEVICES.
THIS IS A STUDY THAT WE DID MANY
YEARS AGO NOW THAT SHOWED THAT
MOST PEDIATRIC NEPHROLOGISTS USE
OSCILLOMETRIC DEVICES FOR BLOOD
PRESSURE MEASUREMENT, FEWER USE
ENEROID OR MERCURY DEVICES.
ACTUALLY MANY OF THEM WERE STILL
USING MERCURY AT THE TIME.
I DON'T KNOW THAT ANYONE IS
ANYMORE.
WE KNOW THIS IS A PROBLEM
BECAUSE OSCILLOMETRIC DEVICES
MAY LEAD TO INACCURATE
MEASUREMENTS, WHICH CAN THEN
LEAD TO MISCLASSIFICATION.
THIS WAS A PAPER WE PUBLISHED A
NUMBER OF YEARS AGO FROM THE
CHRONIC KIDNEY DISEASE IN
CHILDREN STUDY WHERE WE COMPARED
BLOOD PRESSURES MEASURED USING
AN OSCILLOMETRIC DEVICE TO THE
US A CULT TRI BLOOD PRESSURE,
AND YOU CAN SEE THERE WAS QUITE
A BIT OF SCATTER, AND THE
BLAND-ALTMAN PLOTS DIDN'T LOOK
VERY GOOD.
AND THIS IS A STUDY DONE BY
TAMMY'S GROUP WHERE THEY LOOKED
AT THE -- AGAINST THE TRIAGE
BLOOD PRESSURE COMPARED TO THE
MANUAL BLOOD PRESSURE BY THE
GOOD DR. BRADY HERSELF, AND
THERE WAS QUITE A BIT OF SCATTER
THERE AS WELL, AND SO -- AND
THAT DEGREE OF SCATTER IS
SIGNIFICANT, AND WE SHOWED IN
THE STUDY FROM THE CHRONIC
KIDNEY DISEASE IN CHILDREN
COHORT THAT DID LEAD TO
MISCLASSIFICATION OF CHILDREN
BECAUSE OF THE INACCURACIES FROM
THE OSCILLOMETRIC TECHNIQUE.
SO JUST TO SUM IT UP, THERE IS A
NUMBER OF FACTORS THAT CAN
AFFECT ACCURACY OF BLOOD
PRESSURE MEASUREMENT IN
CHILDREN.
WE HAVE A PATIENT POPULATION
WITH VARIABILITY IN ARM SIZE,
THERE ARE FEW VALIDATED DEVICES,
THERE ARE EDUCATION GAPS
REGARDING TECHNIQUE AND
PREFERRED METHOD OF BLOOD
PRESSURE MANAGEMENT.
AND WE NEED TO ADDRESS THESE
PROBLEMS, AND I'VE LISTED THERE
SOME STRATEGIES WHICH COULD BE
USED TO ADDRESS THE PROBLEMS
INCLUDING MORE PEDIATRIC
VALIDATION STUDIES, PERHAPS
STAND DAITISTANDARDIZATION IN C,
MORE EDUCATIONAL EFFORTS AND
QUALITY IMPROVEMENT EFFORTS AND
THEN PATIENT EDUCATION AND
EMPOWERMENT, WHICH IS SOMETHING
THAT WAS RAISED IN THAT ARMS
STUDY RECENTLY WHERE, YOU KNOW,
I HEARD AN INTERVIEW WITH
DR. BRADY ON SCIENCE FRIDAY, AND
THEY WERE TALKING ABOUT HOW
PATIENTS SHOULD BE ASKING THAT
THEIR BLOOD PRESSURE BE MEASURED
USING THE CORRECT SIZE DEVICE.
SO I DON'T KNOW THAT CHILDREN
CAN ACTUALLY DO THAT, BUT I WILL
TELL YOU THAT MANY TIMES,
PARENTS WILL COMMENT TO US THAT,
WOW, THIS IS THE FIRST TIME THAT
SOMEONE HAS ACTUALLY MEASURED MY
CHILD'S ARM AND USED THAT SIZE
CUFF ON MY CHILD.
AND SO WE HAVE A LOT OF WORK TO
DO IN PEDIATRICS, AND AGAIN, I
THANK YOU FOR THE OPPORTUNITY TO
TALK ABOUT SOME OF THE
CHALLENGES.
>> THANK YOU VERY MUCH,
DR. FLYNN, AS ALWAYS, EVEN --
YOU GIVE A LOT OF THE VARIATION
OF THAT TALK, I ALWAYS LEARN
SOMETHING NEW AND YOU ALWAYS
MAKE ME RE-THINK WHAT I WAS
TAUGHT AND WHAT I TAKE FOR
GRANTED.
SO THANK YOU VERY MUCH.
GIVEN THE TIME, WE'RE GOING TO
MOVE RIGHT ALONG AND WE'LL DO
QUESTIONS DURING THE PANEL
DISCUSSION.
AND NEXT UP, WE HAVE DR. KARA
HOPPE FROM UNIVERSITY OF
WISCONSIN AT MADISON HERE TO
TALK TO US ABOUT PREGNANCY IN
THE FOURTH TRIMESTER.
DR. HOPPE IS A MATERNAL FETAL
MEDICINE SPECIALIST WHOSE
RESEARCH FOCUSES ON HYPERTENSION
DURING PREGNANCY AND, VERY
IMPORTIMPORTANTLY, THE POSTPARTM
PERIOD, INCLUDING DEVELOPING
INTERVENTIONS TO IMPROVE
HEALTHCARE DELIVERY IN PATIENT
OUTCOMES IN THIS VERY MUCH
OVERLOOKED POPULATION.
>> THANK YOU SO MUCH TO THE
ORGANIZERS, MODERATORS, AND
INCLUDING PREGNANT PEOPLE IN
THIS WORKSHOP.
I WASN'T PLANNING ON SAYING THIS
BUT JUST REFLECTING ON
DR. FLYNN'S PRESENTATION WHICH
WAS PHENOMENAL, I JUST WANTED TO
SAY AS A PARENT, I JUST RECENTLY
HAD TWO OF MY CHILDREN, ONE IS
10, ONE IS 13 AT THEIR STANDARD
PEDIATRIC VISIT AND MY
13-YEAR-OLD, VERY ACTIVE, PRETTY
MUSCULAR AND NEAR ADULT HA-SIZED
YOUNG LADY HAD HER BPs
REPORTED AS ELEVATED, AND WHEN I
ASKED ABOUT IT, THEY WERE
DISREGARDED AND THEN IT TOOK ME
AS A PHYSICIAN SCIENTIST WHO
CARES ABOUT HYPERTENSION TO SAY,
YOU KNOW, HER BLOOD PRESSURE IS
ELEVATED, I ASKED TO RECHECK IT,
THEY DIDN'T RECHECK IT, AND THEN
SHE WENT BACK FOR A FOLLOW-UP,
BLOOD PRESSURE WAS STILL
ELEVATED, SO THEY SAID, WELL,
WE'LL PUT IT IN HER CHART, YOU
KNOW, TO THINK ABOUT.
AND I WENT HOME AND I THOUGHT
ABOUT IT, I MEASURED HER ARM, I
RECHECKED IT WITH PROPER
TECHNIQUE, AND HER BLOOD
PRESSURES WERE COMPLETELY
NORMAL, SO I MYCHARTED THE
PHYSICIAN AND SHE SAID NOTE
TAKEN, I THINK WE NEED MORE
EDUCATION IN OUR CLINIC.
AND JUST TO NOTE, THEY HAD ONE
BP DEVICE, THEY DID NOT MEASURE
HER ARM AND THE KIDS' LEGS WERE
HANGING FROM ADULT CHAIRS.
SO I JUST WANT TO VALIDATE
EVERYTHING THAT DR. FLYNN JUST
SAID AS A PARENT.
SO ANYWAYS, WHEN WE TALK ABOUT
PREGNANCY, I JUST COMMENTED HERE
REGARDING THE OBJECTIVES OF THE
MEETING.
MY GOAL HERE IS TO JUST TALK
ABOUT THE CURRENT STATE OF
KNOWLEDGE ON BLOOD PRESSURE
ASSESSMENT IN PREGNANT AND
POSTPARTUM PERSONS, KNOWLEDGE
GAPS PERTAINING TO CURRENT BLOOD
PRESSURE ASSESSMENT METHODS IN
THE PREGNANT AND POSTPARTUM
PATIENTS, AND THEN ONGOING
RESEARCH AND IDENTIFY RESEARCH
NEEDS TO IMPROVE THOSE BLOOD
PRESSURE ASSESSMENTS AGAIN IN
OUR PREGNANT AND POSTPARTUM
PERSONS.
I HAVE SOME DISCLOSURES.
JUST A REALLY BRIEF BACKGROUND.
I FEEL LIKE THERE'S SO MUCH TO
COVER REGARDING PREGNANT AND
POSTPARTUM PEOPLE.
SO I JUST KIND OF KEPT IT AS
BROAD STROKES BUT IN JERNTION WE
HAVE INCREASING RATES OF
HYPERTENSION DISORDERS OF
PREGNANCY ACROSS THE U.S.
WE HAVE INCREASING RATES OF
MATERNAL MORTALITY, ESPECIALLY
RELATED TO CARDIOVASCULAR
DISORDERS, AND HYPERTENSION IS A
LARGE CONTRIBUTOR TO THAT.
ADDITIONALLY, PEOPLE WHO HAVE
THESE CONDITIONS HAVE INCREASED
RISK OF LONG TERM CARDIOVASCULAR
DISORDERS AND MORTALITY.
GUIDELINES REGARDING BLOOD
PRESSURE ASSESSMENT AND CONTROL
IN PREGNANCY ARE PRIMARILY BASED
ON EXPERT OPINION AND NOT
CONSISTENT WITH NON-PREGNANT
ADULTS.
POSTPARTUM BLOOD PRESSURE
MONITORING USING REMOTE PATIENT
MONITORING OR SELF-MONITOR BLOOD
PRESSURE HAS INCREASING EVIDENCE
REGARDING THE SUPPORT OF USE OF
THIS, BUT IT'S LIMITED AND
SCALABILITY HAS BEEN
PARTICULARLY CHALLENGING.
WE HAVE LACK OF VALIDATED
DEVICES AND APPROPRIATE CUFF
SIZES FOR OUR PREGNANT AND
POSTPARTUM PEOPLE AND WE HAVE
LACK OF ACCESS TO BLOOD PRESSURE
DEVICES IN GENERAL.
SO EVEN IF WE HAD GOOD DEVICES,
GOOD RECOMMENDATIONS, PEOPLE
REALLY CAN'T ACCESS THE BLOOD
PRESSURE DEVICES THEY NEED.
THEN SPECIFICALLY TO ADDRESS HOW
IS HYPERTENSION CARE IN THIS
AREA DIFFERENT THAN IN
NON-PREGNANT ADULTS?
IN GENERAL WHEN WE'RE TALKING
ABOUT -- IT CONSIDERED AN AREA
WHERE THIS CAN BE AN ACUTE
CONDITION AND A VERY DIFFERENT
SITUATION THAN OUR GENERAL ADULT
POPULATION OR PEOPLE WITH
CHRONIC HYPERTENSION.
ADDITIONALLY, IN COMPARISON TO
ADULT HYPERTENSION RESEARCH,
THERE'S VERY FEW PREGNANCY
TRIALS AVAILABLE.
IN PREPARING FOR THIS TALK, I
FOUND THIS INSIGHTFUL PAPER JUST
TALKING ABOUT THE INTERSECTION
OF CARDIOVASCULAR HEALTH AND
MATERNAL HEALTH WITH A PORTFOLIO
ANALYSIS OF FEDERAL GRANT
FUNDING FROM 2016 TO '21.
KIND OF ASTOUNDINGLY, IT APPEARS
THAT OVERALL MATERNAL HEALTH
GRANTS REMAINED UNCHANGED AND
ONLY MADE UP OF 1.5% OF TOTAL
DHHS GRANT FUNDING.
MATERNAL CARDIOVASCULAR HEALTH
SPECIFIC FUNDING HAD
APPROXIMATELY 755 GRANTS AND YOU
CAN SEE THE TOTALS THERE.
INSTITUTE FUNDING PRIORITIES FOR
NON-NIH, DHHS AGENCIES INCLUDED
MOSTLY GENERAL MATERNAL HEALTH
RELATED TO CARDIOVASCULAR
HEALTH, AND THEN MOST COMMON
METHODOLOGY WAS CLINICALLY
APPLIED RESEARCH IN THE --
HYPERTENSION, DISORDERS OF
PREGNANCY, MATERNAL MORTALITY,
THE MOST COMMON AREAS WITH
METHODOLOGY SPANNING A LARGER
SPECTRUM OF BASIC CLINICAL
TRIALS OR TRANSLATIONAL
RESEARCH.
REGARDING WHERE IS THE FUNDING
PREPARTUM, IT 78.5% POSTPARTUM,
50%, AND THEN THE PREPREGNANCY
PERIPARTUM PERIODS AROUND 10%.
SO IN GENERAL, FEDERAL FUNDING
FOR MATERNAL HEALTH SPECIFICALLY
AROUND CARDIOVASCULAR HEALTH
INCREASE AT THE SAME RATE AS
FUNDING FOR OTHER RESEARCH BUT
ONLY REPRESENTED ABOUT 1.5% OF
OVERALL FUNDING.
WHEN I PULLED ON NIH REPORTER
FUNDING FOR HYPERTENSION VERSUS
PREGNANCY AND KIND OF THE
INSTITUTES THAT ARE FUNDING, YOU
CAN SEE THERE IS AN INCREASE IN
GENERAL OF HYPERTENSION FUNDED
RESEARCH AS WELL AS PREGNANCY
RELATED RESEARCH, I COULDN'T GET
INTO THE DEPTHS OF THE
HYPERTENSION IN PREGNANCY AREAS,
BUT I JUST FIND IT PROMISING
THAT THOSE FUNDING LEVELS ARE
GOING UP.
SO PREGNANCY IS A GREAT TIME OF
CHANGE, AND THERE'S A LOT TO
TALK ABOUT REGARDING HOW DO WE
DIAGNOSE ALL THESE DIFFERENT
TYPES OF HYPERTENSION DISORDERS
AND IT'S PROBABLY REALLY OUTSIDE
THE SCOPE OF THE TALK TODAY, BUT
WE DO HAVE INCREASING RATES OF
PEOPLE WHO COME INTO PREGNANCY
WITH KNOWN CHRONIC HYPERTENSION
AND THERE IS A A KA NUN DUMB TT
THE DIAGNOSTIC BLOOD PRESSURE
THRESHOLD FOR HYPERTENSION IN
PREGNANCY HAS NOT CHANGED, IT
REMAINS 140 GREATER THAN OR
EQUAL TO 140 OVER 90.
SO IF THEY HAD STAGE ONE
HYPERTENSION BASED ON -- WE
DON'T KNOW WHAT TO DO WITH THOSE
PATIENTS AND WE HAVE NOT CHANGED
THE GUIDELINES TO REFLECT
CHRONIC HYPERTENSION WITH THOSE
BLOOD PRESSURE THRESHOLDS NOW
THAT THEY'RE PREGNANT.
AND THEN WE HAVE IN GENERAL ANY
OF THESE OTHER TYPES OF
DISORDERS, AND THEY'RE ALL
DIAGNOSED AT THE BLOOD PRESSURE
THRESHOLD OF 140 OVER 90, AND
THEN THAT ALL KIND OF DETAIL OUT
WHAT TYPE OF HYPERTENSION
DISORDER THEY'RE GOING TO HAVE.
THE OTHER THING I JUST WANT TO
COMMENT REGARDING BLOOD PRESSURE
DEVICES.
WE HAVE A LOT OF OVERWEIGHT
PREGNANT PEOPLE AND OFTENTIMES
WE'RE STRUGGLING TO FIND AN ARM
CUFF THAT ACTUALLY FITS
PROPERLY.
AND ADDITIONALLY THERE'S A LOT
OF PROBLEMS WITH AVAILABILITY
WITH VALIDATED BLOOD PRESSURE
DEVICES IN OUR PREGNANT
PATIENTS.
SO WHEN CONSIDERING PHYSIOLOGIC
CHANGES IN PREGNANCY, WE START
TO SEE CHANGES AS EARLY AS THE
FIRST TRIMESTER.
SPECIFIC CHANGES INCLUDE AN
INCREASED HEART RATE, BLOOD
VOLUME CARDIAC OUTPUT, AS WELL
AS STROKE VOLUME.
THERE'S ALSO INCREASED RENAL AND
UTERINE BLOOD FLOW, THERE'S
INREESED TOTAL BODY WATER, BLOOD
VOLUME AND CAPILLARY HYDROSTATIC
PRESSURE AS WELL AS DECREASES IN
PERIPHERAL RESISTANCE TO
ACCOMMODATE THE DEVELOPING FETUS
IN THE UTERINE CAVITY.
AS PREGNANCY PROGRESSES WE CAN
START TO SEE ANATOMIC
COMPRESSION OF THE INFERIOR VENA
CAVA AGAIN DUAL TO THAT UTERINE
SIZE.
THESE CLASSIC CHANGES CAN ALSO
BE DEVELOPED FURTHER WHEN A
PERSON DEVELOPS PRE-ECLAMPSIA IN
CERTAIN CASES YOU'LL SEE
ACTUALLY THE HEART RATE REDUCES
QUITE A BIT, THE PERIPHERAL
RESISTANCE WITH IN A NORMAL
PREGNANCY FOAS DO GOES DOWN, ITO
UP QUITE A BIT.
I WAS JUST IN A BLOOD PRESSURE
VALIDATION WORKSHOP EARLIER THIS
WEEK AND KNOWING SPECIFICALLY
THAT THOSE PARTICULAR PARAMETERS
MAY ALTER THE CALCULATIONS
PROVIDED IN THE OSCILLATORY
BLOOD PRESSURE MACHINES SO
THERE'S A LOT OF WORK THAT NEEDS
TO BE DONE AND CONSIDERED WHEN
THINKING ABOUT THE PHYSIOLOGICAL
CHANGES IN THIS SPECIAL
POPULATION AND HOW ACCURATE OUR
BLOOD PRESSURE READINGS MIGHT BE
AS WELL AS HOW ARE WE CARING FOR
THEM IN THE PREGNANCY REGARDING
THESE CHANGES.
THE FIGURE ON THE RIGHT, I JUST
PUT HERE AS A HISTORICAL FIGURE
BECAUSE THIS IS ONE OFTEN FOUND
IN OUR TEXTBOOKS AND IT'S FROM
THE 80s WHERE THEY INCLUDED 69
PREGNANT PERSONS AND THEN THEY
HAVE SEQUENTIAL EVALUATIONS OF
THEIR BLOPs THROUGH THEIR
PREGNANCY AND THEN AGAIN ONE
TIME FOR SIX WEEKS POSTPARTUM.
WHAT IT SHOWS IS THAT THE
AVERAGE BLOOD PRESSURE ARE LOWER
DURING PREGNANCY AND -- AROUND
THE 28TH WEEK OR SO BUT THEN
THEY PICK UP AND BLOOD PRESSURES
WILL REACH THEIR BASELINE
TOWARDS THE END OF THE
PREGNANCY.
AND SO WHEN I STARTED IN THIS
FIELD, THAT REALLY WAS LIKE ONE
OF THE ONLY FIGURES OUT THERE,
AND THERE'S BEEN A LOT OF WORK
AND MORE WORK THAT'S COMING OUT
TO TRY TO REALLY UNDERSTAND HOW
DO THESE BLOOD PRESSURES CHANGE
AND HOW CAN OUR RECOMMENDATIONS
PERHAPS BE ALTERED TO PROVIDE
BETTER CARE.
SO THE KNOWLEDGE ABOUT BLOOD
PRESSURE PROFILES, HOW THEY
BEHAVE IN PREGNANCY THROUGH
POSTPARTUM I WOULD SAY IS ONE OF
OUR LARGE E. GAPS ANDEST GAPS AI
MENTIONED HYPERTENSION DISORDERS
ARE GOING UP, MORBIDITY AND
MORTALITY IS GOING UP IT'S LIKE
WHERE ARE WE MISSING THE BOAT.
SO I MADE RECOMMENDATION, YOU
KNOW, HISTORICALLY SPECIFIC
RECOMMENDATIONS FOR WELL MAYBE
PEOPLE COULD STAY IN THE
HOSPITAL LONGER POSTPARTUM OR
THAT THE CLASSIC AND STILL THE
STANDARD IS PEOPLE SHOULD COME
BACK AFTER BIRTH TO HAVE THEIR
BLOOD PRESSURES ASSESSED.
BUT WHEN WE ACTUALLY CAN START
LOOKING AT THESE BLOOD PRESSURE
PROFILES AND UNDERSTAND, I KNOW
THE FIGURES ARE SMALL BUT THESE
ARE ONES THAT MY GRE GROUP HAS
PUBLISHED.
THE ONE ON THE LEFT IS ALL
HYPERTENSION IN PREGNANCY
PATIENTS SPECIFICALLY EXCLUDING
CHRONIC HYPERTENSION.
YOU CAN SEE THAT CLASSIC STORY
OF BLOOD PRESSURE -- EARLY IN
THE PREGNANCY, HOWEVER THEY RISE
AND THEY REACH THEIR PEAK AT
DELIVERY, BUT THEN THEY HAVE A
PERIOD OF TIME OVER THE FIRST
4 TO 7 DAYS POSTPARTUM WHERE
THEY WILL GO DOWN AND THEN PEAK
AGAIN.
AND I THINK THAT'S IMPORTANT
BECAUSE IF WE'RE NOT SEEING
PATIENTS OR ASSESSING THEIR --
EVERY DAY WE'RE GOING TO MISS
THE TIMES WHEN THOSE BLOOD
PRESSURES SPIKE AND THERE MIGHT
BE MORE MORBIDITY.
THE FIGURE ON THE RIGHT IS
SIMILAR, IT'S JUST PULLING APART
THE DIFFERENT TYPES OF
HYPERTENSION DISORDERS AND
INCLUDING -- WE HAD CLOSE TO 900
PEOPLE IN THESE STUDIES, AND YOU
CAN SEE FOR THE CHRONIC
HYPERTENSIVE PATIENTS IN THE
SYSTOLIC AND DIASTOLIC BLOOD
PRESSURE PROFILES THAT THEY
RECOVER THEIR TO AT OR BELOW
THEIR PRECONCEPTION BLOOD
PRESSURES, OF OUR, IN THE FOLKS
WHO HAD A HYPERTENSION RELATED
DISORDER IN THEIR PREGNANCY, NOT
CHRONIC, THE, THEY'RE NOT RECOVG
THEIR DIASTOLIC BLOOD PRESSURE
SPECIFICALLY, SO THIS MIGHT
PROVIDE SOME INSIGHT INTO
NECESSARY CARE BEYOND EVEN THE .
SO WHAT DO WE KNOW CURRENT
STATE?
I POINT OUT HERE SEVERE
HYPERTENSION SHOULD BE TREATED.
SO OUR SEVERE HYPERTENSION
THRESHOLD IS 160/110 MILLIMETERS
OF MERCURY AND THAT'S SORT OF
OUR THRESHOLD WHERE EVERYBODY
SHOULD BE TREATED.
BEFORE THE CHAP TRIAL, MANY
PEOPLE WITH CHRONIC HYPERTENSION
WERE TAKEN OFF THEIR MEDICATIONS
AND WERE NOT TREATED UNTIL
160/110.
SO THAT LEADS TO THE CHAP TRIAL
AND WE LOOKED AT A COMPOSITE OUT
COME OF PRETERM BIRTH LESS THAN
35 WEEKS, PREECLAMPSIA WITH
SEVERE FEATURES, ABRUPTION AND
FETAL DEMISE WHILE NOT AFFECTING
SGA.
WHAT WE FOUND IS THAT THAT
COMPOSITE OUTCOME AS WELL AS THE
INDIVIDUAL COMPONENTS OF THAT
COMPOSITE WERE ALREADY REDUCED
AND WE DID NOT AFFECT THE FETAL
SIZE, SO SGA LESS THAN A THE
FIFTH OR TENTH WAS NOT
SIGNIFICANT.
ADDITIONALLY WE FOUND THE
REDUCTION IN THE COMPOSITE
OUTCOME WAS EVEN BETTER, THE
PROBLEM IS THAT THIS WAS
SPECIFICALLY CHRONIC
HYPERTENSIVE PATIENTS SO THESE
RESULTS REALLY ARE NOT ABLE TO
BE GENERALIZED TO OTHER
HYPERTENSION DISORDERS OF
PREGNANCY AND WE STILL DON'T
KNOW WHAT -- AND CURRENTLY WE
REALLY DON'T PROVIDE
ANTIHYPERTENSIVE TREATMENT UNTIL
THEY REACH THAT SEVERE RANGE.
THE CHIP TRIAL WAS HI HISTORICAY
ALSO ANOTHER TRIAL LOOKING AT
TIGHTER BLOOD PRESSURE CONTROL.
SPECIFICALLY TIGHTER DIASTOLIC
BLOOD PRESSURE CONTROL VERSUS
LESS TIGHT AND IN THAT TRIAL
THEY FOUND ADDITIONALLY THAT
TIGHTER BLOOD PRESSURE CONTROL
IS ASSOCIATED WITH LOWER RISKS
OF SEVERE HYPERTENSION WITHOUT
INCREASING RISK TO THE FETUS OR
NEWBORN.
THERE ARE A LOT OF BLOOD
PRESSURE SPIKES HAPPENING IN
THOSE POSTPARTUM DAYS 4 TO
7 THAT ARE BEFORE THE SCHEDULED
CLINIC OUTPATIENT FOLLOWUPS.
UNDERESTIMATING THE AMOUNT OF
PEOPLE PROBABLY THAT STILL HAVE
PERSISTENT HYPERTENSION THROUGH
THAT 6 WEEK POSTPARTUM PERIOD.
NOW REMOTE PATIENT MONITORING ON
THE UP AND COMING, BUT WE HAVE
SHOWN THAT IT CAN REDUCE
HOSPITAL RO READMISSIONS.
WE'VE ALSO SHOWN SIMILAR
STRATEGIES CAN REDUCE RACIAL
DISPARITIES IN POST HYPERTENSION
CARE ATTENDANCE OR ABILITY TO AT
LEAST ACQUIRE BLOOD PRESSURES.
SO THESE STRATEGIES ARE
UNDERSTUDIED SMALL STUDIES, AND
WE NEED MORE INFORMATION BUT
THERE'S PROMISING HOPE FOR THEM.
AND THEN JUST A COMMENT ABOUT
24-HOUR AMBULATORY BLOOD
PRESSURE TESTING.
THAT IT COULD BE HELPFUL IN
DEFINING -- AGAIN MANY PREGNANT
PERSONS COME TO PREGNANCY
THINKING THEY MAY OR MAY NOT
HAVE HYPERTENSION OR THEY HAVE
WHITE COAT BUT NOBODY IS
THINKING ABOUT VERIFYING THIS
AND THERE'S POTENTIAL RISKS OF
OVERTREATING OR UNDERTREATING IN
THE PREGNANCY IF WE DON'T REALLY
KNOW WHAT PEOPLE HAVE.
JUST A COMMENT ABOUT
SELF-MEASURED BLOOD PRESSURE
MONITORING.
I THINK MOST PEOPLE ON THIS CALL
ARE PROBABLY VERY WELL AWARE OF
THAT BUT REFERRING TO BLOOD
PRESSURE MEASUREMENTS OIB TAINED
BY THE PATIENT OUTSIDE OF THE
CLINICAL SETTING OFTEN AT HOME.
THIS STRATEGY IS MOST COMMONLY
USED IN NON-PREGNANT PEOPLE.
THERE'S MANY RESOURCES DEVELOPED
FOR IMPLEMENTATION AND USE AS
WELL AS FOLLOW-UP.
ON THE OTHER SIDE, REMOTE
PATIENT MONITORING IS WHAT WE'RE
CALLING THE HOME SURVEILLANCE,
WHICH INCORPORATES A DIGITAL
HEALTH SOLUTION THAT CAPTURES
AND -- OUTSIDE THE TRADITIONAL
HEALTHCARE ENVIRONMENT.
THIS IS WHAT WE'RE TENDING TO
OFFER AND DO IN THE PREGNANCY
AND POSTPARTUM SPACE.
MORE RESOURCES ARE COMING, BUT
THERE IS NO STANDARDIZED CARE
MODEL.
IT'S COSTLY.
AND OUR EVIDENCE IS CURRENTLY
LACKING.
WE DID JUST PUBLISH A
MULTICENTER PAPER TO REALLY TALK
ABOUT OUR DIFFERENCES AND
EXPERIENCES ACROSS THE COUNTRY
USING THESE STRATEGIES.
AND THERE'S DEFINITELY
DIFFERENCES IN THE THRESHOLDS
PEOPLE ARE INTERVENING ON BEHALF
OF BLOOD PRESSURES, HOW THEY'RE
UTILIZING THIS STRATEGY, AND
AGAIN, MOST OF NEM A THEM ARE IN
ACADEMIC CENTERS SO NOT
NECESSARILY ABLE TO DISSEMINATE
BROADLY IN OTHER SPACES.
SO A LOT OF WORK NEEDS TO BE
DONE IN THIS SPACE.
I WANTED TO JUST THROW OUT MANY
NATIONWIDE STRATEGIES ARE
WORKING TO IMPROVE HYPERTENSION
CARE AND DELIVERY AS WELL AS
OUTCOMES IN THE PREGNANT AND
POSTPARTUM PERIOD.
SO FOR EXAMPLE, THE MILLION
HEARTS HYPERTENSION AND
PREGNANCY CHANGE PACKAGE, WHICH
HAS BEEN REALLY -- IN WHICH YOU
CAN CHANGE CARE PROCESSES
RELATED TO HYPERTENSION AND
PREGNANCY.
IT WAS AUTHORED BY CDC AND SEVEN
ORGANIZATIONS DEDICATED TO
IMPROVING MATERNAL HEALTH, THE
BULK MADE UP OF TABLES LIKE YOU
CAN SEE ON THIS SLIDE, WITH
CONCEPTS WHICH ARE BROAD NOTIONS
FOR CHANGE AND WAYS TO HAVE
DIFFERENT SPECIFIC CHANGE IDEAS
WHICH ARE ACTIONABLE
IMPLEMENTATION STRATEGIES, AND
THEN EACH CHANGE AIR, THERE ARE
TESTED TOOLS AND RESOURCES FROM
CLINICIANS IN THE FOLD AS WELL
AS NATIONAL ORGANIZATIONS THAT
CAN HELP NEXT SLIDE.
SO IN GENERAL, WHAT'S NEEDED?
SO WE NEED A LOT IN THIS SPACE.
TREATMENT THRESHOLDS FOR
NON-CHRONIC HYPERTENSION DURING
PREGNANCY, AND ALL TYPES,
POSTPARTUM.
WE HAVE LIMITED RECOMMENDATIONS
AND EVIDENCE IN EVEN
HYPERTENSIVE MEDICATIONS.
WE'RE USING VERY UNDERSTUDIED IN
GENERAL, WE HAVE SOME OTHER
OPTIONS BULL THE PRIMARY FIRST
LINE AGENTS USED IN NON-PREGNANT
ADULTS THAT LIKELY WORK BETTER
OR SOMEWHAT ABLE TO BE USED IN
PREGNANCY BUT MANY COULD BE, SO
AGAIN JUST A CALLOUT THAT WE
REALLY COULD USE SOME UPDATES NP
STUDYING THE MEDICATION TYPES WE
HAVE.
AND THAT MAYBE WE COULD USE MORE
EFFECTIVELY.
DEVICE COVERAGE, DEVICE
VALIDATION.
WE REALLY NEED TO ENDORSE AND
REIMBURSE -- HAVE ENDORSEMENT
AND REIMBURSEMENT CARE MODELS
FOR SMBP AND/OR RPM FOR
PREGNANCY AND POSTPARTUM
PERIODS.
WE NEED STANDARD RECOMMENDATIONS
FOR THESE AS WELL AND REALLY
NEED TO OPTIMIZE -- SO WE'RE
TALKING ABOUT CHRONIC
HYPERTENSION FOR TWO DAYS BUT
WHEN SOMEONE HAS HYPERTENSION IN
THEIR PREGNANCY THEY'RE AT RISK
LONG TERM, SO REALLY CLOSING
THAT GAP, SO THAT TRANSITION
THAT WILL CARE IS REALLY
IMPORTANT.
PRIORITY, AGAIN, KEEPING
BIRTHING AND POSTPARTUM PEOPLE
SAFE.
IT'S GOING TO TAKE ALL LEVELS OF
THINGS IN THIS DIAGRAM, AN I
JUST PUT THIS HERE AS AN EXAMPLE
OF INDIVIDUAL LEVEL FACTORS,
HEALTHCARE PROFESSIONAL FACTORS,
HEALTH SYSTEM FACTORS AND
COMMUNITY FACTORS.
IT'S REALLY GOING TO TAKE A
VILLAGE TO MAKE AN IMPACT.
AND THEN THIS WAS MY SUMMARY
SLIDE HERE, KEY GAPS ON THE
LEFT.
SO THIS MIGHT SOUND TERRIBLE,
BUT OUR CURRENT STATE OF
KNOWLEDGE IS POOR, POUR
KNOWLEDGE GAP IS EXTENSIVE, AND
THERE IS A NEED FOR DEFINING
STANDARDS OF CARE MODELS TO
IMPROVE HYPERTENSION CARE AND
REDUCE MATERNAL MORBIDITY AND
MORTALITY.
MANY FEATURE OPPORTUNITIES TO
IDENTIFY PRIORITIES, CREATE
COLLABORATIVE ENVIRONMENTS AND
SUPPORT TRIALS TO CREATE
EVIDENCE TO ADVANCE HYPERTENSION
CARE DURING THESE REPRODUCTIVE
YEARS, FOCUSED ACROSS THE ENTIRE
RESEARCH SPECTRUM, SO TRAINEES,
BASIC SCIENCE, CLINICAL
TRANSLATIONAL TRIALS AND
IMPLEMENTATION TRIALS, AND THEN
THE IDEA OF AI, I JUST WANT TO
SAY, HAS LARGE POTENTIAL.
SO WHEN WE BROUGHT UP A.I. HERE,
IT'S PROBABLY TALKING MORE ABOUT
BP DEVICES AND THINGS, BUT IN
THE CONCEPT OF CARE MODELS, THE
ABILITY TO TELL A PATIENT YOUR
BP LOOKS GOOD, YOU NEED TO GO
IN, YOU NEED PROMPT OR EFFECTIVE
TREATMENT, AGAIN CALLING --
POSTPARTUM PERIOD IS MUCH
DIFFERENT THAN CHRONIC
HYPERTENSION.
SO I'M EXCITED ABOUT ALL THIS,
AND THANK YOU FOR THE
OPPORTUNITY.
THAT'S ALL I HAVE.
>> ALL RIGHT, THANK YOU FOR
THAT, DR. HOPPE.
OUR NEXT SPEAKER IS DR. LEWIS
LIPSITZ, PROFESSOR OF MEDICINE
AT HARVARD MEDICAL SCHOOL,
DIRECTOR OF MARCUS INSTITUTE FOR
AGING RESEARCH AT HEBREW
SENIORLIFE AND CHIEF DIVISION OF
GERONTOLOGY AT BETH ISRAEL
DEACONESS MEDICAL CENTER AND
EDITOR-IN-CHIEF OF THE JOURNAL
OF GERONTOLOGY MEDICAL SCIENCES
RESEARCH, FOCUSES ON THE
MECHANISMS AND MANAGEMENT OF
COGNITIVE AND MOBILITY DISORDERS
AND THEIR INTERACTIONS IN OLDER
ADULTS.
HE'LL BE PRESENTING ON BLOOD
PRESSURE MONITORING IN OLDER
ADULTS, MANAGING COGNITIVE
DECLINE AND BP VARIABILITY.
>> THANK YOU VERY MUCH.
I APPRECIATE THE ORGANIZERS OF
THIS WORKSHOP INVITING ME AND
ASKING ME TO SPEAK ABOUT BLOOD
PRESSURE MONITORING IN OLDER
ADULTS, PARTICULARLY WITH
COGNITIVE DECLINE IN BLOOD
PRESSURE VARIABILITY.
SO THIS SLIDE ILLUSTRATES THE
PREMISE UNDERLYING MY COMMENTS
THIS AFTERNOON, AND REALLY THE
MAIN POINTS THAT I'D LIKE TO
MAKE.
I THINK EVERYONE KNOWS THAT
AGING IS ASSOCIATED WITH BLOOD
PRESSURE ELEVATION.
THIS IS COMMON KNOWLEDGE.
BUT AGING ALSO IMPAIRS BLOOD
PRESSURE REGULATION.
SO DOES BLOOD PRESSURE ELEVATION
IMPAIR BLOOD PRESSURE
REGULATION, SO THAT WHAT WE SEE
IN MANY OLDER ADULTS IS
INCREASED BLOOD PRESSURE
VARIABILITY, PARTICULARLY HEE
POTENTIAL IN RESPONSE TO MANY
COMMON ACTIVITIES.
THERE'S NOT MUCH THAT WE CAN DO
AT THE MOMENT ABOUT AGING OTHER
THAN MAINTAINING OUR HEALTH.
AND I THINK WE ALL WANT TO AGE.
BUT THERE'S A LOT WE CAN DO
ABOUT BLOOD PRESSURE ELEVATION,
AN BY ELIMINATING HYPERTENSION,
WE CAN IMPROVE BLOOD PRESSURE
REGULATION, REDUCE BLOOD
PRESSURE VARIABILITY, AND
PREVENT SOME OF THE ADVERSE
CONSEQUENCES THAT ARE RELATED TO
HYPOTENSION.
SO THE BOTTOM LINE HERE I WANT
TO GET ACROSS TO YOU IS THAT
AGING IS CHARACTERIZED BY AN
INCREASE IN BLOOD PRESSURE
VARIABILITY.
SO MANY TIMES, IT'S NOT THE
MEASUREMENT, PER SE, THAT IS THE
PROBLEM, BUT THE UNDERLYING
PHYSIOLOGY OF AGING.
SO LET'S GO TO THE NEXT SLIDE.
HERE IS JUST A VERY QUICK
SUMMARY OF THE EFFECTS OF AGING
ON BLOOD PRESSURE REGULATION.
ON THE LEFT IS THE BLOOD
PRESSURE EQUATION WHICH YOU ALL
KNOW IS THE PRODUCT OF HEART
RATE TIMES VASCULAR RESISTANCE
TIMES STROKE VOLUME.
BUT AGING AFFECTS EACH OF THESE
PARAMETERS, AGING DECREASES
BAROREFLEX SENSITIVITY BY
DECREASING HEART RATE RESPONSE
TO HYPOTENSION AND DECREASING
VASCULAR RESISTANCE RESPONSES.
IT ALSO INCREASES RENAL, SALT
AND WATER EXCRETION AND IMPAIRS
DIASTOLIC VENTRICULAR FILLING.
SO IF SOMEONE HAS HYPERTENSION
IN ADDITION TO AGE, THERE ARE
FURTHER IMPAIRMENTS IN EACH OF
THESE PHYSIOLOGIC MECHANISMS.
HIGHER BLOOD PRESSURE IS
REQUIRED FOR CEREBRAL PRO
FUSION.
BLOOD PRESSURE REDUCES
BAROREFLEX SENSITIVITY EVEN
ABOVE -- SO AS A RESULT OF THESE
PHYSIOLOGIC CHANGES, WE SEE A
LOT OF BLOOD PRESSURE
VARIABILITY IN OLDER AGE.
THAT'S ILLUSTRATED HERE IN THIS
STUDY THAT WE DID A NUMBER OF
YEARS AGO IN WHICH WE MEASURED
SYSTOLIC BLOOD PRESSURE BETWEEN
THE HOURS OF 7:00 A.M. AND
1:00 P.M. SHOWN ON THE X AXIS IN
RESPONSE TO A STAND DIED SERIES
OF ACTIVITY SHOWN ACROSS THE
TOP.
WE LOOKED AT A GROUP OF HOLDER
INDIVIDUALSS WHO A GROUP OF
YOUNGER INDIVIDUALS WHO WERE
HEALTHY VOLUNTEERED THAT CAME
INTO THE LAN AND HAD EXACTLY THE
SAME CIRCUMSTANCES AS THE OLDER
FOLKS.
THE FIRST THING YOU CAN SEE IS
THE OLDER COHORT STARTED WITH
MUCH HIGHER BLOOD PRESSURES
FIRST THING IN THE MORNING.
THEY WERE RELATIVELY
HYPERTENSIVE, PARTICULARLY
COMPARED TO THE YOUNG.
AND AS YOU CAN SEE, THEY HAVE A
TREMENDOUS BLOOD PRESSURE
VARIABILITY IN RESPONSE TO
COMMON DAILY ACTIVITIES.
AND THESE ARE FIRST -- THEY'RE
SUPINE IN THE MORNING WHEN THEY
WAKE UP FROM BED.
THEY THEN STAND UP TO DO THEIR
MORNING HYGIENE, THEY THEN SIT
DOWN FOR A MORNING MEAL,
BREAKFAST, SIT THERE FOR AN
HOUR, THEN STAND AND AMBULATE.
LATER WE GAVE THEM A
NITROGLYCERIN TABLET WHICH IS
SOMETHING MANY OF OUR OLDER
PATIENTS TAKE FOR HEART DISEASE,
THEN THEY HAD THEM STAND AND
AMBULATE AND LATER TAKE THEIR
USUAL MEDICATIONS AND EAT LUNCH.
NOTE THERE ARE MARKED
HYPOTENSIVE RESPONSES TO
STANDING FIRST THING IN THE
MORNING, AFTER BREAKFAST, AFTER
STANDING AGAIN AFTER
NITROGLYCERIN, AFTER MEDICATIONS
AND LUNCH.
THE YOUNG CERTAINLY HAVE SOME
BLOOD PRESSURE VARIABILITY BUT
NO, EATING BREAKFAST, STANDING
UP, TAKING EXTRA -- AND ALL
REDUCE PRELOAD RETURN, VENOUS
RETURN TO THE HEART, SO WHAT
WOULD A NORMAL PERSON DO TO
COMPENSATE FOR THAT?
THIS IS A VERY SIMILAR SETUP
WITH TIME ON THE X AXIS HERE,
SIMILAR ACTIVITIES, BUT NOW
WE'RE LOOKING AT THE HEART RATE
IN RESPONSE TO THESE ABILITIES,
INCREASING THEIR HEART RATE IN
RESPONSE TO STANDING, WHILE THE
OLD INDIVIDUALS HAVE A BLUNTED
RESPONSE.
AND LARGELY BECAUSE OF THIS
IMPAIRED HEART RATE RESPONSE,
IMPAIRED BAROREFLEX SENSITIVITY,
THE OLDER PATIENTS HAVE A
DRAMATIC BLOOD PRESSURE
VARIABILITY.
SO AGING IS ASSOCIATED NOT JUST
WITH HYPERTENSION AND
HYPOTENSION BUT AN INCREASING
VARIABILITY.
SO WHAT ARE THE CONSEQUENCES OF
THIS?
WELL, FIRST OF ALL, LET ME JUST
POINT OUT THIS PARADOX THAT THE
HIGHER THE BLOOD PRESSURE, THE
FARTHER IT FALLS, AND STEPHEN
RELATED TO THIS EARLIER, AND
THIS JUST SHOWS THIS DIASTOLIC
BLOOD PRESSURE CHANGE AFTER A
MEAL IN 60 MINUTES AS A FUNCTION
OF THE BASAL SYSTOLIC BLOOD
PRESSURE AT OTHER TIMES, AND YOU
CAN SEE THAT THERE IS A LINEAR
RELATIONSHIP SUCH THAT THOSE
WERE HIGHER BLOOD PRESSURES HAVE
THE GREATER DECLINES IN BLOOD
PRESSURE AFTER EATING.
AND THIS IS ALSO TRUE AFTER
STANDING UP.
SO ONE OF THE CONSEQUENCES IS
THAT THE BRAIN MAY NOT GET
ENOUGH CEREBRAL BLOOD FLOW TO
NOURISH NEURONS DURING THESE
HYPOTENSIVE EPISODES.
AND THIS HAS NOW BEEN FAIRLY
WELL DEMONSTRATED, PARTICULARLY
IN WATERSHED AREAS OF THE BRAIN,
AND THOSE ARE AREAS SURROUNDING
THE VENTRICLES WHERE THESE VERY
SMALL PERFORATOR VESSELS BECOME
SMALLER AND SMALLER AND SMALLER,
AND HERE THEY OFTEN BREAK DOWN
OR DIE OUT IF THERE IS NOT
ENOUGH PERFUSION OF THOSE AREAS.
AND THIS IS SHOWN ON CT SCANS
AND MRI SCANS OF THE BRAIN AS
WHITE MATTER HYPERINTENSITIES
SURROUNDING THE VENTRICLES.
AND HERE IT IS IN WHITE AND HERE
IT IS HIGHLIGHTED IN RED.
THESE WHITE MATTER
HYPERINTENSITIES ARE VERY
IMPORTANT CAUSES OF MOBILITY
IMPAIRMENTS AND COGNITIVE
IMPAIRMENTS.
ANOTHER EFFECT OF HYPERTENSION
IS IMPAIRMENTS IN CEREBRAL AUTO
REGULATION.
SO IF WE'RE GOING TO HAVE
HYPOTENSIVE EVENTS, WE MAY NOT
BE ABLE TO AUTO DIAGNOSEREGULATR
BLOOD FLOW TO THE BRAIN
PROPERLY.
THIS IS A CLASSIC AUTOREGULATION
CURVE WHICH SHOWS DIFFERENT
CEREBRAL PRO FUSION PRESSURES ON
THE X AXIS, THAT IS BLOOD
PRESSURE, AND CEREBRAL BLOOD
FLOW ON THE Y AXIS.
THE SOLID LINE IS THE NORMAL
CURVE AND YOU CAN SEE THAT
THERE'S A PERIOD IN WHICH THERE
IS NO DMAING CERE CHANGE IN CERD
FLOW OR CHANGES IN CEREBRAL
BLOOD PRESSURE UNTIL YOU GET TO
MUCH HIGHER VALUES OF BLOOD
PRESSURE OR MUCH LOWER VALUES
WHEN CEREBRAL BLOOD FLOW FALLS
OFF.
SO IF ONE WERE TO GO FROM SUPINE
TO A STANDING POSITION DURING
THIS PLATEAU OF THE
AUTOREGULATION CURVE, YOU
WOULDN'T SEE MUCH OF A CHANGE IN
CEREBRAL BLOOD FLOW AND,
THEREFORE, NO IMPACT ON
COGNITION OR WHITE MATTER.
HOWEVER, HYPERTENSION SHIFTS
THIS CURVE TO THE RIGHT.
SO NOW IF YOU GO FROM SUE BIEN
BLOOD PRSUPINEBLOOD PRESSURE TOR
STANDING BLOOD PRESSURE, YOU
MIGHT FALL BELOW THIS CURVE,
THEREBY THREATENING CEREBRAL
BLOOD FLOW.
THE GOOD NEWS IS THAT THE
TREATMENT OF HYPERTENSION CAN
RESTORE THIS AUTOREGULATION
CURVE BACK TOWARD NORMAL.
AGAIN, PRESERVING THE BRAIN,
BLOOD FLOW AND COGNITIVE
FUNCTION.
WE'VE ALSO SHOWN YEARS AGO THAT
WE CAN IMPROVE CEREBRAL BLOOD
FLOW BY THE TREATMENT OF
HYPERTENSION.
HERE WE TOOK A GROUP OF PATIENTS
WHO WERE INITIALLY HYPERTENSIVE
WITH SYSTOLIC PRESSURES ABOVE
160 AND WE MEASURED CEREBRAL
BLOOD FLOW WITH A DOPPLER
TECHNIQUE AND YOU CAN SEE IN THE
SOLID LINE THAT IT DROPS A BIT
WHEN PEOPLE STAND UP.
WE THEN TREATED THESE PEOPLE
WITH AN ACE INHIBITOR REGIMEN
FOR SIX MONTHS, AND WE THOUGHT
THAT, MY GOSH, THIS
ANTIHYPERTENSIVE MAY REDUCE
CEREBRAL BLOOD FLOW, BUT, IN
FACT THE OPPOSITE OCCURRED, IT
INCREASED CEREBRAL BLOOD FLOW.
SO THE TREATMENT OF HYPERTENSION
IN OLDER ADULTS, THESE ARE
PEOPLE OVER AGE 75, ACTUALLY
IMPROVED CEREBRAL BLOOD FLOW.
THERE ARE NOW SEVERAL STUDIES
THAT SHOW THAT ANTIHYPERTENSIVE
TREATMENT MAY ACTUALLY REDUCE
THE RISK OF DEMENTIA.
KEEP IN MIND THAT THESE STUDIES
WERE DONE WITH A NUMBER OF
DIFFERENT TECHNIQUES OF
MEASURING BLOOD PRESSURE, YET IN
AGGREGATE, THEY ALL HAVE SIMILAR
RESULTS THAT THE TREATMENT OF
HYPERTENSION MIGHT ACTUALLY
REDUCE THE RISK OF DEMENTIA.
THIS IS JUST ONE OF THOSE
STUDIES CALLED THE COSMIC STUDY,
IT'S A META-ANALYSIS OF 17
STUDIES FROM 15 DIFFERENT
COUNTRIES REPRESENTING OVER
34,000 COMMUNITY DWELLING OLDER
ACULTS OF MEAN AGE 72.5, AND
THEY WERE STUDIED FOR FOLLOW-UP
OF ABOUT 4.3 YEARS.
AND I'LL JUST POINT OUT HERE
THAT THOSE WITH TREATED
HYPERTENSION HAD NO DIFFERENCE
THAN THOSE WHO WERE HEALTHY
CONTROLS IN THE RISK OF ALL
CAUSE DEMENTIA.
IN A FULLY ADJUSTED ANALYSIS,
THERE WAS NO SIGNIFICANT
DIFFERENCE BETWEEN TREATED
HYPERTENSIVES AND HEALTHY
CONTROLS.
YET UNTREATED HYPERTENSIVES
COMPARED TO HEALTHY CONTROLS OR
THOSE WERE TREATED HYPERTENSION
HAD A INCREASE IN THEIR RISK OF
DEMENTIA.
SO THIS JUST ILLUSTRATES THAT
THE TREATMENT OF HYPERTENSION,
REGARDLESS OF HOW THAT'S DEFINED
OR MEASURED, MIGHT ACTUALLY
IMPROVE COGNITION AND PREVENT
DEMENTIA.
THE SPRINT-MIND STUDY HAD
SIMILAR RESULTS.
THIS WAS REFERRED TO EARLIER,
AND HERE A SYSTOLIC BLOOD
PRESSURE REDUCTION TO 120
REPRESENTING INTENSIVE TREATMENT
VERSUS STANDARD TREATMENT TO 140
OR BELOW REDUCE THE INCIDENCE OF
MILD COGNITIVE IMPAIRMENT BY
19%.
IT DID NOT SIGNIFICANTLY REDUCE
DEMENTIA, BUT THE COMBINED END
POINT OF MILD COGNITIVE
IMPAIRMENT AND DEMENTIA WAS
SIGNIFICANTLY REDUCED BY 15%.
SO THE TREATMENT OF BLOOD
PRESSURE DID NOT HARM COGNITION
AND GENERALLY WHAT'S GOOD FOR
THE HEART IS GOOD FOR THE BRAIN.
HERE IS A LARGE META-ANALYSIS OF
THE VARIOUS ANTIHYPERTENSIVE
TRIALS FOR THEIR EFFECT ON
DEMENTIA DEFINED IN A NUMBER OF
DIFFERENT WAYS THROUGH SPECIFIC
CRITERIA OR CLINICAL DIAGNOSES
OR DEMENTIA WITH MILD COGNITIVE
IMPAIRMENT.
AND IN AGGREGATE, THE ODDS RATIO
WAS .93, WHICH SHOWED ABOUT A 7%
REDUCTION IN THE RISK OF
DEMENTIA.
SMALL, BUT SIGNIFICANT.
NOT ONLY DOES THE INTENSIVE
TREATMENT OF HYPERTENSION REDUCE
THE RISK OF DEMENTIA IN OLDER
ADULTS BUT IT ALSO REDUCES THE
PROGRESSION OF WHITE MATTER
HYPERINTENSITIES, SUGGESTING
THAT IN FACT IT MAY HAVE AN
IMPORTANT IMPACT ON CEREBRAL
BLOOD FLOW.
HERE YOU CAN SEE AT 18 MONTHS OR
36 MONTHS SHOWN ON THE X AXIS,
THE INTENSIVE TREATMENT SHOWN IN
RED REDUCES THE CHANGE IN WHITE
MATTER HYPERINTENSITIES AT BOTH
TIME POINTS COMPARED TO STANDARD
TREATMENT.
SO THE KEY POINTS I'D LIKE TO
MAKE IS THAT OLDER ADULTS,
ESPECIALLY THOSE WITH
HYPERTENSION, HAVE INCREASED
BLOOD PRESSURE VARIABILITY THAT
PLACES THEM AT RISK OF
HYPOTENSION DURING COMMON DAILY
ACTIVITIES.
REMEMBER THE HIGHER YOU ARE, THE
FARTHER YOU FALL.
THIS, OF COURSE, CREATES ALL
KINDS OF ISSUES ABOUT WHAT THE
THRESHOLD FOR HYPERTENSION WOULD
BE, WHAT THE THRESHOLD FOR
HYPOTENSION WOULD BE, BUT IN
GENERAL, HYPERTENSIVE
INDIVIDUALS, REGARDLESS OF HOW
IT'S DEFINED, ARE AT RISK OF
HYPOTENSIVE EVENTS THROUGHOUT
THE DAY.
ORTHOSTATIC AND POST PRANDIAL
HYPOTENSION ARE PARTICULARLY
COMMON IN OLDER PEOPLE AND
THEY'RE OFTEN OVERLOOKED IN THE
CLINICAL PRACTICE.
REMEMBER THEY THREATEN CEREBRAL
PERFUSION AND MAY RESULT IN
CEREBRAL MICROVASCULAR DISEASE
AND COGNITIVE IMPAIRMENT.
THE TREATMENT OF HYPERTENSION
MAY IMPROVE BLOOD PRESSURE
REGULATORY MECHANISMS AND
PREVENT HYPOTENSION AND ITS
CONSEQUENCES, AND, THEREFORE,
BLOOD PRESSURE MONITORING DURING
ACTIVITIES OF DAILY LIVING,
WHETHER IT BE BY HOME BASED
METHOD USING A DIARY OR
AMBULATORY MEASUREMENTS SHOULD
BE DONE IN ALL OF OUR OLDER
PATIENTS, ESPECIALLY AFTER
MEALS, POSTURE CHANGE AND
MEDICATION ADMINISTRATION.
AND THIS CAN HELP DETECT THE
CIRCUMSTANCES, TIMING AND DEGREE
OF VARIABILITY OF BLOOD PRESSURE
AND ITS RESPONSE TO TREATMENT.
NOW MANY OF THE MONITORING
DEVICES WE USE, PARTICULARLY
AMBULATORY MONITORING, ARE NOT
SPECIFIC ENOUGH TO LOOK AT THE
POSTURAL CHANGE RESPONSE OR
MEDICATION ADMINISTRATION, SO
IT'S VERY IMPORTANT THAT WE'RE
ABLE TO LOOK IN RESPONSE TO
THESE PARTICULAR ACTIVITIES.
AND AVERAGING MEASURES OVER TIME
ALSO DOES NOT ENABLE YOU TO PICK
OUT THE CHANGES THAT OCCUR
DURING THESE COMMON ACTIVITIES.
SO I THINK IT'S VERY IMPORTANT
TO KEEP THIS IN MIND.
SO THE KEY KNOWLEDGE GAPS ARE
SHOWN IN THE LEFT COLUMN HERE
AND OUR FUTURE OPPORTUNITIES,
SOME OF THE FUTURE OPPORTUNITIES
WE HAVE ON THE RIGHT.
THE FIRST GAP IS HOW TO MEASURE
BLOOD PRESSURE CONTINUOUSLY IN
RESPONSE TO SPECIFIC DAILY
ACTIVITIES.
AND THEN AT WHAT STAGE OF
COGNITIVE IMPAIRMENT OR FRAILTY
DOES BLOOD PRESSURE TREATMENT
SLOW OR IMPROVE COGNITIVE
DECLINE?
PROBABLY THE TREATMENT OF
HYPERTENSION IN PEOPLE ALREADY
IMPAIRED WITH ADVANCED DEMENTIA
IS NOT GOING TO IMPROVE THEIR
COGNITION OR CEREBRAL BLOOD FLOW
OR MICROVASCULAR DISEASE, BUT
CERTAINLY EARLY STAGE DEMENTIA
OR PREDEMENTIA PERIODS ARE KEY
TREATMENT OPPORTUNITIES.
AND WE DON'T KNOW WHY
ANTIHYPERTENSIVE MEDICATIONS CAN
IMPROVE BLOOD PRESSURE
REGULATION, PREVENT HYPOTENSION
AND PRESERVE CEREBRAL BLOOD
FLOW.
SO THERE ARE MANY FUTURE
OPPORTUNITIES WHICH WE WILL BE
DISCUSSING DURING THIS WORKSHOP.
WE NEED TO DEVELOP RELIABLE,
CONTINUOUS A AMBULATORY BLOOD
PRESSURE MONITORS THAT HAVE THE
ABILITY TO PROMPT PATIENTS FOR
SYMPTOMS AND TIME MEASUREMENTS
AT SPECIFIC TIMES WE'RE
INTERESTED IN.
I USUALLY GIVE MY PATIENTS A
DIARY TO TAKE HOME AFTER
INSTRUCTING THEM ON BLOOD
PRESSURE MEASUREMENT TECHNIQUE
AND ASK THEM TO FILL OUT THAT
DIARY AT SPECIFIC TIMES OF DAY
AND IN RESPONSE TO SPECIFIC
ACTIVITIES.
WE ALSO NEED TO TEST THE EFFECT
OF DIFFERENT MEDICATIONS ON
CEREBRAL BLOOD FLOW, AS WELL AS
BRAIN STRUCTURE AND FUNCTION.
AND ULTIMATELY CONDUCT
RANDOMIZED CONTROL TRIALS OF
BLOOD PRESSURE MANAGEMENT ON
PATIENTS WITH AND WITHOUT
DIFFERENT STAIMT STAGES OF COGNE
IMPAIRMENT USING BROMOPROPANE
VARIABILITY, CEREBRAL BLOOD
FLOW, MR IMAGING AND BIOMARKERS
AS OUTCOMES.
SO THANK YOU VERY MUCH FOR YOUR
ATTENTION.
I WILL STOP THERE.
>> THANK YOU FOR THAT WONDERFUL
PRESENTATION AND THANKS TO THE
WHOLE PANEL FOR THREE GREAT
TALKS.
WE HAVE ABOUT 15 MINUTES HERE
FOR QUESTIONS.
LEW, I HAVE A QUESTION FOR YOU.
AS YOU THINK ABOUT VARIABILITY
IN THE ELDERLY POPULATION, DO
YOU RECOMMEND EVEN MORE
MEASUREMENTS BEFORE DIAGNOSING
HYPERTENSION OR DECIDING TO
INTENSIFY IN THAT POPULATION
BECAUSE OF THAT VARIABILITY?
>> I DO RECOMMEND MEASUREMENTS,
MORE IS AN INTERESTING ISSUE,
BUT AT SPECIFIC TIMES.
AS YOU SAW IN THE GRAPHS THAT I
SHOWED, MANY MEAN OF OUR OLDER
PATIENTS WAKE UP HYPERTENSIVE IN
THE MORNING.
THEY HAVE A REVERSAL OF THE
NOCTURNAL DIPPING OF THE
CIRCADIAN RHYTHM, THEY WAKE UP
QUITE HYPERTENSIVE AND ALL THAT
IT TAKES TO REDUCE THEIR BLOOD
PRESSURE IS A MEAL AND AFTER
BREAKFAST, MANY OF THEM ARE
RELATIVELY HYPERTENSIVE.
SO IF THAT'S THE CASE MAYBE I'LL
JUST TREAT THEM WITH A MEAL.
SOME OF THEM ARE HYPERTENSIVE
OVERNIGHT BECAUSE THEY HAVE
SLEEP APNEA OR OTHER PROBLEMS.
SO I MIGHT TREAT THEM AT
BEDTIME.
SO I NEED ENOUGH MEASUREMENTS TO
BE ABLE TO DEFINE WHEN THEY ARE
HYPERTENSIVE, WHEN THEY ARE NOT
SO I CAN ADJUST THEIR TREATMENT
ACCORDINGLY.
AND I DON'T NEED IT EVERY DAY, I
USUALLY ASK MY PATIENTS TO TAKE
THEIR BLOOD PRESSURES UNDER
THOSE CIRCUMSTANCES MONDAY,
WEDNESDAY, FRIDAY FOR THREE
WEEKS AND THEN BRING THE RESULTS
TO ME AND THEN I CAN EVALUATE IT
IN THE OFFICE AND MAKE A
DECISION.
>> GREAT, THANK YOU.
SO QUESTION, THERE'S ALSO BEEN A
LOT OF DISCUSSION REGARDING
NON-ADHERENCE IN ROUTINE CARE TO
GUIDELINE RECOMMENDATIONS FOR
BLOOD PRESSURE MEASUREMENT
TECHNIQUES.
I'M WONDERING, KARA AND JOE,
MAYBE IF YOU COULD COMMENT ON
THE SPECIFIC CHALLENGES.
I THINK, JOE, YOU MENTIONED
CHAIRS, CUFF SIZE.
IN YOUR SPECIFIC POPULATIONS FOR
WHAT YOU SEE IN ROUTINE CARE
COMPARED TO WHAT YOU MIGHT SEE
IN YOUR OWN CLINIC.
>> I THINK ONE THING TO JUST
SPEAK ABOUT IN THE PREGNANT AND
POSTPARTUM PATIENTS IS -- AND
THIS IS NOT TO BE DISRESPECTFUL,
BUT WE'RE NOT A CHRONIC CARE
MANAGEMENT OR PRIMARY CARE
CLINIC MOST OF THE TIME, AND SO
THE STAFF AND THE PROVIDERS ARE
NOT THINKING ABOUT BLOOD
PRESSURE TECHNIQUE AND SO I'VE
PERSONALLY TRIED TO DO A LOT AT
MY INSTITUTION OF LIKE PEOPLE
JUST NEED TO BE SITTING PROPERLY
AND FOLLOWING PROPER MY JEAN, AS
PROPER HYGIENE, ASWELL AS THEREN
OF HAVING PEOPLE DO OUT OF
CLINIC MONITORING BUT THERE'S NO
INSTRUCTIONS OR TEACHING OR
INVESTMENT, YOU KNOW, OR THE
PEOPLE THAT ARE DOING THEM DON'T
EVEN KNOW HOW TO TEACH IT, SO
THERE'S REALLY A LACK OF
EDUCATION, I THINK, ON ALL
LEVELS THERE.
ANOTHER ISSUE IS, LIKE, IF WE
HAVE ANTEPARTUM PATIENTS IN THE
HOSPITAL, THEY'RE IN BEDS, SO
PEOPLE ARE NOT GETTING THEM OUT
OF BED TO MEASURE THEIR BLOOD
PRESSURES, AND SO I WOULD JUST
SAY, LIKE, BROAD STROKES ACROSS
THE PREGNANT POPULATION IS A LOT
OF EDUCATION IS NEEDED NOT ONLY
FROM OUTPATIENT BUT INPATIENT
AND STANDARDIZATION OF JUST
SIMPLY TAKING A BLOOD PRESSURE.
THEN ANOTHER THING IS WE HAVE A
LOT OF OBESE PATIENTS AND THE
EXTRA LARGE CUFFS ARE TOO LONG
FOR THEIR ARMS.
THERE'S LACK OF DEVICES THAT FIT
WELL TOO.
SO THOSE ARE JUST SOME IMMEDIATE
COMMENTS I HAVE.
>> AND YOU KNOW, FOR CHILDREN,
LACK OF ADHERENCE TO TECHNIQUE
TO BE EITHER IN THE OFFICE OR AT
HOME, AND SO WE ARE PRETTY, OF
COURSE, COMPULSIVE IN OUR
HYPERTENSION CLINIC TO MAKE SURE
WE'RE DOING THINGS RIGHT.
THERE HAVE BEEN SORT OF LARGE
QUALITY IMPROVEMENT EFFORTS TO
LOOK AT THIS IN GENERAL
PEDIATRIC PRACTICES, AND THERE'S
CLEARLY SOME POOR ADHERENCE TO
THAT, TO ALL OF THE STEPS, AND
SO SOME THINGS THAT POTENTIALLY
COULD OVERCOME THAT.
I WAS INTERESTED TO HEAR ABOUT
THAT YOU DIDN'T NEED TO WAIT AS
LONG BEFORE DOING THE
MEASUREMENT OR WAIT AS LONG IN
BETWEEN, I THINK WE NEED TO LOOK
AT THAT IN CHILDREN, IT NOT
REALLY BEEN STUDIED TO MY
KNOWLEDGE, AND JUST PRODUCING
MORE EDUCATIONAL MATERIALS AND
GETTING THE WORD OUT THERE FOR
GENERAL PEDIATRICIANS.
WE DO SPEND A LOT OF TIME WITH
OUR PATIENTS, SO OUR NURSES HAVE
A STRUCTURED WAY OF TEACHING THE
PATIENTS HOW TO MEASURE THEIR
BLOOD PRESSURE, AND THAT
INCLUDES A HANDOUT AND A REVIEW
OF HOW THE DEVICE WORKS AND SO
FORTH.
AND WE'LL OFTEN SORT OF
REINFORCE THAT WHEN PATIENTS
COME BACK FOR CLINIC VISITS,
ESPECIALLY WHEN I'M SEEING A BIG
DISCREPANCY BETWEEN THE HOME
BLOOD PRESSURE READINGS AND THE
OFFICE BLOOD PRESSURE READINGS.
LIKE DID YOU ACTUALLY SIT DOWN
AND REST FOR A WHILE BEFORE YOU
DID THAT BLOOD PRESSURE THERE,
JOSE?
YOU KNOW, THE ANSWER WILL OFTEN
BE NO, AND YOU DO SOME EDUCATION
IN THAT SETTING.
>> I'M REALLY INTERESTED TO SEE
WHERE WE'RE GOING TO GO AND I
THINK ALL THREE OF YOU TOUCHED
ON THE FACT THAT THERE'S A BIG
IMPLEMENTATION GAP, AND I LOVED
THAT AHA HYPERTENSION SIGN TIFNG
SESSIONS IN NOVEMBER IN CHICAGO,
THIS CAME UP CONSTANTLY, MAYBE
I'M BIASED, IS THAT WE HAVE ALL
THESE GUIDELINES, WE KNOW WHAT
TO DO, WE KNOW WHAT BLOOD
PRESSURE IS THE TARGET, WE KNOW
WHAT MEDS, BUT THEY'RE STILL NOT
BEING IMPLEMENTED ACROSS THE
BOARD, NOT EVEN JUST IN PRIMARY
CARE BUT FOR THOSE OF YOU WHO DO
THIS WORK FOR A LIVING AND I AM
A POSTER CHILD FOR THAT, I FAIL
TO DO STUFF PER GUIDELINES ALL
THE TIME.
OFTENTIMES IT'S NOT BECAUSE I
DON'T BELIEVE IN THEM, BUT
BECAUSE I'M HUMAN AND I FORGET
AND WE GET BUSY IN CLINIC.
SO I'M CURIOUS FOR YOU ALL, HOW
DO WE REALLY TRANSFORM THE FIELD
BY DOING WHAT YOU ALLUDED TO,
JOSEPH, OF EMPOWERING, NOT JUST
OUR PATIENTS OR FAMILIES LIKE
KARA DID WITH HER KIDS, BUT
PROVIDERS TOO, AT ALL LEVELS,
NOT JUST THE PHYSICIANS AND THE
PAs, AND THE NURSE
PRACTITIONERS, BUT THE MAs,
THE NURSES, TO REALLY DO THESE
THINGS BUT IN A SUSTAINABLE WAY,
THE WAY WE CONCEPTUALIZE IT IS
WE HAVE TO CHANGE THE SYSTEM, WE
HAVE TO CHANGE THE CULTURE AND
WE HAVE TO EDUCATE.
SO WE HAVE TO MAKE IT STUPIDLY
EASY FOR PEOPLE TO DO THESE
THINGS, WHICH REALLY REQUIRES
THEIR BUY-IN TO GET THAT
INTERNAL MOTIVATION THAT THEY'RE
INVESTED IN REMEMBERING TO DO
THINGS AND THEN MAKING IT A
REALLY EASY SYSTEM WHERE IT'S
AUTOMATIC, THEY DON'T EVEN HAVE
TO THINK ABOUT IT.
AND I DON'T HAVE A SOLUTION.
SO I'M CURIOUS FOR YOU ALL.
NOT AN EASY ASK.
WHAT DO YOU THINK WE SHOULD DO?
>> I MIGHT JUST MAKE A COMMENT.
IT HARD ENOUGH TO EVEN GET
PEOPLE TO PAY ATTENTION TO BLOOD
PRESSURE, LET ALONE MEASURE IT
CORRECTLY.
SO I'M KIND OF HAPPY IF THEY
MEASURE IT, EVEN IF IT'S NOT
EXACTLY RIGHT.
AND MAYBE THAT SOUNDS A LITTLE
BIT OFF TOPIC, BUT I THINK WE
OFTEN ERR ON THE SIDE OF TRYING
TO MAKE SURE THEY DON'T HAVE
HYPERTENSION THAN DIAGNOSING
THAT THEY DO.
THEY COME IN TO THE OFFICE,
WE'RE WEARING OUR WHITE COAT,
IT'S HIGH BLOOD PRESSURE.
IT'S NOT JUST THE WHITE COAT.
THERE ARE OTHER TIMES OF DAY,
OTHER CIRCUMSTANCES IN THEIR
LIVES WHEN THEY'RE STRESSED, AND
SO IF THEIR PRESSURE IS HIGH
WHEN THEY'RE STRESSED, I WANT TO
KNOW IT.
CERTAINLY POSITION, TIMING, ALL
OF THAT ARE IMPORTANT, NO
QUESTION ABOUT THAT, BUT I THINK
WE KEEP TAKING THE PRESSURE OVER
AND OVER AGAIN UNTIL WE FIND A
VALUE WE LIKE, WHICH IS USUALLY
A VALUE THAT'S NORMATTENTIVE.
SO WE'VE WORKED SO HARD TO
ELIMINATE THE FINDING THE
HYPERTENSION, AND I WOULD KIND
OF THINK EVEN THOUGH I'M A
GERIATRICIAN AND I DON'T WANT TO
TREAT EVERYBODY TOO MUCH, I
THINK WE SHOULDN'T BE SO WORRIED
ABOUT SOMEBODY WHO COMES IN -- I
THINK WE SHOULD TREAT THEM AND
NOT WORRY AS MUCH ABOUT IF WE'RE
EXACTLY RIGHT ACCORDING TO
GUIDELINES.
JUST A THOUGHT.
>> SOME OF MY STRATEGIES ARE
REALLY ABOUT LIKE -- I THINK
THERE NEEDS -- IN MY DREAM
WORLD, IT WOULD BE LIKE WORKING
WITH HIGH LEVEL IMPACTFUL
ORGANIZATIONS THAT MAYBE DO
CMEs AND TEACHING AND OTHER
THINGS, AND THEN SOME SORT OF
LIKE INCENTIVE FOR THIS.
I THINK PREGNANCY IS ONE THING,
BUT I THINK ALSO THE POSTPARTUM
AND TRANSITION TO LONG-TERM
CARE, I MEAN, IF WE CAN REALLY
HELP PEOPLE UNDERSTAND, THIS IS
WHY OUR PEOPLE IN THE U.S. ARE
DYING, YOU KNOW, AND IF YOU CAN
MAKE AN IMPACT, IF WE CAN MAKE
IT PERSONAL AND MAKE IT REALLY
FEEL LIKE YOU'RE REALLY MAKING
AN IMPACT, MAYBE THERE'S A WAY,
BUT I DON'T KNOW, EASY TOOLS
OR -- I DON'T REALLY HAVE A
SOLUTION.
BUT I THINK THAT'S A START, IS
LIKE REALLY MAKING IT PERSONAL
SOMEHOW.
THAT'S NOT REALLY RESEARCH, BUT,
LAKE -- OR ALSO WAYS FOR PEOPLE
WHO DON'T HAVE TIME TO DO
RESEARCH TO GET THE FEEDBACK OF
LIKE WHAT THEY'RE DOING IS
INFORMING RESEARCH, SO COULD
THERE BE SOME WAY THAT WE COULD,
LIKE, INCLUDE PEOPLE IN STANDARD
CLINICAL CARE SETTINGS TO
PROVIDE DATA THAT KNOWS THEY'RE
REALLY MAKING A CHANGE OR
SOMETHING LIKE THAT?
SO ANYWAYS, BUY-IN AND REWARDS,
MAYBE THAT'S THE WAY TO SUCCESS.
>> QUESTIONS FROM THE AUDIENCE?
>> THIS IS DICK DART UP IN
MARSHFIELD.
I'M A CLINICIAN, MANY YEARS IN
CLINIC PRACTICE.
I THINK ALL THE COMMENTS MADE
ARE VERY TYPICAL.
I'M IN A PRIVATE PRACTICE, IT'S
A LARGE GROUP PRACTICE.
BUT I'VE BEEN TREATED TO THE
SAME THING WHERE I GO IN AND GET
SOMEBODY TO TAKE MY BLOOD
PRESSURE, THEY'LL PUT THE WRONG
SIZE CUFF ON, THEY'RE TALKING TO
ME AND THEY WANT TO RUN THROUGH
THINGS, AND I THINK WHAT
DR. SOUTH POINTED OUT, IT'S ON
THE WALL, WHAT YOU SHOULD DO,
AND I'M LIKE, WHAT DO YOU
HAVE -- I TELL THEM, I SAID, I'D
REALLY LIKE YOU TO DO THIS
RIGHT, NOT BECAUSE I WORRY ABOUT
HYPERTENSION.
I HAVE A LITTLE BIT OF BLOOD
PRESSURE BUT IT'S WELL
CONTROLLED, BUT I THINK IT'S THE
ISSUE OF WE OUGHT TO BE MORE
CONCERNED ABOUT OUTCOMES VERSUS
THE INCOMES, MEANING THE MONEY
YOU MAKE FOR DOING SOMETHING
VERSUS THE OUTCOMES WE'RE
GETTING IN TERMS OF ACTUALLY
MAKING PEOPLE HEALTHY, OR
KEEPING THEM HEALTHY.
AND I THINK THAT'S A VERY
DIFFICULT THING TO GET ACROSS
AND GET TO PEOPLE TO GET IN THE
HABIT OF DOING, MEASURING BLOOD
PRESSURE CORRECTLY.
>> YEAH, IF I COULD JUST
COMMENT, THERE'S A QUESTION FROM
TAMMY IN THE CHAT ALSO ABOUT
WHAT SHOULD WE DO TO IMPROVE
CARDIOVASCULAR HEALTH IN YOUTH.
I THINK IT DOES BEGIN WITH
SIMPLIFYING THE RECOGNITION OF
HYPERTENSION, PROVIDING PEOPLE
WITH TOOLS FOR DETECTING IT, AND
THEN WE HAVE THE BIG QUESTION IN
PEDIATRICS OF NOT REALLY KNOWING
THE BEST MODE OF TREATMENT.
AND SO FIGURING THAT OUT.
THAT'S NOT THE FOCUS OF THIS
WORKSHOP, BUT UNDERSTANDING
WHETHER INTERVENING WITH
MEDICATION CHANGE VERSUS
LIFESTYLE CHANGE IS GOING TO BE
MORE BENEFICIAL FOR YOUTH AND
THEN PREVENTION OF FUTURE
CARDIOVASCULAR DISEASE IS A HUGE
RESEARCH GAP THAT WE HAVE IN
PEDIATRICS.
BUT GETTING BACK TO THE BLOOD
PRESSURE MEASUREMENT, I LIKE THE
IDEA OF CMEs.
WE DO WORK WITH THE AMERICAN
ACADEMY OF PEDIATRICS, AND
TYPICALLY THERE ARE WORKSHOPS AT
THEIR ANNUAL CONFERENCE, AND I'M
IN THE MIDDLE OF PREPARING A
PERSPECTIVES FOR THE JOURNAL
THAT MAY HAVE SOME -- CALLING
ATTENTION TO THE ISSUE OF BLOOD
PRESSURE MEASUREMENT.
I THINK THESE ARE THE THINGS
THAT WE ALL NEED TO DO NO MATTER
WHAT SEGMENT OF THE AGE RANGE
WHEWE'RE SORT OF ADDRESSING.
>> I THINK ANOTHER ASPECT IS
REALLY PUTTING IT IN THE PLACE
OF COMMUNITY AND PEOPLE
THEMSELVES, SO IF, FOR EXAMPLE,
LIKE -- AGAIN, I GO BACK TO
PREGNANCY BUT IT COULD BE
APPLICABLE TO A LOT OF PLACES,
LIKE HERE'S A FORM, HERE'S AN
ALERT IN YOUR EMR, LIKE I HAD A
PREGNANCY-RELATED HYPERTENSION
ISSUE, IT THEN FLAGS TO THEIR
PCP, LIKE THEY NEED XYZ EVERY
SINGLE YEAR RATHER THAN, LIKE,
THEY DON'T GET ANY CARE UNTIL
FOUR YEARS LATER WHEN THEY HAVE
THE NEXT PREGNANCY OR THEY HIT
MENOPAUSE OR THEY'RE GERIATRIC
OR SOMETHING.
SO LETTING PEOPLE UNDERSTAND AND
KNOW WHAT REALLY HAPPENED TO
THEM, AND THEN THAT THEY MAY
FEEL GREAT BUT HYPERTENSION CAN
BE ASYMPTOMATIC SOME OF THE
TIME.
I THINK AGAIN INTERVENTIONS OR
TRIALS WHERE WE FOCUS ON THE
PERSON THEMSELVES AND LIKE SELF
STRATEGIES, AND ALSO COMMUNITY
PARTNERS, HOW CAN COMMUNITY
PARTNERS HELP?
SH
>SH>> SO THANK YOU AGAIN TO OUR
PANELISTS HERE FOR THREE GREAT
TALKS TO GET THESE DISCUSSIONS
STARTED.
I DO WANT TO NOTE THAT IF YOU
HAVE A QUESTION AND YOU ARE NOT
A DISCUSSANT OR A MODERATOR,
YOU'LL NEED TO PUT THAT IN THE
CHAT AND WE'LL TRY TO GET TO
THOSE FOR THE FUTURE
DISCUSSIONS.
AND SO I BELIEVE WE HAVE A
10-MINUTE BREAK AND WE'LL BE
COMING BACK AT 12:30, BUT I'M
NOT ONE OF THE ORGANIZERS SO
I'LL TURN THAT OVER TO THE NHLBI
CREW FOR THAT.
>> THIS IS CORRECT.
SO LET US PROMPTLY RETURN AT
12:30 -- I'M SORRY, 1:30 OR
WHATEVER TIMING, 12:30, 1:30,
BUT IN ABOUT 8 MINUTES, AND
THAT'S TO SESSION NUMBER 2.
THANK YOU.
SEE YOU THEN.
THANK YOU.
I APPRECIATE THE INVITATION TO
SPEAK TO YOU ALL ABOUT THIS
MATTER.
CAN I HAVE THE NEXT SLIDE,
PLEASE.
NEXT ONE.
THESE ARE MY DISCLOSURES.
WE ONLY HAVE TIME FOR A VERY
BRIEF OVERVIEW OF THESE
AUTONOAUTO NOM
AUTONOMIC DISORDERS SO I'LL
HIGHLIGHT THE GAPS THAT NEED
IMPROVEMENT AS WE GO ALONG AND
THOSE ARE IN RED.
THE DISTRIBUTION OF ORTHOSTATIC
BLOOD PRESSURE CHANGES AND WE
FOCUS ON THE EXTREME ON THE
LEFT.
PATIENTS THAT HAVE A SIGNIFICANT
DROP IN BLOOD PRESSURE ON
STANDING AND THE PATIENTS ARE
SYMPTOMATIC AND CAN ONLY WALK
FOR A FEW SECONDS AND IMPACTS
QUALITY OF LIFE AND ASSOCIATED
WITH SIGNIFICANT RISK OF FALLS
AND DISABILITY IN THE ELDERLY
AND ALSO AN INDEPENDENT RISK
FACTOR FOR INCREASED MORTALITY.
STUDIES HAVE SHOWN ALSO THE
OTHER EXTREME ORTHOSTATIC
HYPERTENSION IS ASSOCIATE WITH
INCREASED RISK OF CARDIOVASCULAR
AND RENAL DISEASE AND ALSO AN
INDEPENDENT RISK FACTOR FOR
INCREASED MORTALITY.
THE DIFFERENCE BEING OF COURSE
THAT THESE PATIENTS ARE USUALLY
NOT SYMPTOMATIC.
THEY'RE ASYMPTOMATIC WITH THE
EXCEPTION OF YOUNGER PATIENTS WE
FOLLOW IN THE AUTONOMIC CENTER
WITH HYPERSYMPTOMS.
THE IMPAIRED AUTONOMIC REFLEXES
YOU ALMOST NEVER ARE ORTHOSTATIC
HYPERTENSION THAT CAN BE BY
AGING.
BUT OF COURSE THOSE PATIENTS
HAVE A SIGNIFICANT TROP IN BLOOD
PRESSURE WITH VERY LITTLE OR NO
INCREASE IN HEART RATE AND
THAT'S WHAT WE CALL NEUROGENIC
ORTHOSTATIC HYPERTENSION AND
CAN'T COMPENSATE FOR THE DROP IN
BLOOD PRESSURE AND SOME HAVE
SEEN A SIGNIFICANT INCREASE IN
HEART RATE AND THIS IS VERY
IMPORTANT TO MEASURE THAT NOT
ONLY THE BLOOD PRESSURE BUT
HEART RATE BECAUSE IT TELLS US
THERE'S AGGREGATING FACTORS THAT
NEED TO BE CORRECTED AND THAT
ALONE CAN IMPROVE ORTHOSTATIC
HYPERTENSION.
ON THE RIGHT SIDE IS THE
PATHOPHYSIOLOGY AND IN THE OLDER
HYPERTENSIVE SHOWING AORTIC
STIFFNESS AND IN THE YOUNGER
PATIENTS WITH HYPER MINERGIC SIN
SOME VERY HAVE HEART RATE AND
IT'S IMPORTANT TO MEASURE THE
VITALS.
IT'S RARELY DONE UNFORTUNATELY
AND ONE OF THE THINGS WE NEED TO
IMPROVE ON AND STUDY ORTHOSTATIC
HYPERTENSION.
SO ORTHOSTATIC HYPERTENSION IS
DEFINED AS A DROP IN SYSTOLIC
BLOOD PRESSURE 20 OR MORE WITHIN
THREE MINUTES OF STANDING.
THE DEFINITION HAS BEEN AROUND
FOR A WHILE AND TIME TESTED AND
PREDICTIVE OF ADVERSE OUTCOME IN
CLINICAL EPIDEMIOLOGICAL
STUDIES.
THE DEFINITION OF ORTHOSTATIC
HYPERTENSION IS MORE RECENT AND
WE PROPOSED A SUSTAINED INCREASE
IN SYSTOLIC BLOOD PRESSURE OF 20
MERCURY WITH SYSTOLIC BLOOD
PRESSURE GREATER THAN 140.
WE CAN ARGUE WHETHER IT PREDICTS
ADVERSE OUTCOME BUT THAT'S
SOMETHING THAT PROBABLY NEEDS
SOME REFINING OVER TIME.
HOW DO WE MAKE THE DIAGNOSIS?
WITH ORTHOSTATIC HYPERTENSION
MOST PATIENTS COME TO US AND
YOU'LL BE SURPRISED HOW LONG IT
TAKES PHYSICIANS TO RECOGNIZE
THE SYSTEMS AND MEASURE
ORTHOSTATIC VITALS BUT IT'S
USUALLY PRETTY EVIDENT
TYPICALLY.
ON THE OTHER HAND, THE
ORTHOSTATIC HYPERTENSION UNLESS
YOU ROUTINELY MEASURE VITALS
LIKE WE DO IN OUR CENTERS BUT
ALMOST NOBODY DOES THAT IS
BASICALLY A FINDING FROM
CLINICAL TRIALS.
THESE WERE CLINICAL TRIALS THAT
WERE DESIGN TO STUDY ORTHOSTATIC
HYPERTENSION AND NOW OF COURSE
YOU REALIZE YOU ALSO HAVE THE
PROBLEM OF ORTHOSTATIC
HYPERTENSION WHICH IS AS
IMPORTANT.
SO IT'S BEEN A FINDING IN
CLINICAL TRAILS.
IN TERMS OF DIAGNOSIS, WE CAN
MAKE SOME REFINEMENTS FOR
EXAMPLE WHAT IS THE OPTIMAL
DURATION TO DIAGNOSIS OR STUDY
HYPERTENSION.
THERE'S A FEW PATIENTS THAT HAVE
TRADE ORTHOSTATIC HYPERTENSION
AND IT'S HARD TO ARGUE TO CHANGE
THE WHOLE CLINICAL SETTING JUST
TO DIAGNOSIS THE FEW PATIENTS
BUT IN PATIENTS WITH CLASSICAL
SYMPTOMS AND RELIEF ON LYING
DOWN AND MEASURE THE VITALS AND
AUTHOR COMPLETELY NORMAL WE DO
SOMETIMES ORDER LONGERER --
LONGER TESTS AND IT'S MEASURE TO
MEASURE ORTHOSTATIC VITALS BUT
IT'S ALMOST NEVER DONE EVEN IN
PATIENTS THAT NEED IT.
WE HAVE TO FIGHT IN OUR CLINIC
TO IMPLEMENT THE MEASUREMENT OF
ORTHOSTATIC VITALS.
SO SO TO ME THE BEST RETURN ON
INVESTMENT WOULD BE TO DEFINE
CRITERIA FROM SEATED TO STANDING
BLOOD PRESSURE.
BECAUSE THAT WILL FACILITATE
ENORMOUSLY THE DIAGNOSIS IN
CLINIC AND RESEARCH TRIALS.
IT WILL BE ADDING JUST ONE
MEASUREMENT OR TWO OR THREE,
WHATEVER STANDING.
OPPOSED TO HAVING THE PATIENT
LIE DOWN FOR 15 MINUTES IS
ALMOST IMPOSSIBLE TO DO.
FOR MY MONEY, THIS WOULD BE THE
BEST IMPROVEMENT WE CAN MAKE TO
DEFINE CRITERIA, DIAGNOSE THE
CRITERIA USING SEATED TO
STANDING RATHER LYING IT
STANDING.
WHO SHOULD BE SCREENED?
AGAIN, WE FIND IT'S VERY HARD TO
IMPLEMENT MEASURE IN ORTHOSTATIC
VITALS AND A PATIENT WITH
SYMPTOMS AND LIGHT HEADEDNESS IS
THE TYPICAL ONE BUT YOU'D BE
SURPRISED HOW TENSION DOESN'T
DESCRIBE THE SYMPTOMS AS LIGHT
HEADEDNESS BUT FATIGUE OR PAIN
IN THE BACK OF THE NECK.
ANY SYMPTOMS THAT WORSENS AND
IMPROVES BY SITTING OR LYING
DOWN WE NEED TO MEASURE
ORTHOSTATIC MEASUREMENTS AND
THERE'S STUDIES SHOWING PATIENTS
WHO GO TO THE E.R. FOR SYNCHOPE
AND IT CAN IMPROVE QUALITY OF
LIFE.
IT'S A QUESTION WHO SHOULD BE
SCREENED BECAUSE THERE'S NO
SYMPTOMS OR QUALITY OF LIFE TO
IMPROVE SO WHAT IS THE VALUE OF
FINDING THIS AND IS IT
ACTIONABLE FOR SOMETHING WE NEED
TO DO DIFFERENTLY?
IN YOUNG PATIENTS THERE'S SOME
EVIDENCE BY OTHERS THAT IT DOES
PREDICT THE FUTURE DEVELOPMENT
OF HYPERTENSION.
SO THAT MIGHT BE ANOTHER VALUE.
WHAT WE DO?
SHOULD WE TO MORE INTENSIVE
BLOOD PRESSURE CONTROL.
THE STUDIES SHOW YOU EVEN IN
REGULAR HYPERTENSION WITHOUT
ST
STUDYING HYPERTENSION YOU SHOULD
DO MORE AND COULD IT BE WE NEED
TO USE BLOOD PRESSURE OUTCOME AS
OPPOSED TO SEAT AND THE BLOOD
PRESSURE WILL BE HIGHER ARE ALL
QUESTIONS WE NEED TO RESOLVE.
THE DIFFERENCE BETWEEN BOTH
EXTREMES IS ORTHOSTATIC
HYPERTENSION IS A NATURAL
FINDING AND WHAT DO WE DO WITH
THE FINDING?
BUT THERE'S RESEARCH WE NEED TO
DO TO DEFINE THESE THINGS.
IN TERMS OF MANAGEMENT GAPS AND
I APOLOGIZE THIS SHOULD HAVE
BEEN ON THE LEFT BUT THAT'S
OKAY.
THE CHALLENGE YOU CAN UNDERSTAND
THERE'S A CHALLENGE IN TREATING
ORTHOSTATIC HYPERTENSION IN
PATIENTS WITH HYPERTENSION WHICH
ARE THE MOST COMMON CLINICAL
FINDING.
MOST PATIENTS WITH ORTHOSTATIC
HYPERTENSION WILL HAVE SOME
HYPERTENSION SOMETIMES VERY
SEVERE.
SO WHAT MEDICINES CAN WE USE TO
TREAT ORTHOSTATIC HYPERTENSION
WITHOUT WORSENING SUPINE
HYPERTENSION AND THE WORSE WILL
WORSEN IT MORE THAN IMPROVE
STANDING BLOOD PRESSURE.
AND THOSE ARE THE ONLY TWO FDA
APPROVED DRUGS.
THEY BOTH HAVE A WARNING FOR
SUPINE HYPERTENSION.
WE NEED TO DEVELOP OTHER
MEDICATIONS THAT WILL DO A
BETTER JOB.
DIAGNOSTIC MEANS ARE PROBABLY
THE BEST AND THE STUDIES WE HAVE
DONE RECENTLY ARE LESS EFFECTIVE
IN PATIENTS WITH HYPERTENSION
WHICH IS WHERE THEY'LL BE MOSTLY
NEEDED.
THERE'S NEW STUDIES THEN WITH
INHIBITORS LIKE TAMOXIFEN THAT
PLAY BE -- MAY BE HELPFUL AND
IMPROVE STANDING BLOOD PRESSURE.
NEXT SLIDE.
HOW CAN WE TREAT HYPERTENSION
WITHOUT WORSENING ORTHOSTATIC
HYPERTENSION?
IN THE MAJORITY OF THE
HYPERTENSIVE THERE'S EVIDENCE
YOU SHOULD NOT STOP AT THE
HYPERTENSION WHICH IS A COMMON
MISTAKE AND DO INTENSE BLOOD
PRESSURE CONTROL WITHOUT
TRIGGERING ORTHOSTATIC
HYPERTENSION AND SOME
HYPERTENSION SHOULD BE REFERRED
MORE THAN OTHERS AND THERE'S A
LIST WE PUBLISHED WITH STEVEN IN
AN AMERICAN HEART GUIDANCE
DOCUMENT BUT THERE'S SOME
RATIONALE FOR IT BUT IT WILL BE
GOOD TO HAVE SOMEBODY BASED.
IT'S IMPORTANT TO REALIZE IN
THOSE STUDIES PATIENTS WITH
SIGNIFICANT ORTHOSTATIC
HYPERTENSION WERE EXCLUDED FROM
THOSE STUDIES.
SOME HAVE SEVERE ORTHOSTATIC
HYPERTENSION AND HYPERTENSION.
AND THE INTERESTING THING IS THE
SUPINE NOCTURNAL HYPERTENSION
INDUCES DAYTIME ORTHOSTATIC
HYPERTENSION BECAUSE THE SUPINE
BLOOD PRESSURE INDUCES THE
ORTHOSTATIC HYPERTENSION AS A
RESULT DURING THE DAY IT'S
WORSE.
AND THIS DEFINES YEARS OF WORK
AND WE HAVE TRIED TO REDUCE
NOCTURNAL HYPERTENSION AND A LOT
OF THEM DO THAT BUT NONE REDUCE
BLOOD PRESSURE AND THESE ARE
LONG-TERM EFFICACY.
LET ME STOP BECAUSE OF TIME
CONSTRAINTS AND BE HAPPY TO
ANSWER QUESTIONS IN THE PANEL
SECTION.
THANK YOU.
>> THANK YOU FOR A FANTASTIC
PRESENTATION.
WE CAN GO TO THE NEXT -- OKAY,
THANK YOU.
SO NEXT WE HAVE DR. DART, WHO
WILL BE SPEAKING ON THE
MEASUREMENTS OF BLOOD PRESSURE
IN THE OBESE AND WEIGHT LOSS,
THE CLINICAL CHALLENGE.
SO WITHOUT FURTHER ADO, I'LL
TURN THINGS OVER TO DR. DART.
>> THANKS, PAUL.
AND THANK YOU.
I'M DICK DART, I'M AT THE CENTER
FOR PRECISION MEDICINE,
MARSHFIELD CLINIC RESEARCH
INSTITUTE AND MARSHFIELD CLINIC
HEALTH SYSTEM.
THESE ARE MY DISCLOSURES.
I'M CHAIR OF THE ISO LARGE ARM
DEFINITION TASK FORCE AND MOTION
ARTIFACT SUBCOMMITTEE AND ALSO A
MEMBER OF THE AMA VALIDATED
DEVICE LISTING INDEPENDENT
REVIEW COMMITTEE BUT I HAVE NO
OTHER CONFLICTS.
IT WAS VON WRECKLING HAW 16 THAT
OWE HAD MADE AN ERROR IN THE
SIZE OF CUFF HE HAD FOR HIS
BLOOD PRESSURE DEVICE THAT IT
READ BLOOD PRESSURES TOO HIGH,
IT WAS ACTUALLY RICHARD DAY IN
THE JOURN JOURNAL OF PEDIATRICSN
1939 WHO IND IND KATEED THAT ONE
SHOULD SELECT A CUFF FROM
THEWITZ GIVEN READINGS ON THE
FLAT PART OF THE CURVE AND FOR
PRACTICAL PURPOSES THIS MEANS
THE USE OF A CUFF WHICH IS AS
WIDE AS WILL FIT THE ARM WITHOUT
IMPINGING ON THE ELBOW AND
AXILLA, AND THOSE LAST TWO
POINTS ARE GOING TO BE ONES THAT
I'M EMPHASIZING AS WE GO ON.
SO THE PROBLEM WITH THE LARGE OR
OBESE ARM, THERE IS NO
UNIVERSALLY ACCEPTED DEFINITION
FOR LARGE ARMS, NOT REALLY.
THERE ARE DEFINITION PROPOSAL,
SOME OF WHICH I'LL BE
DISCUSSING, THE MANUSCRIPT WAS
ALSO IN PROGRESS AND THAT IS
NOTED BELOW.
DOES THE LARGE ARM INCLUDE
CHILDREN AND ADOLESCENTS, AS DRP
AND GROW OUT BUT BY THE TIME
THEY GET TO US THEY'VE GROWN UP
AND -- HAVE COMMENTED RECENTLY.
AMONGST MANY ARTICLES, STEPHEN
JURASCHEK COMMENTED ON ONE OF
THE MANY EXAMINING EXISTING CUFF
SYSTEMS AND THE ERRORS IN THE
AMERICAN HEART ASSOCIATION
GUIDELINES EXIST OVER A WIDE
RANGE OF ARMS AND SIZES AND
NOTING THE NEED FOR A PROPER
CUFF IN SYSTEMS AND VALIDATION
STUDIES.
SO THE UNIVERSAL STANDARDS FOR
BLOOD PRESSURE VALIDATIONS
REALLY AT THIS POINT HAVE USED
42 CENTIMETERS OR LARGER FOR ARM
CIRCUMFERENCE AS ONE DEFINITION.
HOWEVER, WE ARE PROPOSING A MUCH
MORE DEFINED CONSIDERATION WITH
MID UPPER ARM CIRCUMFERENCE
WHICH VARIES OVER A WIDE RANGE
AND IS NOT LIMITED TO AN UPPER
SIZE THOUGH IT GENERALLY IS
GOING TO BE UP AT LEAST
SOMEWHERE AROUND 50 TO 55 TO BE
TRULY LARGE.
THE INNER ARM, THE PHYSICAL
STATURE COMES INTO PLAY WITH
SOME OF THE RECENT STUFF THAT
PALLATINI AND COLLEAGUES HAVE
DONE.
ADDITIONALLY THERE'S BEEN
REFINEMENT VERSUS THE
CYLINDRICAL SHAPE OF THE ARM AND
ARMS IN GENERAL BUT PARTICULARLY
APPLIED TO LARGE ARMS.
NOW ONE OF THE THINGS IS THE
BLADDER WIDTH WAS AT LEAST COT
FIED IN '76 AND '78 TAKING
MOSTLY AUSCULTATORY DATA AND
USING A SWEET SPOT OF ABOUT 40%
OF THE ARM CIRCUMFERENCE, WOULD
THE -- BLOOD PRESSURE READINGS.
MORE RECENTLY THEY TOOK THIS A
BIT FURTHER AND USING RADIAL ART
REA BLOOD PRESSURES TO COMPARE
THE ARM CIRCUMFERENCE WIDTH
RATIO AND IT CAME OUT FAIRLY
CLOSE TO THIS 40%, AND THAT WAS
SUPPORTED BY ALPERT, IT WOULD
HAVE BEEN NICER TO AS HE NOTES
TO USE BRACHIAL ARTERY STUDIES
BUT THAT IS NOT REASONABLE IN A
CLINICAL SETTING.
THE CRITICAL ISSUE IS REALLY THE
SWEET SPOT FOR MOST ACCURATE
BLOOD PRESSURE LIES BETWEEN 37%
AND 50% OF BLOOD WITH ARMS --
HOWEVER, BWACR IS NOT THE SOLE
PARAMETER REQUIRED BY CUFFS TO
OBTAIN ACCURATE BLOOD PRESSURE
MEASUREMENT.
AND THIS VERY BRIEFLY IS A SLIDE
THAT SHOWS THAT THE INNER ARM
LENGTH OR THE ARM CIRCUMFERENCE,
SHOWS A VIRTUAL LINEAR CONDITION
BETWEEN INNER ARM LENGTH, UPPER
ARM LENGTH, AND MID ARM
CIRCUMFERENCE, BELOW WHICH ANY
CUFF THAT WOULD BE IN THIS AREA
WILL NOT BE ABLE TO BE USED FOR
AN AUSCULTATORY REFERENCE, IT
GOING TO COME OVER THE TIP OF
THE ANTECUBITAL FOSSA AND LIKELY
NOT FIT UP INTO THE ACTS --
WITHOUT PRESSING UP INTO THE
AXILLA.
SO THE NEXT COMPONENT IS THE
TRONCO-CONICAL SHAPE OF THE
UPPER ARM.
THEY DESIGNED A TRAP TRAPEZOIDL
CUFF, AND THEY SHOWED THEM TO BE
MORE ACCURATE IN LARGE ARMS THAN
THE CYLINDRICAL CUFFS.
HOWEVER IT WAS MAXWELL AND MORE
RECENTLY PALATINI AND COLLEAGUES
WHO MEASURED NUMEROUS STUDIES,
YET -- REMAINS TO BE ELUSIVE
THOUGH A SIGNIFICANT STEP
FORWARD AS WAS NOTED BY TAMMY
BRADY AND SANDRA TAYLOR, THE
RECENT STUDY MENTIONED BY
DR. FLYNN EARLIER DONE IN
PEDIATRICS, THERE WERE ONLY
SEVEN CHILDREN IN WHICH THE
TRUNK OF -- THE CUFF WAS USED
AND THEY DIDN'T FIND A
DIFFERENCE.
THAT HAS NOT BEEN PROVEN WITH
THE CASE WITH -- THEY'VE USED
PAPER THIN SENSORS UNDER THE
SPECIAL CUFFS TO ASSESS FOR EVEN
PRESSURE DISTRIBUTION AND IT
SUGGESTS THIS MIGHT SERVE AS A
VALIDATION CUFF YET THRAWS A
GOOD BIT MORE WORK TO BE DONE ON
THIS.
AND THIS IS WHY IT MAKES IT A
LITTLE EASIER TO UNDERSTAND.
IF YOU THINK OF AN ARM AS
CYLINDRICAL AND A CUP FITS
AROUND IT, THAT'S GOING TO BE
FAIRLY LARGER, THAT CUFF BEGINS
TO GET A LITTLE BIT MORE
EXPANDED AT THE UPPER END BUT BY
THE TIME YOU GET TO THE VERY --
JUST CLEARLY PHYSICALLY CANNOT
SATISFACTORILY ENCASE THIS KIND
OF AN ARM AND THAT IS ONE OF THE
REASONS WHY WE'RE PROSING A
TRUNK OF CONICAL COMPONENT.
SO THIS TURNS US TO THE PROBLEM
OF OBESITY AND OVERWEIGHT.
THAT WAS ALLUDED TO BY DR. FL
DR. FLYNN, IT'S BEEN INCREASING
FOR DECADE, THERE'S CONCOMITANT
CO-MORBID, THERE'S TYPE
2 DIABETES, CARDIAC AND RENAL
DISEASE AND THE EFFECT OF
OBESITY AS A CAUSAL FACTOR IN
HIGH BLOOT, I WILL MENTION THAT
THE REFERENCE I LOOKED AT, WHICH
IS BY HALL, ET AL., IN 2024, IS
AN OUTSTANDING REVIEW OF THE
COMPLEX INTERACTIONS OF OBESITY
IN HYPERTENSION AND REMAINING
DISEASES.
IT HAS AN IMPACT ON THE CUFF
SIZE REQUIREMENTS AND THE
EFFECTIVE WEIGHT LOSS ON BLOOD
PRESSURE WILL BE SOMETHING ELSE
THAT WE WILL BRIEFLY TOUCH ON.
THIS IS BEGINNING TO SHOW UP
MORE AND MORE BOTH IN CHILDREN
AS DR. FLYNN POINTED OUT
REFAMILY SIZING BETTHEY'REGOING,
KIDS THAT ARE 1 16 TO
19-YEAR-OLDS, THESE ARE BIG
CUFFS SO THIS IS AFFECTING
CHILDREN AS MUCH AS IT IS
ADULTS.
IN REGARDS TO ADULTS, THE ADULT
LARGE AND EXTRA LARGE CUFFS, YOU
CAN SEE THAT THE NUMBERS ARE
MUCH LARGER WITH ADULT CUFFS BUT
THEY DROP A LITTLE BIT TO
97 MILLION OR ABOUT 8 MILLION
WITH THE VERY LARGE CUFFS AND
ALTHOUGH THE SLANT ANGLE GETS
MORE -- DECREASED MORE AS ARMS
GET LARGER, THERE IS A SPLAY IN
THESE ARMS IN TERMS OF THEIR
ABILITY TO HAVE ACCURATE BLOOD
PRESSURE POSSIBLY BECAUSE OF THE
INNER ARM LENGTH ON SOME OF
THESE PATIENTS, THESE SUBJECTS
BEING SOMEWHAT LARGER THAN IN
OTHER -- THAN SOME OTHER ONES SO
THAT YOU GET THIS LARGE SPLAY.
SO THE MODEL FOR THE LARGE ARM
CUFF/BLADDER SYSTEM, WE DON'T
REALLY HAVE ONE YET AND THERE'S
LIMITATIONS TO THE SPECIAL
TRONCOCONICAL CUFF BECAUSE
THERE'S BEEN SMALL NUMBERS OF
SUBJECTS THAT HAVE BEEN STUDIED
IN THE EXTRA LARGE ARM GROUPS.
THE RESULTS ARE LIKELY GOING TO
BE VALID, IT'S NOT BY CHANCE BY
WHAT THEY GET.
NOTABLY THEY ECK!
CLEUDED PATIENTS WHO HAD LESS
THAN 20 CENTIMETER INTERARM
LENGTH AND THE USE OF A CUFF OF
APPROPRIATE LENGTH WAS NOT
POSSIBLE WITH THESE SMALLER ARMS
AND THIS RESULTED IN ABOUT 5.5%
OF THEIR EXTRA LARGE POPULATION
THAT WAS STUDIED THAT HAD THIS
DISTANCE LESS THAN
20 CENTIMETERS.
IN THE REAL WORLD, PAOLO
SUGGESTED THERE ARE GOING TO BE
MANY MORE SUCH ARMS IF OLDER
ADULTS AND SHORTER PEOPLE ARE
CONSIDERED AND IN LARGER
POPULATIONS BUT THEY PROPOSE
THIS CUFF SYSTEM MIGHT BE USED
AS A REFERENCE CUFF, AGAIN, IF
THEY ARE NOT IN THIS ANTECUBITAL
FOSSA AXILLA RATIO OF LESS THAN
20 CENTIMETERS.
SO OBESITY AND HIGH BLOOD
PRESSURE IN WEIGHT LOSS IS A
VERY COMPLICATED THING BUT IS
PART AND PARCEL TO THE ISSUE
WE'RE DEALING WITH THIS IN
POPULATION.
WE ARE TRYING TO FIND CUFFS THAT
GIVE US ACCURATE BLOOD PRESSURE
READINGS.
THESE ARE ASSOCIATED AS I'VE --
THE EXACT CAUSE AND EFFECT OF
OBESITY AND HIGH BLOOD PRESSURE
IS NOT TOTALLY KNOWN BUT IT'S
MULTIFACTOR YA.
IN THIS NICE REVIEW, THIS
INCLUDES SUCH THINGS AS VISCERAL
ADIPOSE TISSUE, SEUB CUTANEOUS
ADIPOSE TISSUE, ECOLOGICAL,
METABOLIC, GUT MICROBIOME,
INFLAMMATORY COMPONENTS, SALT
AND OTHER FACTORS ASSOCIATED BUT
NOT YET FULLY CLARIFIED.
SO IF WE GET AN APPROACH TO
WEIGHT LOSS, THIS IS GOING TO
IMPACT THINGS.
A COUPLE POINTS IS THAT THERE
ARE MEDICATIONS, THEY CAN BE
EFFECTIVE, BUT THEY HAVE A LOT
OF SIDE EFFECTS AND THERE'S NOT
VERY MUCH IN THE WAY OF LONG
TERM USE.
IN FACT -- THERE ARE SURGICAL
INTERVENTIONS, MANY OF THEM ARE
VERY EFFECTIVE.
HOWEVER, IF YOU CONSUME THE
WRONG KINDS OF FOOD SUCH AS LOTS
OF MALTED MILKS, ET CETERA, YOU
CAN GET AROUND THEM.
WE ALL KNOW THAT EXERCISE IS
VERY EFFECTIVE, AT LEAST IN SOME
ASPECTS OF BOTH IMPROVING
CARDIOVASCULAR HEALTH BUT ALSO
REDUCING WEIGHT, AND WE KNOW
THAT THE DASH DIET IS ASSOCIATED
WITH AT LEAST AN 8-MILLIMETER OF
MERCURY SYSTOLIC DROP.
MEDITERRANEAN IS 2 MILLIMETERS
SYSTOLIC DROP BUT AS STEPHEN
JURASCHEK AND HIS GROUP SHOWED,
DASH PLUS LOW SODIUM INTAKE IN
SOME POPULATION OF GREATER THAN
150 THEY GOT AT LEAST A 10 DROP
OF MERCURY WHICH IS REALLY QUITE
REMARKABLE BUT THE PROBLEMS ARE
THAT IS THE SUSTAINABILITY.
SO CONCLUSION.
THE BLOOD PRESSURE MEASUREMENT
IN THE OBESE AND LARGE ARM
POPULATION LACKS PROPER CUFFS
OVER A WIDE RANGE OF ARM SIZES,
INNER ARM LENGTHS, SHAPES, SLANT
ANGLE, AND INCLUDES THE YOUNG TO
ADULTS.
ADULT AND CHILDHOOD OVERWEIGHT
AND OBESE POPULATIONS HAVE
INCREASED WORLDWIDE.
THE HIGH BLOOD PRESSURE,
METABOLIC SYNDROME AND CO-MORBID
DISEASES ASSOCIATED WITH THESE
ARE INCREASING.
WEIGHT LOSS IS EFFECTIVE IN
LOWERING BLOOD PRESSURE BUT IS
DIFFICULT TO ACHIEVE AND
MAINTAIN.
DASH COMBINED WITH A LOW SODIUM
DIET IS VERY LIKELY TO BE QUITE
EFFECTIVE.
SO WHAT DO I SEE?
WELL, THERE ARE STILL THE LONG
PROBLEM THAT'S BEEN DISCUSSED
EARLIER IN THIS SYMPOSIUM,
ERRORS IN BLOOD PRESSURE MESH.
, WE REALLY NEED TOIM PROVE A
LOT MORE IN TEACHING BLOOD
PRESSURE MEASUREMENT FOR HOME,
IN THE CLINIC, IN THE HOSPITAL.
I THINK IT'S ANOTHER ISSUE
THAT'S VERY MUCH OVERLOOKED IN
TERMS OF JUST SPEED AND
EXPEDITIOUS GETTING THINGS DONE,
IS THE DIRECT BLOOD PRESSURE
CUFF FOR USE IN BLOOD PRESSURE
MEASUREMENTS OF LARGE ARMS.
AND THAT WE OUGHT TO HAVE PROPER
APPLICATION APPROPRIATENESS IN
IF YOU CAN USE AN ACCOMMODATING
UPPER ARM CUFF OR WRIST OR LEG
DEVICE AND THAT WILL BE
DISCUSSED MORE LATER, BUT THE
USE OF THE DIETS PARTICULARLY
NEEDS TO BE MUCH MORE EMPHASIZED
AND IN MY CLINICAL EXPERIENCE,
AT LEAST, MUCH BETTER ACCESS TO
DIETITIAN AND COUNSELING AND
HEALTHY DIET WILL BE SOMETHING
THAT SHOULD IMPROVE THIS
CONSIDERABLY.
AND THANK YOU, AND THAT
COMPLETES.
THAT COMPLETES MY DISCUSSION.
>> THANK YOU, DICK.
WONDERFUL PRESENTATION.
>> THESE ARE MY REFERENCES.
THANK YOU.
>> PEOPLE CAN PUT COMMENTS IN
THE CHAT BOX AND I WILL TURN
THINGS OVER TO DR. BEV GREEN FOR
THE NEXT INTRODUCTION.
>> I NEED TO TURN ON MY VIDEO.
SOMEBODY NEEDS TO DO THAT.
>> OKAY, HI.
OUR NEXT TALK IS ON OPTIMIZING
BLOOD PRESSURE ASSESSMENT IN
CHRONIC KIDNEY DISEASE BY
JORDANA COHEN, WHO IS AN
ASSOCIATE INVESTIGATOR AND A
NEPHROLOGIST AT THE UNIVERSITY
OF PENNSYLVANIA.
GM AHEAD.
>> THANK YOU SO MUCH FOR THE
INTRODUCTION.
AS MENTIONED I'LL BE TALKING TO
YOU ABOUT OPTIMIZING BLOOD
PRESSURE PRESSURE ASSESSMENT IN
CHRONIC KIDNEY DISEASE.
SO MY ONLY DISCLOSURE IS THAT I
GET ROYALTIES FROM UP TO DATE
FOR DOING CARTS OR EDUCATION
BASICALLY IN THE AREA OF BLOOD
PRESSURE MEASUREMENT.
WE KNOW THAT IN PATIENTS WITH
CHRONIC KIDNEY DISEASE THERE ARE
A LOT OF THINGS THAT LEAD TO
HIGH BLOOD PRESSURE THAT WE SORT
OF EXPECT AS TRADITIONAL RISK
FACTORS THAT HAVE BEEN TALKED
ABOUT AT LENGTH TODAY SUCH AS
AGING, AND THEN THERE ARE
SPECIFIC RISK FACTORS TO KIDNEY
DISEASE THAT MAKE HYPERTENSION
ESSENTIALLY UBIQUITOUS IN ALMOST
ALL PATIENTS WHO HAVE CHRONIC
KIDNEY DISEASE WITH MORE COMMON
HIGHER PREVALENCE OF
HYPERTENSION AS KIDNEY FUNCTION
WORSENS.
THIS INCLUDES THAT MOST PEOPLE
WL ADVANCING CHRONIC KIDNEY
DISEASE DEVELOP VOLUME OVERLOAD,
ACCELERATED ARTERIAL STIFFNESS
AND HAVE EXCESS ACTIVITY OF THE
SYMPATHETIC NERVOUS SYSTEM,
ANGIOTENSIN SYSTEM, AS WELL AS
OTHER FACTORS WE SEE IN SEVERAL
OF THE OTHER POPULATIONS THAT
WE'VE SPOKEN ABOUT TODAY SUCH AS
ENDOTHELIAL DYSFUNCTION.
ESA ARE AN ADDITIONAL FACTOR IN
OUR PATIENTS WHO HAVE MORE
ADVANCED KIDNEY DISEASE AND ARE
ON DIALYSIS THAT ALSO CAN
INCREASE BLOOD PRESSURE.
SO BLOOD PRESSURE TREATMENT
THRESHOLD RECOMMENDATIONS TEND
TO DIFFER ACROSS DIFFERENT
POPULATIONS IF YOU LOOK ACROSS
GUIDELINES.
THE 2017ACCHA GUIDELINE AS
EVERYBODY HERE IS WELL AWARE
RECOMMENDED DIAGNOSTIC
THRESHOLDS FOR HYPERTENSION OF
GREATER THAN OR EQUAL TO 130
OVER 80 IN HIGHER RISK ADULTS
AND A TREATMENT THRESHOLD THAT
SHOULD BE LESS THAN 130/80 IN
ALL ADULTS REGARDLESS OF -- ONCE
THEY HAVE A DIAGNOSIS OF
HYPERTENSION.
THERE SHOULD BE SOMETHING ON
THAT PRIOR SLIDE.
I GUESS IT GOT CUT OUT
UNFORTUNATELY.
SO THE BLOOD PRESSURE TREATMENT
THRESHOLD SHOULD BE LESS THAN
120, THIS IS BASED OFF OF
SIMILAR EVIDENCE AS WHAT THE
RECOMMENDATIONS WERE FOR THE
TWEP 17 ACCHA GUIDELINE BUT I
THINK IT'S SPECIFICALLY
RECOMMENDED FOR A FEW REASONS
THAT I'LL TALK ABOUT ON MY NEXT
SLIDE.
SO THERE'S A LOT OF RATIONALE
FOR WHY I THINK THERE COULD BE
THIS DISCREPANCY.
KDIGO RECOMMENDS THIS MORE
STRINGENT BLOOD PRESSURE, FIRST
OF ALL HINGING ON REQUIRING
STANDARDIZED OFFICE BLOOD
PRESSURE.
OTHER RECOMMENDATIONS ALSO
RECOMMEND THIS, BUT THEY TRY TO
BE EVEN MORE STRINGENT ABOUT IT.
ADDITIONALLY, THERE'S THIS
DISPROPORTIONATE CARDIOVASCULAR
RISK IN PATIENTS WITH CHRONIC
KIDNEY DISEASE WHERE OUR
PATIENTS TEND TO ALL
UBIQUITOUSLY BE AT ELEVATED RISK
FOR CARDIOVASCULAR RISK FACTOR
AND SO BECAUSE THE MEAN GOAL OF
LOWERING BLOOD PRESSURE IS THAT
REDUCTION IN CARDIOVASCULAR
RISK, NOT REALLY A KIDNEY PRO
TECH.
IF ANYTHING SOMETIMES WE'LL SEE
MORE OF THIS THERAPEUTIC
HYPERCREATININEIA AS PATIENTS
HAVE THE RISE IN CREATININE BUT
LOWERING OF CARDIOVASCULAR RISK,
AND SO THIS REALLY MAY BE
DISTINCTIVELY WHY KDIGO PUSHED
SO MUCH FOR THAT LOWER BLOOD
PRESSURE GOAL.
ADDITIONALLY, PATIENTS WITH
CHRONIC KIDNEY DISEASE ARE OFTEN
EXCLUDED FROM BLOOD PRESSURE
TRIALS AND I'LL TALK A BIT ABOUT
THE IMPLICATIONS OF THIS IN
PEOPLE WITH MORE ADVANCED KIDNEY
TEASE WHO REALLY AREN'T INCLUDED
IN THAT KDIGO RECOMMENDATION.
WE REALLY DON'T HAVE ANY
GUIDANCE IN WHAT THEIR GOAL FOR
BLOOD PRESSURE WOULD BE EVEN
THOUGH THEY'RE AT GREATER RISK
OF DEVELOPING CARDIOVASCULAR
EVENTS.
THEN THERE'S ALSO THE QUESTION
OF WHETHER IT'S THE ACHIEVED
VERSUS ASSIGNED BLOOD PRESSURE
GOALS AND THE GUIDELINES
BASICALLY WERE MORE STRINGENT IN
SAYING SPRINT ASSIGNED PEOPLE TO
A BLOOD PRESSURE GOAL OF LESS
THAN 120 AND THAT'S WHAT WE
SHOULD BE RECOMMENDING TO ARE
OUR PATIENTS, UNDERSTANDING
THERE COULD BE A SLIGHT LEHIGHER
RISK OF ADVERSE EVENTS, THAT'S
SUPER SEEDED BY THEIR EXCESS
CARDIOVASCULAR RISK.
AND SO THERE ARE SOME REALLY
IMPORTANT DISTINCTIONS
PARTICULARLY IN BLOOD PRESSURE
ASSESSMENT, WHICH WAS WHAT I WAS
TASKED WITH DISCUSSING IN PEOPLE
WHO HAVE CHRONIC KIDNEY DISEASE
COMPARED TO NON-CHRONIC KIDNEY
DISEASE POPULATIONS.
FIRST AND FOREMOST, AS HAS COME
UP PREVIOUSLY WHEN TALKING ABOUT
PREGNANT PATIENTS, THERE ARE
PARTICULAR CHALLENGES WITH BLOOD
PRESSURE MEASUREMENT ACCURACY
AND DEVICE VALIDATION IN
PATIENTS WITH CHRONIC KIDNEY
DISEASE.
THERE ARE NO GUIDELINES THAT
RECOMMEND DISTINCTIVE BLOOD
PRESSURE VALIDATION, HOWEVER
THESE PATIENTS ARE MUCH, MUCH
MORE SUSCEPTIBLE TO HAVING
BROADER OSCILLOMETRIC WAVEFORMS
WHICH CAN BE DIFFERENTIALLY
INTERPRETED BY THESE DEVICES AND
MAY RESULT IN DIFFERENT
VALIDATION, MEANING THAT IN A
COUPLE OF STUDIES THAT HAVE
TRIED TO VALIDATE BLOOD PRESSURE
DEVICES IN CHRONIC KIDNEY
DISEASE POPULATIONS AND DIALYSIS
POPULATIONS, WHICH HAVE BEEN
VALIDATED IN NON-CKD
POPULATIONS, THEY FOUND THAT THE
DEVICES OFTEN ARE NOT ACCURATE.
AND IT'S NOT CLEAR IF THIS COULD
BE RELATED TO SOME ISSUES WITH
ACTUALLY BEING ABLE TO PERFORM
THE VALIDATION PROTOCOLS
PERFECTLY IN THOSE POPULATIONS
OR IF IT'S REALLY THE FACT THAT
THEY HAD DIFFERENT BLOOD VESSEL
CHARACTERISTICS THAT ARE KNOWN
TO IMPACT THAT OSCILLOMETRIC
WAVE ENVELOPE THAT'S USED TO
EXTRAPOLATE BLOOD PRESSURE FROM
THESE AUTOMATED DEVICES.
OUR PATIENT ALSO HAVE A HIGHER
BURDEN OF ARRHYTHMIAS THAN MOST
PATIENTS IN THE GENERAL
POPULATION AND THIS COULD
CONTRIBUTE TO DIFFICULTIES WITH
GETTING ACCURATE BLOOD PRESSURE
MORE SO THAN IN THE GENERAL
POPULATION AND THEY ALSO HAVE A
LOT MORE INTERSTITIAL EDEMA
BROADLY WHICH CAN CREATE ISSUES
WITH BLOOD PRESSURE ACCURACY AND
THE POSSIBILITY TO GET AN
ACCURATE BLOOD PRESSURE.
ADDITIONALLY OUR PATIENTS IN
GENERAL WHEN WE FRID TRY TO ASSN
THEM TO SELF-MONITORING OF BLOOD
PRESSURE HAVE MUCH MORE
DIFFICULTY BROADLY WITH
SELF-EFFICACY AND UPTAKE OF
INTERVENTIONS FOR MANY REASONS
IN PART DUE TO THE FACT THAT
THESE PATIENTS ARE OFTEN CH
LOWER SOCIOECONOMIC STATUSES AND
OFTEN HAVE LOWER HEALTH
LITERACY, SO THESE ARE REALLY
DISTINCTIVE CHALLENGES, MORE SO
THAN ANY OTHER POPULATIONS.
ADDITIONALLY CHRONIC KIDNEY
DISEASE IS A RISK FACTOR FOR
MASKED HYPERTENSION.
ABOUT A QUARTER OF OUR PATIENTS
OFTEN ARE FOUND TO HAVE MASKED
HYPERTENSION BEFORE STARTING
DIALYSIS AND WE DON'T HAVE ANY
DATA ON OUT OF OFFICE TREATMENT
TARGETS IN PEOPLE WHO HAVE A
NORMAL OFFICE BLOOD PRESSURE IN
ALL THESE RANDOMIZED CONTROL
TRIALS USING OFFICE OUT MATED
BLOOD PRESSURES BUT HAVE AN
ELEVATED BLOOD PRESSURE THE REST
OF THE TIME.
THEN HEMODIALYSIS OPENS AN
ENTIRELY NEW CAN OF WORMS.
THEY HAVE UNFORTUNATELY EVEN
GREATER CHALLENGES IN GETTING
ACCURATE BLOOD PRESSURE
MEASUREMENTS.
PERIDIALYSIS BLOOD PRESSURE,
MEANING THOSE THAT ARE PERFORMED
BEFORE, DURING AND AFTER
DIALYSIS, HAVE BEEN THE CLASSIC
TARGETS FOR VOLUME MANAGEMENT
AND ANTIHYPERTENSIVE THERAPY.
AS A DIALYSIS PROVIDER I CAN'T
TELL YOU HOW MANY PHONE CALLS I
GET ON A REGULAR BASIS ASKING
FOR TITRATIONS AND DRY WEIGHTS
AND BLOOD PRESSURE MEDICATIONS
BASED OFF OF THESE READINGS AND
THERE IS A LARGE VOLUME OF THESE
READINGS.
AND THEY'RE OFTEN TAKEN WHILE
THE PATIENT IS SUPINE, OVER
CLOTHING, GETTING STUCK WITH A
NEEDLE AND IN PAIN OR FEARING
THE PAIN THAT'S ABOUT TO HAPPEN,
WITH A LOT OF SUBSTANTIAL
AMBIENT NOISE IN THESE DIALYSIS
UNITS WITH ALARMS CONSTANTLY
GOING OFF SIMILAR TO WHAT YOU
WOULD GET IN AN INTENSIVE CARE
UNIT.
OFTEN POOR ANATOMICAL PLACEMENT
BECAUSE MANY OF OUR PATIENTS
HAVE HAD MULTIPLE ARTERIAL
VENOUS FISH TEU LAS AND NO
LONGER HAVE A LIMB TO OBTAIN A
BLOOD PRESSURE FROM AND YOU'RE
GETTING AN ARTERIAL BRACHIAL
INDEX AND MANY OF THEM HAVE
VOLUME OVERLOAD THAT'S OFTEN
MUCH MORE COMPLICATED AND OFTEN
WORSE THAN IN THE PREDIALYSIS
POPULATION.
THERE'S ALSO AGAIN A LOT OF
CONFOUNDING FROM COMORBIDITIES,
FOR EXAMPLE, MANY PATIENTS ARE
PRELOAD DEPENDENT, WE SEE A HIGH
PORTION OF INDIVIDUALS WITH PAIR
-- WHEREYOUR BLOOD PRESSURE CA,
VERY QUICKLY PLUMMET AS SOON AS
THERE'S FLUID REMOVAL ON
DIALYSIS.
THEN THEIR PATIENTS ALSO SPEND
MOST OF THE TIME OUTSIDE THE
DIALYSIS SETTING, THERE'S
GROWING EVIDENCE SAYING THESE
PATIENTS HAVE EVEN MORE MAS MASD
THAN WHAT'S SEEN IN THE
PREDIALYSIS CHRONIC KIDNEY
DISEASE POPULATION.
SO IT'S NOT SURPRISING THAT WE
HAVE DATA, MOST OF US ALL OF
WHICH HAVE BEEN -- WHICH THAT
SHOWS A VERY BIG -- AND
NON-DIALYSIS UNIT BLOOD
PRESSURES IN PATIENTS WHO ARE
HEMODIALYSIS PATIENTS, SO THIS
DATA, FOR EXAMPLE, CRICK SHOWS
THAT THE PERIDIALYSIS BLOOD
PRESSURES IN THE UPPER LEFT
REALLY HAVE THIS U-SHAPED
ASSOCIATION WITH MORTALITY AND
THE LOWEST RISK IS SEEN AT BLOOD
PRESSURES AROUND 150, EVEN UNTO
160, WHEREAS PATIENTS' BLOOD
PRESSURES OUTSIDE OF THE
DIALYSIS UNIT FOLLOW MORE WHAT
WE'RE USED TO SEEING, WHERE
BLOOD PRESSURES MEASURED OUT ARE
ASSOCIATED WITH LOWER MORTALITY
AND THOSE THAT ARE HIGHER ARE
ASSOCIATED HIGHER IN
CARDIOVASCULAR EVENTS.
WE DON'T HAVE A GOLD STANDARD ON
HOW TO OBTAIN BLOOD PRESSURES
FROM THESE PATIENTS, WE DO FEEL
THAT -- EVEN THESE PATIENTS WHO
OFTEN NO LONGER URINATE OR
URINATE A VERY SMALL AMOUNT
WHERE THEIR BLOOD PRESSURE CAN
VARY A GREAT DEAL OVER THE
44 HOUR PERIOD BETWEEN DIALYSIS
SESSIONS AND THAT'S HISTORICALLY
WHAT'S BEEN DONE TO COLLECT
THEIR OUT OF DIALYSIS BLOOD
PRESSURES BUT IT'S VERY POORLY
TOLERATED TO DO IT FOR THAT LONG
AND WITH PATIENTS WITH SO MUCH
CO-MORBIDITY BURDEN AND OTHER
DEED BURDEN, THIS IS AN EXAMPLE
OF A SEMI QUALITATIVE MIXED
EFFECT -- OR MIXED METHODS STUDY
THAT WE HAD -- THESE PATIENTS
REALLY, REALLY LOVE DOING HOME
BLOOD PRESSURE MONITORING, FELT
EMPOWERED BY IT AND WERE ABLE TO
DO IT BUT IT'S REALLY
UNDERUTILIZED.
DIALYSIS PROVIDERS WHEN GIVEN
HOME PRESSURES REALLY DON'T KNOW
WHAT TO DO WITH THEM AND HAVE
NOT BEEN ACTING ON THEM
HISTORICALLY.
AND SO IN SUMMARY, WE REALLY
DON'T HAVE SUFFICIENT EVIDENCE
TO GUIDE BLOOD PRESSURE TARGETS
IN THESE PATIENTS.
PERIDIALYSIS BLOOD PRESSURE IS
THE CLASSIC TARGET OF VOLUME
MANAGEMENT IN ANTIHYPERTENSIVE
THERAPY BUT IT'S REALLY
SUBOPTIMAL BASED ON
EPIDEMIOLOGIC DATA.
OBVIOUSLY -- ARE BETTER TO
TARGET WHEN INDIVIDUALIZING
TREATMENT STRATEGIES BUT THERE'S
VERY LITTLE DATA IN THIS AREA.
CURRENTLY A CO-INVESTIGATOR ON A
MULTICENTER TRIAL THAT'S JUST
STARTING TO SCRATCH THE SURFACE
OF UNDERSTANDING THE SAFETY OF
DOING THIS, AND THE FEASIBILITY
AND WHETHER PATIENTS CAN UPTAKE
THIS, BUT THERE'S A LOT MORE
WORK THAT NEEDS TO BE DONE.
SO TO CONCLUDE I THINK THERE ARE
SEVERAL KNOWLEDGE GAPS IN THIS
SPACE.
IN TERMS OF GAPS WE REALLY DON'T
KNOW WHETHER SEPARATE BLOOD
PRESSURE DEVICE VALIDATION IS
REQUIRED, WHAT THE OPTIMAL BLOOD
PRESSURE TREATMENT TARGETS
SETTING AN APPROACH SHOULD BE IN
DIALYSIS PATIENTS IN PARTICULAR.
THE APPROPRIATENESS AND
IDENTIFICATION OF OUT OF OFFICE
BECAUSE OF THIS MARKEDLY
HIGHER -- SELF-EFFICACY AND
OTHER ISSUES AND APPROACHES TO
IMPROVING IMPLEMENTATION OF
OFFICE AND HOME BLOOD PRESSURE
MEASUREMENTS FOCUSING ON THE
DISTINCTIVE NEEDS OF THOSE
PATIENTS WITH ISSUES IN MIND.
I THINK MY LAST SLIDE IS SKIPPED
BUT I HAD A FUTURE
OPPORTUNITIES, THANK YOU.
SO I THINK SPECIFICALLY THE
FUTURE OPPORTUNITIES ARE IN
DEVELOPING TRIALS AND
OBSERVATIONAL STUDIES THAT I'LL
FOCUS ON THESE MAIN GAPS,
PLAYERLY BROADENING THE
INCLUSION OF CHRONIC KIDNEY
DISEASE PATIENTS IN TRIALS
BECAUSE OF THEIR EX- -- WE REDI
DON'T KNOW HOW TO TREAT THESE
PATIENTS, ESPECIALLY THOSE WITH
MORE CHRONIC KIDNEY DISEASE OR
AT LEAST DEVELOPING TRIALS THAT
WILL FOCUS ON THEM TO FILL IN
THOSE GAPS.
SO THANK YOU VERY MUCH.
>> THANK YOU, JORDY, FOR AN
EXCELLENT TALK.
I HAVE A LOT OF QUESTIONS, I
HOPE OUR AUDIENCE DOES TOO.
PUT THEM IN THE CHAT, PLEASE.
AND OUR NEXT SPEAKER IS ADAM
BRESS, WHO IS A DOCTOR OF
PHARMACOLOGY AT THE UNIVERSITY
OF UTAH AND A
PHARMACOEPIDEMIOLOGIST.
AND HE'S GOING TO SPEAK ABOUT
BLOOD PRESSURE AS A CRITICAL
VITAL SIGN, TRANSITIONING FROM
HOSPITAL TO HOME SETTINGS.
THANK YOU.
>> THANKS SO MUCH, DR. GREEN.
IT'S REALLY A PLEASURE AND AN
HONOR TO BE HERE TODAY WITH SUCH
ESTEEMED LEADERS, EXPERTS AND
FRIENDS.
I'VE ALREADY LEARNED QUITE A
BIT.
SO MY TALK IS ON BLOOD PRESSURE
AS IT RELATES TO THE HOSPITAL TO
HOME TRANSITION.
AS WE'VE HEARD FROM DR. GOFF AND
ALL THE OTHER TALKS, WE KNOW
THAT HIGH BLOOD PRESSURE IS THE
LEADING CAUSE OF CARDIOVASCULAR
DISEASE AND IS ALSO AN EMERGING
CAUSE AND RISK FACTOR FOR
COGNITIVE DECLINE AND DEMENTIA,
AND THE CONTEXT FOR MY TALK IS
DESPITE THE WIDESPREAD
AVAILABILITY OF SAFE,
INEXPENSIVE, EFFECTIVE
ANTIHYPERTENSIVE MEDICATIONS,
BLOOD PRESSURE CONTROL RATES
COULD BE HIGHER, PARTICULARLY IN
GROUPS THAT DON'T HAVE A REGULAR
HEALTHCARE PROVIDER OR USUAL
SOURCE OF CARE.
THE ADDITIONAL CONTEXT IS THERE
ARE ABOUT 36 MILLION
HOSPITALIZATION EVENTS IN THE
UNITED STATES EACH YEAR.
IN WHICH MANY BLOOD PRESSURE
VALUES AND READINGS ARE TAKEN
AND PERHAPS UTILIZED FOR CARE.
AND THESE BLOOD PRESSURE
READINGS COULD BE ELEVATED FOR
NUMEROUS REASONS, FOR UNDERLYING
HYPERTENSION ITSELF, COULD BE
BECAUSE OF INACCURATE
MEASUREMENT, COULD BE FROM AN
ATROAGENIC CAUSE SUCH AS
MEDICATIONS, IT ALSO COBBLE
SERRATED BECAUSE OF THE STRESS
FROM THE ACUTE ILLNESS OR
PHYSIOLOGICAL PROCESS OR PERHAPS
SLEEP DEPRIVATION.
SO WITH ALL THAT, MY TALK IS
GOING TO TALK ABOUT WHAT'S THE
STATE OF THE EVIDENCE, PERHAPS
THE GUIDANCE FOR WHAT TO DO WITH
ALL THESE BLOOD PRESSURE
READINGS IN THE HOSPITAL?
AND WHILE THERE IS A LOT OF
EVIDENCE, A LOT OF REALLY GOOD
EVIDENCE, A LOT OF RANDOMIZED
EVIDENCE AND GUIDELINES FOR THE
MANAGEMENT OF HYPERTENSION IN
THE OUTPATIENT SETTING, THERE'S
VERY LITTLE HIGH QUALITY
EVIDENCE, BEST PRACTICES, FOR
HOW TO MANAGE BLOOD PRESSURE IN
THE INPATIENT SETTING.
WE DON'T REALLY HAVE GOOD
EVIDENCE TO TELL US SHOULD WE BE
TREATING HIGH BLOOD PRESSURE
WITH MEDICATIONS DURING THE
HOSPITAL AND WHAT TO DO AT
DISCHARGE IN THE ABSENCE OF
HYPERTENSION EMERGENCY, WHERE
THERE'S SIGNS AND SYMPTOMS OF
NEW OR WORSENING TARGET ORGAN
DAMAGE.
BUT IN THE CONTEXT OF
ASYMPTOMATIC HYPERTENSION,
THERE'S VERY LIMITED EVIDENCE ON
WHAT TO DO.
SO THE NEXT SLIDE, SO I HAD THE
HONOR OF LEADING AN ESTEEMED
GROUP ALONG WITH MYCOCHAIR TO
REVIEW THE LITERATURE AND
INCREASE SOME FRAME WORKS AND
PERHAPS HIGHLIGHT SOME BEST
PRACTICES AND EVIDENCE GAPS FOR
THE MANAGEMENT, ELEVATED BLOOD
PRESSURE IN ACUTE CARE SETTINGS
AND IT WAS PUBLISHED, INCLUDED A
DIVERSE GROUP OF CLINICIANS AND
SCIENTISTS FROM HOSPITAL
MEDICINE, CARDIOLOGY,
NEPHROLOGY, EMERGENCY MEDICINE
AND OTHERS.
I DO THINK THERE'S TWO POINTS OF
VIEW ON THIS.
ONE POINT OF VIEW IS THERE IS A
CASE TO BE MADE THAT THE
HOSPITALIZATION MAY BE A GOOD
TIME TO HELP IMPROVE THE
OUTPATIENT MANAGEMENT OF HIGH
BLOOD PRESSURE.
ONE ARGUMENT IS IDENTIFY
INDIVIDUALS WITH UNDIAGNOSED
ESSENTIAL HYPERTENSION.
AND FOR THE REASONS I MENTIONED
BEFORE, THIS MAY BE CHALLENGING.
IT ALSO MAY PROVIDE AN
OPPORTUNITY TO OPTIMIZE POOR
QUALITY REGIMENS, PARTICULARLY
PATIENTS WHO DON'T HAVE REGULAR
ACCESS TO CARE AND THERE'S MORE
OP THIS LATER.
SO THE COMMITTEE DID THINK A LOT
ABOUT THE CAUSES OF ELEVATED
BLOOD PRESSURE IN THE ACUTE CARE
SETTING AND WE ORGANIZE THEM
INTO PATIENT FACTORS AND
HOSPITAL ENVIRONMENTAL FACTORS.
AND THERE'S TWO HEMISPHERES ON
THIS FIGURE THAT WAS INCLUDED IN
THE REPORT, AND THE PATIENT
FACTORS IN THE NORTHERN
HEMISPHERE IN THE GREEN AND THE
HOSPITAL ENVIRONMENTAL -- SOME
THAT ARE A LITTLE BIT OF BOTH,
SO THE CLINICAL CONDITION
OVERLOAD, UNCONTROLLED CHRONIC
HYPERTENSION.
COULD BE BIOLOGICAL RESPONSES TO
PLA MA CORTISOL AND CAT CHOLINE
LEVELS, COULD BE -- A BIG ONE
SUCH AS FAILURE TO START A HOME
ANTIHYPERTENSIVE MEDICATION.
OF COURSE A BIG ONE,
INAPPROPRIATE PPE MEASURING, OR
INBOUND A DEVICE THAT HASN'T
BEEN CAL GRATED OR VALIDATED, SO
THIS IS A FRAMEWORK WHY -- SO
NOW I WANT TO TRANSITION TO A
LITTLE BIT OF THE 70 -- HOW
OFTEN ANTIHYPERTENSIVE
MEDICATIONS HAVE PERHAPS
CHANGED.
AND I WANT TO FIRST FOCUS ON
DISCHARGE.
THIS IS DATA FROM TIM ANDERSON.
HE LOOKED AT VETERAN DATA FROM
THE VHA, VETERAN 65 YEARS OR
OLDER WITH A DIAGNOSIS OF
HYPERTENSION, WHO WERE
HOSPITALIZED FOR KNOWLEDGE
CARDIAC REASONS.
WHAT YOU'RE SEEING HERE IS THE
RATE OF INTENSIFICATION AT
DISCHARGE BASED ON THE INPATIENT
BLOOD PRESSURE LEVELS, NOT
ELEVATED, MODERATELY ELEVATED,
AND THEY ALSO LOOKED AT THEIR
OUTPATIENT MEASURES BEFORE
HOSPITALIZED, AND WHO THINGS YOU
DO HERE, ONE IS THE PROBABILITY
OF INTENSIFICATION WAS STRONGLY
ASSOCIATED WITH THE INPATIENT
READINGS, WHICH MAKES SENSE, BUT
IF YOU LOOK AT THE SEVERELY
ELEVATED GROUP, HOW WELL THEY
WERE CONTROLLED AS AN OUTPATIENT
WASN'T STRONGLY ASSOCIATED WITH
INTENSIFICATION AT DISCHARGE.
ANOTHER ELEGANT ASPECT OF TIM'S
PAPER IS HE LOOKED AT THE
INTENSIFICATION RATES BY GROUPS
OF PATIENTS THAT MAY HAVE A
LOWER LIKELIHOOD OF BENEFIT ON
THE LEFT, CATEGORIES OF LIFE
EXPECTANCY WITH OR WITHOUT
DEMENTIA, METASTATIC FLIG MAN
SEE, AND WE CAN ARGUE ABOUT WHAT
THE DETERMINATIONS OF LOW
LOWER -- -- CONDITIONS LIKE
RENAL DISEASE, WHAT YOU SEE IS A
SIMILAR INTENSIFICATION RATE.
SO TIM IN THIS PAPER MADE A
POINT THAT AMONGST PEOPLE WHO
MAY BE LESS LIKELY TO BEN FID,
ARE STILL GETTING INTENSIFIED AT
THE SAME RATE AND WHO HAVE HIGH
RISK OF ASCVD HAVE THE SAME
INTENSIFICATION RATES.
NOW TIM TOOK THIS ONE STEP
FURTHER AND LOOKED AT OUTCOMES,
AGAIN IN AN OBSERVATIONAL
DESIGN, THIS WAS A PROPENSITY
MATCHED ANALYSIS AND HE COMPARED
HOSPITAL READMISSION, SERIOUS
ADVERSE EVENTS, CARDIOVASCULAR
DISEASE EVENTS BETWEEN THESE
PATIENTS, MATCHED PATIENTS WHO
WERE INTENSIFIED.
THE SURPRISING FINDING HERE IS
THAT AMONG PATIENTS THAT HAD
THEIR ANTIHYPERTENSIVE
MEDICATION REGIMEN INTENSIFIED
AT DISK CHARGE, HAD A HIGHER
RATE OF ADVERSE EVENTS:
READMISSION, SERIOUS ADVERSE
EVENTS.
SO THIS IS SOME OF THE DATA WHEN
PEOPLE MAKE THE ARGUMENT THAT
MAYBE IT'S BETTER TO NOT TUNE
UP, CHANGE OR INTENSIFY
ANTIHYPERTENSIVE, A. WHAT ARE E
OF THE STEPS TO CONSIDER AT
DISCHARGE?
WE ORGANIZED THIS BASICALLY INTO
TWO, CAREFUL REVIEW AND
POTENTIAL ADJUSTMENT, CAREFUL
ADJUSTMENT OF THE
ANTIHYPERTENSIVE MEDICATION
REGIMEN.
AGAIN THERE'S NOT GOOD EVIDENCE
AROUND IS IT WHAT THE RISK
BENEFIT OF DOING THIS IS.
THERE'S THE ANALYSIS FROM TIM,
WHICH SHOWS THERE MIGHT -- IT
MAY NOT BE IDEAL, BUT WE'RE NOT
SURE IN WHICH PATIENTS.
TO HELP WITH THINKING THROUGH
THE TRANSITION FROM HOSPITAL TO
HOME, WE CREATED THIS FIGURE.
WE CALL IT AIM AS AN ALGORITHM,
A FOR ARRANGE, COMPREHENSIVE
FOLLOW-UP CARE WITHIN TWO WEEKS
OF DISCHARGE.
FOR ASSESSMENT AND CORE
FORMATION OF THE DIAGNOSIS IF IT
HAPPENS TO BE A NEW DIAGNOSIS.
AS WELL AS MANAGEMENT OF
MEDICATIONS AND SO FORTH.
INFORM, I FOR INFORM PATIENTS
ABOUT THE IMPORTANCE OF
BROMOPROPANE AND STEPS TO TAKE
AT HOME AND INCLUDING NON-FARM
CLA JIK INTERVENTIONS AND THEN
MONITOR.
OF COURSE TRYING TO FACILITATE
PATIENTS GETTING INTO PROGRAMS
WITH TEAM-BASED CARE.
I APPRECIATE THESE AREN'T
AVAILABLE AS MUCH AS WE'D LIKE,
BUT TO REALLY TRY TO HELP
PATIENTS GET INTO CENTERS LIKE
THAT.
WE ALSO TALK ABOUT MEDICATION
COUNSELING AT DISCHARGE.
1 IN 7 PATIENTS EXPRESS
CONFUSION ABOUT THEIR MEDICATION
AT DISCHARGE.
SO HIGHLIGHTING THE IMPORTANCE
OF CLEAR COMMUNICATION, DURING
EMISSION AND OCCUPATION.
ANOTHER AREA AGAIN IS THINKING
ABOUT THE PHARMACEUTICAL CARE OR
THE ANTIHYPERTENSIVE MEDICATION
REGIMEN AT DISCHARGE.
AGAIN, ASSESSING THE WHOLE
MEDICATION REGIMEN, NOT JUST THE
ANTIHYPERTENSIVE MEDICATIONS
LOOKING FOR DRUG-DRUG
INTERACTIONS.
TRYING TO ASSESS THE QUALITY OF
THE ANTIHYPERTENSIVE MEDICATION
REGIMEN, I'LL SHARE SOME DATA ON
THIS IN A MINUTE, OF COURSE NEW
MEDICATION INITIATION SHOULD
ALIGN WITH THE 2017 -- THE MOST
RECENT U.S. GUIDELINES, SINGLE
PILL COMBINATIONS, HOME
MONITORING AND TEAM-BASED CARE.
IN TERMS OF GAPS IN QUALITY OF
PHARMACEUTICAL CARE IN
HYPERTENSION, I JUST WANT TO
POINT OUT A FEW.
THIS IS DATA FROM OUR GROUP LED
BY KATIE DARINGTON SHOWING NEW
TREATMENT OF HYPERTENSION BASED
ON BLOOD PRESSURE LEVEL, AND WE
FOUND THAT ABOUT 60% OF VETERANS
WITH A PRE-TREATMENT OF GREATER
THAN 160, WEAR STARTING ON ONLY
SINGLE AGENT.
SO THIS IS A SIGNIFICANT GAP IN
CARE, WE KNOW THAT MOST PATIENTS
WITH HYPERTENSION NEED TWO OR
THREE AND THEN INITIAL
COMBINATION THERAPY IS A LITTLE
MORE EFFECTIVE THAN USUAL CARE
OR STEP CARE.
ANOTHER QUALITY GAP THAT WE'VE
LOOKED AT IS BETA BLOCK EARLY
THERAPY AMONG PEOPLE WITHOUT
COMPELLING INDICATIONS, SUCH AS
CORONARY DISEASE, HEART FAILURE
WITH REDUCED EJECTION FRACTION
OR ATRIAL FIBRILLATION.
THIS IS SHOWING THE PREVALENCE
OF BETA BLOCKER USE AMONG
VETERANS WITHOUT COMPELLING
INDICATIONS.
RESISTANT HYPERTENSION.
THIS WAS DATA LANGFORD LED IN
THE JACKSON HEART STUDY LOOKING
AT THE PREVALENCE OF THE
LONG-ACTING MORE PR AND THE FOUH
LINE, FOUND THAT ONLY ABOUT 7%
OF PATIENTS IN THE JACKSON HEART
STUDY WITH RESISTANCE -- AND
ONLY 17% WERE TAKING SPYRO OR --
CAN BE EVALUATED AND TAKEN CARE
FOUND THAT ABOUT 20% OF PATIENTS
WITH HYPERTENSION WERE TAKING AT
LEAST ONE DRUG THAT COULD
INCREASE BLOOD PRESSURE.
IT USUALLY ANTI-DEPRESSANTS OR
NSAIDs.
ANTI-DEPRESSANTS ARE PROBABLY A
LITTLE MORE TRICKY TO MODIFY BY
NSAIDs ARE SOMETHING WE CAN
HELP WITH.
ADHERENCE.
CRITICAL TO STUDY MORE
INTERVENTIONS THAT CAN ACTUALLY
HELP PATIENTS WITH ADHERENCE,
THIS IS ANOTHER PAPER FROM TIM'S
GROUP LOOKING AT AT HOSPITAL
DISCHARGE WHAT THE PERSISTENCE
RATES ARE OF NEW MEDICATIONS OR
DOSE INCREASES, AND JUST LIKE
ALL THE OTHER ANALYSIS, IT'S
VERY LOW AT ONE YEAR, ABOUT 50%.
IN THE INTEREST OF TIME I'LL
SKIP THROUGH THESE NEXT COUPLE
SLIDES AND JUST GO RIG RIGHT TOY
GAPS AND FUTURE DIRECTIONS.
ABOUT TWO MORE.
I JUST WAS TALKING A LITTLE BIT
ABOUT FBCs AND TEAM-BASED
CARE.
SO WE'LL GO BACK ONE SLIDE.
THE KEY KNOWLEDGE GAPS ARE
ADDRESSING THE IMPACT OF
INACCURATE BLOOD PRESSURE
MEASUREMENT.
SHOULD WE BE MODIFYING
MEDICATIONS AND THE
ANTIHYPERTENSIVE MEDICATIONS IN
THE HOSPITAL OR NOT IN THE
ABSENCE OF NEW OR WORSENING
TARGET ORGAN DAMAGE, AND THEN
WHAT ARE THE BP GOALS FOR
INPATIENTS?
THOSE ARE THREE KNOWLEDGE GAPS
AND THEN HOME MONITORING,
EVALUATING APPROACHES TO ENSURE
PATIENTS ARE DISCHARGED WITH
VALIDATED HOME BEEPING MONITORS
AND TRAINING.
WHAT LEVEL OF PHARMACEUTICAL
CARE SHOULD BE PROVIDED AT
DISCHARGE?
WHAT PROVIDES A FAVORABLE RI RIK
BENEFIT PROFILE?
AND THEN THERAPY ESCALATION
THRESHOLDS.
SO WITH THAT, THANK YOU VERY
MUCH.
>> THANK YOU, ADAM.
FANTASTIC PRESENTATION AS
ALWAYS.
FOR THE DISCUSSION, MAYBE ALL OF
THE SPEAKERS FROM THE SESSION
CAN TURN ON THEIR CAMERAS?
PLEASE, IF PEOPLE HAVE QUESTIONS
OR COMMENTS, PLEASE PUT THEM IN
THE CHAT.
WOULD YOU LIKE TO GET US
STARTED?
>> I HAVE A COUPLE THINGS.
ONE WAS ABOUT MEASURING BLOOD
PRESSURE, WE GOT SOME QUESTIONS
ON THAT IN PEOPLE THAT ARE
OVERWEIGHT.
THERE WAS ONE QUESTION ABOUT
USING THE FOREARM, ALSO WRIST
MONITORS BEING USEFUL FOR PEOPLE
THAT ARE OTHERWISE HARD TO FIT
IN UPPER ARM MONITORS.
>> SURE.
THANKS, BEV.
THE DEFAULT IN MOST OF THE
GUIDELINES IS TO PUT A STANDARD
UPPER ARM CUFF, WHATEVER THAT
MAY BE, 14 CENTIMETERS OR SO ON
A FOREARM.
I KNOW OF NO -- AND THEN MEASURE
THE RADIAL PULSE, RADIAL
PRESSURE BY EITHER AUSCULTATION
OR PALPATION.
MOST OF THE GUIDELINES HAVE
EITHER BEEN TENUOUS OR AT LEAST
CAREFUL THAT THE USE OF PRESENT
WRIST DEVICES, ET CETERA, NEED
FURTHER EVALUATION.
SO I DON'T WANT TO DIP INTO THAT
BECAUSE I KNOW THAT'S COMING UP
AS A FULL DISCUSSION.
BUT I THINK THAT ONE OF THE
CONCERNS I HAVE ABOUT THIS IS
THAT THE FOREARMS IN SOME PEOPLE
ARE REMARKABLY LARGE, THEY'RE
ALSO TRUNCOCONAL IN WRISTS, SO
I'M NOT SURE HOW ACCURATE THAT
IS.
I DON'T OTHERWISE HAVE A GOOD
ANSWER FOR THIS.
I'M SIMPLY REFLECTING WHAT IS
PRINCE BLI MY KNOWLEDGE OF
WHAT'S IN THE LITERATURE, AND
THE FACT IS WE ALREADY KNOW
THESE CUFFS AND CUFF DEVICES FOR
ARMS AND FOREARMS AND FINGERS
ARE OUT THERE.
I THINK THAT'S THE BEST ANSWER I
CAN GIVE.
>> WE'VE HAD SOME COMMENTS ABOUT
CHILDREN WITH LARGE ARMS AS
WELL-BEING VERY, VERY DIFFICULT
AND NEEDING MORE RESEARCH.
ANYBODY ELSE WANT TO CHIME IN?
GO AHEAD.
>> ANOTHER QUESTION ABOUT
OBESITY, WHICH IS MAJOR WEIGHT
LOSS, IS BLOOD PRESSURE
MEASUREMENT A CHALLENGE WITH
EXCESS SKIN TISSUE OR ARE WE
GOING TO BE SEEING THIS AS A
PROBLEM COMING UP, GIVEN THE
INCREASE IN GLP1 USE AND PEOPLE
LOSING SUBSTANTIAL WEIGHT?
>> THAT'S A GREAT QUESTION AND I
DON'T KNOW THE -- I HAVE NOT
SEEN ANYTHING THAT HAS REALLY
ADDRESSED THIS.
MUCH OF THE LITERATURE I'VE
SEEN -- USE OF CLOTHING, WHETHER
THAT IMPACTS ON IT.
THE REAL ISSUE, I THINK, PAUL
AND THE BEST ANSWER I CAN GIVE
IS WHETHER A CUFF IS ADEQUATE TO
THE BLADDER WIDTH TO THE ARM
CIRCUMFERENCE, NUMBER ONE.
NUMBER TWO IS THAT IT HAS
COMPRESSIBILITY THAT IS
SYMMETRICAL TO THE ARM.
BEYOND THAT, I DON'T THINK THAT
THERE'S ANYTHING -- I'M NOT
SEEING ANYTHING.
MAYBE SOMEBODY ELSE ON THE PANEL
HAS OR OTHERS IN THE AUDIENCE,
BUT I'M NOT SEEING ANYTHING THAT
SAYS WHAT DO YOU DO WHEN THE ARM
GETS MUCH, MUCH SMALLER?
>> I THINK FOR DR. BIAGGIONI,
HOPE I DID THAT RIGHT -- WHAT'S
THE SINGLE MOST IMPORTANT
THING -- I'M A FAMILY PHYSICIAN,
AND I KNOW THAT FAMILY
PHYSICIANS OFTEN DON'T INTENSIFY
MEDICATIONS IN PEOPLE WHO ARE 7E
AFRAID THEY'RE GOING TO FALL.
OF COURSE THEY SHOULD BE DOING
THE PASTORAL BP BEFORE THEY MAKE
THAT ASSUMPTION AND ALSO ASK
THEM ABOUT THE SYMPTOMS, BUT
WHAT IS THE MOST IMPORTANT THING
YOU MIGHT TELL THEM ONCE THEY'VE
DONE THOSE ASSESSMENTS OR NOT
HOW TO BE GENERICALLY WORRIED
ABOUT LOWERING OLDER PEOPLE'S
BLOOD PRESSURE WHO MIGHT GET A
BENEFIT?
>> THANKS SO MUCH FOR THE
QUESTION.
I'M NOT GOING TO -- I MEAN, IT
CAN GET COMPLICATED BASED ON
HYPOTENSION NEEDS.
BUT IN MOST PATIENTS EVEN IF
THEY HAVE MILD ORTHOSTATIC
HYPOTENSION, THEIR HYPERTENSION
NEEDS TO BE TREAT TREATED LIKE
EVERYBODY ELSE.
WE SEE FOR EXAMPLE PHYSICIANS
ARE USING A LOT OF CARVEDILOL
AND OF COURSE THAT'S AN ALMA
BLOCKER.
AND IF YOU HAVE POSTURAL --
OTHER TYPE OF BETA-BLOCKERS.
EXAMPLES LIKE THAT.
AND A LOT OF PATIENTS AT THAT
AGE MAY BE ON -- SO IDENTIFYING
FACTORS THAT CAN AGGRAVATE
HYPOTENSION THAT HAVE NOTHING TO
DO WITH GOOD TREATMENT FOR
HYPERTENSION, THAT WOULD BE THE
FIRST STEP.
BUT IN MOST PATIENTS, YOU CAN DO
BOTH.
LEW'S COMMENT ALREADY ON THIS
QUESTION SAYING THAT THERE'S
EVIDENCE THAT THE SLOW GRADUAL
TREATMENT OF AN OLDER ADULT
MIGHT ACTUALLY ROW DUES RATHER
THAN WORSEN IT, AND I THINK
THAT'S CORRECT.
HE'S DONE A VERY NICE STUDY
SHOWING THAT UNCONTROLLED
FORTIFYING HYPOTENSION, PERHAPS
MAKE A MECHANISM THAT I
MENTIONED WITH NOCTURNAL
DIURESIS -- IT CAN BE A
COMPLICATED ISSUE BUT IF YOU
REMOVE AGGRAVATING FACTORS AND
YOU FOCUS ON THE TREATMENT OF
HYPERTENSION, IN GENERAL, THAT
IS THE BEST FOR THE PATIENT.
>> THANK YOU.
YOU WANT TO HAVE ANOTHER ONE,
PAUL?
>> I'M GOING TO ASK ADAM A
QUESTION, BECAUSE SOMETHING HE
SAID AT THE END OF HIS TALK
PIQUED MY INTEREST, AND THIS IS
FOCUSED ON WHAT TO DO FOR BLOOD
PRESSURE MEASUREMENT POST
DISCHARGE.
YOU MENTIONED BLOOD PRESSURE
HOME MONITORING.
DO YOU THINK THAT SHOULD BE --
DO YOU THINK THAT IS THE BEST
APPROACH POST DISCHARGE?
I'VE READ SOME DATA THAT SOME
SEVERE HYPERTENSION, I GUESS,
RETURNS TO NORMAL POST
DISCHARGE.
BUT I'M NOT SURE WHAT YOUR
THOUGHTS ARE ABOUT BLOOD
PRESSURE MEASUREMENT, BOTH I
GUESS, YOU KNOW, FOR THOSE WITH
SEVERE HYPERTENSION IN THE
HOSPITAL BUT THEN ALSO POST
DISCHARGE, WHETHER THERE SHOULD
BE PROGRAMS OR HOW THAT BEST
SHOULD BE DONE.
>> I THINK IT'S A GREAT
QUESTION, PAUL, AND I GUESS
BASED ON MY UNDERSTANDING OF THE
LITERATURE, I THINK IT AN OPEN
QUESTION AND I THINK IT AN AREA
THAT COULD HELP REVEAL
THE DEGREE TO WHICH THE BLOOD
PRESSURES ARE ELEVATED IN THE
HOSPITAL AS A RESULT OF THE
ACUTE PHYSIOLOGICAL PROCESS OR
THE STRESSORS IN CONFIRMING IF
BLOOD PRESSURES GO DOWN AT HOME
WITHOUT ANY INTERVENTION,
THE DEGREE TO WHICH KIND OF THAT
IS CONTRIBUTING AND COULD HELP
CONFIRM THE HYPOTHESIS THAT ON
AVERAGE, IN GENERAL, WE SHOULD
BE VERY CONSERVATIVE WITH
INTENSIFYING OR INITIATING
MEDICATIONS IN THE HOSPITAL.
I THINK IT'S A REALLY
INTERESTING QUESTION.
I THINK WE WOULD LEARN A LOT
FROM LIKE AN IMPLEMENTATION
STUDY OR AN ACTUAL STUDY THAT
UTILIZED HOME READINGS AFTER
HOSPITALIZATIONS TO KIND OF SEE
MORE OF WHAT HAPPENS.
>> I MIGHT ADD IT WOULD BE
GREAT -- IN MY PERFECT WORLD
THERE WOULD BE AN RPM PROGRAM
WITH PHARMACISTS AND REVIEW
MY -- ALMOST KIND OF LIKE
POSTPARTUM HYPERTENSION.
>> THANK YOU.
THERE'S A COMMENT IN THE CHAT
FOR JORDY OR A QUESTION.
DO YOU THINK THERE'S ENOUGH
EVIDENCE TO SUGGEST SOME DEVICES
WORK DIFFERENTLY IN --
WARRANTING THEM BECOMING A
SPECIAL POPULATION?
I'M GOING TO ADD ON TO MY -- SO
YOU CAN COMMENT -- VERSUS MORE
ADVANCED KIDNEY DISEASE, IF YOU
DON'T MIND?
>> SO THEN TAMMY ADDED ANOTHER
QUESTION TOO THAT I'M HAPPY TO
ANSWER.
I THINK IT'S WORSE AS KIDNEY
DISEASE WORSENS, YOU WORK --
HIGHER BLOOD PRESSURES ON
AVERAGE IN THE POPULATION WHICH
ARE REALLY THE FACTORS THAT
LIKELY CONFOUND THE WAY THAT THE
DEVICE IS ABLE TO CALCULATE THE
READINGS.
I THINK WE DON'T HAVE ENOUGH
EVIDENCE TO EVEN KNOW WHETHER
THEY HAVE TO BE SPECIAL
POPULATION TO TAMMY'S QUESTION.
THE STUDIES THAT HAVE IDENTIFIED
THAT DEVICES ARE NOT VALID IN
PATIENTS WITH CKD HAVE ISSUES
AND HAVE VIOLATIONS TO PROTOCOLS
AND SO I'VE NOT SEEN ONE TO MY
KNOWLEDGE THAT HAS NOT VIOLATED
A PROTOCOL OR THAT HAS PROVIDED
ENOUGH INFORMATION IN THEIR
PUBLICATION TO KNOW AND THEY
DIDN'T -- SO IT NOT 100% CLEAR
BUT PART OF IT IS THAT CKD
PATIENTS TEND TO RUN
HYPERTENSIVE AND THE MORE
HYPERTENSIVE, THE LESS ACCURATE
A LOT OF THESE GUYS, WHERE NO
MATTER WHAT YOU DO, YOU'RE GOING
TO STRUGGLE TO END UP SEEING
SUBSTANTIAL VALIDITY WITH THE
DEVICES.
I DON'T MEAN TO BE ANILIST IN
THAT REGARD, I HOPE I'M WRONG
BUT THERE UNFORTUNATELY ISN'T
SUFFICIENT EVIDENCE TO SAY FOR
SURE.
IN TERMS OF TAMMY'S OTHER
QUESTION OF WHETHER THERE IS
POTENTIALLY A POPULATION WITH
CKD AND MILD PO MODERATE -- YES,
I THINK IT VERY SIMILAR TO WHAT
WE END UP SEEING WITH THE
REDUCTION OF HYPERFILTRATION
JUST WITH USING IRBs THAT IN
PEOPLE WHO PARTICULARLY HAVE
SECONDARY FSGS MEANING YOU WOULD
SEE RENAL BENEFIT FROM BLOOD
PRESSURE LOWERING IN THOSE
PATIENTS.
ADDITIONALLY WE DEFINITELY SEE
THAT, THERE HAS NOT BEEN A LARGE
SCALE TRIAL THAT HAS LOOKED AT
THAT.
BUT WE GENERALLY AS A GROUP OF
NEUROLOGISTS TEND TO AGREE THERE
IS KIDNEY BENEFIT IN CERTAIN
PATIENTS WITH BLOOD PRESSURE
LOWERING AND THEN IN EVERYBODY
ELSE THERE IS DEFINITELY
CARDIOVASCULAR BENEFIT WHETHER
OR NOT --
>> SO A FOLLOW-UP TO THAT.
I THINK ONE OF THE ADVERSE EVENT
WE'VE SEEN IN SOME OF THE
INTENSIFIED MEDICATION TRIALS
GOING DOWN TO 120 SYSTOLIC IS
ACUTE RENAL ISSUES, AND YOU SAID
SOME VERY INTERESTING THINGS TO
ME ABOUT IT, ABOUT WHETHER WE
SHOULD BE CONCERNED ABOUT THAT
OR NOT AS WE GO TO THESE LOWER
TARGETS.
>> THERE WERE SEVERAL REALLY
ELEGANT STUDIES DONE POST HOC IN
SPRINT IN PARTICULAR WHERE THEY
LOOKED AT TUBULAR BIOMARKERS IN
PATIENTS WHO HAD INTENSIVE BLOOD
PRESSURE LOWERING, AND BASICALLY
THE CONCLUSION WAS THAT MOST OF
IT IS HEMODYNAMIC.
MOST OF IT IS WHAT I WAS
STARTING TO ALLUDE TO IN THE
TALK WHERE WHEN YOUR BLOOD
PRESSURES ARE HIGHER, YOU'RE
PUPERFUSING YOUR KIDNEYS MORE, R
YOU MAY TEND TO SEE -- ANY LONG
TERM RISK, IT DOESN'T RELATE TO
PROGRESSION OF CHRONIC KIDNEY
DISEASE.
AT LEAST NOT IN THE STUDIES I'VE
LOOKED AT REALLY CLOSELY --
TRULY CAUSES LASTING KIDNEY
HARM, ONLY THAT IT DOESN'T
NECESSARILY BENEFIT THE KIDNEYS.
>> THANK YOU.
>> ACTUALLY -- DID DO -- IN
DIABETIC PATIENTS I FORGOT ABOUT
THAT ONE BUT IT SMALL AND VERY
NEGLIGIBLE RELATIVE TO THE A
CARDIOVASCULAR BENEFIT.
>> DO YOU HAVE ANOTHER QUESTION,
PAUL?
>> PLEASE, GO AHEAD.
>> ONE OF THE THINGS I HEAR THE
NEPHROLOGISTS TALK ABOUT
SOMETIMES IS PSEUDOHYPERTENSION,
AND IT'S SOMETHING WE NEED TO BE
CAUTIOUS ABOUT WHEN WE MEASURE
BLOOD PRESSURE.
COULD YOU TALK ABOUT THAT A
LITTLE?
JORDY, I'M ADDRESSING THAT TO
YOU.
>> I'M NOT SURE IN WHICH REGARD
BUT I THINK OF
PSEUDOHYPERTENSION ACROSS THE
BOARD IN SO MANY SITUATIONS HAVE
BEEN TALKED ABOUT, MOST OF OUR
PATIENTS JUST END UP IN THE
CLINIC MORE OFTEN AND HAVE --
BUT I THINK THAT VOLUME CAN
DEFINITELY CONFOUND BLOOD
PRESSURE BUT MOST OF IT ENDS UP
BEING A LOT OF ARTIFACT.
I DO THINK THAT OUT OF OFFICE
BLOOD PRESSURE MONITORING CAN
HELP TO OVERCOME THAT, BUT
UNFORTUNATELY WE'RE LACKING IN
GREAT DATA SHOWING THAT BESIDES
REALLY GOOD QUALITY DATA FROM
THE CRICK STUDY THAT PAUL HELP
TODAY LEAD WHICH SHOWS THAT WE
HAVE VERY SUBSTANTIAL LINKAGE OF
THE AMBULATORY BLOOD PRESSURE
MONITORING IN CKD PATIENTS WITH
ADVERSE OUTCOMES, THAT'S
STRONGER THAN WHAT WE WOULD SEE
WITH CLINIC BLOOD PRESSURE
MEASUREMENTS.
>> AND HOW ABOUT SEVERE
ATHEROSCLEROSIS, WOULD THAT
AFFECT THE BLOOD PRESSURE
READINGS?
ANYBODY COMMENT ON THAT?
>> IT CAN INS LOW METRIC
DEVICES, SIMILAR TO WIDE BLOOD
PRESSURE, IT MAKES THE ENVELOPE
MORE ASYMMETRIC SO THESE DEVICES
HAVE TO BE DEVELOPED IN A WAY
THAT CAN HANDLE THOSE CHANGES IN
THE CHARACTERISTICS OF THE
WAVEFORMS.
SOME DEVICES HAVE BEEN DEVELOPED
TO TRY TO ADDRESS THAT AND MANY
HAVEN'T AND THAT'S PART OF WHY
THE VALIDATION PROCESS IS SO
IMPORTANT IN A BROAD RANGE OF
INDIVIDUALS.
>> I THINK THE OTHER COMMENT TO
THAT, JUROR TEE, IS THAT IN
TERMS OF OUR WORK WITH THE --
THAT WHICH IS SUBMITTED, IT IS
NOT OFTEN VERY CHARACTERISTIC OF
THE ACTUAL UNDERLYING VASCULAR
PATHOLOGY THAT MIGHT BE PRESENT.
SO THAT THE THING -- YOUR
QUESTION IS IT DIFFICULT TO KNOW
FOR SURE WHEN YOU GET A DEVICE
WHETHER OR NOT THERE HAVE BEEN
PATIENTS WHO HAVE SUBSTANTIAL
ATHEROSCLEROSIS THAT MIGHT, IN
FACT, TEST OUT THE DEVICES'
ALGORITHMS.
>> PLEASE KEEP THE QUESTIONS
COMING IN THE CHAT BOX.
YOU MENTIONED SOMETHING ABOUT A
LOT OF THE DATA ON ORTHOSTATIC
HYPOTENSION COMES FROM THE
1990s AND BEFORE.
DID I UNDERSTAND THAT CORRECTLY?
AND CAN YOU TALK ABOUT WHAT THE
MORE NEED FOR RECENT DATA?
>> YOU KNOW, WE CONTINUE TO WORK
ON STUDYING HYPERTENSION AND
THERE'S A LOT OF STUDIES
RECENTLY MOSTLY SHOWING THAT
PRECISE LEA, YOU CAN EVEN TO
TIGHT BLOOD PRESSURE CONTROL
WITHOUT NECESSARILY TRIGGERING
OR WORSENING ORTHOSTATIC
HYPOTENSION.
THERE'S A LOT OF NEW DATA THAT
ARE VERY GOOD FOR THAT.
NOW, AGAIN, I ONLY EMPHASIZE THE
FACT THAT IN THOSE STUDIES, WE
EXCLUDED PATIENTS WITH SEVERE
ORTHOSTATIC HYPOTENSION.
SO YOU NEED TO BE CAREFUL ABOUT
THAT AND THAT'S SOMETHING THAT
NEEDS TO BE CONSIDERED, BUT THE
RESEARCH WITH ORTHOSTATIC
HYPOTENSION HAS BEEN GOING ON
FOR MANY, MANY YEARS AND WE'RE
STILL LEARNING.
THE ORTHOSTATIC HYPERTENSION IS
A LITTLE BIT MORE RECENT.
AND IN PART BECAUSE THE STUDIES
THAT WERE DONE FOR ORTHO IS THAT
TICK HYPOTENSION, YOU KNOW, LET
US REALIZE THAT WE ALSO HAVE
THIS PROBLEM WITH ORTHO IS THAT
TICK HYPERTENSION THAT WE KNOW
WE DIDN'T RECOGNIZE BEFORE, AND
CAN BE AS MUCH OF A RISK FACTOR
AS MUCH AS IT IS --
>> GIVEN A QUICK FOLLOW-UP,
THANK YOU FOR THE ANSWER, GIVEN
IT'S NOT REALLY MEASURED, ALMOST
NEVER DOB, I THINK WHAT YOU
SAID, WHAT WOULD BE THE FIRST
STEP, IF WE CAN'T GET EVERYONE,
HOW WOULD YOU TACKLE
IMPLEMENTATION?
>> IN ORDER TO START A
POTENTIAL -- IT MORE IMMEDIATE
BECAUSE YOU CAN INTERVENE,
IMPROVE QUALITY OF LIFE AND
PREVENT FALLS.
STUDYING HYPERTENSION, I THINK
WE NEED TO LEARN MORE ON WHAT DO
WE GAIN BY DETECTING IT?
I'M NOT CONVINCED THAT WE
SHOULD -- I MEAN, IDEALLY
MEASURE ORTHOSTATIC VITALS WHEN
YOU FIRST DIAGNOSE A PATIENT,
NOT IN EVERY SINGLE VISIT, BUT
YOU KNOW, ONCE A YEAR PERHAPS, I
THINK THAT WILL BE HELPFUL, BUT
I HAVE NO BASIS TO TELL YOU THAT
THAT RECOMMENDATION WILL LEAD TO
IMPROVEMENT IN QUALITY OF CARE.
THAT IS WHAT IS MISSING.
BUT IF WE ARE ABLE TO DETERMINE
IF IDENTIFYING ORTHOSTATIC
HYPERTENSION WILL MAKE A
DIFFERENCE IN THE TYPE OF
MEDICATIONS, THE
ANTIHYPERTENSIVE WE USE, IF IT
MAKES A DIFFERENCE WHETHER THE
OUTCOME IS STANDING BLOOD
PRESSURE RATHER THAN SEATED
BLOOD PRESSURE, IF OUR INTENSIVE
BLOOD PRESSURE CONTROLS TO
TARGET STANDING RATHER THAN
SEATED, THOSE ARE THE TYPE OF
RESEARCH WE NEED TO MAKE IT
USEFUL TO TAKE OURSELF TO
MEASURE UPRIGHT BLOOD PRESSURES.
>> THERE'S A FOLLOW-UP QUESTION
IN THE CHAT BOX ABOUT HOW MUCH
DO WE KNOW ABOUT SEX DIFFERENCES
IN ORTHOSTATIC HYPO AND
HYPERTENSION?
>> I DON'T KNOW THAT THERE'S
MUCH DIFFERENCE.
I THINK FOR ONCE FEMALES ARE AS
BAD AS MALES FOR THE FIRST TIME,
AND THE ONLY DIFFERENCE,
PERHAPS, IS IN THE YOUNG
PATIENTS WITH HYPERADRENERGIC
SYNDROMES, THAT UNFORTUNATELY
TENDS TO BE MORE COMMON IN
WOMEN.
BUT IN TERMS OF THE REGULAR
HYPERTENSIVE PATIENTS, WHICH,
YOU KNOW, TEND TO BE OLDER, WE
DON'T SEE ANY SEX DIFFERENCE IN
TERMS OF THE PREVALENCE OR THE
SEVERITY OF ORTHOSTATIC
HYPOTEPTION OR HYPERTENSION.
HYPOTENSION OR HYPERTENSION.
>> THANKS.
OBVIOUSLY SEX DIFFERENCES ARE
IMPORTANT SO IT'S GOOD TO KNOW.
>> OF COURSE.
>> ANY OTHER QUESTIONS BEFORE WE
WRAP UP THE SESSION?
I THINK WE HAVE A SHORT BREAK
COMING UP.
>> DO THE PANELISTS HAVE ANY
QUESTIONS FOR EACH OTHER?
NO?
WELL I THINK THIS WAS REALLY AN
EXCELLENT SESSION.
THERE ARE A LOT OF NEW THINGS
THAT I'VE LEARNED AND IMPORTANT
THINGS FOR US TO WORK ON TO KNOW
MORE ABOUT IN EACH OF THESE
AREAS.
SO THANK YOU.
>> YES, THANKS, EVERYONE, FOR
FANTASTIC PRESENTATIONS.
I'LL TURN THINGS BACK TO PAOLO
TO TELL US WHAT'S NEXT.
>> SO THIS SESSION IS -- WELL,
WE HAVE A LITTLE BIT LONGER
BREAK, SO EVERYONE CAN GET SOME
REFRESHMENT OVER THAT TIME.
SO LET US RECONVENE, AND I
WANTED TO THANK FOR TWO
EXCELLENT SESSIONS THAT WE JUST
HAD, AND LET US CONVENE AT
3:15 OR 2:15, 3:15 EASTERN TIME.
FOR THE SESSION NUMBER THREE.
THANK YOU.
>> WELCOME TO SESSION 3.
KATE KIRLEY AND KIMBERLY CROWLEY
PLEASE TAKE OVER FROM ME.
THANK YOU.
>> WELCOME TO SESSION 3, FROM
CUFF TO CUFFLESS AND EVERYTHING
IN BETWEEN, NEW FRONTIERS IN BP
MONITORING AND ASSESSMENT.
I'M KATE KIRLEY, ONE OF THE
MODERATORS, I'M A FAMILY
PHYSICIAN AND I WORK FOR THE
AMERICAN MEDICAL ASSOCIATION.
KIMBERLY?
>> I'M A BIOMEDICAL ENGINEER AND
TEAM LEAD AT THE CENTER FOR
DEVICES AND RADIOLOGICAL HEALTH
AT THE FDA.
OUR FIRST PRESENTER TODAY IS DR.
SHE'S A CARDIOLOGIST, CLINICAL
RESEARCHER AND AN ASSOCIATE
PROFESSOR OF MEDICINE AT
COLUMBIA UNIVERSITY, AS WELL AS
ALSO A CO-CHAIR FOR THIS
WORKSHOP.
SHE WILL BE SPEAKING ABOUT THE
CONTEXTUAL GAPS AND CHALLENGES
IN BLOOD PRESSURE MEASUREMENT,
IN THE OFFICE AND OUT OF OFFICE
BROMOPROPANE MONITORING.
>> THANK YOU SO MUCH.
I HAVE NO DISCLOSURES.
I AM SUPPORTED BY THE NHLBI.
THANK YOU.
AS WE ALL KNOW FOR SOME
INDIVIDUALS, BLOOD PRESSURE IN
THE OFFICE SETTING IS NOT
REFLECTIVE OF THEIR USUAL BLOOD
PRESSURE OUTSIDE OF THE OFFICE
SETTING.
AS SUCH THE 2017 ACCHA
GUIDELINES HAVE OUT OF OFFICE
BROMOPROPANE MEASUREMENTS VIA
OUT OF OFFICE OR IN HOME
BROMOPROPANE MONITORING.
WE HAVE FOUR BLOOD PRESSURE
PHENOTYPES.
TWO OF THESE REPRESENT A
MISMATCH, WHITE COAT
HYPERTENSION AND THE SECOND IS
MASKED HYPERTENSION DEFINED AS
NON-ELEVATED OFFICE BLOOD
PRESSURE WITH ELEVATED OUT OF
OFFICE BLOOD PRESSURE, WHICH HAS
BEEN ASSOCIATED WITH TARGET
ORGAN DAMAGE AND CARDIOVASCULAR
DISEASE EVENTS.
NEXT SLIDE.
AMBULATORY BLOOD PRESSURE IS
USUALLY MEASURED IN THE
NATURALISTIC ENVIRONMENT
TYPICALLY OVER A 24 HOUR PERIOD
WHICH CAN IDENTIFY THESE
PHENOTYPES AS WELL AS MEASURE
SLEEP IN THE 24 HOUR PATTERN OF
BLOOD PRESSURE.
AMBULATORY BLOOD PRESSURE HAS A
STRONGER ASSOCIATION WITH
CARDIOVASCULAR DISEASE THAN
OFFICE BLOOD PRESSURE.
HOWEVER WE KNOW THAT THERE ARE
SEVERAL LIMITATIONS OF ABPM,
INCLUDING POOR PATIENT
TOLERABILITY, THE DEVICE ITSELF
IS EXPENSIVE, USUALLY PLACED AT
SPECIALIZED CENTERS WITH
EXPERTISE, THE DEVICE ISN'T
READILY AVAILABLE, DEVITAL CMS
REIMBURSEMENT.
DATA FROM OUR GROUP SHOWS FROM
2007 TO 2010, ONLY 0.1% OF
MEDICARE BENEFICIARIES ACTUALLY
HAD ABPM CLAIMS.
IN CONTRAST, HOME MEASURED BLOOD
PRESSURE MAY BE A MORE PRAGMATIC
APPROACH IN CLINICAL PRACTICE.
OBVIOUSLY WE KNOW TO DO IT
PROPERLY REQUIRES A CERTAIN
AMOUNT OF TRAINING, GUIDELINES
OBVIOUSLY SUGGEST INDIVIDUALS
PERFORM TWO READINGS IN THE
MORNING AND TWO AT NIGHT FOR AT
LEAST SEVEN DAYS ALTHOUGH THERE
ARE SOME DATA FROM OUR GROUP
SHOWING EVEN THREE DAYS OF
READINGS ARE ACCEPTABLE AND
OBVIOUSLY ENSURING A VALIDATED
DEVICE.
THERE'S SOME DATA SHOWING THAT
ALSO HOME BLOOD PRESSURE
MONITORING MAY BE MORE RELIABLE
THAN OFFICE BLOOD PRESSURE AND
MORE STRONGLY CORRELATED WITH
END ORGAN DAMAGE.
HERE'S DATA FROM OUR GROUP USING
THE IMPROVING THE DETECTION OF
HYPERTENSION STUDY, NEW YORK
CITY ADULTS WITHOUT A HIS TRIF
HYPERTENSION, OFFICE BLOOD
PRESSURE ASSESSMENT, AMBULATORY
BLOOD PRESSURE MOB TORING AND
TWO WEEKS OF HOME BLOOD PRESSURE
MONITORING.
IT WAS CONDUCTED ON THREE VISIT
WITH THREE READINGS PURVIS IT.
BLOOD PRESSURE WAS MEASURED BY
ABPM EVERY 30 MINUTES OVER A 24
HOUR PERIOD AND BLOOD PRESSURE
WAS MEASURED BY HOME BLOOD
PRESSURE MONITORING USING A
PROTOCOL OF TWO READINGS IN THE
MORNING AND TWO EVENING READINGS
OVER A WEEK.
-- AS A MEASURE OF TARGET ORGAN
DAMAGE.
THE FIRST TABLE ABOVE WAS
HIGHEST FOR HOME BLOOD PRESSURE
AS .94.
IN THE TABLE BELOW IT SHOWS
THREE SEPARATE MODELS WE
EXAMINE, MODEL ONE IS AN
UNADJUSTED MODEL, TWO IS
ADJUSTING FOR DEMOGRAPHICS,
DIABETES STA TURKS AND MODEL
THREE IS FULLY ADJUSTED
INCLUDING THE COVARIATES IN
MODEL TWO AS WELL AS THE OTHER
BLOOD PRESSURE MEASURES.
A 10-MILLIMETER HIGHER SYSTOLIC
AND DIASTOLIC HOME BLOOD
PRESSURE WERE ASSOCIATED WITH
NEARLY 5-GRAM PER METER SQUARED
HIGHER.
AFTER ADJUSTMENT FOR HOME BLOOD
PRESSURE, NEITHER OFFICE BLOOD
PRESSURE NOR AMBULATORY BLOOD
PRESSURE WAS ACTUALLY ASSOCIATED
WITH LEFT VENTRICULAR MASS INDEX
IN THE STUDY.
THIS MAY SUGGEST WHEN BLOOD
PRESSURE IS ASSESSED USING
GUIDELINE RECOMMENDED
APPROACHES, HOME BLOOD PRESSURE
MONITORING MAY ACTUALLY BE
SUPERIOR TO OFFICE IN A WEEK
ABPM AND MAY BE EVEN THAT ABPM
MAY NOT BE NEEDED WHEN YOU
CONDUCT OFFICE AND HOME PRESSURE
MONITORING.
HOWEVER AS WE KNOW, THERE ARE
CERTAIN LIMITATIONS OF HOME
BLOOD PRESSURE MONITORING.
UNLIKE ABPM, MOST DEVICES CANNOT
MEASURE BLOOD PRESSURE DURING
SLEEP, ALTHOUGH THERE ARE NOW
SOME NOCTURNAL HOME BLOOD
PRESSURE DEVICES BUT THOSE ARE
NOT WIDELY AVAILABLE.
WE KNOW THAT HOME BLOOD PRESSURE
MONITORING IS BEST WITH
COINTERVENTIONS, AUTOMATIC
RECORDINGS AND TELEHEALTH
INTEGRATIONS IS NOT AVAILABLE IN
EVERY SINGLE MEDICAL CENTER AND
SPACE, AND OBVIOUSLY LONG-TERM
PATIENT ADHERENCE IS CHALLENGING
AND REIMBURSEMENT RATES ARE LOW.
SO WHICH IS SUPERIOR, ABPM OR
HOME BLOOD PRESSURE MONITORING?
THAT'S ONE OF THE BIGGEST
UNANSWERED QUESTIONS.
WHICH DEVICE IS MORE ASSOCIATED
WITH CVD EVENTS OR MORTALITY.
WE IDENTIFIED ONLY NINE ARTICLES
THAT EXAMINED WHETHER BLOOD
PRESSURE FROM ABMPM OR -- WE
FOUND WHEN AMBULATORY BLOOD
PRESSURE WAS ADJUSTED FOR HOME
BLOOD PRESSURE, SI STOLG BLOOD
PRESSURE WAS ASSOCIATED WITH THE
OUTCOMES OF INTEREST IN TWO OF
FOUR COHORTS AND TWO OF THREE
FOR DIASTOLIC BLOOD PRESSURE.
WHEN HOME BLOOD PRESSURE WAS
ADJUSTED FOR AMBULATORY BLOOD
PRESSURE, SYSTOLIC BLOOD
PRESSURE AND HOME BLOOD PRESSURE
MONITORING WAS ASSOCIATED WITH
OUTCOMES IN ZERO OF THREE
COHORTS AND ONLY ONE OF TWO FOR
DIASTOLIC BLOOD PRESSURE.
SO CLEARLY THIS REMAINS AN
UNANSWERED QUESTION GIVEN THE
SMALL NUMBER OF STUDIES IN THE
LITERATURE.
NONETHELESS, THE 2017 GUIDELINES
DO SUGGEST THE FOLLOWING
ALGORITHM, FOR INDIVIDUALS WHO
RUN TREATED THE USE OF DAY TIME
ABPM IS PREFERRED WITH HOME
BLOOD PRESSURE MONITORING AS AN
ALTERNATIVE WHEREAS FOR TREATED
ADULTS, HOME BLOOD PRESSURE
MONITORING IS PREFERRED WITH AN
ALTERNATIVE DAY TIME ABPM.
BESIDES A LACK OF DATA ON
OUTCOMES, VALUES OBTAINED VERSUS
HOME VERSUS -- DON'T ALWAYS
AGREE.
USING DATA FROM THE STUDY.
IN OUR SAMPLE THE MAJORITY, 61%,
HAD MASKED HYPERTENSION ONLY
DETECTED ON ABPM.
APPROXIMATELY 30% HAD MASKED
HYPERTENSION DETECTED ON BOTH
ABPM AND HOME BLOOD PRESSURE
MONITORING.
FLEURN WHILE A SMALL MINORITY,
9%, HAD MASKED HYPERTENSION THAT
WAS DETECTED ONLY ON HOME BLOOD
PRESSURE MONITORING BUT NOT ON
AMBULATORY BLOOD PRESSURE
MONITORING.
SO I THINK THESE FINDINGS
SUGGEST THAT IF YOU ONLY USE
HOME BLOOD PRESSURE MONITORING,
YOU MAY MISCLASSIFY MANY IF NOT
THE MAJORITY OF INDIVIDUALS WITH
MASKED HYPERTENSION AS YOU'RE
GOING TO MISS APPROXIMATELY 60%
OF THOSE WHO ARE DETECTED ON
ABPM.
SO AS I MENTIONED EARLIER,
MASKED HYPERTENSION IS
ASSOCIATED WITH CVD EVENTS AND
MISSED IN THE OFFICE SETTING SO
USE OF HOME BLOOD PRESSURE ALONE
MAY ALSO FAIL TO DETECT THIS
PHENOTYPE.
BECAUSE MASKED HYPERTENSION IS
MISSED IN THE OFFICE ANOTHER
CRITICAL RESEARCH PRIORITY IS
HOW BEST TO SCREEN FOR MASKED
HYPERTENSION.
WE CAN'T SCREEN EVERYONE IN THE
U.S. WITH ELEVATED BP, I'VE
ALREADY DISCUSSED SOME OF THE
LIMITATIONS OF BOTH DEVICES AND
WIDESPREAD IMPLEMENTATION
BARRIERS SO REALLY IS THERE A
BETTER APPROACH TO MEASURE
OFFICE BLOOD PRESSURE WITHOUT
THE NEED TO CONDUCT ABPM WHICH
WOULD POTENTIALLY BE A PARADIGM
SHIFT IN HYPERTENSION DIAGNOSIS
AND MANAGEMENT.
SO WHAT IS THIS NEW PARADIGM?
WHAT'S PROPOSED HAS BEEN THE USE
OF UNATTENDED OFFICE BLOOD
PRESSURE MEASUREMENT WITHOUT A
CLINICIAN PRESENT IN THE OFFICE
TO MEASURE OFFICE BLOOD
PRESSURE.
SO UNATTENDED BROMOPROPANE
MEASUREMENT SHOULD IDEALLY USE
STANDARDIZED PROTOCOL WITH A
WAIT PERIOD FOLLOWED BY
AUTOMATED OFFICE BLOOD PRESSURE
MEASUREMENTS WITHOUT THE
CLINICIAN PRESENT IN THE ROOM IN
ORDER TO ELIMINATE THE WHITE
COAT EFFECT AND, THEREFORE,
WHITE COAT HYPERTENSION FOR SOME
INDIVIDUALS.
HOWEVER WHEN YOU LOCK AT THE LOE
DATA, THERE'S SCARCITY OF HIGH
QUALITY DATA WITH SOME SHOWING
NO DIFFERENCE BETWEEN UNATTENDED
AND ATTENDED OFFICE BLOOD
PRESSURE AND UNATTENDED OFFICE
BROMOPROPANE IS LOWER THAN
ATTENDED BROMOPROPANE.
YOU LOOK AT THE STUDIES THEY
WERE OFTEN NOT PERFORMED ON THE
SAME PARTICIPANT.
AN EXAMPLE OF THAT WOULD BE THE
SPRIPT TSPRINT TRIAL WHICH DID M
UNATTENDED BROMOPROPANE
MEASUREMENTS BUT WERE NOT DONE
IN THE SAME PARTICIPANTS AND
THERE WERE DIFFERENTS ACROSS
SITES.
ALSO SPRINT WAS NOT A PRIORI
DESIGNED.
SO A RECENT SYSTEMATIC ANALYSIS
OF 12 STUDIES, THE DIFFERENCE
BETWEEN UNATTENDED AND ATTENDED
BMP MEASUREMENTS WAS MINUS
3.66 AND 1.67 MILLIMETERS OF
MERCURY RESPECTIVELY.
WHEN YOU CLOSELY EXAMINE THESE
STUDIES AND THESE META-ANALYSES,
IN ADDITION TO THE FACT THAT
MEASUREMENTS WERE NOT PERFORMED
WITHIN THE SAME PARTICIPANTS, SO
WITHIN INDIVIDUAL IN DIFFERENCES
CANNOT BE DETERMINED.
THE FEW DID COMPARE ATTENDED --
MANY OF THESE STUDIES DID NOT
RANDOMIZE THE ORDER OF BLOOD
PRESSURE ME MEASUREMENTS.
ORDER EFFECTS AND REGRESSION TO
THE MEAN CANNOT BE EXCLUDED AND
FURTHER WITHIN THE SAME
RANDOMIZED STUDIES, MOST DID NOT
COMPARE OFFICE BLOOD PRESSURE TO
AWAKE BLOOD PRESSURE ON ABPM.
FURTHER THERE STILL REMAINS A
CRITICAL RESEARCH GAP AS TO
WHETHER ATTENDED OR UNATTENDED
OFFICE BLOOD PRESSURE IS CLOSER
TO AWAKE BLOOD PRESSURE ABPM.
SO WHAT ARE THE CLINICAL
IMPLICATIONS OF UNATTENDED
BROMOPROPANE?
SO FOR THE PURPOSE OF THIS
SLIDE, I'M GOING TO WALK YOU
THROUGH, LET'S ASSUME YOU'RE
OMNI SHENT, SENT, YOU KNOW THEY
ABPM IS REALLY THE TRUTH AND IT
CORRECTLY REFLECTS AN
INDIVIDUAL'S BLOOD PRESSURE.
SO LET GO THROUGH THE FIRST
SCENARIO.
IF ATTENDED OFFICE BLOOD
PRESSURE WHEN PERFORMED USING
PROPER TECHNIQUE IS ACTUALLY
SIMILAR TO AWAKE BLOOD PRESSURE
ON ABPM THEN THERE'S NO NEED TO
CHANGE OUR CLINICAL PRACTICE.
FOR SCENARIO TWO, IF UNATTENDED
OFFICE BLOOD PRESSURE IS
ACTUALLY CLOSER TO AWAKE BLOOD
PRESSURE IN ABPM WHEN COMPARED
TO ATTENDED OFFICE BLOOD
PRESSURE THEN WE REALLY SHOULD
BE USING UNATTENDED OFFICE BLOOD
PRESSURE.
OUR CLINICAL WORKFLOW WOULD HAVE
TO CHANGE, OUR PATIENTS WOULD
NEED TO BE INSTRUCTED ON HOW TO
SELF-MEASURE BROMOPROPANE DURINE
VISITS.
WE NEED TO FIND TIME IN AN
OFFICE SPACE TO HAVE PEOPLE
SITTING ALONE.
IN THEORY THE PRESENCE OF WHITE
COAT HYPERTENSION AND MASKED
HYPERTENSION WOULD BE LOWER AND
WOULD NOT BE OVERTREATED OR
UNDERTREATED RESPECTIVELY.
A THIRD EXAMPLE, WE'RE IMAGINING
YOU STILL KNOW THE TRUTH, THE
PATIENT HAS HIGHER -- YOU ALSO
KNOW THE TRUTH THEIR ATTENDED
OFFICE BLOOD PRESSURE IF YOU
CHECK IT WAS ALSO HIGH AND IT'S
ACTUALLY CLOSER IN VALUE TO THE
AWAKE BLOOD PRESSURE, MEANING
THAT THIS PERSON YOU ACTUALLY
KNOW TRULY HAS A DIAGNOSIS OF
SUSTAINED HYPERTENSION.
INSTEAD YOU HAD THIS PATIENT
PERFORM UNATTENDED OFFICE BLOOD
PRESSURE AND FOR WHATEVER
REASON, THEY'RE UNATTENDED
OFFICE BLOOD PRESSURE MAY BE
BECAUSE OF POOR TECHNIQUE OR
OTHERWISE IS M STA MISTAKENLY NT
HIGH, THEY WOULD NOT MEET THE
THRESHOLD FOR SUSTAINED
HYPERTENSION.
IN THIS CASE, THE LIKELIHOOD OF
MASKED HYPERTENSION THEN WOULD
INCREASE.
IN THIS THIRD SCENARIO,
INDIVIDUALS WITH SUSTAINED
HYPERTENSION WOULD NOW BE
CONVERTED TO HAVING MASKED
HYPERTENSION.
THIS DIAGNOSIS WOULD THEN BE
MISSED IN THE OFFICE IF YOU JUST
USE UNATTENDED OFFICE BLOOD
PRESSURE ONLY.
IIN EFFECT, THE PATIENT WOULD
OTHERWISE BE DIAGNOSED AS HAVING
SUSTAINED HYPERTENSION IF YOU
HAD CONDUCTED ABPM AND TREATMENT
MAY HAVE BEEN INITIATED.
THERE ARE NOT MANY STUDIES THAT
LOOKED AT WHAT HAPPENS TO THE
PREVALENCE OF MASKED
HYPERTENSION IN THESE SCENARIOS.
SO WHAT ABOUT SLEEP BLOOD
PRESSURE?
THE SOLE RELIANCE ON OFFICE
BLOOD PRESSURE I THINK IGNORES
THE IMPACT OF HIGH SLEEP BLOOD
PRESSURE AND CARDIOVASCULAR
OUTCOMES, PARTICULARLY IN BLACK
ADULTS.
WE FOUND THAT THE PREVALENCE OF
MASKED NIGHTTIME HYPERTENSION
AMONG INDIVIDUALS WITHOUT A
HISTORY OF HYPERTENSION WAS
PARTICULARLY HIGH IN BLACK
ADULTS IN THE JACKSON HEART
STUDY, THAT'S A FIGURE ON THE
LEFT SIDE.
AND WITH OVER 40% HAVING HIGH
NIGHTTIME BLOOD PRESSURE VERSUS
22% HAVE HIGH DAY TIME BLOOD
PRESSURE, SO THESE INDIVIDUALS
WERE BEING SEEN I SEATED IN THED
JUST HAD AN OFFICE BLOOD
PRESSURE, THEY WOULD NOT HAVE
BEEN DIAGNOSED AT ALL OBVIOUSLY.
WE ALSO SHOWED THAT NOCTURNAL
HYPERTENSION DEFINED AS SLEEP --
IS ALSO ASSOCIATED WITH HIGH
CARDIOVASCULAR DISEASE EVENTS.
THERE'S A TABLE ON THE RIGHT
SIDE IN THE TABLE -- MODEL FOUR,
FULLY ADJUSTED MODEL, THAT HAS A
RATIO FOR CVD EVENTS ASSOCIATED
WITH HIGH SLEEP BLOOD PRESSURE
WAS 2.07 IN THE FULLY ADJUSTED
MODEL.
SO HIGH NIGHTTIME BLOOD PRESSURE
HAS ALSO BEEN ASSOCIATED WITH
HIGH SLEEP BLOOD PRESSURE -- I
PRESENT ONE FROM 13
POPULATION-BASED STUDIES OVER
11,000 INDIVIDUALS FROM EUROPE,
ASIA AND SOUTH AMERICA.
MEDIAN AGE WAS 54, ALMOST HALF
WERE WOMEN AND THE STUDY HAD
13.8 YEARS OF FOLLOW-UP DATA.
WHAT THEY FOUND FOR EACH
20-MILLIMETER OR HIGHER
NIGHTTIME SYSTOLIC BLOOD
PRESSURE WAS ASSOCIATED WITH ALL
CAUSE MORTALITY IN THE
MULTIVARIABLE ADJUSTED HAZARD
RATIO WAS 1.23.
IN THE SAME STUDY THEY ALSO
LOOKED AT CBD EVENTS WHICH WAS
DEFINED AS CARDIOVASCULAR
MORTALITY COMBINED WITH
NON-FATAL CORONARY EVENTS, HEART
FAILURE OR STROKE, HAVING A
SIMILAR ASSOCIATION EACH
20-MILLIMETER OF MERCURY HIGHER
NIGHTTIME SYSTOLIC BLOOD
PRESSURE ASSOCIATED WITH
CARDIOVASCULAR DISEASE EVENT.
THERE ARE THE MULTIVARIABLE
ADJUSTED RATIO WAS 1.16 AND
WHICH DID NOT CHANGE WITH
FURTHER ADJUSTED FOR 24 HOUR
BLOOD PRESSURE.
SO ANOTHER GAP AND ONE OF THE
MAIN CHALLENGES WAS BLOOD
PRESSURE THRESHOLDS IN THE CHASE
TO UNDERSTAND WHAT MODALITY
PROVIDES THE BEST ESTIMATE OF
TRUE BLOOD PRESSURE.
TO QUOTE THE 2017AAC GUIDELINES,
THE PRECISE RELATIONSHIPS
BETWEEN OFFICE READINGS,
AMBULATORY HOME READINGS IS
UNSETTLED.
THERE'S GENERAL AGREEMENT
THEY'RE OFTEN HIGHER THAN
AMBULATORY HOME BLOOD PRESSURE
AND HERE I HIGHLIGHT FROM THE
GUIDELINES THE EXAMPLE THAT THEY
PROVIDE WITH THE DIFFERENCES IN
BLOOD PRESSURE THRESHOLDS FROM
HOME, BLOOD PRESSURE DAY TIME
SLEEP AND 24 HOUR -- 120 OVER
80, 130 OVER 80 AND 140 OVER 90.
ONLY FOR AN OFFICE BLOOD
PRESSURE THRESHOLD OF 120 OVER
80 AND 130 OVER 80 DO YOU HAVE
THE SAME THRESHOLD FOR HOME
BLOOD PRESSURE AND DAY TIME
ABPM, WHEREAS THAT'S NOT TRUE AT
A THRESHOLD OF 140/90 AND THIS
DISCREPANCY ACTUALLY INCREASES
WITH HIGHER BLOOD PRESSURES.
OBVIOUSLY NIGHTTIME BLOOD
PRESSURE AND 24 HOUR ABPM ON THE
CHART SHOWS THEY HAVE THEIR OWN
SEPARATE BLOOD PRESSURE
THRESHOLDS WHICH ON A PRACTICAL
LEVEL LEADS TO A LOT OF
CONFUSION FOR PATIENTS AND
CLINICIANS ALIKE WHEN YOU'RE
TRYING TO COMPARE OFFICE AND OUT
OF OFFICE BLOOD PRESSURE.
SO OBVIOUSLY THE NEXT GAP TO
CONSIDER THIS IS WHERE -- WITH
THE INTRODUCTION OF CONTINUOUS
BLOOD PRESSURE MONITORING, WHAT
DOES THIS MEAN IN THE CONTEXT OF
ESTABLISHING BLOOD PRESSURE
THRESHOLDS?
WILL THE SAME THRESHOLDS APPLY
OR SHOULD THEY EVEN?
SO IN SUMMARY, I PROVIDE SOME
KEY KNOWLEDGE GAPS AND FUTURE
OPPORTUNITIES.
SOME KEY GAPS INCLUDE DEFINING
UNIFORM BLOOD PRESSURE
THRESHOLDS ACROSS OFFICE AND OUT
OF OFFICE BLOOD PRESSURE
MEASUREMENTS AND OBVIOUSLY NEW
DEVICES.
CAN WE IMPROVE UPON OFFICE BLOOD
PRESSURE MEASUREMENT?
IT'S A SELF MEASURED BLOOD
PRESSURE BUT JUST IN A DIFFERENT
ENVIRONMENTAL CONTEXT.
I HAVE NOT SPOKEN TO
IMPLEMENTATION BARRIERS AT
LENGTH BUT OBVIOUSLY THE IMPACT
OF STRUCTURE LEVEL FACTORS IS A
KEY GAP.
WHAT ARE SOME FUTURE
OPPORTUNITIES?
I THINK CAN WE TOTALLY DISRUPT
THE CONCEPT OF OFFICE BLOOD
PRESSURE AND ONLY RELY ON OUT OF
OFFICE BLOOD PRESSURE?
DO WE THINK UNATTENDED OFFICE
BLOOD PRESSURE MAY ACTUALLY BE A
GATEWAY FOR IMPROVING PATIENT
EDUCATION AND ENGAGEMENT IN SELF
HELP BLOOM INSTRUMENT AND
THINKING ABOUT THE ENVIRONMENTAL
CONTEXT FOR WHICH WE START TO
ENGAGE INDIVIDUALS FOR SELF
BLOOD PRESSURE MESH M.
SECOND FUTURE OPPORTUNITIES, I
KNOW THERE ARE MANY PEOPLE WHO
WILL SPEAK WITH B. ABOUT THIS ,
AND LASTLY CAN WE RELIABLY
ASSESS NOCTURNAL BLOOD PRESSURE
FOR MORE THAN A 24 TO 48 HOUR
PERIOD.
CAN YOU MEASURE BLOOD PRESSURE
WITHOUT DISTURBING SLEEP.
THANK YOU SO MUCH.
>> THANK YOU SO MUCH,
DR. ABDALLA.
NEXT UP I BELIEVE WE HAVE
DR. RICHARD CARAMAKRISHNA MUKKAO
US ABOUT CUFFLESS BLOOD PRESSURE
MEASUREMENT.
TAKE IT AWAY.
>> NEXT SLIDE, PLEASE.
GOOD AFTERNOON, THANK YOU TO THE
CHAIRS AND ORGANIZERS FOR THE
INVITATION TO PARTICIPATE IN
THIS IMPORTANT WORKSHOP.
I'VE STUDIED CUFFLESS BLOOD
PRESSURE MEASUREMENT FOR MORE
THAN A DECADE NOW, AND I'M GOING
TO TELL YOU WHERE WE ACTUALLY
STAND AT PRESENT WITH THIS
TECHNOLOGY.
AND BEFORE I BEGIN, I SHOULD
MENTION THAT I HAVE NIH FUNDING,
AND PATENTS ON CUFFLESS BLOOD
PRESSURE TECHNOLOGY THAT IS
DIFFERENT FROM THE METHODS THAT
I'LL FOCUS ON TODAY.
SO HERE ARE THE CONVENTIONAL
METHODS FROM NONINVASIVE
MEASUREMENT OF BLOOD PRESSURE.
AMONGST THESE METHODS,
OSCILLOMETRY IN THE FORM OF
AUTOMATIC ARM CUFF DEVICES HAS
EMERGED AS THE MOST WIDELY USED
METHOD BY SIGNIFICANT EXTENT.
THIS IS 50-YEAR-OLD TECHNOLOGY.
IT'S EASIEST TO USE, IT'S
INEXPENSIVE, AND CLOSEST IN
ACCURACY TO THE STANDARD MANUAL
AUSCULTATORY METHOD.
HOWEVER, AS WITH ALL
CONVENTIONAL METHODS, OS LOM
TREE REQUIRES AN INFLATABLE CUFF
AND IS NOT READILY AVAILABLE AND
CUMBERSOME TO USE.
SO MANY WANT TO ELIMINATE THE
CUFF FROM BLOOD PRESSURE
MEASUREMENT AND CUFFLESS BLOOD
PRESSURE MEASUREMENT HAS NOW
BECOME A FIELD.
STUDIES ARE INCREASINGLY
APPEARING IN THE LITERATURE AS
SHOWN IN THE UPPER LEFT, AND
SEVERAL WEARABLE DEVICES ARE NOW
CLEARED BY THE FDA AS WELL AS
THE EUROPEAN COMMISSION AS SHOWN
ON THE RIGHT.
A COMPREHENSIVE REVIEW OF THE
FLURRY OF ACTIVITY CAN BE FOUND
IN THE LOWER LEFT.
SO MOST OF THE STUDIES AND
LIKELY ALL OF THE REGULATORY
CLEARED DEVICES EMPLOY PULSE
WAVE ANALYSIS WITH OR WITHOUT
PULSE ARRIVAL TIME.
SO PULSE WAVE ANALYSIS METHODS
TYPICALLY MEASURE A
PHOTOPLETHYSMOGRAPHY OR PPG
WAVEFORM WHICH INDICATES SMALL
VESSEL BLOOD VOLUME OSCILLATIONS
WHICH INDICATES THAT PERIPHERAL
ARTERY FORCES.
SO NEITHER WAVTHIS THEN WILL EXS
FROM THE WAVEFORM AND MAP OR CAL
GREAT THESE FEATURES TO BLOOD
PRESSURE VALUES USING MACHINE
LEARNING.
PULSE WAVE ANALYSIS WITH PULSE
ARRIVAL TIME METHODS ALSO RECORD
AN ECG WAVEFORM TO EXTRACT PULSE
ARRIVAL TIME AS THE TIME DELAY
BETWEEN THE ECG AND HEMODYNAMIC
WAVEFORMS, AND POSSIBLY OTHER
FEATURES.
AND AS SHOWN IN THE GOLD BOX,
THESE METHODS REQUIRE PERIODIC
MEASUREMENT WITH AN ARM CUFF
DEVICE AS PART OF THE
CALIBRATION PROCEDURE OR USE
ONLY DEMOGRAPHIC INFORMATION
SUCH AS AGE, BIOLOGICAL SEX, AND
BMI FOR LESS RELIABLE
CALIBRATION.
AND, THEREFORE, AND THE MOST
IMPORTANT THING TO UNDERSTAND,
IS THAT THE SOLE PURPOSE OF
THESE DEVICES IS TO MEASURE
BLOOD PRESSURE CHANGES IN A
PERSON RELATIVE TO THE
CALIBRATION RATHER THAN
MEASURING THE ABSOLUTE BLOOD
PRESSURE LEVEL.
SO I THINK IT'S IMPORTANT TO
NOTE THAT THESE METHODS ARE NOT
SUPPORTED BY GENERALLY ACCEPTED
PHYSIOLOGICAL PRINCIPLES.
SO AS JUST ONE EXAMPLE, A BASIC
PHYSIOLOGICAL MODEL TO THE LEFT
INDICATES THAT PPG CHANGES ARE
EQUAL TO THE PRODUCT OF SMALL
VESSEL COMPLIANCE AND BLOOD
PRESSURE CHANGES.
SMALL VESSEL COMPLIANCE IS
MODULATED BY SMOOTH MUSCLE
CONTRACTION AND CAN, THEREFORE,
VARY INDEPENDENTLY OF BLOOD
PRESSURE.
SO IF YOU LOOK TO THE RIGHT,
THERE ARE DATA SHOWING THAT AS A
CONSEQUENCE, CHANGES IN BLOOD
PRESSURE INDUCED BY VARIOUS
INTERVENTIONS HAVE LITERAL
RELATIONSHIP WITH THE INDUCED
CHANGE IN PPG AMPLITUDE.
SO YOU CAN SEE THAT MENTAL
ARITHMETIC WHICH IS PRIMARILY A
CARDIAC INTERVENTION INCREASES
BOTH BLOOD PRESSURE AND THE PPG
AMPLITUDE, WHEREAS COLD PRESSOR,
WHICH IS A VASCULAR
INTERVENTION, INCREASES BLOOD
PRESSURE BY A SIMILAR AMOUNT BUT
DECREASES THE PPG AMPLITUDE VIA
A REDUCTION IN SMALL VESSEL
COMPLIANCE.
SO EVEN SO, NUMEROUS STUDIES
CLAIM THAT PULSE WAVE ANALYSIS
METHODS ARE ACCURATE.
HOWEVER, MANY OF THE STUDIES ARE
ACTUALLY PROBLEMATIC.
SO FIRSTLY, RESULTS IN PUBLISHED
PAPERS ARE OFTEN PRESENTED
INCORRECTLY.
SO WE PERFORMED COMPUTER STUDIES
TO SIMULATE CUFFLESS BLOOD
PRESSURE MEASUREMENTS WITH ZERO
CORRELATION TO REFERENCE CUFF
BLOOD PRESSURE MEASUREMENTS AND
THEN PRESENTED THE RESULTS LIKE
IN MANY PAPERS.
THAT'S WHAT'S SHOWN IN GREY.
THE RESULTS SHOW IMPRESSIVE
CORRELATION OF A CUFF CALIBRATED
METHOD WITH CUFF BLOOD PRESSURE.
HOWEVER, WHEN THE DATA ARE
PRESENTED CORRECTLY, AS THE
CHANGE IN THE CUFFLESS BLOOD
PRESSURE RELATIVE TO THE
CALIBRATION VERSUS THE CHANGE IN
CUFF BLOOD PRESSURE RELATIVE TO
THE CALIBRATION, WE SEE THE TRUE
LACK OF CORRELATION IN THE LOWER
LEFT.
STEKDLY SECONDLY THE TESTING PRL
EMPLOYED IN MANY STUDIES OFTEN
DO NOT INCLUDE BLOOD PRESSURE
CHANGES AND BLOOD PRESSURE
CHANGES AGAIN ARE WHAT PULSE
WAVE ANALYSIS MEASURE.
AND MOST NOTABLY, A NUMBER OF
STUDIES HAVE EMPLOYED THE
AAMI/ESH/ISO STANDARD FOR
TESTING CUFF DEVICES TO ASSESS
PULSE WAVE ANALYSIS METHODS.
HOWEVER, THIS STANDARD IS NOT
APPLICABLE TO PULSE WAVE
ANALYSIS METHODS BECAUSE IT DOES
NOT INCLUDE THE NECESSARY BLOOD
PRESSURE CHANGES.
STUDIES OF CUFF CALIBRATED PULSE
WAVE ANALYSIS METHODS WITHOUT
ANY BLOOD PRESSURE CHANGES CAN
BE SIMPLY DISMISSED.
THIRDLY, AND PERHAPS MOST
IMPORTANTLY, MANY STUDIES DO NOT
INCLUDE COMPARISONS TO FAIR
BASELINE MODELS AS SHOWN IN THE
LOWER RIGHT.
SO PULSE WAVE ANALYSIS METHODS
AGAIN COMPUTE BLOOD PRESSURE
FROM A HEMODYNAMIC WAVEFORM
MEASUREMENT AND A NON-WAVEFORM
INFORMATION SUCH AS THE CUFF
BLOOD PRESSURE FOR CALIBRATION,
AGE, SEX, AND BMI.
IT IS WELL-KNOWN THAT THIS OTHER
INFORMATION, THE OTHER
NON-WAVEFORM INFORMATION
CORRELATES WITH THE BLOOD
PRESSURE FOR MEASUREMENT.
SO THE METHODS MUST, THEREFORE,
BE COMPARED TO BASELINE MODELS
IN WHICH BLOOD PRESSURE IS
COMPUTED ONLY FROM THE
NON-WAVEFORM INFORMATION TO
DETERMINE IF THE METHOD IS WORTH
USING OR NOT.
A PULSE WAVE ANALYSIS DEVICE IS
SUPERFLUOUS IF THE WAVEFORM THAT
IT MEASURING DOES NOT OFFER ANY
VALUE TO BLOOD PRESSURE
MEASUREMENT ACCURACY.
SO SOME STUDIES OF PULSE WAVE
ANALYSIS DEVICES WITH COMPANY
INVOLVEMENT APPEAR TO BE
PROPERLY DONE AND SHOW
REMARKABLE RESULTS.
SO TO THE LEFT ARE RESULTS FROM
ONE STUDY OF A DEMOGRAPHIC
CALIBRATED RISK TONOMETRY DEVICE
AGAINST INVASIVE BLOOD PRESSURE.
YOU CAN SEE THE CORRELATION IS
STRONG, ESPECIALLY CONSIDERING
THE DEMOGRAPHIC CALIBRATION WAS
EMPLOYED.
TO THE RIGHT ARE RESULTS FROM
ANOTHER STUDY OF A CUFF
CALIBRATED WRIST PPG DEVICE
AGAINST 24 HOUR ABPM.
THE R SCAR SQUARED VALUES ARE .O
.99.
I'M TALKING R SQUARED, NOT R.
NOTE THAT CUFF BLOOD PRESSURE
MEASUREMENTS HAVE SIGNIFICANT
ERROR IN PLOTTING THE
MEASUREMENTS OF ONE CUFF DEVICE
VERSUS ANOTHER CUFF DEVICE WOULD
NOT YIELD THIS R SQUARED LEVEL.
SO AS STEPHEN MENTIONED, A
MICROSOFT RESEARCH TEAM RECENTLY
PUBLISHED A COMPREHENSIVE STUDY
TO DETERMINE IF PULSE WAVE
ANALYSIS METHODS CAN ACTUALLY
TRACK BLOOD PRESSURE CHANGES.
THEY DESIGNED A PRACTICAL YET
INFORMATIVE STUDY AND INCLUDED
OVER A THOUSAND DIVERSE
SUBJECTS.
THEY BUILT WRIST DEVICES TO
MEASURE PPG, TO NO, MA'AM TREE,
AND ECG WAVEFORMS, AND THEY THEN
EXPLORED AN ARRAY OF MACHINE
LEARNING ALGORITHMS TO DEVELOP
MODELS FOR COMPUTING BLOOD
PRESSURE FROM WAVEFORM FEATURES
AND NON-WAVEFORM INFORMATION
SUCH AS THE CUFF BLOOD PRESSURE
MEASUREMENT FOR CALIBRATION AND
THE TIME OF DAY, YES, THE TIME
OF DAY TO HELP WITH DIE URGE
BLOOD PRESSURE CHANGES.
CRUCIALLY, THEY CREATED FAIR
BASELINE MODELS TO COMPUTE BLOOD
PRESSURE FROM THE NON-WAVEFORM
INFORMATION ALONE AS SHOWN ON
THE LOWER LEFT.
AND THEY FOUND THAT THE WAVEFORM
FEATURE MODELS WERE ONLY ABLE TO
YIELD SLIGHTLY LOWER BLOOD
PRESSURE ERRORS AGAINST
REFERENCE CUFF DEVICES THAN THE
BASELINE MODELS AS SHOWN ON THE
LOWER RIGHT.
THEIR RESULTS, THEREFORE,
INDICATE THAT PULSE WAVE
ANALYSIS METHODS OFFER
ESSENTIALLY NO VALUE IN BLOOD
PRESSURE MONITORING.
SO THE MICROSOFT RESEARCH
PROJECT SHOULD BE REGARDED AS AN
AUTHORITATIVE STUDY OF PULSE
WAVE ANALYSIS METHODS FOR THE
FOLLOWING REASONS.
AN ELITE RESEARCH TEAM PERFORMED
AN UNBIASED STUDY OF CUFFLESS
BLOOD PRESSURE WITHOUT FINANCIAL
OR PUBLISHING CONCERNS.
THE STUDY COST MILLIONS OF
DOLLARS.
THE STUDY CONSTITUTED AN
EXHAUSTIVE ASSESSMENT OF WRIST
PULSE WAVE ANALYSIS METHODS WITH
HIGH SIMILARITY TO THE
REGULATORY CLEARED WRIST DEVICES
THAT I SHOWED EARLIER.
THE TEAM FOUND THAT THESE
METHODS OFFERED NO VALUE IN
MEASURING BLOOD PRESSURE OVER
FAIR BASELINE MODELS.
THIS MEANS THAT THEY DID NOT
WORK AT ALL, ZERO.
THE TEAM IS OFFERING THEIR DATA
FOR FREE TO THE PUBLIC.
AND THE TEAM EVIDENTLY QUIT
CUFFLESS BLOOD PRESSURE RESEARCH
FOLLOWING THEIR STUDY.
A FEW STUDIES OF THE LATEST FDA
CLEARED PULSE WAVE ANALYSIS
DEVICES HAVE SHOWN THAT THEY
PERFORM SIMILARLY TO BASELINE
MODELS.
TO THE LEFT ARE RESULTS OF A
CALIBRATED GARMENT DEVICE
SHOWING THAT IT YIELDED A
SYSTOLIC BLOOD PRESSURE ERROR OF
8.7 MILL ME TUR MERCURY AGAINST
CUFF BLOOD PRESSURE, WHEREAS A
BASELINE MODEL THAT COMPUTED
BLOOD PRESSURE FROM ONLY
DEMOGRAPHIC INFORMATION PRODUCED
A SLIGHT LEHIGHER ELY HIGHER ERF
9.4-MILLIMETER OF MERCURY.
TO THE RIGHT ARE A DEMOGRAPHIC
CALIBRATED TOE NO, MA'AM TREE
DEVICE AGAINST INVASIVE BLOOD
PRESSURE IN INFANTS.
ALTHOUGH RESULTS FROM BASELINE
MODELS WERE NOT PROVIDED, THE
CORRELATION PLOTS INDICATE THAT
BODY WEIGHT ALONE COULD HAVE
ESTIMATED THE BLOOD PRESSURE
FAIRLY WELL HERE.
BECAUSE OF THE LACK OF
CONVINCING VALIDATION DATA, THE
EUROPEAN SOCIETY OF HYPERTENSION
RECOMMENDS THAT CUFFLESS BLOOD
PRESSURE MEASUREMENT DEVICES
SHOULD NOT BE USED IN CLINICAL
PRACTICE.
SO I WOULD LIKE TO AT LEAST
MENTION THAT CONCEPTS FOR
CUFFLESS AND CALIBRATION-FREE,
THAT IS TRULY CUFFLESS BLOOD
PRESSURE MONITORING, HAVE BEEN
PROPOSED, AND NONE OF THESE FAR
LESS INVESTIGATED METHODS WOULD
BE AS CONVENIENT AS PULSE WAVE
ANALYSIS DEVICES AFTER CUFF
CALIBRATION, BUT THEY OR OTHER
FUTURE METHODS MIGHT EVENTUALLY
BE SHOWN TO YIELD SUFFICIENT
BLOOD PRESSURE ACCURACY WITHOUT
USING A CUFF.
SO IN SUMMARY, THE FIELD OF
CUFFLESS BLOOD PRESSURE CAN ONLY
BE UNDERSTOOD BY TAKING A DEEP
DIVE.
POPULAR CUFFLESS DEVICES HAVE
NOT BEEN PROVEN TO OFFER
SIGNIFICANT VALUE IN BLOOD
PRESSURE MEASUREMENT ACCURACY UP
TO NOW.
SO IF YOU HAVE ANY DOUBTS,
CONSIDER THIS: BLOOD PRESSURE
IS BY FAR THE MOST IMPORTANT
PHYSIOLOGICAL VARIABLE FOR A
CONSUMER DEVICE TO BE ABLE TO
MONITOR.
IF PULSE WAVE ANALYSIS METHODS
REALLY WORKED, THEN WHY DON'T
THE LEADING COMPANIES IN THE
WORLD WITH ELITE MACHINE
LEARNING TEAMS AND VAST
RESOURCES OFFER CUFFLESS BLOOD
PRESSURE MONITORING?
FUTURE TECHNOLOGY DEVELOPMENT
WORK IS WORTHWHILE AND NEEDED TO
REALIZE THE DREAM OF CUFFLESS
BLOOD PRESSURE MEASUREMENT.
THANK YOU.
>>
>> THANK YOU, DR. MUKKAMALA.
OUR NEXT PRESENTER IS DR. TAMMY
BRADY, WHO IS A PROFESSOR OF
PEDIATRICS AND EPIDEMIOLOGY AND
MEDICAL DIRECTOR OF PEDIATRIC
HYPERTENSION PROGRAM AT JOHNS
HOPKINS UNIVERSITY.
SHE WILL BE TALKING ABOUT THE
BEST PRACTICES FOR BLOOD
PRESSURE VOL DAITION.
VALIDATION.
>> THANK YOU VERY MUCH,
KIMBERLY.
IT'S MY PLEASURE TO BE HERE.
THANK YOU VERY MUCH TO THE
ORGANIZERS FOR INVITING ME.
AND TODAY I'M GOING TO BE
TALKING TO YOU ABOUT SOMETHING
THAT I'M VERY PASSIONATE ABOUT,
SO IN ADDITION TO BEING
PASSIONATE ABOUT BLOOD PRESSURE
MEASUREMENT, I'M PASSIONATE
ABOUT DEVICE VALIDATION.
I'M ABOUT TO FINISH OUT MY THIRD
TERM AS CO-CHAIR OF THE
ASSOCIATION FOR THE ADVANCEMENT
OF MEDICAL INSTRUMENTATION
COMMITTEE WHICH HELPED DEVELOP
VALIDATION PROTOCOLS.
I'M ALSO CO-CHAIR OF THE AMA --
ALONG WITH DR. JORDY COHEN.
SO THERE ARE A NUMBER OF
VALIDATION PROTOCOLS THAT HAVE
BEEN AVAILABLE ACROSS THE LAST
SEVERAL DECADES.
YOU CAN SEE THAT THIS IS
AVAILABILITY OF VALIDATION
PROTOCOLS FOR DEVICE
MANUFACTURERS TO TEST IF THEIR
DEVICE IS CLINICALLY ACCURATE.
IT'S BEEN AVAILABLE SINCE THE
80s.
THERE HAVE BEEN A VARIETY OF
DIFFERENT ORGANIZATIONS, SOME
PROFESSIONAL ORGANIZATIONS,
PROFESSIONAL SOCIETIES THAT HAVE
COME UP WITH DIFFERENT PROTOCOLS
AND PARTICULARLY WITH -- THERE
HAS BEEN MULTIPLE ITERATIONS OF
PROTOCOLS TO IMPROVE ON THEM.
THE MOST RECENT ITERATION WAS
PUBLISHED IN 2018, AND THIS HAS
BEEN LARGELY THOUGHT OF AS THE
UNIVERSAL STANDARD.
THIS IS CURRENTLY BEING UPDATED
AS WE SPEAK AND A NEWER VERSION
WILL LIKELY BE OUT IN THE NEXT
YEAR OR SO.
SO I'M GOING TO BEGIN THE
TASK -- THESE DOCUMENTS ARE
QUITE DENSE BUT I'M GOING TO DO
MY BEST TO GO THROUGH WHAT SOME
OF THE KEY CONCEPTS ARE.
SO MOST OF US THINK ABOUT
VALIDATION STANDARDS ARE
THINKING ABOUT CUFF DEVICES THAT
PROVIDE BLOOD PRESSURE
MEASUREMENTS.
THE DASH 2 STANDARD.
SO THERE ARE SEVERAL OTHER
STANDARDS THAT WE WORK ON.
THERE IS THE DASH 3 STANDARD
WHICH ADDRESSES BLOOD PRESSURE
DEVICES THAT PROVIDE CONTINUOUS
CUFFLESS MEASUREMENT.
I WILL GO TO THAT IN A LITTLE
BIT LATER ON.
THERE IS THE DASH 4 STANDARD
WHICH IS IN PROGRESS.
WHICH IS INTENDED FOR USE FOR
DEVICES IN PATIENT TRANSPORT.
THERE IS THE DASH 5 STANDARD,
WHICH ALLOWS US TO TEST
REPEATABILITY AND
REPRODUCIBILITY OF SIMULATORS
USED FOR TESTING OF AUTOMATED
NONINVASIVE SPHIG KNOW MAN
METERS, THEN THERE'S THE DASH
7 STANDARD WHICH IS IN
PRODUCTION OR IN PROGRESS WHICH
WILL HELP US TEST THE
INTERMITTENT CUFFLESS
MEASUREMENT DESPISES.
THIS HAS BEEN GOING ON FOR OVER
A YEAR, IT'S BEEN A VERY ACTIVE
GROUP AND IT IS HOPEFUL THAT WE
WILL HAVE AT LEAST A DRAFT
STANDARD OF THIS BY THE END OF
FEBRUARY 2025.
SO WE'RE GOING TO TALK FIRST
ABOUT THE DASH 2 STANDARD.
I JUST WANTED TO GIVE SOME
DEFINITIONS TO SET THE STAGE.
SO IN DOING VALIDATION TESTING,
THAT NEEDS TO BE TESTED AGAINST
A REFERENCE STANDARD.
IN THE VALIDATION PROTOCOLS
THERE ARE TWO POTENTIAL
REFERENCE STANDARDS FOR USE.
AN INVASIVE ONE USING ARTERIAL
LINE BLOOD PRESSURES OR
NONINVASIVE ONE WHICH IS AN US A
CULL TRI MEASUREMENT THAT IS
EITHER OBTAINED FROM THE MERCURY
DEVICE OR ANEROID DEVICE WITH A
SPECIFIC AMOUNT OF ACCURACY.
THESE ARE USING A TWO-PIECE
CUFF, IT HAS A BLADDER THAT
MEETS VERY SPECIFIC DIMENSIONS
WHICH YOU CAN SEE ON THE SLIDE.
THIS TESTING IS TYPICALLY DONE
IN EITHER A GENERAL POPULATION
OR IT WILL ALSO BE DONE IN A
SPECIAL POPULATION.
SO A SPECIAL POPULATION IS ONE
WHO THERE IS EITHER A -- OR
CLINICAL EVIDENCE THAT THE
DEVICE WILL ACT DIFFERENTLY IN
THAT POPULATION.
AND ADULT POPULATION IS
ALL-COMERS OVER -- OF AGE WHO
ARE EITHER UNTREATED OR TREATED
AS HYPERTENSIVE, SO FOR A
GENERAL POPULATION STUDY, LIKE I
SAID YOU CAN EITHER HAVE AN US A
CULL TA TRI REFERENCE OR HAVE 8N
HAVE INVASIVE REFERENCE IN WHICH
WOULD YOU HAVE AT LEAST 15
SUBJECTS ENROLLED.
THE POPULATION THAT YOU'RE
STUDYING NEEDS TO BE AT LEAST 12
YEARS OF AGE, AT LEAST 30% MALE
SEX AND 30% FEMALE SEX, AND MEET
SPECIFIC BROMOPROPANE
DISTRIBUTION WHICH YOU CAN SEE
DELINEATED IN THE TABLE TO THE
RIGHT.
THIS IS SO THAT WE CAN DETERMINE
WHETHER OR NOT THE DEVICE
PERFORMS SUFFICIENTLY WELL
ACROSS A WIDE RANGE OF BLOOD
PRESSURE VALUES.
IN ADDITION TO FULFILLING THESE
REQUIREMENTS, EACH OF THE CUFFS
THAT COME WITH THE DEVICE NEED
TO BE TESTED, AND NEED TO HAVE
SPECIFIC NUMBER OF INDIVIDUALS
TESTED USING THOSE CUFFS, AND
THEN THE ENTIRE CUFF RANGE, YOU
NEED TO MAKE SURE THE CUFF RANGE
IS TESTING, AND I'LL SHOW YOU
WHAT I MEAN IN THE NEXT SLIDES.
SO WHEN WE THINK ABOUT A DEVICE,
THE CUFF IS INTEGRAL TO THE
DEVICE, AND MANY DEVICES COME --
WILL COME WITH SEVERAL DIFFERENT
COSTS.
SO THIS FIGURE IS SOMETHING THAT
WAS SHOWN EARLIER TODAY, AND
THIS IS LOOKING AT ALL OF THE
DEVICES THAT WERE AVAILABLE ON
THE AMA -- WEBSITE SO YOU CAN
SEE ON THE LEFT THE VARIOUS
DEVICES, TO THE RIGHT WHAT
YOU'LL SEE WHAT CUFFS ARE
AVAILABLE WITH EACH DEVICE AND
THEN YOU CAN SEE USING THE
REFERENCE ALONG THE TOP WHAT
THE -- RANGE IS APPROPRIATE FOR
EACH ONE OF THOSE CUFFS.
SO TO GO THROUGH WHAT I WAS
DESCRIBING EARLIER, IN TERMS OF
THE NUMBER OF TESTS --
[INAUDIBLE].
SO I'M GOING TO USE THIS EXAMPLE
HERE.
AND YOU CAN SEE THAT THIS DEVICE
COMES WITH THREE DIFFERENT
CUFFS.
AND THAT THE CUFFS HAVE A NICE
DISTRIBUTION OF 14 TO
40 CENTIMETERS AND THEY ACHIEVED
THAT DISTRIBUTION USING THREE
DIFFERENT CUFFS.
NOW THIS DEVICE COMES WITH FOUR
DIFFERENT CUFFS AND THESE FOUR
DIFFERENT CUFFS ACCOMMODATE A
DIFFERENT GROUP OR DIFFERENT --
SIZE DISTRIBUTION, ANYWHERE
BETWEEN 20 AND 55 CENTIMETERS.
SO WHEN MANUFACTURERS ARE
TESTING EITHER ONE OF THOSE
CUFFS, THEY HAVE TO FIGURE OUT
HOW MANY INDIVIDUALS NEED TO BE
TESTED PER CUFF.
SO ON THIS SLIDE YOU'LL SEE ON
THE TOP THERE ARE THREE GREENISH
RECTANGLES AND THAT'S SUPPOSED
TO REFER TO THE DEVICE THAT'S
DELINEATED IN RED, AND THEN THE
FOUR BLUISH RECTANGLES ARE THE
DEVICE [INAUDIBLE].
SO WHEN YOU HAVE A CUFF THAT IS
12 CENTIMETERS OR LESS, THERE'S
A VERY SPECIFIC FORMULA THAT YOU
USE TO DETERMINE HOW MANY PEOPLE
NEED TO BE TESTED IN THE CUFF
AND WHEN YOU HAVE LARGER CUFFS
LIKE YOU SEE WITH THE YELLOW
STAR, YOU WILL HAVE A DIFFERENT
FORMULA TO DETERMINE HOW MANY
INDIVIDUALS NEED TO BE TESTED.
SO THIS WILL TELL YOU HOW MANY
PER CUFF, BUT YOU NEED TO ALSO
LIKE I SAID EARLIER MAKE SURE
THAT THERE ARE -- THAT EACH ONE
OF THE CUFFS IS TESTED ACROSS
THAT --.
SO USING THOSE FORMULAS, YOU
WILL SEE THAT THE FIRST CUFF
FAMILY, THERE ARE 12 AND 15
INDIVIDUALS THAT NEED TO BE
TESTED IN EACH OF THE CUFFS, AND
THEN YOU CAN SEE IN THE CUFF
FAMILY WHERE THERE ARE -- FOR
THE LARGER CUFF, THERE'S A MUCH
LARGER NUMBER OF INDIVIDUALS
THAT NEED TO BE TESTED.
SO IN ADDITION, EACH -- FOR THE
CUFFS THAT ARE THE SMALLER SIZE,
12 CENTIMETERS OR LESS, IT'S NOT
JUST ENOUGH TO HAVE 12 PEOPLE,
PER SE, IN THAT FIRST CUFF THAT
YOU SEE ON THE UPPER LEFT, BUT
HALF OF THE -- 40% OF THE
SUBJECTS NEED TO BE TESTED
WITHIN THE UPPER HALF OF THE
SPECIFIED RANGE AND HALF OF
THEM -- 40% OF THEM NEED TO BE
TESTED IN THE OTHER HALF.
AND SO AS AN EXAMPLE, YOU CAN
SEE THE FIRST CUFF, FIVE OF THEM
HAVE TO BE TESTED -- AND FIVE OF
THEM TESTED IN THE UPPER HALF.
THE LARGE E. CUFFS, THE ONES
16 CENTIMETERS OR GREATER,
THERE'S EVEN GREATER
REQUIREMENTS.
AT LEAST 20% OF THE SUBJECTS
WERE ALLOCATED TO THE CUFF TO BE
TESTED SO 30 IN THIS EXAMPLE
NEED TO BE IN EACH ONE OF THE
QUARTILES OF THE ARM
CIRCUMFERENCE THAT IS
ACCOMMODATED BY THAT CUFF.
AND THEN AT LEAST 10% OF THE
SUBJECTS NEED TO BE IN THE
UPPER -- AND THE LOWER QUARTILE
RANGE.
SO ONCE YOU'VE GOTTEN YOUR
PATIENT POPULATION, YOUR STUDY
POPULATION, THEN YOU'RE MOVING
ON TO THE ACTUAL TESTING.
SO THE TESTING THAT OCCURS IS
EXACTLY THE PATIENT PREPARATION
AND THE ACTUAL MEASUREMENT
PROCEDURE IS THE SAME AS OUR
USUAL CLINICAL PRACTICE
GUIDELINES.
IN OUR CURRENT AAMI PROTOCOL, WE
USE WHAT'S CALLED THE SAME ARM
SEQUENTIAL METHOD.
WHAT THAT MEANS IS THE CUFF
IS -- THE REFERENCE CUFF IS PUT
ON ONE OF THE ARMS, WE HAVE TWO
INDEPENDENT OBSERVERS, THEY USE
A DOUBLE-HEADED STETHOSCOPE,
THEY SIMULTANEOUSLY WILL
DETERMINE WHAT THE K1 AND THE KH
THE SYSTOLIC AND DIASTOLIC
PRESSURE.
THEN ONCE THEY GET THEIR
REFERENCE MEASUREMENTS, THE CUFF
IS REMOVED, THE DEVICE ALONG
WITH THE DEVICE CUFF IS PUT ON
THE DEVICE IN THE TEST.
-- THAT DIFFER IN MORE THAN
4 MILLIMETERS OF MERCURY IS
EXCLUDED AND YOU NEED ULTIMATELY
AT THE END OF THE DAY AT
LEAST -- AND YOUR ANALYSIS.
SO THIS IS JUST TABLES NOTATING
THE ALTERNATING OF THE REFERENCE
AND THE TEST DEVICE AND SO
FORTH.
SO AGAIN, AT THE END, YOU WILL
HAVE AT LEAST 255 PAIRED
MEASUREMENTS.
TO DETERMINE WHETHER OR NOT
THOSE MEASUREMENTS INDICATE A
DEVICE THAT IS ACCURATE PER THE
VALIDATION PROTOCOL, THERE ARE
TWO CR CRITERION, THE FIRST DEAS
WITH INDIVIDUAL READINGS AND THE
SECOND CRITERION DEALS WITH
INDIVIDUAL SUBJECTS.
YOU LOOK AT THE MEAN BLOOD
PRESSURE DIFFERENCE AND OVERALL
THAT NEEDS TO HAVE A DIFFERENCE
OF LESS THAN OR EQUAL TO
5 MILLIMETERS OF MERCURY WITH NO
MORE THAN 8 MILLIMETERS OF
MERCURY AS A STANDARD DEVIATION.
THEN FOR CRITERIA 2, YOU TAKE 8E
DIFFERENCES AND THEN YOU
DETERMINE WHAT THAT AVERAGE
DIFFERENCE IS, AND THEN ON THE
TABLE I'LL SHOW YOU ON THE NEXT
SLIDE EU ABLE TO DETERMINE WHAT
THE ALLOWABLE STANDARD DEVIATION
IS AND THAT WILL ALLOW TO YOU
KNOW WHETHER OR NOT THE DEVICE
CAN PASS.
IN THIS EXAMPLE WHEN THEY'RE
DOING THAT CRITERIA TWO, THEY
CAME UP WITH A BLOOD PRESSURE
DIFFERENCE OF 2 MILLIMETERS OF
MERCURY, WHICH ALLOWED THEM TO
HAVE NO MORE THAN 5.49 STANDARD
DEVIATION SO THAT WOULD BE USED
TO INTERPRET WHAT THE RESULTS
WERE.
SO THAT'S OVERALL HOW YOU CAN
CONDUCT VALIDATION TESTING FOR A
DEVICE USING THIS REFERENCE --
SUCH AS EXERCISE -- OR ABPM
THERE ARE SEPARATE REQUIREMENTS
AND CERTAINLY I DID NOT REVIEW
WHAT NEEDS TO HAPPEN FOR
INVASIVE REFERENCE STUDY.
SO ONE OF THE THINGS I'M VERY
INTERESTED IN AS A PEDIATRIC
PATHOLOGIST IS SOME OF THESE
SPECIAL POPULATIONS.
THEY INCLUDE -- DEVICES ARE
LIKELY TO PERFORM DIFFERENTLY,
SO THEY HAVE BEEN DESIGNATED AS
A SPECIAL POPULATION, MEANING
THERE'S ADDITIONAL TESTING THAT
FLEEDZ TO BE DONE IN THESE
POPULATIONS TO MAKE SURE THAT
THEY'RE ACCURATE.
SO WHAT THIS MEANS IS THAT IF
YOU WANT TO HAVE A DEVICE THAT
IS TESTED OR DESIGNATED FOR
INFANTS, THEN YOU CAN SEE THAT
THESE ARE THE DIFFERENCES IN
TERMS OF TESTING REQUIREMENTS
FOR EACH OF THESE SPECIAL
POPULATIONS.
FOR INFANTS WHO ARE ANYWHERE
FROM BIRTH UP TO 3 YEARS OF AGE,
[INAUDIBLE] NEED 18 SUNTS.
18 SUBJECTS.
YOU CAN SEE THERE ARE VERY
SPECIFIC REQUIREMENTS REGARDING
EIGHT AND WAGE.
THERE'S NO -- DISTRIBUTION
REQUIREMENTS AND THERE IS SOME
SIMPLY TIS ANALYSIS THAT IS DONE
AND THERE IS -- CRITERIA.
FOR CHILDREN WHO ARE 3 TO 12
YEARS OF AGE YOU CAN USE
INVASIVE OR US A CULL TA TRI
METHODS.
YOU CAN DO TESTING IN 85 KIDS OR
YOU CAN DO A GENERAL POPULATION
STUDY IN WHICH THE -- GENERAL
POPULATION PARTICIPANTS ABOVE 12
YEARS OF AGE AND 35 CHILDREN FOR
A TOTAL OF 85 POPULATION, OR YOU
CAN DO 35 -- A STUDY IN 35
CHILDREN AS A SPECIAL POPULATION
AFTER 85 PARTICIPANTS HAVE
COMPLETED AND PASSED A GENERAL
POPULATION STUDY.
AND THEN FOR PREGNANT WOMEN, THE
REQUIREMENTS IN THE -- STANDARD
ARE THAT YOU CAN DO TESTING,
INVASIVE OR -- IN PREGNANT WOMEN
OR IN -- AS A SPECIAL POPULATION
AFTER 85% GENERAL POPULATION
STUDY HAS BEEN COMPLETED.
NOTABLY PREGNANT WOMEN IN THE
SECOND OR THIRD TRIMESTER, A
THIRD OF EACH OF THE WOMEN WHO
ARE INCLUDED IN WHICHEVER STUDY
YOU DO NEED TO HAVE VARIOUS
BLOOD PRESSURE REQUIREMENTS,
REQUIREMENTS OF HAVING EITHER
PROTEINURIA -- SO THAT WAS THE
DASH 2 STANDARD.
I'M GOING TO GO BRIEFLY OVER THE
OTHER STANDARDS.
SO UNTIL 2022, THERE HAVE BEEN
NO STANDARDS FOR AAMI STANDARDS
FOR CUFFLESS DEVICES SO MANY
MANUFACTURERS USED DASH
2 STANDARD FOR THIS, AND AS WE
JUST HEARD THAT THAT WAS NOT
NECESSARILY APPROPRIATE.
SO WHAT CUFFLESS DEVICES DO THAT
GIVE CONTINUOUS MEASUREMENTS,
THIS IS IMPORTANT TO THINK ABOUT
IN TERMS OF THE MORE -- LIKE THE
WATCHES AND THE RINGS THAT WE'VE
BEEN HEARING ABOUT THAT ARE
COMING AWAY, THESE DEVICES --
GIVE YOU AN OUTPUT FREQUENTLY,
SO ONE OR MORE OUTPUT EVERY
30 SECONDS.
THIS BECAUSE OF THE FREQUENCY OF
THE OUTPUT REQUIRES AN INVASIVE
REFERENCE.
THESE DEVICES CAN PROVIDE EITHER
TREND DATA, WHICH I THINK OF AS
DELTA BLOOD PRESSURE SO THE
CHANGE IN BLOOD PRESSURE, OR IT
GIVES YOU AN APP MEANT TO BE
ESTIMATED BLOOD PRESSURE.
THIS IS TIMENTED TO BE TYPE B OR
TYPE A.
UP WITH OF THE THINGS IN THE
STANDARD THAT'S IMPORTANT FOR
ALL OF US TO KNOW IS THAT USERS
OF THESE CONTINUOUS AUTOMATED
COMPLEX DEVICES COULD BE MISLED
TO THINK THE VALUES DISPLAYING
ON THE SCREEN ARE ABSOLUTELY
ACCURATE WHEN IN REALITY THEY
ARE NOT.
SO FOR THE TYPE A -- AND GIVE
YOU BLOOD PRESSURE CHANGES,
WHEREAS THE ONES THAT PROVIDE
TREND DATA -- ONLY REQUIRE THE
LAST TWO OF THOSE PERFORMANCE
ASSESSMENTS.
SO I'LL BRIEF GO THROUGH THIS,
SO AGAIN, AN INVASIVE REFERENCE,
SIMILAR SEX DISTRIBUTION.
THERE IS A REQUIREMENT FOR AN
AGE DISTRIBUTION TO RECOGNIZE
THAT AS WITH OLDER INDIVIDUALS,
THERE'S MORE ARTERIAL STIFFNESS
AND DEVICES MAY ACT DIFFERENTLY
SO THERE IS AN -- REQUIREMENT
AND THERE IS A DIFFERENT BLOOD
PRESSURE DISTRIBUTION AS MANY OF
THESE DEVICES ARE INTENDED TO BE
USED IN ICUs OR IN OPERATING
ROOMS WHERE THERE HAS TO BE
BIGGER SWINGS IN BLOOD PRESSURE
SO THE BLOOD PRESSURE
DISTRIBUTION IS DIFFERENT TO
AFFECT THAT.
THERE'S NO REQUIRED AGE
DISTRIBUTION WHEN BEING TESTED
IN CHILDREN UNDER 12.
UNDER -- THERE IS AN AGE WEIGHT
DISTRIBUTION THAT NEEDS TO BE
FULFILLED.
LET'S GO PAST THAT ONE TO THE
NEXT ONE.
SO THE ONE THING I DO WANT TO
HIGHLIGHT FOR THE CONTINUOUS
BLOOD PRESSURE DEVICES, THE
STANDARD REQUIRES THE PAIRED
VALUES BE LESS THAN
6 MILLIMETERS OF MERCURY.
SO THAT WAS REALLY FOCUSING ON
THE ACCURACY OF BLOOD PRESSURE,
IN TERMS OF STABILITY AND BLOOD
PRESSURE CHANGES, THERE'S
ADDITIONAL TESTING.
WHAT THE STANDARDS GOES THROUGH
IS THAT THESE DEVICES NEED TO
HAVE SPECIFIC THINGS THAT TELL
YOU HOW THEY PERFORM IMMEDIATELY
POST CALIBRATION IN DIFFERENT
DEVICE POSITIONS AFTER INDUCING
THE BLOOD PRESSURE CHANGE AND
BEFORE THOSE DEVICES GET RECAL
RECALIBRATED SO ALL THOSE THINGS
GET HANDLED IN THE STANDARD.
SO WHAT ABOUT HOW WE TEST
DEVICES THAT GIVE YOU
INTERMITTENT CUFFLESS BLOOD
PRESSURE MEASUREMENTS?
SO THIS IS IN PROGRESS.
THESE DEVICES ARE DIFFERENT THAN
THE CONTINUOUS ONES BECAUSE
THESE GIVE YOU AN OUTPUT LESS
FREQUENTLY SO MORE THAN EVERY
30 SECONDS.
OR UPON WHEN THE USER ACTUATES
IT, PUSHES A BUTTON.
SO AS WE'RE DEVELOPING THIS
STANDARD, WE ARE THINKING ABOUT
AND WE'RE DEVELOPING THE
STANDARD TO ADDRESS SIX
POTENTIAL AND/OR EXISTING
DEVICES ON THE MARKET.
SO MANY OF THESE DEVICES AS WAS
JUST DESCRIBED IN THE EARLIER
PRESENTATION REQUIRE SOME SORT
OF INITIALIZATION AND -- MANY
REQUIRE DEMOGRAPHICS OR
ANTHROPOMETRICS, AND MANY NOW
REQUIRE INITIALIZATION I WITH A
CUFF, PUT IT INTO THE DEVICE AND
ALL THAT INFORMATION IS USED
ALONG WITH OTHER METHODS LIKE
PULSE WAVE ANALYSIS AND -- WITH
OUTPUT.
SO THE SIX DIFFERENT TYPES ARE
THE ONES THAT DON'T REQUIRE ANY
INITIALIZATION OF PERSONAL
INFORMATION, CONSIDERED TO BE
PLUG AND PLAY D DEVICES, AND YOU
CAN SEE HERE THE ONES THAT
REQUIRE CUFF BLOOD PRESSURE.
THOSE DO NOT REQUIRE PERSONAL
INFORMATION AND NEITHER PROVIDES
YOU WITH ABSOLUTE BLOOD PRESSURE
IN MILLIMETERS MILL METERS OF
MERCURY OR ATTRACTS BLOOD
PRESSURE AS DESCRIBED EARLIER
PROVIDING MORE OF A CHANGE IN
BLOOD PRESSURE.
SO AS WE HAVE BEEN DEVELOPING
THE STANDARDS, THERE ARE THINGS
THAT WE'VE BEEN THINKING ABOUT,
SOME OF THEM ARE HIGHLIGHTED
HERE WHICH IS THE ESH
RECOMMENDATIONS AND THINGS THAT
WE MIGHT CONSIDER FOR VALIDATION
OF CUFFLESS INTERMITTENT
DEVICES.
SO THINGS THAT ARE BEING
CONSIDERED, THINKING ABOUT HOW
DO WE TEST STATIC, ABSOLUTE
BROMOPROPANE ACCURACY, HOW DO WE
TEST FOR HYDROSTATIC PRESSURE
EFFECT ROBUSTNESS, WEAKNESS OR
EFFECTIVENESS OF BLOOD PRESSURE
DECREASING AND IS IT ACTIVE ARE
THE BLOOD PRESSURE DOES
DECREASE?
WE'RE THINKING ABOUT HOW DO WE
TEST IT WHEN WE'RE AWAKE AND
ASLEEP, BROMOPROPANE CHANGE AND
ACCURACY POSITION WHEN BLOOD
PRESSURE -- EXERCISE -- THAT'S A
THING WE'D WANT TO TR TO HELP --
BLOOD PRESSURE AND ACTIVE
INCREASING BLOOD PRESSURE AND
SEEING HOW THE DEVICE IS
ACCURATE OVER TIME THE FURTHER
IT GETS AWAY FROM THE INITIAL
CUFF CALIBRATION.
SO THERE ARE MANY, MANY, MANY
BLOOD PRESSURE MEASURING DEVICES
ON THE MARKET, HOWEVER, MANY
PEOPLE DON'T RECOGNIZE THAT
ABOUT 20% OF THEM HAVE EVER BEEN
SUBJECTED TO VALIDATION TESTING.
SO YOU CAN PUT YOUR DEVICE ON
THE MARKET EVEN IF IT HASN'T
UNDERGONE -- VIOLATIONS IN -- SO
I GET PEOPLE ASKING ME ALL THE
TIME, WHAT ABOUT AN FDA-APPROVED
DEVICE?
THE ONE THING I WANT TO BE ABOUT
IS THAT THE FDA DOES NOT APPROVE
BLOOD PRESSURE DEVICES, THEY
CLEAR THEM.
SO APPROVAL GENERALLY ONLY
APPLIES TO HIGH RISK MEDICAL
DEVICES AND BLOOD PRESSURE
DEVICES ARE NOT SUFFICIENTLY
HIGH RISK.
SO THEY GET CLEARED THROUGH THE
PATHWAY.
SO A CLEARED DEVICE IS ONE THAT
IS AT LEAST A SAFE AND EFFECTIVE
SUBSTANTIALLY EQUIVALENT TO A
LEGALLY MARKETED DEVICE -- NOT
NECESSARILY CLINICAL TESTING OF
THE NEW DEVICE.
THE NEW DEVICE DOES NOT
NECESSARILY NEED TO BE TESTED IF
IT WAS DEEMED TO BE
SUBSTANTIALLY APPROPRIATE.
I THINK WE'RE GOING TO SKIP THIS
ONE AND THE NEXT ONE.
KEEP GOING.
AND THEN ONE MORE.
SO AGAIN, DEVICES CAN BE CLEARED
WITHOUT THEY THEMSELVES
UNDERGOING SEPARATE VALIDATION
TESTING IF THE MANUFACTURER
CLAIMS SUBSTANTIAL EQUIVALENT TO
THE MARKETED DEVICE.
LET'S SKIP TO THE SUMMARY SLIDE.
SO IN SUMMARY, THERE ARE
MULTIPLE VALIDATION PROTOCOLS
AVAILABLE FOR TESTING NUMEROUS
DEVICES INTENDED TO MEASURE
BLOOD PRESSURE, THEY'RE VERY
COMPLEX, AND THEY'RE SPECIFIC TO
MAKE SURE THAT THEY'RE ACCURATE
ACROSS THE -- POPULATION, VERY
FEW DEVICES FOR SALE HAVE EVER
BEEN TESTED FOR ACCURACY AND
DEVICES CAN RECEIVE FDA
CLEARANCE IF THEY'RE
SUBSTANTIALLY EQUIVALENT.
TECHNOLOGY IS EVOLVING QUICKLY,
NEW TECH INNOVATIONS REQUIRE
INNOVATIVE APPROACHES BY
REGULATORS, PROFESSIONAL
SOCIETIES, CLINICIANS, AND HOW
WE CAN INTEGRATE THEM INTO
CLINICAL CARE SO ONE THING -- TO
COLLABORATE MORE CLOSELY.
AND ONE THING WE CONSTANTLY HAVE
TO THINK ABOUT WHEN WE'RE
TALKING ABOUT VALIDATION
STANDARDS IS THAT THAT REALLY
PERTAINS TO ACCURACY AND
STANDARD DIED RESEARCH SETTING,
IT DOESN'T ADDRESS HOW THE
DEVICE IS PERFORMING, OPTIMAL
SETTINGS.
SO WHAT'S MISSING WHEN YOU HAVE
A VALIDATED DEVICE YOU DON'T
HAVE A PERFORMANCE IN THE REAL
WORLD WITH TYPICAL USE.
ONE THING I FOUND PARTICULARLY
INTERESTING IS AS WE WERE
TALKING ABOUT SOME OF THE
LIMITATIONS TO THESE DEVICE,
PARTICULARLY HOW THEY DON'T
REALLY PERFORM WELL DURING
SLEEP, AND THINKING ABOUT WHAT
YOU NEED TO DO TO TEST THEM
DURING, ONE THING TO HIGHLIGHT
ISHIGHLIGHT -- HOW CAN WE IMPROE
AND INCREASE THE CONSISTENCY
BETWEEN THE PROTOCOLS?
I THINK MY LAST SLIDE IS NEXT.
AND SO WITH THOSE ADDITIONAL
TESTING REQUIREMENTS FOR SPECIAL
POPULATIONS, ONE OF THE
DOWNSTREAM EFFECTS IS THAT THESE
POPULATIONS TEND TO NOT HAVE AS
MANY DEVICES AVAILABLE FOR USE,
AND WITH CHILDREN AND -- WE NEED
TO THINK ABOUT THAT, ARE THERE
INNOVATIVE WAYS THAT YOU CAN
TEST AND MAKE SURE THEY'RE
ACCURATE WITHIN THESE
POPULATIONS.
THANK YOU VERY MUCH FOR YOUR
ATTENTION.
>> THANK YOU SO MUCH, DR. BRADY.
WE'LL HAND IT OVER TO ALMOST
HILARY WALL FROM CDC'S MILLION
HEARTS.
>> THANKS A BUNCH, KATE.
IF WE CAN GO TO THE NEXT SLIDE.
GREAT.
SO HILARY WALL, I'M HERE TO TALK
TO YOU ABOUT USING BIG DATA FOR
HYPERTENSION CLINICAL
DECISION-MAKING.
I AM GOING TO MENTION SOME SORT
OF TRADE NAMES NOT FOR
ENDORSEMENT, JUST USING THEM FOR
IDENTIFICATION AND EXAMPLES.
SO AGAIN, I WAS ASKED TO GEF A
TALK ABOUT USING BIG DATA FOR
HYPERTENSION CLINICAL
DECISION-MAKING AND SOME OF THE
CHALLENGES AND OPPORTUNITIES
THAT THERE ARE IN THAT FIELD.
I'M NOT A CLINICIAN, I AM AN
EPIDEMIOLOGIST BY TRAINING SO
THAT'S REALLY THE LENS THROUGH
WHICH I'M LOOKING THROUGH, BUT I
ALSO WORK WITH A LOT OF
CLINICIANS, ESPECIALLY COMMUNITY
HEALTH CENTERS, AS THEY DIG DEEP
INTO THEIR ELECTRONIC HEALTH
RECORD DATA FOR QUALITY
IMPROVEMENT PURPOSES IN
PARTICULAR AND IMPACTS THAT
MIGHT HAVE ON CLINICAL QUALITY
MEASURES.
SO I'M GOING TO HIT SORT OF A
WHOLE BUNCH OF TOPICS HERE
TODAY.
BUT I'M GOING TO START A LITTLE
BIT WITH PUBLIC HEALTH
SURVEILLANCE BECAUSE THAT'S
WHERE I COME FROM AND OUR WORK
USING ELECTRONIC HEALTH RECORD
DATA FOR PUBLIC HEALTH
SURVEILLANCE HAS ACTUALLY
PROVIDED US AN OPPORTUNITY TO
SORT OF LOOK UNDER THE HOOD AND
SEE HOW THE SAUSAGE IS MADE WITH
REGARD TO ELECTRONIC HEALTH
RECORD DATA AND ALL OF THEIR
SORT OF BEAUTIFUL MESSINESS THAT
THEY BRING.
JUST IN CASE YOU WEREN'T AWARE,
IN THE UNITED STATES THE
NATIONAL HEALTH AND NUTRITION
EXAMINATION SURVEY IS
ESSENTIALLY OUR ONLY
SURVEILLANCE DATA SOURCE FOR
HYPERTENSION PREVALENCE AND
BLOOD PRESSURE CONTROL.
THERE ARE OTHER DATA SOURCES
THAT GET AT SORT OF -- BUT THIS
IS REALLY OUR ONLY DATA SOURCE
THAT GIVES US HYPERTENSION AND
BLOOD PRESSURE CONTROL.
HOWEVER, IT'S CONSIDERED A GOLD
STANDARD BUT HOWEVER, THERE'S
CHALLENGES WITH IT JUST LIKE ANY
DATA SOURCE, RIGHT?
IT'S VERY EXPENSIVE TO MAINTAIN,
IT'S NOT VERY TIMELY, YOU'RE NOT
GETTING REALTIME DATA FROM IT IN
ANY WAY, SHAPE OR FORM AND IF
YOU'RE A STATE OR LOCAL HEALTH
DEPARTMENT, YOU'RE REALLY NOT
ABLE TO GET -- FROM NHANES.
WHAT WE FOUND OUT WHEN COVID-19
HIT, WHEN THE COUNTRY SHUT DOWN,
NHANES DATA COLLECTION SHUT DOWN
AND FRANKLY HAS BEEN DISRUPTED
IN DIFFERENT WAYS SORT OF
INCONSISTENTLY OVER THE LAST
FIVE YEARS, AND IT ONLY NEXT
YEAR WHEN THEIR DATA COLLECTION
CYCLES ABOUT BEGIN AGAIN.
SO FOR FIVE YEARS, WE'VE HAD NOT
GREAT ESTIMATES FOR BLOOD
PRESSURE CONTROL.
AND THAT'S A PROBLEM.
BUT THE CHALLENGE, WHEN YOU HAVE
SOMETHING CALLED A GOLD
STANDARD, PEOPLE AREN'T VERY
QUICK TO LOOK FOR AN
ALTERNATIVE.
SO THEY'RE NOT QUICK TO THINK
OUTSIDE OF THE BOX AND HOW ELSE
WE MIGHT GET TO THOSE INDICATORS
THAT I MENTIONED.
WHEN I HEARD ABOUT MEANINGFUL
USE, YES, I WAS HAPPY WAS GOING
TO IMPROVE EFFICIENCY AND
PATIENT OUTCOMES POTENTIALLY,
BUT I JUST WAS SALIVATING OVER
THE HUGE VOLUME OF DATA THAT WE
WOULD BE SITTING ON TOP.
AND YES IT WAS GOING TO BE MESSY
AND WE NEEDED TO FIGURE OUT
METHODS FOR IT, BUT THIS WAS A
HUGE OPPORTUNITY IN MY MIND, SO
I STARTED SQUAWKING TO ANYONE
WHO HAD DOLLARS AND
DECISION-MAKING CAPABILITY AT
CDC, AND EVENTUALLY WE DID GET
TO THE POINT WHERE WE WERE USING
EHR DATA FOR SURVEILLANCE.
I CERTAINLY WAS NOT THE ONLY
PERSON WHO WAS THINKING ABOUT
ELECTRONIC HEALTH RECORD DATA
FOR SURVEILLANCE AND OTHER
PURPOSES.
YOU CAN SEE ON THE LEFT
ESPECIALLY PUBLIC HEALTH
JURISDICTIONS THAT CAN'T BENEFIT
FROM NHANES WE'RE THINKING --
WHAT CAN I DO AT THE STATE LEVEL
IN MARWAH ABDALLA, TO REALLY USE
ELECTRONIC HEALTH RECORD DATA TO
ANSWER QUESTIONS THAT I HAVE
ABOUT SERIOUS HEALTH CONDITIONS.
HRSA HAS BEEN COLLECTING THEIR
EUN FOM DATA SYSTEM FOR YEARS
FROM COMMUNITY HEALTH CENTERS.
IT'S REALLY A PROGRAMMATIC
DATABASE BUT EVEN THAT HAS BEEN
COLLECTING ROUTINELY CLINICAL
QUALITY MEASURES DATA.
IT'S ALLOWED OUR NATION TO
REALLY LOOK AT HOW WE'RE DOING
FROM A SAFETY NET PROVIDER
PERSPECTIVE AND THAT'S BEEN
MORPHING AND CHANGING OVER TIME
AS WELL, I'LL TALK A LITTLE BIT
ABOUT THAT.
WE ALSO HAVE HEALTH CENTER
CONTROLLED NETWORKS AND HEALTH
INFORMATION EXCHANGES THAT
REALLY A AGGREGATE DATA THAT THN
CAN BE USED FOR DIFFERENT
PURPOSES, AND WE HAVE RESEARCH
PER FOR -- HELPED INFORM WHAT WE
CALL OUR MULTISTATE EHR BASED
NETWORK FOR DISEASE SURVEILLANCE
OR MENDS.
AGAIN, THE LESSONS WE'VE LEARNED
BY BEING EPIDEMIOLOGISTS AND
DIGGING INTO THE VERY MICRO
LEVEL DETAILS OF THIS PARTICULAR
SURVEILLANCE SYSTEM CAN
ABSOLUTELY BE APPLIED TO
CLINICAL DECISION-MAKING.
BUT LET'S LOOK AT WHAT ARE SOME
TOOLS FOR CLINICAL
DECISION-MAKING?
FIRST QUALITY IMPROVEMENT RUN
CLARTS.
IF YCHARTS.
IF YOU'RE DOING CONTINUOUS
QUALITY IMPROVEMENT, THIS IS ONE
WAY YOU CAN MONITOR YOUR
PROGRESS THERE.
USUALLY USING A LONGITUDAL
PERFORMANCE MEASURE, A CLINICAL
QUALITY MEASURE TO REALLY SEE
HOW QUALITY IMPROVEMENT CHANGES
HAVE IMPACTED THE PERFORMANCE ON
SOMETHING LIKE BLOOD PRESSURE
CONTROL.
YOU CAN ALSO BE USING CLINICAL
QUALITY MEASURE DASHBOARDS OR
JUST DASHBOARDS IN GENERAL AND
THANKS TO THE AMA FOLKS WHO LET
ME USE THIS PARTICULAR SLIDE.
HERE YOU CAN SEE WE'VE GOT OUR
OUT COME MEASURE OF INTEREST,
AND THEN ALSO SOME PROCESS
MEASURES THAT ARE RELATED.
AND THEN HERE, WE'VE GOT -- YOU
DIG DOWN ONE MORE LAYER, WHAT
PATIENTS ARE FALLING OUT OF THE
NUMERATOR ON OUR PERFORMANCE
MEASURES, WE CAN LOOK AT
REGISTRY TO FIGURE OUT WHO MIGHT
NEED ADDITIONAL CLINICAL
ATTENTION, AND THEN OUR NEXT
SLIDE, WE CAN LOOK AT EITHER
PRE-VISIT OR AT THE POINT OF
CARE, WHAT'S GOING ON WITH THAT
INDIVIDUAL PATIENT AND HOPEFULLY
SOME OF THEIR LONGITUDAL DATA ON
BLOOD PRESSURE.
BUT SO ANY OF THOSE CLINICAL
DECISION-MAKING TOOLS I JUST
SHOWED YOU AND MANY OTHERS, YOUR
LITTLE TRIGGERS THAT GO OFF IN
YOUR ELECTRONIC HEALTH RECORD,
THEY REALLY ALL RELY ON WHAT IT
IS THAT TRIGGERS HYPERTENSION OR
BLOOD PRESSURE CONTROL IN OUR
FAVORITE TOOL OF OUR CHOOSING.
AND I CAN HEAR YOU ALL SAYING IT
ICD10 CODES, HILARY.
OBVIOUSLY.
AND IF YOU SAID THAT TO ME, I
WOULD SAY WELL, YES, YOU'RE
PARTIALLY RIGHT, ICD10 CODES
CERTAINLY CAN BE USED TO TRIGGER
HYPERTENSION AND USED TO SORT OF
BUILD BLOOD PRESSURE CONTROL
MEASURES BUT I WOULD SAY YOU'RE
ONLY PARTIALLY RIGHT.
WHAT WE -- WHAT I AND MANY
RESEARCHERS IN THE FIELD HAVE
COME TO UNDERSTAND IS THAT WHEN
YOU REALLY DIG INTO ELECTRONIC
HEALTH RECORD DATA RELATED TO
HYPERTENSION, YOU START SEEING
NON-TRIVIAL NUMBERS OF PATIENTS
WHO HAVE NOT BEEN GIVEN A
DIAGNOSIS CODE, HAVE NOT BEEN
GIVEN AN ICD10 CODE, BUT THEY
HAVE MULTIPLE ELEVATED BLOOD
PRESSURE READ READINGS SO WE
SORT OF -- THIS IS POTENTIALLY
UNDIAGNOSED HYPERTENSION IN
ELECTRONIC HEALTH RECORDS, AND
MILLION HEARTS MY PROGRAM HAS
REALLY DONE THIS HIDING IN PLAIN
SIGHT, BECAUSE IF WE JUST START
TO LOOK FOR FOLKS, YOU'RE GOING
TO START FINDING OTHER PATIENTS
THAT POTENTIALLY HAVE
HYPERTENSION.
AND YOU CAN SEE HERE MIKE
RAYCOTS HAS PUBLISHED ON THIS,
WE'VE PUBLISHED ON WORK WE'VE
DONE SPECIFICALLY WITH COMMUNITY
HEALTH CENTERS TO REALLY DIG
INTO THE MICRO LEVEL DETAILS.
KAESER HAS PUBLISHED ON THIS IN
BOTH PREGNANT AS WELL AS NON
NON-PREGNANT AS WELL AS WITH
HYPERTENSION.
WHAT THIS IS REALLY COMING DOWN
TO IS DEVELOPING A HYPERTENSION
PHENOTYPE, USING ELECTRONIC
HEALTH RECORD DATA.
SO YES, OF COURSE ICD10 CODES
AND ICD10 ESSENTIAL HYPERTENSION
THAT'S WHAT'S USED MOST COMMONLY
IN OUR CLINICAL QUALITY MEASURES
AND -- BUT MIGHT YOU FOR YOUR
PRURPSES, FOR YOUR HEALTHCARE
SETTINGS PURPOSES, MIGHT YOU
WANT TO EXPAND THE ICD10 CODES
THAT YOU'RE LOOKING AT?
WE HEARD JORDY TALK ABOUT
HYPERTENSIVE CKD.
MIGHT WE WANT TO LOOK AT THAT IN
SOME OF OUR TOOLS?
DO YOU KNOW WHAT ICD10 CODES ARE
ACTUALLY BEING USED TO BUILD THE
DATA VISH SAYINGS THAT YOU'RE
SEEING?
MANY ON THE CALL ARE
HYPERTENSION RESEARCHERS SO
YOU'RE VERY INVOLVED IN YOUR
DATA, BUT EVERY DAY CLINICIAN
MIGHT NOT BE AS INVOLVED IN THE
NUTS AND BOLTS OF THEIR DATA
VISUALIZATIONS AND THEIR
CLINICAL DECISION-MAKING TOOLS.
SO THESE ARE JUST SOME
CONSIDERATIONS FROM AN ICD10
PERSPECTIVE.
BUT I WOULD ALSO ENCOURAGE FOLKS
TO THINK ABOUT LOOKING FOR
PATIENTS THAT ARE ON AN
ANTIHYPERTENSIVE MEDICATION, AND
I HEAR YOU, THEY'RE USED FOR OFF
LABEL REASONS.
WE LOOKED AT THAT IN THAT MEN'S
SURVEILLANCE -- THAT MENDS
SURVEILLANCE SYSTEM I TALKED
ABOUT AND IT ACTUALLY HAPPENED
MUCH LESS FREQUENTLY THAN I
ANTICIPATED.
I WOULD ABSOLUTELY CONSIDER
USING TWO OR MORE ELEVATED BLOOD
PRESSURE VALUES.
BUT YOU HAVE TO SYRINGE ABOUT
WHAT THRESHOLD DO YOU USE?
JUST AT 130/80 OR 140/90?
YOU MIGHT WANT TO START LOOKING
AT HIGHER BLOOD PRESSURE VALUES
BECAUSE YOU HAVE MORE CONFIDENCE
THAT THOSE PEOPLE LIKELY HAVE
HYPERTENSION.
ARE YOU THEKING ABOUT USING IT
SELF MEASURED BLOOD MONITORING
VALUES, ABOP IF IT'S AVAILABLE
TO YOU AND THEN ALSO SOME
HEALTHCARE SETTINGS USED TO BE
MORE PERTINENT, BUT THEY TAKE
INTO CONSIDERATION WHETHER
HYPERTENSION IS WRITTEN IN THE
CLINICAL NOTES.
SO ALL OF THESE SORT OF DATA
ELEMENTS COULD BE USED TO
BUILD -- LOOK LIKE FROM AN
ELECTRONIC HEALTH RECORD
PERSPECTIVE.
YOU CAN DO THE SAME THING WITH
BLOOD PRESSURE CONTROL, LOTS OF
DIFFERENT CONSIDERATIONS.
ARE YOU USING OFFICE BLOOD
PRESSURE VALUES, WHICH ONE, IF
THERE ARE MULTIPLE VALUES IN ONE
DAY, YOU NEED TO MAKE A DECISION
ABOUT HOW YOU'RE HANDLING THOSE.
ARE YOU DROPPING THE FIRST ONE,
ARE YOU AVERAGING THEM ALL, ARE
YOU TAKING THE LOWEST SYSTOLIC
AND THE LOWEST DIE STOL FROM TWO
DIFFERENT MEASURES -- CMS WANTS
65 AND Q F-18.
SO THERE'S LOTS OF DIFFERENT
DISSECTION POINTS IN THERE AND
DO YOU TOE WHAT DECISION POINTS
HAVE BEEN MADE WHEN YOU'RE
LOOKING AT THINGS LIKE A BLOOD
PRESSURE CONTROL REPORT, SMBP,
SAME THING, HOW ARE YOU HANDLING
THOSE VALUES, WHAT IF A PATIENT
BRINGS IN THEIR VALUES WRITTEN
DOWN ON PAPER, ARE YOU USING
THOSE THE SAME WAY YOU MIGHT IF
THEY WERE TRANSMITTED
ELECTRONICALLY?
HOW ARE YOU HANDLING SMBP OR RPM
IN THE PREGNANCY AND POSTPARTUM
POPULATION?
AOBP, SAME KINDS OF THINGS, THEN
FUTURE TECHNOLOGIES, THESE ARE
THINGS THAT AS PEOPLE ARE
DEVELOPING FUTURE TECHNOLOGIES,
I WISH THAT WHEN THEY GOT TO THE
FDA CLEARANCE POINT, THEY WOULD
START SAYING OKAY, LET'S ASSUME
I'M GOING TO GET FDA CLEARANCE,
WHAT DO WE NEED TO DO TO REALLY
IMPLEMENT THIS BROADLY IN THE
CLINICAL SETTINGS IN THE UNITED
STATES?
THESE ARE THE THINGS, THESE ARE
CONSIDERATIONS THAT I WISH
DEVICE MANUFACTURERS WOULD KEEP
IN MIND.
SO A LOT OF THIS, A LOT OF THE
CHALLENGES AND LIKE HOW YOU
FIGURE OUT WHETHER OR NOT THINGS
HAVE BEEN DONE, THESE ARE
MAPPING ISSUES.
AND THIS GETS LIKE REALLY SORT
OF INFORMATICS-HEAVY, BUT IT'S
ALSO NOT VERY WELL EXPLORED IN
THE PUBLISHED LITERATURE.
THIS IS ONE EXAMPLE THAT WE
LOOKED AT THOSE SORT OF
MEANINGFUL USE THE MEDICARE EHR
INCENTIVE PROGRAM DATA FROM
PHYSICIANS ONLY WHO REPORTED ON
IN Q F-18 WHICH IS CONTROLLING
HIGH BLOOD PRESSURE.
THE BOTTOM TWO, IF YOU LOOK AT
2014, THE DATA ON THE RIGHT, THE
BOTTOM TWO PIECES OF THE COLUMN
ARE JUST LIKE HOW THEY
PERFORMED.
THE TOP TWO PIECES ARE WHAT I
WANT TO POINT OUT.
4.4% OF PHYSICIANS REPORTED THEY
HAD ZERO PATIENTS WITH BLOOD
PRESSURE CONTROL, NO ONE HAD
THEIR BLOOD PRESSURE OVER 140/90
AND THEN ANOTHER 12% REPORTED
THAT THEY HAD ZERO PATIENCE WITH
HYPERTENSPATIENTS WITHHYPERTENS.
THAT SEEMED REALLY STRANGE TO US
THAT YOU HAD THIS BIG PORTION OF
PHYSICIANS CLAIMING THINGS ON
THE OPPOSITE ENDS OF THE
SPECTRUM, SO I THINK WHAT WE
DECIDED WAS THIS WAS REALLY A
MAPPING ISSUE AND THOSE
CLINICIANS NEEDED TO WORK WITH
THEIR ELECTRONIC HEALTH RECORD
PROVIDERS TO FIX WHATEVER ISSUE
THEY HAD.
THEY WEREN'T -- WHEREVER THEY
WERE ENTERING BLOOD PRESSURE
INTO THEIR INTERFACE OR EHR
INTERFACE TO WHERE IT WAS BEING
REPORTED OUT.
SO YOU ALL ARE LIKELY FAMILIAR
WITH THE FIVE RIGHTS OF CLINICAL
DECISION SUPPORT, YOU'VE GOT THE
RIGHT PERSON TO THE RIGHT PERSON
IN THE RIGHT FORMAT THROUGH THE
RIGHT CHANNEL AT THE RIGHT TIME.
AND I THINK WHEN IT COMES TO THE
RIGHT INFORMATION, SOME OF THAT
HAS TO DO WITH DATA VALIDATION,
AND I'M NOT GOING TO DIVE DEEPLY
INTO THIS BECAUSE WE HAVE A
PUBLICATION I INCLUDED ON THE
SLIDE WHERE WE REALLY DUG VERY,
VERY DEPLY AND WENT DOWN A
VALIDATION RABBIT HOLE FOR THAT
SYSTEM I TALKED ABOUT, YOU
REALLY HAVE AN OPPORTUNITY TO
PICK APART DATA ELEMENTS ANDLY
DISCOVER SOME VERY INTERESTING
THINGS.
SO NOT EVERYTHING IN THIS
PUBLICATION IS DIRECTLY
APPLICABLE TO A CLINICAL SETTING
BUT I THINK MANY OF THE CONCEPTS
CAN BE APPLIED FROM A VALIDATION
STANDPOINT.
SO I SORT OF WAS OUTLINING
CHALLENGES THERE.
SOME OF THE OPPORTUNITIES WE
HAVE, THE CLINICAL QUALITY ME
MEASURES THAT SORT OF ARE AN
INDICATOR OF CLINICAL
DECISION-MAKING, THERE ARE
OPPORTUNITIES THERE, THEY ONLY
LOOK AT ESSENTIAL HYPERTENSION,
MAYBE THAT'S OKAY, THEY EXCLUDE
PREGNANT INDIVIDUALS SO IF WE'RE
TRYING TO LOOK AT WHAT BLOOD
PRESSURE CONTROL, BLOOD PRESSURE
MANAGEMENT LOOKS LIKE IN
PREGNANT POPULATION, WE DON'T
HAVE THOSE MEASURES.
THEY ARE BEING DEVELOPED, THEY
HAVE M LINE INNOVATION AND EARLY
NEXT YEAR WE'LL LOOK AT -- IN
BOTH THE PREGNANT AND IMMEDIATE
POSTPARTUM PERIOD.
AGAIN AS FUTURE TECHNOLOGIES
COME TO LIGHT, WE NEED, THE
BROADER WE, NEED TO BE THICKING
ABOUT HOW DO WE INCORPORATE
THESE VALIDATED ACCEPTABLE BLOOD
PRESSURE TECHNOLOGIES INTO
MEASURES OF BLOOD PRESSURE
CONTROL.
IF WE'RE NOT THINKING ABOUT IT
NOW OR WHEN THESE TECHNOLOGIES
FIRST SORT OF COME TO LIGHT,
IT'S LIKE WE HAVE TO WAIT YEARS
AND YEARS FOR THEM TO ACTUALLY
GET INTO PRACTICE.
SMBP, MANY OF YOU KNOW THOSE
VALUES HAVE BEEN EVOLVING OVER
TIME HOW THEY'RE BEING DIGESTED
BY THE CLINICAL QUALITY
MEASURES.
RIGHT NOW THEY DON'T SAY YOU
HAVE TO USE AN AVERAGE BLOOD
PRESSURE SO THAT'S PROBLEMATIC,
BUT AT LEAST THERE'S AN ESSENCE
OF SMBP IN THOSE VALUES.
THE PREVENT CALCULATOR, THIS IS
OUT.
WE THINK LIKELY IT'S GOING TO BE
INVOLVED IN FUTURE HYPERTENSION
GUIDELINES.
WE KNOW RIGHT NOW THERE ARE EHR
INSTALLATIONS THAT CAN'T DO AN
ASCBD RISK CALCULATION AND IT'S
BEEN YEARS SINCE THAT WAS THE
RECOMMENDATION IN THE GUIDELINE.
SO NOW IS THE TIME TO BE
THINKING ABOUT HOW DO WE
INCORPORATE IT INTO AN
ELECTRONIC HEALTH RECORD SO THAT
IT READY TO GO WHEN NEW
GUIDELINES COME OUT.
I'M GOING TO SKIP AHEAD A LITTLE
BIT JUST FOR THE SAKE OF TIME.
SO I AM A HUGE SMBP FAN AND I
HEARD DR. INJURE CHECK JURASCHEF
US HAVE BEEN WORKING TO CLOSE
THOSE GAPS OVER THE LAST NUMBER
OF YEARS.
THERE ARE A FEW THINGS THAT HAVE
HAPPENED IN THE PAST TWO OR SO
YEARS I WANT TO MAKE SURE
EVERYONE KNOWS ABOUT.
ONE OF THE BIGGEST BARRIERS THAT
I'VE HEARD FROM CLINICIANS IS
THAT THERE'S NO PLACE TO CAPTURE
AN AVERAGE BLOOD PRESSURE IN THE
EHR.
WELL, THERE'S SOMETHING CALLED
THE US CHORDAE TA FOR
INTEROPERABILITY THAT WILL BE
MANDATORY IN CERTIFIED
ELECTRONIC HEALTH RECORD
PRODUCTS.
AND MANY OF US ON THIS CALL AND
MANY OTHER FOLKS CONCERNED ABOUT
HYPERTENSION, BLOOD PRESSURE
CONTROL, WE SORT OF ADVOCATED
WITH A LOWER CASE A AND PUT
COMMENTS IN, PUBLIC COMMENTS IN
SUPPORTING THE USE OF AVERAGE
BLOOD PRESSURE IN ELECTRONIC
HEALTH RECORDS, SO SOON IN
COMING YEARS, THAT WILL BE A
MANDATORY FIELD THAT ELECTRONIC
HEALTH RECORDS WILL HAVE TO BE
ABLE TO CAPTURE, AND CARDX IS A
STANDARDS EFFORT THAT I
ENCOURAGE TO YOU CHECK OUT.
I THINK THIS WILL REALLY HELP
STREAMLINE DATA TRANSMISSION FOR
SMBP AS WELL.
I'M GOING TO END IT THERE
BECAUSE I KNOW WE'RE OVER TIME,
BUT I'LL PASS IT OVER TO YOU,
KATE.
THANK YOU.
>> THANK YOU, HILARY.
WE'LL HAVE ALL OUR SPEAKERS COME
BACK ON CAMERA HERE AND I JUST
WANT TO KICK OFF OUR DISCUSSION
SECTION BY THANKING ALL OF OUR
SPEAKERS.
THESE WERE WONDERFUL, WONDERFUL
PRESENTATIONS, REALLY I THINK
THE WHOLE DAY HAS BEEN
FANTASTIC.
AS WE GET INTO QUESTIONI QUESTIM
REFLECTING THAT COMING FROM THE
IMPLEMENTATION SIDE OF THINGS
AND WORKING WITH PHYSICIANS AND
CARE TEAMS.
I SEE THAT MANY OF THE ISSUES
THAT WE'VE DISCUSSED TODAY ARE
REALLY NOT TOP OF MIND TO THEM.
THEY REALLY DO NOT HAVE A LOT OF
AWARENESS INTO SOME OF THE
QUESTIONS THAT WE'RE THINKING
ABOUT, TRYING TO SUR FAR, TRYING
TO ANSWER WITH FURTHER RESEARCH.
SO I HOPE THIS GROUP IN ADDITION
TO REALLY IDENTIFYING RESEARCH
GAPS, I HOPE WE CAN ALSO
IDENTIFY WHAT IS SETTLED AND
REALLY KIND OF SURFACE SET AND
OUTLINE THAT AND MAKE IT VERY
CLEAR TO CLINICIANS AND CARE
TEAMS WHAT BEST PRACTICES ARE
AND WORK TOWARDS GETTING THOSE
THINGS ALL INCORPORATED INTO
GUIDELINES AND THEN SOME OF US
HERE ON THIS CALL CAN REALLY
TAKE THAT AND WORK ON THE
IMPLEMENTATION SIDE OF THINGS.
BUT I KNOW PART OF OUR CHARGE
TODAY IS REALLY TALKING ABOUT
THOSE RESEARCH GAPS.
SO MY FIRST QUESTION REALLY TO
ALL THE SPEAKERS, YOU ALL
IDENTIFIED MAJOR GAPS AND
OPPORTUNITIES.
BUT IF WE HAD TO PUSH YOU ON
THAT SINGLE SORT OF LOW HANGING
FRUIT OR THAT SINGLE HIGHEST
PRIORITY FOR US TO SOLVE WITH
FURTHER INVESTIGATION THAT WOULD
REALLY ADVANCE THIS FIELD, WHAT
WOULD IT BE?
MAYBE WE CAN GO IN ORDER OF OUR
SPEAKERS, STARTING WITH YOU,
MARWAH.
>> I'M GOING TO SAY WE SHOULD BE
IMPLEMENTING THINGS WE ALREADY
KNOW WORK.
SO FOCUSING ON THE WORK THATTA
THATTAMMY AND OTHERS HAVE DONE S
PROPER TECHNIQUE AND EDUCATION
AND IT IS BARRIERS WITHIN OUR
OWN COMMUNITIES AS CLINICIANS
BROADLY DEFINED WHETHER IT'S
COMMUNITY HEALTH WORKERS, ALL
THE WAY TO PHYSICIANS AND OTHER
TYPES OF PROFESSIONALS.
I WORRY THAT ACTUALLY WITH MORE
INFORMATION, MORE NEW DEVICES,
MORE CONTINUOUS THRESHOLDS, ALL
THE THINGS THAT I BROUGHT UP,
WE'RE GOING TO DO WORSE BECAUSE
WE HAVEN'T GOTTEN THE BASICS
CORRECT.
AND THAT'S GOING TO CAUSE MORE
PROBLEMS IN THE FUTURE RATHER
THAN SOLVING THEM.
>> KEEP IT SIMPLE.
I THINK THERE'S A LOT OF VALUE
THERE.
RAMA, WHAT ABOUT YOU?
>> WELL, I TALKED ABOUT CUFFLESS
BLOOD PRESSURE TECHNOLOGY AND
WHERE IT STANDS AT PRESENT, BUT
I'LL TRY TO ANSWER YOUR QUESTION
MORE BROADLY THAN MY TALK.
THE UNFORTUNATE THING IS IN
CUFFLESS BLOOD PRESSURE
MEASUREMENT, THERE IS NO LOW
HANGING FRUIT.
DEVELOPING ACCURATE CUFFLESS
BLOOD PRESSURE DEVICES, IT'S A
SUPER HARD TECHNICAL PROBLEM,
AND SINCE THE REGULATORY CLEARED
CUFFLESS DEVICES ONLY MEASURE
BLOOD PRESSURE CHANGES, THEIR
VALIDATION REQUIRES INDUCING
BLOOD PRESSURE CHANGES.
AND THIS MAKES VALIDATION A HARD
PROBLEM AS WELL.
AND SO I WOULD SAY, FOR THE
ATTENDEES OF THIS WORKSHOP THAT
PROBABLY THE SINGLE HIGH
PRIORITY ITEM TO ADDRESS WOULD
BE TO DEVELOP A VALIDATION
STANDARD FOR CUFFLESS DEVICES
WITH CONSENSUS FROM MULTIPLE
GROUPS, AND I THINK THAT SOME OF
THE PEOPLE SHOULD HAVE THE
TECHNICAL KNOWLEDGE AND BE
IMPARTIAL, LIKE NEED TO HAVE
BOTH OF THOSE.
AND A VALIDATION ST STANDARD, IT
WOULD BE IMPORTANT FOR TWO
REASONS.
ONE REASON IS TO PREVENT
INADEQUATE DEVICES FROM BEING
USED IN PATIENT CARE, AND THE
OTHER REASON, I THINK IT'S JUST
AS IMPORTANT, IS TO FOSTER THE
DEVELOPMENT OF NEW TECHNOLOGY
THAT COULD SUCCESSFULLY PASS THE
VALIDATION STANDARD.
>> THAT SEEMS LIKE A GOOD TEE-UP
FOR TAMMY.
>> SO I THINK -- WELL, ACTUALLY
I LIKE WHAT MARWAH WAS SAYING, I
THINK WE CAN DO A BETTER JOB OF
USING THE TOOLS THAT WE HAVE,
BUT I ALSO THINK I WOULD LOVE TO
MAKE IT EASIER FOR PATIENTS TO
PROVIDE US WITH HOME OR OUT OF
OFFICE BLOOD PRESSURE
MEASUREMENTS THAT ARE ACCURATE.
IT IS SUCH AN AMAZING TOOL,
THAT'S WHERE MOST OF OUR
PATIENTS ARE SPENDING THEIR
TIME, BUT ESPECIALLY IN
CHILDREN, IT'S REALLY HARD TO
GET GOOD OUT OF OFFICE BLOOD
PRESSURE.
WE DON'T HAVE ENOUGH DEVICES,
THE KIDS DON'T REALLY ENJOY
WEARING THEM, IT'S HARD FOR
FAMILIES TO HAVE TO -- IF WE'RE
DOING AN AMBULATORY BLOOD
PRESSURE MONITORING TEST, THEY
HAVE TO COME TO THE CLINIC TO
GET THE DEVICE, THEY HAVE TO
RETURN IT, THEY HAVE TO TAKE OFF
TIME, AND WE JUST DON'T MAKE IT
EASY FOR PATIENTS AND SO I THINK
A LOT OF OUR PATIENTS ARE NOT
GETTING OPTIMAL CARE.
SO I THINK IF WE COULD COME UP
WITH WAYS TO MAKE IT EASIER TO
GET OUT OF OFFICE BLOOD PRESSURE
MEASUREMENTS FOR ALL PATIENTS,
AND MAKE SURE WE ADDRESS SOME OF
THOSE DISPARITIES FOR THAT, I
THINK THAT WOULD BE REALLY
GREAT, THAT WOULD BE WHERE I
THINK THE PRIORITY SHOULD BE.
>> I TOTALLY AGREE WE NEED TO
MAKE IT EASIER AND ONE OF THE
WAYS WE CAN MAKE IT EASIER IS BY
FOCUSING ON INTEROPERABILITY AND
STANDARDS, BECAUSE RIGHT NOW,
ALL OF OUR TECHNICAL HEL I.T.
TOOLS, THEY ALL SPEAK A
DIFFERENT LANGUAGE, A
PROPRIETARY LANGUAGE, AND SO
WHEN YOU TRY TO TRANSMIT FROM
ONE DIRECTION OR THE OTHER, YOU
HAVE TO, LIKE, TRANSLATE BETWEEN
EVERY UNIQUE SYSTEM.
AND THAT POSES ITS OWN SET OF
CHALLENGES.
SO THERE ARE -- I TRIED TO -- I
WAS ENDING BUT THERE ARE
STANDARDS THAT EXIST AND MORE
STANDARDS NEED TO BE BUILT, BUT
I THINK FOCUSING ON
INTEROPERABILITY HELPS US NOW
FOR THE TOOLS THAT WE HAVE, AND
HELPS US AS WE THINK FORWARD
LIKE WHAT TOOLS ARE COMING.
>> ONE COMMENT ON THAT BEFORE --
I KNOW KIMBERLY WANTS TO ASK A
QUESTION.
I AGREE WITH YOU ON THE
STANDARDS, HILARY, BUT I ALSO
HAVE CONCERNS ABOUT THE PACE AT
WHICH THIS WORKS.
YOU'VE MENTIONED THE U.S. CDI
VERSION 4 THAT WILL INCLUDE
AMBULATORY -- OR AVERAGE BLOOD
PRESSURE.
I'M NOT SURE WE KNOW THE
IMPLEMENTATION DATA OF THAT YET.
I THINK IT'S GOING TO BE 2027 OR
2028.
>> WE DON'T KNOW FOR SURE, BUT I
THINK WE CAN PRESSURE -- I THINK
IF EVERYONE IS PRESSURING EHR
VENDORS TO PRECERTIFY ON THOSE
DATA ELEMENTS, I THINK WE MIGHT
BE ABLE TO MAKE SOME HEADWAY.
>> THANK YOU SO MUCH.
I THINK MY QUESTION ACTUALLY
FOLLOWS THAT PRETTY WELL.
YOU KNOW, RAMA TOUCHED ON THE
FACT THAT CUFFLESS BLOOD
PRESSURE DEVICES MAY NOT BE, YOU
KNOW, CLINICALLY READY.
ONCE THEY ARE CLINICALLY READY,
HOW DO WE SEE THESE DEVICES
BEING INCORPORATED INTO CLINICAL
DECISION-MAKING AS A FIRST STEP,
YOU KNOW, HAVING THESE DEVICES
CONNECT TO EHRs?
WHAT'S THE FIRST STEP IN
INCORPORATING THOSE INTO THE
CLINICAL DECISION-MAKING?
>> THERE ARE MANY FIRST STEPS
THAT HAVE TO HAPPEN ALL AT THE
SAME TIME, I THINK.
>> WELL, AS A CLINICIAN, I HAVE
TO SAY, I'M A LITTLE WORRIED
ABOUT ONCE WE GET ALL THAT
INFORMATION FROM PATIENTS, IT
GOING TO BE A MASSIVE AMOUNT OF
DATA, AND I DON'T KNOW -- YOU
KNOW, I THINK THAT'S GOING TO BE
CHALLENGING TO FIGURE OUT WHAT
TO DO WITH IT.
AND I ALSO THINK THINGS THAT ARE
GOING TO BE CHALLENGING, YOU
KNOW, JUST AS A STEP BACK, WHEN
I GET HOME BLOOD PRESSURE
MEASUREMENTS, SOMETIMES I'M NOT
SURE WHAT TO DO WITH THEM
BECAUSE DO THEY GET A VALIDATED
DEVICE, IS THE CUFF THE RIGHT
SIZE, I CAN'T TELL YOU HOW MANY
KIDS ARE SENT TO THE ED FOR
HYPERTENSIVE CRISIS BECAUSE THEY
USED A SMALL CUFF, IS IT THE
RIGHT SIZE CUFF, DID THEY ADHERE
TO ALL OF THE DIFFERENT STEPS
THAT YOU NEED FOR VARIOUS
ACCURACY, AND I'VE BEEN SPENDING
THE LAST COUPLE YEARS OF MY
CAREER WORKING ON ACCURACY, AND
SO WHEN WE HAVE NOW THESE
CUFFLESS DEVICES WHERE I THINK
THAT THERE'S EVEN MORE CHANCE
FOR ERROR WITH WHAT I'M SEEING,
IT GOING TO BE CHALLENGING, NOT
ONLY AM I GOING TO HAVE A LOT OF
NUMBERS TO LOOK AT, BUT I'M
GOING TO NEED TO THINK ABOUT ALL
THESE DIFFERENT THINGS THAT
MIGHT HAVE LED TO SOME ERROR.
SO I THINK WE -- I THINK AS A
CLINICIAN, I DON'T KEEP UP WITH
THE TECH IN THE SAME WAY THAT
SOME REALLY TECH-MINDED PEOPLE
DO, AND SO I'M GOING TO NEED
SOME HELP AS THESE THINGS BECOME
MORE AVAILABLE TO FIGURE OUT HOW
TO INTERPRET THIS INFORMATION
WHEN PATIENTS ARE SENDING THEM
TO ME.
>> I'D ALSO ADD THE PATIENT
PERSPECTIVE, SO IN THE SLEEP
WORLD, THERE'S TERMINOLOGY OF
ORTHOSOMNIA, PERSONAL SLEEP
TRACKING, FITBIT DEVICES,
WEARABLE DEVICES AND THERE ARE
PEOPLE WHO ARE NOW GETTING
OBSESSED WITH THE CONTINUOUS
INFORMATION, AND IT ACTUALLY
CAUSING WORSE SLEEP AND SLEEP
QUALITY.
THIS IS NOW A NEW PHENOMENON,
AND WHAT WE STARTED WITH, LET'S
MAKE IT BETTER, BETTER, I'M
CONCERNED FROM THE PATIENT
PERSPECTIVE, NOT JUST THE
CLINICIAN AND MANAGEMENT, THINK
ABOUT ALL THE EHR ALARMS THAT
ARE GOING TO GO OFF ONCE THIS IS
NOW INCORPORATED.
BUT ALSO FOR OUR PATIENTS, IF
THEY'RE CONTINUOUSLY LOOKING AT
THEIR SMARTPHONES, YOU KNOW, FOR
THEIR BLOOD PRESSURE OUTPUT,
JUST THE WAY THAT NOW CONTINUOUS
GLUCOSE MONITORS ARE DOING,
PEOPLE ARE NOW GETTING OBSESSED
WITH CONCEPT OF CONTINUOUS
GLUCOSE MONITOR, WHAT IS THAT
GOING TO LOOK LIKE FOR BLOOD
PRESSURE IN PEOPLE WHO ARE
POTENTIALLY GOING TO GET MORE
AND MORE OBSESSED?
I THINK SOME PEOPLE, SOME
CLINICIANS WILL ALSO LIKE TO
TURN OFF FOR ABPM DEVICES WOULD
LIKE TO HIDE AND MASK THE
NUMBERS THROUGHOUT THE 24 HOUR
PERIOD SO WE'RE NOT ALWAYS
GETTING THIS BURDEN OF ALERTS
AND, YOU KNOW, MESSAGES THROUGH
THE EHR, LIKE HEY, MY BLOOD
PRESSURE THIS MINUTE WAS THIS,
WHAT DO I DO?
AND THERE MAY BE NOTHING TO DO,
RIGHT?
SO THAT'S MY OTHER CONCERN ON
THE OTHER SIDE OF WHAT WILL ALL
THIS DATA DO FOR PATIENTS.
>> WE NEED TO BE SMART WITH ALL
THIS DATA, THERE'S NO QUESTION.
I SAW A COUPLE QUESTIONS COMING
IN TO THE Q & A AND THE CHAT
THAT WERE RELATED TO KIND OF THE
FUNDAMENTAL DIFFERENCES
POTENTIALLY BETWEEN ABPM AND
HOME BLOOD PRESSURE MONITORING.
I THINK MARWAH MAYBE YOUR TALK
MIGHT HAVE PROMPTED SOME OF
THESE QUESTIONS, SO THE IDEA
THAT ARE THEY FUNDAMENTALLY
MEASURING DIFFERENT THINGS AND
HOW DO WE KIND OF APPROACH THAT.
I THINK, TAMMY, YOU EVEN POSED A
QUESTION RELATED TO IN CHILDREN,
SEEING DIFFERENCES WITH ABPM
BECAUSE OF THE ACTIVITY THAT MAY
BE ASSOCIATED WITH KIDS WHILE
THEY'RE RECEIVING ABPM AND ALSO
SOME EARLIER DATA WE SAW TODAY
ABOUT ACTIVE ADULTS MAYBE HAVING
DIFFERENCES IN THEIR ABPM, SO
ANY COMMENTS YOU HAVE THERE
ABOUT SORT OF THOSE FUNDAMENTAL
DIFFERENCES BETWEEN ABPM AND
BLOOD PRESSURE MONITORING?
>> I THINK THEY'RE MEASURING
DIFFERENT THINGS.
AS A CLINICIAN, I TRY TO THINK
WHICH PATIENT WOULD BENEFIT IN
ADDITION TO WHAT THE GUIDELINES
SAY, BUT WHICH BENEFIT, DO I
JUST NEED A 24 HOUR, LIKE,
SNAPSHOT ON?
AND THAT I ACTUALLY WANTED TO
KNOW, IS THERE SOMETHING IN
THEIR HOME ENVIRONMENTS?
I KNOW -- IS THERE SOMETHING IN
THEIR HOME ENVIRONMENT THAT MAY
BE CAUSING THEIR HOME BLOOD
PRESSURE TO BE ELEVATED, MAYBE
IT'S INTERACTIONS, WHATEVER IT
IS, AS OPPOSED TO SORT OF HOME
BLOOD PRESSURE WHERE I'M TRYING
TO GET A LONGER TERM PERSPECTIVE
OF WHAT IT GOING TO DO AND
REALLY TRYING TO ADVISE PEOPLE
ON HOW TO MODIFY MAYBE LIFESTYLE
MODIFICATIONS AND INTERVENTIONS
BECAUSE THAT'S, I THINK, MORE OF
A DIALOGUE BETWEEN THE PATIENT
AND THEIR OWN INFORMATION.
SO I THINK IT'S JUST HOME BLOOD
PRESSURE JUST IN A DIFFERENT
ENVIRONMENTAL CONTEXT.
AND I ACTUALLY THINK IF THE DATA
TRULY HIGH QUALITY DATA THAT I
MENTIONED WITH WITHIN PERSON
RANDOMIZATION DOES SHOW
POTENTIALLY MAYBE BETTER THAN
UNATTENDED, THAT'S REALLY AN
OPPORTUNITY FOR NEW PATIENT
ENGAGEMENT AND SAYING LET ME
TEACH YOU THE PROPER TECHNIQUE
WHILE YOU'RE WITH ME IN THE
OFFICE.
THAT ADDRESSES SOME OF THE
BARRIERS, IT'S LIKE I'M GOING TO
TAKE THE TIME TO SHOW YOU HOW TO
DO THIS RIGHT WHILE YOU'RE HERE
IN THE OFFICE, YOU'RE GOING TO
PRACTICE BY YOURSELF.
YOU CAN ASK QUESTIONS, AND I
WANT YOU TO CONTINUE THIS IN AN
OUTSIDE ENVIRONMENT AND THIS IS
HOW I'M GOING TO USE YOUR DATA
ACROSS THESE DIFFERENT
ENVIRONMENTAL CONTEXTS.
I THINK WHEN YOU PRESENT IT THAT
WAY, YOU REALLY CAN HAVE AN
OPPORTUNITY TO USE OFFICE --
HOME BLOOD PRESSURE AND OFFICE
BLOOD PRESSURE IN A WAY THAT'S
POTENTIALLY THE SAME AND I THINK
THAT'S WHAT DR. TOWNSEND WAS
THINKING IN TERMS OF SOME OF THE
QUESTIONS HE POSED.
>> I WAS JUST GOING TO ADD ON
THAT TO MARWAH'S POINT, I
ACTUALLY MAKE A BIG PRODUCTION
ABOUT WHAT I'M DOING WHEN
MEASURING BLOOD PRESSURE BECAUSE
AS SOON AS I WALK INTO THE ROOM,
I SAY WE'RE GOING TO MOVE YOU
OVER HERE SO YOU'RE POSITIONED
IN THE RIGHT SPOT SO YOUR ARM IS
POSITIONED WELL, I MEASURE THEIR
ARM, TALK ABOUT THE CUFF.
SO I MAKE SURE THAT -- AGAIN I
MAKE A BIG SHOW OF IT, NOT --
BUT FOR EDUCATION, THIS IS WHY
I'M DOING THESE THINGS, I WANT
YOU TO REMEMBER THIS NEXT TIME
YOU'RE AT YOUR PRIME RYE CARE
DOCTOR SO YOU CAN MAKE SURE YOU
REMEMBER TO REMIND THEM TO DO IT
THIS WAY MOVING FORWARD, SO I
THINK THAT'S SUPER IMPORTANT.
>> THERE'S ANOTHER QUESTION IN
THE CHAT SIMILAR TO THIS ABPM
CONVERSATION.
WHEN WE'RE COMPARING CUFFLESS
DEVICES TO ABPM TO ESTIMATE THAT
ASLEEP BLOOD PRESSURE,
POTENTIALLY THERE'S THE
DIFFERENCE IN THE CUFFLESS BLOOD
PRESSURE VERSUS THE ABPM OUTPUT
DUE TO JUST THE ABPM MAKING THE
USER AWARE THAT THEY ARE GETTING
THEIR MEASUREMENT TAKEN, AND SO
HOW DO WE FACTOR THAT IN TO THE
VALIDATION OF THESE CUFFLESS
DEVICES?
ACTUALLY I WON'T EVEN PROVIDE
ANY EXAMPLES, JUST SEE WHAT THE
GROUP HAS TO SAY ABOUT THAT.
>> I WOULD SAY THAT YOU COULD
COMPARE THEM AT THE SAME TIME.
YOU KNOW, WHEN THE CUFF IS
INFLATING, A PATIENT DOESN'T
HAVE INTERARM DIFFERENCE, YOU
COULD TEST THAT AND BOTH UNDER
THE PERTURBATION OF THE CUFF
INFLATION, BUT IF YOU LOOK AT --
YOU KNOW, STEPHEN HAD SHOWED
SOME DATA OF A COMMERCIAL DEVICE
BEING TESTED INDEPENDENTLY UNDER
ABPM, A CUFFLESS DEVICE, AND THE
ABPM DEVICE SHOWED THE NIGHTTIME
DIP, BUT THE CUFFLESS DEVICE
DIDN'T.
SO YOU KNOW, YOU THINK IT WOULD
BE THE OTHER WAY AROUND, IF THE
CUFF DEVICE WAS CAUSING THE --
PERTURBING THE PATIENT, AND I
JUST WANT TO ALSO ADD, ONE OF
THE KEY POINTS OF WHAT I WAS
TRYING TO SAY IS THAT, IF YOU
SEE CUFFLESS DEVICES DETECTING
THE NIGHTTIME DIP IN THE FUTURE,
THAT COULD BE JUST BECAUSE THE
CUFFLESS DEVICE TAKES THE TIME
OF DAY, SO IF IT'S LIKE
1:00 A.M., 2:00 A.M., 3:00 A.M.,
MAYBE IT TAKES THE ACCELEROMETER
AND SEES YOU'RE NOT MOVING AND
JUST TAKES A BLOOD PRESSURE 15%
LOWER THAN DAY TIME.
AND SO THOSE ARE THE THINGS
WE'VE GOT TO WORRY ABOUT WITH
THE CUFFLESS DEVICE.
IT'S TAKING THE WAVEFORM
MEASUREMENT FROM A WEARABLE AND
IT TAKING LIKE DEMOGRAPHICS AND
CUFF CALIBRATION.
YOU HAVE TO THINK ABOUT DID THE
WAVEFORM HELP IN THE MEASUREMENT
OR NOT BECAUSE IF IT DIDN'T, WHY
WOULD YOU WEAR IT?
YOU COULD JUST HAVE THE CUFF,
DEMOGRAPHICS, PUT IN YOUR
SMARTPHONE AND GET SOME
CALCULATION OUT.
THAT'S WHAT I MEAN, THERE'S NO
EVIDENT TO DATE THAT THERE'S NO
WAVEFORM PROVIDING ANY ADDED
VALUE.
>> ONE THING TO ADD ON TO THAT,
FOR ME, WHEN I'VE BEEN IN A LOT
OF THESE HYPERTENSION MEETINGS
AND I'VE SEEN THAT DATA THAT'S
BEING DISPLAYED AND THERE'S BEEN
A LOT OF CONVERSATION ABOUT HOW
TO TEST THESE DEVICES WHILE
WE'RE SLEEPING.
YOU KNOW, AMBULATORY BLOORP
MONITORS ARE NEVER TESTED DURING
SLEEP, THEY'RE NEVER TESTED
WHILE SUPINE SO WE'RE COMPARING
A DEVICE WHERE WE DON'T EVEN
KNOW HOW IT PERFORMS IN THAT
POSITION AND THAT CONDITION, AND
WE'RE ASSUMING IT'S THE
REFERENCE STANDARD BUT WE DON'T
KNOW IF IT PERFORMS THE WAY THEY
EXPECT TO PERFORM.
SO I THINK TO ME, IT'S
CHALLENGING WHEN I WAS SAYING
THE VALIDATION PROTOCOLS ALIGN A
LITTLE BIT BETTER, THIS MAKES WE
WANT TO REVISIT WHILE WE DO
AMBULATORY BLOOD PRESSURE
MONITORING TESTING -- MOVING
FORWARD.
>> I THINK WE MAY BE AT OUR
TIME.
I'M NOT SURE, PAULA, IF WE
SHOULD HAND IT BACK TO YOU OR
ANYTHING ELSE RIGHT NOW?
>> I WOULD LIKE TO INVITE THE
MEETING CHAIRS FOR SOME CLOSING
COMMENTS FOR DAY ONE.
>> FROM MY PERSPECTIVE, IT'S
BEEN A FABULOUS CONVERSATION.
I KNOW THERE'S MANY MORE THINGS
WE CAN DISCUSS.
I WANTED TO FIRST SAY THANK YOU
TO ALL THE SPEAKERS.
IT'S BEEN A GREAT DAY ONE.
PLEASE KEEP THE ENGAGEMENT UP
AND WE'RE GOING TO TRY AND
COLLECT ALL THESE QUESTIONS AS
WELL SO THAT WE CAN USE THEM
MOVING FORWARD FOR DAY TWO.
AND SOME OF THE BREAKOUT
SESSIONS.
STEPHEN, I KNOW YOU'RE --
>> THIS EXCEEDED EXPECTATIONS.
I CAME IN WITH REALLY A LOT OF
EXCITEMENT FOR TODAY, THE TALKS
HAVE BEEN FABULOUS, THE QIS HAVE
BEEN REALLY WONDERFUL AND
THOUGHT-PROVOKING.
I FEEL LIKE WE DON'T HAVE ENOUGH
TIME, AND I KIND OF DID EXPECT
THAT.
SO I'M REALLY EXCITED TO
CONTINUE WITH THE SAME LEVEL OF
PASSION AND ENGAGEMENT TOMORROW,
AND THANK YOU ALL FOR JOINING
TODAY AND AGAIN, PAULA, FOR ALL
YOUR LEADERSHIP IN ORGANIZING
THIS.
>> THANK YOU ALL FOR A GREAT DAY
TODAY, AND SEE YOU TOMORROW AT
11:00 A.M.
BYE-BYE.
>> TAKE CARE.