I am a general cardiologist. Managing blood pressure is one of the major health issues I manage in helping to prevent progression of cardiovascular disease. Optimal blood pressure targets have been an ongoing source of debate amongst cardiologists, primary care providers and other health care providers. In fact, a recent randomized control trial, the SPRINT trial, was stopped prior to completion. This was due to statistically significant reductions in the primary composite outcome of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular amongst patients with increased cardiovascular risk and a systolic blood pressure > 130 mmHg when randomized to an intensive blood pressure lowering regimen targeting a systolic blood pressure of < 120 mmHg versus standard treatment to a systolic blood pressure less than 140 mmHg (1).
This study and others further highlight the growing importance of categorization, risk stratification, and individualization of blood pressure targets. An analysis from the Dallas Heart Study examined “white coat hypertension”, defined as elevated clinic blood pressures > 140/90 and normal home blood pressures of < 135/85 mm Hg, “masked hypertension”, defined as elevated home blood pressure of > 135/85 mm Hg and normal clinic blood pressures of <140/90 mm Hg , and “sustained hypertension”, or elevation of both home blood pressure (> 135/85 mm Hg) and clinic BP (> 140/90 mm Hg) (2). In this analysis, both white coat hypertension and masked hypertension were associated with increased aortic stiffness, renal injury, and incident cardiovascular events (2). The prevalence of white coat hypertension is high and varies from 20% to 45%.
Understanding overall blood pressure trends and being able to easily sub-categorize individual patient’s blood pressure findings will continue to play a key role in helping to determine their optimal treatment strategy and, ultimately, to reduce their risk of cardiovascular events.
Right now, ambulatory blood pressure monitors are relatively expensive, large, and cumbersome to use. It is hard for patients to be compliant and it can be distracting during periods of sleep. Additionally, the data collected is difficult for the patient to access, and almost impossible for the patient to interpret. The data is also difficult for the physician to access and interpret.
Today, there is inexpensive technology the size of a wristwatch that can measure a person's blood pressure. One example is the HE Wearable Blood Pressure Monitor (coolwearable.com/h2-wearable/).
I propose using this small, inexpensive wearable blood pressure monitor in place of the big, bulky ambulatory blood pressure monitors of today.
Important points of design execution:
1) Integrate it with a step counter/activity monitor so that the physician knows if the blood pressure was captured at rest or during physical activity
2) Blood pressure needs to be captured at regular intervals over the day (to account for the natural blood pressure variation by time)
3) Should be a continuous feed of data into an interface that can be accessed by the patient and the physician
4) Should be easy to sort and interpret the data (have it divided and averaged over time periods to help with categorization and diagnosis)
5) Data should be integrated into the patient’s electronic health record
6) Integrate it with pulse oximetry to evaluate for other etiologies of hypertension like obstructive sleep apnea
Cheaper and easier evaluation and diagnosis of hypertension and characterization of the subtype of hypertension (e.g. “white coat hypertension”) for more personalized tailoring of lifestyle and treatment recommendations at the point of care.
The first pilot would need to validate the accuracy of a wearable blood pressure monitor.
Once accuracy is established, the second pilot should be to determine the sensitivity and specificity of a wearable blood pressure monitor in diagnosing and/or ruling out hypertension as compared to the established ambulatory blood pressure monitor.
The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015;Nov 9:[Epub ahead of print].
Tientcheu D, Ayers C, Das SR, et al. Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study. J Am Coll Cardiol. 2015;66(20):2159-2169. doi:10.1016/j.jacc.2015.09.007.
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