Quantifying Blood Pressure Visit-to-Visit Variability in the Real-World Setting: A Retrospective Cohort Study

Minimum number of readings necessary for determining long-term visit-to-visit blood pressure variability to predict cardiovascular outcomes in people with diabetes

BACKGROUND

People with diabetes often have increased blood pressure (BP) variability because of autonomic dysfunction and arterial stiffness, making it a critical factor in predicting clinical outcomes. We investigated the reproducibility of long-term visit-to-visit BP variability (VVV) and the minimum number of BP readings to reliably determine VVV in people with diabetes.

METHODS

This multicenter retrospective study used data from electronic health records of the Korea University Medical Center database. Altogether, 10 475 people with diabetes who had more than nine BP readings during a maximum period of 2 years were identified. This study focused on the coefficient of variation of these readings and their correlation with major adverse cardiovascular events (MACE) over a 3-year follow-up period.

RESULTS

The mean age of the participants was 65.2 years. Of these, 53.2% were men, and 87.4% had hypertension. The mean coefficient of variation of multiple SBP readings that best predicted the 3-year MACE were 8.4, 9.5, 9.0, 9.0, and 9.7 for three, five, seven, nine, and all readings, respectively. Patients with high VVV (coefficient of variation of five SBP readings >9) exhibited a higher incidence of 3-year MACE (10.1%) than those with low VVV (5.4%, P  < 0.001). In the multivariable analysis, high VVV of both SBP and DBP were independently associated with 3-year MACE.

CONCLUSION

Long-term VVV in the BP is a reproducible and reliable predictor of cardiovascular outcomes in people with diabetes. A minimum of five BP measurements are recommended for effective intraindividual VVV estimation and cardiovascular risk assessment.

The Long-Term Blood Pressure Trends Following a Remote Hypertension Intervention: A Secondary Analysis of the Digital Care Transformation - Remotely Delivered Hypertension Management Program

BACKGROUND

Hypertension is a major cardiovascular risk factor, yet traditional care often results in suboptimal blood pressure (BP) control at the population level. We implemented a remote hypertension management program that monitored home BP and titrated medications per algorithm. This study assessed the program's long-term effects by examining participants' office BP up to 42 months post-enrollment.

METHODS

Participants of the remote hypertension program were categorized into 4 groups: (1) enrolled-maintenance (achieved goal home BP of ≤130/80 mm Hg), (2) enrolled-early exit (left before achieving goal BP), (3) education-only (lifestyle modifications and medications compliance), and (4) white coat hypertension group (high office BP but normal home BP). Office BP readings of participants were collected up to 42 months post-enrollment. A linear mixed-effects regression model estimated mean BP levels and studied factors associated with above-goal systolic BP in the maintenance group.

RESULTS

Office BP readings from 3601 participants (mean age, 61±11 years; 57% female; 60% white; 52% atherosclerotic cardiovascular disease) were extracted from electronic health records and analyzed. All groups sustained office BP below their qualifying values (P<0.001) over 42 months. In the maintenance group, 89.7% of participants maintained systolic BP at goal, compared with 63.5% in the early exit group, 69.4% in the education-only group, and 90.7% in the white coat hypertension group. Age >50 years was associated with above-goal systolic BP in the maintenance group.

CONCLUSIONS

Participants who achieved BP control through the remote hypertension program maintained goal systolic BP in 90% of cases up to 42 months post-enrollment. These findings highlight the long-term benefits of remote, intensive management programs for effective hypertension control.

Controversy in Hypertension: Pro-Side of the Argument Using Artificial Intelligence for Hypertension Diagnosis and Management

Hypertension presents the largest modifiable public health challenge due to its high prevalence, its intimate relationship to cardiovascular diseases, and its complex pathogenesis and pathophysiology. Low awareness of blood pressure elevation and suboptimal hypertension diagnosis serve as the major hurdles in effective hypertension management. Advances in artificial intelligence in hypertension have permitted the integrative analysis of large data sets including omics, clinical (with novel sensor and wearable technologies), health-related, social, behavioral, and environmental sources, and hold transformative potential in achieving large-scale, data-driven approaches toward personalized diagnosis, treatment, and long-term management. However, although the emerging artificial intelligence science may advance the concept of precision hypertension in discovery, drug targeting and development, patient care, and management, its clinical adoption at scale today is lacking. Recognizing that clinical implementation of artificial intelligence-based solutions need evidence generation, this opinion statement examines a clinician-centric perspective of the state-of-art in using artificial intelligence in the management of hypertension and puts forward recommendations toward equitable precision hypertension care.

A deep learning digital biomarker to detect hypertension and stratify cardiovascular risk from the electrocardiogram

Hypertension is a major risk factor for cardiovascular disease (CVD), yet blood pressure is measured intermittently and under suboptimal conditions. We developed a deep learning model to identify hypertension and stratify risk of CVD using 12-lead electrocardiogram waveforms. HTN-AI was trained to detect hypertension using 752,415 electrocardiograms from 103,405 adults at Massachusetts General Hospital. We externally validated HTN-AI and demonstrated associations between HTN-AI risk and incident CVD in 56,760 adults at Brigham and Women's Hospital. HTN-AI accurately discriminated hypertension (internal and external validation AUROC 0.803 and 0.771, respectively). In Fine-Gray regression analyses model-predicted probability of hypertension was associated with mortality (hazard ratio per standard deviation: 1.47 [1.36-1.60], p < 0.001), HF (2.26 [1.90-2.69], p < 0.001), MI (1.87 [1.69-2.07], p < 0.001), stroke (1.30 [1.18-1.44], p < 0.001), and aortic dissection or rupture (1.69 [1.22-2.35], p < 0.001) after adjustment for demographics and risk factors. HTN-AI may facilitate diagnosis of hypertension and serve as a digital biomarker of hypertension-associated CVD.

The Impact of an Enhanced Data Visualization Tool for Hypertension in the Electronic Health Record on Physician Judgments About Hypertension Control

PURPOSE

Uncontrolled hypertension is a significant US health problem, despite existing effective treatments. This study assessed the impact of variations in patterns of blood pressure data on physician perceptions of hypertension control using different forms of data visualization.

METHOD

Physicians (N = 57) reviewed eight brief vignettes describing a fictitious patient; each vignette included a graph of the patient's blood pressure data. We examined how variations in mean systolic blood pressure (SBP), blood pressure standard deviation (SD), and form of visualization (e.g., line graph with raw values or smoothed values only) affected judgments about hypertension control and need for medication change.

RESULTS

Smoothing successfully reduced visual noise for the physicians. For controlled hypertension, physician judgments were more consistent with clinical guidelines when using the smoothed graph compared with the raw data graph. Judgments about hypertension control with the smoothed graph were similar to judgments made using the raw data graph for cases of uncontrolled hypertension.

CONCLUSION

Data visualization can direct physicians to attend to more clinically meaningful information, thereby improving their judgments of hypertension control.

SPRINT Treatment Among Adults With Chronic Kidney Disease From 2 Large Health Care Systems

Importance

It is unclear whether the effects of intensive vs standard blood pressure (BP) targets seen in clinical trials generalize to patients with chronic kidney disease (CKD) encountered in everyday practice due to differences in the distribution of cardiovascular risk factors and coexisting conditions.

Objective

To evaluate whether the beneficial and adverse effects of intensive vs standard BP control observed in the Systolic Blood Pressure Intervention Trial (SPRINT) are transportable to a target population of adults with CKD in clinical practice.

Design, Setting, and Participants

This comparative effectiveness study identified 2 populations with CKD who met the eligibility criteria for SPRINT between January 1 and December 31, 2019, in the Veterans Health Administration (VHA) and Kaiser Permanente of Southern California (KPSC). Baseline covariate, treatment, and outcome data from SPRINT were combined with covariate data from these populations to estimate the treatment effects in the target population, applying models that estimated outcomes using distributions in the trial. Analysis was performed between May 2023 and October 2024.

Main Outcomes and Measures

The main outcomes were major cardiovascular events, all-cause death, cognitive impairment, CKD progression, and adverse events at 4 years.

Results

A total of 85 938 patients (mean [SD] age, 75.7 [10.0] years; 81 628 [95.0%] male) from the VHA and 13 983 patients (mean [SD] age, 77.4 [9.6] years; 5371 [38.4%] male) from KPSC were included. Compared with 9361 SPRINT participants (mean [SD] age, 67.9 [9.4] years; 6029 [64.4%] male), these patients were older, had less prevalent cardiovascular disease, higher albuminuria, and used more statins. The associations of intensive vs standard BP control with major cardiovascular events, all-cause death, and adverse events were transportable from the trial to the VHA and KPSC populations; however, the trial's effects on cognitive and CKD outcomes were not transportable in 1 or both clinical populations. Intensive vs standard BP treatment was associated with lower absolute risks for major cardiovascular events at 4 years by 5.1% (95% CI, -9.8% to 3.2%) in the VHA population and 3.0% (95% CI, -6.3% to 0.3%) in the KPSC population and higher risks for adverse events by 1.3% (95% CI, -5.5% to 7.7%) in the VHA population and 3.1% (95% CI, -1.5% to 8.3%) in the KPSC population.

Conclusions and Relevance

In this comparative effectiveness study, the reduction in fatal and nonfatal cardiovascular end points and the increase in adverse events observed in SPRINT were largely transportable to trial-eligible CKD populations from clinical practice, suggesting benefits of implementing intensive BP targets.

Novel approaches to define responders to interventional treatment in hypertension: insights from the SPYRAL HTN-OFF and HTN-ON MED trials

Multiple sham-controlled clinical trials have demonstrated significant reductions in both office and 24-h blood pressure (BP) following radiofrequency renal denervation (RDN) in the uncontrolled hypertension population. Notably, the blood pressure response varies widely within individual participants, thus showing a clinical need to identify potential RDN "responders" prior to the procedure. Despite multiple analytic efforts, no single parameter, aside from baseline blood pressure, has been consistently associated with BP reduction following RDN. However, this failure may be due to limitations in empiric definitions of responders. Indeed, commonly applied responder definitions based on the difference between two point-in-time BP measurements are fraught due to visit-to-visit variability in office and 24-h blood pressure endpoints. Several factors should be considered to develop a more clinically useful operational definition of procedural response including relative changes in office and 24-h BP, consideration of the temporal response to RDN, as well as adjustment for baseline BP. The current evidence may provide incentives for future expert consensus to precisely define responders to hypertension treatments.

Disentangling the phenotypic patterns of hypertension and chronic hypotension

OBJECTIVE

2017 blood pressure (BP) categories focus on cardiac risk. We hypothesize that studying the balance between mechanisms that increase or decrease BP across the medical phenome will lead to new insights. We devised a classifier that uses BP measures to assign individuals to mutually exclusive categories centered in the upper (Htn), lower (Hotn) and middle (Naf) zones of the BP spectrum; and examined the epidemiologic and phenotypic patterns of these BP-categories.

METHODS

We classified a cohort of 832,560 deidentified electronic health records by BP-category; compared the frequency of BP-categories and four subtypes of Htn and Hotn by sex and age-decade; visualized the distributions of systolic, diastolic, mean arterial and pulse pressures stratified by BP-category; and ran Phenome-wide Association Studies (PheWAS) for Htn and Hotn. We paired knowledgebases for hypertension and hypotension and computed aggregate knowledgebase status (KB-status) indicating known associations. We assessed alignment of PheWAS results with KB-status for phecodes in the knowledgebase, and paired PheWAS correlations with KB-status to surface phenotypic patterns.

RESULTS

BP-categories represent distinct distributions within the multimodal distributions of systolic and diastolic pressure. They are centered in the upper, lower, and middle zones of mean arterial pressure and provide a different signal than pulse pressure. For phecodes in the knowledgebase, 85% of positive correlations align with KB-status. Phenotypic patterns for Htn and Hotn overlap for several phecodes and are separate for others. Our analysis suggests five candidates for hypothesis testing research, two where the prevalence of the association with Htn or Hotn may be under appreciated, three where mechanisms that increase and decrease blood pressure may be affecting one another's expression.

CONCLUSION

PairedPheWAS methods may open a phenome-wide path to disentangling hypertension and chronic hypotension. Our classifier provides a starting point for assigning individuals to BP-categories representing the upper, lower, and middle zones of the BP spectrum. 4.7 % of individuals matching 2017 BP categories for normal, elevated BP or isolated hypertension, have diastolic pressure < 60. Research is needed to fine-tune the classifier, provide external validation, evaluate the clinical significance of diastolic pressure < 60, and test the candidate hypotheses.

Germline predictors for bevacizumab induced hypertensive crisis in ECOG-ACRIN 5103 and BEATRICE

BACKGROUND

Bevacizumab is a beneficial therapy in several advanced cancer types. Predictive biomarkers to better understand which patients are destined to benefit or experience toxicity are needed. Associations between bevacizumab induced hypertension and survival have been reported but with conflicting conclusions.

METHODS

We performed post-hoc analyses to evaluate the association in 3124 patients from two phase III adjuvant breast cancer trials, E5103 and BEATRICE. Differences in invasive disease-free survival (IDFS) and overall survival (OS) between patients with hypertension and those without were compared. Hypertension was defined as systolic blood pressure (SBP) ≥ 160 mmHg (n = 346) and SBP ≥ 180 mmHg (hypertensive crisis) (n = 69). Genomic analyses were performed to evaluate germline genetic predictors for the hypertensive crisis.

RESULTS

Hypertensive crisis was significantly associated with superior IDFS (p = 0.015) and OS (p = 0.042), but only IDFS (p = 0.029; HR = 0.28) remained significant after correction for prognostic factors. SBP ≥ 160 mmHg was not associated with either IDFS or OS. A common single-nucleotide polymorphism, rs6486785, was significantly associated with hypertensive crisis (p = 8.4 × 10-9; OR = 5.2).

CONCLUSION

Bevacizumab-induced hypertensive crisis is associated with superior outcomes and rs6486785 predicted an increased risk of this key toxicity.

Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health

Background

Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation.

Methods

Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI).

Results

Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results.

Conclusions

In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.

Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults

Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.

Association Between Self-Reported Medication Adherence and Therapeutic Inertia in Hypertension: A Secondary Analysis of SPRINT (Systolic Blood Pressure Intervention Trial)

BACKGROUND

Therapeutic inertia (TI), failure to intensify antihypertensive medication when blood pressure (BP) is above goal, remains prevalent in hypertension management. The degree to which self-reported antihypertensive adherence is associated with TI with intensive BP goals remains unclear.

METHODS AND RESULTS

Cross-sectional analysis was performed of the 12-month visit of participants in the intensive arm of SPRINT (Systolic Blood Pressure Intervention Trial), which randomized adults to intensive (<120 mm Hg) versus standard (<140 mm Hg) systolic BP goals. TI was defined as no increase in antihypertensive regimen intensity score, which incorporates medication number and dose, when systolic BP is ≥120 mm Hg. Self-reported adherence was assessed using the 8-Item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (MMAS-8 score <6), medium (MMAS-8 score 6 to <8), and high (MMAS-8 score 8). Poisson regressions estimated prevalence ratios (PRs) and 95% CIs for TI associated with MMAS-8. Among 1009 intensive arm participants with systolic BP >120 mm Hg at the 12-month visit (mean age, 69.6 years; 35.2% female, 28.8% non-Hispanic Black), TI occurred in 50.8% of participants. Participants with low adherence (versus high) were younger and more likely to be non-Hispanic Black or smokers. The prevalence of TI among patients with low, medium, and high adherence was 45.0%, 53.5%, and 50.4%, respectively. After adjustment, neither low nor medium adherence (versus high) were associated with TI (PR, 1.11 [95% CI, 0.87-1.42]; PR, 1.08 [95% CI, 0.84-1.38], respectively).

CONCLUSIONS

Although clinician uncertainty about adherence is often cited as a reason for why antihypertensive intensification is withheld when above BP goals, we observed no evidence of an association between self-reported adherence and TI.

Biomarkers to Guide Medical Therapy in Primary Aldosteronism

Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.

Implementing a Blood Pressure Measurement Curriculum for First-Year Medical Students

A core clinical skill medical students need to learn is obtaining an accurate blood pressure (BP) reading. We developed a standardized BP curriculum for first-year medical students. Medical students completed online modules and a hands-on skills session to learn BP skills. Pre- and post-surveys and an observed structured clinical encounter (OSCE) assessed student confidence and ability to accurately measure BP. Student confidence and mean OSCE scores (pre = 2.63, post = 6.51; p < 0.001) improved upon completion of the curriculum. The curriculum was feasible, well received, and improved student's skills for taking an accurate BP.