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Off the cuff: rebooting blood pressure treatment
Perspectives
Digital medicine Off the cuff: rebooting blood pressure treatment The sphygmomanometer was first introduced into clinical practice some 120 years ago, followed decades later by the concept of high blood pressure as a disease. It took several more decades before antihypertensive medications became available, and today there are nearly a dozen individual classes of blood pressure-lowering drugs. Yet despite having the basic tools necessary to diagnose and treat hypertension for over half a century, high blood pressure remains one of the leading contributors to morbidity and mortality worldwide. There are many reasons for this problem, including the need for better awareness of lifestyle and environmental factors, policies that promote healthy behaviours, and universal access to affordable antihypertensive drugs. Another key issue is that we don’t yet have a clear understanding of “normal” blood pressure. This is mainly due to the fairly cumbersome act of cuff-based blood pressure determination, which has mostly relegated blood pressure monitoring to one-off measurements in a clinic. This approach prevents us from understanding night-time versus daytime blood pressure, day-to-day or even minute-to-minute variability, and blood pressure trajectories over years and decades. Additionally, there are inadequate systems of care to enable the identification and proper management of individuals with hypertension or those at high risk. Many people with hypertension globally do not have their blood pressure adequately controlled. This is partly due to the fact that hypertension is undiagnosed in many patients, but also because only about a third of those diagnosed are adequately controlled. Today, with innovative digital technologies, we have the potential to re-engineer blood pressure management, eliminating not only the cuff but also the century-old approach which requires monitoring, decision making, education, and treatment be tied to a clinical visit. To simplify and improve blood pressure measurement capabilities devices are in development that range from handheld devices, to wristbands, to weight scales. These emerging technologies use techniques such as photoplethysmography (the optical sensing of changes in light absorption with each heartbeat, as in pulse oximetry) or radar to measure blood pressure. Probably the greatest advancement these non-cuff sensing technologies will bring is in enabling the development of wearable sensors for continuous and non-invasive measurement of blood pressure. So far the only devices that have regulatory approval in the USA and Europe are for continuous non-invasive blood pressure monitoring in the inpatient setting. But with the future availability of consumer grade wearables that are able to monitor blood pressure continuously in all settings, we are likely to gain a more comprehensive understanding of environmental and behavioural influences on blood pressure, and how that differs between individuals and over time. www.thelancet.com Vol 388 August 20, 2016
Innovative digital technologies for self-tracking of blood pressure alone, however, don’t overcome all the obstacles to achieving better blood pressure control. They do not address inadequate management once an individual is identified as someone who would benefit from therapeutic interventions to lower their blood pressure. One future possible solution incorporates other components of the ongoing digital revolution—ubiquitous connectivity, pervasive computational capability, and accessible artificial intelligence—all potentially available through a smartphone. A smartphone allows for blood pressure data to be aggregated, visualised, and made instantaneously available for feedback, if desired. In the near future, that feedback might be via virtual medical assistants embedded in smartphones that use machine learning to analyse the individual’s unique blood pressure trends, along with streaming data from other covariates including sleep, activity, weight, nutrition, comorbidities, and medication, to enable and guide an individualised approach to blood pressure management. This external “wisdom of the body” could complement the internal capabilities that Walter Cannon described in his classic book on haemostasis and autoregulation back in 1932. Going digital to better understand and treat hypertension holds great promise. Through the use of new technologies the imprecise diagnosis of essential hypertension could be recharacterised into distinct phenotypes allowing for a much deeper understanding of what constitutes high blood pressure. And we could transform clinical care so that it’s more patient centred, pragmatic, inexpensive, and globally scalable. Let’s hope emerging technologies enable the medical community to reboot a century-old practice into the 21st century.
See Comment page 740
*Steven R Steinhubl, Evan D Muse, Paddy M Barrett, Eric J Topol
Irazola VE, Gutierrez L, Bloomfield G, et al. Hypertension prevalence, awareness, treatment, and control in selected LMIC communities: results from the NHLBI/UHG network of Centers of Excellence for chronic diseases. Glob Heart 2016; 11: 47–59
Scripps Translational Science Institute, La Jolla, CA 92037, USA steinhub@scripps,edu
Further reading Cannon WB. The wisdom of the body. New York: W W Norton & Company, 1932 Chow CK, Teo KK, Rangarajan S, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013; 310: 959–68 Ezzati M, Riboli E. Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med 2013; 369: 954–64.
Rothwell PM. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet 2010; 375: 938–48
The authors are supported by the National Institutes of Health (NIH) /National Center for Advancing Translational Sciences grant UL1TR001114 and a grant from the Qualcomm Foundation.
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Digital medicine Off the cuff: rebooting blood pressure treatment The sphygmomanometer was first introduced into clinical practice some 120 years ago, followed decades later by the concept of high blood pressure as a disease. It took several more decades before antihypertensive medications became available, and today there are nearly a dozen individual classes of blood pressure-lowering drugs. Yet despite having the basic tools necessary to diagnose and treat hypertension for over half a century, high blood pressure remains one of the leading contributors to morbidity and mortality worldwide. There are many reasons for this problem, including the need for better awareness of lifestyle and environmental factors, policies that promote healthy behaviours, and universal access to affordable antihypertensive drugs. Another key issue is that we don’t yet have a clear understanding of “normal” blood pressure. This is mainly due to the fairly cumbersome act of cuff-based blood pressure determination, which has mostly relegated blood pressure monitoring to one-off measurements in a clinic. This approach prevents us from understanding night-time versus daytime blood pressure, day-to-day or even minute-to-minute variability, and blood pressure trajectories over years and decades. Additionally, there are inadequate systems of care to enable the identification and proper management of individuals with hypertension or those at high risk. Many people with hypertension globally do not have their blood pressure adequately controlled. This is partly due to the fact that hypertension is undiagnosed in many patients, but also because only about a third of those diagnosed are adequately controlled. Today, with innovative digital technologies, we have the potential to re-engineer blood pressure management, eliminating not only the cuff but also the century-old approach which requires monitoring, decision making, education, and treatment be tied to a clinical visit. To simplify and improve blood pressure measurement capabilities devices are in development that range from handheld devices, to wristbands, to weight scales. These emerging technologies use techniques such as photoplethysmography (the optical sensing of changes in light absorption with each heartbeat, as in pulse oximetry) or radar to measure blood pressure. Probably the greatest advancement these non-cuff sensing technologies will bring is in enabling the development of wearable sensors for continuous and non-invasive measurement of blood pressure. So far the only devices that have regulatory approval in the USA and Europe are for continuous non-invasive blood pressure monitoring in the inpatient setting. But with the future availability of consumer grade wearables that are able to monitor blood pressure continuously in all settings, we are likely to gain a more comprehensive understanding of environmental and behavioural influences on blood pressure, and how that differs between individuals and over time. www.thelancet.com Vol 388 August 20, 2016
Innovative digital technologies for self-tracking of blood pressure alone, however, don’t overcome all the obstacles to achieving better blood pressure control. They do not address inadequate management once an individual is identified as someone who would benefit from therapeutic interventions to lower their blood pressure. One future possible solution incorporates other components of the ongoing digital revolution—ubiquitous connectivity, pervasive computational capability, and accessible artificial intelligence—all potentially available through a smartphone. A smartphone allows for blood pressure data to be aggregated, visualised, and made instantaneously available for feedback, if desired. In the near future, that feedback might be via virtual medical assistants embedded in smartphones that use machine learning to analyse the individual’s unique blood pressure trends, along with streaming data from other covariates including sleep, activity, weight, nutrition, comorbidities, and medication, to enable and guide an individualised approach to blood pressure management. This external “wisdom of the body” could complement the internal capabilities that Walter Cannon described in his classic book on haemostasis and autoregulation back in 1932. Going digital to better understand and treat hypertension holds great promise. Through the use of new technologies the imprecise diagnosis of essential hypertension could be recharacterised into distinct phenotypes allowing for a much deeper understanding of what constitutes high blood pressure. And we could transform clinical care so that it’s more patient centred, pragmatic, inexpensive, and globally scalable. Let’s hope emerging technologies enable the medical community to reboot a century-old practice into the 21st century.
See Comment page 740
*Steven R Steinhubl, Evan D Muse, Paddy M Barrett, Eric J Topol
Irazola VE, Gutierrez L, Bloomfield G, et al. Hypertension prevalence, awareness, treatment, and control in selected LMIC communities: results from the NHLBI/UHG network of Centers of Excellence for chronic diseases. Glob Heart 2016; 11: 47–59
Scripps Translational Science Institute, La Jolla, CA 92037, USA steinhub@scripps,edu
Further reading Cannon WB. The wisdom of the body. New York: W W Norton & Company, 1932 Chow CK, Teo KK, Rangarajan S, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013; 310: 959–68 Ezzati M, Riboli E. Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med 2013; 369: 954–64.
Rothwell PM. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet 2010; 375: 938–48
The authors are supported by the National Institutes of Health (NIH) /National Center for Advancing Translational Sciences grant UL1TR001114 and a grant from the Qualcomm Foundation.
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