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Special Report

Commissioning Blood Pressure Meausurement Devices

Microlife WatchBP Blood Pressure Monitors The Silent Killer Not Alone Getting the Measure of Blood Pressure Dealing with High Blood Pressure

Sponsored by

Published by Global Business Media


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

SPECIAL REPORT

Commissioning Blood Pressure Meausurement Devices

Contents Foreword

2

John Hancock, Editor

Microlife WatchBP Blood Pressure Monitors:

for optimal hypertension management and atrial fibrillation detection 3 Microlife Health Management Ltd

Microlife WatchBP Blood Pressure Monitors The Silent Killer Not Alone Getting the Measure of Blood Pressure Dealing with High Blood Pressure

Sponsored by

WatchBP Monitors WatchBP with Atrial Fibrillation Detection System

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks

NICE Recommends: WatchBP Home A, for Diagnosing and Detecting Hypertension and Detecting Atrial Fibrillation WatchBP Office ABI: Qualified as a High Impact Innovation by the Department of Health WatchBP O3: 24hr Ambulatory Blood Pressure Monitor (ABPM): Clinical Blood Pressure Measurement Alone is not Enough

The Silent Killer John Hancock

Risk Factors Lifestyle

Editor John Hancock

Secondary High Blood Pressure

Senior Project Manager Steve Banks

Infants and Children

Pregnancy

Advertising Executives Michael McCarthy Abigail Coombes

Not Alone

Production Manager Paul Davies

Making the Heart Work Harder

For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Š 2013. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

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Camilla Slade, Staff Writer

More than Simply Hypertension A Global Health Matter Prevention is Better than Cure

Getting the Measure of Blood Pressure

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Peter Dunwell, Medical Correspondent

What We Are Looking For Getting Accuracy Devices and Methods Measuring in Line with Life

Dealing with High Blood Pressure

13

John Hancock

Prevention Monitoring Management and Treatment

References 15

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SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Foreword T

here was a time when high blood pressure

There are pointers in the epidemiology with

or hypertension was interpreted as an

some 1 billion people (nearly a quarter of the adult

excess of blood for which one treatment was

population of the world) in 2000 suffering from high

bloodletting through the application of leeches.

blood pressure but with rates varying from as low as

Understanding of the condition has moved

3.4% (men) and 6.8% (women) in rural India to as

on some way since then but, in the majority of

high as 68.9% (men) and 72.5% (women) in Poland.

cases, particularly primary high blood pressure,

While prevention is the best policy, in a condition

while we understand what the condition is and

whose causes remain uncertain and not fully

what damage it can do there is still no certainty

understood, identification of the problem at the

as to what causes it. That said, there are a

earliest opportunity is a very important factor in

number of genetic and lifestyle indicators

the efficacy and effectiveness of any subsequent

often present for people who present with high

treatment or management programme. To achieve

blood pressure.

this, monitoring devices have been improving

This Special Report opens with an article that

over many decades to the point where a number

looks at a family of blood pressure devices

of different methodologies and situations can be

designed for all three forms of non-invasive blood

considered to match the needs of each patient.

pressure measurement: clinical, home, and 24 hour

The importance of continuing to monitor for and

measurement. A number of these devices include

improve the management of high blood pressure

Atrial Fibrillation (AF) detection systems, which

is summed up in the words of Cathy Ross, senior

allows automated AF screening during routine

cardiac nurse at the British Heart Foundation. “Some

blood pressure measurement. Many studies have

12 million people [in the UK] are diagnosed with

shown that patients should not be diagnosed on

[high blood pressure] and it is estimated another

blood pressure measurement taken in a GP’s

5.7 million people have it but are unaware. It’s a

or physician’s office only. The very fact that the

major risk factor for heart disease and strokes so

measurement involves the attendance of a doctor

it’s crucial we do all we can to get people diagnosed

may, in itself, cause an increase in blood pressure. The

and properly treated as soon as possible.”

Ambulatory 24 hour Blood Pressure Monitor avoids this phenomenon, while preventing overtreatment, with a resultant reduction in health costs.

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Microlife WatchBP Blood Pressure Monitors: for optimal hypertension management and atrial fibrillation detection By Microlife Health Management Ltd

WatchBP Monitors WatchBP entails a family of BP devices that are designed for all three forms of non-invasive blood pressure measurement: Clinical (WatchBP Office and equivalents), home (WatchBP Home and equivalents) and 24-h Blood pressure measurement (WatchBP O3 Ambulatory). The concept is based on scientific evidence and provides a solution for the prevention and management of cardiovascular risk factors. All devices are validated according to the British Hypertension Society (BHS), AAMI and/ or International protocol1-3 and aim at helping healthcare professionals and patients to measure according to the guidelines and so improve diagnosis. Recently, another innovative tool with high potential has been implemented in some of the WatchBP monitors: the Atrial Fibrillation (AF) detection system.

WatchBP with Atrial Fibrillation Detection System The WatchBP atrial fibrillation (AF) detection system allows automated AF screening during routine blood pressure measurement,

without any extra effort. The AF detector has been investigated in multiple clinical studies which showed a very high accuracy4-9. When performing three measurements the sensitivity and specificity values of the WatchBP is 97 and 89%, respectively. In comparison, wrist palpation has a much lower accuracy with a sensitivity and specificity of 87 and 81 %, respectively10.

NICE Recommends: WatchBP Home A, for Diagnosing and Detecting Hypertension and Detecting Atrial Fibrillation – http://guidance.nice.org.uk/MT/145 The National Institute for Health and Clinical Excellence (NICE) is at the final stage of the consultation period for WatchBP Home A that will be followed by an official recommendation on the 16th January 2013 for using the WatchBP Home A in a GPs general practice. An analysis that was performed on behalf of NICE showed that general use of the WatchBP Home A device for routine clinical blood pressure measurement by all GPs will lead to the detection of more patients with AF as compared to manual pulse palpation.

WatchBP Home A – As recommended by NICE

www.primarycarereports.co.uk | 3


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

General use of the WatchBP Home A device for routine clinical blood pressure measurement by all GPs will lead to the detection of more patients with AF as compared to manual pulse palpation.

Consequently this will save up to ÂŁ426,000 and prevent between 81 (of which 53 fatal) and 182 (of which 117 fatal) strokes (depending on the age of the patient as older patients benefit more) per 100,000 people of 65 years and older being screened for AF11. In addition to clinical use the WatchBP Home A is also suitable for screening (paroxysmal) atrial fibrillation at home8. Next to the possibility of performing regular blood pressure measurements the WatchBP Home A is equipped with an extra mode: the diagnostic mode. When patients use this diagnostic mode they can only measure according to the recommended NICE-schedule for home BP measurements (7 days 2 x 2 times at predefined times)12. After the measurements the device automatically calculates BP values according to the ESH guidelines (morning, evening and total). This implemented schedule makes it easier for patients to adhere to the prescribed schedule13 and therefore make home BP measurement more reliable for use in clinical practice. As a matter of fact the use of devices with an implemented schedule is recommended by the latest European Society of Hypertension (ESH) guidelines for home BP measurement 14. Finally, the WatchBP Home is one of the few oscillometric devices that have passed the protocol of the British Hypertension Society for the measurement of pregnant women with hypertension or pre-eclampsia15.

WatchBP ABI - Evaluated by the Department of Health

4 | www.primarycarereports.co.uk

WatchBP Office ABI: Qualified as a High Impact Innovation by the Department of Health – www.innovation.nhs.uk/pg/dashboard Peripheral arterial disease (PAD) is an important cardiovascular risk factor which, similar to AF, often remains undetected for too long. A recommended test for diagnosing PAD is performing ankle arm measurements to assess the ankle brachial index (ABI)16. In general clinical practice ABI is often performed with a Doppler device. However, this method is time consuming and requires skills from the observer and therefore is not performed as frequently as it should be17 and if performed in general practice it is often not done correctly18. This leads to the fact that many patients who have PAD remain undetected and therefore remain untreated19, 20. Microlife WatchBP has developed a sophisticated, affordable cardiovascular screening device: the WatchBP Office ABI. This device allows fast and easy ABI assessment to screen for PAD but also provides the possibility of screening for other important cardiovascular risk factors such as atrial fibrillation, hypertension and inter-arm blood pressure difference. With the WatchBP office ABI the ankle arm (brachial) measurement is performed simultaneously and is validated against Doppler for accuracy with positive results21. In addition, it reduces the time by one-third as compared to Doppler so that the left and right ABI can be


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

determined in 5 to 6 minutes22. Finally, as the WatchBP Office ABI automatically calculates the ABI, uniformity is guaranteed and errors due to registration and calculation failures are prevented23. The WatchBP office ABI can also be used as a regular clinical blood pressure monitor and is equipped with an AF detector. Next to routine blood pressure measurement it provides the possibility to perform simultaneous doublearm blood pressure measurements. Double arm measurements are recommended by both the BHS24 and NICE12 guidelines for two reasons. First, if there is a relevant difference in blood pressure between both arms, the arm with the higher blood pressure should be used for diagnosis. Second, a large inter-arm blood pressure difference (IAD) might indicate a pathological cause (e.g. subclavian stenosis) and increased cardiovascular risk25. For determining the IAD the method has a significant influence on outcomes and it has been demonstrated that simultaneous double-arm measurement provides the most reliable indication of the true IAD 26, 27.

main reason for this is that the measurement procedure commonly entails one single occasion whereas blood pressure constantly fluctuates over time and the attendance of a doctor may cause an increase in blood pressure; the so-called white coat effect. Because of the low diagnostic accuracy of office blood pressure measurement the NICE guidelines recently stated that all patients with elevated office pressure should be offered ambulatory (24-h) blood pressure measurement (ABPM)12 because it prevents overtreatment and reduces healthcare costs 29. For this purpose the WatchBP O3 ambulatory can be used. The WatchBP O3 ambulatory is a highly affordable and high quality validated BP monitor with easy to use software available free of charge. The data is provided in either Excell (for research purpose) or PDF format (patient file) and contains a summary of the most relevant data as recommended by the latest guidelines. The WatchBP O3 ambulatory is equipped with a pill button that allows optimal verification of anti-hypertensive drugs and is compatible with Emis software.

Office ABI 16

Because of its multiple possibilities the WatchBP Office ABI is a sophisticated cardiovascular screening device that can detect 4 important cardiovascular risk factors in approximately 10 minutes: 1) Hypertension 2) Subclavian stenosis 3) Atrial fibrillation 4) Peripheral artery disease The Department of Health (DH) recognizes the high potential of the WatchBP Office ABI for overall healthcare hence they presented the device on their website under “High impact innovations”28.

WatchBP O3 24hr ABPM

Microlife WatchBP has a wide range of cardiovascular screening devices, which cannot all be explained in this editorial, for more information we therefore refer you to our website www.watchbp.co.uk.

WatchBP O3: 24hr Ambulatory Blood Pressure Monitor (ABPM): Clinical Blood Pressure Measurement Alone is not Enough Many studies have shown that patients should not be diagnosed on blood pressure measurement taken in the GP’s or physician‘s office only. The www.primarycarereports.co.uk | 5


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

References: 1

 Stergiou, G.S., et al., Validation of the Microlife WatchBP Home device for self home blood pressure measurement according to the International Protocol. Blood Press Monit, 2007. 12: p. 185-8.

Stergiou, G.S., et al., Are there really differences between home and daytime ambulatory blood pressure? Comparison using a novel dual-mode ambulatory and home monitor. J Hum Hypertens, 2009.

2

Stergiou, G.S., et al., Validation of the Microlife Watch BP Office professional device for office blood pressure measurement according to the International protocol. Blood Press Monit, 2008. 13: p. 299-303.

3

Wiesel, J., et al., The use of a modified sphygmomanometer to detect atrial fibrillation in outpatients. Pacing Clin Electrophysiol, 2004. 27: p. 639-43.

4

Stergiou, G.S., et al., Diagnostic accuracy of a home blood pressure monitor to detect atrial fibrillation. J Hum Hypertens, 2009. 23: p. 654-8.

5

Wiesel, J., et al., Detection of atrial fibrillation using a modified microlife blood pressure monitor. Am J Hypertens, 2009. 22: p. 848-52.

6

Marazzi, G., et al., Comparison of Microlife BP A200 Plus and Omron M6 Blood Pressure Monitors to Detect Atrial Fibrillation in Hypertensive Patients. Adv Ther, 2011.

7

Wiesel, J., et al., Home monitoring with a modified automatic sphygmomanometer to detect recurrent atrial fibrillation. J Stroke Cerebrovasc Dis, 2007. 16: p. 8-13.

8

Verberk, W.J., et al., Accuracy of oscillometric blood pressure monitors for the detection of atrial fibrillation: a systematic review. Expert Rev Med Devices, 2012. 9: p. 635-40.

9

Hobbs, F.D., et al., A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess, 2005. 9: p. iii-iv, ix-x, 1-74.

10

NICE, Cost impact of the WatchBP Home A used in a primary healthcare clinic environment http://www.nice.org.uk/nicemedia/live/13570/60604/60604.pdf, 2012.

11

NICE, Hypertension: clinical management of primary hypertension in adults. CG127 http://guidance.nice.org.uk/CG127/Guidance/pdf/English, 2011.

12

Wessel, S.E., et al., ‘Diagnostic mode’ improves adherence to the home blood pressure measurement schedule. Blood Press Monit, 2012.

13

Parati, G., et al., European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens, 2008. 26: p. 1505-26.

14

Chung, Y., et al., Validation and Compliance of a Home Monitoring Device in Pregnancy: Microlife WatchBP Home. Hypertens Pregnancy, 2009: p. 1-12.

15

Mancia, G., et al., 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens, 2007. 25: p. 1105-87.

16

Beckman, J.A., et al., Automated oscillometric determination of the ankle-brachial index provides accuracy necessary for office practice. Hypertension, 2006. 47: p. 35-8.

17

Nicolai, S.P., et al., Ankle brachial index measurement in primary care: are we doing it right? Br J Gen Pract, 2009. 59: p. 422-7.

18

Abramson, B.L., et al., Canadian Cardiovascular Society Consensus Conference: peripheral arterial disease - executive summary. Can J Cardiol, 2005. 21: p. 997-1006.

19

Norgren, L., et al., Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg, 2007. 33 Suppl 1: p. S1-75.

20

Kollias, A., et al., Automated determination of the ankle-brachial index using an oscillometric blood pressure monitor: validation versus Doppler measurement and cardiovasculsr risk factor profile. Hypertens Res, 2011: p. in press.

21

Kollias, A., et al., Automated determination of the ankle-brachial index using an oscillometric blood pressure monitor: validation vs. Doppler measurement and cardiovascular risk factor profile. Hypertens Res, 2011. 34: p. 825-30.

22

Verberk, W.J., et al., Automated oscillometric determination of the ankle-brachial index: a systematic review and meta-analysis. Hypertens Res, 2012. 35: p. 883-91.

23

Williams, B., et al., British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ, 2004. 328: p. 634-40.

24

Clark, C.E., et al., Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. Lancet, 2012. 379: p. 905-14.

25

Verberk, W.J., et al., Blood pressure measurement method and inter-arm differences: a meta-analysis. Am J Hypertens, 2011. 24: p. 1201-8.

26

Lohmann, F.W., et al., Interarm differences in blood pressure should be determined by measuring both arms simultaneously with an automatic oscillometric device. Blood Press Monit, 2011. 16: p. 37-42.

27

www.innovation.nhs.uk/dl/cv_content/31720.

28

Lovibond, K., et al., Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet, 2011.

29

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SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

The Silent Killer John Hancock

Raised blood pressure rarely offers clues as to its cause or shows itself in good time

T

here’s nothing intrinsically wrong with blood pressure. “Blood pressure is an essential part of the way your body works. Your blood carries oxygen and nutrients around your body and is pumped by your heart. Your blood is under pressure as a result of the pumping action of your heart and the size and flexibility of your arteries, which carry your blood.”1 This succinct description of blood pressure is taken from a BUPA article on high blood pressure or hypertension. Problems arise when blood pressure becomes higher or lower than what is considered correct for our age and the one that most concerns clinicians and health care providers is high blood pressure. In fact, the majority of low blood pressure cases require no treatment at all. The BUPA article goes on to explain that about three in 10 adults in the UK have high blood pressure and, of people over 65, more than six in 10 have high blood pressure. What makes this a problem is explained further on in this paper, but it is important to understand what high blood pressure is and what might be the causes of the condition. Hypertension is a chronic medical condition manifesting as high blood pressure in the arteries. It is summarised by two measurements, systolic and diastolic pressures, taken when the heart muscle is contracting (systolc) or relaxed, between beats (diastolic). “Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is persistently at or above 140/90 mmHg.”2 About 90 to 95% of hypertension cases are classified as primary or essential hypertension. As yet, no underlying medical cause has been discovered relating to primary hypertension but, for about 5 to 10% of cases, classified as secondary hypertension, a number of pre-existing conditions and/or lifestyle factors have been associated with the condition. Secondary hypertension is more common in preadolescent children, with most cases caused

by renal disease. Primary or essential hypertension is more common in adolescence and adults.

Risk Factors According to the National Health Service (NHS)3 in the UK, “[while] there is often no clear cause of high blood pressure… you are at increased risk if you: • Are overweight. • Have a relative with high blood pressure. • Are of African or Caribbean descent. • Eat a lot of salt. • Don’t eat enough fruit and vegetables. • Don’t do enough exercise. • D  rink a lot of coffee (or rather, caffeine-based drinks). • Drink a lot of alcohol. • Are aged over 65. It has also been noted that people with a family history of high blood pressure, where the condition seems to have run in their family, are statistically more likely to suffer from it themselves. While genetic contributors to hypertension have been poorly understood up until now, an 11th of September 2011 report from the BBC4 confirmed that “more than 20 new sections of genetic code have been linked to blood pressure by an international team of scientists. Almost everyone will carry at least one of the genetic variants, according to studies published in Nature and Nature Genetics.” In the study, scientists in 24 countries analysed data from more than 200,000 people. However, researchers say they have still uncovered only 1% of the genetic contribution to blood pressure and the British Heart Foundation’s medical director, Prof Peter Weissberg, while welcoming the findings, added, “… your genes are only one piece of the puzzle. You are less likely to have high blood pressure if you stick to a healthy diet, do plenty of exercise and maintain a healthy weight.” The lethal thing about high blood pressure is that people often don’t know they have it; there may be no outward symptoms or signs. The NHS estimates that around one third of people who have hypertension don’t know it: for these reasons it is sometimes called a silent disease or silent killer. The only way to really establish www.primarycarereports.co.uk | 7


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

As yet, no underlying medical cause has been discovered relating to primary hypertension but, for about 5 to 10% of cases, classified as secondary hypertension, a number of pre-existing conditions and/or lifestyle factors have been associated with the condition.

whether an individual’s blood pressure is normal or high is through routinely monitoring them as part of a healthcare plan. Currently, identification is often only made when somebody seeks healthcare for an unrelated problem. A proportion of people found to have high blood pressure report headaches, lightheadedness, vertigo, tinnitus, altered vision or fainting. However, these symptoms are not usually directly related to high blood pressure, but rather to the anxiety that often accompanies the condition.

Lifestyle The kind of lifestyle factors that might be associated with high blood pressure include the usual culprits; smoking, excess alcohol, obesity, lack of exercise, diet (particularly too much salt) and the stress of modern lifestyles. As well as the usual suggestions that patients stop doing the things that might be causing the problem, some clinicians also suggest that laughter might help release the stress that underlies hypertension.

Secondary High Blood Pressure Some of the common causes in those 5 to 10% of cases categorised as secondary high blood pressure include: • Kidney disease. • Diabetes. •N  arrowing of the arteries (large blood vessels) supplying the kidneys. • Hormonal conditions. • Conditions that affect the body’s tissue. • Taking the oral contraceptive pill. •P  ainkillers known as non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. • Recreational drugs. • Herbal remedies and herbal supplements. While primary high blood pressure may not be curable but can be managed, it is often the 8 | www.primarycarereports.co.uk

case that when the underlying causes of secondary high blood pressure are addressed the condition will be corrected and blood pressure return to normal.

Pregnancy Pregnant women should have their blood pressure monitored regularly, regardless of whether they are known to have high blood pressure or not. Long-term high blood pressure may well be picked up at an antenatal appointment but it is also possible for women to develop high blood pressure during pregnancy (gestational hypertension). Later in the pregnancy, after 20 weeks, it might point to risk of pre-eclampsia. Where women who are known to have high blood pressure are trying to become pregnant, clinicians must monitor their condition very carefully, bearing in mind that some medicines used for treating the condition will not be suitable for a pregnant woman. Gestational hypertension occurs in approximately 8 to 10% of pregnancies.

Infants and Children While hypertension is most often associated with adults, it can also occur in infants and children. Failure to thrive, seizures, irritability, lack of energy and difficulty breathing are all signs that might point to hypertension in neonates and young infants. In older infants and children these conditions may be accompanied by blurred vision, nosebleeds or even facial paralysis. While blood pressure is not measured routinely in healthy new-born infants, when there are any high risk factors, it should be considered. The prevalence of high blood pressure in the young is increasing but most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. Other than obesity (a growing contributor to many childhood ills) kidney disease is the most common cause of hypertension in children.


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Not Alone Camilla Slade, Staff Writer

High blood pressure impacts on health in more ways than one

O

ne of the problems in getting people to understand how serious high blood pressure can be is the fact that there are rarely any symptoms of the condition. However, “High blood pressure (hypertension) can quietly damage your body three years before symptoms develop. Left uncontrolled you may wind up with a disability, a poor quality of life or even a fatal heart attack.”5 Not only is high blood pressure in itself a danger but also, as is the case with many conditions related to long-term poor health, high blood pressure (hypertension) does not come alone but rather is often accompanied by one or more of a number of co-related conditions. Some may be associated with the causes of high blood pressure others are caused as a result of the condition but whatever is the case, treatment may well have to take more than just the hypertension into account.

Making the Heart Work Harder At the root of the problems, hypertension causes the heart to work harder than normal putting both the heart and arteries at greater risk of damage. As the BBC Health6 article ‘High blood pressure’ puts it; “Arteries also suffer the effects of high blood pressure, becoming scarred, hardened and less elastic. Though this hardening of the arteries often occurs with age, high blood pressure accelerates the process. The hardened or narrowed arteries are unable to supply the amount of blood the body’s organs need, preventing them working effectively. Another risk is that a blood clot may lodge in an artery narrowed by atherosclerosis, blocking blood supply.”

More than Simply Hypertension Related conditions and complications range from a higher risk of heart disease and/or stroke to kidney disease, eye disease, diabetes, preeclampsia (during pregnancy) and erectile dysfunction. Hypertension is also a risk factor for cognitive impairment and dementia as well as those conditions directly associated with it (see above). All of these conditions are serious enough on their own, as is made clear in the article ‘High Blood Pressure’ on About.com7. A summary is below but the whole articles can be read at:

http://highbloodpressure.about. com/od/associatedproblems/tp/ hypertension-complications.htm Heart Attack High blood pressure raises the risk of heart attacks and increases the likelihood that a heart attack, if one occurs, will be severe. Stroke Strokes, like heart attacks, are caused by an interruption of blood flow. In the case of stroke, the interruption is in the brain. When blood flow to the brain is interrupted, the areas of the brain depending on that blood are damaged. In addition to the potentially disabling impact of full strokes, there are also what are somewhat disarmingly referred to as minor strokes; however their impact may not be at all minor. The technical term is transient ischaemic attack (TIA) and, as well as being a precursor to a full stroke, a series of TIAs can cumulatively reduce brain function in the condition known as vascular dementia. Kidney Damage Kidney damage and high blood pressure are a self-reinforcing circle, with high blood pressure causing damage which, in turn, leads to even higher blood pressure. Kidney damage is one of the most dangerous long-term complications of high blood pressure. Atrial Fibrillation Atrial fibrillation is a type of arrhythmia, or disorganized heart beat. High blood pressure changes the pumping dynamics of the heart, and can cause the heart to grow and stretch, favouring the development of atrial fibrillation. Coronary Artery Disease Evidence suggests that chronic elevations in blood pressure contribute to damage and inflammation in the walls of blood vessels. This damage and inflammation attracts macrophages which, in turn, provide a “sticky” place where fats and cholesterol are more likely to adhere, leading to the development of blockages. www.primarycarereports.co.uk | 9


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Given that even moderate elevation of arterial blood pressure is associated with a shortened life expectancy, everything points to the wisdom of regular monitoring for those in the high-risk group as far as high blood pressure is concerned and less frequent but nonetheless regular monitoring for everybody.

Blockages caused by coronary artery disease are a major cause of heart attack. Other cardiovascular conditions might include angina where patients suffer significant chest pain caused by reduced blood flow. One of the recognised conditions accompanying high blood pressure is stress and, in the complex matrix of relationships between various conditions, dealing with this one issue can offer a range of gains, whereas… “Left unmanaged, stress can lead to emotional, psychological, and even physical problems, including coronary artery disease and high blood pressure.”8 Hypertension can even manifest its own complications including ‘resistant hypertension’ when blood pressure remains above normal levels in spite of the usual treatments. The value in identifying high blood pressure and in treating it is succinctly put by the Royal College of General Practitioners (RCGP) in the UK which, in its introduction to the book ‘ABC of Hypertension’ states; “Hypertension is a condition which affects millions of people worldwide and its treatment greatly reduces the risk of stroke and heart attacks.”9

A Global Health Matter Not to understate the case, hypertension and its associated conditions are often cited as the most important preventable risk factor for premature death. The World Health Organisation (WHO) has cited it as the leading cause of cardiovascular 10 | www.primarycarereports.co.uk

mortality. Such is its importance that there exists an organisation of 85 national hypertension societies, The World Hypertension League (WHL), which initiated a global awareness campaign on hypertension in 2005 and has dedicated May the 17th of each year as World Hypertension Day.

Prevention is Better than Cure Given that even moderate elevation of arterial blood pressure is associated with a shortened life expectancy, everything points to the wisdom of regular monitoring for those in the highrisk group as far as high blood pressure is concerned and less frequent but nonetheless regular monitoring for everybody. On the principle that prevention is better than cure the ability to identify hypertension and or any of its causal or related conditions will add significantly to the healthcare stock of any population. There are also economic benefits to be gained from preventing, treating or managing this condition.


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Getting the Measure of Blood Pressure Peter Dunwell, Medical Correspondent

Finding the all-important readings from which the correct treatment can be prescribed

What We Are Looking For Generally speaking, most people’s experience of having their blood pressure checked is that a GP or nurse will measure their blood pressure with a sphygmomanometer using the oscillometric method. In layman’s terms, this involves putting a cuff around the upper arm, inflating it to a certain level and then deflating it slowly and using a stethoscope to observe the oscillations in blood flow, i.e. the pulse. Blood pressure is measured in mmHg, or millimetres of mercury. The blood pressure monitor will provide a reading as two numbers, one number on top of the other, such as 120/80mmHg (one hundred and twenty over eighty millimetres of mercury). The first figure, systolic blood pressure, measures the pressure when the heart muscle is contracted and pumping blood out of the heart; the highest pressure in your blood vessels. The second figure, diastolic blood pressure, is the pressure between heart beats when the heart is resting and filling with blood and is the lowest pressure in blood vessels10. In older people there can be a condition called isolated systolic hypertension in which the systolic pressure is abnormally high but diastolic pressure may be normal or low. This is normally explained by increased arterial stiffness which typically accompanies ageing but the condition may be exacerbated by high blood pressure. The BUPA article from which the above is taken, continues to explain that, generally speaking, the lower an individual’s blood pressure, the better it is for their health. For people under the age of 80, doctors recommend that blood pressure is kept below 140/90 measured in the clinic, or 135/85 measured at home. A slightly higher level is acceptable for people over 80. For people with diabetes, kidney disease or cardiovascular disease, blood pressure should be lower than this – ideally less than 130/80.

Getting Accuracy Any measurements also have to take into account natural variations: for instance pressure rises

during exercise and decreases during sleep. This means that sometimes blood pressure measurements have to be taken either at different times or over longer periods. This breaks down to three forms of non-invasive blood pressure measurement: clinical (within the healthcare system), home (at the patient’s residence) and 24-hour or ambulatory (over an extended period to record blood pressure levels associated with the patient’s normal lifestyle). These non-invasive methods are most common while measuring pressure invasively, by penetrating the arterial wall to take the measurement, is much less common and would normally take place within a hospital. Non-invasive auscultatory and oscillometric measurements are more acceptable to patients and require less expertise in the clinician administering the test11.

Devices and Methods The first two instances, clinical and home measurement, are essentially similar, using a standard blood pressure machine but making allowances for either the environmental influence on blood pressure levels and/or the convenience of patients who may be less able to reach a surgery. It can also be useful for some people at particular risk to be able to regularly check their pressure without the need to take the time and resources of a clinical practice every time. This may be appropriate for patients already diagnosed with prehypertension or hypertension or who are known to present risk factors for high blood pressure. FamilyDoctor.org12 suggests that, “Measuring your blood pressure at home and keeping a record of the measurements will show you and your doctor how much your blood pressure changes during the day… [and] is a good way to take part in managing your own health and recognising changes.” It is normally advised that home readings are taken while at rest. NICE has undertaken some research in this area, incorporating the results into a ‘hypertension pathway’13. www.primarycarereports.co.uk | 11


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

It has been estimated that, in up to 25% of patients, blood pressure measured in the doctor’s surgery may be higher than their typical blood pressure as a result of a phenomenon known as ‘white coat hypertension’.

It has been estimated that, in up to 25% of patients, blood pressure measured in the doctor’s surgery may be higher than their typical blood pressure as a result of a phenomenon known as ‘white coat hypertension’, i.e. anxiety related to the environment. This can be overcome with a 24-hour ambulatory blood pressure monitor, a device that is strapped around the patient’s waist and attached to a cuff wrapped around their upper arm. The cuff inflates and deflates automatically and takes recordings of blood pressure throughout the 24 hours, while the patient can carry on with their normal activities, excepting that they cannot have a bath or shower. “As a rule,” according to Patient.co.uk14, “an average of the ambulatory blood pressure readings gives the most true account of your usual blood pressure… Ambulatory and home readings are often [lower] because people are much more relaxed and less stressed at home than in a formal clinic or surgery situation.”

Measuring in Line with Life Where home measurement is impractical, several measurements may be taken over quarter to half an hour in a quiet part of the practice premises. Sometimes it can be helpful for a clinician to take repeat measurements over a number of days or even weeks or to arrange a 24-hour pressure recording. Equally, where high blood pressure is found, there may need to be additional tests such as a urine test, a blood test to check sugar levels or an electrocardiogram to check for any damage to the heart. The auscultatory method of measurement has already been described above but, in an emergency, clinicians may use palpation to try 12 | www.primarycarereports.co.uk

and gauge whether blood pressure is normal or elevated. Palpation is usually used to detect soreness and swelling so will only provide a roughly estimated measurement. Other than the standard measurement methods, for some purposes, measurements of, say, the pressure differences between both arms, between an arm and a leg or between an ankle and an arm to gauge ‘ankle Brachial index’ (ABI) can provide more specific information to a clinician looking for conditions like peripheral arterial disease (PAD). However the measurement is achieved, using one of the above methods and/or systems will ensure that a patient’s condition is better understood, properly monitored and appropriately treated.


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Dealing with High Blood Pressure John Hancock

Better to prevent it or identify it before it becomes a problem

With most healthcare issues there are three levels on which the condition can be addressed. The first is prevention; taking steps and making lifestyle choices which minimise or remove the conditions that underpin or lead to ill-health. The next is monitoring; for both preventable and unavoidable conditions, early detection and treatment often equates to better outcomes. The third level is that of management or treatment to live with or resolve the underlying condition. High blood pressure or hypertension is no different and while the causes of primary high blood pressure are not fully established, it still falls squarely into the category of health issues where prevention and/or early detection is a better course than cure.

Prevention While the causes of primary high blood pressure have not been clearly established, for the secondary type of condition they are well known and healthcare professionals believe there are steps that can either reduce the chance of the condition manifesting or minimize its effects. NHS Choices15 sums this up as, “Having high blood pressure can be prevented by eating healthily, maintaining a healthy weight, taking regular exercise, drinking alcohol in moderation

and not smoking.” To some, this might seem little more than common sense packaged as healthcare guidance. However, the reality is that if most people followed such ‘common sense’ guidance, high blood pressure or hypertension and its associated conditions might not be such a serious healthcare issue. Continuing with this ‘informed common sense’ approach, NHS Choices goes on to suggest that, for a sensible diet, one should cut down on the amount of salt in food while also eating plenty of fruit and vegetables. Elsewhere, the NHS16 suggests that more specifically those at risk of or wishing to avoid high blood pressure might reduce their consumption of foods high in saturated fats while foods high in unsaturated fats can actually reduce cholesterol levels and the likelihood of high blood pressure. Also, regular consumption of alcohol above recommended limits or more than four cups of coffee a day is likely to raise blood pressure over time. Additionally, excess weight, lack of exercise and smoking are believed to be contributory factors in high blood pressure.

Monitoring High blood pressure is regarded as the condition when pressure moves outside of what has been

Typical blood pressure readings and what they might indicate Classification

Systolic pressure (mmHg)

Diastolic pressure (mmHg)

Normal 90–119 60–79 Prehypertension 120–139

80–89

Stage 1 hypertension

140–159

90–99

Stage 2 hypertension

≥160

≥100

Isolated systolic hypertension

≥140 <90

Key:

mmHg = millimeters of mercury; a unit of pressure Systolic pressure – the force of the blood as the heart contracts (beats) to pump it around the body. This is the higher of the two readings. Diastolic pressure – the pressure while the heart is relaxed and filling with blood again in preparation for the next contraction or heart beat. This value is lower than the systolic pressure. Isolated systolic hypertension – where systolic pressure is abnormally high but diastolic pressure may be normal or low; often caused by increased arterial stiffness with ageing.

www.primarycarereports.co.uk | 13


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

Proper management and treatment cannot only make the patient feel better right now, but also can help to avoid some of the potential consequences of unmanaged hypertension such as heart attack and stroke.

14 | www.primarycarereports.co.uk

established as normal ranges of blood pressure for most age groups17. According to a BBC Health article ‘High blood pressure’ in January 201018, “What is considered to be an acceptable blood pressure and what is hypertension (and then what needs treatment) depends on several factors. A single high reading isn’t enough to warrant a diagnosis of hypertension as blood pressure can be raised in all of us now and then – even the sight of a doctor can be enough to put it up. So there must be at least three high readings to cause concern. When high blood pressure is first diagnosed, tests may be done for an underlying cause (i.e. secondary hypertension) especially if the person is young or has very high blood pressure. If an underlying cause is found it should be treated.” An article in The Lancet19 in January 2012 also highlighted an “Association of a difference in systolic blood pressure between arms with vascular disease and mortality…” There are a number of ways in which blood pressure can be measured in order to establish the presence of particular conditions. For those diagnosed as having high blood pressure, their doctor will usually examine them and run further routine tests including20… • A urine test to check if you have protein or blood in your urine. • A blood test to check that your kidneys are working fine, and to check your cholesterol level and sugar (glucose) level. • A heart tracing, called an electrocardiogram (ECG). The purpose of the examination and tests is to: • Rule out (or diagnose) a secondary cause of high blood pressure, such as kidney disease.

•T  o check to see if the high blood pressure has affected the heart. • To check for other risk factors such as a high cholesterol level or diabetes.

Management and Treatment Whatever management or treatment programme might be prescribed for someone with high blood pressure, particularly the ‘primary’ condition, is likely to be long term because the condition cannot usually be cured. As well as a range of drug therapies, patients might be advised on: • Stopping smoking. •C  hanging diet to one that emphasises low-fat, low-salt and includes fruit and vegetables. • Cutting down on alcohol. • Cutting down on coffee and high-caffeine drinks, such as cola. • Taking regular, aerobic exercise. • Losing any excess weight. It might also help for patients to reduce the levels of stress in their lives – sometimes easier said than done, but relaxation techniques such as yoga or meditation could be useful. Proper management and treatment cannot only make the patient feel better right now, but also can help to avoid some of the potential consequences of unmanaged hypertension such as heart attack and stroke, either of which can be at least disabling, at worst fatal. As always, ‘prevention’ and ‘monitoring’ are better routes than ‘cure’ to improved health outcomes with the added advantage that they will usually cost less – something to consider in an age of budgetary constraints.


SPECIAL REPORT: COMMISSIONING BLOOD PRESSURE MEASUREMENT DEVICES

References: 1

 BUPA http://www.bupa.co.uk/individuals/health-information/directory/h/hypertension

2

Wikipedia http://en.wikipedia.org/wiki/High_blood_pressure

3

NHS Choices http://www.nhs.uk/conditions/blood-pressure-%28high%29/Pages/Introduction.aspx

4

BBC News http://www.bbc.co.uk/news/health-14851651 Mayo Clinic http://www.mayoclinic.com/health/high-blood-pressure/HI00062

5

6

BBC Health http://www.bbc.co.uk/health/physical_health/conditions/in_depth/heart/hypertension1.shtml

7

About.com http://highbloodpressure.about.com/od/associatedproblems/tp/hypertension-complications.htm

8

WebMD http://www.webmd.boots.com/hypertension-high-blood-pressure/default.htm

9

RCGP http://www.rcgp.org.uk/shop/books/abc-series/abc-of-hypertension.aspx

10

BUPA http://www.bupa.co.uk/individuals/health-information/directory/h/hypertension and scroll down

11

Wikipedia http://en.wikipedia.org/wiki/Blood_pressure

12

FamilyDoctor.org http://familydoctor.org/familydoctor/en/diseases-conditions/high-blood-pressure/diagnosis-tests/blood-pressure-monitoring-at-home.html

13

NICE Medical technologies guidance http://www.nice.org.uk/MTG13

14

Patient.co.uk http://www.patient.co.uk/health/high-blood-pressure-hypertension

15

NHS Choices http://www.nhs.uk/Conditions/Blood-pressure-%28high%29/Pages/Prevention.aspx

16

NHS Inform http://www.nhsinform.co.uk/health-library/articles/b/blood-pressure-high/prevention

17

Wikipedia http://en.wikipedia.org/wiki/High_blood_pressure

18

BBC Health ‘High blood pressure’ http://www.bbc.co.uk/health/physical_health/conditions/in_depth/heart/hypertension1.shtml

19

The Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961710-8/abstract

20

Patient.co.uk http://www.patient.co.uk/health/high-blood-pressure-hypertension

www.primarycarereports.co.uk | 15


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Special Report – Commissioning Blood Pressure Measurement Devices  

Primary Care – Special Report on Commissioning Blood Pressure Measurement Devices

Special Report – Commissioning Blood Pressure Measurement Devices  

Primary Care – Special Report on Commissioning Blood Pressure Measurement Devices