It’s no secret among healthcare professionals that hypertension is a rampant problem across the worldwide population. If you’re a physician reading this, you know the facts; an estimated 1 in 4 adults have high blood pressure (BP) which equates to 1.13 billion worldwide [1]. As a condition that rarely causes symptoms, most hypertensives are living unaware of their condition and of the extreme damage it is wreaking on their health. High BP is known to be the most powerful and independent risk factor for cardiovascular disease and contributes to half of all strokes and heart attacks [2-4]. In 2015, cardiovascular diseases accounted for 10.7 million deaths worldwide [5]. It is also a known risk factor in kidney disease which can then lead to kidney failure, for which high BP is one of the top causes, second only to diabetes. In 2012, more than 1.8 million people in the UK alone had a diagnosis of kidney disease and another 1.0 million were suspected to be undiagnosed [6]. In addition to the human suffering, globally suboptimal BP control is estimated to cost $370 billion USD in healthcare spending each year [7].

It is safe to conclude, then, that this risk factor has reached epidemic proportions and, despite the fact that the knowledge necessary to prevent and control hypertension exists, control rates are dismal in every part of the world [8]. So, why is this?

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Why Is High Blood Pressure Such A Huge Problem?

To be fair to us (read: humanity), it’s tricky to effectively treat and monitor a condition that is by its very nature symptomless and therefore difficult to detect in the first place. As well as being symptomless, there are a range of other factors which have led this very preventable and controllable silent killer to run riot. 

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Challenges surrounding the diagnosis and monitoring of hypertension include the prevalence of ‘white coat’ and masked hypertension. White coat hypertension is a condition by which patients persistently have elevated BP in the presence of a healthcare professional but have normal out-of-office BP. This is associated with an increased risk of organ damage and cardiovascular morbidity and mortality [9], accounting for approximately 25-46% of all patients identified as having elevated blood pressure in the clinic [10]. Conversely, masked hypertension is characterised by normal in-office BP accompanied by elevated BP in out-of-office measurements [9]. Masked hypertension is also associated with a higher prevalence of organ damage as well as increased cardiovascular risk and all-cause mortality [11]. These two conditions can also be compounded by improper BP measuring techniques (e.g. incorrect patient positioning, left arm vs right arm discrepancies, use of an incorrectly sized blood pressure cuff for the patient’s arm, inadequate rest periods before measurements taken etc.) and are subject to operator bias, which muddies the waters of monitoring and diagnosis even further. 

Treatment-related challenges also contribute to hypertension’s advance. Antihypertensive drug resistance affects the 10% of the hypertensive patient population who require ≥4 antihypertensive drugs of different classes to achieve BP control, and even after effective control is achieved, these patients are still associated with an increased risk of cardiovascular disease [12]. Poor medication adherence is also a huge issue, with as many as 50-80% of hypertensive patients demonstrating suboptimal adherence to their prescribed antihypertensive medications [13]. 

How Is The Problem Currently Being Dealt With?

Once elevated BP readings are first detected at a clinic visit, patients have traditionally been sent home with either ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) kits to confirm the diagnosis by collecting readings over a longer period of time, thus providing physicians with more holistic insight into the patient’s condition to help inform interventions. However, the devices used in these kits can often be costly, hard to use accurately, and uncomfortable. They often interfere with a patient’s daily life and open up the opportunity for patients to report unreliable readings, leading to undiagnosed health risks or misinformed treatments such as over- and underuse of medications [14]. They also take up the invaluable and increasingly in-demand resource of the supervising practitioner’s time needed to fill the role of receiving, monitoring and managing the patient based on regular review of the BP readings.

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This is not to say that home BP monitoring holds no value. Multiple studies have found evidence that, on the whole, home BP monitoring provides more accurate and reproducible measurements than in-office readings [15, 16]. It can also help in detecting white coat hypertension and may result in improved BP control [17 - 24]. Home monitoring can help patients see the effect lifestyle modifications and medication are having on their readings and make them more likely to adhere to treatment. Importantly, physicians have found that involvement in this form of home monitoring process improves patient care, and may reduce their need to intervene as much [25].

The true value, however, lies in the aforementioned ability to give physicians more insight into a patient’s BP over longer periods of time and make more rapid adjustments to medications to improve patient outcomes, and it is this benefit which has in recent years driven technological advancements into remote BP monitoring. Connected wearable devices taking the form of wristwatches, rings, stick-on patches, and more, are today offering a ‘cuffless’ BP solution to many of the problems cited in this article. Instead of hard-to-use, uncomfortable BP cuffs, patients wear a comfortable, Bluetooth-enabled device which at regular intervals uses advanced vitals monitoring technology to track BP-related biomarkers, store this data in a smartphone app and in turn transmit the data to a remote computer where diagnostic algorithms can analyse this data, detect abnormal readings and trigger an alert for the physician. Remote BP monitoring systems detect early deterioration and provide peace of mind as well as better access to care for patients. They can also track patient adherence to treatment and enable timely intervention reducing both healthcare utilisation and costs.