From 2020 Home BP Consensus to 2022 TSOC/THS Hypertension Guideline

ABSTRACT

Background: Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Numerous epidemiological studies and pharmacological intervention trials have demonstrated that lower and lowering blood pressures (BP) are associated with fewer CV events and lower mortality. Despite the positive correlations between BP levels and later CV events are continuous since BP levels as low as 90/60 mmHg in almost all large-scale epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years (since the release of the Fifth Report of the Joint National Committee [JNC 5] on high BP in 1993). The publication of both the SPRINT and the STEP trials (comprising >8,500 Caucasian/African and Chinese participants, respectively) provides enough evidence to shake this 140/90 mmHg dogma. In both trials, lowering systolic BP (SBP) to <130 mmHg, compared to the traditional SBP target of <140 (130-139) mmHg, was consistently associated with a 25-30% relative risk reduction in CV events. Another dogma regarding hypertension management is "office (or clinic) BP measurements" Although standardized office BP measurement has been widely recommended, the practice of office BP measurements is hard to be or has never been ideal in real-world practice. Further, the debate regarding the numerical equivalence between automated office BP (AOBP) measurements adopted in the SPRINT trial and office BP measurements has never been settled. The variations of office BP readings and the differences between office BP and home BP readings bewilder not only patients, but also healthcare professionals. On the other hand, out-of-office BP monitoring receives growing attention in contemporary hypertension guidelines. Home BP monitoring (HBPM) and ambulatory BP monitoring (ABPM) are two recognized approaches to obtaining out-of-office BP. HBPM is easy-to-use, more likely to be free of environmental and/or emotional stress (such as white-coat effect), feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events. Methods/Results: The Taiwan Hypertension Society (THS) and the Taiwan Society of Cardiology (TSOC) jointly issued the Consensus Statement on HBPM in 2020. The "722" protocol to standardize HBPM has been advocated by both Societies and widely accepted by healthcare professionals. In the 2022 Taiwan Hypertension Guidelines, we break the dogma of "office BP-based management strategy" and further expand the role of HBPM to the whole hypertension management process, from diagnosis to long-term follow-up. The Task Force considers that, to improve the quality of long-term management of all chronic diseases including hypertension, patients themselves should take an active role and HBPM is the right tool to achieve this goal, regardless of many other advantages of HBPM. This approach is of particularly importance in the post-COVID era and can bridge the management with artificial intelligence technologies. Conclusion(s) To facilitate implementation of the guidelines, a series of flowcharts to encompass assessment, adjustment, and HBPM-guided hypertension management are provided.