2022 Thai Hypertension Society guidelines on home blood pressure monitoring.

In 2021, the Universal Health Coverage Payment Scheme of Thailand approved home blood pressure monitoring (HBPM) devices for reimbursement. National utilization of HBPM devices will begin in 2022. This article provides the recommendations for HBPM from the Thai Hypertension Society. In this report, the authors review the benefits of HBPM and recommend confirming the diagnosis of hypertension by HBPM. Devices for HBPM should be the automated and validated upper arm cuff devices. HBPM should be ideally done for seven consecutive days before each clinic visit and take at least two readings (1 min apart) in the morning and before going to bed. The average blood pressure (BP) of 125-134/75-84 mmHg is classified as high normal BP and hypertension is BP of 135/85 mmHg or more. Target BP levels depend on the age of the patients; that is, < 125/75 mmHg for patients aged 18-65 years old, and <135/85 mmHg for patients over 65 years of age.

Home Blood Pressure Control and Drug Prescription Patterns among Thai Hypertensives: A 1-Year Analysis of Telehealth Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project.

BACKGROUND: Several interventions have been proposed to improve hypertension control with various outcomes. The home blood pressure (HBP) measurement is widely accepted for assessing the response to medications. However, the enhancement of blood pressure (BP) control with HBP telemonitoring technology has yet to be studied in Thailand. OBJECTIVE: To evaluate the attainment of HBP control and drug prescription patterns in Thai hypertensives at one year after initiating the TeleHealth Assisted Instrument in Home Blood Pressure Monitoring (THAI HBPM) nationwide pilot project. METHODS: A multicenter, prospective study enrolled treated hypertensive adults without prior regular HBPM to obtain monthly self-measured HBP using the same validated, oscillometric telemonitoring devices. The HBP reading was transferred to the clinic via a cloud-based system, so the physicians can adjust the medications at each follow-up visit on a real-life basis. Controlled HBP is defined as having HBP data at one year of follow-up within the defined target range (<135/85 mmHg). RESULTS: A total of 1,177 patients (mean age 58 ± 12.3 years, 59.4% women, 13.1% with diabetes) from 46 hospitals (81.5% primary care centers) were enrolled in the study. The mean clinic BP was 143.9 ± 18.1/84.3 ± 11.9 mmHg while the mean HBP was 134.4 ± 15.3/80.1 ± 9.4 mmHg with 609 (51.8%) patients having HBP reading <135/85 mmHg at enrollment. At one year of follow-up after implementing the HBP telemonitoring, 671 patients (57.0%) achieved HBP control. Patients with uncontrolled HBP had a higher prevalence of dyslipidemia and greater waist circumference than the controlled group. The majority of uncontrolled patients were still prescribed only one (36.0%) or two drugs (34.4%) at the end of the study. The antihypertensive drugs were not uptitrated in 136 (24%) patients with uncontrolled HBP at baseline. Calcium channel blocker was the most prescribed drug class (63.0%) followed by angiotensin-converting enzyme inhibitor (44.8%) while the thiazide-type diuretic was used in 18.9% of patients with controlled HBP and 16.4% in uncontrolled patients. CONCLUSION: With the implementation of HBP telemonitoring, the BP control rate based on HBP analysis was still low. This is possibly attributed to the therapeutic inertia of healthcare physicians. Calcium channel blocker was the most frequently used agent while the diuretic was underutilized. The long-term clinical benefit of overcoming therapeutic inertia alongside HBP telemonitoring needs to be validated in a future study.

Hypertension Subtypes among Thai Hypertensives: An Analysis of Telehealth-Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project.

BACKGROUND: White-coat hypertension (HT), masked HT, HT with white-coat effect, and masked uncontrolled HT are well-recognized problems of over- and undertreatment of high blood pressure in real-life practice. However, little is known about the true prevalence in Thailand. OBJECTIVES: To examine the prevalence and characteristics of each HT subtype defined by mean home blood pressure (HBP) and clinic blood pressure (CBP) using telemonitoring technology in Thai hypertensives. METHODS: A multicenter, observational study included adult hypertensives who had been diagnosed for at least 3 months based on CBP without the adoption of HBP monitoring. All patients were instructed to manually measure their HBP twice a day for the duration of at least one week using the same validated automated, oscillometric telemonitoring devices (Uright model TD-3128, TaiDoc Corporation, Taiwan). The HBP, CBP, and baseline demographic data were recorded on the web-based system. HT subtypes were classified according to the treatment status, CBP (≥or <140/90 mmHg), and mean HBP (≥or <135/85 mmHg) into the following eight subtypes: in nonmedicated hypertensives, there are four subtypes that are normotension, white-coat HT, masked HT, and sustained HT; in treated hypertensives, there are four subtypes that are well-controlled HT, HT with white-coat effect, masked uncontrolled HT, and sustained HT. RESULTS: Of the 1,184 patients (mean age 58 ± 12.7 years, 59% women) from 46 hospitals, 1,040 (87.8%) were taking antihypertensive agents. The majority of them were enrolled from primary care hospitals (81%). In the nonmedicated group, the prevalence of white-coat and masked HT was 25.7% and 7.0%, respectively. Among the treated patients, the HT with white-coat effect was found in 23.3% while 46.7% had uncontrolled HBP (a combination of the masked uncontrolled HT (9.6%) and sustained HT (37.1%)). In the medicated older subgroup (n = 487), uncontrolled HBP was more prevalent in male than in female (53.6% vs. 42.4%, p=0.013). CONCLUSIONS: This is the first nationwide study in Thailand to examine the prevalence of HT subtypes. Almost one-fourth had white-coat HT or HT with white-coat effect. Approximately half of the treated patients especially in the older males had uncontrolled HBP requiring more intensive interventions. These results emphasize the role of HBP monitoring for appropriate HT diagnosis and management. The cost-effectiveness of utilizing THAI HBPM in routine practice needs to be examined in the future study.

Clinical safety and performance of a MRI conditional pacing system in patients undergoing cardiac MRI.

BACKGROUND: Utilization of cardiac magnetic resonance imaging (cMRI) as an imaging modality in clinical practice is rapidly increasing. More evidence from randomized studies establishing clinical safety and performance of pacing systems in patients undergoing a cMRI scan is needed. OBJECTIVES: The purpose of this prospective, multicenter, randomized study was to demonstrate safety and efficacy of the Accent MRI™ conditional pacing systems (St. Jude Medical, St. Paul, MN, USA) in patients undergoing cMRI scan. METHODS: Patients (n  =  283) indicated for dual-chamber pacemaker implant were randomized to either the MRI Group (MG) (n  =  140) or the Control Group (CG) (n  =  143) after successful device implantation of the Accent MRI™ system. Clinical evaluation and device interrogation were performed at pre- and post-MRI scan, and 1 month post-MRI for all patients. At 9-12 weeks postimplant, patients in MG underwent a nondiagnostic cMRI scan at 1.5 Tesla (T), while patients in CG underwent device interrogation and clinical evaluation twice with a 45-minute waiting period in between. The safety endpoint was freedom from MRI scan-related complications and that for efficacy was significant changes in right atrial/ventricular capture threshold and sensing amplitude between right before MRI, immediately after MRI, and 1 month post-MRI. RESULTS: Results showed 100% freedom from MRI scan-related complications. There were no significant changes in device performance between pre-MRI scan and 1 month post-MRI scan time points in both study groups. CONCLUSIONS: cMRI scanning with 1.5 T scanners is safe in patients implanted with the Accent MRI™ conditional pacing system and has no significant effect on the electrical parameters of the device and leads.

Idiopathic left ventricular tachycardia in children.

BACKGROUND: Idiopathic left ventricular tachycardia (ILVT) is a rare but well-recognized clinical entity. The clinical characteristics and prognosis of this form of ventricular tachycardia (VT) in Thai children is not known. OBJECTIVE: To define clinical presentations, drug therapies, roles of radiofrequency (RF) catheter ablation, and the short-term outcome of these children in Thailand. PATIENTS AND METHOD: From April 1999 to June 2007, 10 patients were diagnosed as ILVT by specific electrocardiographic features and therapeutic response. All patients had a structurally normal heart. Data were collected retrospectively. Baseline clinical information, 12-lead electrocardiography (ECG) during VT, responses to drug therapy, results of RF catheter ablation therapy, and outcome were determined. RESULTS: Median age at presentation was 9.5 years (range, 3.8 to 14.0 years). Three patients (30%) were male. Eight patients (80%) were diagnosed as supraventricular tachycardia (SVT) before ILVT diagnosis. Median duration from SVT diagnosis to the correct diagnosis was 1.5 years (range, 0 to 6.0 years). Palpitation and chest pain were usual clinical manifestations while congestive heart failure was the presentation in one due to incessant tachycardia. Two patients had recurrent VT episodes during acute febrile illnesses. The majority of patients responded to intravenous verapamil. RF catheter ablation was performed in 3 patients with recurrence of the VT in one. CONCLUSION: Prompt recognition of the ILVTespecially in the emergency department is very important. Verapamil is effective for acute termination as well as prevention of VT recurrence. When VT is refractory to medical therapy, RF catheter ablation is safe and effective. The short-term prognosis was good.

Feasibility, safety, and mid-term efficacy of cardiac resynchronization therapy in patients with severe heart failure and ventricular conduction delay: Chulalongkorn experience.

BACKGROUND: Heart failure is a major and growing public health problem in developed and developing countries. Despite major advances in medical therapy, morbidity and mortality remain high. Cardiac resynchronization therapy (CRT) has been proposed as an adjunctive therapy in patients with drug-refractory heart failure and ventricular conduction delay. Short and long-term studies have demonstrated the clinical benefits of CRT. OBJECTIVE: The present study was designed to assess the feasibility, safety, and mid-term efficacy of CRT in patients with severe heart failure and ventricular conduction delay in the institute. MATERIAL AND METHOD: Ten patients with severe heart failure in New York Heart Association (NYHA) functional class III or IV with left ventricular ejection fraction (LVEF) < 35%, QRS duration >120 ms with left bundle branch block morphology received CRT At baseline, and 6 months after implantation, the following parameters were evaluated: NYHA class, QRS duration, LVEF N-terminal pro-brain natriuretic peptide (NT-pro BNP) level, 6-minute walking distance, SF-36 quality-of-life (QOL) score, and number of heart failure visit. RESULTS: All clinical parameters improved significantly at 6 months. NYHA class decreased from 3.5 +/- 0.5 to 2.4 +/- 0.7 (p < 0.01). QRS duration decreased from 145 +/- 22 ms to 126 + 6 ms (p < 0.01). LVEF increasedfrom 21 +/- 6% to 31 +/- 12% (p < 0.01). NT-pro BNP level decreased from 2503 +/- 1953 pg/ml to 767 +/- 342 pg/ml (p < 0.01). The 6-minute walking distance increased from 153 +/- 122 m to 278 +/- 128 m (p < 0.01). QOL score improved from 66 +/- 14 to 98 +/- 25 (p < 0. 01). The number of heart failure visits was reduced from 3.8 +/- 3.7 per year to 0.5 +/- 0.8 visit per year (p < 0.01). Seventy percent of patients were free of heart failure visit for one year after implantation. One patient had sudden cardiac death eleven months after implantation. There was no procedure-related mortality. One patient had left ventricular lead dislodgement 3 months after implantation. CONCLUSION: In the present study, CRT was safe and effective in improving heart failure symptom, functional status, LV function, and quality of life. CRT also reduced heart failure hospitalization in the presented severe heart failure and ventricular conduction delay patients.

Defibrillator Versus beta-Blockers for Unexplained Death in Thailand (DEBUT): a randomized clinical trial.

BACKGROUND: Sudden Unexplained Death Syndrome (SUDS) is the leading cause of death in young, healthy, Southeast Asian men. The role of an implantable cardioverter defibrillator (ICD) for mortality reduction in these patients remains unclear. METHODS AND RESULTS: The Defibrillator Versus beta-Blockers for Unexplained Death in Thailand (DEBUT) study is a randomized, clinical trial conducted in 2 phases (pilot study followed by the main trial) to compare the annual all-cause mortality rates among SUDS patients treated with beta-blockers versus that among those treated with an ICD. A total of 86 patients who were SUDS survivors and probable SUDS survivors were randomized to receive an ICD or propranolol (20 patients were in the pilot study and 66 were in the main trial). The primary end point was death from all causes. The secondary end point was recurrent ventricular tachycardia/ventricular fibrillation (VF) or cardiac arrest. During the 3-year follow-up period of the main trial, there were 4 deaths; all occurred in the beta-blocker group (P=0.02). Seven subjects in the ICD arm had recurrent VF, and all were effectively treated by the ICD. On the basis of the main trial results, the Data Safety Monitoring Board stopped the study. In total (both from the Pilot study and the main trial), there were 7 deaths (18%) in the beta-blocker group and no deaths in the ICD group, but there were a total of 12 ICD patients receiving ICD discharges due to recurrent VF. CONCLUSIONS: ICD treatment provides full protection from death related to primary VF in a SUDS population and is superior to beta-blockade treatment.