Sponsor: DCVS, NHLBI, Virtual Workshop

The National Heart, Lung, and Blood Institute (NHLBI), of the National Institutes of Health (NIH), convened a virtual workshop titled "Blood Pressure Assessment Across the Lifespan: Improving Clinical Research and Clinical Practice" on December 5-6, 2024. This workshop brought together early career investigators, leading experts in basic, translational, and clinical research in cardiovascular health, and representatives from academic institutions, federal agencies, and non-federal organizations. The primary objective of the workshop was to identify high-priority research gaps and opportunities to advance blood pressure assessment strategies across different stages of life. Specific objectives included:

1. Evaluate the current state of knowledge on blood pressure assessment in clinical practice and clinical research.
2. Identify knowledge gaps pertaining to current blood pressure assessment methods and identify obstacles with which NIH may be able to make an impact in addressing.
3. Review ongoing research and identify research needs to improve blood pressure assessment in clinical practice and clinical research.
4. Complement and expand on the 2023 workshop on Transforming Hypertension Diagnosis and Management in the Era of Artificial Intelligence.

The workshop aligns with the NHLBI's Strategic Vision Objectives, focusing on improving public health through advancements in cardiovascular research and practice.

Background

Hypertension is a leading cause of morbidity and mortality globally, affecting a significant portion of the population across various age groups. Accurate blood pressure measurement is crucial for diagnosing hypertension, guiding treatment, and reducing the risk of cardiovascular events. Despite advances in technology and methodology, challenges persist in accurately measuring blood pressure in clinical settings and integrating out-of-office measurements into routine care. Additionally, a variety of levels of care exist in hypertension diagnosis and management, particularly among vulnerable populations such as children, pregnant women, and the socio-economically disadvantaged. Addressing these challenges is essential for improving health outcomes and reducing disparities in cardiovascular care.

Discussions

The workshop discussions focused on several key areas, including:

1. Integration of patient-generated data with clinical assessments to improve blood pressure management.
2. Challenges and opportunities in measuring blood pressure in special populations, such as children and pregnant women.
3. The role of emerging technologies, including cuffless devices, in enhancing blood pressure monitoring.
4. Ensuring access to blood pressure assessment tools and addressing measurement biases in technology and methodology across various population groups.

Gaps and Challenges:

1. Variability in Measurement Techniques: Evidence of discrepancies between different blood pressure measurement techniques (office, home, ambulatory, and cuffless devices) was presented. The variability and potential biases in these methods were highlighted, particularly concerning the accuracy and reliability of automated devices in real-world settings.
2. Variability Across the Life Span: Gaps in current measurement techniques and guidelines, particularly regarding the lack of validated devices for pediatric and geriatric populations and the insufficient consideration of pregnancy- and age-specific physiological changes and blood pressure variability. Variability in methods over time can introduce bias in estimates of trends.
3. Environmental Impact: Environmental factors were shown to affect blood pressure. Factors like ambient temperature, noise, and air pollution were shown to acutely influence blood pressure readings, suggesting that environmental exposure might contribute to blood pressure variability.
4. Community-Based Measurements: Using non-traditional settings, such as barbershops and churches, for blood pressure measurement has demonstrated in clinical trials notable success in engaging communities and improving blood pressure control, but the practice has not been widely adopted. Research opportunities exist to identify obstacles and methods to better support efforts to lower blood pressure within communities.
5. Challenges with Technology and Integration: The difficulties in integrating home blood pressure monitoring data into electronic health records were emphasized, especially regarding privacy concerns and the technical barriers that prevent seamless data transfer. These challenges were highlighted as major impediments to implementing remote monitoring effectively.
6. Patient Engagement and Education: Several speakers noted that patients often lack understanding of blood pressure variability and its implications. The need for improved education and communication strategies to engage patients in managing their blood pressure effectively was a recurring theme.

Research Opportunities:

1. Environmental Influence on Blood Pressure: The impact of environmental factors such as temperature, noise, and air pollution on blood pressure was highlighted. This suggests a opportunities for research to better understand how these factors specifically affect blood pressure readings and management, and how they can be integrated into clinical practice.
2. Cultural and Behavioral Factors: Discussions indicated that cultural perceptions and behaviors significantly influence blood pressure management and monitoring. Research is needed to explore these cultural factors more deeply, including how they affect patient engagement and adherence to blood pressure monitoring protocols.
3. Technological Integration and Privacy Concerns: The challenge of integrating home blood pressure monitoring data into electronic health records was noted, along with privacy concerns related to third-party software applications. Research could focus on developing standardized protocols for data integration and addressing privacy issues to facilitate seamless and secure data transfer.
4. Variability and Thresholds: There is a need for studies to determine optimal thresholds for out-of-office blood pressure readings and to explore the variability in blood pressure, including its implications for treatment and management. Research could aim to identify which drugs most effectively reduce intra-individual variability.
5. Special Populations: More research is needed to understand how emerging blood pressure technologies can be adapted for special populations and across life span, such as pregnant women, children, and individuals with chronic kidney disease, especially considering data gaps and lack of validated devices.
6. Community-Based Interventions: The effectiveness and sustainability of community-based interventions, such as those in barber shops or using mobile health units, require further investigation to determine best practices for engagement and long-term impact.
7. Bias in Blood Pressure Measurement: The potential for threshold bias in blood pressure recording, even with automated devices, suggests a gap in understanding how to detect and prevent such biases systematically.
8. Patient and Clinician Education: There is a need for more effective educational strategies to improve both patient and clinician understanding of blood pressure variability and the importance of accurate measurement techniques.

Publication Plans

A white paper detailing the gaps and opportunities identified during the workshop is currently being prepared for publication.

Workshop Participants

Co-Chairs

• Marwa Abdullah, MD, MPH, Department of Medicine, Columbia University Irving Medical Center, New York, NY
• Stephen Juraschek, MD, PhD, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA

Faculty Speakers

• Italo Baggioni, MD, Vanderbilt University Medical Center, Vanderbilt University Medical Center, Nashville, TN
• Christopher Barrett Bowling, MD, MSPH, Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC
• Tammy Brady, MD, PhD, Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
• Adam Bress, MS, PharmD, Department of Population Health Sciences, Division of Health System Innovation & Research, Spencer Fox Eccles School of Medicine, Salt Lake City, UT
• Robert Brook, MD, Division of Cardiovascular Diseases, Department of Internal Medicine, Wayne State University, Detroit, MI
• Jordana Cohen, MD, Renal-Electrolyte and Hypertension Division, Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
• Yvonne Commodore-Mensah, PhD, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology ,Johns Hopkins University, Baltimore, MD
• Kimberly Crowley, MS, Office of Cardiovascular Devices, Center of Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
• Daichi Shimbo, MD, Department of Medicine, Columbia University Irving Medical Center, New York, NY
• Richard Dart, MD, Center for Precision Medicine, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI
• Paul Drawz, MD, MHS, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
• Keith Ferdinand, MD, KCF Department of Medicine-Section of Cardiology, Tulane University School of Medicine, New Orleans, LA
• Joseph Flynn, MD, MS, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
• Kathryn Foti, PhD, MPH, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
• Beverly Green, MD, MPH, Kaiser Permanente Washington Health Research Institute
• Kara Hoppe, DO, PhD, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
• Kate Kirley, MD, MS, American Medical Association, Chicago, IL
• Lewis Lipsitz, MD, Marcus Institute for Aging Research at Hebrew SeniorLife, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
• Jesus Melgarejo, MD, PhD, Neuro & Behavioral Integrated Service Unit, Institute of Neuroscience, School of Medicine, University of Texas Rio Grande Valley, TX
• Rama Mukkamala, PhD, Department of Bioengineering and Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
• Paul Muntner, PhD, MHS, Perisphere Real World Evidence, LLC, Austin, TX; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
• Joseph Ravenell, MD, MS, Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY
• Andrew South, MD,  Department of Pediatrics-Section of Nephrology, Wake Forest University School of Medicine, Winston Salem, NC
• Raymond Townsend, MD, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
• Hilary K Wall, MPH,  Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA
• Paul J Wang, MD, Stanford University School of Medicine, Palo Alto, CA

NIH/NHLBI Staff

• Paula Einhorn, MD
• Youngsuk Oh, PhD
• Jasmina Varagic, MD, PhD
• Patrice Desvigne-Nickens, MD
• Ravi Balijepalli, PhD
• Michael Wolz, MA