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PL 03-1 HYPERTENSION MANAGEMENT IN THE ERA OF DIGITAL INFORMATION AND COMMUNICATION TECHNOLOGIES.

Despite having the basic tools necessary to appropriately identify and manage individuals with hypertension for over half a century it remains the single greatest contributing risk factor to morbidity and mortality worldwide today. Since diagnosis and effective treatment availability are not issues, this major failing in care can be attributed to inadequate systems of care: systems that have led to only <20% of hypertensive individuals globally having their blood pressure adequately controlled. Even in the US, where it is one of the most common reasons for a primary care visit, and with over $42.9 billion (USD) in direct costs annually, only 53% are under adequate control.There is a clear need for transformative change in our management of hypertension. Fortunately, through the use of a variety of innovative digital technologies, it is now possible to completely reengineer BP management, eliminating the century-old approach requiring all decision-making, education, and therapeutic changes be tied to a clinical visit, but rather to one that is more patient-centered, engaging, pragmatic and globally scalable. Additionally, through the use of some of these novel technologies we will be able to completely re-characterize the imprecise diagnosis of "essential hypertension" into a collection of distinct phenotypes allowing for more individualized therapeutic approaches.The ability for individuals to easily measure their own BP outside the clinical setting has been possible since 1981 with the availability of the first automated BP cuff for home use. Today, for the person wanting to measure their blood pressure at home there are literally hundreds of options for BP cuffs: manual, semi-automated, or automated; wrist-based or arm-based; manual data logging or wirelessly connected to a smartphone. Most exciting are the number of devices being developed that do not require a cuff, but rather use photoplethysmography or other methods like radar to determine blood pressure in a much simpler, and less obtrusive manner. These novel non-cuff-based technologies have enabled the development of a new family of wearable sensor that can measure BP continuously and non-invasively, and are poised to completely transform our understanding of hypertension and how we treat it. Most are based on tracking of the pulse waveform, allowing for measurement almost anywhere on the body surface, although the majority being developed are wrist based. Several such devices have already received regulatory approval for continuous noninvasive blood pressure monitoring, although they were designed and approved for use in the inpatient setting only. With the future availability of consumer grade wearables able to monitor blood pressure in all settings we will gain a much greater understanding of sleep- and stress-related changes in blood pressure, as well as identify currently unknown unique environmental and behavioral influencesBut does just measuring your blood pressure outside of the doctor's office improve control? A recent meta-analysis would suggests it doesn't, at least not beyond 6 months.10 On the other hand, when self-monitoring is combined with feedback and support - whether web-based, through text messaging, or phone calls - significant improvement has been demonstrated out to 12 months. In fact, when self-monitoring has been coupled with guided self-treatment the benefit over usual care has been even more striking. Therefore, a true solution to our global hypertensive crisis requires both simplified monitoring and tracking coupled with real-time feedback as needed.A complete solution is possible through incorporation of other components of the ongoing digital revolution - ubiquitous connectivity and miniaturized computational capability, both via the smartphone, and accessible artificial intelligence. A smartphone allows for BP data to be aggregated, visualized and made instantaneously available for feedback, if desired. That feedback could be provided asynchronously by a member of the individual's healthcare team, or alternatively, using artificial intelligence supported by guidelines, published algorithms, and that patient's unique characteristics available through their personal medical record, 24/7. A complete, digitally enabled feedback loop designed to meet all of a person's needs to support BP management is necessary and possible today.Going digital in order to better understand and treat hypertension holds great promise for addressing one of the world's greatest unmet medical needs. We have the necessary tools. All that is needed is the desire to bring a century old practice into the 21st century.

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