Analytics4Medicine

To better: Define, Diagnose, Measure, and Manage Hypertension



Hypertension is poorly managed, only 48.3 % are controlled nationwide

Where do we go wrong?

Predictive Analytics

Health Care Analytics

A4M CDST

(Clinical Decision Support Tool)

HTN Quiz

If you get more than 50%,You do not need us

The Problem

Hypertension (HTN) is a common, dangerous, expensive, time consuming, ailment. Depending on the blood pressure cut off, hypertension affects 30 to 46% of the world’s population. It causes 18% of the heart attacks, 35% of the strokes, 39% of heart failure in men and 59% of heart failure in women. It causes 1/4 of all cases of renal failure. It leads to 500,000 deaths each year from cardiovascular disease, costs $118 billion a year, and consumes over 36 million office visits per year. Despite its high prevalence, significant morbidity and mortality, and excessive costs; it is poorly managed. NHANES data showed that only 48.3% are controlled nationwide.

Usual care

If the blood pressure is above goal in the office on three separate occasions a diagnosis of "hypertension" is made.

Problem #1- Office-based blood pressure is unreliable. If your blood pressure is high in the office and high at home, you have hypertension. If your blood pressure is high in the office but normal at home, you have white coat hypertension that may not require treatment. If you were normal in the office but high at home, you would be misdiagnosed as normal but all the risk of HTN would go untreated.

Problem #2- BP varies by time of day with the highest readings usually occurring between 8:00 AM and noon and 4:00 PM at 8:00 PM in dipping when you sleep. It is best to monitor your blood pressure twice a day at a fixed time of your choosing between 8:00 AM and noon and 4:00 PM and 8:00 PM three days a week Monday Wednesday Saturday or Tuesday Thursday Sunday and use those values to determine your rate of BP control.

Problem #3- Hypertension (HTN) is treated as a singular disease, and that is no more helpful than the diagnosis of "cancer". Knowing the types of cancer (nosology) alters the definition and effects diagnosis, therapy, and prognosis. An ideal classification system would define categories of HTN to improve diagnosis, therapy, and prognosis.

Where do we go wrong?

Definition

The definition is inappropriate. A high BP reading is not Hypertension. Everyone has a high reading during the day. It must be consistently elevated and the more time out of the day it is elevated, the worse it is for your brain, heart, and kidneys.  HTN is dynamic. It should be defined over a time frame. BP Load refers to the amount of time your BP is above the recommended goal BP. Your BP should be elevated less than 30% of the time.

Measurement

Office based blood pressure is unreliable. If your BP is high in the office and high at home, you have hypertension. If your Blood Pressure is high in the office but normal at home, you have white coat hypertension that may not need treatment. If you were normal in the office but high at home, you would be misdiagnosed as normal when you in fact have dangerously high blood pressure.  Blood pressure varies by time of day with the highest readings usually occurring between 8:00 AM and noon and 4:00 PM and 8:00 PM and dipping when you sleep. It is best to monitor your blood pressure twice a day at a fixed time of your choosing between 8AM and noon and 4:00 PM in 8:00 PM three days a week (M,W,Saturday) or (T,T,Sunday) and report those numbers to your doctor.

Diagnosis

The diagnosis is suspect. Presently, if your blood pressure is elevated on three occasions in the office and lifestyle changes do not control it, you would be diagnosed with "Hypertension" and started on a medication. This default diagnosis was originally called Essential Hypertension but is now called Primary Hypertension. Primary Hypertension means the doctor ruled out all secondary causes of Hypertension and this is not the case. There are more than 50 secondary causes of Hypertension with treatments that vary from medication to angioplasty to surgery. A systematic approach to diagnosis is preferred.

Management

If the definition is inappropriate. The measurement is unreliable, and the diagnosis is suspect you have no change at management. Over the past 50 years hypertension has been managed with a trial-and-error approach. "Try this, let's see what happens" and the result with guidelines and everything available to modern medicine is worse than a coin flip. Less than half of patients are controlled.

Is there a better way?

  • The A4M method

    The A4M Clinical Decision Support Tool (CDST) improves the definition, diagnosis, measurement, and management of hypertension.

    Definition & Measurement- A4M uses twice-a-day home blood pressure monitoring to define hypertension. This eliminates white coat HTN and detects masked HTN. We use peak diurnal home blood pressure readings to approximate the highest blood pressure levels over a 10-day time frame to measure BP load, the time burden of hypertension. A BP flow chart tracks your progress over time and relays rates of control to your provider.

    Diagnosis- We use a nine-category renin/aldosterone diagnostic Matrix (low renin-low aldosterone HTN to high renin – high aldosterone HTN) to sort over 50 secondary causes of HTN and direct disease specific therapy. The matrix also helps with prognosis (poorer outcomes at the same level of BP control). We use a proprietary drug sequencing algorithm to match the mechanism of hypertension to the mechanism of action of the antihypertensive drugs in those without a determined secondary cause of HTN.

    Time Management- We use templated virtual visits to reduce provider management time by up to 75%.

    Quality Improvement- We provide performance monitoring to determine best practices, relative drug cost, time management, disease distribution rates, drug side effect rates, event rates and outcomes over time. As the database grows, machine learning will refine the algorithms for improved efficacy and further cost reductions.