The major obstacles to BP control have been identified by Spence1 as:

Lifestyle issues

Obesity, drugs (oral contraceptives, NSAIDs, alcohol, illicit drugs) sedentary lifestyle, etc.

Compliance / Adherence

Patient & Provider compliance to a relatively asymptomatic problem is suboptimal.

Diagnostic inertia

Failure to look for secondary causes seen in 20-30% of patients.

Therapeutic inertia

Failure to increase meds when goals are not reached or to match the mechanism of HTN to the mechanism of the anti-hypertensive drugs.

Time commitment

HTN is the #2 office visit, > 42 Million visits/year, consumes > 14,000,000 provider hours/year

The A4M Approach

We provide educational materials to help the patient with lifestyle issues. The material is available online in their web application or you can reenforce the information by printing copies and handing them out.

The patient records their peak diurnal home blood pressure readings on a Tuesday, Thursday, Saturday, Tuesday, Thursday schedule. The computer calculates the percent control for each patient in your panel. You get a list every 10 days of uncontrolled patients that need medication adjustment. If they are controlled, they come off the list and are sent an email congratulating them reenforcing lifestyle changes and continuing their medications. Every 10-day monitoring improves both patient and provider compliance. If the patient stops their medication, the blood pressure will acutely rise alerting you to intervene. If they come off their meds and they are controlled, they do not need anti-hypertensives. Frequent adjustment has been shown to improve the rate of control.

We use a 9 box matrix to divide hypertension into nine categories based on renin and aldosterone levels from low renin - low aldosterone hypertension, to high renin high aldosterone hypertension. Clicking on the appropriate category provides an extensive differential diagnosis with peer reviewed therapy for each specific condition found under that category. Given that 20 to 30% of patients will have a secondary diagnosis, some form of systematic evaluation is required.

The application has a drug sequencing algorithm based on age, ethnicity, associated disease, and renin aldosterone levels. The attempt is to match the mechanism of hypertension to the mechanism of the anti -hypertensive drugs. For example, low renin - normal aldosterone hypertension is most often due to low renin primary hypertension and this should respond to a diuretic alone. High renin hypertension implies renal vascular disease where ACE inhibitors, ARBs and beta blockers would be better first choice medications.

Time commitment

HTN is the #2 office visit in the US. There are over 42 Million visits/year. This consumes more than 14,000,000 provider hours/year that could be spent seeing other patients. A4M provides templated virtual visits to replace an office visit with essentially a text message. Home blood pressure monitoring can eliminate 20 to 45% of people with white coat hypertension that do not necessarily need to be followed in the clinic. Time management can be reduced by 75% improving access.

What is the evidence?

TeAM-HTN2 was a feasibility study of the CDST published in Military Med. Sept 20202. The program of peak diurnal home BP monitoring with every10-day reminders, templated Virtual Visits, a diagnostic Matrix and a drug sequencing algorithm, improved control rates in resistant HTN (rHTN) from 0% to 58%. 45% of patients were mislabeled with apparent resistant HTN (white coat HTN-high in the office but normal at home and were excluded from the study), 20% had AM masked HTN (high in AM but normal in PM) and 22% had PM masked HTN. 45% of resistant patients had abnormal renin and aldosterone levels. Overall, the rate of control for all office based “uncontrolled patients” (apparent resistant HTN and rHTN) was 76%. Provider management time was reduced by 75% compared to “usual care”. This study emphasized the importance of definition and measurement of HTN using peak diurnal home BP monitoring to exclude white coat HTN and identify AM and PM masked HTN.