Prognostic Implications of Home-Based Blood Pressure Monitoring in Older Adults

Hypertension affects over 85% of adults over 75 years of age and represents one of the few modifiable risk factors to prevent dementia and cardiovascular disease (CVD) events in older adults. However, current practice guidelines for hypertension screening and treatment focus heavily on blood pressure (BP) measurements obtained in clinic settings. This reliance on brick-and-mortar offices for BP measurement represents a significant barrier for older adults, who often depend on others for transportation and who are at increased risk of severe morbidity from the current COVID-19 pandemic. Home BP monitoring (HBPM) has shown incredible promise for more effective and timely BP treatment and control. Furthermore, the current pandemic has catalyzed widespread adoption of HBPM for hypertension screening and management. However, evidence for this practice is severely lacking in older adults. In fact, there are virtually no HBPM cohort studies in elderly populations in the United States. This is particularly concerning as the discordance between clinic and home BP increases with age, making older adults especially susceptible to harms from either overly aggressive or delayed BP treatment. In this proposed study, we apply our unique expertise with HBPM and 24-hour ambulatory blood pressure monitoring to one of the most long-standing and well-respected American cohorts of community-dwelling adults, the Atherosclerosis Risk in Communities Study (ARIC). While ARIC already rigorously measures BP in the clinic setting via automated devices, our proposal will additionally assess 8 days of HBPM and 24 hours of ambulatory BP (once every 20 minutes) in 2,142 racially diverse adults over age 80 years, establishing possibly the largest prospective study of home, ambulatory, and clinic-based BP measurement among older adults in the world. This proposal is designed to directly inform clinical practice with HBPM by characterizing its measurement performance (bias and variance), predictiveness with respect to key long-term events (dementia and CVD), and interpretation (i.e. what a home BP measure equals in terms of BP measured by ABPM or in clinic). The accomplishment of this proposal will address critical gaps in knowledge related to an increasingly utilized form of BP measurement, improving access to timely hypertension care by establishing an efficient protocol for precise BP measurement at home. Moreover, by investing in the digital monitoring platform of the ARIC study, this proposal will lay the foundation for remote collection of a wide range of detailed, longitudinal, biosensor data that can be leveraged by many investigators through subsequent ARIC proposals in years to come. With current trends in BP control worsening among older adults in the United States, there has never been a greater need for research on innovative technologies to improve access to high quality BP measurement. Ultimately, our proposal directly answers the call by NHLBI's 2017 expert panel on BP measurement for high impact research that determines “the role of ABPM and HBPM in the diagnosis…of hypertension” and “the optimal protocol for using HBPM…to diagnose and assess…hypertension.”