Hypertension and nephrology

[The improvement of the rate of reaching the target blood pressure and the quality of care of hypertensive patients with applying telemedicine facilities]

KISS István, KÉLES Ede

DECEMBER 30, 2012

Hypertension and nephrology - 2012;16(06)

[The authors summarize the facilities of the telemedicine and telemonitoring system. The methods of telemedicine and their combination with home blood pressure measurement or the help of a nurse or pharmacist are reviewed. In the light of the latest results the authors are led to the conclusion that the intensive spread of using the facilities of telemedicine is necessary in the present-day Hungarian healthcare system. At the same time it is also determined that the methodical and technical potential is not enough to further enhance the efficiency in itself. The personal contact and the possibility of interactive monitoring from distance are definitely crucial for the continuous maintenance of the reached target blood pressure in patients suffering from hypertension and also for the augmentation of patient adherence regarding applying medicine.]

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[The apparatus which controls our kidney too. Part 2 - Structure and function of the juxtaglomerular apparatus]

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[The juxtaglomerular apparatus is comprised of the macula densa (a specialregion of the distal tubule), the renin producing granular or epithelioid-cells of the afferent arteriole, the extraglomerular mesengial cells, and the efferent arteriole’s section bordering this region. Somewhat more general definitions also exist. Recently, distinctive morphological and functional associations have been identified between the components of the JGA and some common mediators (e.g. adenosine, angiotensin, NO, prostaglandins, etc.). Current data suggest that each cell of the macula densa also contain few cilia that may have a role in sensing fluid flow. The distal section of the afferent arteriole (possessing the same structure as the glomerular capillaries) is covered by fenestrated endothelium. Trace dose of ferritin particles can pass through the afferent arteriole’s fenestrae into the interstitium of the JGA due to the considerable hydrostatic pressure gradient. The parietal lamina of Bowman’s capsule, which covers the renin granulated cells of the afferent arteriole behaves much like the visceral lamina in that the epithelial cells of the parietal lamina exhibit foot processes and filtration slits. The urinary space is regularly bulging into the extraglomerular mesangium. Therefore, the notion has been refuted that the JGA, which contains neither blood nor lymph capillaries, is a closed system engaging in only slow fluid exchange. Furthermore it is affirmed that the afferent arteriole consists of two morphologically and functionally disparate segments, the ratio of which is considerably modified by the activity of the renin-angiotensin system.]

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[Acute heart failure and acute renal injury: pathophysiology and management of cardiorenal syndrome type 1]

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[The functional connection between heart and kidney is well known. Several types of this relationship have been recently characterized as cardiorenal syndromes. The relevance of this relationship in clinical practice is supported by the fact, that the consequences of the primary dysfunction are profoundly influenced by the magnitude and the treatment possibilities of the secondary dysfunction. Moreover, the administered therapy for heart failure can deteriorate renal hemodinamics, or side effects of the treatment can lead to the worsening of the clinical picture. Loop diuretics decrease venous congestion, but also induce neurohormonal activation and a decrease in glomerular filtration rate. The body of positive evidence with the use of mineralocorticoid receptor antagonists in acute settings is limited. Inotropic agents on the one hand improve hemodinamics, on the other hand increase the danger of arrhythmia and mortality (levosimendan seems to be an exception). Aquaretics decrease symptoms without influencing mortality. The natriuretic peptide neseritid improved clinical symptoms, but did not improve endpoints in clinical trials. Vasodilators improve hemodinamics, but their usefulness is limited because of their profound hypotensive effect. The effectiveness and benefits of ultrafiltration has to be tested in more clinical trials. Because of such treatment difficulties the management of these patients is a complex task that needs the involvement of intensive therapeutic specialists, nephrologists and cardiologists. This review focuses on the pathophysiology and possible management of the patients with acute heart failure with acute kidney injury, called type 1 cardiorenal syndrome from the cardiologist’s point of view.]

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[Authors present the guidelines, indications and utility value of home selfmeasurements of blood pressure. They report the results of the most important clinical studies. They analyze the methodology of the measurements within telemedicinal solutions and describe the consultative scopes associated with the measurement methods already applied in clinical practice. Their own telemonitoring system - called Medistance - is then presented. They have created three modules for the long term registration of blood pressure in hypertensive patients: 1. an individual module for the hypertensive patients, the elderly, the family, for patients with high cardiovascular risk and for the physicians. 2. a module for the pharmaceutical care, 3. a module for the communities (social homes, club for the elderly, etc.). The Medistance system is functioning for two years in our count]

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Hypertension and nephrology

[Methods of using telemedicine devices (smartphones, tablets) during home blood pressure measurement]

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[Change in the approach of the treatment of hypertension in Hungary. Five years results of the „Live below 140/90!” Program]

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[One of the potentials of the effective fight against endemic diseases is their exposition and the recognition of their dangers and risk factors. The other possibility is to increase the professional knowledge of the medical and healthcare employees along with the patients’ co-operation. For the prevention of complications and the adequate treatment of hypertension an extensive compliance program, called „Live below 140/90!” was initiated by the Hungarian Society of Hypertension in 2005. The mission was to give knowledge to the non-professional public about the symptoms of the disease and how to get information about it while helping patients’ relatives. The first message was the “Hit the target blood pressure value!”. With careful planning, treatment and taking of medicines the next phase could begin. The ratio of the patients who reached the target blood pressure increased by 5% during the two years of the Program between 2005 and 2007 therefore the message changed to “Hold the blood pressure there!”. The next step in the Program was to prevent the forming of complications and to treat the co-morbidities effectively among patients with pre-diabetes or diabetes and hypertension in 2008. The slogan was “Prevent the complications!”. As part of the Program we organized a roadshow named the “Day of caring!” and we announced the “Conscious Care” substudy focused on the public summoning about the stroke which is the most dangerous complication of hypertension. The year of 2011 is an absolutely new beginning in the communication of the Program since we started to use some very modern tools of the 21st century including YouTube, Facebook and others for the better education of the people. Based on the results of the initial Program we got to know the risks, co-morbidities, complications and the characteristics of the Hungarian hypertensive patients. We have recognized that most of the patients belong to the high and very high risk hypertensive category. Also more than 30 percent of them have a pre-diabetes condition. We have found that increased caring helps to build up the patients’ co-operation which in return improves the decrease of their blood pressure significantly. The Program therefore continues in 2011! Our intention is to enlarge the Hungarian Hypertension Register database and to get to know more and more epidemiologic and therapeutic features of the hypertension disease.]

Lege Artis Medicinae

[PErindopril-Amlodipine Reducing Blood Pressure Level Trial - The PEARL Study]

NAGY Viktor, LANTOS Éva, HABONY Norbert

[Background and aims - In order to reach target blood pressure values more successfully and to achieve better therapeutic compliance, concomitant use of more antihypertensive agents with different mechanisms of action has gained much attention recently. In the PEARL study we investigated the antihypertensive effect of fixed dose combinations of perindopril and amlodipine (5/5, 5/10, 10/5, 10/10 mg Covercard) by measuring blood pressure values in the doctor’s office and with a 24-hour ambulatory blood pressure monitor (ABPM) in outpatients with primary, grade 1 or 2 hypertension, whose target values could not be reached with prior treatment. We also assessed changes of metabolic parameters and how patients felt themselves throughout the study. Patients and methods - In this open-label, multicentre, non-interventional, observational, 3 month long study we evaluated the data of 10 335 patients (5 483 female, 4 852 male, mean age: 61.0±12.4 years, waist circumference 99.0±13.8 cm). The mean duration of hypertension was 9.5±7.7 years. After signing the informed consent form, patients attended three visits (inclusion, months 1 and 3), and they were asked to fill in the data sheets (visit 1: gender, age, waist circumference, blood pressure and heart rate measured at the doctor’s office, duration of hypertension, risk factors, complications, accompanying diseases, previous antihypertensive treatments, complaints), laboratory blood tests and ABPM were optionally performed; visits 2 and 3: blood pressure and heart rate measured at the doctor’s office, adverse events, patient’s evaluation about the way they felt themselves, treatment, optionally performed laboratory blood tests and ABPM. Patients were asked to take perindopril-amlodipine fixed combination tablets in the mornings; the dose was increased if no normalization of blood pressure was observed. Data were analyzed with a one-sample t-test. The consistency of the different frequency distributions was tested with a Chi-square test. The two-sided level of significance was set at 5%. Results - All the parameters sensitive to treatment efficacy (blood pressure values measured on-site and with ABPM) were significantly improved with perindopril-amlodipine fixed combination treatment. Blood pressure measured at the doctor’s office reduced from 158/93 mmHg to 132/80 mmHg, while 24-hour mean blood pressure reduced from 145/84 mmHg to 128/76 mmHg (p<0.001), the diurnal index sensitive to blood pressure variability did not change and a dipper curve was observed throughout the study. Target blood pressure (<140/90 mmHg) was reached by 75.5 % of the patients. The mean dosage at the end of the study was 8 mg perindopril and 7.3 mg amlodipine. The results were consistent across subgroups of different previously received treatments and cardiovascular risks. Regarding laboratory findings, the reduction of total cholesterol from 5.67 to 5.21 mmol/L and that of LDL cholesterol from 3.18 to 2.83 mmol/L (p<0.001 for both) were of clinical importance. Eighty-five percent of the patients evaluated the way they felt themselves as excellent or improved. No serious adverse events were reported. Conclusion - Perindopril-amlodipine fixed combination can be administered effectively and safely to a large population of hypertensive patients who do not reach target blood pressure values.]

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[The present and future of hypertension-care in Hungary]

SZEGEDI János, KÉKES Ede, KISS István

[Hypertension is a population disorder of a kind that basically affects the health status, morbidity, mortality, quality of life of the population. The decrease complications its prevalence is favorably influenced by the correct treatment -defined by guidelines-, effective care, reaching and its sustained maintenance of target blood pressure, successful patient-physician co-operation. The importance of cooperation between the patient- physician- assistants- pharmacist is emphasized by numerous international organizations. The general quality of the health care system, the extensive use of the unified information system and the modern tools of telemedicine are increasingly important. The degree of drug adherence is also extremely important. According to our own experience, 40% of patients did not take the prescribed drugs in the second to third months of therapy. The Home Blood Pressure Measurement, Blood Pressure Monitoring as well as the patient education and drug revenue check mediated by smartphones, increase adherence. Real progress would mean that, like the care of heart failure, hypertension outpatients clinic (within the university centers, and the hospital departments of the county) would provide the therapeutic controll and care of the hypertensive patients.]

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[Telemedicine care for high-risk hypertensive patients with antihypertensive for reaching better blood pressure target ratio and smaller blood pressure variability]

KISS István, ÁDÁM Ágnes, HERCZEG Béla, MATOLTSY András, POÓR Ferenc, SZEGEDI János, VÁRALLYAY Zoltán, PAKSY András, KÉKES Ede

[Telehealth care of high-risk hypertensive patients for a better target blood pressure and smaller size blood pressure fluctuation. Authors conducted a one-year, multicentre, prospective, observational study with no intervention. Their aim was to achieve better targeting and smaller blood pressure fluctuation in patients with high risk hypertensive patients with the new type of doctorpatient co-operation and telemedicinal care than the conventional control method. In the active group, 50 patients, in the non-active group 47 treated hypertensive patients were analysed. During the observation period (1 year) the mean (± SD) of the systolic blood pressure decreased from 143.3 (15.1) mmHg to 134.5 (9.2) mmHg in the active group, but in the non-active group there was no significant decrease. The target blood pressure (< 140/90 mmHg) could be increased from 46% to 62%. The two characteristics of interpersonal visit-to-visit variability index. The standard deviation (SD) and variation coefficient (VC) showed a significant decrease in the active group. There was no change in the inactive group. A method supported by telemedicine-assisted and better patientphysician- assistant co-operation is suitable for increasing target blood pressure rates and reducing blood pressure fluctuation.]