Hypertension is the lifetime risk for organ damage and cardiovascular disease. The risk of high blood pressure (BP) is initiated before the diagnosis of hypertension. From healthy younger adult subjects with high-normal BP in the early lifetime stage to the elderly hypertensive patients with cardiovascular risk factors and/or organ damage, higher BP exhibits increased the risk than normotensive subjects. In this issue of Hypertension Research, two prospective papers from Suita study demonstrated the significant increased risk of cardiovascular disease (CVD) and heart failure even in high-normal BP [1, 2]. Compared to normal BP (systolic BP (SBP) < 120 and diastolic BP (DBP) < 80 mmHg), elevated BP (SBP 130–139 and/or DBP 80–89 mmHg) and hypertension (SBP ≥ 140 and/or DBP ≥ 90 mmHg) were associated with a higher risk of CVD, stroke, coronary heart disease (CHD) and heart failure. In addition, high-normal BP (SBP 120–129 and DBP < 80 mmHg) was associated with a higher risk of CVD and CHD. CVD preventive interventions should begin at lower BP levels than those applied in the 2019 Japanese Society of Hypertension (JSH2019) guidelines.
Proposal of home BP-centered approach
Here we are proposing the home BP-centered approach for the management of hypertension. This approach is effective from the healthcare to medical treatment for the suppression of the onset and aggravation of hypertension (Fig. 1). Recent guidelines and recommendations stressed the importance of home BP for the management of hypertension [3,4,5,6]. There are accumulated prospective evidence that home BP is the stronger prognostic risk factor of cardiovascular events both in a community-based populations and in hypertensive patients [7, 8]. The Kamogawa-HBP study on the diabetic patients demonstrated that higher home BP is associated with the risk of cardiovascular events and the progression of diabetic nephropathy [9, 10]. However, home BP, especially morning home BP has not been controlled yet. In total, 50% or more medicated patients have not achieved morning SBP controlled <135 mmHg [11, 12]. The JSH2019 stressed the importance of home BP expressed by the sentence that when there is discrepancy in the diagnosis of hypertension between office and home BPs, the home BP-based diagnosed should be prioritized [3, 13]. In addition, the latest guidelines Taiwan Hypertension Society recommend diagnosing hypertension by home BP [14].
Especially, home BP-centered approach is facilitated by the recent advance in digital techniques. Hypertension Research is now focusing and facilitating the research on the digital hypertension [15]. In the era of COVID-19 pandemic, telemedicine using digital techniques have been widely introduced into the clinical practice [16,17,18,19]. Thus, home BP-centered approach on the home BP-based diagnosis and treatment of hypertension is the primetime. Home BP monitoring per se may increase self-efficacy of lifestyle modification and drug adherence, and improve patient-doctor relationship and clinical inertia. A metaanalysis on the effect of home BP monitoring demonstrated that home BP monitoring with the education and/or consultation significantly lower BP [20]. In 2021, the first randomized control trial of digital therapeutics (application) for hypertension (HERB-DH1) demonstrated the significant 24-h SBP reduction, compared with control group [21, 22]. Both digital therapeutics group and control group received doctor’s routine lifestyle education with home BP morning. Morning home SBP significantly reduced by 10.9 mmHg in digital therapeutics group, and by 6.2 mmHg in the control group (the group-difference: 4.3 mmHg, p < 0.001) [21, 22]. In 2022, in Japan, the digital therapeutics of hypertension was first approved by regulatory authority in the condition of combined use of home BP monitoring [23]. This first hypertension digital therapeutics facilitated to support the patients to get correct knowledge and to execute the six components of lifestyle modification such as salt restriction, adequate body weight, exercise, alcohol restriction, sleep and stress management [21]. In the platform of this digital therapeutics, the daily-base time-trend data of home BP and self-reported behavioral modification was shared by patients and sometimes by doctors, resulting in improving the patient-doctor relationship. Thus, the home BP monitoring with some objective behavioral index (B-index) would be the first step to modify the personal behaviors.
B-index of sodium reduction
Sodium restriction, the validated BP-lowering behavioral modification [24,25,26], would be effective in Asia, because Asians have higher prevalence of masked hypertension with higher salt intake [6, 27]. In the first hypertension digital therapeutics, we used self-reported sodium intake score, and found that home BP reduction was correlated with the reduction of this score [19]. The urinary Na/K ratio could be considered as the objective B-index of dietary intervention to reduce the onset and aggravation of hypertension. There are accumulated evidence of research on urinary sodium (Na)/potassium (K) ratio (urinary Na/K ratio) [28,29,30]. Salt substitutes with reduced sodium levels and increased potassium levels have been shown to lower BP. In addition, a recent open-label, cluster-randomized trial of salt substitute (75% sodium chloride and 25% potassium chloride) vs. regular salt (100% sodium chloride), in community-dwelling persons who had a history of stroke or were 60 years of age or older and had high BP, the rates of stroke, major cardiovascular events, and death from any cause were lower with the salt substitute than with regular salt [31].
The cross-sectional study in this issue demonstrated that the urinary Na/K ratio was associated with SBP in 684 community-dwelling older adults older adults (mean age, 76.8 years) [32]. Interestingly, urinary Na/K ratio was influenced by other habitual dietary patterns. A positive history of daily milk consumption predicted a mean urinary Na/K ratio of 2.8, and a negative history of daily milk consumption predicted a mean urinary Na/K ratio of 3.3. Furthermore, the frequency of fruit and vegetable consumption also predicted the urinary Na/K ratio. The relationship between the urinary Na/K ratio and hypertension was influenced by the frequency of consumption of milk, fruits, and vegetables in the subjects, indicating the importance of comprehensive nutritional education in older subjects.
The lifetime home BP-centered approach combined with salt restriction is the core in the national and global health strategy from heath care to medicine to reduce cardiovascular event “zero”. This strategy could be facilitated by digital era with COVID-19 pandemic [33].
References
Arafa A, Kashima R, Kokubo Y. New 2019 JSH guidelines and the risk of incident cardiovascular disease: the Suita study. Hypertens Res. 2022. https://doi.org/10.1038/s41440-022-01142-5.
Arafa A, Kokubo Y, Teramoto M, Kashima R, Shimamoto K, Yoko M, et al. Blood pressure per the 2017 ACC/AHA and 2018 ESC/ESH guidelines and heart failure risk: the Suita study. Hypertens Res. 2023. https://doi.org/10.1038/s41440-022-01128-3.
Umemura S, Arima H, Arima S, Asayama K, Dohi Y, Hirooka Y, et al. The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2019). Hypertens Res. 2019;42:1235–481.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269–324.
Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–104.
Kario K, Chia YC, Siddique S, Turana Y, Li Y, Chen CH, et al. Seven-action approaches for the management of hypertension in Asia—the HOPE Asia network. J Clin Hypertens. 2022;24:213–23.
Kario K, Shimbo D, Hoshide S, Wang JG, Asayama K, Ohkubo T, et al. The emergence of home blood pressure-guided management of hypertension based on global evidence. Hypertension. 2019;74:229–36.
Kario K. Home blood pressure monitoring: current status and new developments. Am J Hypertens. 2021;34:783–94.
Ushigome E, Kitagawa N, Kitagawa N, Tanaka T, Hasegawa G, Ohnishi M, et al. Predictive power of home blood pressure measurement for cardiovascular outcomes in patients with type 2 diabetes: KAMOGAWA-HBP study. Hypertens Res. 2021;44:348–54.
Hata S, Ushigome E, Hosomi Y, Yoshimura T, Takegami M, Kitagawa N, et al. Impact of continued high blood pressure on the progression of diabetic nephropathy after 10 years: KAMOGAWA-HBP study. Hypertens Res. 2023. https://doi.org/10.1038/s41440-022-01136-3.
Kario K, Hoshide S, Mogi M. Uncontrolled hypertension: the greatest challenge and perspectives in Asia. Hypertens Res. 2022;45:1847–9.
Kario K, Tomitani N, Nishizawa M, Harada N, Kanegae H, Hoshide S. Concept, study design, and baseline blood pressure control status of the nationwide prospective HI–JAMP study using multisensor ABPM. 2022. https://doi.org/10.1038/s41440-022-01087-9.
Imai Y. A personal history of research on hypertension From an encounter with hypertension to the development of hypertension practice based on out-of-clinic blood pressure measurements. Hypertens Res. 2022;45:1726–42.
Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, et al. 2022 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. Acta Cardiol Sin. 2022;38:225–325.
Kario K, Hoshide S, Mogi M. Digital hypertension 2023: concept, hypothesis, and new technology. Hypertens Res. 2022;45:1529–30.
Khan NA, Stergiou GS, Omboni S, Kario K, Renna N, Chapman N, et al. Virtual management of hypertention: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension. J Hypertens. 2022;40:1435–48.
Omboni S, Ballatore T, Rizzi F, Tomassini F, Campolo L, Panzeri E, et al. 24-hour ambulatory blood pressure telemonitoring in patients at risk of atrial fibrillation: results from the TEMPLAR project. Hypertens Res. 2022;45:1486–95.
Omboni S, Padwal RS, Alessa T, Benczúr B, Green BB, Hubbard I, et al. The worldwide impact of telemedicine during COVID-19: current evidence and recommendations for the future. Connect Health. 2022;1:7–35.
McManus RJ, Little P, Stuart B, Morton K, Raftery J, Kelly J, et al. Home and online management and evaluation of blood pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial. BMJ. 2021;372:m4858.
Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. PLoS Med. 2017;14:e1002389.
Kario K, Nomura A, Harada N, Okura A, Nakagawa K, Tanigawa T, et al. Efficacy of a digital therapeutics system in the management of essential hypertension: the HERB-DH1 pivotal trial. Eur Heart J. 2021;42:4111–22.
Kario K, Harada N, Okura A. Digital therapeutics in hypertension: evidence and perspectives. Hypertension. 2022;79:2148–58.
Kario K, Harada N, Okura A. The first software as medical device of evidence-based hypertension digital therapeutics for clinical practice. Hypertension Res. 2022;45:1899–905.
Nakano M, Eguchi K, Sato T, Onoguchi A, Hoshide S, Kario K. Effect of intensive salt-restriction education on clinic, home, and ambulatory blood pressure levels in treated hypertensive patients during a 3-month education period. J Clin Hypertens. 2016;18:385–92.
Lai JS, Aung YN, Khalid Y, Cheah SC. Impact of different dietary sodium reduction strategies on blood pressure: a systematic review. Hypertens Res. 2022;45:1701–12.
Tsuchihashi T. Dietary salt intake in Japan—past, present, and future. Hypertens Res. 2022;45:748–57.
Kario K, Chen CH, Park S, Park CG, Hoshide S, Cheng HM, et al. Consensus document on improving hypertension management in Asian patients, taking into account Asian characteristics. Hypertension. 2018;71:375–82.
Salman E, Kadota A, Okami Y, Kondo K, Yoshita K, Okuda N, et al. Investigation of the urinary sodium-to-potassium ratio target level based on the recommended dietary intake goals for the Japanese population: the INTERMAP Japan. Hypertens Res. 2022;45:1850–60.
Ma Y, He FJ, Sun Q, Yuan C, Kieneker LM, Curhan GC, et al. 24-hour urinary sodium and potassium excretion and cardiovascular risk. N Engl J Med. 2022;386:252–63.
Yatabe J, Ishida K, Yatabe MS. Old story, new twist: reducing salt and increasing potassium intake as a social issue according to the INTERMAP Japan. Hypertens Res. 2022. https://doi.org/10.1038/s41440-022-01082-0.
Neal B, Wu Y, Feng X, Zhang R, Zhang Y, Shi J, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med. 2021;385:1067–77.
Yamanaka N, Itabashi M, Fujiwara Y, Nofuji Y, Abe T, Kitamura A, et al. Relationship between the urinary Na/K ratio, diet and hypertension among community-dwelling older adults. Hypertens Res. 2022. (in press).
Kario K. Essential manual of perfect 24-hour blood pressure management from morning to nocturnal hypertension. 2nd ed. London: Wiley; 2022. p. 1–374.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Kario, K., Hoshide, S. & Mogi, M. Lifetime home BP-centered approach is the core from onset to aggravation of hypertension. Hypertens Res 46, 553–555 (2023). https://doi.org/10.1038/s41440-023-01174-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41440-023-01174-5
Keywords
This article is cited by
-
The Editorial Structure 2024 of Hypertension Research for global initiatives
Hypertension Research (2024)
-
The importance of regular home blood pressure monitoring over the life course
Hypertension Research (2024)
-
What impacts do the new ESH 2023 guidelines have on the management of hypertension in Japan?
Hypertension Research (2023)
-
Evidence for the surge blood pressure resonance hypothesis as a trigger for cardiovascular disease events
Hypertension Research (2023)
-
Topics 2023 in Hypertension Research leading to guidelines in Asia
Hypertension Research (2023)