HJAR Nov/Dec 2023

HEALTHCARE JOURNAL OF ARKANSAS  I  NOV / DEC 2023 49 Mohammad Ilyas, MD Pediatric Nephrologist Arkansas Children’s which patients are normotensive in the clinic but have high blood pressures out- side the clinic, contribute to a false diag- nosis. The benefits of accurate diagnosis Medicines for treating high blood pres- sure can have long-lasting adverse side effects, especially on a child’s developing body. Furthermore, blood and urine tests and the ultrasounds or echocardiograms required for patients diagnosed with hy- pertension can be costly. Avoiding unwar- ranted and potentially harmful medica- tions and expensive procedures provides additional motivation for accurate diag- nosis. ABPM is more predictive of future blood pressure and can help detect secondary hypertension. The results collected via ABPM are more reproducible and cor- relate better with target organ damage. ABPM has value as both a diagnostic tool and a means to evaluate the effec- tiveness of treatment plans. In the case of pharmacological treatments, intermittent use of ABPM can be used for the titration of blood pressure medications. Collaboration, referrals and patient education For many years, ABPM at Arkansas Chil- dren’s Hospital was used exclusively by the Nephrology/Hypertension Clinic. Recog- nizing the importance of accurate blood pressure measurements, the nephrology department prioritized collaborating with other departments and clinics and now evaluates high-risk patients referred by the cardiology department, endocrinol- ogy/weight management clinic, and Ar- kansas Children’s Hospital’s primary care pediatricians and community clinics and pediatricians from the region. High-risk patients include those with chronic kidney disease, renal transplantation, obstructive sleep apnea, coarctation of the aorta, and who are on dialysis. Elevated blood pressure based on two standard readings on three separate visits triggers suspected hypertension and war- rants a referral to the ABPM program. Providers must educate patients on the device and which events should be noted in the journal to ensure accurate readings. The Nephrology department at Arkan- sas Children’s Hospital uses the following three-pronged approach to ensure accu- rate readings: 1. In-person demonstrations while the patient and caregiver are in the clinic facilitate comfort with the technology and allow immediate answers to any questions. 2. Written materials, like brochures or pamphlets, illustrating the topics dis- cussed during in-person demonstra- tions provide important reminders once the patient and caregiver are outside the clinic. 3. Videos posted online, either by hospi- tals or the device manufacturers, of- fer another helpful tool for ensuring the correct usage of the device. Recent advances in the comfort and use of telemedicine by patients and medical providers present additional opportunities for patient education. Additional considerations The ability to capture nocturnal blood pressure readings is another unique ad- vantage of ABPM. Studies have linked an increase in blood pressure while sleeping — or the absence of an expected dip in blood pressure — with increased cardiovascular risk. Nocturnal blood pressure data pres- ents exciting opportunities for additional research. Despite the strong recommendation and explicit medical value of using ABPM, monetary and time costs have slowed the widespread adoption of the technique. Ambulatory blood pressure monitoring is currently the highest standard of care and is vital in identifying one of the most sig- nificant preventable risk factors for death. Standard blood pressure cuffs, once the primary method for diagnosis, are still an essential first step in identifying hyperten- sion. Reliable estimates indicate that near- ly half of the 1.4 billion people with hyper- tension are undiagnosed and unaware of their condition. Ensuring appropriate staff stay current on the effective use of standard cuffs and recognize when to initiate referrals for ABPM will increase diagnosis, speed treat- ment, and reduce deaths. n Mohammad Ilyas, MD, is a pediatric nephrologist at Arkansas Children’s and an associate professor in the Department of Pediatrics in the College of Medicine at the University of Arkansas for Medical Sciences.