Impact of Ambulatory Blood Pressure Monitoring on patient health in remote areas: the role of Community Pharmacy

INTRODUCTION

Cardiovascular diseases (CVD) are the leading cause of mortality worldwide. In Spain, they account for almost 30% of all mortality, and there is a direct relationship between arterial hypertension (HTN) and the incidence of cardiovascular events.

HTN remains the most important preventable factor in CVD. There is ample evidence that lowering blood pressure (BP) slows the progression of atherosclerotic disease and its complications.(1)

Scientific societies recommend methods such as ambulatory blood pressure monitoring (ABPM) for clinical decision making because they allow more accurate identification of the relationship between HTN and the presence of cardiovascular disease or target organ damage.(2)

There is little evidence of the use of ABPM in community pharmacies, although more and more pharmacists are offering this professional service, which is particularly important in areas where an ABPM monitor is not available in the clinic or the nearest hospital is far from the patient’s home.

The main objective of this study was to evaluate the effectiveness of pharmaceutical intervention in HTN using ABPM in community pharmacies. Secondary objectives are to analyze the results of monitoring according to the sociodemographic characteristics of the patients, to evaluate the rate of referral to the primary care physician, and to observe changes in pharmacological treatment after the intervention.

MATERIAL AND METHODS

The observational study was conducted from July 2021 to December 2023 in a community pharmacy located in a rural area with difficult access to hospitals and serving approximately 900 residents.

Inclusion criteria:

Patients over 18 years of age, normotensive or with a previous diagnosis of hypertension, who agreed to participate in the study by signing the informed consent form.

Exclusion criteria:

Pregnant patients and those who did not sign the informed consent.

Patients were informed about the availability of the Community Pharmacy Services (CPS) in the pharmacy and those who agreed to participate were given written information about the description of the ABPM method and their questions were answered through a pre-device interview in the personalized pharmaceutical care area (PPCA).

The general practitioner was informed of the objectives of the study and the possibility of referring patients.

BP readings were taken over a 29-hour period using the MicrolifeWatch BP03 device, which recorded BP every 20 minutes during the activity period and every 60 minutes during the rest period, allowing identification of cases of uncontrolled HTN, white-coat HTN, or masked HTN.

Professional training was provided through the ImpacHta training; refresher course on hypertension and vascular risk for community pharmacists of the Spanish Society of Clinical, Family and Community Pharmacy (Sefac).(3)

The results of the pharmaceutical interventions were recorded and subsequently provided to each patient in the form of two reports; one for the patient him/herself and another for referral to the general practitioner, if necessary. Both reports were generated using the Sefac Expert CPS registration platform.(4)

RESULTS

A total of 21 patients who underwent ABPM were included in the study, 20 of whom were referred because their mean blood pressure values were outside the ranges specified in the guidelines that establish the criteria for the diagnosis, treatment, and control of hypertension in patients.(2)

The profiles found in the patients in the study included masked hypertension, white coat hypertension and resistant hypertension.

The results of these interventions from the community pharmacy and in collaboration with the physician were as follows:

• Medication adjustments.
• Lifestyle recommendations and health education.
• Improved patient follow-up.
• Increased adherence to treatment.

Patient satisfaction was high, demonstrating the accessibility of the CPS in the community pharmacy.

The following table shows the data of the 21 patients according to: age, sex, reason for inclusion in the study, result of the ABPM and subsequent intervention from the pharmacy:

 

Table 1. 

 

Table 1. (Continued)

 

DISCUSSION

The results of this study demonstrate the efficacy of ABPM in the management of HTN in rural areas from the community pharmacy, where access to specialized medical services is limited and may pose an additional difficulty for patients.

The accessibility and proximity of community pharmacies facilitates the implementation of these interventions, which could not only reduce the burden on the healthcare system, but also promote better control of blood pressure in the general population through appropriate screening programs and the prevention of related cardiovascular complications.

These results are consistent with previous studies that have demonstrated the usefulness of ABPM in identifying blood pressure patterns that may not be apparent in health centers.(5)

A high percentage of referrals is observed, reinforcing the importance of teamwork in controlling blood pressure and improving patients’ quality of life.

In addition, the results of this study support previous research that underscores the fundamental role of the pharmacist in the management and control of hypertension in the primary care setting.(1)

CONCLUSIONS

The availability of professional services such as ambulatory blood pressure monitoring in community pharmacies can make a significant difference in the screening, prevention and control of HTN, especially for patients living in areas far from hospital centers.

The main results of this study support the effectiveness of pharmaceutical intervention in these aspects, since 95% of the patients, of whom 48% were women and the mean age was 67 years, were referred to the general practitioner for both pharmacological and non-pharmacological adjustments to achieve more adequate BP control. ABPM allowed the detection of specific patterns of HTN, such as uncontrolled, masked, and white-coat hypertension, contributing to a more accurate diagnosis.

Observation of BP changes following the pharmaceutical intervention allowed for better control and follow-up of the intervention.

This study highlights the importance of multidisciplinary work in the appropriate management of arterial hypertension and the need to integrate the community pharmacist into the primary care team.

Implementation of similar programs in other contexts, such as urban or rural pharmacies with better access to specialized medical services, would allow validation and extrapolation of the conclusions of this study.

ACKNOWLEDGMENTS

I would like to express my sincere gratitude to my colleague Oscar Penín Álvarez for the opportunity to collaborate as a co-author in the preparation of the Guide for the Approach to Hypertension by the Community Pharmacist in Primary Care. Thanks to this guide, community pharmacists have established protocols for an adequate approach, screening, management, and follow-up of blood pressure in our patients. It has been a privilege to contribute to this project under your expert guidance and within the framework of the SEFAC Hypertension and Vascular Risk working group.

We extend our profound gratitude for the trust you have demonstrated and for your exemplary leadership in this significant undertaking.

REFERENCES

1. Penín O, Villasuso B, Domenech M, Moyá A, Torras J, Peña M J, et al. Guía para el abordaje de la hipertensión por el farmacéutico comunitario en el ámbito de la atención primaria: documento de consenso multidisciplinar. Farm Comunitarios. 2022 Sep 05;14(Supl 2. HTA). https://www.farmaceuticoscomunitarios.org/es/journal-issue/hta
2. McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 7 de octubre de 2024;45(38):3912-4018. https://doi.org/10.1093/eurheartj/ehae178
3. Servicio Profesional Farmacéutico Asistencial de medición y control de la Presión arterial y el riesgo vascular desde la farmacia comunitaria. Ediciones 3 a 4 | CAMPUS SEFAC [Internet]. [citado 19 de octubre de 2024]. Disponible en: https://www.campussefac.org/p-impachta/inicio
4. SEFAC eXPERT – Plataforma Digital de Gestión de Pacientes. [Internet] Madrid. Sociedad Española de Farmacia Clínica, Familiar y Comunitaria. Ultimo acceso 19/02/2024. [citado 19 de octubre de 2024] Disponible en https://www.sefacexpert.org/
5. Gijón-Conde T, Gorostidi M, Banegas JR, De La Sierra A, Segura J, Vinyoles E, et al. Documento de la Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA) sobre monitorización ambulatoria de la presión arterial (MAPA) 2019. Hipertens Riesgo Vasc. octubre de 2019;36(4):199-212. https://doi.org/10.1016/j.hipert.2019.05.002