Home Blood Pressure Monitoring in Patients After Carotid Endarterectomy: A Feasibility Study

Abstract

Introduction: Around fifty percent of perioperative strokes following carotid endarterectomy (CEA) are related to hemodynamic disturbances (hypertensive and hypotensive episodes) and can occur up to 30 days after surgery. Therefore, tight perioperative blood pressure (BP) control is an essential component of stroke prevention after CEA. Despite the importance of in-hospital perioperative hemodynamics, little is known of BP changes in the first weeks after CEA. Self-measurement of BP at home could close this knowledge gap and might help targeting patients who are most at risk. It might also allow earlier recognition of deterioration and early intervention. In this pilot study, we asked patients who had undergone CEA to perform BP measurements twice daily at home during the first 30 days after discharge and observed BP remotely. The primary study aim was to assess feasibility and patient experiences with daily BP self-measurement. Secondary, to gain insight into postoperative BP trends. Methods: Thirty patients undergoing CEA at a tertiary referral center, were included in this study. Patients received an ambulatory BP monitor (OMRON HEM-9210T, Healthcare Co.Lt., Kyoto, Japan) that transmits BP values to a secured online dashboard via a telemonitoring application (Luscii Vitals, Luscii Healthtech BV, Amsterdam, the Netherlands) on iPad. Patients were trained to use the equipment and asked to record BP twice daily for 30 days after hospital discharge. For each patient, systolic BP restrictions were determined based on postoperative increase of cerebral blood flow measured by Transcranial Doppler (TCD). An alert was generated if BP exceeded this threshold with ≥15%. If four consecutive alerts were generated, patients were requested to visit the outpatient clinic. At the end of the study, patients were asked to complete a survey regarding their experiences and perceived feasibility of home BP monitoring following CEA. We also recorded patient adherence to the monitoring protocol, BP time series, and any interventions. Results: Patient age was 68(±8) years (87% male). Ninety percent had symptomatic stenosis, and 90% underwent internal carotid CEA. Five patients(17%) were prolonged observed postoperatively in a high care unit, two(7%) had TCD-measured cerebral hyperperfusion, and six(20%) had a postoperative event (bleeding:2, TIA:2, myocardial infarction:1; one patient was readmitted for stress-induced hypertension). One patient visited his general practitioner for concerns regarding high BP values recorded at home. Patient adherence to home BP measurement was high; 24 patients provided ≥90% of the expected BP measurements. Regarding feasibility, 67% of patients experienced home BP monitoring as very positive, and 25% moderately positive. All patients except one would recommend home BP monitoring as part of standard care after CEA. In no patients four consecutive BP measurements exceeded the individual systolic BP threshold. Mean intra-individual variability of systolic and diastolic BP of all patients was 13.2mmHg and 7.4mmHg, respectively. No significant differences in variability of systolic BP measurements were found between patients with an event and those without an event. Conclusion: Postoperative home BP monitoring was well accepted and recommended by patients undergoing CEA. Future trials need to address the ability of home BP monitoring to timely recognize patients at risk for postoperative deterioration. Disclosure: Nothing to disclose