Firefighters Checking Smoke Alarms and Blood Pressure: HOPE 4 – Medscape

MONTREAL An intervention involving trained firefighters and other nonphysicians identified and counseled people with hypertension in two disadvantaged Canadian communities, which led to reduced cardiovascular risk, in a small pilot study that was part of Heart Outcomes Prevention and Evaluation4 (HOPE4).

Jon David Schwalm, MD, associate professor, McMaster University, Hamilton, Ontario, Canada, presented these findings from the Canadian pilot study here at the Canadian Cardiovascular Congress 2019, and the results were similar to those in the larger international part of HOPE4, he said.

As previously reported, HOPE4 was a randomized controlled trial of more than 1000 patients in 30 communities in two middle-income countries: Columbia and Malaysia. The results were presented at the ESC Congress 2019 and published online in the Lancet on September2.

In the Canadian pilot study, firefighters going door-to-door to check smoke alarms in Surrey, British Columbia and nonphysicians who were part of a community outreach program Hamilton identified 54 adults with hypertension.

These trained lay people had tablets with an algorithm that helped them counsel people about lifestyle changes and recommend antihypertensive treatments.

The study participants also identified a family member or friend who would help them adhere to their medicine and make lifestyle changes.

At 6 months, the participants had a 25% decrease in Framingham risk score.

"The whole crux of this study both the international and Canadian [parts] is that we did not do screening within medical clinics; this was all done out in the community, trying to capture patients who are not already in the system," said Schwalm.

"It's early days, but we're developing committees now at the larger international level to try to move this forward into implementation," he told theheart.org| Medscape Cardiology.

"It's already being implemented in early stages in Columbia and Malaysia, within their healthcare system," and the next steps are to learn from this pilot study and see how it can be integrated into existing community programs in Canada.

"Unfortunately, our firefighters had to shift their allocation of resources to the growing fentanyl epidemic that's happening out there," he said, so the planned larger study was curtailed.

But the researchers intend to build on this pilot study, to target vulnerable populations in Canada that would be ideal for this intervention.

This intervention had an impact and is scalable, Peter Liu, MD, chief scientific officer and vice president of research, University of Ottawa Heart Institute, Ontario told theheart.org| Medscape Cardiology.

"Keeping in mind that hypertension is the worldwide number one cardiovascular challenge and adherence to medication is usually less than 50%," he said, "this is really a great example that when you put all those components together [technology, family support, and a simple intervention], you can do very well."

Asked if this is a similar approach to that in a study that showed that barbershop healthcare cuts hypertension in blacks, he replied, "absolutely."

According to Liu, "we really have to take a lot of these very important health solutionsinto the real world in the patient's environment rather than in the artificial locations in hospital or in the [doctor's] office."

This type of intervention can be adapted from middle-income countries to high-income countries, especially for disadvantaged people, such as indigenous populations, he said.

Liu and colleagues recently published findings from the related DREAMGLOBAL study, which showed that a blood-pressure-lowering program that used text messages could be implemented in First Nations communities. There was, however, no difference in blood-pressure-lowering with text messages about hypertension compared with text messages about health behaviors.

"I think the work led by McMaster in the HOPE program to improve the uptake of lifesaving treatments for hypertension and the prevention of cardiovascular disease is world-leading and really important," keynote speaker at this featured research session, Nicholas Mills, MD, PhD, University of Edinburgh, United Kingdom, told theheart.org| Medscape Cardiology.

"Although the priority has been to understand the impact in the developing world, there are major challenges in optimizing prevention of heart disease and cardiovascular risk in the developed world," said Mills, who was chief investigator for the High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction (HiSTORIC) study reported at the ESC Congress 2019.

"And HOPE Canada," he said, "is a great start to understand how we can think differently about the provision of our services in order to really try to improve cardiovascular health in Canada and other countries like it."

"We'd love to work with [these researchers] in Scotland."

"There is clear evidence that lowering blood pressure will reduce cardiovascular disease and mortality, yet hypertension detection, treatment, and control is low globally," Schwalm said.

To attempt to improve this, the HOPE4 study identified barriers to hypertension management and then developed a community-based comprehensive intervention.

The people who were trained to give the intervention attended a nine-module 1-week training course, based on World Health Organization's HEARTS Technical Package.

The study randomized 1371 adults in 30 communities in Columbia and Malaysia to the intervention or usual care.

At 12 months, there was an absolute 5% reduction in the Framingham risk score.

"What was very pleasing to see," Schwalm said, "was this result was consistent across all subgroups two different countries, two different health systems, two different continents with the exact same response and was similar in urban and rural communities, men and women, young and old, [and] high education, low education."

"We know that hypertension detection, treatment, and control is low even in high-income countries," he continued.

For example, the PURE study reported that control in high-income countries is less than 20%, "so we have a lot of room to improve as well."

The researchers tailored the HOPE4 intervention to the Canadian context; for example, they did not provide free medications upfront because it wasn't identified as a big barrier. And they tried to use nonphysician health workers who were already in the community.

In Surrey, firefighters have a home-safe program, where they go door to door in lower socioeconomic areas and check fire alarms, Schwalm said, and the Hamilton Urban Core Community Health Center serves a downtown area with less advantaged individuals.

The participants were 50 years and older with new or uncontrolled systolic blood pressure above 140mmHg.

Of 193 adults who were screened, 89 were eligible for the study and 54 provided signed consent: 20 in Hamilton and 34 in Surrey.

At the 6-month follow-up, 85% of the participants remained in the study.

The Canadian study participants were a bit older (mean age, 75 vs 65 years), but otherwise they had similar baseline characteristics as those in the study in Malaysia and Columbia. In addition, 53% were female, 71% had a history of hypertension, 29% had diabetes, and 5% had a previous MI or atherosclerotic cardiovascular disease.

At baseline, the participants had a mean systolic blood pressure of 153.1mmHg, which dropped to 136.7mmHg at 6 months.

The percentage of participants with controlled blood pressure went from 2.4% to 56.5% at 6 months.

There was a significant reduction in the mean Framingham risk score, from 18.4 to 16.1 (P< .01)

There were no significant changes in the use of two antihypertensives, the use of a statin, total cholesterol, LDL cholesterol, smoking, or being physically active but this was a very small, exploratory study.

The HOPE4 study was funded by the Canadian Institutes of Health Research; Grand Challenges Canada; Ontario SPOR Support Unit and the Ontario Ministry of Health and Long-term Care; Boehringer Ingelheim; Department of Management of Non-Communicable Diseases, WHO; and Population Health Research Institute. Schwalm reports no disclosures.

Canadian Cardiovascular Congress 2019: Abstract034. Presented October24, 2019.

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Firefighters Checking Smoke Alarms and Blood Pressure: HOPE 4 - Medscape