home visit plan for hypertension

Effectiveness of home visiting on patients with hypertension: A systematic review and meta-analysis

Affiliations.

• 1 The First School of Clinical Medicine, Lanzhou University.
• 2 Evidence-Based Nursing Center, School of Nursing of Lanzhou University.
• 3 Delivery Center, Gansu Provincial Maternity and Child-care Hospital.
• 4 Department of Nursing, Gansu Provincial Hospital, Lanzhou, China.
• PMID: 33725818
• PMCID: PMC7969236
• DOI: 10.1097/MD.0000000000024072

Background: Blood pressure lowering treatments can help prevent cardiovascular disease. However, little is known about the possibility of home visiting programs for hypertension. This study aims to evaluate the effectiveness of home visiting programs on hypertensive patients.

Methods: We systematically reviewed the medical literature and performed a meta-analysis. Five electronic databases were systematically searched from their inception to September 2019. Two reviewers independently assessed the risk of bias of the studies included in the review using tools developed by the Cochrane Collaboration. The meta-analysis was performed using Review Manager software (version 5.3).

Results: Thirteen RCTs with 2674 participants were identified. The home visiting program demonstrated a greater reduction in systolic blood pressure (MD = -5.63, 95% confidence interval (CI): -8.32 to -2.94), diastolic blood pressure (MD = -4.14, 95% CI: -6.72 to -1.56) and waist circumference (MD = -2.61, 95% CI: -3.5, -1.72) during a 6 month intervention. However, there were no significant differences between the groups in terms of body mass index, weight, or blood lipids.

Conclusion: Home visiting programs were associated with improved BP control and reduced blood pressure, which indicate that it might be an effective method for management of hypertension.

Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

Publication types

• Meta-Analysis
• Systematic Review
• Aftercare / methods*
• Blood Pressure Determination / statistics & numerical data
• House Calls*
• Hypertension / diagnosis
• Hypertension / therapy*
• Nursing Care / methods*
• Randomized Controlled Trials as Topic
• Treatment Outcome

Grants and funding

• 71663002, 71704071/National Nature Science Foundation of China
• #20-374/The fund of China Medical Board
• LZUSON202002/The Research Funds for the School of Nursing of Lanzhou University
• 20JR10RA603/Natural Science Foundation of Gansu Province
• lzujbky-2020-10/the Fundamental Research Funds for the Central Universities

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2017 Guideline for High Blood Pressure in Adults

The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

Part 1: General Approach, Screening, and Follow-up

• The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.
• It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic  140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.
• For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. In 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites.  Often overlooked, the risk for CVD increases in a log-linear fashion; from SBP levels <115 mm Hg to >180 mm Hg, and from DBP levels <75 mm Hg to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.
• It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.
• Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.
• Nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg.
• The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of  ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg. The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women compared with men. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.
• Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.

Part 2:  Principles of Drug Therapy and Special Populations

• Principles of drug therapy: Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K + or K + -sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K + , but should be avoided with GFR <45 ml/min. Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided. Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF. Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha 2 -agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.
• Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components. For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.
• CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
• Adults with stroke and cerebral vascular disease are complex. To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm. In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective. Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke or TIA. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.
• Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.
• Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.
• Valvular heart disease: Asymptomatic aortic stenosis with hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed. In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).
• Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
• Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
• Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.
• Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered. For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
• For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.
• Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions. Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Diet, Exercise, Hypertension, Chronic Angina

Keywords: Adrenergic beta-Antagonists, AHA17, AHA Annual Scientific Sessions, Antihypertensive Agents, Aortic Diseases, Atherosclerosis, Atrial Fibrillation, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Body Weight Changes, Cerebral Hemorrhage, Cerebrovascular Disorders, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Diagnostic Techniques, Cardiovascular, Diet, Electronic Health Records, Exercise, Geriatrics, Heart Failure, Heart Valve Diseases, Hypertension, Life Style, Mass Screening, Medical History Taking, Metabolic Syndrome, Patient Compliance, Patient Care Team, Perioperative Period, Peripheral Arterial Disease, Peripheral Vascular Diseases, Pregnancy, Primary Prevention, Quality of Health Care, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Risk Reduction Behavior, Secondary Prevention, Self Care, Angina, Stable, Stroke, Telemedicine, Therapeutics, Transplantation

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• 10 ways to control high blood pressure without medication

By making these 10 lifestyle changes, you can lower your blood pressure and reduce your risk of heart disease.

If you have high blood pressure, you may wonder if medication is necessary to bring the numbers down. But lifestyle plays a vital role in treating high blood pressure. Controlling blood pressure with a healthy lifestyle might prevent, delay or reduce the need for medication.

Here are 10 lifestyle changes that can lower blood pressure and keep it down.

1. Lose extra pounds and watch your waistline

Blood pressure often increases as weight increases. Being overweight also can cause disrupted breathing while you sleep (sleep apnea), which further raises blood pressure.

Weight loss is one of the most effective lifestyle changes for controlling blood pressure. If you're overweight or have obesity, losing even a small amount of weight can help reduce blood pressure. In general, blood pressure might go down by about 1 millimeter of mercury (mm Hg) with each kilogram (about 2.2 pounds) of weight lost.

Also, the size of the waistline is important. Carrying too much weight around the waist can increase the risk of high blood pressure.

In general:

• Men are at risk if their waist measurement is greater than 40 inches (102 centimeters).
• Women are at risk if their waist measurement is greater than 35 inches (89 centimeters).

These numbers vary among ethnic groups. Ask your health care provider about a healthy waist measurement for you.

2. Exercise regularly

Regular physical activity can lower high blood pressure by about 5 to 8 mm Hg . It's important to keep exercising to keep blood pressure from rising again. As a general goal, aim for at least 30 minutes of moderate physical activity every day.

Exercise can also help keep elevated blood pressure from turning into high blood pressure (hypertension). For those who have hypertension, regular physical activity can bring blood pressure down to safer levels.

Some examples of aerobic exercise that can help lower blood pressure include walking, jogging, cycling, swimming or dancing. Another possibility is high-intensity interval training. This type of training involves alternating short bursts of intense activity with periods of lighter activity.

Strength training also can help reduce blood pressure. Aim to include strength training exercises at least two days a week. Talk to a health care provider about developing an exercise program.

3. Eat a healthy diet

Eating a diet rich in whole grains, fruits, vegetables and low-fat dairy products and low in saturated fat and cholesterol can lower high blood pressure by up to 11 mm Hg . Examples of eating plans that can help control blood pressure are the Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet.

Potassium in the diet can lessen the effects of salt (sodium) on blood pressure. The best sources of potassium are foods, such as fruits and vegetables, rather than supplements. Aim for 3,500 to 5,000 mg a day, which might lower blood pressure 4 to 5 mm Hg . Ask your care provider how much potassium you should have.

4. Reduce salt (sodium) in your diet

Even a small reduction of sodium in the diet can improve heart health and reduce high blood pressure by about 5 to 6 mm Hg .

The effect of sodium intake on blood pressure varies among groups of people. In general, limit sodium to 2,300 milligrams (mg) a day or less. However, a lower sodium intake — 1,500 mg a day or less — is ideal for most adults.

To reduce sodium in the diet:

• Read food labels. Look for low-sodium versions of foods and beverages.
• Eat fewer processed foods. Only a small amount of sodium occurs naturally in foods. Most sodium is added during processing.
• Don't add salt. Use herbs or spices to add flavor to food.
• Cook. Cooking lets you control the amount of sodium in the food.

5. Limit alcohol

Limiting alcohol to less than one drink a day for women or two drinks a day for men can help lower blood pressure by about 4 mm Hg . One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.

But drinking too much alcohol can raise blood pressure by several points. It can also reduce the effectiveness of blood pressure medications.

6. Quit smoking

Smoking increases blood pressure. Stopping smoking helps lower blood pressure. It can also reduce the risk of heart disease and improve overall health, possibly leading to a longer life.

7. Get a good night's sleep

Poor sleep quality — getting fewer than six hours of sleep every night for several weeks — can contribute to hypertension. A number of issues can disrupt sleep, including sleep apnea, restless leg syndrome and general sleeplessness (insomnia).

Let your health care provider know if you often have trouble sleeping. Finding and treating the cause can help improve sleep. However, if you don't have sleep apnea or restless leg syndrome, follow these simple tips for getting more restful sleep.

• Stick to a sleep schedule. Go to bed and wake up the same time each day. Try to keep the same schedule on weeknights and on weekends.
• Create a restful space. That means keeping the sleeping space cool, quiet and dark. Do something relaxing in the hour before bedtime. That might include taking a warm bath or doing relaxation exercises. Avoid bright light, such as from a TV or computer screen.
• Watch what you eat and drink. Don't go to bed hungry or stuffed. Avoid large meals close to bedtime. Limit or avoid nicotine, caffeine and alcohol close to bedtime, as well.
• Limit naps. For those who find napping during the day helpful, limiting naps to 30 minutes earlier in the day might help nighttime sleep.

8. Reduce stress

Long-term (chronic) emotional stress may contribute to high blood pressure. More research is needed on the effects of stress reduction techniques to find out whether they can reduce blood pressure.

However, it can't hurt to determine what causes stress, such as work, family, finances or illness, and find ways to reduce stress. Try the following:

• Avoid trying to do too much. Plan your day and focus on your priorities. Learn to say no. Allow enough time to get done what needs to be done.
• Focus on issues you can control and make plans to solve them. For an issue at work, talk to a supervisor. For conflict with kids or spouse, find ways to resolve it.
• Avoid stress triggers. For example, if rush-hour traffic causes stress, travel at a different time or take public transportation. Avoid people who cause stress if possible.
• Make time to relax. Take time each day to sit quietly and breathe deeply. Make time for enjoyable activities or hobbies, such as taking a walk, cooking or volunteering.
• Practice gratitude. Expressing gratitude to others can help reduce stress.

9. Monitor your blood pressure at home and get regular checkups

Home monitoring can help you keep tabs on your blood pressure. It can make certain your medications and lifestyle changes are working.

Home blood pressure monitors are available widely and without a prescription. Talk to a health care provider about home monitoring before you get started.

Regular visits with a provider are also key to controlling blood pressure. If your blood pressure is well controlled, ask your provider how often you need to check it. You might be able to check it only once a day or less often.

10. Get support

Supportive family and friends are important to good health. They may encourage you to take care of yourself, drive you to the care provider's office or start an exercise program with you to keep your blood pressure low.

If you find you need support beyond your family and friends, consider joining a support group. This may put you in touch with people who can give you an emotional or morale boost and who can offer practical tips to cope with your condition.

There is a problem with information submitted for this request. Review/update the information highlighted below and resubmit the form.

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• Feehally J, et al., eds. Nonpharmacologic prevention and treatment of hypertension. In: Comprehensive Clinical Nephrology. 6th ed. Elsevier; 2019. https://www.clinicalkey.com. Accessed April 20, 2022.
• AskMayoExpert. Hypertension (adult). Mayo Clinic; 2021.
• Hall ME, et al. Weight-loss strategies for prevention and treatment of hypertension: A scientific statement from the American Heart Association. Hypertension. 2021; doi:10.1161/HYP.0000000000000202.
• Shimbo D, et al. Self-measured blood pressure monitoring at home: A joint policy statement from the American Heart Association and the American Medical Association. Circulation. 2020; doi:10.1161/CIR.0000000000000803.
• 2020-2025 Dietary guidelines for Americans. U.S. Department of Health and Human Services and U.S. Department of Agriculture. https://www.dietaryguidelines.gov. Accessed April 23, 2022.
• Libby P, et al., eds. Systemic hypertension: Mechanisms, diagnosis, and treatment. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed April 23, 2022.
• Sleep deprivation and deficiency: Healthy sleep habits. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/sleep-deprivation/healthy-sleep-habits. Accessed April 23, 2022.
• Managing stress to control high blood pressure. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-stress-to-control-high-blood-pressure. Accessed April 23, 2022.

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Clinical Practice Guideline

Hypertension, management of high blood pressure in adults, ( developed by the aafp, july 2022 ).

The  2022 Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP , was developed by the American Academy of Family Physicians and approved by the Board of Directors in July 2022. The guideline was then published in the American Family Physician.

Key Recommendations

• Treating to a lower blood pressure target (less than 135/85 mm Hg) does not provide additional benefit at preventing mortality; however, a lower blood pressure target could be considered based on patient preferences and value.
• Although treatment to a standard blood pressure target (less than 140/90 mm Hg) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. There was no observed additional benefit in preventing stroke with the lower blood pressure target.

More About Practice Guidelines

These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Improving Hypertension Care for Underserved Populations with Remote Patient Monitoring

Given the impact that RPM can have in addressing chronic conditions like hypertension, there is a distinct need for more funding to ensure all people have access to proven, digital health interventions. Regulations must be revamped so FQHCs, RHCs and CHCs are able to bill for RPM, much like other hospitals and health centers.

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Hypertension is a growing concern in the U.S. Today, it’s estimated that about 122 million adults – more than half the population over age 20 – have high blood pressure. Yet data suggests that only one in four have their hypertension under control, despite doctors recommending prescription medications and lifestyle changes to decrease their risks. Furthermore, at least 14 million more individuals may not even realize they have hypertension and thus are not taking the necessary steps to control their blood pressure.

Underserved populations – such as those who don’t have access to quality healthcare because of where they live, lack of health insurance, racial or ethnic disparities, or socioeconomic factors – make up the vast majority of those who are either unaware of their hypertension or not properly addressing it to minimize the chance of strokes, heart attacks, and kidney and eye problems.

Integrated Enrollment Platforms and Consumer Assistance Centers: The Strongest Advantage for State-Based Exchanges

In the ever-evolving landscape of state-based health insurance exchanges, the convergence of technology and customer service is reshaping how these exchanges operate. The increasing advent of automation and artificial intelligence (AI) is rapidly dismantling the traditional business model that relies on the siloing of technology and customer service centers.

Such inattention to hypertension is costly. Adults with hypertension face healthcare costs of nearly $2,000 more per year compared to those with normal blood pressure. And the total cost of healthcare services, medications to treat high blood pressure and loss of productivity from premature death is estimated to be as much as $198 billion annually .

Reaching underserved communities through remote patient monitoring

To overcome the health risks and costs associated with hypertension, the healthcare community must find new ways to reach these underserved populations. Regular doctor visits are important. Yet for many, this step is a challenge.

Fortunately, there are ways to better reach these individuals where they are, breaking down the barriers and making healthcare more accessible. One effective way is through digital health technologies, such as cellular-enabled blood pressure monitors and remote monitoring platforms. Leveraging such offerings, patients are provided with connected devices and are instructed to take daily readings in the comfort of their own homes. The data is transmitted via cellular networks to their care providers, who, through the help of insights from remote patient monitoring (RPM) platforms and electronic health records (EHRs), can determine if medication or lifestyle changes are needed – all without the patient stepping foot in the office.

The Impact Brands: Empowering Wellness Through Natural and Holistic Solutions

In an era of escalating healthcare costs and a growing preference for natural, holistic approaches to health, The Impact Brands emerges as a collective of diverse brands dedicated to supporting overall wellness through natural means.

Gaining momentum and achieving results for patients with hypertension

RPM is gaining considerable momentum for as a tool for managing hypertension across populations. An analysis of Centers for Medicare & Medicaid Services codes show that 51% of all RPM claims in 2021 were related to the diagnosis of primary hypertension, with another 5.4% for blood pressure diagnosis, hypertension with complications and secondary hypertension.

More importantly, there are measurable results from using RPM to manage hypertension. Take, for example, the experience of a Federally Qualified Health Center (FQHC) in California that launched an RPM program in March 2021 because many patients were missing blood pressure readings and having problems controlling their hypertension. At the onset of the RPM pilot program, patients reported a 38% control rate of their high blood pressure. By providing technology they could easily use at home to provide regular blood pressure data to their doctors, these patients increased their control rate to 70% within just five months.

RPM is also benefiting new mothers, who are at high risk of complications from postpartum hypertension, a  leading cause of postpartum hospital readmissions and severe maternal morbidity. A private, not-for-profit academic medical center in the northeast that serves a diverse, safety-net population, implemented RPM for its new mothers. By collecting patient data from cellular-connected blood pressure cuffs used at home, this intervention provided an important safety net since blood pressure spikes often happen three days to six weeks after birth, well after most women are released from the hospital. In an abstract published in the American Heart Association Journal, Circulation , the medical center reported success ascertaining multiple BP measures in the postpartum period for more than 500 patients. This included nearly 9,000 total BP readings, 914 high blood pressure alerts and about 800 messages between the care team and patients that enabled them to address significant health changes, to provide better postpartum care and to answer important questions.

Funding is required for equity in healthcare

These pioneering examples of hypertension management show how RPM can be effectively used to provide high-quality care to underserved populations. Yet, unlike at most hospitals and health systems, there is no reimbursement code that FQHCs, rural health clinics (RHCs) or community health centers (CHCs) can use to pay for these services.

These facilities – which are dedicated to some of the populations most impacted by hypertension – rely on grants to support RPM programs. And when pilot programs serving a small slice of patients show promising results, they seek out additional grants or other funding mechanisms to scale and make an RPM program sustainable for all who can benefit from it.

Given the impact that RPM can have in addressing chronic conditions like hypertension, there is a distinct need for more funding to ensure all people have access to proven, digital health interventions. Regulations must be revamped so FQHCs, RHCs and CHCs are able to bill for RPM, much like other hospitals and health centers. Doing so will provide an effective way to ensure that those with hypertension receive the care they need, reducing the costs and health complications that result when left untreated or poorly managed.

Photo: Luis Alvarez, Getty Images

Dr. Lucienne Marie Ide

Lucienne Marie Ide, M.D., PH.D., is the founder and CEO of Rimidi , a cloud-based software platform that enables personalized management of health conditions across populations. She brings her diverse experiences in medicine, science, venture capital and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry and society, Lucie left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize an industry.

This post appears through the  MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers.  Click here to find out how .

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Practitioners' Guide: Key Tenets of Successful Lifestyle Programs for Hypertension Control and Management

At a glance.

The Practitioners' Guide highlights four key tenets that are successful in addressing hypertension and improving blood pressure outcomes. It describes ways to tailor lifestyle programs to different populations and settings, spotlights examples of programs, and addresses health inequities and how to adapt programs to the specific needs of potential participants.

The Practitioners' Guide: Key Tenets of Successful Lifestyle Programs for Hypertension Control and Management highlights four key tenets for implementing effective lifestyle programs:

• Implement programs in community settings.
• Engage frontline public health workers who can bridge the gap between the patient and health care systems.
• Use shorter program durations.
• Target multiple lifestyle behaviors.

Within each tenet, the guide describes implementation strategies and considerations and provides a program spotlight to highlight the tenet in action.

Who should use this guide?

This Practitioners' Guide was developed to help clinicians, other health care professionals, public health professionals, decision-makers, community organizations, and other partners in the field identify and implement effective lifestyle programs to improve hypertension outcomes.

Suggested citation

Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention. 2023. Practitioners' Guide: Key Tenets of Successful Lifestyle Programs for Hypertension Control and Management . US Department of Health and Human Services. Available at https://hdsbpc.cdc.gov/s/article/Practitioner-s-Guide-Key-Tenets-of-Successful-Lifestyle-Programs-for-Hypertension-Control-and-Management . Last updated, 12/20/2023.

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Biden's family starts discussing his possible exit plan from the 2024 race

WASHINGTON — Members of President Joe Biden’s family have discussed what an exit from his campaign might look like, according to two people familiar with the discussions. 

The overall tone of the conversations has been that any exit plan — should Biden decide to take that step, as some of his closest allies increasingly believe he will — should put the party in the best position to beat former President Donald Trump while also being worthy of the more than five decades he has served the country in elected office, these people said. 

Biden’s family members have specifically discussed how he would want to end his re-election bid on his own timing and with a carefully calculated plan in place. Considerations about the impact of the campaign on his health, his family and the stability of the country are among those at the forefront of the discussions, the people familiar with those discussions said.

The prospect of Biden’s considering stepping aside, much less that his family is gaming out a possible exit plan, is an extraordinary development that comes after he has repeatedly said he would not relinquish his position as the presumptive nominee of the party. 

But concerns have mounted among party leaders, donors and even officials who are part of his re-election effort with every day that has passed since a devastating debate three weeks ago. At the same time, Democrats are watching Republicans rally around Trump, who just survived an assassination attempt and accepted his party’s nomination Thursday night. 

White House spokesman Andrew Bates denied that any such exit discussions are happening among the family.

"That is not happening, period," he said. "The individuals making those claims are not speaking for his family or his team — and they will be proven wrong. Keep the faith."

On MSNBC's "Morning Joe" Friday, Biden campaign manager Jen O'Malley Dillon acknowledged that the campaign has seen some "slippage," but she said it's been "a small movement" and insisted Biden is "absolutely" still in the race.

Ron Klain, Biden’s former White House chief of staff and an adviser to him for decades, said in an interview that Biden is hearing the public and private calls for him to exit the race.

“I think he’s feeling the pressure,” said Klain, who has spoken to Biden recently. “I want him to stay in.”

Klain’s take is that it makes no sense for Biden to be pushed aside. He said some in his party underestimate Trump at their own peril and undervalue the fact that Biden is the only one who has beaten him.

Biden and the people closest to him have felt burned by efforts to push him out that they see as backhanded and disrespectful . The family is distraught and moving through the stages of anger and grief over how people they perceived to be friends have treated the president.

“There was a much more dignified way to do this if this is what they wanted,” a Biden ally said. “This is no way to treat a public servant who has done a lot for this country.”

Discussions about how to game out a fitting plan for Biden to step aside have also played out among senior staff members, not just the president’s family, according to a person close to the re-election effort. Bates also denied these discussions are happening.

The family members Biden has relied on most include first lady Jill Biden, his son Hunter and his sister, Valerie Owens, as well as a few longtime close aides who have been at the core of the discussions.

The conversations about Biden’s political future have raged while he remains at his home in Rehoboth Beach, Delaware, sidelined after he tested positive for Covid on Wednesday. 

On Thursday, some of Biden’s closest aides were calling trusted allies to get a sense of where they thought his political standing is, according to a person familiar with the phone calls. 

A Democratic lawmaker described Biden in this moment as “reflective." A third person close to Biden described the president as politically “fighting for his life.”

There are growing expectations among some allies that if Biden were to exit, it could be in the coming days. But they also caution that it still is up to him to make the decision and that he is not wired to quit even when he faces seemingly insurmountable adversity. 

About the possibility any announcement is imminent, a person close to the Bidens said, “We don’t even know what we’re doing tomorrow.”  

Still, Biden is not insusceptible to the mounting pressure from his own party, and he has said himself since the debate that he may consider leaving the race if there were no path for him to win. 

“I think it’s inevitable,” a second person close to the re-election effort said of Biden’s withdrawing from the race. 

As reports surfaced, including from NBC News , that Biden had shown signs that he could budge from his insistence that he remain the nominee, rumors and reports — some that the president's allies flatly denied — began to fly. They included speculation about timing of a potential exit, whether Biden would immediately endorse Vice President Kamala Harris and who was on the shortlist to be her vice presidential running mate.  

Among the reports: that longtime speechwriter and historian Jon Meacham was writing Biden’s exit remarks. 

Meacham rebuffed the account. 

“The report is totally false,” he said. 

Amid the turmoil the Biden campaign sent out talking points to Democrats, according to a Democratic strategist: “President Biden has not spoken to congressional leadership today. The president is his party’s nominee, having won 14 million votes during the Democratic primary. He’s running for re-election, and that will not change until he wins re-election.” 

Related coverage

• 'We're close to the end': Biden world braces for the possibility he will step aside
• Democrats are banking on outperforming Biden in key Senate races
• Biden left feeling angry and betrayed by top Democratic leaders wavering on his campaign

As many in his own party turned against him, Biden continued this week to check in with allies and gauge their sentiments. 

“With all the rumors that I’m leaving, I’m not,” Biden told the Rev. Al Sharpton, the civil rights leader and MSNBC host, in a phone call Monday, Sharpton said.

“I will support whatever you decide,” Sharpton said he told the president.

Sharpton said in an interview Thursday that legacy is something Biden “has to think of” as he contemplates his political future. “If there’s anyone that could make a comeback … it’s Joe Biden. Whether he chooses to or not, I don’t know.”

Some in Biden’s camp had hoped he would be able to weather the storm of pressure for him to step aside — that news events, including the Republican National Convention, would turn the national conversation away from whether and when he might end his campaign. But even the attempted assassination of Trump on Saturday did little to quell the furor around Biden. If anything, Democrats have since turned up the heat.

A major factor driving the private pressure on Biden is the fear among Democrats that his candidacy could rob them not only of the White House and the Senate but also of a chance to flip the House to their control. That helps explain why senior lawmakers have pushed on Biden to reconsider his decision to stay in the race.

“The House is on the brink,” said Brian Wolff, the treasurer of the House Majority PAC, the main super PAC supporting House Democratic candidates. “These candidates don’t deserve that.”

Wolff said Democratic incumbents and challengers in tough races cannot risk splintering their own voter coalitions by publicly taking one side or the other as Biden considers his options.

“They can’t afford to alienate the base that wants to support Biden or the base that wants someone else,” he said.

Carol E. Lee is the Washington managing editor.

Monica Alba is a White House correspondent for NBC News.

Sarah Fitzpatrick is a senior investigative producer and story editor for NBC News. She previously worked for CBS News and "60 Minutes." 

Jonathan Allen is a senior national politics reporter for NBC News.

Natasha Korecki is a senior national political reporter for NBC News.

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Home Blood Pressure Monitoring for Hypertension Diagnosis by Current Recommendations: A Long Way to Go

Kelsey b. bryant.

Division of General Medicine, Icahn School of Medicine at Mount Sinai, NY (K.B.B.).

Matthew B. Green

Division of General Medicine, Columbia Irving Medical Center, NY (M.B.G., D.S., J.E.S., I.M.K., Y.Z., A.E.M., B.K.B.).

Daichi Shimbo

Joseph e. schwartz.

Stony Brook University, NY (J.E.S.).

Ian M. Kronish

James p. sheppard.

University of Oxford, United Kingdom (J.P.S., R.J.M.).

Richard J. McManus

Andrew e. moran, brandon k. bellows.

Out-of-office blood pressure (BP) monitoring (eg, home BP monitoring [HBPM] or ambulatory BP monitoring) to confirm a diagnosis of hypertension before treatment initiation after initial office screening is recommended by the United States Preventive Services Task Force and 2017 American College of Cardiology and American Heart Association (ACC/AHA) BP guidelines. 1 , 2 One tool that may be used to help identify those in need of confirmatory BP monitoring is the Predicting Out-of-Office BP (PROOF-BP) algorithm, which uses office BP measurements and clinical characteristics to predict a patient’s out-of-office BP. 3 Though many providers report recommending out-of-office BP monitoring to patients, the baseline frequency of its use for specific indications, such as confirming a diagnosis of hypertension, is not known. 4 Further, barriers relevant to the accessibility and affordability of out-of-office BP monitoring have led to concerns that there may be disparities in the uptake of hypertension screening recommendations. 5 This analysis examined how historical use of HBPM aligns with current out-of-office BP monitoring recommendations for hypertensive US adults without a previous hypertension diagnosis, and how HBPM use varies by patient characteristics.

Adults aged ≥20 years without a diagnosis of hypertension or antihypertensive medication use and a high office BP (≥130/80 mm Hg) who participated in the National Health and Nutrition Examination Survey 2009 to 2014 cycles were identified (n=7185). Included participants had complete data needed to apply the ACC/AHA BP guideline criteria and PROOF-BP algorithm (ie, age, sex, at least three office systolic blood pressure and diastolic blood pressure readings, body mass index, and history of cardiovascular disease). 3 Participants who reported self-initiated or physician-recommended HBPM were categorized as having used or been told to use HBPM. Participants were categorized as having met criteria to undergo out-of-office BP monitoring according to the 2017 ACC/AHA recommendations if they had a mean office systolic blood pressure/diastolic blood pressure 130 to 159/<100 mm Hg and according to PROOF-BP if they had a predicted out-of-office BP 120 to 134/75 to 84 mm Hg. The age-adjusted proportion of individuals that would meet criteria for out-of-office BP monitoring who reported using or being told to use HBPM was examined overall and was compared by race/ethnicity (ie, non-Hispanic White, non-Hispanic Black, Hispanic, and other), sex, health insurance status, and source of routine health care. All analyses were performed using SAS (version 3.8; Cary, NC) and were weighted to be representative of the 2013 to 2014 US adult population.

An estimated 31.4 million US adults did not have diagnosed hypertension, were not taking antihypertensive medications and had an office BP ≥130/80 mm Hg. Of the 95.3% (29.3 million) who would have met criteria to undergo out-of-office BP monitoring by the ACC/AHA guidelines, only 3.6% (1.1 million) were told to use HBPM, and 15.7% (4.7 million) had used HBPM (Figure). There were no differences in HBPM use by race/ethnicity, sex, health insurance status, or source of routine healthcare. Though the PROOF-BP algorithm would have recommended fewer individuals for out-of-office BP monitoring (61.9%, 19.5 million), the age-adjusted proportion who were told to use (2.6%, 0.5 million) or used (13.8%, 2.7 million) HBPM was similar overall, and differences were not identified by any of the patient characteristics examined (Table).

Characteristics and HBPM Use Among Included Participants From NHANES 2009–2014

Out-of-office blood pressure (BP) monitoring recommendations and self-reported use and physician-recommended use of home blood pressure monitoring (HBPM) in National Health and Nutrition Examination Survey (NHANES) 2009–2014. The figure shows US adults (age ≥20 y) from the NHANES 2009–2014 cycles without diagnosed hypertension, not using antihypertensive medications, and an office blood pressure (BP) ≥130/80 mm Hg (n=7185). A , the proportion who would meet criteria to undergo out-of-office BP measurement by the 2017 American College of Cardiology and American Heart Association (ACC/AHA) BP guidelines and the age-adjusted proportion of those who either used or were told to use HBPM by a healthcare provider. B , the proportion who would meet criteria to undergo out-of-office BP measurement by the Predicting Out-of-Office Blood Pressure (PROOF-BP) algorithm and the age-adjusted proportion of those who either used or were told to use HBPM by a healthcare provider.

There is a substantial gap between baseline out-of-office BP thresholds for recommended out-of-office BP monitoring and recent HBPM use and recommended use among US adults without a diagnosis of hypertension and a high office BP (≥130/80 mm Hg). Among those with a high office BP who would now meet criteria for out-of-office BP monitoring according to ACC/AHA guidelines or the alternative PROOF-BP strategy, 24.9 million and 16.7 million, respectively, had not used HBPM to confirm hypertension. Evidence-based recommendations from the 2021 United States Preventive Services Task Force report and 2017 ACC/AHA guideline stress the need for confirmatory out-of-office BP measurement before the initiation of antihypertensive medications. To meet these recommendations, HBPM use must dramatically increase, and will require removing systemic barriers to use, including insurance coverage for home BP devices and reimbursement for patient training in home BP use. 4 The use of a telemonitoring system may improve ease of HBPM use for both physicians and patients, but also introduces additional cost and logistic considerations. Although we did not observe statistically significant differences by race/ethnicity or other patient characteristics, health systems should ensure that implementation plans are equitable and close rather than widen racial/ethnic and geographic hypertension disparities. 5 These findings are limited in that National Health and Nutrition Examination Survey had office BP from a single visit and were collected before recent screening recommendations; thus, our analyses do not reflect the impact of these guidelines on clinician or patient uptake of HBPM for hypertension diagnosis. Additionally, the impact of the COVID-19 pandemic, which accelerated adoption of remote patient management, on current HBPM use for hypertension diagnosis is unknown. Further, our analyses may underestimate out-of-office BP monitoring as ambulatory BP monitoring data are not available in National Health and Nutrition Examination Survey. However, these data do demonstrate the immense number of individuals who are eligible for out-of-office BP monitoring as part of an evidence-based screening algorithm and quantify an unmet opportunity for clinicians and health systems to improve the quality of hypertension screening.

Article Information

Sources of funding.

Dr Bellows receives support through K01 HL140170 from the National Heart, Lung, and Blood Institute, Bethesda, MD. Dr Sheppard receives support through the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship (ref: 211182/Z/18/Z), National Institute for Health Research (NIHR) School for Primary Care Research, the NIHR Oxford Biomedical Research Centre at Oxford Health NHS Foundation Trust, British Heart Foundation and Stroke Association. Dr Kronish receives funding support from AHRQ (R01 HS024262) and NHLBI (R01 152699). Dr Shimbo receives support through K24HL125704 from the NHLBI. Dr Schwartz receives support from the National Heart, Lung, and Blood Institute (NHLBI) National Institute of Aging, National Institute on Drug Abuse, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr McManus is a NIHR Senior Investigator and receives support from the NIHR Thames Valley ARC and NIHR School for Primary Care Research. Dr Moran receives support through R01 HL130500-01A1 and R01 HL139837 from the National Heart, Lung, and Blood Institute, Bethesda, MD.

Disclosures

Nonstandard abbreviations and acronyms.

For Sources of Funding and Disclosures, see page e17.

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What We Know About the Global Microsoft Outage

Airlines to banks to retailers were affected in many countries. Businesses are struggling to recover.

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By Eshe Nelson and Danielle Kaye

Eshe Nelson reported from London and Danielle Kaye from New York.

Across the world, critical businesses and services including airlines, hospitals, train networks and TV stations, were disrupted on Friday by a global tech outage affecting Microsoft users.

In many countries, flights were grounded, workers could not get access to their systems and, in some cases, customers could not make card payments in stores. While some of the problems were resolved within hours, many businesses, websites and airlines continued to struggle to recover.

What happened?

A series of outages rippled across the globe as information displays, login systems and broadcasting networks went dark.

The problem affecting the majority of services was caused by a flawed update by CrowdStrike , an American cybersecurity firm, whose systems are intended to protect users from hackers. Microsoft said on Friday that it was aware of an issue affecting machines running “CrowdStrike Falcon.”

But Microsoft had also said there was an earlier outage affecting U.S. users of Azure, its cloud service system. Some users may have been affected by both. Even as CrowdStrike sent out a fix, some systems were still affected by midday in the United States as businesses needed to make manual updates to their systems to resolve the issue.

George Kurtz, the president and chief executive of CrowdStrike, said on Friday morning that it could take some time for some systems to recover.

How a Software Update Crashed Computers Around the World

Here’s a visual explanation for how a faulty software update crippled machines.

What was affected?

It is more apt to ask what was not affected. Everything from airlines to banks to health care systems in many countries was hit.

In Australia, passengers were stuck in long lines at Sydney airport as information screens went blank, and programming was disrupted at the national broadcaster. Airports in Britain, Germany and Taiwan had long delays at check-ins and flights were delayed or canceled. At an airport in South Korea, handwritten boarding passes were being slowly handed out.

How the airline cancellations rippled around the world (and across time zones)

Share of canceled flights at 25 airports on Friday

50% of flights

Ai r po r t

Bengalu r u K empeg o wda

Dhaka Shahjalal

Minneapolis-Saint P aul

Stuttga r t

Melbou r ne

Be r lin B r anden b urg

London City

Amsterdam Schiphol

Chicago O'Hare

Raleigh−Durham

B r adl e y

Cha r lotte

Reagan National

Philadelphia

1:20 a.m. ET

Flights continued to be disrupted at some U.S. airports into the morning because of the cascading effect of flight delays and cancellations. The Federal Aviation Administration said in a statement that ground stops and delays would be “intermittent” at some airports as airlines grapple with residual technology issues.

The outage affected emergency 911 lines in multiple states, the U.S. Emergency Alert System said on social media — but most if not all of the emergency system problems appeared to be resolving themselves by midmorning.

A few hospitals in Germany said they would cancel elective procedures; and in Britain, some doctors in the National Health Service were unable to gain access to systems. Kaiser Permanente, a medical system that provides care to 12.6 million members in the United States, said all of its hospitals’ systems were affected, and it activated backup systems to keep caring for patients.

At some banks, including JPMorgan Chase, there were delays in processing trades because bankers could not log into their work systems. TD Bank, the 10th largest in the United States, said customers complained that they could not access their online accounts.

But the problems were not uniform. London’s Heathrow Airport said that its flights were still operating. The London Stock Exchange said that it could not publish news updates but the exchange, where trades take place, was working as normal. The auction system at the Norwegian central bank was briefly interrupted, but other major central banks, the European Central Bank and Bank of England, said there was no effect on their systems.

In some cases, issues were resolved relatively quickly. In Ukraine, Sense Bank and the mobile operator Vodafone reported brief problems with their services. At Dubai International Airport, two airlines switched to alternative systems, allowing operations to resume.

Major grocery chains in the United States appeared largely unaffected, with most stores operating as usual. But the world’s biggest logistics companies, including United Parcel Service and FedEx, did report disruptions, causing delivery delays in some regions. A spokesman for UPS said the company’s computer systems in the United States and Europe were affected.

Who’s to blame?

Mr. Kurtz said CrowdStrike took responsibility for the software bug, sent in a system update, that caused the outage. He said in a post on X that Mac and Linux users were not affected.

The incident was not a cyberattack, Mr. Kurtz said, adding that customers remain “fully protected.” But Mr. Kurtz warned on NBC’s “Today” show that the fix could take some time to put in place.

“We understand the gravity of the situation and are deeply sorry for the inconvenience and disruption,” Mr. Kurtz said. Microsoft offered suggestions to users to help resolve the issue, including restoring backup systems.

While CrowdStrike is at fault for the software bug, J.J. Guy, chief executive of cybersecurity company Sevco, said poor resiliency of Microsoft’s operating system is to blame for extent of the damage.

“Bugs happen all the time and are unavoidable, the result of business complexity and technology,” Mr. Guy said. “But this became a catastrophic incident because of the remediation procedures. The resiliency of the operating system was not sufficient to mitigate the risk of that.”

Microsoft did not immediately respond to requests for comment on its operating system. The company’s chief executive, Satya Nadella, said in a post on X that Microsoft is working with CrowdStrike to offer customers technical guidance and bring systems back online.

Eshe Nelson is a reporter based in London, covering economics and business news for The New York Times. More about Eshe Nelson

Danielle Kaye is a business reporter and a 2024 David Carr Fellow, a program for journalists early in their careers. More about Danielle Kaye