Martha N. Hill

Recommendations for Blood Pressure Measurement in Humans and Experimental Animals Part 1: Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds, including in pregnant women. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. The oscillometric method can be used for office measurement, but only devices independently validated according to standard protocols should be used, and individual calibration is recommended. They have the advantage of being able to take multiple measurements. Proper training of observers, positioning of the patient, and selection of cuff size are all essential. It is increasingly recognized that office measurements correlate poorly with blood pressure measured in other settings, and that they can be supplemented by self-measured readings taken with validated devices at home. There is increasing evidence that home readings predict cardiovascular events and are particularly useful for monitoring the effects of treatment. Twenty-four-hour ambulatory monitoring gives a better prediction of risk than office measurements and is useful for diagnosing white-coat hypertension. There is increasing evidence that a failure of blood pressure to fall during the night may be associated with increased risk. In obese patients and children, the use of an appropriate cuff size is of paramount importance.

The Multilevel Compliance Challenge: Recommendations for a Call to Action A Statement for Healthcare Professionals

Despite the universally accepted importance of compliance, strategies known for more than two decades to be effective are not routinely incorporated into clinical practice. For the benefits of primary and secondary prevention to be realized in diverse population groups and settings, emphasis must be placed on implementing strategies at the patient, provider, and organization levels. Current knowledge of compliance strategies, if integrated into a multilevel approach, offers enormous promise for decreasing risk and improving patient outcomes.

Primary Prevention of Ischemic Stroke A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association

Stroke ranks as the third leading cause of death in the United States. It is now estimated that there are more than 700 000 incident strokes annually and 4.4 million stroke survivors.1 2 The economic burden of stroke was estimated by the American Heart Association to be

Compliance with cardiovascular disease prevention strategies: A review of the research,

51 billion (direct and indirect costs) in 1999.3 Despite the advent of treatment of selected patients with acute ischemic stroke with tissue plasminogen activator and the promise of other experimental therapies, the best approach to reducing the burden of stroke remains prevention.4 5 High-risk or stroke-prone individuals can be identified and targeted for specific interventions.6 This is important because epidemiological data suggest a substantial leveling off of prior declines in stroke-related mortality and a possible increase in stroke incidence.7 8 The Stroke Council of the American Heart Association formed an ad hoc writing group to provide a clear and concise overview of the evidence regarding various established and potential stroke risk factors. The writing group was chosen based on expertise in specific subject areas, and it used literature review, reference to previously published guidelines, and expert opinion to summarize existing evidence and formulate recommendations (Table 1⇓). View this table: Table 1. Levels of Evidence and Grading of Recommendations As given in Tables 2 through 4⇓⇓⇓, risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented, less well documented).5 The tables give the estimated prevalence, population attributable risk, relative risk, and risk reduction with treatment for each factor when known. Population attributable risk reflects the proportion of ischemic strokes in the population that can be attributed to a particular risk factor and is given by the formula 100×[prevalence(relative risk−1)/prevalence(relative risk−1)+1]). …

National Heart, Lung, and Blood Institute Workshop on Sodium and Blood Pressure A Critical Review of Current Scientific Evidence

The efficacy of cardiovascular risk-reduction programs has been established. However, the extent to which risk-reduction interventions are effective may depend on adherence. Non-compliance, or non-adherence, may occur with any of the recommended or prescribed regimens and may vary across the treatment course. Compliance problems, whether occurring early or late in the treatment course, are clinically significant, as adherence is one mediator of the clinical outcome. This article, which is based on a review of the empirical literature of the past 20 years, addresses compliance across four regimens of cardiovascular risk reduction: pharmacological therapy, exercise, nutrition, and smoking cessation. The criteria for inclusion of a study in this review were: (a) focus on cardiovascular disease risk reduction; (b) report of a quantitative measure of compliance behavior; and (c) use of a randomized controlled design. Forty-six studies meeting these criteria were identified. A variety of self-report, objective, and electronic measurement methods were used across these studies. The interventions employed diverse combinations of cognitive, educational, and behavioral strategies to improve compliance in an array of settings. The strategies demonstrated to be successful in improving compliance included behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids. A series of tables summarize the intervention strategies, compliance measures, and findings, as well as the interventions demonstrated to be successful. This review reflects the progress made over two decades in compliance measurement and research and further, advances made in the application of behavioral strategies to the promotion of cardiovascular risk reduction.

Recommendations for blood pressure measurement in humans: An AHA scientific statement from the council on high blood pressure research professional and public education subcommittee

The Workshop on Sodium and Blood Pressure was convened by the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, Md, on January 28 and 29, 1999, to update earlier reviews of this topic.1 2 3 Other topics covered were sodium intake in relation to other cardiovascular disease (CVD) and non-CVD conditions, research needs, and public policy considerations. More than 55 invited speakers and other attendees from the United States and abroad reviewed and discussed the scientific information. This review synthesizes the presentations and discussions. Epidemiological studies conducted over the past 50 years have shown a clear curvilinear relation of higher adult blood pressure (BP) levels to higher rates of coronary heart disease (CHD), stroke, heart failure, and kidney failure. A continuous relation is apparent from below the 120/80 mm Hg level. Thus, a significant portion of CVD occurs in persons whose BP has not reached the arbitrary 140/90 mm Hg level defining hypertension. Studies show unequivocally that lowering high BP in hypertensive patients can reduce the likelihood of developing or dying from CVD, including CHD and stroke. Dietary factors in individuals and in the population at large have important effects on BP levels, which are generally assumed to translate to CVD risk. For the nonhypertensive subset, a population-wide approach to lowering BP (an approach based on lifestyle modifications that have been shown to prevent or delay increases in BP) could affect the total CVD burden as much as or more than treating only those with established hypertension. There is an abundance of scientific evidence demonstrating a direct relation between salt intake and BP. Studies in laboratory animals show that high BP can be induced by diet.4 Recent evidence comes from a randomized trial involving 26 chimpanzees that were given a low salt/high potassium diet (preintervention period). Subsequently, …

Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans

VOL. 7 NO. 2 FEBRUARY 2005 102 Ten years have passed since the last version of the American Heart Association (AHA) blood pressure (BP) measurement recommendations,1 during which time there have been major changes in the ways in which BP is measured in clinical practice and research; hence this document represents a major revision of previous versions.2 BP determination continues to be one of the most important measurements in clinical medicine, and still one of the most inaccurately performed. The gold standard for clinical BP measurement has always been readings taken by a trained health care provider using a mercury sphygmomanometer and the Korotkoff sound technique. There is increasing evidence, however, that this procedure may lead to the misclassification of large numbers of individuals as hypertensive, and fail to diagnose other individuals whose BP may be normal in the clinic setting but elevated at other times. There are three reasons for this: 1) inaccuracies in the methods, some of which are avoidable; 2) the inherent variability of BP; and 3) the tendency for BP to increase in the presence of a physician (the so-called “white coat effect”). Numerous surveys have shown that physicians and other health care providers rarely follow established guidelines for BP measurement, but when they do, the readings they get correlate more closely with more objective measures of BP than the usual clinic readings. It is generally agreed that conventional clinic readings, when made correctly, are a surrogate marker for a patient’s true BP, which is conceived as the average level over prolonged periods of time, and which is thought to be the most important component of BP in determining its adverse effects. Usual clinic readings give a poor estimate of this, not only because of poor technique, but also because they typically consist only of one or two individual measurements, and the beat-to-beat BP variability is such that a small number of readings may only give a crude estimate of the average level. The recognition of these limitations of traditional clinic readings has led to two parallel developments: first, increasing use of measurements out of the clinic, Recommendations for Blood Pressure Measurement in Humans: An AHA Scientific Statement from the Council on High Blood Pressure Research Professional and Public Education Subcommittee

Hypertension Knowledge, Awareness, and Attitudes in a Hypertensive Population

BACKGROUND African Americans suffer disproportionately from diabetes complications, but little research has focused on how to improve diabetic control in this population. There are also few or no data on a combined primary care and community-based intervention approach. METHODS We randomly assigned 186 urban African Americans with type 2 diabetes (76% female, mean A SD age 59 A 9 years) to 1 of 4 parallel arms: (1) usual care only; (2) usual care + nurse case manager (NCM); (3) usual care + community health worker (CHW); (4) usual care + nurse case manager/community health worker team. Using the framework of the Precede-Proceed behavioral model, interventions included patient counseling regarding self-care practices and physician reminders. RESULTS The 2-year follow-up visit was completed by 149 individuals (84%). Compared to the Usual care group, the NCM group and the CHW group had modest declines in HbA(1c) over 2 years (0.3 and 0.3%, respectively), and the combined NCM/CHW group had a greater decline in HbA(1c) (0.8%. P = 0.137). After adjustment for baseline differences and/or follow-up time, the combined NCM/CHW group showed improvements in triglycerides (-35.5 mg/dl; P = 0.041) and diastolic blood pressure, compared to the usual care group (-5.6 mmHg; P = 0.042). CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes. Although results were clinically important, they did not reach statistical significance. This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans.

The Effects of a Nurse Case Manager and a Community Health Worker Team on Diabetic Control, Emergency Department Visits, and Hospitalizations Among Urban African Americans With Type 2 Diabetes Mellitus: A Randomized Controlled Trial

OBJECTIVE: Improved recognition of the importance of systolic blood pressure (SBP) has been identified as one of the major public health and medical challenges in the prevention and treatment of hypertension (HTN). SBP is a strong independent risk factor for cardiovascular disease but no information is available on whether patients understand the importance of their SBP level. The purpose of this study was to assess HTN knowledge, awareness, and attitudes, especially related to SBP in a hypertensive population.DESIGN/SETTING/PATIENTS: We identified patients with HTN (N=2,264) in the primary care setting of a large midwestern health system using automated claims data (International Classification of Diseases, Ninth Revision [ICD-9] codes 401.0–401.9). We randomly selected 1,250 patients and, after excluding ineligible patients, report the results on 826 completed patient telephone interviews (72% response rate [826/1,151]).MAIN RESULTS: Ninety percent of hypertensive patients knew that lowering blood pressure (BP) would improve health and 91% reported that a health care provider had told them that they have HTN or high BP. However, 41% of patients did not know their BP level. Eighty-two percent of all patients correctly identified the meaning of HTN as “high blood pressure.” Thirty-four percent of patients correctly identified SBP as the “top” number of their reading; 32% correctly identified diastolic blood pressure (DBP) as the “bottom” number; and, overall, only 30% of patients were able to correctly identify both systolic and diastolic BP measures. Twenty-seven percent of patients with elevated SBP and DBP (as indicated by their medical records) perceived that their BP was high. Twenty-four percent of patients did not know the optimal level for either SBP or DBP. When asked whether the DBP or SBP level was more important in the control and prevention of disease, 41% reported DBP, 13% reported SBP, 30% reported that both were important, and 17% did not know.CONCLUSIONS: These results suggest that, although general knowledge and awareness of HTN is adequate, patients do not have a comprehensive understanding of this condition. For instance, patients do not recognize the importance of elevated SBP levels or the current status of their BP control. An opportunity exists to focus patient education programs and interventions on the cardiovascular risk associated with uncontrolled HTN, particularly elevated SBP levels.

Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months*

BACKGROUND Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care. METHODS We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data. RESULTS At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], -14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, -31.0; adjusted RR, 0.66; 95% CI, 0.43-1.00; rate reduction downward arrow 34%). CONCLUSION These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00022750.