Faculty Bibliography

OBJECTIVES: It is not well known how clinic, home, and ambulatory measures of blood pressure (BP) correlate with each other. We performed this study to clarify the level of agreement among these different BP measures. MATERIALS AND METHODS: We enrolled 56 hypertensive patients (mean age: 60 +/- 14 years; 54% were females). The study consisted of three clinic visits, self-monitoring of home BP between visits, and ambulatory blood pressure (ABP) monitoring at the second visit. Patients were given a home BP monitor programmed to automatically take three consecutive readings at fixed intervals of 1 min. The associations between clinic BP (mercury sphygmomanometer and HEM-5001), home BP (the average of morning and evening, second and third BP readings), and average awake ABP were compared using the intraclass correlation for agreement and Bland-Altman plots. RESULTS: The averages of clinic sphygmomanometer, clinic HEM-5001, awake ABP, and home BP were 129 of 77, 131 of 76, 131 of 79, and 133 of 77 mmHg, respectively. Clinic BP by HEM-5001 was strongly correlated with that of mercury sphygmomanometer. Home systolic blood pressure was moderately correlated with awake ABP, but mercury diastolic blood pressure (DBP) was more closely correlated with awake DBP than home DBP. CONCLUSION: Clinic BP measured with the automated monitor could be used as an alternative for the evaluation of BP in the office. Under rigorously standardized conditions, clinic and home BP could be used as an alternative to awake ABP.

Evidence suggests that coronary heart disease (CHD) is the most common outcome of hypertension. Hypertension accelerates the development of atherosclerosis, and sustained elevation of blood pressure (BP) can destabilize vascular lesions and precipitate acute coronary events. Hypertension can cause myocardial ischemia in the absence of CHD. These cardiovascular risks attributed to hypertension can be reduced by optimal BP control. Although several antihypertensive agents exist, the choice of agent and the appropriate target BP for patients with CHD remain controversial. In this succinct paper, we examine the evidence and the mechanisms for the linkage between hypertension and CHD and we discuss the treatment options and the goals of therapy that are consistent with the report of the seventh Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and American Heart Association scientific statement. We anticipate changes in the recommendations of the forthcoming JNC 8.

We ascertained the prevalence of resistant hypertension (RH) among blacks and determined whether RH patients are at greater risk for obstructive sleep apnea (OSA) than hypertensives. Method. Data emanated from Metabolic Syndrome Outcome Study (MetSO), a study investigating metabolic syndrome among blacks in the primary-care setting. Sample of 200 patients (mean age = 63 +/- 13 years; female = 61%) with a diagnosis of hypertension provided subjective and clinical data. RH was defined using the JNC 7and European Society guidelines. We assessed OSA risk using the Apnea Risk Evaluation System ARES), defining high risk as a total ARES score >/=6. Results. Overall, 26% met criteria for RH and 40% were at high OSA risk. Logistic regression analysis, adjusting for effects of age, gender, and medical co morbidities, showed that patients with RH were nearly 2.5 times more likely to be at high OSA risk, relative to those with hypertension (OR = 2.46, 95% CI: 1.03-5.88, P < .05). Conclusion. Our findings show that the prevalence of RH among blacks fell within the range of RH for the general hypertensive population (3-29%). However, patients with RH were at significantly greater risk of OSA compared to patients with hypertension.

Hypertension (HTN) is the most common co-morbidity in the world, and its sequelae, heart failure (HF) is one of most common causes of mortality and morbidity in the world. Current understanding of pathophysiology and management of HTN in HF is mainly based on studies, which have mainly included whites. Among racial groups, African-American adults have the highest rates (44%) of hypertension in the world and are more resistant to treatment. There is an emerging consensus on the significance of racial disparities in the pathophysiology and treatment options of hypertension and heart failure. However, African Americans had been underrepresented in all the trials until the initiation of the A-HEFT trial. Since the recognition of obstructive sleep apnea (OSA) as an important medical condition, large clinical trials have shown benefits of OSA treatment among patients with HTN and HF. This paper focuses on the pathophysiology, causes of secondary hypertension, and treatment of hypertension among African-American patients with heart failure. There is increasing need for randomized clinical trials testing innovative treatment options for African-American patients.

OBJECTIVES: To assess the impact of an electronic medical record (EMR) with clinical decision support (CDS) and performance feedback on provider adherence to guideline-recommended care and blood pressure (BP) control compared with a standard EMR alone. STUDY DESIGN: Quasi-experimental with repeated measures. METHODS: The study was conducted in a 4-site, federally qualified health center, Open Door Family Medical Centers, located in New York. The research team, Open Door leadership, providers, and staff developed and implemented a tailored multicomponent CDS system, which included a BP alert, a hypertension (HTN) order set, an HTN template, and clinical reminders. We extracted patient-level data for each encounter 17 months prior to implementation of the intervention (June 2007-October 2008) and 15 months post-intervention (April 2009-June 2010), from the EMR's data tables for all adult nonobstetric patients with a diagnosis of HTN (N = 3636). RESULTS: Rates of HTN control were significantly greater in the post-intervention period compared with the baseline period (50.9% vs 60.8%; P <.001). Process measures, derived from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines, also improved significantly. Logistic regression with generalized estimating equations showed that patients were 1.5 times more likely to have controlled BP post-intervention than pre-intervention. Correlates of poor BP control were black race, higher body mass index, diabetes, female gender, income, and a greater number of prescribed antihypertensive medications. CONCLUSIONS: Our findings suggest that health information technology that is implemented as part of a multicomponent quality improvement initiative can lead to improvements in HTN care and outcomes.

BACKGROUND: Observational studies suggest that there are differences in adherence to antihypertensive medications in different classes. Our objective was to quantify the association between antihypertensive drug class and adherence in clinical settings. METHODS AND RESULTS: Studies were identified through a systematic search of English-language articles published from the inception of computerized databases until February 1, 2009. Studies were included if they measured adherence to antihypertensives using medication refill data and contained sufficient data to calculate a measure of relative risk of adherence and its variance. An inverse-variance-weighted random-effects model was used to pool results. Hazard ratios (HRs) and odds ratios were pooled separately, and HRs were selected as the primary outcome. Seventeen studies met inclusion criteria. The pooled mean adherence by drug class ranged from 28% for beta-blockers to 65% for angiotensin II receptor blockers. There was better adherence to angiotensin II receptor blockers compared with angiotensin-converting enzyme inhibitors (HR, 1.33; 95% confidence interval, 1.13 to 1.57), calcium channel blockers (HR, 1.57; 95% confidence interval, 1.38 to 1.79), diuretics (HR, 1.95; 95% confidence interval, 1.73 to 2.20), and beta-blockers (HR, 2.09; 95% confidence interval, 1.14 to 3.85). Conversely, there was lower adherence to diuretics compared with the other drug classes. The same pattern was present when studies that used odds ratios were pooled. After publication bias was accounted for, there were no longer significant differences in adherence between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors or between diuretics and beta-blockers. CONCLUSION: In clinical settings, there are important differences in adherence to antihypertensives in separate classes, with lowest adherence to diuretics and beta-blockers and highest adherence to angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. However, adherence was suboptimal regardless of drug class.

BACKGROUND: Despite improved hypertension (HTN) awareness and treatment, racial disparities in HTN prevalence persist. An understanding of the biopsychosocial determinants of HTN is necessary to address racial disparities in the prevalence of HTN. This review examines the evidence directly and indirectly linking multiple levels of racism to HTN. METHODS: Published empirical research in EBSCO databases investigating the relationships of three levels of racism (individual/interpersonal, internalized, and institutional racism) to HTN was reviewed. RESULTS: Direct evidence linking individual/interpersonal racism to HTN diagnosis is weak. However, the relationship of individual/interpersonal racism to ambulatory blood pressure (ABP) is more consistent, with all published studies reporting a positive relationship of interpersonal racism to ABP. There is no direct evidence linking internalized racism to BP. Population-based studies provide some evidence linking institutional racism, in the forms of residential racial segregation (RRS) and incarceration, to HTN incidence. Racism shows associations to stress exposure and reactivity as well as associations to established HTN-related risk factors including obesity, low levels of physical activity and alcohol use. The effects vary by level of racism. CONCLUSIONS: Overall the findings suggest that racism may increase risk for HTN; these effects emerge more clearly for institutional racism than for individual level racism. All levels of racism may influence the prevalence of HTN via stress exposure and reactivity and by fostering conditions that undermine health behaviors, raising the barriers to lifestyle change

Introduction: Participation in a medically-supervised weight management (MSWM) program before bariatric surgery is mandated by several insurance payers. However, this requirement is not evidencebased and serves as a barrier to medically necessary treatment. We conducted a pilot randomized trial funded by SAGES to determine the effect of an insurance-mandated MSWM prior to surgery. Our hypotheses are: (1) There is no difference in BMI between patients who have participated in a medically-supervised weight management program and those who don't. (2) MSWM does not change self-reported adherence, physical activity, eating behavior, and health beliefs. Methods & Procedures: 55 patients were scheduled for laparoscopic adjustable gastric banding (LAGB) and consented to enroll in an ongoing prospective pilot study in a large public hospital. of these, 12 patients cancelled surgery and 10 patients have been enrolled for less than 6 months. Thus, 33 patients were included in the analysis, with 17 randomized to MSWM (defined as monthly visits over 6 months directed by a physician or nutritionist) and 16 randomized to usual care. Measures of weight, height, adherence, activity level, health beliefs, and eating behavior were obtained at enrollment (ie, baseline) and 6 months after enrollment (ie, MSWM program completion and 2 weeks prior to surgery). For categorical and continuous data, Fisher's Exact Test and t-test were used to compare groups at the 2 time points before surgery. Results: Mean age was 45.5 (SD = 12.5) years. Majority were female (97%) and non-Caucasian (85%) with an income of less than $20,000 (64%). No significant differences were found between MSWM and usual care for age, gender, ethnicity, education, and income, indicating that the 2 groups were evenly matched for demographic variables. Mean BMI for the MSWM group was 46.3 kg/m2 at baseline and 46.0 kg/m2 at 6 months. Mean BMI for usual care was 44.7 kg/m2 and 44.6 kg/m2 (see Table 1). After 6 months of eitherMSWMor wait and at pre-surgery, no significant differences in BMIor patient behaviors were found between the 2 groups. Preliminary analysis of available 3-month post-operative data (n = 13) showed similar mean BMI when comparing MSWM (41.3 kg/m2) and usual care (41.2 kg/m 2). Conclusion: Our preliminary results indicate that MSWM does not affect BMI changes or patient behaviors prior to or after LAGB surgery

ABSTRACT: BACKGROUND: Effectiveness of combined physician and patient-level interventions for blood pressure (BP) control in low-income, hypertensive African Americans with multiple co-morbid conditions remains largely untested in community-based primary care practices. Demographic, clinical, psychosocial, and behavioral characteristics of participants in the Counseling African American to Control Hypertension (CAATCH) Trial are described. CAATCH evaluates the effectiveness of a multi-level, multi-component, evidence-based intervention compared with usual care (UC) in improving BP control among poorly controlled hypertensive African Americans who receive primary care in Community Health Centers (CHCs). METHODS: Participants included 1,039 hypertensive African Americans receiving care in 30 CHCs in the New York Metropolitan area. Baseline data on participant demographic, clinical (e.g., BP, anti-hypertensive medications), psychosocial (e.g., depression, medication adherence, self-efficacy), and behavioral (e.g., exercise, diet) characteristics were gathered through direct observation, chart review, and interview. RESULTS: The sample was primarily female (71.6%), middle-aged (mean age = 56.9 +/- 12.1 years), high school educated (62.4%), low-income (72.4% reporting less than $20,000/year income), and received Medicaid (35.9%) or Medicare (12.6%). Mean systolic and diastolic BP were 150.7 +/- 16.7 mm Hg and 91.0 +/- 10.6 mm Hg, respectively. Participants were prescribed an average of 2.5 +/- 1.9 antihypertensive medications; 54.8% were on a diuretic; 33.8% were on a beta blocker; 41.9% were on calcium channel blockers; 64.8% were on angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). One-quarter (25.6%) of the sample had resistant hypertension; one-half (55.7%) reported medication non-adherence. Most (79.7%) reported one or more co-morbid medical conditions. The majority of the patients had a Charlson Co-morbidity score >/= 2. Diabetes mellitus was common (35.8%), and moderate/severe depression was present in 16% of participants. Participants were sedentary (835.3 +/- 1,644.2 Kcal burned per week), obese (59.7%), and had poor global physical health, poor eating habits, high health literacy, and good overall mental health. CONCLUSIONS: A majority of patients in the CAATCH trial exhibited adverse lifestyle behaviors, and had significant medical and psychosocial barriers to adequate BP control. Trial outcomes will shed light on the effectiveness of evidence-based interventions for BP control when implemented in real-world medical settings that serve high numbers of low-income hypertensive African-Americans with multiple co-morbidity and significant barriers to behavior change