Faculty Bibliography

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (class IIa; level of evidence A). This call-to-action article makes the following recommendations: 1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; 2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; 3) Two to three readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >/=12 readings are recommended for making clinical decisions; 4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; 5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; 6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; 7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; 8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; 9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; 10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and 11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

OBJECTIVE: To determine what health behaviors patients choose to change in response to medical advice when they are given the potential net-present value (reduction in biological age) of modifying a behavior. METHODS: Baseline data for multiple health-risk behaviors that were recommended for change among 660 coronary angioplasty patients at the New York-Presbyterian Hospital-Weill-Cornell Medical Center who were enrolled during 2000--02 in one of two arms of a behavioral intervention trial designed to compare different approaches to communicating health risk (net-present vs. future value) were analyzed using multivariate statistical methods. RESULTS: Although there was no difference between study arms, knowing the biological-age value of behaviors, stage of change, and the total number of behaviors recommended for change was associated with choosing several behaviors. Notably, stage of change was associated in both groups with strength training (intervention OR 2.82, 95% CI 1.85, 4.30; comparison OR 2.84, 95% CI 1.83, 4.43, p<.0001) and reducing weight (intervention OR 2.49, 95% CI 1.32, 4.67, p=.005; comparison OR 1.98, 95% CI 1.80, 3.31, p=.01). CONCLUSION: Patients with coronary disease are more likely to choose strength training and reducing weight regardless of knowing the biological-age reduction of any given behavior

OBJECTIVE: Cardiovascular prognosis in diabetic white-coat hypertension (WCH) has not yet been described. We designed this study to investigate the impact of WCH on cardiovascular events in patients with type 2 diabetes, compared with those having type 2 diabetes along with sustained hypertension (SH), and with nondiabetic hypertensive individuals. METHODS: We performed ambulatory blood pressure (BP) monitoring in 1207 consecutive hypertensive patients at baseline, and they were followed up for 49+/-22 months. The mean age was 70.7+/-9.8 years; 262 had type 2 diabetes; and 945 did not. They were classified as having SH with diabetes (n=210); diabetic WCH (n=52); SH alone (n=719); or WCH alone (n=226), using awake BP of 135/85 mmHg as the cutoff value. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals of the risk for cardiovascular events, after controlling for age, sex, body mass index, current smoking, serum creatinine, and clinical systolic BP. RESULTS: During the follow-up period, 97 cardiovascular events occurred. The incidence of cardiovascular events in the diabetic SH group was significantly higher than in the diabetic WCH, nondiabetic SH, and nondiabetic WCH (P<0.05; log-rank test) groups. In Cox regression analysis, the diabetic SH group had significantly higher risk of cardiovascular events compared with the diabetic WCH group (HR: 8.2; 95% confidence intervals: 1.09-61.8; P=0.04). Although nonsignificant, the HRs in the SH and WCH groups, relative to diabetic WCH, exceeded 3.0. CONCLUSIONS: The cardiovascular prognosis for diabetic WCH was better than that for diabetic SH during 4 years of follow-up

Secondary prevention of adverse outcomes in patients with cardiopulmonary disease requires that patients become actively engaged in self-management efforts such as participation in physical activity or medication adherence. However, despite assiduous efforts to find strategies that help cardiovascular patients to adopt and maintain such behaviors, many studies of interventions designed to improve physical activity and adherence to medication have shown disappointing results. To this end, the Translational Behavioral Science Research Consortium was created by the National Heart, Lung, and Blood Institute to identify promising, but underutilized findings from basic behavioral science that might have potential application for translation to clinical populations where behavioral change has been refractory to standard intervention approaches. This paper describes the rationale and methods of a novel research project designed to test the efficacy of a behavioral intervention that combines constructs from two behavioral science theories (positive affect and self-affirmation) in order to help patients with coronary artery disease, asthma, and hypertension successfully change behaviors. The project consists of an intervention framed upon positive affect and self-affirmation and tested in three concurrent randomized controlled trials among three distinct populations. Each trial had a qualitative phase that served as a formative stage to inform the intervention; a pilot phase during which the feasibility of the intervention was tested and refined; and a randomized controlled phase conducted to investigate the effects of the interventions in these three patient groups

OBJECTIVE: The relationship between appointment-keeping behavior, medication adherence (ADH), and systolic and diastolic blood pressure (SBP and DBP) was assessed in 153 hypertensive African Americans followed in a community-based practice. METHODS: ADH was assessed with a self-report questionnaire. BP was obtained from electronic medical records and appointment attendance was determined from the log of all appointments made during the 12-month study period. Nonadherence rates were compared across appointment attendance categories with chi-square. Logistic regression was used to assess the relationship between ADH and appointment attendance, whereas multivariate analysis of covariance (MANCOVA) was used to examine the relationship between appointment attendance and BP. RESULTS: Twenty-five percent of patients (87% women, mean age 52 years) did not miss any appointments, 44% missed 1-30%, and 31% missed greater than 30%. Adjusted nonadherence rates were similar for all 3 categories (70%, 66%, and 65%, respectively, p = 0.88) as were adjusted mean SBP and DBP in the MANCOVA model, [F (4, 218) = 1.13, p = .34]. Logistic regression analysis did not indicate a significant relationship between appointment attendance and ADH. CONCLUSIONS: Appointment-keeping behavior was not related to ADH or BP among hypertensive African Americans. It should not be used as a proxy for ADH in this patient population

BACKGROUND: The white coat effect can lead to overdiagnosis of hypertension and unnecessary pharmacologic treatment. Mechanisms underlying the white coat effect remain poorly understood but are critical to improving the accuracy of clinic blood pressure measurement. PURPOSE: This study investigated whether perceived hypertension status was associated with state anxiety levels during a clinic visit and the magnitude of the white coat effect, independent of true blood pressure status. METHODS: This observational study included 214 normotensive and mildly hypertensive participants who were 18 to 80 years old, had no cardiac history, and were willing to discontinue antihypertensive medications for 8 weeks. Participants underwent 36 hr ambulatory blood pressure monitoring and physician blood pressure measurement. Outcome measures were state anxiety reported during the clinic visit and the white coat effect. RESULTS: An analysis of covariance indicated that participants who perceived themselves as hypertensive reported greater state anxiety (p<.001) and showed larger white coat effects (ps<.01) compared with those who perceived themselves as normotensive. True hypertension status based on ambulatory blood pressure was not related to either outcome. Anxiety accounted for approximately 19% of the association between perceived hypertension status and the white coat effect. CONCLUSIONS: These findings suggest that the perception of being hypertensive is associated with greater anxiety during clinic blood pressure measurement and a larger white coat effect, independent of the true blood pressure level. Anxiety appears to be a mechanism by which perceived hypertension status contributes to the white coat effect

The Medication Adherence and BP Control Trial (ABC Trial) is a randomized, controlled, multi-site, medication adherence and blood pressure (BP) control trial in an economically disadvantaged and multi-cultural population of hypertensive patients followed in primary care practices. To date, no other such trial has been published in which objective measures of adherence (electronic pill bottles) were used to assess the effectiveness of these behavioral interventions for hypertension. This study tested a combination of commercially-available interventions that can be easily accessed by health care providers and patients, and therefore may provide a real-world solution to the problem of non-adherence among hypertensives. The aim of the ABC Trial was to test the effectiveness of a stepped care intervention in improving both medication adherence to an antihypertensive medication regimen and BP control. Step 1 of the intervention employed home Self-BP Monitoring (SBPM); at this stage, there were two arms: (1) Usual Care (UC) and (2) Intervention. At Step 2, patients in the intervention arm whose BP had not come under control after 3 months were further randomized to one of two conditions: (1) continuation of SBPM (alone) or (2) continuation of SBPM plus telephone-based nurse case management (SBPM+NCM). Electronic Medication Event Monitoring (MEMS) was the primary measure of medication adherence, and in-office BP was the primary measure of hypertension control. We present an overview of the study design, details of the administrative structure of the study and a description of clinical site recruitment, patient recruitment, and follow-up assessments

PURPOSE: The purpose of this pilot study was to explore African American definitions of practicing spirituality and to describe the process of spirituality and its relationship to health promotion. METHOD: Data were collected using semi-structured interview questions via two focus groups from a total of 12 participants who self-identified as African American. FINDINGS: This grounded theory methodology generated three categories of spirituality: (a) love in action, (b) relationships and connections, and (c) unconditional love. The overall process of practicing spirituality and its relationship to health identified a process of honoring God, self, and others. CONCLUSION: Research studies that investigate the concept of spirituality and its relationship to health promotion and disease management need to address the subjective experience of spirituality based on participant definitions rather than researcher-focused definitions of spirituality