Faculty Bibliography

A body of epidemiologic and clinical evidence dating back to the early 1960s establishes the relationships between sleep apnea and cardiovascular disease (CVD). Individuals with obstructive sleep apnea, the most common type of sleep-disordered breathing, are at increased risk for coronary artery disease, congestive heart failure, and stroke. Evidence that treatment of sleep apnea with continuous positive airway pressure reduces blood pressure, improves left ventricular systolic function, and diminishes platelet activation further supports linkage between obstructive sleep apnea and CVD. Notwithstanding, complex associations between these two conditions remain largely unexplained due to dearth of systematic experimental studies. Arguably, several intermediary mechanisms including sustained sympathetic activation, intrathoracic pressure changes, and oxidative stress might be involved. Other abnormalities such as dysfunctions in coagulation factors, endothelial damage, platelet activation, and increased systemic inflammation might also play a fundamental role. This review examines evidence for the associations between obstructive sleep apnea and CVD and suggested underlying anatomical and physiological mechanisms. Specific issues pertaining to definition, prevalence, diagnosis, and treatment of sleep apnea are also discussed. Consistent with rising interest in the potential role of the metabolic syndrome, this review explores the hypothesized mediating effects of each of the components of the metabolic syndrome

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.

OBJECTIVES: To test the feasibility, acceptability, and effect of a senior center-based behavioral counseling lifestyle intervention on systolic blood pressure (BP). DESIGN: A pre-post design pilot trial of behavioral counseling for therapeutic lifestyle changes in minority elderly people with hypertension. Participants completed baseline visit, Visit 1 (approximately 6 weeks postbaseline), and a final study Visit 2 (approximately 14 weeks postbaseline) within 4 months. SETTING: The study took place in six community-based senior centers in New York City with 65 seniors (mean age 72.29+/-6.92; 53.8% female; 84.6% African American). PARTICIPANTS: Sixty-five minority elderly people. INTERVENTION: Six weekly and two monthly 'booster' group sessions on lifestyle changes to improve BP (e.g., diet, exercise, adherence to prescribed antihypertensive medications). MEASUREMENTS: Primary outcome was systolic BP (SBP) measured using an automated BP monitor. Secondary outcomes were diastolic BP (DBP), physical activity, diet, and adherence to prescribed antihypertensive medications. RESULTS: There was a significant reduction in average SBP of 13.0+/-21.1 mmHg for the intervention group (t(25)=3.14, P=.004) and a nonsignificant reduction in mean SBP of 10.6+/-30.0 mmHg for the waitlist control group (t(29)=1.95, P=.06). For the intervention group, adherence improved 26% (t(23)=2.31, P=.03), and vegetable intake improved 23% (t(25)=2.29, P=.03). CONCLUSION: This senior center-based lifestyle intervention was associated with a significant reduction in SBP and adherence to prescribed antihypertensive medications and diet in the intervention group. Participant retention and group attendance rates suggest that implementing a group-counseling intervention in senior centers is feasible

BackgroundPoor medication adherence is a significant problem in hypertensive African Americans. Although motivational interviewing (MINT) is effective for adoption and maintenance of health behaviors in patients with chronic diseases, its effect on medication adherence remains untested in this population.MethodsThis randomized controlled trial tested the effect of a practice-based MINT counseling vs. usual care (UC) on medication adherence and blood pressure (BP) in 190 hypertensive African Americans (88% women; mean age 54 years). Patients were recruited from two community-based primary care practices in New York City. The primary outcome was adherence measured by electronic pill monitors; the secondary outcome was within-patient change in office BP from baseline to 12 months.ResultsBaseline adherence was similar in both groups (56.2 and 56.6% for MINT and UC, respectively, P = 0.94). Based on intent-to-treat analysis using mixed-effects regression, a significant time x group interaction with model-predicted posttreatment adherence rates of 43 and 57% were found in the UC and MINT groups, respectively (P = 0.027), with a between-group difference of 14% (95% confidence interval, -0.2 to -27%). The between-group difference in systolic and diastolic BP was -6.1 mm Hg (P = 0.065) and -1.4 mm Hg (P = 0.465), respectively, in favor of the MINT group.ConclusionsA practice-based MINT counseling led to steady maintenance of medication adherence over time, compared to significant decline in adherence for UC patients. This effect was associated with a modest, nonsignificant trend toward a net reduction in systolic BP in favor of the MINT group.American Journal of Hypertension (2008). doi 10.1038/ajh.2008.240American Journal of Hypertension (2008). doi 10.1038/ajh.2008.240

BACKGROUND: Electronic monitoring devices (EMDs) are regarded as the gold standard for assessing medication adherence in clinical research. However, little is known about the effect of patients' acceptance of EMDs on medication adherence in African Americans with hypertension who are followed in primary care practices OBJECTIVE: To assess patients' perceptions of EMDs, their acceptance of EMDs, and the relationship of these perceptions to medication adherence in African Americans with hypertension who are followed in community-based practices. METHODS: Patients were recruited from a larger randomized controlled trial assessing the effect of motivational interviewing on medication adherence and blood pressure in hypertensive African American patients followed in 2 New York City primary care practices. Medication adherence was assessed with a Medication Event Monitoring System (MEMS) during a 12-month monitoring period. At the 12-month follow-up, patients' perceptions of the MEMS were assessed with a 17-item questionnaire. ANOVA was used to compare patients' responses (agree, neither, disagree) with the MEMS adherence over the monitoring period. Tukey's post hoc tests were used to determine whether there were significant differences among the 3 groups. RESULTS: Participants were predominantly women, low-income, unemployed, had a high school education, and were a mean age of 53 years. Approximately two-thirds of the participants stated that the MEMS helped them remember to take their medications, 93% reported that the MEMS was easy to open, 85% did not find it stressful, and 75% liked the MEMS and used it everyday. One-third of patients preferred using a pillbox and 25% did not like traveling with the MEMS. Patients who stated that they used the MEMS every day, felt comfortable using it in front of others, and remembered to put refills in the MEMS had significantly better adherence over the study period than did those who disagreed (p </= 0.05). CONCLUSIONS: African American patients treated for hypertension in community-based practices held positive perceptions about a MEMS. Perceptions about the practicality of a MEMS may yield important information about actual medication-taking behavior

There is an obvious gap in the translation of clinical trial evidence into practice with regards to optimal hypertension control. The three major categories of barriers to BP control are patient-related, physician-related, and medical environment/health care system factors. Patient-related barriers include poor medication adherence, beliefs about hypertension and its treatment, depression, health literacy, comorbidity, and patient motivation. The most pertinent is medication adherence, given its centrality to the other factors. The most salient physician-related barrier is clinical inertia--defined, as the failure of health care providers to initiate or intensify drug therapy in a patient with uncontrolled BP. The major reasons for clinical inertia are: 1) overestimation of the amount of care that physicians provide; 2) lack of training on how to attain target BP levels; and 3) clinicians' use of soft reasons to avoid treatment intensification by adopting a 'wait until next visit' approach in response to patients' excuses

Racial disparities in hypertension prevalence and its attendant complications are well documented. Spirituality is an important component of African American beliefs and a small body of literature suggests that spirituality influences hypertension management in African Americans. This article describes a conceptual model of spirituality that may be useful for developing interventions for increasing medication adherence and decreasing blood pressure in African Americans diagnosed with hypertension

BACKGROUND: The high prevalence of depressive symptoms in patients with coronary artery disease has been well documented. However, little is known about the prevalence and correlates of depressive symptoms in Latino patients with coronary artery disease. PURPOSE: Among Latino and white patients who had percutaneous transluminal coronary angioplasty (PTCA), this study examined whether differences in the prevalence of depressive symptoms exist and the degree to which psychosocial factors (years of education, employment status, stressful life events, emotional social support) explained any differences. METHODS: Using a cross-sectional design, closed-format questionnaires were used to obtain clinical and psychosocial history. The definition of high depressive symptoms was based on a score of > or =16 on the Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS: Compared to whites (n=492), Latinos (n=59) were younger, and a greater proportion were female, but fewer completed high school and fewer were employed (P<0.05). More Latinos reported experiencing > or =2 recent stressful life events, but fewer reported having emotional social support (P<0.05). There was a significant association between race/ethnicity and depressive symptoms (OR=2.3, 95% CI: 1.3-4.5). In multivariate analyses, the significance of this association diminished when psychosocial variables were added to the model. CONCLUSIONS: In this study, education, employment, stressful life events and emotional social support partially explained the observed racial/ethnic differences in depressive symptoms

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 3 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