African-Americans commonly develop hypertension at a younger age, are less likely to have their blood pressure under control, and disproportionately suffer strokes and fatality when compared with their Caucasian counterparts. Statistics include a 30 percent greater rate of non-fatal stroke, an 80 percent greater rate of fatal stroke, and a staggering 420 percent greater rate of end-stage kidney disease for African-Americans.

But research estimates show that only 51 percent of all patients with hypertension adhere to their medications and that adherence rates are even lower for African-American patients.

Dr. Lewis identified self-efficacy, depression, and patient-provider communication among the factors in medication nonadherence. She called for further study, but advised that these factors are important for healthcare providers to consider when treating hypertensive African-American patients.

“Increasing blood pressure control requires a comprehensive approach,” wrote Dr. Lewis. “Given that self-efficacy and patient-provider communication are modifiable factors, they can be the focus of interventions to increase medication adherence. [Clinicians also] may want to screen their hypertensive patients for depression and treat if necessary.”

Source University of Pennsylvania School of Nursing

Jan A. Staessen, MD, PhD, FESC, FAHA

Studies Coordinating Centre,
Laboratory of Hypertension,
Campus Sint Rafaël,Kapucijnenvoer 35, Block d, Level 00,
B-3000 Leuven, Belgium

What are the main findings of the study?

We analyzed subjects from the population based 11-country IDACO database who had daytime ambulatory blood pressure (ABP) and conventional blood pressure (CBP) measurements.

After excluding persons with diastolic hypertension by CBP (≥90 mmHg) or by daytime ABP (≥85 mmHg), a history of cardiovascular disease, and persons younger than 18 years, our analysis included 7295 persons, of whom 1593 had isolated systolic hypertension.

During a median follow-up of 10.6 years, there were a total of 655 fatal and non-fatal cardiovascular events.  The analyses were stratified by treatment status.  In untreated subjects, those with white coat hypertension (CBP ≥140/<90 mmHg and ABP <135/<85 mmHg) and subjects with normal BP (CBP <140/<90 mmHg and ABP <135/<85 mmHg) were at similar risk (adjusted hazard rate 1.17; 95% confidence interval 0.87-1.57, P=0.29).

Furthermore, in treated subjects with ISH, the cardiovascular risk was similar in elevated conventional and normal daytime systolic BP as compared to those with normal conventional and normal daytime BP (1.10; 0.79-1.53; P=0.57).

However, both treated ISH subjects with white-coat hypertension (2.00; 1.43-2.79; P<0.0001) and treated subjects with normal BP (2.00; 1.58-2.54; P<0.0001) were at higher risk as compared to untreated normotensive subjects.

Were any of the findings unexpected?

Yes.  The finding that treated ISH subjects with white-coat hypertension and treated subjects with normal BP were at higher risk as compared with treated normotensive subjects was unexpected.

What should clinicians and patients take away from this study?

Treated patients with white-coat hypertension or even normotension have a higher risk than truly normotensive untreated subjects.

What recommendations do you have for future research as a result of your study?

White-coat hypertension must probably be redefined taking into account treatment status.

Reference:

Hypertension. 2012 Jan 17. [Epub ahead of print]

Significance of White-Coat Hypertension in Older Persons With Isolated Systolic Hypertension: A Meta-Analysis Using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes Population.

Franklin SS, Thijs L, Hansen TW, Li Y, Boggia J, Kikuya M, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E,Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Imai Y,Wang J, Ibsen H, O’Brien E, Staessen JA; on behalf of the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators.

Researchers found people who maintained or reduced their blood pressure to normal levels by age 55 had the lowest lifetime risk for CVD (between 22 percent to 41 percent risk). In contrast, those who had already developed high blood pressure by age 55 had a higher lifetime risk (between 42 percent to 69 percent risk).

Using data from 61,585 participants in the Cardiovascular Lifetime Risk Pooling Project, researchers examined how changes in blood pressure during middle age affected lifetime CVD risk. Previous studies had considered a single measurement at a given age. In this study, age 55 was considered a mid-point for middle age.

Starting with baseline blood pressure readings from an average of 14 years prior, researchers tracked blood pressure changes until age 55, then continued to follow the patients until the occurrence of a first cardiovascular event (including heart attack or stroke), death or age 95.

“Taking blood pressure changes into account can provide more accurate estimates for lifetime risk of cardiovascular disease, and it can help us predict individualized risk, and thus, individualized prevention strategies,” said Norrina Allen, Ph.D., lead author of the study and assistant professor in the Department of Preventive Medicine at the Northwestern University Feinberg School of Medicine in Chicago. “Both avoiding hypertension during middle age or delaying the onset of the development of hypertension appear to have a significant impact on an individual’s remaining lifetime risk for CVD.”

Researchers also found:

• Almost 70 percent of all men who develop high blood pressure in middle age will experience a CVD event by 85.
• Women who develop high blood pressure by early middle-age (average age 41) have a higher lifetime risk for CVD (49.4 percent) than those who have maintained normal blood pressure up to age 55.
• Women, in general, had higher increases in blood pressure during middle age.
• At an average age 55, 25.7 percent of men and 40.8 percent of women had normal blood pressure levels; 49.4 percent of men and 47.5 of women had prehypertension.
• The overall lifetime CVD risk for people 55 years or older was 52.5 percent for men and 39.9 percent for women, when factoring in all blood pressure levels.
• The lifetime risk for CVD was higher among Blacks compared with Whites of the same sex, and increased with rising blood pressure at middle age. 

“Since the data suggests that both early elevations and changes over time in blood pressure measurements impact the future risk of CVD, people can take preventive steps early on to reduce their chances of heart attack or stroke,” said Donald M. Lloyd-Jones, M.D., Sc.M., co-author of the study and chair of the Department of Preventive Medicine at the Northwestern University Feinberg School of Medicine. “Maintaining a healthy diet, combined with exercise and weight control, can help reduce blood pressure levels and, consequently, your risk for CVD later in life.”

Co-authors are Jarett D. Berry, M.D., M.S.; Hongyan Ning, M.D., M.S.; Linda Van Horn, Ph.D., R.D.; and Alan Dyer, Ph.D. Author disclosures are on the manuscript.

Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.

Source: Eurekalert

In 2005, the American Heart Association (AHA) released updated recommendations for blood pressure monitoring, to ensure accurate and consistent blood pressure measurements. Numerous factors including body position, arm position, inter-arm differences, cuff size and cuff placement can affect the reading.

Ray and colleagues compared the blood pressure readings of 40 patients obtained by the traditional method routinely used in clinics, as well as by the AHA-recommended method. Based on these two readings for each patient, the researchers produced two medical profile summaries (one for each technique used), covering past medical history, medication list, drug allergies, vital signs, presence or absence of pain, physical examination and laboratory findings, as well as the last two blood pressure readings. These profiles were reviewed by three physicians who provided hypothetical hypertension treatment recommendations.

Ray and colleagues found that overall, individual blood pressure measurements varied greatly between the two methods. As many as 93 percent of patients had a significant blood pressure difference between the two readings (either over 5 mmHg systolic or over 2 mmHg diastolic), with implications for potential cardiovascular complications.

The researchers observed multiple technical errors during the method that most likely accounted for differences between the blood pressure readings. Out of ten possible errors (as defined by the AHA), the average number of errors per patient during the traditional assessment was four. The most common technical error was the absence of measurements on both arms, presumably to save time during measurement. The time to measure blood pressure using the AHA method was over eight minutes (due to the required five minute resting period between arm measurements) versus two minutes using the traditional method.

According to the hypertension medication treatment decisions provided by the three physicians, 45 percent of patients would have received different treatments based on their two blood pressure measurements.

Ray concludes: “Inaccurate blood pressure assessment is common and may impact hypertension treatment. Clinic staff need to be educated on the AHA recommendations for accurate blood pressure measurement, and encouraged to follow them in order to obtain a more accurate reading. More accurate blood pressure measurement could result in improved hypertension management decisions.”

References
1. Ray GM et al (2011). Blood pressure monitoring technique impacts hypertension treatment. Journal of General Internal Medicine. DOI 10.1007/s11606-011-1937-9
2. The Journal of General Internal Medicine is the official journal of the Society of General Internal Medicine.

Source: Eurekalert

Prehypertension, which affects more than 50 million adults in the United States, is blood pressure ranging between 120/80 mm Hg and 139/89 mm Hg. Hypertension is 140/90 mm Hg or higher.

“Our study pertains to people with pre-hypertensive blood pressure levels and shows that the excess risk of stroke associated with these high-normal readings (top number 120-140) can be altered by taking blood pressure pills,” said Ilke Sipahi, M.D., lead author of the study and associate director of Heart Failure and Transplantation at the Harrington-McLaughlin Heart and Vascular Institute in Cleveland, Ohio.

In a meta-analysis of 16 studies, researchers examined data that compared anti-hypertensive drugs against placebo in 70,664 people with average baseline blood pressure levels within the pre-hypertensive range. The researchers found:

• Patients taking blood pressure-lowering medicines had a 22 percent lower risk of stroke compared to those taking a placebo. This effect was observed across all classes of anti-hypertensive drugs studied.
• No significant reduction in the risk of heart attack occurred, but there was a trend toward lower cardiovascular death in patients taking blood pressure medications compared to those on placebo.
• To prevent one stroke in the study population, 169 people had to be treated with a blood pressure-lowering medication for an average 4.3 years.

American Heart Association treatment guidelines call for lifestyle changes, not medications, to reduce blood pressure in people with prehypertension. Those lifestyle changes include weight loss, physical activity, a diet rich in fruit and vegetables and low in salt and fat, and keeping alcohol consumption moderate (no more than two drinks per day for men and no more than one drink per day for women).

“We do not think that giving blood pressure medicine instead of implementing the lifestyle changes is the way to go,” Sipahi said. “However, the clear-cut reduction in the risk of stroke with blood pressure pills is important and may be complementary to lifestyle changes.”

The cost of long-term therapy and the risks associated with blood pressure medicines need to be discussed extensively within the medical community before undertaking guideline changes, Sipahi said.

Co-authors are: Aparna Swaminathan, fourth-year medical student; Viswanath Natesan, M.D.; Sara M. Debanne, Ph.D.; Daniel I. Simon, M.D.; and James C. Fang, M.D. Author disclosures are on the manuscript.

Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.

Source: Eurekalert

The findings, from a team of scientists led by Bruce Ovbiagele, MD, professor of neurosciences at the University of California, San Diego School of Medicine, are published in the November 16 issue of JAMA, the Journal of the American Medical Association.

The 5-year study examined the cases of 20,330 patients (age 50 years and older) at 695 centers in 35 countries who had suffered a recent non-cardioembolic ischemic stroke, which is caused by drifting blood clots formed outside of the heart. Patients were categorized by their average Systolic blood pressure (SBP) level: very low-normal (less than 120 mmHg), low-normal (120 to less than 130 mm Hg), high-normal (130 to less than 140 mm Hg), high (140 to less than 150 mm Hg) and very high (150 mm Hg or greater).

The occurrence rate for the primary or first stroke was highest in patients with a very high SBP (14.1 percent), followed by patients with high SBP (8.7 percent). Next came patients with very low-normal SBP at 8 percent, low-normal SBP at 7.2 percent and then high-normal SBP at 6.8 percent. The occurrence rate for a second stroke or other vascular event followed the same pattern.

SBP is the maximum pressure applied to arterial walls as blood is pumped through the body. Diastolic blood pressure (DBP) is the minimum. Typically, normal blood pressure is defined as less than 120 mm Hg for SBP and less than 80 mm Hg for DBP.

“For most patients at high vascular risk, including diabetics, the general approach has been that much lower is much better,” said Ovbiagele. “For stroke patients, whose condition is most strongly related to elevated blood pressure, it has been believed that much, much lower is much, much better, and that the relationship of SBP with stroke was likely a linear one.”

The new findings indicate the association between blood pressure and stroke risk is more complicated than previously suspected. While the researchers said it was not surprising to find that higher-than-normal SBP levels boosted recurrent stroke risk, it was somewhat unexpected to discover the same effect among patients with very low SBP levels.

The apparent narrowing of what constitutes a “healthy” SBP for stroke patients may not be the only relevant factor. Ovbiagele said timing also appears to be important because the effects were most pronounced in the first six months after the primary stroke.

“It’s conceivable that the brain may still require a certain threshold of blood perfusion early-on after the index vascular brain injury and so is susceptible to more strokes if SBP dips below that threshold. This is just a theory, but there are a couple of other clinical studies that suggest early BP reduction after an acute stroke may be associated with some harm.”

Ovbiagele said the message to patients and clinicians is that “it increasingly appears there is no one-size-fits-all approach with regard to treating blood pressure to prevent stroke. This study and other recent data now suggest that there are several factors to take into consideration when lowering blood pressure to prevent stroke, including the age of the patient, level of blood pressure, any history of prior stroke, type of prior stroke and timing of prior stroke.”

Co-authors of the study are Hans-Christopher Diener, Department of Neurology, University of Duiberg-Essen, Germany; Salim Yusuf, Population Health Research Institute, McMaster University, Canada; Renee H. Martin, Division of Biostatistics and Epidemiology, Department of Medicine, Medical University of South Carolina; Daniel Cotton and Richard Vinisko, Boehringer Ingelheim Pharmaceuticals Inc, Connecticut; Geoffrey A. Donnan, National Stroke Research Institute, University of Melbourne, Australia; Philip M. Bath, Stroke Trials Unit, University of Nottingham,England.

Source: Eurekalert November 15 2011

Highlights

• A test done mid-pregnancy accurately predicts which women will later develop preeclampsia, a late-pregnancy disorder characterized by high blood pressure and excess protein in the urine. Left untreated, preeclampsia can lead to serious — even fatal — complications for a pregnant woman and her baby.
• Women with high blood pressure during pregnancy risk experiencing high blood pressure, kidney problems, and stroke in the future compared to women with normal blood pressure during pregnancy.

Two studies from the Mayo Clinic presented during the American Society of Nephrology’s Annual Kidney Week provide new information related to high blood pressure during pregnancy.

In one study, Vesna Garovic, MD and her team examined the potential of a test done mid-pregnancy to predict which women will later develop preeclampsia, a late-pregnancy disorder that is characterized by high blood pressure and excess protein in the urine and that affects 3% to 5% of pregnancies. Left untreated, preeclampsia can lead to serious — even fatal — complications for a pregnant woman and her baby.

Among a group of 315 patients, 15 developed preeclampsia and 15 developed high blood pressure (but not preeclampsia) during pregnancy. All of the patients who developed preeclampsia tested positive in mid-pregnancy for a test that detects the shedding of certain kidney cells called podocytes in the urine. None of those with only high blood pressure tested positive, and none of 44 women with normal pregnancies tested positive. Therefore, this test is highly accurate for predicting preeclampsia, which could alert clinicians to take steps to safeguard against the condition.

In another study, Dr. Garovic’s team looked at the long-term health effects of high blood pressure during pregnancy. They identified female residents of Rochester, Minnesota and the surrounding townships in Olmsted County who delivered between 1976 and 1982. The investigators divided the women into two groups — those with high blood pressure during pregnancy and those without — and followed them after they reached 40 years of age to monitor their heart and kidney health.

A total of 6,051 mothers delivered between 1976 and1982, and 607 women had high blood pressure at the time while 5,444 did not. After the women reached age 40, women who had high blood pressure during pregnancy were much more likely to experience high blood pressure, kidney disease, and strokes than women who did not have high blood pressure during pregnancy (51% vs 31%, 14% vs 10%, and 8% vs 4%, respectively).

“Studies of the associations of hypertensive pregnancy disorders with maternal risks for future cardiovascular disease could lead to new guidelines for screening and treatment of women at risk, with the ultimate goal of improving cardiovascular health in women,” said Dr. Garovic.

Study authors for “Podocyturia Is an Early Marker That Distinguishes among Normotensive Pregnancy, Gestational Hypertension, and Preeclampsia” (abstract FR-OR292) include Steven Wagner, MD, Iasmina Craici, MD, Juan C. Calle, MD, Christina Wood-wentz, Kent R. Bailey, PhD, Stephen T. Turner, MD, Joseph P. Grande, MD, PhD and Vesna D. Garovic, MD.

Study authors for “Women with a History of Hypertensive Pregnancy Disorders Are at Increased Risk for Future Cardiovascular and Renal Disease: A Population-Based Cohort Study” (abstract TH-OR115) include Catherine M. Brown, MD, Slavica Katusic, Cynthia L. Leibson, Jeanine Ransom, Stephen T. Turner, MD, Veronique L. Roger and Vesna D. Garovic, MD.

Source: Eurekalert November 11 2011

CLEMSON — Your ability to recognize emotional content in faces and texts is linked to your blood pressure, according to a Clemson University researcher.

A recently published study by Clemson University psychology professor James A. McCubbin and colleagues has shown that people with higher blood pressure have reduced ability to recognize angry, fearful, sad and happy faces and text passages.

“It’s like living in a world of email without smiley faces,” McCubbin said. “We put smiley faces in emails to show when we are just kidding. Otherwise some people may misinterpret our humor and get angry.”

Some people have what McCubbin calls “emotional dampening” that may cause them to respond inappropriately to anger or other emotions in others.

“For example, if your work supervisor is angry, you may mistakenly believe that he or she is just kidding,” McCubbin said. “This can lead to miscommunication, poor job performance and increased psychosocial distress.”

In complex social situations like work settings, people rely on facial expressions and verbal emotional cues to interact with others.

“If you have emotional dampening, you may distrust others because you cannot read emotional meaning in their face or their verbal communications,” he said. “You may even take more risks because you cannot fully appraise threats in the environment.”

McCubbin said the link between dampening of emotions and blood pressure is believed to be involved in the development of hypertension and risk for coronary heart disease, the biggest killer of both men and women in the U.S. Emotional dampening also may be involved in disorders of emotion regulation, such as bipolar disorders and depression.

His theory of emotional dampening also applies to positive emotions.

“Dampening of positive emotions may rob one of the restorative benefits of close personal relations, vacations and hobbies,“ he said.

McCubbin’s study, published in the journal Psychosomatic Medicine, was supported by the National Heart, Lung and Blood Institute and the National Institute on Aging, both parts of the National Institutes of Health.

The journal article was co-authored by Marcellus M. Merritt of the University of Wisconsin-Milwaukee psychology department; John J. Sollers III if the psychological medicine department at the University of Auckland; Dr. Michele K. Evans of the Laboratory of Immunology, National Institute on Aging; Alan B. Zonderman, Laboratory of Behavioral Neuroscience, National Institute on Aging; Dr. Richard D. Lane of the psychiatry department, University of Arizona; and Julian F. Thayer of the Ohio State University psychology department.

A billion people worldwide suffer from high blood pressure and are therefore in the danger zone for the likes of heart disease and stroke. Effective prediction and control of high blood pressure is therefore one of the most pressing global health issues.

Analyzing genetic data

Researchers from the Sahlgrenska Academy at the University of Gothenburg are among an international consortium of more than 400 researchers from the US, Europe, Asia and Australia hoping to identify which parts of our genes influence blood pressure by sifting through vast quantities of genetic data.

2.5 million DNA variations

In their latest study, the researchers analysed more than 2.5 million DNA variations from more than 200,000 Europeans. The results, published in the renowned journal Nature, reveal 16 previously unknown genetic regions with interesting genes that regulate the body’s blood pressure – both the lower level when the heart expands (diastolic) and the upper level when the heart contracts (systolic).

Genetic risk groups

With the help of these newly discovered genetic variations, the researchers have constructed genetic risk groups to help predict the risk of strokes and heart attacks.

“We’ve been able to classify individuals on the basis of how many risk variants for hypertension they have in their genes” says Fredrik Nyberg, a researcher from the Sahlgrenska Academy working on the project.

Important step forward

In another study published at the same time in Nature Genetics, the researchers from Gothenburg identify additional new genetic regions and genes controlling two other measures of blood pressure: pulse pressure (the difference between systolic and diastolic) and mean arterial pressure (an average of systolic and diastolic). The study shows how important it is to analyse different measures of blood pressure. For example, pulse pressure is a marker of rigidity in the arteries carrying blood from the heart to the body, and different genes seem to control different aspects of blood pressure.

The results of the two studies are considered to be an important step towards understanding how the body regulates blood pressure, and the newly discovered genetic regions are potential targets for future treatments.

Blacks with prehypertension also have a 35 percent greater risk of progressing to high blood pressure than whites, according to health records of 18,865 adults 18 to 85.

Prehypertension is blood pressure ranging between 120/80 mm Hg and 139/89 mm Hg. Hypertension is 140/90 mm Hg or higher.

Previous research has shown that coronary heart disease, stroke and high blood pressure are more common among blacks than whites.

“The fact that African-Americans progress faster to hypertension has a direct link to the higher prevalence of hypertension and its complications, such as stroke and kidney disease, in blacks than whites,” said Anbesaw Selassie, Dr.P.H., lead researcher and an epidemiologist at the Medical University of South Carolina in Charleston.

Selassie and his colleagues analyzed electronic health records from 197 community-based clinics in the Southeastern U.S. from 2003-2009.

Patients didn’t have high blood pressure at the beginning of the study. Thirty percent of the patients were black and 70 percent were white.

Patients who did not have high blood pressure at baseline and whose blood pressure was checked at least four times over two years, had high blood pressure if two consecutive measurements were at or above 140 mmHg systolic or 90 mmHg diastolic.

The researchers analyzed each person’s relative risk of progressing from prehypertension to high blood pressure as a function of race, accounting for the effects of other factors that could affect risk, including age, sex, weight, initial blood pressure, type 2 diabetes and kidney disease.

Some conditions beyond race were also strongly associated with a faster conversion to high blood pressure such as systolic blood pressure 130� and age 75 years and older. Other factors associated with faster conversion to high blood pressure include being overweight or obese, and having type 2 diabetes.

Lifestyle changes to reduce risk for people with prehypertension include weight loss, physical activity, a diet high in fruits and vegetables and low in salt and fat, and moderate alcohol consumption. Treatment guidelines don’t call for using medications to lower the risk of high blood pressure for people with prehypertension.

The study results suggest a strong need for more aggressive early interventions and lifestyle changes for African-Americans with prehypertension, Selassie said. “I firmly believe that without early therapeutic interventions such as medication, we cannot narrow the gap between blacks and whites on these outcomes.”

“Ultimately, tangible and fundamental answers must be forthcoming in order to explain why the black population develops hypertension more frequently and rapidly,” said Edward D. Frohlich, M.D., Alton Ochsner Distinguished Scientist at the Ochsner Clinic Foundation in New Orleans, La., in an accompanying editorial.

Frohlich said one possible explanation may be based on African Americans’ greater dietary intake of salt during a lifetime.

Co-authors are C. Shaun Wagner, M.S.; Marilyn L. Laken, Ph.D., R.N.; M. LaFrance Ferguson, M.D.; Keith C. Ferdinand, M.D. and Brent M. Egan, M.D. Author disclosures are on the manuscript.

The National Institutes of Health funded part of the study.

Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events.