Long-term prognostic impact of repeated measurements over 1 year of pulse pressure and systolic blood pressure in the elderly

Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Systematic Review

Background

Long-term care for patients with chronic diseases poses a huge challenge in primary care. In particular, there is a deficit regarding monitoring and structured follow-up. Appropriate electronic medical records (EMRs) could help improving this but, so far, there are no evidence-based specifications concerning the indicators that should be monitored at regular intervals.

Objective

The aim was to identify and collect a set of evidence-based indicators that could be used for monitoring chronic conditions at regular intervals in primary care using EMRs.

Methods

We searched MEDLINE (Ovid), Embase (Elsevier), the Cochrane Library (Wiley), the reference lists of included studies and relevant reviews, and the content of clinical guidelines. We included primary studies and guidelines reporting about indicators that allow for the assessment of care and help monitor the status and process of disease for five chronic conditions, including type 2 diabetes mellitus, asthma, arterial hypertension, chronic heart failure, and osteoarthritis.

Results

The use of the term “monitoring” in terms of disease management and long-term care for patients with chronic diseases is not widely used in the literature. Nevertheless, we identified a substantial number of disease-specific indicators that can be used for routine monitoring of chronic diseases in primary care by means of EMRs.

Conclusions

To our knowledge, this is the first systematic review summarizing the existing scientific evidence on the standardized long-term monitoring of chronic diseases using EMRs. In a second step, our extensive set of indicators will serve as a generic template for evaluating their usability by means of an adapted Delphi procedure. In a third step, the indicators will be summarized into a user-friendly EMR layout.

Does blood pressure variability modulate cardiovascular risk?

Exactly how hypertension causes end organ damage and vascular events is poorly understood. Yet the concept that underlying "usual" blood pressure (BP) accounts for all BP-related risk of vascular events and for the benefits of BP-lowering drugs has come to underpin clinical guidelines on the diagnosis and treatment of hypertension. This article reviews evidence that variability in BP also predicts risk of stroke and other vascular events independently of mean BP and evidence that drug-class effects on variability in BP explain differences in the effectiveness of BP-lowering drugs in preventing stroke.

Smoking and atherosclerotic cardiovascular disease: part III: functional biomarkers influenced by smoking

Smoking cigarettes induces rapidly occurring and reversible functional changes in the cardiovascular system, which precede morphologic changes. These functional changes are also related to atherosclerotic disease development and thus may qualify as prognostic parameters in chronic smokers. As opposed to smoking-induced morphologic changes functional alterations occur and revert within minutes, thus, allowing for the detection of smoking-induced effects on the cardiovascular system within minutes following exposure to mainstream smoke. Some alterations represent 'direct' changes (e.g., endothelial function), others reflect changes in a different organ system (e.g., the autonomous nervous system influencing heart rate variability), while some represent the sum of alterations in many organs and systems (e.g., exercise performance influenced by the autonomous nervous and by endothelial and cardiac function). Since a specific functional parameter usually changes with at least one or several others, caution should be exercised when trying to establish a direct cause relationship between the alteration of a single parameter and a clinical outcome.

Effects of blood pressure on the prothrombotic risk in 1235 patients with non-valvular atrial fibrillation

BACKGROUND

Increased levels of plasma von Willebrand factor (vWf, an index of endothelial damage/dysfunction) and soluble P-selectin (sP-sel, an index of platelet activation) concentrations have been reported as indices of the prothrombotic state in both non-valvular atrial fibrillation and hypertension separately. However, the effect of hypertension on the levels of these indices in the setting of atrial fibrillation, and whether increasing severity of hypertension presents an additive prothrombotic risk, is unclear.

METHODS

Plasma concentrations of vWf and sP-sel were measured by ELISA in 1235 patients with atrial fibrillation, and levels related to a history of hypertension and rising quartiles of systolic, diastolic and pulse pressure in those with and without diabetes mellitus and prior vascular events.

RESULTS

Mean plasma vWf was higher among patients with atrial fibrillation with a history of hypertension (149 vs 145 IU/dl, p = 0.005). Also, an increase in the levels of vWf with increasing quartiles of pulse pressure (p = 0.042) was noticed. However, on multivariate analysis, after adjusting for potential confounders, the effects of both hypertension and pulse pressure became non-significant (p = 0.261 and p = 0.5, respectively). Levels of sP-sel were unaffected by a history of hypertension and rising quartiles of systolic and diastolic blood pressure, or pulse pressure.

CONCLUSION

Among patients with atrial fibrillation, patients with hypertension have higher vWf levels, indicating endothelial damage/dysfunction, which is associated with increasing pulse pressure. However, these associations are probably owing to the presence of other associated cardiovascular disease, rather than hypertension itself. Furthermore, platelet activation (sP-sel) was unrelated to hypertension or blood pressure in this atrial fibrillation cohort. Hypertension or blood pressure levels do not seem to have an independent additive affect on the prothrombotic state in atrial fibrillation.