Assessment of the white-coat effect

Coloring complex shapes decreases patient anxiety in three care environments: a pilot study with color analysis

Introduction

This study was conducted to determine the effectiveness of coloring activity of circular symmetrical shape with complex patterns, so-called mandala, on anxiety associated with chronic illness in three different ambulatory medical situations (general consultation, psychiatric day hospital, and hemodialysis session).

Methods

Thirty patients were included in three groups and came from three different ambulatory medical situations: a hemodialysis group (n = 10), a psychiatric day hospital group (n = 10), and a nephrology consultation group (n = 10). We asked the patients to fill STAI-S and STAI-T questionnaires before to color complex circular shape with complex patterns, then to fill the STAI-S questionnaire again and a questionnaire on the experience of the activity.

Results

The results show that the STAI-S score was significantly lower after coloring for the hemodialysis (p = 0.02) and psychiatric groups (p = 0.005) but not for the general consultation group (p = 0.26). STAI-T scores did not differ between groups. The distribution of colors in the mandala was different in the three groups of patients. A positive subjective experience of the activity was found in all groups.

Discussion

These results show the effectiveness of a coloring activity of a circular shape with complex patterns on anxiety associated with chronic illness in care environment. The different distribution of the colors of the mandala in the three groups raises the question of the influence of the context on the mood of the patients and the deeper meaning of the choice of colors and their placement in the mandala. Our study reinforces the multiple applications of art activities in different medical disciplines and encourages their development within healthcare settings.

White Coat Effect: Is It Because of the Hospital Setting, or Is It Physician-Induced?

INTRODUCTION

White coat hypertension (WCH) patients are those individuals who have high blood pressure (BP) in the medical environment but are normal during their daily activities. White coat hypertensive patients with normal daytime ambulatory blood pressure monitoring (ABPM) rapidly progress to sustained hypertension. WCH is mainly treated with non-pharmacological methods. Alpha-1 agonists and beta blockers are logical treatment choices for patients with fixed hypertension with the White Coat Effect (WCE). Masked hypertension patients are those individuals who have normal values at the doctor's office but elevated BP at home or during 24-hour ABPM (24-hour or daytime). ABPM is a more practical and reliable method for detecting patients with WCH.

MATERIAL AND METHODS

This observational study was conducted at Dayanand Medical College & Hospital, Ludhiana, over the course of one year (December 2015 to November 2016). The primary objective of the study was to determine whether there was a difference in blood pressure readings between the home setting and the hospital setting. The secondary objective was to determine whether the difference, if present, between the hospital and home readings was due to the hospital setting, physician presence, or a combination of both. Patients with stage 1 hypertension were included in the study, irrespective of antihypertensive treatment. Patients with ischemic heart disease, chronic liver failure, and chronic kidney disease who could not follow protocol instructions were excluded.

RESULTS

In our study, the mean age of patients was 53.91±12.86 years. The patient's mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings at the hospital were higher than their home readings (p-0.012; p-0.001, respectively). Mean hospital SBP and DBP readings recorded by the physician were higher than readings recorded by patients alone at home (p-0.002; p-0.014, respectively) and alone at the hospital (p-0.004; p-0.001, respectively). BP readings taken by the physician with a manual sphygmomanometer were significantly lower than those taken with a digital sphygmomanometer by patients and physicians in all settings (p<0.05). The mean rise in BP was significant in both the physician's presence and the hospital environment (p<0.05 for both), and this rise was more significantly associated with the hospital effect than the physician effect (p<0.05).

CONCLUSION

Misdiagnosis of hypertension results in inappropriate prescription and overuse of antihypertensive medications for individuals who are not persistently hypertensive. So it is very important to rule out WCH in both the hospital setting and the physician's presence, more precisely by ABPM. WCH can be diagnosed with regular BP monitoring by a digital sphygmomanometer at home.

Recent Advances in Non-Invasive Blood Pressure Monitoring and Prediction Using a Machine Learning Approach

Blood pressure (BP) monitoring can be performed either invasively via arterial catheterization or non-invasively through a cuff sphygmomanometer. However, for conscious individuals, traditional cuff-based BP monitoring devices are often uncomfortable, intermittent, and impractical for frequent measurements. Continuous and non-invasive BP (NIBP) monitoring is currently gaining attention in the human health monitoring area due to its promising potentials in assessing the health status of an individual, enabled by machine learning (ML), for various purposes such as early prediction of disease and intervention treatment. This review presents the development of a non-invasive BP measuring tool called sphygmomanometer in brief, summarizes state-of-the-art NIBP sensors, and identifies extended works on continuous NIBP monitoring using commercial devices. Moreover, the NIBP predictive techniques including pulse arrival time, pulse transit time, pulse wave velocity, and ML are elaborated on the basis of bio-signals acquisition from these sensors. Additionally, the different BP values (systolic BP, diastolic BP, mean arterial pressure) of the various ML models adopted in several reported studies are compared in terms of the international validation standards developed by the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS) for clinically-approved BP monitors. Finally, several challenges and possible solutions for the implementation and realization of continuous NIBP technology are addressed.

Association between anxiety and hypertension in adults: A systematic review and meta-analysis

We assessed the association between anxiety and hypertension in adults via a systematic review/meta-analysis. We searched PubMed, Ovid, and PsycINFO through 27 March 2020 with no language or publication type restrictions and systematically contacted study authors for unpublished information/data. We meta-analysed 59 studies including a total of 4,012,775 participants. Study quality was rated with the Newcastle-Ottawa Scale and random-effects analyses were performed. A significant anxiety-hypertension association was found in cross-sectional (OR = 1.37, 95 % CI = 1.21-1.54) and prospective studies (OR = 1.40, 95 % CI = 1.23-1.59). In sensitivity analyses, results were influenced by method of hypertension diagnosis, but not by study quality, method of anxiety diagnosis, study population, and effect size type. In subgroup analyses, study location, in particular country economic status, but not participant age, influenced the results. Longitudinal data and theoretical literature indicate that anxiety may precede hypertension. These findings have important clinical implications for the early detection and treatment of both anxiety and hypertension. Suggestions for future research are discussed.

Wearable Wireless-Enabled Oscillometric Sphygmomanometer: A Flexible Ambulatory Tool for Blood Pressure Estimation

This article presents the design of an unobtrusive and wireless-enabled blood pressure (BP) monitoring system that is suitable for ambulatory use. By adopting low-profile electromechanical actuators and a compact printed circuit board design, this lightweight device can be worn directly on the occlusive cuff, therefore eliminating the need of a long and obtrusive tubing interconnect between the device and the cuff, as seen in traditional ambulatory BP monitors (ABPM). Instead of executing the BP estimation algorithm directly on the device, the proposed design rather sends the raw oscillometric signal through a Bluetooth Low Energy link, thus granting any Bluetooth-enabled device to gather and process the signal using a dedicated application. This in turn allows to assess several BP estimation algorithms found in the literature without being limited by the device resources. Three of them were tested with the designed prototype and validated with a reference equipment on 11 subjects. Overall, two of the algorithms revealed a mean absolute difference with the reference equipment of less than 5 mmHg and almost zero bias along with a standard deviation of less than 6 mmHg. Reproducibility results shown a mean difference between successive measurements of less than 3.1 mmHg and a standard deviation of less than 2.4 mmHg. The assembled prototype dimensions are 63.8 × 134.8 × 24.8 mm and features an autonomy of 63.1 hours. Comparison with commercial ABPM devices shown that the proposed design is 18% to 33% smaller volume-wise, 5% to 27% weight-wise and height is reduced by 17% to 25%.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

BACKGROUND

To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements.

METHODS

A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles.

RESULTS

A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP.

CONCLUSION

A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

Muscle and skin sympathetic nerve traffic during physician and nurse blood pressure measurement

OBJECTIVE

Previous studies have shown that blood pressure assessment by a nurse markedly attenuates the pressor and tachicardic responses triggered by the physician blood pressure measurement. Whether and to what extent this attenuation reflects a different pattern of the neuroadrenergic responses to doctor or nurse blood pressure evaluation is unknown.

METHODS

In 19 lean untreated mild essential hypertensive patients (age 39.1 ± 2.4 years, mean ± SEM), we measured beat-to-beat mean arterial pressure (Finapres), heart rate (ECG), and efferent postganglionic muscle and skin sympathetic nerve traffic [muscle sympathetic nerve activity (MSNA) and skin sympathetic nerve activity (SSNA), respectively, by microneurography], before, during, and following a 10-min sphygmomanometric BP measurement by a doctor or by a nurse unfamiliar to the patients. Measurements were repeated at a 30-min interval to obtain, in separate periods, muscle and skin sympathetic nerve traffic recordings. Both the sequences (doctor vs. nurse and muscle vs. skin sympathetic nerve traffic) were randomized.

RESULTS

A doctor visit induced sudden, marked, and prolonged blood pressure and heart rate increases, accompanied by a muscle sympathetic nerve traffic inhibition (average response: -18.1 ± 4.3%, P < 0.01) coupled with a skin sympathetic nerve traffic excitation (average response: +46.1 ± 5.5%, P < 0.01). In contrast, a nurse visit elicited blood pressure and heart rate responses markedly and significantly reduced (-72.1 ± 11 and -81.7 ± 13% respectively, P < 0.01) as compared with those seen during the doctor's visit. This was the case also for muscle and skin sympathetic neural responses (-44.3 ± 9 and -65.6 ± 13%, P < 0.01).

CONCLUSION

These data provide the first evidence that the blunted pressor and tachicardic responses to nurse's blood pressure measurements are accompanied by an attenuation of the adrenergic neural responses seen during the alerting reaction accompanying doctor's blood pressure measurement.

Acute effects of trauma-focused research procedures on participant safety and distress

The ethical conduct of research on posttraumatic stress disorder (PTSD) requires assessing the risks to study participants. Some previous findings suggest that patients with PTSD report higher distress compared to non-PTSD participants after trauma-focused research. However, the impact of study participation on participant risk, such as suicidal/homicidal ideation and increased desire to use drugs or alcohol, has not been adequately investigated. Furthermore, systematic evaluation of distress using pre- and post-study assessments, and the effects of study procedures involving exposure to aversive stimuli, are lacking. Individuals with a history of PTSD (n=68) and trauma-exposed non-PTSD controls (n=68) responded to five questions about risk and distress before and after participating in research procedures including a PTSD diagnostic interview and a behavioral task with aversive stimuli consisting of mild electrical shock. The desire to use alcohol or drugs increased modestly with study participation among the subgroup (n=48) of participants with current PTSD. Participation in these research procedures was not associated with increased distress or participant risk, nor did study participation interact with lifetime PTSD diagnosis. These results suggest some increase in distress with active PTSD but a participant risk profile that supports a favorable risk-benefit ratio for conducting research in individuals with PTSD.

Screening medical patients for distress and depression: does measurement in the clinic prior to the consultation overestimate distress measured at home?

BACKGROUND

Medical patients are often screened for distress in the clinic using a questionnaire such as the Hospital Anxiety and Depression Scale (HADS) while awaiting their consultation. However, might the context of the clinic artificially inflate the distress score ? To address this question we aimed to determine whether those who scored high on the HADS in the clinic remained high scorers when reassessed later at home.

METHOD

We analysed data collected by a distress and depression screening service for cancer out-patients. All patients had completed the HADS in the clinic (on computer or on paper) prior to their consultation. For a period, patients with a high score (total of > or = 15) also completed the HADS again at home (over the telephone) 1 week later. We used these data to determine what proportion remained high scorers and the mean change in their scores. We estimated the effect of ‘ regression to the mean’ on the observed change.

RESULTS

Of the 218 high scorers in the clinic, most [158 (72.5 %), 95% confidence interval (CI) 66.6–78.4] scored high at reassessment. The mean fall in the HADS total score was 1.74 (95% CI 1.09–2.39), much of which could be attributed to the estimated change over time (regression to the mean) rather than the context.

CONCLUSIONS

Pre-consultation distress screening in clinic is widely used. Reassuringly, it only modestly overestimates distress measured later at home and consequently would result in a small proportion of unnecessary further assessments. We conclude it is a reasonable and convenient strategy.

Increasing the validity and efficiency of blood pressure estimates using ambulatory and clinic measurements and modern missing data methods

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is considered the gold standard for BP measurement, compared to clinic BP measurements (CBP), which are a less valid predictor of target organ damage and cardiovascular events. However, ABPM is considerably more expensive than CBP, leaving BP researchers with a difficult dilemma: Use the less efficient CBP measure, or bear the cost of the more expensive ABPM. Recent developments in missing data methods, notably the two-method measurement (TMM) design, address this problem. With the TMM design, all research participants receive the less expensive CBP measure, but only a random subset receives the more expensive ABPM. The total number of participants must be increased, with additional participants receiving only CBP measurements. Even so, the TMM still reduces costs.

METHODS

We applied the TMM approach, which makes use of a "bias correction" structural equation model, to an empirical data set in which data were available for ABPM and CBP, as well as an echocardiographic measure of left ventricular mass (LVM).

RESULTS

Based on an estimated fivefold difference in cost for using ABPM compared to CBP, we found that statistical power can be considerably increased, or that BP measurement costs can be considerably reduced, when using this planned missing data design.

CONCLUSIONS

These benefits were observed with no loss of predictive validity (i.e., the observed association between BP and LVM). This suggests that the TMM design is a promising technique that in some studies may be able to decrease costs and/or increase one's power to detect effects.

Magnitude of the white-coat effect in the community pharmacy setting: the MEPAFAR study

BACKGROUND

There is little information regarding the community pharmacy blood pressure (CPBP) measurement method and their differences with home (HBP) or ambulatory BP (ABP). The aim of this study was to measure such differences and their variation over successive visits.

METHOD

Cross-sectional study carried out in eight pharmacies in Gran Canaria (Spain). The study included 169 treated hypertensive patients. BP was measured at the pharmacy (four visits), at HBP (4 days) and 24-h ABP monitoring. We defined pharmacy white-coat effect (PWCE) as differences between CPBP and HBP (home PWCE) or daytime ABP (ambulatory PWCE).

RESULTS

The overall (pooled values for all visits) ambulatory PWCE was not significantly different from zero for systolic BP (SBP) (-0.4 mm Hg (95% confidence interval (CI): -1.8 to 1.1)), but greater than zero for diastolic BP (DBP) (3.4 mm Hg (95% CI: 2.3 to 4.6)). The overall home PWCE was not significantly different from zero, both for SBP (1.2 mm Hg (95% CI: -0.1 to 2.6)) and DBP (0.1 mm Hg (95% CI: -0.7 to 1.0)). The ambulatory and home PWCE on the first visit were greater than zero (P < 0.001) (SBP/DBP): 3.5/4.8 and 1.9/1.5 mm Hg, respectively; but showed important reductions at the second visit and became not significantly different from zero, except the ambulatory PWCE in DBP, which persisted until the last visit.

CONCLUSION

The trend in the PWCE decreased over the successive visits to the pharmacy. Only the ambulatory PWCE in DBP proved to be statistically greater than zero after the second visit. Repeated CPBP measurements could be a useful alternative to assess the response to antihypertensive treatment.

Twenty-four-hour ambulatory blood pressure measurement in clinical practice and research: a critical review of a technique in need of implementation

This review presents evidence that ambulatory blood pressure measurement (ABPM) should be used more widely in clinical practice and hypertension research. The technique, which should be mandatory in trials of antihypertensive drugs, is not being used in all studies of antihypertensive drug efficacy. ABPM is also being under-used in outcome studies. The failure to implement ABPM in primary care and hypertension research is impeding patient management and scientific advancement. ABPM offers so many advantages in assessing the efficacy of blood pressure (BP)-lowering drugs that it should be mandatory in pharmacological trials. Likewise, the technique provides a means of achieving BP control in clinical practice, which is essential if we are to halt the epidemic of the cardiovascular consequences of hypertension. However, if ABPM is to be implemented for these purposes, certain requirements will need to be fulfilled. These include the availability of accurate, patient-friendly and inexpensive devices; standardization of the presentation and plotting of data with summary statistics for day-to-day practice; provision of comprehensive data analysis for research; an interpretative report to facilitate use in busy clinical practice; a trend report to demonstrate efficacy or otherwise of treatment in clinical practice and online transmission of data to provide immediate real-time data analysis. The reasons why ABPM is not being implemented are reviewed, and proposals are made to make the technique more acceptable.

Prevalence and factors affecting home blood pressure documentation in routine clinical care: a retrospective study

BACKGROUND

Home blood pressure (BP) is closely linked to patient outcomes. However, the prevalence of its documentation has not been examined. The objective of this study was to analyze the prevalence and factors affecting documentation of home BP in routine clinical care.

METHODS

A retrospective study of 142,973 encounters of 9,840 hypertensive patients with diabetes from 2000 to 2005 was performed. The prevalence of recorded home BP and the factors associated with its documentation were analyzed. We assessed validity of home BP information by comparing the difference between home and office BP to previously published prospective studies.

RESULTS

Home BP was documented in narrative notes for 2.08% of encounters where any blood pressure was recorded and negligibly in structured data (EMR flowsheets). Systolic and diastolic home BP in narrative notes were lower than office BP readings by 9.6 and 2.5 mm Hg, respectively (p < 0.0001 for both), consistent with prospective data. Probability of home BP documentation increased by 23.0% for each 10 mm Hg of office systolic BP (p < 0.0001), by 6.2% for each $10,000 in median income of zip code (p = 0.0055), and by 17.7% for each decade in the patient's age (p < 0.0001).

CONCLUSIONS

Home BP readings provide a valid representation of the patient's condition, yet are seldom documented despite their potential utility in both patient care and research. Strong association between higher patient income and home BP documentation suggests that the cost of the monitors may be a limiting factor; reimbursement of home BP monitoring expenses should be pursued.

Preventing misdiagnosis of ambulatory hypertension: algorithm using office and home blood pressures

OBJECTIVES

An algorithm for making a differential diagnosis between sustained and white coat hypertension (WCH) has been proposed - patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cut-off in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM.

METHODS

Two hundred twenty-nine normotensive and untreated mildly hypertensive participants (mean age 52.5 +/- 14.6 years, 54% female participants) underwent OBP measurements, HBPM, and 24-h ABPM. Using the algorithm, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for sustained hypertension and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cut-off at a specificity of 95% for ambulatory hypertension - those with office hypertension but OBP levels below the upper cut-off underwent HBPM and subsequent ABPM, if appropriate.

RESULTS

Using the original algorithm, sensitivity and PPV for sustained hypertension were 100% and 93.8%, respectively. Despite a specificity of 44.4%, NPV was 100%. These values correspond to specificity, NPV, sensitivity, and PPV for WCH, respectively. Using the modified algorithm, the diagnostic accuracy for sustained hypertension and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15).

CONCLUSION

In this sample, the original and modified algorithms are excellent at diagnosing sustained hypertension and WCH. However, the latter requires far fewer participants to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of sustained hypertension and WCH.

White-coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications

OBJECTIVES

To evaluate the prevalence of white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment.

METHODS

This prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self-blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject's insight; anxiety disorder was evaluated using the seven-question Generalized Anxiety Disorder scale (GAD-7).

RESULTS

Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of cognitive impairment.

CONCLUSIONS

WCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.

Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries

BACKGROUND

The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006-07 in 22 countries to see whether preventive cardiology had improved and if the Joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice.

METHODS

EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women </=70 years) were identified after coronary artery bypass graft or percutaneous coronary intervention, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later.

FINDINGS

3180 patients were interviewed in the first survey, 2975 in the second, and 2392 in the third. Overall, the proportion of patients who smoke has remained nearly the same (20.3% in EUROASPIRE I, 21.2% in II, and 18.2% in III; comparison of all surveys p=0.64), but the proportion of women smokers aged less than 50 years has increased. The frequency of obesity (body-mass index >/=30 kg/m(2)) increased from 25.0% in EUROASPIRE I, to 32.6% in II, and 38.0% in III (p=0.0006). The proportion of patients with raised blood pressure (>/=140/90 mm Hg in patients without diabetes or >/=130/80 mm Hg in patients with diabetes) was similar (58.1% in EUROASPIRE I, 58.3% in II, and 60.9% in III; p=0.49), whereas the proportion with raised total cholesterol (>/=4.5 mmol/L) decreased, from 94.5% in EUROASPIRE I to 76.7% in II, and 46.2% in III (p<0.0001). The frequency of self-reported diabetes mellitus increased, from 17.4%, to 20.1%, and 28.0% (p=0.004).

INTERPRETATION

These time trends show a compelling need for more effective lifestyle management of patients with coronary heart disease. Despite a substantial increase in antihypertensive and lipid-lowering drugs, blood pressure management remained unchanged, and almost half of all patients remain above the recommended lipid targets. To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.

Impact of patient-general practitioner short-messages-based interaction on the control of hypertension in a follow-up service for low-to-medium risk hypertensive patients: a randomized controlled trial

The evaluation in real-life settings of services for the follow-up and control of hypertensive patients is a complex intervention, which still needs analysis of the roles, tasks, and resources involved in the basic items: patient, healthcare professional, and the interaction between the two. To evaluate the impact of patient-general practitioner (GP) short-messages-based interaction, isolated from other items, on the degree of hypertension control in the follow-up of medium-to-low-risk patients in primary care, a randomized controlled trial has been performed: 38 GPs enrolled 285 hypertensive patients who recorded the results of self-blood-pressure (BP) monitoring, heart rate, and body weight, and completed an optional questionnaire in an identical manner over a six-month period. The telemedicine group (TmG) sent the data to a telemedicine-based system that enabled patient-GP interaction; the control group (CG) recorded the data on paper and could only deliver it to their GP personally in the routine visits. In the TmG, the results were better, but not significantly so, for: 1) degree of hypertension control, in terms of the percentage of uncontrolled hypertensives at the final visit (TmG versus CG: 31.7% versus 35.6%; p = 0.47); 2) reduction in hypertension during follow-up, comparing measurements (performed by a professional) at the initial and final visits of systolic BP (15.5 versus 11.9; p = 0.13) and diastolic BP (9.6 versus 4.4; p = 0.40); and 3) adherence to the protocol within compliance levels of interest in a real-life follow-up service: >>50% (84.8% versus 73.3%) and >>25% (92.4.8% versus 75.4%) ( p = 0.053). Other factors such as average values of self-measured systolic BP, diastolic BP and heart rate, acceptability of the protocol, and median number of consultations and hospital admissions were similar in both groups. Outcomes show that, taken alone, the patient-GP short-messages-based interaction has very little impact on the degree of hypertension control in patients with this profile. In complex interventions, to discriminate the impact of each of its components in isolation will enable us to design an efficient follow-up service, little demanding in terms of healthcare professional dedication, and optimized in other basic aspects.

Can the pressor response accompanying blood pressure measurement be limited in young, normotensive women?

BACKGROUND

A decrease in blood pressure (BP) values observed over consecutive measurements may lead to significant discrepancies, affecting individual diagnostic and therapeutic decision making. The goal of the study was to assess whether it was possible to limit or eliminate the tendency for BP values to decline in successive measurements.

METHODS

In a group of 148 normotensive women aged 21.6+/-1.5 years, two series (S1, S2) consisting of three brachial BP measurements each (I, II, and III) were performed, using an Omron 907 oscillometric manometer.

RESULTS

Systolic blood pressure (SBP) (mmHg) was higher in measurement I than in II and III, in both S1 and S2: S1-I: 114.9+/-10.5 vs. S1-II: 112.6+/-9.9, P<0.00003, vs. S1-III: 111.0+/-9.6, P<0.000001; S2-I: 111.5+/-9.8 vs. S2-II: 110.1+/-9.1 P<0.007, vs. S2-III: 110.1+/-9.2, P<0.0008. Furthermore, measurement II was higher than III in S1 (P<0.002). Similarly, diastolic blood pressure (mmHg) was higher in measurement I than in II and III, in both S1 and S2: S1-I: 68.3+/-8.4 vs. S1-II: 67.3+/-8.7, P<0.008, vs. S1-III: 65.7+/-8.7, P<0.000001; S2-I: 66.6+/-8.3 vs. S2-II: 65.8+/-8.2, P<0.04, vs. S2-III: 65.7+/-8.7, P<0.02. Measurement II was again higher than III in S1 (P<0.00003).

CONCLUSIONS

The common alerting reaction to BP measurements cannot be avoided in young, normotensive women, but it can be limited, as demonstrated by the results of BP measurements in S2. The simple procedure of automatic cuff inflation and noninvasive, oscillometric BP measurement may carry an independent pressor effect, which corrupts the accuracy of BP measurements.

Clinical implications of white-coat effect among patients attending at a lipid clinic

We evaluated clinical implications of the white-coat effect (WCE) in cardiovascular (CV) risk stratification in the primary prevention setting of a Lipid Clinic. We compared home self blood pressure measurement (SBPM) with office blood pressure (BP) readings and BP measured by a nurse before and after the visit on consecutive subjects, free of previous CV diseases, attending at a Lipid Clinic for a first visit. Additionally, we evaluated whether and to what extent the difference between these measurements affect the 10-year cardiovascular risk calculated according to current guidelines. Mean home self-measured systolic and diastolic BP values were significantly lower than physician's and nurse's readings (p=0.000). A WCE was observed in 60.3% of patients during the physician's visit, and in 33.9% and 36.6% of nurse's measurements before and after visit, respectively. Compared with computation of SBPM, inclusion in risk predictive model of systolic BP values obtained by physician and nurse (before or after visit) resulted in significantly higher calculated CV risk (p=0.000) and in a higher risk-class allocation in 16.5%, 8.5% and 9.4% of patients, respectively (p=0.000). Our findings show that among patients attending at a Lipid Clinic there is a high prevalence of WCE, which is roughly halved when nurse's BP measurements were considered. Nurse's BP measurements before or after the doctor's visit may reduce, but not eliminate at all, the clinic overestimation of BP. The WCE associated with physician's office visit carries a substantial probability of 10-year CV risk overestimation in the primary prevention setting.

The impact of perceived hypertension status on anxiety and the white coat effect

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.

Estimate of white-coat effect and arterial stiffness

OBJECTIVES

Blood pressure (BP) measured in the office is usually higher than the average ambulatory BP, a difference generally taken as an estimate of the white-coat effect. This study was designed to assess whether such a difference is associated with impairment of the conduit arterial system.

METHODS

We calculated the difference between office and average daytime peak systolic blood pressure (DeltaSBP) in 2778 hypertensive participants (1240 women) of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale cohort. Arterial stiffness was evaluated using an adjusted office pulse pressure to stroke volume ratio (PP/SV), measured at rest, which has previously been shown to predict cardiovascular outcome independent of echocardiographic left ventricular hypertrophy. Effective arterial elastance was also estimated.

RESULTS

Across quintiles of PP/SV, significant linear, positive trends were found with age, the proportion of women, plasma glucose and triglyceride levels (0.05 > P < 0.0001). Heart rate measured in the office increased mildly with quintiles of PP/SV (P < 0.05). After adjusting for age, sex, body weight and office heart rate, DeltaSBP progressively increased with increasing quintiles of PP/SV (P for trend < 0.0001), whereas stroke volume decreased, paralleling the increase in left ventricular relative wall thickness (both P < 0.0001) and left ventricular mass index (P < 0.05). The significant increase in effective arterial elastance with quintiles of PP/SV was also independent of peak systolic BP, in addition to age, sex, heart rate and body weight.

CONCLUSIONS

The difference between office BP and ambulatory BP, an estimate of the white-coat effect, is strongly associated with increased arterial stiffness, evaluated by a two-element fluid system accumulator.

Appointment-keeping behavior is not related to medication adherence in hypertensive African Americans

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.

Relative utility of home, ambulatory, and office blood pressures in the prediction of end-organ damage

BACKGROUND

Home blood pressure (HBP) monitoring plays an increasingly important role in the diagnosis and treatment of hypertension. We evaluated the independent value of HBP compared with ambulatory blood pressure (ABP) and office blood pressure (OBP) in the prediction of cardiovascular end-organ damage in normotensive subjects and untreated patients with mild hypertension.

METHODS

One hundred sixty-three subjects underwent measurements of OBP, HBP, ABP, and echocardiography. A physician using a mercury-column sphygmomanometer performed three OBP measurements. The ABP was recorded using a noninvasive ambulatory monitor (mean, 35.4 awake readings per subject). Participants took HBP readings with an automatic, oscillometric device over a 10-week period (mean, 277.9 readings per subject). The left-ventricular mass index (LVMI) was calculated from measurements obtained from two-dimensionally guided M-mode or linear tracings on echocardiography.

RESULTS

For systolic and diastolic blood pressures (SBP/DBP), the correlation coefficients of the LVMI with OBP, awake ABP, and HBP were 0.29/0.27, 0.41/0.26, and 0.47/0.35, respectively (all P < .01). In a multivariate regression analysis in which age, sex, body mass index, OBP, awake ABP, and HBP were included, only age, sex, and HBP were significant predictors of LVMI. When only the first 12 home readings were used, the superiority of HBP was no longer evident.

CONCLUSIONS

In contrast to OBP and ABP, HBP measurements, when averaged over a 10-week period, are independently related to LVMI. The HBP adds prognostic information over and above OBP and ABP in the prediction of cardiovascular end-organ damage, but this relationship appears to depend on the number of readings taken.

The circadian nuances of hypertension: a reappraisal of 24-h ambulatory blood pressure measurement in clinical practice

Ambulatory blood pressure measurement has been in use in clinical practice for nearly half a century. However, despite the benefits the technique brings to managing patients with hypertension it is much under-used in practice. The purpose of this review is to examine critically the information that can be derived from the technique and to highlight the application of this evidence in clinical practice.

The Health and Life device (HL888HA): accuracy assessment in an adult population according to the British Hypertension Society protocol

OBJECTIVE

Over the last two decades, concerns over mercury toxicity have given rise to the continuous release of new and improved automated blood pressure measurement devices as a replacement for the mercury sphygmomanometer. Out-of-office blood pressure monitoring has been shown to have various advantages, including a reduced white-coat effect and observer error, as well as better prediction of cardiovascular risk/complications. We assessed the accuracy of the Health and Life device (HL888HA) (Health and Life Co. Ltd., Taipei, Taiwan) in an adult population according to the British Hypertension Society protocol.

METHODS

Local ethics committee approval was obtained and participants were recruited from a large teaching hospital. Nine blood pressure measurements were taken from each participant, alternating between a mercury sphygmomanometer and the test device. Data from 85 participants who fulfilled the British Hypertension Society criteria were analysed according to the protocol guidelines.

RESULTS

The device achieved the highest possible grade (A/A) according to the British Hypertension Society protocol. The mean difference and SD of 0.5 (7.3) mmHg for systolic and -2.1 (7.8) mmHg for diastolic pressure, which complies with the standard of the American Association for the Advancement of Medical Instrumentation.

CONCLUSION

The Health and Life device (HL888HA) can be recommended for use in an adult population according to the criteria of the British Hypertension Society protocol.