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Arjmand B, Dehghanbanadaki H, Yoosefi M, Rezaei N, Mohammadi Fateh S, Ghodssi-Ghassemabadi R, Najjar N, Hosseinkhani S, Tayanloo-beik A, Adibi H, Farzadfar F, Larijani B, Razi F. Association of plasma acylcarnitines and amino acids with hypertension: A nationwide metabolomics study. PLoS One 2023; 18:e0279835. [PMID: 36649284 PMCID: PMC9844860 DOI: 10.1371/journal.pone.0279835] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Identification of metabolomics profile in subjects with different blood pressure, including normal blood pressure, elevated blood pressure, stage 1 hypertension, and stage 2 hypertension, would be a promising strategy to understand the pathogenesis of hypertension. Thus, we conducted this study to investigate the association of plasma acylcarnitines and amino acids with hypertension in a large Iranian population. METHODS 1200 randomly selected subjects from the national survey on the Surveillance of Risk Factors of Non-Communicable Diseases in Iran (STEPs 2016) were divided into four groups based on the ACC/AHA hypertension criteria: normal blood pressure (n = 293), elevated blood pressure (n = 135), stage 1 hypertension (n = 325), and stage 2 hypertension (n = 447). Plasma concentrations of 30 acylcarnitines and 20 amino acids were measured using a targeted approach with flow-injection tandem mass spectrometry. Univariate and multivariate logistic regression analysis was applied to estimate the association between metabolites level and the risk of hypertension. Age, sex, BMI, total cholesterol, triglyceride, HDL cholesterol, fasting plasma glucose, use of oral glucose-lowering drugs, statins, and antihypertensive drugs were adjusted in regression analysis. RESULTS Of 50 metabolites, 34 were associated with an increased likelihood of stage 2 hypertension and 5 with a decreased likelihood of stage 2 hypertension. After full adjustment for potential confounders, 5 metabolites were still significant risk markers for stage 2 hypertension including C0 (OR = 0.75; 95%CI: 0.63, 0.90), C12 (OR = 1.18; 95%CI: 1.00, 1.40), C14:1 (OR = 1.20; 95%CI: 1.01, 1.42), C14:2 (OR = 1.19; 95%CI: 1.01, 1.41), and glycine (OR = 0.81; 95%CI: 0.68, 0.96). An index that included glycine and serine also showed significant predictive value for stage 2 hypertension after full adjustment (OR = 0.86; 95%CI: 0.75, 0.98). CONCLUSIONS Five metabolites were identified as potentially valuable predictors of stage 2 hypertension.
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Affiliation(s)
- Babak Arjmand
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran, Iran
| | - Hojat Dehghanbanadaki
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Yoosefi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Mohammadi Fateh
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Niloufar Najjar
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Hosseinkhani
- Department of Clinical Biochemistry, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Tayanloo-beik
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Adibi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farideh Razi
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- * E-mail:
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Zhang M, Zhu Y, Wang J, Li Y, Hua Z. Association between acupuncture and grade 1 hypertension: A systematic review and meta-analysis. Complement Ther Clin Pract 2022; 49:101649. [DOI: 10.1016/j.ctcp.2022.101649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/23/2022] [Accepted: 07/24/2022] [Indexed: 01/10/2023]
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Adler TE, Coovadia Y, Cirone D, Khemakhem ML, Usselman CW. Device-guided slow breathing reduces blood pressure and sympathetic activity in young normotensive individuals of both sexes. J Appl Physiol (1985) 2019; 127:1042-1049. [DOI: 10.1152/japplphysiol.00442.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Slow breathing (SLOWB) is recommended for use as an adjuvant treatment for hypertension. However, the extent to which blood pressure (BP) responses to SLOWB differ between men and women are not well-established. Therefore, we tested the hypothesis that an acute bout of SLOWB would induce larger decreases in BP in males than in females, given that males typically have higher resting BP. We also examined autonomic contributors to reduced BP during SLOWB; that is, muscle sympathetic nerve activity and spontaneous cardiovagal (sequence method) and vascular sympathetic baroreflex sensitivity. We tested normotensive females ( n = 10, age: 22 ± 2 y, body mass index: 22 ± 2 kg/m2) and males ( n = 12, age: 23 ± 3 y, body mass index: 26 ± 4 kg/m2). Subjects were tested at baseline and during the last 5 min of a 15-min RESPeRATE-guided SLOWB session. Overall, SLOWB reduced systolic BP by 3.2 ± 0.8 mmHg (main effect, P < 0.01). Females had lower systolic BP (main effect, P = 0.02); we observed no interaction between sex and SLOWB. SLOWB also reduced muscle sympathetic nerve activity burst incidence by −5.0 ± 1.4 bursts/100 heartbeats (main effect, P < 0.01). Although females tended to have lower burst incidence (main effect, P = 0.1), there was no interaction between sex and SLOWB. Cardiovagal baroreflex sensitivity improved during SLOWB (21.0 vs. 36.0 ms/mmHg, P = 0.03) with no effect of sex. Despite lower overall BP in females, our data support a lack of basement effect on SLOWB-induced reductions in BP, as SLOWB was equally effective in reducing BP in males and females. Our findings support the efficacy of the RESPeRATE device for reducing BP in both sexes, even in young, normotensive individuals. NEW & NOTEWORTHY We provide support for the effectiveness of device-guided slow breathing for blood pressure reduction in young normotensive women and men. Despite having lower baseline blood pressure and sympathetic nerve activity, women experienced equivalent reductions in both measures in response to RESPeRATE-guided slow breathing as men. Thus, slow breathing appears to be effective in young healthy normotensive individuals of both sexes and may be an ideal preventative therapy against future hypertension.
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Affiliation(s)
- Tessa E. Adler
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Quebec, Canada
| | - Yasmine Coovadia
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Quebec, Canada
| | - Domenica Cirone
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Quebec, Canada
| | - Maha L. Khemakhem
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Quebec, Canada
| | - Charlotte W. Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Quebec, Canada
- McGill Research Centre for Physical Activity and Health, McGill University, Quebec, Canada
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Goh VJ, Le TT, Bryant J, Wong JI, Su B, Lee CH, Pua CJ, Sim CPY, Ang B, Aw TC, Cook SA, Chin CWL. Novel Index of Maladaptive Myocardial Remodeling in Hypertension. Circ Cardiovasc Imaging 2017; 10:e006840. [PMID: 28847911 PMCID: PMC5617557 DOI: 10.1161/circimaging.117.006840] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/26/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hypertensive left ventricular hypertrophy (HTN-LVH) is a leading cause of heart failure. Conventional patterns of cardiac geometry do not adequately risk-stratify patients with HTN-LVH. Using cardiovascular magnetic resonance, we developed a novel Remodeling Index (RI) that was designed to detect an exaggerated hypertrophic response to hypertension and tested its potential to risk-stratify hypertensive patients. METHODS AND RESULTS The RI was derived using LaPlace's Law (), and normal RI ranges were established in 180 healthy volunteers. The utility of the RI was examined in 256 asymptomatic hypertensive patients and 10 patients with heart failure with preserved ejection fraction. Hypertensive patients underwent multimodal cardiac assessment: contrast-enhanced cardiovascular magnetic resonance, echocardiograms, 24-hour blood pressure monitoring, and cardiac biomarkers (high-sensitivity cardiac troponins, NT-proBNP [N-terminal pro-B-type natriuretic peptide], and galectin-3). Blood pressure accounted for only 20% of the variance observed in LV mass. Although there was no association between blood pressure and myocardial fibrosis, LV mass was independently associated with fibrosis. Compared with hypertensive patients without LVH (n=191; 74.6%) and those with HTN-LVH and normal RI (n=50; 19.5%), patients with HTN-LVH and low RI (HTN-LVH/low RI; n=15, 5.9%) had an amplified myocardial response: elevated indexed LV masses (83±24 g/m2), more fibrosis (73%), and higher biomarkers of myocardial injury and dysfunction (P<0.05 for all). RI was similar in HTN-LVH/low RI and heart failure with preserved ejection fraction (4.1 [3.4-4.5] versus 3.7 [3.4-4.0], respectively; P=0.15). CONCLUSIONS We suggest that RI provides an approach for stratifying hypertensive patients and is suitable for testing in other disease cohorts to assess its clinical utility. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT02670031.
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Affiliation(s)
- Vera J Goh
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Thu-Thao Le
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Jennifer Bryant
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Jia Ing Wong
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Boyang Su
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Chi-Hang Lee
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Chee Jian Pua
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Chloe P Y Sim
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Briana Ang
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Tar Choon Aw
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Stuart A Cook
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.)
| | - Calvin W L Chin
- From the Department of Internal Medicine, Singapore General Hospital, Singapore (V.J.G.); Department of Cardiology, National Heart Centre Singapore (T.-T.L., J.B., J.I.W., B.S., C.J.P., C.P.Y.S., B.A., S.A.C., C.W.L.C.); National University Heart Centre Singapore (C.-H.L.); Duke-NUS Medical School, Singapore, Singapore (S.A.C., C.W.L.C.); and Depatrment of Laboratory Medicine, Changi General Hospital, Singapore (T.C.A.).
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Lacruz ME, Kluttig A, Kuss O, Tiller D, Medenwald D, Nuding S, Greiser KH, Frantz S, Haerting J. Short-term blood pressure variability - variation between arm side, body position and successive measurements: a population-based cohort study. BMC Cardiovasc Disord 2017; 17:31. [PMID: 28100183 PMCID: PMC5241970 DOI: 10.1186/s12872-017-0468-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/06/2017] [Indexed: 11/18/2022] Open
Abstract
Background Precise blood pressure (BP) measurements are central for the diagnosis of hypertension in clinical and epidemiological studies. The purpose of this study was to quantify the variability in BP associated with arm side, body position, and successive measurements in the setting of a population-based observational study. Additionally, we aimed to evaluate the influence of different measurement conditions on prevalence of hypertension. Methods The sample included 967 men and 812 women aged 45 to 83 years at baseline. BP was measured according to a standardized protocol with oscillometric devices including three sitting measurements at left arm, one simultaneous supine measurement at both arms, and four supine measurements at the arm with the higher BP. Hypertension was defined as systolic BP (SBP) ≥140 mmHg and/or diastolic BP (DBP) ≥90 mmHg. Variability in SBP and DBP were analysed with sex-stratified linear covariance pattern models. Results We found that overall, no mean BP differences were measured according to arm-side, but substantial higher DBP and for men also higher SBP was observed in sitting than in supine position and there was a clear BP decline by consecutive measurement. Accordingly, the prevalence of hypertension depends strongly on the number and scheme of BP measurements taken to calculate the index values. Conclusions Thus, BP measurements should only be compared between studies applying equal measurement conditions and index calculation. Moreover, the first BP measurement should not be used to define hypertension since it overestimates BP. The mean of second and third measurement offers the advantage of better reproducibility over single measurements. Electronic supplementary material The online version of this article (doi:10.1186/s12872-017-0468-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Elena Lacruz
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle Saale, Germany.
| | - Alexander Kluttig
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle Saale, Germany
| | - Oliver Kuss
- Centre for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Tiller
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle Saale, Germany
| | - Daniel Medenwald
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle Saale, Germany
| | - Sebastian Nuding
- Department of Medicine III, Martin-Luther University Halle-Wittenberg, Halle Saale, Germany
| | - Karin Halina Greiser
- German Cancer Research Centre, Division of Cancer Epidemiology, Heidelberg, Germany
| | - Stefan Frantz
- Department of Medicine III, Martin-Luther University Halle-Wittenberg, Halle Saale, Germany
| | - Johannes Haerting
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle Saale, Germany
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Zhao XF, Hu HT, Li JS, Shang HC, Zheng HZ, Niu JF, Shi XM, Wang S. Is Acupuncture Effective for Hypertension? A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0127019. [PMID: 26207806 PMCID: PMC4514875 DOI: 10.1371/journal.pone.0127019] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 04/10/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the efficacy of acupuncture for hypertension. METHOD Seven electronic databases were searched on April 13, 2014 to include eligible randomized controlled trials (RCTs). Data were extracted and risk of bias was assessed. Subgroup analyses and meta- analysis were performed. RESULTS 23 RCTs involving 1788 patients were included. Most trials had an unclear risk of bias regarding allocation concealment, blinding, incomplete outcome data and selective reporting. Compared with sham acupuncture plus medication, a meta-analysis of 2 trials revealed that acupuncture as an adjunct to medication was more effective on systolic (SBP) and diastolic (DBP) blood pressure change magnitude (n=170, SBP: mean difference (MD)= -7.47,95% confidence intervals (CI):-10.43 to -4.51,I2 =0%; DBP: -4.22,-6.26 to -2.18, 0%).A subgroup analysis of 4 trials also showed acupuncture combined with medication was superior to medication on efficacy rate (n=230, odds ratio (OR)=4.19, 95%CI: 1.65 to 10.67, I2 =0%). By contrast, compared with medication, acupuncture alone showed no significant effect on SBP /DBP after intervention and efficacy rate in the subgroup analysis. (7 trials with 510 patients, SBP: MD=-0.56, 95%CI:-3.02 to 1.89,I2 =60%; DBP: -1.01,-2.26 to 0.24, 23%; efficacy rate: 10 trials with 963 patients, OR=1.14, 95% CI: 0.70 to 1.85, I2 =54%).Adverse events were inadequately reported in most RCTs. CONCLUSION Our review provided evidence of acupuncture as an adjunctive therapy to medication for treating hypertension, while the evidence for acupuncture alone lowing BP is insufficient. The safety of acupuncture is uncertain due to the inadequate reporting of it. However, the current evidence might not be sufficiently robust against methodological flaws and significant heterogeneity of the included RCTs. Larger high-quality trials are required.
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Affiliation(s)
- Xiao-Feng Zhao
- Institute of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Key Laboratory of Acupuncture of Tianjin, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Han-Tong Hu
- Institute of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jia-Shen Li
- Institute of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hong-Cai Shang
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hai-Zhen Zheng
- Institute of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jian-Fei Niu
- Institute of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xue-Ming Shi
- Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shu Wang
- Department of Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Key Laboratory of Acupuncture of Tianjin, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Giorgini P, Weder AB, Jackson EA, Brook RD. A review of blood pressure measurement protocols among hypertension trials: implications for “evidence-based” clinical practice. ACTA ACUST UNITED AC 2014; 8:670-6. [DOI: 10.1016/j.jash.2014.07.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/03/2014] [Accepted: 07/03/2014] [Indexed: 11/17/2022]
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Akindele AJ, Iyamu EA, Dutt P, Satti NK, Adeyemi OO. Ameliorative Effect of Hydroethanolic Leaf Extract of Byrsocarpus coccineus in Alcohol- and Sucrose-Induced Hypertension in Rats. J Tradit Complement Med 2014; 4:177-88. [PMID: 25161923 PMCID: PMC4142456 DOI: 10.4103/2225-4110.129562] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Hypertension remains a major health problem worldwide considering the prevalence of morbidity and mortality. Plants remain a reliable source of efficacious and better tolerated drugs and botanicals. This study was designed to investigate the effect of the chemo-profiled hydroethanolic leaf extract of Byrsocarpus coccineus in ethanol- and sucrose-induced hypertension. Groups of rats were treated orally (p.o.) with distilled water (10 ml/kg), ethanol (35%; 3 g/kg), sucrose (5-7%), and B. coccineus (100, 200, and 400 mg/kg), and nifedipine together with ethanol and sucrose separately for 8 weeks. At the end of the treatment period, blood pressure and heart rate of rats were determined. Blood was collected for serum biochemical parameters and lipid profile assessment, and the liver, aorta, kidney, and heart were harvested for estimation of in vivo antioxidants and malondialdehyde (MDA). Results obtained in this study showed that B. coccineus at the various doses administered reduced the systolic, diastolic, and arterial blood pressure elevated by ethanol and sucrose. Also, the extract reversed the reduction in catalase (CAT), reduced glutathione (GSH), glutathione peroxidase (GPx), and superoxide dismutase (SOD) induced by ethanol and sucrose. The level of MDA was reduced compared to the ethanol- and sucrose-induced hypertensive group. With respect to lipid profile, administration of B. coccineus at the various doses reduced the levels of triglycerides, low-density lipoprotein (LDL), cholesterol, and atherogenic indices, compared to the ethanol and sucrose groups. In conclusion the hydroethanolic leaf extract of B. coccineus exerted significant antihypertensive effect and this is probably related to the antioxidant property and improvement of lipid profile observed in this study.
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Affiliation(s)
- Abidemi J. Akindele
- Department of Pharmacology, Therapeutics and Toxicology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, P. M. B. 12003 Lagos, Nigeria
| | - Endurance A. Iyamu
- Department of Pharmacology, Therapeutics and Toxicology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, P. M. B. 12003 Lagos, Nigeria
| | - Prabhu Dutt
- Natural Products Chemistry (Plants) Division, Indian Institute of Integrative Medicine (Council of Scientific and Industrial Research), Canal Road, Jammu - 180001, India
| | - Naresh K. Satti
- Natural Products Chemistry (Plants) Division, Indian Institute of Integrative Medicine (Council of Scientific and Industrial Research), Canal Road, Jammu - 180001, India
| | - Olufunmilayo O. Adeyemi
- Department of Pharmacology, Therapeutics and Toxicology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, P. M. B. 12003 Lagos, Nigeria
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Félez-Carrobé E, Sagarra-Tió M, Romero A, Rubio M, Planas L, Pérez-Lucena MJ, Baiget M, Cabistañ C, Félez J. Nurse-driven training courses: impact on implementation of ambulatory blood pressure monitoring. Open Nurs J 2013; 7:35-40. [PMID: 23750185 PMCID: PMC3636488 DOI: 10.2174/1874434601307010035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 02/07/2013] [Accepted: 02/07/2013] [Indexed: 11/28/2022] Open
Abstract
Background: Ambulatory blood pressure monitoring (ABPM) predicts cardiovascular risk and identifies white-coat and masked hypertension, efficacy of treatment and the circadian cycle of hypertensive patients. Objective: To analyze the effectiveness of ABPM implementation thoughtout a nurse-driven training program. Materials and Methodology: Twenty eight professionals were involved in the study carried out in the primary care center of the metropolitan area of Barcelona that serves 34,289 inhabitants. The ABPM implementation program was driven by two nurses that held four education sessions. After a 2-year follow-up period, we assessed the outcome of attendance at the educational sessions. First, we evaluated whether the program increased the number of orders of ABPM. Second, we used a survey to evaluate to what extent the input of our educational sessions was understood by attendants. Third, we analyzed the effect ABPM results had on the treatment of patients with a bad control of their hypertension. Results: After the training sessions we found a 6-fold increase in the number of patients undergoing ABPM. We analyzed 204 hypertensive individuals: 41% dippers, 34% were non-dippers, 20% were risers and 5% were extremely dippers. According to our survey, 100% of attendants had a good practice regarding ABPM management. However only 27% of riser patients were studied with a second ABPM. Conclusions: Specific training processes are needed for implementation of ABPM and an even more concentrated effort should be focused on training in the correct interpretation of ABPM results.
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Affiliation(s)
- Estel Félez-Carrobé
- ABS Canaletes, Institut Català de la Salut. Cerdanyola del Vallès and Barcelona ; ABS Guinardó, Institut Català de la Salut. Cerdanyola del Vallès and Barcelona
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10
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Minor DS, Butler KR, Artman KL, Adair C, Wang W, McNair V, Wofford MR, Griswold M. Evaluation of blood pressure measurement and agreement in an academic health sciences center. J Clin Hypertens (Greenwich) 2012; 14:222-7. [PMID: 22458743 DOI: 10.1111/j.1751-7176.2012.00599.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The authors assessed the process of blood pressure (BP) measurement and level of adherence to recommended procedures at representative sites throughout a large academic health sciences center. A casual observer assessed the setting and observed the process, noting the equipment, technique, and BP recorded by site personnel. A trained observer then repeated the patient's BP measurement following American Heart Association recommendations. Significant biases were observed between measurements by site personnel and the trained observer. Site personnel reported on average an increased systolic BP (SBP) of 5.66 mm Hg (95% confidence interval [CI], 3.09-8.23; P<.001) and a decreased diastolic BP (DBP) of -2.96 mm Hg (95% CI, -5.05 to -0.87; P=.005). Overall, 41% of patients had a ≥10-mm Hg difference in SBP between measurements. Similarly, 54% had differences of ≥5 mm Hg in DBP between measurements. Inaccurate BP measurement and poor technique may lead to misclassification, misdiagnosis, and inappropriate medical decisions. Concordance of measured SBP between our site personnel and trained observer was less than optimal. Several areas for improvement were identified. Routine calibration and use of system-wide standardized equipment, establishment of BP measurement protocols, and periodic technique and equipment recertification can be addressed in future quality initiatives.
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Affiliation(s)
- Deborah S Minor
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA.
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11
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Boll LFC, Irigoyen MC, Goldmeier S. Diretrizes brasileiras de hipertensão arterial: realidade da enfermagem em hospital especializado. ACTA PAUL ENFERM 2012. [DOI: 10.1590/s0103-21002012000500020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o conhecimento sobre a técnica da verificação da pressão arterial nos profissionais de enfermagem em uma instituição de saúde. Identificar a relação entre a qualificação profissional e o desenvolvimento correto da técnica. MÉTODOS: O pesquisador aplicou um questionário aos profissionais de enfermagem durante a verificação da pressão arterial dos pacientes, questões estas relativas às V Diretrizes Brasileiras de Hipertensão Arterial. RESULTADOS: Dos profissionais de enfermagem, técnicos e auxiliares, 8,41 %, atingiram o ponto de corte estipulado como adequado de acertos (80%). Houve relação direta entre a qualificação profissional e a quantidade de acertos. CONCLUSÃO: As V Diretrizes Brasileiras de Hipertensão Arterial não são seguidas em sua plenitude pelos profissionais de enfermagem. A ampla divulgação das diretrizes, a implementação de programas de capacitação e a monitoração da técnica devem ser incentivadas.
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12
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Mujtaba SH, Ashraf T, Anjum Q. Improving General Practitioners’ Knowledge Regarding Blood Pressure Measurement in Selected Cities of Pakistan Through Workshop. Asia Pac J Public Health 2011; 25:84-91. [DOI: 10.1177/1010539511415662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to evaluate enhancement in the knowledge of general practitioners (GPs), from the urban cities in the province of Sindh, Pakistan, regarding blood pressure measurement through workshop. This was a quasi-experimental study that involved GPs from 5 cities of Sindh province, Pakistan. The GPs were required to complete a pretested self-administered questionnaire before and after the workshop session. The questionnaire included few demographic variables and 17 questions based on the American Heart Association recommendations. The mean pretest and posttest scores were compared using Student’s t test. A total of 350 GPs returned completed questionnaires, with a preponderance of males (n = 264, 75.4%) than females (n = 86, 24.6%). The mean correct responses increased significantly after the workshop session from 8 ± 2.1 to 14 ± 2.5 ( P = .01). The knowledge of GPs was almost doubled after the workshop and was significantly different for variables such as qualification, affiliation with teaching hospital, and number of years of practice ( P = .001). This survey, a representation of GPs from the Sindh province, indicated a significant doubling in knowledge after the workshop, proving that continuing medical education sessions play an important role in increasing awareness and staying updated.
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Affiliation(s)
| | - Tariq Ashraf
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Qudsia Anjum
- International Medical Center, Rabigh, Saudi Arabia
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13
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Chakraborty BS. Clinical trials of antihypertensives: Nature of control and design. Indian J Pharmacol 2011; 43:13-7. [PMID: 21455414 PMCID: PMC3062112 DOI: 10.4103/0253-7613.75659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 08/21/2010] [Accepted: 10/21/2010] [Indexed: 01/13/2023] Open
Abstract
This paper reviews the critical issues in the control and design of antihypertension (anti-HT) clinical trials. The international guidelines and current clinical and biostatistical practices were reviewed for relevant clinical, design, end-point assessments and regulatory issues. The results are grouped mainly into ethical, protocol and assessment issues. Ethical issues arise as placebo-controlled trials (PCTs) for HT-lowering agents in patients with moderate to severe HT are undertaken. Patients with organ damage due to HT should not be included in long-term PCT. Active-control trials, however, are suitable for all randomized subsets of patients, including men and women, and different ethnic and age groups. Severity subgroups must be studied separately with consideration to specific study design. Mortality and morbidity outcome studies are not required in anti-HT trials except when significant mortality and cardiovascular morbidity are suspected. Generally, changes in both systolic and diastolic blood pressures (BP) at the end of the dosing interval from the baseline are compared between the active and the control arms as the primary endpoint of anti-HT effect. Onset of the anti-HT effect can be studied as the secondary endpoint. For maintenance of efficacy, long-term studies of ≥6 months need to be undertaken. Error-free measurement of BP is a serious issue as spontaneous changes in BP are large and active drug effect on diastolic BP is often small. Placebo-controlled short-term studies (of ~12 weeks) for dose-response and titration are very useful. Safety studies must be very vigilant on hypotension, orthostatic hypotension and effects on heart. In dose-response studies, at least three doses in addition to placebo should be used to well characterize the benefits and side-effects.
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14
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Wan Y, Heneghan C, Stevens R, McManus RJ, Ward A, Perera R, Thompson M, Tarassenko L, Mant D. Determining which automatic digital blood pressure device performs adequately: a systematic review. J Hum Hypertens 2010; 24:431-8. [PMID: 20376077 PMCID: PMC2897978 DOI: 10.1038/jhh.2010.37] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study is to systematically examine the proportion of accurate readings attained by automatic digital blood pressure (BP) devices in published validation studies. We included studies of automatic digital BP devices using recognized protocols. We summarized the data as mean and s.d. of differences between measured and observed BP, and proportion of measurements within 5 mm Hg. We included 79 articles (10 783 participants) reporting 113 studies from 22 different countries. Overall, 25/31 (81%), 37/41 (90%) and 34/35 (97%) devices passed the relevant protocols [BHS, AAMI and ESH international protocol (ESH-IP), respectively]. For devices that passed the BHS protocol, the proportion of measured values within 5 mm Hg of the observed value ranged from 60 to 86% (AAMI protocol 47–94% and ESH-IP 54–89%). The results for the same device varied significantly when a different protocol was used (Omron HEM-907 80% of readings were within 5 mm Hg using the AAMI protocol compared with 62% with the ESH-IP). Even devices with a mean difference of zero show high variation: a device with 74% of BP measurements within 5 mm Hg would require six further BP measurements to reduce variation to 95% of readings within 5 mm Hg. Current protocols for validating BP monitors give no guarantee of accuracy in clinical practice. Devices may pass even the most rigorous protocol with as few as 60% of readings within 5 mm Hg of the observed value. Multiple readings are essential to provide clinicians and patients with accurate information on which to base diagnostic and treatment decisions.
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Affiliation(s)
- Y Wan
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
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15
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Balestrieri E, Rapuano S. Calibration of Automated Non Invasive Blood Pressure Measurement Devices. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/978-3-642-05167-8_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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16
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Validation of the Andon KD-391 semiautomated blood pressure monitor in adults according to the International Protocol. Blood Press Monit 2009; 14:181-4. [PMID: 19512888 DOI: 10.1097/mbp.0b013e32832db4c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Accurate blood pressure measurement is important for both the patients and the health service in appropriate treatment and estimation of clinical risk. Few automated devices have been shown to be accurate when compared with mercury sphygmomanometer. This study presents the validation results of the Andon KD-391 semiautomated blood pressure monitor according to the International Protocol of the European Society of Hypertension (ESH) in an adult population. METHODS Sequential measurements of systolic and diastolic blood pressures were obtained in 33 participants who fulfilled the requirements of the International Protocol using the mercury sphygmomanometer (two observers) and the test device (one supervisor). According to the ESH validation protocol, 99 couples of test device and reference blood pressure measurements were obtained during the two phases of the study (three pairs for each of the 33 participants). RESULTS In phase 1, the Andon KD-391 device produced 29, 38 and 44 measurements for systolic blood pressure and 28, 39 and 43 for diastolic blood pressure falling within the zones 5, 10 and 15 mmHg, respectively. The test device also passed phase 2 of the validation study with a mean (+/-SD) device-observer difference of -0.17+/-7.07 mmHg for systolic and -1.01+/-5.95 mmHg for diastolic blood pressure. CONCLUSION According to the results of the validation study on the basis of the ESH International Protocol, the Andon KD-391 can be recommended for clinical use in an adult population.
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Chiolero A, Paccaud F, Bovet P. Upward Hypertension Trends: Changes in Blood Pressure or in Antihypertensive Treatment? Hypertension 2009; 53:e22; author reply e23. [DOI: 10.1161/hypertensionaha.108.126870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arnaud Chiolero
- Institute of Social and Preventive Medicine, University Hospital Center, and University of Lausanne, Lausanne, Switzerland, and, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Fred Paccaud
- Institute of Social and Preventive Medicine, University Hospital Center, and University of Lausanne, Lausanne, Switzerland
| | - Pascal Bovet
- Institute of Social and Preventive Medicine, University Hospital Center, and University of Lausanne, Lausanne, Switzerland
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Chavanu K, Merkel J, Quan AM. Role of ambulatory blood pressure monitoring in the management of hypertension. Am J Health Syst Pharm 2008; 65:209-18. [PMID: 18216005 DOI: 10.2146/ajhp060663] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Chiolero A, Gervasoni JP, Rwebogora A, Balampama M, Paccaud F, Bovet P. Difference in Blood Pressure Readings with Mercury and Automated Devices: Impact on Hypertension Prevalence Estimates in Dar es Salaam, Tanzania. Eur J Epidemiol 2006; 21:427-33. [PMID: 16826452 DOI: 10.1007/s10654-006-9015-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES (1) To compare blood pressure (BP) readings with an automated arm cuff oscillometric device (AutoBP) to readings with a mercury sphygmomanometer (HgBP) and (2) to evaluate the impact on the prevalence of hypertension (HBP) in a population-based survey. METHODS (1) In a convenience sample ("Comparison Study"), we measured BP with both AutoBP (Visomat OZ2) and HgBP and we modeled BP difference (DeltaBP = HgBP-AutoBP) with multiple regression analysis. (2) Using DeltaBP, we calculated HgBP in a survey previously conducted in Dar es Salaam ("Population Survey") in which BP was measured with the automatic device Visomat OZ2 and we compared the prevalence of HBP (> or =140/90 mmHg or treatment). RESULTS In the Comparison Study (404 subjects aged 25-64), systolic/diastolic BP was higher by 4.4/4.7 mmHg (SE: 0.4/0.3) with HgBP than AutoBP. The prevalence of HBP was 42% with HgBP and 36% with AutoBP (relative difference of 14%). DeltaBP was associated with age, BP and arm circumference. In the Population Survey (9.254 subjects aged 25-64), the prevalence of HBP was 17% with calculated HgBP and 14% with AutoBP (relative difference of 20%). CONCLUSION A small systematic bias in BP readings between two different devices had large impact on hypertension prevalence estimates. This suggests that automated devices used in epidemiological studies should be validated with particular care.
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Affiliation(s)
- Arnaud Chiolero
- Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
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Franco G. Agreement of medical decisions in occupational health as a quality requirement. Int Arch Occup Environ Health 2006; 79:607-11. [PMID: 16450158 DOI: 10.1007/s00420-006-0084-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Accepted: 01/03/2006] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Workers' medical examination by the occupational physician (OPs) is a decision-making process whose output consists of a variety of evaluations, including assessment of fitness for work. The medical literature reports that there is no complete agreement among OPs assessing the same workers, evidencing a critical aspect of professional performance. This study aims at evaluating the inter-individual variability of medical decisions by different occupational physicians. METHODS Four specialists in occupational medicine participated in the study. Each specialist examined 100 records of subjects with different medical conditions selected from about 2,500 health care workers. Each physician completed a form including the following items: assessment of fitness for work, advice to workers, need of further investigations, report of occupational disease, recommendation for the general practitioner. To assess the inter-individual variability the percent agreement and the agreement strength or Cohen's kappa were measured. RESULTS The study shows a variable agreement in the assessment of fitness for work among different professionals, with percent agreement ranging from 58% for the whole group to an average of 77% for physicians' pairs. By taking into account the variability expected by chance, the agreement ranged from fair to substantial. The agreement of other decisions (workers' advice, referral to other specialists, request of further investigation, report of occupational disease, recommendation for the general practitioner) was more variable. CONCLUSION The study shows that an inter-individual variability exists for some decisions taken by OPs. According to the need to continuously improve professional practice, in the absence of qualitative standards based on the outcome, reduction of inter-individual variability that should be considered as a quality requirement of the performance of the occupational physician.
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Affiliation(s)
- Giuliano Franco
- Azienda Ospedaliera-Universitaria Policlinico di Modena, Università di Modena e Reggio Emilia, Largo del Pozzo, 71, 41100, Modena, Italy.
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