Hypertensive Blood Pressure Levels Research Articles

Hyperuricemia during Pregnancy Leads to a Preeclampsia-Like Phenotype in Mice.

Hyperuricemia is a common feature in pregnancies compromised by pre-eclampsia, a pregnancy disease characterized by hypertension and proteinuria. The role of uric acid in the pathogenesis of pre-eclampsia remains largely unclear. The aim of this study was to investigate the effect of elevated uric acid serum levels during pregnancy on maternal blood pressure and neonatal outcome using two different murine knockout models. Non-pregnant liver-specific GLUT9 knockout (LG9KO) mice showed elevated uric acid serum concentrations but no hypertensive blood pressure levels. During pregnancy, however, blood pressure levels of these animals increased in the second and third trimester, and circadian blood pressure dipping was severely altered when compared to non-pregnant LG9KO mice. The impact of hyperuricemia on fetal development was investigated using a systemic GLUT9 knockout (G9KO) mouse model. Fetal hyperuricemia caused distinctive renal tissue injuries and, subsequently an impaired neonatal growth pattern. These findings provide strong evidence that hyperuricemia plays a major role in the pathogenesis of hypertensive pregnancy disorders such as pre-eclampsia. These novel insights may enable the development of preventive and therapeutic strategies for hyperuricemia-related diseases.

Obstructive sleep apnea during REM sleep: effects on morning and evening blood pressure.

Obstructive sleep apnea (OSA) is linked to the emergence and progression of cardiovascular complications including hypertension, stroke, arrhythmias, coronary artery disease, and heart failure. Epidemiological studies have reported that hypertension is associated with respiratory events during REM sleep. We examined the relationship between respiratory events during REM and morning and evening hypertensive blood pressure (BP) levels in a clinical sleep population. This study included data from in-laboratory diagnostic polysomnographic studies (n = 797) from adults attending for investigation of OSA. Hypertensive BP levels were defined using BP measurements taken in the evening before and morning after polysomnography, and the use of antihypertensive medication. Regression modeling was undertaken to examine the probability of evening and morning hypertensive BP levels according to REM apnea-hypopnea index (AHI), NREM AHI, gender, age, body mass index (BMI), alcohol use, total sleep time (TST), sleep time SpO2 <90%, and smoking status. The probability of morning hypertensive BP levels was significantly independently associated with age (p < .001), BMI (p < .001), and REM AHI (p < .001). No significant effect was found for the male gender, NREM AHI, alcohol use, TST, sleep time SpO2 <90%, or smoking (p > .05 for all). The probability of evening hypertensive BP levels was only significantly associated with age (p < .001), male gender (p = .012), BMI (p < .001), and TST (p = .032). Respiratory events during REM sleep are significantly associated with morning hypertensive BP levels. Future research is needed to determine whether treatment of these events can prevent or reverse morning hypertensive BP levels.

Blood pressure control in the general and high risk populations, longitudinal trends

Abstract Introduction Despite better control of high blood pressure (BP) in the general as well as high cardiovascular (CV) risk populations as a factor contributing to the decrease in CV mortality since 1990, the targets set by the guidelines may not have been reached. Purpose We analysed longitudinal trends in BP control in the general and high risk populations, to assess implementation of guidelines and to identify subpopulations with still unsatisfactory BP control. Methods Analysis of seven independent surveys of the general population (Czech MONICA and post-MONICA studies, 1985–2017) and five independent surveys of patients with stable manifest coronary heart disease (CHD) 1995–2017 (Czech samples of the EUROASPIRE I-V surveys). Results A total of 15 000 persons (Czech MONICA) and 2 098 patients (Czech EUROASPIRE) were investigated. In the 1985–2017 period, mean systolic BP decreased in the general population (MONICA) from 134 to 128 mmHg (p&amp;lt;0.001) and diastolic BP from 84 to 82.5 mmHg (p&amp;lt;0.01), hypertensive levels of BP (&amp;gt;140/90mmHg) were found in 45% in 1995 but only in 27.5% in 2017, and the prevalence of uncontrolled severe hypertension (BP&amp;gt;180/110 mmHg) decreased from 3 to 1%. The proportion of properly controlled hypertension increased from 13.2 to 53% (p&amp;lt;0.0001). In the 1995–2017 surveys of the high-risk population (EUROASPIRE) systolic BP decreased from 144.1 to 135.5 mmHg (p&amp;lt;0.001), diastolic BP from 87.5to 83.5mmHg (p&amp;lt;0.01), higher than recommended BP (&amp;gt;140/90mmHg, &amp;gt;140/85mmHg in diabetics) was found in 66.2% in 1995, still present as much as in 54.4% in 2017. Proportion of patients with very high BP (BP&amp;gt;180/110 mmHg) decreased from 18.4 to 1% only. Drugs with a potentially antihypertensive effect were used in 79.9 and 95.3% of patients in 1995 and 2017, respectively (p&amp;lt;0.0001). Population BP levels ceased to decline since 2000/01 survey, in the CHD population since the 2012/13 survey. This is obviously due to considerable increase in prevalence of obesity, and an increasing prevalence of diabetes, both in the general and high-risk populations. The more intensive medical high BP treatment seems to have a beneficial effect on hypertension control, even more in the general than in the high risk population. Conclusions The recent trend in BP levels, both in the general and high-risk populations, are far from satisfactory, with the main causative factor suggested to be the increasing prevalence of obesity and diabetes. While there has been progress in hypertension control, more in the general nad limited in high-risk population, truly effective BP control may be illusory without comprehensive CV risk factor control. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Agency for Medical Research, Ministry of Health of the Czech Republic

Can respiratory muscle training change the blood pressure levels in hypertension? A systematic review with meta-analysis.

The aim was to systematically review randomized controlled trials investigating the effects of respiratory training on blood pressure control in hypertensive individuals. Systematic review with meta-analysis was coducted following the guidelines from PRISMA statement. Searches for randomized controlled trials were performed in four electronic databases (PubMed, Cochrane Library, SCOPUS, and PEDro). Studies were included if they were randomized controlled trialsthat examined the impact of respiratory training on blood pressure of individuals with systemic arterial hypertension and the patients had no other associated disease. Eight studies were included for final analysis (total of 270 participants; 18-85years) and presented an average score of 6.25 in the PEDro scale, being considered of high methodological quality. The meta-analysis showed a reduction in systolic and diastolic blood pressure for respiratory training when the load was applied [-15.72 (-18.63; -12.81) and -7.08 (-9.03; -5.13) mmHg, respectively]. There was also a reduction in systolic, but not in diastolic blood pressure when the training was performed without load [-5.08 (-7.49; -2.66) and -1.04 (-2.55; +0.46) mmHg, respectively]. The respiratory training has a positive effect in BP in hypertensive patients, however, only when performed with load seems to be able to promote some beneficial effect on diastolic blood pressure reduction.

Persistent Hypertension in Children and Adolescents: A 6-Year Cohort Study.

To determine the natural history of pediatric hypertension. We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared. Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or <3 hypertensive blood pressure levels, and 29% (542) had ≥3 hypertensive blood pressure levels. Of 2144 patients with elevated blood pressure in the first 36 months, 70% (1492) had no abnormal blood pressure levels, 18% (378) had persistent elevated blood pressure levels, and 13% (274) developed hypertension in the second 36-months. Among the 7775 patients with abnormal blood pressure levels in the first 36-months, only 52% (4025) had ≥3 blood pressure levels recorded during the second 36-months. In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.

Antihypertensive medications and risk for incident dementia and Alzheimer's disease: a meta-analysis of individual participant data from prospective cohort studies

Dementia is a major health concern for which prevention and treatment strategies remain elusive. Lowering high blood pressure with specific antihypertensive medications (AHMs) could reduce the burden of disease. We investigated whether specific AHM classes reduced the risk for dementia. We did a meta-analysis of individual participant data from eligible observational studies published between Jan 1, 1980, and Jan 1, 2019. Cohorts were eligible for inclusion if they prospectively recruited community-dwelling adults; included more than 2000 participants; collected data for dementia events over at least 5 years; had measured blood pressure and verified use of AHMs; included in-person exams, supplemented with additional data, to capture dementia events; and had followed up cases for mortality. We assessed the association of incident dementia and clinical Alzheimer's disease with use of five AHM classes, within strata of baseline high (systolic blood pressure [SBP] ≥140 mm Hg or diastolic blood pressure [DBP] ≥90 mm Hg) and normal (SBP <140 mm Hg and DBP <90 mm Hg) blood pressure. We used a propensity score to control for confounding factors related to the probability of receiving AHM. Study-specific effect estimates were pooled using random-effects meta-analyses. Six prospective community-based studies (n=31 090 well phenotyped dementia-free adults older than 55 years) with median follow-ups across cohorts of 7-22 years were eligible for analysis. There were 3728 incident cases of dementia and 1741 incident Alzheimer's disease diagnoses. In the high blood pressure stratum (n=15 537), those using any AHM had a reduced risk for developing dementia (hazard ratio [HR] 0·88, 95% CI 0·79-0·98; p=0·019) and Alzheimer's disease (HR 0·84, 0·73-0·97; p=0·021) compared with those not using AHM. We did not find any significant differences between one drug class versus all others on risk of dementia. In the normal blood pressure stratum (n=15 553), there was no association between AHM use and incident dementia or Alzheimer's disease. Over a long period of observation, no evidence was found that a specific AHM drug class was more effective than others in lowering risk of dementia. Among people with hypertensive levels of blood pressure, use of any AHM with efficacy to lower blood pressure might reduce the risk for dementia. These findings suggest future clinical guidelines for hypertension management should also consider the beneficial effect of AHM on the risk for dementia. The Alzheimer's Drug Discovery Foundation and the National Institute on Aging Intramural Research Program.

Exercise training initiated at old stage of lifespan attenuates aging-and ovariectomy-induced cardiac and renal oxidative stress: Role of baroreflex.

The association of aging and menopause is a potent risk factor for cardiometabolic disease. We studied the impact of aerobic exercise training (ET) initiated in the old stage of lifespan in hemodynamics, metabolic, autonomic and oxidative stress. Aged (18 months old) female Wistar rats were divided into: ovariectomized and untrained (AG-OVX), and ovariectomized and trained (AG-OVXt, ET for 8 weeks). Intact aged (AG) and young female rats (3 months old; Y) were also studied. Blood pressure and metabolic parameters were measured. Baroreflex sensitivity (BRS) was studied by bradycardic (BR) and tachycardic (TR) responses to vasoactive drugs. Cardiac and renal lipid peroxidation (LPO), catalase (CAT), superoxide dismutase (SOD) and gluthatione peroxidase (GPx), and gluthatione redox balance (GSH/GSSG) were analyzed. AG-OVXt group increased aerobic performance in 35%, decreased adipose tissue and triglycerides in 36% and 27%, respectively, and improved insulin tolerance in 50% in comparison to AG-OVX. AG-OVX presented hypertensive levels of blood pressure (systolic: 155 ± 5, diastolic: 111 ± 3 mmHg). In contrast, AG-OVXt presented blood pressure values similar to Y rats (systolic: 129 ± 3, diastolic: 112 ± 3 mmHg). TR and BR were reduced by 70% and 46%, respectively, in AG-OVX vs. Y. Once more, AG-OVXt presented similar results to Y. ET decreased LPO in the heart and kidney. In the latter, renal CAT and SOD were corrected by ET, while cardiac redox balance was partially recovered. Improved BRS was correlated with improved oxidative stress markers. Even when initiated after aging and ovariectomy deleterious effects, ET is able to normalize BRS and highly improve cardiac and renal oxidative stress.

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.

Systolic blood pressure increases in patients with atrial fibrillation regaining sinus rhythm after electrical cardioversion.

Direct current (DC) cardioversion is used to convert persistent atrial fibrillation (AF) to sinus rhythm (SR), but there is limited knowledge about how blood pressure (BP) is affected by conversion to SR. We sought to evaluate how BP changed in AF patients who converted to SR, compared to patients still in AF. In this retrospective registry analysis, we included a total of 487 patients, treated with DC cardioversion for persistent AF. We obtained data regarding medical history, medication, BP, and electrocardiogram the day before and 7days after cardioversion. Systolic BP increased by 9 (±16)mmHg (P<0.01) and diastolic BP decreased by 3 (±9) mmHg (P<0.01) after conversion to SR. In the group of patients with restored SR, there was a 40% increase in the proportion of patients with a hypertensive BP level (≥140/90mmHg) after DC cardioversion compared to before. Patients still in AF had no significant change in BP. Systolic BP increases and diastolic BP slightly decreases when persistent AF is converted to SR. The underlying mechanisms explaining these findings are not known, but may involve either hemodynamic changes that occur when SR is restored, an underestimation of systolic BP in AF, or a combination of both. Our findings suggest that an increased attention to BP levels after a successful cardioversion is warranted.

Obesity and season as determinants of high blood pressure in a school-based screening study.

This school-based screening study assessed the prevalence of high blood pressure (BP) levels according to the European Society of Hypertension (ESH) 2016 guidelines. Moreover, risk factors for BP elevation, and the effect of geographic and seasonal factors on BP screening were investigated. BP and anthropometric measurements were obtained from 2832 children and adolescents, aged 6-18 years, during the period 2013-2016. Three BP measurements were performed using a mercury sphygmomanometer, and the mean of the last two was used for the analysis. Obesity was defined according to the International Obesity Task Force (IOTF) criteria. The prevalence of high-normal BP/hypertension and overweight/obesity was 3.7%/0.9%, and 22.9%/8.5%, respectively. The majority of the participants presenting high BP (≥90th percentile) were overweight or obese. Increased prevalence of high BP was observed during spring (5.5%) and winter (5%) compared with 2.5% in autumn (P<0.05). SBP z scores were higher in males, during spring and summer, and in urban areas. In conclusion, a low rate of high-normal and hypertensive BP levels was found despite the high prevalence of overweight and obesity. Overweight and obesity were associated with higher BP levels, but there was also a seasonal difference in the prevalence of high BP levels.

Abstract 04: Validation of the Instant Blood Pressure Smartphone Application (App)

Introduction: Mobile health (‘mHealth’) technologies include unregulated smartphone apps. Instant Blood Pressure (IBP; AuraLife, Newport Beach, CA) estimates blood pressure (BP) using the integrated sensors in the phone, without requiring a cuff. For 392 days in 2014-15, it was a top 50 best-selling iPhone app in the US (requiring ≥950 copies sold on those days). App store reviews document use of the app for treatment of hypertension. IBP has not been independently validated. Hypothesis: The absolute mean difference (MD) between IBP and a standard device will be ≤5.0 mmHg for systolic and diastolic BP measurements. Methods: Between Jul. and Sep. 2015, we enrolled adults age ≥18 yrs old, at Johns Hopkins clinics. Exclusion criteria were an active arrhythmia, internal device, or contraindication for arm BP measurement. Two order-randomized measurements were taken on two devices: IBP and a validated standard device (Omron-907). Each IBP measurement was compared to the average of the standard measurements. SBP and DBP MD were log transformed and T-tests were used to compare MD and the cutoff of ≤5.0 mmHg. Results: Of 85 participants, 52% (44 of 85) were women, mean ± SD age was 57 ± 16 years, and mean BMI was 28 ± 6 kg/m2; 53% (45 of 85) had hypertension. The mean ± SD absolute BP differences (IBP minus standard) were 12.4 ± 10.5 mmHg for systolic (P&lt;0.001) and 10.1 ± 8.1 mmHg for diastolic BP (P&lt;0.001). The app overestimated low BP and underestimated high BP (Figure). Sensitivity and specificity for hypertensive measurements (systolic ≥140 or diastolic ≥90 mmHg) were 0.2 and 0.9. Conclusions: BP measurements from an unregulated mHealth app with &gt;148,000 units sold were highly inaccurate. The low sensitivity for hypertensive readings means that four-fifths of individuals with hypertensive BP levels will be falsely reassured that their BP is in the non-hypertensive range.

Perioperative Hemodynamic Management and Pharmacotherapeutics of Patients Undergoing Thoracic Endovascular Aortic Repair

Thoracic endovascular aortic repair (TEVAR) has become an attractive alternative treatment option for many patients with specific thoracic aortic disease. New devices and advanced image-guided procedures are continuously expanding the indications and improve neurological outcomes. Hemodynamic management of these patients is a critical aspect in reducing neurological deficit and it is different compared to patients undergoing open thoracic aortic operations. There are two different phases of blood pressure management for patients with thoracic aortic disease. Before and during the critical steps of TEVAR anti-impulsive therapy facilitates safe positioning and stent deployment. After stent grafts are deployed, controlled hypertensive blood pressure levels are achieved to avoid spinal cord ischemia. This precise blood pressure strategy is essential to ensure a safe procedure and good long-term results.

Essential role of RVL medullary neuronal activity in the long term maintenance of hypertension in conscious SHR.

It is well established that sympathetic nervous system is responsible for the onset, development and maintenance of neurogenic hypertension. The rostroventrolateral medulla (RVLM) and medullo-cervical pressor area (MCPA) are important central sympathoexcitatory regions whose role on neurogenic hypertension remains unknown. To establish RVLM and MCPA roles in the long-term regulation of blood pressure by depressing their neuron activity through the over-expression of hKir2.1-potassium channel in conscious spontaneously hypertensive rats (SHR). In SHR, a lentiviral vector LVV-hKir2.1 was microinjected into RVLM or MCPA areas. A sham group was injected with LVV-eGFP. Blood pressure (BP) and heart rate (HR) were continuously monitored for 75 days. Baroreflex and chemoreflex functions were evaluated. Baroreflex gain, chemoreflex sensitivity, BP and HR variability were calculated. LVV-hKir2.1 expression in RVLM, but not in MCPA, produced a significant time-dependent decrease in systolic, diastolic, mean-BP and LF of systolic BP at 60-days post-injection. No significant changes were seen in LVV-eGFP RVLM injected SHR. Data show that chronic expression of Kir2.1 in the RVLM of conscious SHR caused a marked and sustained decrease in BP without changes in the baro- and peripheral chemoreceptor reflex evoked responses. This decrease was mostly due to a reduction in sympathetic output revealed indirectly by a decrease in the power density of the SBP-LF band. Our data are amongst the firsts to demonstrate the role of the RVLM in maintaining BP levels in hypertension in conscious SHR. We suggest that a decrease in RVLM neuronal activity is an effective anti-hypertensive treatment strategy.

Age and gender may influence the results of Roux-en-Y gastric bypass? Metabolic syndrome parameters.

Severe obesity affects the body favoring the development of serious diseases, including hypertension, diabetes mellitus, atherosclerosis and non alcoholic fatty liver disease. Bariatric procedures increased in Brazil in the last decade. The purpose of this study was to verify if gender and age in date of procedure resulted significant differences in metabolic syndrome parameters after surgery. The study involved 205 medical records of adult patients undergoing Roux-en-Y gastric bypass, stratified by gender and age groups and followed one year by a multidisciplinary team. It was observed significant decrease in body mass index, fasting glucose and insulin at all ages and both genders. Lipid profile showed significant improvements except high density lipoprotein cholesterol. Ectopic fat in the liver has decreased after 6 months in patients classified with steatosis at baseline. Patients classified as hypertensive blood pressure levels decreased 6 months after surgical intervention. Roux-en-Y gastric bypass proved to be an important tool in remission of metabolic syndrome parameters. The reduction of body mass accompanied to decrease in insulin resistance resulted in lower prevalence of comorbidities associated with obesity. The benefits were similar and extended both genders and all age groups between 18 and 65 years old.

Prehypertension and Hypertension in Community-Based Pediatric Practice

To examine the prevalence of prehypertension and hypertension among children receiving well-child care in community-based practices. Children aged 3 to 17 years with measurements of height, weight, and blood pressure (BP) obtained at an initial (index) well-child visit between July 2007 and December 2009 were included in this retrospective cohort study across 3 large, integrated health care delivery systems. Index BP classification was based on the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents: normal BP, <90th percentile; prehypertension, 90th to 94th percentile; hypertension, 3 BP measurements ≥95th percentile (index and 2 subsequent consecutive visits). The cohort included 199 513 children (24.3% aged 3-5 years, 34.5% aged 6-11 years, and 41.2% aged 12-17 years) with substantial racial/ethnic diversity (35.9% white, 7.8% black, 17.6% Hispanic, 11.7% Asian/Pacific Islander, and 27.0% other/unknown race). At the index visit, 81.9% of participants were normotensive, 12.7% had prehypertension, and 5.4% had a BP in the hypertension range (≥95th percentile). Of the 10 848 children with an index hypertensive BP level, 3.8% of those with a follow-up BP measurement had confirmed hypertension (estimated 0.3% prevalence). Increasing age and BMI were significantly associated with prehypertension and confirmed hypertension (P < .001 for trend). Among racial/ethnic groups, blacks and Asians had the highest prevalence of hypertension. The prevalence of hypertension in this community-based study is lower than previously reported from school-based studies. With the size and diversity of this cohort, these results suggest the prevalence of hypertension in children may actually be lower than previously reported.

Real-life safety and effectiveness of amlodipine/valsartan combination in the treatment of hypertension

The aim of our study was to evaluate the safety and effectiveness of the free combination of amlodipine/valsartan in patients with arterial hypertension in a real-life setting. This was a multicenter, open-label, observational, noninterventional, postmarketing surveillance study conducted in 298 centers in China, Malaysia, Pakistan, Bangladesh, Egypt, and Russia. We evaluated changes in heart rate, systolic and diastolic office blood pressure (BP), as well as BP control rate (<140/90 mmHg) overall, and in clinically relevant subgroups of hypertensive patients (BP >140/90 mmHg) after 12 weeks of treatment with 5/10 mg amlodipine and 80/160 mg valsartan combination. Two thousand seven hundred and eighty-five patients with arterial hypertension were enrolled, 52 discontinued (eight due to adverse events), and four patients' data were missing. In total, 2729 patients completed the study: mean age 57.9 years, 54.5% men, 54.2% Asian, 44.6% Caucasian; 86.5% had prior hypertension treatment (which was discontinued), baseline BP was 163.1/96.2 mmHg. The significant reduction in BP (-33.2/-16.9 mmHg, P<0.0001) was achieved with amlodipine/valsartan treatment resulting in a final BP of 129.9/79.3 mmHg. A dose-dependent effect was observed with the least BP reduction for 5/80 mg (-29.2/-15.1 mmHg, P<0.0001) and the greatest for the 10/160 mg dose regimen (-43.6/-22.4 mmHg, P<0.0001). Treatment response increased with increasing initial severity of hypertension with the least BP reduction in patients with baseline grade 1 hypertension BP level (SBP 140-159 mmHg): -20.0/-13.4 mmHg, P<0.0001, and the greatest BP drops observed in grade 3 hypertensive patients with baseline systolic BP over 200 mmHg: -73.1/-26.3 mmHg, P<0.0001. Patients with isolated systolic hypertension had BP reductions of -24.2/-4.8 mmHg, P<0.0001. An optimal BP reduction was achieved for all hypertension grades as well as isolated systolic hypertension, providing evidence that most hypertensive patients may benefit from amlodipine/valsartan combination treatment.

Meaningful Variation in Performance

Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves. To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. Adult members (n = 62,596-410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006. Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment. ICCs were low for all 4 indicators at both levels (0.0021-0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities. Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.

Metabolic Syndrome in Children and Adolescents: Prevalence, Public Health Issue, and Time for Initiative

Screening for features of the metabolic syndrome is being recommended by many learned societies and scientists in the field. Guidelines and recommendations as to how and whom to screen still vary from country to country and are not solely based on evidence from large, longitudinal studies. Whether the term ‘‘metabolic syndrome’’ is of clinical relevance in children and adolescents and more meaningful than individual components such as hypertension, insulin resistance, and type 2 diabetes mellitus or dyslipidemia is still open for debate. In addition, comorbidities of obesity such as sleep-disordered breathing and sleep apnea even at a young age have been recognized more recently. Nevertheless, along with the increasing prevalence of obesity in childhood and adolescence, the existence of the metabolic syndrome in obese children and adolescents is being recognized. The prevalence of any feature of the metabolic syndrome is being reported to be up to 30%, irrespective of the definition that is applied. Signaling molecules, termed adipocytokines, secreted from the adipose tissue, are thought to play a major role in the pathophysiology of the metabolic syndrome. Leptin and its soluble receptor may be more important in states of energy deficiency rather than as a predictor of the metabolic syndrome in

Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes

ContextControl of blood glucose levels, blood pressure, and cholesterol levels is proven to reduce the risk of vascular disease among individuals with diabetes mellitus; however, the current state of control of these risk factors among individuals in the United States is uncertain.ObjectivesTo examine 1999-2000 national data on control of risk factors for vascular disease among adults with previously diagnosed diabetes and to assess trends during the past decade.Design, Setting, and ParticipantsReview of data from the Third National Health and Nutrition Examination Survey (NHANES III, conducted 1988-1994) and NHANES 1999-2000, cross-sectional surveys of a nationally representative sample of the noninstitutionalized civilian US population. Participants were adults aged 20 years and older with previously diagnosed diabetes who participated in both the interview and examination in either NHANES III (n = 1265) or NHANES 1999-2000 (n = 441).Main Outcome MeasuresLevels of glycosylated hemoglobin (HbA1c), blood pressure, and total serum cholesterol in reference to target goals.ResultsCompared with NHANES III, participants with previously diagnosed diabetes in NHANES 1999-2000 were similar by age and sex, were less likely to be non-Hispanic white, were diagnosed at an earlier age, had a higher body mass index, and were more likely to use insulin in combination with oral agents. In NHANES 1999-2000, only 37.0% of participants achieved the target goal of HbA1c level less than 7.0% and 37.2% of participants were above the recommended take action HbA1c level of greater than 8.0%; these percentages did not change significantly from NHANES III (P = .11 and P = .87, respectively). Only 35.8% of participants achieved the target of systolic blood pressure (SBP) less than 130 mm Hg and diastolic blood pressure (DBP) less than 80 mm Hg, and 40.4% had hypertensive blood pressure levels (SBP ≥140 or DBP ≥90 mm Hg). These percentages did not change significantly from NHANES III (P = .10 and P = .56, respectively). Over half (51.8%) of the participants in NHANES 1999-2000 had total cholesterol levels of 200 mg/dL or greater (vs 66.1% in NHANES III; P<.001). In total, only 7.3% (95% confidence interval, 2.8%-11.9%) of adults with diabetes in NHANES 1999-2000 attained recommended goals of HbA1c level less than 7%, blood pressure less than 130/80 mm Hg, and total cholesterol level less than 200 mg/dL (5.18 mmol/L).ConclusionFurther public health efforts are needed to control risk factors for vascular disease among individuals with diagnosed diabetes.

Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.

Control of blood glucose levels, blood pressure, and cholesterol levels is proven to reduce the risk of vascular disease among individuals with diabetes mellitus; however, the current state of control of these risk factors among individuals in the United States is uncertain. To examine 1999-2000 national data on control of risk factors for vascular disease among adults with previously diagnosed diabetes and to assess trends during the past decade. Review of data from the Third National Health and Nutrition Examination Survey (NHANES III, conducted 1988-1994) and NHANES 1999-2000, cross-sectional surveys of a nationally representative sample of the noninstitutionalized civilian US population. Participants were adults aged 20 years and older with previously diagnosed diabetes who participated in both the interview and examination in either NHANES III (n = 1265) or NHANES 1999-2000 (n = 441). Levels of glycosylated hemoglobin (HbA1c), blood pressure, and total serum cholesterol in reference to target goals. Compared with NHANES III, participants with previously diagnosed diabetes in NHANES 1999-2000 were similar by age and sex, were less likely to be non-Hispanic white, were diagnosed at an earlier age, had a higher body mass index, and were more likely to use insulin in combination with oral agents. In NHANES 1999-2000, only 37.0% of participants achieved the target goal of HbA1c level less than 7.0% and 37.2% of participants were above the recommended "take action" HbA1c level of greater than 8.0%; these percentages did not change significantly from NHANES III (P =.11 and P =.87, respectively). Only 35.8% of participants achieved the target of systolic blood pressure (SBP) less than 130 mm Hg and diastolic blood pressure (DBP) less than 80 mm Hg, and 40.4% had hypertensive blood pressure levels (SBP > or =140 or DBP > or =90 mm Hg). These percentages did not change significantly from NHANES III (P =.10 and P =.56, respectively). Over half (51.8%) of the participants in NHANES 1999-2000 had total cholesterol levels of 200 mg/dL or greater (vs 66.1% in NHANES III; P<.001). In total, only 7.3% (95% confidence interval, 2.8%-11.9%) of adults with diabetes in NHANES 1999-2000 attained recommended goals of HbA1c level less than 7%, blood pressure less than 130/80 mm Hg, and total cholesterol level less than 200 mg/dL (5.18 mmol/L). Further public health efforts are needed to control risk factors for vascular disease among individuals with diagnosed diabetes.