Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries.

OBJECTIVE: To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia. DESIGN: Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories. SETTINGS: Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan). PARTICIPANTS: Nationally representative samples of 30 455 adults aged 25-65 years. RESULTS: HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction. CONCLUSIONS: There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Efficacy of an mHealth App to Support Patients' Self-Management of Hypertension: Randomized Controlled Trial.

BACKGROUND: Hypertension is a significant global disease burden. Mobile health (mHealth) offers a promising means to provide patients with hypertension with easy access to health care services. Yet, its efficacy needs to be validated, especially in lower-income areas with a high-salt diet. OBJECTIVE: This study aims to assess the efficacy of an mHealth app-based intervention in supporting patients' self-management of hypertension. METHODS: A 2-arm randomized controlled trial was conducted among 297 patients with hypertension at the General Hospital of Ningxia Medical University, Ningxia Hui Autonomous Region, China. Participants selected via convenience sampling were randomly allocated into intervention and control groups. Intervention group participants were trained and asked to use an mHealth app named Blood Pressure Assistant for 6 months. They could use the app to record and upload vital signs, access educational materials, and receive self-management reminders and feedback from health care providers based on the analysis of the uploaded data. Control group participants received usual care. Blood pressure (BP) and 2 questionnaire surveys about hypertension knowledge and lifestyle behavior were used to assess all participants at baseline and 6 months. Data analysis was performed with SPSS software using 2-tailed t tests and a chi-square test. RESULTS: There were no significant differences in baseline characteristics and medication use between the 2 groups (all P>.05). After 6 months, although both groups show a significant pre-post improvement (P<.001 each), the BP control rate (ie, the proportion of patients with a systolic BP of <140 mm Hg and diastolic BP of <90 mm Hg) in the intervention group was better than that in the control group (100/111, 90.1% vs 75/115, 65.2%; P<.001). The mean systolic and diastolic BP were significantly reduced by 25.83 (SD 8.99) and 14.28 (SD 3.74) mm Hg in the intervention group (P<.001) and by 21.83 (SD 6.86) and 8.87 (SD 4.22) mm Hg in the control group (P<.001), respectively. The differences in systolic and diastolic BP between the 2 groups were significant (P<.001 and P=.01, respectively). Hypertension knowledge significantly improved only in the intervention group in both pre-post and intergroup comparisons (both P<.001). However, only intragroup improvement was observed for lifestyle behaviors in the intervention group (P<.001), including medication adherence (P<.001), healthy diet (P=.02), low salt intake (P<.001), and physical exercises (P=.02), and no significant difference was observed in the control group or on intergroup comparisons. CONCLUSIONS: This research shows that the mHealth app-based intervention has the potential to improve patient health knowledge and support self-management among them toward a healthier lifestyle, including medication adherence, low-salt diets, and physical exercises, thereby achieving optimal BP control. Further research is still needed to verify the specific effects of these interventions. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900026437; https://www.chictr.org.cn/showproj.html?proj=38801.

Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care.

PURPOSE: Evidence shows the value of home blood pressure (BP) monitoring in hypertension management. Questions exist about how to effectively incorporate these readings into BP follow-up visits. We developed and implemented a tool that combines clinical and home BP readings into an electronic health record (EHR)-integrated visualization tool. We examined how this tool was used during primary care visits and its effect on physician-patient communication and decision making about hypertension management, comparing it with home BP readings on paper. METHODS: We video recorded the hypertension follow-up visits of 73 patients with 15 primary care physicians between July 2018 and April 2019. During visits, physicians reviewed home BP readings with patients, either directly from paper or as entered into the EHR visualization tool. We used conversation analysis to analyze the recordings. RESULTS: Home BP readings were viewed on paper for 26 patients and in the visualization tool for 47 patients. Access to home BP readings during hypertension management visits, regardless of viewing mode, positioned the physician and patient to assess BP management and make decisions about treatment modification, if needed. Length of BP discussion with the visualization tool was similar to or shorter than that with paper. Advantages of the visualization tool included ease of use, and enhanced and faster sense making and decision making. Successful use of the tool required patients' ability to obtain their BP readings and enter them into the EHR via a portal, and an examination room configuration that allowed for screen sharing. CONCLUSIONS: Reviewing home BP readings using a visualization tool is feasible and enhances sense making and patient engagement in decision making. Practices and their patients need appropriate infrastructure to realize these benefits.

Association of socioeconomic status with hypertension prevalence and control in Nanjing: a cross-sectional study.

BACKGROUND: The role of socioeconomic status (SES) on hypertension prevalence and hypertension control has gotten much attention but with conflicting results. This paper aimed to quantify the association of SES with both hypertension prevalence and hypertension control rate in Nanjing, China. METHODS: A community-based cross-sectional study was conducted using multistage random sampling on 60,283 adults aged more than 18 years between March 2017 and June 2018. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg or self-reported diagnosis of hypertension or respondent's report of taking antihypertensive medications. The controlled hypertension was defined by systolic BP < 140 mmHg and diastolic BP of < 90 mmHg among the subjects that self-reported exhibiting hypertensive and taking antihypertensive medications. The associations between SES with hypertension prevalence and hypertension control were quantified using generalized mixed model regression analysis and reported as odds ratios (ORs) and 95% confidence interval (CI). RESULTS: There was a high prevalence of subjects with primary educational level (49.6%) or unemployed and retired (49.5%) or lower annual household income level (44.9%) in each SES group, respectively. After adjustments for potential confounding factors, there were higher odds of hypertension among those with primary educational level (OR = 1.56), but lower odds for controlled BP (OR = 0.51). Higher odds of hypertension could be found among unemployed and retired, and higher odds of controlled BP was observed in the mental laborers or students (OR = 1.30), compared with the other categories, respectively. The lower-income group was more likely to be hypertensive (OR = 1.35) and less likely to have controlled hypertension (OR = 0.73). CONCLUSION: Socioeconomic status played an important role in hypertension prevalence and hypertension control among adults in Nanjing, China. Strategies for hypertension prevention and control should especially focus on people in the vulnerable lower SES groups.

Gaps in hypertension care and control: a population-based study in low-income urban Medellin, Colombia.

OBJECTIVES: To assess hypertension prevalence and the extent and associated factors of hypertension diagnosis, follow-up, treatment and control gaps in low-income urban Medellin, Colombia. METHODS: We randomly sampled 1873 adults aged 35 or older. Unaware hypertensive individuals were defined as those without previous diagnosis whose average blood pressure was equal to or above 140/90 mmHg. For aware hypertensive patients, control was delimited as average blood pressure below 140/90 if under 59 years old or diabetic, and as less than 150/90 otherwise. We used logistic regression to identify care gap-associated factors. RESULTS: Hypertension prevalence was 43.5% (95% CI 41.2-45.7). We found 28.2% aware and 15.3% unaware hypertensive individuals, which corresponds to a 35.1% (95% CI 31.9-38.5) underdiagnosis. This gap was determined by age, sex, education and lifestyle factors. 14.4% (95% CI 11.6-17.6) of aware hypertensive patients presented a follow-up gap, 93.4% (95% CI 90.9-95.2) were prescribed antihypertensive drugs, but 38.9% (95% CI 34.7-43.3) were not compliant. The latter was strongly associated with follow-up. The hypertension control gap in aware hypertensive patients, 39.0% (95% CI: 34.9-43.2), was associated with being older, having diabetes, weakly adhering to pharmacological treatment and receiving poor non-pharmacological advice. Overall, 60.4% (95% CI 57.0-63.8) of aware and unaware hypertensive participants had either diagnosed but uncontrolled or undiagnosed hypertension. CONCLUSIONS: We found high hypertension prevalence coupled with, from an international perspective, encouraging awareness and control figures. Still, there remains ample room for improvement. Our findings can assist in designing integrated primary healthcare measures that further strengthen equitable and effective access to hypertension care and control.

Reasons for poor blood pressure control in Eastern Sub-Saharan Africa: looking into 4P's (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review.

AIM: Hypertension control in Sub-Saharan Africa (SSA) is the worst (less than one out of ten) when compared to the rest of the world. Therefore, this scoping review was conducted to identify and describe the possible reasons for poor blood pressure (BP) control based on 4Ps' (patient, professional, primary healthcare system, and public health policy) factors. METHODS: PRISMA extension for scoping review protocol was used. We systematically searched articles written in the English language from January 2000 to May 2020 from the following databases: PubMed/Medline, Embase, Scopus, Web of Science, and Google scholar. RESULTS: Sixty-eight articles were included in this scoping review. The mean prevalence of hypertension, BP control, and patient adherence to prescribed medicines were 20.95%, 11.5%, and 60%, respectively. Only Kenya, Malawi, and Zambia out of ten countries started annual screening of the high-risk population for hypertension. Reasons for nonadherence to prescribed medicines were lack of awareness, lack of access to medicines and health services, professional inertia to intensify drugs, lack of knowledge on evidence-based guidelines, insufficient government commitment, and specific health behaviors related laws. Lack of screening for high-risk patients, non-treatment adherence, weak political commitment, poverty, maternal and child malnutrition were reasons for the worst BP control. CONCLUSION: In conclusion, the rate of BP treatment, control, and medication adherence was low in Eastern SSA. Screening for high-risk populations was inadequate. Therefore, it is crucial to improve government commitment, patient awareness, and access to medicines, design country-specific annual screening programs, and empower clinicians to follow individualized treatment and conduct medication adherence research using more robust tools.

Factors hindering hypertension control: perspectives of front-line health professionals in rural Ghana.

OBJECTIVE: Hypertension (HTN) control remains a major public health challenge in sub-Saharan Africa (SSA). Health professionals influence patient adherence and self-management practices for HTN particularly in rural and lower socio-economic communities in SSA. Contextual evidence on the reasons for the suboptimal control of HTN in clinical settings is crucial to improving health delivery practices for HTN and preventing HTN related-complications. STUDY DESIGN: A cross-sectional qualitative study. METHODS: Semistructured interviews were conducted among 40 purposively sampled front-line health professionals in seven health facilities in northern Ghana. Data were analysed using a thematic approach through pre-identified and evolving themes. RESULTS: We identified three key themes underlying the poor HTN control. First, health professionals' barriers included communication difficulties, poor collaboration and referrals among health professionals and limited training on HTN and other non-communicable diseases (NCDs). Secondly, health system-related barriers included limited health personnel, drug shortages, inadequate facilities and equipment and challenges with National Health Insurance (NHIS). The third theme was patient-related barriers including non-adherence, use of traditional treatments, sociocultural factors and lack of appreciation. CONCLUSION: A holistic public health approach, which builds upon health professionals' capacities, harnesses and integrates into existing health policy and systems structures and empowers and collaborates with communities could contribute to improving HTN control in rural settings. Health policymakers need to consider the sociocultural, economic and geographical characteristics in such settings, which influence health service delivery practices in designing and implementing HTN interventions. There is also a need for health policy to integrate NCD training and management of multiple and comorbid conditions into the training curriculum of health training institutions to build health professionals capacity to facilitate the uptake of evidence-based NCD interventions and manage the double burden of diseases.

Considerable international variation exists in blood pressure control and antihypertensive prescription patterns in chronic kidney disease.

Although blood pressure control is a major goal in chronic kidney disease, no worldwide overview of either its achievement or antihypertensive prescriptions is currently available. To evaluate this we compared crude prevalence of uncontrolled blood pressure among 17 cohort studies, including 34 602 individuals with estimated glomerular filtration rate under 60 ml/min/1.73 m2 and treated hypertension across four continents, and estimated observed to expected prevalence ratios, adjusted for potential confounders. Crude prevalence of blood pressure of 140/90 mm Hg or more varied from 28% to 61% and of blood pressure of 130/80 or more from 54% to 84%. Adjusted prevalence ratios indicated poorer hypertension control than expected in cohorts from European countries, India, and Uruguay, and better control in patients from North American and high-income Asian countries. Four antihypertensive drug classes or more were prescribed to more than 30% of participants in North American and some European cohorts, but this practice was less common elsewhere. Renin angiotensin-aldosterone system inhibitors were the most common antihypertensive drugs, prescribed for 54% to 91% of cohort participants. Differences for other drug classes were much stronger, ranging from 11% to 79% for diuretics, 22% to 70% for beta-blockers, and 27% to 75% for calcium-channel blockers. The confounders studied explain only a part of the international variation in blood pressure control among individuals with chronic kidney disease. Thus, considerable heterogeneity in prescription patterns worldwide calls for further investigation into the impact of different approaches on patient outcomes.

Opportunities to Leverage Telehealth Approaches Along the Hypertension Control Cascade in Sub-Saharan Africa.

PURPOSE OF REVIEW: To review the current literature on use of telehealth at different stages of the hypertension control cascade in sub-Saharan Africa (SSA) and to discuss opportunities to harness technology infrastructure in SSA to improve population-level blood pressure control. RECENT FINDINGS: Despite the high burden of hypertension in SAA, strategies to improve awareness, diagnosis, and management are inadequate. In high-income countries, telehealth has increased patient access to high-quality care at reduced costs. Notwithstanding the limited evidence on the use of telehealth at the different stages of the hypertension control cascade in SSA, the few published interventions in this review reported reduction of blood pressure and increase in the proportion of individuals with controlled blood pressure. Telehealth use across the hypertension control cascade in SSA is promising. These under-resourced settings provide opportunity to better understand the demand for these interventions in order to achieve meaningful clinical outcomes.

Race-Specific Patterns of Treatment Intensification Among Hypertensive Patients Using Home Blood Pressure Monitoring: Analysis Using Defined Daily Doses in the Heart Healthy Lenoir Study.

BACKGROUND: Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown. OBJECTIVE: To compare AMI by race for patients with elevated home BP readings. METHODS: This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value. RESULTS: A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P = 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P = 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (-8.2 vs -3.9 mm Hg; P = 0.14). Conclusion/Relevance: Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

Multivariate analysis of hypertension in general US adults based on the 2017 ACC/AHA guideline: data from the national health and nutrition examination survey 1999 to 2016.

PURPOSE: Since the publication of the 2017 ACC/AHA hypertension guideline, few studies have analyzed the epidemiology and management of hypertension across many heterogeneous subgroups in the US. MATERIALS AND METHODS: We analyzed the data collected by the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2016. Participants greater than 20 years of age, who had valid blood pressure measurements, were included in the study. A comprehensive analysis of 14 population subgroups was done to systematically examine how hypertension awareness, treatment, and control varied by subpopulations. RESULTS: Our study included 45,557 participants with a mean age of 47.1 years, 48.3% were male and 51.7% were female. 47.8% participants had hypertension, of which 59.9% were aware of their diagnosis. Among the participants who were aware of their hypertension, 90.3% were prescribed medication(s) to lower blood pressure, of which 39.2% had achieved control. Multivariate analysis showed age, gender, Race/ethnicity, annual family income, education level, BMI, waist to height ratio, diabetes, and previous cardiovascular events to be independent risk factors for hypertension. Lower likelihoods of awareness and treatment were associated with male sex, younger age, Mexican ethnicity, participants without health insurance, absence of previous cardiovascular events, diabetes, obesity, or smoking. Overall, hypertension control rate was suboptimal across most of subgroups (<40%). CONCLUSION: Based on the 2017 ACC/AHA guideline, almost half of the US adult population has hypertension. The suboptimal number of people with controlled blood pressure is pervasive in all subgroups and warrants greater efforts in prevention, as well as more effective treatment.

High rate of hypertension control among treated patients attending a teaching primary healthcare centre in Jordan.

INTRODUCTION: The purpose of this study was to determine the hypertension control rate and its associated factors among treated patients attending a teaching primary healthcare centre in Jordan. STUDY DESIGN: We conducted a retrospective cohort study of 286 patients with HTN, treated with medications, who attended Jordan University of Science and Technology primary healthcare centre in Irbid, Jordan, from July through September 2018. Data were abstracted from the patient's medical records and personal interviews. Multivariate logistic regression analysis was used to examine independent factors associated with hypertension control. RESULTS: Blood pressure control rate was 90.9% and was significantly higher among patients who were married (p=0.02), with higher income level (p<0.01), non-smokers (p=0.01), free of diabetes mellitus or dyslipidaemia (p=0.048), highly consuming fruits and vegetables (p<0.01), non-obese (p<0.01), adherent to blood pressure medications (p=0.02) and among patients on lower number of antihypertensive medications (p=0.01). Multivariate analysis with adjusted OR of factors associated with hypertension control were higher fruit and vegetable intake (p<0.01), higher income level (p=0.02) and medication adherence (p<0.01). CONCLUSION: Participants in this study achieved a relatively high rate of blood pressure control. Associated factors with this rate were higher fruit and vegetable intake, higher income level and medication adherence. For better hypertension control, patients should be advised to adhere to their medications and consume more fruits and vegetables besides other lifestyle changes.

Differences in the treatment and control of hypertension in urban and rural residents of the northeastern region of the People's Republic of China: a cross-sectional study.

BACKGROUND: Hypertension is a significant global public health problem and an important risk factor for cardiovascular diseases. We aimed to determine treatment and control rates of hypertension and to explore related risk factors by urban and rural areas. METHODS: A cross-sectional survey of 14,956 participants (≥ 15 years) was conducted in Jilin Province, China from July 2014 to December 2015 using questionnaire forms and physical measurements. RESULTS: Total rates of hypertension treatment, control, and controlled blood pressure among treated subjects were 31.7%, 8.8%, and 27.9% in the Jilin Province. Rates of hypertension treatment, control, and controlled blood pressure among treated subjects were 35.9%, 13.7%, and 38.3% in urban areas and 28.4%, 5.0%, and 17.5% in rural areas, respectively. Higher treatment of hypertension was associated with older age, female sex, other races (except Han), and higher body fat percentage in both areas. Among urban residents, higher education was additionally associated with higher treatment of hypertension; among rural residents, a family history of coronary artery disease and unemployment were associated with higher treatment of hypertension. Higher control of hypertension was associated with unemployment, married status, higher education, healthy body mass index, lower abdominal waist circumference, non-smoking status, and lower visceral adiposity index in urban residents; higher control of hypertension was associated with younger age in rural residents. CONCLUSION: Treatment and control rates of hypertension in urban and rural areas were lower than the national average; blood pressure control in patients taking antihypertensive drugs needs further improvement.

Patient Judgments About Hypertension Control: The Role of Variability, Trends, and Outliers in Visualized Blood Pressure Data.

BACKGROUND: Uncontrolled hypertension is a significant health problem in the United States, even though multiple drugs exist to effectively treat this chronic disease. OBJECTIVE: As part of a larger project developing data visualizations to support shared decision making about hypertension treatment, we conducted a series of studies to understand how perceptions of hypertension control were impacted by data variations inherent in the visualization of blood pressure (BP) data. METHODS: In 3 Web studies, participants (internet sample of patients with hypertension) reviewed a series of vignettes depicting patients with hypertension; each vignette included a graph of a patient's BP. We examined how data visualizations that varied by BP mean and SD (Study 1), the pattern of change over time (Study 2), and the presence of extreme values (Study 3) affected patients' judgments about hypertension control and the need for a medication change. RESULTS: Participants' judgments about hypertension control were significantly influenced by BP mean and SD (Study 1), data trends (whether BP was increasing or decreasing over time-Study 2), and extreme values (ie, outliers-Study 3). CONCLUSIONS: Patients' judgment about hypertension control is influenced both by factors that are important predictors of hypertension related-health outcomes (eg, BP mean) and factors that are not (eg, variability and outliers). This study highlights the importance of developing data visualizations that direct attention toward clinically meaningful information.

Effectiveness of mHealth Interventions in Improving Medication Adherence Among People with Hypertension: a Systematic Review.

PURPOSE OF REVIEW: This study aims to systematically review existing evidence on the effectiveness of mobile health technology (mHealth) interventions in addressing medication adherence among people with hypertension. RECENT FINDINGS: Twenty-one studies of mHealth interventions were included in the final review after systematic searching and screening of publications from 2000 to 2017 in PubMed, Web of Science, and Embase. Key features of the mHealth interventions include high intervention intensity, multifactorial components, and patient-centered approaches with tailored content and interaction. All studies found tendencies to improvement in medication adherence, but only 12 studies reported that the improvements were statistically significant in the intervention groups compared with the control groups. Twelve studies also found that mHealth interventions were beneficial for blood pressure control. None of the studies was conducted in a low-income country. Our systematic review found evidence that mHealth interventions improved medication adherence and blood pressure control among people with hypertension. However, most studies were small in sample size and short in study duration, and not all results were statistically significant. Future research should focus on investigating the sustainability and generalizability of mHealth interventions.

Therapeutic Inertia and Treatment Intensification.

PURPOSE OF REVIEW: This review aims to emphasize how therapeutic inertia, the failure of clinicians to intensify treatment when blood pressure rises or remains above therapeutic goals, contributes to suboptimal blood pressure control in hypertensive populations. RECENT FINDINGS: Studies reveal that the therapeutic inertia is quite common and contributes to suboptimal blood pressure control. Quality improvement programs and standardized approaches to support antihypertensive treatment intensification are ways to combat therapeutic inertia. Furthermore, programs that utilize non-physician medical professionals such as pharmacists and nurses demonstrate promise in mitigating the effects of this important problem. Therapeutic inertia impedes antihypertensive management and requires a broad effort to reduce its effects. There is an ongoing need for renewed focus and research in this area to improve hypertension control.

Psychosocial Stressors at Work and Ambulatory Blood Pressure.

PURPOSE OF REVIEW: Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP). RECENT FINDINGS: Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Low-Sodium Versus Standard-Sodium Peritoneal Dialysis Solution in Hypertensive Patients: A Randomized Controlled Trial.

BACKGROUND: Peritoneal dialysis (PD) solutions with reduced sodium content may have advantages for hypertensive patients; however, they have lower osmolarity and solvent drag, so the achieved Kt/Vurea may be lower. Furthermore, the increased transperitoneal membrane sodium gradient can influence sodium balance with consequences for blood pressure (BP) control. STUDY DESIGN: Prospective, randomized, double-blind clinical trial to prove the noninferiority of total weekly Kt/Vurea with low-sodium versus standard-sodium PD solution, with the lower confidence limit above the clinically accepted difference of -0.5. SETTING & PARTICIPANTS: Hypertensive patients (≥ 1 antihypertensive drug, including diuretics, or office systolic BP ≥ 130 mmHg) on continuous ambulatory PD therapy from 17 sites. INTERVENTION: 108 patients were randomly assigned (1:1) to 6-month treatments with either low-sodium (125 mmol/L of sodium; 1.5%, 2.3%, or 4.25% glucose; osmolarity, 338-491 mOsm/L) or standard-sodium (134 mmol/L of sodium; 1.5%, 2.3%, or 4.25% glucose; osmolarity, 356-509 mOsm/L) PD solution. OUTCOMES: Primary end point: weekly total Kt/Vurea; secondary outcomes: BP control, safety, and tolerability. MEASUREMENTS: Total Kt/Vurea was determined from 24-hour dialysate and urine collection; BP, by office measurement. RESULTS: Total Kt/Vurea after 12 weeks was 2.53 ± 0.89 in the low-sodium group (n = 40) and 2.97 ± 1.58 in the control group (n = 42). The noninferiority of total Kt/Vurea could not be confirmed. There was no difference for peritoneal Kt/Vurea (1.70 ± 0.38 with low sodium, 1.77 ± 0.44 with standard sodium), but there was a difference in renal Kt/Vurea (0.83 ± 0.80 with low sodium, 1.20 ± 1.54 with standard sodium). Mean daily sodium removal with dialysate at week 12 was 1.188 g higher in the low-sodium group (P < 0.001). BP changed marginally with standard-sodium solution, but decreased with low-sodium PD solution, resulting in less antihypertensive medication. LIMITATIONS: Broader variability of study population than anticipated, particularly regarding residual kidney function. CONCLUSIONS: The noninferiority of the low-sodium PD solution for total Kt/Vurea could not be proved; however, it showed beneficial clinical effects on sodium removal and BP.

On the transition from a nurse-led hypertension clinic to hypertension control in primary care: identifying barriers to and factors acting against continuous hypertension control.

Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner's office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.

Hypertension related knowledge and behaviour associated with awareness, treatment and control of hypertension in a rural hypertensive population: a community based, cross-sectional survey.

BACKGROUND AND OBJECTIVE: Hypertension-related knowledge and behaviour have been identified as influential factors associated with awareness, treatment and control of hypertension in urban regions. However, there were few studies on rural areas. This study aims to investigate whether hypertension related knowledge and behaviour were associated with hypertension awareness, treatment and control in Gaoyou, a rural area of Jiangsu province, China. METHODS: A cross-sectional, population-based survey was conducted among hypertensive individuals in rural areas of Gaoyou, the south-eastern of China in 2010. We identified 1943 subjects with hypertension among 4536 subjects participated in this study and collected information about medical history, use of medication, hypertension related knowledge and behaviour by a standardized questionnaire. RESULTS: This study showed that 41.07% of subjects were aware of their disease, 30.01% of subjects were taking antihypertensive medication and 5.04% of subjects controlled their blood pressure. Multivariate logistic regression analysis showed that subjects who knew the threshold, the lifelong treatment of hypertension and measured blood pressure at least once a year had better detection, treatment or control of hypertension. CONCLUSION: Hypertension related knowledge and behaviour were associated with awareness, treatment and control rate of hypertension in the rural areas of south-eastern China.