Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Improved control of blood pressure and albuminuria among patients with type-2 diabetes in Finnish open care.

Risk of cardiovascular events within the diabetic population has decreased and survival increased with patients living longer and thus facing the development of end-stage renal disease (ESRD). This calls for good care of patient with diabetes with a focus on hypertension. Patient data were collected from 42 Finnish primary care centres. Each was asked to enrol 10-12 consecutive patients with type-2 diabetes between March 2011 and August 2012. Along with the office blood pressure measurements and laboratory tests, the presence of albuminuria was measured and glomerular filtration rate estimated (eGFR). The 2013 ESH criteria for diabetic hypertensive patients (<140/85 mmHg) was reached by 39% of all 625 study patients and 38% of the pharmacologically treated 520 patients. The absence of detectable albumin in urine was significantly associated with the control of systolic blood pressure and achievement of treatment goals. Beta blockers were the most common antihypertensive agents and patients treated with them had lower eGFR compared to those not treated with these agents. The blood pressure of patients was not in full concordance with the present guideline recommendations. However, satisfactory improvement in blood pressure control, reduction of albuminuria and hence ESRD prevention was achieved.

Health 2000 score - development and validation of a novel cardiovascular risk score.

BACKGROUND: Previous risk scores for predicting myocardial infarctions and strokes have mainly been based on conventional risk factors. We aimed to develop a novel improved risk score that would incorporate other widely available clinical variables for predicting the broadest range of endpoints, including revascularizations. METHODS: A nationwide sample of 5843 Finns underwent a clinical examination in 2000-2001. The participants were followed for a median of 11.2 years for incident cardiovascular events. Model discrimination and calibration were assessed and internal validation was performed. RESULTS: Sex, age, systolic blood pressure, total cholesterol, HDL cholesterol, smoking status, parental death from cardiovascular disease, left ventricular hypertrophy, hemoglobin A1c, and educational level remained significant predictors of cardiovascular events (p ≤ 0.005 for all). The share of participants with ≥10% estimated cardiovascular risk was 28.9%, 18.5%, 36.9% and 23.8% with the Health 2000, Finrisk, Framingham and Reynolds risk scores. The Health 2000 score (c-statistic: 0.850) showed superior discrimination to the Framingham (c-statistic improvement: 0.021) and Reynolds (c-statistic improvement: 0.007) scores (p < 0.001 for both comparisons). Model including left ventricular hypertrophy, hemoglobin A1c, and educational level improved the model prediction (c-statistic improvement: 0.006, p = 0.003). CONCLUSIONS: The Health 2000score improves cardiovascular risk prediction in the current study population. KEY MESSAGES Previous risk scores for predicting myocardial infarctions and strokes have mainly been based on conventional risk factors. We aimed to develop a novel improved risk score that would incorporate other widely available clinical variables (including left ventricular hypertrophy, hemoglobin A1c, and education level) for predicting the broadest range of endpoints, including revascularizations. The Health 2000 score improved cardiovascular risk prediction in the current study population compared with traditional cardiovascular risk prediction scores.

Prevalence and prognosis of ECG abnormalities in normotensive and hypertensive individuals.

OBJECTIVE: To define the prevalence and prognosis of ECG abnormalities in hypertensive individuals. METHODS: ECG, blood pressure and other cardiovascular risk factors were recorded in a nationwide population sample of 5800 Finns. The presence of 15 ECG abnormalities was evaluated. Participants were divided into categories by blood pressure and followed for coronary heart (CHD) and cardiovascular disease (CVD) events. RESULTS: Mean follow-up was 10.4 ±â€Š2.2 years. The age- and sex-adjusted prevalence rates of ECG abnormalities were generally higher in the hypertensive participants than in normotensive individuals. In multivariable-adjusted Cox models, the following ECG abnormalities predicted CHD in hypertensive participants: left ventricular hypertrophy (LVH) by Sokolow-Lyon criteria [hazard ratio, 1.47; 95% confidence interval (CI), 1.07-2.01; P = 0.02], LVH with ST-depression and negative T wave (ST/T changes) (hazard ratio, 2.31; 95% CI, 1.20-4.43, P = 0.01), ST/T changes (hazard ratio, 2.12; 95% CI, 1.34-3.36; P = 0.001), positive T wave in lead aVR (AVRT+) (hazard ratio, 1.74; 95% CI, 1.15-2.64; P = 0.009) and poor R-wave progression (hazard ratio, 2.02; 95% CI, 1.27-3.22; P = 0.003). These ECG abnormalities were also significant predictors of CVD in hypertensive participants (P ≤ 0.03 for all). Nonspecific intraventricular conduction delay predicted CVD in the whole population (hazard ratio, 1.50; 95% CI, 1.06-2.13; P = 0.02). Prolonged QT interval, abnormal P-wave indices, left axis deviation and early repolarization pattern were not associated with CHD or CVD. CONCLUSION: ECG abnormalities are highly prevalent in hypertensive individuals. LVH is still the cornerstone of cardiovascular risk assessment in hypertensive patients. The additional assessment of ST/T changes, AVRT+ and poor R-wave progression in ECGs could improve risk prediction in hypertensive patients.

Individual patient data meta-analysis of self-monitoring of blood pressure (BP-SMART): a protocol.

INTRODUCTION: Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed. METHODS AND ANALYSIS: We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD. ETHICS AND DISSEMINATION: This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations. CONCLUSIONS: IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.

ECG left ventricular hypertrophy is a stronger risk factor for incident cardiovascular events in women than in men in the general population.

OBJECTIVE: Left ventricular hypertrophy (LVH) is a strong risk factor for cardiovascular events. ECG is the most widely used method for LVH detection. Despite the abundance of ECG LVH criteria, their prognostic values have been compared in only a few studies, and little has been known about how sex modifies the prognostic value of LVH. We assessed the relationship between ECG LVH and incident cardiovascular events in the general population. METHODS: Several ECG LVH criteria were measured in 3059 women and 2456 men participating in the Health 2000 Study - a national general population survey. Association between ECG LVH and cardiovascular events were analyzed with Cox proportional-hazards models. RESULTS: ECG LVH was more prevalent in women than in men when measured with Cornell-based criteria, but less prevalent or nondifferent when measured with other criteria. The association between ECG LVH and events showed higher hazard ratios for women than in men. Sex × LVH interaction terms were statistically significant in part of the LVH criteria. In adjusted Cox models, Sokolow-Lyon voltage performed the best. The composite of Sokolow-Lyon voltage and Cornell voltage was statistically significantly associated with events in both sexes. CONCLUSION: Sex affects both the prevalence rates and prognostic values of ECG LVH criteria in the general population, while showing higher prognostic value of ECG LVH in women than in men. For clinical use, the composite of the Sokolow-Lyon voltage and the Cornell voltage seems to be a good option.

Risk assessment of echocardiographic left ventricular hypertrophy with electrocardiography, body mass index and blood pressure.

AIMS: Electrocardiography (ECG) has a high specificity but unfortunately low sensitivity to detect anatomic left ventricular hypertrophy (LVH). In this study, ECG amplitude and products were examined as continuous variables together with blood pressure (BP) and body mass index (BMI) to find out a simple method to predict echocardiographic (ECHO)-LVH. An age- and gender-stratified population-based sample of men (n = 121) and women (n = 135) aged 35-64 years enriched with newly diagnosed untreated hypertensive men (n = 138) and women (n = 97) in the Turku area in south-western Finland was studied. MAJOR FINDINGS: Cornell voltage (or Cornell product), systolic BP (SBP) and BMI were all independent determinants of ECHO-LVH and left ventricular mass (LVM) indexed by height (LVMI). According to multivariate regression analyses with Cornell voltage (Cornell product), BMI and BP as explanatory variables, the three determinants explained 46-48% (47-49%) of the variation in LVMI among men and 50-54% (52-57%) among women. Score tables were constructed to estimate the probability of LVH. The estimated probability of ECHO-LVH increased in men gradually from 0% to 81% (79%) along with increased Cornell voltage (Cornell product) tertiles and in women respectively from 0% to 95% (97%). CONCLUSION: The sensitivity of ECG to detect ECHO-LVH can be markedly enhanced by using ECG amplitudes and products as continuous variables. The risk tables using Cornell voltages or products, BMI and SBP enable an easy and effective way to estimate the probability of ECHO-LVH.

[Blue toe syndrome--a rare but possible complication of anticoagulant therapy]. / Sinisten varpaiden oireyhtymä-- antikoagulanttihoidon harvinainen komplikaatio.

Cholesterol microembolization syndrome (CMS) is a multiorgan ischemic disorder resulting from occlusion of small vessels by cholesterol crystals that are derived from atherosclerotic plaques of major arteries. Flow distribution of cholesterol crystals determines the clinical picture of CMS. Cholesterol crystals distributed to the lower extremities cause a typical "blue toe" appearance. The predisposing factors of CMS include various vascular procedures that scratch the luminal surface of the vascular wall and make the release of cholesterol crystals from the atherosclerotic plaques possible. However, CMS can also occur as a consequence of continuous anticoagulant use. Therefore, patients on anticoagulant therapy complaining even minor toe symptoms should be examined for possible CMS.

Both hypertensive men and women are inadequately treated in Finnish general practice.

A general comprehension is that men are treated poorer than women. This study was planned to assess the Finnish hypertensive care with interests in possible hypertensive and cardiovascular control differences between men and women. A cross-sectional study was carried out by nationwide questionnaire survey of 714 consecutive drug-treated hypertensive patients having visited general practice during autumn 2006. Mean (SD) blood pressure (BP) of the women was 148.3 (21.1)/86.8 (11.7) mm Hg and of men 146.5 (19.5)/89.0 (11.8). Women had significantly lower diastolic BP (P = .016). The mean LDL cholesterol of women was 2.94 (0.91) mmol/L and of men 2.95 (0.94) mmol/L (P = .94). The blood pressure target <140/85 mm Hg was reached by 25% of the women and 23% of the men (P = .70). Of the women 30.7% and of the men 31.1% reached low-density lipoprotein (LDL)-cholesterol <2.5 mmol/L. Women used more diuretics than men (P = .06). No significant difference was seen between women and men in the number of patients reaching the target pressure <140/85 mm Hg, although diastolic blood pressure of the women was significantly lower. Hypertensive women and men were equally undertreated, and regardless of the sex, antihypertensive and hyperlipidemic control of hypertensive patients should be intensified.

Low-dose acetylsalicylic acid and blood pressure control in drug-treated hypertensive patients.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase blood pressure (BP) and potentially reduce the efficacy of several antihypertensive drugs. We evaluated the effect of low-dose acetylsalicylic acid (ASA) on BP control in drug-treated hypertensive patients in a primary care population. DESIGN/METHODS: Nine hundred and five successive patients aged 25­91 years (mean 65.5 years) from 15 health centers in south-west Finland were studied. The patients were on antihypertensive monotherapy (45.7%) or on combination therapy (54.3%). Office BP was measured twice with a 2-min interval after at least a 10-min rest using an ordinary sphygmomanometer. RESULTS: Patients receiving ASA (n = 246) showed lower diastolic BP (83.9 ± 9.0 vs. 87.0 ± 9.6 mmHg; P < 0.001) compared with those who were not using any NSAIDs (n = 659). No significant difference in systolic BP was observed between the groups. As a result, pulse pressure was slightly higher in the ASA group (66.9 ± 18.9 vs. 63.3 ± 17.7 mmHg, P = 0.01). Mean arterial pressure was lower in the ASA group (106.2 ± 10.6 vs. 108.1 ± 10.4 mmHg, P = 0.02). In a stepwise linear multivariate model, ASA remained a significant predictor of lower diastolic BP even after the adjustment with the confounding effects of age and sex. CONCLUSION: According to our population-based study low-dose ASA does not have deleterious effects on BP control in drug-treated hypertensive patients.

Prognostic implications of quantitative ST-segment characteristics and T-wave amplitude for cardiovascular mortality in a general population from the Health 2000 Survey.

AIMS: We determined the gender-specific prognostic importance of quantitative measures of the ST segment and T wave in a community cohort. METHODS: Data were collected from 5613 Finnish individuals. Four electrocardiogram (ECG) lead groups were used: anterior, lateral, inferior, and lead V5. ST-segment depression, determined at four points along the ST segment, and T-wave amplitude were treated as continuous variables in Cox regression analyses. RESULTS: During a median follow-up period of 72.4 months, 120 cardiovascular deaths were registered. Among women, lateral lead group as well as lead V5 showed highly significant adjusted hazard ratios at all four ST-depression assessment points. This significance was lost in women ≥ 55 years when those with ECG-based criteria of left ventricular hypertrophy (LVH) were excluded. Results for ST-segment depression were not significant among men. As those with LVH were excluded, men ≥ 55 years showed borderline significance. T-wave amplitude did not reach significance among men, while lateral leads and lead V5 bore prognostic information among women. CONCLUSION: Quantitative ST-segment depression, regardless of the measurement point, allows prediction of cardiovascular death in women within a general population. However, the effect disappears as those with LVH are excluded. This observation highlights the need for consideration of LVH when depressed ST segments are clinically observed.

The choice of home blood pressure result reporting method is essential: Results mailed to physicians did not improve hypertension control compared with ordinary office-based blood pressure treatment.

Effective antihypertensive care is not possible without regular and reliable blood pressure measurements. The use of blood pressure home measurement has increased a lot during the last years. Various methods have been used in communication between the patients and physicians. In a randomized study we compared traditional office-based hypertension treatment protocol (n=68) to the home-based blood pressure measurement protocol (n=89) in which the patient mailed their home-measured BP diary in a letter to the office of their physician. The studied home-based antihypertensive care system was not more effective than the ordinary office-based treatment. The results highlight the importance of continuous home measurement data interpretation by the physician. The system based on mailing the results to the physician office does not seem to be a suitable method in communication between the patient and the physician. Online or other telemedicine-aided means of communication might yield better antihypertensive control.

Experiences of telemedicine-aided hypertension control in the follow-up of Finnish hypertensive patients.

The prevalence of hypertension is high in Finland. Only one fourth of the drug-treated hypertensive patients reach their target pressure. We evaluated a commercially available telemedicine system for impact in reaching better blood pressure control among Finnish hypertensive patients. A telemedicine system, the Doc@home, was used to assist blood pressure treatment in 19 Finnish hypertensive patients. Blood pressure control improved during the 3-month follow-up. Patient-to-Doc@home compliance was good, but study physicians found the system time consuming in the beginning. According to our results, the Doc@home telemedicine system showed a promising approach in hypertension treatment but needs some further development and trained staff to become a still more practical alternative.

Treatment of hypertension in Finnish general practice seems unsatisfactory despite evidence-based guidelines.

OBJECTIVES: This study was performed to clarify whether treatment of hypertension and concomitant risk factors in Finland has improved after the introduction of national evidence-based guidelines for antihypertensive treatment in 2002. Changes in the other cardiovascular risk factors of the Finnish hypertensive patients were also assessed. DESIGN: Nationwide questionnaire survey of consecutive hypertensive patients having met by general practitioners during a given week in autumn 2006. SETTING: Finnish general practice offices in primary care. SUBJECTS: Data from 715 hypertensive patients, 358 men and 357 women, from 72 general practice offices. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure, serum lipids, smoking status and information about other risk factors. RESULTS: The mean blood pressure of the patients was 147/88 mmHg. Eighty-one men (23%) and 85 women (24%) reached the treatment goal of 140/85 mmHg or less. Low-density lipoprotein-cholesterol level below 2.5 mmol/l was reached by 104 (29%) men and 104 (29%) women. Only 13% of the hypertensive patients (16.8% of the men and 9.2% of the women) were active smokers. CONCLUSIONS: Roughly three-quarters of hypertensive patients still failed to reach the blood pressure target of 140/85 mmHg recommended by the current Finnish Hypertension Guidelines. Our results are disappointing, considering the homogenous Finnish population and thorough primary healthcare system. Although the mean serum cholesterol concentration of the hypertensive population exceeded target values set by the guidelines, a clear improvement compared with early 21st century is seen. Also smoking has diminished considerably.