Population-derived comparisons of ambulatory and office blood pressures. Implications for the determination of usual blood pressure and the concept of white coat hypertension.

BACKGROUND: Ambulatory blood pressures (BPs) have generally been reported to be lower than office blood pressures, but population-based data are lacking. METHODS: To better characterize ambulatory and office BP relationships, we explored the interrelationships of BPs measured in the office by mercury sphygmomanometry, 24-hour ambulatory BP measured with a portable device, and echocardiographic left ventricular mass in a random sample of 50 men aged 51 to 72 years drawn from a much larger pool. Office BP was based on the mean of 10 measurements performed over five visits. RESULTS: Among all participants, mean 24-hour ambulatory and mean office BPs were highly correlated: r (systolic/diastolic) = .90/.79; and both mean 24-hour and mean awake ambulatory BPs were significantly higher than mean office BPs. For the subsample not receiving antihypertensive therapy, mean ambulatory and office BPs were similar in terms of their associations with Penn left ventricular mass index (LVMI). No association between BP and left ventricular mass was observed among the subjects receiving antihypertensive medication. CONCLUSIONS: We conclude that a single session of 24-hour ambulatory BP monitoring is unlikely to improve the determination of usual BP in older white men beyond that achievable with BP carefully measured over five separate office visits; and that white coat hypertension is rare in this population.

Cost-minimization and the number needed to treat in uncomplicated hypertension.

The goal of this study was to compare the direct costs associated with the prescription of thiazide diuretics, beta-receptor blockers (beta-blockers), angiotensin converting enzyme inhibitors (ACEI), a-receptor blockers (alpha-blockers), and calcium channel blockers (CCB) for the prevention of stroke, myocardial infarction (MI) and premature death in uncomplicated hypertension. We performed a cost-minimization analysis based on numbers-needed-to-treat (NNT) derived from the metaanalysis of 15 major clinical trials of hypertension treatment, and the average wholesale prices of both the most commonly prescribed and the least expensive drugs in each class. The inclusion criteria for clinical trials were that they be randomized, controlled trials of drug therapy of uncomplicated mild-to-moderate hypertension with stroke, MI, or death as endpoints. The wholesale drug costs and the total direct outpatient treatment costs to prevent a stroke, MI or death among middle-aged and elderly hypertensives were our outcome measures. The estimated wholesale drug acquisition cost to prevent one major event (MI or stroke or death) ranged from $4730 to $346,236 among middle-aged patients, and from $1595 to $116,754 in the elderly; generic diuretic or beta-blocker therapy was more economical than treatment with an ACEI, alpha-blocker, or CCB. The associated 5-year NNT was 86 for middle-aged patients and 29 for elderly patients. Diuretic therapy remained more cost-effective even under the unlikely assumption that the newer drugs were 50% more effective than diuretics at preventing these major events. The costs associated with potassium supplementation did not eliminate the advantage of diuretics. Treatment costs to prevent major hypertensive complications are much lower with diuretics and beta-blockers than with ACEI, CCB, or alpha-blockers, especially in middle-aged patients.

A developmental study of practical problem solving in adults.

Previous research indicates that young and middle-aged adults perform better than other age groups on problems similar to those they might encounter in their everyday lives. However, elderly adults have not performed better than other age groups on problems designed to give them the advantage. In order to ensure that the problems used in the present study were ones that elderly adults might encounter, elderly adults were recruited to help develop the problems. The resulting problems were administered to adults between the ages of 20 and 80. Performance was found to increase from the 20- to 40-year-old age group and decrease thereafter. Thus, when elderly adults devise practical problems that are intended to give elderly adults the advantage, the elderly adults still perform less well than do middle-aged adults.

Using standardized patient instructors to teach health promotion interviewing skills.

BACKGROUND: Medical students report knowledge, but inadequate skills, in health promotion and disease prevention (HPDP) technology. An established methodology using standardized patient instructors (SPIs) was adapted and tested for effectiveness in teaching HPDP. METHODS: Thirteen lay persons were trained and given profiles showing high cardiovascular risks. During their family medicine clerkship, 104 students engaged in one-to-one exercises with the SPIs. Half of these sessions were spent in the doctor-patient interview; in the other half, the SPI gave specific feedback using a validated scale. Encounters were videotaped. RESULTS: The students rated the SPI feedback as the program's most valuable aspect and the videotaping as the least valuable. The SPI feedback was rated valuable by 90%-96% of the students. The students also reported that the skills acquired were likely to be used, and they had learned "much" or "very much." As a group, students' self-assessments did not differ from the SPIs' assessments of the students. CONCLUSION: Lay SPIs are a powerful educational tool.

Troglitazone or metformin in combination with sulfonylureas for patients with type 2 diabetes?

BACKGROUND: Combination oral therapy is often used to control the hyperglycemia of patients with type 2 diabetes. We compared the effectiveness of metformin and troglitazone when added to sulfonylurea therapy for patients with type 2 diabetes who had suboptimal blood glucose control. METHODS: We used a randomized 2-group design to compare the efficacy, safety, and tolerability of troglitazone and metformin for patients with type 2 diabetes mellitus that was inadequately controlled with diet and oral sulfonylureas. Thirty-two subjects were randomized to receive either troglitazone or metformin for 14 weeks, including a 2-week drug-titration period. The primary outcome variable was mean change in the level of glycosylated hemoglobin (Hb A1c) from baseline. Secondary outcomes included mean changes from baseline in fasting plasma glucose and C-peptide levels, renal or metabolic side effects, and symptomatic tolerability. RESULTS: The addition of either troglitazone or metformin to oral sulfonylurea therapy significantly decreased Hb A1c levels. Both treatment regimens also significantly reduced fasting plasma glucose and C-peptide levels. We found no significant differences between the treatment arms in efficacy, metabolic side effects, or tolerability. CONCLUSIONS: Our results demonstrate that troglitazone and metformin each significantly improved Hb A1c, fasting plasma glucose, and C-peptide levels when added to oral sulfonylurea therapy for patients with type 2 diabetes who had inadequate glucose control.

Comparisons of ambulatory blood pressure monitoring and repeated office measurements in primary care.

BACKGROUND: The accuracy of office blood pressure (BP) readings is questionable because of blood pressure variability and measurement errors. The primary aim of this study was to determine the number of office visits required to optimize the estimation of usual blood pressure in older adults in primary care. METHODS: Ambulatory blood pressure monitoring was used to define usual blood pressure in an observational study of 75 randomly selected family practice patients. Each subject made six visits for office BP measurements and had 24-hour ambulatory BP monitoring done twice. Mean office BP, based on one through six visits, was compared with mean ambulatory BP. RESULTS: The sample consisted of 29 men and 46 women; 18 were black and 57 were white. Twenty-one subjects were taking antihypertensive medication. The mean age +/- 1/standard deviation (SD) was 60 (+/- 8) years. The correlation between mean office BP and mean ambulatory BP rose with the number of visits averaged, with most of the gain obtained within 3 visits. The maximal correlation for 24-hour ambulatory BP was r = .85/.75 (systolic/diastolic) (P < .01). However, even when using average office BP over six visits to estimate mean ambulatory BP, a discrepancy of > or = 10 mm Hg between estimated and observed ambulatory BP levels persisted in 18% to 20% of subjects. CONCLUSIONS: Readings from at least three office visits should be averaged to estimate usual blood pressure. It should be noted, however, that important discrepancies between estimated and observed mean ambulatory BP persist even after readings taken over six visits. Ambulatory BP monitoring probably provides unique information about usual blood pressure that cannot be captured by repeated office BP readings.

Hypertensive cardiovascular disease and the treatment of hypertension in the elderly.

Hypertension affects most elderly Americans. In eight major randomized, controlled trials evaluating the treatment of hypertension in the elderly, drug therapy for high blood pressure (including isolated systolic hypertension) has been shown to prevent fatal and nonfatal strokes and coronary events. The relative reduction in strokes was greater than that seen in coronary events. An analysis of the combined data shows that the treatment of hypertension in the elderly also reduces mortality from stroke, coronary heart disease, and all causes. All of these major clinical trials used primarily diuretics and beta-blockers. Low-dose diuretics may be superior to beta-blockers in the elderly; however, reliable comparisons of these and other antihypertensive agents in terms of cardiovascular risk reduction are not yet available. Limited comparisons on the efficacy of blood pressure-lowering and patient tolerance characteristics are reviewed.

A lifespan study of classification preference.

Individuals between the ages of 4 and 70 were presented with a revised version of the Conceptual Styles Test. The number of similarity classifications was found to increase from the 4- to the 45- to 50-year-old group and to decrease thereafter; the number of complementary responses was found to decrease and then increase. The 20- to 25-year-old group used more perceptual similarity classifications, whereas the 35- to 40- and 45- to 50-year-old groups used more functional similarity classifications. One purpose of the study was to determine whether, as Kogan has suggested, elderly adults are more creative and free-wheeling in their classification responses than younger individuals. Two measures of creativity were employed; one was based on the experimenter's judgements and one based on the frequency with which the same response was given by other subjects. Neither measure indicated that the elderly individuals were more creative than the other age groups.

Does antihypertensive treatment of the elderly prevent cardiovascular events or prolong life? A meta-analysis of hypertension treatment trials.

OBJECTIVE: To estimate the short-term effects of drug treatment of hypertension in the elderly (> or = 60 years of age) on stroke, major coronary events, and mortality rates. DESIGN: Meta-analysis of all published randomized, controlled trials that addressed the impact of drug treatment of hypertension in the elderly on the above outcomes. SETTING AND PATIENTS: All published clinical trials that met the above criteria involved men and women recruited from primary care practices or through community screenings, who were then treated according to protocol at either community or specialty clinics. Eight randomized, controlled trials that included 15,990 patients treated for an average of 4.6 years were included in this meta-analysis. INTERVENTIONS: Patients received either active antihypertensive treatment or placebo in seven of the studies and programmed stepped care vs referral back to the usual care source in one study. MAIN OUTCOME MEASURES: Fatal or nonfatal myocardial infarction or sudden coronary death; fatal or nonfatal stroke; and all-cause mortality. Outcomes were analyzed on an intention-to-treat basis. RESULTS: Mean baseline blood pressure was 179/90 mm Hg, with a mean treatment effect of 15/6 mm Hg. Homogeneity tests indicated validity of the combined results. Pooled relative risks, calculated as treatment or control (with 95% confidence intervals) for the main end points, were as follows: fatal or nonfatal major coronary event, 0.82 (0.73 to 0.92); fatal or nonfatal stroke, 0.65 (0.57 to 0.75); and death from any cause, 0.85 (0.78 to 0.92) (P < .005 for each). CONCLUSION: Antihypertensive treatment in the elderly prevents major coronary events and stroke and prolongs life, with significant treatment effects observed within only 5 years.

Update on vitamin supplements for the prevention of coronary disease and stroke.

Dietary antioxidants and folic acid may play a role in the pathophysiology of coronary disease and stroke. We review patient-oriented evidence on the effectiveness of supplementation with antioxidants and/or folic acid in the prevention of myocardial infarction and stroke. Observational data suggest cardiovascular benefit of vitamin E supplementation, but results of controlled clinical trials are inconsistent regarding the effect on nonfatal myocardial infarction. Moreover, studies have not shown a protective effect of vitamin E against fatal myocardial infarction and have not addressed stroke. For vitamin C and folic acid supplementation, observational data are inconsistent and controlled clinical trials are lacking. Thus, the available evidence is insufficient to recommend the routine use of vitamin E, vitamin C or folate supplements for the prevention of myocardial infarction or stroke. The evidence argues against the use of beta carotene supplements for this purpose. The costs and risks associated with these supplements are low, however, and physicians may choose to recommend vitamin E, folate and/or vitamin C supplementation pending conclusive evidence from clinical trials.

A developmental study of adults' performance on traditional and practical problem-solving tasks.

Ninety-six individuals between the ages of 20 and 80 were presented with two types of problem-solving tasks. One was a traditional laboratory problem-solving task; the other was composed of a number of practical problems. Three types of practical problems were employed--problems that young adults might encounter in their daily lives, problems that middle-aged adults might encounter, and problems that elderly adults might encounter. On the traditional laboratory task, performance decreased with increasing age. On the practical problems, however, performance increased from the 20- to the 30-year-old group and decreased thereafter with the most drastic decreases occurring in the 60- and 70-year-old groups. When the three types of practical problems were analyzed separately, the performance of the younger adults was better than the performance of older adults on all of the problem-solving tasks, even on the practical problems that were designed specifically to be ones that older adults would be more likely to encounter in their daily lives.

A study of post traumatic stress disorder in Vietnam veterans.

Three groups of Vietnam-era veterans were compared on the frequency of symptoms typical of the diagnostic criteria for Post Traumatic Stress Disorder (PTSD), a diagnostic category introduced in DSM III (N = 90). The three groups consisted of veterans who had experienced (a) a war-related traumatic event; (b) a non-war-related traumatic event; or (c) no traumatic event. The results indicated that the two groups who experienced a traumatic event reported significantly more symptoms than the group who never experienced a traumatic event. Furthermore, the group who experienced a war-related traumatic event reported more symptoms than the group who experienced a non-war-related traumatic event. These results support the validity of PTSD.