Between-person and within-person approaches to the prediction of ambulatory blood pressure: the role of affective valence and intensity.

Identifying momentary influences on ambulatory blood pressure (ABP) will help explain ABP variability; however, most research only examines aggregate ABP at the between-person level. This study used within-person methods to examine whether affective dimensions-valence and arousal-differentially predicted momentary ABP levels. A community sample (n = 39) wore an ABP cuff that took BP measurements every 20 min for 24 h. At each measurement, participants reported levels of valence and arousal on electronic diaries. Multilevel modeling was used to examine the effects of momentary and person-averaged levels of valence and arousal on ABP. Greater momentary negative valence and arousal predicted higher systolic BP compared to more positive or lower arousal assessments; higher averaged levels of arousal predicted higher DBP. The results suggest the independence of the effects of valence and arousal on BP. These findings have important implications for designing interventions to lower ABP.

High trait rumination is associated with blunted nighttime diastolic blood pressure dipping.

BACKGROUND: Blunted blood pressure (BP) dipping during nighttime sleep has been associated with an increased risk of cardiovascular events. Psychological traits have been associated with prolonged cardiovascular activation and a lack of cardiovascular recovery. This activation may extend into nighttime sleep and reduce BP dipping. PURPOSE: This study aims to evaluate the association between trait rumination and nighttime BP dipping. METHODS: Sixty women scoring either high or low on trait rumination underwent one 24-h ambulatory BP monitoring session. Self-reported wake and sleep times were used to calculate nighttime BP. RESULTS: High trait rumination was associated with less diastolic blood pressure (DBP) dipping relative to low trait rumination. Awake ambulatory BP, asleep systolic blood pressure (SBP) and DBP, and asleep SBP dipping were not associated with trait rumination. CONCLUSIONS: In a sample of young women, high trait rumination was associated with less DBP dipping, suggesting that it may be associated with prolonged cardiovascular activation that extends into nighttime sleep, blunting BP dipping.

Child-Mediated Stroke Communication: findings from Hip Hop Stroke.

BACKGROUND AND PURPOSE: Low thrombolysis rates for acute ischemic stroke are linked to delays in seeking immediate treatment due to low public stroke awareness. We aimed to assess whether "Child-Mediated Stroke Communication" could improve stroke literacy of parents of children enrolled in a school-based stroke literacy program called Hip Hop Stroke. METHODS: Parents of children aged 9 to 12 years from 2 public schools in Harlem, New York City, were recruited to participate in stroke literacy questionnaires before and after their child's participation in Hip Hop Stroke, a novel Child-Mediated Stroke Communication intervention delivered in school auditoriums. Parental recall of stroke information communicated through their child was assessed 1-week after the intervention. RESULTS: Fifth and sixth grade students (n=182) were enrolled into Hip Hop Stroke. One hundred two parents were approached in person to participate; 75 opted to participate and 71 completed both the pretest and post-test (74% response rate and 95% retention rate). Parental stroke literacy improved after the program; before the program, 3 parents of 75 (3.9%) were able to identify the 5 cardinal stroke symptoms, distracting symptom (chest pains), and had an urgent action plan (calling 911) compared with 21 of 71 parents (29.6%) postintervention (P<0.001). The FAST mnemonic was known by 2 (2.7%) of participants before the program versus 29 (41%) after program completion (P<0.001). CONCLUSIONS: Knowledge of stroke signs and symptoms remains low among residents of this high-risk population. The use of Child-Mediated Stroke Communication suggests that school children aged 9 to 12 years may be effective conduits of critical stroke knowledge to their parents.

Heart rate recovery after cognitive challenge is preserved with age.

OBJECTIVE: To investigate the effect of age on heart rate recovery (HRR) from cognitive challenge. BACKGROUND: Aging is an independent risk factor for the development of cardiovascular disease. HRR from exercise is an established predictor of cardiac morbidity and mortality, and evidence suggests that HRR from cognitive challenge is predictive of cardiac morbidity as well. Aging is associated with delayed HRR from exercise stress, but little is known about the effect of aging on HRR from psychological stress. We tested the hypothesis that age would be related to delayed HRR from psychological stress. METHODS: HRR post exposure to cognitive challenge (mental arithmetic and Stroop) was investigated in a sample of 436 participants aged 35 to 84 years in MIDUS II, a national study of health and well-being. HRR was measured as 1) the amount of change from the stress level; 2) time to recover; and 3) the area under the curve. The analyses were controlled for medical comorbidities and medications that influence HR, such as body mass index, smoking, sex, menopausal status, and amount of physical activity/exercise. RESULTS: There was no effect for age on HRR as evaluated by all three recovery assessment methods. CONCLUSIONS: Contrary to expectation and in contrast to findings concerning HRR from exercise, HRR from cognitive challenge was preserved with age. These findings require further inquiry into differential mechanism(s) underlying HRR from psychological versus exercise stress, including any role for improved emotion regulation with greater age.

The Effectiveness of Home Blood Pressure on 24-Hour Blood Pressure Control: A Randomized Controlled Trial.

BACKGROUND: Home blood pressure monitoring (HBPM) is cited as an effective approach for improving blood pressure control. The objective of this study was to determine the effectiveness of HBPM combined with a health education session in reducing blood pressure and improving medication adherence among adults with hypertension. METHODS: Two hundred thirteen participants were enrolled in a 3-month study and randomized to receive HBPM or usual care. Participants were also randomized to receive an educational session delivered using a pamphlet or a computer-based program. Topics of the educational session included preventing hypertension, managing weight, staying active, and cutting down on salt and fat. RESULTS: At the 3-month follow-up, there was a reduction in ambulatory blood pressure among the HBPM group. However, the differences found within the HBPM group were no greater than those found among the control group. We did not detect a statistically significant difference in adherence to medication when comparing the HBPM to the usual care group. CONCLUSIONS: HBPM and educational session did not lower blood pressure or improve medication adherence in our sample. A greater effect may have been seen if coupled with an enhanced educational intervention and if blood pressure measures were shared with the provided. The findings of this study provide useful insights for future HBPM studies.

Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension.

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic-daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future.

Racism and ambulatory blood pressure in a community sample.

OBJECTIVE: Racism has been identified as a psychosocial stressor that may contribute to disparities in the prevalence of cardiovascular disease. The goal of the present article was to investigate the relationship of perceived racism to ambulatory blood pressure (ABP) in a sample of American-born Blacks and Latinos. METHODS: Participants included English-speaking Black or Latino(a) adults between the ages of 24 and 65. They completed daily mood diaries and measures of perceived racism, socioeconomic status, and hostility. Participants were outfitted with ABP monitors; 357 provided data on waking hours only, and 245 provided data on both waking and nocturnal ABP. RESULTS: Perceived racism was positively associated with nocturnal ABP even when controlling for personality factors and socioeconomic status. CONCLUSIONS: The results suggest that racism may influence cardiovascular disease risk through its effects on nocturnal BP recovery.

Cardiovascular prognosis of sustained and white-coat hypertension in patients with type 2 diabetes mellitus.

OBJECTIVE: Cardiovascular prognosis in diabetic white-coat hypertension (WCH) has not yet been described. We designed this study to investigate the impact of WCH on cardiovascular events in patients with type 2 diabetes, compared with those having type 2 diabetes along with sustained hypertension (SH), and with nondiabetic hypertensive individuals. METHODS: We performed ambulatory blood pressure (BP) monitoring in 1207 consecutive hypertensive patients at baseline, and they were followed up for 49+/-22 months. The mean age was 70.7+/-9.8 years; 262 had type 2 diabetes; and 945 did not. They were classified as having SH with diabetes (n=210); diabetic WCH (n=52); SH alone (n=719); or WCH alone (n=226), using awake BP of 135/85 mmHg as the cutoff value. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals of the risk for cardiovascular events, after controlling for age, sex, body mass index, current smoking, serum creatinine, and clinical systolic BP. RESULTS: During the follow-up period, 97 cardiovascular events occurred. The incidence of cardiovascular events in the diabetic SH group was significantly higher than in the diabetic WCH, nondiabetic SH, and nondiabetic WCH (P<0.05; log-rank test) groups. In Cox regression analysis, the diabetic SH group had significantly higher risk of cardiovascular events compared with the diabetic WCH group (HR: 8.2; 95% confidence intervals: 1.09-61.8; P=0.04). Although nonsignificant, the HRs in the SH and WCH groups, relative to diabetic WCH, exceeded 3.0. CONCLUSIONS: The cardiovascular prognosis for diabetic WCH was better than that for diabetic SH during 4 years of follow-up.

Consistency of blood pressure differences between the left and right arms.

BACKGROUND: It is unclear to what extent interarm blood pressure (BP) differences are reproducible vs the result of random error. The present study was designed to resolve this issue. METHODS: We enrolled 147 consecutive patients from a hypertension clinic. Three sets of 3 BP readings were recorded, first using 2 oscillometric devices simultaneously in the 2 arms (set 1); next, 3 readings were taken sequentially for each arm using a standard mercury sphygmomanometer (set 2); finally, the readings as performed for set 1 were repeated (set 3). The protocol was repeated at a second visit for 91 patients. RESULTS: Large interarm systolic BP differences were consistently seen in 2 patients with obstructive arterial disease. In the remaining patients, the systolic BP and the diastolic BP, respectively, were slightly higher in the right arm than in the left arm by 2 to 3 mm Hg and by 1 mm Hg for all 3 sets (P<.01 for all). For the systolic BP and the diastolic BP, respectively, the numbers of patients who had a mean interarm difference of more than 5 mm Hg were 11 (7.5%) and 4 (2.7%) across all 3 sets of readings. Among patients who repeated the test, none had a consistent interarm BP difference of more than 5 mm Hg across the 2 visits. CONCLUSIONS: The interarm BP difference was consistent only when obstructive arterial disease was present. Although BP in the right arm tended to be higher than in the left arm, clinically meaningful interarm differences were not reproducible in the absence of obstructive arterial disease and are attributable to random variation.

Stress management in the workplace for employees with hypertension: a randomized controlled trial.

While behavioral interventions can improve blood pressure (BP) in individuals with hypertension, getting such services to people who could benefit remains difficult. Workplace programs have potential as dissemination vehicles. The objective is to evaluate the effectiveness of a standardized stress management program delivered in groups at the workplace for reducing BP compared with enhanced usual care. This randomized controlled trial studied 92 urban medical center employees with hypertension randomized into two groups. The intervention was a 10-week group workshop on cognitive-behavioral coping skills. Enhanced usual care included self-help materials for BP reduction and physician referral. Intervention group participants' systolic BP (SBP) decreased 7.5 mm Hg over controls between baseline and follow-up, from 149.1 (95% CI: 146.0-152.1) to 140.0 (95% CI: 134.7-145.2), p < .001. The differential change between intervention and enhanced usual care groups (Group × Time interaction) was 7.5 mm Hg (t = -2.05; p = .04). Diastolic BP reductions were not significantly different. Scores on measures of emotional exhaustion and depressive rumination showed significant improvements and correlated with reductions in SBP. There was no significant change in the usual care group. A standardized worksite group intervention produced clinically meaningful reductions in SBP in participants with hypertension.

Effect of anger provocation on endothelium-dependent and -independent vasodilation.

Anger is an independent predictor of coronary heart disease events, although the mechanisms for this relation are unclear. The effects of an anger-provoking interview compared with a neutral interview on endothelium-dependent and -independent vasodilation assessed by brachial artery ultrasound were examined in 14 healthy subjects without coronary heart disease risk factors. The anger provocation condition, but not the neutral condition, caused a significant impairment in endothelium-dependent vasodilation at 90 minutes compared with baseline (p = 0.004) and 30 minutes (p = 0.013). Similarly, endothelium-independent vasodilation was significantly impaired at 90 minutes after the angry interview compared with baseline (p = 0.003) and 30 minutes (p = 0.001). The decreases in endothelium-dependent and -independent vasodilation were greater after the anger-provoking interview than after the neutral interview, especially between 30 and 90 minutes. In conclusion, preliminary results suggest that an episode of anger is associated with a dysregulation in endothelium-dependent and -independent pathways, suggesting that these mechanisms might contribute to the link between anger and coronary heart disease events.

Relative utility of home, ambulatory, and office blood pressures in the prediction of end-organ damage.

BACKGROUND: Home blood pressure (HBP) monitoring plays an increasingly important role in the diagnosis and treatment of hypertension. We evaluated the independent value of HBP compared with ambulatory blood pressure (ABP) and office blood pressure (OBP) in the prediction of cardiovascular end-organ damage in normotensive subjects and untreated patients with mild hypertension. METHODS: One hundred sixty-three subjects underwent measurements of OBP, HBP, ABP, and echocardiography. A physician using a mercury-column sphygmomanometer performed three OBP measurements. The ABP was recorded using a noninvasive ambulatory monitor (mean, 35.4 awake readings per subject). Participants took HBP readings with an automatic, oscillometric device over a 10-week period (mean, 277.9 readings per subject). The left-ventricular mass index (LVMI) was calculated from measurements obtained from two-dimensionally guided M-mode or linear tracings on echocardiography. RESULTS: For systolic and diastolic blood pressures (SBP/DBP), the correlation coefficients of the LVMI with OBP, awake ABP, and HBP were 0.29/0.27, 0.41/0.26, and 0.47/0.35, respectively (all P < .01). In a multivariate regression analysis in which age, sex, body mass index, OBP, awake ABP, and HBP were included, only age, sex, and HBP were significant predictors of LVMI. When only the first 12 home readings were used, the superiority of HBP was no longer evident. CONCLUSIONS: In contrast to OBP and ABP, HBP measurements, when averaged over a 10-week period, are independently related to LVMI. The HBP adds prognostic information over and above OBP and ABP in the prediction of cardiovascular end-organ damage, but this relationship appears to depend on the number of readings taken.

The medication Adherence and Blood Pressure Control (ABC) trial: a multi-site randomized controlled trial in a hypertensive, multi-cultural, economically disadvantaged population.

The Medication Adherence and BP Control Trial (ABC Trial) is a randomized, controlled, multi-site, medication adherence and blood pressure (BP) control trial in an economically disadvantaged and multi-cultural population of hypertensive patients followed in primary care practices. To date, no other such trial has been published in which objective measures of adherence (electronic pill bottles) were used to assess the effectiveness of these behavioral interventions for hypertension. This study tested a combination of commercially-available interventions that can be easily accessed by health care providers and patients, and therefore may provide a real-world solution to the problem of non-adherence among hypertensives. The aim of the ABC Trial was to test the effectiveness of a stepped care intervention in improving both medication adherence to an antihypertensive medication regimen and BP control. Step 1 of the intervention employed home Self-BP Monitoring (SBPM); at this stage, there were two arms: (1) Usual Care (UC) and (2) Intervention. At Step 2, patients in the intervention arm whose BP had not come under control after 3 months were further randomized to one of two conditions: (1) continuation of SBPM (alone) or (2) continuation of SBPM plus telephone-based nurse case management (SBPM+NCM). Electronic Medication Event Monitoring (MEMS) was the primary measure of medication adherence, and in-office BP was the primary measure of hypertension control. We present an overview of the study design, details of the administrative structure of the study and a description of clinical site recruitment, patient recruitment, and follow-up assessments.

Recreating cardiovascular responses with rumination: the effects of a delay between harassment and its recall.

Cardiovascular responses occur not only in the immediate presence of stressors, but also while later thinking about those experiences. Evidence suggests that these delayed responses, such as those produced by ruminating about prior angering experiences, may play an important role in the development of cardiovascular disease. We examine whether physiological consequences of rumination depend on the delay between a stressor and its recall, and whether the magnitude of physiological responses decreases with repetition. Twenty-two participants experienced a three-minute harassment stressor, and later spent 3 min vividly recalling the task. Half the subjects returned for the first time after a week, and half returned after half an hour, and then also after a week. Blood pressure and heart rate were monitored during a baseline period, and during each session's stressor or rumination period. Results indicated that rumination was sufficient to elevate blood pressure (systolic and diastolic) above baseline, that the delay made no difference to the magnitude of the elevation, but that the second rumination seemed to be associated with a smaller response than the first. Response to the stressor was not associated with rumination responses, but the first rumination response was significantly correlated with the second. The effects of stress may be experienced long after the actual stressor is passed, and people who experience large delayed responses may not be the same as those with high initial responses. The "hot" affective portion of rumination may not be diminished by the passage of time, but by prior recreation of the experience.

Metabolic syndrome less strongly associated with target organ damage than syndrome components in a healthy, working population.

The authors investigated the associations between target organ damage and individual components of the metabolic syndrome (MS) compared with the MS itself. Carotid intima-media thickness (IMT), carotid plaque, and left ventricular mass index (LVMI) were assessed by ultrasonography in 356 participants who were free of overt cardiovascular disease. Participants with the MS (n=33) had higher LVMI and carotid IMT than those without the MS (n=323), but the percentage of patients who had carotid plaque was similar. Individually, each component of the MS was significantly associated with the 3 measures of target organ damage. In bivariate and multivariate analyses, the association of clinic systolic blood pressure to both LVMI and carotid IMT and the negative association of high-density lipoprotein cholesterol with carotid plaque were stronger than and independent of the MS. The data suggest that physicians should evaluate blood pressure and high-density lipoprotein cholesterol as well as other cardiovascular risk factors without regard to whether a patient meets the criteria for the MS.

Ambulatory blood pressure variability: a conceptual review.

Ambulatory blood pressure (ABP) has long been recognized by researchers as the gold standard of blood pressure (BP) measurement. Researchers and clinicians typically rely on the mean measure of ABP; however, there is considerable variability in the beat-to-beat BP. Although often ignored, this variability has been found to be an independent predictor of cardiovascular disease and mortality. The aim of this paper is to provide a conceptual review of ABP variability (ABPV) focusing on the following: associations between ABPV and health, whether ABPV is reliable, how to calculate ABPV, predictors of ABPV, and treatments for ABPV. Two future directions are discussed involving better understanding ABPV by momentary assessments and improving knowledge of the underlying physiology that explains ABPV. The results of this review suggest that the unique characteristics of ABPV provide insight into the role of BP variability in hypertension and subsequent cardiovascular illness.

Revisiting the lack of association between affect and physiology: Contrasting between-person and within-person analyses.

OBJECTIVE: Despite experimental manipulations that reliably elicit affective and physiological responses, the relationship between the two frequently appears small or nonexistent. We propose that this is, at least in part, due to a mismatch between the nature of the question being asked and the analytic methods applied. For example, to test if levels of affect reliably covary with physiology over time-a within-person question-one cannot apply analytic approaches that test whether people are similarly reactive across domains-a between-person question. The purpose of this paper is to compare within-person and between-person analyses testing the association between affect and physiology. METHOD: Participants (N = 60) recalled an event from their lives that made them angry. Self-reported anger and objective blood pressure levels were recorded at baseline, after the recall, and 5 times during recovery. RESULTS: Between-person correlations between anger and blood pressure were nonsignificant across all phases of the study, suggesting that those least/most reactive for anger were not least/most reactive for blood pressure. These null findings held regardless of whether linear or nonlinear assumptions were modeled. In contrast, within-person multilevel modeling indicated a clear relationship, suggesting that when a person was angrier that person's blood pressure was higher compared with when that person was less angry. CONCLUSION: Results suggest the importance of appropriately matching analytic strategy to the nature of the question regarding the relationships between affect and physiology. Implications for past and future research are discussed. (PsycINFO Database Record

Persistent depressive symptoms lower aspirin adherence after acute coronary syndromes.

BACKGROUND: Even mild depressive symptoms during hospitalization are an independent risk factor for mortality after acute coronary syndromes (ACS). The mortality risk is highest for patients whose depressive symptoms persist after ACS. Low adherence to medications that reduce the risk of subsequent cardiac events may be one of the mechanisms underlying the relationship between persistent depression and risk of ACS recurrence. We compared electronically monitored adherence to aspirin in 3 groups of patients with ACS: persistently depressed, remittent depressed, and persistently nondepressed. METHODS: Using an electronic device stored in the cap of a pill bottle, we monitored aspirin adherence over a 3-month period in 165 consecutive patients recruited within 1 week of an ACS event. Depressive symptom severity was assessed by using the Beck Depression Inventory at baseline and at 3 months. Adherence was determined by the percentage of days aspirin was taken as prescribed. RESULTS: Among the patients, 10.5% of nondepressed patients, 9.8% of remittent depressed patients, and 42.1% of persistently depressed patients took aspirin < or of the time (P < .001). Examined a different way, the mean percentage of days that the correct aspirin dosage (1 pill per day for all patients) was taken was significantly lower in the persistently depressed patients (76.1%) than in the remittent depressed (87.4%) and persistently nondepressed (89.5%) patients (P < .01). Remittent depressed patients did not differ from nondepressed patients. Results remained unchanged after controlling for baseline depressive symptom severity and medical comorbidity. CONCLUSIONS: Poor medication adherence--a potentially modifiable behavior--may contribute to the high mortality risk observed in patients with persistent symptoms of depression after ACS.

Assessment of the white-coat effect.

BACKGROUND: A limitation of blood pressure measurements made in the physician's office is the transient elevation in pressure seen in many patients that does not appear to be linked to target organ damage or prognosis. This has been labeled the 'white-coat effect' (WCE), computed as the difference between blood pressure measurements taken by the physician and the ambulatory level or resting measures. It is unclear, however, which resting measure is most appropriate. The awake ambulatory blood pressure is the most widely used. However, while arguably the most useful measure for prediction of clinical outcomes, it is less appropriate for use as a resting measure, because it is influenced by many factors, including posture and physical activity level. Resting levels taken in the clinic may also be elevated, and will therefore underestimate the WCE. METHODS: We addressed this question by taking resting measures in a non-medical setting on the day before patients were seen at a Hypertension Clinic (day 1), and comparing these with resting measures taken on the following day, in the clinic before the patient saw the physician. RESULTS: As predicted, the day 1 resting levels were lower than those taken in the clinic prior to seeing the physician (P < 0.05 and P < 0.001 for systolic and diastolic pressures, respectively) in both normotensive and hypertensive patients. Using the day 1 resting levels, the estimated WCE for hypertensive patients was 5.3/6.9 mmHg (systolic/diastolic blood pressures), compared with estimates, using the clinic resting levels, of 0.3/0.5 mmHg. The pattern of changes was different in normotensive patients and hypertensive patients, with the physician pressures being slightly lower than day 1 pressures in the former, and substantially higher in the latter. Heart rate changes were similar and modest in both groups. CONCLUSION: The WCE may not just be limited to that narrow interval in which the patient actually sees the physician, but may generalize to the clinic setting, rendering a clinic 'resting' level invalid. While it is strongly positive in most hypertensive patients, it is frequently negative in normotensive patients. Our results suggest that improved methods of measuring blood pressure in the clinic setting are unlikely to resolve the confounding influence of the WCE, and that greater reliance will need to be placed on out-of-office monitoring.

The role of angry rumination and distraction in blood pressure recovery from emotional arousal.

OBJECTIVE: Cardiovascular recovery of prestress baseline blood pressure has been implicated as a possible additional determinant of sustained blood pressure elevation. We hypothesize that angry ruminations may slow the recovery process. METHOD: A within-subjects design was used in which resting baseline blood pressure and heart rate measurements were assessed on 60 subjects, who then took part in two anger-recall tasks. After each task, subjects sat quietly and alone during a 12-minute recovery period randomized to with or without distractions. During baseline, task, and recovery, blood pressure was continuously monitored; during recovery, subjects reported their thoughts at five fixed intervals. RESULTS: Fewer angry thoughts were reported in the distraction condition (17%) compared with no distraction (31%; p = .002); an interaction showed that this effect was largely the result of the two intervals immediately after the anger-recall task. Trait rumination interacted with distraction condition such that high ruminators in the no-distraction condition evidenced the poorest blood pressure recovery, assessed as area under the curve (p = .044 [systolic blood pressure] and p = .046 [diastolic pressure]). CONCLUSIONS: People who have a tendency to ruminate about past anger-provoking events may be at greater risk for target organ damage as a result of sustained blood pressure elevations; the effect is exacerbated when distractions are not available to interrupt the ruminative process.