A community-oriented primary care project in a rural population: reducing cardiovascular risk

A controlled community-oriented primary care (COPC) program designed to reduce cardiovascular risk was conducted in two towns in a poor, rural area of New York State that have populations with high levels of cardiovascular mortality. In both towns, house-to-house visits were used to screen for blood pressure, gather information about cardiovascular risk knowledge and behavior, and provide a cardiovascular educational program. Persons with elevated blood pressure were advised to seek follow-up. Additional interventions, carried out in the study town only, included ongoing follow-up for those with elevated blood pressure and their providers, and sliding-fee medical services for those with financial barriers to care. At rescreening 2 years later, residents of the study population had an adjusted systolic blood pressure 3.1 mm Hg lower than those in the control population (95% confidence interval [CI] = 0.9, 5.3). Furthermore, those who were screened at both rounds had an adjusted systolic blood pressure 2.7 mm Hg lower than those who had not previously been screened (95% CI = 0.6, 4.8). Although knowledge of cardiovascular risk factors increased among those who were surveyed in both rounds, there was little demonstrable effect on cardiovascular risk behaviors. Difficulties were encountered in engaging the participation of all medical providers, and less use was made of the sliding-scale program than expected. While it appears feasible to implement the technical methodology of a COPC model in a rural setting, it is crucial to engage the support of the local and medical community.     

Cardiovascular disease risk factor intervention in low-income women: the North Carolina WISEWOMAN project

OBJECTIVES: The North Carolina WISEWOMAN project was initiated to evaluate the feasibility of expanding an existing cancer screening program to include a cardiovascular disease (CVD) screening and intervention program among low-income women. METHODS: Seventeen North Carolina county health departments were designated as minimum intervention (MI), and 14 as enhanced intervention (EI). The EI included three specially constructed counseling sessions spanning 6 months using a structured assessment and intervention program tailored to lower income women. RESULTS: Of the 2,148 women screened, 40% had elevated total cholesterol (> or = 240 mg/dL), 39% had low high-density lipoprotein cholesterol (HDL-C) levels (< 45 mg/dL), and 63% were hypertensive (systolic blood pressure 140 and/or diastolic blood pressure > or = 90 mm Hg or on hypertensive medication). The majority of women (86%) had at least one of these three risk factors. Seventy-six percent were either overweight or obese. After 6 months of follow-up in the EI health departments, changes in total cholesterol levels, HDL-C levels, diastolic blood pressure, and BMI were observed (-5.8 mg/dL, -0.9 mg/dL, -1.7 mm Hg, and -0.3 kg/m(2), respectively), but were not significantly different from MI health departments. A dietary score that summarized fat and cholesterol intake improved by 2.1 units in the EI group, compared with essentially no change in the MI group. CONCLUSIONS: Expanding existing cancer screening programs to include CVD intervention was feasible and may be an effective means for promoting healthful dietary practices among low-income women.     

Aerobic exercise and resting blood pressure among women: a meta-analysis

PURPOSE: The aim of this study was to use the meta-analytic approach to examine the effects of aerobic exercise on resting systolic and diastolic blood pressure among adult women. METHODS: Studies were retrieved from computer searches (MEDLINE, Sport Discus, Current Contents) and bibliographies of retrieved articles were cross-referenced. Inclusion criteria were as follows: (1) randomized trials, (2) aerobic activity as the primary exercise intervention, (3) comparative nonexercise control group included, (4) changes in resting systolic and/or diastolic blood pressure assessed for women ages 18 and older, and (5) studies published in English-language journals between January 1966 and January 1998. The primary outcomes retrieved in this study were changes in resting systolic and diastolic blood pressure calculated as the difference (exercise minus control) of the changes (initial minus final) in these mean values. RESULTS: Ten studies representing 732 subjects and 36 primary outcomes (19 systolic, 17 diastolic) met the criteria for inclusion. Overall, an approximate 2% decrease in resting systolic and 1% decrease in resting diastolic blood pressure were observed (systolic,;x +/- SD = -2 +/- 2.6 mm Hg, 95% bootstrap confidence interval -3 to -1 mm Hg; diastolic,;x +/- SD = -1 +/- 1.9 mm Hg, 95% bootstrap confidence interval -2 to -1 mm Hg). CONCLUSION: Aerobic exercise results in small reductions in resting systolic and diastolic blood pressure among adult women. However, a need exists for additional, well-designed studies on this topic, especially among hypertensive adult women.     

The effect of a weight reduction program on cardiovascular risk factors among overweight hypertensives in primary health care

The aim of the study was to test the effect of a nonpharmacological weight reduction program on cardiovascular risk factors among overweight hypertensives in a primary health care setting. Forty-nine overweight hypertensive patients completed the 12-month program. The patients were randomly allocated into either intervention or control groups. The examinations included interviews by a nutritionist, pertinent laboratory tests, and a medical examination. The intervention involved an individually planned energy-restricted diet of 1000-1500 kcal per day, weekly discussions, and various leaflets on diet modification and on increase of physical activity. The mean body weight was reduced by 5 kg in the intervention group, but remained unchanged in the control group. The intervention group reduced their fat intake by 14 g/day while the control group increased it by 9 g/day on the average. In the intervention group, the total serum cholesterol decreased, HDL-cholesterol increased and triglycerides decreased significantly. The systolic blood pressure fell by 8 mm Hg and 15 mm Hg in the intervention and control groups, respectively. The diastolic blood pressure fell on average by 11 mm Hg in both groups. The results demonstrate the comprehensive weight reduction program to be effective in the control of cardiovascular risk factors.     

苯那普利上市后流行病学监测

目的 了解苯那普利在一般高血压患者中长期应用的药效及安全性。方法 对上海市某社区1831例原发性高血压患者进行为期3年的药物上市后流行病学监测。结果 3年随访74.3％的患者坚持服药,且具有理想的服药依从性。用药3年后,按规定服药者的收缩压达标率为75.7％,舒张压达标率为87.4％,总达标率为71.5％。总体收缩压水平较服药前降低了近15mm Hg(1mmHg=0.133kPa),舒张压降低了约10mmHg,脉压降低了近5mmHg。用药期间,未见有严重不良反应发生。咳嗽是该药主要的一种不良反应。3年累积咳嗽发生率,女性达23.6％,高于男性的18.8％。结论 苯那普利应用于一般高血压患者群体时,具有较好的长期效果和安全性。     

The effects of a health education intervention program among Cretan adolescents

BACKGROUND. An educational intervention program for the prevention of cardiovascular disease among 171 Cretan school students (13- and 14-year-olds) is assessed. Three schools from the province of Agios Vassilios acted as the intervention group while two schools from a neighboring province (Amari) formed the control group. METHODS. Variables measured included: systolic and diastolic blood pressures, body mass index, triceps skinfold thickness, serum total and high-density lipoprotein cholesterol, triglycerides, and smoking habits. The intervention, based upon social learning theory, consisted of 10 sessions of theoretical and practical instruction on health issues in the classroom, supplemented with discussion, in the classroom, of the issues raised by different sessions. RESULTS. At the end of 1 academic year of intervention the results showed, after adjusting for age, sex, baseline value, height, and weight, an increase in total serum cholesterol of 0.70 mg/dl in the intervention group and 17.91 mg/dl in the control group (P less than 0.0001). Diastolic blood pressure (fourth phase) decreased by 2.95 mm Hg in the intervention group and by 0.48 mm Hg in the control group (P less than 0.05). Similar changes were observed in the body mass index (P less than 0.05). The proportion of school children starting smoking was significantly lower in the intervention group (6%) than in the control (20%) (P less than 0.01). The results indicate that this health education program in schools is effective in decreasing some of the major CVD risk factors. The long-term effect remains to be evaluated.     

Personalized versus usual care of previously uncontrolled hypertensive patients: An exploratory analysis

This study was conducted to explore whether the quality of provider care may contribute to blood pressure reduction and whether other factors related to the treatment of hypertension may explain decline in blood pressure. In the study, 46 uncontrolled (greater than or equal to 140/90 mm Hg), medically treated hypertensive patients who received more personalized care differed significantly in the magnitude of blood pressure reduction from 36 usual-care patients (10/7 vs 2/2 mm Hg means for systolic and diastolic blood pressure reduction, respectively). About twice as many experimental patients as controls were reclassified as having "controlled" blood pressure, and this difference reached statistical significance. A multiple regression analysis for personalized-care subjects showed that no dynamic variables were related to blood pressure changes. It was postulated that more personalized care may have accounted for the significant difference between groups in blood pressure reduction. Similar personalized monitoring services might be important additions to usual medical care in order to control blood pressure more fully in high-risk hypertensive patients.     

Cardiovascular risk education and social support (CaRESS): report of a randomized controlled trial from the Kentucky Ambulatory Network (KAN)

PURPOSE: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. METHODS: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters. RESULTS: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high. CONCLUSION: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.     

Can dietary interventions change diet and cardiovascular risk factors? A meta-analysis of randomized controlled trials.

OBJECTIVES: This study evaluated the effectiveness of dietary advice in primary prevention of chronic disease. METHODS: A meta-analysis was conducted of 17 randomized controlled trials of dietary behavior interventions of at least 3 months' duration. Results were analyzed as changes in reported dietary fat intakes and biomedical measures (serum cholesterol, urinary sodium, systolic and diastolic blood pressure) in the intervention group minus changes in the control group at 3 to 6 months and 9 to 18 months of follow-up. RESULTS: After 3 to 6 months, mean net changes in each of the five outcomes favored intervention. For dietary fat as a percentage of food energy, the change was -2.5% (95% confidence interval [CI] = -3.9%, -1.1%). Mean net changes over 9 to 18 months were as follows: serum cholesterol, -0.22 (95% CI = -0.39, -0.05) mmol/L; urinary sodium, -45.0 (95% CI = -57.1, -32.8) mmol/24 hours; systolic blood pressure, -1.9 (95% CI = -3.0, 0.8) mm Hg; and diastolic blood pressure, -1.2 (95% CI = -2.6, 0.2) mm Hg. CONCLUSIONS: Individual dietary interventions in primary prevention can achieve modest improvements in diet and cardiovascular disease risk status that are maintained for 9 to 18 months.     

北京市中关村社区高血压病例管理方案实施效果评价

目的探索适合社区应用的、规范有效的高血压病例管理方案。方法采取以正常血压值为管理目标,以《中国高血压防治指南》为指导的社区高血压病例管理方案,对中关村社区卫生服务中心567例签约的高血压患者进行随访研究。结果6个月后,高血压患者的血压控制率明显上升(P<0.0001),由原来的50.44%上升到69.84%,整体血压水平显著下降(P<0.0001),收缩压(SBP)下降了3.72mmHg(1mmHg=0.133kPa),舒张压(DBP)下降了2.67mmHg,基线血压异常者SBP下降了8.59mmHg,DBP下降了5.26mmHg。患者的危险行为如吸烟、食盐过多、不参加体育锻炼的比例明显下降(P<0.05)。家庭医生对患者6个月内人均随访次数为7.69次±2.37次,按要求随访患者的血压控制率明显高于不按要求随访患者的血压控制率(P<0.0001),随年龄、文化程度的增高按时随访率有升高趋势(P<0.001)。结论社区卫生服务机构实施的高血压病例管理方案,对提高社区患者的血压控制率是一种有效的管理模式,患者按照家庭医生的要求随访有利于血压控制。     

老年高血压患者症状自评量表及相关因素分析

目的探究症状自评量表对老年性高血压病患者生活质量改善疗效。方法截取某科2010年3月～2011年3月接受治疗的140例高血压病患者随机分组,观察组70例、对照组70例,对照组患者予高血压病防治宣教,观察组在宣教基础上加用治疗型生活方式干预。结果 70例观察组中患者收缩压、舒张压下降幅度均大于对照组(观察组对比对照组收缩压平均下降9mmHg,舒张压下降5mmHg),在SF-36观察量表中,除疼痛感觉、器官功能恢复情况差异不存在统计学意义,其余差异有统计学意义。观察组并发症出现率2例(2.9%),对照组:出现并发症8例(11.49%)。结论症状自评量表可在老年性高血压患者生活质量中起到积极作用。     

Case in Point

Abstract

Epidemiologic and clinical trial data suggest that blood pressure in patients with hypertension who are at high risk for cardiovascular events because of coronary artery disease, diabetes, chronic kidney disease, stroke, or heart failure should be reduced to < 140/90 mm Hg in patients aged < 80 years, and that systolic blood pressure should be reduced to 140 to 145 mm Hg, if tolerated, in patients aged ≥ 80 years. Studies on patients with coronary artery disease, diabetes, chronic kidney disease, stroke, and heart failure are discussed, supporting a blood pressure goal of < 140/90 mm Hg in patients aged < 80 years who are at high risk for cardiovascular events.     

Multiple risk factor intervention trial (MRFIT).: VI. Intervention on blood pressure

The MRFIT blood pressure data derived from the Special Intervention (SI) group of men over the first 4 years are presented, and the results of the hypertension treatment program are reviewed. A therapeutic goal diastolic blood pressure (DBP) was established for each man determined to be hypertensive which included men with DBP ?90 mm Hg and men who were already taking antihypertensive drugs. A stepped care protocol was used to guide the drug treatment. At the fourth annual examination, 63.8% of the 5,790 SI men seen had been previously declared hypertensive. The mean baseline blood pressure (BP) for the hypertensive group was 140.3 mm Hg, systolic, and 94.5 mm Hg, diastolic, and at the 48-month visit, the mean BP was 120.7 mm Hg, systolic, and 82.5 mm Hg, diastolic. Of the hypertensive men seen at 48 months, 87.3% were taking antihypertensive drugs, 65.4% were at or below their goal pressure, and 83.5% had a DBP <90 mm Hg. Most men on antihypertensive drug therapy were at protocol Step 1 or Step 2, receiving a diuretic agent alone (32.9%), or in combination with an antiadrenergic drug (40.4%). Data for specific drug regimens are presented. Older men and men with higher BP levels at entry had a better response. The MRFIT BP results, achieved within a context of a multiple-risk-factor intervention program, compare favorably with the results from recently reported trials that focused solely on the treatment of mild hypertension.     

欠发达地区农村高血压患者规范化管理对其血压水平的干预效果评价

目的探索高血压规范化管理的思路,创新解决欠发达地区农村高血压防治问题。方法以甘肃民勤县为研究现场,采用类试验流行病学方法,并评价患者的收缩压和舒张压水平变化情况。结果试验组血压值在结局期较基线期均有显著降低,试验组血压值降低水平与对照组相比,差异有统计学意义;其干预前后的平均净效益值分别为5．27mmHg（1mmHg=0．133kPa）和3．01m／nHg,而与对照组比较差异无统计学意义;试验组结局期血压控制率较基线期显著提高;试验组收缩压和舒张压在不同随访阶段呈逐渐下降的趋势。结论在欠发达地区农村,以乡镇卫生院医务人员为主导的初级卫生保健力量在高血压规范化管理方案的指导下,通过对高血压患者开展主动的筛查、随访和健康教育,可以有效降低人群的血压水平。     

Women, employment status, and hypertension: cross-sectional and prospective findings from the Atherosclerosis Risk in Communities (ARIC) Study.

PURPOSE: This study examined the cross-sectional and prospective associations between employment status and hypertension among middle-aged, African-American (AA) and European-American (EA) women participating in the Atherosclerosis Risk in Communities Study. METHODS: Employed women and homemakers from the baseline examination (1987-89) were included in the cross-sectional study (n = 7351). Associations between employment and the incidence of hypertension ascertained at visit 2 (1990-92) were determined among those who at baseline, had low-normal blood pressure (not hypertensive and systolic blood pressure (SBP) < or = 120 mm Hg systolic and diastolic blood pressure (DBP) < or =80 mm Hg (n = 3194). Logistic regression analysis was used to examine the association between employment status and hypertension by ethnicity, taking into account covariates. RESULTS: At baseline, employed women were less likely to be hypertensive (SBP > or =140 mm Hg or DBP > or =90 mm Hg or current use of antihypertensive drugs) than were homemakers (prevalence odds ratio) (POR) = 0.70; 95% confidence interval (CI) = 0.62-0.79), controlling for age, body mass index, and education. Among the subgroup who had low-normal blood pressure at baseline, employed women were less likely to develop hypertension during the three-year time period than were homemakers (odds ratio (OR) = 0.68; 95% CI = 0.44-1.05). The inverse association was stronger among AA (RR = 0.37; 95% CI = 0.16-0.88) than EA (OR = 0.83; 95% CI = 0.50-1.38) women. CONCLUSIONS: These findings suggest that the inverse association between hypertension and employment status is not due to a healthy worker effect, and that employment may confer protection against incident hypertension in women.     

我国成年人单纯性收缩期高血压患病率调查

目的评估我国成年人单纯性收缩期高血压的患病率及其人群分布。方法亚洲国际心血管病合作研究(InterASIA)于2000至2001年进行,应用多阶段抽样方法选择15540名35～74岁成年人为代表性样本,分析单纯性收缩期高血压和其他亚型高血压的患病率。应用标准问卷调查高血压病史及其治疗情况。血压值为休息5min后3次坐位血压测量值的平均值。未接受抗高血压治疗的个体通过以下标准确定高血压亚型单纯性收缩期高血压为收缩压≥140mmHg(1mmHg=0133kPa),舒张期血压<90mmHg;单纯性舒张期高血压为收缩压<140mmHg,舒张压≥90mmHg,而收缩期和舒张期联合性高血压为收缩压≥140mmHg,舒张压≥90mmHg。结果15540名35～74岁成年人样本中,76%(1181人)患有单纯性收缩期高血压,74%(1150人)患有收缩期和舒张期联合性高血压,而44%(683人)患有单纯性舒张期高血压。收缩期高血压的患病率随着年龄的增长而增加,且老年女性比老年男性更为常见。南方与北方地区的单纯性收缩期高血压患病率没有明显差异;农村单纯性收缩期高血压患病率高于城市。结论我国收缩期高血压患病率较高,应引起重视。     

Maternal calcium intake during pregnancy and blood pressure in the offspring at age 3 years: a follow-up analysis of the Project Viva cohort

A previous analysis of the Project Viva cohort (eastern Massachusetts, 1999-2002 recruitment) found an association between higher second-trimester supplemental maternal calcium intake and lower systolic blood pressure in offspring at 6 months. The authors analyzed 5,527 systolic blood pressure measurements from 1,173 mother-child pairs from this same cohort when the children were aged 3 years. They estimated the change in offspring blood pressure for a 500-mg difference in maternal total, dietary-only, and supplemental-only calcium intake during the first 2 trimesters of pregnancy. Mean daily total calcium intake was 1,311 mg (standard deviation, 421) in the first trimester and 1,440 mg (standard deviation, 386) in the second trimester. Mean systolic blood pressure of the offspring at age 3 years was 92.1 mm Hg (standard deviation, 10.3). None of the maternal calcium intake measures during the first and second trimesters was associated with systolic blood pressure in the offspring. For example, for each 500-mg increment in maternal total elemental calcium intake in the second trimester, child's 3-year systolic blood pressure was 0.1 mm Hg lower (95% confidence interval: -0.9, 0.6). Maternal calcium intake during pregnancy was not associated with offspring blood pressure at the age of 3 years.     

Effects of alterations in fatty acid intake on the blood pressure of adolescents: the Exeter-Andover Project.

To judge the effect on blood pressure, the ratio of polyunsaturated to saturated fatty acids (P:S) of foods served to students at two boarding high schools was modified alternately at each school for one school year. The average P:S of the diet of males increased from 0.53 to 0.93 during the intervention whereas among females it increased from 0.64 to 0.98. Comparison of repeated systolic and diastolic blood pressure measurements near the end of the school year did not demonstrate a beneficial effect of the dietary fat changes on the blood pressure of these normotensive adolescents. Compared with the blood pressure patterns during control years, the dietary intervention resulted in slightly higher systolic (+0.88 mm Hg; 95% CI -0.66, +2.42) and diastolic (+1.23 mm Hg; 95% CI = +0.04, +2.42) blood pressure readings among males. Among females the intervention resulted in slightly lower systolic (-0.54 mm Hg; 95% CI = -1.95, +0.88) and diastolic (-0.80 mm Hg (95% CI -2.18, +0.58) blood pressure readings.     

Integration of depression and hypertension treatment: a pilot, randomized controlled trial

PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients.METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence.RESULTS In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks.CONCLUSION A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.     

Hypertension in the nursing home

Hypertension in a nursing home patient is a systolic blood pressure of 140 mm Hg or higher and 130 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency, or a diastolic blood pressure of 90 mm Hg or higher and 80 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency. Numerous prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of new coronary events, stroke, and congestive heart failure in older persons. The goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mm Hg and to less than 130/80 mm Hg in older persons with diabetes mellitus or chronic renal insufficiency. Elderly persons with diastolic hypertension should have their diastolic blood pressure reduced to 80 to 85 mm Hg. Diuretics should be used as initial drugs in the treatment of older persons with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their associated medical conditions. If the blood pressure is more than 20/10 mm Hg above the goal blood pressure, drug therapy should be initiated with 2 antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated in patients with hypertension.