Randomized Pilot Study of a Behavioral Feedback Intervention to Improve Medication Adherence in Older Adults With Hypertension Rationale and design of the Medication adherence Improvement Support App For Engagement-Blood Pressure (MedISAFE-BP) trial. Home and Online Management and Evaluation of Blood Pressure (HOME BP) digital intervention for self-management of uncontrolled, essential hypertension: a protocol for the randomised controlled HOME BP trial Effectiveness of Digital Medicines to Improve Clinical Outcomes in Patients with Uncontrolled Hypertension and Type 2 Diabetes: Prospective, Open-Label, Cluster-Randomized Pilot Clinical Trial The veterans' study to improve the control of hypertension (V-STITCH): design and methodology. Predictors of uncontrolled hypertension and antihypertensive medication nonadherence A coordinated PCP-Cardiologist Telemedicine Model (PCTM) in China’s community hypertension care: study protocol for a randomized controlled trial Cloud-based BP system integrated with CPOE improves self-management of the hypertensive patients: A randomized controlled trial Clinical Impact of Patient Adherence to a Fixed-Dose Combination of Olmesartan, Amlodipine and Hydrochlorothiazide Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol Review: E-health interventions improve blood pressure level and control in hypertension A Culturally Adapted Telecommunication System to Improve Physical Activity, Diet Quality, and Medication Adherence Among Hypertensive African–Americans: A Randomized Controlled Trial Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. 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Improvement of hypertension management by structured physician education and feedback system: cluster randomized trial Effects of isometric handgrip training on blood pressure (resting and 24 h ambulatory) and heart rate variability in medicated hypertensive patients Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring: A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association Call to action on use and reimbursement for home blood pressure monitoring: executive summary a joint scientific statement from the american heart association, american society of hypertension, and preventive cardiovascular nurses association. 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Background and Objectives : Older adults ' adherence to antihypertensive medications is far lower than what is considered necessary for clinical effectiveness , despite the risks for adverse cardiovascular events from uncontrolled blood pressure ( BP ) in the elderly . This pilot study tested a novel 8-week behavioral feedback intervention to improve antihypertensive medication adherence ( MA ) and BP control among older adults on existing treatment for hypertension . Methods : Adults 60 years old , or older taking at least 1 antihypertensive medication were r and omized to receive the nurse-delivered adherence intervention or usual care . Medication adherence was monitored continuously using electronic monitoring for 20 weeks . Intervention-group participants received biweekly MA and BP feedback , habit counseling , medication and disease education , a medication instruction card , and were given an electronic medication bottle cap with a digital display that provided daily adherence feedback during the 8-week intervention . Blood pressure was measured by a nurse at 12 and 20 weeks after r and omization . Adherence and BP outcomes were described using descriptive statistics and analyzed for between- and within-group differences using Mann-Whitney U tests . Results : Fifteen participants ( median age , 71 years ; 73 % female ) were eligible for r and omization . Participants took an average of 5.8 prescription medications and 2.93 over-the-counter medications per day . A nonsignificant difference was noted in baseline MA between groups . At the end of the intervention , the treatment group had better antihypertensive MA than did the control group ( median MA : 100 % vs 27.3 % , U = 5.00 , P = .013 ) . Systolic BP improved slightly in the intervention group during the study and was significantly different at week 12 ( median systolic BP : 130 vs 152 mm Hg ; U = 4.50 , P = .008 ) . Diastolic BP was largely unchanged over the course of the study . Conclusion : The results indicate that the intervention had a positive effect on MA . Additional testing is needed to further evaluate the intervention and its effect on adherence behavior and BP control BACKGROUND Hypertension is a major contributor to the health and economic burden imposed by stroke , heart disease , and renal insufficiency . Antihypertensives can prevent many of the harmful effects of elevated blood pressure , but medication nonadherence is a known barrier to the effectiveness of these treatments . Smartphone-based applications that remind patients to take their medications , provide education , and allow for social interactions between individuals with similar health concerns have been widely advocated as a strategy to improve adherence but have not been subject to rigorous testing . METHODS / DESIGN The MedISAFE-BP study is a prospect i ve , r and omized control trial design ed to evaluate the impact on blood pressure and medication adherence of an mhealth application ( Medisafe ) .  Four hundred thirteen patients with uncontrolled hypertension have been enrolled and r and omized in a 1:1 fashion to usual care or to the use of the Medisafe mhealth platform  . Patients will be followed up for 12 weeks and the trial 's co- primary outcomes will be change in systolic blood pressure and self-reported medication adherence . DISCUSSION The MedISAFE-BP trial is the first study to rigorously evaluate an mhealth application 's effect on blood pressure and medication adherence . The results will inform the potential effectiveness of this simple system in improving cardiovascular disease risk factors and clinical outcomes Introduction Self-management of hypertension , including self-monitoring and antihypertensive medication titration , lowers blood pressure ( BP ) at 1 year compared to usual care . The aim of the current trial is to assess the effectiveness of the Home and Online Management and Evaluation of Blood Pressure ( HOME BP ) intervention for the self-management of hypertension in primary care . Methods and analysis The HOME BP trial will be a r and omised controlled trial comparing BP self-management — consisting of the HOME BP online digital intervention with self-monitoring , lifestyle advice and antihypertensive drug titration — with usual care for people with uncontrolled essential hypertension . Eligible patients will be recruited from primary care and r and omised to usual care or to self-management using HOME BP . The primary outcome will be the difference in mean systolic BP ( mm Hg ) at 12-month follow-up between the intervention and control groups adjusting for baseline BP and covariates . Secondary outcomes ( also adjusted for baseline and covariates where appropriate ) will be differences in mean BP at 6 months and diastolic BP at 12 months ; patient enablement ; quality of life , and economic analyses including all key re sources associated with the intervention and related services , adopting a broad societal perspective to include NHS , social care and patient costs , considered within trial and modelled with a lifetime horizon . Medication beliefs , adherence and changes ; self-efficacy ; perceived side effects and lifestyle changes will be measured for process analyses . Qualitative analyses will explore patient and healthcare professional experiences of HOME BP to gain insights into the factors affecting acceptability , feasibility and adherence . Ethics and dissemination This study has received NHS ethical approval ( REC reference 15/SC/0082 ) . The findings from HOME BP will be disseminated widely through peer- review ed publications , scientific conferences and workshops . If successful , HOME BP will be directly applicable to UK primary care management of hypertension . Trial registration number IS RCT N13790648 ; pre- results Background Hypertension and type 2 diabetes mellitus are major modifiable risk factors for cardiac , cerebrovascular , and kidney diseases . Reasons for poor disease control include nonadherence , lack of patient engagement , and therapeutic inertia . Objective The aim of this study was to assess the impact on clinic-measured blood pressure ( BP ) and glycated hemoglobin ( HbA1c ) using a digital medicine offering ( DMO ) that measures medication ingestion adherence , physical activity , and rest using digital medicines ( medication taken with ingestible sensor ) , wearable sensor patches , and a mobile device app . Methods Participants with elevated systolic BP ( SBP ≥140 mm Hg ) and HbA1c ( ≥7 % ) failing antihypertensive ( ≥2 medications ) and oral diabetes therapy were enrolled in this three-arm , 12-week , cluster-r and omized study . Participants used DMO ( includes digital medicines , the wearable sensor patch , and the mobile device app ) for 4 or 12 weeks or received usual care based on site r and omization . Providers in the DMO arms could review the DMO data via a Web portal . In all three arms , providers were instructed to make medical decisions ( medication titration , adherence counseling , education , and lifestyle coaching ) on all available clinical information at each visit . Primary outcome was change in SBP at week 4 . Other outcomes included change in SBP and HbA1c at week 12 , and low-density lipoprotein cholesterol ( LDL-C ) and diastolic blood pressure ( DBP ) at weeks 4 and 12 , as well as proportion of patients at BP goal ( < 140/90 mm Hg ) at weeks 4 and 12 , medical decisions , and medication adherence patterns . Results Final analysis included 109 participants ( 12 sites ; age : mean 58.7 , SD years ; female : 49.5 % , 54/109 ; Hispanic : 45.9 % , 50/109 ; income ≤ US $ 20,000 : 56.9 % , 62/109 ; and ≤ high school education : 52.3 % , 57/109 ) . The DMO groups had 80 participants ( 7 sites ) and usual care had 29 participants ( 5 sites ) . At week 4 , DMO result ed in a statistically greater SBP reduction than usual care ( mean –21.8 , SE 1.5 mm Hg vs mean –12.7 , SE 2.8 mmHg ; mean difference –9.1 , 95 % CI –14.0 to –3.3 mm Hg ) and maintained a greater reduction at week 12 . The DMO groups had greater reductions in HbA1c , DBP , and LDL-C , and a greater proportion of participants at BP goal at weeks 4 and 12 compared with usual care . The DMO groups also received more therapeutic interventions than usual care  . Medication adherence was ≥80 % while using the DMO . The most common adverse event was a self-limited rash at the wearable sensor site ( 12 % , 10/82 ) . Conclusions For patients failing hypertension and diabetes oral therapy , this DMO , which provides dose-by-dose feedback on medication ingestion adherence , can help lower BP , HbA1c , and LDL-C , and promote patient engagement and provider decision making . Trial Registration Clinical trials.gov NCT02827630 ; https:// clinical trials.gov/show/NCT02827630 ( Archived by WebCite at http://www.webcitation.org/6rL8dW2VF BACKGROUND Among the 60 million Americans with hypertension , only approximately 31 % have their blood pressure ( BP ) under control ( < 140/90 mm Hg ) . Despite the damaging impact of hypertension and the availability of evidence -based target values for BP , interventions to improve BP control have had limited success . OBJECTIVES A r and omized controlled health services intervention trial with a split-plot design is being conducted to improve BP control . This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans . METHODS In a cluster-r and omization , 30 primary care providers in the Durham VAMC Primary Care Clinic were r and omly assigned to receive the provider intervention or control . The provider intervention is a patient-specific electronically generated hypertension decision support system ( DSS ) delivering guideline -based recommendations to the provider at each patient 's visit , design ed to improve guideline -concordant therapy . For these providers , a sample of their hypertensive patients ( n=588 ) was r and omly assigned to receive a telephone-administered patient intervention or usual care . The patient intervention incorporates patients ' need assessment s and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors .  All modules are delivered over the telephone bi-monthly for 24 months . In this trial , the primary outcome is the proportion of patients who achieve a BP < or = 140/90 mm Hg at each outpatient clinic visit over 24 months . CONCLUSION Despite the known risk of poor BP control , a majority of adults still do not have their BP controlled . This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting Background : Although hypertension is , in most cases , a controllable major risk factor in the development of cardiovascular disease , studies have demonstrated that hypertension remains poorly controlled in Portugal . Our aim was to evaluate the covariates associated with poor blood pressure ( BP ) control in a Portuguese hypertensive population . Patients and Results : We conducted a cross-sectional survey in a hospital hypertension outpatient clinic , located in the Eastern Central Region of Portugal . Patients attending the clinic from July to September 2009 were asked to participate in a structured interview including medication adherence and knowledge about hypertension .  Eligible participants were all adults aged 18 or over with an established diagnosis of arterial hypertension and had been on antihypertensive drug treatment for at least 6 months . Exclusion criteria were dementia , pregnancy , and breastfeeding . Detailed clinical information was prospect ively obtained from medical records . A total of 197 patients meeting the inclusion criteria and consenting to participate completed the interview . Of these , only 33.0 % had their BP controlled according to the JNC 7 guidelines . Logistic regression analysis revealed three independent predictors of poor BP control : living alone ( OR = 5.3 , P = 0.004 ) , medication nonadherence ( OR = 4.8 , P < 0.001 ) , and diabetes ( OR = 4.4 , P = 0.011 ) . Predictors of medication nonadherence were : unawareness of target BP values ( OR = 3.7 , P < 0.001 ) , a report of drug side effects ( OR = 3.7 , P = 0.002 ) , lack of BP monitoring ( OR = 2.5 , P = 0.015 ) and unawareness of medication indications ( OR = 2.4 , P = 0.021 ) , and of hypertension risks ( OR = 2.1 , P = 0.026 ) . Conclusions : Poor medication adherence , lack of information about hypertension , and side effects should be considered as possible underlying causes of uncontrolled BP and must be addressed in any intervention aim ed to improve BP control Background Hypertension is a major risk factor for cardiovascular disease , and its control rate has remained low worldwide . Studies have found that telemonitoring blood pressure ( BP ) helped control hypertension in r and omized controlled trials . However , little is known about its effect in a structured primary care model in which primary care physicians ( PCPs ) are partnering with cardiology specialists in electronic healthcare data sharing and medical interventions . This study aims to identify the effects of a coordinated PCP-cardiologist model that applies telemedicine tools to facilitate community hypertension control in China . Methods / design Patients with hypertension receiving care at four community healthcare centers that are academically affiliated to Shanghai Chest Hospital , Shanghai JiaoTong University are eligible if they have had uncontrolled BP in the previous 3 months and access to mobile Internet . Study subjects are r and omly assigned to three interventional groups : ( 1 ) usual care ; ( 2 ) home-based BP telemonitor with embedded Global System for Mobile Communications ( GSM ) module and unlimited data plan , an app to access personal healthcare record and receive personalized lifestyle coaching contents , and proficiency training of their use ; or ( 3 ) this plus coordinated PCP-cardiologist care in which PCPs and cardiologists share data via a secure CareLinker website to determine interventional approaches . The primary outcome is mean change in systolic blood pressure over a 12-month period . Secondary outcomes are changes of diastolic blood pressure , HbA1C , blood lipids , and medication adherence measured by the eight-item Morisky Medication Adherence Scale . Discussion This study will determine whether a coordinated PCP-Cardiologist Telemedicine Model that incorporates the latest telemedicine technologies will improve hypertension care . Success of the model would help streamline the present community healthcare processes and impact a greater number of patients with uncontrolled hypertension . Trial registration Clinical Trials.gov , NCT02919033 . Registered on 23 September 2016 BACKGROUND Less than 50 % of patients with hypertensive disease manage to maintain their blood pressure ( BP ) within normal levels . OBJECTIVE The aim of this study is to evaluate whether cloud BP system integrated with computerized physician order entry ( CPOE ) can improve BP management as compared with traditional care . METHODS A r and omized controlled trial done on a r and om sample of 382 adults recruited from 786 patients who had been diagnosed with hypertension and receiving treatment for hypertension in two district hospitals in the north of Taiwan . Physicians had access to cloud BP data from CPOE . Neither patients nor physicians were blinded to group assignment . The study was conducted over a period of seven months . RESULTS At baseline , the enrollees were 50 % male with a mean ( SD ) age of 58.18 ( 10.83 ) years . The mean sitting BP of both arms was no different . The proportion of patients with BP control at two , four and six months was significantly greater in the intervention group than in the control group . The average capture rates of blood pressure in the intervention group were also significantly higher than the control group in all three check-points . CONCLUSIONS Cloud-based BP system integrated with CPOE at the point of care achieved better BP control compared to traditional care . This system does not require any technical skills and is therefore suitable for every age group . The praise and assurance to the patients from the physicians after review ing the Cloud BP records positively reinforced both BP measuring and medication adherence behaviors Background and objectives Recent findings from r and omized clinical trials indicate an improved patient adherence and blood pressure ( BP ) control by using fixed-dose combinations ( FDCs ) in the treatment of hypertension . The aim of the present study was to verify those data in a large real-world sample of hypertensive patients and to cross-check adherence evaluation performed by physicians and patients self- assessment . Methods A European multi-center , prospect i ve , 24-week , non-interventional study was conducted including 14,979 patients with essential hypertension and new treatment with olmesartan , amlodipine and hydrochlorothiazide as an FDC .  Patients ’ adherence was measured using the  Morisky Medication Adherence Scale ( MMAS-8 ) and a non-st and ardized question naire was used by physicians and patients for self- assessment . Results The mean age of the patients was 63.9 ± 11.78 years and 46.5 % were women . One or more cardiovascular risk factors were present in 71.9 % of patients and 94.7 % had been treated for hypertension before study entry . Mean adherence to medication by MMAS-8 improved from 6.0 to 6.9 at study end . Corresponding improvements of adherence were seen on physicians ’ and patients ’ self- assessment s throughout the study . Mean decrease of systolic/diastolic BP was 26.4/12.8 mmHg without a relevant difference between the MMAS-8 adherence levels . BP target achievement improved from 55.3 to 67.7 % in patients with low versus high adherence . The overall rate of patients with adverse drug reactions was very low ( 1.76 % ) but more frequent in patients with low adherence . Conclusions Our data confirm previous clinical trial data on the improvement of medication adherence by switching antihypertensive combination therapy to an FDC and a subsequent improvement in BP target achievement . An observed trend toward a reduction in adverse drug reactions needs to be further investigated in clinical trials Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Question In patients with hypertension , do electronic health ( e-health ) interventions improve blood pressure ( BP ) control and other outcomes ? Review scope Included studies compared e-health interventions with usual or st and ard care or attention control in patients with adequately or inadequately controlled hypertension .  E-health interventions had to use portable , Web-based , interactive wireless communication devices and focus on self-care , self-management , self-care behavior change , or education . Studies of interventions that only displayed information ( not interactive ) , were only used for follow-up , or that mostly benefitted health care providers were excluded . Outcomes included physical outcomes ( inadequate BP control , systolic [ SBP ] and diastolic BP [ DBP ] , body mass index [ BMI ] , body weight , and cholesterol levels ) , and self-care behavioral outcomes ( sodium and alcohol intake , smoking , and physical activities ) . Review methods MEDLINE , EMBASE /Excerpta Medica , Cochrane Data base of Systematic Review s , Cochrane Central Register of Controlled Trials , CINAHL Plus , PsycINFO , SCOPUS , Web of Science , Joanna Briggs Institute EBP Data base , INSPEC , China Journal Net , and WanFang Data ( all 2000 to Nov 2017 ) were search ed for English- and Chinese- language r and omized controlled trials ( RCTs ) . 14 RCTs ( n = 3998 , mean age 50 to 68 y ) , ranging in size from 44 to 778 patients , met the selection criteria . Follow-up ranged from 3 to 24 months . Studies were conducted in various setting s , including primary care clinics , community health centers , and hospitals . Intervention strategies included BP monitoring , lifestyle modification techniques , and motivation and maintenance . 9 RCTs had adequate r and omization sequence generation , 6 concealed allocation , 4 blinded outcome assessors , and none adequately reported blinding participants . Main results Results for inadequate BP control , SPB , DBP , BMI , body weight , and sodium intake are in the Table . E-health interventions did not improve total cholesterol levels at 3 to 6 months after the intervention ( 3 RCTs ) ; or alcohol intake , smoking , or physical activity at 6 months after the intervention ( 3 RCTs ) . Conclusion In patients with hypertension , electronic health interventions reduce blood pressure levels and increase likelihood of blood pressure control .  Electronic health interventions vs control in patients with hypertension * Outcomes Assessment times ( after intervention ) Number of trials ( n ) RRR ( 95 % CI ) NNT ( CI ) Inadequate BP control 3 to 12 mo 5 ( 1518 ) 31 % ( 16 to 43 ) 6 ( 4 to 11 ) Mean between-group difference ( CI ) Change in systolic BP ( mm Hg ) 6 mo 12 ( 3171 ) 5.50 ( 9.85 to 1.16 ) 12 mo 3 ( 1272 ) 7.68 ( 9.95 to 5.41 ) 18 mo 2 ( 735 ) 6.26 ( 9.29 to 3.23 ) Change in diastolic BP ( mm Hg ) 6 mo 12 ( 3171 ) 3.40 ( 7.79 to 0.99 ) 12 mo 3 ( 1272 ) 3.36 ( 4.80 to 1.92 ) 18 mo 2 ( 735 ) 2.53 ( 4.72 to 0.34 ) Change in body mass index ( kg/m2 ) 6 mo 5 ( 1486 ) 0.22 ( 0.46 to 0.02 ) 12 mo 3 ( 1272 ) 0.24 ( 0.82 to 0.33 ) 18 mo 2 ( 735 ) 0.07 ( 0.77 to 0.91 ) Change in body weight ( kg ) 3 to 6 mo 3 ( 517 ) 1.08 ( 2.04 to 0.13 ) Change in sodium intake ( SMD ) 6 mo 2 ( 768 ) 0.34 ( 0.49 to 0.20 ) 12 mo 2 ( 753 ) 0.39 ( 0.54 to 0.25 ) 18 mo 2 ( 735 ) 0.30 ( 0.45 to 0.16 ) * BP = blood pressure ; SMD = st and ardized mean difference ; other abbreviations defined in Glossary . Weighted electronic health intervention event rate , RRR , NNT , and CI calculated using control event rate and relative risk in article . Blood pressure 140/90 mm Hg . Weighted event rates 42 % vs 60 % . Commentary The systematic review and meta- analysis by Ma and colleagues showed a small but clinical ly meaningful reduction in SBP and DBP  in patients who received e-health re sources . However , some health outcomes , including BMI and cholesterol levels , were not improved . Despite a risk for selection bias in some of the studies and substantial heterogeneity between studies , the meta- analysis is of high quality . The interventions in the included studies varied greatly and included use of telephone calls , Web sites , and smartphone applications . The comparison treatments were either attention control or usual care , and trials did not directly compare e-health interventions . The outcomes measured also varied among studies . Because clinic BP measurements may overestimate the degree of elevation and ambulatory monitoring is costly and limited to brief periods of measurement , home BP monitoring using newer e-health re sources may provide a cost-effective alternative ( 1 ) . This is an exciting new avenue for improving BP control by allowing for more accurate and streamlined monitoring , leading to more precise and timely interventions . However , based on the heterogeneity of intervention types , the optimum method is unknown . Further studies should directly compare e-health platforms and assess patient-centered outcomes , including usability , satisfaction , affordability , and quality of life as well as BP . Although the evidence indicates that these interventions are not yet ready for routine clinical practice , there is a promising signal that they could be useful for BP management Background Hypertension is more prevalent and clinical ly severe among African – Americans than whites . Several health behaviors influence blood pressure ( BP ) control , but effective , accessible , culturally sensitive interventions that target multiple behaviors are lacking . Purpose We evaluated a culturally adapted , automated telephone system to help hypertensive , urban African – American adults improve their adherence to their antihypertensive medication regimen and to evidence -based guidelines for dietary behavior and physical activity . Methods We r and omized 337 hypertensive primary care patients to an 8-month automated , multi-behavior intervention or to an education-only control . Medication adherence , diet , physical activity , and BP  were assessed at baseline and every 4 months for 1 year . Data were analyzed using longitudinal modeling . Results The intervention was associated with improvements in a measure of overall diet quality ( + 3.5 points , p < 0.03 ) and in energy expenditure ( + 80 kcal/day , p < 0.03 ) . A decrease in systolic BP between groups was not statistically significant ( −2.3 mmHg , p = 0.25 ) . Conclusions Given their convenience , scalability , and ability to deliver tailored messages , automated telecommunications systems can promote self-management of diet and energy balance in urban African – Americans OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology ( TSOC ) . There is new evidence regarding the management of hypertension , including r and omized controlled trials , non-r and omized trials , post-hoc analyses , subgroup analyses , retrospective studies , cohort studies , and registries . More recently , the European Society of Hypertension ( ESH ) and the European Society of Cardiology ( ESC ) published joint hypertension guidelines in 2013 . The panel members who were appointed to the Eighth Joint National Committee ( JNC ) also published the 2014 JNC report . Blood pressure ( BP ) targets have been changed ; in particular , such targets have been loosened in high risk patients . The Executive Board members of TSOC and the Taiwan Hypertension Society ( THS ) aim ed to review up date d information about the management of hypertension to publish an up date d hypertension guideline in Taiwan . We recognized that hypertension is the most important risk factor for global disease burden . Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world . In most countries in East Asia , stroke surpassed coronary heart disease ( CHD ) in causing premature death . A diagnostic algorithm was proposed , emphasizing the importance of home BP monitoring  and ambulatory BP monitoring  for better detection of night time hypertension , early morning hypertension , white-coat hypertension , and masked hypertension . We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to < 140/90 mmHg for all patients . We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to < 150/90 mmHg for patients between 60 - 80 years of age . For patients with diabetes , CHD , chronic kidney disease who have proteinuria , and those who are receiving antithrombotic therapy for stroke prevention , we propose BP targets of < 130/80 mmHg in our guidelines . BP targets are < 140/90 mmHg for all other patient groups , except for patients ≥80 years of age in whom a BP target of < 150/90 mmHg would be optimal . For the management of hypertension , we proposed a treatment algorithm , starting with life style modification ( LSM ) including S-ABCDE ( Sodium restriction , Alcohol limitation , Body weight reduction , Cigarette smoke cessation , Diet adaptation , and Exercise adoption ) . We emphasized a low-salt strategy instead of a no-salt strategy , and that excessively aggressive sodium restriction to < 2.0 gram/day may be harmful . When drug therapy is considered , a strategy called " PROCEED " was suggested ( Previous experience , Risk factors , Organ damage , Contraindications or unfavorable conditions , Expert 's or doctor 's judgment , Expenses or cost , and Delivery and compliance issue ) . To predict drug effects in lowering BP , we proposed the " Rule of 10 " and " Rule of 5 " . With a st and ard dose of any one of the 5 major classes of anti-hypertensive agents , one can anticipate approximately a 10-mmHg decrease in systolic BP ( SBP ) ( Rule of 10 ) and a 5-mmHg decrease in diastolic BP ( DBP ) ( Rule of 5 ) . When doses of the same drug are doubled , there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP . Preferably , when 2 drugs with different mechanisms are to be taken together , the decrease in BP is the sum of the decrease of the individual agents ( approximately 20 mmHg in SBP and 10 mmHg in DBP ) . Early combination therapy , especially single-pill combination ( SPC ) , is recommended . When patient 's initial treatment can not get BP to targeted goals , we have proposed an adjustment algorithm , " AT GOALs " ( Adherence , Timing of administration , Greater doses , Other classes of drugs , Alternative combination or SPC , and LSM + Laboratory tests ) . Treatment of hypertension in special conditions , including treatment of resistant hypertension , hypertension in women , and perioperative management of hypertension , were also mentioned . The TSOC/THS hypertension guidelines provide the most up date d information available in the management of hypertension . The guidelines are not m and atory , and members of the task force fully realize that treatment of hypertension should be individualized to address each patient 's circumstances . Ultimately , the decision of the physician decision remains of the utmost importance in hypertension management Efforts to increase blood pressure ( BP ) control rates in blacks , a traditionally underserved high-risk population must address both provider practice and patient adherence issues . The home-based BP Intervention for blacks study is a 3-arm r and omized controlled trial design ed to test 2 strategies to improve hypertension management and outcomes in a de central ized service setting serving a vulnerable and complex home care population . The primary study outcomes are systolic BP , diastolic BP , and BP control ; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication , healthy diet  , and other self-management strategies .  Nurses ( n=312 ) in a nonprofit Medicare-certified home health agency are r and omized along with their eligible hypertensive patients ( n=845 ) . The 2 interventions being tested are ( 1 ) a " basic " intervention delivering key evidence -based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care ; and ( 2 ) an " augmented " intervention that includes that same as the basic intervention , plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months . Outcomes are measured at 3 and 12 months after baseline interview . The interventions will be assessed relative to usual care and to each other . Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact . Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population This blinded placebo-controlled crossover study evaluated the acute effects of an orally disintegrating lozenge that generates nitric oxide ( NO ) in the oral cavity on blood pressure ( BP ) response , endothelial function , and vascular compliance in unmedicated hypertensive patients . Thirty patients with clinical hypertension were recruited and enrolled in a blinded placebo-controlled clinical trial in an outpatient setting . Average baseline BP in 30 patients was 144±3/91±1 mm Hg . NO supplementation result ed in a significant decrease of 4 mm Hg in resting systolic BP ( P<.003 ) and a significant decrease of 5 mm Hg in diastolic BP ( P<.002 ) from baseline and placebo after 20 minutes . In addition , there was a further statistically significant reduction by 6 mm Hg in both systolic and diastolic pressure after 60 minutes ( P<.0001 vs baseline ) . After a half hour of a single dose , there was a significant improvement in vascular compliance as measured by augmentation index and , after 4 hours , a statistically significant improvement in endothelial function as measured by the EndoPAT ( Itamar Medical , Franklin , MA ) . A single administration of an oral active NO supplement appears to acutely lower BP , improve vascular compliance , and restore endothelial function in patients with hypertension Background —Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects . Effective programs to address this problem are lacking . We hypothesized that an information technology – supported management program could help improve blood pressure ( BP ) control . Methods and Results —This r and omized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP > 130/80 and daytime BP > 135/85 mm Hg measured with ambulatory monitoring ( ABPM ) . Intervention subjects received a BP monitor and access to an information technology – supported adherence and BP monitoring system providing nurses , pharmacists , and physicians with monthly reports . Control subjects received usual care . The mean ( ±SD ) follow-up was 348 ( ±78 ) and 349 ( ±84 ) days in the intervention and control group , respectively . The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic ( −11.9 versus −7.1 mm Hg ; P<0.001 ) and diastolic BP ( −6.6 versus −4.5 mm Hg ; P=0.007 ) . The proportion of subjects that achieved Canadian Guideline target BP ( 46.0 % versus 28.6 % ) was also greater in the intervention group ( P=0.006 ) . We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control . The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents ( P=0.03 ) , more antihypertensive classes at study end ( P=0.007 ) , and a trend toward improved adherence measured by prescription refills ( P=0.07 ) . Conclusions —This multidisciplinary information technology – supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting Abstract FURIN is a proprotein convertase subtilisin/kexin enzyme important in pro‐renin receptor processing , and FURIN ( furin , paired basic amino acid cleaving enzyme ) variants are involved in multiple aspects of blood pressure ( BP ) regulation . Therefore , we examined associations among FURIN variants and the immediate blood pressure ( BP ) response to bouts of aerobic exercise , termed postexercise hypotension ( PEH ) . Obese ( 30.9 ± 3.6 kg m−2 ) Black‐ ( n = 14 ) and White‐ ( n = 9 ) adults 42.0 ± 9.8 year with hypertension ( 139.8 ± 10.4/84.6 ± 6.2 mmHg ) performed three r and om experiments : bouts of vigorous ( VIGOROUS ) and moderate ( MODERATE ) intensity cycling and control . Subjects were then attached to an ambulatory BP monitor for 19 h. We performed deep‐targeted exon sequencing with the Illumina TruSeq Custom Amplicon kit . FURIN genotypes were coded as the number of minor alleles ( # MA ) and selected for additional statistical analysis based upon Bonferonni or Benjamini – Yekutieli multiple testing corrected P‐values under time‐adjusted linear models for 19 hourly BP measurements . After VIGOROUS over 19 h , as FURIN # MA increased in rs12917264 ( P = 2.4E‐04 ) and rs75493298 ( P = 6.4E‐04 ) , systolic BP ( SBP ) decreased 30.4–33.7 mmHg ; and in rs12917264 ( P = 1.6E‐03 ) and rs75493298 ( P = 9.7E‐05 ) , diastolic BP ( DBP ) decreased 17.6–20.3 mmHg among Blacks only . In addition , after MODERATE over 19 h in FURIN rs74037507 ( P = 8.0E‐04 ) , as # MA increased , SBP increased 20.8 mmHg among Blacks only . Whereas , after MODERATE over the awake hours in FURIN rs1573644 ( P = 6.2E‐04 ) , as # MA increased , DBP decreased 12.5 mmHg among Whites only . FURIN appears to exhibit intensity and race‐dependent associations with PEH that merit further exploration among a larger , ethnically diverse sample of adults with hypertension Context Can self-management interventions help improve blood pressure control in hypertensive patients ? Contribution In this trial , 636 patients with hypertension were r and omly assigned to receive usual care ; a telephone-delivered , nurse-administered behavioral self-management intervention ; home blood pressure self-monitoring ; or both of the latter 2 interventions . Compared with usual care , the adjusted improvement in the proportion of patients with blood pressure control at 24 months was 4.3 % for the behavioral intervention group , 7.6 % for the blood pressure monitoring group , and 11.0 % for the combined intervention group . Caution Patients were recruited from 2 university-affiliated clinics , and most ( 73 % ) already had reasonable blood pressure control at trial entry . The Editors Although multiple treatment options are available for hypertension , only one third of U.S. patients with hypertension have their blood pressure ( BP ) under effective control ( 1 ) . Home BP monitoring is a potentially important aspect of successful hypertension management ( 2 ) . Adopting a healthy lifestyle and adhering to provider recommendations are also important in managing hypertension . Few educational and BP monitoring studies have provided long-term follow-up ( > 12 months ) or implemented a multidimensional intervention that is tailored to patients ' needs and delivered by telephone ( 3 ) . A tailored telephone behavioral intervention and home BP monitoring may be a cost-effective method for improving BP outcomes ( 4 ) . We compared the effectiveness of BP self-monitoring , a tailored , nurse-administered behavior self-management intervention , and a combination of the 2 interventions with that of usual care . Methods The study was approved by the Duke University Institutional Review Board , and all patients provided written informed consent . Setting and Participants Recruitment occurred from May 2004 to December 2005 , with follow-up from November 2004 to January 2008 . Potentially eligible study patients were identified through weekly data extraction s from the billing and appointment data base for 2 Duke University Health System primary care clinics . Patients were cared for by 7 faculty general internists in 1 clinic and 85 residents under the supervision of faculty at the other clinic . Initial inclusion criteria were hypertension diagnosed at least 12 months before the data extraction date ( International Classification of Diseases , 9th revision , codes 401.0 , 401.1 , or 401.9 ) , enrollment with a primary care physician at the included clinic for at least 12 months before data extraction , self-report of current antihypertensive medication use , a scheduled appointment with a nonlaboratory primary care provider during the next 30 days , and residence in 1 of 32 specified ZIP codes in the areas around Duke University Health System . Exclusion criteria applied before r and omization were a diagnosis of dementia , Parkinson disease , atrial fibrillation , or end-stage renal disease ; patient of a study investigator or physician not expected to remain at the practice during the entire study period ; resident in nursing home or receiving home health care ; hospitalization for stroke or heart attack , surgery for blocked arteries , or diagnosis of metastatic cancer in the previous 3 months ; poor vision or difficulty hearing on the telephone ; difficulty underst and ing English on the telephone ; participant in another BP study ; spouse participating in current study ; arm circumference greater than 17 inches and wrist circumference greater than 8.5 inches ; pregnant or planning to become pregnant in the next 2 years ; or not receiving most medical care from Duke clinics . Patients also were excluded after r and omization because they were no longer receiving medical care at the Duke clinics , had initiated dialysis , had received an organ transplant in the previous 6 months , resided in a nursing home or receiving home health care , had no telephone , or received a diagnosis of pulmonary hypertension in the previous 6 months . The study team mailed qualifying patients a letter from the patient 's primary care provider that gave information about the study and stated that the study team may contact them to participate . Research assistants made weekly screening telephone calls to patients from a r and omly ordered list of eligible patients with upcoming clinic appointments . Figure 1 shows the flow of participants in the study . Overall , 2060 invitation letters were mailed to patients . Research assistants attempted to contact 1728 potential participants by telephone . Six hundred fifty-six patients were enrolled and consented to participate ; the remaining 1072 were not enrolled for various reasons . Twenty additional patients were excluded at the time of the baseline interview . Figure 1 . Study flow diagram . BP = blood pressure . * No longer receiving care at Duke clinics , receiving dialysis , received an organ transplant , residing in a nursing home or receiving home health care , had no telephone , or had pulmonary hypertension . R and omization and Intervention The 636 eligible patients were r and omly assigned to receive usual care , a tailored behavioral telephone intervention , home BP monitoring , or the behavioral intervention plus BP monitoring . In a 22 design , r and omization was stratified at baseline by enrollment site ( 2 primary care clinics ) and health literacy status , as determined by using the Rapid Estimate of Adult Literacy in Medicine ( 5 ) ( low literacy , score of 0 to 60 [ 9th- grade level or less ] [ 6 ] , vs. adequate literacy , score of 61 to 66 [ greater than 9th- grade level ] [ 7 ] ) . Consecutively numbered envelopes were used to r and omly assign patients in each stratum . R and omization blocks of 16 were computer generated by the study statistician and used to ensure ongoing balanced enrollment across the 4 groups . The research assistants were blinded to block size , and patient r and omization sequences were maintained by the study statistician in a separate office from the clinics . At completion of the baseline interview , a research assistant opened an envelope and disclosed the patient 's r and omization status . Participants were reimbursed $ 25 for the baseline visit and for each of the 4 subsequent 6-month BP measurement visits ( $ 125 total ) . Usual Care Patients assigned to usual care received hypertension care from their primary care provider . They were not provided home BP monitors and did not have access to the nurse-administered behavioral intervention . They underwent the same 6-month outcome assessment measurements as the other groups . Tailored Behavioral Self-management Intervention Patient factors targeted in the behavioral intervention included perceived risk for hypertension , memory , literacy , social support , patients ' relationships with their health care providers , and side effects of antihypertension medication . In addition , the intervention focused on improving  adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern  ( 811 ) ,  weight loss  ( 12 , 13 ) ,  reduced sodium intake  ( 13 , 14 ) ,  regular moderate-intensity physical activity  ( 15 , 16 ) ,  smoking cessation  , and moderation of alcohol intake  ( 17 ) . The intervention was delivered by 1 nurse during bimonthly telephone calls . All information was presented in an easily understood format with a FleschKincaid readability score of less than 9th grade ( 18 ) . Each encounter included a core group of modules potentially implemented during each call ( for example , medication and side effects ) plus additional modules activated at specific intervals ( for example , diet and social support ) ( 19 ) . Home BP Monitoring Intervention Patients assigned to home BP monitoring received an Omron HEM 773AC arm monitor ( OMRON Healthcare , Bannockburn , Illinois ) if arm circumference was 17 inches or less or an Omron HEM 637 wrist monitor if arm circumference was greater than 17 inches and wrist circumference was less than 8.5 inches . Two research assistants trained patients in proper use of the home BP devices . At each 6-month assessment , patients were retrained if their BP assessment procedure was incorrect . Patients were asked to measure their BP 3 times weekly on 3 separate days , at the same time of day , and record their values in a log . Patients were asked to mail their logs in every 2 months by using study -provided , preaddressed , stamped envelopes . Combined Intervention Patients assigned to the combined intervention received a home BP monitor , training on its use , and the behavioral self-management intervention . The nurse did not examine home BP values and did not use the home BP values to adjust the intervention . Outcomes and Measurements Baseline Measurement Patient demographic information and diagnosis of diabetes were obtained from patients during a face-to-face baseline interview . Inadequate income was assessed by asking patients to report whether they had enough money to pay bills only by cutting back on things or had difficulty paying bills ( 20 ) . Health literacy was evaluated as a dichotomous variable ( 7 ) . Body weight abstract ed from the medical record and self-reported height were used to calculate body mass index . Study Outcomes : BP Control and Systolic and Diastolic BP The primary outcome was the proportion of participants with adequate BP control at each study time point ( baseline and 6 , 12 , 18 , and 24 months ) . Blood pressure control was defined as systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg for patients without diabetes , and systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg for patients with diabetes ( 21 ) . Secondary outcomes were systolic and diastolic BP at each time point over 24 months . At each time point , a research assistant who was blinded to the patient 's group assignment obtained 2 BP measurements with a digital sphygmomanometer ( BPTRU Automated Non-invasive BP monitor , Model BPM-100 , BpTRU Medical Devices Headquarters , Coquitlam , British Columbia , Canada ) ; the first was obtained after patients were ABSTRACT Background It is important to underst and which components of successful multifaceted interventions are responsible for study outcomes , since some components may be more important contributors to the intervention effect than others . Objective We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure ( BP ) after 6 months in a trial to improve hypertension control . Design The study was a preplanned secondary analysis of a cluster-r and omized clinical trial . Eight clinics in an integrated health system were r and omized to provide usual care to their patients ( n = 222 ) , and eight were r and omized to provide a telemonitoring intervention ( n = 228 ) . Participants Four hundred three of 450 trial participants completing the 6-month follow-up visit were included . Interventions Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists , who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits . Main measures Path analytic models estimated indirect effects of the seven potential mediators of intervention effect ( defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months ) . The potential mediators were change in home BP monitor use , number of BP medication classes , adherence to BP medications , physical activity , salt intake , alcohol use , and weight . Key Results The difference in change in systolic BP was 11.3 mmHg . The multivariable mediation model explained 47 % ( 5.3 mmHg ) of the intervention effect . Nearly all of this was mediated by two factors : an increase in medication treatment intensity ( 24 % ) and increased home BP monitor use ( 19 % ) . The other five factors were not significant mediators , although medication adherence and salt intake improved more in the intervention group than in the usual care group . Conclusions Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification . High adherence at baseline and the relatively low intensity of re sources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP Diabetes mellitus ( DM ) is now considered as the major cause of end-stage kidney failure , and hypertension ( HTN ) is one of the main determinants of progression of renal disease . The aim of this study was to assess the role of blood pressure ( BP )  by  ambulatory blood pressure monitoring ( ABPM ) in children and adolescents with type-1 DM and its correlation with micro-albuminuria ( MA ) and diabetic control . Eighty-one patients with type-1 DM ( mean age 13 ± 4 years ) , whose duration of DM was at least two years , were enrolled in this study . The prevalence of HTN based on ABPM was 28.4 % , while by casual method it was 32.1 % . The pattern of HTN was as follows : mean systolic HTN 27.2 % , mean diastolic HTN 11.2 % , daytime systolic HTN 17.3 % , daytime diastolic HTN 6.2 % , night systolic HTN 30.9 % , and night diastolic HTN 29.7 % . The systolic and diastolic BP loads were 33.4 and 27.2 % , respectively . About 70.4 % of the patients were non-dippers , 12.4 % had masked HTN , and 3.7 % had white coat HTN . The pre-valence of MA was 34.6 % and that of abnormal HbA 1 c was 82.7 % . There was no correlation between HTN and both MA and HbA 1 c ; also , no correlation was found between the duration of diabetes and HbA 1 c. Moreover , no significant correlation was found between the duration of diabetes and MA ( P = 0.080 ) . Despite the high prevalence of abnormal BP profile among diabetic children , prospect i ve longitudinal studies considering the other major risk factors , particularly genetic factors , which have an impact on the progression to diabetic nephropathy , are recommended CONTEXT Weight loss , sodium reduction , increased physical activity , and limited alcohol intake are established recommendations that reduce blood pressure ( BP ) . The Dietary Approaches to Stop Hypertension ( DASH ) diet also lowers BP . To date , no trial has evaluated the effects of simultaneously implementing these lifestyle recommendations . OBJECTIVE To determine the effect on BP of 2 multicomponent , behavioral interventions . DESIGN , SETTING , AND PARTICIPANTS R and omized trial with enrollment at 4 clinical centers ( January 2000-June 2001 ) among 810 adults ( mean [ SD ] age , 50 [ 8.9 ] years ; 62 % women ; 34 % African American ) with above-optimal BP , including stage 1 hypertension ( 120 - 159 mm Hg systolic and 80 - 95 mm Hg diastolic ) , and who were not taking antihypertensive medications . INTERVENTION Participants were r and omized to one of 3 intervention groups : ( 1 ) " established , " a behavioral intervention that implemented established recommendations ( n = 268 ) ; ( 2 ) " established plus DASH,"which also implemented the DASH diet ( n = 269 ) ; and ( 3 ) an " advice only " comparison group ( n = 273 ) . MAIN OUTCOME MEASURES Blood pressure measurement and hypertension status at 6 months . RESULTS Both behavioral interventions significantly reduced weight , improved fitness , and lowered sodium intake . The established plus DASH intervention also increased fruit , vegetable , and dairy intake . Across the groups , gradients in BP and hypertensive status were evident . After subtracting change in advice only , the mean net reduction in systolic BP was 3.7 mm Hg ( P<.001 ) in the established group and 4.3 mm Hg ( P<.001 ) in the established plus DASH group ; the systolic BP difference between the established and established plus DASH groups was 0.6 mm Hg ( P = .43 ) . Compared with the baseline hypertension prevalence of 38 % , the prevalence at 6 months was 26 % in the advice only group , 17 % in the established group ( P = .01 compared with the advice only group ) , and 12 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .12 compared with the established group ) . The prevalence of optimal BP ( < 120 mm Hg systolic and < 80 mm Hg diastolic ) was 19 % in the advice only group , 30 % in the established group ( P = .005 compared with the advice only group ) , and 35 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .24 compared with the established group ) . CONCLUSION Individuals with above-optimal BP , including stage 1 hypertension , can make multiple lifestyle changes that lower BP and reduce their cardiovascular disease risk BACKGROUND Only 31 % of Americans with hypertension have their blood pressure ( BP ) under effective control . We describe a study that tests 3 different interventions in a r and omized controlled trial using home BP telemedicine monitoring . METHODS A sample of hypertensive patients with poor BP control at baseline ( N = 600 ) are r and omized to 1 of 4 arms : ( 1 ) control group -- a group of hypertensive patients who receive usual care ; ( 2 ) nurse-administered tailored behavioral intervention ; ( 3 ) nurse-administered medication management according to a hypertension decision support system ; ( 4 ) combination of the 2 interventions . The interventions are triggered based on home BP values transmitted via telemonitoring devices over st and ard telephone lines . The tailored behavioral intervention involves promoting adherence with medication and health behaviors . Patients r and omized to the medication management or the combined arm have their hypertension regimen changed by the study team using a vali date d hypertension decision support system based on evidence -based hypertension treatment guidelines and individualized to patients ' comorbid illnesses . The primary outcome is BP control : < or = 140/90 mm Hg ( nondiabetic ) and < or = 130/80 mm Hg ( diabetics ) measured at 6-month intervals over 18 months ( 4 total measurements ) . CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care , testing novel interventions in patients ' homes may improve access , quality , and outcomes Objectives This service evaluation examines how efficiently an innovative , simple and interactive blood pressure ( BP ) management intervention improves BP control in general practice . Design Prospect i ve service evaluation . Setting Ten volunteer general practitioner ( GP ) practice s in Stoke on Trent , UK . Participants Practice staff identified 124 intervention patients and invited them to participate based on two inclusion criteria : ( 1 ) patient has chronic kidney disease ( CKD ) stages 3 or 4 with BP persistently > 130/85 mm Hg or ( 2 ) patient is > 50 years-old ( without CKD stages 3–5 ) with BP persistently > 140/90 mm Hg despite prescribed antihypertensive medication . Three selected hypertensive control patients per intervention patient underwent usual clinical care ( n=364 ) . Interventions Intervention patients used ‘ Florence ’ , a simple , interactive mobile phone texting service with BP management intervention for 3 months , or for less time if their BP became controlled . Patients measured their BP , text their readings to Florence , received an immediate automatic response and had results review ed by their GP/ practice nurse at least weekly . Main outcome measures Baseline data including recent BP readings and medications were collected ; similar information was obtained for 6 months for both control and intervention patients . Average BP readings and medication usage were determined . Results At final data collection , five intervention patients had not yet completed the full programme . Control and intervention patients were well matched except that intervention patients had significantly greater baseline BP . Greatest BP reductions were among hypertensive intervention patients without CKD stages 3–5 . Intervention patients had significantly more BP readings and more changes in medication over the 3-month data collection period . Conclusions Simple telehealth is acceptable and effective in reducing patients ’ BP . In future , poorly controlled patients could be targeted to maximise BP reductions or broader use could improve diagnostic accuracy and accessibility for patients who struggle to regularly attend their GP surgery BACKGROUND Poor long-term adherence is an important cause of uncontrolled hypertension . We examined whether monitoring drug adherence with an electronic system improves long-term blood pressure ( BP ) control in hypertensive patients followed by general practitioners ( GPs ) . METHODS A pragmatic cluster r and omised controlled study was conducted over one year in community pharmacists/GPs ' networks r and omly assigned either to  usual care ( UC ) where drugs were dispensed as usual , or to intervention ( INT ) group where drug adherence could be monitored with an electronic system ( Medication Event Monitoring System ) . No therapy change was allowed during the first 2 months in both groups . Thereafter , GPs could modify therapy and use electronic monitors freely in the INT group . The primary outcome was a target office BP<140/90 mmHg . RESULTS Sixty-eight treated uncontrolled hypertensive patients ( UC : 34 ; INT : 34 ) were enrolled . Over the 12-month period , the likelihood of reaching the target BP was higher in the INT group compared to the UC group ( p<0.05 ) . At 4 months , 38 % in the INT group reached the target BP vs. 12 % in the UC group ( p<0.05 ) , and 21 % vs. 9 % at 12 months ( p : ns ) . Multivariate analyses , taking account of baseline characteristics , therapy modification during follow-up , and clustering effects by network , indicate that being allocated to the INT group was associated with a greater odds of reaching the target BP at 4 months ( p<0.01 ) and at 12 months ( p=0.051 ) . CONCLUSION GPs monitoring drug adherence in collaboration with pharmacists achieved a better BP control in hypertensive patients , although the impact of monitoring decreased with time Background Mobile phone based programs for kidney transplant recipients are promising tools for improving long-term graft outcomes and better managing comorbidities ( eg , hypertension , diabetes ) . These tools provide an easy to use self-management framework allowing optimal medication adherence that is guided by the patients ’ physiological data . This technology is also relatively inexpensive , has an intuitive interface , and provides the capability for real-time personalized feedback to help motivate patient self-efficacy . Automated summary reports of patients ’ adherence and blood pressure can easily be uploaded to providers ’ networks helping reduce clinical inertia by reducing regimen alteration time . Objective The aim of this study was to assess the feasibility , acceptability , and preliminary outcomes of a prototype mobile health ( mHealth ) medication and blood pressure ( BP ) self-management system for kidney transplant patients with uncontrolled hypertension . Methods A smartphone enabled medication adherence and BP self-management system was developed using a patient and provider centered design . The development framework utilized self-determination theory with iterative stages that were guided and refined based on patient/provider feedback . A 3-month proof-of-concept r and omized controlled trial was conducted in 20 hypertensive kidney transplant patients identified as non-adherent to their current medication regimen based on a month long screening using an electronic medication tray . Participants r and omized to the mHealth intervention had the reminder functions of their electronic medication tray enabled and received a bluetooth capable BP monitor and a smartphone that received and transmitted encrypted physiological data and delivered reminders to measure BP using text messaging . Controls received st and ard of care and their adherence continued to be monitored with the medication tray reminders turned off . Providers received weekly summary reports of patient medication adherence and BP readings . Results Participation and retention rates were 41/55 ( 75 % ) and 31/34 ( 91 % ) , respectively . The prototype system appears to be safe , highly acceptable , and useful to patients and providers . Compared to the st and ard care control group ( SC ) , the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations . Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the st and ard care group ( 7 adjustments in 5 patients versus 3 adjustments in 3 patients ) during the 3-month trial based on the information provided in the weekly reports . Conclusions These data support the acceptability and feasibility of the prototype mHealth system . Further trials with larger sample sizes and additional biomarkers ( eg , whole blood medication levels ) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control  after kidney transplantation over longer time periods . Trial Registration Clinical trials.gov NCT01859273 ; http:// clinical trials.gov/ct2/show/NCT01859273 ( Archived by WebCite at http://www.webcitation.org/6IqfCa3A3 ) BACKGROUND Half of patients with hypertension have poor  blood pressure ( BP ) control . Recent models for treating hypertension have integrated disease monitoring and telephone-based interventions delivered in patients ' homes . This study evaluated the costs of the Hypertension Intervention Nurse Telemedicine Study ( HINTS ) , aim ed to improve BP control  in veterans . METHODS Eligible veterans were r and omized to either  usual care  or 1 of 3 telephone-based intervention groups using home BP telemonitoring : ( 1 ) behavioral management , ( 2 ) medication management , or ( 3 ) combined . Intervention costs were derived from information collected during the trial . Direct medical costs ( inpatient , outpatient , and outpatient pharmacy , including hypertension-specific pharmacy ) at 18 months by group were calculated using Veterans Affairs ( VA ) Decision Support System data . Bootstrapped CIs were computed to compare intervention and medical costs between intervention groups and usual care . RESULTS Patients receiving behavior or medication management showed significant gains in BP control at 12 months ; there were no differences in BP control at 18 months . In subgroup analysis , patients with poor baseline BP control receiving combined intervention significantly improved BP at 12 and 18 months . In overall and subgroup sample s , average intervention costs were similar in the 3 study arms , and at 18 months , there were no statistically significant differences in direct VA medical costs or total VA costs between treatment arms and usual care . CONCLUSIONS To optimize investment in telephone-based home interventions such as the HINTS , it is important to identify groups of patients who are most likely to benefit from more intensive home BP management BACKGROUND Poor adherence explains poor blood pressure ( BP ) control ; however African Americans suffer worse hypertension-related outcomes . METHODS This r and omized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation ( PA ) was more effective than patient education ( PE ) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practice s. Patients in both groups received a culturally tailored hypertension self-management workbook , a behavioral contract , and bimonthly telephone calls design ed to help them overcome barriers to medication adherence . Also , patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation . The main outcome measures were medication adherence ( assessed with electronic pill monitors ) and within-patient change in BP from baseline to 12 months . RESULTS The baseline characteristics were similar in both groups : the  mean BP was 137/82 mm Hg ; 36 % of the patients had diabetes ; 11 % had stroke ; and 3 % had chronic kidney disease . Based on the intention-to-treat principle , medication adherence at 12 months was higher in the PA group than in the PE group ( 42 % vs 36 % , respectively ; P = .049 ) . The within-group reduction in systolic BP ( 2.14 mm Hg vs 2.18 mm Hg ; P = .98 ) and diastolic BP ( -1.59 mm Hg vs -0.78 mm Hg ; P = .45 ) for the PA group and PE group , respectively , was not significant . CONCLUSIONS A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans . Future studies should assess the cost-effectiveness of integrating such interventions into primary care . Trial Registration clinical trials.gov Identifier : NCT00227175 BACKGROUND AND OBJECTIVES The SBP values to be achieved by antihypertensive therapy in order to maximize reduction of cardiovascular outcomes are unknown ; neither is it clear whether in patients with a previous cardiovascular event , the optimal values are lower than in the low-to-moderate risk hypertensive patients , or a more cautious blood pressure ( BP ) reduction should be obtained . Because of the uncertainty whether ' the lower the better ' or the ' J-curve ' hypothesis is correct , the European Society of Hypertension and the Chinese Hypertension League have promoted a r and omized trial comparing antihypertensive treatment strategies aim ing at three different SBP targets in hypertensive patients with a recent stroke or transient ischaemic attack . As the optimal level of low-density lipoprotein cholesterol ( LDL-C ) level is also unknown in these patients , LDL-C-lowering has been included in the design . PROTOCOL DESIGN The European Society of Hypertension-Chinese Hypertension League Stroke in Hypertension Optimal Treatment trial is a prospect i ve multinational , r and omized trial with a 3 × 2 factorial design comparing : three different SBP targets ( 1 , < 145 - 135 ; 2 , < 135 - 125 ; 3 , < 125 mmHg ) ; two different LDL-C targets ( target A , 2.8 - 1.8 ; target B , < 1.8 mmol/l ) . The trial is to be conducted on 7500 patients aged at least 65 years ( 2500 in Europe , 5000 in China ) with hypertension and a stroke or transient ischaemic attack 1 - 6 months before r and omization .  Antihypertensive and statin treatments will be initiated or modified using suitable registered agents chosen by the investigators , in order to maintain patients within the r and omized SBP and LDL-C windows . All patients will be followed up every 3 months for BP and every 6 months for LDL-C. Ambulatory BP will be measured yearly . OUTCOMES Primary outcome is time to stroke ( fatal and non-fatal ) . Important secondary outcomes are : time to first major cardiovascular event ; cognitive decline ( Montreal Cognitive Assessment ) and dementia . All major outcomes will be adjudicated by committees blind to r and omized allocation . A Data and Safety Monitoring Board has open access to data and can recommend trial interruption for safety . SAMPLE SIZE CALCULATION It has been calculated that 925 patients would reach the primary outcome after a mean 4-year follow-up , and this should provide at least 80 % power to detect a 25 % stroke difference between SBP targets and a 20 % difference between LDL-C targets Background — Hypertension control rates remain suboptimal . Pharmacists ’ scope of practice is evolving , and their position in the community may be ideal for improving hypertension care . We aim ed to study the impact of pharmacist prescribing on blood pressure ( BP ) control in community-dwelling patients . Methods and Results — We design ed a patient-level , r and omized , controlled trial , enrolling adults with above-target BP ( as defined by Canadian guidelines ) through community pharmacies , hospitals , or primary care teams in 23 communities in Alberta . Intervention group patients received an assessment of BP and cardiovascular risk , education on hypertension , prescribing of antihypertensive medications , laboratory monitoring , and monthly follow-up visits for 6 months ( all by their pharmacist ) . Control group patients received a wallet card for BP recording , written hypertension information , and usual care from their pharmacist and physician . Primary outcome was the change in systolic BP at 6 months . A total of 248 patients ( mean age , 64 years ; 49 % male ) were enrolled .  Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg . The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group , an adjusted difference of 6.6±1.9 mm Hg ( P=0.0006 ) . The adjusted odds of patients achieving BP targets was 2.32 ( 95 % confidence interval , 1.17–4.15 in favor of the intervention ) . Conclusions — Pharmacist prescribing for patients with hypertension result ed in a clinical ly important and statistically significant reduction in BP . Policy makers should consider an exp and ed role for pharmacists , including prescribing , to address the burden of hypertension . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00878566 Background : Suboptimal utilisation of pharmacotherapy , non-adherence to prescribed treatment , and a lack of monitoring all contribute to poor blood ( BP ) pressure control in patients with hypertension . Objective : The objective of this study was to evaluate the implementation of a pharmacist-led hypertension management service in terms of processes , outcomes , and method ological challenges . Method : A prospect i ve , controlled study was undertaken within the Australian primary care setting . Community pharmacists were recruited to one of three study groups : Group A ( Control – usual care ) , Group B ( Intervention ) , or Group C ( Short Intervention ) . Pharmacists in Groups B and C delivered a service comprising screening and monitoring of BP , as well as addressing poor BP control through therapeutic adjustment and adherence strategies . Pharmacists in Group C delivered the shortened version of the service . Results : Significant changes to key outcome measures were observed in Group C : reduction in systolic and diastolic BPs at the 3-month visit ( P<0.01 and P<0.01 , respectively ) , improvement in medication adherence scores ( P=0.01 ) , and a slight improvement in quality of life ( EQ-5D-3L Index ) scores ( P=0.91 ) . There were no significant changes in Group B ( the full intervention ) , and no differences in comparison to Group A ( usual care ) . Pharmacists fed-back that patient recruitment was a key barrier to service implementation , highlighting the method ological implication s of screening . Conclusion : A collaborative , pharmacist-led hypertension management service can help monitor BP , improve medication adherence , and optimise therapy in a step-wise approach . However , blood pressure screening can effect behaviour change in patients , presenting method ological challenges in the evaluation of services in this context Background The effectiveness of salt restriction to lower blood pressure ( BP ) in Bangladeshi patients with chronic kidney disease ( CKD ) is uncertain . Objective To test the hypothesis that a tailored intervention intended to reduce salt intake in addition to st and ard care will achieve a greater reduction in BP in UK Bangladeshi patients with CKD than st and ard care alone . Design A r and omised parallel-group controlled trial conducted over a 6 month period . Setting A tertiary renal unit based in acute care hospital in East London . Participants 56 adult participants of Bangladeshi origin with CKD and BP > 130/80 mm Hg or on antihypertensive medication . Intervention Participants were r and omly allocated to receive a tailored low-salt diet or the st and ard low-salt advice .  BP medication , physical activity and weight were monitored . Main outcome measures The primary outcome was change in ambulatory BP . Adherence to dietary advice was assessed by measurement of 24 h urinary salt excretion . Results Of 56 participants r and omised , six withdrew at the start of the study . During the study , one intervention group participant died , one control group participant moved to Bangladesh . Data were available for the primary endpoint on 48 participants . Compared with control group the intervention urinary sodium excretion fell from 260 mmol/d to 103 mmol/d ( −131 to −76 , p<0.001 ) at 6 months and result ed in mean ( 95 % CI ) falls in 24 h systolic/diastolic BP of −8 mm Hg ( −11 to −5)/2 ( −4 to −2 ) both p<0.001 . Conclusions A tailored intervention can achieve moderate salt restriction in patients with CKD , result ing in clinical ly meaningful falls in BP independent of hypertensive medication . Trial Registration Clinical Trials.gov NCT00702312 Background —Few studies have investigated the effectiveness of multifaceted interventions from the study participants ' perspective . We conducted qualitative interviews to underst and patients ' experiences with a multifaceted blood pressure ( BP ) control intervention involving interactive voice response technology , home BP monitoring , and pharmacist-led BP management . In the r and omized study , the intervention result ed in clinical ly significant decreases in BP . Methods and Results —We used insights generated from in-depth interviews from all study participants r and omly assigned to the multifaceted intervention or usual care ( n=146 ) to create a model explaining the observed improvements in health behavior and clinical outcomes . The data were analyzed using qualitative content analysis methods and consultative and reflexive team analysis . Six explanatory factors emerged from the patients ' interviews : ( 1 ) improved relationships with medical personnel ; ( 2 ) increased knowledge of hypertension ; ( 3 ) increased participation in their health care and personal empowerment ; ( 4 ) greater underst and ing of the impact of health behavior on BP ; ( 5 ) high satisfaction with technology used in the intervention ; and , for some patients , ( 6 ) increased health care utilization .  Eighty-six percent of the intervention patients and 62 % of the usual care patients stated that study participation had a positive effect on them . Of those expressing a positive effect , 68 % ( intervention ) and 55 % ( usual care ) reached their systolic BP goal . Conclusions —Establishing bidirectional conversations between patients and providers is a key element of successful hypertension management . Home BP monitoring coupled with interactive voice response technology reporting facilitates such conversations BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension Introduction We aim ed to assess whether hypertension management with a structured physician information program and a feedback system leads to improved blood pressure ( BP ) control and cardiovascular outcomes . Methods Cluster r and omized ( 3 : 1 ) , open , monitored , multicenter trial in Germany . Primary care-based physicians  in the information group ( IG ) received detailed training on hypertension guidelines , feedback on target-level attainment , and a reminder to intensify treatment after each patient visit , whereas the observation/control group ( CG ) did not receive any such measures . A three-level mixed model was developed . Time-independent level differences between groups , group-independent changes , and nonparallel group-specific changes over time were tested . Results A total of 15 041 ( 78.1 % ) hypertensive patients were in the IG and 4213 ( 21.9 % ) in the CG . By 1-year follow-up , 82.9 % of patients in the IG and 81.5 % in the CG remained in the study . The guideline -oriented BP target was attained by 56.8 % in the IG and 52.5 % in the CG ( + 4.3 % , P = 0.03 ) , whereas the individual BP target was attained by 57.0 % in the IG and 51 % in the CG ( P = NS ) . BP control in the IG was achieved 2 months earlier on average . Clinical inertia , defined as the absence of medication changes , despite noncontrol of BP , occurred significantly less often in the IG group . One-year cardiovascular outcomes did not differ between groups . Conclusion The delivery of systematic information in connection with a feedback system reduces clinical inertia and improves guideline adherence . Although compared with earlier studies , the hypertension control rates obtained are higher , there is still considerable room for improvement . Eur J Cardiovasc Prev Rehabil 17:271 - 279 © 2010 The European Society of Objectives Isometric h and grip ( IHG ) training ( four , 2-min sustained contractions at 30 % of maximal voluntary contraction , three times per week for 8–10 weeks ) lowers resting arterial blood pressure ( BP ) in hypertensive patients , including those receiving pharmacotherapy , although the mechanisms remain elusive . Ambulatory BP measurements are more efficacious in predicting cardiovascular disease-related events , yet the effects of IHG training on ambulatory BP are unknown . The objective of the current investigation was to test the hypotheses that 8 weeks of IHG training lowers resting and 24 h ambulatory BP concomitantly in medicated hypertensive patients , and may be the result of improved vagal modulation . Methods BP was assessed using brachial artery oscillometry , and coarse-graining spectral analysis was used to determine spectral power . Resting and 24 h ambulatory BP and heart rate variability ( HRV ) were measured pretraining , midtraining , and post-training in 11 medicated hypertensive patients ( mean±SD , resting BP : 113.9±12.7/60.7±11.6 mmHg ) , and in nine medicated hypertensive controls ( resting BP : 117.8±14.3/67.5±4.2 mmHg ) . Results Indices of BP and HRV were not significantly altered with IHG training ( all P>0.05 ) . Conclusion IHG training does not lower resting or ambulatory BP  in hypertensive patients successfully treated with pharmacotherapy to within the normal range ( ⩽120/80 mmHg ) , nor does it improve HRV . Future studies should examine alternative IHG training protocol s in well-managed hypertensive patients and /or target poorly controlled medicated hypertensive patients Home blood pressure monitoring ( HBPM ) overcomes many of the limitations of traditional office blood pressure ( BP ) measurement and is both cheaper and easier to perform than ambulatory BP monitoring . Monitors that use the oscillometric method are currently available that are accurate , reliable , easy to use , and relatively inexpensive . An increasing number of patients are using them regularly to check their BP at home , but although this has been endorsed by national and international guidelines , detailed recommendations for their use have been lacking . There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors , which is the BP that best predicts cardiovascular risk . Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect ( the increase of BP during an office visit ) , home readings are more reproducible than office readings and show better correlations with measures of target organ damage . In addition , prospect i ve studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP ( Class IIa ; Level of Evidence A ) . This call-to-action article makes the following recommendations : ( 1 ) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension ; ( 2 ) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to st and ard international protocol s. They should be shown how to use them by their healthcare providers ; ( 3 ) Two to 3 readings should be taken while the subject is resting in the seated position , both in the morning and at night , over a period of 1 week . A total of ≥12 readings are recommended for making clinical decisions ; ( 4 ) HBPM is indicated in patients with newly diagnosed or suspected hypertension , in whom it may distinguish between white-coat and sustained hypertension . If the results are equivocal ,  ambulatory BP  monitoring may help to establish the diagnosis ; ( 5 ) In patients with prehypertension , HBPM may be useful for detecting masked hypertension ; ( 6 ) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence ; ( 7 ) The target HBPM goal for treatment is < 135/85 mm Hg or < 130/80 mm Hg in high-risk patients ; ( 8) HBPM is useful in the elderly , in whom both BP variability and the white-coat effect are increased ; ( 9 ) HBPM is of value in patients with diabetes , in whom tight BP control is of paramount importance ; ( 10 ) Other population s in whom HBPM may be beneficial include pregnant women , children , and patients with kidney disease ; and ( 11 ) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed Home blood pressure monitoring ( HBPM ) overcomes many of the limitations of traditional office blood pressure ( BP ) measurement and is both cheaper and easier to perform than ambulatory BP monitoring . Monitors that use the oscillometric method are currently available that are accurate , reliable , easy to use , and relatively inexpensive . An increasing number of patients are using them regularly to check their BP at home , but although this has been endorsed by national and international guidelines , detailed recommendations for their use have been lacking . There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors , which is the BP that best predicts cardiovascular risk . Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect ( the increase of BP during an office visit ) , home readings are more reproducible than office readings and show better correlations with measures of target organ damage . In addition , prospect i ve studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP ( class IIa ; level of evidence A ) . This call-to-action article makes the following recommendations : 1 ) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension ; 2 ) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to st and ard international protocol s. They should be shown how to use them by their healthcare providers ; 3 ) Two to three readings should be taken while the subject is resting in the seated position , both in the morning and at night , over a period of 1 week . A total of > /=12 readings are recommended for making clinical decisions ; 4 ) HBPM is indicated in patients with newly diagnosed or suspected hypertension , in whom it may distinguish between white-coat and sustained hypertension . If the results are equivocal , ambulatory BP monitoring may help to establish the diagnosis ; 5 ) In patients with prehypertension , HBPM may be useful for detecting masked hypertension ; 6 ) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence ; 7 ) The target HBPM goal for treatment is < 135/85 mm Hg or < 130/80 mm Hg in high-risk patients ; 8) HBPM is useful in the elderly , in whom both BP variability and the white-coat effect are increased ; 9 ) HBPM is of value in patients with diabetes , in whom tight BP control is of paramount importance ; 10 ) Other population s in whom HBPM may be beneficial include pregnant women , children , and patients with kidney disease ; and 11 ) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed Objective Older adults with chronic kidney disease have a high rate of uncontrolled hypertension . Home monitoring of  blood pressure ( BP ) is an integral part of management , but requires that patients bring records to clinic visits . Telemonitoring interventions , however , have not targeted older , less technologically-skilled population s. Methods Veterans with stage 3 or greater chronic kidney disease and uncontrolled hypertension were r and omized to a novel telemonitoring device pairing a Bluetooth-enabled BP cuff with an Internet-enabled hub , which wirelessly transmitted readings ( n=28 ) , or usual care ( n=15 ) . Home recordings were review ed weekly and telemonitoring participants were contacted if BP was above goal . The prespecified primary endpoints were improved data exchange and device acceptability . Secondary endpoint was BP change . Results Forty-three participants ( average age 68 years , 75 % white ) completed the 6-month study . Average start-of- study BP was 147/78 mmHg . Those in the intervention arm had a median of 29 ( IQR 22 , 53 ) transmitted BP readings per month , with 78 % continuing to use the device regularly , whereas only 20 % of those in the usual care group brought readings to in-person visits . The median number of telephone contacts triggered by the wireless monitoring was 2 ( IQR 1 , 4 ) per patient . Both groups had a significant improvement in systolic BP ( P<0.05 , for both changes ) ; systolic BP fell a median of 13 mmHg in monitored participants compared with 8.5 mmHg in usual care participants ( P for comparison 0.31 ) . Conclusion This low-cost wireless monitoring strategy led to greater sharing of data between patients and clinic and produced a trend toward improvements in BP control over usual care at 6 months Background : Research in industrialized countries has demonstrated that a key factor limiting the control of hypertension is poor patient adherence and that the most successful interventions for long-term adherence employ multiple strategies . Very little data exist on this question in low-income countries , wherein medication-taking behavior may be less well developed . Method : We conducted a treatment adherence trial of 544 patients [ mean age ∼63 years , mean blood pressure ( BP ) ∼168/92 mmHg ] with previously untreated hypertension in urban and rural Nigeria . Eligible participants were r and omized to one of two arms : clinic management only , or clinic management and home visits . Both interventions included three elements : a community based , nurse-led treatment program with physician backup ; facilitation of clinic visits and health education ; and the use of diuretics and a & bgr ; blocker as needed . After initial diagnosis , the management protocol was implemented by a nurse with physician backup . Participants were evaluated monthly for 6 months . Results : Medication adherence was assessed with pill count and urine testing . Drop-out rates , by treatment group , ranged from 12 to 28 % . Among participants who completed the 6-month trial , overall adherence was high ( ∼77 % of participants took > 98 % of prescribed pills ) . Adherence did not differ by treatment arm , but was better at the rural than the urban site and among those with higher baseline BP . Hypertension control ( BP < 140/90 mmHg ) was achieved in approximately 66 % of participants at 6 months . Conclusion : This community-based intervention confirms relatively modest default rates compared with industrialized societies , and suggests that medication adherence can be high in developing world setting s in clinic attenders Background Despite recent high- quality evidence for their cost-effectiveness , thiazides are underused for controlling hypertension . The goal of this study was to design and test a practice -based intervention aim ed at increasing the use of thiazide-based antihypertensive regimens . Methods This quasi-experimental study was carried out in general medicine ambulatory practice s of a large , academically-affiliated Veterans Affairs hospital . The intervention group consisted of the practitioners ( 13 staff and 215 trainees ) , nurses , and patients ( 3,502 ) of the teaching practice ; non-r and omized concurrent controls were the practitioners ( 31 providers ) and patients ( 18,292 ) of the non-teaching practice s. Design of the implementation intervention was based on Rogers ' Diffusion of Innovations model . Over 10.5 months , intervention teams met weekly or biweekly and developed and disseminated informational material s among themselves and to trainees , patients , and administrators . These teams also review ed summary electronic-medical-record data on thiazide use and blood pressure ( BP ) goal attainment . Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen  , and the proportion of hypertensive patients attaining BP goals regardless of regimen . Thirty-three months of time-series data were available ; statistical process control charts , change point analyses , and before-after analyses were used to estimate the intervention 's effects . Results Baseline use of thiazides and rates of BP control were higher in the intervention group than controls . During the intervention , thiazide use and BP control increased in both groups , but changes occurred earlier in the intervention group , and primary change points were observed only in the intervention group . Overall , the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients ( 0.091 vs. 0.058 ; p = 0.0092 ) , as was the proportion achieving BP goals ( 0.092 vs. 0.044 ; p = 0.0005 ) . At the end of the implementation period , 41.4 % of intervention patients were prescribed thiazides vs. 30.6 % of controls ( p < 0.001 ) ; 51.6 % of intervention patients had achieved BP goals vs. 44.3 % of controls ( p < 0.001 ) . Conclusion This multi-faceted intervention appears to have result ed in modest improvements in thiazide prescribing and BP control . The study also demonstrates the value of electronic medical records for implementation research , how Rogers ' model can be used to design and launch an implementation strategy , and how all members of a clinical microsystem can be involved in an implementation effort WHAT IS KNOWN AND OBJECTIVES About half of all patients taking antihypertensives discontinue treatment by 12 months . There is potential for substantial health gains at both individual and population levels through improved treatment adherence . The objective was to evaluate a community pharmacist intervention to improve adherence with antihypertensive medicines with a view to improving blood pressure ( BP ) control . METHODS DESIGN prospect i ve , non-blinded , cluster-r and omized , controlled trial . PARTICIPANTS adults with primary hypertension who obtained antihypertensives in the previous 6 months . Patients with poor refill adherence were preferentially identified with the help of a purpose -built software application . INTERVENTION package comprising BP monitor ; training on BP self-monitoring ; motivational interviewing ; medication use review ; prescription refill reminders . FOLLOW-UP six months . PRIMARY OUTCOME change in proportion self-reporting medication adherence . Secondary outcome : BP changes . RESULTS Participants ( n = 395 ; intervention - 207 ; control - 188 ) had a mean age of 66.7 years ; 51.1 % were males . The proportion of adherent participants increased in both groups but was not significantly different between groups [ 57·2 % to 63·6 % ( control ) vs. 60·0 % to 73·5 % ( intervention ) , P = 0·23 ] . The mean reduction in systolic BP was significantly greater in the intervention group ( 10·0 mmHg vs. 4·6 mmHg ; P = 0·05 ) . The proportion of patients who were non-adherent at baseline and adherent at 6 months was 22·6 % ( 95%CI 5·1 - 40·0 % ) higher in the intervention group ( 61·8 % vs. 39·2 % , P = 0·007 ) . Among participants with baseline  BP above target , reduction of systolic BP was significantly greater in the intervention group [ by 7·2 mmHg ( 95%CI 1·6 - 12·8 mmHg ) ; ( P = 0·01 ) ] . Among participants non-adherent at baseline and above target BP , the proportion reporting adherence at 6 months was significantly greater in the intervention group [ 56·8 % vs. 35·9 % , P = 0·039 ) . WHAT IS NEW AND CONCLUSION This community pharmacist intervention result ed in improved adherence to antihypertensive medication and reduced systolic BP OBJECTIVES Despite a broad and efficient pharmacological antihypertensive armamentarium , blood pressure ( BP ) control is suboptimal and heterogeneous throughout Europe . Recent representative data from Switzerl and are limited . The goal of the present survey was therefore to assess the actual control rate of high BP in Switzerl and in accordance with current guidelines . The influence of risk factors , target organ damage and medication on BP levels and control was also evaluated . METHODS A cross-sectional visit-based survey of ambulatory hypertensive patients was performed in 2009 in Switzerl and . 281 r and omly selected physicians provided data on 5 consecutive hypertensive patients attending their practice s for BP follow-up . Data were anonymously collected on demographics , comorbidities and current medication , and BP was recorded . Subsequent modification of pharmacological antihypertensive therapy was assessed . RESULTS Data from 1376 patients were available . Mean age was 65 ± 12 years , 53.9 % were male subjects . 26.4 % had complicated hypertension . Overall , BP control ( < 140/90 mm Hg for uncomplicated and < 130/80 mm Hg for complicated hypertension ) was achieved in 48.9 % . Compared to patients with complicated hypertension , BP control was better in patients with uncomplicated hypertension ( 59.4 % vs. 19.2 % , p < 0.001 ) . As a monotherapy the most prescribed drug class were angiotensin receptor blockers ( ARB , 41 % ) , followed by angiotensin converting enzyme ( ACE ) inhibitors ( 21.5 % ) , betablockers ( 20.8 % ) and calcium channel blockers ( CCB , 10.8 % ) . The most prescribed drug combinations were ARB + diuretic ( 30.1 % ) and ACE inhibitors + diuretic ( 15.3 % ) . 46 % were receiving a fixed drug combination . In only 32.7 % of patients with uncontrolled hypertension was a change in drug therapy made . CONCLUSION This representative survey on treated adult hypertensive patients shows that , compared to earlier reports , the control rate of hypertension has improved in Switzerl and for uncomplicated but not for complicated , particularly diabetes-associated hypertension . ARBs and ACE inhibitors are the most prescribed antihypertensive drugs for monotherapy , whereas diuretics and ARBs were the most used for combination therapy Background : Nearly one in three adults in the United States has hypertension . Hypertension is one of the largest risk factors for cardiovascular diseases , and it is growing in prevalence , especially among African Americans . Objectives : To test the hypothesis that individuals who participate in usual care ( UC ) plus blood pressure ( BP ) telemonitoring ( TM ) will have a greater reduction in BP from baseline to 12-month follow-up than would individuals who receive UC only . Methods : A two-group , experimental , longitudinal design with block stratified r and omization for antihypertensive medication use was used . African Americans with hypertension were recruited through free BP screenings offered in the community . Data were collected through a structured interview and brief physical exam . Cross tabs , repeated measures analysis of variance , and independent t tests were used to analyze the study 's hypothesis . Results : The TM intervention group had a greater reduction in systolic BP ( 13.0 mm Hg ) than the enhanced UC group ( 7.5 mm Hg ; t = −2.09 , p = .04 ) from baseline to the 12-month follow-up . Although the TM intervention group had a greater reduction in diastolic BP ( 6.3 mm Hg ) compared with the enhanced UC group ( 4.1 mm Hg ) , the differences were not statistically significant ( t = −1.56 , p = .12 ) . Discussion : Telemonitoring of BP result ed in clinical ly and statistically significant reductions in systolic BP over a 12-month period ; if maintained over a longer period of time , the reductions could improve care and outcomes significantly for African Americans with hypertension Despite pharmacologic advances , medication non-adherence continues to challenge primary care providers in blood pressure ( BP ) management .  Medical , nursing and pharmacy students ( n = 11 ) were recruited and trained as health coaches for uninsured , hypertensive patients ( n = 25 ) of a free clinic in an uncontrolled open trial . Pre – post analysis was conducted on BP , medication adherence , frequency of home BP monitoring , and health behavior ( eg  ,  diet , exercise ) . Patient satisfaction and feasibility of a student coach model was qualitatively evaluated . In the 12 patients who completed the intervention , an increase in medication adherence as measured by the Brief Medication Question naire was observed ( P < .01 ) , with a 11mmHg reduction in systolic BP ( P = .03 ) . Qualitative data showed patient satisfaction with the intervention and other health behavior change . This feasibility study shows use of student health coaches to combat medication non-adherence in uninsured , hypertensive adults is promising BACKGROUND Cigarette smokers with elevated blood pressure ( BP ) are at substantially higher risk for cardiovascular events compared to normotensive smokers . Although smoking cessation should be a primary treatment goal for these patients , increases in body weight accompanying smoking abstinence may further increase BP . Intervention strategies that facilitate smoking cessation and modify adverse changes in body weight and BP are needed . METHODS We describe an ongoing multi-site , two-phase , five-year r and omized clinical trial . Participants are cigarette smokers with Prehypertension or Stage I Hypertension . In the first phase , participants receive a smoking cessation intervention combining behavioral counseling and nicotine replacement in an open-label fashion . In the second phase , participants who successfully quit smoking are r and omly assigned to one of three lifestyle interventions : 1 ) weight gain prevention , 2 ) blood pressure control , or 3 ) usual lifestyle . Participants are followed for one year to assess changes in blood pressure , body weight , dietary intake , and physical activity . CONCLUSIONS Results from the proposed study will provide important insights into the efficacy of various approaches to lifestyle modification in smokers at increased risk for cardiovascular events Noncompliance with treatment has long been the plague of the national health-care system . Each year it is estimated that noncompliance with medication costs the UK economy billions of pounds , as a result of preventable hospital admissions and loss of productivity due to illness . In addition , noncompliance has been identified as the predominant reason for the failure of medical therapy and disease progression . Compliance has been defined as ‘ the extent to which a person ’s behaviour coincides with medical care or advice ’ . In the management of hypertension , figures from the United States suggest that noncompliance with medication may be as high as 50–80 % , with compliance decreasing rapidly over time . Based on the current definition of hypertension ( blood pressure ( BP ) of X140/90 mm Hg ) , the 1998 Health Survey for Engl and revealed that 42 % and 33 % of adult ( X16 years ) men and women , respectively , were hypertensive . Fewer than 10 % of all UK hypertensive patients currently achieve the recommended target BP of o140/90 mmHg , despite the well-known risks associated with hypertension and the overwhelming evidence from numerous clinical trials of the benefits of antihypertensive medication . A recent study , based on a meta- analysis of 61 prospect i ve BP studies , calculated that if all hypertensive patients in the UK reduced their systolic BP to o140 mmHg , approximately 21 400 stroke deaths , 41 400 ischaemic heart disease ( IHD ) deaths , and 125 600 events ( nonfatal stroke or IHD ) could be prevented each year . Why then , in the face of such overwhelming evidence of the benefits of BP reduction , are less than one in 10 people in the UK achieving adequate control of their BP ? Various explanations have been proffered to explain why such a large percentage of patients have resistant hypertension , including secondary hypertension and endogenous resistance to treatment . However , the main reason for inadequate control of BP is poor compliance with the treatment regimen , both pharmacological and behavioural ( eg , weight reduction , sodium intake restriction , and exercise ) . Underst and ing the reasons for patient noncompliance with antihypertensive medication is essential if BP is to be more effectively managed . Table 1 presents some possible factors contributing to noncompliance with medication regimens . Much of the earlier research focused on identifying patient characteristics of noncomplaint individuals and the complexity of the medication regimen . BP control typically requires more than one antihypertensive medication and the frequency of dosing may vary . The complexity of the drug regimen effects compliance ; compliance among hypertensive patients improves considerably when drugs are prescribed just once a day . In addition , many patients experience unpleasant side effects from their medication that may be unacceptable in a largely asymptomatic disease . This is often reported as one of the main reasons for nonor partial compliance . However , more recent studies have focused on patient ’s decisions and the complex relationship between the patient and physician as possible mediating factors for compliance . Patients often make rational decisions about the benefits of medication compared to the risks before they decide whether or not to comply with treatment . Several studies , some qualitative , have investigated how hypertensive patients balance these concerns with their reasons for taking such medication . The majority of patients ( 80 % ) also express general concerns about taking medication ; previous bad experiences , perceptions that drugs are unnatural or unsafe and are best avoided , and that drugs signify ill health . With regard to Received/accepted 03 February 2004 ; published online 18 March 2004 Correspondence : Dr D Lane , University Department of Medicine , City Hospital , Dudley Road , Birmingham B18 7QH , UK . E-mail : deirdre.lane@swbh.nhs.uk Journal of Human Hypertension ( 2004 ) 18 , 595–597 & 2004 Nature Publishing Group All rights reserved 0950 - 9240/04 $ The effectiveness of a quality improvement program for hypertension management practice s and patient health outcomes in a group-model managed care organization was evaluated . Health-system pharmacists analyzed medical and pharmacy cl aims data to identify hypertensive patients . Chart review was conducted on a r and om sample of these patients to vali date a hypertension diagnosis and to obtain blood pressure ( BP ) control rates and prevalence of cardiovascular risk factors and comorbid conditions . The interventions consisted of educating health care providers and recommending appropriate pharmacotherapy for compelling indications . Patient outcomes were compared with baseline hypertension data . After interventions were implemented , medical and pharmacy cl aims identified 30,721 hypertensive patients and chart review s were performed on a r and om sample of 417 patients . Pharmacy cl aims revealed a total of 193,311 antihypertensive prescriptions . Approximately 47 % of all hypertensive patients were managed with monotherapy , while 24 % received dual therapy , and 11 % were taking three or more antihypertensive medications per day . Of the patients on monotherapy , 93 % received an angiotensin-converting-enzyme inhibitor ( 27.3 % ) , diuretic ( 26.6 % ) , beta-blocker ( 23.4 % ) , or calcium channel blocker ( 15.4 % ) . The overall level of BP control significantly improved from 37.2 % at baseline to 49.2 % at follow-up ( p = 0.0007 ) . BP control in the follow-up evaluation was 22.2 % in diabetic patients . For treatment of patients with comorbid disease states , provider practice patterns were evaluated at baseline and follow-up . Improving the quality of hypertension management increased BP control from 37.2 % to 49.2 % . Continued efforts to improve hypertension management , particularly in patients with concomitant diabetes and in elderly patients with isolated systolic hypertension , are needed
The most commonly described determinants at the patient level were lack of education , lack of self-awareness , lack of self-efficacy , and forgetfulness .
Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level .
Taking medication , interactive patient-provider communication , self-measurement , and lifestyle management were the most cited patient behaviors at both levels .
Most of the DIs did not include support from peers or family members , despite its reported effectiveness and the rate of social media penetration .
Background Information on how behavior change strategies have been used to design digital interventions ( DIs ) to improve blood pressure ( BP ) control or medication adherence ( MA ) for patients with hypertension is currently limited .
Objective Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication .
Many interventions that target MA to improve BP are increasingly using modern digital technologies .
This systematic review was conducted to discover how DIs have been design ed to improve MA and BP control among patients with hypertension in the recent 10 years .