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This study introduces a Generative Artificial Intelligence (GenAI) assistant designed to address key challenges in Remote Patient Monitoring (RPM) for hypertension. After a comprehensive needs assessment from clinicians and patients, we identified pivotal issues in RPM data management and patient engagement. The GenAI RPM assistant integrates a patient-facing chatbot, clinician-facing smart summaries, and automated draft portal messages to enhance communication and streamline data review. Validated through six rounds of testing and evaluations by ten participants, the initial prototype was positively received, highlighting the importance of personalized interactions. Our findings demonstrate GenAI's potential to improve RPM by optimizing data management and enhancing patient-provider communication.

It has been hypothesized that high visit-to-visit variability (VVV) of systolic blood pressure (SBP) may be the result of poor antihypertensive medication adherence. The authors studied this association using data from 1391 individuals taking antihypertensive medication selected from a large managed care organization. The 8-item Morisky Medication Adherence Scale, administered during 3 annual surveys, captured self-report adherence, with scores<6, 6 to <8, and 8 representing low, medium. and high adherence, respectively. The mean (standard deviation [SD]) for SD of SBP across study visits was 12.9 (4.4), 13.5 (4.8), and 14.1 (4.5) mm Hg in participants with high, medium, and low self-reported adherence, respectively. After multivariable adjustment and compared with those with high self-report adherence, SD of SBP was 0.60 (95% confidence interval, 0.13-1.07) and 1.08 (95% confidence interval, 0.29-1.87) mm Hg higher among participants with medium and low self-report adherence, respectively. Results were consistent when pharmacy fill was used to define adherence. These data suggest that low antihypertensive medication adherence explains only a small proportion of VVV of SBP., (© 2012 Wiley Periodicals, Inc.)

Several landmark studies based on the DASH diet have established the effectiveness of a lifestyle approach to blood pressure control that emphasizes a diet rich in fruits and vegetables with moderate portions of low-fat dairy and lean protein along with increased physical activity and reduced sodium intake. However, this evidence base remains underused due feasibility limitations of implementing these intense in-person interventions and poor engagement with desktop computer based versions. Mobile technologies such as smartphones and wireless sensors have the ability to deliver behavioral interventions in-the-moment and with reduced user burden. DASH Mobile is a new mHealth system being developed to deliver this evidence-based lifestyle intervention to hypertensive patients. The system consists of an Android based "app" that facilitates easy tracking of DASH food portions, integrated Bluetooth blood pressure, weight and pedometer monitoring, goal setting, simple data visualizations and multimedia video clips to train patients in the basic concepts of the lifestyle change plan. At present, the system is undergoing usability testing with a pilot clinical trial planned for Spring 2013.

Low medication adherence may explain part of the high prevalence of apparent treatment-resistant hypertension (aTRH). The authors assessed medication adherence and aTRH among 4026 participants taking ≥ 3 classes of antihypertensive medication in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) trial using the 4-item Morisky Medication Adherence Scale (MMAS). Low adherence was defined as an MMAS score ≥ 2. Overall, 66% of participants taking ≥ 3 classes of antihypertensive medication had aTRH. Perfect adherence on the MMAS was reported by 67.8% and 70.9% of participants with and without aTRH, respectively. Low adherence was present among 8.1% of participants with aTRH and 5.0% of those without aTRH (P<.001). Among those with aTRH, female sex, residence outside the US stroke belt or stroke buckle, physical inactivity, elevated depressive symptoms, and a history of coronary heart disease were associated with low adherence. In the current study, a small percentage of participants with aTRH had low adherence., (© 2012 Wiley Periodicals, Inc.)

The association between within-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and all-cause and cardiovascular (CVD) mortality was examined using the Third National Health and Nutrition Survey (n=15,317). Three SBP and DBP readings were taken by physicians during a single medical evaluation. Within-visit variability for each participant was defined using the standard deviation of SBP and DBP across these measurements. Mortality was assessed over 14 years (n=3848 and n=1684 deaths from all causes and CVD, respectively). After age, sex, and race-ethnicity adjustment, the hazard ratios (95% confidence intervals) for all-cause mortality associated with the 4 highest quintiles of within-visit standard deviation of SBP (2.00-2.99 mm Hg, 3.00-3.99 mm Hg, 4.00-5.29 mm Hg, and ≥5.30 mm Hg) compared with participants in the lowest quintile of within-visit standard deviation of SBP (<2.0 mm Hg) were 1.04 (0.87-1.26), 1.09 (0.92-1.29), 1.06 (0.88-1.28), and 1.13 (0.95-1.33), respectively (P=.136). The analogous hazard ratios for CVD mortality were 0.95 (0.69-1.32), 0.96 (0.67-1.36), 0.95 (0.74-1.23), and 1.04 (0.80-1.35), respectively (P=.566). No association with mortality was present after further adjustment and when modeling within-visit standard deviation of SBP as a continuous variable. Standard deviation of DBP was not associated with mortality., (© 2012 Wiley Periodicals, Inc.)

Background: Observational studies suggest that there are differences in adherence to antihypertensive medications in different classes. Our objective was to quantify the association between antihypertensive drug class and adherence in clinical settings., Methods and Results: Studies were identified through a systematic search of English-language articles published from the inception of computerized databases until February 1, 2009. Studies were included if they measured adherence to antihypertensives using medication refill data and contained sufficient data to calculate a measure of relative risk of adherence and its variance. An inverse-variance-weighted random-effects model was used to pool results. Hazard ratios (HRs) and odds ratios were pooled separately, and HRs were selected as the primary outcome. Seventeen studies met inclusion criteria. The pooled mean adherence by drug class ranged from 28% for β-blockers to 65% for angiotensin II receptor blockers. There was better adherence to angiotensin II receptor blockers compared with angiotensin-converting enzyme inhibitors (HR, 1.33; 95% confidence interval, 1.13 to 1.57), calcium channel blockers (HR, 1.57; 95% confidence interval, 1.38 to 1.79), diuretics (HR, 1.95; 95% confidence interval, 1.73 to 2.20), and β-blockers (HR, 2.09; 95% confidence interval, 1.14 to 3.85). Conversely, there was lower adherence to diuretics compared with the other drug classes. The same pattern was present when studies that used odds ratios were pooled. After publication bias was accounted for, there were no longer significant differences in adherence between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors or between diuretics and β-blockers., Conclusion: In clinical settings, there are important differences in adherence to antihypertensives in separate classes, with lowest adherence to diuretics and β-blockers and highest adherence to angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. However, adherence was suboptimal regardless of drug class.

Increased left ventricular (LV) mass and changes in LV geometry may precede hypertension onset. The authors examined the associations of LV mass and geometry, assessed by cardiac magnetic resonance imaging, with hypertension incidence in 2,567 normotensive participants enrolled in 2000-2002 in the Multi-Ethnic Study of Atherosclerosis, an ethnically diverse, population-based, US study. Over a median follow-up of 4.8 years, 745 (29%) participants developed hypertension. In a fully adjusted model including baseline blood pressure, the relative risks of incident hypertension from the lowest to highest LV mass quartile were 1.00 (referent), 1.13 (95% confidence interval (CI): 0.89, 1.43), 1.28 (95% CI: 1.00, 1.63), and 1.78 (95% CI: 1.38, 2.30) (P < 0.001 for linear trend). Higher levels of LV concentric geometry, defined by higher LV mass to end-diastolic volume quartiles, were associated with higher risk of incident hypertension in a fully adjusted model (P = 0.044 for linear trend). In a final model containing both quartiles of LV mass and LV mass/volume along with all covariates including baseline blood pressure, higher LV mass quartiles were associated with incident hypertension (P < 0.001 for linear trend), whereas higher LV mass/volume quartiles were not (P = 0.643 for linear trend). In this multiethnic cohort, alterations in LV mass preceded hypertension onset among normotensive individuals.

Background: Nonadherence to statins limits the benefits of this common drug class. Individual studies assessing predictors of nonadherence have produced inconsistent results., Objective: To identify reliable predictors of nonadherence to statins through systematic review and meta-analysis., Methods: Multiple databases, including MEDLINE, EMBASE, and PsycINFO, were searched (from inception through February 2009) to identify studies that evaluated predictors of nonadherence to statins. Studies were selected using a priori defined criteria, and each study was reviewed by 2 authors who abstracted data on study characteristics and outcomes. Relative risks were then pooled, using an inverse-variance weighted random-effects model., Results: Twenty-two cohort studies met inclusion criteria. Age had a U-shaped association with adherence; the oldest (>/=70 years) and youngest (<50 years) subjects had lower adherence than the middle-aged (50-69 years) subjects. Women and patients with lower incomes were more likely to be nonadherent than were men (odds of nonadherence 1.07; 95% CI 1.04 to 1.11) and those with higher incomes (odds of nonadherence 1.18; 95% CI 1.10 to 1.28), respectively. A history of cardiovascular disease predicted better adherence to statins (odds of nonadherence 0.68; 95% CI 0.66 to 0.78). Similarly, a diagnosis of hypertension or diabetes was associated with better adherence. Although there were too few studies for quantitative pooling, increased testing of lipid levels and lower out-of-pocket costs appeared to be associated with better adherence. There was substantial (I(2) range 68.7-96.3%) heterogeneity between studies across factors., Conclusions: Several sociodemographic, medical, and health-care utilization characteristics are associated with statin nonadherence. These factors may be useful guides for targeting statin adherence interventions.

A prediction model, developed in the Framingham Heart Study (FHS), has been proposed for use in estimating a given individual's risk of hypertension. We compared this model with systolic blood pressure (SBP) alone and age-specific diastolic blood pressure categories for the prediction of hypertension. Participants in the Multi-Ethnic Study of Atherosclerosis, without hypertension or diabetes mellitus (n=3013), were followed for the incidence of hypertension (SBP > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg and/or the initiation of antihypertensive medication). The predicted probability of developing hypertension among 4 adjacent study examinations, with a median of 1.6 years between examinations, was determined. The mean (SD) age of participants was 58.5 (9.7) years, and 53% were women. During follow-up, 849 incident cases of hypertension occurred. The c statistic for the FHS model was 0.788 (95% CI: 0.773 to 0.804) compared with 0.768 (95% CI: 0.751 to 0.785; P=0.096 compared with the FHS model) for SBP alone and 0.699 (95% CI: 0.681 to 0.717; P<0.001 compared with the FHS model) for age-specific diastolic blood pressure categories. The relative integrated discrimination improvement index for the FHS model versus SBP alone was 10.0% (95% CI: -1.7% to 22.7%) and versus age-specific diastolic blood pressure categories was 146.0% (95% CI: 116.0% to 181.0%). Using the FHS model, there were significant differences between observed and predicted hypertension risks (Hosmer-Lemeshow goodness of fit: P<0.001); recalibrated and best-fit models produced a better model fit (P=0.064 and 0.245, respectively). In this multiethnic cohort of US adults, the FHS model was not substantially better than SBP alone for predicting hypertension.

Hypertension is associated with impaired endothelial function in cross-sectional studies. However, few longitudinal data exist on whether endothelial dysfunction precedes the development of hypertension. We examined the cross-sectional and longitudinal relationships between endothelial-dependent brachial artery flow-mediated dilation (FMD) and hypertension prevalence and incidence in 3500 participants from the Multi-Ethnic Study of Atherosclerosis, an ethnically diverse, community-based cohort study. At baseline, the prevalence ratios (95% CI) of hypertension from the highest to the lowest quartile of FMD were 1.00 (referent), 1.26 (1.12 to 1.40), 1.35 (1.21 to 1.52), and 1.68 (1.50 to 1.87; linear trend P<0.001). This association remained (P=0.017) after adjustment for demographics (age, sex, and ethnicity), Multi-Ethnic Study of Atherosclerosis site, and other risk factors. Of the 1869 participants without hypertension at baseline, 584 (31.3%) developed hypertension over a median follow-up of 4.8 years. The unadjusted relative risks (95% CI) of incident hypertension from the highest to the lowest quartile of FMD were 1.00 (referent), 1.38 (1.14 to 1.67), 1.44 (1.19 to 1.74), and 1.64 (1.36 to 1.97; linear trend P<0.001). However, after adjustment for demographics and Multi-Ethnic Study of Atherosclerosis site, the relationship between FMD and incident hypertension was attenuated and not statistically significant: 1.00 (referent), 1.26 (1.04 to 1.52), 1.19 (0.98 to 1.44), and 1.18 (0.97 to 1.44). The longitudinal results also did not appreciably change after adjustment for additional risk factors and baseline blood pressure levels. In this sample, reduced FMD was not an independent predictor of hypertension incidence, suggesting that impaired endothelial function does not play a major role in the development of hypertension.

Background: Studies suggest end-stage renal disease incidence and all-cause mortality rates among patients with chronic kidney disease (CKD) differ by age. The association of diabetes mellitus and hypertension with CKD across the adult lifespan is not well established., Methods: Data from NHANES 1999-2004 were used to determine the association of risk factors for stage 3 or 4 CKD (n = 12,518) and albuminuria (n = 12,778) by age grouping (20 to 49, 50 to 69, and > or =70 years). Stage 3 or 4 CKD was defined as an estimated glomerular filtration rate of 15 to 59 ml/min/1.73 m2 and albuminuria as an albumin to creatinine ratio > or =30 mg/g., Results: For adults 20 to 49, 50 to 69 and > or =70 years of age, the prevalence ratios (95% confidence interval) of stage 3 or 4 CKD associated with hypertension were 1.94 (0.86 - 4.35), 1.51 (1.09 - 2.07), 1.31 (1.15 - 1.49), respectively (p-trend = 0.038). The analogous prevalence ratios (95% confidence interval) were 3.01 (1.35 - 6.74), 1.61 (1.15 - 2.25), 1.40 (1.15 - 1.69), respectively, for diagnosed diabetes mellitus (p-trend = 0.067); and 2.67 (0.53 - 13.4), 1.35 (0.69 - 2.63), 1.08 (0.78 - 1.51), respectively, for undiagnosed diabetes mellitus (p-trend = 0.369). The prevalence ratios of albuminuria associated with hypertension and diagnosed and undiagnosed diabetes mellitus were lower at older age (each p < 0.05)., Conclusion: Among US adults, diabetes mellitus and hypertension are associated with CKD and albuminuria regardless of age. However, the associations were stronger at younger ages.

Several models for estimating risk of incident diabetes in US adults are available. The authors aimed to determine the discriminative ability and calibration of published diabetes risk prediction models in a contemporary multiethnic cohort. Participants in the Multi-Ethnic Study of Atherosclerosis without diabetes at baseline (2000–2002; n = 5,329) were followed for a median of 4.75 years. The predicted risk of diabetes was calculated using published models from the Framingham Offspring Study, the Atherosclerosis Risk in Communities (ARIC) Study, and the San Antonio Heart Study. The mean age of participants was 61.6 years (standard deviation, 10.2); 29.3% were obese, 53.1% had hypertension, 34.9% had a family history of diabetes, 27.5% had high triglyceride levels, 33.8% had low high density lipoprotein cholesterol levels, and 15.3% had impaired fasting glucose. There were 446 incident cases of diabetes (fasting glucose level ≥126 mg/dL or initiation of antidiabetes medication use) diagnosed during follow-up. C statistics were 0.78, 0.84, and 0.83 for the Framingham, ARIC, and San Antonio risk prediction models, respectively. There were significant differences between observed and predicted diabetes risks (Hosmer-Lemeshow goodness-of-fit chi-squared test for each model: P < 0.001). The recalibrated and best-fit models achieved sufficient goodness of fit (each P > 0.10). The Framingham, ARIC, and San Antonio models maintained high discriminative ability but required recalibration in a modern, multiethnic US cohort. [ABSTRACT FROM PUBLISHER]