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Aims Few studies have examined the relationship of blood pressure (BP) change in adults with elevated BP or stage 1 hypertension according to the American College of Cardiology (ACC)/American Heart Association (AHA) guideline with cardiovascular outcomes. We sought to identify the effect of BP change among individuals with elevated BP or stage 1 hypertension on incident heart failure (HF) and other cardiovascular diseases (CVDs). Methods and results We conducted a retrospective cohort study including 616 483 individuals (median age 46 years, 73.7% men) with elevated BP or stage 1 hypertension based on the ACC/AHA BP guideline. Participants were categorized using BP classification at one-year as normal BP (n = 173 558), elevated BP/stage 1 hypertension (n = 367 454), or stage 2 hypertension (n = 75 471). The primary outcome was HF, and the secondary outcomes included (separately) myocardial infarction (MI), angina pectoris (AP), and stroke. Over a mean follow-up of 1097 ± 908 days, 10 544 HFs, 1317 MIs, 11 070 APs, and 5198 strokes were recorded. Compared with elevated BP/stage 1 hypertension at one-year, normal BP at one-year was associated with a lower risk of developing HF [hazard ratio (HR): 0.89, 95% CI:0.85–0.94], whereas stage 2 hypertension at one-year was associated with an elevated risk of developing HF (HR:1.43, 95% CI:1.36–1.51). This association was also present in other cardiovascular outcomes including MI, AP, and stroke. The relationship was consistent in all subgroups stratified by age, sex, baseline BP category, and overweight/obesity. Conclusion A one-year decline in BP was associated with the lower risk of HF, MI, AP, and stroke, suggesting the importance of lowering BP in individuals with elevated BP or stage 1 hypertension according to the ACC/AHA guideline to prevent the risk of developing CVD.

BACKGROUND Results of preceding studies on the relationship between blood pressure (BP) and cancers have been confounded due to individuals taking antihypertensive medications or shared risk factors. We assessed whether medication-naïve high BP is a risk factor for incident cancers. METHODS This retrospective observational study included 1,388,331 individuals without a prior history of cancer and not taking antihypertensive medications enrolled in the JMDC Claims Database between 2005 and 2018. The primary outcome was 16 cancers. RESULTS The median [interquartile range] age was 45 [40–52] years and 56.2% were men. Mean systolic BP (SBP) and diastolic BP (DBP) were 117.7 ± 15.8 and 72.8 ± 11.6 mm Hg. Multivariate Cox regression analysis demonstrated that SBP per 1-SD was associated with a higher incidence of thyroid (hazard ratio [HR]: 1.09, 95% confidence interval [CI]: 1.03–1.16), esophageal (HR: 1.15, 95% CI: 1.07–1.24), colorectal (HR: 1.04, 95% CI: 1.01–1.07), liver (HR: 1.11, 95% CI: 1.03–1.20), and kidney (HR: 1.22, 95% CI: 1.14–1.31) cancers, but with a lower incidence of stomach cancer (HR: 0.94, 95% CI: 0.91–0.98). These associations remained significant after adjustment for multiple testing. DBP was associated with higher incidences of thyroid, esophageal, colorectal, kidney, and corpus uteri cancers, but with a lower incidence of stomach cancer. The associations between SBP and incidences of thyroid, esophageal, colorectal, liver, and kidney cancers were confirmed in the Korean National Health Insurance Service database. CONCLUSIONS Medication-naïve BP was associated with higher incidences of thyroid, esophageal, colorectal, liver, and kidney cancers. Uncovering the underlying mechanisms for our results may help identify novel therapeutic approach for hypertension and cancer.

ObjectiveTo explore trends in blood pressure (BP) control before and during the COVID-19 pandemic.Patients and methodsHealth systems participating in the National Patient-Centered Clinical Research Network (PCORnet) Blood Pressure Control Laboratory Surveillance System responded to data queries, producing 9 BP control metrics. Averages of the BP control metrics (weighted by numbers of observations in each health system) were calculated and compared between two 1-year measurement periods (January 1, 2019, through December 31, 2019, and January 1, 2020, through December 31, 2020).ResultsAmong 1,770,547 hypertensive persons in 2019, BP control to

AIMS/HYPOTHESIS: Type 2 diabetes and non-alcoholic fatty liver disease (NAFLD) are prevalent diseases of metabolic origin. We examined the association between NAFLD and the development of type 2 diabetes among non-Asian adults, and whether the association differs by race. METHODS: We analysed data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort study. Participants underwent non-contrast abdominal computed tomography (CT) at baseline (2010–2011) and assessment of glucose measures at the follow-up exam (2015–2016). NAFLD was defined as liver attenuation ≤51 Hounsfield units on CT images after exclusion for other liver fat causes. Race was self-reported. We used targeted maximum likelihood estimation (TMLE) with machine-learning algorithms to estimate difference in type 2 diabetes risk between the NAFLD and non-NAFLD groups. RESULTS: Of the 1995 participants without type 2 diabetes at baseline (mean age±SD, 50.0±3.6 years; 59% women; 55.0% White and 45.0% Black), 21.7% of White and 16.8% of Black participants had NAFLD at baseline, and 3.7% of White and 8.0% of Black participants developed type 2 diabetes at follow up. After multivariable adjustment, risk difference for type 2 diabetes associated with NAFLD vs no NAFLD was 4.1% (95% CI 0.3%, 7.9%) among White participants and −1.9% (95% CI −5.7%, 2.0%) in Black participants. CONCLUSIONS/INTERPRETATION: NAFLD was associated with a higher risk of type 2 diabetes among White participants but not among Black participants. This finding suggests that the effect of liver fat on impaired glucose metabolism may be smaller in Black than in White individuals.

Background: The association between variability in body mass index (BMI) in early adulthood and cardiac structure and function in midlife has not been previously examined. Methods: We examined 2371 Coronary Artery Risk Development in Young Adults (CARDIA) participants who had BMI assessments across 25-years (CARDIA exam year 0 [1985-1986], 2 [1987-1989], 5 [1990-1991], 7 [1992-1993], 10 [1995-1996], 15 [2000-2001], 20 [2005-2006], and 25 [2010-2011]) as well as echocardiography data at the year-25 exam (2010-2011). BMI variability was assessed by standard deviation (SD) across 25 years. Adjusted multivariable linear regression models were used to assess the association between echocardiography variables (dependent variable) and SD of BMI (independent variable). Model 1 was adjusted for standard cardiac risk factors (age, sex, race, education, blood pressure, anti-hypertension medication use, smoking, fasting plasma glucose, alcohol consumption, physical activity, HDL and total cholesterol. Model 2 was additionally adjusted for mean BMI. Results: Among participants included in the analysis, mean [SD] age at the year 25 exam [2010-2011] was 50.4 [3.6] years; 44.5% were men; and 41.3% were black). In model 1, greater SD of BMI was associated with greater left ventricular mass (β 5.18g, p.05 for all). Greater SD of BMI was associated with worse diastolic function (E/é) (β 0.11, p Conclusions: Greater body weight variability in young adulthood was associated with modest unfavorable midlife alterations in diastolic function.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache. Most headaches that are diagnosed in the primary care setting are benign. Among primary headache disorders, tension-type headache is the most common, although a migraine headache is more debilitating and likely to present in the primary care setting. Signs such as predictable timing, sensitivity to smells or sounds, family history of migraine, recurrent sinus headache, or recurrent severe headaches with a normal neurologic examination could indicate migraine headache. Evaluating acute headaches using a systematic framework such as the SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches. Red flag signs or symptoms such as acute thunderclap headache, fever, meningeal irritation on physical examination, papilledema with focal neurologic signs, impaired consciousness, and concern for acute glaucoma warrant immediate evaluation. For emergent evaluations, noncontrast computed tomography of the head is recommended to exclude acute intracranial hemorrhage or mass effect. A lumbar puncture is also needed to rule out subarachnoid hemorrhage if the scan result is normal. For less urgent cases, magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features. Primary headache disorders without red flags or abnormal examination findings do not need neuroimaging.

The fact that up to one-third of the 800,000 yearly cardiovascular disease (CVD) deaths in the United States may be preventable by diet and physical activity makes a compelling case for lifestyle interventions as a primary prevention strategy. The U.S. Preventive Services Task Force (USPSTF) recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. Although few US adults have ideal cardiovascular health, there exists a dose-response relationship whereby an increasing number of ideal cardiovascular health metrics is associated with lower CVD and all-cause mortality. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet have proven benefits in reducing CVD. Among individuals without CVD, high levels of physical activity are associated with an approximately 32% reduced risk of CVD death, and moderate levels are associated with approximately a 22% reduction. Resistance exercises confer additional benefits.

As part of the approach to primary prevention of cardiovascular disease (CVD), adults should have their CVD risk estimated using a population-appropriate risk equation. In the United States, the atherosclerotic cardiovascular disease (ASCVD) pooled cohort equations are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) to estimate risk in patients ages 40 to 79 years. A 10-year ASCVD risk estimate of 20% or higher is considered high, and patients having this level of risk should be offered and counseled to receive statin therapy. A 10-year risk estimate of 7.5% to less than 20% is considered intermediate, and clinicians should discuss the potential benefits of statin therapy for primary prevention in the context of the patient's preferences and values. In some situations, use of CVD risk enhancers, particularly coronary artery calcium assessed by computed tomography, may help inform the clinician-patient discussion. All patients should be counseled about healthy lifestyle modifications to reduce CVD risk. The AHA's Life's Simple 7 defines ideal cardiovascular health as no tobacco use; ideal blood pressure, blood glucose, and cholesterol levels; adequate physical activity; weight management; and healthy diet. An 8th component (sleep) was very recently added and 4 of the original components have been updated. These metrics provide goals that can drive efforts toward primordial prevention (ie, keeping risk factors themselves from developing).

Several drugs have shown benefits in primary and secondary prevention of cardiovascular disease (CVD). Aspirin should be used routinely for the secondary prevention of CVD. Low-dose aspirin should not be used for the primary prevention of CVD in adults ages 60 years and older. Aspirin can be considered for primary prevention in adults ages 40 to 59 years with a 10% or greater 10-year CVD risk. Moderate- to high-intensity statin therapy should be prescribed for most patients with known atherosclerotic CVD, those with a low-density lipoprotein (LDL) cholesterol level of 190 mg/dL or higher, and those ages 40 to 75 years with diabetes or with a 10-year risk of CVD of 7.5% or greater. Newer lipid-lowering drugs have shown benefits in lowering LDL cholesterol levels, but at high cost and with limited evidence of reduction of CVD outcomes. Polypills provide a method to deliver multiple proven drugs at lower cost and to a broader population. Sodium-dependent glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists should be added to metformin as the preferred second-line drug in the management of diabetes because of their proven ability to improve cardiovascular outcomes. No supplements have proven benefits in CVD prevention. Omega-3 fatty acids and folic acid have shown benefits when consumed in food.

Diabetes, hypertension, tobacco use, and obesity each substantially increases the risk of cardiovascular disease (CVD) and must be controlled as part of CVD prevention. Among patients with diabetes, the reduction of CVD risk from lower A1c goals must be balanced against the risks of hypoglycemia. The American Diabetes Association (ADA) recommends an A1c goal for adults of less than 7% if hypoglycemia can be avoided. A less stringent goal of less than 8% is appropriate in patients with limited life expectancy. A blood pressure (BP) goal of less than 140/90 mm Hg is prudent for all adults younger than 60 years. A goal of less than 140/90 mm Hg also is advised for initiating or intensifying pharmacotherapy in adults 60 years and older with a history of stroke or who are at high cardiovascular risk. BP targets should be individualized to balance the known benefits of lowering BP to 120/80 mm Hg with the risks of morbidity because of hypotension and adverse effects. Varenicline is the most effective drug for smoking cessation, and abstinence rates are increased by combining it with nicotine replacement therapy. Bariatric surgery is the most effective management for long-term weight loss and reduction of obesity-related comorbidities. Social drivers of health are the primary cause of CVD outcomes differences among races and ethnicities.

Isolated diastolic hypertension (IDH), defined as diastolic blood pressure in the hypertensive range but systolic blood pressure not in the hypertensive range, is not uncommon (

Compared with the Seventh Report of the Joint National Committee (JNC7), the 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline uses lower BP thresholds to define hypertension and BP control.We pooled data from five US-based studies to compare the association of masked hypertension (MHT) and masked uncontrolled hypertension, defined using the 2017 ACC/AHA guideline ( n = 1653 without high office BP;130/80 mmHg) versus the JNC7 guideline ( n = 2451 without high office BP;140/90 mmHg), with left ventricular hypertrophy (LVH). MHT and masked uncontrolled hypertension were defined using office BP and awake BP alone and awake, asleep, or 24-h BP. LVH was assessed by echocardiography.Among participants without high office BP not taking antihypertensive medication, the prevalence of MHT defined by the JNC7 guideline and the 2017 ACC/AHA BP guideline was 25.0 and 33.5% using awake BP only and 37.1 and 52.0% when using awake, asleep, or 24-h BP. The adjusted prevalence ratios for LVH associated with MHT versus sustained normotension defined by the JNC7 and 2017 ACC/AHA BP guidelines were 1.72 [95% confidence interval (CI): 1.12-2.64] and 1.56 (95% CI: 0.97-2.51), respectively, when using awake BP only and 2.16 (95% CI: 1.36-3.44) and 1.03 (95% CI: 0.58-1.82), respectively, when using awake, asleep or 24-h BP. There was no evidence that masked uncontrolled hypertension was associated with LVH when defined using the BP thresholds in either the JNC7 or the 2017 ACC/AHA BP guideline.The association of MHT with LVH may depend on the BP thresholds used.

Recent evidence links long-term (visit-to-visit) blood pressure (BP) variability to the risk of cardiovascular disease, independent of mean BP levels. Potential associations between long-term BP variability and cardiovascular disease risk may be reflected in early life course alterations in coronary artery calcium (CAC) and carotid intima-media thickness. We evaluated 2482 CARDIA study (Coronary Artery Risk Development in Young Adults) participants (mean [SD] age at the year 20 exam [2005–2006] was 45.4 [3.6] years, 43.2% men, and 41.3% black). We included participants with BP assessments across 20-years (year 0, 2, 5, 7, 10, 15, 20 exams) and carotid intima-media thickness and CAC data at the year 20 exam. BP variability was assessed using variability independent of the mean and SD. Adjusted multivariable linear or logistic regression models (as appropriate) were used to assess associations between long-term BP variability measures and carotid intima-media thickness. and CAC (ln [CAC+1] and prevalent CAC). Long-term systolic BP variability independent of the mean (per 1 SD) was positively associated with carotid intima-media thickness (β=10 μm, SE=3, P =0.002). Similarly, long-term diastolic BP variability independent of the mean was associated with carotid intima-media thickness (β=10 μm, SE (3), P =0.001). Long-term BP variability was not associated with either ln [CAC+1] or prevalent CAC. Long-term systolic and diastolic BP variability across early adulthood was positively associated with modest adverse midlife alterations in carotid intima-media thickness but not to CAC. Our findings provide further insights into pathophysiologic mechanisms that link long-term BP variability to cardiovascular disease.

Aim of the study Since over 80% of sudden cardiac arrests occur in the home, cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this approach, but evidence regarding its efficacy is lacking. Methods We conducted a multicenter, pragmatic, cluster-randomized trial assessing CPR training for family members of cardiac patients. The interventions were mApp (video, no manikin) and VSI (video + manikin). CPR skills were evaluated 6-months post-training. We hypothesized that chest compression (CC) rate from training with an mApp would be no worse than 5 compressions per minute (CPM) lower compared to VSI. Results From 01/2016 to 01/2018, we enrolled 1325 eligible participants (mean age 51.6 years, 68.2% female and 59.4% white). CPR skills were evaluated 6-months post-training in 541 participants (275 VSI, 266 mApp). Mean rate was 84.6 CPM (95% CI: 80.4, 88.6) in VSI, compared to 82.7 CPM (95% CI: 76.2, 89.1) in the mApp, and mean depth was 42.1 mm (95% CI: 40.3, 43.8) in VSI, compared to 38.9 mm (95% CI: 36.2, 41.6) in the mApp. After adjustment, the mean difference in CC rate was −2.3 CPM (95% CI −9.4, 4.8, p = 0.25, non-inferiority) and CC depth was −3.2 mm (95% CI −5.9, 0.1, p = 0.056). Conclusion In this large prospective trial of CPR skill retention for family members of cardiac patients, mApp training was associated with lower CC quality. Future work is required to understand additional approaches to improve CPR skill retention. Clinical Trial Registration URL: ClinicalTrials.gov, Identifier: NCT02548793 .

Follow these strategies and tips for using home and 24-hour ambulatory measurements to more accurately assess a patient's blood pressure.

Masked hypertension - a blood pressure (BP) phenotype characterized by a clinic BP in the normal range but elevated BP outside the office - is associated with early hypertension-mediated organ damage. This study examined early target organ manifestations of masked hypertension diagnosed by home (HBPM) and ambulatory (ABPM) BP monitoring.Left ventricular (LV) structure and diastolic function measured by echocardiography, microalbuminuria, and coronary artery calcification were evaluated in 420 patients with high clinic BP (SBP 120-150 mmHg or DBP 80-95 mmHg). Evidence of hypertension-mediated organ damage was compared in patients with sustained normotension, masked hypertension, and sustained hypertension based on measurements by HBPM, daytime ABPM, and 24-h ABPM.The 420 participants averaged 48 (12) [mean (SD)] years of age; the average clinic BP was 130 (13)/81 (8) mmHg. In individuals with masked hypertension diagnosed by HBPM, indexed LV mass, relative wall thickness, and e' and E/e' (indices of LV relaxation), were generally intermediate between values observed in normotensives and sustained hypertensive patients, and were significantly greater in masked hypertension than normotensives. Similar trends were observed when masked hypertension was diagnosed by ABPM but a diagnosis of masked hypertension was not as reliably associated with LV remodeling or impaired LV relaxation in comparison to normotensives. There were trends towards greater likelihoods of detectable urinary microalbumin and coronary calcification in masked hypertension than in normotensives.These results support previous studies demonstrating early hypertension-mediated organ damage in patients with masked hypertension, and suggest that HBPM may be superior to ABPM in identifying patients with masked hypertension who have early LV remodeling and diastolic LV dysfunction.

Hospitalists perform key roles as inpatient educators for family medicine residents. For the past decade, Duke University Family Medicine Residency Program had its inpatient family medicine resident rotation at non-Duke facilities.The authors describe the steps taken in 2020 to develop an inpatient Duke family medicine rotation at a North Carolina community hospital, Duke Regional Hospital, and provide outcomes data.Duke Family Medicine Residency and Duke Regional Hospital Medicine collaborated in addressing key issues to develop an inpatient rotation for family medicine residents. Performance metrics of patients cared for by both the family medicine inpatient resident team and internal medicine teams were compared. Resident satisfaction survey results were reviewed.Retrospective cohort evaluation comparing the two inpatient services (internal medicine and family medicine) revealed the family medicine resident inpatient service performed comparatively in length of stay and 30-day readmission rates. Resident evaluation surveys of the family medicine inpatient rotation showed overall satisfaction with learning objectives.This new family medicine inpatient rotation has benefitted all parties. Key quality performance metrics such as LOS and readmissions are comparable to internal medicine, hospitalists have more teaching opportunities, and Duke family medicine has its residents training in a Duke-affiliated community hospital for their core inpatient rotation.

BACKGROUND Masked hypertension (nonhypertensive in the clinic setting but hypertensive outside the clinic during wakefulness) is characterized by increased blood pressure in response to physical and emotional stressors that activate the sympathetic nervous system (SNS). However, no studies have assessed vascular reactivity to a pharmacological SNS challenge in individuals with masked hypertension. METHODS We analyzed data from 161 adults aged 25 to 45 years (mean ± standard deviation age 33 ± 6 years; 48% were African American and 43% were female). Participants completed ambulatory blood pressure monitoring, and a standardized α 1-adrenergic agonist phenylephrine test that determines the dose of phenylephrine required to increase a participant’s mean arterial pressure by 25 mm Hg (PD25). RESULTS Twenty-one participants were considered to have masked hypertension (clinic systolic blood pressure (SBP) CONCLUSIONS Among young and middle-aged adults, masked hypertension is associated with increased vascular reactivity to a SNS challenge, which may contribute to elevated awake BPs as well as to increased cardiovascular disease risk.

Background Regular physical activity is an important component of healthy living and wellbeing. Current guidelines recommend that adults participate in at least 150 min of moderate or vigorous-intensity physical activity weekly. In spite of the benefits, just over half of U.S. adults meet these recommendations. Calorie-only food labels at points of food purchase have had limited success in motivating people to change eating behaviors and increase physical activity. One new point of purchase approach to promote healthy behaviors is the addition of food labels that display the physical activity requirement needed to burn the calories in a food item (e.g. walk 15 min). Methods The Physical Activity Calorie Expenditure (PACE) Study compared activity-based calorie-expenditure food labels with calorie-only labels at three Blue Cross and Blue Shield of North Carolina worksite cafeterias. After 1 year of baseline data collection, one cafeteria had food items labeled with PACE labels, two others had calorie-only food labels. Cohort participants were asked to wear an accelerometer and complete a self-report activity questionnaire on two occasions during the baseline year and twice during the intervention year. Results A total of 366 study participants were included in the analysis. In the PACE-label group, self-reported physical activity increased by 13–26% compared to the calorie-only label group. Moderate-to-vigorous physical activity (MVPA) increased by 24 min per week in the PACE-label group compared to the calorie-label group (p = 0.06). Changes in accelerometer measured steps, sedentary time, and MVPA had modest increases. Change ranged from 1 to 12% with effect size values from 0.08 to 0.15. Baseline physical activity level significantly moderated the intervention effects for all physical activity outcomes. Participants in both label groups starting in the lowest tertile of activity saw the largest increase in their physical activity. Conclusion Results suggest small positive effects for the PACE labels on self-reported and objective physical activity measures. Minutes of weekly MVPA, strength training, and exercise activities showed modest increases. These results suggest that calorie-expenditure food labels may result in some limited increases in physical activity.

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Importance Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment. Objective To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM. Data Sources PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles. Data Extraction and Synthesis Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed. Main Outcomes and Measures Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard. Results A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%). Conclusions and Relevance Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included “Life’s Simple 7,” we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.

Introduction: Bystander CPR (B-CPR) and defibrillation for sudden cardiac arrest (SCA) vary by gender with females being less likely to receive these interventions. Despite known differences by race and ethnicity, it is unknown whether gender disparities in B-CPR and defibrillation persist by neighborhood race and ethnicity. Objectives: We examined the likelihood of receiving B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition. We hypothesized that in public locations within Black neighborhoods, females will have a lower likelihood of receiving B-CPR compared to males. Methods: We conducted a retrospective cohort study using data from the US Cardiac Arrest Registry to Enhance Survival (CARES) registry. Neighborhoods were classified by census tract based on percent of Black or Hispanic residents using the threshold in the definition of “White flight” where Whites leave a neighborhood when it exceeds >30% of a minority population. We independently modeled the likelihood of receipt of B-CPR and defibrillation by gender stratified by public location and neighborhood racial/ethnic composition controlling for confounding variables. Results: From 2013-2018, CARES collected 350,722 US arrests; after excluding pediatric arrests, those witnessed by EMS, or those that occurred in a healthcare facility, 214,464 were included. Mean age was 64±16 and 65% were male; 39% received B-CPR, 9% received bystander defibrillation prior to 9-1-1 responders arrival, and 18% occurred in the public. In Black neighborhoods, females who had SCA in public locations were 22% less likely to receive B-CPR (OR: 0.78 (0.64-0.95), p=0.01) and 42% less likely to receive defibrillation (OR: 0.58 (0.45-0.74), p Conclusion: Females with public SCA have a decreased likelihood of receiving B-CPR and defibrillation, and these findings persist in Black and Hispanic neighborhoods. This has implications for strategies to reduce disparities around bystander response to SCA.

RESEARCH OBJECTIVE: Patient continuity of care (CoC) with a primary care (PC) provider is associated with improved outcomes, particularly for medically complex patients. Given the difficulty for a single provider to deliver all services required to the patients on his/her panel, PC providers often provide care to each other’s patients, or “share” common patients. This patient sharing, or interdependence, is not well described, and its impact on patient CoC is unknown. Objectives include the following: (a) To describe PC provider (PC physician, physician assistant [PA], or nurse practitioner [NP]) interdependence (the extent to which patients on a provider’s panel are served by other providers within the practice) and (b) to evaluate the association of patient and panel characteristics, including PC provider interdependence, on patient CoC. STUDY DESIGN: This patient‐level cohort study used electronic health record data from 26 health system‐affiliated PC practices in central North Carolina. Patients’ usual PC provider was the provider most frequently seen during 2016. Patient‐level variables (demographic, medical complexity, and PC utilization variables) were used to calculate panel level variables [panel size, visit number, and provider interdependence (# shared patients / # supplemental providers)]. We examined the association of patient CoC (% of PC visits with usual PC provider) with all variables simultaneously using binomial regression with clustering by practice. Postestimation margins of CoC were calculated using delta method standard errors for a complex patient based on age, number of chronic conditions, and number of PC visits for a complex patient (80‐year‐old woman with ≥ 9 chronic conditions and 43 PC visits) and less complex patient (55‐year‐old man with two chronic conditions and four primary care visits). CoC was calculated for each patient on panels with a range of values (minimums, maximums, and/or means) for panel level variables. POPULATION STUDIED: Adult patients with diabetes (N = 19 957). PRINCIPAL FINDINGS: PC patient panels (N = 164) were led by physicians (N = 134), NPs (N = 20) and PAs (N = 10). Panels for physicians were larger (mean = 131) than NP (mean = 80) or PA (mean = 80). Thirty‐nine % of patients had a visit with a supplemental provider. Panels were served by a mean of 7.6 providers (PCP + supplemental providers), with a mean interdependence of 7.3 patients/supplemental provider. Patient‐level CoC ranged from 6% to 99%. Panel characteristics affected the CoC of complex patients (6‐98%) more than less complex patients (61‐99%). CoC values of the complex patient were lowest when on small panels (6%‐27%) for all provider types. Higher interdependence reduced CoC for complex patients, but improved CoC for less complex patients. CONCLUSIONS: Patient characteristics and panel characteristics affect patient CoC. Complex, high utilizing patients are at greater risk of low CoC, particularly if they are on small panels that are served by many providers. Less complex patients experienced acceptable CoC regardless of panel characteristics. IMPLICATIONS FOR POLICY OR PRACTICE: Organizations using or considering interdependent, multiple‐provider teams should pay special attention to the impact on high utilizing, complex patients. Complex patients benefit most from CoC, a measure known to be associated with improved health outcomes. PRIMARY FUNDING SOURCE: National Institutes of Health.

Previous cost-effectiveness models found ambulatory blood pressure monitoring (ABPM) to be a favorable strategy to diagnose hypertension; however, they mostly focused on older adults with a positive clinic blood pressure (BP) screen. We evaluated the cost-effectiveness of 3 methods of BP measurement for hypertension diagnosis in primary care settings among 14 age- and sex-stratified hypothetical cohorts (adults ≥21 years of age), accounting for the possibility of both false-positive (white-coat hypertension) and false-negative (masked hypertension) clinic measurements. We compared quality-adjusted life-years and lifetime costs ($US 2017 from the US healthcare perspective) associated with clinic BP measurement, home BP monitoring, and ABPM under 2 scenarios: positive and negative initial screen. Model parameters were obtained from published literature, publicly available data sources, and expert input. In the screen-positive scenario, ABPM was the dominant strategy among all age and sex groups. Compared with clinic BP measurement, ABPM was associated with cost-savings ranging from $77 (women 80 years of age) to $5013 (women 21 years of age). In the screen-negative scenario, ABPM was the dominant strategy in all men and women

Background Low-wage workers suffer disproportionately high rates of chronic disease and are important targets for workplace health and safety interventions. Child care centers offer an ideal opportunity to reach some of the lowest paid workers, but these settings have been ignored in workplace intervention studies. Methods Caring and Reaching for Health (CARE) is a cluster-randomized controlled trial evaluating efficacy of a multi-level, workplace-based intervention set in child care centers that promotes physical activity and other health behaviors among staff. Centers are randomized (1:1) into the Healthy Lifestyles (intervention) or the Healthy Finances (attention control) program. Healthy Lifestyles is delivered over six months including a kick-off event and three 8-week health campaigns (magazines, goal setting, behavior monitoring, tailored feedback, prompts, center displays, director coaching). The primary outcome is minutes of moderate and vigorous physical activity (MVPA); secondary outcomes are health behaviors (diet, smoking, sleep, stress), physical assessments (body mass index (BMI), waist circumference, blood pressure, fitness), and workplace supports for health and safety. Results In total, 56 centers and 553 participants have been recruited and randomized. Participants are predominately female (96.7%) and either Non-Hispanic African American (51.6%) or Non-Hispanic White (36.7%). Most participants (63.4%) are obese. They accumulate 17.4 (±14.2) minutes/day of MVPA and consume 1.3 (±1.4) and 1.3 (±0.8) servings/day of fruits and vegetables, respectively. Also, 14.2% are smokers; they report 6.4 (±1.4) hours/night of sleep; and 34.9% are high risk for depression. Conclusions Baseline data demonstrate several serious health risks, confirming the importance of workplace interventions in child care.

RESEARCH OBJECTIVE: Quality of diabetes care delivered to patients with different types of usual providers of care [i.e., physician, physician assistant (PA) or nurse practitioner (NP)] is similar. However, primary care (PC) providers often provide care to each other's patients (i.e., “share” common patients). The impact of patient sharing, or interdependence, is on quality of diabetes care is unknown. As a result, some providers and organizations hesitate to formalize patient sharing by creating multi‐provider teams due to concerns about the impact of impact of such teams on quality of care. We sought to both 1) evaluate the association of usual provider type (physician or PA/NP) provider and 2) interdependence on outcomes for patients with diabetes. STUDY DESIGN: This patient‐level cohort study used electronic health record data from 24 health system‐affiliated PC practices in central North Carolina. Patients' usual PC provider was the provider most frequently seen during 2016 and 2017. Patient‐level independent variables included demographic, medical complexity, and healthcare utilization (separate variables for PC, specialty, emergency department, and hospital). Provider panel‐level variables [usual provider of care type (physician or PA/NP), panel size, and provider interdependence (# shared patients / # supplemental providers then categorized into quartiles)]. We examined the association of diabetes quality (at least two hemoglobin A1c (HbA1c) tests, at least one low‐density lipoprotein (LDL) cholesterol test, mean HbA1c and LDL values) during 2017 with all variables simultaneously using logistic or linear regression with clustering by practice. POPULATION STUDIED: Adults with diabetes (N = 10,498) on 131 panels (physician = 111; PA/NP = 20). PRINCIPAL FINDINGS: Ninety percent of patients had physicians as usual providers (N = 9462). Patient demographics, complexity and utilization were similar for patients of different usual provider types except for mean age (physician = 64.6; PA/NP = 59.7) and insurance type (% Medicaid/uninsured: physician: 5.5; PA/NP: 11.2). Most patients had at least two HbA1c tests (72%) and one LDL test (65%). Average HbA1c (7.5 mmHg) and LDL (109 mg/dL) was also similar by usual provider type. Average panel size was 80 diabetes patients (physician = 85; PA/NP = 52) Panels had a mean interdependence of 6.1 patients/supplemental provider (physician = 6.2; PA/NP = 5.8). There were no statistically significant differences in HbA1c or LDL testing by usual provider type or interdependence. Similarly, there was no statistically significant difference in HbA1c for mean HbA1c values by usual provider type or interdependence. However, increases in interdependence quartile resulted in increases in mean LDL values (β = 13.8, p = 0.016). CONCLUSIONS: The quality of diabetes care does not differ based on provider type, either PA/NPs or physicians. Increases in provider interdependence (greater numbers of patients per provider) resulted in higher mean LDL values, but only the interdependence values in the highest quartile would result in a mean LDL in the borderline high range. IMPLICATIONS FOR POLICY OR PRACTICE: Organizations using or considering interdependent, multiple‐provider teams will likely not see a reduction in diabetes‐specific quality metrics. However, additional patient and provider outcomes should be evaluated, such as delivery of preventive services, outcomes important to patients with multiple chronic conditions, and provider satisfaction and burn‐out. PRIMARY FUNDING SOURCE: National Institutes of Health.

Purpose This study aims to test the utility of the theory of planned behavior (TPB) for explaining intention to eat a healthful diet in a sample of Southeastern US office workers. Design/methodology/approach Participants in a worksite nutrition study (n = 357) were invited to complete an online questionnaire including measures of TPB constructs at baseline. The questionnaire included valid and reliable measures of TPB constructs: behavioral beliefs, normative beliefs, control beliefs, attitudes toward behavior, subjective norm, perceived behavioral control and intention. Data were collected from 217 participants (60.8 per cent response rate). Confirmatory factor analysis and structural equation modeling were conducted to test the hypothesized TPB model. Findings The model fit was satisfactory (χ2 = p < 0.0001, RMSEA = 0.06, CFI = 0.91, TLI = 0.90, SRMR = 0.09). All structural relationships between TPB constructs were statistically significant in the hypothesized direction (p < 0.05). Attitude toward behavior, subjective norm and perceived behavioral control were positively associated with intention (R2 = 0.56). Of all TPB constructs, the influence of perceived behavioral control on intention was the strongest (β = 0.62, p < 0.001). Originality/value Based on this sample of Southeastern US office workers, TPB-based interventions may improve intention to eat a healthful diet. Interventions that strengthen perceived control over internal and external factors that inhibit healthful eating may be particularly effective in positively affecting intention to eat a healthful diet, and subsequent food intake.