Home Blood Pressure Telemonitoring and Nurse Case Management in Black and Hispanic Patients With Stroke: A Randomized Clinical Trial.

Importance: Black and Hispanic patients have high rates of recurrent stroke and uncontrolled hypertension in the US. The effectiveness of home blood pressure telemonitoring (HBPTM) and telephonic nurse case management (NCM) among low-income Black and Hispanic patients with stroke is unknown. Objective: To determine whether NCM plus HBPTM results in greater systolic blood pressure (SBP) reduction at 12 months and lower rate of stroke recurrence at 24 months than HBPTM alone among Black and Hispanic stroke survivors with uncontrolled hypertension. Design, Setting, and Participants: Practice-based, multicenter, randomized clinical trial in 8 stroke centers and ambulatory practices in New York City. Black and Hispanic study participants were enrolled between April 18, 2014, and December 19, 2017, with a final follow-up visit on December 31, 2019. Interventions: Participants were randomly assigned to receive either HBPTM alone (12 home BP measurements/week for 12 months, with results transmitted to a clinician; n = 226) or NCM plus HBPTM (20 counseling calls over 12 months; n = 224). Main Outcomes and Measures: Primary outcomes were change in SBP at 12 months and rate of recurrent stroke at 24 months. Final statistical analyses were completed March 14, 2024. Results: Among 450 participants who were enrolled and randomized (mean [SD] age, 61.7 [11.0] years; 51% were Black [n = 231]; 44% were women [n = 200]; 31% had ≥3 comorbid conditions [n = 137]; 72% had household income <$25 000/y [n = 234/324]), 358 (80%) completed the trial. Those in the NCM plus HBPTM group had a significantly greater SBP reduction than those in the HBPTM alone group at 12 months (-15.1 mm Hg [95% CI, -17.2 to -13.0] vs -5.8 mm Hg [95% CI, -7.9 to -3.7], respectively; P < .001). The between-group difference in SBP reduction at 12 months, adjusted for primary care physician clustering, was -8.1 mm Hg (95% CI, -11.2 to -5.0; P < .001) at 12 months. The rate of recurrent stroke was similar between both groups at 24 months (4.0% in the NCM plus HBPTM group vs 4.0% in the HBPTM alone group, P > .99). Conclusions and Relevance: Among predominantly low-income Black and Hispanic stroke survivors with uncontrolled hypertension, addition of NCM to HBPTM led to greater SBP reduction than HBPTM alone. Additional studies are needed to understand the long-term clinical outcomes, cost-effectiveness, and generalizability of NCM-enhanced telehealth programs among low-income Black and Hispanic stroke survivors with significant comorbidity. Trial Registration: Clinical Trials.gov Identifier: NCT02011685.

Role of digital health communication, sociodemographic factors, and medical conditions on perceived quality of patient-centered communication.

OBJECTIVE: To simultaneously explore associations between digital health, sociodemographic factors, and medical conditions on patient-centered communication (PCC). These are under-explored, yet important knowledge gaps to fill because perceived quality PCC may influence health information seeking behaviors and health outcomes. METHODS: Data from the 2019 Health Information National Trends Survey were analyzed. The primary outcome was PCC, which was the summed score of 7 PCC-related questions. Factors of interest included whether participants used electronic methods to communicate with health professionals, age, gender, race/ethnicity, education, feelings about household income, and history of medical conditions. Descriptive statistics and linear regressions were conducted. RESULTS: In the multivariate linear regression model, people aged 65-74 years compared with 18-34 year-olds, those with some college compared with college graduates, and those who felt they were living comfortably on their household income compared with all others reported higher PCC scores. People with a history of hypertension compared with those without reported higher PCC scores. CONCLUSION: Similar to past studies, sociodemographic factors were associated with PCC. A novel finding was that a history hypertension was associated with perceived quality of PCC. PRACTICE IMPLICATIONS: This research may inform methods to enhance communication between patients and clinicians.

An Evaluation of Alternative Technology-Supported Counseling Approaches to Promote Multiple Lifestyle Behavior Changes in Patients With Type 2 Diabetes and Chronic Kidney Disease.

OBJECTIVES: Although technology-supported interventions are effective for reducing chronic disease risk, little is known about the relative and combined efficacy of mobile health strategies aimed at multiple lifestyle factors. The purpose of this clinical trial is to evaluate the efficacy of technology-supported behavioral intervention strategies for managing multiple lifestyle-related health outcomes in overweight adults with type 2 diabetes (T2D) and chronic kidney disease (CKD). DESIGN AND METHODS: Using a 2 × 2 factorial design, adults with excess body weight (body mass index ≥27 kg/m2, age ≥40 years), T2D, and CKD stages 2-4 were randomized to an advice control group, or remotely delivered programs consisting of synchronous group-based education (all groups), plus (1) Social Cognitive Theory-based behavioral counseling and/or (2) mobile self-monitoring of diet and physical activity. All programs targeted weight loss, greater physical activity, and lower intakes of sodium and phosphorus-containing food additives. RESULTS: Of 256 randomized participants, 186 (73%) completed 6-month assessments. Compared to the ADVICE group, mHealth interventions did not result in significant changes in weight loss, or urinary sodium and phosphorus excretion. In aggregate analyses, groups receiving mobile self-monitoring had greater weight loss at 3 months (P = .02), but between 3 and 6 months, weight losses plateaued, and by 6 months, the differences were no longer statistically significant. CONCLUSIONS: When engaging patients with T2D and CKD in multiple behavior changes, self-monitoring diet and physical activity demonstrated significantly larger short-term weight losses. Theory-based behavioral counseling alone was no better than baseline advice and demonstrated no interaction effect with self-monitoring.

Blood Pressure Visit Intensification in Treatment (BP-Visit) Findings: a Pragmatic Stepped Wedge Cluster Randomized Trial.

BACKGROUND: Shortening time between office visits for patients with uncontrolled hypertension represents a potential strategy for improving blood pressure (BP). OBJECTIVE: We evaluated the impact of multimodal strategies on time between visits and on improvement in systolic BP (SBP) among patients with uncontrolled hypertension. DESIGN: We used a stepped-wedge cluster randomized controlled trial with three wedges involving 12 federally qualified health centers with three study periods: pre-intervention, intervention, and post-intervention. PARTICIPANTS: Adult patients with diagnosed hypertension and two BPs ≥ 140/90 pre-randomization and at least one visit during post-randomization control period (N = 4277). INTERVENTION: The core intervention included three, clinician hypertension group-based trainings, monthly clinician feedback reports, and monthly meetings with practice champions to facilitate implementation. MAIN MEASURES: The main measures were change in time between visits when BP was not controlled and change in SBP. A secondary planned outcome was changed in BP control among all hypertension patients in the practices. KEY RESULTS: Median follow-up times were 34, 32, and 32 days and the mean SBPs were 142.0, 139.5, and 139.8 mmHg, respectively. In adjusted analyses, the intervention did not improve time to the next visit compared with control periods, HR = 1.01 (95% CI: 0.98, 1.04). SBP was reduced by 1.13 mmHg (95% CI: -2.10, -0.16), but was not maintained during follow-up. Hypertension control (< 140/90) in the practices improved by 5% during intervention (95% CI: 2.6%, 7.3%) and was sustained post-intervention 5.4% (95% CI: 2.6%, 8.2%). CONCLUSIONS: The intervention failed to shorten follow-up time for patients with uncontrolled BP and showed very small, statistically significant improvements in SBP that were not sustained. However, the intervention showed statistically and clinically relevant improvement in hypertension control suggesting that the intervention affected clinician decision-making regarding BP control apart from visit frequency. Future practice initiatives should consider hypertension control as a primary outcome. CLINICAL TRIAL: www.ClinicalTrials.gov Identifier: NCT02164331.

Prevalence and correlates of depression among black and Latino stroke survivors with uncontrolled hypertension: a cross-sectional study.

OBJECTIVE: To examine the prevalence and correlates of depression in a cohort of black and Hispanic stroke survivors with uncontrolled hypertension. SETTING: Baseline survey data from 10 stroke centres across New York City. PARTICIPANTS: Black and Hispanic stroke survivors with uncontrolled hypertension (n=450). OUTCOME MEASURES: Depressive symptoms were assessed with the 8-item Patient Reported Outcomes Measurement Information System (PROMIS) measure. Depression was defined as a PROMIS score ≥55. Other data collected included clinical factors, health-related quality of life (EuroQoL five dimensions (EQ-5D)), functional independence (Barthel Index, BI), stroke-related disability (Modified Rankin Score), physical function (PROMIS Physical Function) and executive functioning (Frontal Assessment Battery). RESULTS: The mean age was 61.7±11.1 years, 44% of participants were women and 51% were black. Poststroke depression was noted in 32% of the cohort. Examining bivariate relationships, patients with depression were observed to have poorer function and quality of life as evidenced by significantly lower PROMIS physical function scores (36.9±8.32 vs 43.4±10.19, p<0.001); BI scores (79.9±19.2 vs 88.1±15.1, p<0.001); EQ-5D scores (0.66±0.24 vs 0.83±0.17, p<0.001) and higher Rankin scores (2.10±1.00 vs 1.46±1.01, p<0.001) compared with those without depression. Multivariate (model adjusted) significant correlates of depression included lower self-reported quality of life (OR=0.02 (CI 0.004 to 0.12) being younger (OR=0.94; 95% CI 0.91 to 0.97); not married (OR=0.46; CI 0.24 to 0.89)); and foreign-born (OR=3.34, 95% CI 1.4 to 7.97). There was a trend for higher comorbidity to be uniquely associated with depression (≥3 comorbid conditions, OR=1.49, 95% CI 1.00 to 2.23). CONCLUSIONS: Poststroke depression is common among black and Hispanic stroke survivors with higher rates noted among foreign-born patients and those with high comorbidity. These findings highlight the importance of screening for depression in minority stroke survivors. TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov. Unique identifier: NCT01070056.

The role of data and safety monitoring boards in implementation trials: When are they justified?

The National Institutes of Health requires data and safety monitoring boards (DSMBs) for all phase III clinical trials. The National Heart, Lung and Blood Institute requires DSMBs for all clinical trials involving more than one site and those involving cooperative agreements and contracts. These policies have resulted in the establishment of DSMBs for many implementation trials, with little consideration regarding the appropriateness of DSMBs and/or key adaptations needed by DSMBs to monitor data quality and participant safety. In this perspective, we review the unique features of implementation trials and reflect on key questions regarding the justification for DSMBs and their potential role and monitoring targets within implementation trials.

Protocol paper: Stepped wedge cluster randomized trial translating the ABCS into optimizing cardiovascular care for people living with HIV.

People living with HIV (PWH) are at higher risk for cardiovascular disease (CVD) and stroke in comparison to their non-infected counterparts. The ABCS (aspirin-blood pressure control-cholesterol control-smoking cessation) reduce atherosclerotic (ASCVD) risk in the general population, but little is known regarding strategies for promoting the ABCS among PWH. Guided by the Consolidated Framework for Implementation Research (CFIR), we designed multilevel implementation strategies that target PWH and their clinicians to promote appropriate use of the ABCS based on a 10-year estimated ASCVD risk. Implementation strategies include patient coaching, automated texting, peer phone support, academic detailing and audit and feedback for the patient's clinician. We are evaluating implementation through a stepped wedge cluster randomized trial based on the Reach-Effectiveness-Adoption-Maintenance/Qualitative-Evaluation-for-Systematic-Translation (RE-AIM/QuEST) mixed methods framework that integrates quantitative and qualitative assessments. The primary outcome is change in ASCVD risk. Findings will have important implications regarding strategies for reducing ASCVD risk among PWH.

Mobile Phone Ownership, Health Apps, and Tablet Use in US Adults With a Self-Reported History of Hypertension: Cross-Sectional Study.

BACKGROUND: Mobile phone and tablet ownership have increased in the United States over the last decade, contributing to the growing use of mobile health (mHealth) interventions to help patients manage chronic health conditions like diabetes. However, few studies have characterized mobile device ownership and the presence of health-related apps on mobile devices in people with a self-reported history of hypertension. OBJECTIVE: This study aimed to describe the prevalence of smartphone, tablet, and basic mobile phone ownership and the presence of health apps by sociodemographic factors and self-reported hypertension status (ie, history) in a nationally representative sample of US adults, and to describe whether mobile devices are associated with health goal achievement, medical decision making, and patient-provider communication. METHODS: Data from 3285 respondents from the 2017 Health Information National Trends Survey were analyzed. Participants were asked if they owned a smartphone, tablet, or basic mobile phone and if they had health apps on a smartphone or tablet. Participants were also asked if their smartphones or tablets helped them achieve a health-related goal like losing weight, make a decision about how to treat an illness, or talk with their health care providers. Chi-square analyses were conducted to test for differences in mobile device ownership, health app presence, and app helpfulness by patient characteristics. RESULTS: Approximately 1460 (37.6% weighted prevalence) participants reported a history of hypertension. Tablet and smartphone ownership were lower in participants with a history of hypertension than in those without a history of hypertension (55% vs 66%, P=.001, and 86% vs 68%, P<.001, respectively). Participants with a history of hypertension were more likely to own a basic mobile phone only as compared to those without a history of hypertension (16% vs 9%, P<.001). Among those with a history of hypertension exclusively, basic mobile phone, smartphone, and tablet ownership were associated with age and education, but not race or sex. Older adults were more likely to report having a basic mobile phone only, whereas those with higher education were more likely to report owning a tablet or smartphone. Compared to those without a history of hypertension, participants with a history of hypertension were less likely to have health-related apps on their smartphones or tablets (45% vs 30%, P<.001) and report that mobile devices helped them achieve a health-related goal (72% vs 63%, P=.01). CONCLUSIONS: Despite the increasing use of smartphones, tablets, and health-related apps, these tools are used less among people with a self-reported history of hypertension. To reach the widest cross-section of patients, a mix of novel mHealth interventions and traditional health communication strategies (eg, print, web based, and in person) are needed to support the diverse needs of people with a history of hypertension.

Types of Sedentary Behavior and Risk of Cardiovascular Events and Mortality in Blacks: The Jackson Heart Study.

Background Previous cross-sectional studies have shown conflicting results regarding the effects of television viewing and occupational sitting on cardiovascular disease ( CVD ) risk factors. The purpose of this study was to compare the association of both television viewing and occupational sitting with CVD events and all-cause mortality in blacks. Methods and Results Participants included 3592 individuals enrolled in the Jackson Heart Study, a community-based study of blacks residing in Jackson, Mississippi. Television viewing (<2, 2-4, and >4 h/day) and occupational sitting (never/seldom, sometimes, often/always) were self-reported. Over a median follow-up of 8.4 years, there were 129 CVD events and 205 deaths. The highest category of television viewing (>4 h/day) was associated with a greater risk for a composite CVD events/all-cause mortality end point compared with the lowest category (<2 h/day; hazard ratio, 1.49; 95% CI , 1.13-1.97). In contrast, the highest category of occupational sitting (often/always) was not associated with risk for a composite CVD events/all-cause mortality end point compared with the lowest category (never/seldom; hazard ratio, 0.90; 95% CI , 0.69-1.18). Moderate-to-vigorous physical activity moderated the association of television viewing with CVD events/all-cause mortality such that television viewing was not associated with greater risk among those with high moderate-to-vigorous physical activity levels. Conclusions Television viewing was associated with greater risk of CVD events and all-cause mortality, while occupational sitting had no association with these outcomes. These findings suggest that minimizing television viewing may be more effective for reducing CVD and mortality risk in blacks compared with reducing occupational sedentary behavior.

Partnerships to Improve Shared Decision Making for Patients with Hypertension - Health Equity Implications.

Shared decision making (SDM) has increasingly become appreciated as a method to enhance patient involvement in health care decisions, patient-provider communication, and patient-centered care. Compared with cancer, the literature on SDM for hypertension is more limited. This is notable because hypertension is the leading risk factor for cardiovascular disease and both conditions disproportionately affect certain subgroups of patients. However, SDM holds promise for improving health equity by better engaging patients in their health care. For example, many reasonable options exist for treating uncomplicated stage-1 hypertension. These options include medication and/or lifestyle changes such as healthy eating, physical activity, and weight management. Deciding on "the best" plan of action for hypertension management can be challenging because patients have different goals and preferences for treatment. As hypertension management may be considered a preference-sensitive decision, adherence to treatment plans may be greater if those plans are concordant with patient preferences. SDM can be implemented in a broad array of care contexts, from patient-provider dyads to interprofessional collaborations. In this article, we argue that SDM has the potential to advance health equity and improve clinical care. We also propose a process to evaluate whether SDM has occurred and suggest future directions for research.

Different Relationship Between Systolic Blood Pressure and Cerebral Perfusion in Subjects With and Without Hypertension.

Although there is an increasing agreement that hypertension is associated with cerebrovascular compromise, relationships between blood pressure (BP) and cerebral blood flow are not fully understood. It is not known what BP level, and consequently what therapeutic goal, is optimal for brain perfusion. Moreover, there is limited data on how BP affects hippocampal perfusion, a structure critically involved in memory. We conducted a cross-sectional (n=445) and longitudinal (n=185) study of adults and elderly without dementia or clinically apparent stroke, who underwent clinical examination and brain perfusion assessment (age 69.2±7.5 years, 62% women, 45% hypertensive). Linear models were used to test baseline BP-blood flow relationship and to examine how changes in BP influence changes in perfusion. In the entire group, systolic BP (SBP) was negatively related to cortical (ß=-0.13, P=0.005) and hippocampal blood flow (ß=-0.12, P=0.01). Notably, this negative relationship was apparent already in subjects without hypertension. Hypertensive subjects showed a quadratic relationship between SBP and hippocampal blood flow (ß=-1.55, P=0.03): Perfusion was the highest in subjects with mid-range SBP around 125 mm Hg. Longitudinally, in hypertensive subjects perfusion increased with increased SBP at low baseline SBP but increased with decreased SBP at high baseline SBP. Cortical and hippocampal perfusion decrease with increasing SBP across the entire BP spectrum. However, in hypertension, there seems to be a window of mid-range SBP which maximizes perfusion.

Beliefs about the causes of hypertension and associations with pro-health behaviors.

OBJECTIVE: To describe behavioral and genetic beliefs about developing hypertension (HTN) by sociodemographic factors and self-reported HTN status, and among those with a history of HTN, evaluate associations between HTN-related causal beliefs and behavior change attempts. METHOD: Data from the 2014 Health Information National Trends Survey were evaluated. HTN causal beliefs questions included (a) "How much do you think health behaviors like diet, exercise, and smoking determine whether or not a person will develop high blood pressure/HTN?"; and (b) "How much do you think genetics, that is characteristics passed from one generation to the next, determine whether or not a person will develop high blood pressure/HTN?" Multivariate logistic regressions evaluated associations between HTN causal beliefs and behavior change attempts including diet, exercise, and weight management. RESULTS: Approximately 1,602 out of 3,555 respondents with nonmissing data (33% weighted) reported ever having HTN. In logistic regression models, results show that the more strongly people believed in the impact of behavior on developing HTN, the higher their odds for behavior change attempts. Beliefs about genetic causes of HTN were not associated with behavior change attempts. Women had higher odds of attempts to increase fruit and vegetable intake, reduce soda intake, and lose weight compared to men. Blacks and Hispanics were significantly more likely than Whites to report attempts to lose weight. CONCLUSIONS: Beliefs about behavioral causes of HTN, but not genetic, were associated with behavior change attempts. Health messages that incorporate behavioral beliefs and sociodemographic factors may enhance future prohealth behavior changes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Sleep Duration and Physical Activity Profiles Associated With Self-Reported Stroke in the United States: Application of Bayesian Belief Network Modeling Techniques.

Introduction: Physical activity (PA) and sleep are associated with cerebrovascular disease and events like stroke. Though the interrelationships between PA, sleep, and other stroke risk factors have been studied, we are unclear about the associations of different types, frequency and duration of PA, sleep behavioral patterns (short, average and long sleep durations), within the context of stroke-related clinical, behavioral, and socio-demographic risk factors. The current study utilized Bayesian Belief Network analysis (BBN), a type of machine learning analysis, to develop profiles of physical activity (duration, intensity, and frequency) and sleep duration associated with or no history of stroke, given the influence of multiple stroke predictors and correlates. Such a model allowed us to develop a predictive classification model of stroke which can be used in post-stroke risk stratification and developing targeted stroke rehabilitation care based on an individual's profile. Method: Analysis was based on the 2004-2013 National Health Interview Survey (n = 288,888). Bayesian BBN was used to model the omnidirectional relationships of sleep duration and physical activity to history of stroke. Demographic, behavioral, health/medical, and psychosocial factors were considered as well as sleep duration [defined as short < 7 h. and long ≥ 9 h, referenced to healthy sleep (7-8 h)], and intensity (moderate and vigorous) and frequency (times/week) of physical activity. Results: Of the sample, 48.1% were ≤ 45 years; 55.7% female; 77.4% were White; 15.9%, Black/African American; and 45.3% reported an annual income < $35 K. Overall, the model had a precision index of 95.84%. We found that adults who reported 31-60 min of vigorous physical activity six times for the week and average sleep duration (7-8 h) had the lowest stroke prevalence. Of the 36 sleep (short, average, and long sleep) and physical activity profiles we tested, 30 profiles had a self-reported stroke prevalence lower than the US national average of approximately 3.07%. Women, compared to men with the same sleep and physical activity profile, appeared to have higher self-reported stroke prevalence. We also report age differences across three groups 18-45, 46-65, and 66+. Conclusion: Our findings indicate that several profiles of sleep duration and physical activity are associated with low prevalence of self-reported stroke and that there may be sex differences. Overall, our findings indicate that more than 10 min of moderate or vigorous physical activity, about 5-6 times per week and 7-8 h of sleep is associated with lower self-reported stroke prevalence. Results from the current study could lead to more tailored and personalized behavioral secondary stroke prevention strategies.

Theoretical and Pragmatic Adaptation of the 5As Model to Patient-Centered Hypertension Counselling.

Patient-centered communication is a means for engaging patients in partnership. However, patient centered communication has not always been grounded in theory or in clinicians' pragmatic needs. The objective of this report is to present a practical approach to hypertension counselling that uses the 5As framework and is grounded in theory and best communication practices.

The Healthy Hearts and Kidneys (HHK) study: Design of a 2×2 RCT of technology-supported self-monitoring and social cognitive theory-based counseling to engage overweight people with diabetes and chronic kidney disease in multiple lifestyle changes.

Patients with complex chronic diseases usually must make multiple lifestyle changes to limit and manage their conditions. Numerous studies have shown that education alone is insufficient for engaging people in lifestyle behavior change, and that theory-based behavioral approaches also are necessary. However, even the most motivated individual may have difficulty with making lifestyle changes because of the information complexity associated with multiple behavior changes. The goal of the current Healthy Hearts and Kidneys study was to evaluate, different mobile health (mHealth)-delivered intervention approaches for engaging individuals with type 2 diabetes (T2D) and concurrent chronic kidney disease (CKD) in behavior changes. Participants were randomized to 1 of 4 groups, receiving: (1) a behavioral counseling, (2) technology-based self-monitoring to reduce information complexity, (3) combined behavioral counseling and technology-based self-monitoring, or (4) baseline advice. We will determine the impact of randomization assignment on weight loss success and 24-hour urinary excretion of sodium and phosphorus. With this report we describe the study design, methods, and approaches used to assure information security for this ongoing clinical trial. Clinical Trials.gov Identifier: NCT02276742.

Blood pressure control and mortality in US- and foreign-born blacks in New York City.

This retrospective cohort study compared blood pressure (BP) control (BP <140/90 mm Hg) and all-cause mortality between US- and foreign-born blacks. We used data from a clinical data warehouse of 41 868 patients with hypertension who received care in a New York City public healthcare system between 2004 and 2009, defining BP control as the last recorded BP measurement and mean BP control. Poisson regression demonstrated that Caribbean-born blacks had lower BP control for the last BP measurement compared with US- and West African-born blacks, respectively (49% vs 54% and 57%; P<.001). This pattern was similar for mean BP control. Caribbean- and West African-born blacks showed reduced hazard ratios of mortality (0.46 [95% CI, 0.42-0.50] and 0.28 [95% CI, 0.18-0.41], respectively) compared with US-born blacks, even after adjustment for BP. BP control rates and mortality were heterogeneous in this sample. Caribbean-born blacks showed worse control than US-born blacks. However, US-born blacks experienced increased hazard of mortality. This suggests the need to account for the variations within blacks in hypertension management.

Hypertension Treatment in Blacks: Discussion of the U.S. Clinical Practice Guidelines.

Blacks are especially susceptible to hypertension (HTN) and its associated organ damage leading to adverse cardiovascular, cerebrovascular and renal outcomes. Accordingly, HTN is particularly significant in contributing to the black-white racial differences in health outcomes in the US. As such, in order to address these health disparities, practical clinical practice guidelines (CPGs) on how to treat HTN, specifically in blacks, are needed. This review article is a timely addition to the literature because the most recent U.S. CPG more explicitly emphasizes race into the algorithmic management of HTN. However, recent clinical research cautions that use of race as a proxy to determine therapeutic response to pharmaceutical agents may be erroneous. This review will address the implications of the use of race in the hypertension CPGs. We will review the rationale behind the introduction of race into the U.S. CPG and the level of evidence that was available to justify this introduction. Finally, we will conclude with practical considerations in the treatment of HTN in blacks.

Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial.

BACKGROUND: Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension. METHODS/DESIGN: A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing. DISCUSSION: The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.

Sleep as a mediator in the pathway linking environmental factors to hypertension: a review of the literature.

Environmental factors, such as noise exposure and air pollution, are associated with hypertension. These environmental factors also affect sleep quality. Given the growing evidence linking sleep quality with hypertension, the purpose of this review is to investigate the role of sleep as a key mediator in the association between hypertension and environmental factors. Through this narrative review of the extant literature, we highlight that poor sleep quality mediates the relationship between environmental factors and hypertension. The conceptual model proposed in this review offers opportunities to address healthcare disparities in hypertension among African Americans by highlighting the disparate impact that the predictors (environmental factors) and mediator (sleep) have on the African-American community. Understanding the impact of these factors is crucial since the main outcome variable (hypertension) severely burdens the African-American community.