Randomized Pilot Study of a Behavioral Feedback Intervention to Improve Medication Adherence in Older Adults With Hypertension Rationale and design of the Medication adherence Improvement Support App For Engagement-Blood Pressure (MedISAFE-BP) trial. Home and Online Management and Evaluation of Blood Pressure (HOME BP) digital intervention for self-management of uncontrolled, essential hypertension: a protocol for the randomised controlled HOME BP trial Effectiveness of Digital Medicines to Improve Clinical Outcomes in Patients with Uncontrolled Hypertension and Type 2 Diabetes: Prospective, Open-Label, Cluster-Randomized Pilot Clinical Trial The veterans' study to improve the control of hypertension (V-STITCH): design and methodology. Predictors of uncontrolled hypertension and antihypertensive medication nonadherence A coordinated PCP-Cardiologist Telemedicine Model (PCTM) in China’s community hypertension care: study protocol for a randomized controlled trial Cloud-based BP system integrated with CPOE improves self-management of the hypertensive patients: A randomized controlled trial Clinical Impact of Patient Adherence to a Fixed-Dose Combination of Olmesartan, Amlodipine and Hydrochlorothiazide Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol Review: E-health interventions improve blood pressure level and control in hypertension A Culturally Adapted Telecommunication System to Improve Physical Activity, Diet Quality, and Medication Adherence Among Hypertensive African–Americans: A Randomized Controlled Trial Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. Home-based blood pressure interventions for blacks. Acute effects of an oral nitric oxide supplement on blood pressure, endothelial function, and vascular compliance in hypertensive patients. The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care FURIN variant associations with postexercise hypotension are intensity and race dependent Two self-management interventions to improve hypertension control: a randomized trial. A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work? Ambulatory blood pressure monitoring in children and adolescents with type-1 diabetes mellitus and its relation to diabetic control and microalbuminuria. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial.
Background and Objectives : Older adults ' adherence to antihypertensive medications is far lower than what is considered necessary for clinical effectiveness , despite the risks for adverse cardiovascular events from uncontrolled blood pressure ( BP ) in the elderly . This pilot study tested a novel 8-week behavioral feedback intervention to improve antihypertensive medication adherence ( MA ) and BP control among older adults on existing treatment for hypertension . Methods : Adults 60 years old , or older taking at least 1 antihypertensive medication were r and omized to receive the nurse-delivered adherence intervention or usual care . Medication adherence was monitored continuously using electronic monitoring for 20 weeks . Intervention-group participants received biweekly MA and BP feedback , habit counseling , medication and disease education , a medication instruction card , and were given an electronic medication bottle cap with a digital display that provided daily adherence feedback during the 8-week intervention . Blood pressure was measured by a nurse at 12 and 20 weeks after r and omization . Adherence and BP outcomes were described using descriptive statistics and analyzed for between- and within-group differences using Mann-Whitney U tests . Results : Fifteen participants ( median age , 71 years ; 73 % female ) were eligible for r and omization . Participants took an average of 5.8 prescription medications and 2.93 over-the-counter medications per day . A nonsignificant difference was noted in baseline MA between groups . At the end of the intervention , the treatment group had better antihypertensive MA than did the control group ( median MA : 100 % vs 27.3 % , U = 5.00 , P = .013 ) . Systolic BP improved slightly in the intervention group during the study and was significantly different at week 12 ( median systolic BP : 130 vs 152 mm Hg ; U = 4.50 , P = .008 ) . Diastolic BP was largely unchanged over the course of the study . Conclusion : The results indicate that the intervention had a positive effect on MA . Additional testing is needed to further evaluate the intervention and its effect on adherence behavior and BP control BACKGROUND Hypertension is a major contributor to the health and economic burden imposed by stroke , heart disease , and renal insufficiency . Antihypertensives can prevent many of the harmful effects of elevated blood pressure , but medication nonadherence is a known barrier to the effectiveness of these treatments . Smartphone-based applications that remind patients to take their medications , provide education , and allow for social interactions between individuals with similar health concerns have been widely advocated as a strategy to improve adherence but have not been subject to rigorous testing . METHODS / DESIGN The MedISAFE-BP study is a prospect i ve , r and omized control trial design ed to evaluate the impact on blood pressure and medication adherence of an mhealth application ( Medisafe ) .  Four hundred thirteen patients with uncontrolled hypertension have been enrolled and r and omized in a 1:1 fashion to usual care or to the use of the Medisafe mhealth platform  . Patients will be followed up for 12 weeks and the trial 's co- primary outcomes will be change in systolic blood pressure and self-reported medication adherence . DISCUSSION The MedISAFE-BP trial is the first study to rigorously evaluate an mhealth application 's effect on blood pressure and medication adherence . The results will inform the potential effectiveness of this simple system in improving cardiovascular disease risk factors and clinical outcomes Introduction Self-management of hypertension , including self-monitoring and antihypertensive medication titration , lowers blood pressure ( BP ) at 1 year compared to usual care . The aim of the current trial is to assess the effectiveness of the Home and Online Management and Evaluation of Blood Pressure ( HOME BP ) intervention for the self-management of hypertension in primary care . Methods and analysis The HOME BP trial will be a r and omised controlled trial comparing BP self-management — consisting of the HOME BP online digital intervention with self-monitoring , lifestyle advice and antihypertensive drug titration — with usual care for people with uncontrolled essential hypertension . Eligible patients will be recruited from primary care and r and omised to usual care or to self-management using HOME BP . The primary outcome will be the difference in mean systolic BP ( mm Hg ) at 12-month follow-up between the intervention and control groups adjusting for baseline BP and covariates . Secondary outcomes ( also adjusted for baseline and covariates where appropriate ) will be differences in mean BP at 6 months and diastolic BP at 12 months ; patient enablement ; quality of life , and economic analyses including all key re sources associated with the intervention and related services , adopting a broad societal perspective to include NHS , social care and patient costs , considered within trial and modelled with a lifetime horizon . Medication beliefs , adherence and changes ; self-efficacy ; perceived side effects and lifestyle changes will be measured for process analyses . Qualitative analyses will explore patient and healthcare professional experiences of HOME BP to gain insights into the factors affecting acceptability , feasibility and adherence . Ethics and dissemination This study has received NHS ethical approval ( REC reference 15/SC/0082 ) . The findings from HOME BP will be disseminated widely through peer- review ed publications , scientific conferences and workshops . If successful , HOME BP will be directly applicable to UK primary care management of hypertension . Trial registration number IS RCT N13790648 ; pre- results Background Hypertension and type 2 diabetes mellitus are major modifiable risk factors for cardiac , cerebrovascular , and kidney diseases . Reasons for poor disease control include nonadherence , lack of patient engagement , and therapeutic inertia . Objective The aim of this study was to assess the impact on clinic-measured blood pressure ( BP ) and glycated hemoglobin ( HbA1c ) using a digital medicine offering ( DMO ) that measures medication ingestion adherence , physical activity , and rest using digital medicines ( medication taken with ingestible sensor ) , wearable sensor patches , and a mobile device app . Methods Participants with elevated systolic BP ( SBP ≥140 mm Hg ) and HbA1c ( ≥7 % ) failing antihypertensive ( ≥2 medications ) and oral diabetes therapy were enrolled in this three-arm , 12-week , cluster-r and omized study . Participants used DMO ( includes digital medicines , the wearable sensor patch , and the mobile device app ) for 4 or 12 weeks or received usual care based on site r and omization . Providers in the DMO arms could review the DMO data via a Web portal . In all three arms , providers were instructed to make medical decisions ( medication titration , adherence counseling , education , and lifestyle coaching ) on all available clinical information at each visit . Primary outcome was change in SBP at week 4 . Other outcomes included change in SBP and HbA1c at week 12 , and low-density lipoprotein cholesterol ( LDL-C ) and diastolic blood pressure ( DBP ) at weeks 4 and 12 , as well as proportion of patients at BP goal ( < 140/90 mm Hg ) at weeks 4 and 12 , medical decisions , and medication adherence patterns . Results Final analysis included 109 participants ( 12 sites ; age : mean 58.7 , SD years ; female : 49.5 % , 54/109 ; Hispanic : 45.9 % , 50/109 ; income ≤ US $ 20,000 : 56.9 % , 62/109 ; and ≤ high school education : 52.3 % , 57/109 ) . The DMO groups had 80 participants ( 7 sites ) and usual care had 29 participants ( 5 sites ) . At week 4 , DMO result ed in a statistically greater SBP reduction than usual care ( mean –21.8 , SE 1.5 mm Hg vs mean –12.7 , SE 2.8 mmHg ; mean difference –9.1 , 95 % CI –14.0 to –3.3 mm Hg ) and maintained a greater reduction at week 12 . The DMO groups had greater reductions in HbA1c , DBP , and LDL-C , and a greater proportion of participants at BP goal at weeks 4 and 12 compared with usual care . The DMO groups also received more therapeutic interventions than usual care  . Medication adherence was ≥80 % while using the DMO . The most common adverse event was a self-limited rash at the wearable sensor site ( 12 % , 10/82 ) . Conclusions For patients failing hypertension and diabetes oral therapy , this DMO , which provides dose-by-dose feedback on medication ingestion adherence , can help lower BP , HbA1c , and LDL-C , and promote patient engagement and provider decision making . Trial Registration Clinical trials.gov NCT02827630 ; https:// clinical trials.gov/show/NCT02827630 ( Archived by WebCite at http://www.webcitation.org/6rL8dW2VF BACKGROUND Among the 60 million Americans with hypertension , only approximately 31 % have their blood pressure ( BP ) under control ( < 140/90 mm Hg ) . Despite the damaging impact of hypertension and the availability of evidence -based target values for BP , interventions to improve BP control have had limited success . OBJECTIVES A r and omized controlled health services intervention trial with a split-plot design is being conducted to improve BP control . This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans . METHODS In a cluster-r and omization , 30 primary care providers in the Durham VAMC Primary Care Clinic were r and omly assigned to receive the provider intervention or control . The provider intervention is a patient-specific electronically generated hypertension decision support system ( DSS ) delivering guideline -based recommendations to the provider at each patient 's visit , design ed to improve guideline -concordant therapy . For these providers , a sample of their hypertensive patients ( n=588 ) was r and omly assigned to receive a telephone-administered patient intervention or usual care . The patient intervention incorporates patients ' need assessment s and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors .  All modules are delivered over the telephone bi-monthly for 24 months . In this trial , the primary outcome is the proportion of patients who achieve a BP < or = 140/90 mm Hg at each outpatient clinic visit over 24 months . CONCLUSION Despite the known risk of poor BP control , a majority of adults still do not have their BP controlled . This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting Background : Although hypertension is , in most cases , a controllable major risk factor in the development of cardiovascular disease , studies have demonstrated that hypertension remains poorly controlled in Portugal . Our aim was to evaluate the covariates associated with poor blood pressure ( BP ) control in a Portuguese hypertensive population . Patients and Results : We conducted a cross-sectional survey in a hospital hypertension outpatient clinic , located in the Eastern Central Region of Portugal . Patients attending the clinic from July to September 2009 were asked to participate in a structured interview including medication adherence and knowledge about hypertension .  Eligible participants were all adults aged 18 or over with an established diagnosis of arterial hypertension and had been on antihypertensive drug treatment for at least 6 months . Exclusion criteria were dementia , pregnancy , and breastfeeding . Detailed clinical information was prospect ively obtained from medical records . A total of 197 patients meeting the inclusion criteria and consenting to participate completed the interview . Of these , only 33.0 % had their BP controlled according to the JNC 7 guidelines . Logistic regression analysis revealed three independent predictors of poor BP control : living alone ( OR = 5.3 , P = 0.004 ) , medication nonadherence ( OR = 4.8 , P < 0.001 ) , and diabetes ( OR = 4.4 , P = 0.011 ) . Predictors of medication nonadherence were : unawareness of target BP values ( OR = 3.7 , P < 0.001 ) , a report of drug side effects ( OR = 3.7 , P = 0.002 ) , lack of BP monitoring ( OR = 2.5 , P = 0.015 ) and unawareness of medication indications ( OR = 2.4 , P = 0.021 ) , and of hypertension risks ( OR = 2.1 , P = 0.026 ) . Conclusions : Poor medication adherence , lack of information about hypertension , and side effects should be considered as possible underlying causes of uncontrolled BP and must be addressed in any intervention aim ed to improve BP control Background Hypertension is a major risk factor for cardiovascular disease , and its control rate has remained low worldwide . Studies have found that telemonitoring blood pressure ( BP ) helped control hypertension in r and omized controlled trials . However , little is known about its effect in a structured primary care model in which primary care physicians ( PCPs ) are partnering with cardiology specialists in electronic healthcare data sharing and medical interventions . This study aims to identify the effects of a coordinated PCP-cardiologist model that applies telemedicine tools to facilitate community hypertension control in China . Methods / design Patients with hypertension receiving care at four community healthcare centers that are academically affiliated to Shanghai Chest Hospital , Shanghai JiaoTong University are eligible if they have had uncontrolled BP in the previous 3 months and access to mobile Internet . Study subjects are r and omly assigned to three interventional groups : ( 1 ) usual care ; ( 2 ) home-based BP telemonitor with embedded Global System for Mobile Communications ( GSM ) module and unlimited data plan , an app to access personal healthcare record and receive personalized lifestyle coaching contents , and proficiency training of their use ; or ( 3 ) this plus coordinated PCP-cardiologist care in which PCPs and cardiologists share data via a secure CareLinker website to determine interventional approaches . The primary outcome is mean change in systolic blood pressure over a 12-month period . Secondary outcomes are changes of diastolic blood pressure , HbA1C , blood lipids , and medication adherence measured by the eight-item Morisky Medication Adherence Scale . Discussion This study will determine whether a coordinated PCP-Cardiologist Telemedicine Model that incorporates the latest telemedicine technologies will improve hypertension care . Success of the model would help streamline the present community healthcare processes and impact a greater number of patients with uncontrolled hypertension . Trial registration Clinical Trials.gov , NCT02919033 . Registered on 23 September 2016 BACKGROUND Less than 50 % of patients with hypertensive disease manage to maintain their blood pressure ( BP ) within normal levels . OBJECTIVE The aim of this study is to evaluate whether cloud BP system integrated with computerized physician order entry ( CPOE ) can improve BP management as compared with traditional care . METHODS A r and omized controlled trial done on a r and om sample of 382 adults recruited from 786 patients who had been diagnosed with hypertension and receiving treatment for hypertension in two district hospitals in the north of Taiwan . Physicians had access to cloud BP data from CPOE . Neither patients nor physicians were blinded to group assignment . The study was conducted over a period of seven months . RESULTS At baseline , the enrollees were 50 % male with a mean ( SD ) age of 58.18 ( 10.83 ) years . The mean sitting BP of both arms was no different . The proportion of patients with BP control at two , four and six months was significantly greater in the intervention group than in the control group . The average capture rates of blood pressure in the intervention group were also significantly higher than the control group in all three check-points . CONCLUSIONS Cloud-based BP system integrated with CPOE at the point of care achieved better BP control compared to traditional care . This system does not require any technical skills and is therefore suitable for every age group . The praise and assurance to the patients from the physicians after review ing the Cloud BP records positively reinforced both BP measuring and medication adherence behaviors Background and objectives Recent findings from r and omized clinical trials indicate an improved patient adherence and blood pressure ( BP ) control by using fixed-dose combinations ( FDCs ) in the treatment of hypertension . The aim of the present study was to verify those data in a large real-world sample of hypertensive patients and to cross-check adherence evaluation performed by physicians and patients self- assessment . Methods A European multi-center , prospect i ve , 24-week , non-interventional study was conducted including 14,979 patients with essential hypertension and new treatment with olmesartan , amlodipine and hydrochlorothiazide as an FDC .  Patients ’ adherence was measured using the  Morisky Medication Adherence Scale ( MMAS-8 ) and a non-st and ardized question naire was used by physicians and patients for self- assessment . Results The mean age of the patients was 63.9 ± 11.78 years and 46.5 % were women . One or more cardiovascular risk factors were present in 71.9 % of patients and 94.7 % had been treated for hypertension before study entry . Mean adherence to medication by MMAS-8 improved from 6.0 to 6.9 at study end . Corresponding improvements of adherence were seen on physicians ’ and patients ’ self- assessment s throughout the study . Mean decrease of systolic/diastolic BP was 26.4/12.8 mmHg without a relevant difference between the MMAS-8 adherence levels . BP target achievement improved from 55.3 to 67.7 % in patients with low versus high adherence . The overall rate of patients with adverse drug reactions was very low ( 1.76 % ) but more frequent in patients with low adherence . Conclusions Our data confirm previous clinical trial data on the improvement of medication adherence by switching antihypertensive combination therapy to an FDC and a subsequent improvement in BP target achievement . An observed trend toward a reduction in adverse drug reactions needs to be further investigated in clinical trials Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Question In patients with hypertension , do electronic health ( e-health ) interventions improve blood pressure ( BP ) control and other outcomes ? Review scope Included studies compared e-health interventions with usual or st and ard care or attention control in patients with adequately or inadequately controlled hypertension .  E-health interventions had to use portable , Web-based , interactive wireless communication devices and focus on self-care , self-management , self-care behavior change , or education . Studies of interventions that only displayed information ( not interactive ) , were only used for follow-up , or that mostly benefitted health care providers were excluded . Outcomes included physical outcomes ( inadequate BP control , systolic [ SBP ] and diastolic BP [ DBP ] , body mass index [ BMI ] , body weight , and cholesterol levels ) , and self-care behavioral outcomes ( sodium and alcohol intake , smoking , and physical activities ) . Review methods MEDLINE , EMBASE /Excerpta Medica , Cochrane Data base of Systematic Review s , Cochrane Central Register of Controlled Trials , CINAHL Plus , PsycINFO , SCOPUS , Web of Science , Joanna Briggs Institute EBP Data base , INSPEC , China Journal Net , and WanFang Data ( all 2000 to Nov 2017 ) were search ed for English- and Chinese- language r and omized controlled trials ( RCTs ) . 14 RCTs ( n = 3998 , mean age 50 to 68 y ) , ranging in size from 44 to 778 patients , met the selection criteria . Follow-up ranged from 3 to 24 months . Studies were conducted in various setting s , including primary care clinics , community health centers , and hospitals . Intervention strategies included BP monitoring , lifestyle modification techniques , and motivation and maintenance . 9 RCTs had adequate r and omization sequence generation , 6 concealed allocation , 4 blinded outcome assessors , and none adequately reported blinding participants . Main results Results for inadequate BP control , SPB , DBP , BMI , body weight , and sodium intake are in the Table . E-health interventions did not improve total cholesterol levels at 3 to 6 months after the intervention ( 3 RCTs ) ; or alcohol intake , smoking , or physical activity at 6 months after the intervention ( 3 RCTs ) . Conclusion In patients with hypertension , electronic health interventions reduce blood pressure levels and increase likelihood of blood pressure control .  Electronic health interventions vs control in patients with hypertension * Outcomes Assessment times ( after intervention ) Number of trials ( n ) RRR ( 95 % CI ) NNT ( CI ) Inadequate BP control 3 to 12 mo 5 ( 1518 ) 31 % ( 16 to 43 ) 6 ( 4 to 11 ) Mean between-group difference ( CI ) Change in systolic BP ( mm Hg ) 6 mo 12 ( 3171 ) 5.50 ( 9.85 to 1.16 ) 12 mo 3 ( 1272 ) 7.68 ( 9.95 to 5.41 ) 18 mo 2 ( 735 ) 6.26 ( 9.29 to 3.23 ) Change in diastolic BP ( mm Hg ) 6 mo 12 ( 3171 ) 3.40 ( 7.79 to 0.99 ) 12 mo 3 ( 1272 ) 3.36 ( 4.80 to 1.92 ) 18 mo 2 ( 735 ) 2.53 ( 4.72 to 0.34 ) Change in body mass index ( kg/m2 ) 6 mo 5 ( 1486 ) 0.22 ( 0.46 to 0.02 ) 12 mo 3 ( 1272 ) 0.24 ( 0.82 to 0.33 ) 18 mo 2 ( 735 ) 0.07 ( 0.77 to 0.91 ) Change in body weight ( kg ) 3 to 6 mo 3 ( 517 ) 1.08 ( 2.04 to 0.13 ) Change in sodium intake ( SMD ) 6 mo 2 ( 768 ) 0.34 ( 0.49 to 0.20 ) 12 mo 2 ( 753 ) 0.39 ( 0.54 to 0.25 ) 18 mo 2 ( 735 ) 0.30 ( 0.45 to 0.16 ) * BP = blood pressure ; SMD = st and ardized mean difference ; other abbreviations defined in Glossary . Weighted electronic health intervention event rate , RRR , NNT , and CI calculated using control event rate and relative risk in article . Blood pressure 140/90 mm Hg . Weighted event rates 42 % vs 60 % . Commentary The systematic review and meta- analysis by Ma and colleagues showed a small but clinical ly meaningful reduction in SBP and DBP  in patients who received e-health re sources . However , some health outcomes , including BMI and cholesterol levels , were not improved . Despite a risk for selection bias in some of the studies and substantial heterogeneity between studies , the meta- analysis is of high quality . The interventions in the included studies varied greatly and included use of telephone calls , Web sites , and smartphone applications . The comparison treatments were either attention control or usual care , and trials did not directly compare e-health interventions . The outcomes measured also varied among studies . Because clinic BP measurements may overestimate the degree of elevation and ambulatory monitoring is costly and limited to brief periods of measurement , home BP monitoring using newer e-health re sources may provide a cost-effective alternative ( 1 ) . This is an exciting new avenue for improving BP control by allowing for more accurate and streamlined monitoring , leading to more precise and timely interventions . However , based on the heterogeneity of intervention types , the optimum method is unknown . Further studies should directly compare e-health platforms and assess patient-centered outcomes , including usability , satisfaction , affordability , and quality of life as well as BP . Although the evidence indicates that these interventions are not yet ready for routine clinical practice , there is a promising signal that they could be useful for BP management Background Hypertension is more prevalent and clinical ly severe among African – Americans than whites . Several health behaviors influence blood pressure ( BP ) control , but effective , accessible , culturally sensitive interventions that target multiple behaviors are lacking . Purpose We evaluated a culturally adapted , automated telephone system to help hypertensive , urban African – American adults improve their adherence to their antihypertensive medication regimen and to evidence -based guidelines for dietary behavior and physical activity . Methods We r and omized 337 hypertensive primary care patients to an 8-month automated , multi-behavior intervention or to an education-only control . Medication adherence , diet , physical activity , and BP  were assessed at baseline and every 4 months for 1 year . Data were analyzed using longitudinal modeling . Results The intervention was associated with improvements in a measure of overall diet quality ( + 3.5 points , p < 0.03 ) and in energy expenditure ( + 80 kcal/day , p < 0.03 ) . A decrease in systolic BP between groups was not statistically significant ( −2.3 mmHg , p = 0.25 ) . Conclusions Given their convenience , scalability , and ability to deliver tailored messages , automated telecommunications systems can promote self-management of diet and energy balance in urban African – Americans OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology ( TSOC ) . There is new evidence regarding the management of hypertension , including r and omized controlled trials , non-r and omized trials , post-hoc analyses , subgroup analyses , retrospective studies , cohort studies , and registries . More recently , the European Society of Hypertension ( ESH ) and the European Society of Cardiology ( ESC ) published joint hypertension guidelines in 2013 . The panel members who were appointed to the Eighth Joint National Committee ( JNC ) also published the 2014 JNC report . Blood pressure ( BP ) targets have been changed ; in particular , such targets have been loosened in high risk patients . The Executive Board members of TSOC and the Taiwan Hypertension Society ( THS ) aim ed to review up date d information about the management of hypertension to publish an up date d hypertension guideline in Taiwan . We recognized that hypertension is the most important risk factor for global disease burden . Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world . In most countries in East Asia , stroke surpassed coronary heart disease ( CHD ) in causing premature death . A diagnostic algorithm was proposed , emphasizing the importance of home BP monitoring  and ambulatory BP monitoring  for better detection of night time hypertension , early morning hypertension , white-coat hypertension , and masked hypertension . We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to < 140/90 mmHg for all patients . We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to < 150/90 mmHg for patients between 60 - 80 years of age . For patients with diabetes , CHD , chronic kidney disease who have proteinuria , and those who are receiving antithrombotic therapy for stroke prevention , we propose BP targets of < 130/80 mmHg in our guidelines . BP targets are < 140/90 mmHg for all other patient groups , except for patients ≥80 years of age in whom a BP target of < 150/90 mmHg would be optimal . For the management of hypertension , we proposed a treatment algorithm , starting with life style modification ( LSM ) including S-ABCDE ( Sodium restriction , Alcohol limitation , Body weight reduction , Cigarette smoke cessation , Diet adaptation , and Exercise adoption ) . We emphasized a low-salt strategy instead of a no-salt strategy , and that excessively aggressive sodium restriction to < 2.0 gram/day may be harmful . When drug therapy is considered , a strategy called " PROCEED " was suggested ( Previous experience , Risk factors , Organ damage , Contraindications or unfavorable conditions , Expert 's or doctor 's judgment , Expenses or cost , and Delivery and compliance issue ) . To predict drug effects in lowering BP , we proposed the " Rule of 10 " and " Rule of 5 " . With a st and ard dose of any one of the 5 major classes of anti-hypertensive agents , one can anticipate approximately a 10-mmHg decrease in systolic BP ( SBP ) ( Rule of 10 ) and a 5-mmHg decrease in diastolic BP ( DBP ) ( Rule of 5 ) . When doses of the same drug are doubled , there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP . Preferably , when 2 drugs with different mechanisms are to be taken together , the decrease in BP is the sum of the decrease of the individual agents ( approximately 20 mmHg in SBP and 10 mmHg in DBP ) . Early combination therapy , especially single-pill combination ( SPC ) , is recommended . When patient 's initial treatment can not get BP to targeted goals , we have proposed an adjustment algorithm , " AT GOALs " ( Adherence , Timing of administration , Greater doses , Other classes of drugs , Alternative combination or SPC , and LSM + Laboratory tests ) . Treatment of hypertension in special conditions , including treatment of resistant hypertension , hypertension in women , and perioperative management of hypertension , were also mentioned . The TSOC/THS hypertension guidelines provide the most up date d information available in the management of hypertension . The guidelines are not m and atory , and members of the task force fully realize that treatment of hypertension should be individualized to address each patient 's circumstances . Ultimately , the decision of the physician decision remains of the utmost importance in hypertension management Efforts to increase blood pressure ( BP ) control rates in blacks , a traditionally underserved high-risk population must address both provider practice and patient adherence issues . The home-based BP Intervention for blacks study is a 3-arm r and omized controlled trial design ed to test 2 strategies to improve hypertension management and outcomes in a de central ized service setting serving a vulnerable and complex home care population . The primary study outcomes are systolic BP , diastolic BP , and BP control ; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication , healthy diet  , and other self-management strategies .  Nurses ( n=312 ) in a nonprofit Medicare-certified home health agency are r and omized along with their eligible hypertensive patients ( n=845 ) . The 2 interventions being tested are ( 1 ) a " basic " intervention delivering key evidence -based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care ; and ( 2 ) an " augmented " intervention that includes that same as the basic intervention , plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months . Outcomes are measured at 3 and 12 months after baseline interview . The interventions will be assessed relative to usual care and to each other . Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact . Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population This blinded placebo-controlled crossover study evaluated the acute effects of an orally disintegrating lozenge that generates nitric oxide ( NO ) in the oral cavity on blood pressure ( BP ) response , endothelial function , and vascular compliance in unmedicated hypertensive patients . Thirty patients with clinical hypertension were recruited and enrolled in a blinded placebo-controlled clinical trial in an outpatient setting . Average baseline BP in 30 patients was 144±3/91±1 mm Hg . NO supplementation result ed in a significant decrease of 4 mm Hg in resting systolic BP ( P<.003 ) and a significant decrease of 5 mm Hg in diastolic BP ( P<.002 ) from baseline and placebo after 20 minutes . In addition , there was a further statistically significant reduction by 6 mm Hg in both systolic and diastolic pressure after 60 minutes ( P<.0001 vs baseline ) . After a half hour of a single dose , there was a significant improvement in vascular compliance as measured by augmentation index and , after 4 hours , a statistically significant improvement in endothelial function as measured by the EndoPAT ( Itamar Medical , Franklin , MA ) . A single administration of an oral active NO supplement appears to acutely lower BP , improve vascular compliance , and restore endothelial function in patients with hypertension Background —Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects . Effective programs to address this problem are lacking . We hypothesized that an information technology – supported management program could help improve blood pressure ( BP ) control . Methods and Results —This r and omized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP > 130/80 and daytime BP > 135/85 mm Hg measured with ambulatory monitoring ( ABPM ) . Intervention subjects received a BP monitor and access to an information technology – supported adherence and BP monitoring system providing nurses , pharmacists , and physicians with monthly reports . Control subjects received usual care . The mean ( ±SD ) follow-up was 348 ( ±78 ) and 349 ( ±84 ) days in the intervention and control group , respectively . The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic ( −11.9 versus −7.1 mm Hg ; P<0.001 ) and diastolic BP ( −6.6 versus −4.5 mm Hg ; P=0.007 ) . The proportion of subjects that achieved Canadian Guideline target BP ( 46.0 % versus 28.6 % ) was also greater in the intervention group ( P=0.006 ) . We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control . The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents ( P=0.03 ) , more antihypertensive classes at study end ( P=0.007 ) , and a trend toward improved adherence measured by prescription refills ( P=0.07 ) . Conclusions —This multidisciplinary information technology – supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting Abstract FURIN is a proprotein convertase subtilisin/kexin enzyme important in pro‐renin receptor processing , and FURIN ( furin , paired basic amino acid cleaving enzyme ) variants are involved in multiple aspects of blood pressure ( BP ) regulation . Therefore , we examined associations among FURIN variants and the immediate blood pressure ( BP ) response to bouts of aerobic exercise , termed postexercise hypotension ( PEH ) . Obese ( 30.9 ± 3.6 kg m−2 ) Black‐ ( n = 14 ) and White‐ ( n = 9 ) adults 42.0 ± 9.8 year with hypertension ( 139.8 ± 10.4/84.6 ± 6.2 mmHg ) performed three r and om experiments : bouts of vigorous ( VIGOROUS ) and moderate ( MODERATE ) intensity cycling and control . Subjects were then attached to an ambulatory BP monitor for 19 h. We performed deep‐targeted exon sequencing with the Illumina TruSeq Custom Amplicon kit . FURIN genotypes were coded as the number of minor alleles ( # MA ) and selected for additional statistical analysis based upon Bonferonni or Benjamini – Yekutieli multiple testing corrected P‐values under time‐adjusted linear models for 19 hourly BP measurements . After VIGOROUS over 19 h , as FURIN # MA increased in rs12917264 ( P = 2.4E‐04 ) and rs75493298 ( P = 6.4E‐04 ) , systolic BP ( SBP ) decreased 30.4–33.7 mmHg ; and in rs12917264 ( P = 1.6E‐03 ) and rs75493298 ( P = 9.7E‐05 ) , diastolic BP ( DBP ) decreased 17.6–20.3 mmHg among Blacks only . In addition , after MODERATE over 19 h in FURIN rs74037507 ( P = 8.0E‐04 ) , as # MA increased , SBP increased 20.8 mmHg among Blacks only . Whereas , after MODERATE over the awake hours in FURIN rs1573644 ( P = 6.2E‐04 ) , as # MA increased , DBP decreased 12.5 mmHg among Whites only . FURIN appears to exhibit intensity and race‐dependent associations with PEH that merit further exploration among a larger , ethnically diverse sample of adults with hypertension Context Can self-management interventions help improve blood pressure control in hypertensive patients ? Contribution In this trial , 636 patients with hypertension were r and omly assigned to receive usual care ; a telephone-delivered , nurse-administered behavioral self-management intervention ; home blood pressure self-monitoring ; or both of the latter 2 interventions . Compared with usual care , the adjusted improvement in the proportion of patients with blood pressure control at 24 months was 4.3 % for the behavioral intervention group , 7.6 % for the blood pressure monitoring group , and 11.0 % for the combined intervention group . Caution Patients were recruited from 2 university-affiliated clinics , and most ( 73 % ) already had reasonable blood pressure control at trial entry . The Editors Although multiple treatment options are available for hypertension , only one third of U.S. patients with hypertension have their blood pressure ( BP ) under effective control ( 1 ) . Home BP monitoring is a potentially important aspect of successful hypertension management ( 2 ) . Adopting a healthy lifestyle and adhering to provider recommendations are also important in managing hypertension . Few educational and BP monitoring studies have provided long-term follow-up ( > 12 months ) or implemented a multidimensional intervention that is tailored to patients ' needs and delivered by telephone ( 3 ) . A tailored telephone behavioral intervention and home BP monitoring may be a cost-effective method for improving BP outcomes ( 4 ) . We compared the effectiveness of BP self-monitoring , a tailored , nurse-administered behavior self-management intervention , and a combination of the 2 interventions with that of usual care . Methods The study was approved by the Duke University Institutional Review Board , and all patients provided written informed consent . Setting and Participants Recruitment occurred from May 2004 to December 2005 , with follow-up from November 2004 to January 2008 . Potentially eligible study patients were identified through weekly data extraction s from the billing and appointment data base for 2 Duke University Health System primary care clinics . Patients were cared for by 7 faculty general internists in 1 clinic and 85 residents under the supervision of faculty at the other clinic . Initial inclusion criteria were hypertension diagnosed at least 12 months before the data extraction date ( International Classification of Diseases , 9th revision , codes 401.0 , 401.1 , or 401.9 ) , enrollment with a primary care physician at the included clinic for at least 12 months before data extraction , self-report of current antihypertensive medication use , a scheduled appointment with a nonlaboratory primary care provider during the next 30 days , and residence in 1 of 32 specified ZIP codes in the areas around Duke University Health System . Exclusion criteria applied before r and omization were a diagnosis of dementia , Parkinson disease , atrial fibrillation , or end-stage renal disease ; patient of a study investigator or physician not expected to remain at the practice during the entire study period ; resident in nursing home or receiving home health care ; hospitalization for stroke or heart attack , surgery for blocked arteries , or diagnosis of metastatic cancer in the previous 3 months ; poor vision or difficulty hearing on the telephone ; difficulty underst and ing English on the telephone ; participant in another BP study ; spouse participating in current study ; arm circumference greater than 17 inches and wrist circumference greater than 8.5 inches ; pregnant or planning to become pregnant in the next 2 years ; or not receiving most medical care from Duke clinics . Patients also were excluded after r and omization because they were no longer receiving medical care at the Duke clinics , had initiated dialysis , had received an organ transplant in the previous 6 months , resided in a nursing home or receiving home health care , had no telephone , or received a diagnosis of pulmonary hypertension in the previous 6 months . The study team mailed qualifying patients a letter from the patient 's primary care provider that gave information about the study and stated that the study team may contact them to participate . Research assistants made weekly screening telephone calls to patients from a r and omly ordered list of eligible patients with upcoming clinic appointments . Figure 1 shows the flow of participants in the study . Overall , 2060 invitation letters were mailed to patients . Research assistants attempted to contact 1728 potential participants by telephone . Six hundred fifty-six patients were enrolled and consented to participate ; the remaining 1072 were not enrolled for various reasons . Twenty additional patients were excluded at the time of the baseline interview . Figure 1 . Study flow diagram . BP = blood pressure . * No longer receiving care at Duke clinics , receiving dialysis , received an organ transplant , residing in a nursing home or receiving home health care , had no telephone , or had pulmonary hypertension . R and omization and Intervention The 636 eligible patients were r and omly assigned to receive usual care , a tailored behavioral telephone intervention , home BP monitoring , or the behavioral intervention plus BP monitoring . In a 22 design , r and omization was stratified at baseline by enrollment site ( 2 primary care clinics ) and health literacy status , as determined by using the Rapid Estimate of Adult Literacy in Medicine ( 5 ) ( low literacy , score of 0 to 60 [ 9th- grade level or less ] [ 6 ] , vs. adequate literacy , score of 61 to 66 [ greater than 9th- grade level ] [ 7 ] ) . Consecutively numbered envelopes were used to r and omly assign patients in each stratum . R and omization blocks of 16 were computer generated by the study statistician and used to ensure ongoing balanced enrollment across the 4 groups . The research assistants were blinded to block size , and patient r and omization sequences were maintained by the study statistician in a separate office from the clinics . At completion of the baseline interview , a research assistant opened an envelope and disclosed the patient 's r and omization status . Participants were reimbursed $ 25 for the baseline visit and for each of the 4 subsequent 6-month BP measurement visits ( $ 125 total ) . Usual Care Patients assigned to usual care received hypertension care from their primary care provider . They were not provided home BP monitors and did not have access to the nurse-administered behavioral intervention . They underwent the same 6-month outcome assessment measurements as the other groups . Tailored Behavioral Self-management Intervention Patient factors targeted in the behavioral intervention included perceived risk for hypertension , memory , literacy , social support , patients ' relationships with their health care providers , and side effects of antihypertension medication . In addition , the intervention focused on improving  adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern  ( 811 ) ,  weight loss  ( 12 , 13 ) ,  reduced sodium intake  ( 13 , 14 ) ,  regular moderate-intensity physical activity  ( 15 , 16 ) ,  smoking cessation  , and moderation of alcohol intake  ( 17 ) . The intervention was delivered by 1 nurse during bimonthly telephone calls . All information was presented in an easily understood format with a FleschKincaid readability score of less than 9th grade ( 18 ) . Each encounter included a core group of modules potentially implemented during each call ( for example , medication and side effects ) plus additional modules activated at specific intervals ( for example , diet and social support ) ( 19 ) . Home BP Monitoring Intervention Patients assigned to home BP monitoring received an Omron HEM 773AC arm monitor ( OMRON Healthcare , Bannockburn , Illinois ) if arm circumference was 17 inches or less or an Omron HEM 637 wrist monitor if arm circumference was greater than 17 inches and wrist circumference was less than 8.5 inches . Two research assistants trained patients in proper use of the home BP devices . At each 6-month assessment , patients were retrained if their BP assessment procedure was incorrect . Patients were asked to measure their BP 3 times weekly on 3 separate days , at the same time of day , and record their values in a log . Patients were asked to mail their logs in every 2 months by using study -provided , preaddressed , stamped envelopes . Combined Intervention Patients assigned to the combined intervention received a home BP monitor , training on its use , and the behavioral self-management intervention . The nurse did not examine home BP values and did not use the home BP values to adjust the intervention . Outcomes and Measurements Baseline Measurement Patient demographic information and diagnosis of diabetes were obtained from patients during a face-to-face baseline interview . Inadequate income was assessed by asking patients to report whether they had enough money to pay bills only by cutting back on things or had difficulty paying bills ( 20 ) . Health literacy was evaluated as a dichotomous variable ( 7 ) . Body weight abstract ed from the medical record and self-reported height were used to calculate body mass index . Study Outcomes : BP Control and Systolic and Diastolic BP The primary outcome was the proportion of participants with adequate BP control at each study time point ( baseline and 6 , 12 , 18 , and 24 months ) . Blood pressure control was defined as systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg for patients without diabetes , and systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg for patients with diabetes ( 21 ) . Secondary outcomes were systolic and diastolic BP at each time point over 24 months . At each time point , a research assistant who was blinded to the patient 's group assignment obtained 2 BP measurements with a digital sphygmomanometer ( BPTRU Automated Non-invasive BP monitor , Model BPM-100 , BpTRU Medical Devices Headquarters , Coquitlam , British Columbia , Canada ) ; the first was obtained after patients were ABSTRACT Background It is important to underst and which components of successful multifaceted interventions are responsible for study outcomes , since some components may be more important contributors to the intervention effect than others . Objective We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure ( BP ) after 6 months in a trial to improve hypertension control . Design The study was a preplanned secondary analysis of a cluster-r and omized clinical trial . Eight clinics in an integrated health system were r and omized to provide usual care to their patients ( n = 222 ) , and eight were r and omized to provide a telemonitoring intervention ( n = 228 ) . Participants Four hundred three of 450 trial participants completing the 6-month follow-up visit were included . Interventions Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists , who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits . Main measures Path analytic models estimated indirect effects of the seven potential mediators of intervention effect ( defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months ) . The potential mediators were change in home BP monitor use , number of BP medication classes , adherence to BP medications , physical activity , salt intake , alcohol use , and weight . Key Results The difference in change in systolic BP was 11.3 mmHg . The multivariable mediation model explained 47 % ( 5.3 mmHg ) of the intervention effect . Nearly all of this was mediated by two factors : an increase in medication treatment intensity ( 24 % ) and increased home BP monitor use ( 19 % ) . The other five factors were not significant mediators , although medication adherence and salt intake improved more in the intervention group than in the usual care group . Conclusions Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification . High adherence at baseline and the relatively low intensity of re sources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP Diabetes mellitus ( DM ) is now considered as the major cause of end-stage kidney failure , and hypertension ( HTN ) is one of the main determinants of progression of renal disease . The aim of this study was to assess the role of blood pressure ( BP )  by  ambulatory blood pressure monitoring ( ABPM ) in children and adolescents with type-1 DM and its correlation with micro-albuminuria ( MA ) and diabetic control . Eighty-one patients with type-1 DM ( mean age 13 ± 4 years ) , whose duration of DM was at least two years , were enrolled in this study . The prevalence of HTN based on ABPM was 28.4 % , while by casual method it was 32.1 % . The pattern of HTN was as follows : mean systolic HTN 27.2 % , mean diastolic HTN 11.2 % , daytime systolic HTN 17.3 % , daytime diastolic HTN 6.2 % , night systolic HTN 30.9 % , and night diastolic HTN 29.7 % . The systolic and diastolic BP loads were 33.4 and 27.2 % , respectively . About 70.4 % of the patients were non-dippers , 12.4 % had masked HTN , and 3.7 % had white coat HTN . The pre-valence of MA was 34.6 % and that of abnormal HbA 1 c was 82.7 % . There was no correlation between HTN and both MA and HbA 1 c ; also , no correlation was found between the duration of diabetes and HbA 1 c. Moreover , no significant correlation was found between the duration of diabetes and MA ( P = 0.080 ) . Despite the high prevalence of abnormal BP profile among diabetic children , prospect i ve longitudinal studies considering the other major risk factors , particularly genetic factors , which have an impact on the progression to diabetic nephropathy , are recommended CONTEXT Weight loss , sodium reduction , increased physical activity , and limited alcohol intake are established recommendations that reduce blood pressure ( BP ) . The Dietary Approaches to Stop Hypertension ( DASH ) diet also lowers BP . To date , no trial has evaluated the effects of simultaneously implementing these lifestyle recommendations . OBJECTIVE To determine the effect on BP of 2 multicomponent , behavioral interventions . DESIGN , SETTING , AND PARTICIPANTS R and omized trial with enrollment at 4 clinical centers ( January 2000-June 2001 ) among 810 adults ( mean [ SD ] age , 50 [ 8.9 ] years ; 62 % women ; 34 % African American ) with above-optimal BP , including stage 1 hypertension ( 120 - 159 mm Hg systolic and 80 - 95 mm Hg diastolic ) , and who were not taking antihypertensive medications . INTERVENTION Participants were r and omized to one of 3 intervention groups : ( 1 ) " established , " a behavioral intervention that implemented established recommendations ( n = 268 ) ; ( 2 ) " established plus DASH,"which also implemented the DASH diet ( n = 269 ) ; and ( 3 ) an " advice only " comparison group ( n = 273 ) . MAIN OUTCOME MEASURES Blood pressure measurement and hypertension status at 6 months . RESULTS Both behavioral interventions significantly reduced weight , improved fitness , and lowered sodium intake . The established plus DASH intervention also increased fruit , vegetable , and dairy intake . Across the groups , gradients in BP and hypertensive status were evident . After subtracting change in advice only , the mean net reduction in systolic BP was 3.7 mm Hg ( P<.001 ) in the established group and 4.3 mm Hg ( P<.001 ) in the established plus DASH group ; the systolic BP difference between the established and established plus DASH groups was 0.6 mm Hg ( P = .43 ) . Compared with the baseline hypertension prevalence of 38 % , the prevalence at 6 months was 26 % in the advice only group , 17 % in the established group ( P = .01 compared with the advice only group ) , and 12 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .12 compared with the established group ) . The prevalence of optimal BP ( < 120 mm Hg systolic and < 80 mm Hg diastolic ) was 19 % in the advice only group , 30 % in the established group ( P = .005 compared with the advice only group ) , and 35 % in the established plus DASH group ( P<.001 compared with the advice only group ; P = .24 compared with the established group ) . CONCLUSION Individuals with above-optimal BP , including stage 1 hypertension , can make multiple lifestyle changes that lower BP and reduce their cardiovascular disease risk
The most commonly described determinants at the patient level were lack of education , lack of self-awareness , lack of self-efficacy , and forgetfulness .
Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level .
Taking medication , interactive patient-provider communication , self-measurement , and lifestyle management were the most cited patient behaviors at both levels .
Most of the DIs did not include support from peers or family members , despite its reported effectiveness and the rate of social media penetration .
Background Information on how behavior change strategies have been used to design digital interventions ( DIs ) to improve blood pressure ( BP ) control or medication adherence ( MA ) for patients with hypertension is currently limited .
Objective Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication .
Many interventions that target MA to improve BP are increasingly using modern digital technologies .
This systematic review was conducted to discover how DIs have been design ed to improve MA and BP control among patients with hypertension in the recent 10 years .