Abstract-Hypertension remains the most common modifiable cardiovascular risk factor, yet hypertension control rates remain dismal. Home blood pressure (BP) monitoring has the potential to improve hypertension control. The purpose of this review was to quantify both the magnitude and mechanisms of benefit of home BP monitoring on BP reduction. Using a structured review, studies were selected if they reported either changes in BP or percentage of participants achieving a pre-established BP goal between randomized groups using home-based and office-based BP measurements.A random-effects model was used to estimate the magnitude of benefit and relative risk. Key Words: home blood pressure Ⅲ meta analysis Ⅲ hypertension Ⅲ blood pressure Ⅲ ambulatory blood pressure monitoring A lthough clinic blood pressure (BP) measurement still remains the cornerstone hypertension management, the broad availability of electronic BP measurement devices has led to their widespread adoption. Home BP monitoring is now uniformly advocated for the evaluation and management of hypertension. 1,2 This is so because BP control among treated hypertensives remains poor, and it is believed that home BP monitoring can improve hypertension control. 1,2 This improvement may be attributable to both better adherence with antihypertensive therapy and detection and treatment of masked hypertension. Further, in contrast to clinic BP measurement, which is associated with a white coat effect, home BP monitoring may reduce white coat effect and may obviate unnecessary therapy. In addition to improving hypertension control, home BP is superior to clinic BP in predicting cardiovascular prognosis 3 and end-stage renal disease. 4 A previous meta-analysis reported that home BP monitoring may improve hypertension control by only a small amount; 5 however, even this small reduction was considered to be of public health importance. Since the publication of that metaanalysis, several trials have been published that provide important information on how home BP monitoring may improve BP control. The purpose of this systematic review and meta-analysis is to update the magnitude of benefit in BP reduction with home BP monitoring. Further, and more important, it is to discover factors that may lead to improvement in BP control with this simple measurement technique. Methods Identification and Selection of TrialsTo identify randomized controlled trials that evaluated home BP monitoring to clinic BP measurements, we performed a structured Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.
Abstract-Vitamin D receptor activation is associated with improved survival in patients with chronic kidney disease, but the mechanism of this benefit is unclear. To better understand the effects of vitamin D on endothelial function, blood pressure, albuminuria, and inflammation in patients with chronic kidney disease (2 patients stage 2, remaining stage 3), we conducted a pilot trial in 24 patients who were randomly allocated equally to 3 groups to receive 0, 1, or 2 g of paricalcitol, a vitamin D analog, orally for 1 month. Placebo-corrected change in flow mediated dilatation with a 1-g dose was 0.5% and 0.4% with a 2-g dose (PϾ0.2). At 1 month, the treatment:baseline ratio of high sensitivity C-reactive protein was 1.5 (95% CI: 1.1 to 2.1; Pϭ0.02) with placebo, 0.8 (95% CI: 0.3 to 1.9; Pϭ0.62) with a 1-g dose, and 0.5 (95% CI: 0.3 to 0.9; Pϭ0. 03) with a 2-g dose of paricalcitol. At 1 month, the treatment:baseline ratio of 24-hour albumin excretion rate was 1.
Abstract-Although obesity is associated with poor outcomes, among patients with chronic kidney disease (CKD), obesity is related to improved survival. These results may be related to poor diagnostic performance of body mass index (BMI) in assessing body fat content. Accordingly, among 77 patients with CKD and 20 controls, body fat percentage was estimated by air displacement plethysmography (ADP), skinfold thickness, and body impedance analysis. Defined by BMI Ն30 kg/m 2 , the prevalence of obesity was 20% in controls and 65% in patients with CKD. Defined by ADP, the prevalence increased to 60% among controls and to 90% among patients with CKD. Although sensitivity and positive predictive value of BMI to diagnose obesity were 100%, specificity was 72%, but the negative predictive value was only 30%. BMI correctly classified adiposity in 75%. Regardless of the presence or absence of CKD, subclinical obesity (defined as BMI Ͻ30 kg/m 2 but excess body fat by ADP) was often missed in people with low lean body mass. The adjusted odds ratio for subclinical obesity per 1 kg of reduced lean body mass by ADP was 1.14 (95% CI: 1.06 to 1.23; PϽ0.001). Skinfold thickness measurements correctly classified 94% of CKD patients, but bioelectrical impedance analyzer-assessed body fat estimation did so in only 65%. Air displacement plethysmography-, skinfold thickness-, and bioelectrical impedance analyzer-assessed body fat all provided reproducible estimates of adiposity. Skinfold thickness measurements may be a better test to classify obesity among those with CKD. Given the low negative predictive value of BMI for obesity, our study may provide an explanation of the "obesity paradox." (Hypertension. 2010;56:893-900.)
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