The American journal of medicine
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The most important factor in treating hypertension is assessing an individual patient's true blood pressure load, the cornerstone being research-grade office determination. Office blood pressure should be supplemented with out-of-office measurement, including home and ambulatory monitoring (if available), which we consider complementary and not interchangeable. Controversy remains for initiation of treatment of white coat hypertension, where cardiovascular risk lies between normotension and sustained hypertension; antihypertensive therapy should be considered unless low cardiovascular risk, wherein pressures should be followed for progression to sustained hypertension. ⋯ Given the higher cardiovascular risk of the masked effect, initiation of therapy for masked hypertension and intensification for masked uncontrolled hypertension are indicated, acknowledging the dearth of supporting data. Optimally, randomized controlled trials are needed to determine the benefit of treating the 4 incongruous phenotypes between office and out-of-office measurements, that is, those with white coat or masked effects. We make no recommendations regarding chronotherapy pending results of ongoing trials.
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Increasing adverse outcomes in patients with chronic kidney disease reflect growth of patients with early-stage chronic kidney disease and their increasing per population rates of these outcomes. Progression of chronic kidney disease, more than current level of kidney function, is the primary driver of adverse chronic kidney disease-related outcomes. Racial/ethnic minorities progress faster to end-stage kidney disease with greater risk for adverse outcomes. ⋯ Patients with early-stage chronic kidney disease are appropriately managed by primary care practices but most lack infrastructure to facilitate this integration that reduces adverse chronic kidney disease-related outcomes. Individuals of low socioeconomic status are at greater chronic kidney disease risk, and flexible regulatory options in Medicaid can fund infrastructure to facilitate healthy eating and healthy moving integration with primary medical care. This integration promises to reduce chronic kidney disease-related adverse outcomes, disproportionately in racial/ethnic minorities, and thereby reduce chronic kidney disease-related health disparities.
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This study examined how certain aspects of residential neighborhood conditions (ie, observed built environment, census-based area-level poverty, and perceived disorder) affect readmission in urban patients with heart failure. ⋯ The effect of high poverty is partly explained by high rates of hypertension and diabetes in these areas. Improving diabetes and blood pressure control or structural aspects of impoverished areas may help reduce hospital readmissions.
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Decongestion is an important goal in the management of acute heart failure. Whether the rate of decongestion is associated with mortality and cardiovascular outcomes is unknown. ⋯ Faster rates of decongestion are associated with reduced risk of mortality and a composite of cardiovascular mortality and heart failure hospitalization. It remains unknown whether more rapid decongestion provides cardiovascular benefit or whether it serves as a proxy for less treatment resistant heart failure.
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It is uncertain if lipids or lipoproteins are associated with osteoporotic fractures. In this study, incident hip fracture risk according to conventional lipid levels and lipoprotein levels and sizes was examined. ⋯ Lipids and lipoproteins are associated with hip fracture risk in older adults. The associations are complex. Mechanistic studies are needed to understand these findings.