Publications by authors named "Norm R C Campbell"

164 Publications

Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients.

Clin Biochem 2021 Oct 29;96:1-7. Epub 2021 Jun 29.

Department of Cardiac Sciences, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. Electronic address:

Background: The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting.

Methods: Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study.

Results: A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively.

Conclusion: The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.
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http://dx.doi.org/10.1016/j.clinbiochem.2021.06.004DOI Listing
October 2021

Salt reduction to prevent hypertension: the reasons of the controversy.

Eur Heart J 2021 07;42(25):2501-2505

Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.

There is a causal relationship between dietary salt intake and blood pressure. A reduction in salt intake from the current world average of ∼10 g/day to the WHO recommended level of <5 g/day, lowers blood pressure and reduces the risk of cardiovascular disease and all-cause mortality. However, a few cohort studies have claimed that there is a J-shaped relationship between salt intake and cardiovascular risk, i.e. both high and low salt intakes are associated with an increased risk. These cohort studies have several methodological problems, including reverse causality, and inaccurate and biased estimation of salt intake, e.g. from a single spot urine sample with formulas. Recent studies have shown that the formulas used to estimate salt intake from spot urine cause a spurious J-curve. Research with inappropriate methodology should not be used to refute the robust evidence on the enormous benefits of population-wide reduction in salt intake. Several countries, e.g. Finland, the UK, have successfully reduced salt intake, which has resulted in falls in population blood pressure and deaths from stroke and ischaemic heart disease. Every country should develop and implement a coherent, workable strategy to reduce salt intake. Even a modest reduction in salt intake across the whole population will lead to a major improvement in public health, along with huge cost-savings to the healthcare service.
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http://dx.doi.org/10.1093/eurheartj/ehab274DOI Listing
July 2021

Within-visit and between-visit intra-individual blood pressure variability in an unselected adult population from rural China.

J Hypertens 2021 Jul;39(7):1346-1351

Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, China.

Objective: To assess the association between the variability of blood pressure (BP) readings within an initial clinic visit, the variability within subsequent visits and the variability between visits over 1 week in a general population.

Methods: This study included 1401 adult residents, who were not taking antihypertensive drugs, having BP measurements at three visits over 1 week. The difference between maximal and minimal BP readings (ΔBP), ΔBP/BPm (the mean BP value in a visit), the standard deviation (SD) and coefficient of variation (coefficient of variation = SD × 100/mean) of three BP values in each visit were used to estimate the within-visit BP variability (BPV). The SD and coefficient of variation of all nine BP readings over the three visits were calculated as SD9 or CV9 to reflect the overall BPV during the study visits. The SD and coefficient of variation on the mean BP values (BPm) of three visits were computed as SD-3 or CV-3, whereas the difference between maximal and minimal BP in three visits was computed as ΔBP-3 to estimate visit-to-visit BPV. The average BP or HR was the mean values of nine BP or HR readings over three visits.

Results: The systolic and diastolic mean BP (SBP and DBP) decreased from the first to the third visit. The ΔBP, SD and coefficient of variation for both SBP and DBP at the first visit were positively and significantly correlated with the corresponding variables computed at the second and third visits, as well as with overall BPV (ΔBP9, SD9 and CV9). A positive correlation was also found between overall BPV and visit-to visit BPV (SD-3, CV-3 and ΔBP9). Multivariate analysis showed: no association between average SBP and systolic coefficient of variation or ΔBP/BPm but a negative association between average DBP and coefficient of variation or ΔBP/BPm for DBP at the first visit, DBP-3 and DBP9. Age was positively correlated with coefficient of variation or ΔBP/BPm for SBP at the first visit, SBP-3 and SBP9, and correlated with coefficient of variation and ΔBP/BPm for DBP only at the first visit.

Conclusion: In a general population, within-visit BPV at an initial visit is associated with within-visit BPV at subsequent visits and with visit-to-visit BPV over three visits within 1 week.
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http://dx.doi.org/10.1097/HJH.0000000000002810DOI Listing
July 2021

Spot Urine Formulas to Estimate 24-Hour Urinary Sodium Excretion Alter the Dietary Sodium and Blood Pressure Relationship.

Hypertension 2021 Jun 5;77(6):2127-2137. Epub 2021 Apr 5.

Department of Medicine, O'Brien Institute of Public Health, Libin Cardiovascular Institute of Alberta at the University of Calgary, Canada (N.R.C.C.).

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115426PMC
June 2021

Mapping stages, barriers and facilitators to the implementation of HEARTS in the Americas initiative in 12 countries: A qualitative study.

J Clin Hypertens (Greenwich) 2021 04 18;23(4):755-765. Epub 2021 Mar 18.

Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA.

The World Health Organization (WHO) Global Hearts Initiative offers technical packages to reduce the burden of cardiovascular diseases through population-wide and targeted health services interventions. The Pan American Health Organization (PAHO) has led implementation of the HEARTS in the Americas Initiative since 2016. The authors mapped the developmental stages, barriers, and facilitators to implementation among the 371 primary health care centers in the participating 12 countries. The authors used the qualitative method of document review to examine cumulative country reports, technical meeting notes, and reports to regional stakeholders. Common implementation barriers include segmentation of health systems, overcoming health care professionals' scope of practice legal restrictions, and lack of health information systems limiting operational evaluation and quality improvement mechanisms. Main implementation facilitators include political support from ministries of health and leading scientific societies, PAHO's role as a regional catalyst to implementation, stakeholder endorsement demonstrated by incorporating HEARTS into official documents, and having a health system oriented to primary health care. Key lessons include the need for political commitment and cultivating on-the-ground leadership to initiate a shift in hypertension care delivery, accompanied by specific progress in the development of standardized treatment protocols and a set of high-quality medicines. By systematizing an implementation strategy to ease integration of interventions into delivery processes, the program strengthened technical leadership and ensured sustainability. These study findings will aid the regional approach by providing a staged planning model that incorporates lessons learned. A systematic approach to implementation will enhance equity, efficiency, scale-up, and sustainability, and ultimately improve population hypertension control.
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http://dx.doi.org/10.1111/jch.14157DOI Listing
April 2021

The impact of baseline potassium intake on the dose-response relation between sodium reduction and blood pressure change: systematic review and meta-analysis of randomized trials.

J Hum Hypertens 2021 Mar 5. Epub 2021 Mar 5.

The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.

Sodium and potassium appear to interact with each other in their effects on blood pressure with potassium supplementation having a greater blood pressure lowering-effect when sodium intake is high. Whether the effect of sodium reduction on blood pressure varies according to potassium intake levels is unclear. We carried out a systematic review and meta-analysis to examine the impact of baseline potassium intake on blood pressure response to sodium reduction in randomized trials in adult populations, with sodium and potassium intake estimated from 24-h urine samples. We included 68 studies involving 5708 participants and conducted univariable and multivariable meta-regression. The median intake of baseline potassium was 67.7 mmol (Interquartile range: 54.6-76.4 mmol), and the mean reduction in sodium intake was 128 mmol (95% CI: 107-148). Multivariable meta-regression that included baseline 24-h urinary potassium excretion, age, ethnicity, baseline blood pressure, change in 24-h urinary sodium excretion, as well as the interaction between baseline 24-h urinary potassium excretion and change in 24-h urinary sodium excretion did not identify a significant association of baseline potassium intake levels with the blood pressure reduction achieved with a 50 mmol lowering of sodium intake (p > 0.05 for both systolic and diastolic blood pressure). A higher starting level of blood pressure was consistently associated with a greater blood pressure reduction from reduced sodium consumption. However, the nonsignificant findings may subject to the limitations of the data available. Additional studies with more varied potassium intake levels would allow a more confident exclusion of an interaction.
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http://dx.doi.org/10.1038/s41371-021-00510-xDOI Listing
March 2021

The 2020 "WHO Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices With Cuff".

Hypertension 2021 03 1;77(3):806-812. Epub 2021 Feb 1.

Biomedical Engineer, Independent Senior Consultant, Veracrus, México (L.P.L.M.).

High systolic blood pressure (BP) is the single leading modifiable risk factor for death worldwide. Accurate BP measurement is the cornerstone for screening, diagnosis, and management of hypertension. Inaccurate BP measurement is a leading patient safety challenge. A recent World Health Organization report has outlined the technical specifications for automated noninvasive clinical BP measurement with cuff. The report is applicable to ambulatory, home, and office devices used for clinical purposes. The report recommends that for routine clinical purposes, (1) automated devices be used, (2) an upper arm cuff be used, and (3) that only automated devices that have passed accepted international accuracy standards (eg, the International Organization for Standardization 81060-2; 2018 protocol) be used. Accurate measurement also depends on standardized patient preparation and measurement technique and a quiet, comfortable setting. The World Health Organization report provides steps for governments, manufacturers, health care providers, and their organizations that need to be taken to implement the report recommendations and to ensure accurate BP measurement for clinical purposes. Although, health and scientific organizations have had similar recommendations for many years, the World Health Organization as the leading governmental health organization globally provides a potentially synergistic nongovernment government opportunity to enhance the accuracy of clinical BP assessment.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884242PMC
March 2021

WHO HEARTS: A Global Program to Reduce Cardiovascular Disease Burden: Experience Implementing in the Americas and Opportunities in Canada.

Can J Cardiol 2021 05 10;37(5):744-755. Epub 2020 Dec 10.

Department of Non-Communicable Diseases, World Health Organisation, Geneva, Switzerland.

Globally, cardiovascular diseases (CVDs) are the leading cause of death. Viewed as a threat to the global economy, the United Nations included reducing noncommunicable diseases, including CVDs, in the 2030 sustainable development goals, and the World Health Assembly agreed to a target to reduce noncommunicable diseases 25% by the year 2025. In response, the World Health Organisation led the development of HEARTS, a technical package to guide governments in strengthening primary care to reduce CVDs. HEARTS recommends a public health and health system approach to introduce highly simplified interventions done systematically at a primary health care level and has a focus on hypertension as a clinical entry point. The HEARTS modules include healthy lifestyle counselling, evidence-based treatment protocols, access to essential medicines and technology, CVD risk-based management, team-based care, systems for monitoring, and an implementation guide. There are early positive global experiences in implementing HEARTS. Led by the Pan American Health Organisation, many national governments in the Americas are adopting HEARTS and have shown early success. Unfortunately, in Canada hypertension control is declining in women since 2010-2011 and the dramatic reductions in rates of CVD seen before 2010 have flattened when age adjusted and increased for rates that are not age adjusted, and there are marked increases in absolute numbers of Canadians with adverse CVD outcomes. Several steps that Canada could take to enhance hypertension control are outlined, the core of which is to implement a strong governmental nongovernmental collaborative strategy to prevent and control CVDs, focusing on HEARTS.
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http://dx.doi.org/10.1016/j.cjca.2020.12.004DOI Listing
May 2021

The slowdown in the reduction rate of premature mortality from cardiovascular diseases puts the Americas at risk of achieving SDG 3.4: A population trend analysis of 37 countries from 1990 to 2017.

J Clin Hypertens (Greenwich) 2020 08;22(8):1296-1309

Pan American Health Organization, Washington, DC, USA.

Cardiovascular diseases (CVD) are leading causes of mortality and morbidity in the Americas, resulting in substantial negative economic and social impacts. This study describes the trends and inequalities of CVD burden in the Americas to guide programmatic interventions and health system responses. We examined the CVD burden trends by age, sex, and countries between 1990 and 2017 and quantified social inequalities in CVD burden across countries. In 2017, CVD accounted for 2 million deaths in the Americas, 29% of total deaths. Age-standardized DALY rates caused by CVD declined by -1.9% (95% uncertainty interval, -2.0 to -1.7) annually from 1990 to 2017. This trend varied with a striking decreasing trend over the interval 1994-2003 (annual percent change (APC) -2.4% [-2.5 to 2.2]) and 2003-2007 (APC -2.8% [-3.4 to -2.2]). This was followed by a slowdown in the rate of decline over 2007-2013 (APC -1.83% [-2.1 to -1.6]) and a stagnation during the most recent period 2013-2017 (APC -0.1% [-0.5 to 0.3]). The social inequality in CVD burden along the socio-demographic gradient across countries decreased 2.75-fold. The CVD burden and related social inequality have both substantially decreased in the Americas since 1990, driven by the reduction in premature mortality. This trend occurred in parallel with the improvement in the socioeconomic development and health care of the region. The deceleration and stagnation in the rate of improvement of CVD burden and persistent social inequality pose major challenges to reduce the CVD burden and the achievement of the United Nations' Sustainable Development Goals Target 3.4.
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http://dx.doi.org/10.1111/jch.13922DOI Listing
August 2020

Serum Sodium and Potassium Distribution and Characteristics in the US Population, National Health and Nutrition Examination Survey 2009-2016.

J Appl Lab Med 2021 01;6(1):63-78

Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

Background: Concern has been expressed by some that sodium reduction could lead to increased prevalence of hyponatremia and hyperkalemia for specific population subgroups. Current concentrations of serum sodium and potassium in the US population can help address this concern.

Methods: We used data from the National Health and Nutrition Examination Survey 2009-2016 to examine mean and selected percentiles of serum sodium and potassium by sex and age group among 25 520 US participants aged 12 years or older. Logistic regression models with predicted residuals were used to examine the age-adjusted prevalence of low serum sodium and high serum potassium among adults aged 20 or older by selected sociodemographic characteristics and by health conditions or medication use.

Results: The distributions of serum sodium and potassium concentrations were within normal reference intervals overall and across Dietary Reference Intake life-stage groups, with a few exceptions. Overall, 2% of US adults had low serum sodium (<135 mmol/L) and 0.6% had high serum potassium (>5 mmol/L). Prevalence of low serum sodium and high serum potassium was higher among adults aged 71 or older (4.7 and 2.0%, respectively) and among adults with chronic kidney disease (3.4 and 1.9%), diabetes (5.0 and 1.1%), or using certain medications (which varied by condition), adjusted for age; whereas, prevalence was <1% among adults without these conditions or medications.

Conclusions: Most of the US population has normal serum sodium and potassium concentrations; these data describe population subgroups at higher risk of low serum sodium and high serum potassium and can inform clinical care.
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http://dx.doi.org/10.1093/jalm/jfaa127DOI Listing
January 2021

Urgent need to increase the rates of diagnosing, treating and controlling hypertension in older women: A call for action.

Can Pharm J (Ott) 2020 Sep-Oct;153(5):264-269. Epub 2020 Aug 19.

Departments of Medicine (Campbell, Leung), Physiology and Pharmacology (Campbell) and Community Health Sciences (Campbell, Leung), University of Calgary, Calgary, AB.

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http://dx.doi.org/10.1177/1715163520947006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7560563PMC
August 2020

Take urgent action diagnosing, treating, and controlling hypertension in older women.

Can Fam Physician 2020 10;66(10):726-731

Professor and Research Director in the Department of Family and Emergency Medicine at the University of Montreal and the Centre de recherche du CHUM in Quebec.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571660PMC
October 2020

Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative.

J Clin Hypertens (Greenwich) 2020 12 12;22(12):2285-2295. Epub 2020 Oct 12.

Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA.

Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.
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http://dx.doi.org/10.1111/jch.14072DOI Listing
December 2020

Weak and fragmented regulatory frameworks on the accuracy of blood pressure-measuring devices pose a major impediment for the implementation of HEARTS in the Americas.

J Clin Hypertens (Greenwich) 2020 12 6;22(12):2184-2191. Epub 2020 Oct 6.

Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA.

Global HEARTS is a WHO initiative for cardiovascular disease prevention and control. Accurate blood pressure (BP) measurement is an essential component of the initiative. This study aimed to determine the regulatory frameworks governing the accuracy of BPMDs in countries of the Americas participating in the HEARTS initiative. Quantitative and qualitative analysis of the laws and regulations relevant to ensuring the accuracy of BPMDs were determined from the Ministries of Health/Regulatory Agencies among 13 countries in Latin America and the Caribbean. Analysis included characterizing the scope of regulations (ie, pre-market approval, sales and promotion, labeling, cuff sizes, and procurement), information systems for monitoring the models of BPMDs used in primary health care (PHC), and systems to enforce compliance with regulations. Ten of the 13 countries had medical device laws, but regulations that specifically address BPMDs only existed in three countries. Only one country (Brazil) had regulations for mandatory accuracy validation testing and only two countries regulated internet sales of BPMDs. Labeling and cuff size regulations existed in four and two countries, respectively. Less than half the countries reported having a data repository on the BPMD models being used in PHC facilities (four countries) or sold (five countries). Weak and fragmented regulatory frameworks on the accuracy of BPMDs exist among countries of the Americas. This will adversely affect the accuracy of blood pressure assessment and hence poses a major impediment for successful implementation of HEARTS initiative.
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http://dx.doi.org/10.1111/jch.14058DOI Listing
December 2020

How to check whether a blood pressure monitor has been properly validated for accuracy.

J Clin Hypertens (Greenwich) 2020 12 5;22(12):2167-2174. Epub 2020 Oct 5.

Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.

Hypertension guidelines recommend that blood pressure (BP) should be measured using a monitor that has passed validation testing for accuracy. BP monitors that have not undergone rigorous validation testing can still be cleared by regulatory authorities for marketing and sale. This is the situation for most BP monitors worldwide. Thus, consumers (patients, health professionals, procurement officers, and general public) may unwittingly purchase BP monitors that are non-validated and more likely to be inaccurate. Without prior knowledge of these issues, it is extremely difficult for consumers to distinguish validated from non-validated BP monitors. For the above reasons, the aim of this paper is to provide consumers guidance on how to check whether a BP monitor has been properly validated for accuracy. The process involves making an online search of listings of BP monitors that have been assessed for validation status. Only those monitors that have been properly validated are recommended for BP measurement. There are numerous different online listings of BP monitors, several are country-specific and two are general (international) listings. Because monitors can be marketed using alternative model names in different countries, if a monitor is not found on one listing, it may be worthwhile cross-checking with a different listing. This information is widely relevant to anyone seeking to purchase a home, clinic, or ambulatory BP monitor, including individual consumers for use personally or policy makers and those procuring monitors for use in healthcare systems, and retailers looking to stock only validated BP monitors.
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http://dx.doi.org/10.1111/jch.14065DOI Listing
December 2020

Further evidence that methods based on spot urine samples should not be used to examine sodium-disease relationships from the Science of Salt: A regularly updated systematic review of salt and health outcomes (November 2018 to August 2019).

J Clin Hypertens (Greenwich) 2020 10 10;22(10):1741-1753. Epub 2020 Sep 10.

Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada.

The aim of this eighth Science of Salt outcomes review is to identify, summarize, and critically appraise studies on dietary sodium and health outcomes published between November 1, 2018, and August 31, 2019, to extend this series published in the Journal since 2016. The standardized Science of Salt search strategy was conducted. Studies were screened based on a priori defined criteria to identify publications eligible for detailed critical appraisal. The search strategy resulted in 2621 citations with 27 studies on dietary sodium and health outcomes identified. Two studies met the criteria for detailed critical appraisal and commentary. We report more evidence that high sodium intake has detrimental health effects. A post hoc analysis of the Dietary Approaches to Stop Hypertension (DASH) sodium trial showed that lightheadedness occurred at a greater frequency with a high sodium DASH diet compared to a low sodium DASH diet. In addition, evidence from a post-trial analysis of the Trials of Hypertension (TOHP) I and II cohorts showed that estimates of sodium intake from methods based on spot urine samples are inaccurate and this method alters the linearity of the sodium-mortality association. Compared to measurement of 24-hour sodium excretion using three to seven 24-hour urine collections, estimation of average 24-hour sodium excretion with the Kawasaki equation appeared to change the mortality association from linear to J-shaped. Only two high-quality studies were identified during the review period, both were secondary analyses of previously conducted trials, highlighting the lack of new methodologically sound studies examining sodium and health outcomes.
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http://dx.doi.org/10.1111/jch.13958DOI Listing
October 2020

Urinary Sodium Excretion and Blood Pressure Relationship across Methods of Evaluating the Completeness of 24-h Urine Collections.

Nutrients 2020 Sep 11;12(9). Epub 2020 Sep 11.

Department of Medicine, O'Brien Institute of Public Health, Libin Cardiovascular Institute of Alberta at the University of Calgary, Calgary, AB T2N 4Z6, Canada.

We compared the sodium intake and systolic blood pressure (SBP) relationship from complete 24-h urine samples determined by several methods: self-reported no-missed urine, creatinine index ≥0.7, measured 24-h urine creatinine (mCER) within 25% and 15% of Kawasaki predicted urine creatinine, and sex-specific mCER ranges (mCER 15-25 mg/kg/24-h for men; 10-20 mg/kg/24-h for women). We pooled 10,031 BP and 24-h urine sodium data from 2143 participants. We implemented multilevel linear models to illustrate the shape of the sodium-BP relationship using the restricted cubic spline (RCS) plots, and to assess the difference in mean SBP for a 100 mmol increase in 24-h urine sodium. The RCS plot illustrated an initial steep positive sodium-SBP relationship for all methods, followed by a less steep positive relationship for self-reported no-missed urine, creatinine index ≥0.7, and sex-specific mCER ranges; and a plateaued relationship for the two Kawasaki methods. Each 100 mmol/24-h increase in urinary sodium was associated with 0.64 (95% CI: 0.34, 0.94) mmHg higher SBP for self-reported no-missed urine, 0.68 (95% CI: 0.27, 1.08) mmHg higher SBP for creatinine index ≥0.7, 0.87 (95% CI: 0.07, 1.67) mmHg higher SBP for mCER within 25% Kawasaki predicted urine creatinine, 0.98 (95% CI: -0.07, 2.02) mmHg change in SBP for mCER within 15% Kawasaki predicted urine creatinine, and 1.96 (95% CI: 0.93, 2.99) mmHg higher SBP for sex-specific mCER ranges. Studies examining 24-h urine sodium in relation to health outcomes will have different results based on how urine collections are deemed as complete.
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http://dx.doi.org/10.3390/nu12092772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551660PMC
September 2020

Brief online certification course for measuring blood pressure with an automated blood pressure device. A free new resource to support World Hypertension Day Oct 17, 2020.

J Clin Hypertens (Greenwich) 2020 10 3;22(10):1754-1756. Epub 2020 Sep 3.

Menzies Institute for Medical Research, University of Tasmania, Hobart, Tas, Australia.

Detection, diagnosis, and treatment of hypertension require accurate blood pressure assessment. However, in clinical practice, lack of training in or nonadherence to measurement recommendations, lack of patient preparation, unsuitable environments where blood pressure is measured, and inaccurate and inappropriate equipment are widespread and commonly lead to inaccurate blood pressure readings. This has led to calls to require regular training and certification for people assessing blood pressure. Hence, the Pan American Health Organization in collaboration with Resolve to Save Lives, the World Hypertension League, Lancet Commission on Hypertension Group, and Hypertension Canada has developed a free brief training and certification course in blood pressure measurement. The course is available at www. The release of the online certification course is timed to help support World Hypertension Day. This year World Hypertension Day has been delayed to October 17 due to the COVID-19 pandemic. For 2020, the World Hypertension League calls on all health care professionals, health care professional organizations, and indeed all of society, to assess the blood pressure of all adults, measure blood pressure accurately, and achieve blood pressure control in those with hypertension.
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http://dx.doi.org/10.1111/jch.14017DOI Listing
October 2020

Global Marketing and Sale of Accurate Cuff Blood Pressure Measurement Devices.

Circulation 2020 07 27;142(4):321-323. Epub 2020 Jul 27.

Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (N.R.C.C.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046205DOI Listing
July 2020

[Optimizing observer performance of clinic blood Pressure measurement: a position statement from the Lancet Commission on Hypertension GroupOtimização do desempenho do observador na medição clínica da pressão arterial: posicionamento do Grupo da ].

Rev Panam Salud Publica 2020 15;44:e88. Epub 2020 Jul 15.

Instituto Menzies de Investigación Médica, Universidad de Tasmania Hobart Australia Instituto Menzies de Investigación Médica, Universidad de Tasmania, Hobart (Australia).

High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-tomiddle- income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.
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http://dx.doi.org/10.26633/RPSP.2020.88DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7363287PMC
July 2020

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence.

Adv Nutr 2020 11;11(6):1616-1630

The George Institute for Global Health, University of New South Wales, Sydney, Australia.

Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products.
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http://dx.doi.org/10.1093/advances/nmaa067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666895PMC
November 2020

The impact of small to moderate inaccuracies in assessing blood pressure on hypertension prevalence and control rates.

J Clin Hypertens (Greenwich) 2020 06 2;22(6):939-942. Epub 2020 Jun 2.

Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.

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http://dx.doi.org/10.1111/jch.13915DOI Listing
June 2020

Nonvalidated Home Blood Pressure Devices Dominate the Online Marketplace in Australia: Major Implications for Cardiovascular Risk Management.

Hypertension 2020 06 10;75(6):1593-1599. Epub 2020 Apr 10.

From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.).

Self-home blood pressure (BP) monitoring is recommended to guide clinical decisions on hypertension and is used worldwide for cardiovascular risk management. People usually make their own decisions when purchasing BP devices, which can be made online. If patients purchase nonvalidated devices (those not proven accurate according to internationally accepted standards), hypertension management may be based on inaccurate readings resulting in under- or over-diagnosis or treatment. This study aimed to evaluate the number, type, percentage validated, and cost of home BP devices available online. A search of online businesses selling devices for home BP monitoring was conducted. Multinational companies make worldwide deliveries, so searches were restricted to BP devices available for one nation (Australia) as an example of device availability through the global online marketplace. Validation status of BP devices was determined according to established protocols. Fifty nine online businesses, selling 972 unique BP devices were identified. These included 278 upper-arm cuff devices (18.3% validated), 162 wrist-cuff devices (8.0% validated), and 532 wrist-band wearables (0% validated). Most BP devices (92.4%) were stocked by international e-commerce businesses (eg, eBay, Amazon), but only 5.5% were validated. Validated cuff BP devices were more expensive than nonvalidated devices: median (interquartile range) of 101.1 (75.0-151.5) versus 67.4 (30.4-112.8) Australian Dollars. Nonvalidated BP devices dominate the online marketplace and are sold at lower cost than validated ones, which is a major barrier to accurate home BP monitoring and cardiovascular risk management. Before purchasing a BP device, people should check it has been validated at https://www.stridebp.org.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.14719DOI Listing
June 2020

[Lancet Commission on Hypertension Group position statement on the global improvement of accuracy standards for devices that measure blood pressurePosicionamento do Grupo da sobre a melhoria global dos padrões de acurácia para aparelhos que medem a pressão arterial].

Rev Panam Salud Publica 2020 1;44:e21. Epub 2020 Mar 1.

Departamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional Chungbuk Departamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional Chungbuk Cheongju República de Corea Departamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional Chungbuk, Cheongju, República de Corea.

The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3 000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organization for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP.
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http://dx.doi.org/10.26633/RPSP.2020.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039279PMC
March 2020

Effect of dose and duration of reduction in dietary sodium on blood pressure levels: systematic review and meta-analysis of randomised trials.

BMJ 2020 Feb 24;368:m315. Epub 2020 Feb 24.

Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK

Objective: To examine the dose-response relation between reduction in dietary sodium and blood pressure change and to explore the impact of intervention duration.

Design: Systematic review and meta-analysis following PRISMA guidelines.

Data Sources: Ovid MEDLINE(R), EMBASE, and Cochrane Central Register of Controlled Trials (Wiley) and reference lists of relevant articles up to 21 January 2019.

Inclusion Criteria: Randomised trials comparing different levels of sodium intake undertaken among adult populations with estimates of intake made using 24 hour urinary sodium excretion.

Data Extraction And Analysis: Two of three reviewers screened the records independently for eligibility. One reviewer extracted all data and the other two reviewed the data for accuracy. Reviewers performed random effects meta-analyses, subgroup analyses, and meta-regression.

Results: 133 studies with 12 197 participants were included. The mean reductions (reduced sodium usual sodium) of 24 hour urinary sodium, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were 130 mmol (95% confidence interval 115 to 145, P<0.001), 4.26 mm Hg (3.62 to 4.89, P<0.001), and 2.07 mm Hg (1.67 to 2.48, P<0.001), respectively. Each 50 mmol reduction in 24 hour sodium excretion was associated with a 1.10 mm Hg (0.66 to 1.54; P<0.001) reduction in SBP and a 0.33 mm Hg (0.04 to 0.63; P=0.03) reduction in DBP. Reductions in blood pressure were observed in diverse population subsets examined, including hypertensive and non-hypertensive individuals. For the same reduction in 24 hour urinary sodium there was greater SBP reduction in older people, non-white populations, and those with higher baseline SBP levels. In trials of less than 15 days' duration, each 50 mmol reduction in 24 hour urinary sodium excretion was associated with a 1.05 mm Hg (0.40 to 1.70; P=0.002) SBP fall, less than half the effect observed in studies of longer duration (2.13 mm Hg; 0.85 to 3.40; P=0.002). Otherwise, there was no association between trial duration and SBP reduction.

Conclusions: The magnitude of blood pressure lowering achieved with sodium reduction showed a dose-response relation and was greater for older populations, non-white populations, and those with higher blood pressure. Short term studies underestimate the effect of sodium reduction on blood pressure.

Systematic Review Registration: PROSPERO CRD42019140812.
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http://dx.doi.org/10.1136/bmj.m315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190039PMC
February 2020

The impact of changes in population blood pressure on hypertension prevalence and control in China.

J Clin Hypertens (Greenwich) 2020 02 31;22(2):150-156. Epub 2020 Jan 31.

Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China.

In China, there are approximately 250 million adults who have hypertension with low rates of awareness, treatment and control. Changes in lifestyles at a population level have the potential to enhance or deteriorate the prevention and control of hypertension. We used data from a regional hypertension survey to examine the impact of 2/1 mm Hg decreases or increases in population blood pressure on hypertension prevalence, and rates of unawareness of the hypertension diagnosis, treatment, and control. The primary analysis was based on the average blood pressure of respondents from three visits and a diagnostic threshold of 140/90 mm Hg for hypertension. Secondary analyses examined average blood pressure from the first survey visit and also a diagnostic threshold of 130/80 mm Hg for hypertension. The baseline hypertension prevalence was 33.4%, and rates of unawareness of the hypertension diagnosis, treatment, and control were 74.2%, 25.8%, and 9.7%, respectively. Decreases or increases in blood pressure by 10/5 mm Hg resulted in changes in hypertension prevalence (22.1% vs 53.4%) and rates of unawareness of the diagnosis (60.9% vs 83.8%), treatment (39.1% vs 16.2%), and control (21.2% vs 3.6%), respectively. Similar trends were seen in the secondary analyses. Population changes in lifestyle could have a very large impact on the prevalence and control of hypertension in China. The results support implementation of programs to improve population lifestyles while implementing health services policies to enhance the clinical management of hypertension.
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http://dx.doi.org/10.1111/jch.13820DOI Listing
February 2020

Strategies for prevention of cardiovascular disease in adults with hypertension.

J Clin Hypertens (Greenwich) 2020 02 31;22(2):132-134. Epub 2020 Jan 31.

Beijing Hypertension Institute, Beijing, China.

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http://dx.doi.org/10.1111/jch.13797DOI Listing
February 2020

Implementation of a community-based hypertension control program in Matanzas, Cuba.

J Clin Hypertens (Greenwich) 2020 02 22;22(2):142-149. Epub 2020 Jan 22.

Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA.

Increased blood pressure is a leading risk factor for death worldwide, and improving the control of hypertension is a major health goal to reduce non-communicable disease. Thus, in 2016, as part of a regional effort between the Pan American Health Organization and Cuban Ministry of Public Health to reduce cardiovascular risk and disease, a community demonstration project was implemented to enhance hypertension control. The intervention project was in a population of 25 868 people served by the Carlos Verdugo Martínez Polyclinic in Matanzas, Cuba. The project implemented interventions currently recommended in the World Health Organization HEARTS modules, including a standardized clinical training program with certification for blood pressure measurement, routine screening for hypertension in clinics and in the community, a simple directive pharmacologic treatment algorithm, and a registry with performance reporting and feedback. Qualitative and quantitative program monitoring and evaluation was established. In a 2010 national survey, the prevalence of hypertension and the rate of hypertension control were estimated to be 31% and 36%, respectively. Following less than one year of the full implementation of the program, the prevalence of hypertension, proportion of the hypertensive population registered as having hypertension, proportion of those drug-treated who were controlled, and estimated population rate of control were 30%, 90%, 68%, and 58%, respectively. Based on these positive results, the program has been expanded to include another demonstration program initiated in a second region. In addition, preliminary efforts to disseminate and scale-up aspects of the program to the full Cuban population have started.
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http://dx.doi.org/10.1111/jch.13814DOI Listing
February 2020
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