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If you can't remember the last time you had your blood pressure checked, make an appointment with your doctor. You can have high blood pressure for years without a single symptom. Generally, ask your doctor for a blood pressure reading at least every two years. He or she may recommend more-frequent readings if you have high blood pressure or other risk factors for heart disease.

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Primary care is at crisis point and under pressure to change

The short term crisis in A&E and the long term need to move care out of hospitals are two pressures facing primary care. Photograph: David Levene for the Guardian

Primary care is about to be seized by a degree of turbulence and change that will make the acute sector look ordered and calm.

The pressures for change are coming from every direction: the short-term crisis in A&E, the long-term need to move care out of hospitals, the need to improve access to GPs while reducing their workload, the tightening economics of general practice and the need to improve clinical quality.

Looming over all this is the determination of Jeremy Hunt, the health secretary, to claim the government has "sorted out primary care". His speech to the King's Fund last week made plain his game: having decided that the Labour's 2004 GP contract is the source of problems ranging from poor care of older people to A&E pressures, he is going to rewrite it by next April, sweeping away bureaucracy and securing a "dramatic simplification" of targets and incentives.

The demands for higher clinical standards and a wider range of community services are combining with the need for GPs to cut costs to eradicate singlehanded practices slowly. While GP federations and networks are growing, others are taking a more radical approach.

The Vitality Partnership in Birmingham, one of the models debated at the King's Fund primary care conference, is standardising procedures, has clinical peer review backed up by its own turnaround team, runs an effective patient records system which is gradually reaching local hospitals and has centralised, low-cost administration. It is now a major provider of services such as rheumatology and dermatology.

GP culture can often present itself as conservative, suspicious, even cynical, but the reaction of groups such as Vitality to the threats and opportunities shows the passionate and entrepreneurial side of primary care. It is also striking how leading players are not waiting for the local area team or clinical commissioning group to tell them what to do; they are leading change themselves.

These organisations are a long way from the public's traditional perceptions of the family doctor. They are increasingly large, multidisciplinary teams with efficient, benchmarked systems run across several sites. Against this background, the independent contractor model for general practice looks archaic. Professor Clare Gerada – soon to begin her part-time role for NHS England as clinical chair for primary care transformation in London – is already preparing us for its demise.

On top of all this, everyone, from NHS England to clinical commissioning groups, now recognises that shunting primary care commissioning to NHS England's local area teams was a bad idea. It will fail to align primary services with the groups' wider goals and it will not deal effectively with substandard doctors.

Involving groups in primary commissioning means solving the issue of GP commissioners facing a conflict of interest. One solution could be for councils' health and wellbeing boards to play a role in awarding primary care contracts, such as overseeing the governance.

With all this change, it is difficult to see how the GP workload is going to fall. The widely claimed 14-hour days are simply unsafe. As the Care Quality Commission's new chief inspector for primary care, professor Steve Field, begins work, there is a risk of GP services becoming the next part of the NHS to be accused of serious failings.

Hunt has promised more primary care funding, and Health Education England has been charged with getting many more GPs into the system, but even the minister admits existing plans may be inadequate. And beneath these national numbers many areas with the worst health are desperately short of GPs.

Overall, significant parts of the primary care system are unsustainable financially and clinically, but elsewhere GPs are building new, integrated care systems in the community which hold out the prospect of reducing emergencies, shifting treatment away from hospitals and improving access. This is a cause for optimism, but it needs more money and more staff. Funding has to be moved from acute to primary care, which means shutting some hospital services.

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Primary care can ease pressure on hospitals

Primary care should be recognised as critical to finding a solution, rather than part of the problem, say James Kingsland and Graham Roberts. Photograph: Getty

Inadequate staffing levels and limited provision during the weekend are thought to have led to a rise in mortality rates in hospitals across the country. As a result, we need to refocus on the role that primary care can play in relieving the pressure on secondary care. It may be over-simplifying, but improved access to GP and other services in the community will reduce the burden on hospitals, particularly if there is an increased focus on preventative care. Primary care should be recognised as critical to rectifying this situation as opposed to being part of the problem.

We are seeing an ever-increasing demand on public services, with an expectation for immediate access to everything from our bank balance to consumer goods and not least to healthcare. Waiting lists and pre-booking appointments do not fit well with improving response times and rapid access. Too many people now prefer to seek help for a range of non-urgent health needs from an accident and emergency (A&E) department. While they can at least guarantee that they will be seen on the day, they can wait for up to four hours (or more, when the national waiting time target is breached) for what may not be the right care.

This means that the distinction between serious illnesses requiring urgent attention and those that would be better scheduled through an appointment system are blurred, and hospital staff are put under a greater strain than is necessary.

Many blame this "crisis" on poor access to general practice and the consequences of the 2004 GP contract, which saw most GPs opt out of out-of-hours care. However, this only identifies one small part of the bigger picture of increasing demand but poorer management of this, demographic changes, societal expectation and technological advances (to name but a few). Since 2004 there has been an eight-fold increase in out-of-hours activity in some areas, which suggests that there are other issues that need to be addressed aside from an alteration in working hours.

A significant problem is that many GPs do not have the facilities to enable them to increase provision and extend care facilities. Too many practices are still based in cramped converted dwellings, and while often in residential areas this actually adds to the restriction on the extension of services.

Expanding and equipping our GP surgeries to provide services that may have traditionally rested within hospitals is a major step in solving the current plight of the NHS. Integrated primary, community and social care centres with room for third-sector services and which also house diagnostic facilities and minor surgery suites, that serve a registered population, must be the future of primary care if we are to continue to enjoy an NHS free at the point of delivery. International evidence consistently demonstrates that a strong, well-resourced system of primary care reduces the risk of hospitalisation. The good news is that this vision already exists, but still reflects a minority of general practices.

The NHS, now 65 years old, is continuing to develop and grow. We would be naïve not to build on the best of what we have already. The less well-informed response to the healthcare crisis is to create alternative, poorly evaluated services. This is not the answer, as was the case with the walk-in centres and NHS 111, which have risked fragmenting precious available resources and often provide questionable value for money.

Ultimately, in order to increase efficiency in the NHS and meet the public's top priorities of waiting and access, GPs need to be resourced and equipped to do more. They also need to build teams to perform and complete more episodes of care in their primary care setting in modern, purpose-built 21st-century facilities. It is extremely difficult to change the expectations of the general population, but what we can do is ensure that healthcare practitioners are working in the right environment to respond to the demands effectively.

Dr James Kingsland is national clinical lead for NHS clinical commissioning and Graham Roberts is chief executive of Assura Group

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Too-low diastolic blood pressure can be deadly for CKD patients

Main Category: Urology / Nephrology
Article Date: 20 Aug 2013 - 1:00 PDT Current ratings for:
Too-low diastolic blood pressure can be deadly for CKD patients

Having too-low diastolic blood pressure (DBP) may be deadly for patients with chronic kidney disease (CKD). Blood pressure (BP) recommendations are stricter for patients with CKD than for the general population and focus on lowering actual BP (the measurement of both systolic BP [SBP] and DBP) without consideration for achieving a DBP that is too low.

Researchers reviewed health records for 651,749 U.S. veterans with CKD to assess the association between BP and death. Both actual BP and measurements of SBP and DBP considered separately were assessed.

The researchers found that having a systolic blood pressure of 130 to 159 mm Hg and diastolic blood pressure of 70 to 89 mm Hg was associated with the lowest risk for death. Patients with a DBP less than 70 mm Hg, regardless of their SBP, had higher mortality rates.

An accompanying editorial highlights some of the limitations of the study. Among them, the authors suggest that it may not be BP combination but instead the characteristics of the persons with that combination that lead to greater mortality risk.

Blood Pressure and Mortality in U.S. Veterans With Chronic Kidney Disease: A Cohort Study, Csaba P. Kovesdy, MD; Anthony J. Bleyer, MD; Miklos Z. Molnar, MD, PhD; Jennie Z. Ma, PhD; John J. Sim, MD; William C. Cushman, MD; L. Darryl Quarles, MD; and Kamyar Kalantar-Zadeh, MD, PhD, Ann Intern Med. 2013;159(4):233-242. doi:10.7326/0003-4819-159-4-201308200-00004

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Safer heart surgery from humble blood pressure cuff

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Academic Journal
Main Category: Surgery
Also Included In: Cardiovascular / Cardiology
Article Date: 16 Aug 2013 - 8:00 PDT Current ratings for:
Safer heart surgery from humble blood pressure cuff

Scientists have discovered that inflating a blood pressure cuff on the upper arm immediately prior to heart bypass surgery could decrease risk of heart injury and increase long-term survival rate.

According to the US Centers for Disease Control and Prevention (CDC), around 395,000 coronary artery bypass graft surgeries were carried out in the US in 2010.

Heart surgery, such as coronary bypass, can often cause heart muscle damage, the researchers say. It is linked to reduced long-term survival and can cause severe health outcomes such as heart attacks.

Researchers from the University School of Medicine, Essen, Germany, analyzed the effects of a procedure called remote ischemic preconditioning on 162 patients scheduled to undergo coronary artery bypass graft surgery.

A control group of 167 patients undergoing heart surgery who did not have remote ischemic preconditioning were also monitored.

Remote ischemic preconditioning is a procedure that involves temporarily cutting off the blood supply, then restoring it to an area away from the heart.

The study, published in the The Lancet, looked at whether this procedure affects long-term survival following bypass surgery, and whether it has effects on other health issues, such as stroke and heart attack.

Blood pressure cuff: blood flow of the heart bypass patients was restricted before surgery by simple use of a sphygmomanometer

The patients undergoing remote ischemic preconditioning were:

Anesthetized prior to surgery and had their blood flow restricted for 5 minutes with a standard blood pressure cuff, which was inflated on their upper left arm.They then had their blood supply restored for 5 minutes as the cuff deflated.This procedure was repeated three times.

Following the surgery, the patients' blood concentrations of a substance called troponin 1 was measured. This substance is a biomarker protein that reveals any damage to the heart muscle. A higher concentration of troponin 1 means extensive damage has occurred.

Additionally, the patients were monitored for up to 4 years after surgery in order to see whether remote ischemic preconditioning had any effects on their long-term health.

Results of the study showed that patients who had remote ischemic preconditioning had troponin 1 levels 17% lower compared with those who did not undergo the treatment 72 hours after surgery.

One year after surgery, the findings showed that: Patients who had remote ischemic preconditioning were 73% less likely to have died of any cause compared with patients who did not have the treatment.They were also 86% less likely to die from a stroke or heart attack.

Professor Gerd Heusch of the Institute of Pathophysiology at the University School of Medicine, says:

"The results of our study are very encouraging that remote ischemic preconditioning not only reduces heart muscle injury but also improves long-term health outcomes for heart bypass patients."

The study authors say that it was already common knowledge that remote ischaemic preconditioning helps reduce injury to heart muscle, but they add that this study is the first randomized control trial to provide evidence that the procedure encourages longer survival in coronary bypass patients.

"The beauty of remote ischemic preconditioning is that it is non-invasive, simple, cheap, and safe," said Dr. Matthias Thielmann of the department of thoracic and cardiovascular surgery at the university.

"This procedure could be a promising and simple strategy to protect patients' heart muscle during surgery and hopefully improve health outcomes after surgery," he said.

But in a comment piece at the end of the study, Professor Michel Ovize of the Louis Pradel Hospital in France says that although this research highlights the benefits of remote ischemic preconditioning directly related to the heart, he believes the findings show the potential of possibilities beyond that.

"The incidence of non-heart-related events, such as sepsis or stroke, was lower in the remote ischemic preconditioning group than in the control group, albeit of few events overall," said Prof. Ovize.

"These findings suggest that the effect on the heart might be only one aspect of a much wider effect, and that remote conditioning, unlike local conditioning, might lead to persistent protection."

Written by Honor Whiteman

Copyright: Medical News Today
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Link between race consciousness and blood pressure in black patients

Main Category: Hypertension
Also Included In: Psychology / Psychiatry
Article Date: 15 Aug 2013 - 1:00 PDT Current ratings for:
Link between race consciousness and blood pressure in black patients

Black patients preoccupied with racial concerns have higher blood pressure than those who aren't, according to results of new Johns Hopkins-led research. The findings suggest that heightened race consciousness could at least in part account for the disproportionately high rate of hypertension in black Americans - the highest prevalence of any group in the United States and one of the highest rates in the world.

"A preoccupation with race among blacks leads to hyper-vigilance, a heightened awareness of their stigmatized status in society and a feeling that they need to watch their backs constantly," says Lisa A. Cooper, M.D., M.P.H., a professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and senior author of the study described online in the American Journal of Hypertension. "African-Americans have higher blood pressure, and it has been difficult to explain why this is true. It doesn't appear to be genetic, and while things like diet, exercise and reduced access to health care may contribute, we think that a tense social environment, the sense of being treated differently because of your race, could also possibly explain some of what's behind the higher rates."

Cooper says the issue of such hyper-vigilance and race consciousness has drawn more public attention in the wake of the killing of Trayvon Martin, an unarmed black teenager, in Florida. Her own African-American son, she says, is very aware of his surroundings.

"It's stressful for him to walk around thinking at anytime someone might think he's dong something wrong just because of his race," she says. "That's just something he lives with. If you don't live with it, maybe it's hard to understand it. It's something people often don't want to talk about."

As part of ongoing research into doctor-patient relationships and racial disparities, Cooper and her colleagues surveyed 266 patients in urban health clinics in Baltimore between September 2003 and August 2005. Sixty-two percent of the patients were black. To test for race consciousness, they used the 2002 Behavioral Risk Factor Surveillance System "Reactions to Race" module developed by the U.S. Centers for Disease Control and Prevention. Patients - both black and white - were asked how often they thought about their race.

Two categories were created: Those who said they ever think about their race and those who said they never do. Half of the black patients responded that they "ever" think about it, and one in five white patients said they did.

When blood pressures were measured, being a race-conscious black patient was associated with significantly higher diastolic blood pressure (roughly five millimeters of mercury) and somewhat higher systolic blood pressure (some four millimeters of mercury) than black patients who were not preoccupied with race. There was no effect on blood pressure in race conscious white patients. Systolic blood pressure, the top number in a blood pressure reading, measures the force that pressure from the beating heart places on the arteries moving blood to the rest of the body, while diastolic blood pressure, the bottom number, indicates the pressure in the arteries when the heart rests between beats.

Cooper, director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, says it is well known that chronic stress can increase blood pressure. Similarly, she says tasks that require active coping efforts may increase heart rate and systolic blood pressure, while tasks that require quiet attentiveness and vigilance may lead to decreased cardiac output as well as increased diastolic blood pressure.

In addition to the link between race consciousness and blood pressure, Cooper's team found that whites who were race conscious were more likely to feel respected in the doctor-patient relationship than whites who were not concerned with race, though they were less likely to take their blood pressure medication as prescribed.

"Given the socially dominant status of whites in the United States, higher levels of race consciousness could reflect greater awareness of white privilege," the authors note in the study. "Another explanation, particularly among whites who reside in areas with a high black population, is that race consciousness reflects a heightened fear of victimization, an anxiety-provoking stressor. Scholars of critical race theory are still debating whether race consciousness enhances or adversely effects the health of whites."

Cooper notes that it can be stressful for black people to go shopping in a store and feel they are being watched extra closely. Equally stressful, she says, is for example, waiting a long time to be served at a restaurant, and being ignored, possibly because of one's race.

More research is needed to understand the biological consequences of race consciousness, including those related to stress, she adds, with a goal of developing interventions to help people effectively cope with environmental stressors.

"We need to help people of all races cope with race-related stress in a healthier way," she says.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our hypertension section for the latest news on this subject.

This study is supported by grants from the National Institutes of Health's National Heart, Lung and Blood Institute (K24 HL083113, P50 HL0105187 and R01 HL069403).

Association of Race Consciousness With the Patient–Physician Relationship, Medication Adherence, and Blood Pressure in Urban Primary Care Patients

LaPrincess Brewer, M.D., M.P.H., who was a medical resident at Johns Hopkins Bayview Medical Center at the time of the study and is now a cardiology fellow at the Mayo Clinic, was the first author of the study. Kathryn A. Carson, Sc.M., of Johns Hopkins Bloomberg School of Public Health, also contributed to this study. doi: 10.1093/ajh/hpt116

Johns Hopkins Medicine

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High blood pressure risk and playing college football linked

Main Category: Hypertension
Also Included In: Sports Medicine / Fitness
Article Date: 30 Jul 2013 - 2:00 PDT Current ratings for:
High blood pressure risk and playing college football linked

College football players, especially linemen, may develop high blood pressure over the course of their first season, according to a small study in the American Heart Association's journal Circulation.

Researchers documented higher blood pressure levels among 113 first-year college players. Only one player had already been diagnosed with hypertension before the season and 27 percent had a family history of hypertension. At post-season, researchers noted:

47 percent of players were considered pre-hypertensive, while 14 percent had stage 1 hypertension.

While previous studies indicate blood pressure elevation during adolescence and young adulthood can increase heart disease and heart-related death later in life, the unique findings of this study suggest early careful monitoring of young football players and timely treatment could improve their heart health later in life.

"High blood pressure is not a good thing at any point in life, but especially during the first two decades," said the study's senior investigator, Aaron L. Baggish, M.D.

"The findings shouldn't scare players," said Baggish, associate director of the Cardiovascular Performance Program at Massachusetts General Hospital. "The earlier in life we can identify and begin treating it the better, and identifying special at-risk groups, like these players, is essential."

From 2006-11, researchers at Massachusetts General Hospital, Harvard Medical School, and Harvard Department of Athletics tracked blood pressure changes among players on the Harvard University team, before and after their first season. Researchers also examined changes in endurance-trained competitive rowers, but found no corresponding increase in blood pressure, suggesting the phenomenon may be related to periodic episodes of intense exertion such as football, Baggish said.

Overall, blood pressure levels averaged 116/64 millimeters of mercury (mm Hg) - which is normal - before the season, but afterward rose to an average 125/66 mm Hg, which is pre-hypertensive.

Players on the offensive or defensive line who gain weight during the season and have a family history of high blood pressure were most likely to have post-season hypertension.

Researchers also noted structural changes in players' left ventricle, the heart's main pumping chamber, which can be a potential indicator of worsening heart health since it can grow thicker if the chamber is overworked. In this study, left ventricle thickening (left ventricular hypertrophy) was more prevalent among football players than endurance athletes, and it was significantly greater among linemen.

"Importantly, left ventricular hypertrophy among football players was strongly associated with resting blood pressure suggesting that heart remodeling in some athletes may be due to what happens off the playing field," he said.

"Considering the popularity of football in the United States, I believe this knowledge of an association with enhanced prevalence of prehypertension and stage 1 hypertension after one season in some players is extremely important," said American Heart Association spokesperson Ernesto Schiffrin, M.D., Ph.D., who is not affiliated with the study. "However, the study should not be interpreted to mean that playing football causes hypertension. Instead, it suggests increased surveillance particularly in those most susceptible: those with a family history of hypertension or playing on the offensive or defensive line."

Professional football players tend to have higher rates of both hypertension and premature death from heart disease, especially linemen, Baggish noted. He and his colleagues are continuing to monitor players identified as at-risk to gain a better understanding of hypertension and heart disease, if and when it develops, as they age.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our hypertension section for the latest news on this subject.

Article: "Blood Pressure and Left Ventricular Hypertrophy During American-Style Football Participation" Rory B. Weiner, MD; Francis Wang, MD; Stephanie K. Isaacs, BS; Rajeev Malhotra, MD; Brant Berkstresser, MS, ATC; Jonathan H. Kim, MD; Adolph M. Hutter Jr, MD; Michael H. Picard, MD; Thomas J. Wang, MD; Aaron L. Baggish, MD. doi: 10.1161/?CIRCULATIONAHA.113.003522. Author disclosures are on the manuscript.

Editorial: "Tackling Cardiovascular Health Risks in College Football Players" Gary J. Balady, MD; Jonathan A. Drezner, MD, doi: 10.1161/?CIRCULATIONAHA.113.004039

The American Heart Association funded the study.

American Heart Association

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