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Naylor and colleagues conducted a prospective randomized clinical trial evaluating hospital readmission in elderly patients after initiation of a comprehensive, multidisciplinary discharge program. For the intervals from 2 to 6 weeks and from 6 to 12 weeks after discharge, the percentages of patients readmitted were similar for the intervention and control groups. In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost saving Table 44-2). During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs. There was no statically significant difference in mortality between the control versus the intervention groups. Unfortunately, the need for intense face-to-face follow-up strategies limits the number of patients who can participate in these programs. Given these limitations, alternative heart failure disease management approaches have been studied, including visiting home nurses, telephone monitoring, and telemonitoring. Based on current available data,45,54,55 however, it is unclear if a homebased approach is superior to other types of heart failure disease management programs. The primary endpoint was all-cause, unplanned hospitalization or death during a 12- to 18-month follow-up. The primary endpoint was frequency of unplanned readmissions, plus out-of-hospital deaths within 6 months of discharge. Therefore, alternative methods of heart failure disease management have been explored, such as telephone-based interventions and telemonitoring. Patients do not routinely go to a clinic or other outpatient setting to receive care; rather, the health care provider calls on the telephone or comes to the home. The home is the most important context of care for individuals with chronic heart failure. Both models of care have the potential to provide access to specialist care for a much larger number of patients across a much greater geography and might reduce the cost of care. This study reported total number of hospitalizations (all-cause and heart failure) and was included in those analyses. Although no difference in rehospitalization rates was found, the AlereNet group had a 56. A total of 1069 patients with symptoms of heart failure and documented systolic or diastolic dysfunction were enrolled. This was a multicenter, randomized controlled trial conducted in Argentina that enrolled 1518 patients. Outpatients with stable, chronic heart failure were randomized to receive usual care versus education, counseling, and monitoring by nurses through frequent telephone follow-up. The difference was mostly due to a reduction in heart failure hospitalizations (relative risk reduction = 29%; P = 0.
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What is less clear is the blood pressure threshold for initiation of antihypertensive therapy or the treatment target for lowering blood pressure, which provide the most benefit in the prevention of cardiovascular events. A blood pressure of 140/90 mm Hg is a reasonable threshold/target recommended for most patients in recent hypertension guidelines,177,178 although some guidelines recommend more lenient thresholds in elderly patients179 or more stringent thresholds in high-risk patients, such as African Americans. Whether the same principle applies to chronic treatment of hypertension, however, is unknown. One explanation for this finding is that an abnormal myocardial microvasculature, which does not keep up with the left ventricular hypertrophic response to pressure overload and neurohumoral stimulation, loses the ability to maintain coronary blood flow with acute drops in blood pressure. Clinical evidence in favor of the J curve comes from post hoc analyses of randomized clinical trials. Adapted from Polese A, De Cesare N, Montorsi P, et al: Upward shift of the lower range of coronary flow autoregulation in hypertensive patients with hypertrophy of the left ventricle. The fact that in some papers the J-shaped association of lower blood pressure is eliminated or at least reduced by multivariate analyses supports this hypothesis. Note the large confidence interval (black arrow) of diastolic blood pressure due to small patient numbers on both ends of the blood pressure range, making these estimates less stable. A J curve was not seen with lowering of systolic blood pressure (left panel, blue line) and was less pronounced after adjustment for patient characteristics (not shown). Guo F, He D, Zhang W, et al: Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. Liu L, An Y, Chen M, et al: Trends in the prevalence of hospitalization attributable to hypertensive diseases among United States adults aged 35 and older from 1980 to 2007. Gosse P, Cremer A, Vircoulon M, et al: Prognostic value of the extent of left ventricular hypertrophy and its evolution in the hypertensive patient. Cuspidi C, Rescaldani M, Sala C, et al: Prevalence of electrocardiographic left ventricular hypertrophy in human hypertension: an updated review. Cuspidi C, Sala C, Negri F, et al: Prevalence of left-ventricular hypertrophy in hypertension: an updated review of echocardiographic studies. Russo C, Jin Z, Homma S, et al: Race/ethnic disparities in left ventricular diastolic function in a triethnic community cohort. A cardiovascular magnetic resonance study of the Framingham Heart Study Offspring cohort. Harada M, Itoh H, Nakagawa O, et al: Significance of ventricular myocytes and nonmyocytes interaction during cardiocyte hypertrophy: evidence for endothelin-1 as a paracrine hypertrophic factor from cardiac nonmyocytes. Messaoudi S, Gravez B, Tarjus A, et al: Aldosterone-specific activation of cardiomyocyte mineralocorticoid receptor in vivo. Sun Y, Zhang J, Lu L, et al: Aldosterone-induced inflammation in the rat heart: role of oxidative stress. Tsukamoto O, Minamino T, Sanada S, et al: the antagonism of aldosterone receptor prevents the development of hypertensive heart failure induced by chronic inhibition of nitric oxide synthesis in rats. Pitt B, Reichek N, Willenbrock R, et al: Effects of eplerenone, enalapril, and eplerenone/ enalapril in patients with essential hypertension and left ventricular hypertrophy: the 4E-left ventricular hypertrophy study. Masaki T, Kimura S, Yanagisawa M, et al: Molecular and cellular mechanism of endothelin regulation.