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Herein, updated evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in Canadian adults are detailed. For 2014, 3 existing recommendations were modified and 2 new recommendations were added. The following recommendations were modified: (1) the recommended sodium intake threshold was changed from ≤ 1500 mg (3.75 g of salt) to approximately 2000 mg (5 g of salt) per day; (2) a pharmacotherapy treatment initiation systolic blood pressure threshold of ≥ 160 mm Hg was added in very elderly (age ≥ 80 years) patients who do not have diabetes or target organ damage (systolic blood pressure target in this population remains at < 150 mm Hg); and (3) the target population recommended to receive low-dose acetylsalicylic acid therapy for primary prevention was narrowed from all patients with controlled hypertension to only those ≥ 50 years of age. The 2 new recommendations are: (1) advice to be cautious when lowering systolic blood pressure to target levels in patients with established coronary artery disease if diastolic blood pressure is ≤ 60 mm Hg because of concerns that myocardial ischemia might be exacerbated; and (2) the addition of glycated hemoglobin (A1c) in the diagnostic work-up of patients with newly diagnosed hypertension. The rationale for these recommendation changes is discussed. In addition, emerging data on blood pressure targets in stroke patients are discussed; these data did not lead to recommendation changes at this time. The Canadian Hypertension Education Program recommendations will continue to be updated annually., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: A review of the literature was conducted to assess the association between oxytocin (OT) and pain., Methods: PsychInfo, PubMed, and Medline (EBSCO) research databases were searched for peer-reviewed articles written between 1950 and 2012. Of a total of 1166 articles returned, 50 (9 human, 33 animal, and 8 spinal cord samples) met full inclusion criteria and were included in the review., Results: OT had a reliable effect as defined by increasing pain tolerance in 29 of 33 animal studies reviewed. This effect persisted across central and peripheral modes of administration and type of noxious stimulus used (eg, heat, electric). The results suggest that OT acts as an analgesic for acute pain in animals. Preliminary research with humans offers consistent evidence to suggest that OT decreases pain sensitivity, though the reliability and stability of such effects cannot yet be determined. Although the findings are encouraging, there is a need for methodologically rigorous work in humans where OT is administered centrally., Discussion: Further research seems to be warranted as the existence of biologically and psychologically plausible mechanisms linking OT and pain have been well supported using animal models with limited but encouraging human research. Implications and recommendations are discussed. Findings from this research may inform therapeutic methods for the management of pain.

Objective: A treatment-as-usual randomized wait-list controlled trial was conducted to investigate the feasibility and impact of an online synchronous Mindfulness-Based Cancer Recovery (MBCR) group program for underserved distressed cancer survivors., Methods: Sixty-two men and women exhibiting moderate to high distress within 3 years of completing primary cancer treatment without access to in-person MBCR were randomized to either immediate online MBCR (n = 30) or to wait for the next available program (n = 32). Participants completed questionnaires preintervention and postintervention or wait period online. Program evaluations were completed after MBCR. Feasibility was tracked through monitoring eligibility and participation through the protocol. Intent-to-treat mixed-model analyses for repeated measures were conducted., Results: Feasibility targets for recruitment and retention were achieved, and participants were satisfied and would recommend online MBCR. There were significant improvements and moderate Cohen d effect sizes in the online MBCR group relative to controls after MBCR for total scores of mood disturbance (d = 0.44, p = .049), stress symptoms (d = 0.49, p = .021), spirituality (d = 0.37, p = .040), and mindfully acting with awareness (d = 0.50, p = .026). Main effects of time were observed for posttraumatic growth and remaining mindfulness facets., Conclusions: Results provide evidence for the feasibility and efficacy of an online adaptation of MBCR for the reduction of mood disturbance and stress symptoms, as well as an increase in spirituality and mindfully acting with awareness compared with a treatment-as-usual wait-list. Future study using larger active control RCT designs is warranted., Trial Registration: ClinicalTrials.gov: NCT01476891.

Purpose: Our study examined whether mindfulness-based stress reduction (MBSR) is noninferior to cognitive behavioral therapy for insomnia (CBT-I) for the treatment of insomnia in patients with cancer., Patients and Methods: This was a randomized, partially blinded, noninferiority trial involving patients with cancer with insomnia recruited from a tertiary cancer center in Calgary, Alberta, Canada, from September 2008 to March 2011. Assessments were conducted at baseline, after the program, and after 3 months of follow-up. The noninferiority margin was 4 points measured by the Insomnia Severity Index. Sleep diaries and actigraphy measured sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency. Secondary outcomes included sleep quality, sleep beliefs, mood, and stress., Results: Of 327 patients screened, 111 were randomly assigned (CBT-I, n = 47; MBSR, n = 64). MBSR was inferior to CBT-I for improving insomnia severity immediately after the program (P = .35), but MBSR demonstrated noninferiority at follow-up (P = .02). Sleep diary-measured SOL was reduced by 22 minutes in the CBT-I group and by 14 minutes in the MBSR group at follow-up. Similar reductions in WASO were observed for both groups. TST increased by 0.60 hours for CBT-I and 0.75 hours for MBSR. CBT-I improved sleep quality (P < .001) and dysfunctional sleep beliefs (P < .001), whereas both groups experienced reduced stress (P < .001) and mood disturbance (P < .001)., Conclusion: Although MBSR produced a clinically significant change in sleep and psychological outcomes, CBT-I was associated with rapid and durable improvement and remains the best choice for the nonpharmacologic treatment of insomnia.

Background. Studies assessing the association between psychological factors and hypertension have been equivocal, which may reflect limitations in the assessment of psychological factors. Purpose. To assess the relationship between mood and anxiety disorders, measured using a psychiatric interview, and 1-year incident hypertension. Methods. 197 nonhypertensive individuals undergoing exercise stress testing at baseline provided follow-up data at 1 year. Baseline assessments included a structure psychiatric interview (PRIME-MD), physician diagnosis of hypertension, and measured blood pressure. At follow-up, hypertension status was assessed via self-reported physician diagnosis. Results. Having an anxiety disorder was associated with a 4-fold increase in the risk of developing hypertension (adjusted OR = 4.14, 95% CIs = 1.18-14.56). In contrast, having a mood disorder was not associated with incident hypertension (adjusted OR = 1.21, 95% CIs = 0.24-5.86). Conclusions. There are potential mechanisms which could explain our differential mood and anxiety findings. The impact of screening and treatment of anxiety disorders on hypertension needs to be explored.

Background: The experience of low socioeconomic position in childhood may increase risk for adult cardiovascular disease above and beyond the effects of current socioeconomic position. One limitation of most previous research is that childhood socioeconomic position was assessed retrospectively., Methods: Measures of ambulatory blood pressure, heart rate, and heart rate variability were obtained from 110 young men (22 years) who were enrolled in a long-term study of child development at age 6., Results: Men who had lower childhood socioeconomic position had smaller decreases in systolic blood pressure (SBP) during sleep independent of current education, daytime SBP, and body mass index (BMI). They also displayed smaller decreases in low-frequency heart rate variability during sleep. Twenty-four-hour SBP was negatively associated with childhood socioeconomic position independent of current education and BMI., Conclusions: While the mechanisms are unclear, childhood socioeconomic position may influence blood pressure in early adulthood independent of current life circumstances.

Background: Irritable bowel syndrome (IBS) is a functional disorder of the lower gastrointestinal (GI) tract affected by stress, which may benefit from a biopsychosocial treatment approach such as mindfulness-based stress reduction (MBSR)., Purpose: A treatment as usual (TAU) wait-list controlled trial was conducted in Calgary, Canada to investigate the impact of MBSR on IBS symptoms. It was hypothesized that MBSR patients would experience greater reduction in overall IBS symptom severity and self-reported symptoms of stress relative to control patients., Method: Ninety patients diagnosed with IBS using the Rome III criteria were randomized to either an immediate MBSR program (n = 43) or to wait for the next available program (n = 47). Patients completed IBS symptom severity, stress, mood, quality of life (QOL), and spirituality scales pre- and post-intervention or waiting period and at 6-month follow-up. Intent-to-treat linear mixed model analyses for repeated measures were conducted, followed by completers analyses., Results: While both groups exhibited a decrease in IBS symptom severity scores over time, the improvement in the MBSR group was greater than the controls and was clinically meaningful, with symptom severity decreasing from constantly to occasionally present. Pre- to post-intervention dropout rates of 44 and 23 % for the MBSR and control groups, respectively, were observed. At 6-month follow-up, the MBSR group maintained a clinically meaningful improvement in overall IBS symptoms compared to the wait-list group, who also improved marginally, resulting in no statistically significant differences between groups at follow-up. Improvements in overall mood, QOL, and spirituality were observed for both groups over time., Conclusions: The results of this trial provide preliminary evidence for the feasibility and efficacy of a mindfulness intervention for the reduction of IBS symptom severity and symptoms of stress and the maintenance of these improvements at 6 months post-intervention. Attention and self-monitoring and/or anticipation of MBSR participation may account for smaller improvements observed in TAU patients.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the dose-dependent effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation on heart rate variability (HRV) at rest and during standard laboratory stress tasks. We also investigated whether EPA + DHA supplementation was associated with changes in mood state., Methods: This placebo-controlled, double-blind, randomized, three-period crossover trial (8-week treatment, 6-week washout) compared two doses of EPA + DHA supplementation (0.85 and 3.4 g/d) in 26 adults with elevated triglycerides. After each treatment period, HRV was assessed during an acute stress protocol that included a resting baseline, standard laboratory stress tasks (speech task and cold pressor), and recovery periods. In addition, mood state was assessed., Results: Root mean square of successive differences in interbeat interval and total power increased 9.9% and 20.6%, respectively, after the high dose relative to placebo (Tukey p = .016 and .012, respectively). The low dose was not significantly different from the high dose or placebo dose. There was a trend for a treatment effect on high-frequency HRV (p = .058), with 21.0% greater power observed after the high dose compared with placebo (Tukey p = .052). Mood did not differ between treatments, and there was no association between mood state and HRV., Conclusions: In healthy adults with elevated triglycerides, supplementation of 3.4 g/d EPA + DHA resulted in greater HRV, whereas 0.85 g/d EPA + DHA had no effect. These results indicate that EPA + DHA supplementation may improve autonomic tone in adults at increased risk for cardiovascular disease within 8 weeks., Trial Registration: NCT00504309 (ClinicalTrials.gov).

Background: Elevated stress can exacerbate cancer symptom severity, and after completion of primary cancer treatments, many individuals continue to have significant distress. Mindfulness-Based Cancer Recovery (MBCR) is an 8-week group psychosocial intervention consisting of training in mindfulness meditation and yoga designed to mitigate stress, pain, and chronic illness. Efficacy research shows face-to-face (F2F) MBCR programs have positive benefits for cancer patients; however barriers exist that impede participation in F2F groups. While online MBCR groups are available to the public, none have been evaluated., Primary Objective: determine whether underserved patients are willing to participate in and complete an online MBCR program., Secondary Objectives: determine whether online MBCR will mirror previous efficacy findings from F2F MBCR groups on patient-reported outcomes., Method/design: The study includes cancer patients in Alberta, exhibiting moderate distress, who do not have access to F2F MBCR. Participants will be randomized to either online MBCR, or waiting for the next available group. An anticipated sample size of 64 participants will complete measures online pre and post treatment or waiting period. Feasibility will be tracked through monitoring numbers eligible and participating through each stage of the protocol., Discussion: 47 have completed/completing the intervention. Data suggest it is possible to conduct a randomized waitlist controlled trial of online MBCR to reach underserved cancer survivors., Trial Registration: Clinical Trials.gov Identifier: NCT01476891.

Background: Adherence to inhaled corticosteroids (ICS) remains poor among asthmatics, yet little is known about the efficacy of interventions to improve adherence. Implementing the Chronic Care Model (CCM) components among patients with respiratory disorders has been associated with an improvement in outcomes, yet little is known about its effects on ICS adherence in asthmatics., Objective: We conducted a systematic review to assess the efficacy of interventions to improve ICS adherence among adult-asthmatics, and whether the use of CCM components (i.e., teaching self-management skills, providing decision support, delivery system design, and clinical information systems) resulted in greater ICS adherence., Methods: All English language articles testing the efficacy of an intervention including ICS medication on outcome from MEDLINE and PsychINFO databases through Aug-2010 were reviewed. Interventions were categorized based on the inclusion of CCM components. We standardized treatment effects to obtain effect-size's (ES's) and we combined the ES's of studies according to the number of CCM components included in their interventions., Results: Eighteen studies met inclusion criteria. Inclusion of a greater number of CCM components within interventions was associated with stronger effects on ICS adherence outcomes, with interventions featuring one, two, and four CCM components having medium (ES = 0.29; 95%CI, 0.16-0.42), large (0.53; 0.40-0.66), and very-large (0.83; 0.69-0.98) effects respectively., Conclusions: Findings provide support for using the CCM as a framework for the design and implementation of interventions to improve adherence among adult-asthmatics., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The present study is a waitlist-controlled investigation of the impact of a Mindfulness-Based Stress Reduction (MBSR) program on mindful attentiveness, rumination and blood pressure (BP) in women with cancer. Female post-treatment cancer patients were recruited from the MBSR program waitlist. Participants completed self-report measures of mindfulness and rumination and measured casual BP at home before and after the 8-week MBSR program or waiting period. MBSR group participants demonstrated higher levels of mindful attentiveness and decreased ruminative thinking following the intervention but no difference in BP, when compared to controls. In the MBSR group, decreases in rumination correlated with decreases in SBP and increases in mindful attention. When participants were assigned to "Higher BP" and "Lower BP" conditions based on mean BP values at week 1, "Higher BP" participants in the MBSR group (n=19) had lower SBP at week 8 relative to the control group (n=16). A MBSR program may be efficacious in increasing mindful attention and decreasing rumination in women with cancer. Randomized controlled trials are needed to evaluate an impact on clinically elevated BP.

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Little is known about transient effects of foods and nutrients on reactivity to mental stress. In a randomized crossover study of healthy adults (n=20), we measured heart rate variability (respiratory sinus arrhythmia), blood pressure, and other hemodynamic variables after three test meals varying in type and amount of fat. Measurements were collected at rest and during speech and cold pressor tasks. There were significant postmeal changes in resting diastolic blood pressure (-4%), cardiac output (+18%), total peripheral resistance (-17%), and interleukin-6 (-27%). Heart rate variability and hemodynamic reactivity to stress was not affected by meal content. We recommend that future studies control for time since last meal and continue to examine effects of meal content on heart rate variability., (Copyright © 2012 Society for Psychophysiological Research.)

Background. The effects of smoking, alcohol consumption, obesity, and a sedentary lifestyle on endothelial function (EF) have only been examined separately. The relative contributions of these behaviours on EF have therefore not been compared. Purpose. To compare the relative associations between these four risk factors and brachial artery reactivity in the same sample. Methods. 328 patients referred for single-photon emission computed tomography (SPECT) exercise stress tests completed a nuclear-medicine-based forearm hyperaemic reactivity test. Self-reported exercise behaviour, smoking habits, and alcohol consumption were collected and waist circumference was measured. Results. Adjusting for relevant covariates, logistic regression analyses revealed that waist circumference, abstinence from alcohol, and past smoking significantly predicted poor brachial artery reactivity while physical activity did not. Only waist circumference predicted continuous variations in EF. Conclusions. Central adiposity, alcohol consumption, and smoking habits but not physical activity are each independent predictors of poor brachial artery reactivity in patients with or at high risk for cardiovascular disease.

Excess intake of dietary salt is estimated to be one of the leading risks to health worldwide. Major national and international health organizations, along with many governments around the world, have called for reductions in the consumption of dietary salt. This paper discusses behavioural and population interventions as mechanisms to reduce dietary salt. In developed countries, salt added during food processing is the dominant source of salt and largely outside of the direct control of individuals. Population-based interventions have the potential to improve health and to be cost saving for these countries. In developing economies, where salt added in cooking and at the table is the dominant source, interventions based on education and behaviour change have been estimated to be highly cost effective. Regardless, countries with either developed or developing economies can benefit from the integration of both population and behavioural change interventions.

Major depressive disorder (MDD) is associated with increased cardiovascular (CV) mortality. Dysfunctional autonomic control of the CV system may represent a mechanism explaining this relationship. Poor CV recovery after exercise, indicative of dysfunctional autonomic control of the CV system, predicts CV events and death. This is the first study to examine the association between MDD and postexercise CV recovery. Some 886 patients underwent exercise stress tests. Heart rate (HR), systolic blood pressure, and diastolic blood pressure were measured at rest, peak exercise, 1 min, and 5 min after exercise. Patients with MDD had slower HR recovery (p=.026) 1 min after exercise than non-MDD patients. No other effects of MDD were found. MDD is accompanied by a dysregulation in autonomic control of exercise-related CV recovery, suggesting that depressed individuals have a slow parasympathetic recovery from exercise., (Copyright © 2011 Society for Psychophysiological Research.)

Motivational interviewing, a directive, patient-centred counselling approach focused on exploring and resolving ambivalence, has emerged as an effective therapeutic approach within the addictions field. However, the effectiveness of motivational interviewing in weight-loss interventions is unclear. Electronic databases were systematically searched for randomized controlled trials evaluating behaviour change interventions using motivational interviewing in overweight or obese adults. Standardized mean difference (SMD) for change in body mass, reported as either body mass index (BMI; kg m(-2) ) or body weight (kg), was the primary outcome, with weighted mean difference (WMD) for change in body weight and BMI as secondary outcomes. The search strategy yielded 3540 citations and of the 101 potentially relevant studies, 12 met the inclusion criteria and 11 were included for meta-analysis. Motivational interviewing was associated with a greater reduction in body mass compared to controls (SMD = -0.51 [95% CI -1.04, 0.01]). There was a significant reduction in body weight (kg) for those in the intervention group compared with those in the control group (WMD = -1.47 kg [95% CI -2.05, -0.88]). For the BMI outcome, the WMD was -0.25 kg m(-2) (95% CI -0.50, 0.01). Motivational interviewing appears to enhance weight loss in overweight and obese patients., (© 2011 The Authors. obesity reviews © 2011 International Association for the Study of Obesity.)

We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2011. The major guideline changes this year are: (1) a recommendation was made for using comparative risk analogies when communicating a patient's cardiovascular risk; (2) diagnostic testing issues for renal artery stenosis were discussed; (3) recommendations were added for the management of hypertension during the acute phase of stroke; (4) people with hypertension and diabetes are now considered high risk for cardiovascular events if they have elevated urinary albumin excretion, overt kidney disease, cardiovascular disease, or the presence of other cardiovascular risk factors; (5) the combination of an angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker (CCB) is preferred over the combination of an ACE inhibitor and a thiazide diuretic in persons with diabetes and hypertension; and (6) a recommendation was made to coordinate with pharmacists to improve antihypertensive medication adherence. We also discussed the recent analyses that examined the association between angiotensin II receptor blockers (ARBs) and cancer., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Impedance cardiography is a technique commonly used in psychophysiological studies. However, concerns about the utility of full circumferential band electrodes (FB) have been raised. The current study was designed to compare FB with a three-quarter circumferential band configuration (PB). A total of 47 participants (66% female, mean [SD] age=20.4 [3.0] years) underwent 2 testing sessions, once using FB and once using PB. Session order was randomized and balanced. Each session consisted of 5 min of rest, math task, recovery, and cold pressor test. Average baseline and task pre-ejection period (PEP), stroke volume (SV), cardiac output (CO), heart rate (HR), blood pressure (BP), and total peripheral resistance (TPR) was calculated from impedance cardiography and blood pressure monitoring. Participants were are asked to rate measures of comfort after each session. There were no significant difference between the mean levels of PEP, SV, CO, HR, and TPR for the PB versus the FB configurations. However, both systolic BP and diastolic BP were higher during the FB session. Intraclass correlations were high (r(icc) =.63-.93) between PB and FB. Bland-Altman analyses revealed a low level of bias (≤5%) between the configurations. Based on limits of agreement between ±30%, there was equivalence in PEP between the 2 configurations, and SV, CO, and TPR were close to reaching equivalence. Participants clearly indicated greater comfort with the PB configuration compared to the FB. The current study provides incremental evidence that suggests a three-quarter PB configuration may be utilized for standard psychophysiological testing instead of the standard FB configuration. However, further studies are needed to validate the PB configuration against other techniques., (Copyright © 2010 Society for Psychophysiological Research.)

Background: Blood donors may hold conflicting thoughts about future donation. While they may perceive the direct benefit to themselves and others, they often report compelling reasons not to give again. As a result the standard encouragements to return may not be sufficient to motivate some donors. This study examined the effects of a postdonation adapted motivational interview (AMI) on blood donor attitudes and repeat donation behavior., Study Design and Methods: Donors (n = 215) were randomly assigned to either an AMI or a no-interview control group. Approximately 1 month after their index donation, donors in the AMI group completed a brief telephone interview to clarify individual-specific motivations and values concerning blood donation and address potential barriers. They were then asked to complete questionnaires regarding donation attitudes, anxiety, self-efficacy, and intention to donate. Donors in the control group were also contacted 1 month after donation and asked to complete the same series of questionnaires., Results: Donors in the AMI group reported greater intention to provide a future donation (F = 8.13, p < 0.05), more positive donation attitudes (F = 4.59, p < 0.05), and greater confidence in their ability to avoid adverse reactions (F = 10.26, p < 0.01). Further, AMI was associated with higher rates of attempted donation at 12 months (odds ratio, 2.48; 95% confidence interval, 1.27-4.87)., Conclusion: Application of an AMI may be an effective strategy to increase the donor pool by enhancing retention of existing donors., (© 2010 American Association of Blood Banks.)

Heart rate variability (HRV) is a noninvasive, practical and reproducible measure of autonomic nervous system function. A heart rate that is variable and responsive to demands is believed to bestow a survival advantage, whereas reduced HRV may be associated with poorer cardiovascular health and outcomes. In recent years, many researchers have investigated the prognostic implications of HRV in a variety of clinical populations. Evidence suggests that reduced HRV has prognostic significance for individuals with myocardial infarction, chronic heart failure, unstable angina and diabetes mellitus. Interventions to increase HRV, such as exercise therapy, have also been examined. The findings of the present review suggest that exercise therapy may improve HRV in myocardial infarction, chronic heart failure and revascularization patients by increasing vagal tone and decreasing sympathetic activity. One hypothesis is that a shift toward greater vagal modulation may positively affect the prognosis of these individuals. While the underlying mechanisms by which exercise training improves vagal modulation are speculative at present, angiotensin II and nitric oxide may be potential mediators.

Sustained and acute increases in blood pressure can dampen pain in experimental animals and humans. The most important clinical implication of this relationship may be the phenomenon of silent cardiac ischemia. High blood pressure is common in people at risk for cardiac ischemia and may reduce angina, the key symptom of life-threatening ischemia. The relationship between resting blood pressure and angina was examined in 904 people undergoing exercise stress testing for coronary artery disease. The presence or absence of ischemia was documented with single photon emission computed tomography (SPECT). Participants with ischemia had higher scores on the McGill Pain Questionnaire (MPQ) following exercise though this was moderated significantly by diastolic blood pressure (DBP), especially in women. People with higher pre-exercise resting DBP who displayed SPECT-diagnosed ischemia had MPQ scores comparable to people who did not display ischemia, independent of age, exercise duration, medication, and cardiac history. Awareness of the potential association between blood pressure and angina may provide patients with coronary artery disease and their physicians' important guidance.

Objective: To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010., Options and Outcomes: For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually., Sponsors: The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.

Objective: To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009., Options and Outcomes: For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

There is growing evidence linking psychological stress to atopic disease, particularly asthma. Anxiety sensitivity, which is the fear of anxiety-related symptoms, may be particularly important in the study of anxiety and atopic disease. The present study examined the association between atopy and anxiety sensitivity in adult asthmatics. A total of 217 asthma patients who had undergone standard pulmonary function and allergen skin prick testing were included. Participants completed the Anxiety Sensitivity Index, Penn State Worry Questionnaire, Type D Personality Scale-16 and Beck Depression Inventory-II on the day of their asthma clinic visit. Total Anxiety Sensitivity Index score was found to be significantly higher in atopic (M = 17.15, SE = .9) versus non-atopic (M = 12.68, SE = 1.5) asthmatics, independent of age, sex, smoking status, asthma severity, asthma duration, and anxiolytic medication use (F = 6.11, p = .014). There was no evidence for a significant association between any of the other questionnaire scores and atopic status.

Background: Achieving optimal asthma control relies upon several behavioral factors (self-monitoring, treatment adherence) that may be influenced by asthma self-efficacy (ASE)., Purpose: To assess the extent to which levels of ASE are associated with asthma control and asthma-related quality of life in patients with asthma., Methods: A total of 557 adult patients with documented asthma completed a battery of questionnaires (Asthma Self-Efficacy Scale, ASES; Asthma Control Questionnaire, ACQ; Asthma Quality of Life Questionnaire, AQLQ) and standard spirometry. Patients also underwent a sociodemographic, medical history, and psychiatric interview. Partial correlations adjusting for covariates were conducted to assess associations between ASES scores and ACQ and AQLQ scores., Results: Results indicated that ASES scores were negatively correlated with ACQ total score and individual items scores, indicating that higher levels of ASE were associated with improved asthma control, and positively correlated with AQLQ total and subscale scores, indicating that higher levels of ASE were associated with better asthma-related quality of life. All findings were independent of covariates., Conclusions: Findings suggest that being confident in one's ability to control asthma symptoms is associated with better asthma control and quality of life. Future studies should assess the direction of the association between self-efficacy and asthma morbidity in order to determine optimal treatment targets.

Objective: To update the evidence-based recommendations for the prevention and management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium intake to less than 100 mmol/day (and 65 mmol/day to 100 mmol/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered for initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. Other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension but who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Objective: To provide updated, evidence-based recommendations for the prevention and management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence was reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. For treatment of patients with kidney disease, the progression of kidney dysfunction was also accepted as a clinically relevant primary outcome., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to update the 2006 Canadian Hypertension Education Program recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: Dietary lifestyle modifications for prevention of hypertension, in addition to a well-balanced diet, include a dietary sodium intake of less than 100 mmol/day. In hypertensive patients, the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day. Other lifestyle modifications for both normotensive and hypertensive patients include: performing 30 min to 60 min of aerobic exercise four to seven days per week; maintaining a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm in men and less than 88 cm in women); limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women; following a diet reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and considering stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions: blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients require more than one agent to achieve these blood pressure targets. In adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction, or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor plus diuretic combination is preferred; in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

The consumption of high levels of saturated fat over the course of several weeks may lead to exaggerated cardiovascular reactivity. The consumption of a single high-fat meal has been associated with a transient impairment of vascular function. In a randomized, repeated measures, crossover study we tested whether the consumption of a single high-fat meal by healthy, normotensive participants would affect cardiovascular reactivity when compared with an isocaloric, low-fat meal. Thirty healthy participants ate a high-fat (42 g) and a low-fat (1 g) meal on 2 separate occasions, and their cardiovascular response to 2 standard laboratory stressors was measured. Systolic blood pressure, diastolic blood pressure, and total peripheral resistance were greater in participants following the consumption of the high-fat meal relative to the low-fat meal. The findings of the present study are consistent with the hypothesis that even a single high-fat meal may be associated with heightened cardiovascular reactivity to stress and offer insight into the pathways through which a high-fat diet may affect cardiovascular function.

Reptiles, particularly snakes, could serve as bioindicators of contamination because some are comparatively long-lived, exhibit different trophic levels, and are at the top of their food chains. We test the null hypothesis that there are no differences in the concentrations of heavy metals in the blood, muscle and liver of water snakes (Nerodia spp.) from rivers in New Jersey, Tennessee and South Carolina. While the former site is in an urban/suburban area, the latter two sites are relatively rural and are located on Department of Energy sites. For the snakes from New Jersey, there were significant differences in metal concentrations among tissues for all metals, the highest levels for arsenic and selenium were in liver and kidney, for cadmium were in the liver, for chromium and lead were in skin, and for mercury and manganese were in the muscle. Body length was not correlated with metal levels, and there were more significant correlations for skin with internal tissues than for blood with other tissues. There were more significant correlations for mercury than for other metals. In comparing metal levels among states, levels were generally higher for snakes collected from South Carolina. These data indicate that, since water snakes accumulate contaminants differentially as a function of location, they can be useful bioindicators of environmental exposure to contaminants. Moreover, because of their wide geographical distribution and use of varying trophic compartments, this genus can be useful for cross-site comparisons.

Dysregulations in several biological systems in breast cancer patients have been reported, including abnormalities in endocrine and sympathetic nervous system indices, as well as psychological disturbances and sleep disorders. The purpose of this exploratory study was to compare women with breast cancer to healthy control women on measures of salivary cortisol, urinary catecholamines, overnight urinary melatonin, and self-reported sleep quality, symptoms of stress, depression, anxiety and mood disturbance, to determine if discernable patterns of dysregulations across systems were apparent. Thirty-three women were tested in each group, with an average age of approximately 52 years, primarily Caucasian and well-educated. Forty percent of the women with breast cancer had stage 2 disease and they were an average of 1.36 years post-diagnosis. Women with breast cancer had significantly higher levels of disturbance on all the psychological indices, but there were no differences between groups on any of the biological measures, with the exception that the control women had higher dopamine values than the participants with breast cancer. None of the psychological scores were correlated with the biological measures. These results are consistent with other studies of early-stage breast cancer and highlight the importance of considering disease characteristics when investigating endocrine and sympathetic nervous system functioning.

Existing evidence suggests that experimenter characteristics can influence research participants' pain reports. To examine the possibility that cardiovascular reactivity may serve as a potential mediating mechanism, blood pressure responses to stress were recorded in 117 healthy women during an arithmetic task and a subsequent cold pressor pain task. Laboratory sessions were conducted by two experimenters (i.e., a university professor and a graduate research assistant), who differed significantly on participant ratings of perceived social status. Participants tested by the university professor showed greater blood pressure responsivity to arithmetic and had higher pain tolerance and lower pain unpleasantness ratings compared to those tested by the research assistant. Further, hierarchical regression analyses indicated that blood pressure reactivity was a potential mediator of the association between experimenter status and both pain tolerance and unpleasantness, suggesting that perceived experimenter status may elicit physiological adaptations that can reduce sensitivity to painful laboratory stimuli.

Background: Emotional stress has been considered an important asthma trigger for years, though the mechanisms by which stress may exacerbate asthma remain poorly understood. The stress-asthma morbidity association could occur through cognitive-behavioral pathways, such as decreased asthma self-efficacy and disorganized self-care, or through the more direct physiological effects of stress on autonomic (parasympathetic) nervous system activity. No study has examined how these two mechanisms may interact to contribute to greater airflow obstruction during emotional stress in daily life. This study investigated associations between peak expiratory flow rate (PEFR) and high frequency heart rate variability (HFHRV) during periods of negative affect and physical activity in daily life in patients with higher versus lower asthma self-efficacy scores., Methods: Fifty-three patients with mild to moderate asthma completed the Asthma Self-Efficacy Scale (ASES) and underwent a 15 h ambulatory assessment of daytime HFHRV and PEFR, while completing self-report diaries of their physical activities and affect., Results: In patients with lower asthma self-efficacy scores, increased levels of negative affect during daily life were associated with higher levels of HFHRV and decreased PEFR relative to patients with higher asthma self-efficacy scores. Increased levels of physical activity were associated with decreased levels of HFHRV irrespective of asthma self-efficacy scores., Conclusions: Findings suggest that lower asthma self-efficacy may be associated with increased parasympathetic activity and airflow obstruction during periods of negative affect during daily life.

Silent myocardial ischaemia is a common phenomenon in patients with coronary heart disease. However, very little is known about the underlying mechanisms of silent ischaemia. One potential pathway that may contribute to this absence of pain is increased blood pressure. The main aim of the current study was to assess the associations among blood pressure, pain and ischaemia in patients undergoing a standard exercise stress test. We hypothesized that patients who experienced chest pain during exercise would have lower baseline and peak blood pressures compared to those who did not experience chest pain. A total of 1,355 patients (418 women) who underwent a single-photon emission computed tomography treadmill exercise stress test and had not experienced a cardiac event in the past 2 weeks participated in the current study. Myocardial perfusion defects were assessed at rest and during the stress challenge. Systolic blood pressure (SBP), diastolic blood pressure, heart rate (HR) and rate pressure product (RPP) were assessed during rest and at peak exercise. There were no main effects of either pain or ischaemia on the baseline cardiovascular variables. Peak exercise data revealed main effects of pain on SBP, RPP and HR, and main effects of ischaemia on SBP and RPP, controlling for age, sex, baseline level, medication status and cardiac history. These findings suggest that acute rather than chronic increases in blood pressure may be one mechanism to explain the phenomena of silent myocardial ischaemia in cardiac patients, and may potentially provide a target for future treatment strategies.

Objective: To provide updated, evidence-based recommendations for the management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence from randomized, controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome., Evidence: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence., Recommendations: Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week in men or nine standard drinks per week in women; follow a diet that is reduced in saturated fat and cholesterol and that emphasizes fruits, vegetables and low-fat dairy products; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy., Validation: All recommendations were graded according to strength of the evidence and voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

We compared the levels of arsenic, cadmium, chromium, lead, manganese, mercury and selenium in a small species of fish (Central stonerollers, Campostoma anomalum) collected from East Fork Poplar Creek (EFPC) and a reference site in eastern Tennessee. Stonerollers are minnows in the Cyprinidae family that serve as prey for many carnivores in aquatic systems. Fish were collected from East Fork Poplar Creek within the U.S. Department of Energy's Y-12 National Security Complex, part of the Oak Ridge Reservation, and from a reference stretch of the Little River in East Tennessee. Whole fish were homogenized for analysis. Concentrations of all metals (except arsenic) were significantly higher in stonerollers from EFPC compared to the reference site. Mercury levels in minnows from EFPC averaged 0.4 ppm (microg/g), four times higher than the average for fish in the U.S. in general. This was higher than levels in fish from the nearby Clinch River and higher than fillets of white bass (Morone chrysops) from the same creek. Most metal levels were inversely related to size and weight of the stonerollers, perhaps due to growth dilution.

The impact of stress on respiratory airflow in asthmatics is unclear. Part of the uncertainty may spring from the different physiological effects of different stressors. Given their potential to elicit increases in parasympathetic vagal activity, stressful situations that present few opportunities for coping (passive coping stressors) may be particularly problematic for people with asthma. Thirty-one adult asthmatics participated in a protocol including a widely used passive coping stressor (the cold pressor test), an active coping stressor (mental arithmetic), an interview about an upsetting asthma-related incident (viewed as a potential passive coping stressor given the exposure to unpleasant memories), and progressive muscle relaxation. Repeated measurements of airflow (via peak expiratory flow), vagal tone (via heart rate variability), and other variables were obtained. The cold pressor test, asthma interview and progressive muscle relaxation produced significant decreases in airflow compared to the baseline period. The cold pressor test and progressive muscle relaxation produced significant, complementary increases in vagal tone. These results suggest that passive coping stressors and other stimuli (e.g., certain forms of relaxation) that elicit increased vagal tone may be associated with poorer asthma control, a view consistent with a significant negative correlation between the participant's mean vagal tone response to the tasks and score on a measure of asthma self-efficacy.

Relatively little is known about contaminants in reptiles, particularly snakes. The concentrations of arsenic, cadmium, chromium, lead, manganese, mercury, and selenium were examined in blood and skin of 46 northern water snakes (Nerodia sipedon) in Tennessee and correlated with concentrations in internal tissues (liver, kidney, muscle) to determine if blood or skin could serve as a nonlethal indicator of internal metal exposure or body burden. Snakes were collected from the East Fork Poplar Creek (EFPC) within the United States Department of Energy's Y-12 National Security Complex (part of the Oak Ridge National Laboratory) and from a reference stretch of the Little River in East Tennessee. For blood, the only consistent positive correlations with internal organs were for mercury, and correlations were low except for muscle. Skin showed significant positive correlations with all three organs for mercury, chromium, selenium, and lead. For manganese and cadmium, skin level was positively correlated with liver level. Blood generally reflects recent exposure, not necessarily body burden, but in water snakes it correlates with body burden for mercury. Skin proved useful for more metals, although patterns were not necessarily consistent across sex and locality subgroups. The most consistent pattern was for mercury, the metal of greatest concern in many aquatic ecosystems, including EFPC.

We compared the levels of arsenic, cadmium, chromium, lead, manganese, mercury, and selenium in the blood, kidney, liver, muscle, and skin of northern water snakes (Nerodia sipedon) collected from the upper reach of East Fork Poplar Creek (EFPC) within the United States Department of Energy's (USDOE's) Y-12 National Security Complex with concentrations in tissues of northern water snakes from a reference reach of the Little River downstream from the Great Smoky Mountains National Park in East Tennessee. Our objectives were to determine whether concentrations of these metals were higher in tissues of water snakes collected from EFPC compared with the reference site and if northern water snakes were suitable bioindicators of metal contamination. Except for chromium, metal levels were significantly higher in tissues (kidney, liver, muscle, and skin) of EFPC northern water snakes compared with those in tissues of snakes from the reference site. Although female northern water snakes were significantly larger than male snakes, their tissues did not contain significantly higher metal concentrations compared with those from male snakes, possibly because of maternal transfer of metals to eggs. This study was the first to examine the accumulation of contaminants resulting from the operations of the USDOE's Oak Ridge Reservation in snakes.

Unlabelled: A growing literature has reported significant reductions in pain sensitivity associated with increasing levels of blood pressure. However, most of this research has been limited to casual blood pressure assessments in white men. The present study examined associations between pain reports and ambulatory blood pressure in a sample of African American and white men and women. Possible response bias during pain assessment due to ethnicity and gender was evaluated with individualized pain rating scales. One hundred thirty-five (72 African American and 63 white) men and women underwent 24-hour blood pressure monitoring and arm ischemia pain sensitivity evaluation with both standard verbal rating scales and individually ordered verbal rating scales of intensity and unpleasantness. Lower individualized pain intensity and unpleasantness ratings were associated with higher levels of ambulatory blood pressure. African Americans and women reported higher levels of pain intensity when using the standard verbal rating scale but not when using the individually ordered rating scale. Collectively, these results support previous research relating reduced pain sensitivity with increased blood pressure among men and women. Furthermore, reported differences in pain sensitivity between ethnic groups and genders might in part be associated with variations in response styles to standard pain assessment tools., Perspective: The findings of the present study suggest that, in some instances, different ethnic groups and genders may use the same descriptors to report different levels of pain. In the context of clinical pain assessment, it may be important to consider the possibility that descriptions of painful sensations reflect, in part, demographic characteristics., (Copyright 2004 American Pain Society)

Comparatively little is known about heavy metal levels in reptiles, particularly for lizards. Yet lizards often are common predators that could serve as bioindicators of contamination on a small spatial scale. This study examined the differences in metal concentrations of adult brown anoles (Anolis sagrei) for arsenic, cadmium, chromium, lead, manganese, mercury, and selenium in six locations in southern Florida, USA, from Lake Okeechobee (Pahokee) south to Key West. We predicted that levels of contaminants would be higher in the industrialized ports (Port Everglades, Port of Miami) and at a landfill (in Key West) compared to a campground, tropical garden, and marine laboratory. Males were significantly larger than females, as expected. Although there were significant locational differences in metal concentrations, they did not fit a consistent pattern, either among sites or between reference and study sites. However, the lowest levels were generally found at Everglades Marina and Campground (except for selenium) and at Fairchild Tropical Garden (except for manganese). For females, size was significantly correlated with cadmium, lead, and mercury levels, while for males, there were significant correlations between length and arsenic, chromium, and manganese concentrations. Where there were gender differences in metal levels, females had significantly higher levels than males even though they were smaller. We attribute these gender differences to differences in diet due to microhabitat differences in foraging locations. Females spend more time feeding near the ground and males spend more time feeding on tree trunks and branches where they consume more flying insects. This is the first study that examines concentrations of metals in lizards in the United States, and suggests that nonnative lizards may be useful in toxicological studies.

Low pain sensitivity has been reported in hypertensive subjects as well in groups deemed to be at increased risk of development of the disorder. However, it is uncertain whether individual differences in pain sensitivity are associated prospectively with increases in blood pressure. In the current study, 24-hour blood pressure and heart rate variability were recorded in 110, 22-year-old men previously assessed at age 14 years for casual blood pressure and pain sensitivity (mechanical finger pressure). Significant correlations were observed between pain tolerance in 14-year-olds and current 24-hour systolic blood pressure (r=0.37, P<0.01) and diastolic blood pressure (r=0.36, P<0.01). Hierarchical multiple regression analyses indicated that information regarding pain tolerance improved prediction of systolic and diastolic blood pressure at age 22 years beyond that afforded by differences in blood pressure, parental history of hypertension, and body mass index at age 14 years. Similar analyses revealed that average pain sensitivity at age 14 was also associated with 24-hour high-frequency heart rate variability (r=0.28, P<0.01) and low-frequency/high-frequency heart rate variability at age 22 (r=-0.35, P<0.01), suggesting increased sympathetic and reduced parasympathetic tone among individuals less sensitive to pain. These results provide further evidence that blood pressure related hypoalgesia might be related to processes involved in blood pressure regulation as well as in the development of sustained high blood pressure.

The purpose of this study was to examine the effects of cold-water immersion on power output, heart rate, and time to peak power in 10 well-trained cyclists. The Compu-trainer Professional Model 8001 computerized stationary trainer was used to evaluate maximum power, average power, and time to peak power during a simulated cycling sprint. The heart rate was measured using a Polar heart rate monitor. Subjects performed 2 maximum-effort sprints (for approximately 30 seconds) separated by either an experimental condition (15 minutes of cold-water immersion at 12 degrees C up to the level of the iliac crest) or a control condition (15 minutes of quiet sitting). All subjects participated under both control and experimental conditions in a counterbalanced design in which 5 subjects performed the experimental condition first and the other 5 subjects performed the control condition first. Each condition was separated by at least 2 days. The time to peak power was not different between the 2 conditions. Maximum and average powers declined by 13.7 and 9.5% for the experimental condition but only by 4.7 and 2.3% for the control condition, respectively. The results also demonstrated a significantly greater decline in maximum heart rate after cold-water immersion (8.1%) than under the control condition (2.4%). Average heart rate showed a decrease of 4.2% under the experimental condition, as compared with an increase of 1.5% under the control condition. The major findings of this study suggest that a relatively brief period of cold-water immersion can manifest significant physiological effects that can impair cycling performance.

A growing literature has observed a significant reduction in pain sensitivity among hypertensive animals and humans. It is uncertain whether a reduced sensitivity to pain can be observed in nonnotensive individuals who go on to develop high blood pressure. Blood pressure (BP) was reassessed in one hundred fifteen 19-year-old boys initially tested at age 14, when they were also presented with a pain stimulus (mechanical finger pressure). Hierarchical regression analyses indicated that information regarding pain tolerance improved prediction of changes in systolic and diastolic blood pressure beyond that afforded by differences in BP at age 14, parental history of hypertension, and body mass index. These analyses suggest that pain sensitivity may be associated with physiological processes involved in the development of sustained high blood pressure.