But these numbers are simply unacceptable, since high blood pressure—when blood pushes against artery walls more forcefully than normal—caused or contributed to more than 670,000 deaths in the United States in 2020, according to the U.S. Centers for Disease Control and Prevention (CDC). The condition is defined as blood pressure that’s at or above 130 mmHg (systolic pressure) over 80 mmHg (diastolic pressure).

Since the condition, known medically as hypertension, places people at risk for heart disease, stroke, and kidney disease—leading causes of death in the United States—high blood pressure just can’t be ignored, Dr. Segal says.

“What makes it even more dangerous is that it often produces no symptoms,” says Dr. Segal, a fellow of the American College of Cardiology whose research has been published in many respected medical journals. “Some people with high blood pressure may experience headaches, shortness of breath, or nosebleeds, but these signs aren’t exclusive to it and often don’t occur until high blood pressure has become severe or life-threatening.”

What leads to high blood pressure? 

Anyone can develop high blood pressure, but certain risk factors make it more likely, Dr. Segal says. These include:

• Family history: Family members have high blood pressure, heart disease, or diabetes.
• Race: Black people are more predisposed than those from other groups.
• Age: It’s more common in people over 55.
• Weight: Those overweight or obese are more apt to develop high blood pressure.
• Sedentary: Exercise can help stave off the condition.
• High-salt diet
• Tobacco use
• Alcohol use:More than one drink per day for women, or two for men, can raise the odds.

“It’s clear that lifestyle choices play a large role in who develops high blood pressure, though that’s not always the case,” Dr. Segal explains. “There’s no single cause for the condition, but there are certainly plenty of contributing factors.”

How high blood pressure is diagnosed and treated  

High blood pressure is fairly straightforward to diagnose, Dr. Segal says. Doing so involves checking blood pressure with a special cuff or device. This is usually done at an annual check-up or doctor’s appointment. “If the reading is high at two or more visits, your doctor may tell you that you have high blood pressure,” he explains.  

Treating the condition, however, is quite individualized, depending on a person’s other health conditions, lifestyle, age and other contributing factors. Medical guidelines help doctors match the best blood pressure drugs to each person, with several main classes of medications available—each working a little differently to reduce blood pressure. According to Dr. Segal, these include:

• Beta blockers, reducing heart rate and cutting the heart’s workload
• Diuretics, which help the kidneys remove extra salt and water from the body
• ACE inhibitors, which help blood vessels stay relaxed by blocking an enzyme that causes them to tighten
• ARBs, which block a receptor that constricts blood vessels
• Calcium channel blockers, which relax blood vessels

Often, people with high blood pressure need more than one medication to successfully treat it, Dr. Segal notes. But they should also blend a healthy lifestyle with prescription medications for a one-two punch to keep the condition at bay.

“Eat foods lower in fat, salt and calories, and make physical activity a bigger part of your day,” he advises. “Simple, commonsense measures can both prevent high blood pressure and help keep it under control.”

Manhattan Cardiology is the premier facility for preventive cardiology treatment in New York. Our cardiologists practice under the guiding principle that early detection is the best form of prevention. www.manhattancardiology.com

Dr. Robert Segal is a board-certified cardiologist and the founder of Manhattan Cardiology, Medical Offices of Manhattan and co-founder of LabFinder. www.manhattancardiology.com www.medicalofficesofmanhattan.com www.LabFinder.com

In contrast, the study found that one cup of coffee and daily green tea consumption did not increase the risk of death related to cardiovascular disease at any blood pressure measurement, though both drinks contain caffeine. According to the FDA, an 8-ounce cup of green or black tea has 30-50 milligrams of caffeine, and an 8-ounce cup of coffee has closer to 80 to 100 milligrams.

Previous research found that drinking one cup of coffee a day may help heart attack survivors by lowering their risk of death after a heart attack and may prevent heart attacks or strokes in healthy individuals. In addition, separate studies have suggested drinking coffee regularly may reduce the risk of developing chronic illnesses, such as Type 2 diabetes and some cancers; may help to control appetite; may help to lower the risk of depression or boost alertness, though it is not clear if this effect is from the caffeine or something else in coffee. On the harmful side, too much coffee may raise blood pressure and lead to anxiety, heart palpitations and difficulty sleeping.

“Our study aimed to determine whether the known protective effect of coffee also applies to individuals with different degrees of hypertension; and also examined the effects of green tea in the same population,” explained the study’s senior author Hiroyasu Iso, M.D., Ph.D., M.P.H., director of the Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine in Tokyo, Japan, and professor emeritus at Osaka University. “To the best of our knowledge,” he said in an AHA news release, “this is the first study to find an association between drinking 2 or more cups of coffee daily and cardiovascular disease mortality among people with severe hypertension.”

High blood pressure, also known as hypertension, occurs when the force of blood pushing against the walls of blood vessels is consistently too high, making the heart work harder to pump blood. It is measured in millimeters of mercury (mm Hg). The current blood pressure guidelines from the and the AHA and the American College of Cardiology (ACC) classifies hypertension as a blood pressure reading of 130/80 mm Hg or higher.

The blood pressure criteria for this study are slightly different from the ACC/AHA guidelines. Researchers classified blood pressure into five categories: optimal and normal (less than 130/85 mm Hg); high normal (130-139/85-89 mm Hg); grade 1 hypertension (140-159/90-99 mm Hg); grade 2 (160-179/100-109 mm Hg); and grade 3 (higher than 180/110 mm Hg). Blood pressure measures in grades 2 and 3 were considered severe hypertension in this study.

Study participants included more than 6,570 men and more than 12,000 women, ages 40 to 79 years at the start of the research. They were selected from the Japan Collaborative Cohort Study for Evaluation of Cancer Risk – a large, prospective study established between 1988 and 1990 of adults living in 45 Japanese communities. Participants provided data through health examinations and self-administered questionnaires assessing lifestyle, diet, and medical history.

During nearly 19 years of follow-up (through 2009), 842 cardiovascular-related deaths were documented. The analysis of data for all participants found:

Drinking two or more cups of coffee a day was associated with twice the risk of cardiovascular disease death in people whose blood pressure was 160/100 mm Hg or higher compared to those who did not drink any coffee.

Drinking one cup of coffee a day was not associated with increased risk of death from cardiovascular disease across any blood pressure categories.

Green tea consumption was not associated with an increased risk of cardiovascular disease mortality across any blood pressure categories.

“These findings may support the assertion that people with severe high blood pressure should avoid drinking excessive coffee,” said Iso. “Because people with severe hypertension are more susceptible to the effects of caffeine, caffeine’s harmful effects may outweigh its protective effects and may increase the risk of death.”

The study found that people with more frequent coffee consumption were more likely to be younger, current smokers, current drinkers, eat fewer vegetables, and have higher total cholesterol levels and lower systolic blood pressure (top number) regardless of the blood pressure category.

The benefits of green tea may be explained by the presence of polyphenols, which are micronutrients with healthy antioxidant and anti-inflammatory properties found in plants. The researchers noted that polyphenols may be part of the reason only coffee consumption was associated with an increased risk of death in people with severe high blood pressure despite both green tea and coffee containing caffeine.

The research has several limitations: coffee and tea consumption were self-reported; blood pressure was measured at a single point, which did not account for changes over time; and the observational nature of the study could not draw a direct cause-and-effect connection between coffee consumption and cardiovascular disease risk among people with severe high blood pressure.

Further study is needed, researchers said, to learn more about the effects of coffee and green tea consumption in people with high blood pressure and to confirm the effects of coffee and green tea consumption in other countries.

“The latest research published in JAMA [the Journal of the American Medical Association] showing that a greater proportion of Americans, particularly communities of color, were living with uncontrolled high blood pressure in 2017-2018 than previously is extremely troublesome,” Susan R. Bailey, M.D., President, American Medical Association (AMA), and Mitchell S.V. Elkind, M.D., President, American Heart Association (AHA), said in a joint statement.

The physicians said that blood pressure control has worsened “despite the fact that we have more scientific evidence than ever before pointing to the devastating effects of uncontrolled high blood pressure, as well as broader access to low-cost generic medications to treat the condition, blood pressure control has worsened. Without intervention, more people will be at high-risk of heart attack, stroke, disability and death.”

In their statement, Bailey and Elkind said the issue has a particular urgency during the COVID-19 pandemic.

“This research reinforces the need for all health care providers and their patients to prioritize blood pressure control, especially now as cardiovascular disease places people at greater risk for adverse outcomes associated with COVID-19. The data also highlight the need for us to address upstream factors, including structural racism, that continue to contribute to the greater prevalence of hypertension and lower rates of blood pressure control among Black, Latino, Asian and Indigenous populations compared to White adults.

“The AMA and AHA will continue to build on their collective work to ensure physicians and all Americans, especially those within underrepresented and under-resourced communities, have the health care access and support they need to control high blood pressure and reduce the burden of cardiovascular disease in the United States.”

Recognizing that high blood pressure is a major health threat to patients, the AMA developed a framework for improving blood pressure control, with online resources to make it easier for physicians and care teams to access the latest evidence-based information and they need to help manage their patients’ high blood pressure. These resources are available to all physicians and health systems as part of the AMA and AHA’s joint Target: BP initiative—a national program launched in 2016 aimed at reducing the number of Americans who die from heart attacks and strokes each year by urging physician practices, health systems and patients to prioritize blood pressure control.

Additionally, earlier this year, the AMA and AHA teamed up with a group of national health care organizations and ESSENCE on the Release the Pressure campaign to advocate for improved heart health with Black women.

For more information on heart health, click here to visit the AHA’s website.

Researchers, led by study author Karen L. Margolis, M.D., M.P.H., executive director of research at HealthPartners Institute in Minneapolis, Minn., found that a heart attack, stroke, stent placement or heart failure hospitalization occurred in 5.3% of the telemonitoring group vs. 10.4% of the routine primary care group.

“Home blood pressure monitoring linked with treatment actions from the health care team delivered remotely (telehealth support) in between office visits has been shown to lower blood pressure more than routine care, and patients really like it,” said Margolis. “In addition, by avoiding serious cardiovascular events over five years, our results indicate significant cost savings.” Patients reported that they liked having support from a trusted professional, rapid feedback and adjustments to their treatment, and having someone to be accountable to.

Margolis reported that over five years, the savings from reduced cardiovascular disease events exceeded the telemonitoring intervention costs by $1,900 per patient.

“The findings were just short of statistical significance,” said Margolis, “meaning they could have been due to chance. However, we were surprised that the figures on serious cardiovascular events pointed so strongly to a benefit of the telemonitoring intervention.”

Uncontrolled high blood pressure is the largest modifiable risk factor contributing to death from all causes. Nearly half of U.S. adults have high blood pressure, defined as equal to or greater than 130 mm Hg systolic (top number), or 80 mm Hg diastolic (bottom number). However, most adults with high blood pressure don’t have their numbers under control.

450 participants with uncontrolled high blood pressure were enrolled in the study, conducted at 16 primary care clinics within the HealthPartners system in Minnesota. Participants were blinded and randomized to two groups: 222 patients were in the routine primary care group, and 228 in the telemonitoring group that also received one year of remote care managed by a pharmacist. In the telemonitoring group, patients were able to measure their blood pressure at home and send it electronically to the pharmacist, who then worked with them to make medication and lifestyle changes in their treatment.

In clinic visits for all participants, researchers monitored blood pressure at enrollment, 6 months, 12 months, 18 months and 5 years; kept track of any heart attacks, strokes, coronary stents, heart failure hospitalizations and heart-related deaths that occurred; and counted all the costs of their blood pressure-related care and cardiovascular event care.

According to a news release from the AHA, the researchers found:

In the telemonitoring group, there were 15 serious cardiovascular events (5 non-fatal heart attacks, 4 non-fatal strokes, 5 heart failure hospitalizations, 1 CV death) among 10 patients. This group also had 2 stent placements, making the total event rate 5.3%.

In the routine primary care group, there were 26 serious cardiovascular events (11 non-fatal heart attacks, 12 non-fatal strokes, 3 heart failure hospitalizations) among 19 patients. They also had 10 stent placements, making the total event rate 10.4%.

Based on these findings, “widespread adoption of the telemonitoring model might help U.S. adults with uncontrolled high blood pressure avoid serious cardiovascular events and reduce health care costs,” according to Margolis and colleagues. They recommend future studies to figure out how to increase the number of patients engaged in home blood pressure monitoring over many years, and to measure cardiovascular risk factors and cardiovascular events over that extended period.

The study’s limitations are its relatively small size, and it was at a single medical group’s urban and suburban primary care clinics, which may not represent the diversity of patients who receive care in other settings across the country.

Most people can control high blood pressure with lifestyle changes, medications, or a combination of both. But many adults don’t even know they have the condition. They often don’t have symptoms before it has caused damage.

According to the National Institutes of Health (NIH), both awareness and treatment of high blood pressure started rising around the turn of the century. Researchers led by Dr. Paul Muntner from the University of Alabama at Birmingham looked into whether that increase was sustained. To examine recent trends in high blood pressure, they used data from a large national health survey. The survey is conducted every two years using a representative sample of Americans.

The team compared the number of people with hypertension from 10 cycles of the survey, from 1999 through 2018. At the time, hypertension was defined by a blood pressure reading of 140/90 mm Hg or higher. The team also looked at how many people with the condition knew they had it and how many were receiving treatment.

The study was funded in part by NIH’s National Heart, Lung, and Blood Institute (NHLBI). Results were published on September 9, 2020, in JAMA.

Out of more than 50,000 adults surveyed between 1999-2018, over 18,000 had high blood pressure. The percentage of people who had the condition rose from 30% in 1999 to 32% in 2017.

The number of those with hypertension who had their blood pressure under control rose from about 32% in 1999-2000 to almost 54% in 2013-2014. However, by 2017-2018 that number had dropped to just under 44%.

Awareness of high blood pressure also increased from about 70% of adults with hypertension in 1999-2000 to almost 85% in 2013-2014. But it then dropped to 77% by 2017-2018.

Adults aged 46-64 were more likely to have their blood pressure controlled than both younger adults and people aged 75 and older. Black adults were less likely than white adults to have controlled high blood pressure. People with health insurance and a usual health care provider were more likely to have control over their high blood pressure than those without health insurance or regular contact with the health care system.

“The reversal in hypertension awareness is a real setback in the fight to reduce heart disease and stroke,” Muntner said, according to NIH. “While lifestyle factors are big contributors to hypertension, awareness and appropriate treatment are key to lowering blood pressure and keeping it in a healthy range to greatly reduce the risk for heart disease and stroke.”

Greater efforts are needed to increase screening for high blood pressure, particularly among younger adults, support adherence to treatment.

In this study, the researchers looked at the online blood pressure device marketplace in Australia, including large, multi-national, e-commerce businesses such as Amazon and eBay, which was the source of over 90% of the devices examined. Validating a blood pressure device means it has gone through rigorous testing to make sure it is measuring accurate blood pressure readings. The researchers, according to a news release from the AHA, found:

Only 6% of the 972 models of blood pressure monitoring devices available for purchase had been validated;

More than half of the blood pressure monitors on the market were wristband models, and none had been validated;

Slightly over 18% of the upper-arm cuff blood pressure devices had been validated; and

Non-validated devices were cheaper than those that had been tested for accuracy.

“If the devices haven’t been  properly validated, treatment decisions could be based on bad information.”

“People around the world monitor their blood pressure using home devices to help to effectively manage hypertension and to help determine their risk for heart attacks or strokes,” said James E. Sharman, Ph.D., lead researcher for the study and deputy director at the Menzies Institute for Medical Research at the University of Tasmania in Australia.

“If the devices haven’t been properly validated for accuracy, treatment decisions could be based on incorrect information. We found non-validated devices dominate the Australian marketplace, which is a major barrier to accurate blood pressure monitoring and cardiovascular risk management.

“Inaccurate blood pressure measuring devices could have a major implication for public health. If blood pressure is incorrectly overestimated it could lead to unnecessary prescriptions or higher doses than needed of blood pressure lowering medications, which are usually prescribed for life. Medications are costly, have potential side effects and patients incorrectly labeled with high blood pressure could suffer unnecessarily. When blood pressure is incorrectly underestimated, people might remain at increased risk for a heart attack or stroke that could otherwise be avoided with the appropriate medication and dose, and/or lifestyle changes,” Sharman said.

“International policies need to be strengthened to ensure that home use medical devices are rigorously tested for accuracy before being cleared for sale by regulatory authorities. Currently, manufacturers of blood pressure devices conduct their own accuracy testing, an honor system with potential real-life consequences for patients,” said Sharman.

Home blood pressure monitoring is recommended by the AHA for people with high blood pressure because it provides more blood pressure readings rather than the occasional measurement in a doctor’s office or health care clinic. The Association recommends using a blood pressure monitor with an upper-arm cuff that has been independently validated. In addition, the Association suggests taking the device to their healthcare provider to double-check it for accuracy.

The study may be limited because it reviewed only devices purchased via Australia’s online marketplace. These suppliers also sell products in the U.S. and worldwide. But the focus of this study is the Australian market, so it is not known if these same blood pressure devices are sold in the U.S.  The FDA requires manufacturers to submit documentation that the devices are tested for precision before they can be available for sale in the U.S. However, the devices are not independently evaluated; rather, the manufacturers conduct their own accuracy tests.

The findings, presented as preliminary research presented at the American Heart Association’s Hypertension 2019 Scientific Sessions, are important because high blood pressure and cognitive decline are two of the most common conditions associated with aging, and more people are living longer worldwide.

According to the American Heart Association’s 2017 Hypertension Guidelines, high blood pressure is a global health threat, affecting approximately 80 million U.S. adults and one billion people globally. Moreover, the relationship between brain health and high blood pressure is a growing interest as researchers examine how elevated blood pressure affects the brain’s blood vessels, which in turn, may impact memory, language and thinking skills.

I

In this observational study, researchers from Columbia University analyzed data collected on nearly 11,000 adults from the China Health and Retirement Longitudinal Study (CHARLS) between 2011-2015, to assess how high blood pressure and its treatment may influence cognitive decline. High blood pressure was defined as having a systolic blood pressure (top number) of 140 mmHg or higher and a diastolic blood pressure (bottom number) of 90 mmHg or higher, and/or taking antihypertensive medications. (The American Heart Association guidelines define high blood pressure as a systolic blood pressure number of 130 mmHg or higher or a diastolic reading of 80 mmHg or higher.)

Experts say there should be an expansion in screenings for high blood pressure.

Researchers in China interviewed study participants at home about their high blood pressure treatment, education level and noted if they lived in a rural or urban environment. They were also asked to perform cognitive tests, such as immediately recalling words as part of a memory quiz.

Among the study’s findings:

Overall cognition scores declined over the four-year study.

Participants ages 55 and older who had high blood pressure showed a more rapid rate of cognitive decline compared with participants who were being treated for high blood pressure and those who did not have high blood pressure; and the rate of cognitive decline was similar between those receiving high blood pressure treatment and those who did not have high blood pressure.

The study did not evaluate why or how high blood pressure treatments may have contributed to slower cognitive decline or if some treatments were more effective than others.

“We think efforts should be made to expand high blood pressure screenings, especially for at-risk populations, because so many people are not aware that they have high blood pressure that should be treated,” said presenting study author Shumin Rui, a biostatistician at the Mailman School of Public Health, Columbia University in New York. “This study focused on middle-aged and older adults in China; however, we believe our results could apply to populations elsewhere as well. We need to better understand how high blood pressure treatments may protect against cognitive decline and look at how high blood pressure and cognitive decline are occurring together.”

Participants in a low-income area had a 25% higher chance of dying from any cause and a 25% higher likelihood of hospitalization and death related to heart failure over the course of the study period, than those receiving care in higher income areas.

In addition, participants at low-income sites also had an 86% higher likelihood of developing end stage kidney disease and were 30% less likely to receive a procedure performed to open the blood vessels to the heart for patients experiencing chest pain or heart attack.

The findings are based on data obtained from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the largest randomized clinical trial of high blood pressure treatment in North America, which compared the effectiveness of three blood pressure lowering drugs. The study used 140/90 mm Hg as the threshold for high blood pressure, while the American Heart Association recognizes high blood pressure as 130/80 mm Hg.

Researchers know that living in low-income areas is associated with higher rates of high blood pressure, heart failure and stroke. The new study explored whether cardiovascular outcomes vary by socioeconomic factors in a randomized clinical trial in which participants are treated equally.

Participants in the lower income area were more likely to be female, black, Hispanic, have fewer years of education and live in the South.

“Typically in a randomized controlled trial where we try to equalize care across treatment arms and across clinical sites, we aim to isolate the effect of a medication to understand its efficacy,” said senior study author Erica Spatz, M.D., an associate professor of medicine at Yale School of Medicine. “While medications are the mainstay of hypertension control, there are other factors that we need to pay attention to that are impacting blood pressure control, and the ultimate outcomes we care about – heart disease, stroke, hospitalization and longevity.”

ALLHAT enrolled men and women aged 55 years and older with untreated or treated hypertension in the United States, Canada, Puerto Rico and the Virgin Islands from 1994 to 2002. Because of differences in comparing socioeconomic status across geographic regions, the new study was restricted to the roughly 13,000 participants in the continental United States. Of these, 7.8% received care in the lowest income sites and 37.6% received care in the highest income sites.

Participants in the low-income areas were more likely to be female, black, Hispanic, have fewer years of education and live in the South. Participants in low-income areas also surprisingly had fewer cardiovascular risk factors such as history of heart attack or stroke, Type 2 diabetes and cigarette smoking. Also, participants in the low-income areas visited their doctors less compared to higher income areas, potentially due to transportation access, social support and health behaviors which may have indirectly impacted some outcomes. The findings suggest that clinical trial design should consider the socioeconomic context of the treatment site and participants’ neighborhoods.

The findings of the analysis, based on a review of medical and dental exam records of more than 3,600 people with high blood pressure, revealed that those with healthier gums have lower blood pressure and responded better to blood pressure-lowering medications, compared with individuals who have gum disease, a condition known as periodontitis. Specifically, people with periodontal disease were 20 percent less likely to reach healthy blood pressure ranges, compared with patients in good oral health.

Considering the findings, the researchers say patients with periodontal disease may warrant closer blood pressure monitoring, while those diagnosed with hypertension, or persistently elevated blood pressure, might benefit from a referral to a dentist.

“Physicians should pay close attention to patients’ oral health, particularly those receiving treatment for hypertension, and urge those with signs of periodontal disease to seek dental care. Likewise, dental health professionals should be aware that oral health is indispensable to overall physiological health, including cardiovascular status,” said study lead investigator Davide Pietropaoli, D.D.S., Ph.D., of the University of L’Aquila in Italy.

The target blood pressure range for people with hypertension is less than 130/80 mmHg according to the latest recommendations from the American Heart Association/American College of Cardiology. In the study, patients with severe periodontitis had systolic pressure that was, on average, 3 mmHg higher than those with good oral health. Systolic pressure, the upper number in a blood pressure reading, indicates the pressure of blood against the walls of the arteries. While seemingly small, the 3mmHg difference is similar to the reduction in blood pressure that can be achieved by reducing salt intake by 6 grams per day (equal to a teaspoon of salt, or 2.4 grams of sodium), the researchers said.

The presence of periodontal disease widened the gap even farther, up to 7 mmHg, among people with untreated hypertension, the study found. Blood-pressure medication narrowed the gap, down to 3 mmHg, but did not completely eliminate it, suggesting that periodontal disease may interfere with the effectiveness of blood pressure therapy.

“Patients with high blood pressure and the clinicians who care for them should be aware that good oral health may be just as important in controlling the condition as are several lifestyle interventions known to help control blood pressure, such as a low-salt diet, regular exercise and weight control,” Pietropaoli said.

While the study was not designed to clarify exactly how periodontal disease interferes with blood pressure treatment, the researchers say their results are consistent with previous research that links low-grade oral inflammation with blood vessel damage and cardiovascular risk.

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Hypertension is estimated to affect up to 40 percent of people over age 25 worldwide.

Untreated or poorly controlled hypertension can lead to heart attacks, strokes and heart failure, as well as kidney disease. Hypertension is estimated to claim 7.5 million lives worldwide.

Red, swollen, tender gums or gums that bleed with brushing and flossing are tell-tale signs of inflammation and periodontal disease. So are teeth that look longer than before, a sign of receding gums, and teeth that are loose or separating from the gum line.

Co-authors on the research included Rita Del Pinto, M.D., PhD candidate; Claudio Ferri, M.D.; Mario Giannoni, M.D., D.D.S.; Eleonora Ortu, D.D.S., Ph.D.; and Annalisa Moaco, D.D.S., M.Sc., of the University of L’Aquila, Italy; and Jackson Wright Jr., M.D., Ph.D., of Case Western Reserve University.