Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018

Trends Over Time in Stroke Incidence by Race in the Greater Cincinnati Northern Kentucky Stroke Study

BACKGROUND AND OBJECTIVES

Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period.

METHODS

In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported.

RESULTS

Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time.

DISCUSSION

Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.

High-Sensitivity Cardiac Troponins I and T and Cardiovascular Outcomes: Findings from the Systolic Blood Pressure Intervention Trial (SPRINT)

BACKGROUND

Cardiac troponins are associated with adverse cardiovascular disease (CVD) outcomes. The value of high-sensitivity cardiac troponin I (hs-cTnI) independently and in concert with troponin T (hs-cTnT) in the management of hypertension has not been well studied.

METHODS

We assessed the utility of hs-cTnI independently and with hs-cTnT in identifying the highest risk individuals in the Systolic Blood Pressure Intervention Trial (SPRINT). Among 8796 eligible SPRINT participants, hs-cTnI was measured at baseline and 1 year. The association of baseline level and 1-year change in hs-cTnI with CVD events and all-cause death was evaluated using adjusted Cox regression models. We further assessed the complementary value of hs-cTnI and hs-cTnT by identifying concordant and discordant categories and assessing their association with outcomes.

RESULTS

hs-cTnI was positively associated with composite CVD risk [myocardial infarction, other acute coronary syndrome, stroke, or cardiovascular death: hazard ratio 1.23, 95% confidence interval 1.08-1.39 per 1-unit increase in log(troponin I)] independent of traditional risk factors, N-terminal pro-B-type natriuretic peptide, and hs-cTnT. Intensive blood pressure lowering was associated with greater absolute risk reduction (4.5% vs 1.7%) and lower number needed to treat (23 vs 59) for CVD events among those with higher baseline hs-cTnI (≥6 ng/L in men, ≥4 ng/L in women). hs-cTnI increase at 1 year was also associated with increased CVD risk. hs-cTnI and hs-cTnT were complementary, and elevations in both identified individuals with the highest risk for CVD and death.

CONCLUSIONS

Baseline levels and change in hs-cTnI over 1 year identified higher-risk individuals who may derive greater cardiovascular benefit with intensive blood pressure treatment. hs-TnI and hs-TnT have complementary value in CVD risk assessment. ClinicalTrials.gov Registration Number: NCT01206062.

Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities: A Systematic Review and Meta-Analysis

Importance

Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals' access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations.

Objective

To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities.

Data Sources

In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023.

Study Selection

Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data Extraction and Synthesis

Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model.

Main Outcomes and Measures

Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels.

Results

A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (-4.24 mm Hg; 95% CI, -7.33 to -1.14 mm Hg; P = .01) and SBP changes at 12 months (-4.30 mm Hg; 95% CI, -8.38 to -0.23 mm Hg; P = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year.

Conclusions and Relevance

In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.

Relationship of Blood Pressure, Health Behaviors, and New Diagnosis and Control of Hypertension in the BP-CHECK Study

BACKGROUND

Undiagnosed hypertension and uncontrolled blood pressure (BP) are common and contribute to excess cardiovascular morbidity and mortality. We examined whether BP control, changes in BP, and patient behaviors and attitudes were associated with a new hypertension diagnosis.

METHODS

We performed a post hoc analysis of 323 participants from BP-CHECK (Blood Pressure Checks for Diagnosing Hypertension), a randomized diagnostic study of BP measuring methods in adults without diagnosed hypertension with elevated BP recruited from 12 primary care clinics of an integrated health care system in Washington State during 2017 to 2019. All 323 participants returned a positive diagnostic test for hypertension based on 24-hour ambulatory BP monitoring and were followed for 6 months. We used linear regression to examine the relationships between a new hypertension diagnosis (primary independent variable) and differences in the change in study outcomes from baseline to 6-month.

RESULTS

Mean age of study participants was 58.3 years (SD, 13.1), 147 (45%) were women, and 253 (80%) were of non-Hispanic White race. At 6 months, 154 of 323 (48%) participants had a new hypertension diagnosis of whom 88 achieved target BP control. Participants with a new hypertension diagnosis experienced significantly larger declines from baseline in BP (adjusted mean difference: systolic BP, -7.6 mm Hg [95% CI, -10.3 to -4.8]; diastolic BP, -3.8 mm Hg [95% CI, -5.6 to -2.0]) compared with undiagnosed peers. They were also significantly more likely to achieve BP control by 6 months compared with undiagnosed participants (adjusted relative risk, 1.5 [95% CI, 1.1 to 2.0]). At 6 months, 101 of 323 participants (31%) with a positive ambulatory BP monitoring diagnostic test remained with undiagnosed hypertension, uncontrolled BP, and no antihypertensive medications.

CONCLUSIONS

Approximately one-third of participants with high BP on screening and ambulatory BP monitoring diagnostic testing remained with undiagnosed hypertension, uncontrolled BP, and no antihypertensive medications after 6 months. New strategies are needed to enhance integration of BP diagnostic testing into clinical practice.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03130257.

Impact of home blood pressure monitors on self-monitoring and control of blood pressure in vulnerable adults

To evaluate associations between home blood pressure monitoring (HBPM) and blood pressure (BP) in vulnerable adults during the COVID-19 pandemic, when access to in-person care was restricted. A retrospective cohort study was conducted in adults with hypertension or elevated BP given a home BP monitor vs. usual care. Change in BP from baseline to follow-up was compared between groups, controlling for potential confounders. Subgroup analyses of BP outcomes were also assessed in patients age >50 years. There was no difference in SBP reduction between n = 82 HBPM patients (-11.7/-2.9 mmHg) and n = 280 usual care patients (-12.5/-5.8 mmHg; P > 0.05). Results were similar in multivariable analysis controlling for potential confounders [coefficient 0.44, 95% confidence interval (CI) -3.98 to 4.87]. However, in the subgroup of patients aged>50 years, there was a significant association between SBP reduction and HBPM in the multivariable analyses (coefficient -7.2, 95% CI -13.8 to -0.62, P = 0.032). HBPM use was not associated with BP reduction in vulnerable adults overall during high telehealth use. An association between SBP reduction and HBPM was observed in those aged>50 years. Targeting limited HBPM resources to those aged >50 years old may have the most impact on BP.

Predictors of treatment intensification in uncontrolled hypertension

PURPOSE

Prior studies have shown that treatment intensification for patients presenting with uncontrolled hypertension (HTN) rarely occurs, even during visits to the patient's own primary care physicians (PCPs). In this article, we identified predictors of treatment intensification for uncontrolled HTN.

METHODS

We conducted a cross-sectional study using nationally representative survey data on visits by patients aged 18 or above with uncontrolled HTN, defined as a recorded SBP at least 140 and/or a DBP at least 90 using data from the National Ambulatory Medical Care Survey (NAMCS) 2008-2018. Our outcome is treatment intensification defined as the addition of a new blood pressure medication.

RESULTS

We analyzed 22 559 visits to PCPs where uncontrolled HTN was noted, representing 801 023 786 visits nationally. Among these encounters, 2138 (10.3%) of the visits resulted in treatment intensification. Visits with the patient's own PCP had higher rates of treatment intensification than visits to another PCP (10.8 vs. 5.9%, P  < 0.0001). Visits for patients previously on antihypertensive medications had lower rates of treatment intensification (11% for no medications, 10.4% for one medication, 6.6% for ≥2 medications, P  < 0.0001), but there were no statistically significant differences in rates of intensification for those with relevant comorbidities (9.4% for no chronic conditions, 10.8% for one to two chronic conditions, 8.9% for at least three chronic conditions, P  = 0.12). Multivariable adjusted results were similar to the unadjusted findings.

CONCLUSION

Visits for patients with uncontrolled HTN rarely result in treatment intensification. Substantial opportunity exists to improve management of HTN, particularly for patients on fewer medications or seen by a covering provider.

Comparison of the Omron HeartGuide to the Welch Allyn ProBP 3400 blood pressure monitor

Hypertension affects approximately 100 million U.S. adults and is the leading single contributing risk factor to all-cause mortality. Accurate blood pressure (BP) measurement is essential in the treatment of BP, and a number of devices exist for monitoring. Recently, a new watch-type design was released, the Omron HeartGuide (BP8000), with claims to provide clinically accurate BP measurement while also tracking activity and sleep similar to smart watches. The aim of this research was done in two studies: (1) evaluation of the HeartGuide device for measurement of resting BP and heart rate (HR); and (2) assessment of the HeartGuide for BP, HR, step-counting and sleep monitoring during activities of daily living. Study 1 compared the Omron HeartGuide to the previously validated Welch Allyn ProBP 3400 following a modified version of the Universal Standard for validation of BP measuring devices set by the AAMI/ESH/ISO. While resting HR measured by the HeartGuide was similar to Welch Allyn measures, both systolic and diastolic BP were significantly lower ( P ≤0.001), with differences of 10.4 (11.1) and 3.2 (10.0) mmHg, respectively. Study 2 compared HeartGuide measures to Welch Allyn measures for BP, HR, steps and sleep during various body positions (supine, seated, standing), physiological stressors (cold pressor test, lower body submersion, exercise), and free-living. The HeartGuide significantly underestimated BP though provided accurate HR during most conditions. It also significantly underestimated steps, but reported sleep measures similar to those subjectively reported. Based on the significant differences between the HeartGuide and Welch Allyn, our data indicate the HeartGuide is not a suitable replacement for existing BP monitors.

Access to routine health care and awareness of hypertension status among adults: Results from the National Health and Nutrition Examination Survey, 2011-2018

INTRODUCTION

Hypertension is a growing pandemic affecting over 1 billion people worldwide; about 46% of people with hypertension are unaware.

METHOD

Data from the National Health and Nutrition Examination Survey (NHANES) 2011-2018 were analyzed to assess the relationship between access to a routine place of care and undiagnosed hypertension in adults aged 18 to 64 years old. We defined undiagnosed hypertension as those meeting the 2017 American Heart Association's guidelines for stage 1 or 2 hypertension who reported not being told by their healthcare provider that they had hypertension. We used a multivariable Poisson regression model to assess the relationship between access to a routine place of care and undiagnosed hypertension.

RESULT

The final analytic sample was 5345 hypertensive American adults, with 56% unaware of their status. The results indicate that lack of awareness of hypertension status was highest among those without a routine place of care [PR = 1.20, CI = (1.12-1.29), p < 0.001] compared to those with access to a routine place of care, after adjustment for sociodemographic and clinical characteristics.

CONCLUSION

Access to a routine place of care in a non-emergency department setting is essential to reduce the rate of undiagnosed hypertension among American adults. Policymakers should implement policies to address the shortage of primary care providers and increase access to a routine place of care.

Pharmacist-led rapid medication titration for hypertension management by telehealth: A quality improvement initiative

Hypertension guidelines recommend team-based care for the treatment of high blood pressure (BP). Clinical pharmacists can help patients get to goal BP with rapid medication titration in conjunction with telehealth visits. We conducted a pharmacist-led home BP monitoring pilot program from June 2020 to September 2021. Forty-two patients with a SBP ≥140 despite using ≤2 antihypertensive medications were referred for pharmacist telehealth with expedited medication titration to achieve a BP goal <130/80. The mean enrollment SBP/DBP was 155.2 (SD, 15.8)/89.7 (SD, 11.5) mm Hg, and the mean completion SBP/DBP was 132.1 (SD, 10.9)/77.6 (SD, 10). The number of hypertension medications prescribed increased from 1.3 to 1.6 with no instances of falls or hypotension. At completion, 31% of patients had an automated office blood pressure (AOBP) with SBP <130 mm Hg and DBP <80 mm Hg. A pharmacist-led, home BP monitoring telehealth pilot program helped patients safely achieve BP goals.

Gender differences in the association between healthy eating index-2015 and hypertension in the US population: evidence from NHANES 1999-2018

BACKGROUND

Diet has long been recognized as an important modifiable risk factor for hypertension. Herein, our research goal was to decipher the association of healthy eating index-2015 (HEI-2015) with hypertension, and to explore potential gender differences.

METHODS

We collected the cross-sectional data of 42,391 participants of the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The association of HEI-2015 with hypertension was estimated using weighted multivariate logistic regression, with restricted cubic spline (RCS) regression being adopted to examine the nonlinearity of this association in both genders, and the stability of the results were examined by sensitivity analysis. We also performed subgroup analysis to detect potential difference in the link between HEI-2015 and hypertension stratified by several confounding factors.

RESULTS

After eliminating potential confounding bias, the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for hypertension across higher HEI-2015 quartiles were 0.93 (0.85-1.03), 0.84 (0.77-0.93), and 0.78 (0.72-0.86) compared to the lowest quartile, respectively. HEI-2015 was nonlinearly and inversely associated with hypertension in all participants. The gender-specific RCS curves presented a U-shaped correlation in males, while showed a linear and inverse correlation in females. Besides, subgroup analyses showed a lower risk of hypertension in participants who were females, younger than 40 years, Whites, obese, and diabetic patients.

CONCLUSIONS

We determined a nonlinear and inverse association between HEI-2015 and hypertension in the US general population, and revealed a remarkable gender difference when adhering to a HEI-2015 diet for preventing hypertension.

Association of non-alcoholic fatty liver disease with self-reported osteoarthritis among the US adults

BACKGROUND

The association between non-alcoholic fatty liver disease (NAFLD) and osteoarthritis (OA) has not been well elucidated. The aim of the present study was to investigate the association between NAFLD and OA in the US adults.

METHODS

A cross-sectional study was performed on participants in the 2017-2018 National Health and Nutrition Examination Survey (NHANES) cycle. NAFLD was defined by the vibration-controlled transient elastography. The diagnosis of OA was based on self-reported data. Weighted multiple logistic regression models and stratified analyses were performed to explore the relationship and verify the stability of the conclusions. Sensitivity analysis using multiple imputation for missing data and propensity score matching (PSM) were performed.

RESULTS

In total, 2622 participants [Male: 1260 (47.8%)] were included in this study with a mean age of 48.1 years old (95% CI, 46.6-49.6 years old), containing 317 (12.8%) OA patients and 1140 NAFLD patients (41.5%). A logistic regression indicated a significant association between NAFLD and OA without adjustment [odds ratio (OR) = 2.05; 95% CI, 1.52-2.78]. The association remained stable after adjustment for covariates (OR = 1.72; 95% CI, 1.26-2.34). Sensitivity analysis of missing data with multiple interpolation and PSM found similar results. A significant and consistent association of NAFLD with OA was still observed in each subgroup stratified by age and metabolic syndrome (MetS). Stratified by sex, obesity, and sensitivity c-reactive protein (hs-CRP) category, a statistically significant association was only shown in females, those without obesity, and those without hyper hs-CRP. The results illustrated that the relationship between NAFLD and OA was stable in all subgroups and had no interaction.

CONCLUSIONS

NAFLD was positively correlated with OA. Given the current pandemic of NAFLD and OA, clinicians should screen for NAFLD in arthritis patients and intervene early.

Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application

BACKGROUND

High blood pressure affects approximately 116 million adults in the United States. It is the leading risk factor for death and disability across the world. Unfortunately, over the past decade, hypertension control rates have decreased across the United States. Prediction models and clinical studies have shown that reducing clinician inertia alone is sufficient to reach the target of ≥80% blood pressure control. Digital health tools containing evidence-based algorithms that are able to reduce clinician inertia are a good fit for turning the tide in blood pressure control, but careful consideration should be taken in the design process to integrate digital health interventions into the clinical workflow.

METHODS

We describe the development of a provider-facing hypertension management platform. We enumerate key steps of the development process, including needs finding, clinical workflow analysis, treatment algorithm creation, platform design and electronic health record integration. We interviewed and surveyed 5 Stanford clinicians from primary care, cardiology, and their clinical care team members (including nurses, advanced practice providers, medical assistants) to identify needs and break down the steps of clinician workflow analysis. The application design and development stage were aided by a team of approximately 15 specialists in the fields of primary care, hypertension, bioinformatics, and software development.

CONCLUSIONS

Digital monitoring holds immense potential for revolutionizing chronic disease management. Our team developed a hypertension management platform at an academic medical center to address some of the top barriers to adoption and achieving clinical outcomes. The frameworks and processes described in this article may be used for the development of a diverse range of digital health tools in the cardiovascular space.

Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records

IMPORTANCE

Hypertension poses a significant public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal.

OBJECTIVE

This study aims to develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.

DESIGN

We conducted a qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System who had at least two consecutive visits between January 1, 2013, and October 31, 2018.

SETTING

This was a thematic analysis of EHR data to generate a real-world taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension.

PARTICIPANTS

We identified patients with markedly elevated blood pressure ([BP]; defined as at least 2 consecutive readings of BP ≥160/100 mmHg) and no prescription for antihypertensive medication within a 90-day of the 2nd BP elevation (n=4,828). We randomly selected 100 records from the group of all eligible patients for qualitative analysis.

MAIN OUTCOMES AND MEASURES

The scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management.

RESULTS

Thematic saturation was reached after analyzing 100 patient records. Three content domains emerged: clinician-related scenarios (neglect and diffusion of responsibility), patient-related scenarios (patient non-adherence and patient preference), and clinical complexity-related scenarios (diagnostic uncertainty, maintenance of current intervention and competing medical priorities). Through a metareview of literature, we identified several plausible influencing factors, including a lack of protocols and processes that clearly define the roles within the institution to implement guidelines, infrastructure limitations, and clinicians' lack of autonomy and authority, excessive workload, time constraints, clinician belief that intervention was not part of their role, or perception that guidelines restrict clinical judgment.

CONCLUSIONS AND RELEVANCE

This study illuminates reasons for suboptimal adherence to guidelines for managing markedly elevated BP. The taxonomy of suboptimal adherence scenarios, derived from real-world EHR data, is pragmatic and provides a basis for developing targeted interventions to improve clinician guideline adherence and patient outcomes.

Association between dietary inflammatory index and Stroke in the US population: evidence from NHANES 1999-2018

BACKGROUND

There is an increasing awareness that diet-related inflammation may have an impact on the stroke. Herein, our goal was to decipher the association of dietary inflammatory index (DII) with stroke in the US general population.

METHODS

We collected the cross-sectional data of 44,019 participants of the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The association of DII with stroke was estimated using weighted multivariate logistic regression, with its nonlinearity being examined by restricted cubic spline (RCS) regression. The least absolute shrinkage and selection operator (LASSO) regression was applied for identifying key stroke-related dietary factors, which was then included in the establishment of a risk prediction nomogram model, with the receiver operating characteristic (ROC) curve being built to evaluate its discriminatory power for stroke.

RESULTS

After confounder adjustment, the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for stroke across higher DII quartiles were 1.19 (0.94-1.54), 1.46 (1.16-1.84), and 1.87 (1.53-2.29) compared to the lowest quartile, respectively. The RCS curve showed a nonlinear and positive association between DII and stroke. The nomogram model based on key dietary factors identified by LASSO regression displayed a considerable predicative value for stroke, with an area under the curve (AUC) of 79.8% (78.2-80.1%).

CONCLUSIONS

Our study determined a nonlinear and positive association between DII and stroke in the US general population. Given the intrinsic limitations of cross-sectional study design, it is necessary to conduct more research to ensure the causality of such association.

Lost in Translation: Why Are Rates of Hypertension Control Getting Worse Over Time?

Treatment of hypertension to decrease rates of cardiovascular disease is the most well studied and most broadly applicable treatment in cardiovascular prevention. Blood pressure can be measured anywhere, not just in a physician's office; medications are readily available, inexpensive, and have highly favorable benefit/harm ratios with relatively minimal side effects; and stepped medication regimens can be prescribed in algorithmic fashion by a variety of practitioners. Yet overall hypertension control rates in the United States have never exceeded 60%, and the last 5-10 years have seen decreased, rather than increased, rates of control. Here, I describe the scale of this massive failure to deliver on the promise of preventive hypertension care; outline the populations most affected and the contemporaneous events that have impacted hypertension control; discuss the disparate paths of hypertension science and health care delivery; and highlight novel interventions, approaches, and future opportunities to bend the curve back toward improvements in hypertension control.

Targeting the apelin system for the treatment of cardiovascular diseases

Cardiovascular disease is the leading cause of death worldwide. Its prevalence is rising due to ageing populations and the increasing incidence of diseases such as chronic kidney disease, obesity, and diabetes that are associated with elevated cardiovascular risk. Despite currently available treatments, there remains a huge burden of cardiovascular disease-associated morbidity for patients and healthcare systems, and newer treatments are needed. The apelin system, comprising the apelin receptor and its two endogenous ligands apelin and elabela, is a broad regulator of physiology that opposes the actions of the renin-angiotensin and vasopressin systems. Activation of the apelin receptor promotes endothelium-dependent vasodilatation and inotropy, lowers blood pressure, and promotes angiogenesis. The apelin system appears to protect against arrhythmias, inhibits thrombosis, and has broad anti-inflammatory and anti-fibrotic actions. It also promotes aqueous diuresis through direct and indirect (central) effects in the kidney. Thus, the apelin system offers therapeutic promise for a range of cardiovascular, kidney, and metabolic diseases. This review will discuss current cardiovascular disease targets of the apelin system and future clinical utility of apelin receptor agonism.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

Background

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs.

Methods

We used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented.

Results

Controlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur.

Conclusions

As only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.

Effect of Acute and Chronic Ingestion of Exogenous Ketone Supplements on Blood Pressure: A Systematic Review and Meta-Analysis

Exogenous ketone supplements have been suggested to have potential cardiovascular benefits, but their overall effect on blood pressure is unclear. Our objective was to perform a systematic review and meta-analysis on the effects of exogenous ketone supplements on blood pressure (BP) and concomitant changes in resting heart rate (HR). Five databases were searched on January 27th, 2023, for randomized and non-randomized studies. A random-effects model meta-analysis was performed including all studies jointly and separately for acute and chronic ingestion of ketone supplements. Out of 4012 studies identified in the search, 4 acute and 6 chronic studies with n = 187 participants were included. Pooled results (n = 10) showed no change in systolic (SMD [95% CI]= -0.14 [-0.40; 0.11]; I2= 30%; p = 0.17) or diastolic BP (-0.12 [-0.30; 0.05]; I2= 0%; p = 0.69), with a potential tendency observed toward increased resting heart rate (0.17 [-0.14; 0.47]; I2= 40%; p = 0.10). Similar results for systolic and diastolic BP were observed when assessing separately the effect of acute and chronic ingestion of ketone supplements (p ≥ 0.33). Supplement dosage was found to modulate the increase in resting heart rate (0.019 ± 0.006; p = 0.013; R2=100%), suggesting that higher supplement doses lead to a higher resting heart rate. Based on currently available data, acute or prolonged ingestion of ketone supplements does not seem to modulate BP. However, a tendency for HR to increase after acute ingestion was observed, particularly with higher doses. Higher quality studies with appropriate standardized measurements are needed to confirm these results.

Cardiometabolic and renal phenotypes and transitions in the United States population

Cardiovascular and renal conditions have both shared and distinct determinants. In this study, we applied unsupervised clustering to multiple rounds of the National Health and Nutrition Examination Survey from 1988 to 2018, and identified 10 cardiometabolic and renal phenotypes. These included a 'low risk' phenotype; two groups with average risk factor levels but different heights; one group with low body-mass index and high levels of high-density lipoprotein cholesterol; five phenotypes with high levels of one or two related risk factors ('high heart rate', 'high cholesterol', 'high blood pressure', 'severe obesity' and 'severe hyperglycemia'); and one phenotype with low diastolic blood pressure (DBP) and low estimated glomerular filtration rate (eGFR). Prevalence of the 'high blood pressure' and 'high cholesterol' phenotypes decreased over time, contrasted by a rise in the 'severe obesity' and 'low DBP, low eGFR' phenotypes. The cardiometabolic and renal traits of the US population have shifted from phenotypes with high blood pressure and cholesterol toward poor kidney function, hyperglycemia and severe obesity.

Automated Messaging Program to Facilitate Systematic Home Blood Pressure Monitoring: Qualitative Analysis of Provider Interviews

BACKGROUND

Hypertension is a leading cause of cardiovascular and kidney disease in the United States, yet blood pressure (BP) control at a population level is poor and worsening. Systematic home BP monitoring (HBPM) programs can lower BP, but programs supporting HBPM are not routinely used. The MyBP program deploys automated bidirectional text messaging for HBPM and disease self-management support.

OBJECTIVE

We aim to produce a qualitative analysis of input from providers and staff regarding implementation of an innovative HBPM program in primary care practices.

METHODS

Semistructured interviews (average length 31 minutes) were conducted with physicians (n=11), nurses, and medical assistants (n=6) from primary care settings. The interview assessed multiple constructs in the Consolidated Framework for Implementation Research domains of intervention characteristics, outer setting, inner setting, and characteristics of individuals. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes, followed by mapping to the updated Consolidated Framework for Implementation Research constructs.

RESULTS

Health care providers reported that MyBP has good ease of use and was likely to engage patients in managing their high BP. They also felt that it would directly support systematic BP monitoring and habit formation in the convenience of the patient's home. This could increase health literacy and generate concrete feedback to raise the day-to-day salience of BP control. Providers expressed concern that the cost of BP devices remains an encumbrance. Some patients were felt to have overriding social or emotional barriers, or lack the needed technical skills to interact with the program, use good measurement technique, and input readings accurately. With respect to effects on their medical practice, providers felt MyBP would improve the accuracy and frequency of HBPM data, and thereby improve diagnosis and treatment management. The program may positively affect the patient-provider relationship by increasing rapport and bidirectional accountability. Providers appreciated receiving aggregated HBPM data to increase their own efficiency but also expressed concern about timely routing of incoming HBPM reports, lack of true integration with the electronic health record, and the need for a dedicated and trained staff member.

CONCLUSIONS

In this qualitative analysis, health care providers perceived strong relative advantages of using MyBP to support patients. The identified barriers suggest the need for corrective implementation strategies to support providers in adopting the program into routine primary care practice, such as integration into the workflow and provider education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03650166; https://tinyurl.com/bduwn6r4.

Association between the serum vitamin D level and prevalence of obesity/abdominal obesity in women with infertility: a cross-sectional study of the National Health and Nutrition Examination Survey data

AIMS

To explore the relationship between vitamin D and obesity and abdominal obesity in women with infertility.

MATERIAL AND METHODS

We screened the data from National Health and Nutrition Examination Survey (NHANES) 2013-2016. A total of 201 infertile women between the ages of 20 and 40 years were included in our study. To estimate the independent association of vitamin D with obesity and abdominal obesity, we used weighted multivariate logistic regression models and cubic spline analyses.

RESULTS

Among infertile women in the NHANES 2013-2016 database, serum vitamin D levels were significantly and negatively associated with body mass index (ß= -0.96, 95% CI: -1.40, -0.51, p < 0.001)and waist circumference (ß= -0.40, 95% CI: -0.59, -0.22, p < 0.001), respectively. After multivariable adjustment, lower vitamin D levels were found to be associated with a higher prevalence of obesity (OR: 8.290, 95% CI: 2.451-28.039, p for trend = 0.001) and abdominal obesity (OR: 4.820, 95%CI: 1.351-17.194, p for trend =0.037). Spline regression showed linearity of the associations between vitamin D and obesity/abdominal obesity (p for nonlinearity > 0.05).

CONCLUSION

Our findings suggested that a decreased vitamin D might correspond to a higher prevalence of obesity in infertile women, which reminded us to pay more attention to the supplement of vitamin D in obese infertile women.

Novel approaches: targeting sympathetic outflow in the carotid sinus

Uncontrolled hypertension drives the global burden of increased cardiovascular disease (CVD) morbidity and mortality. Although high blood pressure (BP) is treatable and preventable, only half of the patients with hypertension undergoing treatment have their BP controlled. The failure of polypharmacy to attain adequate BP control may be due to a lack of physiological response, however, medication non-adherence and clinician inertia to increase treatment intensity are critical factors associated with poor hypertension management. The long-time medication titration, lifelong drug therapy, and often multi-drug treatment strategy are frustrating when the BP goal is not achieved, leading to increased CVD risk and a substantial burden on the healthcare system. Growing evidence indicates that neurohumoral activation is critical in initiating and maintaining elevated BP and its adverse consequences. Over the past decades, device-based therapies targeting the mechanisms underlying hypertension pathophysiology have been extensively studied. Among these, robust clinical experience for hypertension management exists for renal denervation (RDN) and baroreflex activation therapy (BAT), carotid body denervation (CBD), central arteriovenous anastomosis, and to a lesser extent, deep brain stimulation. Future studies are warranted to define the role of device-based approaches as an alternative or adjunctive treatment option to treat hypertension.

Efficacy and safety of community-based moxibustion for primary hypertension: A randomized controlled trial with patient preference arms

Moxibustion has been shown to have a potential antihypertensive effect, but its applicability for the primary care of hypertension is unclear. The authors conducted a multicenter randomized controlled trial (RCT) with patient preference arms to investigate the effect, safety, cost-effectiveness, and compliance of moxibustion in community patients with hypertension. Patients with primary hypertension were enrolled from seven communities randomly or nonrandomly assigned to receive self-administered moxibustion + the original hypertensive regimen or the original hypertensive regimen alone for 6 months. The authors mainly evaluated the effects of moxibustion on hypertensive outcomes and adverse events. As a result, a total of 160 and 240 patients were recruited into the randomized and nonrandomized arms, respectively, with 87.5% completing the follow-up. At month 6, there was a significantly greater reduction in systolic blood pressure (SBP) (difference: -10.57 mmHg), a higher proportion of responders (82.2% vs. 53.7%; odds ratio 4.00), and better improvements in hypertensive symptoms and quality of life (QoL) in the moxibustion group than in the control group in the randomized population, but there was no significant between-group difference in diastolic blood pressure (DBP). The nonrandomized findings showed the same effect direction for all outcomes, except for DBP. All moxibustion-related adverse events were mild. In conclusion, moxibustion can reduce SBP and improve hypertensive symptoms and QoL in community patients with hypertension, with good safety and low cost, although its effect on DBP remains uncertain. The findings suggest that moxibustion may be an appropriate technique for community primary care of hypertension.

Analysis of prescription status of antihypertensive drugs in Chinese patients with hypertension based on real-world study

BACKGROUND

Globally, the prevalence of hypertension and the accompanying burden of cardiovascular disease are increasing. Through drug utilization research, we can understand the prescription status of hypertension patients and promote rational drug use. The purpose of this retrospective study was to describe the current prescription pattern of antihypertensive drugs in Chinese patients and determine the compliance level of treatment guidelines.

MATERIALS AND METHODS

Around 11.1 million patients who received a prescription for antihypertensive therapy between January 2021 to December 2021 were obtained from a database of Hangzhou Kang Sheng Health Consulting CO., Ltd.

RESULTS

The mean age of hypertensive patients was 54.75 ± 12.98 years. About 6.7 million (60.30%) were males. About 46.07% of patients had comorbidities. The most common classes of antihypertensive medications used were calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs). Around 78.33% of participants were on monotherapy. Diuretics + ARBs and Diuretics + CCBs + ARBs were the most commonly prescribed pattern in two-drug combination therapy and three-drug combination therapy, respectively.

CONCLUSIONS

CCBs and ARBs were the two most frequently prescribed for patients with hypertension. The prescription pattern of antihypertensive medications in the study largely complied with recommended Chinese hypertension guidelines.Key messagesCardiovascular disease is the most common complication of hypertension.Calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs) are the two most commonly used drugs for hypertension patients in China.The proportion of combination prescription pattern in Chinese hypertensive patients is low.

Process of Engaging Community and Scientific Partners in the Development of the CIRCL-Chicago Study Protocol

Objectives

Hypertension affects 1 in 3 adults in the United States and disproportionately affects African Americans. Kaiser Permanente demonstrated that a "bundle" of evidence-based interventions significantly increased blood pressure control rates. This paper describes a multiyear process of developing the protocol for a trial of the Kaiser bundle for implementation in under-resourced urban communities experiencing cardiovascular health disparities during the planning phase of this biphasic award (UG3/UH3).

Methods

The protocol was developed by a collaboration of faith-based community members, representatives from community health center practice-based research networks, and academic scientists with expertise in health disparities, implementation science, community-engaged research, social care interventions, and health informatics. Scientists from the National Institutes of Health and the other grantees of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Alliance also contributed to developing our protocol.

Results

The protocol is a hybrid type 3 effectiveness-implementation study using a parallel cluster randomized trial to test the impact of practice facilitation on implementation of the Kaiser bundle in community health centers compared with implementation without facilitation. A central strategy to the Kaiser bundle is to coordinate implementation via faith-based and other community organizations for recruitment and navigation of resources for health-related social risks.

Conclusions

The proposed research has the potential to improve identification, diagnosis, and control of blood pressure among under-resourced communities by connecting community entities and healthcare organizations in new ways. Faith-based organizations are a trusted voice in African American communities that could be instrumental for eliminating disparities.

Planning the Implementation of a Multilevel Blood Pressure Control Intervention in Chicago: Community and Clinical Perspectives

Objectives

Hypertension is associated with high morbidity and mortality. The complications of hypertension disproportionately impact African American residents in Chicago's South Side neighborhood. To inform the implementation of an evidence-based multilevel hypertension management intervention, we sought to identify community member- and clinician-level barriers to diagnosing and treating hypertension, and strategies for addressing those barriers.

Methods

We conducted 5 focus groups with members of faith-based organizations (FBOs) (n=40) and 8 focus groups with clinicians and administrators (n=26) employed by community health centers (CHCs) located in Chicago's South Side.

Results

Participants across groups identified the physical environment, including lack of access to clinics and healthy food, as a risk factor for hypertension. Participants also identified inconsistent results from home blood pressure monitoring and medication side effects as barriers to seeking diagnosis and treatment. Potential strategies raised by participants to address these barriers included (1) addressing patients' unmet social needs, such as food security and transportation; (2) offering education that meaningfully engages patients in discussions about managing hypertension (eg, medication adherence, diet, follow-up care); (3) coordinating referrals via community-based organizations (including FBOs) to CHCs for hypertension management; and (4) establishing a setting where community members managing hypertension diagnosis can support one another.

Conclusions

Clinic-level barriers to the diagnosis and treatment of hypertension, such as competing priorities and resource constraints, are exacerbated by community-level stressors. Community members and clinicians agreed that it is important to select implementation strategies that leverage and enhance both community- and clinic-based resources.

Target: BP™: A National Initiative to Improve Blood Pressure Control

TARGET

BP™ is a national initiative launched by the American Heart Association and the American Medical Association in 2017 in response to the high prevalence of uncontrolled blood pressure (BP) in the United States.

TARGET

BP™ provides support to health care organizations and health care teams, with no user fees, to improve the quality of care for adults with hypertension by providing education and resources and recognizing organizations committed to prioritizing and reporting their rate of BP control. Through Target: BP™, the American Heart Association and the American Medical Association also collaborate to align policy with evidence through federal, state, and institutional policy advocacy and raise public awareness through media campaigns. In 2022, Target: BP™ recognized 1309 health care organizations serving 8.4 million patients with hypertension for prioritizing BP control, 675 of which affirmed performance of evidence-based BP measurement activities and 551 of which reported BP control rates ≥70%. With the proportion of US adults with controlled BP falling to 48.2% from 2017 to 2020, Target: BP™ remains focused on regaining lost ground in national BP control rates by emphasizing accurate BP measurement, rapid treatment intensification, healthful lifestyle changes, and evidence-based use of self-measured BP monitoring.

TARGET

BP™ also emphasizes adoption of team-based care models and prioritizing equitable health outcomes. More than 1.37 million unique users have visited https://targetbp.org/ and downloaded 98 341 Target: BP™ resources from 2017 to 2022.

Blood pressure outcomes at 12 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

Remote patient monitoring (RPM) for hypertension enables automatic transmission of blood pressure (BP) and pulse into the electronic health record (EHR), but its effectiveness in primary care is unknown. This pragmatic matched cohort study using EHR data compared BP outcomes between individuals prescribed RPM and temporally-matched controls from six primary care practices. We retrospectively created a cohort of 288 Medicare-enrolled patients prescribed BP RPM (cases) and 1152 propensity score-matched controls (1:4). Matching was based on age, sex, systolic blood pressure (SBP), marital status, and other characteristics. Outcomes at 3, 6, 9 and 12 months were: controlling high BP (most recent BP < 140/90 mm Hg), antihypertensive medication intensification, and most recent SBP assessed using: all measurements, and office measurements only. At baseline, RPM-prescribed patients and controls had similar ages and systolic BP. BP control diverged at 3 months (RPM: 72.2%, control: 51%, p < 0.001). This difference persisted but decreased over follow-up. After 12 months, the RPM-prescribed cohort had greater BP control (RPM: 71.5%, control: 58.1%, p < 0.001) and lower SBP (132.3 versus 136.5 mm Hg, p = 0.003) using all measurements, but they did not differ using only office measurements (12 month BP control: 60.8% versus 58.1%, p = 0.44; SBP: 135.9 versus 136.5 mm Hg, p = 0.91). At 12 months, the most recent BP measurements were more current for RPM-prescribed patients (median [IQR] 8 [0-109] versus 134 [56-239] days). Net increases in antihypertensive medications by 12 months were similar. Implementation of RPM in primary care could inform hypertension management strategies and increase hypertension control. Registration: ClinicalTrials.gov identifier: NCT05562921.

Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019

BACKGROUND

Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD.

METHODS

We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m2 or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications.

RESULTS

The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% (P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased.

CONCLUSIONS

Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.

Prevalence and Factors Associated with Prehypertension and Hypertension Among Adults: Baseline Findings of PURE Malaysia Cohort Study

Background

Although prehypertension and hypertension can be detected at the primary healthcare level and low-cost treatments can effectively control its complications, hypertension is still the world's leading preventable risk factor. Therefore, the present study aimed to determine its prevalence and its risk factors among Malaysian adults.

Methods

A cross-sectional study involving 7585 adults was performed covering the rural and urban areas. Respondents with systolic blood pressure (SBP) of 120-139 mmHg and/or diastolic blood pressure (DBP) of 80-89 mmHg were categorized as prehypertensive, and hypertensive categorization was used for respondents with an SBP of ≥140 mmHg and/or DBP of ≥90 mmHg.

Results

Respondents reported to have prehypertension and hypertension were 40.7% and 38.0%, respectively. Those residing in a rural area, older age, male, family history of hypertension, and overweight or obese were associated with higher odds of prehypertension and hypertension. Unique to hypertension, the factors included low educational level (AOR: 1.349; 95% CI: 1.146, 1.588), unemployment (1.350; 1.16, 1.572), comorbidity of diabetes (1.474; 1.178, 1.844), and inadequate fruit consumption (1.253; 1.094, 1.436).

Conclusions

As the prehypertensive state may affect the prevalence of hypertension, proactive strategies are needed to increase early detection of the disease among specific group of those residing in a rural area, older age, male, family history of hypertension, and overweight or obese.

Cardiovascular Health of Middle-Aged U.S. Adults by Income Level, 1999 to March 2020 : A Serial Cross-Sectional Study

BACKGROUND

Although cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown.

OBJECTIVE

To evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health.

DESIGN

Serial cross-sectional study.

SETTING

NHANES (National Health and Nutrition Examination Survey), 1999 to March 2020.

PARTICIPANTS

Middle-aged adults (aged 40 to 64 years).

MEASUREMENTS

Age-standardized prevalence of hypertension, diabetes, hyperlipidemia, obesity, and cigarette use; treatment rates for hypertension, diabetes, and hyperlipidemia; and rates of blood pressure, glycemic, and cholesterol control.

RESULTS

The study population included 20 761 middle-aged adults. The prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults had an increase in hypertension over the study period (37.2% [95% CI, 33.5% to 40.9%] to 44.7% [CI, 39.8% to 49.5%]) but no changes in diabetes or obesity. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes (7.8% [CI, 5.0% to 10.6%] to 14.9% [CI, 12.4% to 17.3%]) and obesity (33.0% [CI, 26.7% to 39.4%] to 44.0% [CI, 40.2% to 47.7%]). Cigarette use was high and stagnant among low-income adults (33.2% [CI, 28.4% to 38.0%] to 33.9% [CI, 29.6% to 38.3%]) but decreased among their higher-income counterparts (18.6% [CI, 13.5% to 23.7%] to 11.5% [CI, 8.7% to 14.3%]). Treatment and control rates for hypertension were unchanged in both groups (>80%), whereas diabetes treatment rates improved only among the higher-income group (58.4% [CI, 44.4% to 72.5%] to 77.4% [CI, 67.6% to 87.1%]). Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity.

LIMITATION

Sample size limitations could preclude detection of small changes in treatment and control rates.

CONCLUSION

Over 2 decades in the United States, hypertension increased in low-income middle-aged adults, whereas diabetes and obesity increased in their higher-income counterparts. Income-based disparities in hypertension, diabetes, and smoking persisted even after adjustment for other social determinants of health.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Life's essential eight as targets for cardiometabolic risk reduction among non-Hispanic black adults: A primary care approach

Cardiovascular diseases remain the leading cause of death in the United States. Several studies have shown racial disparities in the cardiovascular outcomes. When compared to their Non-Hispanic White (NHW) counterparts, non-Hispanic Black (NHB) individuals have higher prevalence of cardiovascular risk factors and thus, increased mortality from atherosclerotic cardiovascular diseases. This is evidenced by lower scoring in the indices of the American Heart Association's Life Essential 8 among NHB individuals. NHB individuals score lower in blood pressure, blood lipids, nicotine exposure, sleep, physical activity level, glycemic control, weight, and diet when compared to NHW individuals. Measures to improve these indices at the primary care level may potentially hold the key in mitigating the health care disparities in cardiovascular health experienced by NHB individuals.

Manpower cost for a hypertension health campaign: A cross-sectional study

Introduction

The overall prevalence of hypertension is high, and many people are unaware of their condition. Screening campaigns can effectively identify this group of patients. The study aimed to determine the cost of manpower for a health campaign for detecting undiagnosed hypertension and the prevalence of hypertension.

Method

This cross-sectional study was conducted at two health centres. Sociodemographic characteristics, hypertension and treatment statuses were recorded. Blood pressure (BP) was measured by either doctors or nurses using automated BP machines. The cost of manpower was calculated as the average salaries of manpower during the 3-day health campaign divided by the total number of days. The final sum was the cost of detecting undiagnosed hypertension.

Results

A total of 2009 participants median age = 50 (IQR = 18-91) were included in the study. The overall prevalence of hypertension was 41.4% (n=832). Among the patients with hypertension, 49.2% (n=409) were unaware of their hypertension status. Conversely, 21.1% (n=423) were known to have hypertension, among whom 97.4% (n=412) were on medications. Among those who were on medications, 49% (n=202) had good BP control. The average total cost of manpower during the 3-day health campaign was RM 5019.80 (USD 1059). The cost of detecting an individual with elevated BP was RM 12.27 (USD 2.59).

Conclusion

The prevalence of hypertension and unawareness is high. However, the average cost of manpower to detect an individual with elevated BP is low. Therefore, regular public health campaigns aiming to detect undiagnosed hypertension are recommended.

Association between insulin resistance and uncontrolled hypertension and arterial stiffness among US adults: a population-based study

BACKGROUND

Prior research has established the correlation between insulin resistance (IR) and hypertension. While the association between triglyceride-glucose (TyG) index, a reliable surrogate marker of IR, and uncontrolled hypertension as well as arterial stiffness among individuals with hypertension remains undisclosed.

METHODS

In this study, a total of 8513 adults diagnosed with hypertension from the National Health and Nutrition Examination Survey 1999-2018 were included. The primary outcome of the study are arterial stiffness (represented with estimated pulse wave velocity, ePWV) and uncontrolled hypertension. Logistic regression model, subgroup analysis, restricted cubic spine, and smooth curve fitting curve were conducted to evaluate the association between the IR indicators and uncontrolled hypertension and arterial stiffness in individuals with hypertension.

RESULTS

Among included participants, the overall prevalence of uncontrolled hypertension was 54.3%. After adjusting for all potential covariates, compared with the first quartile of TyG index, the risk of uncontrolled hypertension increased about 28% and 49% for participants in the third quartile (OR, 1.28; 95% CI 1.06-1.52) and the fourth quartile (OR, 1.49; 95% CI 1.21-1.89) of TyG index, respectively. The higher OR of TyG index was observed in participants taking antihypertensive medication [fourth quartile versus first quartile (OR, 2.03; 95% CI 1.37-3.11)]. Meanwhile, we explored the potential association between TyG index and arterial stiffness and found that TyG index was significantly associated with increased arterial stiffness (β for ePWV, 0.04; 95% CI 0.00-0.08; P = 0.039). However, traditional IR indicator HOMA-IR showed no significant positive correlation to uncontrolled hypertension as well as arterial stiffness in US adults with hypertension.

CONCLUSION

Elevated levels of the TyG index were positive associated with prevalence of uncontrolled hypertension and arterial stiffness among US adults with hypertension.

Cost-effectiveness analysis of initial treatment with single-pill combination antihypertensive medications

Hypertension guidelines recommend initiating treatment with single pill combination (SPC) antihypertensive medications, but SPCs are used by only one-third of treated hypertensive US adults. This analysis estimated the cost-effectiveness of initial treatment with SPC dual antihypertensive medications compared with usual care monotherapy in hypertensive US adults.The validated BP Control Model-Cardiovascular Disease (CVD) Policy Model simulated initial SPC dual therapy (two half-standard doses in a single pill) compared with initial usual care monotherapy (half-standard dose when baseline systolic BP < 20 mmHg above goal and one standard dose when ≥20 mmHg above goal). Secondary analyses examined equivalent dose monotherapy (one standard dose) and equivalent dose dual therapy as separate pills (two half-standard doses). The primary outcomes were direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) over 10 years from a US healthcare sector perspective.At 10 years, initial dual drug SPC was projected to yield 0.028 (95%UI 0.008 to 0.051) more QALYs at no greater cost ($73, 95%UI -$1 983 to $1 629) than usual care monotherapy. In secondary analysis, SPC dual therapy was cost-effective vs. equivalent dose monotherapy (ICER $8 000/QALY gained) and equivalent dose dual therapy as separate pills (ICER $57 000/QALY gained). At average drug prices, initiating antihypertensive treatment with SPC dual therapy is more effective at no greater cost than usual care initial monotherapy and has the potential to improve BP control rates and reduce the burden of CVD in the US.

Transforming blood pressure control in primary care through a novel remote decision support strategy based on wearable blood pressure monitoring: The NEXTGEN-BP randomized trial protocol

BACKGROUND

Despite high blood pressure being the leading preventable risk factor for death, only 1 in 3 patients achieve target blood pressure control. Key contributors to this problem are clinical inertia and uncertainties in relying on clinic blood pressure measurements to make treatment decisions.

METHODS

The NEXTGEN-BP open-label, multicenter, randomized controlled trial will investigate the efficacy, safety, acceptability and cost-effectiveness of a wearable blood pressure monitor-based care strategy for the treatment of hypertension, compared to usual care, in lowering clinic blood pressure over 12 months. NEXTGEN-BP will enroll 600 adults with high blood pressure, treated with 0 to 2 antihypertensive medications. Participants attending primary care practices in Australia will be randomized 1:1 to the intervention of a wearable-based remote care strategy or to usual care. Participants in the intervention arm will undergo continuous blood pressure monitoring using a wrist-wearable cuffless device (Aktiia, Switzerland) and participate in 2 telehealth consultations with their primary care practitioner (general practitioner [GP]) at months 1 and 2. Antihypertensive medication will be up-titrated by the primary care practitioner at the time of telehealth consults should the percentage of daytime blood pressure at target over the past week be <90%, if clinically tolerated. Participants in the usual care arm will have primary care consultations according to usual practice. The primary outcome is the difference between intervention and control in change in clinic systolic blood pressure from baseline to 12 months. Secondary outcomes will be assessed at month 3 and month 12, and include acceptability to patients and practitioners, cost-effectiveness, safety, medication adherence and patient engagement.

CONCLUSIONS

NEXTGEN-BP will provide evidence for the effectiveness and safety of a new paradigm of wearable cuffless monitoring in the management of high blood pressure in primary care.

TRIAL REGISTRATION

ACTRN12622001583730.

Racial Disparities in Utilization of Emergency Medical Services and Related Impact on Poststroke Disability

BACKGROUND

Prompt seeking of emergency medical services (EMS) assistance at stroke onset is critical to minimize poststroke disability.

OBJECTIVE

The aim was to study how racial differences in EMS decision-relevant factors and EMS use impact stroke care and disability outcomes.

DESIGN

A prospective observational study.

PARTICIPANTS

A total of 1168 acute ischemic stroke patients discharged from April 2016 to October 2017 at a safety net hospital were included; 108 patients were surveyed before discharge.

MEASURES

(1) Prehospital delay: EMS use, timely hospital arrival; (2) Stroke care: alteplase receipt and inpatient rehab; (3) Outcomes: Functional improvement at discharge (admission minus discharge scores on National Institutes of Health Stroke Scale), 90-day modified Rankin Scale; (4) EMS decision-relevant factors: Stroke symptom knowledge, source of knowledge, unfavorable past EMS/care experiences, and financial barriers to EMS use.

RESULTS

Despite more Black patients using EMS than Whites/Asians (56% vs. 48%, P =0.003), their timely hospital arrival was 30% less likely. Adjusted for stroke severity, receipt of alteplase, and inpatient rehab were similar, but Black patients fared worse on functional improvement at discharge (among severe strokes, 2.4 National Institutes of Health Stroke Scale points less improvement, P <0.01), and on functional normalcy at 90 days (modified Rankin Scale score 0-1 being 60% less likely across severity categories) ( P <0.01). Fewer Black patients knew any stroke symptoms before the stroke (72% vs. 87%, P =0.03), and fewer learned about stroke from providers ( P =0.01). Financial barriers and provider mistrust were similar.

CONCLUSIONS

Black patients had less knowledge of stroke symptoms, more care-seeking delay, and poorer outcomes. Including stroke education as a standard of chronic disease care may mitigate stroke outcome disparities.

Defining Meaningful Change in Antihypertensive Medication Adherence in Adults with Established Hypertension: Implications for Clinical Practice

Uncontrolled hypertension and low antihypertensive medication adherence remain significant clinical challenges. There is a critical need to detect meaningful change in adherence in clinical settings. The authors determined that a ≥2-point change in the 4-item Krousel-Wood Medication Adherence Scale score represents meaningful change in antihypertensive medication adherence. Among a sample of participants in an ongoing clinical trial, 5.9% experienced a decline in adherence, which was associated with higher blood pressure (BP) and a higher prevalence of uncontrolled BP at 6 months. Meaningful change in medication adherence behavior may be key in managing hypertension to improve BP control and health outcomes.

Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States

Importance

Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear.

Objective

To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US.

Design, Setting, and Participants

This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023.

Main Outcomes and Measures

Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts.

Results

Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years.

Conclusion and Relevance

These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.

Trends in exercise for hypertension: a bibliometric analysis

Objective

To investigate development trends and research hotspots of exercise for hypertension research and provide researchers with fresh perspectives for further studies.

Materials and methods

Articles and reviews regarding exercise and hypertension spanning May 1st 2003 to May 18th 2023 were retrieved from the Web of Science Core Collection (WOSCC) database. VOSviewer and Citespace were mainly used to perform and visualize co-authorship, co-citation, and co-occurrence analysis of countries, institutions, authors, references and keywords in this field.

Results

A total of 1,643 peer-reviewed papers were identified, displaying a consistent increasing trend over time. The most prolific country and institution were Brazil and University of Sao Paulo, respectively. And we identified the most productive author was lrigoyen, Maria Claudia C, while Pescatello Linda S was the most co-cited author. Journal of hypertension was the most prominent journal, and Hypertension was the journal which was the most co-cited. And this field can be divided into 3 research themes: exercise interventions for hypertension, age-specific relevance of exercise for hypertension, and the global burden of hypertension and the role of exercise. According to the result of keywords analysis, epidemiological information, types of exercise, target population, mechanism, and study design are significant research areas. "Resistance training", "adults", and "heart rate variability" were identified as the major future research foci.

Conclusions

The findings offer a scientific insight into exercise for hypertension research, presenting researchers with valuable information to understand the current research status, hotspots, and emerging trends for future investigation.

Prevalence of Elevated NT-proBNP and its Prognostic Value by Blood Pressure Treatment and Control

BACKGROUND

The prognostic utility of NT-proBNP in the setting of hypertension has not been well-characterized in the general US adult population.

METHODS

We measured NT-proBNP in stored blood samples collected from participants 1 year or older who participated in the 1999-2004 National Health and Nutrition Examination Survey. In adults 20 years or older without a history of cardiovascular disease, we assessed the prevalence of elevated NT-pro-BNP by blood pressure (BP) treatment and control categories. We examined the extent to which NT-proBNP identifies participants at higher risk for mortality across BP treatment and control categories.

RESULTS

Among US adults without CVD, the prevalence of elevated NT-proBNP (≥125 pg/ml) was 27.2% among those with untreated hypertension, 24.9% among those with treated controlled hypertension, and 43.3% among those with treated uncontrolled hypertension. Over a median follow-up of 17.3 years and after adjusting for demographic and clinical risk factors, US adults with treated controlled hypertension and elevated NT-proBNP had increased risk of all-cause mortality (HR 2.29, 95% CI 1.79, 2.95) and cardiovascular mortality (HR 3.83, 95% CI 2.34, 6.29), compared to adults without hypertension and with low levels of NT-proBNP (<125 pg/ml). Across all levels of SBP and irrespective of antihypertensive medication use, elevated NT-proBNP was associated with an increased risk of mortality, compared to low levels of NT-proBNP.

CONCLUSIONS

Among a general population of adults free of CVD, NT-proBNP can provide additional prognostic information within and across categories of BP. Measurement of NT-proBNP may have potential for clinical use to optimize hypertension treatment.

Does Clinical Decision Support Increase Appropriate Medication Prescribing for Cardiovascular Risk Reduction?

PURPOSE

To assess the impact of a clinical decision support (CDS) system's recommendations on prescribing patterns targeting cardiovascular disease (CVD) when the recommendations are prioritized in order from greatest to least benefit toward overall CVD risk reduction.

METHODS

Secondary analysis of trial data from September 20, 2018, to March 15, 2020, where 70 community health center clinics were cluster-randomized to the CDS intervention (42 clinics; 8 organizations) or control group (28 clinics; 7 organizations). Included patients were medication-naïve and aged 40 to 75 years with ≥1 uncontrolled cardiovascular disease risk factor, with known diabetes or cardiovascular disease, or ≥10% 10-year reversible CVD risk.

RESULTS

Among eligible encounters with 29,771 patients, the probability of prescribing a medication targeting hypertension was greater at intervention clinic encounters when CDS was used (34.9% [95% CI, 31.5 to 38.3]) versus dismissed (29.6% [95% CI, 26.7 to 32.6]; P < .001), but not when compared with control clinic encounters (34.9% [95% CI, 31.1 to 38.7]; P = .998). Prescribing for dyslipidemia was significantly higher at intervention encounters where the CDS system was used (11.3% [95% CI, 9.3 to 13.3]) compared with dismissed (7.7% [95% CI, 6.1 to 9.3]; P = .003) and to control encounters (8.7% [95% CI, 7.0 to 10.4]; P = .044); smoking cessation medication showed a similar pattern. Except for dyslipidemia, prescribing rates increased according to their prioritization.

CONCLUSIONS

Use of this CDS system was associated with significantly higher prescribing targeting most cardiovascular risk factors. These results highlight how displaying prioritized actions to reduce reversible CVD risk could improve risk management.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.

Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States

OBJECTIVES

To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States.

METHODS

We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD).

RESULTS

Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons).

DISCUSSION

The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.

Trends in cardiovascular risk factors control among US adults by glycemic statuses, 2007-2018

AIMS

Understanding the national trends in cardiovascular risk factors control of individuals with prediabetes and diabetes is critical for diabetes prevention and management. Our study aims to estimate how cardiovascular risk factors changed in US adults with different glycemic statuses between 2007-2008 and 2017-2018.

METHODS AND RESULTS

This was a serial cross-sectional study based on the National Health and Nutrition Examination Surveys (between 2007-2008 and 2017-2018 cycle). Non-pregnant American participants aged 20 years or older were included. Cardiovascular risk factors including weight, blood pressure, plasma cholesterol, and smoking by glycemic statuses were estimated. A total of 33 040 American adults were included. From 2007-2008 to 2017-2018, the age-adjusted proportions of individuals who reached weight control (body mass index <30 kg/m2) of both normoglycemia group and prediabetes group had a significant decrease over the study period, while the trend in participants with diabetes was not significant (mean difference: -5.34%, 95% confidence interval: -15.28%, 4.59%; P for trend = 0.298). The age-adjusted means of total cholesterol of all three groups decreased during the study decade (P for trend < 0.010), with participants with diabetes maintaining the lowest level. Individuals with high total cholesterol were more likely to receive statin therapy in the diabetes group. Notably, prediabetes participants had the highest level of total cholesterol and low-density lipoprotein cholesterol and were less likely to achieve lipid control with statin therapy. Sensitivity analysis with the second definition of prediabetes and diabetes resulted in a consistent trend.

CONCLUSIONS

In this nationally representative cross-sectional study, we systematically estimated the cardiovascular risk factors control in American adults and found poor weight control in the normoglycemia and prediabetes group. Despite the significant decrease trend of plasma total cholesterol in all groups, the high cholesterol level in the prediabetes group deserves special concern.