Should African Americans with hypertension be treated differently than non-African Americans?

Engaging Nonphysician Staff in Practice Facilitation-Mediated Quality Improvement to Improve Health Outcomes in Under-Resourced Clinical Practices in New York City

In New York City (NYC), hypertension and high cholesterol disproportionately affect residents with low household income and people of color. The NYC Health Department employed practice facilitation (PF) to help nonphysician staff assume added roles aligned with team-based care. The objective was to improve blood pressure (BP) and cholesterol management in 132 small primary care practices serving mostly patients of color. We categorized practices into higher or lower levels of integrated PF, defined as physicians and nonphysician staff collectively participating in PF. Higher integrated PF was associated with improvements in BP (rate ratio [RR] = 1.09, P-value < .05) and cholesterol management (RR = 1.12, P-value < .01). Nonphysician staff in higher integrated PF practices reported skills enhancement and improved teamwork. Involving nonphysician staff in PF-mediated quality improvement efforts can be an effective strategy to improve health outcomes in small clinical practices serving communities with a higher burden of chronic disease and disproportionately impacted by poverty and structural racism.

Practice Facilitation and Clinical Performance Feedback Using the Electronic Health Record Improved Blood Pressure and Cholesterol Management in Small Primary Care Practices in New York City

Cardiovascular disease (CVD) disproportionately affects people of color and those with lower household income. Improving blood pressure (BP) and cholesterol management for those with or at risk for CVD can improve health outcomes. The New York City Department of Health implemented clinical performance feedback with practice facilitation (PF) in 134 small primary care practices serving on average over 84% persons of color. Facilitators reviewed BP and cholesterol management data on performance dashboards and guided practices to identify and outreach to patients with suboptimal BP and cholesterol management. Despite disruptions from the COVID-19 pandemic, practices demonstrated significant improvements in BP (68%-75%, P < .001) and cholesterol management (72%-78%, P = .01). Prioritizing high-need neighborhoods for impactful resource investment, such as PF and data sharing, may be a promising approach to reducing CVD and hypertension inequities in areas heavily impacted by structural racism.

Recruitment, Retention, and Future Direction for a Heart Health Education and Risk Reduction Intervention Led by Community Health Workers in an African American Majority City

Heart disease is a leading cause of death for African Americans. A community-academic partnership cross-trained community health workers to engage African American adults in a 6-month heart health education and risk reduction intervention. We conducted a one-group feasibility study using a one group (pre-posttest) design. A total of 100 adults were recruited from 27 zip codes in an African American majority city through community-based organizations (46%), churches (36%), and home visits (12%). Ninety-six percent were African American; 55% were female, 39% were male, and 6% were transgender. Their mean age was 44.6 years (SD = 15.9). Ninety-two percent had health insurance. Seventy-six percent of participants averaged blood pressure (BP) readings > 130/80 mmHg. Eleven percent of participants had a 30% or higher probability of developing cardiovascular disease in the next 10 years. Six-month follow-up was completed with 96% of participants. There were statistically significant increases in knowledge and in perception of personal risk for heart disease. However, slightly more participants (n = 77, 80.2%) had BP > 130/80 mmHg. The Community Advisory Group recommended expanding the intervention to 12 months and incorporating telehealth with home BP monitoring. Limited intervention duration did not meet longer term objectives such as better control of high BP and sharing risk reduction planning with primary care providers.

The High Blood Pressure-Malaria Protection Hypothesis

RATIONALE

A recently proposed hypothesis states that malaria may contribute to hypertension in endemic areas,¹ but the role of angiotensin II (Ang II), a major regulator of blood pressure, was not considered. Elevated levels of Ang II may confer protection against malaria morbidity and mortality, providing an alternative explanation for hypertension in malaria endemic areas.

OBJECTIVE

To discuss a possible alternative cause for hypertension in populations who have been under the selective pressure of malaria.

METHODS AND RESULTS

We reviewed published scientific literature for studies that could establish a link between Ang II and malaria. Both genetic and functional studies suggested that high levels of Ang II may confer protection against cerebral malaria by strengthening the integrity of the endothelial brain barrier. We also describe strong experimental evidence supporting our hypothesis through genetic, functional, and interventional studies.

CONCLUSIONS

A causal association between high levels of Ang II and protection from malaria pathogenesis can provide a likely explanation for the increased prevalence in hypertension observed in populations of African and South Asian origin. Furthermore, this potential causative connection might also direct unique approaches for the effective treatment of cerebral malaria.

Associations of Apelin, Visfatin, and Urinary 8-Isoprostane With Severe Hypertension in African Americans: The MH-GRID Study

BACKGROUND

Apelin is an adipokine directly associated with adiposity, insulin resistance, and decreased blood pressure. Urinary 8-isoprostane is a marker of chronic oxidative endothelial stress. Visfatin, an adipokine that acts by binding and activating the insulin receptor, has been associated with hypertension. As severe hypertension (SH) is highly prevalent among African Americans (AA), we aimed to assess the association of these biomarkers with SH status.

METHODS

A sample of 250 AA participants (134 normotensive controls and 116 with SH (including 98 treatment controlled, SCH: severe controlled hypertension, and 18 treatment resistant, SRH: severe resistant hypertension)) from the Minority Health Genomics and Translational Research Bio-Repository Database (MH-GRID) in metro Atlanta had blood analyzed for apelin and visfatin and urine for 8-isoprostane. T-tests, sex-specific age-adjusted correlation coefficients, and multivariable logistic regression models were used to assess the association of biomarkers with hypertensive status.

RESULTS

Levels of apelin and 8-isoprostane were not statistically different between controls and SCH or SRH. Statistically significant differences were present in levels of visfatin between controls (1.03±0.84 pg/ml), SCH (1.34±1.14 pg/ml), and SRH (1.59±0.85 pg/ml). After multivariable adjustment, categorization in the middle 2 quartiles of urinary 8-isoprostane were associated with SH. In similar models, categorization into the highest quartile of visfatin was associated with SH (odds ratio = 2.80; 95% confidence interval: 1.02-7.02). A continuous association of visfatin with SH was present.

CONCLUSION

In our community sample of AA, there were increased odds of SH with increased levels of urinary 8-isoprostane and visfatin, but not with apelin.

Mortality risk from comorbidities independent of triple-negative breast cancer status: NCI-SEER-based cohort analysis

PURPOSE

A comparatively high prevalence of comorbidities among African-American/Blacks (AA/B) has been implicated in disparate survival in breast cancer. There is a scarcity of data, however, if this effect persists when accounting for the adverse triple-negative breast cancer (TNBC) subtype which occurs at threefold the rate in AA/B compared to white breast cancer patients.

METHODS

We reviewed charts of 214 white and 202 AA/B breast cancer patients in the NCI-SEER Connecticut Tumor Registry who were diagnosed in 2000-2007. We employed the Charlson Co-Morbidity Index (CCI), a weighted 17-item tool to predict risk of death in cancer populations. Cox survival analyses estimated hazard ratios (HRs) for all-cause mortality in relation to TNBC and CCI adjusting for clinicopathological factors.

RESULTS

Among patients with SEER local stage, TNBC increased the risk of death (HR 2.18, 95 % CI 1.14-4.16), which was attenuated when the CCI score was added to the model (Adj. HR 1.50, 95 % CI 0.74-3.01). Conversely, the adverse impact of the CCI score persisted when controlling for TNBC (Adj. HR 1.49, 95 % CI 1.29-1.71; per one point increase). Similar patterns were observed in SEER regional stage, but estimated HRs were lower. AA/B patients with a CCI score of ≥3 had a significantly higher risk of death compared to AA/B patients without comorbidities (Adj. HR 5.65, 95 % CI 2.90-11.02). A lower and nonsignificant effect was observed for whites with a CCI of ≥3 (Adj. HR 1.90, 95 % CI 0.68-5.29).

CONCLUSIONS

comorbidities at diagnosis increase risk of death independent of TNBC, and AA/B patients may be disproportionately at risk.

Understanding the Importance of Race/Ethnicity in the Care of the Hypertensive Patient

Although several risk factors contribute to cardiovascular disease (CVD) overall, hypertension (HTN) is the major controllable risk factor. Hypertension is disproportionately more prevalent among Blacks or African-Americans compared with other race/ethnic populations, and the control rates among this disparate population are alarming. Several pathophysiologic mechanisms have been demonstrated and evaluated among hypertensives and the conglomeration of genetics, environmental, and personal lifestyle activities concurrently impact the progression of hypertension-related comorbidities (i.e., chronic renal disease, CVD, stroke, etc.). Specific pharmacotherapeutic choices are discussed and the most up-to-date data is presented to optimize the care of hypertensives. National and international guidelines for the treatment of HTN are reviewed and analyzed, presenting the most appropriate approach to the care of hypertensive patients overall. Additionally, national efforts supporting the goal of early HTN screening and treatment, as well as the variety of evidence-based pharmacotherapy, are summarized, applying to the public health impact overall.

Hypertension in the African American population: A succinct look at its epidemiology, pathogenesis, and therapy

Arterial hypertension is prevalent in the black population in the United States. It is directly related to cardiovascular and kidney damage. Its pathogenesis is complex and includes the high incidence of obesity, salt sensitivity and the activation of the renin-angiotensin-aldosterone system. This complexity requires a therapeutic combination that includes changes in dietary habits and appropriate antihypertensive regimes. The International Society of Hypertension in Blacks recommends initiating dietary intervention for values of systolic/diastolic arterial blood pressure above 115/75 mmHg and maintaining arterial blood pressure below 135/85 mmHg using appropiate antihypertensive medication. The most adequate antihypertensive drug for this population has yet to be determined.

Molecular targets of antihypertensive peptides: understanding the mechanisms of action based on the pathophysiology of hypertension

There is growing interest in using functional foods or nutraceuticals for the prevention and treatment of hypertension or high blood pressure. Although numerous preventive and therapeutic pharmacological interventions are available on the market, unfortunately, many patients still suffer from poorly controlled hypertension. Furthermore, most pharmacological drugs, such as inhibitors of angiotensin-I converting enzyme (ACE), are often associated with significant adverse effects. Many bioactive food compounds have been characterized over the past decades that may contribute to the management of hypertension; for example, bioactive peptides derived from various food proteins with antihypertensive properties have gained a great deal of attention. Some of these peptides have exhibited potent in vivo antihypertensive activity in both animal models and human clinical trials. This review provides an overview about the complex pathophysiology of hypertension and demonstrates the potential roles of food derived bioactive peptides as viable interventions targeting specific pathways involved in this disease process. This review offers a comprehensive guide for understanding and utilizing the molecular mechanisms of antihypertensive actions of food protein derived peptides.