2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures

Impact of Social Determinants of Health on Hypertension Outcomes: A Systematic Review

Despite ample evidence linking social determinants of health (SDoH) and hypertension outcomes, efforts to address SDoH in the context of hypertension prevention and self-management are not commensurate with the burden and impact of hypertension. To provide valuable insights into the development of targeted and effective strategies for preventing and managing hypertension, this systematic review, guided by the Healthy People 2030 SDoH framework, aims to summarize the inclusion, measurement, and evaluation of SDoH in studies examining hypertension outcomes, with a focus on characterizing SDoH constructs and summarizing the current evidence of their influence on hypertension outcomes. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a comprehensive search of electronic databases identified 10 608 unique records, from which 57 articles meeting inclusion criteria were analyzed. The studies, conducted nationally or regionally across the United States, revealed that higher educational attainment, health insurance coverage, income, and favorable neighborhood characteristics were associated with lower hypertension prevalence and better hypertension control among US adults. The findings underscore the importance of addressing SDoH such as education, health care access, economic stability, neighborhood environments, and social context to reduce hypertension disparities. Multilevel collaboration and community-engaged practices are necessary to tackle these disparities effectively.

Multiethnic Perspectives of Shared Decision-Making in Hypertension: A Mixed-Methods Study

BACKGROUND

Shared decision-making (SDM) has the potential to improve hypertension care quality and equity. However, research lacks diverse representation and evidence about how race and ethnicity affect SDM. Therefore, this study aims to explore SDM in the context of hypertension management.

METHODS AND RESULTS

Explanatory sequential mixed-methods design was used. Quantitative data were sourced at baseline and 12-month follow up from RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) participants (n=1212) with hypertension. Qualitative data were collected from semistructured individual interviews, at 12-month follow-up, with participants (n=36) selected based on their SDM scores and blood pressure outcome. Patients were cross- categorized based on high or low SDM scores and systolic blood pressure reduction of ≥10 or <10 mm Hg. Multinomial logistic regression analysis showed that predictors of SDM scores and blood pressure outcome were race and ethnicity (relative risk ratio [RRR], 1.64; P=0.029), age (RRR, 1.03; P=0.002), educational level (RRR, 1.87; P=0.016), patient activation (RRR, 0.98; P<0.001; RRR, 0.99; P=0.039), and hypertension knowledge (RRR, 2.2; P<0.001; and RRR, 1.57; P=0.045). Qualitative and mixed-methods findings highlight that provider-patient communication and relationship influenced SDM, being emphasized both as facilitators and barriers. Other facilitators were patients' understanding of hypertension; clinicians' interest in the patient, and clinicians' personality and attitudes; and barriers included perceived lack of compassion, relationship hierarchy, and time constraints.

CONCLUSIONS

Participants with different SDM scores and blood pressure outcomes varied in determinants of decision and descriptions of contextual factors influencing SDM. Results provide actionable information, are novel, and expand our understanding of factors influencing SDM in hypertension.

Design and rationale of the cardiometabolic health program linked with community health workers and mobile health telemonitoring to reduce health disparities (LINKED-HEARTS) program

BACKGROUND

Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-HEARTS Program" (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS"), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program.

METHODS

Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months.

CONCLUSIONS

The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05321368.

Enhancing Chronic-Disease Education through Integrated Medical and Social Care: Exploring the Beneficial Role of a Community Teaching Kitchen in Oregon

Teaching kitchens (TKs) are rapidly being utilized as models to integrate culinary education and chronic-disease education into healthcare settings. Our observational study details the structure and organizational processes (e.g., referral, services, medical and social care integration) of the Community TK at Providence Milwaukie Hospital in Portland, OR. We utilize electronic medical-record data from engaged TK participants (n = 3077) to evaluate between the association of engagement and clinical outcomes (e.g., HbA1c, blood pressure, weight and cholesterol). Mean baseline HbA1c of Highly Engaged TK patients with diabetes (n = 88) reduced from 9.8% to 8.6% at 6 months (p < 0.0001) and sustained significant reductions at 12, 18, 24, 30, and 36 months (p < 0.05). Highly Engaged patients with hypertension (n = 152) had significant, sustained reductions in blood pressure (p < 0.0001). Engaged patients in the same high-risk groups also had significant improvements in HbA1c and blood pressure. Both engagement subgroups had moderate improvements in weight change and cholesterol. This study shows promising associations of TK services that promote chronic-disease self-management with improved clinical outcomes among higher risk patients (e.g., high blood pressure, high HbA1c, high low-density lipoprotein) with different medical issues (e.g., diabetes, obesity) and social barriers (e.g., food insecurity).

Racial Disparities in Shared Decision-Making and the Use of mHealth Technology Among Adults With Hypertension in the 2017-2020 Health Information National Trends Survey: Cross-Sectional Study in the United States

BACKGROUND

Mobile health (mHealth) technology has the potential to support shared decision-making (SDM) and improve hypertension control. However, our understanding of the variations in individuals' involvement in SDM and mHealth usage across different racial and ethnic groups in the United States is still limited.

OBJECTIVE

This study aimed to investigate the extent of involvement in SDM and the usage of mHealth technology in health-related activities among US adults with hypertension from diverse racial and ethnic backgrounds and to examine whether the mHealth usage differed by individuals' level of engagement in SDM.

METHODS

This study used cross-sectional data from the 2017 to 2020 Health Information National Trends Survey, which was conducted on US adults with self-reported hypertension, and race and ethnicity data were included. The exposure of interest was race and ethnicity. The outcomes were SDM and mHealth usage. SDM was assessed using an item: "In the past 12 months, how often did your health professional: involve you in decisions about your healthcare as much as you wanted?" mHealth usage was defined as using a smartphone or tablet to engage in (1) making health decisions, (2) discussing health decisions with health providers, (3) tracking health progress, and (4) sharing health information. Weighted multivariable logistic regression models were used to examine the association between race and ethnicity and SDM or mHealth usage adjusted for covariates and stratified by the level of engagement in SDM.

RESULTS

This study included 4893 adults with hypertension, and the mean age was 61 (SD 13) years. The sample was 53% female, 61% (n=3006) non-Hispanic White, 19% (n=907) non-Hispanic Black or African American, 12% (n=605) Hispanic, 4% (n=193) non-Hispanic Asian, and 4% (n=182) non-Hispanic other. Compared to the non-Hispanic White adults, non-Hispanic Black adults were more likely to use mHealth to make health decisions (adjusted odds ratio [aOR] 1.70, 95% CI 1.23-2.34), share health information (aOR 1.46, 95% CI 1.02-2.08), and discuss health decisions with health providers (aOR 1.38, 95% CI 1.02-1.87). Significant associations were observed specifically among those who were always involved in SDM. Asian adults were less likely to be involved in SDM (aOR 0.51, 95% CI 0.26-0.99) and were more likely to use mHealth to track progress on a health-related goal (aOR 2.07, 95% CI 1.28-3.34) than non-Hispanic White adults. Hispanic adults were less likely to use mHealth to share health information (aOR 0.47, 95% CI 0.33-0.67) and discuss health decisions with health providers (aOR 0.65, 95% CI 0.46-0.94) compared to non-Hispanic White adults.

CONCLUSIONS

This study observed racial and ethnic disparities in SDM and mHealth usage among US adults with hypertension. These findings emphasize the significance of comprehending the involvement of SDM and the usage of mHealth technology within racially and ethnically diverse populations.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

Association between excessive alcohol consumption and hypertension control in hypertensive patients

OBJECTIVES

The purposes of this study were to investigate the association between excessive alcohol consumption and control of hypertension and the associations stratified by sex, age, and duration of hypertension among Korean adults who were diagnosed with hypertension under medication.

METHODS

This study was cross-sectional design with a secondary data analysis using national data from the Korea National Health and Nutrition Evaluation Survey (KNHANES) collected from 2013 to 2018, including 4278 participants who were diagnosed with hypertension under medication. A multiple logistic regression analysis was conducted to evaluate the associations between excessive alcohol consumption and hypertension control while controlling for potential confounding variables.

RESULTS

The hypertensive patients who consumed excessive alcohol were more associated with uncontrolled hypertension (OR, 1.31; 95% CI, 1.04-1.65) than those who do not consumed excessive alcohol. Specially, Excessive consumption of alcohol in men and young adults (<65 years) and short duration of hypertension (<5 years) were significantly more associated with uncontrolled hypertension compared to their counterparts.

DISCUSSION

To improve blood pressure (BP) control in hypertensive patients, healthcare plan should be focused to modifiable risk factors and the intervention for unhealthy alcohol consumption should be part of comprehensive treatment for hypertension.

A Comprehensive Secondary Prevention Benchmark (2PBM) Score Identifying Differences in Secondary Prevention Care in Patients After Acute Coronary Syndrome

PURPOSE

The objective of this study was to quantify secondary prevention care by creating a secondary prevention benchmark (2PBM) score for patients undergoing ambulatory cardiac rehabilitation (CR) after acute coronary syndrome (ACS).

METHODS

In this observational cohort study, 472 consecutive ACS patients who completed the ambulatory CR program between 2017 and 2019 were included. Benchmarks for secondary prevention medication and clinical and lifestyle targets were predefined and combined in the comprehensive 2PBM score with maximum 10 points. The association of patient characteristics and achievement rates of components and the 2PBM were assessed using multivariable logistic regression analysis.

RESULTS

Patients were on average 62 ± 11 yr of age and predominantly male (n = 406; 86%). The types of ACS were ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for components of the 2PBM were 71% for medication, 35% for clinical benchmark, and 61% for lifestyle benchmark. Achievement of medication benchmark was associated with younger age (OR = 0.979: 95% CI, 0.959-0.996, P = .021), STEMI (OR = 2.05: 95% CI, 1.35-3.12, P = .001), and clinical benchmark (OR = 1.80: 95% CI, 1.15-2.88, P = .011). Overall ≥8 of 10 points were reached by 77% and complete 2PBM by 16%, which was independently associated with STEMI (OR = 1.79: 95% CI, 1.06-3.08, P = .032).

CONCLUSIONS

Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. ST-elevation myocardial infarction was associated with the highest 2PBM scores, suggesting best secondary prevention care in patients after ST-elevation myocardial infarction.

Upper-Arm Photoplethysmographic Sensor with One-Time Calibration for Long-Term Blood Pressure Monitoring

Wearable cuffless photoplethysmographic blood pressure monitors have garnered widespread attention in recent years; however, the long-term performance values of these devices are questionable. Most cuffless blood pressure monitors require initial baseline calibration and regular recalibrations with a cuffed blood pressure monitor to ensure accurate blood pressure estimation, and their estimation accuracy may vary over time if left uncalibrated. Therefore, this study assessed the accuracy and long-term performance of an upper-arm, cuffless photoplethysmographic blood pressure monitor according to the ISO 81060-2 standard. This device was based on a nonlinear machine-learning model architecture with a fine-tuning optimized method. The blood pressure measurement protocol followed a validation procedure according to the standard, with an additional four weekly blood pressure measurements over a 1-month period, to assess the long-term performance values of the upper-arm, cuffless photoplethysmographic blood pressure monitor. The results showed that the photoplethysmographic signals obtained from the upper arm had better qualities when compared with those measured from the wrist. When compared with the cuffed blood pressure monitor, the means ± standard deviations of the difference in BP at week 1 (baseline) were -1.36 ± 7.24 and -2.11 ± 5.71 mmHg for systolic and diastolic blood pressure, respectively, which met the first criterion of ≤5 ± ≤8.0 mmHg and met the second criterion of a systolic blood pressure ≤ 6.89 mmHg and a diastolic blood pressure ≤ 6.84 mmHg. The differences in the uncalibrated blood pressure values between the test and reference blood pressure monitors measured from week 2 to week 5 remained stable and met both criteria 1 and 2 of the ISO 81060-2 standard. The upper-arm, cuffless photoplethysmographic blood pressure monitor in this study generated high-quality photoplethysmographic signals with satisfactory accuracy at both initial calibration and 1-month follow-ups. This device could be a convenient and practical tool to continuously measure blood pressure over long periods of time.

Racial Differences and Social Determinants of Health in Achieving Hypertension Control

OBJECTIVE

To investigate whether specific social determinants of health could be a "health barrier" toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP.

RESULTS

Compared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present.

CONCLUSION

Patient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFactores impulsores y métodos de puntuación para mejorar el control de la hipertensión en la práctica clínica de la atención primaria: recomendaciones del grupo de innovación de HEARTS en las Américas]

Fundamentos.

As doenças cardiovasculares (DCV) são as principais causas de morbimortalidade nas Américas, e a hipertensão arterial (HÁ) é o fator de risco modificável mais importante. Porém, as taxas de controle da HA continuam baixas, e a mortalidade por DCV está estagnada ou aumentando após décadas de redução contínua. Em 2016, a Organização Mundial da Saúde (OMS) lançou o pacote de medidas técnicas HEARTS para melhorar o controle da HA. A Organização Pan-Americana da Saúde (OPAS) criou a iniciativa HEARTS nas Américas para melhorar a gestão do risco cardiovascular (RCV), com ênfase no controle da HA. Até agora, essa iniciativa foi implementada em 21 países.

Métodos.

Para impulsionar a implementação, recrutou-se um grupo multidisciplinar de profissionais para selecionar impulsionadores-chave do controle da HA com base em evidências e elaborar um scorecard completo para monitorar sua implementação em unidades de atenção primária à saúde (APS). O grupo estudou sistemas de saúde com alto desempenho que haviam conseguido atingir um alto nível de controle da HA por meio de programas de melhoria da qualidade focados em medidas específicas de processo, com feedback regular para os profissionais das unidades de saúde.

Resultados.

Os oito fatores impulsionadores incluídos na seleção final foram categorizados em cinco domínios principais: (1) diagnóstico (exatidão da medição da pressão arterial e avaliação do RCV); (2) tratamento (protocolo padronizado de tratamento e intensificação do tratamento); (3) continuidade do cuidado e acompanhamento; (4) modelo de atenção (atendimento baseado em equipe, renovação da prescrição); e (5) sistema de avaliação do desempenho. Em seguida, os fatores impulsionadores e as recomendações foram transformados em medidas de processo, gerando dois scorecards inter-relacionados integrados ao sistema de monitoramento e avaliação da Iniciativa HEARTS nas Américas.

Interpretação.

O foco nesses impulsionadores-chave da HA e nos scorecards resultantes orientará o processo de melhoria da qualidade para atingir as metas de controle, a nível populacional, dos centros de saúde participantes nos países que estão implementando a iniciativa HEARTS.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFatores impulsionadores e scorecards para melhorar o controle da hipertensão arterial na atenção primária: recomendações do Grupo de Inovação da Iniciativa HEARTS nas Américas]

Antecedentes.

Las enfermedades cardiovasculares (ECV) son la principal causa de morbilidad y mortalidad en la Región de las Américas y la hipertensión es el factor de riesgo modificable asociado más importante. Sin embargo, las tasas de control de la hipertensión siguen siendo bajas y la mortalidad por ECV está estancada o en aumento después de décadas de reducción continua. En el 2016, la Organización Mundial de la Salud (OMS) presentó el paquete técnico HEARTS para mejorar el control de la hipertensión. La Organización Panamericana de la Salud (OPS) diseñó la iniciativa HEARTS en las Américas para mejorar el control del riesgo de ECV, que hace hincapié en el control de la hipertensión y que, hasta la fecha, se ha implementado en 21 países.

Métodos.

Para avanzar en la implementación, se creó un grupo interdisciplinario de profesionales de la salud con el objetivo de seleccionar los factores impulsores claves del control de la hipertensión basados en la evidencia y diseñar un método de puntuación integral para dar seguimiento a su implementación en los centros de atención de salud primaria (APS). El grupo estudió los sistemas de salud de alto desempeño que logran un control elevado de la hipertensión mediante programas de mejora de la calidad que se centran en medidas específicas con respecto a los procesos, con retroalimentación regular a los prestadores en los centros de salud.

Resultados.

Los ocho factores impulsores finales seleccionados se clasificaron en cinco dominios principales: 1) diagnóstico (exactitud de la medición de la presión arterial y evaluación del riesgo de ECV); 2) tratamiento (protocolo de tratamiento e intensificación del tratamiento estandarizados); 3) continuidad de la atención y seguimiento; 4) sistema de prestación del tratamiento (atención basada en un trabajo en equipo, reposición de la medicación) y 5) sistema para la evaluación del desempeño. Los factores impulsores y las recomendaciones se tradujeron en medidas con respecto a los procesos, lo que llevó a dos métodos de puntuación integrados e interconectados en el sistema de seguimiento y evaluación del programa HEARTS en las Américas.

Conclusiones.

El enfoque que se centra en estos factores impulsores clave de la hipertensión y los métodos de puntuación resultantes servirá de guía para el proceso de mejora de la calidad con objeto de alcanzar los objetivos de control a nivel poblacional en los centros de salud participantes de los países que implementan el programa HEARTS.

Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation Group

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries.

Methods

To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities.

Findings

The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system.

Interpretation

Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.

Funding

No funding to declare.

Race, Ethnicity, Hypertension, and Heart Disease: JACC Focus Seminar 1/9

Hypertension is the leading cause of cardiovascular morbidity and mortality globally. In the United States, the prevalence of hypertension (blood pressure ≥130/80 mm Hg) among adults is approximately 45%. Racial/ethnic disparities in hypertension prevalence are well documented, especially among Black adults who are disproportionately affected and have one of the highest rates of hypertension globally. Hypertension control remains a persistent public health crisis. Recently published data indicate suboptimal hypertension control rates, particularly for racial/ethnic minority groups in the United States. This requires urgent action because of the significant health care burden from cardiovascular- and stroke-related morbidity and mortality. This clinical review delineates racial/ethnic disparities in the epidemiology of hypertension, and the impact of social determinants of health on the quality of cardiovascular care and outcomes. Clinical practice guideline recommendations and various national programs targeted toward hypertension control and proposed solutions to eliminate these disparities are discussed.

CE: Acute Ischemic Stroke

ABSTRACT

Stroke, the most common form of cerebrovascular disease, is a leading cause of death and disability throughout the world. There have been no significant advances in the development of effective therapeutics for hemorrhagic stroke, and for ischemic stroke highly effective, evidence-based therapies such as alteplase and mechanical thrombectomy are widely underutilized. Improving outcomes for patients experiencing ischemic stroke requires faster recognition and appropriate intervention within the treatment window (the first 24 hours after symptom onset). This article discusses the pathophysiology underlying the various types of ischemic stroke; the risk factors for ischemic stroke; stroke presentation; and the evidence-based treatments, nursing assessments, and monitoring protocols that are critical to patient recovery.

Associations Between Social Determinants and Hypertension, Stage 2 Hypertension, and Controlled Blood Pressure Among Men and Women in the United States

BACKGROUND

Social determinants influence the development and control of hypertension.

METHODS

National Health and Nutrition Examination Survey (2011-2018) data for adults aged ≥18 included education, income, employment, race/ethnicity, healthcare access, marital status, and nativity status. Outcomes were hypertension (blood pressure [BP] ≥130/80 mm Hg or self-reported hypertension medication use), stage 2 hypertension (BP ≥140/90 mm Hg), and controlled BP (BP <130/80 mm Hg among those with hypertension). Poisson regression with robust variance estimates was used to examine associations between social determinants and outcomes, by sex.

RESULTS

The analysis included 21,664 adults (mean age 47.1 years), of whom 51% were women. After adjustment, hypertension and stage 2 hypertension prevalence remained higher among Black and Asian than White adults, regardless of sex. Blacks had lower prevalence of controlled BP than Whites. Compared with college graduates, men and women with less education had a higher prevalence of hypertension and stage 2 hypertension. Men (prevalence ratio [PR]: 0.28, 95% confidence interval: 0.16-0.49) and women (PR: 0.44, 0.24-0.78) with no routine place for healthcare had lower prevalence of controlled BP than those who had a routine place for healthcare. Uninsured men (PR: 0.66, 0.44-0.99) and women (PR: 0.67, 0.51-0.88) had lower prevalence of controlled BP than those insured. Unemployed or unmarried women were more likely to have controlled BP than employed or married women.

CONCLUSIONS

Social determinants were independently associated with hypertension outcomes in US adults. Policy interventions are urgently needed to address healthcare access and education, and eliminate racial disparities.

New aspects in the management of hypertension in the digital era

PURPOSE OF REVIEW

Hypertension (HTN) is the most common chronic disease impacting over half the US adult population. Our current office-based model of care is failing in its ability to control blood pressure (BP) as only 44% of adult US hypertensives are achieving minimal levels of BP control (< 140/90 mmHg), leading to high rates of preventable cardiovascular events and death.

RECENT FINDINGS

Reengineering care delivery using a fully digital platform combined with a dedicated team-based approach to HTN management has demonstrated superior BP control rates, very high levels patient acceptance, and the ability to better diagnose and treat masked and white coat HTN.

SUMMARY

A digital medicine program in the clinical care setting can be an effective and convenient mechanism of delivering HTN management, outperforming traditional office-based care, and is well accepted by patients.

Effects of ambulatory blood pressure monitoring on sleep in healthy, normotensive men and women

OBJECTIVES

To determine the effect of ambulatory blood pressure monitoring (ABPM) on sleep quality among healthy adults and to explore possible effect modification by demographics.

METHODS

We examined data from 192 relatively healthy young (median age: 31; 33% men, 18% with clinic BP >130/80 mmHg) participants in an observational study of sleep and arterial stiffness. Demographic/health questionnaires were completed. A wrist-based accelerometer assessed sleep for seven nights, and sleep duration, wakefulness after sleep onset (WASO), fragmentation (physical restlessness), midpoint, and efficiency were estimated. ABPM was conducted for one 36-h period, including one actigraphy night.

RESULTS

Within-subject comparisons indicated that WASO and fragmentation were higher, midpoint was later, and efficiency was lower on the ABPM night (Ps < 0.001-0.038). Neither age nor sex moderated these associations. Among older adults, a later midpoint and worse fragmentation were observed with ABPM (Ps = 0.002-0.010). There was also a main effect of sex: men demonstrated shorter sleep duration, greater WASO and fragmentation, and less efficiency than women (Ps = 0.002-0.046). With ABPM, women had worse fragmentation and a later midpoint (Ps = 0.002-0.049); for men, WASO and fragmentation were worse (Ps = 0.003-0.023). Importantly, this study does not address whether the effect of wearing ABPM on sleep in turn affects BP during sleep.

CONCLUSIONS

ABPM appears to modestly disturb actigraphy-assessed sleep among healthy adults. Researchers and clinicians should consider the downstream effects of performing ABPM and whether these effects are more pronounced in those who typically experience sleep disturbance.

Risk Factors for Progression from Subclinical to Clinical Phase of Psoriatic Arthritis: A Case-Control Study

Introduction

The objective of this study is to identify the potential risk factors for progression from subclinical to clinical psoriatic arthritis (PsA).

Methods

A retrospective, longitudinal, case–control study was conducted at a single hospital, including 25 patients with clinically confirmed PsA in the case group and 137 controls without confirmed PsA. All patients in both groups had a medical history of subclinical PsA. Various baseline covariates were collected from all patients when they had a status of subclinical PsA. Univariate, multivariate, stratified, and interaction analyses were employed to identify potential risk factors of transiting to clinical PsA from subclinical PsA.

Results

In multivariate logistic regression analysis, older age (OR 10.15, 95% CI 2.79–36.91, p = 0.00), alcohol drinking (OR 3.43, 95% CI 1.17–10.12, p = 0.03), elevated high-sensitivity C-reactive protein (hs-CRP) (OR 1.05, 95% CI 1.01–1.09, p = 0.03) were identified as risk factors for transition from subclinical to clinical PsA. Stratified and logistic regression analyses suggest a significant interaction between age and fatty liver. For patients aged less than 45 years old, the association between fatty liver and clinical PsA was statistically significant.

Conclusions

Older age, alcohol drinking, elevated hs-CRP, and the presence of fatty liver at less than 45 years old appear to increase the risk of transition from subclinical to clinical PsA. These findings call for a need to manage these risk factors.

The Ecology of Antihypertensives in the United States, 1997-2017

OBJECTIVE

Antihypertensives are the most used medication type in the USA, yet there remains uncertainty about the use of different antihypertensives. We sought to characterize use of antihypertensives by and within medication class(es) between 1997 and 2017.

PATIENTS AND METHODS

A repeated cross-sectional study of 493,596 adult individuals using the 1997-2017 Medical Expenditure Panel Survey (MEPS). The Orange Book was used for adjunctive information. The primary outcome was the estimated use by and within antihypertensive medication class(es).

RESULTS

The proportion of individuals taking any antihypertensive during a year increased from 1997 to the early 2010s and then remained stable. The proportion of adults using angiotensin II receptor blockers (ARBs) and dihydropyridine calcium channel blockers (CCBs) increased during the study period, while angiotensin-converting enzyme inhibitors (ACE-Is) increased until 2010 after which rates remained stable. Beta-blocker use was similar to that of ACE-Is with an earlier decline starting in 2012. Thiazide diuretic use increased from 1997 to 2007, leveled off until 2014, and declined from 2015 to 2017. Non-dihydropyridine CCB use declined throughout the study. ACE-Is, ARBs, CCBs, thiazide diuretics, and loop diuretics all had one dominant in-class medication. There was a clear increase in the use of losartan within ARBs, lisinopril within ACE-Is, and amlodipine within CCBs following generic conversion. Furosemide and hydrochlorothiazide started with and maintained a dominant position in their classes. Metoprolol use increased throughout the study and became the dominant beta-blocker.

CONCLUSIONS

Antihypertensive classes appear to have a propensity to equilibrate to an individual medication, despite a lack of outcomes-based research to compare medications within a class.

Automated digital design for 3D-printed individualized therapies

Customization of pharmaceutical products is a central requirement for personalized medicines. However, the existing processing and supply chain solutions do not support such manufacturing-on-demand approaches. In order to solve this challenge, three-dimensional (3D) printing has been applied for customization of not only the dose and release characteristics, but also appearance of the product (e.g., size and shape). A solution for customization can be realized via non-expert-guided processing of digital designs and drug dose. This study presents a proof-of-concept computational algorithm which calculates the optimal dimensions of grid-like orodispersible films (ODFs), considering the recommended dose. Further, the algorithm exports a digital design file which contains the required ODF configuration. Cannabidiol (CBD) was incorporated in the ODFs, considering the simple correspondence between the recommended dose and the patient's weight. The ODFs were 3D-printed and characterized for their physicochemical, mechanical, disintegration and drug release properties. The algorithm was evaluated for its accuracy on dose estimation, highlighting the reproducibility of individualized ODFs. The in vitro performance was principally affected by the thickness and volume of the grid-like structures. The concept provides an alternative approach that promotes automation in the manufacturing of personalized medications in distributed points of care, such as hospitals and local pharmacies.

Nomograms for Predicting Non-remission in Patients Who Underwent Bariatric Surgery: A Multicenter Retrospective Study in China

BACKGROUND

As a reflection of the increasing global incidence of obesity, there is a corresponding increase in the proportion of obese patients undergoing bariatric surgery. This study reviewed the factors and outcomes of patients who underwent bariatric surgical procedures and determined the relationships and developed a nomogram to calculate individualized patient risk.

METHODS

The nomogram was based on a retrospective study on 259 patients who underwent bariatric surgery at the Chengdu Third People's Hospital from June 2017 to June 2019. The predictive accuracy and discriminative ability of the nomogram were determined by the ROC curve and C-index, respectively. The results were validated using bootstrap resampling and a retrospective study on 121 patients operated on from May 2015 to May 2019 at the Tenth People's Hospital of Shanghai.

RESULTS

The predictors contained in the prediction nomogram included age, sex, surgical approach, hyperlipidemia, blood pressure (BP), hyperuricemia, body mass index (BMI), and waist circumference (WC). The 6-month model displayed good discrimination with a C-index of 0.765 (95% CI: 0.756 to 0.774) and good calibration. The 1-year model reached a C-index of 0.768 (95% CI, 0.759 to 0.777) in the training cohort.

CONCLUSIONS

The proposed nomogram resulted in more accurate non-remission prediction for patients with obesity after bariatric surgery and may provide a reference for the preoperative choice of surgical methods.

Confounding Factors in Renal Denervation Trials: Revisiting Old and Identifying New Challenges in Trial Design of Device Therapies for Hypertension

Recent randomized sham-controlled trials have demonstrated significant blood pressure reductions following renal denervation (RDN) in patients with hypertension, both in the presence and absence of antihypertensive therapy. These new data encouraged us to revisit previously published insights into potential clinical trial confounding factors that informed the design and conduct of forthcoming trials. Initially identified confounders related to procedural technique, medication variability, and selected patient subgroups have been addressed in contemporary trial design. Regarding procedural method and technology, blood pressure reductions may be improved by ensuring circumferential lesion creation in the distal renal arteries and branch vessels. Safety of the RDN procedure has been demonstrated in multiple independent meta-analyses including thousands of treated patients with low reported rates of renal vessel complications and maintenance of renal function. However, a newer generation of RDN trials has also introduced insights related to medication adherence, patient selection, and the definition of treatment response. Evolving evidence indicates that RDN therapy may be considered in higher risk populations of uncontrolled hypertension regardless of ethnicity and in patients expressing a strong preference for a nondrug therapy option. Despite advances in procedural technique and clinical trial conduct, inconsistent antihypertensive-drug adherence behavior remains perhaps the most critical clinical trial design issue for device-based hypertension therapies. As the balance in clinical equipoise increasingly favors RDN, justification of sham-controlled trial designs will be revisited, and novel study designs may be required to evaluate the safety and efficacy of novel devices and procedures intended to address the escalating prevalence of poorly controlled hypertension.

Onco-Metabolic Surgery: A Combined Approach to Gastric Cancer and Hypertension

Purpose

The purpose of this study was to explore the changes in blood pressure in patients with concurrent gastric cancer and hypertension after gastrectomy, and to identify the factors that affect the changes in blood pressure.

Materials and Methods

Patients with concurrent gastric cancer and hypertension who underwent gastrectomy were retrospectively analyzed from January 2013 to December 2018. The pre- and 6-month postoperative medical records were compared. Predictors for the remission of hypertension were analyzed.

Results

A total of 143 patients with concurrent gastric cancer and hypertension were included in this study. The number of patients with complete remission, partial remission and no remission were 67 (46.9%), 12 (8.4%) and 64 (44.7%), respectively. The average of weight and BMI (body mass index) before gastrectomy were 63.0 ± 9.7 kg and 23.4 ± 2.9 kg/m², respectively, which were significantly higher than those 6-month postgastrectomy: 54.8 ± 9.8 kg and 20.4 ± 3.1 kg/m², respectively (p<0.001). The average number of antihypertensive medications before gastrectomy was 1.5 ± 0.6, while it was 0.8 ± 0.8 6-month postgastrectomy (p<0.001). Age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between partial remission and no remission patients. Furthermore, age (p<0.05) and the surgical techniques used (p<0.05) were significantly different between complete remission and no remission patients. Age (p<0.05, odds ratio =0.933, 95% CI=0.890–0.978) and the surgical techniques used (p<0.05, odds ratio =2.749, 95% CI=1.132–6.677) are predictors for remission of hypertension.

Conclusion

Total gastrectomy is an onco-metabolic surgery that can cure younger patients with concurrent gastric cancer and hypertension. Age and the surgical techniques used can predict the remission of hypertension 6 months after gastrectomy.