Prevalence of hypertension by duration and age at exposure to the stroke belt

Factor VIII and Incident Hypertension in Black and White Adults: The REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort

BACKGROUND

Nearly half of all Americans have hypertension, and Black adults experience a disproportionate burden. Hypercoagulability may relate to hypertension risk, and higher levels of factor VIII increase thrombosis risk. Black adults have higher factor VIII and more hypertension than other groups. Whether higher factor VIII associates with incident hypertension is unknown.

METHODS

The Biomarkers as Mediators of Racial Disparities in Risk Factors (BioMedioR) study measured certain biomarkers in a sex-race stratified sample of 4,400 REGARDS participants who attended both visits. We included BioMedioR participants, excluding those with prevalent hypertension, missing factor VIII level, or covariates of interest. Modified Poisson regression estimated risk ratios (RR) for incident hypertension by higher log-transformed factor VIII level per SD (SD of log-transformed factor VIII, 0.33). Weighting was applied to take advantage of REGARDS sampling design.

RESULTS

Among the 1,814 participants included (55% female, 24% Black race), the median follow-up was 9.5 years and 35% (2,146/6,138) developed hypertension. Black participants had a higher median (IQR) factor VIII level (105.6%; 87.1%-126.9%) than White participants (95.6%; 79.8%-115.9%; P < 0.001). The age- and sex-adjusted Black-White hypertension RR was 1.45 (95% CI 1.28, 1.63). Higher factor VIII was not associated with more hypertension (final model RR 1.01; 95% CI 0.94, 1.07).

CONCLUSIONS

In a prospective study of Black and White adults without prevalent hypertension, factor VIII was not associated with greater hypertension risk.

Cytokines, C-Reactive Protein, and Risk of Incident Hypertension in the REGARDS Study

BACKGROUND

Hypertension is a highly prevalent cardiovascular disease risk factor that may be related to inflammation. Whether adverse levels of specific inflammatory cytokines relate to hypertension is unknown. The present study sought to determine whether higher levels of IL (interleukin)-1β, IL-6, TNF (tumor necrosis factor)-α, IFN (interferon)-γ, IL-17A, and CRP (C-reactive protein) are associated with a greater risk of incident hypertension.

METHODS

The REGARDS study (Reasons for Geographic and Racial Difference in Stroke) is a prospective cohort study that recruited 30 239 community-dwelling Black and White adults from the contiguous United States in 2003 to 2007 (visit 1), with follow-up 9 years later in 2013 to 2016 (visit 2). We included participants without prevalent hypertension who attended follow-up 9 years later and had available laboratory measures and covariates of interest. Poisson regression estimated the risk ratio of incident hypertension by level of inflammatory biomarkers.

RESULTS

Among 1866 included participants (mean [SD] aged of 62 [8] years, 25% Black participants, 55% women), 36% developed hypertension. In fully adjusted models comparing the third to first tertile of each biomarker, there was a greater risk of incident hypertension for higher IL-1β among White (1.24 [95% CI, 1.01-1.53]) but not Black participants (1.01 [95% CI, 0.83-1.23]) and higher TNF-α (1.20 [95% CI, 1.02-1.41]) and IFN-γ (1.22 [95% CI, 1.04-1.42]) among all participants. There was no increased risk with IL-6, IL-17A, or CRP.

CONCLUSIONS

Higher levels of IL-1β, TNF-α, and IFN-γ, representing distinct inflammatory pathways, are elevated in advance of hypertension development. Whether modifying these cytokines will reduce incident hypertension is unknown.

Birth in the U.S. Plantation South and Racial Differences in all-cause mortality in later life

The American South has been characterized as a Stroke Belt due to high cardiovascular mortality. We examine whether mortality rates and race differences in rates reflect birthplace exposure to Jim Crow-era inequalities associated with the Plantation South. The plantation mode of agricultural production was widespread through the 1950s when older adults of today, if exposed, were children. We use proportional hazards models to estimate all-cause mortality in Non-Hispanic Black and White birth cohorts (1920-1954) in a sample (N = 21,941) drawn from REasons for Geographic and Racial Differences in Stroke (REGARDS), a national study designed to investigate Stroke Belt risk. We link REGARDS data to two U.S. Plantation Censuses (1916, 1948) to develop county-level measures that capture the geographic overlap between the Stroke Belt, two subregions of the Plantation South, and a non-Plantation South subregion. Additionally, we examine the life course timing of geographic exposure: at birth, adulthood (survey enrollment baseline), neither, or both portions of life. We find mortality hazard rates higher for Black compared to White participants, regardless of birthplace, and for the southern-born compared to those not southern-born, regardless of race. Race-specific models adjusting for adult Stroke Belt residence find birthplace-mortality associations fully attenuated among White-except in one of two Plantation South subregions-but not among Black participants. Mortality hazard rates are highest among Black and White participants born in this one Plantation South subregion. The Black-White mortality differential is largest in this birthplace subregion as well. In this subregion, the legacy of pre-Civil War plantation production under enslavement was followed by high-productivity plantation farming under the southern Sharecropping System.

Childhood Residential Mobility and Mental and Physical Health in Later Life: Findings From the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

The study objective was to investigate the effects of childhood residential mobility on older adult physical and mental health. In REasons for Geographic and Racial Differences in Stroke (REGARDS) Study, we used linear regression models to investigate if number of moves during childhood predicted mental and physical health (SF-12 MCS, PCS), adjusting for demographic covariates, childhood socioeconomic status (SES), childhood social support, and adverse childhood experiences (ACEs). We investigated interaction by age, race, childhood SES, and ACEs. People who moved more during childhood had poorer MCS scores, β = -0.10, SE = 0.05, p = 0.03, and poorer PCS scores, β = -0.25, SE = 0.06, p < 0.0001. Effects of moves on PCS were worse for Black people compared to White people (p = 0.06), those with low childhood SES compared to high childhood SES (p = 0.02), and high ACEs compared to low ACEs (p = 0.01). As family instability accompanying residential mobility, family poverty, and adversity disproportionately affect health, Black people may be especially disadvantaged.

D-dimer and the risk of hypertension: The REasons for Geographic And Racial Differences in Stroke Cohort Study

Background

Reasons for increased risk of hypertension in Black compared with White people are only partly understood. D-dimer, a thrombo-inflammatory marker higher in Black individuals, is also higher in people with hypertension. However, the impact of D-dimer on racial disparities in risk of incident hypertension has not been studied.

Objectives

To assess whether D-dimer is associated with the risk of incident hypertension, whether the association between D-dimer and the risk of incident hypertension differs by race, and whether the biology reflected by D-dimer explains racial disparities in the risk of incident hypertension.

Methods

This study included 1867 participants in the REasons for Geographic And Racial Differences in Stroke cohort study without baseline hypertension and with a second visit 9.4 years after baseline. Risk ratios of incident hypertension by baseline D-dimer level were estimated, a D-dimer-by-race interaction was tested, and the mediating effect of D-dimer (which represents underlying biological processes) on the association of race and hypertension risk was assessed.

Results

The risk of incident hypertension was 47% higher in persons in the top quartile than in those in the bottom quartile of D-dimer (risk ratio [RR]: 1.47; 95% CI: 1.23-1.76). The association was partly attenuated after adjusting for sociodemographic and adiposity-related risk factors (RR: 1.22; 95% CI: 1.02-1.47). The association of D-dimer and hypertension did not differ by race, and D-dimer did not attenuate the racial difference in the risk of incident hypertension.

Conclusion

D-dimer concentration reflects pathophysiology related to the development of hypertension. Specific mechanisms require further study and may involve adiposity.

Race-Dependent Association of High-Density Lipoprotein Cholesterol Levels With Incident Coronary Artery Disease

BACKGROUND

Plasma lipids are risk factors for coronary heart disease (CHD) in part because of race-specific associations of lipids with CHD.

OBJECTIVES

The purpose of this study was to understand why CHD risk equations underperform in Black adults.

METHODS

Between 2003 and 2007, the REGARDS (REasons for Geographic and Racial Differences in Stroke) cohort recruited 30,239 Black and White individuals aged ≥45 years from the contiguous United States. We used Cox regression models adjusted for clinical and behavioral risk factors to estimate the race-specific hazard of plasma lipid levels with incident CHD (myocardial infarction or CHD death).

RESULTS

Among 23,901 CHD-free participants (57.8% White and 58.4% women, mean age 64 ± 9 years) over a median 10 years of follow-up, 664 and 951 CHD events occurred among Black and White adults, respectively. Low-density lipoprotein cholesterol and triglycerides were associated with increased risk of CHD in both races (P interaction by race >0.10). For sex-specific clinical HDL-C categories: low HDL-C was associated with increased CHD risk in White (HR: 1.22; 95% CI: 1.05-1.43) but not in Black (HR: 0.94; 95% CI: 0.78-1.14) adults (P interaction by race = 0.08); high HDL-C was not associated with decreased CHD events in either race (HR: 0.96; 95% CI: 0.79-1.16 for White participants and HR: 0.91; 95% CI: 0.74-1.12 for Black adults).

CONCLUSIONS

Low-density lipoprotein cholesterol and triglycerides modestly predicted CHD risk in Black and White adults. Low HDL-C was associated with increased CHD risk in White but not Black adults, and high HDL-C was not protective in either group. Current high-density lipoprotein cholesterol-based risk calculations could lead to inaccurate risk assessment in Black adults.

Pro-neurotensin/Neuromedin N and Hypertension Risk: A Prospective Study

BACKGROUND

Neurotensin, a neuropeptide with direct cardiac effects, has been associated with prospective risk of hypertension-related conditions through measurement of its precursor, pro-neurotensin/neuromedin N (pro-NT/NMN). Its association with incident hypertension has not been evaluated.

METHODS

From 2003 to 2007, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30,239 Black or White adults age ≥45. Pro-NT/NMN was measured in 1,692 participants without baseline hypertension (self-reported antihypertensive use or blood pressure ≥140/90 mm Hg) who underwent follow-up assessment in 2013-2016. A sensitivity analysis was conducted using a lower threshold (≥130/80 mm Hg) to define hypertension. Three robust Poisson regression models were fitted to risk of incident hypertension, adding demographics, cardiometabolic risk factors, and dietary covariates.

RESULTS

Six hundred and fourteen participants developed hypertension over 9.4 years of follow-up. Pro-NT/NMN ranged from 14 to 1,246 pmol/l, with median [interquartile range] 154 [112, 206] pmol/l. Pro-NT/NMN was not associated with hypertension overall (fully adjusted incidence rate ratio per SD increment log pro-NT/NMN 1.03, 95% confidence interval 0.95-1.11). Results of sensitivity analysis did not differ substantially.

CONCLUSIONS

Baseline pro-NT/NMN was not associated with incident hypertension. This may be a result of neurotensin's long-term interactions with other molecular regulators of blood pressure, such as the renin-angiotensin-aldosterone system.

County-Level Characteristics Associated with Variation in ESKD Mortality in the United States, 2010-2018

Background

Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation.

Methods

We identified 1,515,986 individuals (aged 18-84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics.

Results

County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (-4.94 per 1000 PY), lower transplant rate (-4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality.

Conclusions

Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.

Lifecourse socioeconomic position and diabetes incidence in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, 2003 to 2016

Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003-07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013-16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7-14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05-2.46) but not white (1.06; 0.74-2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks.

High triglyceride to HDL cholesterol ratio is associated with increased coronary heart disease among White but not Black adults

OBJECTIVE

Black adults are less likely than White adults to present with adverse lipid profiles and more likely to present with low-grade inflammation. The impact of race on the association between atherogenic lipid profiles, inflammation, and coronary heart disease (CHD) is unknown.

METHODS

We evaluated the association between high levels (>50th percentile) of high-sensitivity C-reactive protein (hsCRP) and of triglycerides to high density lipoprotein ratio (TG/HDL-C) and CHD events by race in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort with 30,239 Black and White participants aged 45 and older.

RESULTS

Participants with both high hsCRP and high TG/HDL-C had highest rates of CHD (HR 1.84; 95% CI: 1.48, 2.29 vs HR 1.52; 95% CI: 1.19, 1.94 in White vs Black participants respectively). Whereas isolated high hsCRP was associated with increased CHD risk in both races (HR 1.68; 95% CI: 1.31, 2.15 and HR 1.43; 95% CI: 1.13, 1.81 for White and Black participants respectively), isolated high TG/HDL was associated with increased CHD risk only in White participants (HR 1.44; 95% CI: 1.15, 1.79 vs HR 1.01; 95% CI: 0.74, 1.38). Further, the effects of high hsCRP and high TG/HDL-C were additive, with inflammation being the driving variable for the association in both races.

CONCLUSION

In both races, higher inflammation combined with adverse lipid profile is associated with greater CHD risk. Therefore, inflammation increases CHD risk in both races whereas dyslipidemia alone is associated with a greater risk in White but not in Black adults. hsCRP testing should be a standard feature of CHD risk assessment, particularly in Black patients.

Pro-Neurotensin/Neuromedin N and Risk of Incident Metabolic Syndrome and Diabetes Mellitus in the REGARDS Cohort

CONTEXT

The peptide neurotensin is implicated in insulin resistance, diabetes mellitus (DM), and cardiovascular disease.

OBJECTIVE

We studied the association of neurotensin's stable precursor, pro-neurotensin/neuromedin N (pro-NT/NMN) with incident metabolic syndrome (MetS) and DM.

METHODS

We included 3772 participants from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study who completed the baseline exam (2003-2007), the follow-up exam (2013-2016), and had pro-NT/NMN measured by immunoassay. Weighted logistic regression models were fitted to incident DM, incident MetS, and each MetS component, separately, incorporating demographics, metabolic risk factors, homeostasis model of insulin resistance (HOMA-IR), and diet scores. Incident MetS was defined by 3 or more harmonized criteria at follow-up in those with fewer than 3 at baseline. Incident DM was defined by use of hypoglycemic drugs/insulin, fasting glucose 126 mg/dL or greater, or random glucose 200 mg/dL or greater in those without these at baseline.

RESULTS

Median (IQR) plasma pro-NT/NMN was 160 pmol/L (118-218 pmol/L). A total of 564 (of 2770 without baseline MetS) participants developed MetS, and 407 (of 3030 without baseline DM) developed DM. Per SD higher log-pro-NT/NMN, the demographic-adjusted odds ratio (OR) and 95% CI of incident MetS was 1.22 (1.11-1.35), 1.16 (1.00-1.35) for incident low high-density lipoprotein (HDL), and 1.25 (1.11-1.40) for incident dysglycemia. The association of pro-NT/NMN with MetS was attenuated in the model adding HOMA-IR (OR per SD log-pro-NT/NMN 1.14; 95% CI, 1.00-1.30). There was no association with incident DM (OR per SD log-pro-NT/NMN 1.06; 95% CI, 0.94-1.19).

CONCLUSION

Pro-NT/NMN was associated with MetS and 2 components, dysglycemia and low HDL, likely explained by insulin resistance.

C-Reactive Protein and Incident Hypertension in Black and White Americans in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Cohort Study

BACKGROUND

More inflammation is associated with greater risk incident hypertension, and Black United States (US) adults have excess burden of hypertension. We investigated whether increased inflammation as quantified by higher C-reactive protein (CRP) explains the excess incidence in hypertension experienced by Black US adults.

METHODS

We included 6,548 Black and White REasons for Geographic and Racial Differences in Stroke (REGARDS) participants without hypertension at baseline (2003-2007) who attended a second visit (2013-2016). Sex-stratified risk ratios (RRs) for incident hypertension at the second exam in Black compared to White individuals were estimated using Poisson regression adjusted for groups of factors known to partially explain the Black-White differences in incident hypertension. We calculated the percent mediation by CRP of the racial difference in hypertension.

RESULTS

Baseline CRP was higher in Black participants. The Black-White RR for incident hypertension in the minimally adjusted model was 1.33 (95% confidence interval 1.22, 1.44) for males and 1.15 (1.04, 1.27) for females. CRP mediated 6.6% (95% confidence interval 2.7, 11.3%) of this association in females and 19.7% (9.8, 33.2%) in males. In females, CRP no longer mediated the Black-White RR in a model including waist circumference and body mass index, while in males the Black-White difference was fully attenuated in models including income, education and dietary patterns.

CONCLUSIONS

Elevated CRP attenuated a portion of the unadjusted excess risk of hypertension in Black adults, but this excess risk was attenuated when controlling for measures of obesity in females and diet and socioeconomic factors in males. Inflammation related to these risk factors might explain part of the Black-White disparity in hypertension.

Association and pathways of birth in the stroke belt on old age dementia and stroke Mortality

This paper uses data from the Diet and Health Study (DHS) to examine associations between being born in a "stroke belt" state and old age stroke and mortality outcomes. Adding to prior work that used administrative data, our paper explores educational and health mechanisms that are both stratified by geography and by mortality outcomes. Using logistic regression, we first replicate earlier findings of elevation in risk of dementia mortality (OR 1.13, CI [1.07, 1.20]) and stroke mortality (OR 1.17, CI [1.07, 1.29]) for white individuals born in a stroke belt state. These associations are largely unaffected by controls for educational attainment or by experiences with surviving a stroke and are somewhat attenuated by controls for self-rated health status in old age. The results suggest a need to consider additional life course mechanisms in order to understand the persistent effects of place of birth on old age mortality patterns.

Atrial fibrillation and risk of incident heart failure with reduced versus preserved ejection fraction

OBJECTIVE

Associations between atrial fibrillation (AF) and heart failure (HF) have been established. We compared the extent to which AF is associated with each primary subtype of HF, with reduced (HFrEF) versus preserved ejection fraction (HFpEF).

METHODS

We included 25 787 participants free of baseline HF from the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort. Baseline AF was ascertained from ECG and self-reported history of physician diagnosis. Incident HF events were determined from physician-adjudicated review of hospitalisation medical records and HF deaths. Based on left ventricular ejection fraction (LVEF) at the time of HF event, HFrEF, HFpEF, and mid-range HF were defined as LVEF <40%, ≥50% and 40%-49%, respectively. Multivariable Cox proportional-hazards models examined the association between AF and HF. The Lunn-McNeil method was used to compare associations of AF with incident HFrEF versus HFpEF.

RESULTS

Over a median of 9 years of follow-up, 1109 HF events occurred (356 HFpEF, 388 HFrEF, 77 mid-range and 288 unclassified). In a model adjusted for sociodemographics, cardiovascular risk factors, and incident coronary heart disease, AF was associated with increased risk of all HF events (HR 1.67, 95% CI 1.38 to 2.01). The associations of AF with HFrEF versus HFpEF events did not differ significantly (HR 1.87 (95% CI 1.38 to 2.54) and HR 1.65 (95% CI 1.20 to 2.28), respectively; p value for difference=0.581). These associations were consistent in sex and race subgroups.

CONCLUSIONS

AF is associated with both HFrEF and HFpEF events, with no significant difference in the strength of association among these subtypes.

A comparison of post-stroke hypertension medication use between US Stroke Belt and Non-Stroke Belt residents

Although hypertension is a contributing factor to higher stroke occurrence in the Stroke Belt, little is known about post‐stroke hypertension medication use in Stroke Belt residents. Through the use of national Behavioral Risk Factor Surveillance System surveys from 2015, 2017, and 2019; we compared unadjusted and adjusted estimates of post‐stroke hypertension medication use by Stroke Belt residence status. Similar levels of post‐stroke hypertension medication use were observed between Stroke Belt residents (OR: 1.09, 95% CI: 0.89, 1.33) and non‐Stroke Belt residents. After adjustment, Stroke Belt residents had 1.14 times the odds of post‐stroke hypertension medication use (95% CI: 0.92, 1.41) compared to non‐Stroke Belt residents. Findings from this study suggest that there is little difference between post‐stroke hypertension medication use between Stroke Belt and non‐Stroke Belt residents. However, further work is needed to assess whether use of other non‐medicinal methods of post‐stroke hypertension control differs by Stroke Belt residence status.

State School Policies as Predictors of Physical and Mental Health: A Natural Experiment in the REGARDS Cohort

We used differences in state school policies as natural experiments to evaluate the joint influence of educational quantity and quality on late-life physical and mental health. Using US Census microsample data, historical measures of state compulsory schooling and school quality (term length, student-teacher ratio, and attendance rates) were combined via regression modeling on a scale corresponding to years of education (policy-predicted years of education (PPYEd)). PPYEd values were linked to individual-level records for 8,920 black and 14,605 white participants aged ≥45 years in the Reasons for Geographic and Racial Differences in Stroke study (2003-2007). Linear and quantile regression models estimated the association between PPYEd and Physical Component Summary (PCS) and Mental Component Summary (MCS) from the Short Form Health Survey. We examined interactions by race and adjusted for sex, birth year, state of residence at age 6 years, and year of study enrollment. Higher PPYEd was associated with better median PCS (β = 1.28, 95% confidence interval (CI): 0.40, 1.49) and possibly better median MCS (β = 0.46, 95% CI: -0.01, 0.94). Effect estimates were higher among black (vs. white) persons (PCS × race interaction, β = 0.22, 95% CI: -0.62, 1.05, and MCS × race interaction, β = 0.18; 95% CI: -0.08, 0.44). When incorporating both school quality and duration, this quasiexperimental analysis found mixed evidence for a causal effect of education on health decades later.

Racial and Sex Differences in the Response to First-Line Antihypertensive Therapy

Objective: As compared to whites, the black population develops hypertension (HTN) at an earlier age, has a greater frequency and severity of HTN, and has poorer control of blood pressure (BP). Traditional practices and treatment efforts have had minor impact on these disparities, with over a 2-fold higher death rate currently for blacks as compared to whites. The University of Mississippi Medical Center (UMC) is located in the southeastern US and the Stroke Belt, which has higher rates of HTN and related diseases as compared to the rest of the country. Methods: We retrospectively analyzed the UMC's Research Data Warehouse, containing >30 million electronic health records from >900,000 patients to determine the initial BP response following the first prescribed antihypertensive drug. Results: There were 5,973 white (45% overall HTN prevalence) and 10,731 black (57% overall HTN prevalence) patients who met criteria for the study. After controlling for age, BMI, and drug dosage, black males were overall less likely to have controlled BP (defined as < 140/90 mmHg) and were associated with smaller falls in BP as compared to whites and black females. Blockers of the renin-angiotensin system (RAS) failed to significantly improve odds of HTN control vs. the untreated group in black patients. However, our data suggests that these drugs do provide significant benefit in blacks when combined with THZ, as compared to untreated and as compared to THZ alone. Conclusion: These data support the use of a single-pill formulation with ARB or ACE inhibitor with a thiazide in blacks for initial first-line HTN therapy and suggests that HTN treatment strategies should consider both race and gender. Our study gives a unique insight into initial antihypertensive responses in actual clinical practice and could have an impact in BP control efficiency in a state with prevalent socioeconomic and racial disparities.

A Cross-Sectional Analysis of Differences in Physical Activity Levels between Stroke Belt and Non-Stroke Belt US Adults

BACKGROUND

The Stroke Belt is a region of the United States with elevated stroke incidence and prevalence of stroke risk factors. Physical inactivity is an important stroke risk factor, but little is known about whether current physical activity levels differ between Stroke Belt and non-Stroke Belt states. In this nationally representative study, we determined whether unadjusted and adjusted physical activity levels differ between the Stroke Belt region and the rest of the United States.

METHODS

Using 2017 Behavioral Risk Factor Surveillance System data, we conducted bivariate analyses to obtain unadjusted physical activity levels in Stroke Belt and non-Stroke Belt states. Logistic regressions that controlled for sociodemographic and stroke risk factors were created to estimate adjusted associations between Stroke Belt residence and physical activity.

RESULTS

A higher percentage of Stroke Belt residents were inactive (Stroke Belt: 35.3%, non-Stroke Belt: 29.4%) and failed to meet physical activity guidelines (Stroke Belt: 53.7%, non-Stroke Belt: 47.8%) compared to non-Stroke Belt residents. Stroke Belt residence was significantly associated with lower odds of meeting physical activity guidelines in a model that adjusted for sociodemographic factors only (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.78-0.91) and one that adjusted for both sociodemographic and stroke risk factors (OR: 0.87, 95% CI: 0.81-0.93).

CONCLUSIONS

The considerably lower physical activity levels and likelihood of meeting physical activity guidelines in Stroke Belt residents compared to their non-Stroke Belt counterparts demonstrates a need for clinician attention and public health interventions to increase regular physical activity as part of a stroke reduction strategy in this region.

Eligibility for cardiovascular risk screening among different ethnic groups: The HELIUS study

BACKGROUND

Ethnic differences in the age-of-onset of cardiovascular risk factors may necessitate ethnic-specific age thresholds to initiate cardiovascular risk screening. Recent European recommendations to modify cardiovascular risk estimates among certain ethnic groups may further increase this necessity.

AIMS

To determine ethnic differences in the age to initiate cardiovascular risk screening, with and without implementation of ethnic-specific modification of estimated cardiovascular risk.

METHODS

We included 18,031 participants of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan background from the HELIUS study (Amsterdam). Eligibility for cardiovascular risk screening was defined as being eligible for blood pressure-lowering treatment, based on a combination of systolic blood pressure, estimated cardiovascular risk, and ethnic-specific conversion of estimated cardiovascular risk as recommended by European cardiovascular disease prevention guidelines. Age-specific proportions of eligibility were determined and compared between ethnic groups via logistic regression analyses.

RESULTS

Dutch men reached the specified threshold to initiate cardiovascular risk screening (according to Dutch guidelines) at an average age of 51.5 years. Among ethnic minority men, this age ranged from 39.8 to 52.4. Among Dutch women, the average age threshold was 53.4. Among ethnic minority women, this age ranged from 36.8 to 49.1. Age-adjusted odds of eligibility were significantly higher than in the Dutch among all subgroups, except among Moroccan men. Applying ethnic-specific conversion factors had minimal effect on the age to initiate screening in all subgroups.

CONCLUSIONS

Most ethnic minority groups become eligible for blood pressure-lowering treatment at a lower age and may therefore benefit from lower age-thresholds to initiate cardiovascular risk screening.

Verbal fluency in a national sample: Telephone administration methods

OBJECTIVES

Describe novel methods for ascertaining verbal fluency in a large national sample of adults, examine demographic factors influencing performance, and compare scores to studies using in-person assessment.

METHODS/DESIGN

Participants were from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal study of stroke in adults aged 45 years and older. Letter and semantic fluency were gathered, using Letter "F" and Animal Naming, via a telephone-based assessment with computer-assisted scoring of digital recordings.

RESULTS

Initial letter and semantic fluency scores were obtained on 18 505 and 18 072 participants, respectively. For both fluency tests, scores were normally distributed. Younger age and more years of education were associated with better performances (p < 0.0001). The mean and standard deviation for matched subgroups, based on age, gender, and education, were quite comparable with scores reported out of samples using an in-person administration format. Telephone-based assessment also allowed for a level of quality control not available via in-person measurement.

CONCLUSIONS

Telephone-based assessment of verbal fluency and computer-assisted scoring programs designed for this study facilitated large-scale data acquisition, storage, and scoring of protocols. The resulting scores have similar characteristics to those obtained by traditional methods. These findings extend validation of cognitive assessment methods, using survey research staff and computer-assisted technology for test administration.

Differences in Risk of Sudden Cardiac Death Between Blacks and Whites

BACKGROUND

Prior studies have consistently demonstrated that blacks have an approximate 2-fold higher incidence of sudden cardiac death (SCD) than whites; however, these analyses have lacked individual-level sociodemographic, medical comorbidity, and behavioral health data.

OBJECTIVES

The purpose of this study was to evaluate whether racial differences in SCD incidence are attributable to differences in the prevalence of risk factors or rather to underlying susceptibility to fatal arrhythmias.

METHODS

The Reasons for Geographic and Racial Differences in Stroke study is a prospective, population-based cohort of adults from across the United States. Associations between race and SCD defined per National Heart, Lung, and Blood Institute criteria were assessed.

RESULTS

Among 22,507 participants (9,416 blacks and 13,091 whites) without a history of clinical cardiovascular disease, there were 174 SCD events (67 whites and 107 blacks) over a median follow-up of 6.1 years (interquartile range: 4.6 to 7.3 years). The age-adjusted SCD incidence rate (per 1,000 person-years) was higher in blacks (1.8; 95% confidence interval [CI]: 1.4 to 2.2) compared with whites (0.7; 95% CI: 0.6 to 0.9), with an unadjusted hazard ratio of 2.35; 95% CI: 1.74 to 3.20. The association of black race with SCD risk remained significant after adjustment for sociodemographics, comorbidities, behavioral measures of health, intervening cardiovascular events, and competing risks of non-SCD mortality (hazard ratio: 1.97; 95% CI: 1.39 to 2.77).

CONCLUSIONS

In a large biracial population of adults without a history of cardiovascular disease, SCD rates were significantly higher in blacks as compared with whites. These racial differences were not fully explained by demographics, adverse socioeconomic measures, cardiovascular risk factors, and behavioral measures of health.

Evidence of chronic kidney disease in veterans with incident diabetes mellitus

While chronic kidney disease (CKD) is regularly evaluated among patients with diabetes, kidney function may be significantly impaired before diabetes is diagnosed. Moreover, disparities in the severity of CKD in such a population are likely. This study evaluated the extent of CKD in a national cohort of 36,764 US veterans first diagnosed with diabetes between 2003 and 2013 and prior to initiating oral antidiabetic therapy. Evidence of CKD (any stage) at the time of diabetes diagnosis was determined using eGFR and urine-albumin-creatinine ratios, the odds of which were assessed using logistic regression controlling for patient characteristics. CKD was evident in 31.6% of veterans prior to being diagnosed with diabetes (age and gender standardized rates: 241.8 per 1,000 adults [overall] and 247.7 per 1,000 adult males), over half of whom had at least moderate kidney disease (stage 3 or higher). The odds of CKD tended to increase with age (OR: 1.88; 95% CI: 1.82-1.93), hemoglobin A1C (OR: 1.05; 95% CI: 1.04-1.06), systolic blood pressure (OR: 1.04; 95% CI: 1.027-1.043), and BMI (OR: 1.016; 95% CI: 1.011-1.020). Both Asian Americans (OR: 1.53; 95% CI: 1.15-2.04) and African Americans (OR: 1.11; 95% CI: 1.03-1.20) had higher adjusted odds of CKD compared to whites, and prevalence was highest in the Upper Midwest and parts of the Mid-South. Results suggest that evidence of CKD is common among veterans before a diabetes diagnosis, and certain populations throughout the country, such as minorities, may be afflicted at higher rates.

Association Between Birth in a High Stroke Mortality State, Race, and Risk of Dementia

Importance

Birth in a group of predominantly southern US states is robustly linked to increased stroke risk. Given the role of cerebrovascular disease in dementia risk, geographic patterning may also occur for dementia incidence.

Objective

To determine whether birth in 9 high stroke mortality states (HSMSs) is associated with dementia in a diverse cohort of individuals living in Northern California.

Design, Setting, and Participants

An observational cohort study included 7423 members of Kaiser Permanente Northern California (KPNC), an integrated health care delivery system, with health survey and clinical examination data available. Data were collected between 1964 and 1973 when the individuals were middle-aged and 1996 and 2015 when participants were in later life.

Exposures

Self-reported state of birth in an HSMS (top quintile of states for stroke mortality).

Main Outcomes and Measures

Dementia diagnoses obtained from electronic health records from January 1, 1996, to October 15, 2015. Place of birth, race, educational level, and midlife vascular risk factors data were collected between 1964 and 1973.

Results

Of the 7423 persons included in the analysis, 4049 (54.5%) were women; 1354 (18.2%) were black. The mean (SD) age of study participants at their first visit between 1963 and 1974 was 42.94 (1.73) years and mean (SD) age at the beginning of follow-up for dementia in 1996 was 71.14 (2.72) years. Dementia was diagnosed in 2254 (30.4%) of the participants and was more common among those born in an HSMS than those born outside of one (455 [39.0%] vs 1799 [28.8%]). Birth in an HSMS was 9.6 times more common for black participants (795 [58.7%]) than nonblack participants (371 [6.1%]). Overall, birth in an HSMS was associated with a 28% higher risk of dementia (adjusted hazard ratio [aHR], 1.28; 95% CI, 1.13-1.46) adjusted for age, sex, and race. Compared with nonblack persons born outside of an HSMS, black individuals born in an HSMS had the highest dementia risk (aHR, 1.67; 95% CI, 1.48-1.88), followed by black individuals not born in an HSMS (aHR, 1.48; 95% CI, 1.28-1.72), and nonblack persons born in an HSMS had a 46% increased risk (aHR, 1.46; 95% CI, 1.23-1.74). Cumulative 20-year dementia risks at age 65 years were 30.13% (95% CI, 26.87%-32.93%) and 21.80% (95% CI, 20.51%-22.91%) for individuals born in and outside an HSMS, respectively.

Conclusions and Relevance

To our knowledge, this is the first study to date of place of birth and incident dementia and shows increased risk for individuals born in an HSMS, even though all participants subsequently resided in California. Birth in an HSMS was common among black participants. Place of birth has enduring consequences for dementia risk and may be a major contributor to racial disparities in dementia.

Albuminuria, kidney function, and sudden cardiac death: Findings from The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

BACKGROUND

Moderate-to-severe kidney disease increases risk for sudden cardiac death (SCD). Limited studies have evaluated how mild degrees of kidney dysfunction impact SCD risk.

OBJECTIVE

The purpose of this study was to evaluate the association of albuminuria, which is one of the earliest biomarkers of kidney injury, and SCD.

METHODS

The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study is a prospective, population-based cohort of U.S. adults. Associations between albuminuria, which is categorized using urinary albumin-to-creatinine ratio (ACR), estimated glomerular filtration rate (eGFR), and SCD were assessed independently and in combination.

RESULTS

After median follow-up of 6.1 years, we identified 335 SCD events. Compared to participants with ACR <15 mg/g, those with higher levels had an elevated adjusted risk of SCD (ACR 15-30 mg/g, hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.11-2.11; ACR >30 mg/g, HR 1.56, 95% CI 1.17-2.11). In contrast, compared to the group with eGFR >90 mL/min/1.73 m2, the adjusted risk of SCD was significantly elevated only among those with eGFR <45 mL/min/1.73 m2 (HR 1.66, 95% CI 1.06-2.58). The subgroup with eGFR <45 mL/min/1.73 m2 (n = 1003) comprised 3.7% of REGARDS, whereas ACR 15-30 mg/g (n = 3089 [11.3%]) and ACR >30 mg/g (n = 4040 [14.8%] were far more common. In the analysis that combined ACR and eGFR categories, albuminuria consistently identified individuals with eGFR ≥60 mLmin/1.73 m2 who were at significantly increased SCD risk.

CONCLUSION

Low levels of kidney injury as measured by ACR predict an increase in SCD risk.

Machine Learning Data Imputation and Classification in a Multicohort Hypertension Clinical Study

Health-care initiatives are pushing the development and utilization of clinical data for medical discovery and translational research studies. Machine learning tools implemented for Big Data have been applied to detect patterns in complex diseases. This study focuses on hypertension and examines phenotype data across a major clinical study called Minority Health Genomics and Translational Research Repository Database composed of self-reported African American (AA) participants combined with related cohorts. Prior genome-wide association studies for hypertension in AAs presumed that an increase of disease burden in susceptible populations is due to rare variants. But genomic analysis of hypertension, even those designed to focus on rare variants, has yielded marginal genome-wide results over many studies. Machine learning and other nonparametric statistical methods have recently been shown to uncover relationships in complex phenotypes, genotypes, and clinical data. We trained neural networks with phenotype data for missing-data imputation to increase the usable size of a clinical data set. Validity was established by showing performance effects using the expanded data set for the association of phenotype variables with case/control status of patients. Data mining classification tools were used to generate association rules.

The impact of the combination of income and education on the incidence of coronary heart disease in the prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study

BACKGROUND

We investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study.

METHODS

The REasons for Geographic And Racial Differences in Stroke study recruited 30,239 black and white community-dwelling adults between 2003 and 2007 and collected participant-reported and in-home physiologic variables at baseline, with expert adjudicated CHD endpoints during follow-up. Mutually exclusive income-education groups were: low income (annual household income <$35,000)/low education (< high school), low income/high education, high income/low education, and high income/high education. Cox models estimated hazard ratios (HR) for incident CHD for each exposure group, examining differences by age group.

RESULTS

At baseline, 24,461 participants free of CHD experienced 809 incident CHD events through December 31, 2011 (median follow-up 6.0 years; interquartile range 4.5-7.3 years). Those with low income/low education had the highest incidence of CHD (10.1 [95% CI 8.4-12.1]/1000 person-years). After full adjustment, those with low income/low education had higher risk of incident CHD (HR 1.42 [95% CI: 1.14-1.76]) than those with high income/high education, but findings varied by age. Among those aged <65 years, compared with those reporting high income/high education, risk of incident CHD was significantly higher for those reporting low income/low education and low income/high education (adjusted HR 2.07 [95% CI 1.42-3.01] and 1.69 [95% CI 1.30-2.20], respectively). Those aged ≥ 65 years, risk of incident CHD was similar across income-education groups after full adjustment.

CONCLUSION

For younger individuals, low income, regardless of education, was associated with higher risk of CHD, but not observed for ≥ 65 years. Findings suggest that for younger participants, education attainment may not overcome the disadvantage conferred by low income in terms of CHD risk, whereas among those ≥ 65 years, the independent effects of income and education are less pronounced.

Apparent Treatment-resistant Hypertension Among Individuals with History of Stroke or Transient Ischemic Attack

BACKGROUND

Blood pressure control is a paramount goal in secondary stroke prevention; however, high prevalence of uncontrolled blood pressure and use of multiple antihypertensive medication classes in stroke patients suggest this goal is not being met. We determined the prevalence and factors associated with apparent treatment-resistant hypertension in persons with/without stroke or transient ischemic attack.

METHODS

Data came from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based cohort of 30,239 black and white adults aged ≥45 years, enrolled 2003-2007, restricted to 11,719 participants with treated hypertension. Apparent treatment-resistant hypertension was defined as (1) uncontrolled blood pressure (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) with ≥3 antihypertensive medication classes, or (2) use of ≥4 antihypertensive medication classes, regardless of blood pressure level. Poisson regression was used to calculate characteristics associated with apparent treatment-resistant hypertension.

RESULTS

Among hypertensive participants, prevalence of apparent treatment-resistant hypertension was 24.9% (422 of 1694) and 17.0% (1708 of 10,025) in individuals with and without history of stroke or transient ischemic attack, respectively. After adjustment for cardiovascular risk factors, the prevalence ratio for apparent treatment-resistant hypertension for those with versus without stroke or transient ischemic attack was 1.14 (95% confidence interval, 1.03-1.27). Among hypertensive participants with stroke or transient attack, male sex, black race, larger waist circumference, longer duration of hypertension, and reduced kidney function were associated with apparent treatment-resistant hypertension.

CONCLUSIONS

The high prevalence of apparent treatment-resistant hypertension among hypertensive persons with history of stroke or transient ischemic attack suggests the need for more individualized blood pressure monitoring and management.

Race-sex differences in the management of hyperlipidemia: the REasons for Geographic and Racial Differences in Stroke study

BACKGROUND

Lipid management is less aggressive in blacks than whites and women than men.

PURPOSE

To examine whether differences in lipid management for race-sex groups compared to white men are due to factors influencing health services utilization or physician prescribing patterns.

METHODS

Because coronary heart disease (CHD) risk influences physician prescribing, Adult Treatment Panel III CHD risk categories were constructed using baseline data from REasons for Geographic And Racial Differences in Stroke study participants (recruited 2003-2007). Prevalence, awareness, treatment, and control of hyperlipidemia were examined for race-sex groups across CHD risk categories. Multivariable models conducted in 2013 estimated prevalence ratios adjusted for predisposing, enabling, and need factors influencing health services utilization.

RESULTS

The analytic sample included 7,809 WM; 7,712 white women; 4,096 black men; and 6,594 black women. Except in the lowest risk group, black men were less aware of hyperlipidemia than others. A higher percentage of white men in the highest risk group was treated (83.2%) and controlled (72.8%) than others (treatment, 68.6%-72.1%; control, 52.2%-65.5%), with black women treated and controlled the least. These differences remained significant after adjustment for predisposing, enabling, and need factors. Stratified analyses demonstrated that treatment and control were lower for other race-sex groups relative to white men only in the highest risk category.

CONCLUSIONS

Hyperlipidemia was more aggressively treated and controlled among white men compared with white women, black men, and especially black women among those at highest risk for CHD. These differences were not attributable to factors influencing health services utilization.

Common mechanisms of Alzheimer's disease and ischemic stroke: the role of protein kinase C in the progression of age-related neurodegeneration

Ischemic stroke and Alzheimer's disease (AD), despite being distinct disease entities, share numerous pathophysiological mechanisms such as those mediated by inflammation, immune exhaustion, and neurovascular unit compromise. An important shared mechanistic link is acute and chronic changes in protein kinase C (PKC) activity. PKC isoforms have widespread functions important for memory, blood-brain barrier maintenance, and injury repair that change as the body ages. Disease states accelerate PKC functional modifications. Mutated forms of PKC can contribute to neurodegeneration and cognitive decline. In some cases the PKC isoforms are still functional but are not successfully translocated to appropriate locations within the cell. The deficits in proper PKC translocation worsen stroke outcome and amyloid-β toxicity. Cross talk between the innate immune system and PKC pathways contribute to the vascular status within the aging brain. Unfortunately, comorbidities such as diabetes, obesity, and hypertension disrupt normal communication between the two systems. The focus of this review is to highlight what is known about PKC function, how isoforms of PKC change with age, and what additional alterations are consequences of stroke and AD. The goal is to highlight future therapeutic targets that can be applied to both the treatment and prevention of neurologic disease. Although the pathology of ischemic stroke and AD are different, the similarity in PKC responses warrants further investigation, especially as PKC-dependent events may serve as an important connection linking age-related brain injury.

Disparities in the burden, outcomes, and care of chronic kidney disease

PURPOSE OF REVIEW

Racial, ethnic and socioeconomic disparities in chronic kidney disease (CKD) have been documented for decades, yet little progress has been made in mitigating them. Several recent studies offer new insights into the root causes of these disparities, point to areas in which future research is warranted, and identify opportunities for changes in policy and clinical practice.

RECENT FINDINGS

Recently published evidence suggests that geographic disparities in CKD prevalence exist and vary by race. CKD progression is more rapid for racial and ethnic minority groups compared with whites and may be largely, but not completely, explained by genetic factors. Stark socioeconomic disparities in outcomes for dialysis patients exist and vary by race, place of residence, and treatment facility. Disparities in access to living kidney donation may be driven primarily by the socioeconomic status of the donor as opposed to recipient factors.

SUMMARY

Recent studies highlight opportunities to eliminate disparities in CKD, including efforts to direct resources to areas and populations where disparities are most prevalent, efforts to understand how to best use emerging information on the contribution of genetic factors to disparities, and continued work to identify modifiable environmental, social, and behavioral factors for targeted interventions among high-risk populations.

Aging, the metabolic syndrome, and ischemic stroke: redefining the approach for studying the blood-brain barrier in a complex neurological disease

The blood-brain barrier (BBB) has many important functions in maintaining the brain's immune-privileged status. Endothelial cells, astrocytes, and pericytes have important roles in preserving vasculature integrity. As we age, cell senescence can contribute to BBB compromise. The compromised BBB allows an influx of inflammatory cytokines to enter the brain. These cytokines lead to neuronal and glial damage. Ultimately, the functional changes within the brain can cause age-related disease. One of the most prominent age-related diseases is ischemic stroke. Stroke is the largest cause of disability and is third largest cause of mortality in the United States. The biggest risk factors for stroke, besides age, are results of the metabolic syndrome. The metabolic syndrome, if unchecked, quickly advances to outcomes that include diabetes, hypertension, cardiovascular disease, and obesity. The contribution from these comorbidities to BBB compromise is great. Some of the common molecular pathways activated include: endoplasmic reticulum stress, reactive oxygen species formation, and glutamate excitotoxicity. In this chapter, we examine how age-related changes to cells within the central nervous system interact with comorbidities. We then look at how comorbidities lead to increased risk for stroke through BBB disruption. Finally, we discuss key molecular pathways of interest with a focus on therapeutic targets that warrant further investigation.

Blood pressure levels and stroke: J-curve phenomenon?

The blood pressure J-curve discussion has been ongoing for more than 30 years, yet there are still questions in need of definitive answers. On one hand, existing antihypertensive therapy studies provide strong evidence for J-curve-shaped relationships between both diastolic and systolic blood pressure and primary outcomes in the general hypertensive patient population, as well as in high-risk populations, including subjects with coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and the elderly. On the other hand, we have very limited data on the relationship between systolic and diastolic blood pressure and stroke prevention. Moreover, it seems that this outcome is more a case of “the lower the better.” Further large, well-designed studies are necessary in order to clarify this issue, especially as existing available studies are observational, and randomized trials either did not have or lost statistical power and were thus inconclusive.

Progress of health plans toward meeting the million hearts clinical target for high blood pressure control - United States, 2010-2012

High blood pressure is a major cardiovascular disease risk factor and contributed to >362,895 deaths in the United States during 2010. Approximately 67 million persons in the United States have high blood pressure, and only half of those have their condition under control. An estimated 46,000 deaths could be avoided annually if 70% of patients with high blood pressure were treated according to published guidelines. To assess blood pressure control among persons with health insurance, CDC and the National Committee for Quality Assurance (NCQA) examined data in the 2010-2012 Healthcare Effectiveness Data and Information Set (HEDIS). In 2012, approximately 113 million adults aged 18-85 years were covered by health plans measured by HEDIS. The HEDIS controlling blood pressure (CBP) performance measure is the proportion of enrollees with a diagnosis of high blood pressure confirmed in their medical record whose blood pressure is controlled. Overall, only 64% of enrollees with diagnosed high blood pressure in HEDIS-reporting plans had documentation that their blood pressure was controlled. Although these findings signal that additional work is needed to meet the 70% target, modest improvements since 2010, coupled with focused efforts, might make it achievable.

Incident ESRD and treatment-resistant hypertension: the reasons for geographic and racial differences in stroke (REGARDS) study

BACKGROUND

Studies suggest that treatment-resistant hypertension is common and increasing in prevalence among US adults. Although hypertension is a risk factor for end-stage renal disease (ESRD), few data are available for the association between treatment-resistant hypertension and ESRD risk.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

We analyzed data from 9,974 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants treated for hypertension without ESRD at baseline.

PREDICTOR

Treatment-resistant hypertension was defined as uncontrolled blood pressure (BP) with concurrent use of 3 antihypertensive medication classes including a diuretic or use of 4 or more antihypertensive medication classes including a diuretic regardless of BP.

OUTCOME

Incident ESRD was identified by linkage of REGARDS Study participants with the US Renal Data System.

MEASUREMENTS

During a baseline in-home study visit, BP was measured twice and classes of antihypertensive medication being taken were determined by pill bottle inspection.

RESULTS

During a median follow-up of 6.4 years, there were 152 incident cases of ESRD (110 ESRD cases among 2,147 with treatment-resistant hypertension and 42 ESRD cases among 7,827 without treatment-resistant hypertension). The incidence of ESRD per 1,000 person-years for hypertensive participants with and without treatment-resistant hypertension was 8.86 (95% CI, 7.35-10.68) and 0.88 (95% CI, 0.65-1.19), respectively. After multivariable adjustment, the HR for ESRD comparing hypertensive participants with versus without treatment-resistant hypertension was 6.32 (95% CI, 4.30-9.30). Of participants who developed incident ESRD during follow-up, 72% had treatment-resistant hypertension at baseline.

LIMITATIONS

BP, estimated glomerular filtration rate, and albuminuria assessed at a single time.

CONCLUSIONS

Individuals with treatment-resistant hypertension are at increased risk for ESRD. Appropriate clinical management strategies are needed to treat treatment-resistant hypertension in order to preserve kidney function in this high-risk group.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

The COSEHC™ Global Vascular Risk Management quality improvement program: first follow-up report

The Global Vascular Risk Management (GVRM) Study is a 5-year prospective observational study of 87,863 patients (61% females) with hypertension and associated cardiovascular risk factors began January 1, 2010. Data are gathered electronically and cardiovascular risk is evaluated using the Consortium for Southeastern Hypertension Control™ (COSEHC™)-11 risk score. Here, we report the results obtained at the completion of 33 months since study initiation. De-identified electronic medical records of enrolled patients were used to compare clinical indicators, antihypertensive medication usage, and COSEHC™ risk scores across sex and diabetic status subgroups. The results from each subgroup, assessed at baseline and at regular follow-up periods, are reported since the project initiation. Inference testing was performed to look for statistically significant differences between goal attainments rates between sexes. At-goal rates for systolic blood pressure (SBP) were improved during the 33 months of the study, with females achieving higher goal rates when compared to males. On the other hand, at-goal control rates for total and low-density lipoprotein (LDL) cholesterol (chol) were better in males compared to females. Diabetic patients had lower at-goal rates for SBP and triglycerides but higher rates for LDL-chol. The LDL-chol at-goal rates were higher for males, while high-density lipoprotein (HDL)-chol rates were higher for females. Utilization of antihypertensive medications was similar during and after the baseline period for both men and women. Patients taking two or more antihypertensive medications had higher mean COSEHC™-11 scores compared to those on monotherapy. With treatment, hypertensive patients can reach SBP and cholesterol goals; however, population-wide improvement in treatment goal adherence continues to be a challenge for physicians. The COSEHC™ GVRM Study shows, however, that continuous monitoring and feedback to physicians of accurate longitudinal data is an effective tool in achieving better control rates of cardiovascular risk factors.

Effect of duration and age at exposure to the Stroke Belt on incident stroke in adulthood

OBJECTIVE

To assess whether there are differences in the strength of association with incident stroke for specific periods of life in the Stroke Belt (SB).

METHODS

The risk of stroke was studied in 24,544 black and white stroke-free participants, aged 45+, in the Reasons for Geographic and Racial Differences in Stroke study, a national population-based cohort enrolled 2003-2007. Incident stroke was defined as first occurrence of stroke over an average 5.8 years of follow-up. Residential histories (city/state) were obtained by questionnaire. SB exposure was quantified by combinations of SB birthplace and current residence and proportion of years in SB during discrete age categories (0-12, 13-18, 19-30, 31-45, last 20 years) and entire life. Proportional hazards models were used to establish association of incident stroke with indices of exposure to SB, adjusted for demographic, socioeconomic (SES), and stroke risk factors.

RESULTS

In the demographic and SES models, risk of stroke was significantly associated with proportion of life in the SB and with all other exposure periods except birth, ages 31-45, and current residence. The strongest association was for the proportion of the entire life in SB. After adjustment for risk factors, the risk of stroke remained significantly associated only with proportion of residence in SB in adolescence (hazard ratio 1.17, 95% confidence interval 1.00-1.37).

CONCLUSIONS

Childhood emerged as the most important period of vulnerability to SB residence as a predictor of future stroke. Improvement in childhood health circumstances should be considered as part of long-term health improvement strategies in the SB.

Self-reported hypertension and use of antihypertensive medication among adults - United States, 2005-2009

Hypertension affects one third of adults in the United States and is a major risk factor for heart disease and stroke. A previous report found differences in the prevalence of hypertension among racial/ethnic populations in the United States; blacks had a higher prevalence of hypertension, and Hispanics had the lowest use of antihypertensive medication. Recent variations in geographic differences in hypertension prevalence in the United States are less well known. To assess state-level trends in self-reported hypertension and treatment among U.S. adults, CDC analyzed 2005-2009 data from the Behavioral Risk Factor Surveillance System (BRFSS). The results indicated wide variation among states in the prevalence of self-reported diagnosed hypertension and use of antihypertensive medications. In 2009, the age-adjusted prevalence of self-reported hypertension ranged from 20.9% in Minnesota to 35.9% in Mississippi. The proportion reporting use of antihypertensive medications among those who reported hypertension ranged from 52.3% in California to 74.1% in Tennessee. From 2005 to 2009, nearly all states had an increased prevalence of self-reported hypertension, with percentage-point increases ranging from 0.2 for Virginia (from 26.9% to 27.1%) to 7.0 for Kentucky (from 27.5% to 34.5%). Overall, from 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those reporting hypertension, the proportion using antihypertensive medications increased from 61.1% to 62.6%. Increased knowledge of the differences in self-reported prevalence of hypertension and use of antihypertensive medications by state can help in guiding programs to prevent heart disease, stroke, and other complications of uncontrolled hypertension, including those conducted by state and local public health agencies and health-care providers.

Association of duration of residence in the southeastern United States with chronic kidney disease may differ by race: the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study

Background

Prior evidence suggests that longer duration of residence in the southeastern United States is associated with higher prevalence of diabetes and hypertension. We postulated that a similar association would exist for chronic kidney disease (CKD).

Methods

In a national population-based cohort study that enrolled 30,239 men and women ≥ 45 years old (42% black/58% white; 56% residing in the Southeast) between 2003 and 2007, lifetime southeastern residence duration was calculated and categorized [none (0%), less than half (>0-< 50%), half or more (≥50-< 100%), and all (100%)]. Prevalent albuminuria (single spot urinary albumin:creatinine ratio of ≥30 mg/g) and reduced kidney function (estimated glomerular filtration rate <60 ml/min/1.73 m²) were defined at enrollment. Incident end-stage renal disease (ESRD) during follow-up was identified through linkage to United States Renal Data System.

Results

White and black participants most often reported living their entire lives outside (35.7% and 27.0%, respectively) or inside (27.9% and 33.8%, respectively) the southeastern United States. The prevalence of neither albuminuria nor reduced kidney function was statistically significantly associated with southeastern residence duration, in either race. ESRD incidence was not statistically significantly associated with all vs. none southeastern residence duration (HR = 0.50, 95% CI, 0.22-1.14) among whites, whereas blacks with all vs. none exposure showed increased risk of ESRD (HR = 1.63, 95% CI, 1.02-2.63; P_{raceXduration} = 0.011).

Conclusions

These data suggest that blacks but not whites who lived in the Southeast their entire lives were at increased risk of ESRD, but we found no clear geographic pattern for earlier-stage CKD.

Behavioral mechanisms, elevated depressive symptoms, and the risk for myocardial infarction or death in individuals with coronary heart disease: the REGARDS (Reason for Geographic and Racial Differences in Stroke) study

OBJECTIVES

The aim of this study was to determine whether behavioral mechanisms explain the association between depressive symptoms and myocardial infarction (MI) or death in individuals with coronary heart disease (CHD).

BACKGROUND

Depressive symptoms are associated with increased morbidity and mortality in individuals with CHD, but it is unclear how much behavioral mechanisms contribute to this association.

METHODS

The study included 4,676 participants with a history of CHD. Elevated depressive symptoms were defined as scores ≥4 on the Center for Epidemiologic Studies Depression 4-item Scale. The primary outcome was definite/probable MI or death from any cause. Incremental proportional hazards models were constructed by adding demographic data, comorbidities, and medications and then 4 behavioral mechanisms (alcohol use, smoking, physical inactivity, and medication non-adherence).

RESULTS

At baseline, 638 (13.6%) participants had elevated depressive symptoms. Over a median 3.8 years of follow up, 125 of 638 (19.6%) participants with and 657 of 4,038 (16.3%) without elevated depressive symptoms had events. Higher risk of MI or death was observed for elevated depressive symptoms after adjusting for demographic data (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.15 to 1.72) but was no longer significant after adjusting for behavioral mechanisms (HR: 1.14, 95% CI: 0.93 to 1.40). The 4 behavioral mechanisms together significantly attenuated the risk for MI or death conveyed by elevated depressive symptoms (-36.9%, 95% CI: -18.9 to -119.1%), with smoking (-17.6%, 95% CI: -6.5% to -56.0%) and physical inactivity (-21.0%, 95% CI: -9.7% to -61.1%) having the biggest explanatory roles.

CONCLUSIONS

Our findings suggest potential roles for behavioral interventions targeting smoking and physical inactivity in patients with CHD and comorbid depression.

Association of race and sex with risk of incident acute coronary heart disease events

CONTEXT

It is unknown whether long-standing disparities in incidence of coronary heart disease (CHD) among US blacks and whites persist.

OBJECTIVE

To examine incident CHD by black and white race and by sex.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 24,443 participants without CHD at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, who resided in the continental United States and were enrolled between 2003 and 2007 with follow-up through December 31, 2009.

MAIN OUTCOME MEASURE

Expert-adjudicated total (fatal and nonfatal) CHD, fatal CHD, and nonfatal CHD (definite or probable myocardial infarction [MI]; very small non-ST-elevation MI [NSTEMI] had peak troponin level <0.5 μg/L).

RESULTS

Over a mean (SD) of 4.2 (1.5) years of follow-up, 659 incident CHD events occurred (153 in black men, 138 in black women, 254 in white men, and 114 in white women). Among men, the age-standardized incidence rate per 1000 person-years for total CHD was 9.0 (95% CI, 7.5-10.8) for blacks vs 8.1 (95% CI, 6.9-9.4) for whites; fatal CHD: 4.0 (95% CI, 2.9-5.3) vs 1.9 (95% CI, 1.4-2.6), respectively; and nonfatal CHD: 4.9 (95% CI, 3.8-6.2) vs 6.2 (95% CI, 5.2-7.4). Among women, the age-standardized incidence rate per 1000 person-years for total CHD was 5.0 (95% CI, 4.2-6.1) for blacks vs 3.4 (95% CI, 2.8-4.2) for whites; fatal CHD: 2.0 (95% CI, 1.5-2.7) vs 1.0 (95% CI, 0.7-1.5), respectively; and nonfatal CHD: 2.8 (95% CI, 2.2-3.7) vs 2.2 (95% CI, 1.7-2.9). Age- and region-adjusted hazard ratios for fatal CHD among blacks vs whites was near 2.0 for both men and women and became statistically nonsignificant after multivariable adjustment. The multivariable-adjusted hazard ratio for incident nonfatal CHD for blacks vs whites was 0.68 (95% CI, 0.51-0.91) for men and 0.81 (95% CI, 0.58-1.15) for women. Of the 444 nonfatal CHD events, 139 participants (31.3%) had very small NSTEMIs.

CONCLUSIONS

The higher risk of fatal CHD among blacks compared with whites was associated with cardiovascular disease risk factor burden. These relationships may differ by sex.

Association of prediabetes and diabetes with stroke symptoms: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

OBJECTIVE

Stroke symptoms among individuals reporting no physician diagnosis of stroke are associated with an increased risk of future stroke. Few studies have assessed whether individuals with diabetes or prediabetes, but no physician diagnosis of stroke, have an increased prevalence of stroke symptoms.

RESEARCH DESIGN AND METHODS

This study included 25,696 individuals aged ≥ 45 years from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who reported no history of stroke or transient ischemic attack at baseline (2003-2007). Glucose measurements, medication use, and self-reported physician diagnosis were used to categorize participants into diabetes, prediabetes, or normal glycemia groups. The presence of six stroke symptoms was assessed using a validated questionnaire.

RESULTS

The prevalence of any stroke symptom was higher among participants with diabetes (22.7%) compared with those with prediabetes (15.6%) or normal glycemia (14.9%). In multivariable models, diabetes was associated with any stroke symptom (prevalence odds ratio [POR] 1.28 [95% CI 1.18-1.39]) and two or more stroke symptoms (1.26 [1.12-1.43]) compared with normal glycemia. In analyses of individual stroke symptoms, diabetes was associated with numbness (1.15 [1.03-1.29]), vision loss (1.52 [1.31-1.76]), half-vision loss (1.54 [1.30-1.84]), and lost ability to understand people (1.34 [1.12-1.61]) after multivariable adjustment. No association was present between prediabetes and stroke symptoms.

CONCLUSIONS

In this population-based study, almost one in four individuals with diabetes reported stroke symptoms, which suggests that screening for stroke symptoms in diabetes may be warranted.

Epidemiology, geography and chronic kidney disease

PURPOSE OF REVIEW

Geographic variation in the occurrence and outcomes of chronic kidney disease (CKD) is major area of study in epidemiology and health services and outcomes research. Geographic attributes may be as diverse as the physical, socioeconomic, and medical care characteristics of an environment. This review summarizes the recent literature pertaining to geographic risk factors and CKD.

RECENT FINDINGS

Studies have reported on the association between CKD and physical attributes of place (ambient temperature and altitude), the impact of disasters on CKD populations, new diseases characterized by regional localization, national variations in CKD incidence and prevalence, regional variation in end-stage renal disease incidence, residential mobility and CKD risk factors, and geographic variations in CKD care. The emerging role of tools for geospatial studies - including multilevel analytical designs, which reduce the likelihood of an ecologically biased inference, and geographic information systems, which allow the simultaneous linkage, analysis, and mapping of geospatial data - is illustrated by these studies.

SUMMARY

Our understanding of the occurrence and outcomes of CKD will continue to be expanded and deepened by the explicit study of attributes associated with place as a potential risk factor. Many of the studies reviewed are largely hypothesis generating, and a better understanding of the role of geography in the study of CKD awaits investigations that probe the mechanisms that link attributes of place to disease processes.

Epidemiology and prevention of stroke: a worldwide perspective

This paper reviews how epidemiological studies during the last 5 years have advanced our knowledge in addressing the global stroke epidemic. The specific objectives were to review the current evidence supporting management of ten major modifiable risk factors for prevention of stroke: hypertension, current smoking, diabetes, obesity, poor diet, physical inactivity, atrial fibrillation, excessive alcohol consumption, abnormal lipid profile and psychosocial stress/depression.

Association between family risk of stroke and myocardial infarction with prevalent risk factors and coexisting diseases

BACKGROUND AND PURPOSE

Familial transmission of stroke and myocardial infarction (MI) is partially mediated by transmission of cerebrovascular and cardiovascular risk factors. We examined relationships between family risk of stroke and MI with risk factors for these phenotypes.

METHODS

A cross-sectional association between the stratified log-rank family score for stroke and MI with prevalent risk factors was assessed in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort.

RESULTS

Individuals in the fourth quartile of stratified log-rank family scores for stroke were more likely to have prevalent risk factors including hypertension (OR, 1.43; 95% CI, 1.30-1.58), left ventricular hypertrophy (OR, 1.42; 95% CI, 1.16-1.42), diabetes (OR, 1.26; 95% CI, 1.12-1.43), and atrial fibrillation (OR, 1.23; 95% CI, 1.03-1.45) compared with individuals in the first quartile. Likewise, individuals in the fourth quartile of stratified log-rank family scores for MI were more likely to have prevalent risk factors including hypertension (OR, 1.57; 95% CI, 1.27-1.94) and diabetes (OR, 1.29; 95% CI, 1.12-1.43) than the first quartile. In contrast to stroke, the family risk score for MI was associated with dyslipidemia (OR, 1.38; 95% CI, 1.23-1.55) and overweight/obesity (OR, 1.22; 95% CI, 1.10-1.37).

CONCLUSIONS

Family risk of stroke and MI is strongly associated with the majority of risk factors associated with each disease. Family history and genetic studies separating nonspecific contributions of intermediate phenotypes from specific contributions to the disease phenotype may lead to a more thorough understanding of transmission for these complex disorders.

Vascular risk factors and cognitive impairment in a stroke-free cohort

OBJECTIVE

To examine vascular risk factors, as measured by the Framingham Stroke Risk Profile (FSRP), to predict incident cognitive impairment in a large, national sample of black and white adults age 45 years and older.

METHODS

Participants included subjects without stroke at baseline from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study with at least 2 cognitive function assessments during the follow-up (n = 23,752). Incident cognitive impairment was defined as decline from a baseline score of 5 or 6 (of possible 6 points) to the most recent follow-up score of 4 or less on the Six-item Screener (SIS). Subjects with suspected stroke during follow-up were censored.

RESULTS

During a mean follow-up of 4.1 years, 1,907 participants met criteria for incident cognitive impairment. Baseline FSRP score was associated with incident cognitive impairment. An adjusted model revealed that male sex (odds ratio [OR] = 1.59, 95% confidence interval [CI] 1.43-1.77), black race (OR = 2.09, 95% CI 1.88-2.35), less education (less than high school graduate vs college graduate, OR = 2.21, 95% CI 1.88-2.60), older age (10-year increments, OR = 2.11, per 10-year increase in age, 95% CI 2.05-2.18), and presence of left ventricular hypertrophy (LVH, OR = 1.29, 95% CI 1.06-1.58) were related to development of cognitive impairment. When LVH was excluded from the model, elevated systolic blood pressure was related to incident cognitive impairment.

CONCLUSIONS

Total FSRP score, elevated blood pressure, and LVH predict development of clinically significant cognitive dysfunction. Prevention and treatment of high blood pressure may be effective in preserving cognitive health.

Mortality from cardiovascular diseases in the Semipalatinsk historical cohort, 1960-1999, and its relationship to radiation exposure

The data on risk of mortality from cardiovascular disease due to radiation exposure at low or medium doses are inconsistent. This paper reports an analysis of the Semipalatinsk historical cohort exposed to radioactive fallout from nuclear testing in the vicinity of the Semipalatinsk Nuclear Test Site, Kazakhstan. The cohort study, which includes 19,545 persons of exposed and comparison villages in the Semipalatinsk region, had been set up in the 1960s and comprises 582,656 person-years of follow-up between 1960 and 1999. A dosimetric approach developed by the U.S. National Cancer Institute (NCI) has been used. Radiation dose estimates in this cohort range from 0 to 630 mGy (whole-body external). Overall, the exposed population showed a high mortality from cardiovascular disease. Rates of mortality from cardiovascular disease in the exposed group substantially exceeded those of the comparison group. Dose-response analyses were conducted for both the entire cohort and the exposed group only. A dose-response relationship that was found when analyzing the entire cohort could be explained completely by differences between the baseline rates in exposed and unexposed groups. When taking this difference into account, no statistically significant dose-response relationship for all cardiovascular disease, for heart disease, or for stroke was found. Our results suggest that within this population and at the level of doses estimated, there is no detectable risk of radiation-related mortality from cardiovascular disease.

Prehypertension, racial prevalence and its association with risk factors: Analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BACKGROUND

There are few available data on the epidemiology of prehypertension (preHTN). To determine racial, clinical, and demographic differences in the prevalence of preHTN and its cross-sectional association with vascular risk factors.

METHODS

Cross-sectional analysis of 5,553 prehypertensives, 20,351 hypertensive's, and 4,246 nonhypertensive participants (age ≥45), from a population-based national cohort study (REasons for Geographic And Racial Differences in Stroke (REGARDS) total population 30,239, of whom 30,150 had adequate blood pressure (BP) measurements) enrolled from January 2003-October 2007 with oversampling from the southeastern stroke belt, and black individuals. Baseline data were collected using a combination of telephone interview and in-home evaluation. preHTN was defined according to The Seventh Report of the Joint national Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines.

RESULTS

The prevalence of preHTN was associated with age and black race (62.9% in blacks compared to 54.1% in whites). A higher prevalence of preHTN was observed in obese individuals, self-reported heart disease; and, those with elevated high-sensitivity C reactive protein (hsCRP), diabetes, and microalbuminuria compared to those without these factors. Heavy alcohol consumption in white participants was associated with increased odds of preHTN (odds ratio (OR) = 1.32) but was even greater in black participants (OR = 2.27).

CONCLUSION

The prevalence of preHTN increased by age and African-American race. In addition, a higher prevalence of preHTN was observed with elevated hsCRP, diabetes, microalbuminuria, and those with heavy alcohol consumption compared to those without these factors.