Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991

Association of Duration of Recognized Hypertension and Stroke Risk: The REGARDS Study

BACKGROUND

The focus for reducing hypertension-related cardiovascular disease is the management of blood pressure. Limited data are available on the potential benefit of delaying the onset of hypertension.

METHODS

Stroke-free Black and White participants from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke; recruited 2003-2007) were followed through 2022 for incident stroke events. Participants were stratified by duration of recognized hypertension: normotensive (0 years), ≤5 years, 6 to 20 years, or 21+ years. The baseline systolic blood pressure (SBP), the number of classes of antihypertensive medications, and the risk of incident stroke were assessed by duration strata adjusting for demographics, cerebrovascular risk factors, SBP, and use of antihypertensive medications (where appropriate).

RESULTS

Of 30 239 study participants, we included 27 310 participants (mean age, 65 years; 45% male), followed a median of 12.4 years, during which 1763 incident stroke events occurred. On average, participants with hypertension duration ≤5 years, 6 to 20 years, and 21+ years were taking 1.68 (95% CI, 1.65-1.71), 2.04 (95% CI, 2.01-2.07), and 2.28 (95% CI, 2.25-2.31) classes of antihypertensive medications, respectively. The adjusted mean SBP level was higher with each increasing duration of recognized hypertension (0, ≤5, 6-20, and 21+ years): 123.9 mm Hg (95% CI, 123.3-124.6), 129.7 mm Hg (95% CI, 129.1-130.2), 131.7 mm Hg (95% CI, 130.6-131.5), and 132.6 mm Hg (95% CI, 132.0-133.1). Compared with normotensive individuals, the hazard for incident stroke increased from 1.31 (95% CI, 1.05-1.63) for ≤5 years duration, 1.50 (95% CI, 1.21-1.87) for 6 to 20 years duration, and 1.67 (95% CI, 1.32-2.10) for 21+ years duration.

CONCLUSIONS

Longer duration of recognized hypertension was associated with more classes of antihypertensive medications, higher mean SBP, and higher stroke risk even after adjustment for age and SBP. Collectively, this suggests that delaying the onset of hypertension could reduce the burden of stroke.

Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the United States, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the United States are estimated to be the single largest contributor to the excess risk for cardiovascular disease among Black versus White adults. Worsening disparities in cardiovascular disease and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the United States. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the American Heart Association made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in cardiovascular disease mortality and morbidity. The American Heart Association is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders and public, private, and community organizations to address barriers across multiple socioecological levels.

Exploring the role of blood pressure in the black-white disparity in cardiovascular disease mortality: a causal mediation analysis

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in the USA, and high blood pressure is a major risk factor for CVD. Despite the overall declining rates of CVD mortality in the USA in recent years, marked disparities between racial and ethnic groups persist, with black adults having a higher mortality rate than white adults. We investigated the extent to which blood pressure mediated the black-white disparity in CVD mortality.

METHODS

Data came from the Multi-Ethnic Study of Atherosclerosis, a diverse longitudinal cohort. We included 1325 black and 2256 white community-based adults aged 45-80 years free of clinical CVD at baseline and followed for 14 years. We used causal mediation analysis to estimate the effect of race on CVD mortality that was mediated through blood pressure.

RESULTS

Black participants had a higher hazard of dying from CVD compared with white participants (adjusted hazard ratio (HR): 1.28 (95% CI 0.88, 1.88)), though estimates were imprecise. Systolic blood pressure mediated 27% (HR: 1.02, 95% CI 1.00, 1.06) and diastolic blood pressure mediated 55% (HR: 1.07, 95% CI 1.01, 1.10) of the racial disparities in CVD mortality between white and black participants. Mediation effects were present in men but not in women.

CONCLUSIONS

We found that black-white differences in blood pressure partially explain the observed black-white disparity in CVD mortality, particularly among men. Our findings suggest that public health interventions targeting high blood pressure prevention and management could be important strategies for reducing racial disparities in CVD mortality.

Trends in All-Cause, Cardiovascular, and Noncardiovascular Mortality Among US Adults With Hypertension

BACKGROUND

Death certificate data indicate that hypertension may have increased as a contributing cause of death among US adults. Hypertension is not commonly recorded on death certificates although it contributes to a substantial proportion of cardiovascular disease (CVD) deaths.

METHODS

We estimated changes in all-cause, CVD, and non-CVD mortality over 5 years of follow-up among 4 cohorts of US adults with hypertension using mortality follow-up data from National Health and Nutrition Examination Survey III in 1988 to 1994, and National Health and Nutrition Examination Survey cycles from 1999 to 2000 through 2015 to 2016 (n=20 927). Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or antihypertensive medication use. Participants were grouped according to the date of their National Health and Nutrition Examination Survey study visit (1988-1994, 1999-2004, 2005-2010, 2011-2016).

RESULTS

There were 2646, 1048, and 1598 all-cause, CVD, and non-CVD deaths, respectively. After age, gender, and race/ethnicity adjustment and compared with the 1988 to 1994 cohort, the hazard ratio of all-cause mortality was 0.88 (95% CI, 0.76-1.01) for the 1999 to 2004 cohort, 0.82 (95% CI, 0.70-0.95) for the 2005 to 2010 cohort, and 0.89 (95% CI, 0.75-1.05) for the 2011 to 2016 cohort (P trend=0.123). The age, gender, and race/ethnicity-adjusted hazard ratios for CVD mortality compared with the 1988 to 1994 cohort were 0.74 (95% CI, 0.60-0.90) for the 1999 to 2004 cohort, 0.61 (95% CI, 0.50-0.74) for the 2005 to 2010 cohort, and 0.57 (95% CI, 0.44-0.74) for the 2011 to 2016 cohort (P trend <0.001). There was no evidence of a change in CVD mortality between the 2005 to 2010 and 2011 to 2016 cohorts (P=0.661). Noncardiovascular mortality did not decline over the study period (P trend=0.145).

CONCLUSIONS

The decline in CVD mortality among US adults with hypertension stalled after 2005 to 2010.

Association between English Proficiency and Kidney Disease Knowledge and Communication Quality among Patients with ESKD

Key Points

In one hospital-based safety-net dialysis unit, only one half of patients with ESKD knew their cause of kidney failure, which did not differ by English proficiency status. Patients with limited English proficiency (versus English-proficient patients) reported poorer communication with the dialysis care team (less listening, fewer clear explanations, less time spent). We highlight the need for tailored, patient-centered communication between limited English-proficient patients and dialysis care team members.

Background

ESKD is a chronic health condition for which communication between health care teams and patients is important to guide patient self-management activities. Yet, little is known about the quality of communication among patients with ESKD and their care team members. We examined the influence of patient's limited English proficiency (LEP) status on communication experiences at one dialysis center.

Methods

A survey was administered to adults receiving ESKD care at a dialysis unit within a public health care delivery system between July 2022 and February 2023, to ascertain kidney disease knowledge and perceptions of communication quality with the dialysis care team. Multivariable logistic and ordinal logistic regression models adjusted for age and sex were used to determine associations between LEP status and CKD knowledge.

Results

Among 93 eligible patients, 88.2% (n =82) completed the survey. Approximately 37.8% (n =31) had LEP, mean age was 58.8 years, 68.3% were men, mean dialysis vintage was 3.9 years, and 25% had a positive depression screen (LEP 30%; English-proficient 22%). A higher proportion of English-proficient patients screened positive for limited health literacy compared to those with LEP (74.5% versus 38.7%, P = 0.002). Overall, knowledge of assigned cause of ESKD (53.4%) and CKD/transplant knowledge (57.3%) was suboptimal. After adjustment, LEP status was not significantly associated with knowing the correct cause of kidney failure (odds ratio, 0.49; 95% confidence interval, 0.19 to 1.27) but was significantly associated with having a higher score on a CKD/transplant knowledge scale (odds ratio, 3.99; 95% confidence interval, 1.66 to 9.58). Patients with LEP reported poorer communication quality with dialysis providers and staff (less listening, fewer clear explanations, less time spent with patients) compared with English-proficient patients, although differences were not statistically significant.

Conclusions

Overall communication between patients with ESKD and members of the dialysis care team was suboptimal, regardless of English proficiency. Interventions to enhance communication for ESKD patients are needed.

Sex differences in blood pressure regulation and hypertension: renal, hemodynamic, and hormonal mechanisms

The teleology of sex differences has been argued since at least as early as Aristotle's controversial Generation of Animals more than 300 years BC, which reflects the sex bias of the time to contemporary readers. Although the question "why are the sexes different" remains a topic of debate in the present day in metaphysics, the recent emphasis on sex comparison in research studies has led to the question "how are the sexes different" being addressed in health science through numerous observational studies in both health and disease susceptibility, including blood pressure regulation and hypertension. These efforts have resulted in better understanding of differences in males and females at the molecular level that partially explain their differences in vascular function and renal sodium handling and hence blood pressure and the consequential cardiovascular and kidney disease risks in hypertension. This review focuses on clinical studies comparing differences between men and women in blood pressure over the life span and response to dietary sodium and highlights experimental models investigating sexual dimorphism in the renin-angiotensin-aldosterone, vascular, sympathetic nervous, and immune systems, endothelin, the major renal sodium transporters/exchangers/channels, and the impact of sex hormones on these systems in blood pressure homeostasis. Understanding the mechanisms governing sex differences in blood pressure regulation could guide novel therapeutic approaches in a sex-specific manner to lower cardiovascular risks in hypertension and advance personalized medicine.

Prevalence and associated factors of pediatric hypertension in Jazan region, south of the Kingdom of Saudi Arabia. A pilot cross-sectional study

Hypertension (HTN) is a primary global health concern. Moreover, according to the 2010 Global Burden of Disease, hypertension accounted for roughly a quarter of cardiovascular disease fatalities and 1.9 percent of all deaths in Saudi Arabia in 2010. Also, hypertension is a significant risk factor for cardiovascular disease, morbidity, and mortality. However, assessing blood pressure (BP) and preventing hypertension among children and adolescents has become a global priority. This study aims to determine the prevalence of hypertension among children in the Jazan region of Saudi Arabia. Also, to determine the common risk factors associated with pediatric hypertension. We conducted this cross-sectional study among boys and girls aged 6-14 years visiting Al-Rashid Mall, one of the two main malls in Jazan city, the capital of Jazan region, Saudi Arabia, between November 2021 and January 2022. We included children willing to participate in the study after obtaining their parents' consent and children's assent. We used a standardized questionnaire to interview the parents to collect the children's data. We also measured the children's resting BP. Then we classified the measurements according to the updated International Pediatric Hypertension Association (IPHA) chart. We also measured the height and weight of the children and calculated their BMI. We used SPSS version 25 for the data entry and analysis. Our results showed that the prevalence of hypertension and prehypertension was insignificantly higher in females (11.84% and 12.65%) compared to males (11.52% and 11.52%), respectively. Our participants' main associated factors with prehypertension and hypertension were overweight, obesity, and family income. Pediatric hypertension and prehypertension were highly prevalent in Jazan region. Therefore, being overweight and obese should be considered risk factors for pediatric hypertension. Our study emphasizes the need for early intervention to prevent pediatric HTN, particularly among overweight and obese children.

Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and 10-Year Disease Risk in the US: National Health and Nutrition Examination Surveys, 2013 to March 2020

Importance

The burden of atherosclerotic cardiovascular disease (ASCVD) in the US is higher among Black and Hispanic vs White adults. Inclusion of race in guidance for statin indication may lead to decreased disparities in statin use.

Objective

To evaluate prevalence of primary prevention statin use by race and ethnicity according to 10-year ASCVD risk.

Design, Setting, and Participants

This serial, cross-sectional analysis performed in May 2022 used data from the National Health and Nutrition Examination Survey, a nationally representative sample of health status in the US, from 2013 to March 2020 (limited cycle due to the COVID-19 pandemic), to evaluate statin use for primary prevention of ASCVD and to estimate 10-year ASCVD risk. Participants aged 40 to 75 years without ASCVD, diabetes, low-density lipoprotein cholesterol levels 190 mg/dL or greater, and with data on medication use were included.

Exposures

Self-identified race and ethnicity (Asian, Black, Hispanic, and White) and 10-year ASCVD risk category (5%-<7.5%, 7.5%-<20%, ≥20%).

Main Outcomes and Measures

Prevalence of statin use, defined as identification of statin use on pill bottle review.

Results

A total of 3417 participants representing 39.4 million US adults after applying sampling weights (mean [SD] age, 61.8 [8.0] years; 1289 women [weighted percentage, 37.8%] and 2128 men [weighted percentage, 62.2%]; 329 Asian [weighted percentage, 4.2%], 1032 Black [weighted percentage, 12.7%], 786 Hispanic [weighted percentage, 10.1%], and 1270 White [weighted percentage, 73.0%]) were included. Compared with White participants, statin use was lower in Black and Hispanic participants and comparable among Asian participants in the overall cohort (Asian, 25.5%; Black, 20.0%; Hispanic, 15.4%; White, 27.9%) and within ASCVD risk strata. Within each race and ethnicity group, a graded increase in statin use was observed across increasing ASCVD risk strata. Statin use was low in the highest risk stratum overall with significantly lower rates of use among Black (23.8%; prevalence ratio [PR], 0.90; 95% CI, 0.82-0.98 vs White) and Hispanic participants (23.9%; PR, 0.90; 95% CI, 0.81-0.99 vs White). Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults. Prevalence of statin use did not meaningfully change over time by race and ethnicity or by ASCVD risk stratum.

Conclusions and Relevance

In this study, statin use for primary prevention of ASCVD was low among all race and ethnicity groups regardless of ASCVD risk, with the lowest use occurring among Black and Hispanic adults. Improvements in access to care may promote equitable use of primary prevention statins in Black and Hispanic adults.

Novel superpixel method to visualize fundus blood flow resistivity in healthy adults

We aimed to perform superpixel segmentation of ocular blood flow maps obtained using laser speckle flowgraphy (LSFG) and investigate the effects of systemic parameters such as body weight, height, and sex on ocular blood flow resistivity. We studied 757 healthy participants (583 men, 174 women). We calculated the average beat strength over mean blur rate (BOM) as a LSFG resistivity index, as a function of age and sex using ordinary regions of interest (ROI) centered on the optic nerve head (ONH), the retinal vessels region and tissue around the ONH, and the choroid (CHD). We compared the ROI and superpixel-based methods, which are segmented based on image processing, for calculating the BOM. The sex differences in the BOM for the ONH, retinal-vessels region and tissue region of the ONH and CHD were significant for individuals aged ≤ 50 years (P < 0.01) but not those > 50 years old (P > 0.05). The average BOMs calculated using the ROI and superpixel methods were strongly correlated in the ONH (coefficient = 0.87, R² = 0.8, P < 0.0001, n = 5465). In summary, a superpixel-segmented BOM map is suitable for two-dimensional visualization of ocular blood flow resistivity.

Cardiovascular Risk and Diseases in Patients With and Without Leptin-Melanocortin Pathway Variants

OBJECTIVE

To study differences in cardiovascular risk factors and diseases between patients with and without genetic variants in the leptin-melanocortin pathway.

METHODS

A cross-sectional study of patients with a history of severe obesity genotyped in June 2019 as participants of the Mayo Clinic Biobank was conducted in March 2022 to assess differences in cardiovascular risk and diseases between carriers of a heterozygous variant in the leptin-melanocortin pathway and noncarriers. Cardiovascular risk factors included hypertension, diabetes, dyslipidemia, and smoking. Cardiovascular disease includes coronary artery disease, peripheral artery disease, and cerebrovascular accidents. Patients with a history of bariatric surgery were excluded. We used logistic regression models to estimate the odds ratio and 95% CI, adjusting for age, body mass index (BMI), and sex.

RESULTS

Among a total of 168 carriers (8%; 121 [72%] female; mean [SD] age, 65.1 [14.9] years; BMI, 44.0 [7.4] kg/m2) and 2039 noncarriers (92%; 1446 [71%] female; mean [SD] age, 64.9 [14.4] years; BMI, 42.9 [6.6] kg/m2), carriers had higher prevalence odds of hypertension (odds ratio, 3.26; 95% CI, 2.31 to 4.61; P<.001) and reported higher number of cardiovascular risk factors compared with noncarriers (2.4 [1.1] vs 2.0 [1.1]; P<.001). There were no significant differences in the adjusted odds associated with diabetes, dyslipidemia, smoking, or cardiovascular disease.

CONCLUSION

Despite having similar body weight and BMI, carriers of heterozygous variants in the leptin-melanocortin pathway had higher rates of hypertension than noncarriers. These findings point to an association between hypertension and leptin-melanocortin pathway variants.

Longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in the Czech population. Are there any sex differences?

Background

Hypertension is the most common cardiovascular disease which substantially increases cardiovascular morbidity and mortality. Despite the broad availability of antihypertensive medication, control of hypertension is not satisfactory worldwide.

Objective

The study aim was to assess longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in a representative population sample of the Czechia from 1985 to 2016/2017, focusing on sex differences.

Methods

A total of 7,606 men and 8,050 women aged 25–64 years were screened for major CV risk factors in seven independent cross-sectional surveys run consistently in the same six country districts of the Czechia between 1985 and 2016/2017. The population samples were randomly selected.

Results

Over a study period of 31/32 years, there was a significant decline in systolic and diastolic blood pressure in both sexes, whereas the prevalence of hypertension decreased only in women. There was an increase in hypertension awareness in both sexes over the entire study period with consistently higher rates in women. The proportion of individuals treated with antihypertensive drugs increased significantly in both sexes throughout the study, again with consistently higher rates in women. Control of hypertension increased significantly over the study period with consistently higher rates in women. The age-adjusted trends in blood pressure, prevalence, awareness, and treatment of hypertension were significantly different in men and women, always in favor of women. The age-adjusted trends in control of hypertension in treated patients were equally poor in both sexes.

Conclusion

There are significant differences in longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension between men and women, always in favor of women except for the control of hypertension in treated patients, where it is equally poor in both sexes.

Interactive Effect of Combined Intermittent and Sustained Hypoxia and High-Fat Diet on the Colonic Mucosal Microbiome and Host Gene Expression in Mice

Purpose

Gut dysbiosis can cause cardiometabolic disease. Gut dysbiosis can be independently caused by high-fat diet (HFD) and intermittent hypoxia (IH; characterizing obstructive sleep apnea), but the interactive effect of combined intermittent and sustained hypoxia (IH+SH) (characterizing obesity hypoventilation syndrome) and HFD on gut dysbiosis is unclear. We aimed to investigate the interactive effect of a combination of IH and SH and HFD on proximal colonic microbiota and colonic gene expression pattern.

Methods

Male mice (n=16) were randomly received four different combinations of diet (normal versus HFD) and oxygen conditions (normoxia versus IH+SH) for 4 weeks. Bacterial DNA and mucosal epithelial cell RNA from proximal colon were collected for analysis of adherent microbiome and host's gene expression analysis.

Results

HFD during IH+SH (22.6 ± 5.73; SD) led to greater Firmicutes: Bacteroidetes ratio than HFD during normoxia (5.89 ± 1.19; p=0.029). HFD significantly decreased microbial diversity as compared to normal diet, but the addition of IH+SH to HFD mildly reversed such effects. When compared to HFD during normoxia, HFD with combination of IH+SH resulted in changes to host mucosal gene expression for apical junctional complexes and adhesion molecules. Specifically, when compared to HFD during normoxia, HFD during IH+SH led to upregulation of Claudin 2 and Syk (tight junction dysfunction and increased mucosal permeability), while the barrier promoting claudin 4 was downregulated.

Conclusion

HFD during combined IH and SH causes greater gut dysbiosis and potentially adverse changes in colonic epithelial transcriptome than HFD during normoxia. The latter changes are suggestive of impaired gut barrier function.

Blood Pressure Control Among US Adults, 2009 to 2012 Through 2017 to 2020

BACKGROUND

The National Health and Nutrition Examination Survey data indicate that the proportion of US adults with hypertension that had controlled blood pressure (BP) declined from 2013 to 2014 through 2017 to 2018. We analyzed data from National Health and Nutrition Examination Survey 2009 to 2012, 2013 to 2016, and 2017 to 2020 to confirm this finding.

METHODS

Hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or antihypertensive medication use. BP control among those with hypertension was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg.

RESULTS

The age-adjusted prevalence of hypertension was 31.5% (95% CI, 30.3%-32.8%), 32.0% (95% CI, 30.6%-33.3%), and 32.9% (95% CI, 31.0%-34.7%) in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.218). The age-adjusted prevalence of hypertension increased among non-Hispanic Asian adults from 27.0% in 2011 to 2012 to 33.5% in 2017 to 2020 (P trend=0.003). Among Hispanic adults, the age-adjusted prevalence of hypertension increased from 29.4% in 2009 to 2012 to 33.2% in 2017 to 2020 (P trend=0.029). In 2009 to 2012, 2013 to 2016, and 2017 to 2020, 52.8% (95% CI, 50.0%-55.7%), 51.3% (95% CI, 47.9%-54.6%), and 48.2% (95% CI, 45.7%-50.8%) of US adults with hypertension had controlled BP (P trend=0.034). Among US adults taking antihypertensive medication, 69.9% (95% CI, 67.8%-72.0%), 69.3% (95% CI, 66.6%-71.9%), and 67.7% (95% CI, 65.2%-70.3%) had controlled BP in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.189). Among all US adults with hypertension and those taking antihypertensive medication, a decline in BP control between 2009 to 2012 and 2017 to 2020 occurred among those ≥75 years, women, and non-Hispanic black adults.

CONCLUSIONS

These data confirm that the proportion of US adults with hypertension who have controlled BP has declined.

Obstructive Sleep Apnea as a Risk Factor for COVID-19 Severity-The Gut Microbiome as a Common Player Mediating Systemic Inflammation via Gut Barrier Dysfunction

The novel corona virus that is now known as (SARS-CoV-2) has killed more than six million people worldwide. The disease presentation varies from mild respiratory symptoms to acute respiratory distress syndrome and ultimately death. Several risk factors have been shown to worsen the severity of COVID-19 outcomes (such as age, hypertension, diabetes mellitus, and obesity). Since many of these risk factors are known to be influenced by obstructive sleep apnea, this raises the possibility that OSA might be an independent risk factor for COVID-19 severity. A shift in the gut microbiota has been proposed to contribute to outcomes in both COVID-19 and OSA. To further evaluate the potential triangular interrelationships between these three elements, we conducted a thorough literature review attempting to elucidate these interactions. From this review, it is concluded that OSA may be a risk factor for worse COVID-19 clinical outcomes, and the shifts in gut microbiota associated with both COVID-19 and OSA may mediate processes leading to bacterial translocation via a defective gut barrier which can then foster systemic inflammation. Thus, targeting biomarkers of intestinal tight junction dysfunction in conjunction with restoring gut dysbiosis may provide novel avenues for both risk detection and adjuvant therapy.

A comparative analysis of premature heart disease- and cancer-related mortality in women in the USA, 1999-2018

AIMS

To compare premature heart disease- and cancer-related deaths in women in the USA.

METHODS AND RESULTS

We analysed the US national database of death certificates of women aged <65 from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database between 1999 and 2018. We measured annual percentage changes (APCs) in age-adjusted mortality rates (AAMRs) and years of potential life lost per 100 000 persons due to heart disease and cancer. Overall, cancer was a more prevalent cause of premature death compared with heart disease. Between 1999 and 2018, the AAMRs decreased for both cancer (61.9/100 000 to 45.6/100 000) and heart disease (29.2/100 000 to 22.6/100 000). However, while APC in AAMR for cancer declined consistently over time, after an initial decline, APC in AAMR for heart disease increased between 2010 and 2018 [0.53 95% confidence interval (0.18-0.89)], with a significant rise in Midwest, medium/small metros, and rural areas after 2008. Compared with cancer, APC in AAMR for heart disease increased in women aged 25-34 years [2.24 (0.30-4.22); 2013-18) and 55-64 years [0.46 (0.13-0.80); 2009-13], as well as Non-Hispanic (NH) Whites [APC, 0.79 (0.46-1.13); 2009-18] and NH American Indian/Alaskan Native [2.71 (0.59-4.87); 2011-2018]. Consequently, the mortality gap between cancer and heart disease has narrowed from an AAMR of 32.7/100 000 to 23.0/100 000.

CONCLUSIONS

The mortality gap between cancer and heart disease is decreasing among women <65 years. Intensive cardiovascular health interventions are required focusing on vulnerable young demographic subgroups and underserved regional areas to meet the American Heart Association's Impact Goal and Million Hearts Initiative.

Systolic Blood Pressure to Diastolic Blood Pressure Ratios in Diabetic and Non-diabetic Patients: Deviation from Golden Ratio

INTRODUCTION

Cardiovascular measures like, systolic to diastolic time intervals on ECG recordings, end-diastolic to end-systolic diameters of the left ventricle on echocardiography, pulmonary and systemic hemodynamic measures have gained an interest in terms of Golden ratio or Golden proportions. Ratio of SBP to DBP as a reflection of GR has been recently evaluated in patients who have undergone ABPM to assess the presence of hypertension.

AIM

To assess and compare the ratios of SBP to DBP as a reflection of GR in 24 h ABPM recordings in patients with and without DM who were not on medical treatment.

METHODS

Six hundred and thirty two patients who underwent ABPM were retrospectively screened and enrolled in the study population in between October 2020 and March 2021. After exclusion of 378 who did not meet the inclusion criteria, 254 patients were enrolled in statistical analysis. Systolic blood pressure and diastolic blood pressure measurements were also averaged for the day and the night spans according to the patients' reported time of waking up and going to bed. The ABPM was programmed to measure blood pressure every 45 min during both the day time and night time periods RESULTS: Among those 254 patients included in statistical analysis, 212 patients were classified as non-diabetic and 42 patients as diabetic. SBP/DBP ratios were significantly higher in diabetics compared to those of non-diabetics in all time spans (1.698 vs 1.631, p = 0.041 for 24 h; 1.689 vs 1.618 p = 0.032 for day-time; 1.74 vs 1.66 p = 0.037 for night time). In non-diabetic patients interestingly day time SBP/DBP gave almost the same value of GR i.e 1.618, likewise the 24 h value of SBP/DBP gave the value of 1.631 which was so close to GR. On the other hand SBP/DBP ratios for all time spans were deviated far from the 1.618 in diabetic patients CONCLUSION: We have shown that systolic to diastolic blood pressure ratios of patients with DM are significantly higher than those without DM. These differences are mainly to due to the lower DBP of diabetic patients compared to non-diabetic patients. Beyond these differences SBP/DBP ratio of non-diabetic patients has shown close proximity to 1.618 known as golden ratio.

Hypertension Prevalence, Awareness, and Control Among Parents of School-Aged Children in the United Arab Emirates

BACKGROUND

Increased blood pressure (BP) is a major cardiovascular disease risk factor. The study aimed to determine the prevalence and predictors of hypertension and its awareness and control among parents of school-aged children in the United Arab Emirates (UAE).

METHODS

A total of 605 parents participated in this cross-sectional study. Information on socio-demographics, lifestyle factors, and history of chronic disease were collected through an adapted version of the World Health Organization STEPS questionnaire. Fasting blood glucose samples, BP measurements, body mass index (BMI), and waist and hip circumference were obtained using standard measurement protocols. Prevalence of hypertension was identified in the cohorts by defining hypertension using the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines (BP≥130/80 mmHg) and the World Health Organization-International Society of Hypertension Guidelines Orchid (BP≥140/90 mmHg) in association with antihypertensive medication use.

RESULTS

The mean age of participants was 42.9±7.9 years. The prevalence of hypertension was 37.2% (95% CI: 33.5-41.2) and 18.0% (95% CI: 15.2-21.3), using the 2017 and the previous WHO definitions, respectively. Little over half of the sample (51.5%) who were aware of having hypertension reported using antihypertensive medications. Of those reporting the use of antihypertensive medications in the past two days, 13 of 33 patients (39.4%) had their hypertension under control (<140/90 mmHg). The independent correlates of hypertension included age [(adjusted odds ratio (AOR): 1.09 (1.05-1.13], male sex [AOR: 2.48 (1.41-4.34], college or higher education [AOR: 0.22 (0.09-0.56)], family history of hypertension [AOR: 2.03 (1.17-3.53)], obesity [AOR: 3.15 (1.24-7.12)], and moderate or vigorous physical activity [AOR: 0.50 (0.26-0.98)].

CONCLUSION

Hypertension is prevalent among parents of school-going children. Improving lifestyle, health literacy, and introducing innovative models to raise awareness and education about hypertension are essential to achieve sustainable development goals (SDGs).

A Decade of Decline in Serious Cognitive Problems Among Older Americans: A Population-Based Study of 5.4 Million Respondents

BACKGROUND

Numerous studies suggest the prevalence of dementia has decreased over the past several decades in Western countries. Less is known about whether these trends differ by gender or age cohort, and if generational differences in educational attainment explain these trajectories.

OBJECTIVE

1) To detect temporal trends in the age-sex-race adjusted prevalence of serious cognitive problems among Americans aged 65+; 2) To establish if these temporal trends differ by gender and age cohort; 3) To examine if these temporal trends are attenuated by generational differences in educational attainment.

METHODS

Secondary analysis of 10 years of annual nationally representative data from the American Community Survey with 5.4 million community-dwelling and institutionalized older adults aged 65+. The question on serious cognitive problems was, "Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?"

RESULTS

The prevalence of serious cognitive problems in the US population aged 65 and older declined from 12.2% to 10.0% between 2008 and 2017. Had the prevalence remained at the 2008 levels, there would have been an additional 1.13 million older Americans with serious cognitive problems in 2017. The decline in memory problems across the decade was higher for women (23%) than for men (13%). Adjusting for education substantially attenuated the decline.

CONCLUSION

Between 2008 and 2017, the prevalence of serious cognitive impairment among older Americans declined significantly, although these declines were partially attributable to generational differences in educational attainment.

Preeclampsia and high blood pressure in early pregnancy as risk factors of severe maternal cardiovascular disease during 50-years of follow-up

OBJECTIVES

Studies suggest preeclampsia as a risk factor for long term cardiovascular diseases (CVD), while evidence is limited regarding the risk of high blood pressures (BP) in early pregnancy.

STUDY DESIGN

A register-based follow-up of 2434 mothers in the Helsingborg Birth Cohort. Associations of high BP in early pregnancy (>95th percentile systolic [SBP], diastolic [BDP], or mean arterial BP [MAP]) during the first antenatal visit and/or preeclampsia with an incident CVD event (ischemic heart disease or stroke) were assessed. To model risks and adjust for co-variables, Cox proportional hazard regression was used.

RESULTS

Of the included women, 120 (4.9%) had high SBP, 49 (2%) high DBP, 104 (4.3%) high MAP in early pregnancy; and 115 (4.7%) developed preeclampsia. During 52 years of follow-up, totalling 121,457 person-years, 534 (21.9%) women experienced a CVD event. Women with preeclampsia had a higher risk of developing CVD compared to women without preeclampsia (HR 1.5, 95%CI: 1.1-2.2), while risks among women with high BPs were slightly higher. In adjusted analysis, risk estimates were approximately 50% higher than that of the reference groups for all four studied exposures. Of women with later CVD, 35 (6.6%) had preeclampsia, and another 31 (5,8%) women high SBP or high MAP. Without later preeclampsia, high SBP constituted a significant risk factor (HR 1.6, 95%CI: 1.1-2.4) for CVD.

CONCLUSIONS

Women with SBP > 95th percentile in early pregnancy, but without later preeclampsia, have a higher risk of developing CVD that is comparable to women with history of preeclampsia.

Impact of anesthesia and sex on sympathetic efferent and hemodynamic responses to renal chemo- and mechanosensitive stimuli

Activation of renal sensory nerves by chemo- and mechanosensitive stimuli produces changes in efferent sympathetic nerve activity (SNA) and arterial blood pressure (ABP). Anesthesia and sex influence autonomic function and cardiovascular hemodynamics, but it is unclear to what extent anesthesia and sex impact SNA and ABP responses to renal sensory stimuli. We measured renal, splanchnic, and lumbar SNA and ABP in male and female Sprague-Dawley rats during contralateral renal infusion of capsaicin and bradykinin or during elevation in renal pelvic pressure. Responses were evaluated with a decerebrate preparation or Inactin, urethane, or isoflurane anesthesia. Intrarenal arterial infusion of capsaicin (0.1-30.0 μM) increased renal SNA, splanchnic SNA, or ABP but decreased lumbar SNA in the Inactin group. Intrarenal arterial infusion of bradykinin (0.1-30.0 μM) increased renal SNA, splanchnic SNA, and ABP but decreased lumbar SNA in the Inactin group. Elevated renal pelvic pressure (0-20 mmHg, 30 s) significantly increased renal SNA and splanchnic SNA but not lumbar SNA in the Inactin group. In marked contrast, SNA and ABP responses to every renal stimulus were severely blunted in the urethane and decerebrate groups and absent in the isoflurane group. In the Inactin group, the magnitude of SNA responses to chemo- and mechanosensory stimuli were not different between male and female rats. Thus, chemo- and mechanosensitive stimuli produce differential changes in renal, splanchnic, and lumbar SNA. Experimentally, future investigations should consider Inactin anesthesia to examine sympathetic and hemodynamic responses to renal sensory stimuli.NEW & NOTEWORTHY The findings highlight the impact of anesthesia, and to a lesser extent sex, on sympathetic efferent and hemodynamic responses to chemosensory and mechanosensory renal stimuli. Sympathetic nerve activity (SNA) and arterial blood pressure (ABP) responses were present in Inactin-anesthetized rats but largely absent in decerebrate, isoflurane, or urethane preparations. Renal chemosensory stimuli differentially changed SNA: renal and splanchnic SNA increased, but lumbar SNA decreased. Future investigations should consider Inactin anesthesia to study SNA and hemodynamic responses to renal sensory nerve activation.

Trends in Antihypertensive Medication Use Among Individuals With a History of Stroke and Hypertension, 2005 to 2016

Importance

Hypertension is a well-established, modifiable risk factor for stroke. National hypertension management trends among stroke survivors may provide important insight into secondary preventive treatment gaps.

Objective

To investigate the adequacy of blood pressure control among stroke survivors and antihypertensive treatment trends using National Health and Nutrition Examination Survey (NHANES) data.

Design, Setting, and Participants

Cross-sectional surveys conducted between 2005 and 2016 of nationally representative samples of the civilian US population were analyzed from March 2019 to January 2020. The NHANES is a large, nationally representative cross-sectional survey conducted in 2-year cycles in the United States. Evaluations include interviews, medication lists, physical examinations, and laboratory tests on blood samples. Among 221 982 140 adults 20 years or older in the NHANES from 2005 through 2016, a total of 4 971 136 had stroke and hypertension and were included in this analysis, with 217 011 004 excluded from the primary analysis.

Exposures

Hypertension was defined by self-report, antihypertensive medication use, or uncontrolled blood pressure (>140/90 mm Hg) on physical examination. Antihypertensive medication was classified as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, diuretics, β-blockers, calcium channel blockers, or other.

Main Outcomes and Measures

Weighted frequencies and means were reported using NHANES methods, estimating the proportion of individuals with stroke and hypertension. For all other analyses, 4 971 136 individuals with stroke and hypertension were examined, summarizing number and classes of antihypertensive medications, frequency of uncontrolled hypertension, and associations between antihypertensive classes and blood pressure control. Trends in antihypertensive medication use over time were examined.

Results

Among 4 971 136 individuals with a history of stroke and hypertension, the mean age was 67.1 (95% CI, 66.1-68.1) years, and 2 790 518 (56.1%) were women. In total, 37.1% (33.5%-40.8%) had uncontrolled blood pressure on examination, with 80.4% (82.0%-87.5%) taking antihypertensive medication. The most commonly used antihypertensive medications were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (59.2%; 95% CI, 54.9%-63.4%) and β-blockers (43.8%; 95% CI, 40.3%-47.3%). Examining trends over time, diuretics have become statistically significantly less commonly used (49.4% in 2005-2006 vs 35.7% in 2015-2016, P = .005), with frequencies of other antihypertensive classes remaining constant.

Conclusions and Relevance

In this cross-sectional study that used national survey data, substantial undertreatment of hypertension was found in individuals with a history of stroke, and more than one-third had uncontrolled hypertension. Because hypertension is a major risk factor for stroke, these data demonstrate a missed opportunity nationally for secondary stroke prevention.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Hypertension Prevalence Based on Blood Pressure Measurements on Two vs. One Visits: A Community-Based Screening Programme and a Narrative Review

We assessed the difference in the prevalence of hypertension in community surveys when blood pressure (BP) was measured on two vs. one visits and its impact on hypertension awareness, treatment and control proportions. A community-based BP screening programme was conducted in public places in the Seychelles (619 adults) and BP was rechecked a few days later among untreated participants with high BP (≥140/90 mmHg). A narrative review of the literature on this question was also conducted. Only 64% of untreated participants with high BP still had high BP at the second visit. The prevalence of hypertension in the whole sample decreased by 13% (from 33.8% to 29.5%) when BP was measured on two vs. one visits. These results concurred with our findings in our narrative review based on 10 surveys. In conclusion, the prevalence of hypertension can be markedly overestimated in community surveys when BP is measured on two vs. one visits. The overestimation could be addressed by measuring BP on a second visit among untreated individuals with high BP or, possibly, by taking more readings at the first visit. These findings have relevance for clinical practice, policy and surveillance.

The gut microbiome as a target for adjuvant therapy in obstructive sleep apnea

Introduction: Gut dysbiosis is assumed to play a role in obstructive sleep apnea (OSA)-associated morbidities. Pre- and probiotics, short chain fatty acids (SCFA) and fecal matter transplantation (FMT) may offer potential as novel therapeutic strategies that target this gut dysbiosis. As more mechanisms of OSA-induced dysbiosis are being elucidated, these novel approaches are being tested in preclinical and clinical development. Areas covered: We examined the evidence linking OSA to gut dysbiosis and discuss the effects of pre- and probiotics on associated cardiometabolic, neurobehavioral and gastrointestinal disorders. The therapeutic potential of SCFA and FMT are also discussed. We reviewed the National Center for Biotechnology Information database, including PubMed and PubMed Central between 2000 - 2020. Expert opinion: To date, there are no clinical trials and only limited evidence from animal studies describing the beneficial effects of pre- and probiotic supplementation on OSA-mediated dysbiosis. Thus, more work is necessary to assess whether prebiotics, probiotics and SCFA are promising future novel strategies for targeting OSA-mediated dysbiosis.

Trends of Status of Hypertension in Southern China, 2012-2019

Purpose

Little is known about the recent trends of hypertension in southern China. The aim of the study was to investigate the trends of hypertension in Guangdong Province between 2012 and 2019.

Methods

We conducted two cross-sectional surveys in 2012 and 2019 in southern China, which included 10,970 and 27,483 participants, respectively, aged 35 to 75 years old using a method of stratified, multistage, and cluster sampling. Hypertension was defined as a mean systolic/diastolic blood pressure (SBP/DBP) ≥140/90mmHg, or a self-reported condition, or any pharmacological treatment in the last 2 weeks. In addition, according to the 2017 ACC/AHA guideline for high blood pressure, we estimated the prevalence and control rate of hypertension.

Results

According to the 2010 Chinese guideline, the age-standardized rate of hypertension prevalence was 34.7% in 2012 and 36.9% in 2019 with a slight increase, while the prevalence of prehypertension was stable (14.5% vs 14.3%). Over the period of our study, 45.6% and 60.7% of hypertensive patients knew their diagnosis in 2012 and 2019, and 40.8% and 51.5% were using antihypertensive medications, respectively. The control rates increased from 15.1% to 23.6%. Hypertension prevalence was 64.5% in 2012 and 63.2% in 2019, and the control rate increased from 3.0% to 4.8% during the study period under the 2017 ACC/AHA guideline.

Conclusion

Although the past 7 years have seen some progress in hypertension management, the rates of hypertension awareness, treatment, and control in southern Chinese remained regrettably low, and the prevalence rate was still high.

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

IMPORTANCE

Controlling blood pressure (BP) reduces the risk for cardiovascular disease.

OBJECTIVE

To determine whether BP control among US adults with hypertension changed from 1999-2000 through 2017-2018.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional analysis of National Health and Nutrition Examination Survey data, weighted to be representative of US adults, between 1999-2000 and 2017-2018 (10 cycles), including 18 262 US adults aged 18 years or older with hypertension defined as systolic BP level of 140 mm Hg or higher, diastolic BP level of 90 mm Hg or higher, or use of antihypertensive medication. The date of final data collection was 2018.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Mean BP was computed using 3 measurements. The primary outcome of BP control was defined as systolic BP level lower than 140 mm Hg and diastolic BP level lower than 90 mm Hg.

RESULTS

Among the 51 761 participants included in this analysis, the mean (SD) age was 48 (19) years and 25 939 (50.1%) were women; 43.2% were non-Hispanic White adults; 21.6%, non-Hispanic Black adults; 5.3%, non-Hispanic Asian adults; and 26.1%, Hispanic adults. Among the 18 262 adults with hypertension, the age-adjusted estimated proportion with controlled BP increased from 31.8% (95% CI, 26.9%-36.7%) in 1999-2000 to 48.5% (95% CI, 45.5%-51.5%) in 2007-2008 (P < .001 for trend), remained stable and was 53.8% (95% CI, 48.7%-59.0%) in 2013-2014 (P = .14 for trend), and then declined to 43.7% (95% CI, 40.2%-47.2%) in 2017-2018 (P = .003 for trend). Compared with adults who were aged 18 years to 44 years, it was estimated that controlled BP was more likely among those aged 45 years to 64 years (49.7% vs 36.7%; multivariable-adjusted prevalence ratio, 1.18 [95% CI, 1.02-1.37]) and less likely among those aged 75 years or older (37.3% vs 36.7%; multivariable-adjusted prevalence ratio, 0.81 [95% CI, 0.65-0.97]). It was estimated that controlled BP was less likely among non-Hispanic Black adults vs non-Hispanic White adults (41.5% vs 48.2%, respectively; multivariable-adjusted prevalence ratio, 0.88; 95% CI, 0.81-0.96). Controlled BP was more likely among those with private insurance (48.2%), Medicare (53.4%), or government health insurance other than Medicare or Medicaid (43.2%) vs among those without health insurance (24.2%) (multivariable-adjusted prevalence ratio, 1.40 [95% CI, 1.08-1.80], 1.47 [95% CI, 1.15-1.89], and 1.36 [95% CI, 1.04-1.76], respectively). Controlled BP was more likely among those with vs those without a usual health care facility (48.4% vs 26.5%, respectively; multivariable-adjusted prevalence ratio, 1.48 [95% CI, 1.13-1.94]) and among those who had vs those who had not had a health care visit in the past year (49.1% vs 8.0%; multivariable-adjusted prevalence ratio, 5.23 [95% CI, 2.88-9.49]).

CONCLUSIONS AND RELEVANCE

In a series of cross-sectional surveys weighted to be representative of the adult US population, the prevalence of controlled BP increased between 1999-2000 and 2007-2008, did not significantly change from 2007-2008 through 2013-2014, and then decreased after 2013-2014.

Hypertension Is Associated With an Earlier Age of Onset of Huntington's Disease

BACKGROUND AND OBJECTIVE

Hypertension (HTN) is associated with worsening clinical outcomes in neurodegenerative diseases. The relationship between HTN and the age of diagnosis (ADx) of Huntington's disease (HD) is not clear, however. This study sought to determine if the presence of HTN in adult patients with premanifest HD was associated with an earlier ADx compared with normotensive patients with HD.

METHODS

Premanifest participants from Enroll-HD were included if they had a cytosine-adenine-guanine greater than or equal to 36, baseline diagnostic confidence level less than 4, baseline total functional capacity score greater than 11, and baseline motor score less than 21. There were 3020 premanifest participants with HD, and 293 reported a diagnosis of HTN. HTN was transformed into a time-dependent variable, and a Cox proportional hazard survival model determine if the presence of HTN affected the time to motor conversion. Baseline cytosine-adenine-guanine-age product score, cytosine-adenine-guanine repeat length, baseline age, sex, baseline body mass index, smoking history, and region were included as covariates.

RESULTS

Participants with HTN had an increased annualized hazard of motor conversion compared to normotensive participants with HD (hazard ratio, 1.29; 95% confidence interval, 1.02-1.64; P = 0.034).

CONCLUSIONS

A previous study reported a protective effect of HTN in HD, but did not account for the fact that the prevalence of HTN increases with age. By controlling for this confounder, we more accurately outline the association between the ADx of HD to demonstrate that a diagnosis of HTN may be associated with an earlier ADx of HD. These results represent an association, however, and further investigation is warranted. © 2020 International Parkinson and Movement Disorder Society.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design.

METHODS

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months.

DISCUSSION

This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities.

TRIAL REGISTRATION

Clinicaltrials.govNCT02674464.

US trends in premature heart disease mortality over the past 50 years: Where do we go from here?

Despite the premature heart disease mortality rate among adults aged 25-64 decreasing by 70% since 1968, the rate has remained stagnant from 2011 on and, in 2017, still accounted for almost 1-in-5 of all deaths among this age group. Moreover, these overall findings mask important differences and continued disparities observed by demographic characteristics and geography. For example, in 2017, rates were 134% higher among men compared to women and 87% higher among blacks compared to whites, and, while the greatest burden remained in the southeastern US, almost two-thirds of all US counties experienced increasing rates among adults aged 35-64 during 2010-2017. Continued high rates of uncontrolled blood pressure and increasing prevalence of diabetes and obesity pose obstacles for re-establishing a downward trajectory for premature heart disease mortality; however, proven public health and clinical interventions exist that can be used to address these conditions.

Trends in status of hypertension in rural northeast China: results from two representative cross-sectional surveys, 2013-2018

OBJECTIVE

To investigate the long-term natural trends in the status of hypertension in rural northeast China from 2013 to 2018.

METHODS

Two successive cross-sectional surveys were conducted in Liaoning rural areas in 2013 and 2018, which included 10 753 and 10 926 participants aged at least 40 years from different villages, respectively. A multistage, stratified, and cluster random sampling method was used to ensure that the samples of the two studies were representative. Hypertension was defined as a mean SBP at least 140 mmHg or a mean DBP at least 90 mmHg, and/or self-reported use of antihypertensive medication within the past 2 weeks. The prevalence and control rate of hypertension were also estimated according to the 2017 American College of Cardiology/American Heart Association high blood pressure guideline.

RESULTS

Overall, the age-standardized prevalence of hypertension increased from 52.3 to 53.6%, while the age-specified DBP level increased by 5.2% (82.4 vs. 86.7 mmHg) during the study period. However, the control rate unfortunately remained low (4.1 vs. 3.6%), despite unsatisfied awareness and treatment rates of hypertension in rural northeast China. Under the 2017 American College of Cardiology/American Heart Association guideline, the prevalence of hypertension increased from 73.9 to 79.1%; however, the control rate decreased sharply from 1.8 to 0.5% between 2013 and 2018.

CONCLUSION

Despite the high prevalence of hypertension during the past 5 years, blood pressure levels increased significantly, especially the DBP level. Awareness, treatment, and control of hypertension remained unacceptably low. Therefore, strategies targeting the management of hypertension should be emphasized in rural northeast China.

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

BACKGROUND

Primary aldosteronism (PA) is the most common cause of secondary hypertension; early diagnosis and intervention correlate with outcomes. We hypothesized that race may influence clinical presentation and outcomes.

METHODS

We conducted a retrospective analysis of patients with PA (1997-2017) who underwent adrenal vein sampling (AVS). Patients were classified by self-reported race as black or non-black. Improvement was defined as postoperative decrease in mean arterial pressure (MAP), antihypertensive medications (AHM), or both.

RESULTS

Among patients undergoing AVS (n = 443), 287 underwent adrenalectomy. Black patients (28.2%) had higher body mass index (33.9 vs 31.8 kg/m² ; P = .01), longer median duration of hypertension (12 vs 10 years; P = .003), higher modified Elixhauser comorbidity index (2 vs 1; P = .004), and lower median income ($47 134 vs $78 280; P < .001). Black patients had similar aldosterone:renin ratios (150 vs 135.6 [ng/dL]/[ng·mL·^-1 hr^-1 ]; P = .23) compared to non-blacks. At long-term follow-up, black patients had a similar requirement for AHM (1 vs 0; P = .13) but higher MAP (100.6 vs 95.3 mm Hg; P = .004).

CONCLUSION

Black patients present with longer duration of hypertension and more comorbidities. They are equally likely to lateralize on AVS, suggesting similar disease phenotype. However, black patients demonstrate less improvement with adrenalectomy; this may reflect a delay in diagnosis or concomitant essential hypertension.

Hypertension in Continuous Ambulatory Peritoneal Dialysis Patients: What do we know and What can we do about It?

Despite many advantages of CAPD in maintaining hemodynamic stability, approximately 50% -60% of CAPD patients have hypertension and require antihypertensive treatment. ACE inhibitors and betablockers are the preferred first-line antihypertensive drugs in these patients, but some patients may require additionallong-acting calcium antagonists to enhance antihypertensive effects. Despite antihypertensive treatment, many patients often fail to maintain BP within optimal ranges, and this fact may contribute to the high incidences of cardiovascular morbidity an d mortality. Vigilance is clearly desirable by the patient and the physician to maintain BP within target ranges most of the time. Because dialysis patients also have many other cardiovascular risk factors, the strategy to decrease cardiovascular mortality should be a combined effort targeting all potential risk factors at the same time.

Male Mortality Trends in the United States, 1900-2010: Progress, Challenges, and Opportunities

OBJECTIVES

Male mortality fell substantially during the past century, and major causes of death changed. Building on our recent analysis of female mortality trends in the United States, we examined all-cause and cause-specific mortality trends at each decade from 1900 to 2010 among US males.

METHODS

We conducted a descriptive study of age-adjusted death rates (AADRs) for 11 categories of disease and injury stratified by race (white, nonwhite, and, when available, black), the excess of male mortality over female mortality ([male AADR - female AADR]/female AADR), and potential causes of persistent excess of male mortality. We used national mortality data for each decade.

RESULTS

From 1900 to 2010, the all-cause AADR declined 66.4% among white males and 74.5% among nonwhite males. Five major causes of death in 1900 were pneumonia and influenza, heart disease, stroke, tuberculosis, and unintentional nonmotor vehicle injuries; in 2010, infectious conditions were replaced by cancers and chronic lower respiratory diseases. The all-cause excess of male mortality rose from 9.1% in 1900 to 65.5% in 1980 among white males and a peak of 63.7% in 1990 among nonwhite males, subsequently falling among all groups.

CONCLUSION

During the last century, AADRs among males declined more slowly than among females. Although the gap diminished in recent decades, exploration of social and behavioral factors may inform interventions that could further reduce death rates among males.

The impact of obstructive sleep apnea and PAP therapy on all-cause and cardiovascular mortality based on age and gender - a literature review

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disorder which negatively impacts different body systems, especially the cardiovascular system. The correlation between sleep related breathing disorders and cardiovascular diseases has been well studied. However, the impact of OSA on cardiovascular related mortality and the role of positive airway pressure therapy in decreasing mortality is unclear. We reviewed studies investigating the impact of OSA on all-cause and cardiovascular related mortality in both genders, and in different age groups.

METHODS

A literature search (PubMed) using two phrases "obstructive sleep apnea and co-morbidities in males and females" and "obstructive sleep apnea and co-morbidities by age" yielded a total of 214 articles. Nineteen articles met the inclusion criteria.

RESULTS

The studies reviewed showed conflicting results. Some showed that OSA increases all cause and cardiovascular related mortality predominantly in the middle-aged group (40-65) followed by a plateau or a reduction in mortality. Other studies showed a positive linear correlation between OSA and mortality up to the age of 80. The same controversy was noted for gender; some studies did not observe an increase in mortality in females with OSA, while others observed a trend for an increase in mortality in females.

CONCLUSION

There is a debate in the literature regarding the impact of OSA on all-cause and cardiovascular mortality in both genders and in different age groups. However, the variation in results might be related to different study designs and significant epidemiological prevalence of OSA in males and females.

Obstructive Sleep Apnea and Systemic Hypertension: Gut Dysbiosis as the Mediator?

INTRODUCTION

Obstructive sleep apnea (OSA) and systemic hypertension (SH) are common and interrelated diseases. It is estimated that approximately 75% of treatment-resistant hypertension cases have an underlying OSA. Exploration of the gut microbiome is a new advance in medicine that has been linked to many comorbid illnesses, including SH and OSA. Here, we will review the literature in SH and gut dysbiosis, OSA and gut dysbiosis, and whether gut dysbiosis is common in both conditions.

METHODS

We reviewed the National Center for Biotechnology Information database, including PubMed and PubMed Central. We identified a total of 230 articles. The literature search was conducted using the phrase "obstructive sleep apnea and gut dysbiosis." Only original research articles were included. This yielded a total of 12 articles.

RESULTS

Most of the research conducted in this field was on animal models, and almost all trials confirmed that intermittent hypoxia models resulted in gut dysbiosis. Gut dysbiosis, however, can cause a state of low-grade inflammation through damage to the gut wall barrier resulting in "leaky gut." Neuroinflammation is a hallmark of the pathophysiology of OSA-induced SH.

CONCLUSIONS

Gut dysbiosis seems to be an important factor in the pathophysiology of OSA-induced hypertension. Reversing gut dysbiosis at an early stage through prebiotics and probiotics and fecal microbiota transplantation combined with positive airway pressure therapy may open new horizons of treatment to prevent SH. More studies are needed in humans to elicit the effect of positive airway pressure therapy on gut dysbiosis.

Accelerated Ovarian Failure as a Unique Model to Study Peri-Menopause Influence on Alzheimer's Disease

Despite decades of extensive research efforts, efficacious therapies for Alzheimer's disease (AD) are lacking. The multi-factorial nature of AD neuropathology and symptomatology has taught us that a single therapeutic approach will most likely not fit all. Women constitute ~70% of the affected AD population, and pathology and rate of symptoms progression are 2-3 times higher in women than men. Epidemiological data suggest that menopausal estrogen loss may be causative of the more severe symptoms observed in AD women, however, results from clinical trials employing estrogen replacement therapy are inconsistent. AD pathological hallmarks-amyloid β (Aβ), neurofibrillary tangles (NFTs), and chronic gliosis-are laid down during a 20-year prodromal period before clinical symptoms appear, which coincides with the menopause transition (peri-menopause) in women (~45-54-years-old). Peri-menopause is marked by widely fluctuating estrogen levels resulting in periods of irregular hormone-receptor interactions. Recent studies showed that peri-menopausal women have increased indicators of AD phenotype (brain Aβ deposition and hypometabolism), and peri-menopausal women who used hormone replacement therapy (HRT) had a reduced AD risk. This suggests that neuroendocrine changes during peri-menopause may be a trigger that increases risk of AD in women. Studies on sex differences have been performed in several AD rodent models over the years. However, it has been challenging to study the menopause influence on AD due to lack of optimal models that mimic the human process. Recently, the rodent model of accelerated ovarian failure (AOF) was developed, which uniquely recapitulates human menopause, including a transitional peri-AOF period with irregular estrogen fluctuations and a post-AOF stage with low estrogen levels. This model has proven useful in hypertension and cognition studies with wild type animals. This review article will highlight the molecular mechanisms by which peri-menopause may influence the female brain vulnerability to AD and AD risk factors, such as hypertension and apolipoprotein E (APOE) genotype. Studies on these biological mechanisms together with the use of the AOF model have the potential to shed light on key molecular pathways underlying AD pathogenesis for the development of precision medicine approaches that take sex and hormonal status into account.

Outcomes of bariatric surgery in patients with depression disorders

OBJECTIVE

To determine the impact of sleeve gastrectomy in patients suffering from depression compared with those who are not in a depressive state.

INTRODUCTION

Obesity is considered a global epidemic. Often patients with obesity suffer from depressive state. Depressive disorders may be both a cause and a consequence of obesity.

MATERIAL AND METHODS

The study includes 300 consecutives patients that underwent laparoscopic sleeve gastrectomy. Out of the 300 patients, 253 (84.33%) of them completed the follow up for three years.

RESULTS

Out of the 300-patients, with the average age of 41.65±11.05 years old, the ratio of males to females was 1:2. The average baseline BMI was 42.02 kg/m2. A total of 105 (35.33%) of the patients suffer from depression, which was more common in male (43%) than in female (31.5%), with statistically significant difference (p = .05). Comparing the weight loss after surgery in both groups, the mean weight loss in the depression-group was 12.0 ΔBMI and in the non-depression group was 13.03 ΔBMI, (p< .001). After three years, 94 (88.68%) patients of the depression group responded as they were optimistic and satisfied with the results of the operation, with positive changes in their lives, 8 (7.55%) did not experience change and 4 (3.77%) expressed to have worsened their depressive state.

CONCLUSION

Laparoscopic sleeve gastrectomy is successful and leads to weight loss even in subjects who are affected by depression syndrome.

EPOCHA-AH 1998–2017. Dynamics of prevalence, awareness of arterial hypertension, treatment coverage, and effective control of blood pressure in the European part of the Russian Federation

AIM

To perform a repeated epidemiological study of a representative sample in the European part of the Russian Federation in 2017 and to compare the dynamics of arterial hypertension (AH) prevalence with the effectiveness of blood pressure (BP) control in the population compared to 1998, 2002, and 2007.

MATERIALS AND METHODS

A representative sample of the European part of the Russian Federation was created in 2002 and re-examined in 2007 and 2017. In 1998, a pilot project was performed for examining a representative sample for the Nizhniy Novgorod region.

RESULTS

During 19 years of follow-up, the AH prevalence increased from 35.5 to 43.3%. Te awareness and treatment coverage reached 76.9 and 79.3%, respectively, in 2017. Achievement of the target BP with a single measurement also increased among patients receiving antihypertensive medication from 14.3 to 34.9%. For the treatment of AH, medium-acting antihypertensive drugs are used, ofen at suboptimal doses.

CONCLUSION

Epidemiological indices of awareness, treatment coverage, and number of effectively managed patients with AH have improved. However, the AH prevalence has increased by 7.8% for 19 years, which indicates inefciency of the primary prevention of this disease.

Prevention and Control of Hypertension: JACC Health Promotion Series

Hypertension, the leading risk factor for cardiovascular disease, originates from combined genetic, environmental, and social determinants. Environmental factors include overweight/obesity, unhealthy diet, excessive dietary sodium, inadequate dietary potassium, insufficient physical activity, and consumption of alcohol. Prevention and control of hypertension can be achieved through targeted and/or population-based strategies. For control of hypertension, the targeted strategy involves interventions to increase awareness, treatment, and control in individuals. Corresponding population-based strategies involve interventions designed to achieve a small reduction in blood pressure (BP) in the entire population. Having a usual source of care, optimizing adherence, and minimizing therapeutic inertia are associated with higher rates of BP control. The Chronic Care Model, a collaborative partnership among the patient, provider, and health system, incorporates a multilevel approach for control of hypertension. Optimizing the prevention, recognition, and care of hypertension requires a paradigm shift to team-based care and the use of strategies known to control BP.

Predictors of Undiagnosed and Uncontrolled Hypertension in the Local Community of Byblos, Lebanon

OBJECTIVE

This study aimed to determine the prevalence and predictors of undiagnosed and uncontrolled hypertension (HTN) in a local community in Lebanon.

DESIGN AND METHODS

In this cross-sectional study, we interviewed 911 adults in the local community of Byblos, Lebanon, and 691 were enrolled in the study. Blood pressure (BP), height, and weight were measured. The diagnosis of HTN was based on the 2013 European Society of Hypertension (ESH)/ European Society of Cardiology (ESC) guidelines (systolic BP ⩾140 mm Hg and/or diastolic BP ⩾90 mm Hg). The data collected were analyzed using "Statistical Package for the Social Sciences" software (SPSS).

RESULTS

A total of 260 participants were found to be hypertensive, either previously diagnosed or undiagnosed, yielding an overall prevalence of HTN of 37.62%. Of these participants, 149 (57.31%) were previously diagnosed and had controlled BP, and 111 (42.69%) had undiagnosed or uncontrolled HTN. Of these 111 participants, 44 had undiagnosed HTN and 67 were previously documented as hypertensive but had uncontrolled BP. Younger age and the absence of associated cardiovascular comorbidities were found to be associated with undiagnosed HTN, whereas high body mass index, smoking, and nonadherence to therapy were found to be associated with uncontrolled HTN.

CONCLUSION AND IMPLICATIONS

This study revealed a relatively high prevalence of HTN in the studied population, along with a high prevalence of undiagnosed and uncontrolled HTN. These findings emphasize the need for wider and more efficient screening strategies to better diagnose and control HTN in the general population.

Early sexual experience and hypertension in US adults: results from the National Health and Nutrition Examination Survey 2001-2016

OBJECTIVES

We examined whether the early initiation of sexual activity is associated with hypertension in US adults, and whether the timing of first menstruation is meaningful in regard of this association. We also assessed the effect modification by ethnicity.

METHODS

Using data from 2001 to 2016 National Health and Nutrition Examination Survey, we included 39 788 women. The association of age at the first sexual intercourse (FSI) and hypertension (SBP ≥ 130 mmHg or DBP ≥ 80 mmHg) was examined using multivariate logistic regression. Effect modification by ethnicity was assessed through a cross-product interaction term between age at FSI and ethnicity.

RESULTS

Among women with FSI after their first menstruation, the odds of hypertension decrease by 20% [95% confidence interval (CI) -27 to -13%] in those who experienced FSI after 19 years of age, relative to those with FSI before 19 years of age. Ethnicity significantly modified the inverse association between age at FSI and hypertension (P value for interaction: 0.0003). Among non-Hispanic white, having FSI aged at least 19 years reduced the odds of hypertension by 34% (95% CI -41 to -27%). Turning to Latina women, the FSI before 19 years of age and before first menstruation resulted to a marked increase in the odds of hypertension [odds ratio = 1.38 (95% CI 1.15-1.65)]. In non-Hispanic black, the age at FSI was not linked to hypertension.

CONCLUSION

The FSI before 19 years of age is associated with hypertension during adulthood in US non-Hispanic white and Hispanic women, but not in non-Hispanic black.

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants

BACKGROUND

Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.

METHODS

We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.

RESULTS

In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.

CONCLUSIONS

Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

Trends in Mortality Among Females in the United States, 1900-2010: Progress and Challenges

INTRODUCTION

We analyzed trends in US female mortality rates by decade from 1900 through 2010, assessed age and racial differences, and proposed explanations and considered implications.

METHODS

We conducted a descriptive study of trends in mortality rates from major causes of death for females in the United States from 1900 through 2010. We analyzed all-cause unadjusted death rates (UDRs) for males and females and for white and nonwhite males and females from 1900 through 2010. Data for blacks, distinct from other nonwhites, were available beginning in 1970 and are reported for this and following decades. We also computed age-adjusted all-cause death rates (AADRs) by the direct method using age-specific death rates and the 2000 US standard population. Data for the analysis of decadal trends in mortality rates were obtained from yearly tabulations of causes of death from published compilations and from public use computer data files.

RESULTS

In 1900, UDRs and AADRs were higher for nonwhites than whites and decreased more rapidly for nonwhite females than for white females. Reductions were highest among younger females and lowest among older females. Rates for infectious diseases decreased the most. AADRs for heart disease increased 96.5% in the first 5 decades, then declined by 70.6%. AADRs for cancer rose, then decreased. Stroke decreased steadily. Unintentional motor vehicle injury AADRs increased, leveled off, then decreased. Differences between white and nonwhite female all-cause AADRs almost disappeared during the study period (5.4 per 100,000); differences in white and black AADRs remained high (121.7 per 100,000).

CONCLUSION

Improvements in social and environmental determinants of health probably account for decreased mortality rates among females in the early 20th century, partially offset by increased smoking. In the second half of the century, other public health and clinical measures contributed to reductions. The persistent prevalence of risk behaviors and underuse of preventive and medical services indicate opportunities for increased female longevity, particularly in racial minority populations.