Blood pressure control in Hispanics in the antihypertensive and lipid-lowering treatment to prevent heart attack trial

The Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review

Hypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness in Colombia is generally high, rates of treatment initiation, adherence, and blood pressure (BP) control are suboptimal. Major international hypertension guidelines recommend starting treatment with a combination of antihypertensive agents, and the use of a single-pill combination (SPC) to maximize adherence. In contrast, Colombian hypertension guidelines recommend starting treatment with diuretic monotherapy in most patients, and only initiating combination therapy in those with BP > 160/100 mmHg. Therefore, the aim of the current narrative review is to examine the rationale for using SPCs to treat hypertension in Colombia, in the context of the major issues for BP control there. There is evidence of widespread therapeutic inertia in hypertension management, particularly in primary care, in Colombia. Moreover, combination therapy, angiotensin-converting enzyme inhibitors, and long-acting calcium channel blockers, which are internationally recommended as first-line drug therapies, are underutilized there. Adherence to antihypertensive therapy is low in Colombia and may be enhanced by use of SPCs as well as better patient education and follow-up. While there are promising national initiatives to improve BP management, more needs to be done by individual physicians. Antihypertensive SPCs are available on the national essential medicines list and may help to overcome some of the problems with suboptimal adherence, therapeutic inertia, and low rates of BP control that contribute to the high cardiovascular death rate in Colombia.

Advancing Equity in Blood Pressure Control: A Response to the Surgeon General's Call-to-Action

Hypertension is an established risk factor for cardiovascular disease. Although controlling blood pressure reduces cardiovascular and stroke mortality and target organ damage, poor blood pressure control remains a clinical and public health challenge. Furthermore, racial and ethnic disparities in the outcomes of hypertension are well documented. In October of 2020, the U.S. Department of Health and Human Services published The Surgeon General's Call to Action to Control Hypertension. The Call to Action emphasized, among other priorities, the need to eliminate disparities in the treatment and control of high blood pressure and to address social determinants as root causes of inequities in blood pressure control and treatment. In support of the goals set in the Call to Action, this review summarizes contemporary research on racial, ethnic, and socioeconomic disparities in hypertension and blood pressure control; describes interventions and policies that have improved blood pressure control in minoritized populations by addressing the social determinants of health; and proposes next steps for achieving equity in hypertension and blood pressure control.

Participation in genetic research among Latinx populations by Latin America birth-residency concordance: a global study

Latinx populations are underrepresented in DNA-based research, and risk not benefiting from research if underrepresentation continues. Latinx populations are heterogenous; reflect complex social, migration, and colonial histories; and form strong global diasporas. We conducted a global study using a survey tool (Amazon's Mechanical Turk portal) to ascertain willingness to participate in genetic research by Latin America birth-residency concordance. Participants in the global study identified as Latinx (n=250) were classified as the following: (1) born/live outside of Latin America and the Caribbean (LAC), (2) born within/live outside LAC, and (3) born/live within LAC. Latinx were similarly likely to indicated they would participate DNA-based research as their non-Latinx counterparts (52.8% vs. 56.2%, respectively). Latinx born and living in LAC were significantly more willing to participate in DNA-based research than Latinx born and living outside of LAC (OR: 2.5; 95% CI: 1.3, 4.9, p<.01). Latinx indicating they would participate in genetic research were more likely to trust researchers (<.05), believe genetic research could lead to better understanding of disease (<.05), and that genetic research could lead to new treatments (p<.05) when compared with Latinx not interested in participating in genetic research. In summary, significant variation exists in genetic research interest among Latinx based on where they were born and live, suggesting that this context itself independently influences decisions about participation. Cultivating and investing in a research ecosystem that addresses, values, and respects Latinx priorities, circumstances, and researchers would likely increase research participation and, even more importantly, potentially impact the inequitable health disparities disproportionately represented in Latinx communities.

Effect of Nurse Practitioner Interventions on Hospitalizations in the Community Transitions Intervention Trial

BACKGROUND

Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites.

OBJECTIVE

The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches.

METHODS

We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention.

RESULTS

The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC.

CONCLUSION

The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.

Factors Associated With Failure to Achieve the Intensive Blood Pressure Target in the Systolic Blood Pressure Intervention Trial (SPRINT)

SPRINT (Systolic Blood Pressure Intervention Trial) found that randomization of nondiabetic participants at high cardiovascular risk to an intensive (systolic blood pressure [SBP] <120 mm Hg) versus standard (SBP <140 mm Hg) target resulted in 25% risk reduction in the first cardiovascular composite event (ie, cardiovascular death or nonfatal myocardial infarction, stroke, or hospitalization for heart failure) and a 27% risk reduction in all-cause mortality. In this post hoc analysis, we sought to determine the factors associated with failure to achieve the SBP target in 4678 SPRINT participants randomized to the intensive treatment group. Using a generalized estimating equation model, we assessed variables associated with failure to achieve the intensive SBP target as a repeated outcome collected during serial follow-up visits, including the occurrence of serious adverse events. In the multivariable model adjusted for baseline demographic, clinical, and laboratory variables, older age, higher SBP, underlying chronic kidney disease, higher number of antihypertensives, and moderate cognitive impairment at screening were associated with failure to achieve the intensive SBP target. Occurrence of a serious adverse event during the trial was associated with 20% higher odds of failure to achieve the SBP target. Participants of Hispanic ethnicity had 47% lower odds of failure to achieve the intensive SBP target relative to non-Hispanic Whites. Understanding barriers to achieving intensive SBP targets should allow clinicians to optimize management of hypertension in patients at high risk for cardiovascular disease.

Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial

BACKGROUND

Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group.

METHODS

A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months.

RESULTS

Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC.

CONCLUSION

The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01918891.

Factors Associated With Treatment and Control of Hypertension in a Healthy Elderly Population Free of Cardiovascular Disease: A Cross-sectional Study

BACKGROUND

Despite readily available treatments, control of blood pressure (BP) with population aging remains suboptimal. Further, there are gaps in the understanding of the management of high BP in the aged. We explored antihypertensive treatment and control among elderly hypertensive participants free from overt cardiovascular disease (CVD), and identified factors related to both "untreated" and "treated but uncontrolled" high BP.

METHODS

We analyzed baseline data from 19,114 individuals aged ≥65 years enrolled from Australia and United States (US) in the ASPirin in Reducing Events in the Elderly study. Hypertension was defined as an average systolic/diastolic BP ≥140/90 mm Hg and/or the use of any BP lowering medication. "Controlled hypertension" was defined if participants were receiving antihypertensive medication and BP <140 and 90 mm Hg. Descriptive analyses were used to summarize hypertension control rates; logistic regression was used to investigate relationships with treatment and BP control.

RESULTS

Overall, 74% (14,213/19,114) of participants were hypertensive; and of these 29% (4,151/14,213) were untreated. Among those treated participants, 53% (5,330/10,062) had BP ≥140/90 mm Hg. Participants who were untreated were more likely to be men, have higher educational status, and be in good physical health, and less likely to have significant comorbidities. The factors related to "treated but uncontrolled" BP included older age, male, Black race (vs. White), using antihypertensive monotherapy (vs. multiple) and residing in Australia (vs. US).

CONCLUSIONS

High levels of "untreated" and "treated but uncontrolled" BP occur in healthy elderly people without CVD, suggesting there are opportunities for better BP control in the primary prevention of CVD in this population.

CLINICAL TRIALS REGISTRATION

NCT01038583.

High blood pressure in Hispanics in the United States: a review

PURPOSE OF REVIEW

To provide an overview of the available data on the prevalence of hypertension (HTN) in various groups and segments of the Hispanic population; prevalence of awareness, treatment and control of HTN among Hispanics; and HTN-related disparities, through disproportionate effects on the Hispanic elderly, women, and young adults.

RECENT FINDINGS

Data on HTN in Hispanics has been lacking or aggregated and frequently not inclusive of certain groups of Hispanics but the available data do show a pattern of more prevalent HTN and HTN disparities among Hispanics compared with non-Hispanic whites. Hispanic adults have some of the highest prevalence of poorly controlled blood pressure compared with any other race-ethnic group in the United States. Further, the impact of the most recent iteration of the HTN guidelines among all segments of the Hispanic population has not been well studied.

SUMMARY

The most recent HTN guidelines will likely only further illuminate worsening HTN-related disparities among Hispanics. These findings suggest significant screening and treatment disparities must be addressed to reduce HTN risk among the Hispanic population.

BRInging the Diabetes prevention program to GEriatric populations (BRIDGE): a feasibility study

Background

The purpose of this 6-week intervention was to test the feasibility and acceptability of implementing a telehealth-adapted Diabetes Prevention Program (DPP) at a senior center.

Methods

Older adults (n = 16) attended weekly interactive webinars. At each measurement time point, participants completed questionnaires covering lifestyle, physical activity, quality of life, and food records and wore physical activity trackers. Qualitative data were gathered from 2 focus groups inviting all 16 participants with 13 and 10 participants attending, respectively.

Results

Over 2000 senior center members were contacted, approximately 2% (n = 39) responded to the recruitment email, and 16 were recruited into the study. Retention was 75%, and attendance rates averaged 80% across the six intervention sessions. The focus group participants provided positive opinions for most program components, especially the webinar group interaction and using physical activity trackers. Suggestions for improvement included a greater focus on specific needs of older adults (i.e., adapting activities) and placing a greater emphasis on dietary strategies to prevent diabetes. Mean weight loss was 2.9% (2.7 kg [95% CI 1.6, 3.7]; p value = 0.001).

Conclusion

The feasibility of providing DPP via webinar appears to be high based on the retention and attendance rates. Similar to other behavioral interventions engaging older adults, recruitment rates were low. Acceptability was evidenced by high attendance at the intervention sessions and feedback from participants during focus group sessions. The intervention efficacy should be evaluated based on CDC criteria for program recognition in a larger scale randomized trial.

Trial registration

NCT03524404. Registered 14 May 2018—retrospectively registered. Trial protocol will be provided by the corresponding author upon request.

Sustained blood pressure control and coronary heart disease, stroke, heart failure, and mortality: An observational analysis of ALLHAT

Achieving blood pressure (BP) control is associated with lower cardiovascular disease (CVD) risk, but less is known about CVD risk associated with sustained BP control over time. This observational analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was restricted to participants with four to seven visits with systolic BP (SBP) measurements during a 22-month period (n = 24 309). The authors categorized participants as having sustained BP control (SBP < 140 mm Hg) at 100%, 75% to <100%, 50% to <75%, and <50% of visits during this period. Outcomes included fatal coronary heart disease (CHD)/nonfatal myocardial infarction (MI), stroke, heart failure (HF), a composite CVD outcome (fatal CHD/nonfatal MI, stroke, or HF), and mortality. Hazard ratios (HRs) for the association of category of sustained BP control for each outcome were obtained using proportional hazards models. SBP control was present among 20.0% of participants at 100%, 16.4% at 75% to less than 100%, 27.0% at 50% to less than 75%, and 36.6% at less than 50% of visits. Compared to those with SBP control at 100% visits, adjusted HR (95% CI) among those with SBP control at <50% of visits was 1.16 (0.93-1.44) for fatal CHD/nonfatal MI, 1.71 (1.26-2.32) for stroke, 1.63 (1.30-2.06) for HF, 1.39 (1.20-1.62) for the composite CVD outcome, and 1.14 (0.99-1.30) for mortality. Sustained SBP control may be beneficial for preventing stroke, HF, and CVD outcomes in adults taking antihypertensive medication.

Clinical, Socioeconomic, and Psychosocial Factors Associated with Blood Pressure Control and Adherence: Results from a Multidisciplinary Cardiovascular National Program Providing Universal Coverage in a Developing Country

Background

Limited information exists on blood pressure (BP) control factors and adherence to antihypertensive drug therapy (Rx) in developing countries.

Methods

Cross-sectional study in randomly selected 992 hypertensive patients under a Chilean national comprehensive Cardiovascular Health Program (CVHP). Association of education, income, diabetes, obesity, physical activity, psychosocial characteristics, smoking, and alcohol abuse with BP control and adherence were evaluated by multivariate logistic regression.

Results

BP control (<140/90 mmHg) was achieved in 63.1% of patients, with 38.4% adherent to Rx. Uncontrolled BP significantly associated with male sex (OR: 1.73 [95% CI 1.35-2.22]), low family income, high emotional-stress-depression score, body mass index, no adherence (OR: 1.83 [95% CI 1.44 - 2.32]), multiple Rx, baseline systolic BP value, and sedentary life style. Males (OR: 1.54 [95% CI 1.23 - 1.93]), low family income, high emotional stress-depression score (OR: 2.15 [95% CI 1.68 - 2.76]), low social support, and uncontrolled BP (OR: 1.52 [95% CI 1.22-1.90]) associated with no adherence.

Conclusions

Comparable BP control (63.1%) to higher-income societies was observed. Uncontrolled BP associated significantly to no adherence and both to male sex, socioeconomic, and psychosocial factors. Global low adherence (38.4%) and improved BP control and adherence in diabetics were noted.

Clinical Outcomes by Race and Ethnicity in the Systolic Blood Pressure Intervention Trial (SPRINT): A Randomized Clinical Trial

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) showed that targeting a systolic blood pressure (SBP) of ≤ 120 mm Hg (intensive treatment) reduced cardiovascular disease (CVD) events compared to SBP of ≤ 140 mm Hg (standard treatment); however, it is unclear if this effect is similar in all racial/ethnic groups.

METHODS

We analyzed SPRINT data within non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic subgroups to address this question. High-risk nondiabetic hypertensive patients (N = 9,361; 30% NHB; 11% Hispanic) 50 years and older were randomly assigned to intensive or standard treatment. Primary outcome was a composite of the first occurrence of a myocardial infarction, acute coronary syndrome, stroke, decompensated heart failure, or CVD death.

RESULTS

Average postbaseline SBP was similar among NHW, NHB, and Hispanics in both treatment arms. Hazard ratios (HRs) (95% confidence interval) (intensive vs. standard treatment groups) for primary outcome were 0.70 (0.57-0.86), 0.71 (0.51-0.98), 0.62 (0.33-1.15) (interaction P value = 0.85) in NHW, NHB, and Hispanics. CVD mortality HRs were 0.49 (0.29-0.81), 0.77 (0.37-1.57), and 0.17 (0.01-1.08). All-cause mortality HRs were 0.61 (0.47-0.80), 0.92 (0.63-1.35), and 1.58 (0.73-3.62), respectively. A test for differences among racial/ethnic groups in the effect of treatment assignment on all-cause mortality was not significant (Hommel-adjusted P value = 0.062) after adjustment for multiple comparisons.

CONCLUSION

Targeting a SBP goal of ≤ 120 mm Hg compared to ≤ 140 mm Hg led to similar SBP control and was associated with similar benefits and risks among all racial ethnic groups, though NHBs required an average of ~0.3 more medications.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01206062, ClinicalTrials.gov Identifier at https://clinicaltrials.gov/ct2/show/NCT01206062.

From Sea to Shining Sea and the Great Plains to Patagonia: A Review on Current Knowledge of Diabetes Mellitus in Hispanics/Latinos in the US and Latin America

The past two decades have witnessed many advances in the prevention, treatment, and control of diabetes mellitus (DM) and its complications. Increased screening has led to a greater recognition of type 2 diabetes mellitus (type 2 DM) and prediabetes; however, Hispanics/Latinos, the largest minority group in the US, have not fully benefited from these advances. The Hispanic/Latino population is highly diverse in ancestries, birth places, cultures, languages, and socioeconomic backgrounds, and it populates most of the Western Hemisphere. In the US, the prevalence of DM varies among Hispanic/Latino heritage groups, being higher among Mexicans, Puerto Ricans, and Dominicans, and lower among South Americans. The risk and prevalence of diabetes among Hispanics/Latinos are significantly higher than in non-Hispanic Whites, and nearly 40% of Hispanics/Latinos with diabetes have not been formally diagnosed. Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and non-pharmacological clinical trials has been suboptimal, while the prevalence of diabetes in these populations continues to rise. This review will focus on the epidemiology, etiology and prevention of type 2 DM in populations of Latin American origin. We will set the stage by defining the terms Hispanic, Latino, and Latin American, explaining the challenges identifying Hispanics/Latinos in the scientific literature and databases, describing the epidemiology of diabetes-including type 2 DM and gestational diabetes mellitus (GDM)-and cardiovascular risk factors in Hispanics/Latinos in the US and Latin America, and discussing trends, and commonalities and differences across studies and populations, including methodology to ascertain diabetes. We will discuss studies on mechanisms of disease, and research on prevention of type 2 DM in Hispanics/Latinos, including women with GDM, youth and adults; and finalize with a discussion on lessons learned and opportunities to enhance research, and, consequently, clinical care oriented toward preventing type 2 DM in Hispanics/Latinos in the US and Latin America.

Racial and Ethnic Differences in Antihypertensive Medication Use and Blood Pressure Control Among US Adults With Hypertension

Background—

A key to reduce and eradicate racial disparities in hypertension outcomes is to understand their causes. We aimed at evaluating racial differences in antihypertensive drug utilization patterns and blood pressure control by insurance status, age, sex, and presence of comorbidities.

Methods and Results—

A total of 8796 hypertensive individuals ≥18 years of age were identified from the National Health and Nutrition Examination Survey (2003–2012) in a repeated cross-sectional study. During the study period, all 3 racial groups (whites, blacks, and Hispanics) experienced substantial increase in hypertension treatment and control. The overall treatment rates were 73.9% (95% confidence interval [CI], 71.6%–76.2%), 70.8% (95% CI, 68.6%–73.0%), and 60.7% (95% CI, 57.0%–64.3%) and hypertension control rates were 42.9% (95% CI, 40.5%–45.2%), 36.9% (95% CI, 34.7%–39.2%), and 31.2% (95% CI, 28.6%–33.9%) for whites, blacks, and Hispanics, respectively. When stratified by insurance status, blacks (odds ratio, 0.74 [95% CI, 0.64–0.86] for insured and 0.59 [95% CI, 0.36–0.94] for uninsured) and Hispanics (odds ratio, 0.74 [95% CI, 0.60–0.91] for insured and 0.58 [95% CI, 0.36–0.94] for uninsured) persistently had lower rates of hypertension control compared with whites. Racial disparities also persisted in subgroups stratified by age (≥60 and <60 years of age) and presence of comorbidities but worsened among patients <60 years of age.

Conclusions—

Black and Hispanic patients had poorer hypertension control compared with whites, and these differences were more pronounced in younger and uninsured patients. Although black patients received more intensive antihypertensive therapy, Hispanics were undertreated. Future studies should further explore all aspects of these disparities to improve cardiovascular outcomes.

Baseline blood pressure control in Hispanics: characteristics of Hispanics in the Systolic Blood Pressure Intervention Trial

The Systolic Blood Pressure Intervention Trial (SPRINT) tested whether a systolic blood pressure (SBP) value <120 mm Hg reduces adverse clinical outcomes compared with the goal of <140 mm Hg. Here the authors describe the baseline characteristics of Hispanic participants in SPRINT. Nondiabetic hypertensive patients 50 years and older with SBP 130-180 mm Hg taking zero to four blood pressure (BP) medications were enrolled from the mainland United States and Puerto Rico. Cross-sectional, bivariate analysis was employed comparing sociodemographic and clinical factors in Hispanics vs non-Hispanics. Multivariable logistic regression models restricted to Hispanics were used to identify factors associated with achieved BP control (SBP <140 mm Hg and diastolic BP <90 mm Hg) at baseline. Eleven percent (n=984) of SPRINT participants were Hispanic; 56% (n=549) of Hispanics were living in Puerto Rico and the remainder were living on the US mainland. Hispanics overall were younger, more often female, less likely to live alone, and more likely to have lower education and be uninsured, although just as likely to be employed compared with non-Hispanics. BP control was not different between Hispanics vs non-Hispanics at baseline. However, a significantly higher percentage of Hispanics on the US mainland (compared with Hispanics in Puerto Rico) had controlled BP. BP control was independently associated with cardiovascular disease history and functional status among Hispanics, specifically those living in Puerto Rico, whereas functional status was the only independent predictor of BP control identified among mainland Hispanics. These findings highlight the diversity of the SPRINT population. It remains to be seen whether factors identified among Hispanics impact intervention goals and subsequent clinical outcomes.

Designing and evaluating health systems level hypertension control interventions for African-Americans: lessons from a pooled analysis of three cluster randomized trials

OBJECTIVES

African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions.

METHODS

Using a cluster randomized design, the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling.

RESULTS

2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60±0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167± 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 ± 0.293, p=0.622; group x quadratic time coefficient= -0.017 ± 0.026, p=0.525). RESULTS were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately.

CONCLUSION

Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

Longitudinal genome-wide methylation study of Roux-en-Y gastric bypass patients reveals novel CpG sites associated with essential hypertension

BACKGROUND

Essential hypertension is a significant risk factor for cardiovascular diseases. Emerging research suggests a role of DNA methylation in blood pressure physiology. We aimed to investigate epigenetic associations of promoter related CpG sites to essential hypertension in a genome-wide methylation approach.

METHODS

The genome-wide methylation pattern in whole blood was measured in 11 obese patients before and six months after Roux-en-Y gastric bypass surgery using the Illumina 450 k beadchip. CpG sites located within 1500 bp of the transcriptional start site of adjacent genes were included in our study, resulting in 124 199 probes investigated in the subsequent analysis. Percent changes in methylation states and SBP measured before and six months after surgery were calculated. These parameters were correlated to each other using the Spearman's rank correlation method (Edgeworth series approximation). To further investigate the detected relationship between candidate CpG sites and systolic blood pressure levels, binary logistic regression analyses were performed in a larger and independent cohort of 539 individuals aged 19-101 years to elucidate a relationship between EH and the methylation state in candidate CpG sites.

RESULTS

We identified 24 promoter associated CpG sites that correlated with change in SBP after RYGB surgery (p < 10(-16)). Two of these CpG loci (cg00875989, cg09134341) were significantly hypomethylated in dependency of EH (p < 10(-03)). These results were independent of age, BMI, ethnicity and sex.

CONCLUSIONS

The identification of these novel CpG sites may contribute to a further understanding of the epigenetic regulatory mechanisms underlying the development of essential hypertension.

Patterns and Correlates of Baseline Thiazide-Type Diuretic Prescription in the Systolic Blood Pressure Intervention Trial

Thiazides and thiazide-type diuretics are recommended as first-line agents for the treatment of hypertension, but contemporary information on their use in clinical practice is lacking. We examined patterns and correlates of thiazide prescription in a cross-sectional analysis of baseline data from participants enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT). We examined baseline prescription of thiazides in 7582 participants receiving at least 1 antihypertensive medication by subgroup, and used log-binomial regression to calculate adjusted prevalence ratios for thiazide prescription (versus no thiazide). Forty-three percent of all participants were prescribed a thiazide at baseline, but among participants prescribed a single agent, the proportion was only 16%. The prevalence of thiazide prescription differed significantly by demographic factors, with younger participants, women, and blacks all having higher adjusted prevalence of thiazide prescription than other corresponding subgroups. Participants in the lowest category of kidney function (estimated glomerular filtration rate <30 mL/min per 1.73 m2) were half as likely to be prescribed a thiazide as participants with preserved kidney function. In conclusion, among persons with hypertension and heightened cardiovascular risk, we found that thiazide prescription varied significantly by demographics and kidney disease status, despite limited evidence about relative differences in effectiveness.

Hypertension prevalence, awareness, treatment and control in the over 50s in Ireland: evidence from The Irish Longitudinal Study on Ageing

BACKGROUND

To assess the prevalence, awareness, treatment and control of hypertension among adults in Ireland and to describe the determinants of awareness, treatment and control in order to inform public health policy.

METHODS

A cross-sectional study of a nationally representative sample of community living adults aged 50 years and older using data collected from 2009 to 2011 for the first wave of the Irish Longitudinal Study on Ageing (TILDA) (n = 5857). Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg and/or currently taking antihypertensive medications.

RESULTS

The prevalence of hypertension was 63.7% [95% confidence interval (CI) 62.3-65.1%]. Among those with hypertension, 54.5% (95% CI 52.6-56.2%) were aware of their hypertensive status and 58.9% (95% CI 57.1-60.4%) were on antihypertensive medication. Among those on treatment, 51.6% (95% CI 49.3-53.9%) had their BP controlled to below 140/90 mmHg. Respondents facing financial barriers to primary care and medication were less likely to be on antihypertensive treatment compared with those without financial barriers.

CONCLUSIONS

A high prevalence of hypertension was identified in this cohort, with low levels of awareness, treatment and control. Population and primary care interventions are required to reduce prevalence and to improve awareness, detection and management of hypertension.

Hypertension in minority populations: new guidelines and emerging concepts

Persistent disparities in hypertension, CKD, and associated cardiovascular disease have been noted in the United States among racial/ethnic minority groups. Overall, these disparities are largely mediated by social determinants of health. Yet, emerging data suggest additional biologic factors in racial/ethnic disparities in hypertension prevalence, complications, particularly CKD, and responses to treatment. Nevertheless, race is a social construct and not a physiologic concept, and ethnicity, federally defined as the binary "Hispanic/Latino" or "not Hispanic/Latino," is also imprecise. However, race/ethnicity categories may help interpret health-related data, including surveillance and research, and are important in ensuring that clinical trials remain generalizable to diverse populations. There is significant heterogeneity among prespecified groups and, perhaps, greater genetic differences within than between certain racial/ethnic groups. This review will explore hypertension epidemiology, pathophysiology, and management among the diverse and growing US minority groups, specifically African Americans and Hispanics because much less data are available across the wide spectrum of diverse populations. We will highlight the intersection of hypertension and increasingly prevalent CKD, particularly in African Americans. Finally, we propose multidimensional treatment approaches to hypertension among diverse populations, encompassing population, community, health system, and individual-based approaches.

Clinical characteristics, treatment patterns and outcomes of Hispanic hypertensive patients

Hispanics are the largest and fastest-growing minority population in the United States, currently comprising about 16.3% (52 million) of the total population. With an increased prevalence of metabolic risk factors in this population, the rate of uncontrolled hypertension (HTN) in Hispanics significantly exceeds the rates observed among non-Hispanic blacks and whites. Unfortunately, data on HTN in Hispanics remains limited due to the under-representation of Hispanics in clinical trials; with most of the data primarily restricted to observational and retrospective subgroup analyses. This article aims to review the available data on prevalence, awareness and control of HTN, risk factors and some of the challenges unique to the Hispanics population. We also discuss treatment strategies derived from large HTN trials that included Hispanics.

Inherent inaccuracies and potential utility of race/ethnicity labeling in the treatment of hypertension

The use of racial/ethnic labeling for any purpose is fraught with substantial emotional, social and political consequences even when used for demographic studies or census. In addition to the very real historical conflicts associated with slavery in the Americas and various social classification systems elsewhere, such labeling has been shown by the use of ancestral identification markers to be inaccurate in many cases. Even geographic labeling, such as East Asians, ignores the marked heterogeneity of East Asians. The use of race alone to determine selection of initial antihypertensive therapy is a very limited approach. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents has demonstrated, however, that the use of age and race together may be a useful paradigm for predicting response to a single antihypertensive drug. Furthermore, individuals from populations who consume high levels of sodium and lower levels of potassium may respond better to diuretics and calcium antagonists. Other populations may be more susceptible to angioedema or cough related to the use of angiotensin-converting enzyme inhibitors. Such information may be useful for the selection or avoidance of certain medications. No patient should ever be denied indicated treatment with a drug or drug class because of race or ethnicity.

Costs associated with cardiovascular events in patients with hypertension in US managed care settings

Study quantified incremental cost of cardiovascular (CV) events in 6 high-risk and compelling indication subgroups: post-myocardial infarction (MI), diabetes, diabetic nephropathy, elderly, chronic kidney disease, and prior stroke. Based on claims data from privately insured individuals with 2+ hypertension (HTN) diagnoses in 2004-2006, we estimated regression-adjusted per-member-per-month healthcare costs after CVE. Costs were compared between patients with and without a CV events, and before and after CV events in each subgroup. The following CVevents were studied: acute MI, acute coronary syndrome, angina, ventricular arrhythmia, atrial arrhythmia, heart failure, coronary artery disease, left ventricular hypertrophy, stroke, and sinus tachycardia. Of 1,598,890 HTN patients, 510,118 had >/=1 CV event. Compared with controls, healthcare costs among patients with events were significantly greater across all cost components (inpatient, outpatient, and prescription drug). Acute MI and congestive heart failure generally had the largest incremental total healthcare costs. First-quarter post-event costs were attributable to inpatient costs. CV events are costly sequelae of hypertension in high-risk and CI subgroups.

Epidemiology and management of hypertension in the Hispanic population: a review of the available literature

Hispanics are the fastest growing ethnic minority in the USA. Among Hispanics, lack of hypertension awareness and lack of effective blood pressure (BP) control are problematic, as are higher incidence rates of hypertension-related co-morbidities compared with non-Hispanic populations. Moreover, there are currently no hypertension treatment guidelines that address the unique characteristics of this ethnic group. This article discusses ethnic differences in hypertension and cardiovascular risk factors and reviews the literature on the efficacy of antihypertensive agents in Hispanic patients, with a focus on the role of renin-angiotensin-aldosterone system (RAAS) inhibition in the management of hypertension in these patients. Hypertension in Hispanic patients can be challenging to manage, in part because this population has a higher prevalence of obesity, diabetes, and metabolic syndrome compared with non-Hispanic whites. The presence of these co-morbidities suggests that RAAS-inhibitor-based therapies may be particularly beneficial in this population. However, few studies have evaluated the efficacy of antihypertensive treatments in Hispanic patients. Two outcomes studies in hypertensive patients have shown the benefits of treating Hispanic patients with antihypertensive therapy and included RAAS inhibitors as part of the treatment regimen. In addition, BP-lowering trials have shown the antihypertensive efficacy of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and direct renin inhibitors, although data on the latter are more limited. Additional studies are needed to more thoroughly evaluate the effects of RAAS inhibitors (and other drug classes) on outcomes and BP lowering in the Hispanic hypertensive population.

Predictors of lowering SBP to assigned targets at 12 months in the Secondary Prevention of Small Subcortical Strokes study

OBJECTIVE

Lowering blood pressure for secondary stroke prevention remains a challenge. These analyses were conducted to identify factors predicting achievement of SBP targets in the Secondary Prevention of Small Subcortical Strokes (SPS3) study.

METHODS

SPS3 is a randomized trial assigning patients with lacunar stroke to two targets of SBP control (130-149 mmHg or <130 mmHg). Logistic regression models were used to identify patient and SPS3 site characteristics predictive of lowering SBP to target at the 12-month study visit.

RESULTS

Of those above target at baseline (n = 1041), 69% were within their assigned target at 12 months. In the model with baseline characteristics only, those receiving treatment for hypertension at baseline were 68% less likely to achieve target [odds ratio (OR) = 0.32; 95% confidence interval (CI) = 0.17-0.60], whereas those of Hispanic ethnicity were 1.49 times more likely (95% CI = 1.09-2.03) to achieve SBP target. When clinical site characteristics were added to the model, only treated hypertension at baseline remained significant. In addition, management at a larger site (OR = 1.51; 95% CI = 1.03-2.20), SBP in target at 6 months (OR = 2.39; 95% CI = 1.79-3.19), and medication adherence (OR = 2.73; 95% CI = 1.51-4.95) were positively associated with achieving target SBP. Missed appointments (OR = 0.55; 95% CI = 0.41-0.73) were negatively associated with lowering SBP to target at 12 months.

CONCLUSION

These results demonstrate that it is feasible to achieve targets of SBP control in this multiethnic stroke cohort across multiple sites and countries. The results highlight the important variables reflecting clinical site management.

Hypertension and antihypertensive therapy in Hispanics and Mexican Americans living in the United States

Hypertension is a major independent risk factor for cardiovascular diseases, which are the most frequent cause of death worldwide. In addition, the risk of hypertension has been associated with racial and/or ethnic background. Hispanics are the largest and fastest-growing minority population in the United States, currently comprising about 16.3% (50.5 million) of the total population; these numbers will continue to increase into the next 10 years. The rate of uncontrolled hypertension in Hispanics significantly exceeds the rates observed among non-Hispanic blacks and whites. The reasons for these racial and ethnic differences in blood pressure control may include factors such as lack of access to health care, low socioeconomic status, language barriers, degree of acculturation, poor doctor-patient communication, and genetic factors. This article provides an up-to-date summary of epidemiological and treatment aspects of high blood pressure in the US Hispanic population. Because Mexican Americans constitute approximately 66% of US Hispanics, data sources that focus on Mexican Americans are also discussed.

Cultural Considerations: Pharmacological and Nonpharmacological Means for Improving Blood Pressure Control among Hispanic Patients

Cardiovascular disease is a leading cause of morbidity and mortality in the United States, and its prevention and treatment remain a priority for the medical community. Ethnic variations account for some differences in the prevalence of hypertension and blood pressure (BP) control rates among Hispanics, indicating the need for culturally appropriate management models. Aggressive treatment strategies are key to achieving optimal BP control in high-risk Hispanic patients. Hypertension in this ethnic group continues to be a major health concern. Of note, when provided access to comprehensive care, Hispanics demonstrate similar response rates to treatment as the majority of non-Hispanic whites. This highlights the importance of effective, culturally responsive hypertension management among high-risk Hispanic patients for achieving observable, positive health outcomes.

Long-term follow-up of participants with heart failure in the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT)

BACKGROUND

In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind, practice-based, active-control, comparative effectiveness trial in high-risk hypertensive participants, risk of new-onset heart failure (HF) was higher in the amlodipine (2.5-10 mg/d) and lisinopril (10-40 mg/d) arms compared with the chlorthalidone (12.5-25 mg/d) arm. Similar to other studies, mortality rates following new-onset HF were very high (≥50% at 5 years), and were similar across randomized treatment arms. After the randomized phase of the trial ended in 2002, outcomes were determined from administrative databases.

METHODS AND RESULTS

With the use of national databases, posttrial follow-up mortality through 2006 was obtained on participants who developed new-onset HF during the randomized (in-trial) phase of ALLHAT. Mean follow-up for the entire period was 8.9 years. Of 1761 participants with incident HF in-trial, 1348 died. Post-HF all-cause mortality was similar across treatment groups, with adjusted hazard ratios (95% confidence intervals) of 0.95 (0.81-1.12) and 1.05 (0.89-1.25), respectively, for amlodipine and lisinopril compared with chlorthalidone, and 10-year adjusted rates of 86%, 87%, and 83%, respectively. All-cause mortality rates were also similar among those with reduced ejection fractions (84%) and preserved ejection fractions (81%), with no significant differences by randomized treatment arm.

CONCLUSIONS

Once HF develops, risk of death is high and consistent across randomized treatment groups. Measures to prevent the development of HF, especially blood pressure control, must be a priority if mortality associated with the development of HF is to be addressed. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Improving treatment in Hispanic/Latino patients

The prevalence of type 2 diabetes mellitus is higher in Hispanic/Latino individuals living in the United States compared with their non-Hispanic white counterparts. Many factors contribute to the increased prevalence of type 2 diabetes, including biological characteristics, socioeconomic conditions, and cultural aspects. The contribution of genetics to the risk of type 2 diabetes in Hispanic/Latino patients is becoming increasingly clear, but this inherent risk factor cannot be modified. However, certain socioeconomic and cultural factors, such as reduced access to healthcare, language barriers, cultural beliefs, and lack of cultural competence by the healthcare provider, are modifiable and should be overcome in order to improve the management of type 2 diabetes in Hispanic/Latino patients. At the healthcare system level, policies should be put into place to reduce disparities between Hispanics/Latinos and non-Hispanic whites regarding health insurance coverage and access to healthcare. At the healthcare provider and patient level, cultural beliefs should be taken into consideration when selecting adequate treatment. Overall, type 2 diabetes management should be individualized by identifying the preferred language and level of acculturation for each patient. These considerations are necessary to further improve communication through culturally appropriate educational materials and programs. These strategies may help to overcome the barriers in the treatment of type 2 diabetes in Hispanic/Latino patients.

Self-management of hypertension in Hispanic adults

Almost one third of the U.S. population has hypertension. Compared to non-Hispanic Whites, Hispanic individuals have significantly lower levels of hypertension awareness, treatment, and control. This article provides an integrative review of factors that may influence self-management of hypertension among Hispanic adults. A detailed literature search of articles published between 1985 and 2010 was performed. Twelve articles based on quantitative studies (n = 9) and qualitative studies (n = 3) were reviewed. Barriers and facilitators to self-management of hypertension were identified. The findings in this review may help health care professionals in recognizing factors that need to be considered in the development of self-management interventions for Hispanic patients with hypertension. Future research is needed to further explore facilitators to self-management, and to implement and evaluate intervention studies aimed at blood pressure management in Hispanics with hypertension.

24-Hour ambulatory blood pressure response to combination valsartan/hydrochlorothiazide and amlodipine/hydrochlorothiazide in stage 2 hypertension by ethnicity: the EVALUATE study

Several studies reported racial/ethnic differences in blood pressure (BP) response to antihypertensive monotherapy. In a 10-week study of stage 2 hypertension, 320/25 mg valsartan/hydrochlorothiazide (HCTZ) reduced ambulatory BP (ABP) significantly more effectively than 10/25 mg amlodipine/HCTZ. Results (post hoc analysis) are described in Caucasians (n=256), African Americans (n=79), and Hispanics (n=86). Compared with clinic-measured BP (no significant treatment-group differences in ethnic subgroups), least-squares mean reductions from baseline to week 10 in mean ambulatory systolic BP (MASBP) and mean ambulatory diastolic BP (MADBP) favored valsartan/HCTZ over amlodipine/HCTZ in Caucasians (-21.9/-12.7 mm Hg vs -17.6/-9.5 mm Hg; P=.0004/P<.0001). No treatment-group differences in MASBP/MADBP were observed in African Americans (-17.3/-10.6 vs -17.9/-9.5; P=.76/P=.40) or Hispanics (-17.9/-9.7 vs -14.2/-7.2; P=.20/P=.17). Based on ABP monitoring, valsartan/HCTZ is more effective than amlodipine/HCTZ in lowering ABP in Caucasians. In African Americans and Hispanics, both regimens are similarly effective.

Ethnic disparities in stroke and hypertension among women: the BASIC project

BACKGROUND

Little data exist on stroke burden in Mexican-American (MA) women. The objective of this study was to characterize the burden of stroke in MA and non-Hispanic white (NHW) women and to compare this burden across ethnic groups.

METHODS

Cases of ischemic stroke and intracerebral hemorrhage among women (January 2000-December 2006) were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a stroke surveillance study in a biethnic Texas community. Cumulative incidence of stroke among women was compared by ethnicity and age. Logistic regression was used to compare risk factors and age-adjusted use of antihypertensives between MA and NHW female stroke cases.

RESULTS

MA women had elevated stroke risk compared with NHW women at younger ages (ages 45-59: relative risk (RR) = 2.00 (95% confidence interval (CI): 1.54-2.58); ages 60-74: RR = 1.57 (95% CI: 1.31-1.87); ages > or =75: RR = 1.13 (95% CI: 0.98-1.29)). Stroke severity and stroke type did not differ between ethnic groups. MA female stroke cases were more likely to have hypertension (odds ratio (OR) = 1.41 (95% CI: 1.11-1.80)), diabetes (OR = 3.54 (95% CI: 2.82-4.45)), and the presence of both risk factors (OR = 3.31 (95% CI: 2.61-4.21)) compared with NHW female stroke cases and were more likely to report use of antihypertensives (OR = 1.51 (95% CI: 1.10-2.06)). There was a trend toward greater hypertension awareness among MA female stroke cases (OR = 1.37 (95% CI: 0.98-1.91)).

CONCLUSIONS

MA women have increased risk of stroke at younger ages compared with NHW women. Reasons for this ethnic disparity, including an increased prevalence of hypertension and diabetes, should be explored.