Hypertension Prevalence and Control Among U.S. Women of Reproductive Age

INTRODUCTION

Hypertension is a risk factor for cardiovascular disease, a leading cause of death among women of reproductive age (women aged 18-44 years). This study estimated hypertension prevalence and control among women of reproductive age at the national and state levels using electronic health record data.

METHODS

Nonpregnant women of reproductive age were included in this cross-sectional study using 2019 IQVIA Ambulatory Electronic Medical Records - U.S. national data (analyzed in 2023). Suspected hypertension was identified using any of these criteria: ≥1 hypertension diagnosis code, ≥2 blood pressure readings ≥140/90 mmHg on separate days, or ≥1 antihypertensive medication. Among women of reproductive age with hypertension, the latest blood pressure in 2019 was used to identify hypertension control (blood pressure <140/90 mmHg). Estimates were age standardized and stratified by race or Hispanic ethnicity, region, and states with sufficient data. Tukey tests compared estimates by race or Hispanic ethnicity, region, and comorbidities.

RESULTS

Among 2,125,084 women of reproductive age (62.1% White, 8.8% Black, and 29.1% other [including Hispanic, Asian, other, or unknown]) with a mean age of 31.7 years, hypertension prevalence was 14.5%. Of those with hypertension, 71.9% had controlled blood pressure. Black women of reproductive age had a higher hypertension prevalence (22.3% vs 14.4%, p<0.05) but lower control (60.6% vs 74.0%, p<0.05) than White women of reproductive age. State-level hypertension prevalence ranged from 13.7% (Massachusetts) to 36% (Alabama), and control ranged from 82.9% (Kansas) to 59.2% (the District of Columbia).

CONCLUSIONS

This study provides the first state-level estimates of hypertension control among women of reproductive age. Electronic health record data complements traditional hypertension surveillance data and provides further information for efforts to prevent and manage hypertension among women of reproductive age.

Incidence of Hyperlipidemia among Adults Initiating Antiretroviral Therapy in the HIV Outpatient Study (HOPS), USA, 2007-2021

Current U.S. guidelines recommend integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) as initial treatment for people with HIV (PWH). We assessed long-term effects of INSTI use on lipid profiles in routine HIV care. We analyzed medical record data from the HIV Outpatient Study's participants in care from 2007 to 2021. Hyperlipidemia was defined based on clinical diagnoses, treatments, and laboratory results. We calculated hyperlipidemia incidence rates and rate ratios (RRs) during initial ART and assessed predictors of incident hyperlipidemia by using Poisson regression. Among 349 eligible ART-naïve PWH, 168 were prescribed INSTI-based ART (36 raltegravir (RAL), 51 dolutegravir (DTG), and 81 INSTI-others (elvitegravir and bictegravir)) and 181 non-INSTI-based ART, including 68 protease inhibitor (PI)-based ART. During a median follow-up of 1.4 years, hyperlipidemia rates were 12.8, 22.3, 22.7, 17.4, and 12.6 per 100 person years for RAL-, DTG-, INSTI-others-, non-INSTI-PI-, and non-INSTI-non-PI-based ART, respectively. In multivariable analysis, compared with the RAL group, hyperlipidemia rates were higher in INSTI-others (RR = 2.25; 95% confidence interval (CI): 1.29-3.93) and non-INSTI-PI groups (RR = 1.89; CI: 1.12-3.19) but not statistically higher for the DTG (RR = 1.73; CI: 0.95-3.17) and non-INSTI-non-PI groups (RR = 1.55; CI: 0.92-2.62). Other factors independently associated with hyperlipidemia included older age, non-Hispanic White race/ethnicity, and ART without tenofovir disoproxil fumarate. PWH using RAL-based regimens had lower rates of incident hyperlipidemia than PWH receiving non-INSTI-PI-based ART but had similar rates as those receiving DTG-based ART, supporting federal recommendations for using DTG-based regimens as the initial therapy for ART-naïve PWH.

Trends in Lipid-Lowering Prescriptions: Increasing Use of Guideline-Concordant Pharmacotherapies, U.S., 2017‒2022

INTRODUCTION

Almost one third of U.S. adults have elevated low-density lipoprotein cholesterol, increasing their risk of atherosclerotic cardiovascular disease. The 2018 American College of Cardiology/American Heart Association Multisociety Cholesterol Management Guideline recommends maximally tolerated statin for those at increased atherosclerotic cardiovascular disease risk and add-on therapies (ezetimibe and PCSK9 inhibitors) in those at very high risk and low-density lipoprotein cholesterol ≥70 mg/dL. Prescription fill trends are unknown.

METHODS

Using national outpatient retail prescription data from the first quarter of 2017 to the first quarter of 2022, authors determined counts of patients who filled low-, moderate-, or high-intensity statins alone and with add-on therapies. The overall percentage change and joinpoint regression were used to assess trends. Analyses were conducted in March 2022-May 2022.

RESULTS

During the first quarter of 2017 to the first quarter of 2022, patients filling a statin increased by 25.0%, with the greatest increase in high-intensity statins (64.1%, range=6.6-10.9 million). Low-intensity statins decreased by 29.2% (range=3.3-2.4 million). Concurrent fills of high-intensity statin and ezetimibe rose by 210% to 579,012 patients by the first quarter of 2022, with an increase in slope by the first quarter of 2019 for all statin intensities (p<0.01). Concurrent fills of a statin and PCSK9 inhibitor increased to 2,629, 16,169, and 28,651 by the first quarter of 2022 for low-, moderate-, and high-intensity statins, respectively. For patients on all statin intensities and PCSK9 inhibitor, there were statistically significant increases in slope in the second quarter of 2019 and decreases in the first quarter of 2020.

CONCLUSIONS

Patients filling moderate- and high-intensity statins and add-on ezetimibe and PCSK9 inhibitors have increased, indicating uptake of guideline-concordant lipid-lowering therapies. Improvements in the initiation and continuity of these therapies are important for atherosclerotic cardiovascular disease prevention.

Recommended and observed statin use among U.S. adults - National Health and Nutrition Examination Survey, 2011-2018

BACKGROUND

The American College of Cardiology/American Heart Association Blood Cholesterol Guideline was published in 2013 (2013 Cholesterol Guideline) and the Multi-society Guideline on the Management of Blood Cholesterol in 2018 (2018 Cholesterol Guideline).

OBJECTIVE

To compare differences in population level estimates for statin recommendations and use between guidelines.

METHODS

Using four 2-year cycles from the National Health and Nutrition Examination Survey (2011-2018), we analyzed data from 8,642 non-pregnant adults aged ≥20 years with complete information for blood cholesterol measurements and other cardiovascular risk factors used to define treatment recommendations in the 2013 or 2018 Cholesterol Guidelines. We compared the prevalence of statin recommendations and use between the guidelines, overall and among patient management groups.

RESULTS

Under the 2013 Cholesterol Guideline, an estimated 77.8 million (33.6%) adults would be recommended statins, compared to 46.1 million (19.9%) recommended and 50.1 million (21.6%) considered for statins by the 2018 Cholesterol Guideline. Statin use among those recommended treatment was similar utilizing the 2018 Cholesterol Guideline (47.4%) compared to the 2013 Cholesterol Guideline (47.0%). Differences were observed across demographic and patient management groups.

CONCLUSION

Compared to the 2013 Cholesterol Guideline, the prevalence of statin recommendations decreased utilizing the 2018 Cholesterol Guideline algorithm, though additional persons would be considered for treatment after risk factor assessment and patient-clinician discussion under the 2018 Cholesterol Guideline. Statin use was suboptimal (<50%) for those recommended treatment under either guideline. Optimizing patient-clinician risk discussions and shared decision making may be needed to improve treatment rates.

Abstract 61: Frequency of Pediatric Lipid Screening Using a Large National Electronic Health Record System

Background: Universal lipid screening is recommended for U.S. youth aged 9-11 and 17-21 years. Our objective was to describe the prevalence of pediatric lipid screening and elevated lipid measurements among those screened, by patient characteristics.

Methods: IQVIA’s Ambulatory Electronic Medical Records (version 5, release: October 2021) database, containing medical records from 100,000 physicians in the U.S., was used for this analysis. The study population included 3,131,956 patients aged 9-21 years with ≥1 valid measure of height and weight during our observation period (01/01/2018-11/30/2021). Lipid screening was defined as ≥1 valid measurement any time during the observation period. Body mass index (BMI) was calculated and categorized using pediatric percentiles (ages 9-20 years) and adult interpretations (age ≥21 years) ( Table ). After excluding biologically implausible values, lipid measurements were considered elevated if ≥1 of the following was identified: low density lipoprotein ≥130 mg/dL, very low-density lipoprotein ≥31 mg/dL, non-high-density lipoprotein ≥145 mg/dL, triglycerides ≥130 mg/dL, or total cholesterol ≥200 mg/dL.

Results: A total of 354,764 (11.3%) youth had documented lipid screening. The frequency of lipid screening increased by age group (9-11 years: 9.1%; 12-16 years: 11.0%,17-21 years: 12.9%) and BMI category (underweight and healthy weight: 9.5%; overweight: 11.0%; obesity: 16.7%; severe obesity: 19.6%). Frequency of screening varied across race/ethnicity (White: 10.8%; Black 14.5%; Asian: 18.0%). Among those screened, 30.2% had ≥1 elevated measure with highest prevalence among those with obesity (44.8%) or severe obesity (48.1%).

Conclusions: Our findings indicate that among youth aged 9-11y and 17-21y, lipid screening is suboptimal, and prevalence of elevated lipid levels is high among those screened. Increased pediatric lipid screening could lead to improvements in treatment, management, and prevention of adverse, long-term cardiovascular outcomes.

Blood Pressure Control Among Non-Hispanic Black Adults Is Lower Than Non-Hispanic White Adults Despite Similar Treatment With Antihypertensive Medication: NHANES 2013-2018

BACKGROUND

Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults.

METHODS

Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults.

RESULTS

Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used.

CONCLUSIONS

Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

Characteristics of US Adults Who Would Be Recommended for Lifestyle Modification Without Antihypertensive Medication to Manage Blood Pressure

BACKGROUND

The 2017 American College of Cardiology / American Heart Association Guideline for blood pressure (BP) management newly classifies millions of Americans with elevated BP or stage 1 hypertension for recommended lifestyle modification alone (without pharmacotherapy). This study characterized these adults, including their cardiovascular disease risk factors, barriers to lifestyle modification, and healthcare access.

METHODS

This cross-sectional study examined nationally representative National Health and Nutrition Examination Survey data, 2013-2016, on 10,205 US adults aged ≥18, among whom 2,081 had elevated BP or stage 1 hypertension and met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone.

RESULTS

An estimated 22% of US adults (52 million) would be recommended for lifestyle modification alone. Among these, 58% were men, 43% had obesity, 52% had low-quality diet, 95% consumed excess sodium, 43% were physically inactive, and 8% consumed excess alcohol. Many reported attempting lifestyle changes (range: 39%-60%). Those who reported receiving health professional advice to lose weight (adjusted prevalence ratio 1.21, 95% confidence interval 1.06-1.38), reduce sodium intake (2.33, 2.00-2.72), or exercise more (1.60, 1.32-1.95) were significantly more likely to report attempting changes. However, potential barriers to lifestyle modification included 28% of adults reporting disability, asthma, or arthritis. Additionally, 20% had no health insurance and 22% had no healthcare visits in the last year.

CONCLUSIONS

One-fifth of US adults met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone, and many reported attempting behavior change. However, barriers exist such as insurance gaps, limited access to care, and physical impairment.

Characteristics and trends of PCSK9 inhibitor prescription fills in the United States

BACKGROUND

PCSK9 inhibitors were approved by the Food and Drug Administration in 2015 to lower low-density lipoprotein cholesterol (LDL-C) levels. In the years following, additional research findings, changes in national guideline recommendations, and price reductions have occurred.

OBJECTIVE

The goal of the study is to describe the characteristics and trends in PCSK9 inhibitor prescription fills and price, from initial FDA approval in Quarter 3 2015 through Quarter 4 2019, at the national and state levels.

METHODS

Cross-sectional study of fills obtained using the IQVIA National Prescription Audit®, Extended Insights, New to Brand, and Regional databases. Prescription fills included injections that provided cholesterol-lowering therapy from 14 to 90 days for the two PCSK9 inhibitors: alirocumab (75 mg/mL and 150 mg/mL) or evolocumab (140 mg/mL and 420 mg/3.5 mL). Quarterly prescription fills obtained nationally for Quarter 3 2015 through Quarter 4 2019, by sex, age, and state during 2019.

RESULTS

Over the time period examined, 2.75 million PCSK9 inhibitor prescriptions were filled nationally (alirocumab: 38%; evolocumab: 62%), and the average retail price per fill (unadjusted $US) from retail pharmacies decreased by 40% from $1502 to $896 per fill. Year-over-year percent change in new PCSK9 inhibitor users increased throughout the observation period, with 9611 new alirocumab users and 25,381 new evolocumab users in Q4 2019. PCSK9 inhibitor fill rates ranged from 5.6 per 1000 in the Northeast to 3.4 per 1000 in the West in 2019, with the highest rate per 1000 in Louisiana (9.1), and lowest in Wyoming (1.3).

CONCLUSIONS

PCSK9 inhibitor prescriptions have increased nationally since 2015, coinciding with additional evidence supporting their use for LDL-C lowering and cardiovascular event reduction. Although the retail price has decreased since introduction, cost and delivery mode likely continue as barriers.

Evaluation of measurement error in 24-hour dietary recall for assessing sodium and potassium intake among US adults - National Health and Nutrition Examination Survey (NHANES), 2014

BACKGROUND

Understanding measurement error in sodium and potassium intake is essential for assessing population intake and studying associations with health outcomes.

OBJECTIVE

The aim of this study was to compare sodium and potassium intake derived from 24-h dietary recall (24HDR) with intake derived from 24-h urinary excretion (24HUE).

DESIGN

Data were analyzed from 776 nonpregnant, noninstitutionalized US adults aged 20-69 y who completed 1-to-2 24HUE and 24HDR measures in the 2014 NHANES. A total of 1190 urine specimens and 1414 dietary recalls were analyzed. Mean bias was estimated as mean of the differences between individual mean 24HDR and 24HUE measurements. Correlations and attenuation factors were estimated using the Kipnis joint-mixed effects model accounting for within-person day-to-day variability in sodium excretion. The attenuation factor reflects the degree to which true associations between long-term intake (estimated using 24HUEs) and a hypothetical health outcome would be approximated using a single 24HDR: values near 1 indicate close approximation and near 0 indicate bias toward null. Estimates are reported for sodium, potassium, and the sodium: potassium (Na/K) ratio. Model parameters can be used to estimate correlations/attenuation factors when multiple 24HDRs are available.

RESULTS

Overall, mean bias for sodium was -452 mg (95% CI: -646, -259), for potassium -315 mg (CI: -450, -179), and for the Na/K ratio -0.04 (CI: -0.15, 0.07, NS). Using 1 24HDR, the attenuation factor for sodium was 0.16 (CI: 0.09, 0.21), for potassium 0.25 (CI:0.16, 0.36), and for the Na/K ratio 0.20 (CI: 0.10, 0.25). The correlation for sodium was 0.27 (CI: 0.16, 0.37), for potassium 0.35 (CI: 0.26, 0.55), and for the Na/K ratio 0.27 (CI: 0.13, 0.32).

CONCLUSIONS

Compared with 24HUE, using 24HDR underestimates mean sodium and potassium intake but is unbiased for the Na/K ratio. Additionally, using 24HDR as a measure of exposure in observational studies attenuates the true associations of sodium and potassium intake with health outcomes.

Progress Toward Improved Cardiovascular Health in the United States

The Healthy People Initiative has served as the leading disease prevention and health promotion roadmap for the nation since its inception in 1979. Healthy People 2020 (HP2020), the initiative's current iteration, sets a national prevention agenda with health goals and objectives by identifying nationwide health improvement priorities and providing measurable objectives and targets from 2010 to 2020. Central to the overall mission and vision of Healthy People is an emphasis on achieving health equity, eliminating health disparities, and improving health for all population groups. The Heart Disease and Stroke (HDS) Work Group of the HP2020 Initiative aims to leverage advances in biomedical science and prevention research to improve cardiovascular health across the nation. The initiative provides a platform to foster partnerships and empower professional societies and nongovernmental organizations, governments at the local, state, and national levels, and healthcare professionals to strengthen policies and improve practices related to cardiovascular health. Disparities in cardiovascular disease burden are well recognized across, for example, race/ethnicity, sex, age, and geographic region, and improvements in cardiovascular health for the entire population are only possible if such disparities are addressed through efforts that target individuals, communities, and clinical and public health systems. This article summarizes criteria for creating and tracking the 50 HDS HP2020 objectives in 3 areas (prevention, morbidity/mortality, and systems of care), reports on progress toward the 2020 targets for these objectives based on the most recent data available, and showcases examples of relevant programs led by participating agencies. Although most of the measurable objectives have reached the 2020 targets ahead of time (n=14) or are on track to meet the targets (n=7), others may not achieve the decade's targets if the current trends continue, with 3 objectives moving away from the targets. This summary illustrates the utility of HP2020 in tracking measures of cardiovascular health that are of interest to federal agencies and policymakers, professional societies, and other nongovernmental organizations. With planning for Healthy People 2030 well underway, stakeholders such as healthcare professionals can embrace collaborative opportunities to leverage existing progress and emphasize areas for improvement to maximize the Healthy People initiative's positive impact on population-level health.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Objective

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

Methods

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

Results

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (i.e., angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Infection prevention and control training and capacity building during the Ebola epidemic in Guinea

Background

During the 2014–2016 Ebola epidemic in West Africa, a key epidemiological feature was disease transmission within healthcare facilities, indicating a need for infection prevention and control (IPC) training and support.

Methods

IPC training was provided to frontline healthcare workers (HCW) in healthcare facilities that were not Ebola treatment units, as well as to IPC trainers and IPC supervisors placed in healthcare facilities. Trainings included both didactic and hands-on components, and were assessed using pre-tests, post-tests and practical evaluations. We calculated median percent increase in knowledge.

Results

From October–December 2014, 20 IPC courses trained 1,625 Guineans: 1,521 HCW, 55 IPC trainers, and 49 IPC supervisors. Median test scores increased 40% (interquartile range [IQR]: 19–86%) among HCW, 15% (IQR: 8–33%) among IPC trainers, and 21% (IQR: 15–30%) among IPC supervisors (all P<0.0001) to post-test scores of 83%, 93%, and 93%, respectively.

Conclusions

IPC training resulted in clear improvements in knowledge and was feasible in a public health emergency setting. This method of IPC training addressed a high demand among HCW. Valuable lessons were learned to facilitate expansion of IPC training to other prefectures; this model may be considered when responding to other large outbreaks.

Self-Reported Receipt of Advice and Action Taken To Reduce Dietary Sodium Among Adults With and Without Hypertension - Nine States and Puerto Rico, 2015

Hypertension is a major cardiovascular disease risk factor (1,2). Advice given by health professionals can result in lower sodium intake and lower blood pressure (3).The 2017 Hypertension Guideline released by the American College of Cardiology and the American Heart Association emphasizes nonpharmacologic approaches, including sodium reduction, as important components of hypertension prevention and treatment (4). Data from 50,576 participants in the sodium module of the 2015 Behavioral Risk Factor Surveillance System (BRFSS) in nine states and Puerto Rico were analyzed to determine the prevalence of reported sodium reduction advice and action among participants with and without self-reported hypertension. Among participants with self-reported hypertension, adjusted prevalence of receiving sodium reduction advice from a health professional was 41.9%, compared with 12.8% among participants without hypertension. Among those with hypertension, adjusted prevalence of reported action to reduce sodium intake was 80.9% among participants who received advice and 55.7% among those who did not receive advice. Among participants without hypertension, adjusted prevalence of taking action to reduce sodium intake was 72.7% among those who received advice and 46.9% among those who did not receive advice. The provision of advice on sodium reduction by health professionals is associated with respondent action to watch or reduce sodium intake. Fewer than half of patients with hypertension received this advice from their health professionals, a circumstance that represents a substantial missed opportunity to promote hypertension prevention and treatment.

Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

OBJECTIVE

To review the literature systematically and perform meta-analyses to address these questions: 1) Is there evidence that self-measured blood pressure (BP) without other augmentation is superior to office-based measurement of BP for achieving better BP control or for preventing adverse clinical outcomes that are related to elevated BP? 2) What is the optimal target for BP lowering during antihypertensive therapy in adults? 3) In adults with hypertension, how do various antihypertensive drug classes differ in their benefits and harms compared with each other as first-line therapy?

METHODS

Electronic literature searches were performed by Doctor Evidence, a global medical evidence software and services company, across PubMed and EMBASE from 1966 to 2015 using key words and relevant subject headings for randomized controlled trials that met eligibility criteria defined for each question. We performed analyses using traditional frequentist statistical and Bayesian approaches, including random-effects Bayesian network meta-analyses.

RESULTS

Our results suggest that: 1) There is a modest but significant improvement in systolic BP in randomized controlled trials of self-measured BP versus usual care at 6 but not 12 months, and for selected patients and their providers self-measured BP may be a helpful adjunct to routine office care. 2) systolic BP lowering to a target of <130 mm Hg may reduce the risk of several important outcomes including risk of myocardial infarction, stroke, heart failure, and major cardiovascular events. No class of medications (ie, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium channel blockers, or beta blockers) was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.

Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009-2010

BACKGROUND

Nationally representative estimates of diabetes mellitus (DM) prevalence among HIV-infected adults in the USA are lacking, and whether HIV-infected adults are at increased risk of DM compared with the general adult population remains controversial.

METHODS

We used nationally representative survey (2009-2010) data from the Medical Monitoring Project (n=8610 HIV-infected adults) and the National Health and Nutrition Examination Survey (n=5604 general population adults) and fit logistic regression models to determine and compare weighted prevalences of DM between the two populations, and examine factors associated with DM among HIV-infected adults.

RESULTS

DM prevalence among HIV-infected adults was 10.3% (95% CI 9.2% to 11.5%). DM prevalence was 3.8% (CI 1.8% to 5.8%) higher in HIV-infected adults compared with general population adults. HIV-infected subgroups, including women (prevalence difference 5.0%, CI 2.3% to 7.7%), individuals aged 20-44 (4.1%, CI 2.7% to 5.5%), and non-obese individuals (3.5%, CI 1.4% to 5.6%), had increased DM prevalence compared with general population adults. Factors associated with DM among HIV-infected adults included age, duration of HIV infection, geometric mean CD4 cell count, and obesity.

CONCLUSIONS

1 in 10 HIV-infected adults receiving medical care had DM. Although obesity contributes to DM risk among HIV-infected adults, comparisons to the general adult population suggest that DM among HIV-infected persons may develop at earlier ages and in the absence of obesity.

Cardiovascular Disease Risk Prediction in the HIV Outpatient Study

BACKGROUND

 Cardiovascular disease (CVD) risk prediction tools are often applied to populations beyond those in which they were designed when validated tools for specific subpopulations are unavailable.

METHODS

 Using data from 2283 human immunodeficiency virus (HIV)-infected adults aged ≥18 years, who were active in the HIV Outpatient Study (HOPS), we assessed performance of 3 commonly used CVD prediction models developed for general populations: Framingham general cardiovascular Risk Score (FRS), American College of Cardiology/American Heart Association Pooled Cohort equations (PCEs), and Systematic COronary Risk Evaluation (SCORE) high-risk equation, and 1 model developed in HIV-infected persons: the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study equation. C-statistics assessed model discrimination and the ratio of expected to observed events (E/O) and Hosmer-Lemeshow χ² P value assessed calibration.

RESULTS

 From January 2002 through September 2013, 195 (8.5%) HOPS participants experienced an incident CVD event in 15 056 person-years. The FRS demonstrated moderate discrimination and was well calibrated (C-statistic: 0.66, E/O: 1.01, P = .89). The PCE and D:A:D risk equations demonstrated good discrimination but were less well calibrated (C-statistics: 0.71 and 0.72 and E/O: 0.88 and 0.80, respectively; P < .001 for both), whereas SCORE performed poorly (C-statistic: 0.59, E/O: 1.72; P = .48).

CONCLUSIONS

 Only the FRS accurately estimated risk of CVD events, while PCE and D:A:D underestimated risk. Although these models could potentially be used to rank US HIV-infected individuals at higher or lower risk for CVD, the models may fail to identify substantial numbers of HIV-infected persons with elevated CVD risk who could potentially benefit from additional medical treatment.

Obesity Among HIV-Infected Adults Receiving Medical Care in the United States: Data From the Cross-Sectional Medical Monitoring Project and National Health and Nutrition Examination Survey

Our objective was to compare obesity prevalence among human immunodeficiency virus (HIV)-infected adults receiving care and the U.S. general population and identify obesity correlates among HIV-infected men and women.Cross-sectional data was collected in 2009 to 2010 from 2 nationally representative surveys: Medical Monitoring Project (MMP) and National Health and Nutrition Examination Survey (NHANES).Weighted prevalence estimates of obesity, defined as body mass index ≥30.0 kg/m, were compared using prevalence ratios (PR, 95% confidence interval [CI]). Correlates of obesity in HIV-infected adults were examined using multivariable logistic regression.Demographic characteristics of the 4006 HIV-infected adults in MMP differed from the 5657 adults from the general U.S. population in NHANES, including more men (73.2% in MMP versus 49.4% in NHANES, respectively), black or African Americans (41.5% versus 11.6%), persons with annual incomes <$20,000 (64.5% versus 21.9%), and homosexuals or bisexuals (50.9% versus 3.9%). HIV-infected men were less likely to be obese (PR 0.5, CI 0.5-0.6) and HIV-infected women were more likely to be obese (PR1.2, CI 1.1-1.3) compared with men and women in the general population, respectively. Among HIV-infected women, younger age was associated with obesity (<40 versus >60 years). Among HIV-infected men, correlates of obesity included black or African American race/ethnicity, annual income >$20,000 and <$50,000, heterosexual orientation, and geometric mean CD4+ T-lymphocyte cell count >200 cells/μL.Obesity is common, affecting 2 in 5 HIV-infected women and 1 in 5 HIV-infected men. Correlates of obesity differ for HIV-infected men and women; therefore, different strategies may be needed for the prevention and treatment.

Effect of coenzyme Q₁₀ supplementation on heart failure: a meta-analysis

BACKGROUND

Coenzyme Q₁₀ (CoQ₁₀; also called ubiquinone) is an antioxidant that has been postulated to improve functional status in congestive heart failure (CHF). Several randomized controlled trials have examined the effects of CoQ₁₀ on CHF with inconclusive results.

OBJECTIVE

The objective of this meta-analysis was to evaluate the impact of CoQ₁₀ supplementation on the ejection fraction (EF) and New York Heart Association (NYHA) functional classification in patients with CHF.

DESIGN

A systematic review of the literature was conducted by using databases including MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and manual examination of references from selected studies. Studies included were randomized controlled trials of CoQ₁₀ supplementation that reported the EF or NYHA functional class as a primary outcome. Information on participant characteristics, trial design and duration, treatment, dose, control, EF, and NYHA classification were extracted by using a standardized protocol.

RESULTS

Supplementation with CoQ₁₀ resulted in a pooled mean net change of 3.67% (95% CI: 1.60%, 5.74%) in the EF and -0.30 (95% CI: -0.66, 0.06) in the NYHA functional class. Subgroup analyses showed significant improvement in EF for crossover trials, trials with treatment duration ≤12 wk in length, studies published before 1994, and studies with a dose ≤100 mg CoQ₁₀/d and in patients with less severe CHF. These subgroup analyses should be interpreted cautiously because of the small number of studies and patients included in each subgroup.

CONCLUSIONS

Pooled analyses of available randomized controlled trials suggest that CoQ₁₀ may improve the EF in patients with CHF. Additional well-designed studies that include more diverse populations are needed.