Hypertension in minority populations: new guidelines and emerging concepts

Ethnic variations in cardiovascular disease (CVD) risk factors and associations with prevalent CVD and CVD mortality in the United States

OBJECTIVE

To explore the association between ethnicity and cardiovascular disease (CVD) risk factors, including physical inactivity, obesity, hypertension, type 2 diabetes (T2D), lack of health insurance and low family income in a nationally representative sample of U.S. adults.

RESEARCH DESIGN AND METHODS

Adults from the National Health and Nutrition Examination Survey (NHANES 2011-2020, n = 17,355) were classified as having CVD risk factors based on both self-reported and metabolic data. Ethnic differences in how these CVD risk factors relate to prevalent CVD and CVD mortality was examined in Whites, Blacks, Asians and Hispanics.

RESULTS

Compared to Whites, significant disparities were noted in several CVD risk factors in ethnic minorities, such as lower PA, lower income, and more prevalent metabolic risk factors. Blacks and Hispanics commonly had higher prevalent CVD risk as compared to Whites even after adjusting for income and metabolic risk factors. Physical inactivity was most strongly associated with prevalent CVD and CVD mortality among Whites and Blacks. There were no ethnic differences in the inverse association between income and prevalent CVD risk, but Blacks with low income were associated with the greatest elevated CVD mortality. Hypertension and T2D were similarly related with prevalent CVD across ethnic groups, but Blacks and Hispanics with hypertension or T2D were at greater CVD mortality risk as compared to Whites.

CONCLUSION

Our study identified that socioeconomic and metabolic risk factors may relate differently to CVD outcomes among ethnic minority groups in the United States. Addressing these ethnic disparities in health warrants further investigation.

Regulatory Roles of Long Non-Coding RNAs in Arterial Stiffness and Hypertension: Insights from Two African American Studies

Background

Arterial stiffness, commonly assessed via pulse wave velocity (PWV), is marked by reduced arterial elasticity and serves as a significant risk factor for cardiovascular disease and an early indicator of hypertension. This study investigated the regulatory roles of long non-coding RNAs (lncRNAs) in modulating mRNAs associated with arterial stiffness and hypertension, with a particular focus on African Americans, a population disproportionately impacted by hypertension.

Methods

We utilized whole-blood transcriptome sequencing data from two African American (AA) cohorts with high hypertension prevalence: the GENE-FORECAST study (436 subjects) and the MH-GRID study (179 subjects). Our objectives were to: (1) identify lncRNAs and mRNAs differentially expressed (DE) between the upper and lower tertiles of PWV, (2) determine DE lncRNAs associated with the expression levels of each DE mRNA, and (3) link the lncRNA-modulated mRNAs to hypertension across both datasets.

Results

Differential expression analysis revealed 1,035 DE mRNAs and 31 DE lncRNAs between upper and lower PWV groups. Then lncRNA-mRNA pairs significantly associated were identified, involving 31 unique lncRNAs and 1,034 unique mRNAs. Finally, 22 of the lncRNA-modulated mRNAs initially linked to PWV were found associated with hypertension, in both datasets. Interestingly, 30 lncRNAs were linked to the expression of UCP2 (Uncoupling Protein 2), a gene implicated in oxidative stress and endothelial function.

Conclusions

Our findings underscore the significant roles of lncRNAs in regulating gene expression associated with arterial stiffness and hypertension. The differential expression of UCP2 in relation to PWV and hypertension, along with its potential regulation by lncRNAs, offers valuable insights into the molecular mechanisms underlying arterial stiffness and its connection with hypertension.

Transcriptome Study of 2 Black Cohorts Reveals cis Long Noncoding RNAs Associated With Hypertension-Related mRNAs

BACKGROUND

Long noncoding RNAs (lncRNAs) have emerged as critical regulators of the expression of genes involved in cardiovascular diseases. This project aims to identify circulating lncRNAs associated with protein-coding mRNAs differentially expressed between hypertensive and normotensive individuals and establish their link with hypertension.

METHODS AND RESULTS

The analyses were conducted in 3 main steps: (1) an unbiased whole blood transcriptome-wide analysis was conducted to identify and replicate protein-coding genes differentially expressed by hypertension status in 497 and 179 Black individuals from the GENE-FORECAST (Genomics, Environmental Factors and the Social Determinants of Cardiovascular Disease in African-Americans Study) and MH-GRID (Minority Health Genomics and Translational Research Bio-Repository Database) studies, respectively. Subsequently, (2) proximal lncRNAs, termed cis lncRNA quantitative trait loci, associated with each mRNA were identified in the GENE-FORECAST study and replicated in the MH-GRID study. Finally, (3) the lncRNA quantitative trait loci were used as predictors in a random forest model to predict hypertension in both data sets. A total of 129 mRNAs were significantly differentially expressed between normotensive and hypertensive individuals in both data sets. The lncRNA-mRNA association analysis revealed 249 cis lncRNA quantitative trait loci associated with 102 mRNAs, including VAMP2 (vesicle-associated membrane protein 2), mitogen-activated protein kinase kinase 3, CCAAT enhancer binding protein beta, and lymphocyte antigen 6 complex, locus E. The 249 lncRNA quantitative trait loci predicted hypertension with an area under the curve of 0.79 and 0.71 in GENE-FORECAST and MH-GRID studies, respectively.

CONCLUSIONS

This study leveraged a significant sample of Black individuals, a population facing a disproportionate burden of hypertension. The analyses unveiled a total of 271 lncRNA-mRNA relationships involving mRNAs that play critical roles in vascular pathways relevant to blood pressure regulation. The compelling findings, consistent across 2 independent data sets, establish a reliable foundation for designing in vitro/in vivo experiments.

Weight Gain Prevention Outcomes From a Pragmatic Digital Health Intervention With Community Health Center Patients: Randomized Controlled Trial

BACKGROUND

The prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care.

OBJECTIVE

This study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers.

METHODS

Balance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of ≤3% weight gain in each arm at 24 months after randomization-our primary outcome-using individual empirical best linear unbiased predictors from the linear mixed-effects model. We used individual empirical best linear unbiased predictors from participants with at least 1 electronic health record weight documented within a 6-month window centered on the 24-month time point.

RESULTS

We randomized 443 participants, of which 223 (50.3%) participants were allocated to the intervention arm. At baseline, participants had a mean BMI of 32.6 kg/m2. Most participants were Latino or Hispanic (n=200, 45.1%) or non-Latino or Hispanic White (n=115, 26%). In total, 53% (n=235) of participants had at least 1 visit with weight measured in the primary time window. The intervention group had a higher proportion with ≤3% weight gain at 6 months (risk ratio=1.12, 95% CI 0.94-1.28; risk difference=9.5, 95% CI -4.5 to 16.4 percentage points). This difference attenuated to the null by 24 months (risk ratio=1.00, 95% CI 0.82-1.20; risk difference=0.2, 95% CI -12.1 to 11.0 percentage points).

CONCLUSIONS

In adults with overweight or obesity receiving primary care at a community health center, we did not find long-term evidence to support the dissemination of a digital health intervention for weight gain prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03003403; https://clinicaltrials.gov/study/NCT03003403.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-019-6926-7.

Association between salt sensitivity of blood pressure and the risk of hypertension in a Chinese Tibetan population

Epidemiological studies have confirmed salt sensitivity as a crucial risk factor for the development of hypertension. However, few studies have investigated the association between salt sensitivity of blood pressure (SSBP) and hypertension in Chinese Tibetan population. Therefore, we conducted a cross-sectional study based on a Tibetan population to evaluate the association between SSBP and the risk of hypertension. Seven hundred and eighty-four participants with hypertension and 645 participants without hypertension were included from five villages in Tibetan Autonomous Region of Gannan during 2013-2014. The assessment of salt sensitivity (SS) and non-salt sensitivity (NSS) was performed according to mean arterial pressure (MAP) changes by the modified Sullivan's acute oral saline load and diuresis shrinkage test (MSAOSL-DST). Logistic regression models and restricted cubic models were used to examine the association between SSBP and hypertension. There were 554 (70.5%) salt-sensitive participants with hypertension and 412 (63.9%) salt-sensitive participants without hypertension in this study. Compared with individuals with NSS, individuals with SS had a significantly increased risk of hypertension, and the multiple-adjusted odds ratios were 2.582 with 95% confidence interval of 1.357-4.912. Furthermore, a significant linear trend was found between MAP changes and hypertension. Subgroup analyses showed significant and stronger associations between SSBP and the risk of hypertension in the older (age ≥ 55 years old), males and participants who took exercise less than 1 time per week. Our results suggest that SS is associated with an increased risk of hypertension in Tibetan population, indicating a need for clinicians dealing with SSBP to decrease the risk of hypertension.

Ethnodemographic characterization of stroke incidence and burden of disease in hospital discharge records in Ecuador

Introduction

Stroke is the second most common cause of death and disability-adjusted life years (DALYs) globally. However, the incidence and impact of stroke by ethnicity and gender is frequently distinct. This is particularly the case in Ecuador where geographic and economic marginalization are often correlated with ethnic marginalization and the extent to which females lack the same opportunities as their male counterparts. The aim of this paper is to investigate the differential impacts in terms of stroke diagnosis and burden of disease by ethnicity and gender, using hospital discharge records over the years 2015-2020.

Methods

This paper calculates stroke incidence, and fatality rates using hospital discharge and death records over the years 2015-2020. The DALY package in R was employed to calculate the Disability Adjusted Life Years lost due to stroke in Ecuador.

Results

The results show that while the incidence rate of stroke in males (64.96 per 100,000 persons-year) is higher than that for females on average (57.84 per 100,000 persons-year), males accounted for 52.41% of all stroke cases and 53% of all surviving cases. Thus, hospital data suggests that females had a higher death rate when compared to males. Case fatality rates also differed significantly by ethnicity. The highest fatality rate corresponded to the Montubio ethnic group (87.65%), followed by Afrodescendants (67.21%). The estimated burden of disease of stroke calculated using Ecuadorian hospital records (2015-2020) varied from 1,468 to 2,991 DALY per 1,000 population on average.

Discussion

Differences in the burden of disease by ethnic group are likely to reflect differential access to care by region and socio-economic group, both of which are frequently correlated with ethnic composition in Ecuador. Equitable access to health services remains an important challenge in the country. The gender discrepancy in fatality rates suggests that there is a need for targeted educational campaigns to identify stroke signs early, especially in the female population.

Salt sensitivity of blood pressure in childhood and adolescence

Although moderation of sodium intake is recommended population-wide, it remains uncertain who benefits from salt restriction. Salt sensitivity refers to changes in blood pressure in response to sodium intake and may occur with or without hypertension. Unfortunately, there is no practical way to assess salt sensitivity in daily practice. Assessment of salt sensitivity even in research studies is challenging with varying protocols utilized which may contribute to differing results. Building on studies in animals and adults, risk factors and conditions associated with salt sensitivity have been identified in the pediatric and young adult populations. This review presents the limited evidence linking obesity, low birth weight, diabetes, chronic kidney disease, and race/ethnicity with salt sensitivity in children, adolescents, and young adults. The impact of stress on sodium handling is also reviewed. The influence of age on the timing of introduction of dietary salt restriction and the long-term influence of salt sensitivity on risk for hypertension are considered. Lastly, interventions other than salt restriction that may improve salt sensitivity and may inform recommendations to families are reviewed.

Treating hypertension in Black patients

ABSTRACT

For the first time in its history, the Eighth Joint National Committee (JNC-8) published hypertension guidelines that varied depending on patient race, with different treatment recommendation for Black and non-Black patients. Although initial therapy in non-Black patients is to be carried out with one of four agents-thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs)-the recommendation for Black patients removed ACE inhibitors and ARBs from the algorithm. This article reviews some of the physiologic theories for the difference in recommendations and discusses potential complications with race-based treatment algorithms.

National Trends and Disparities in Hospitalization for Acute Hypertension Among Medicare Beneficiaries (1999-2019)

BACKGROUND

In the past 2 decades, hypertension control in the US population has not improved and there are widening disparities. Little is known about progress in reducing hospitalizations for acute hypertension.

METHODS

We conducted serial cross-sectional analysis of Medicare fee-for-service beneficiaries age 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files. We evaluated trends in national hospitalization rates for acute hypertension overall and by demographic and geographical subgroups. We identified all beneficiaries admitted with a primary discharge diagnosis of acute hypertension on the basis of International Classification of Diseases codes. We then used a mixed effects model with a Poisson link function and state-specific random intercepts, adjusting for age, sex, race and ethnicity, and dual-eligible status, to evaluate trends in hospitalizations.

RESULTS

The sample consisted of 397 238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for acute hypertension increased significantly, from 51.5 to 125.9 per 100 000 beneficiary-years; the absolute increase was most pronounced among the following subgroups: adults ≥85 years (66.8-274.1), females (64.9-160.1), Black people (144.4-369.5), and Medicare/Medicaid insured (dual-eligible, 93.1-270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Black and White people from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South. Among patients hospitalized for acute hypertension, the observed 30-day and 90-day all-cause mortality rates (95% CI) decreased from 2.6% (2.27-2.83) and 5.6% (5.18-5.99) to 1.7% (1.53-1.80) and 3.7% (3.45-3.84) and 30-day and 90-day all-cause readmission rates decreased from 15.7% (15.1-16.4) and 29.4% (28.6-30.2) to 11.8% (11.5-12.1) and 24.0% (23.5-24.6).

CONCLUSIONS

Among Medicare fee-for-service beneficiaries age 65 years or older, hospitalization rates for acute hypertension increased substantially and significantly from 1999 to 2019. Black adults had the highest hospitalization rate in 2019 across age, sex, race and ethnicity, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South.

Case-control study of hypertension and Parkinson's disease

We evaluate the association of hypertension with PD in an Asian population and performed a meta-analysis on similar studies to address the effect of hypertension on PD risk. A matched case-control study involving 1342 Chinese subjects (671 PD and 671 age and gender-matched controls (with a mean age of 63.9 ± 9.7 and 63.5 ± 9.8 years, and identical proportion of gender distribution) was conducted. Hypertension increases PD risk by 1.9 times [OR 1.86 (1.46–2.38)]. The literature search identified 618 studies initially; however, only three matched case-control studies (all in Caucasians) met the inclusion criteria for meta-analysis. Overall analysis showed that hypertension decreases PD risk by 0.2 times [OR 0.80 (0.66–0.96)]. Hypertension increases PD risk by 1.9 times in our Asian population. However, a meta-analysis comprising of Caucasian populations showed a protective effect of hypertension suggesting that ethnic differences or other genetic or environmental factors may contribute to the divergent observation. Early diagnosis and treatment of hypertension may potentially reduce the risk of PD, at least in our population.

The prevalence of hypertension in multiple sclerosis based on 37 million electronic health records from the United States

BACKGROUND AND PURPOSE

Hypertension (HTN) is a common comorbidity in multiple sclerosis (MS), and it significantly contributes to adverse outcomes. Unfortunately, the distribution of HTN in persons with MS has not been well characterized, and prior estimates have primarily relied on modest sample sizes. The objective of this study was to robustly describe the distribution of HTN in the MS population in comparison to the non-MS population with considerations for age, sex, and race. To date, this is the largest investigation of its kind.

METHODS

We conducted a cross-sectional study of 37 million unique electronic health records available in the IBM Explorys Enterprise Performance Management: Explore database (Explorys) spanning the United States. This resource has previously been validated for use in MS. We evaluated the prevalence of HTN in MS (N = 122 660) and non-MS (N = 37 075 350) cohorts, stratifying by age, sex, and race.

RESULTS

The prevalence of HTN was significantly greater among those with MS than among those without MS across age, sex, and race subpopulations, even after adjusting for age and sex. HTN was 25% more common in MS. In both MS and non-MS cohorts, the prevalence of HTN progressively increased with age and was higher in Black Americans and in males.

DISCUSSION

This study demonstrated that HTN is significantly more common in the MS population compared to the non-MS population, irrespective of sex and race. Because HTN is the leading global risk factor for disability and death, these results emphasize the need for aggressive screening for, and management of, HTN in the MS population.

Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.

State-of-the-Art review: Hypertension practice guidelines in the era of COVID-19

The global burden of hypertension (HTN) is immense and increasing. In fact, HTN is the leading risk factor for adverse cardiovascular disease outcomes. Due to the critical significance and increasing prevalence of the disease, several national and international societies have recently updated their guidelines for the diagnosis and treatment of HTN. In consideration of the COVID-19 pandemic, this report provides clinicians with the best strategies to prevent HTN, manage the acute and long-term cardiac complications of HTN, and provide the best evidence-based care to patients in an ever-changing healthcare environment. The overarching goal of the various HTN guidelines is to provide easily accessible information to healthcare providers and public health officials, which is key for optimal clinical practice. However, the COVID-19 pandemic has challenged the ability to provide safe care to the most vulnerable hypertensive populations throughout the world. Therefore, this review compares the most recent guidelines of the 2017 American College of Cardiology/American Heart Association and multiple U.S. societies, the 2018 European Society of Cardiology/European Society of Hypertension, the 2019 National Institute for Care and Health Excellence, and the 2020 International Society of Hypertension. While a partial emphasis is placed on the management of HTN in the midst of COVID-19, this review will summarize current concepts and emerging data from the listed HTN guidelines on the diagnosis, monitoring, management, and evidence-based treatments in adults.

Latin American Consensus on the management of hypertension in the patient with diabetes and the metabolic syndrome

: The prevalence of hypertension, type 2 diabetes mellitus (DM2) and the metabolic syndrome continues to increase in Latin America, while the rates of diagnosis, treatment and control of these disorders remain low. The frequency of the risk factors that constitute the metabolic syndrome and are associated with an increased risk of cardiovascular disease has not diminished since the publication of the previous consensus. This document discusses the socioeconomic, demographic, environmental and cultural characteristics of most associated Latin American countries and partially explains the lack of better results in improving clinical and public health actions that allow high morbidity and mortality rates caused by cardiovascular diseases and DM2 to be reduced through programs aligned with the so-called precision medicine, which should be predictive, preventive, personalized and participatory. The Consensus ratifies the diagnostic criteria expressed in the previous consensus to define hypertension and DM2 but, for the metabolic syndrome, and in the absence of evidence, the recommendation is to implement a cohort study that determines the abdominal perimeter value associated with hard outcomes, such as DM2 and CVD. Meanwhile, we recommend modifying the criterion to more than 94 cm in men and more than 84 cm in women according to WHO recommendations. We also recommend the carrying out of a study that identifies the situation of hypertension and DM2 in people of African ancestry who, in Latin America, exceed 75 million and whose epidemiology does not include solid studies. With respect to the proposed therapeutic targets, we recommended maintaining those defined in the previous consensus, but insisting that early pharmacological management of prediabetes with metformin should be introduced, as should the treatment of diabetic hypertensive patients with a combination therapy of two fixed-dose antihypertensive drugs and management with statins. To increase adherence, the use of different drugs combined in a single pill (polypill) is recommended. The simplification of the therapeutic regimen is accompanied by greater control of cardiovascular risk factors, both in primary and secondary prevention, and has been shown to be cost-effective. The consensus recommends the use of the currently available polypill combining an angiotensin-converting enzyme inhibitor, a statin and aspirin for secondary cardiovascular prevention and in patients with a high cardiovascular risk, such as hypertension patients with DM2.

Prevalência autorreferida de hipertensão e fatores associados em comunidades quilombolas do Rio Grande do Sul, Brasil

Resumo Este estudo teve como objetivo identificar a prevalência e fatores associados à hipertensão arterial (HA) em adultos quilombolas do Rio Grande do Sul (RS). Trata-se de um estudo transversal de base populacional, realizado em 2011, com 589 adultos responsáveis por domicílios e amostragem proporcional ao tamanho. O desfecho foi obtido com a pergunta: “Algum médico já lhe disse que você tem hipertensão?”. Foi empregada regressão de Poisson, com variância robusta e entrada hierarquizada das variáveis. Por fim, foram calculadas as frações atribuíveis populacionais por componente (FAPC) para fatores modificáveis associados à HA. A prevalência autorreferida de HA foi de 38,3% (IC95% 31,4%-45,1%). A análise ajustada revelou associação do desfecho com faixa etária, escolaridade, consumo excessivo de álcool, circunferência da cintura acima do adequado e presença de diabetes. A análise dos FAPC revelou que, se os indivíduos tivessem maior escolaridade, a prevalência de HA seria reduzida. Diante da elevada prevalência de HA e da extrema vulnerabilidade social dessa população, políticas públicas que garantam seu acesso a direitos fundamentais (saúde, renda e escolaridade) poderiam ter impacto importante na diminuição desse desfecho.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Balance protocol: a pragmatic weight gain prevention randomized controlled trial for medically vulnerable patients within primary care

BACKGROUND

For patients with obesity who are not ready for or experience barriers to weight loss, clinical practice guidelines recommend provider counseling on preventing further weight gain as a first-line treatment approach. Unfortunately, evidence-based weight gain prevention interventions are not routinely available within primary care. To address this gap, we will implement a pragmatic 12-month randomized controlled trial of a digital weight gain prevention intervention delivered to patients receiving primary care within a network of Federally Qualified Community Health Centers in central North Carolina.

METHODS

Balance (Equilibrio in Spanish) is a pragmatic effectiveness trial that will randomize adult patients who have overweight or obesity (BMI of 25-40 kg/m2) to either: 1) a weight gain prevention intervention with tailored behavior change goals and tracking, daily weighing on a network-connected electronic scale, and responsive weight and goal coaching delivered remotely by health center registered dietitians; or 2) a usual care program with automated healthy living text messages and print materials and routine primary care. The primary outcome will be weight gain prevention at 24-months, defined as ≤3% change in baseline weight. To align with its pragmatic design, trial outcome data will be pulled from the electronic health record of the community health center network.

DISCUSSION

For underserved, often rurally-located patients with obesity, digital approaches to promote a healthy lifestyle can curb further weight gain. Yet enrolling medically vulnerable patients into a weight gain prevention trial, many of whom are from racial/ethnic minorities, can be difficult. Despite these potential challenges, we plan to recruit a large, diverse sample from rural areas, and will implement a remotely-delivered weight gain prevention intervention to medically vulnerable patients. Upcoming trial results will demonstrate the effectiveness of this pragmatic approach to implement and evaluate a digital weight gain prevention intervention within primary care.

TRIALS REGISTRATION

NCT03003403 . Registered December 28, 2016.

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.

Hypertension and Diagnosis of Parkinson's Disease: A Meta-Analysis of Cohort Studies

Background

Hypertension has been associated with cognitive dysfunction in the general population and patients with Alzheimer's disease (AD). However, there are contradictory data regarding the potential association between hypertension and diagnosis of Parkinson's disease (PD), the second most common neurodegenerative disorder after AD. The purpose of this meta-analysis is to synthesize data from cohort studies to explore the potential association between preexisting hypertension and subsequent PD diagnosis.

Methods

The PubMed and Embase databases were searched to identify all relevant studies. Two independent investigators performed the data extraction. Eligible cohort studies providing risk and precision estimates related to hypertension and PD were selected. Pooled risk ratios (RRs) with 95% confidence interval (CI) were calculated by using a random-effects model or a fixed-effects model. Sensitivity analyses after excluding one study at a time were performed to assess the stability of the results. Publication bias was assessed with Begg's test and Egger's test.

Results

Seven cohort studies were identified, including 3,170 persons who were confirmed to have developed PD and 339,517 participants who did not have PD during follow-up. The onset of hypertension before PD diagnosis was significantly associated with an increased risk of motor stage PD (RR = 1.799, 95% CI [1.066-3.037]). This relationship was further confirmed by secondary analyses based on estimates adjusted for potential vascular confounders (RR = 1.319, 95% CI [1.073-1.622]). After excluding one study at a time, the sensitivity analyses still showed that hypertension history was significantly associated with an increased risk of motor stage PD (RR with 95% CI ranging from 1.11 [1.075-1.35] to 1.42 [1.65-1.83]). No publication bias was observed in this meta-analysis.

Conclusion

The findings of this meta-analysis suggest that hypertension may be a risk factor for motor stage PD, which may provide novel insights into the etiology and pathogenesis of this neurodegenerative disorder. However, large-scale well-designed studies that consider various confounders are still needed to further verify and clarify the association between hypertension and PD diagnosis.

Ethnicity, Race, and Postoperative Stroke Risk Among 53,593 Patients with Asymptomatic Carotid Stenosis Undergoing Revascularization

BACKGROUND

The incidence of postoperative stroke after carotid endarterectomy is an uncommon event, and differences by racial and ethnic subgroups are not described fully in the literature.

OBJECTIVE

To investigate the impact of race and ethnicity on postoperative stroke risk among patients with asymptomatic carotid stenosis undergoing carotid endarterectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched for patients between the dates 2008 and 2015 to identify patients undergoing carotid endarterectomy with no history of stroke. Four racial and ethnic subgroups were included: non-Hispanic white, Hispanic white, non-Hispanic back, and non-Hispanic Asian. In addition to a descriptive statistical analysis, univariate and multivariate regression models were created to adjust for cardiovascular and perioperative risk factors and corrected for multiple comparisons.

RESULTS

Among the 53,593 patients identified meeting the inclusion criteria, 788 (1.45%) patients experienced a stroke within 30 days. The non-Hispanic white group compared with the minority subgroups had a lower risk of postoperative stroke (1.43% vs. 1.67%, P = 0.18). The greatest difference was between the non-Hispanic white and Hispanic white groups, but this was not significant on multivariable analysis (odds ratio 1.40, 95% confidence interval 0.97-2.02, P = 0.08) after adjustment for risk stroke factors. The strongest predictors of postoperative stroke were perioperative blood transfusion, dependent functional status, and longer operative time.

CONCLUSIONS

There was no difference between the racial and ethnic groups and the proportion of postoperative stroke among patients undergoing revascularization for asymptomatic carotid stenosis.

Protocol for a prospective longitudinal study of risk factors for hypertension incidence in a Mexico City population: the Tlalpan 2020 cohort

INTRODUCTION

Systemic hypertension (HTN) is a common risk factor for cardiovascular disease. In Mexico, HTN prevalence has increased over time and is currently 31%. Nonetheless, information about the country's HTN incidence and its associated risk factors is scarce. Understanding this condition is a priority for identifying the scope of primary prevention. The main objective of this study is to evaluate the effect of traditional and non-traditional risk factors on the incidence of HTN in a cohort of healthy Mexico City residents under biannual follow-up for 10 years.

METHODS AND ANALYSIS

A prospective longitudinal study is proposed in which clinically healthy residents of Mexico City between 20 and 50 years old will be recruited; the participants will be evaluated every 2 years over a period of 10 years or until they develop HTN. Evaluations regarding sociodemographic, clinical, anthropometric, biochemical, diet, physical activity, stress, sleep quality, alcohol and tobacco consumption factors will be performed. The participants will be recruited from the 16 municipalities of Mexico City through promotional strategies aimed at the community and will be clinically evaluated at a tertiary care institution, Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez), located in Mexico City, Mexico. Sample size estimated for this study is 3436, and the Cox proportional hazards model will be used to estimate HRs for the association between explanatory variables and HTN using both raw and adjusted data.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Bioethics Committee of the Instituto Nacional de Cardiología Ignacio Chávez (National Institute of Cardiology Ignacio Chavez) under number 13-802. Findings from this study will be disseminated through scientific papers and research conferences.

Controlling hypertension and reducing its associated morbidity and mortality in the Caribbean: implications of race and ethnicity

Cardiovascular diseases and stroke, especially hypertension, represent a significant global disease burden for both morbidity and mortality, with a disproportionately higher impact in vulnerable low- to middle-income countries. International initiatives such as the Centers for Disease and Prevention and the Pan American Health Organization Standardized Hypertension Treatment Project have been developed to address this burden on the Caribbean and Latin America populations. The disparity in disease burden observed in low- to middle-income countries is explained, in part, by differences in disease risks for different racial and ethnic groups with high blood pressure more prevalent and hypertension-related morbidity significantly higher in men and women of African heritage. In addition to the race and ethnic differences in indicators of socioeconomic status, access to care and health service delivery, the physiologic mechanism of high blood pressure including salt-sensitivity, may also play a significant role in the disparities in hypertension and hypertension-related outcomes. This article focuses on potential racial and ethnic differences in influences on the pathophysiology of hypertension in the Caribbean region of the world. The identification of such differences may be used in the development of population hypertension control strategies and treatment approach that address the excess disease burden in these populations. The consideration of strategies, such as salt reduction and hypertension awareness and treatment, are particularly relevant to the high-risk Caribbean region.

Nutrition Interventions for Cardiovascular Disease

Nutrition therapy is effective at controlling cardiovascular disease risk factors and therefore reducing cardiovascular disease risk. Physicians should play an active role in providing nutrition interventions for patients who would benefit from cardiovascular disease risk reduction or refer them to other professionals as needed. The evidence on nutrition interventions for blood pressure and lipid control, including overall dietary patterns, dietary fat and macronutrients, dietary cholesterol, sodium, and alcohol intake, is discussed.

A Comparison of the Use of Clinical-Guideline-Recommended Antihypertensive Regimens in Mexican American, Non-Hispanic Black, and Non-Hispanic White Adults With Type 2 Diabetes and Hypertension in the United States: NHANES 2003-2012

PURPOSE

The purpose of this study was to determine the use of clinical-guideline-recommended antihypertensive regimens among Mexican Americans (MAs) and non-Hispanic blacks and whites with type 2 diabetes and hypertension.

METHODS

A secondary data analysis based on National Health and Nutrition Examination Survey 2003-2012 cohort data included 1857 noninstitutionalized civilian MA, black, and white adults with type 2 diabetes and hypertension. Unadjusted and adjusted 2-way analysis of variance models evaluated whether there was a difference in the use of recommended antihypertensive regimens across race/ethnic group.

RESULTS

There was no difference in the use of recommended regimens across race/ethnic group (MAs, 79.1%; blacks, 81.7%; whites, 82.3%). Similarly, there was no difference between blood pressure goal levels and the use of recommended therapies across race/ethnicity (P = .632). Mexican Americans were least likely and blacks most likely to be on 3 or more antihypertensive drug classes (16.8% vs 28%). Furthermore, MAs were least likely to be on recommended add-on therapies such as calcium channel blockers and diuretics.

CONCLUSION

Racial/ethnic medication use disparities were observed when looking at the number of antihypertensive drug classes per patient regimen, and add-on therapy use was evaluated. Along with lifestyle modifications, frequent antihypertensive regimen reassessment is necessary.

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases (NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a PubMed search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Epidemiology of hypertension in CKD

Both hypertension (HTN) and CKD are serious interrelated global public health problems. Nearly 30% and 15% of US adults have HTN and CKD, respectively. Because HTN may cause or result from CKD, HTN prevalence is higher and control more difficult with worse kidney function. Etiology of CKD, presence and degree of albuminuria, and genetic factors all influence HTN severity and prevalence. In addition, socioeconomic and lifestyle factors influence HTN prevalence and control. There are racial and ethnic disparities in the prevalence, treatment, risks, and outcomes of HTN in patients with CKD. Control of blood pressure (BP) in Hispanic and African Americans with CKD is worse than it is whites. There are disparities in the patterns of treatment and rates of progression of CKD in patients with HTN. The presence and severity of CKD increase treatment resistance. HTN is also extremely prevalent in patients receiving hemodialysis, and optimal targets for BP control are being elucidated. Although the awareness, treatment, and control of HTN in CKD patients is improving, control of BP in patients at all stages of CKD remains suboptimal.