Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement

Treatment Strategies to Control Blood Pressure in People With Hypertension in Tanzania and Lesotho: A Randomized Clinical Trial

Importance

Hypertension is the primary cardiovascular risk factor in Africa. Recently revised World Health Organization guidelines recommend starting antihypertensive dual therapy; clinical efficacy and tolerability of low-dose triple combination remain unclear.

Objectives

To compare the effect of 3 treatment strategies on blood pressure control among persons with untreated hypertension in Africa.

Design, Setting, and Participants

This was an open-label, parallel, 3-arm randomized clinical trial to evaluate noninferiority of a strategy starting 2 pills vs full-dose monotherapy with stepped escalation (noninferiority margin 10%) and superiority of starting low-dose 3 pills vs monotherapy allowing for monthly up titration. Recruitment lasted from March 5, 2020, to March 30, 2022. The setting was 2 hospitals in rural Lesotho and Tanzania. Participants included nonpregnant Black African individuals 18 years and older with uncomplicated, untreated hypertension (standardized office blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic).

Interventions

Participants were randomized 2:2:1 to stepped monotherapy (amlodipine, 10 mg, with escalation to add hydrochlorothiazide if needed), 2-pill strategy (amlodipine, 5 mg; losartan, 50 mg), or 3-pill strategy (amlodipine, 2.5 mg; losartan, 12.5 mg; hydrochlorothiazide, 6.25 mg). Drugs were up titrated monthly until reaching the target blood pressure (≤ 130/80 mm Hg for participants aged <65 years; ≤140/90 mm Hg for those aged ≥65 years).

Main Outcomes and Measures

Proportion of participants reaching target blood pressure at 12 weeks.

Results

Of 1761 participants screened, 1268 were enrolled (median [IQR] age, 54 [45-65] years; 914 female [72%]), with 505 in the monotherapy cohort, 510 in the 2-pill cohort, and 253 in the 3-pill cohort. In noninferiority analyses, 207 of 370 participants (56%) receiving the 2-pill strategy and 173 of 338 participants (51%) receiving the stepped monotherapy strategy achieved the blood pressure target (adjusted odds ratio [aOR], 1.18; 95% CI, 0.87-1.61), fulfilling noninferiority. In superiority analyses after multiple imputation for missing outcome data, 57% of participants receiving the 3-pill strategy, 55% receiving the 2-pill strategy, and 49% receiving the stepped monotherapy strategy reached the target blood pressure (aOR, 1.24; 95% CI, 0.94-1.63; P = .12 and aOR, 1.28; 95% CI, 0.91-1.79; P = .16 for the 2-pill and 3-pill vs stepped monotherapy strategies, respectively).

Conclusions and Relevance

Results of this randomized clinical trial show that in 2 African settings, for adults with uncomplicated untreated hypertension, a strategy starting a 2-pill low-dose treatment was noninferior to starting stepped monotherapy. Two-pill and 3-pill low-dose strategies were not superior to stepped monotherapy. Wide CIs preclude the ability to rule out potentially clinically important effects of the additional pill strategies for hypertension control.

Trial Registration

ClinicalTrials.gov Identifier: NCT04129840.

Visit-to-visit lipid variability and adverse kidney events in real-world type 2 diabetes patients

AIM

To examine the association between long-term variability in low-density lipoprotein cholesterol (LDL-C) and the development of adverse kidney events among type 2 diabetes patients.

METHODS

Kidney events of interest included sustained estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2, 30 % eGFR decline, and composite kidney events. The Cox proportional hazard model was used to assess the association between LDL-C variability and kidney events.

RESULTS

A total of 15,444 patents were included (54 % male, mean age of 62.3 years, baseline HbA1c of 7.6 %, and eGFR of 84.2 mL/min/1.73 m2). The risk of kidney events increased with greater LDL-C variability across variability indices, except for that measured by coefficient of variation. Specifically, average real variability had the best predictive performance, with an optimal cut-off value of 19.26 for discriminating patients' risk of a sustained eGFR < 15 mL/min/1.73 m2. A greater effect of lipid variability on kidney event risk was observed among a subset of patients aged < 75 years, with eGFR ≥ 90 mL/min/1.73 m2, or having fewer diabetes-related complications.

CONCLUSIONS

An increased risk of adverse kidney events with greater visit-to-visit variability in LDL-C highlights the clinical importance of monitoring both the single-point LDL-C and its stability over time.

Trends in hypertensive heart disease-related mortality among older adults in the USA: a retrospective analysis from CDC WONDER between 1999 and 2020

BACKGROUND

While hypertensive heart disease (HHD) has been widely studied, this study uniquely examines the impact of the COVID-19 pandemic on HHD mortality trends, which has not been thoroughly explored in the current literature. The pandemic's effects on healthcare access, economic instability, and social isolation present new challenges and opportunities for understanding HHD mortality among the elderly.

RESULTS

Age-adjusted mortality rates (AAMRs) increased overall between 1999 and 2020, from 36.7 to 133.9 per 100,000 people, according to analysis. The data on AAMRs indicated a consistent rise from 1999 to 2017, with a notable uptick from 2017 to 2020. An investigation based on gender revealed that older men had a consistently higher AAMR than older women. The biggest AAMRs were found among the non-Hispanic (NH) Black or African-American population, according to variations in AAMR based on race and ethnicity. Geographic differences between states revealed that compared to Nebraska, Oregon, North Dakota, Maine, and Minnesota, the District of Columbia, Oklahoma, Nevada, Vermont, and Mississippi had substantially higher AAMRs. The West, Northeast, and Midwest were in second place with a continuously higher AAMR, followed by the South. Furthermore, compared to non-metropolitan areas, metropolitan areas had a higher AAMR.

CONCLUSION

The importance of including demographic and geographic factors in public health planning and interventions is highlighted by these findings, which provide insightful information on mortality trends associated with HHD in the elderly.

Comparative Effectiveness of Calcium-Channel Blockers, Angiotensin-Converting Enzyme/Angiotensin Receptor Blockers and Diuretics on Cardiovascular Events Likelihood in Hypertensive African-American and Non-Hispanic Caucasians: A Retrospective Study Across HCA Healthcare

BACKGROUND

Hypertension, a leading global risk factor for mortality and disability, disproportionately affects racial and ethnic minorities. Our study investigates the association between the type of prior antihypertensive medication use and the likelihood of cardiovascular events (CVE) and assesses whether the patient's race influences this relationship.

METHODS

A retrospective study of 14 836 hypertension cases aged ≥ 40 years was conducted using data from HCA Healthcare between 2017 and 2023. Logistic regression was employed to predict the likelihood of CVE and mortality at admission, adjusting for baseline comorbidities, with Race added as an effect modifier. Interaction analysis was performed among races based on antihypertensive medication types.

RESULTS

African American patients on ACE inhibitors (ACE) or angiotensin receptor blockers (ARBs) were 1.7 times more likely to have cardiovascular events (CVE) compared to those on calcium channel blockers (CCBs) and 0.66 times as likely compared to diuretics. CCB users had a lower CVE risk than diuretic users. Among White patients, ACE/ARB users had a 1.18 times higher CVE risk than CCB users and 0.45 times lower compared to diuretics, while CCBs offered a 0.38 times lower risk than diuretics. Only ACE/ARB use showed significantly higher CVE odds for African Americans compared to White patients, with similar risks across racial groups for CCBs and diuretics.

CONCLUSION

Prior antihypertensive type significantly influenced CVE risk, with race as an effect modifier. CCB users had lower CVE odds than ACE/ARBs or diuretics, and ACE/ARBs showed reduced CVE likelihood compared to diuretics in both racial groups.

The potential impact of optimal blood pressure treatment intensity to reduce disparities in dementia between Black and White individuals

BACKGROUND

Black adults have higher dementia risk than White adults. Whether tighter population-level blood pressure (BP) control reduces this disparity is unknown.

OBJECTIVE

Estimate the impact of optimal BP treatment intensity on racial disparities in dementia.

METHODS

A microsimulation study of US adults ≥18 across a life-time policy-planning horizon. BP treatment strategies were the Systolic Blood Pressure Intervention Trial (SPRINT) protocol, the Eighth Joint National Committee (JNC-8) recommendations, and usual care (non-intervention control). Outcomes were all-cause dementia, atherosclerotic cardiovascular disease (ASCVD), stroke, myocardial infarction, non-ASCVD death, global cognitive performance, and optimal brain health (being free of dementia, cognitive impairment, or stroke). Population-level and individual-level effects stratified by race were estimated.

RESULTS

Optimal population-level implementation of a SPRINT-based BP treatment strategy, compared to usual care, would increase average annual dementia incidence in White, but not Black, adults (1% versus 0%), due to hypertensive individuals' greater survival, and reduce annual ASCVD events more in Black than White adults (13% versus 5%). Under a SPRINT-based strategy, individuals with hypertension gained more years lived without dementia, ASCVD, myocardial infarction, or stroke and more years lived in optimal brain health. A SPRINT-based strategy did not attenuate individual-level race disparities in outcomes, except stroke. Due to longer life expectancy, a SPRINT-based strategy did not substantially reduce lifetime dementia risk in either group. The JNC-8-based strategy had similar but smaller effects as the SPRINT-based strategy.

CONCLUSIONS

Our results suggest that tighter population-level BP control would not reduce population-level disparities in dementia between US Black and White adults.

Bridging the Gap: Tackling Racial and Ethnic Disparities in Hypertension Management

Hypertension is a prevalent health concern with significant implications for cardiovascular disease risk, affecting diverse populations worldwide and imposing substantial health system burdens. This review article explores racial and ethnic disparities in hypertension prevalence, treatment, and management, highlighting the disproportionate impact on minority populations. Certain racial and ethnic groups in the United States exhibit higher prevalence rates of hypertension and related complications due to a confluence of genetic, social, and economic factors. Despite comparable treatment rates, blood pressure control is often less effective among these groups, partly due to less intensive treatment and systemic barriers to care. Different populations encounter unique challenges, with prevalence and control rates influenced by dietary habits, socioeconomic status, and healthcare disparities. This review summarizes current management practices and highlights the necessity for tailored approaches that consider ethnic-specific treatment responses. It underscores the importance of addressing socioeconomic and cultural barriers while incorporating both pharmacological and nonpharmacological treatments. Future research should focus on developing culturally relevant assessment tools, enhancing data collection, and evaluating interventions designed to mitigate these disparities. To promote health equity and optimize the management of hypertension in a variety of populations, it is imperative to address these inequities using individualized, evidence-based strategies.

Evolving the Role of Black Race in Hypertension Therapeutics

Black race has been used to guide antihypertensive drug selection for Black patients based on predominant between race (same drug) and intra-race (different drugs) blood pressure (BP) response patterns. Accordingly, thiazide diuretics and calcium antagonists have been recommended over renin-angiotensin system (RAS) inhibitors (angiotensin-receptor blockers, angiotensin-converting enzyme inhibitors) and beta blockers for Black patients. Current antihypertensive drug prescribing reflects historical guidance as calcium antagonists and thiazide diuretics are prescribed more and RAS blockers less in Black than White patients. Hypertension control rates in Blacks, lag those for Whites despite their greater use of combination drug therapy and lesser use of monotherapy. This is also true across drug regimens containing any of the 4 recommended classes for initial therapy as well as for evidence-based combination drug therapy (calcium antagonist or thiazide diuretic + RAS blocker) regimens for which there is no known racial disparity in BP response. Current recommendations acknowledge the need for combination drug therapy in most, especially in Black patients. One exemplary comprehensive hypertension control program achieved >80% control rates in Black and White patients with minimal racial disparity while utilizing a race-agnostic therapeutic algorithm. Black patients manifest robust, if not outsized, BP responses to diet/lifestyle modifications. Importantly, race neither appears to be a necessary nor sufficient consideration for the selection of effective drug therapy. Accordingly, we urge the initiation of adequately intense race-agnostic drug therapy coupled with greater emphasis on diet/lifestyle modifications for Black patients as the cornerstone of a race-informed approach to hypertension therapeutics.

Ethnic Disparities in the Risk Factors, Morbidity, and Mortality of Cardiovascular Disease in People With Diabetes

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes. Compared with European Americans, African Americans have more favorable lipid profiles, as indicated by higher high-density lipoprotein cholesterol, lower triglycerides, and less dense low-density lipoprotein particles. The less atherogenic lipid profile translates to lower incidence and prevalence of CVD in African Americans with diabetes, despite higher rates of hypertension and obesity. However, African Americans with CVD experience worse clinical outcomes, including higher mortality, compared with European Americans. This mini-review summarizes the epidemiology, pathophysiology, mechanisms, and management of CVD in people with diabetes, focusing on possible factors underlying the "African American CVD paradox" (lower CVD incidence/prevalence but worse outcomes). Although the reasons for the disparities in CVD outcomes remain to be fully elucidated, we present a critical appraisal of the roles of suboptimal control of risk factors, inequities in care delivery, several biological factors, and psychosocial stress. We identify gaps in current knowledge and propose areas for future investigation.

Impact of Antihypertensive Medication Changes After Renal Denervation Among Different Patient Groups: SPYRAL HTN-ON MED

BACKGROUND

The SPYRAL HTN-ON MED (Global Clinical Study of Renal Denervation With the Symplicity Spyral Multi-electrode Renal Denervation System in Patients With Uncontrolled Hypertension in the Absence of Antihypertensive Medications)trial showed significant office and nighttime systolic blood pressure (BP) reductions in patients with hypertension following renal denervation (RDN) compared with sham-control patients, despite similar 24-hour BP reductions. We compared antihypertensive medication and BP changes among prespecified subpopulations.

METHODS

The multicenter, randomized, sham-controlled, blinded SPYRAL HTN-ON MED trial (n=337) evaluated BP changes after RDN compared with a sham procedure in patients with hypertension prescribed 1 to 3 antihypertensive drugs. Most patients (n=187; 54%) were enrolled outside the United States, while 156 (46%) US patients were enrolled, including 60 (18%) Black Americans.

RESULTS

Changes in detected antihypertensive drugs were similar between RDN and sham group patients in the outside US cohort, while drug increases were significantly more common in the US sham group compared with the RDN group. Patients from outside the United States showed significant reductions in office and 24-hour mean systolic BP at 6 months compared with the sham group, whereas BP changes were similar between RDN and sham in the US cohort. Within the US patient cohort, Black Americans in the sham control group had significant increases in medication burden from baseline through 6 months (P=0.003) but not in the RDN group (P=0.44).

CONCLUSIONS

Patients enrolled outside the United States had minimal antihypertensive medication changes between treatment groups and had significant office and 24-hour BP reductions compared with the sham group. Increased antihypertensive drug burden in the US sham cohort, especially among Black Americans, may have diluted the treatment effect in the combined trial population.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02439775.

Racial and Ethnic Disparities in Neurological Care in the United States

The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.

Seven Strategies to Integrate Equity within Translational Research in Neurology

The rapidly accelerating translation of biomedical advances is leading to revolutionary therapies that are often inaccessible to historically marginalized populations. We identified and synthesized recent guidelines and statements to propose 7 strategies to integrate equity within translational research in neurology: (1) learn history; (2) learn about upstream forces; (3) diversify and liberate; (4) change narratives and adopt best communication practices; (5) study social drivers of health and lived experiences; (6) leverage health technologies; and (7) build, sustain, and lead culturally humble teams. We propose that equity should be a major goal of translational research, equally important as safety and efficacy. ANN NEUROL 2024;95:432-441.

Salt Sensitivity of Blood Pressure in Black People: The Need to Sort Out Ancestry Versus Epigenetic Versus Social Determinants of Its Causation

Race is a social construct, but self-identified Black people are known to have higher prevalence and worse outcomes of hypertension than White people. This may be partly due to the disproportionate incidence of salt sensitivity of blood pressure in Black people, a cardiovascular risk factor that is independent of blood pressure and has no proven therapy. We review the multiple physiological systems involved in regulation of blood pressure, discuss what, if anything is known about the differences between Black and White people in these systems and how they affect salt sensitivity of blood pressure. The contributions of genetics, epigenetics, environment, and social determinants of health are briefly touched on, with the hope of stimulating further work in the field.

Ten-Year Review of Antihypertensive Prescribing Practices After Stroke and the Associated Disparities From the Florida Stroke Registry

BACKGROUND

Guideline-based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescriber's blood pressure (BP) medication choice adheres to clinical practice guidelines (BP-guideline adherence).

METHODS AND RESULTS

The FSR (Florida Stroke Registry) uses statewide data prospectively collected for all acute stroke admissions. Based on established guidelines, we defined optimal BP-guideline adherence using the following hierarchy of rules: (1) use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker as first-line antihypertensive among diabetics; (2) use of thiazide-type diuretics or calcium channel blockers among Black patients; (3) use of beta blockers among patients with compelling cardiac indication; (4) use of thiazide, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, or calcium channel blocker class as first line in all others; (5) beta blockers should be avoided as first line unless there is a compelling cardiac indication. A total of 372 254 cases from January 2010 to March 2020 are in the FSR with a diagnosis of acute ischemic stroke, hemorrhagic stroke, transient ischemic attack, or subarachnoid hemorrhage; 265 409 with complete data were included in the final analysis. Mean age was 70±14 years; 50% were women; and index stroke subtypes were 74% acute ischemic stroke, 11% intracerebral hemorrhage, 11% transient ischemic attack, and 4% subarachnoid hemorrhage. BP-guideline adherence to each specific rule ranged from 48% to 74%, which is below quality standards of 80%, and was lower among Black patients (odds ratio, 0.7 [95% CI, 0.7-0.83]; P<0.001) and those with atrial fibrillation (odds ratio, 0.53 [95% CI, 0.50-0.56]; P<0.001) and diabetes (odds ratio, 0.65 [95% CI, 0.61-0.68]; P<0.001).

CONCLUSIONS

This large data set demonstrates consistently low rates of BP-guideline adherence over 10 years. There is an opportunity for monitoring hypertensive management after stroke.

Susceptibility to hypertension based on MTHFR rs1801133 single nucleotide polymorphism and MTHFR promoter methylation

Background

The aetio-pathologenesis of hypertension is multifactorial, encompassing genetic, epigenetic, and environmental factors. The combined effect of genetic and epigenetic changes on hypertension is not known. We evaluated the independent and interactive association of MTHFR rs1801133 single nucleotide polymorphism (SNP) and MTHFR promoter methylation with hypertension among Taiwanese adults.

Methods

We retrieved data including, MTHFR promoter methylation, MTHFR rs1801133 genotypes (CC, CT, and TT), basic demography, personal lifestyle habits, and disease history of 1,238 individuals from the Taiwan Biobank (TWB).

Results

The distributions of hypertension and MTHFR promoter methylation quartiles (β < 0.1338, 0.1338 ≤ β < 0.1385, 0.1385 ≤ β < 0.1423, and β ≥ 0.1423 corresponding to

Conclusion

Independently, rs1801133 TT was associated with a higher risk of hypertension, but methylation was not. Based on genotypes, lower methylation was dose-dependently associated with a higher risk of hypertension in individuals with the CC genotype. Our findings suggest that MTHFR rs1801133 and MTHFR promoter methylation could jointly influence hypertension susceptibility.

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Key Words

• MTHFR
• hypertension
• interaction
• promoter methylation
• rs1801133
• susceptibility

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Affiliation(s)

Ming-Huang Chiu Department of Pulmonology and Respiratory Care, Cathay General Hospital, Taipei City, Taiwan
Chia-Hsiu Chang Cardiovascular Center, Cathay General Hospital, Taipei City, Taiwan
Disline Manli Tantoh Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, Taiwan Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
Tsui-Wen Hsu Superintendent Office, Institute of Medicine, Cathay General Hospital, Taipei City, Taiwan
Chih-Hsuan Hsiao Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
Ji-Han Zhong Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
Yung-Po Liaw Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, Taiwan Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan Institute of Medicine, Chung Shan Medical University, Taichung City, Taiwan

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Treatment Intensity, Prescribing Patterns, and Blood Pressure Control in Rural Black Patients with Uncontrolled Hypertension

BACKGROUND/OBJECTIVE

Because racial disparities in hypertension treatment persist, the objective of the present study was to examine patient vs. practice characteristics that influence antihypertensive selection and treatment intensity for non-Hispanic Black (hereafter "Black") patients with uncontrolled hypertension in the rural southeastern USA.

METHODS

We enrolled 25 Black patients from each of 69 rural practices in Alabama and North Carolina with uncontrolled hypertension (systolic blood pressure (BP) ≥ 140 mm Hg) in a 4-arm cluster randomized trial of BP control interventions. Patients' antihypertensive medications were abstracted from medical records and reconciled at the baseline visit. Treatment intensity was computed using the defined daily dose (DDD) method of the World Health Organization. Correlates of greater antihypertensive medication intensity were assessed by linear regression modeling, and antihypertensive medication classes were compared by baseline systolic BP (SBP) level.

RESULTS

A total of 1431 patients were enrolled and had complete baseline data. Antihypertensive treatment intensity averaged 3.7 ± 2.6 equivalent medications at usual dosages and was significantly related to higher baseline systolic BP, older age, male sex, insurance availability, higher BMI, and concurrent diabetes, but not to practice type or medication barriers in regression models. Renin-angiotensin system inhibitors were the most commonly used medications, followed by diuretics and calcium channel blockers.

CONCLUSION/RELEVANCE

Antihypertensive treatment intensity for Black patients in the rural southeastern USA with a history of uncontrolled hypertension averaged the equivalent of almost four medications at usual dosages and was significantly associated with baseline SBP levels and other patient characteristics, but not clinic type.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02866669.

Associated factors with hypertension, known poorly controlled hypertension, and newly diagnosed hypertension among people aged 18-70 in Senegal

Introduction

In this study, we aimed to determine the factors associated with hypertension, known poorly controlled hypertension, and newly diagnosed hypertension in 2015 to improve the prevention of this pathology in our country.

Methods

This was a secondary analysis of the national WHO STEPwise survey database. It had a quantitative, descriptive, and analytical aim. The sampling was done in stratification in three stages of sampling. Statistical analysis was performed using Rstudio 4.0.2 software. It was a descriptive, bivariate, and multivariate analysis using binomial logistic regression for explanatory purposes.

Results

The risk factors for being hypertensive among 18-70- year-olds in Senegal in 2015 were: having taken their blood pressure at least once in their life; having taken their cholesterol levels at least once in their life; having received advice to reduce salt consumption; having received advice on how to reduce the amount of sugar; having a lean body mass index; being overweight; being obese III; and being between 35-39 and 65-70 years old. The protective factors are: checking the salt content indicated on the labels; and consuming salt-rich dishes "often" compared to "never". The risk factors for being newly diagnosed with hypertension among 18-70-year-olds in Senegal in 2015 were: having a history of stroke; having a resting heart rate greater than 80 beats per minute; consuming palm oil; and having high fasting blood sugar. The protective factors are: having a high average number of meals eaten per week not prepared at home; checking the salt content indicated on the label; and being of female sex. The risk factors for being known to have poorly controlled hypertension among 18-70- year-olds in Senegal in 2015 were: judging their reduction in salt consumption as "very important"; and having received advice to reduce their salt consumption. The protective factors are: performing physical activity only when traveling; and limiting the consumption of salty meals.

Conclusion

Senegalese family cooking exposes to hypertension, small actions limiting salt consumption strongly protect against hypertension, and simple physical activity during travel strongly protects against hypertension, but the health system is very little proactive in the primordial and primary prevention of hypertension.

Religion/Spirituality and Prevalent Hypertension among Ethnic Cohorts in the Study on Stress, Spirituality, and Health

BACKGROUND

Hypertension is a significant public health issue, particularly for Blacks, Hispanics/Latinos, and South Asians who are at greater risk than whites. Religion and spirituality (R/S) have been shown to be protective, but this has been identified primarily in whites with limited R/S measures examined (i.e., religious service attendance).

PURPOSE

To assess hypertension prevalence (HP) in four racial/ethnic groups while incorporating an array of R/S variables, including individual prayer, group prayer, nontheistic daily spiritual experiences, yoga, gratitude, positive religious coping, and negative religious coping.

METHODS

Data were drawn from the Study on Stress, Spirituality, and Health, a consortium of ethnically diverse U.S. cohorts. The sample included 994 Black women, 838 Hispanic/Latino men and women, 879 South Asian men and women, and 3681 white women. Using a cross-sectional design, prevalence ratios for R/S and hypertension were reported for each cohort, in addition to pooled analyses. Given differences in R/S among men and women, all models were stratified by gender.

RESULTS

Different patterns of associations were found between women and men. Among women: 1) religious attendance was associated with lower HP among Black and white women; 2) gratitude was linked to lower HP among Hispanic/Latino, South Asian, and white women; 3) individual prayer was associated with higher HP among Hispanic/Latino and white women; 4) yoga was associated with higher HP among South Asian women, and 5) negative religious coping was linked to higher HP among Black women. Among men: significant results were only found among Hispanic/Latino men. Religious attendance and individual prayer were associated with higher HP, while group prayer and negative religious coping were associated with lower HP.

CONCLUSION

Religion/spirituality is a multifaceted construct that manifests differently by race/ethnicity and gender. Medical practitioners should avoid a one-size-fits-all approach to this topic when evaluating prevalent hypertension in diverse communities.

Demographic Disparities in the Federal Drug Approval Process for Allergic Rhinitis Medications

OBJECTIVE

Demographic minorities are underrepresented in clinical trials. For the approval of new drug applications (NDAs), the Food and Drug Administration (FDA) has asserted that clinical trial enrollment should represent the demographics of patients likely to receive the trial drug. The aim of this study is to assess the demographics of clinical trials included in NDAs and biologics license applications (BLAs) approved by the FDA since 1990 for allergic rhinitis (AR), a condition whose demographic prevalence mirrors the US population.

METHODS

Federal Freedom of Information Act requests were submitted to the US government to obtain documents related to all relevant NDAs and BLAs. The Drugs@FDA database was queried for all clinical trial documentation. Demographic data were extracted from clinical trials used to inform FDA approval for AR pharmacotherapies. Demographics were analyzed relative to national US Census data.

RESULTS

Since 1990, 22 drugs have been approved for AR. The racial, ethnic, and sex composition of all included study populations differed significantly (p < 0.05) from the demographics of AR and from US Census data. Most NDAs and BLAs included overrepresentation of White participants and underrepresentation of Black, Asian, Pacific Island, Native American, and Hispanic participants.

CONCLUSION

The patients enrolled in clinical trials used to inform FDA approval for AR pharmacotherapeutics do not represent the demographics of the United States or the demographics of AR. The clinical significance of unrepresentative demography between study and treatment populations has been examined for several medical disorders, but has not been studied for AR.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:755-763, 2023.

A 10-year review of antihypertensive prescribing practices after stroke and the associated disparities from the Florida Stroke Registry

Background

Guideline based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescribers' blood pressure medication choice adheres to clinical practice guidelines (Prescribers'-Choice Adherence).

Methods

The Florida Stroke registry (FSR) utilizes statewide data prospectively collected for all acute stroke admissions. Based on established guidelines we defined optimal Prescribers'-Choice Adherence using the following hierarchy of rules: 1) use of an angiotensin inhibitor (ACEI) or angiotensin receptor blocker (ARB) as first-line antihypertensive among diabetics; 2) use of thiazide-type diuretics or calcium channel blockers (CCB) among African-American patients; 3) use of beta-adrenergic blockers (BB) among patients with compelling cardiac indication (CCI) 4) use of thiazide, ACEI/ARB or CCB class as first-line in all others; 5) BB should be avoided as first line unless CCI.

RESULTS

A total of 372,254 cases from January 2010 to March 2020 are in FSR with a diagnosis of acute ischemic, hemorrhagic stroke, transient ischemic attack or subarachnoid hemorrhage; 265,409 with complete data were included in the final analysis. Mean age 70 +/-14 years, 50% female, index stroke subtype of 74% acute ischemic stroke and 11% intracerebral hemorrhage. Prescribers'-Choice Adherence to each specific rule ranged from 48-74% which is below quality standards of 85%. There were race-ethnic disparities with only 49% Prescribers choice Adherence for African Americans patients.

Conclusion

This large dataset demonstrates consistently low rates of Prescribers'-Choice Adherence over 10 years. There is an opportunity for quality improvement in hypertensive management after stroke.

Does Vitamin D Provide Added Benefit to Antihypertensive Therapy in Reducing Left Ventricular Hypertrophy Determined by Cardiac Magnetic Resonance?

BACKGROUND

Left ventricular hypertrophy (LVH) and vitamin D deficiency have been linked to hypertension (HTN) and cardiovascular disease, particularly in African Americans (AAs). Our objective was to determine if the addition of vitamin D to antihypertensive therapy would lead to greater regression of LV mass index (LVMI) as determined by cardiac magnetic resonance (CMR) after 1 year in vitamin D deficient AA patients with uncontrolled HTN and LVH.

METHODS

This study was a randomized, double-blind, placebo-controlled, single-center study. AA patients with HTN (systolic blood pressure [BP] >160 mm Hg), increased LVMI, and vitamin D deficiency (<20 ng/ml) were randomized. All patients received antihypertensive therapy combined with biweekly 50,000 IU vitamin D3 (vitamin D group, n = 55) or placebo (placebo group, n = 58).

RESULTS

At 1 year, there were no statistical differences between the vitamin D and placebo groups in LVMI (-14.1 ± 14.6 vs. -16.9 ± 13.1 g/m2; P = 0.34) or systolic BP (-25.6 ± 32.1 vs. -25.7 ± 25.6 mm Hg; P = 0.99) reduction, respectively. Serum vitamin D levels increased significantly in the vitamin D group compared with placebo (12.7 ± 2.0 vs. 1.8 ± 8.2 ng/ml; P < 0.001).

CONCLUSIONS

In this high-risk cohort of AAs we did not find an association between vitamin D supplementation and differential regression of LVMI or reduction in systolic BP. However, our study suffered from a small sample size with low statistical power precluding a definitive conclusion on the therapeutic benefit of vitamin D in such patients.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01360476. Full trial protocol is available from corresponding author.

Attenuated Relationships Between Indexes of Volume Overload and Atrial Natriuretic Peptide in Uncontrolled, Sustained Volume-Dependent Primary Hypertension

BACKGROUND

Whether systolic blood pressure (SBP) control in sustained volume-dependent primary hypertension is associated with blunted ANP (atrial natriuretic peptide) relationships with indexes of volume load is unknown.

METHODS

Systemic hemodynamics (central pressure, echocardiographic aortic velocity and diameter measurements in the outflow tract), circulating ANP concentrations (ELISA assays) and glomerular and tubular function (24-hour urine collections [n=519]) were determined in a community of African ancestry (n=772).

RESULTS

As compared with those with a controlled SBP, those with an uncontrolled SBP (n=198) showed lower ANP concentrations (P<0.005) despite higher stroke volume and cardiac output (P<0.0001) and renal differences consistent with enhanced fluid retention. In those with a controlled SBP, fractional Na⁺ excretion (FeNa⁺; P<0.0005) and creatinine clearance (glomerular filtration rate; P<0.005) were inversely associated with ANP concentrations independent of confounders. Moreover, in those with a controlled SBP, stroke volume and cardiac output (P<0.0001) were independently and positively associated with ANP concentrations. In addition, in those with a controlled SBP, ANP concentrations were independently and inversely associated with systemic vascular resistance (SVR; P<0.0001) and aortic characteristic impedance (Zc; P<0.005). By contrast, in those with uncontrolled SBP, no relationships between either stroke volume (P>0.25), cardiac output (P>0.29), FeNa⁺ (P>0.77), or glomerular filtration rate (P>0.47) and ANP concentrations were noted. Furthermore, in those with an uncontrolled SBP, no relationships between ANP concentrations and SVR or Zc were observed (P>0.34).

CONCLUSIONS

In a population where primary hypertension is strongly volume-dependent, those with an uncontrolled SBP have an attenuated relationship between ANP and both renal and hemodynamic indexes of volume overload and the vascular effects of ANP.

Effect of renin-angiotensin-aldosterone system inhibitors on survival outcomes in cancer patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis

Background

Effect of renin-angiotensin-aldosterone system inhibitors (RAASIs) in combination with immune checkpoint inhibitors (ICIs) on prognoses in cancer patients remains controversial. This study systematically evaluated the effect of RAASIs on survival outcomes in cancer patients receiving ICIs treatment and provided an evidence-based reference for the rational use of RAASIs and ICIs combination therapy in clinical practice.

Methods

Studies evaluating the prognosis of RAASIs-used versus RAASIs-free in cancer patients receiving ICIs treatment from inception to 1 November 2022 were retrieved by searching PubMed, Cochrane Library, Web of Science, Embase, and major conference proceedings. Studies in English reporting hazard ratios (HRs) with 95% confidence intervals (CIs) for overall survival (OS) and/or progression-free survival (PFS) were included. Statistical analyses were conducted using the software Stata 17.0.

Results

A total of 12 studies containing 11739 patients were included, comprising ~4861 patients in the RAASIs-used and ICIs-treated group and ~6878 patients in RAASIs-free and ICIs-treated group. The pooled HR was 0.85 (95%CI, 0.75-0.96; P = 0.009) for OS and 0.91 (95%CI, 0.76-1.09; P = 0.296) for PFS, indicating a positive effect of RAASIs concomitant with ICIs on cancer patients. This effect was observed especially in patients with urothelial carcinoma (HR, 0.53; 95%CI, 0.31-0.89; P = 0.018) and renal cell carcinoma (HR, 0.56; 95%CI, 0.37-0.84; P = 0.005) on OS.

Conclusion

Concomitant use of RAASIs and ICIs enhanced the efficacy of ICIs and this combination regimen was associated with significantly improved OS and a trend towards better PFS. RAASIs can be considered as adjuvant drugs when hypertensive patients receive ICIs treatment. Our results provide an evidence-based reference for the rational use of the RAASIs and ICIs combination therapy to improve the efficacy of ICIs in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022372636; https://inplasy.com/, identifier INPLASY2022110136.

Relationship Between Risks for Obstructive Sleep Apnea, Resistant Hypertension, and Aldosterone Among African American Adults in the Jackson Heart Study

BACKGROUND

African Americans have a higher prevalence of resistant hypertension compared with Caucasians. Racial differences in obstructive sleep apnea (OSA) and increased aldosterone level may explain the racial disparity in resistant hypertension prevalence. Therefore, the purpose of this study is to investigate if aldosterone level and hypertension status differ by risks for OSA (e.g., obesity, loud snoring, and daytime sleepiness) and how aldosterone level varies with hypertension severity and control among African Americans.

METHODS

A cross-sectional analysis was performed using baseline data on 5,052 African American adults in the Jackson Heart Study to investigate the relationships of interest using multivariable linear and multinomial logistic regression models adjusted for potential confounders. Risks for OSA were defined by a "risk score" consisting of the number of risks for OSA.

RESULTS

Of the 5,052 participants, 623 had no risks for OSA. Body mass index was the highest among those with a risk score of 6. About 39% of the sample had no hypertension, 29% had controlled hypertension, 26% had uncontrolled hypertension, and 6% had resistant hypertension. Higher odds of having uncontrolled hypertension or resistant hypertension were present in those with a higher risk score compared with those without risks for OSA. Log-aldosterone level increased with each additional risk for OSA (P-trend <0.05). Similarly, log-aldosterone also increased with more severe hypertension (P-trend <0.001). The highest aldosterone level was found in those with resistant hypertension that was inadequately controlled with medications.

CONCLUSIONS

Risks for OSA were positively associated with resistant hypertension and higher aldosterone level in African American adults.

Vulnerability to Hypertension Is a Major Determinant of Racial Disparities in Alzheimer's Disease Risk

BACKGROUND

Higher incidence levels of Alzheimer's disease (AD) in Black Americans are well documented. However, quantitative explanations of this disparity in terms of risk-factor diseases acting through well-defined pathways are lacking.

METHODS

We applied a Blinder-Oaxaca-based algorithm modified for censored data to a 5% random sample of Medicare beneficiaries age 65+ to explain Black/White disparities in AD risk in terms of differences in exposure and vulnerability to morbidity profiles based on 10 major AD-risk-related diseases.

RESULTS

The primary contribution to racial disparities in AD risk comes from morbidity profiles that included hypertension with about 1/5th of their contribution due to differences in prevalence (exposure effect) and 4/5ths to differences in the effects of the morbidity profile on AD risk (vulnerability effect). In total, disease-related effects explained a higher proportion of AD incidence in Black Americans than in their White counterparts.

CONCLUSIONS

Disease-related causes may represent some of the most straightforward targets for targeted interventions aimed at the reduction of racial disparities in health among US older adults. Hypertension is a manageable and potentially preventable condition responsible for the majority of the Black/White differences in AD risk, making mitigation of the role of this disease in engendering higher AD incidence in Black Americans a prominent concern.

Mid- to Late-Life Time-Averaged Cumulative Blood Pressure and Late-Life Retinal Microvasculature: The ARIC Study

Background The associations of time-averaged cumulative blood pressure (BP) from midlife to late life with microvasculature expressed as retinal vessel diameters is not well studied. The aim of this study was to evaluate the association of cumulative systolic BP and diastolic BP (DBP) with retinal vessel calibers, focusing on race differences. Methods and Results The analysis included 1818 adults from the ARIC (Atherosclerosis Risk in Communities) study attending the fifth visit (2011-2013; age 77±5 years, 17.1% Black participants). Time-averaged cumulative BPs were calculated as the sum of averaged BPs from adjacent consecutive visits (visits 1-5) indexed to total observation time (24±1 years). Summarized estimates for central retinal arteriolar equivalent and central retinal venular equivalent at the fifth visit represent average retinal vessel diameters. The arteriole:venule ratio was calculated. We tested for effect modification by race. Results from multiple linear regression models suggested that higher time-averaged cumulative DBP (β [95% CI] per 1-SD increase: -1.78 [-2.53, -1.02], P<0.001 and -0.005 [-0.009, -0.002], P=0.004, respectively) but not systolic BP (-0.52 [-1.30, 0.26], P=0.189 and 0.001 [-0.002, 0.005], P=0.485, respectively) was associated with smaller central retinal arteriolar equivalent and arteriole:venule ratio. The association between time-averaged cumulative DBP and arteriole:venule ratio was strongest in White participants (interaction P=0.007). The association of cumulative systolic BP and DBP with central retinal venular equivalent was strongest in Black participants (interaction P=0.015 and 0.011, respectively). Conclusions Exposure to higher BP levels, particularly DBP, from midlife to late life is associated with narrower retinal vessel diameters in late life. Furthermore, race moderated the association of cumulative BP exposure with retinal microvasculature.

Barriers to up-titrated antihypertensive strategies in 12 sub-Saharan African countries: the Multination Evaluation of hypertension in Sub-Saharan Africa Study

BACKGROUND

Sub-Saharan Africa (SSA) faces the highest rate of hypertension worldwide. The high burden of elevated blood pressure (BP) in black people has been emphasized. Guidelines recommend two or more antihypertensive medications to achieve a BP control. We aimed to identify factors associated with prescription of up-titrated antihypertensive strategies in Africa.

METHODS

We conducted a cross-sectional study on outpatient consultations for hypertension across 12 SSA countries. Collected data included socioeconomic status, antihypertensive drugs classes, BP measures, cardiovascular risk factors and complication of hypertension. We used ordinal logistic regression to assess factors associated with prescription of up-titrated strategies.

RESULTS

The study involved 2123 treated patients with hypertension. Patients received monotherapy in 36.3 vs. 25.9%, two-drug in 42.2 vs. 45% and three and more drugs strategies in 21.5 vs. 29.1% in low (LIC) and middle (MIC) income countries, respectively. Patients with sedentary lifestyle [OR 1.4 (1.11-1.77)], complication of hypertension [OR 2.4 (1.89-3.03)], former hypertension [OR 3.12 (2.3-4.26)], good adherence [OR 1.98 (1.47-2.66)], from MIC [OR 1.38 (1.10-1.74)] and living in urban areas [OR 1.52 (1.16-1.99)] were more likely to be treated with up-titrated strategies. Stratified analysis shows that in LIC, up-titrated strategies were less frequent in rural than in urban patients (P for trend <0.01) whereas such difference was not observed in MIC.

CONCLUSION

In this African setting, in addition to expected factors, up-titrated drug strategies were associated with country-level income, patient location and finally, the interplay between both in LIC. These results highlight the importance of developing policies that seek to make multiple drug classes accessible particularly in rural and LIC.

Effect of Lifestyle Coaching or Enhanced Pharmacotherapy on Blood Pressure Control Among Black Adults With Persistent Uncontrolled Hypertension: A Cluster Randomized Clinical Trial

IMPORTANCE

Greater difficulty in controlling blood pressure (BP) and adverse lifestyle practices such as higher salt intake or less physical activity may account for some of the differences between BP control rates in Black vs White adults, thereby exposing Black adults to a higher risk of vascular events.

OBJECTIVE

To determine whether a lifestyle coaching intervention or an enhanced pharmacotherapy protocol is more effective than usual care in improving BP control rates in Black adults treated within an integrated health care delivery system.

DESIGN, SETTING, AND PARTICIPANTS

Shake, Rattle & Roll, a cluster randomized clinical trial, was conducted from June 5, 2013, to June 11, 2018, in a large integrated health care delivery system. Enrollment was completed during a 12-month period and interventions were implemented for 12 months. Follow-up lasted 48 months after enrollment. Panels of Black adult members of the health care delivery system with BP of at least 140/90 mm Hg from 98 adult primary care physicians were randomly assigned at the primary care physician level to usual care (UC group [n = 1129]), enhanced pharmacotherapy monitoring (EP group [n = 346]) of current BP management protocol, or diet and lifestyle coaching consisting of photographs, stories, and recipes, for example, that are appropriate for Black adults (LC group [n = 286]) focused on the Dietary Approaches to Stop Hypertension (DASH) diet. Data were analyzed from June 1, 2016, to March 25, 2022.

INTERVENTIONS

The UC group received care per customary protocol. The EP group was contacted by a research nurse and/or a clinical pharmacist to discuss barriers to hypertension control, and drug therapy emphasized the use of thiazide diuretic intensification and addition of spironolactone as needed. The LC group received as many as 16 telephone sessions with a lifestyle coach and an emphasis on implementing reduction of sodium intake and the DASH diet.

MAIN OUTCOMES AND MEASURES

Intention-to-treat analysis of BP control rates at end of the 12-month intervention.

RESULTS

Among the 1761 participants, the mean (SD) age was 61 (13) years, and 1214 (68.9%) were women. At the end of the 12-month intervention period, there was no significant difference in BP control rate among study groups (UC, 61.8% [95% CI, 58.8%-64.9%]; EP, 64.5% [95% CI, 59.0%-69.4%]; LC, 67.8% [95% CI, 62.1%-73.2%]; LC vs EP, P = .07). However, greater BP control was present in the LC group vs UC at 24 months (UC, 61.2% [95% CI, 57.3%-64.7%]; EP, 67.6% [95% CI, 61.9%-72.8%]; LC, 72.4% [95% CI, 66.9%-78.1%]; LC vs UC, P = .001), and 48 months (UC, 64.5% [95% CI, 61.6%-67.2%]; EP, 66.5% [95% CI, 61.3%-71.3%]; LC, 73.1% [95% CI, 67.6%-77.9%]; LC vs UC, P = .006) after enrollment. The contribution of BP medication adherence to explain group differences was inconclusive.

CONCLUSIONS AND RELEVANCE

In this cluster randomized clinical trial including Black adults with persistent uncontrolled hypertension, a 12-month LC intervention was more effective at controlling BP than UC at 24 and 48 months after enrollment. Further research is needed to explore the potential implementation of this intervention into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01892592.

Tissue Sodium in Patients With Early Stage Hypertension: A Randomized Controlled Trial

Background

Sodium (Na⁺) stored in skin and muscle tissue is associated with essential hypertension. Sodium magnetic resonance imaging is a validated method of quantifying tissue stores of Na⁺. In this study, we evaluated tissue Na⁺ in patients with elevated blood pressure or stage I hypertension in response to diuretic therapy or low Na⁺ diet.

Methods and Results

In a double‐blinded, placebo‐controlled trial, patients with systolic blood pressure 120 to 139 mm Hg were randomized to low sodium diet (<2 g of sodium), chlorthalidone, spironolactone, or placebo for 8 weeks. Muscle and skin Na⁺ using sodium magnetic resonance imaging and pulse wave velocity were assessed at the beginning and end of the study. Ninety‐eight patients were enrolled to undergo baseline measurements and 54 completed randomization. Median baseline muscle and skin Na⁺ in 98 patients were 16.4 mmol/L (14.9, 18.9) and 13.1 mmol/L (11.1, 16.1), respectively. After 8 weeks, muscle Na⁺ increased in the diet and chlorthalidone arms compared with placebo. Skin sodium was decreased only in the diet arm compared with placebo. These associations remained significant after adjustment for age, sex, body mass index, systolic blood pressure, and urinary sodium. No changes were observed in pulse wave velocity among the different groups when compared with placebo.

Conclusions

Diuretic therapy for 8 weeks did not decrease muscle or skin sodium or improve pulse wave velocity in patients with elevated blood pressure or stage I hypertension.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02236520.

Hypertension continuum of care: Blood pressure screening, diagnosis, treatment, and control in a population-based cohort in Haiti

Cardiovascular disease (CVD) is the number one cause of death in low-income countries including Haiti, with hypertension (HTN) being the leading risk factor. This study aims to identify gaps in the HTN continuum of screening, diagnosis, treatment, and blood pressure (BP) control. Sociodemographic and clinical data were collected from a population-based sample of adults ≥18 years in Port-au-Prince (PAP) from March 2019 to April 2021. HTN was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or use of antihypertensive medication. Screening was defined as ever having had a BP measurement; diagnosis as previously being informed of a HTN diagnosis; treatment as having taken antihypertensives in the past 2 weeks; and controlled as taking antihypertensives and having BP < 140/90 mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions. Among 2737 participants, 810 (29% age-standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI ≥ 30) was a significant factor associated with receiving treatment compared to normal weight (BMI < 25), with a prevalence ratio (PR) of 1.5 (95% CI 1.1-2.0). Having secondary or higher education was associated with higher likelihood of controlled BP (PR 1.9 [95% CI 1.1-3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.

Racial Differences in Blood Pressure Control from Users of Antihypertensive Monotherapy: Results from the ELSA-Brasil Study

BACKGROUND

It seems that the worst response to some classes of antihypertensive drugs, especially angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, on the part of the Black population, would at least partially explain the worse control of hypertension among these individuals. However, most of the evidence comes from American studies.

OBJECTIVES

This study aims to investigate the association between self-reported race/skin color and BP control in participants of the Longitudinal Study of Adult Health (ELSA-Brasil), using different classes of antihypertensive drugs in monotherapy.

METHODS

The study involved a cross-sectional analysis, carried out with participants from the baseline of ELSA-Brasil. Blood pressure control was the response variable, participants with BP values ≥140/90 mmHg were considered out of control in relation to blood pressure levels. Race/skin color was self-reported (White, Brown, Black). All participants were asked about the continuous use of medication. Association between BP control and race/skin color was estimated through logistic regression. The level of significance adopted in this study was of 5%.

RESULTS

Of the total of 1,795 users of antihypertensive drugs in monotherapy at baseline, 55.5% declared themselves White, 27.9% Brown, and 16.7% Black. Even after adjusting for confounding variables, Blacks using angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blocker (ARB), thiazide diuretics (thiazide DIU), and beta-blockers (BB) in monotherapy had worse blood pressure control compared to Whites.

CONCLUSIONS

Our results suggest that in this sample of Brazilian adults using antihypertensive drugs in monotherapy, the differences in blood pressure control between different racial groups are not explained by the possible lower effectiveness of ACEIs and ARBs in Black individuals.

Methylenetetrahydrofolate Reductase Gene rs1801133 and rs1801131 Polymorphisms and Essential Hypertension Risk: A Comprehensive Analysis

Background

Essential hypertension (EH) is a common and multifactorial disorder that is likely to be influenced by multiple genes. The methylenetetrahydrofolate reductase (MTHFR) gene rs1801133 and rs1801131 polymorphisms influence MTHFR enzyme activity and plasma homocysteine concentration. In addition, variations in MTHFR functions likely play roles in the etiology of EH. Thus far, a large number of studies investigating the associations between the MTHFR polymorphisms and EH have provided controversial or inconclusive results. To better assess the purported relationship, we performed a comprehensive analysis of 52 published studies. Objective and Methods. Eligible studies were identified by searching the PubMed, Wanfang, and China National Knowledge Infrastructure (CNKI) databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated to assess the potential association between the MTHFR rs1801133 polymorphism and EH.

Results

Overall, 10712 patients and 11916 controls were involved; we observed significantly increased association between the MTHFR rs1801133 polymorphism and EH risk (such as T vs. C: OR = 1.38, 95% CI = 1.25 - 1.54, P ≤ 0.001), with similar results evident within race subgroups (such as Asian: T vs. C: OR = 1.47, 95% CI = 1.30 - 1.67, P ≤ 0.001; compared to Chinese: T vs. C: OR = 1.54, 95% CI = 1.33 - 1.79, P ≤ 0.001). Similar associations were also found in subgroups defined by the source of controls and genotype methods. To our regret, based on the limited studies, no association was detected for rs1801131 polymorphism.

Conclusions

Our study provides evidence that the MTHFR rs1801133 null genotype may increase EH risk. Future studies with larger sample sizes are warranted to evaluate this association in more detail.

Prescription Patterns for the Use of Antihypertensive Drugs for Primary Prevention Among Patients With Hypertension in the United Kingdom

BACKGROUND

Several antihypertensive drugs are available for the primary prevention of cardiovascular disease (CVD). However, existing evidence on prescription patterns was primarily generated among patients at high CVD risk with short-term follow-up, and failed to capture impacts of time and patient characteristics. Our objective was therefore to describe longitudinal prescription patterns for antihypertensive drugs for the primary prevention of CVD among patients with arterial hypertension in the United Kingdom.

METHODS

This population-based cohort study used data from the Clinical Practice Research Datalink, included 660,545 patients with hypertension who initiated an antihypertensive drug between 1998 and 2018. Antihypertensive treatments were measured by drug class and described overall and in subgroups, focusing on first-line therapy (first antihypertensive drug(s) recorded after a diagnosis of hypertension) and second-line therapy (antihypertensive drug(s) prescribed as part of a treatment change following first-line therapy).

RESULTS

Angiotensin-converting enzyme (ACE) inhibitors (29.0%), thiazide diuretics (22.1%), and calcium-channel blockers (CCBs) (21.0%) were the most prescribed first-line therapies. ACE inhibitors have been increasingly prescribed as first-line therapy since 2001. Men were more likely to be prescribed ACE inhibitors than women (43.5% vs. 32.1%; difference: 11.4%; 95% confidence interval [CI], 11.0%-11.8%), and Black patients were more likely to be prescribed CCBs than White patients (63.6% vs. 37.0%; difference: 26.6%; 95% CI, 24.8%-28.4%).

CONCLUSIONS

Antihypertensive prescription patterns for the primary prevention of CVD among patients with hypertension are consistent with treatment guidelines that were in place during the study period, providing reassurance regarding the use of evidence-based prescribing.

Co-occurring conditions and racial-ethnic disparities: Medicaid enrolled adults on the autism spectrum

Evidence suggests that autistic adults have higher odds of developing several co-occurring conditions, but less is known about disparities by race and ethnicity in this population. Using 2008-2012 Medicaid Analytic eXtract (MAX) data, we (i) identify the prevalence of co-occurring conditions among the population of autistic adult Medicaid beneficiaries compared to a matched sample of those without an autism spectrum disorder (ASD) diagnosis, (ii) conduct logistic regression to estimate odds ratios for these health conditions predicted by an autism diagnosis, and (iii) estimate odds of having these health conditions as predicted by racial/ethnic group among the autistic population only. Overall, autistic adults did not have higher prevalence of some major health conditions (cardiovascular conditions, stroke, cancer, cardiovascular disease), but they did have higher odds of others (nutrition conditions, epilepsy, disorders of the central nervous system). Analysis by racial/ethnic group, however, shows that Black, Hispanic, and Asian autistic beneficiaries had higher odds of diabetes, hospitalized cardiovascular diseases, and hypertension, among other conditions. Policymakers should be aware that racial disparities found in the general population persist in the autistic population and should work to implement systems and programs to improve screening and preventive care for minority autistic populations. LAY SUMMARY: Autistic adults may have several co-occurring physical and mental health conditions, which could differ by racial/ethnic group. We find that, compared to the general Medicaid population, autistic adult Medicaid beneficiaries have elevated odds of some health conditions, like epilepsy and nutrition conditions, as well as some psychiatric conditions, such as anxiety and attention disorders. We also find that many of the same health disparities by racial/ethnic group in the general population persist among the autistic adult Medicaid population. For example, Black, Hispanic, and Asian Medicaid autistic beneficiaries have higher odds of diabetes, and Black and Hispanic autistic beneficiaries have higher odds of obesity and nutrition conditions than white autistic beneficiaries.

Prevalence of hypertension and determinants of poor blood pressure control in patients with Type 2 diabetes mellitus attending a Tertiary Clinic in Lagos, Nigeria

Objective

The objective is to determine the prevalence of comorbid hypertension and blood pressure (BP) control among patients with Type-2-diabetes-mellitus attending a tertiary-hospital in Lagos, and identify the determinants of poor BP control.

Materials and Methods

A cross-sectional study of 238 consecutive patients with Type-2-diabetes Mellitus (DM) at the adult diabetes-clinic of a tertiary health-facility in Lagos, Nigeria over a 5-month period. Data were retrieved with the aid of structured-investigator-administered-questionnaire, physical examination, and review of hospital record. Hypertension was defined as BP ≥140/90 mmHg and target BP control was defined as <130/80 mmHg. Logistic regression analysis was used to identify the independent determinants of poor BP control.

Results

Comorbid hypertension was present in 187 (78.6%) of study participants with males (68/87 [78.8%]) and females (119/151 [78.2%]) similarly affected, P = 0.907. Older age (62.9 ± 10.1 vs. 54.9 ± 9.6 years) and obesity (35.3% vs. 17.6%) were associated with comorbid hypertension, P < 0.05. Awareness, treatment, and medication adherence rates were 96.3%, 100%, and 46%, respectively. Only 17.1% (n = 32/187) had BP controlled to target. Waist circumference (WC) (adjusted odd ratio: 1.04, 95% confidence interval [CI]: 1.01-1.06) and poor glycemic control (adjusted odd ratio: 5.39, 95% CI: 2.07-13.99) were the predictors of poor BP control.

Conclusion

The prevalence of co-morbid hypertension in Type 2 DM patients in our setting is high and the BP control rate is low. Increasing WC and poor glycemic control are the independent determinants of poor BP control. Individualized weight reduction and glycemic control strategies may help achieve target BP control.

Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines

The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for β-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P=0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P=0.204), although CCB monotherapy increased (29.5% versus 21.0%, P=0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P=0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.

Racial and Ethnic Differences in Blood Pressure Among US Adults, 1999-2018

[Figure: see text].

Heterogeneity in treatment effects across diverse populations

Differences in patient characteristics, including age, sex, and race influence the safety and effectiveness of drugs, biologic products, and medical devices. Here we provide a summary of the topics discussed during the opening panel at the 2018 Johns Hopkins Center for Excellence in Regulatory Science and Innovation symposium on Assessing and Communicating Heterogeneity of Treatment Effects for Patient Subpopulations: Challenges and Opportunities. The goal of this session was to provide a brief overview of FDA-regulated therapeutics, including drugs, biologics and medical devices, and some of the major sources of heterogeneity of treatment effects (HTE) related to patient demographics, such as age, sex and race. The panel discussed the US Food and Drug Administration's role in reviewing and regulating drugs, devices, and biologic products and the challenges associated with ensuring that diverse patient populations benefit from these therapeutics. Ultimately, ensuring diverse demographic inclusion in clinical trials, and designing basic and clinical research studies to account for the intended patient population's age, sex, race, and genetic factors among other characteristics, will lead to better, safer therapies for diverse patient populations.

Narrative arcs and shaping influences in long-term medication adherence

Long-term adherence to medications is not well understood and poses a significant challenge for many chronically ill persons. Past research provides insights on adherence in short durations such as a day or several weeks, even though chronically ill patients are required to take medications for periods as long as a lifetime. To fill this important knowledge gap, we study the temporal unfolding of prolonged medication-taking experiences among thirty adults, mostly African American, with chronic hypertension in the U.S. Specifically, we take an extended, experience-centered, narrative approach to examine retrospective patient accounts of adherence efforts over spans of one year to more than four decades. Applying Gergen and Gergen's concept of narrative forms (1983), we find four distinct narrative arcs, or patterned sequences of medication consumption, that we term Out of the Gate, Existential Turn, Fits and Starts, and Slow Climb, along with individual and social elements that shape and shift practices in the context of time.

Association Between Patient-Clinician Relationships and Adherence to Antihypertensive Medications Among Black Adults: An Observational Study Design

Background We assessed the associations between patient-clinician relationships (communication and involvement in shared decision-making [SDM]) and adherence to antihypertensive medications. Methods and Results The 2010 to 2017 Medical Expenditure Panel Survey (MEPS) data were analyzed. A retrospective cohort study design was used to create a cohort of prevalent and new users of antihypertensive medications. We defined constructs of patient-clinician communication and involvement in SDM from patient responses to the standard questionnaires about satisfaction and access to care during the first year of surveys. Verified self-reported medication refill information collected during the second year of surveys was used to calculate medication refill adherence; adherence was defined as medication refill adherence ≥80%. Survey-weighted multivariable-adjusted logistic regression models were used to measure the odds ratio (OR) and 95% CI for the association between both patient-clinician constructs and adherence. Our analysis involved 2571 Black adult patients with hypertension (mean age of 58 years; SD, 14 years) who were either persistent (n=1788) or new users (n=783) of antihypertensive medications. Forty-five percent (n=1145) and 43% (n=1016) of the sample reported having high levels of communication and involvement in SDM, respectively. High, versus low, patient-clinician communication (OR, 1.38; 95% CI, 1.14-1.67) and involvement in SDM (OR, 1.32; 95% CI, 1.08-1.61) were both associated with adherence to antihypertensives after adjusting for multiple covariates. These associations persisted among a subgroup of new users of antihypertensive medications. Conclusions Patient-clinician communication and involvement in SDM are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence among Black adults with hypertension.

Blood pressure control in patients with chronic kidney disease

Uncontrolled blood pressure (BP) in patients with chronic kidney disease (CKD) can lead to serious adverse outcomes. To prevent the occurrence of cardiovascular events (CVEs), and end-stage kidney disease, achieving an optimal BP level is important. Recently, there has been a paradigm shift in the management of BP largely as a result of the Systolic Blood Pressure Intervention Trial (SPRINT), which showed a reduction in CVEs by lowering systolic BP to 120 mmHg. A lower systolic blood pressure (SBP) target has been accepted by the Kidney Disease: Improving Global Outcomes (KDIGO) 2021 guidelines. However, whether intensive control of SBP targeting < 120 mmHg is also effective in patients with CKD is controversial. Notably, this lower target SBP is associated with a higher risk of adverse kidney outcomes. Unfortunately, there have been no randomized controlled trials on this issue involving only patients with CKD, particularly those with advanced CKD. In this review, we discuss the optimal control of BP in patients with CKD in terms of reduction in death and CVEs as well as attenuation of CKD progression based on the evidence-based literature.

Race-Specific Comparisons of Antihypertensive and Metabolic Effects of Hydrochlorothiazide and Chlorthalidone

BACKGROUND

Chlorthalidone is recommended over hydrochlorothiazide (HCTZ) as the preferred thiazide, but the supporting evidence is not robust at routinely used doses, or in whites vs blacks, in whom differences in response to thiazides are well known. We compare the efficacy and safety of HCTZ and chlorthalidone as first-line therapies for white and black hypertensive patients.

METHODS

We compared treatment-related outcomes between the HCTZ arm (12.5 mg for 2-3 weeks; 25 mg for additional 6 weeks) of the Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR, n = 376) and chlorthalidone arm (15 mg for 2 weeks; 25 mg for additional 6 weeks) of PEAR-2 (n = 326) clinical trials, in 17-65-year-old mild-moderate uncomplicated hypertensive whites and blacks.

RESULTS

Mean systolic/diastolic blood pressure (SBP/DBP) reduction with HCTZ vs chlorthalidone: 8 ± 8/4 ± 5 vs 12 ± 9/7 ± 5 mm Hg in whites (P < 10^-6 SBP and DBP); 12 ± 10/7 ± 6 vs 15 ± 10/9 ± 6 in blacks (P = .008 SBP, P = .054 DBP). Treatment with HCTZ vs chlorthalidone in whites resulted in significantly fewer patients achieving target BP (<140/90 mm Hg) (44% vs 57%, P = .018) and clinical response rate (≥10 mm Hg DBP reduction); and significantly higher nonresponse rate (<6 mm Hg DBP reduction); but no significant differences in rates among blacks (eg, target-BP rate: 56% vs 63%, P = .31). HCTZ treatment led to significantly lower rates of hypokalemia and hyperuricemia in whites and blacks, vs chlorthalidone, and significantly lower odds of requiring potassium supplementation among blacks (odds ratio 0.16; 95% confidence interval, 0.07-0.37; P = 3.4e^-7).

CONCLUSION

Compared with HCTZ, chlorthalidone showed greater blood pressure lowering and adverse metabolic effects in whites, but similar blood pressure lowering and greater adverse effects in blacks; suggesting that the recent guideline recommendations to choose chlorthalidone over HCTZ may not be warranted in blacks.

Do Federal Regulations Affect Gender, Racial, and Ethnic Disparities in Chronic Rhinosinusitis Research?

OBJECTIVE

The Food and Drug Administration and the National Institutes of Health (NIH) have asserted that diverse demographic representation in clinical trials is essential. In light of these federal guidelines, the objective of this study is to assess the racial, ethnic, and gender demographics of patients enrolled in clinical trials registered with the NIH that evaluate chronic rhinosinusitis with nasal polyposis (CRSwNP) relative to the demographics of the US population.

STUDY DESIGN

Cross-sectional study.

SETTING

Not applicable.

METHODS

ClinicalTrials.gov was queried to identify all prospective clinical trials for CRSwNP. Individual study and pooled data were compared with national US census data.

RESULTS

Eighteen studies were included comprising 4125 patients and evaluating dupilumab, mepolizumab, omalizumab, fluticasone/OptiNose, MediHoney, mometasone, and SINUVA. Women constituted 42.7% of clinical trial participants. Of the 4125 participants, 69.6% identified as White, 6.6% as Black, 20.8% as Asian, 0.1% as Pacific Islander, 0.4% as American Indian, 8.0% as Hispanic, and 2.4% as other. The racial, ethnic, and gender composition of the pooled study population differs significantly from national US census data, with underrepresentation of Black, Hispanic, Pacific Island, and American Indian individuals, as well as females (P < .05).

CONCLUSION

The racial, ethnic, and gender demographics of patients enrolled in CRSwNP clinical trials registered with the NIH differ significantly from the demographics of the US population, despite federal guidelines advising demographically representative participation. Proactive efforts to enroll participants that better represent anticipated treatment populations should be emphasized by researchers, institutions, and editorial boards.

Differential responses of resistance arterioles to elevated intraluminal pressure in blacks and whites

Black Americans have an earlier onset, higher average blood pressure, and higher rates of hypertension-related mortality and morbidity, compared to whites. The racial difference may be related to microvasculature, the major regulatory site of blood pressure. The goal of this study was to compare the response of resistance vessels to high intraluminal pressure between black and white participants. A total of 38 vessels were obtained from human fat samples [21 black, 17 white; mean age 32 ± 12 yr and body mass index (BMI) 26.9 ± 4.9; between-group P ≥ 0.05] and included in this study. Internal diameter was measured in response to the flow induced by various pressure gradients (Δ10, Δ20, Δ40, Δ60, and Δ100 cmH₂O), and flow-induced dilation (FID) was calculated before and after high intraluminal pressure (150 cmH₂O). Before high intraluminal pressure, FID was not different between blacks and whites (P = 0.112). After exposure to high intraluminal pressure, FID was reduced at every pressure gradient in vessels from blacks (P < 0.001), whereas FID did not change in white participants except at Δ100 cmH₂O. When incubated with the hydrogen peroxide (H₂O₂) scavenger polyethylene glycol-catalase (PEG-catalase), the FID response in vessels from black, but not white, individuals was significantly reduced and the magnitude was higher at normal pressure relative to high pressure. Our findings suggest that the vessels from self-identified black individuals are more susceptible to microvascular dysfunction following transient periods of high intraluminal pressure compared to whites and show greater dependence on H₂O₂ as a main contributor to FID at normal pressures.NEW & NOTEWORTHY Microvascular function regulates blood pressure and may contribute to racial differences in the incidence and prevalence of hypertension and other cardiovascular diseases. Here, we show that using an ex vivo model of resistance arterioles isolated from human gluteal fat tissue, flow-induced dilation is not different between black and white participants. However, when exposed to transient increases in intraluminal pressure, the flow-induced dilation in resistance arterioles from black participants demonstrated greater reductions relative to their white counterparts, indicating a higher sensitivity to pressure change in the microvasculature.

Effects of firibastat in combination with enalapril and hydrochlorothiazide on blood pressure and vasopressin release in hypertensive DOCA-salt rats

In the brain, aminopeptidase A (APA) generates angiotensin III, one of the effector peptides of the brain renin-angiotensin system (RAS), exerting tonic stimulatory control over blood pressure (BP) in hypertensive rats. Oral administration of firibastat, an APA inhibitor prodrug, in hypertensive rats, inhibits brain APA activity, blocks brain angiotensin III formation and decreases BP. In this study, we evaluated the efficacy of firibastat in combination with enalapril, an angiotensin I-converting enzyme inhibitor, and hydrochlorothiazide (HCTZ), in conscious hypertensive deoxycorticosterone acetate (DOCA)-salt rats, which display high plasma arginine-vasopressin levels, low circulating renin levels and resistance to treatment by systemic RAS blockers. We determined mean arterial BP, heart rate, plasma arginine-vasopressin levels and renin activity in DOCA-salt rats orally treated with firibastat, enalapril or HCTZ administered alone or in combination. Acute oral firibastat administration (30 mg/kg) induced a significant decrease in BP, whereas enalapril (10 mg/kg) or HCTZ (10 mg/kg) administered alone induced no significant change in BP in conscious DOCA-salt rats. The BP decrease induced by acute and nine-day chronic tritherapy [Firibastat+Enalapril+HCTZ] was significantly greater than that observed after bitherapy [Enalapril+HCTZ]. Interestingly, the chronic administration of a combination of firibastat with [Enalapril+HCTZ] reduced plasma arginine-vasopressin levels by 62% relative to those measured in DOCA-salt rats receiving bitherapy. Our data show that tritherapy with firibastat, enalapril and HCTZ improves BP control and arginine-vasopressin release in an experimental salt-dependent model of hypertension, paving the way for the development of new treatments for patients with currently difficult-to-treat or resistant hypertension.

Effect of an emergency department education and empowerment intervention on uncontrolled hypertension in a predominately minority population: The AHEAD2 randomized clinical pilot trial

OBJECTIVE

To determine whether an emergency department (ED) education and empowerment intervention coupled with early risk assessment can help improve blood pressure (BP) in a high-risk population.

METHODS

A hypertension emergency department intervention aimed at decreasing disparities (AHEAD2) is a 3-arm, single-site randomized pilot trial for feasibility in an urban academic ED. A total of 150 predominantly ethnic minorities with no primary care provider and severely elevated blood pressure (BP) (≥160/100 mm Hg) were enrolled over 10 months. Participants were randomized into 1 of 3 study arms: (1) enhanced usual care (EUC), (2) ED-initiated screening, brief intervention, and referral for treatment (ED-SBIRT), or (3) ED- SBIRT plus a 48-72 hours post-acute care hypertension transition clinic (ED-SBIRT+PACHT-c). Primary outcomes were change in systolic and diastolic BP (SBP and DBP) from baseline to 9 months. Secondary outcomes were BP control (BP <140/90 mm Hg), changes in hypertension knowledge, medication adherence, and limited bedside echocardiogram (LBE) findings.

RESULTS

SBP reduction from baseline to month 9 was -26.8 (95% confidence interval [CI]: -32.8, -20.7) mm Hg for ED-SBIRT, -23.4 (95% CI: -29.5, -17.3) mm Hg for ED-SBIRT+PACHT-c, and -18.9 (95% CI: -24.9, -12.9) mm Hg for EUC. DBP decreased by -12.5 (95% CI: -16.1, -9.0) mm Hg for ED-SBIRT, -11.3 (95% CI: -14.8, -7.7) mm Hg for ED-SBIRT+PACHT-c, and -8.4 (95% CI: -11.9, -4.9) mm Hg for EUC. A multicomponent intervention compared with EUC resulted in SBP decrease of -7.9 mm Hg (95% CI: -16.4, 0.6). At 9 months, hypertension was controlled for 29.3% (95% CI: 20.3, 38.3) of intervention and 23.5% (95% CI: 11.9, 35.2) of EUC participants. All groups saw improvements in hypertension knowledge, medication adherence, and LBEs, with greater improvements in intervention groups.

CONCLUSIONS

The study findings suggest that a multicomponent intervention comprising of ED education and empowerment coupled with early risk assessment may help improve BP in a high-risk population.

Study protocol of a randomized controlled trial evaluating the Prime Time Sister Circles (PTSC) program's impact on hypertension among midlife African American women

BACKGROUND

The Prime-Time Sister Circles® (PTSC) program is a multifaceted, community-based peer support intervention targeting African American women who are 40 to 75 years of age. It aims to reduce hypertension disparities observed among African American women by promoting adherence to antihypertensive therapies, including lifestyle modification and therapeutic regimens.

METHODS

The PTSC randomized controlled trial will evaluate the effectiveness of the PTSC Program on improved blood pressure control, healthcare utilization attributed to cardiovascular events, and healthcare costs. The study began in 2016 and will end in 2022. African American women who are 40-75 years old, have been diagnosed with hypertension, reside in Washington, D.C. or Baltimore, Maryland, and receive their care from Unity Health Care, a federally qualified health center in Washington, D.C., or Baltimore Medical System, a federally qualified health center in Baltimore, Maryland, are eligible to participate. Those randomized to the intervention group participate in the PTSC Program, which spans 13 weeks and comprises facilitator-led discussions, didactic training about hypertension management, and peer-based problem-solving concerning CVD risk factors and their amelioration. Blood pressure, weight, body mass index, waist circumference, self-reported adherence, physical activity, dietary practices, stress, and healthcare utilization data are collected at baseline, 13 weeks (end of the intervention), 9 months (months post-intervention), and 15 months (one year after the intervention). Healthcare costs will be computed at the end of the study. The study's design is reported in the present manuscript, wherein we employed the SPIRIT checklist to guide its construction.

DISCUSSION

Disparities in hypertension prevalence and management observed among mid-life African American women exist as a result of a confluence of structural determinants of health. Consequently, there is a need to develop, implement, and evaluate culturally appropriate and relevant interventions that are tailored to their lived experiences. The PTSC Trial aims to assess the impact of the program on participants' cardiovascular, psychosocial, and cost outcomes. Its results have implications for advancing the science of designing and implementing culturally relevant interventions for African American women.

TRIAL REGISTRATION

Unique identifier: NCT04371614 . Retrospectively registered on April 30, 2020.