Cumulative Incidence of Hypertension by 55 Years of Age in Blacks and Whites: The CARDIA Study

The positive association between the atherogenic index of plasma and the risk of new-onset hypertension: a nationwide cohort study in China

BACKGROUND

The atherogenic index of plasma (AIP) is a novel metabolic biomarker of atherosclerosis. Nevertheless, the association between the AIP and new-onset hypertension has not been elucidated in the Chinese population.

METHODS

Prospective data were obtained from 3150 participants aged ≥ 18 years in the China Health and Nutrition Survey from 2009 to 2015. The AIP is a logarithmically transformed ratio of triglycerides to high-density lipoprotein cholesterol in molar concentration. Cox regression analysis was used to determine the association of AIP index with new-onset hypertension.

RESULTS

After the six-year follow-up, 1054 (33.4%) participants developed new-onset hypertension. The participants were divided into AIP quartile groups (Q1-Q4). Compared with those in Q1, subjects in Q3-4 had nearly 1.35 times the risk of new-onset hypertension after full adjustment [Q3: hazard ratio (HR): 1.35, 95% confidence interval (CI): 1.13-1.62; Q4: HR: 1.35, 95% CI: 1.13-1.64]. The risks of new-onset hypertension were nearly 1.30 times higher in subjects in Q2-4 than in subjects in Q1 (p < .01) after the full adjustment when we excluded subjects with diabetes and/or chronic kidney diseases. There was a significant difference [HR (CI): 1.27 (1.04-1.54) vs. 0.90 (0.69-1.18)] when subjects were divided into two groups according to body mass index (BMI) level (<24 vs. ≥24 kg/m2).

CONCLUSIONS

The present study suggested that individuals with a higher AIP index are associated with new-onset hypertension, independent of kidney function and glucose levels. The association was stronger in subjects with normal BMI, which may provide early screening of metabolomics in hypertension prevention.

Characteristics of heart failure with a preserved ejection fraction in black South African patients

Background

Heart failure with a preserved ejection fraction (HFpEF) is common in the elderly (≥75 years) and associated with arterial stiffness. The mean age of HFpEF presentation is lower (40-55 years) in sub-Saharan Africa. No clinical study has been conducted on HFpEF in identifying and characterising this phenotype at a younger age, moreover in a South African black population where the risk of HFpEF is two times higher than in other ethnic groups. This study investigated the characteristics of HFpEF in a black South African population, the biochemical markers that predict HFpEF and cardiac structural changes in this HF phenotype.

Methods

Sixty-six participants with HFpEF and 213 controls were enrolled. All participants gave informed consent and completed a standardised questionnaire. Echocardiographic, anthropometric, central haemodynamic measurements, pulse wave velocity (PWV) and biomarker analysis were done.

Results

The mean age of HFpEF participants was 54.88 ± 13.51 years. Most of the participants (76 %) were between 20 and 64 years, while only 24 % were older. HFpEF participants were hypertensive, and more obese with increased incidence of alcohol consumption. PWV was increased in HFpEF (9.97 ± 2.78 m/s) when compared to participants without HFpEF (6.11 ± 2.18 m/s), p < 0.0001. There were no significant associations between central haemodynamic parameters, N-terminal pro B-type natriuretic peptide (NT-proBNP) (p = 0.9746), and galectin-3 (p = 0.2166). NT-proBNP, but not galectin-3, was associated with left ventricular hypertrophy (p = 0.0002) and left atrial diameter (p = 0.0005).

Conclusion

HFpEF in South Africa is predominant in obese young to middle-age individuals with arterial stiffness and who consume alcohol regularly. NT-proBNP could be used to diagnose HFpEF, however, should be interpreted with caution in populations with a high prevalence of obesity.

Carotid Intima-Media Thickness and Improved Stroke Risk Assessment in Hypertensive Black Adults

BACKGROUND

We aim to determine the added value of carotid intima-media thickness (cIMT) in stroke risk assessment for hypertensive Black adults.

METHODS

We examined 1,647 participants with hypertension without a history of cardiovascular (CV) disease, from the Jackson Heart Study. Cox regression analysis estimated hazard ratios (HRs) for incident stroke per standard deviation increase in cIMT and quartiles while adjusting for baseline variables. We then evaluated the predictive capacity of cIMT when added to the pool cohort equations (PCEs).

RESULTS

The mean age at baseline was 57 ± 10 years. Each standard deviation increase in cIMT (0.17 mm) was associated with approximately 30% higher risk of stroke (HR 1.27, 95% confidence interval: 1.08-1.49). Notably, cIMT proved valuable in identifying residual stroke risk among participants with well-controlled blood pressure, showing up to a 56% increase in the odds of stroke for each 0.17 mm increase in cIMT among those with systolic blood pressure <120 mm Hg. Additionally, the addition of cIMT to the PCE resulted in the reclassification of 58% of low to borderline risk participants with stroke to a higher-risk category and 28% without stroke to a lower-risk category, leading to a significant net reclassification improvement of 0.22 (0.10-0.30).

CONCLUSIONS

In this community-based cohort of middle-aged Black adults with hypertension and no history of CV disease at baseline, cIMT is significantly associated with incident stroke and enhances stroke risk stratification.

Financial responsibility, financial context, and ambulatory blood pressure in early middle-aged African-American women

BACKGROUND

African-American women have excess rates of elevated blood pressure (BP) and hypertension compared to women of all other racial/ethnic backgrounds. Several researchers have speculated that race and gender-related socioeconomic status (SES) stressors might play a role.

OBJECTIVE

To examine the association between a novel SES-related stressor highly salient among African-American women, financial responsibility for one's household, and 48-h ambulatory BP. We further examined whether aspects related to African-American women's financial context (e.g., single parenthood, household income, marital status) played a role.

METHODS

Participants were N = 345 employed, healthy African-American women aged 30-46 from diverse SES backgrounds who underwent 48-h ambulatory BP monitoring. Linear regression analyses were conducted to examine associations between self-reported financial responsibility and daytime and nighttime BP, adjusting for age, SES and other sociodemographics, cardiovascular risk factors, financial strain and depressive symptoms. Interactions between financial responsibility and single parenthood, household income, and marital/partnered status were tested.

RESULTS

In age-adjusted analyses, reporting financial responsibility was associated with higher daytime systolic (β = 4.42, S.E. = 1.36, p = 0.0013), and diastolic (β = 2.82, S.E. = 0.98, p = 0.004) BP. Associations persisted in fully adjusted models. Significant associations were also observed for nighttime systolic and diastolic BP. There were no significant interactions with single parenthood, household income, nor marital/partnered status.

CONCLUSION

Having primary responsibility for one's household may be an important driver of BP in early middle-aged African-American women, independent of SES, financial strain, and across a range of financial contexts. Future studies examining prospective associations are needed, and policy interventions targeting structural factors contributing to financial responsibility in African-American women may be warranted.

Neighborhood Deprivation, Perceived Stress, and Pregnancy-Related Hypertension Phenotypes a Decade Following Pregnancy

BACKGROUND

Hypertensive disorders in pregnancy and other adverse pregnancy outcomes (APOs) increase the risk of developing chronic hypertension and cardiovascular disease. Perceptions of stress and neighborhood context also influence blood pressure (BP) fluctuations. We examined if APOs, higher perceived stress, and neighborhood deprivation were associated with hypertension phenotypes a decade after pregnancy in untreated individuals.

METHODS

Participants were 360 individuals who gave birth between 2008 and 2009 and participated in a research study 8-10 years following pregnancy. Standardized office and home BP readings were obtained, and we applied the AHA/ACC 2017 guidelines to identify sustained, white coat, and masked hypertension phenotypes. We measured personal stress with the perceived stress scale and neighborhood deprivation with the CDC Social Vulnerability Index.

RESULTS

Of the 38.3% (138/360) with any hypertension, 26.1% (36/138) reported a diagnosis of hypertension but were currently untreated. Sustained hypertension was the most common (17.8%), followed by masked and white coat hypertension, both 10.3%. Hypertensive disorders in pregnancy were associated with sustained (odds ratio [OR] 5.54 [95% confidence interval, CI 2.46, 12.46] and white coat phenotypes (OR 4.20 [1.66, 10.60], but not masked hypertension (OR 1.74 [0.62, 4.90]). Giving birth to a small for gestational age infant was also associated with sustained hypertension. In covariate adjusted models, perceived stress, but not neighborhood deprivation, was significantly associated with masked hypertension.

CONCLUSIONS

A decade after delivery, APOs were associated with sustained and white coat hypertension, but not masked hypertension. Exploration of the mechanisms underlying, and clinical implications of, these associations is warranted.

Elevated Blood Pressure and Aldosterone Dysregulation in Young Black Women Versus White Women on Controlled Sodium Diets

CONTEXT

Black women have a higher prevalence of hypertension as compared to White women. Differences in dietary sodium intake have been implicated as a contributing factor for the disparities in hypertension.

OBJECTIVE

Our objective was to understand whether young Black women would have higher systolic blood pressure (SBP) than White women even on controlled sodium diets and to determine whether SBP differences were due to differences in dietary sodium intake and/or aldosterone regulation.

DESIGN

The analyses included 525 hypertensive and normotensive women (ages 18-71) from the International Hypertensive Pathotype consortium, who were maintained on liberal sodium (LIB; >200 mEq sodium/day) and restricted sodium (RES; 10 mEq sodium/day) diets.

RESULTS

Multivariate regression analyses (adjusted for age, race, study site, body mass index) found that Black women (ages 18-50) had significantly higher SBP than White women on both sodium diets: +8.7 ± 2.7 mmHg (P-value = .002) on a LIB diet and +8.5 ± 2.5 mmHg (P-value = .001) on a RES diet. Even among 18- to 35-year-olds-who were normotensive and nonobese-Black women had higher SBP: +7.9 ± 2.4 mmHg (P-value = .001) on a LIB diet and +7.6 ± 2.7 mmHg (P-value = .005) on a RES diet. Younger Black women also had higher plasma aldosterone concentration to plasma renin activity ratio (ARR) on both LIB and RES diets as well as a higher sodium-modulated aldosterone suppression-stimulation index-an indicator of aldosterone dysregulation. In younger Black women-but not in White women-there was a significant association between SBP and ARR on both LIB and RES diets.

CONCLUSION

Young Black women had increased SBP and ARR as compared to White women on LIB and RES diets, which offers insights into the possible mechanisms for the increased hypertension and cardiovascular disease risk in an at-risk and understudied population.

Association Between Alcohol Consumption and Blood Pressure Levels Among HIV Sero-Positive and Sero-Negative Cohorts: A Secondary Analysis of the Vukuzazzi Study

BACKGROUND

The effect of hypertension is aggravated by lifestyle factors such as alcohol consumption. This study sought to determine the association between alcohol consumption and the level of blood pressures among HIV seronegative and seropositive cohorts.

METHODS

This secondary analysis was performed on a cross-sectional survey data of 17 922 participants during the period between 2018 and 2020. A questionnaire was used to obtain participants' alcohol consumption history, which was categorized into non-alcohol consumers, non-heavy alcohol consumers, and heavy alcohol consumers. A linear regression model was used to establish relationships among participants with raised blood pressure (BP ≥ 140/90 mmHg).

RESULTS

Out of the total participants, 3553 (19.82%) were hypertensives. Almost 13% of the hypertensives (n = 458; 12.89%) were undiagnosed, and 12.44 % (442) had uncontrolled hypertension. About 14.52% of the hypertensives (3553) were not on any antihypertensive medication. Male non-consumers of alcohol had the highest systolic and diastolic BP; uncontrolled systolic BP (165.53 ± 20.87 mmHg), uncontrolled diastolic BP (102.28 ± 19.21mmHg). Adjusted for covariates, moderate alcohol consumption was associated with HTN among participants who were HIV seropositive [unadjusted (RR = 1.772, P = .006, 95% CI (1.178-2.665)], [RR = 1.772, P = .005, 95% CI (1.187-2.64)]. [unadjusted RR = 1.876, P = .036, 95% CI (1.043-3.378)], adjusted RR = 1.876, P = .041, 95% CI (1.024-3.437). Both moderate and heavy alcohol consumption were significantly related to hypertension among HIV sero-negative [unadjusted model, moderate consumption RR = 1.534 P = .003, 95% CI (1.152-2.044)], [adjusted model, moderate alcohol consumption RR = 1.535, P = .006, 95% CI (1.132-2.080)], [unadjusted model, heavy alcohol consumption, RR = 2.480, P = .030, 95% CI (1.091-5.638)], [adjusted model RR = 2.480, P = .034, 95% CI (1.072-5.738)].

CONCLUSION

Alcohol consumption is significantly related to increase BP regardless of HIV infection.

Managing hypertension in African Americans with heart failure: A guide for the primary care clinician

Hypertension is the predominant risk factor for cardiovascular disease related morbidity and mortality among Black adults in the United States. It contributes significantly to the development of heart failure and increases the risk of death following heart failure diagnosis. It is also a leading predisposing factor for hypertensive disorders of pregnancy and peripartum cardiomyopathy in Black women. As such, all stakeholders including health care providers, particularly primary care clinicians (including physicians and advanced practice providers), patients, and communities must be aware of the consequences of uncontrolled hypertension among Black adults. Appropriate treatment strategies should be identified and implemented to ensure timely and effective blood pressure management among Black individuals, particularly those with, and at risk for heart failure.

Role of diet and exercise in aging, Alzheimer's disease, and other chronic diseases

Alzheimer's disease (AD) is a progressive neurodegenerative disease, characterized by memory loss and multiple cognitive impairments. Genetic mutations cause a small proportion (1-2%) of early-onset AD, with mutations in amyloid precursor protein (APP), presenilin 1 (PS1) and presenilin 2 (PS2). Major contributing factors of late-onset AD are ApoE4 genotype, traumatic brain injury, diabetes, obesity, hypertension, cardiovascular conditions, in addition to lifestyle factors, such as unhealthy diet and lack of physical exercise. Disease progression can be delayed and/or prevented to a greater extent by adopting healthy lifestyle with balanced and antioxidant enriched diet and daily exercise. The interaction and interplay of diet, exercise, age, and pharmacological interventions holds a crucial role in the progression, pathogenesis and management of AD and its comorbidities, including diabetes, obesity, hypertension and cardiovascular conditions. Antioxidant enriched diet contributes to brain health, glucose control, weight management, and cardiovascular well-being. Regular exercise removes toxins including free radicals and enhances insulin sensitivity, and supports cardiovascular function. In the current article, we discussed, the role of diet, and exercise in aging, AD and other conditions including diabetes, obesity, hypertension, cardiovascular conditions. This article also highlights the impact of medication, socioeconomic and lifestyle factors, and pharmacological interventions. These aspects were discussed in different races and ethnic groups in Texas, and the US.

Plasma metabolomics profiles in Black and White participants of the Adventist Health Study-2 cohort

BACKGROUND

Black Americans suffer disparities in risk for cardiometabolic and other chronic diseases. Findings from the Adventist Health Study-2 (AHS-2) cohort have shown associations of plant-based dietary patterns and healthy lifestyle factors with prevention of such diseases. Hence, it is likely that racial differences in metabolic profiles correlating with disparities in chronic diseases are explained largely by diet and lifestyle, besides social determinants of health.

METHODS

Untargeted plasma metabolomics screening was performed on plasma samples from 350 participants of the AHS-2, including 171 Black and 179 White participants, using ultrahigh-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and a global platform of 892 metabolites. Differences in metabolites or biochemical subclasses by race were analyzed using linear regression, considering various models adjusted for known confounders, dietary and/or other lifestyle behaviors, social vulnerability, and psychosocial stress. The Storey permutation approach was used to adjust for false discovery at FDR < 0.05.

RESULTS

Linear regression revealed differential abundance of over 40% of individual metabolites or biochemical subclasses when comparing Black with White participants after adjustment for false discovery (FDR < 0.05), with the vast majority showing lower abundance in Blacks. Associations were not appreciably altered with adjustment for dietary patterns and socioeconomic or psychosocial stress. Metabolite subclasses showing consistently lower abundance in Black participants included various lipids, such as lysophospholipids, phosphatidylethanolamines, monoacylglycerols, diacylglycerols, and long-chain monounsaturated fatty acids, among other subclasses or lipid categories. Among all biochemical subclasses, creatine metabolism exclusively showed higher abundance in Black participants, although among metabolites within this subclass, only creatine showed differential abundance after adjustment for glomerular filtration rate. Notable metabolites in higher abundance in Black participants included methyl and propyl paraben sulfates, piperine metabolites, and a considerable proportion of acetylated amino acids, including many previously found associated with glomerular filtration rate.

CONCLUSIONS

Differences in metabolic profiles were evident when comparing Black and White participants of the AHS-2 cohort. These differences are likely attributed in part to dietary behaviors not adequately explained by dietary pattern covariates, besides other environmental or genetic factors. Alterations in these metabolites and associated subclasses may have implications for the prevention of chronic diseases in Black Americans.

Cross-sectional analysis of racial differences in hydration and neighborhood deprivation in young adults

BACKGROUND

Inadequate hydration is associated with cardiovascular and kidney disease morbidity and all-cause mortality. Compared with White individuals, Black individuals exhibit a higher prevalence of inadequate hydration, which may contribute to racial health disparities. However, the underlying reasons for these differences in hydration remain unclear.

OBJECTIVE

This cross-sectional study aimed to investigate whether neighborhood deprivation contributes to racial differences in hydration status.

METHODS

We assessed 24 Black and 30 White college students, measuring 24-hour urine osmolality, urine flow rate, urine specific gravity, and plasma copeptin concentration. Participants recorded their food and fluid intake for 3 d to assess total water intake from food and beverages. Neighborhood socioeconomic deprivation was measured using a tract-level Area Deprivation Index.

RESULTS

Black participants exhibited higher urine osmolality (640 [314] compared with 440 [283] mOsm/kg H2O, respectively, P = 0.006) and lower urine flow rate (1.06 [0.65] compared with 1.71 [0.89] ml/min, respectively, P = 0.009) compared with White participants, indicating greater hypohydration among Black participants. Black participants reported lower total water intake from food and beverages than White participants (2.3 ± 0.7 compared with 3.5 ± 1.1 L/day, respectively, P < 0.01). Black participants exhibited higher copeptin than White participants (6.3 [3.1] compared with 4.5 [2.3] pmol/L, P = 0.046), and urine osmolality mediated 67% of the difference (P = 0.027). Black participants reported greater cumulative exposure to neighborhood deprivation during childhood (ages 0-18 y). Furthermore, neighborhood deprivation during childhood was associated with urine specific gravity (P = 0.031) and total water intake from food and beverages (P = 0.042) but did not mediate the racial differences in these measures.

CONCLUSION

Our data suggest that compared with White young adults, Black young adults are hypohydrated and exhibit higher plasma copeptin concentration, and that greater neighborhood deprivation is associated with chronic underhydration irrespective of race. This trial was registered at clinicaltrials.gov as NCT04576338.

Interplay of Race and Neighborhood Deprivation on Ambulatory Blood Pressure in Young Adults

Background

Ambulatory blood pressure (BP) monitoring measures nighttime BP and BP dipping, which are superior to in-clinic BP for predicting cardiovascular disease (CVD), the leading cause of death in America. Compared with other racial/ethnic groups, Black Americans exhibit elevated nighttime BP and attenuated BP dipping, including in young adulthood. Social determinants of health contribute to disparities in CVD risk, but the contribution of neighborhood deprivation on nighttime BP is unclear. Therefore, we examined associations between neighborhood deprivation with nighttime BP and BP dipping in young Black and White adults.

Methods

We recruited 21 Black and 26 White participants (20 M/27 F, mean age: 21 years, body mass index: 25±4 kg/m2) for 24-hour ambulatory BP monitoring. We assessed nighttime BP and BP dipping (nighttime:daytime BP ratio). The area deprivation index (ADI) was used to measure neighborhood deprivation. Associations between ADI and ambulatory BP were examined.

Results

Black participants exhibited higher nighttime diastolic BP compared with White participants (63±8 mmHg vs 58±7 mmHg, p=0.003), and attenuated BP dipping ratios for both systolic (0.92±0.06 vs 0.86±0.05, p=0.001) and diastolic BP (0.86±0.09 vs 0.78±0.08, p=0.007). Black participants experienced greater neighborhood deprivation compared with White participants (ADI scores: 110±8 vs 97±21, p<0.001), and ADI was associated with attenuated systolic BP dipping (ρ=0.342, p=0.019).

Conclusions

Our findings suggest neighborhood deprivation may contribute to higher nighttime BP and attenuated BP dipping, which are prognostic of CVD, and more prevalent in Black adults. Targeted interventions to mitigate the effects of neighborhood deprivation may help to improve nighttime BP.

Clinical Trial Registry

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04576338.

Race- and Sex-Specific Factors Associated With Age-Related Slopes in Systolic Blood Pressure: Findings From the CARDIA Study

BACKGROUND

Although blood pressure (BP) increases throughout young adulthood for most individuals, the age-related slope is not uniform. This study aimed to assess associations of demographic, clinical, behavioral, psychosocial, and neighborhood characteristics with age-related BP slope among 4 race-sex groups who participated in the Coronary Artery Risk Development in Young Adults study.

METHODS

Individuals (n=3554) aged 18 to 30 years were included in this analysis if they had normal BP at baseline and ≥2 BP measurements during the years 1985/1986 to 2015/2016. Associations of exposure variables with systolic BP slope were assessed using multivariate linear models.

RESULTS

Over a mean follow-up of ~30 years, greater decade increases in systolic BP were estimated among Black than White participants (mean difference between Black females and White females: 3.0 mm Hg/decade; between Black males and White males: 4.7 mm Hg/decade). The exposure risk factors associated with greater increases in systolic BP throughout adulthood varied by race and sex. None of these factors were associated with increases in systolic BP in all race-sex groups. Parent history of high BP was associated with a steeper positive slope among Black females (effect size per decade: 1.1 [95% CI, 0.6-1.6]; P<0.01), Black males (0.6 [95% CI, 0.02-1.2]; P<0.05), and White females (0.6 [95% CI, 0.2-1.0]; P<0.01). Other risk factors were associated with greater age-related yearly increases in systolic BP among 1 or 2 of the 4 race-sex groups or were not statistically significant.

CONCLUSIONS

Culturally tailored BP reduction approach should be considered in conjunction with primordial prevention, to moderate increases in BP throughout adulthood.

Longitudinal profiles of neighborhood socioeconomic vulnerability influence blood pressure changes across the female midlife period

PURPOSE

To examine whether longitudinal exposure to neighborhood socioeconomic vulnerability influences blood pressure changes throughout midlife in a racially, ethnically, and geographically-diverse cohort of women transitioning through menopause.

METHODS

We used longitudinal data on 2738 women (age 42-52 at baseline) living in six United States cities from The Study of Women's Health Across the Nation. Residential histories, systolic blood pressures (SBP), and diastolic blood pressures (DBP) were collected annually for ten years. We used longitudinal latent profile analysis to identify patterns of neighborhood socioeconomic vulnerability occurring from 1996 to 2007 in participant neighborhoods. We used linear mixed-effect models to determine if a woman's neighborhood profile throughout midlife was associated with blood pressure changes.

RESULTS

We identified four unique profiles of neighborhood socioeconomic vulnerability - differentiated by residential socioeconomic status, population density, and vacant housing conditions - which remained stable across time. Women residing in the most socioeconomically vulnerable neighborhoods experienced the steepest increase in annual SBP growth by 0.93 mmHg/year (95% CI: 0.65-1.21) across ten-year follow-up.

CONCLUSIONS

Neighborhood socioeconomic vulnerability was significantly associated with accelerated SBP increases throughout midlife among women.

Acute beetroot juice reduces blood pressure in young Black and White males but not females

A complex interplay of social, lifestyle, and physiological factors contribute to Black Americans having the highest blood pressure (BP) in America. One potential contributor to Black adult's higher BP may be reduced nitric oxide (NO) bioavailability. Therefore, we sought to determine whether augmenting NO bioavailability with acute beetroot juice (BRJ) supplementation would reduce resting BP and cardiovascular reactivity in Black and White adults, but to a greater extent in Black adults. A total of 18 Black and 20 White (∼equal split by biological sex) young adults completed this randomized, placebo-controlled (nitrate (NO3-)-depleted BRJ), crossover design study. We measured heart rate, brachial and central BP, and arterial stiffness (via pulse wave velocity) at rest, during handgrip exercise, and during post-exercise circulatory occlusion. Compared with White adults, Black adults exhibited higher pre-supplementation resting brachial and central BP (Ps ≤0.035; e.g., brachial systolic BP: 116(11) vs. 121(7) mmHg, P = 0.023). Compared with placebo, BRJ (∼12.8 mmol NO3-) reduced resting brachial systolic BP similarly in Black (Δ-4±10 mmHg) and White (Δ-4±7 mmHg) adults (P = 0.029). However, BRJ supplementation reduced BP in males (Ps ≤ 0.020) but not females (Ps ≥ 0.299). Irrespective of race or sex, increases in plasma NO3- were associated with reduced brachial systolic BP (ρ = -0.237, P = 0.042). No other treatment effects were observed for BP or arterial stiffness at rest or during physical stress (i.e., reactivity); Ps ≥ 0.075. Despite young Black adults having higher resting BP, acute BRJ supplementation reduced systolic BP in young Black and White adults by a similar magnitude, an effect that was driven by males.

Racial Differences in Mental Stress-Induced Transient Endothelial Dysfunction and Its Association With Cardiovascular Outcomes

OBJECTIVE

This study aimed to investigate differences in transient endothelial dysfunction (TED) with mental stress in Black and non-Black individuals with coronary heart disease (CHD), and their potential impact on cardiovascular outcomes.

METHODS

We examined 812 patients with stable CHD between June 2011 and March 2016 and followed through February 2020 at a university-affiliated hospital network. Flow-mediated vasodilation (FMD) was assessed before and 30 minutes after mental stress. TED was defined as a lower poststress FMD than prestress FMD. We compared prestress FMD, post-stress FMD, and TED between Black and non-Black participants. In both groups, we examined the association of TED with an adjudicated composite end point of cardiovascular death or nonfatal myocardial infarction (first and recurring events) after adjusting for demographic, clinical, and socioeconomic factors.

RESULTS

Prestress FMD was lower in Black than non-Black participants (3.7 [2.8] versus 4.9 [3.8], p < .001) and significantly declined with mental stress in both groups. TED occurred more often in Black (76%) than non-Black patients (67%; multivariable-adjusted odds ratio = 1.6, 95% confidence interval = 1.5-1.7). Over a median (interquartile range) follow-up period of 75 (65-82) months, 142 (18%) patients experienced either cardiovascular death or nonfatal myocardial infarction. Black participants had a 41.9% higher risk of the study outcome than non-Black participants (95% confidence interval = 1.01-1.95). TED with mental stress explained 69% of this excess risk.

CONCLUSIONS

Among CHD patients, Black individuals are more likely than non-Black individuals to develop endothelial dysfunction with mental stress, which in turn explains a substantial portion of their excess risk of adverse events.

Associations of Urine Biomarkers of Kidney Tubule Health With Incident Hypertension and Longitudinal Blood Pressure Change in Middle-Aged Adults: The CARDIA Study

BACKGROUND

Urine biomarkers of kidney tubule injury associate with incident hypertension in older adults with comorbidities, but less is known about these associations in younger adults.

METHODS

In 1170 participants of the CARDIA study (Coronary Artery Risk Development in Young Adults; mean age, 45 years; 40% Black people; 56% women) without hypertension, cardiovascular disease, or kidney disease at baseline, we examined associations of urine MCP-1 (monocyte chemoattractant protein-1), α1m (alpha-1-microglobulin), KIM-1 (kidney injury molecule-1), EGF (epidermal growth factor), IL (interleukin)-18, YKL-40 (chitinase-3-like protein 1), and UMOD (uromodulin) with incident hypertension (onset of systolic blood pressure [BP] ≥130 mm Hg or diastolic BP ≥80 mm Hg or initiation of hypertension medications) and longitudinal BP change in models adjusted for hypertension risk factors, estimated glomerular filtration rate, and albuminuria.

RESULTS

After a median 9.9 (interquartile range, 5.9-10.2) years, 376 participants developed incident hypertension. In demographic-adjusted analyses, higher tertiles of EGF associated with lower risk of incident hypertension in both Black and White participants. After multivariable adjustment, the risk of incident hypertension remained lower in tertile 2 (hazard ratio, 0.70 [95% CI, 0.50-0.97]) and tertile 3 (hazard ratio, 0.58 [0.39-0.85]) of EGF versus tertile 1. In fully adjusted models, participants in EGF tertile 3 had smaller 10-year increases in systolic (-3.4 [95% CI, -6.1 to -0.7] mm Hg) and diastolic BP (-2.6 [95% CI, -4.6 to -0.6] mm Hg) than tertile 1. Other biomarkers showed inconsistent associations with incident hypertension and BP change.

CONCLUSIONS

In middle-aged adults without hypertension, cardiovascular disease, or kidney disease, higher urine EGF associated with lower risk of incident hypertension and lower 10-year BP elevations.

Gender, race/skin colour and incidence of hypertension in ELSA-Brasil: an intersectional approach

OBJECTIVE

Race and gender inequities in the incidence of hypertension (HTN) are well documented; however, few empirical investigations looked into these associations, considering the synergies and heterogeneous experiences of intersectional gender and race/skin colour groups. This study investigated the association of intersectional identities defined by gender and race/skin colour with HTN incidence, and verified whether they are affected by educational level in adulthood.

DESIGN

We used the Longitudinal Study of Adult Health (ELSA-Brasil) data to estimate the incidence of HTN between visits 1 (2008-2010) and 2 (2012-2014), in 8528 participants without hypertension at visit 1. HTN was defined as systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg, or use of antihypertensive drugs. Generalized linear models with Poisson distribution and log link function were used to assess the associations.

RESULTS

The incidence of HTN was 43.4/1000 person-years, ranging from 30.5/1000 in White women to 59.4/1000 in Black men. After adjusting by age and family history of HTN, the incidence rate ratio (IRR) was higher in Black men (2.25; 95%CI: 1.65-3.08), Brown (Pardo) men (1.89; 95%CI: 1.59-2.25), Black women (1.85; 95%CI: 1.50-2.30), Brown (Parda) women (1.47; 95%CI: 1.31-1.67) and White men (1.76; 95%CI: 1.49-2.08), compared to White women. These associations were maintained even after considering socioeconomic, behavioural and health mediators in the model. No interaction was found between education level and intersectional identities in the IRRs observed.

CONCLUSION

By using an intersectional approach, we showed the complex relations between race/skin colour and gender inequities in the incidence of HTN, pointing not only that Black men have the highest risk of developing HTN, but also that the risk of HTN is greater in Black women than in White men, when compared to White women.

Reliability and Validity of self-reported Vascular Risk Factors in a Multi-Ethnic Community Based Study of Aging and Dementia

INTRODUCTION

The reliability and validity of self-reported cardiovascular and cerebrovascular risk factors remains inconsistent in aging research.

METHODS

We assessed the reliability, validity, sensitivity, specificity, and percent agreement of self-reported hypertension, diabetes, and heart disease, in comparison with direct measures of blood pressure, hemoglobin A1c (HbA1c), and medication use in 1870 participants in a multiethic study of aging and dementia.

RESULTS

Reliability of self-reported for hypertension, diabetes, and heart disease was excellent. Agreement between self-reports and clinical measures was moderate for hypertension (kappa: 0.58), good for diabetes (kappa: 0.76-0.79), and moderate for heart disease (kappa: 0.45) differing slightly by age, sex, education, and race/ethnic group. Sensitivity and specificity for hypertension was 88.6%-78.1%, for diabetes was 87.7%-92.0% (HbA1c > 6.5%) or 92.7%-92.8% (HbA1c > 7%), and for heart disease was 85.8%-75.5%.

DISCUSSION

Self-reported history of hypertension, diabetes, and heart disease are reliable and valid compared to direct measurements or medication use.

AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension

BACKGROUND

The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network.

METHODS

The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension.

CONCLUSIONS

The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease: Development of a Situation-Specific Theory for African American Emerging Adults

BACKGROUND

Emerging adulthood (18-25 years old) is a distinct developmental period in which multiple life transitions pose barriers to engaging in healthy lifestyle behaviors that reduce cardiovascular disease risk. There is limited theory-based research on African American emerging adults.

OBJECTIVE

This article introduces a synthesized empirically testable situation-specific theory for cardiovascular disease prevention in African American emerging adults.

METHODOLOGY

Im and Meleis' integrative approach was used to develop the situation-specific theory.

RESULTS

Unlocking Population-Specific Treatments to Render Equitable Approach and Management in Cardiovascular Disease is a situation-specific theory developed based on theoretical and empirical evidence and theorists' research and clinical practice experiences.

DISCUSSION

African American emerging adults have multifaceted factors that influence health behaviors and healthcare needs. Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease has the potential to inform theory-guided clinical practice and nursing research. Recommendations for integration in nursing practice, research, and policy advocacy are presented. Further critique and testing of the theory are required.

'They should walk with you': the perspectives of African Americans living with hypertension and their family members on disease self-management

OBJECTIVES

African Americans are at significantly greater risk for hypertension, as well as worse hypertension-related morbidity and mortality than other racial/ethnic groups. Prior research aiming to address these health disparities has focused on improving individual patient self-management, with few studies testing family-centered interventions. We aimed to explore the perspectives of African Americans with hypertension and their family members on hypertension, self-management, and reciprocal family-hypertension impacts to inform future intervention design.

DESIGN

We conducted four dyadic focus groups (90-120 minutes) of African American adults with hypertension (i.e. patients) and their family members. We recruited patients (n = 23) and their family members (n = 23) from four African American-serving Christian churches over a period of three months (69.6% female, M age = 60.73 years). Patient-family member dyads were interviewed conjointly (groups ranged from 4 to 6 dyads, each) by facilitators using open-ended questions to elicit perspectives regarding contributors to hypertension, self-management strategies, family influence on self-management, and the impact of hypertension on the family. A grounded theory approach was used for analysis.

RESULTS

Participants' responses highlighted themes of societal risk factors and barriers (e.g. racism-related stress worsens blood pressure), influences of African American culture (e.g. culturally-informed diet practices), the patient-physician relationship (e.g. proactive communication is beneficial), family-level influences on health (e.g. family monitoring patients' health behaviors), and patient-level risk factors and self-management strategies (e.g. prayer to cope with stress). Themes reflected a hierarchical, nested, ecological structure such that themes within unique levels of participants' social systems affected, and were affected by, stress, change, or behavior in the other levels.

CONCLUSIONS

African American adults with hypertension and their family members described multilevel influences on hypertension and disease self-management, with a strong emphasis on the value of family support. Developing culturally appropriate, family-centered interventions to improve hypertension self-management will be an important next step.

Microbiota-associated mechanisms underlying sexual dimorphism in hypertension

Consistent research over the last 20 years has shown that there are clear sex differences in the pathogenesis of hypertension, the leading risk factor for the development of cardiovascular diseases. More recently, there is evidence in both humans and experimental animal models that causally implicates the gut microbiota in hypertension. It therefore follows that sex differences in the gut microbiota may mediate the extent of disease between sexes. This new field is rapidly changing and advancing, and the purpose of this review is to cover the most up-to-date evidence regarding the sexual dimorphism of the gut microbiota and its potential influence on the differential manifestation of hypertension in males versus females. Emphasis will be placed on the mechanisms thought to contribute to these sex differences in both the gut microbiota and hypertension, including sex steroid hormones, gut-derived metabolites, the immune system, and pregnancy.

Neighborhood social organization exposures and racial/ethnic disparities in hypertension risk in Los Angeles

Despite a growing evidence base documenting associations between neighborhood characteristics and the risk of developing high blood pressure, little work has established the role played by neighborhood social organization exposures in racial/ethnic disparities in hypertension risk. There is also ambiguity around prior estimates of neighborhood effects on hypertension prevalence, given the lack of attention paid to individuals' exposures to both residential and nonresidential spaces. This study contributes to the neighborhoods and hypertension literature by using novel longitudinal data from the Los Angeles Family and Neighborhood Survey to construct exposure-weighted measures of neighborhood social organization characteristics-organizational participation and collective efficacy-and examine their associations with hypertension risk, as well as their relative contributions to racial/ethnic differences in hypertension. We also assess whether the hypertension effects of neighborhood social organization vary across our sample of Black, Latino, and White adults. Results from random effects logistic regression models indicate that adults living in neighborhoods where people are highly active in informal and formal organizations have a lower probability of being hypertensive. This protective effect of exposure to neighborhood organizational participation is also significantly stronger for Black adults than Latino and White adults, such that, at high levels of neighborhood organizational participation, the observed Black-White and Black-Latino hypertension differences are substantially reduced to nonsignificance. Nonlinear decomposition results also indicate that almost one-fifth of the Black-White hypertension gap can be explained by differential exposures to neighborhood social organization.

Continuous ECG monitoring should be the heart of bedside AI-based predictive analytics monitoring for early detection of clinical deterioration

The idea that we can detect subacute potentially catastrophic illness earlier by using statistical models trained on clinical data is now well-established. We review evidence that supports the role of continuous cardiorespiratory monitoring in these predictive analytics monitoring tools. In particular, we review how continuous ECG monitoring reflects the patient and not the clinician, is less likely to be biased, is unaffected by changes in practice patterns, captures signatures of illnesses that are interpretable by clinicians, and is an underappreciated and underutilized source of detailed information for new mathematical methods to reveal.

Reliability and Validity of Self-Reported Vascular Risk Factors: Hypertension, Diabetes, and Heart Disease, in a Multi-Ethnic Community Based Study of Aging and Dementia

BACKGROUND

Queries for the presence of cardiovascular and cerebrovascular risk factors are typically assessed through self-report. However, the reliability and validity of self-reported cardiovascular and cerebrovascular risk factors remain inconsistent in aging research.

OBJECTIVE

To determine the reliability and validity of the most frequently self-reported vascular risk factors: hypertension, diabetes, and heart disease.

METHODS

1,870 individuals aged 65 years or older among African Americans, Caribbean Hispanics, and white non-Hispanic individuals were recruited as part of a community study of aging and dementia. We assessed the reliability, validity, sensitivity, specificity, and percent agreement of self-reported hypertension, diabetes, and heart disease, in comparison with direct measures of blood pressure, hemoglobin A1c (HbA1c), and medication use. The analyses were subsequently stratified by age, sex, education, and ethnic group.

RESULTS

Reliability of self-reported hypertension, diabetes, and heart disease was excellent. Agreement between self-reports and clinical measures was moderate for hypertension (kappa: 0.58), good for diabetes (kappa: 0.76-0.79), and moderate for heart disease (kappa: 0.45) differing slightly by age, sex, education, and ethnic group. Sensitivity and specificity for hypertension was 88.6% -78.1%, for diabetes was 87.7% -92.0% (HbA1c ≥6.5%) or 92.7% -92.8% (HbA1c ≥7%), and for heart disease was 85.8% -75.5%. Percent agreement of self-reported was 87.0% for hypertension, 91.6% -92.6% for diabetes, and 77.4% for heart disease.

CONCLUSION

Ascertainment of self-reported histories of hypertension, diabetes, and heart disease are reliable and valid compared to direct measurements or medication use.

Job Demand-Control and Hypertension in African Americans and Non-African Americans

OBJECTIVES

The aim of this study was to determine if occupational stress is a social determinant of elevated hypertension among African Americans.

METHODS

Currently employed, full-time adults from the Midlife in the United States Refresher and Midlife in the United States Milwaukee Refresher studies reported data on demographics, job characteristics, and medical history.

RESULTS

African American workers reported less job control and greater physical job demands than non-African Americans. Both physical and psychological job demands were independently associated with greater odds of high blood pressure. Job strain was associated with high blood pressure and differed by race ( P < 0.05).

CONCLUSIONS

The elements of the job-demand control model differed by race and were most relevant for African Americans when exposed to high job demands and low job control. However, there was no evidence of differential vulnerability for either psychological demands, control, or physical demands for African Americans.

Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD

BACKGROUND

Disproportionate exposure to poor food environments and food insecurity among Black Americans may partially explain critical chronic disease disparities by race and ethnicity. A complex set of structural factors and interactions between Black residents and their food environments, including store types, quantity, proximity, and quality of goods and consumer interactions within stores, may affect nutritional behaviors and contribute to higher cardiovascular and kidney disease risk.

METHODS

We used the Photovoice methodology to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension between August and November 2019. Twenty-four participants were enrolled in the study (mean age: 65.1 years; 67% female). After a brief photography training, participants captured photos of their food environment, which they discussed in small focus groups over the course of 5 weeks. Discussions were audiotaped and analyzed for emergent themes using a line-by-line inductive approach. Themes were, then, organized into a collective narrative.

RESULTS

Findings describe physical and social features of the food environment as well as participants' perceptions of its origins and holistic and generational health effects. The study illustrates the interrelationships among the broader socio-political environment, the quality and quantity of stores in the food landscape, and the ways in which they engage with the food environment as residents and consumers who have been marginalized due to their race and/or social class. The following meta-themes emerged from the data: (1) social injustice; (2) structural racism and classism; (3) interpersonal racism; (4) generational effects; (5) mistrust; (6) social programs; and (7) community asset-based approaches, including advocacy and civic engagement.

CONCLUSIONS

Understanding residents' perceptions of the foundations and effects of the food environment on their health may help stakeholders to cocreate multilevel interventions alongside residents to improve access to healthy food and health outcomes among disparities affected populations.

Short-Chain Fatty Acid Receptors and Blood Pressure Regulation: Council on Hypertension Mid-Career Award for Research Excellence 2021

The gut microbiome influences host physiology and pathophysiology through several pathways, one of which is microbial production of chemical metabolites which interact with host signaling pathways. Short-chain fatty acids (SCFAs) are a class of gut microbial metabolites known to activate multiple signaling pathways in the host. Growing evidence indicates that the gut microbiome is linked to blood pressure, that SCFAs modulate blood pressure regulation, and that delivery of exogenous SCFAs lowers blood pressure. Given that hypertension is a key risk factor for cardiovascular disease, the examination of novel contributors to blood pressure regulation has the potential to lead to novel approaches or treatments. Thus, this review will discuss SCFAs with a focus on their host G protein-coupled receptors including GPR41 (G protein-coupled receptor 41), GPR43, and GPR109A, as well as OLFR78 (olfactory receptor 78) and OLFR558. This includes a discussion of the ligand profiles, G protein coupling, and tissue distribution of each receptor. We will also review phenotypes relevant to blood pressure regulation which have been reported to date for Gpr41, Gpr43, Gpr109a, and Olfr78 knockout mice. In addition, we will consider how SCFA signaling influences physiology at baseline, and, how SCFA signaling may contribute to blood pressure regulation in settings of hypertension. In sum, this review will integrate current knowledge regarding how SCFAs and their receptors regulate blood pressure.

Coaching quality improvement in primary care to improve hypertension control

BACKGROUND

Effective management of hypertension (HTN) is a priority in primary care, necessary to decrease the costs, morbidity, and mortality associated with cardiovascular disease. Strategies to support quality improvement (QI) efforts in primary care are needed to make significant improvements in population health, especially for patients who experience socioeconomic inequalities.

LOCAL PROBLEM

To address the high rate (>50%) of uncontrolled HTN in the state of Ohio, a statewide QI project was implemented in high-volume Medicaid practices, aimed at improving blood pressure control and addressing racial disparities. The initiative expanded to include coaching QI to support efforts in primary care practices.

METHODS

The Model for Improvement guided development of Plan-Do-Study-Act (PDSA) cycles facilitated by QI coaching and APRN collaboration to implement key components of HTN guidelines: accurate blood pressure measurement, effective treatment, and timely follow-up.

INTERVENTIONS

Interventions were implemented after PDSA cycles over 18 months in two practice sites to address HTN control. Linking multiple PDSA test cycles and review of data bimonthly allowed for reflection on the impact of interventions for non-Hispanic Black patients and the overall patient population.

RESULTS

The percentage of patients with controlled HTN, repeat blood pressure measurement, and timely follow-up improved in an urban primary care practice associated with an academic medical center and in a rural federally qualified health center.

CONCLUSIONS

Primary care practices can benefit from the external support of coaching when implementing QI processes to make meaningful change. APRNs are key collaborators for expanding QI efforts in primary care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How Do We Jump-Start Self-measured Blood Pressure Monitoring in the United States? Addressing Barriers Beyond the Published Literature

Hypertension is highly prevalent in the United States, and many persons with hypertension do not have controlled blood pressure. Self-measured blood pressure monitoring (SMBP), when combined with clinical support, is an evidence-based strategy for lowering blood pressure and improving control in persons with hypertension. For years, there has been support for widespread implementation of SMBP by national organizations and the federal government, and SMBP was highlighted as a primary intervention in the 2020 Surgeon General's Call to Action to Control Hypertension, yet optimal SMBP use remains low. There are well-known patient and clinician barriers to optimal SMBP documented in the literature. We explore additional high-level barriers that have been encountered, as broad policy and systems-level changes have been attempted, and offer potential solutions. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage and increase affordability, integrate SMBP into routine care and reimbursement practices, and strengthen patient engagement, trust, and access.

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

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

Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Physiological underpinnings

Coronavirus disease 2019 (COVID-19) is a highly contagious respiratory illness caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that began spreading globally in late 2019. While most cases of COVID-19 present with mild to moderate symptoms, COVID-19 was the third leading cause of mortality in the United States in 2020 and 2021. Though COVID-19 affects individuals of all races and ethnicities, non-Hispanic Black and Hispanic/Latinx populations are facing an inequitable burden of COVID-19 characterized by an increased risk for hospitalization and mortality. Importantly, non-Hispanic Black and Hispanic/Latinx adults have also faced a greater risk of non-COVID-19-related mortality (e.g., from cardiovascular disease/CVD) during the pandemic. Contributors to the racial disparities in morbidity and mortality during the pandemic are multi-factorial as we discuss in our companion article on social determinants of health. However, profound racial variation in the prevalence of CVD and metabolic diseases may serve as a key driver of worse COVID-19-related and non-COVID-19-related health outcomes among racial and ethnic minority groups. Within this review, we provide data emphasizing the inequitable burden of CVD and metabolic diseases among non-Hispanic Black and Hispanic/Latinx populations. We also discuss the pathophysiology of these conditions, with a focus on how aberrant physiological alterations in the context of CVD and metabolic diseases manifest to increase susceptibility to severe COVID-19.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Approach to Hypertension in Adolescents and Young Adults

PURPOSE OF REVIEW

The prevalence of hypertension in adolescents and young adults has increased in part due to the obesity epidemic. The clinical impact and future cardiovascular risk of this underestimated public health problem is an evolving field.

RECENT FINDINGS

The development of hypertension is predicted by tracking of elevated blood pressure from childhood to adulthood. Young hypertensive individuals have lower awareness, slower diagnosis rates, and poorer blood pressure control than older patients. Increased awareness, appropriate screening, early identification, and individualized treatment approaches for elevated blood pressure could prevent development of hypertension in adulthood and cardiovascular events in later life. The optimal blood pressure management for young adults with a low 10-year risk of atherosclerotic cardiovascular disease of < 10% remains challenging due to lack of randomized controlled trials. Evidence-based recommendations are needed to implement appropriate measures for time of treatment initiation, preferred antihypertensive drug class to be used and optimal target blood pressure level from childhood through young adulthood.

Exploring Feasibility of mHealth to Manage Hypertension in Rural Black Older Adults: A Convergent Parallel Mixed Method Study

OBJECTIVE

The purpose of this study was to explore perceived ease of use, usability, and the feasibility of using mobile health applications to manage hypertension self-care in rural Black older adults with hypertension.

METHODS

A convergent parallel mixed method design was used to study a purposeful sample of 30 Black older adults (29 females, 1 male) from rural East Texas. Quantitative data included demographic characteristics and measured blood pressure, height, and weight, along with questionnaires: the Hill-Bone Compliance to High Blood Pressure Therapy Scale, the Krousel-Wood Medication Adherence Scale-4, and the Technology Acceptance Model Questionnaire (adapted). Qualitative data were obtained from five focus groups and analyzed using thematic analysis.

RESULTS

Mean age was 66.3 ± 9.6 years. Less than half of the participants (46.7%) had a systolic and/or diastolic blood pressure >130/80. Greater participant adherence was noted with the Hill-Bone Compliance scale (63.3%) than the Krousel-Wood scale (23.3%). With the Technology Acceptance Model, perceived ease of use was significantly correlated with behavioral intention (r = 0.654, p < 0.000) and perceived usefulness (r = 0.585, p < 0.001), while behavioral intention was negatively associated with age r = -0.047 (p=0.009). Focus group data revealed five themes: 1) useful, 2) counterintuitive, 3) communication, 4) comfort with the status quo, and 5) educate/show me how.

CONCLUSION

Smartphone technology and other health-related computer technologies were not preferred by older adults in this study due to limited digital literacy. Simplicity and easy navigation in the design of mHealth apps are needed to improve treatment adherence and blood pressure control in rural older adults with hypertension.

CLINICAL RELEVANCE

Mobile health applications have the potential to increase self-management of chronic hypertension if users are digitally literate. Health-care providers need to assess older patients for digital literacy and offer educational support and assistance.

Pathophysiologically based antihypertensive pharmacotherapeutics rationality, efficacy and safety in Sub Saharan African Nations – A review

Background

Hypertension (HT) prevalence, Uncontrolled Blood Pressure (UBP), morbidity and mortality are highest in Sub-Saharan Africa (SSA). Correlating pathophysiology of HT to pharmaco-therapy with antihypertensive drugs (AHD) may bring amelioration. Aims:To review peculiarities of HT in SSA, UBP causes, diagnostic modalities, AHD use, rationality and efficacy.

Methods and results

14 published therapeutic audits in 4 SSA nations on Google Scholar or PUBMED, (total n = 6496 patients) were evaluated. Calcium Channel blockers (CCB) amlodipine, and thiazide diuretics (TD), hydrochlorothiazide (HCTZ) were the commonest AHD. Thiazide Like Diuretics (TLD) were underutilized. The % of patients on AHD were: 1 drug 5.4–55%; 2 drugs 37–82%; >/ = 3 drugs 6–50.3%. 2-drug combinations were: ACEI/ARB + TD (42%); CCB + TD (36.8%); ACEI + CCB (15.8%) of studies. Triple/quadruple therapy included Methyldopa (MTD) with ACEI + CCB or TD. The (%) attaining BP < 140/< 90 mmHg, ranged from 29 to 53.6%, median, 44%. The co-morbidities, range and median were: Diabetes Mellitus (DM): 9.8–64%, 19.2%; Chronic Kidney Disease (CKD): 5.7–7.5%, 6.9%, and Coronary artery Disease (CAD): 0.9–2.6%, 2.3%. ACEI + CCB ± TD were the preferred AHD for comorbidities.

Conclusions

Therapeutic inertia; Non-compliance; co-morbidities; refractory HT; ignorance; substandard AHD; contribute to UBP. Studies relating 24 hour ABPM to complications and mortality in SSA hypertensives; and impact of different AHD classes on ABPM, are needed. Study of ACEI + alpha-₁ blockers + TLD on 24 hour ABPM and personalized care, are required.

Decision Tree-Based Classification for Maintaining Normal Blood Pressure Throughout Early Adulthood and Middle Age: Findings From the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

For most individuals, blood pressure (BP) is related to multiple risk factors. By utilizing the decision tree analysis technique, this study aimed to identify the best discriminative risk factors and interactions that are associated with maintaining normal BP over 30 years and to reveal segments of a population with a high probability of maintaining normal BP.

METHODS

Participants from the Coronary Artery Risk Development in Young Adults study aged 18-30 years with normal BP level at baseline visit (Y0, 1985-1986) were included in this study.

RESULTS

Of 3,156 participants, 1,132 (35.9%) maintained normal BP during the follow-up period and 2,024 (64.1%) developed higher BP. Systolic BP (SBP) within the normal range, race, and body mass index (BMI) were the most discriminative factors between participants who maintained normal BP throughout midlife and those who developed higher BP. Participants with a baseline SBP level ≤92 mm Hg and White women with baseline BMI < 23 kg/m2 were the two segments of the population with the highest probability for maintaining normal BP throughout midlife (69.2% and 59.9%, respectively). Among Black participants aged >26.5 years with BMI > 27 kg/m2, only 5.4% of participants maintained normal BP throughout midlife.

CONCLUSIONS

This study emphasizes the importance of early life factors to later life SBP and support efforts to maintain ideal levels of risk factors for hypertension at young ages. Whether policies to maintain lower BMI and SBP well below the clinical thresholds throughout young adulthood and middle age can reduce later age hypertension should be examined in future studies.

Clinical Correlates of Early-Onset Hypertension

BACKGROUND

Early-onset hypertension has been established as a heritable trait and a risk factor for cardiovascular disease outcomes. However, the clinical correlates of early-onset hypertension remain unidentified.

METHODS

In this study, we assessed the demographic characteristics and lifestyle factors related to hypertension onset age in a sample of 3,286 Coronary Artery Risk Development in Young Adults (CARDIA) study participants (mean baseline age 25 ± 4 years, 57% women). We examined the association between the participants’ baseline characteristics and age of hypertension onset subgroups (<35, 35‒44, or ≥45 years) using a multinomial logistic regression model with those who did not develop hypertension as the reference group. Hypertension onset was defined as blood pressure ≥140/90 mm Hg or antihypertensive medication use on 2 consecutively attended follow-up visits.

RESULTS

In the multinomial logistic regression model, individuals who were black (odds ratio [OR], 5.08; 95% confidence interval [CI], 3.17–8.14), were more obese (OR, 1.57; 95% CI, 1.32–1.88), or had higher total cholesterol (OR, 1.34; 95% CI, 1.13–1.60 per SD) had increased odds of early-onset hypertension (onset at <35 years) vs. not developing hypertension. In contrast, 1-SD higher high-density lipoprotein (HDL)-cholesterol was related to decreased odds of early-onset hypertension (OR, 0.71; 95% CI, 0.57–0.89). The odds for having earlier hypertension onset increased linearly across age of onset categories in black individuals and individuals with lower HDL-cholesterol (P < 0.05 for trend for both).

CONCLUSIONS

Our findings suggest that individuals who are black, obese, have higher total cholesterol, or have lower HDL-cholesterol level, are potentially at an increased risk of having early-onset hypertension.

Melanoma and hypertension, is there an association? A U.S. population based study

BACKGROUND

Melanoma is one of the three major types of skin cancer. In this study we aimed to investigate the association between melanoma and hypertension comorbidity.

METHODS

We performed a population based study using NHANES database during the period 1999-2004. Data were analyzed using SPSS version 24.

RESULTS

Data for 12446 individuals of which 146 had a diagnosis for melanoma were extracted. Melanoma group were older than the no melanoma group as 51% of the melanoma group were 60 years or elder; however 53.6% of the no melanoma group falls below 30 years old. Melanoma group had higher frequency of hypertension (37%) compared to the no melanoma group (22.5%). Logistic regression revealed that melanoma patients had higher odds of hypertension prevalence using the unadjusted model (odds ratio (OR): 2.03, 95% confidence interval (CI): 1.45-2.84, p <0.001). However, after controlling of all potential confounding factors the significance was lost (OR: 0.89, 95% CI: 0.61-1.3, p = 0.54).

CONCLUSIONS

There may be a possible association of melanoma with hypertension comorbidity. With the limitations we faced, we encourage further research to confirm the association of melanoma and hypertension comorbidity.

Obesity and Race May Explain Differential Burden of White Matter Hyperintensity Load

OBJECTIVE

Compared to European Americans, research indicates that African Americans have higher white matter hyperintensity (WMH) load; however, the clinical and biological bases underlying this higher burden are poorly understood. We hypothesize that obesity may explain differences in WMH between African and European Americans.

METHODS

Participants enrolled in longitudinal brain aging studies (n=292; 61% Female; 92% European American; mean age=69.6±7.7) completed evaluations including medical exams, neuroimaging, and sociodemographic surveys. Overweight/obese status defined as body mass index ≥30 kg/m2, and WMH load, captured by FLAIR images, as sum of deep and periventricular volumes, scored using the Fazekas scale (0-6), WMH≥4 considered high.

RESULTS

Logistic regression analyses, adjusted for age, sex, hypertension, and smoking history, indicated that age and interaction between race and obesity were significant predictors of WMH, demonstrating that obesity significantly moderated the relationship between race and WMH. Age independently increased the odds of high WMH by 16% (OR=1.16, 95% CI=1.09-1.23, p<0.001). Stratified analysis indicates that older European Americans had increased WMH (OR=1.17, 95% CI=1.09-1.23, p<0.001), while obese African Americans had increased WMH (OR=27.65, 95% CI=1.47-519.13, p<0.05). In a case controlled subgroup matched by age, sex, and education (n=48), African Americans had significantly higher WMH load (27% vs 4%, Χ 2=5.3, p=0.02).

CONCLUSION

Results denote that age predicted WMH among European Americans, while obesity predicted WMH among African Americans. Matched sample analyses indicate that obesity increases the odds of WMH, though more pronounced in African Americans. These findings suggest that obesity may explain the differential burden of white matter hyperintensity load, signifying public health and clinical importance.

Obesity-associated cardiovascular risk in women: hypertension and heart failure

The pathogenesis of obesity-associated cardiovascular diseases begins long prior to the presentation of a cardiovascular event. In both men and women, cardiovascular events, and their associated hospitalizations and mortality, are often clinically predisposed by the presentation of a chronic cardiovascular risk factor. Obesity increases the risk of cardiovascular diseases in both sexes, however, the clinical prevalence of obesity, as well as its contribution to crucial cardiovascular risk factors is dependent on sex. The mechanisms via which obesity leads to cardiovascular risk is also discrepant in women between their premenopausal, pregnancy and postmenopausal phases of life. Emerging data indicate that at all reproductive statuses and ages, the presentation of a cardiovascular event in obese women is strongly associated with hypertension and its subsequent chronic risk factor, heart failure with preserved ejection fraction (HFpEF). In addition, emerging evidence indicates that obesity increases the risk of both hypertension and heart failure in pregnancy. This review will summarize clinical and experimental data on the female-specific prevalence and mechanisms of hypertension and heart failure in women across reproductive stages and highlight the particular risks in pregnancy as well as emerging data in a high-risk ethnicity in women of African ancestry (AA).

Twenty-Five-Year Changes in Office and Ambulatory Blood Pressure: Results From the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Blood pressure (BP) measured in the office setting increases from early through later adulthood. However, it is unknown to what extent out-of-office BP derived via ambulatory BP monitoring (ABPM) increases over time, and which participant characteristics and risk factors might contribute to these increases.

METHODS

We assessed 25-year change in office- and ABPM-derived BP across sex, race, diabetes mellitus (DM), and body mass index (BMI) subgroups in the Coronary Artery Risk Development in Young Adults study using multivariable-adjusted linear mixed effects models.

RESULTS

We included 288 participants who underwent ABPM at the Year 5 Exam (mean [SD] age, 25.1 [3.7]; 45.8% men) and 455 participants who underwent ABPM at the Year 30 Exam (mean [SD] age, 49.5 [3.7]; 42.0% men). Office, daytime, and nighttime systolic BP (SBP) increased 12.8 (95% confidence interval [CI], 7.6-17.9), 14.7 (95% CI, 9.7-19.8), and 16.6 (95% CI, 11.4-21.8) mm Hg, respectively, over 25 years. Office SBP increased 6.5 (95% CI, 2.3-10.6) mm Hg more among black compared with white participants. Daytime SBP increased 6.3 (95% CI, 0.2-12.4) mm Hg more among participants with a BMI ≥25 vs. <25 kg/m2. Nighttime SBP increased 4.7 (95% CI, 0.5-8.9) mm Hg more among black compared with white participants, and 17.3 (95% CI, 7.2-27.4) mm Hg more among participants with vs. without DM.

CONCLUSIONS

Office- and ABPM-derived BP increased more from early through middle adulthood among black adults and participants with DM and BMI ≥25 kg/m2.

Maintaining Normal Blood Pressure Across the Life Course: The JHS

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Management of Stage 1 Hypertension in Adults With a Low 10-Year Risk for Cardiovascular Disease: Filling a Guidance Gap: A Scientific Statement From the American Heart Association

High blood pressure (BP) is the leading cause of worldwide cardiovascular disease morbidity and mortality. Patients and clinicians dealing with hypertension have benefited from the evidence of event-based randomized controlled clinical trials. One result from those trials has been the development of evidence-based guidelines. The commitment to using evidence from these event-based randomized trials has been a cornerstone in the development of guideline treatment recommendations. However, in some situations, evidence from event-based trials is not available to guideline writers or clinicians for assistance in treatment decision making. Such is the case for the management of many patients with stage 1 hypertension. The purpose of this scientific statement is to provide information complementary to the 2017 Hypertension Clinical Practice Guidelines for the patient with untreated stage 1 hypertension (systolic BP/diastolic BP, 130-139/80-89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% who fails to meet the systolic BP/diastolic goal (<130/80 mm Hg) after 6 months of guideline-recommended lifestyle therapy. This statement provides evidence from sources other than event-based randomized controlled clinical trials and offers therapy options for consideration by clinicians.

Low sun exposure habits is associated with a dose-dependent increased risk of hypertension: a report from the large MISS cohort

In prospective observational cohort studies, increasing sun exposure habits have been associated with reduced risk of cardiovascular mortality. Our aim was to assess possible observational mechanisms for this phenomenon. A written questionnaire was answered by 23,593 women in the year 2000 regarding risk factors for melanoma, including factors of possible interest for hypertension, such as detailed sun exposure habits, hypertension, marital status, education, smoking, alcohol consumption, BMI, exercise, and chronic high stress. Hypertension was measured by the proxy "use of hypertension medication" 2005-2007, and high stress by "need of anti-depressive medication". Sun exposure habits was assessed by the number of `yes' to the following questions; Do you sunbath during summer?, During winter vacation?, Do you travel south to sunbath?, Or do you use sun bed? Women answering 'yes' on one or two questions had moderate and those answering 'yes' on three or four as having greatest sun exposure. The main outcome was the risk of hypertension by sun exposure habits adjusted for confounding. As compared to those women with the greatest sun exposure, women with low and moderate sun exposure were at 41% and 15% higher odds of hypertension (OR 1.41, 95% CI 1.3‒1.6, p < 0.001 and OR 1.15, 95% CI 1.1‒1.2, p < 0.001), respectively. There was a strong age-related increased risk of hypertension. Other risk factors for hypertension were lack of exercise (OR 1.36), a non-fair phenotype (OR 1.08), chronic high stress level (OR 1.8), and lack of university education (OR 1.3). We conclude that in our observational design sun exposure was associated with a dose-dependent reduced risk of hypertension, which might partly explain the fewer deaths of cardiovascular disease with increasing sun exposure.

An interactive technology enhanced coaching intervention for Black women with hypertension: Randomized controlled trial study protocol

In the United States, hypertension (HTN) is the leading risk factor for cardiovascular disease, and a more significant health problem for Blacks compared with other racial/ethnic groups. The prevalence of HTN in Black women is among the highest in the world, underscoring the need for effective prevention and management approaches for blood pressure (BP) control. We developed a two-arm randomized controlled trial repeated measures design study for improving HTN self-management among Black women. The study tests whether the Chronic Disease Self-Management Program (CDSMP) combined with interactive technology-enhanced coaching, can improve BP control and adherence to treatment (e.g., medication-taking, physical activity, calorie intake, and weight management) compared with the CDSMP alone. Repeated measurements were conducted at 3, 6, and 9 months. A sample of 90 community-dwelling Black women with uncontrolled Stage 1 HTN (BP ≥ 130/80) were enrolled, completed CDSMP training, and randomized. This study will contribute to our understanding of novel methods to empower Black women to increase their active involvement in self-care management of HTN.