Publications by authors named "Paul Muntner"

654 Publications

Multiple Social Vulnerabilities to Health Disparities and Hypertension and Death in the REGARDS Study.

Hypertension 2021 Nov 17:HYPERTENSIONAHA12015196. Epub 2021 Nov 17.

Department of Medicine, Weill Medical College of Cornell University, Columbia University Vagelos College of Physicians and Surgeons. (L.C.P., J.B.R., M.M.S.).

Social vulnerabilities increase the risk of developing hypertension and lower life expectancy, but the effect of an individual's overall vulnerability burden is unknown. Our objective was to determine the association of social vulnerability count and the risk of developing hypertension or dying over 10 years and whether these associations vary by race. We used the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) and included participants without baseline hypertension. The primary exposure was the count of social vulnerabilities defined across economic, education, health and health care, neighborhood and built environment, and social and community context domains. Among 5425 participants of mean age 64±10 SD years of which 24% were Black participants, 1468 (31%) had 1 vulnerability and 717 (15%) had ≥2 vulnerabilities. Compared with participants without vulnerabilities, the adjusted relative risk ratio for developing hypertension was 1.16 (95% CI, 0.99-1.36) and 1.49 (95% CI, 1.20-1.85) for individuals with 1 and ≥2 vulnerabilities, respectively. The adjusted relative risk ratio for death was 1.55 (95% CI, 1.24-1.93) and 2.30 (95% CI, 1.75-3.04) for individuals with 1 and ≥2 vulnerabilities, respectively. A greater proportion of Black participants developed hypertension and died than did White participants (hypertension, 38% versus 31%; death, 25% versus 20%). The vulnerability count association was strongest in White participants ( value for vulnerability count×race interaction: hypertension=0.046, death=0.015). Overall, a greater number of socially determined vulnerabilities was associated with progressively higher risk of developing hypertension, and an even higher risk of dying over 10 years.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.15196DOI Listing
November 2021

The association of actigraphy-assessed sleep duration with sleep blood pressure, nocturnal hypertension, and nondipping blood pressure: the coronary artery risk development in young adults (CARDIA) study.

J Hypertens 2021 Dec;39(12):2478-2487

Department of Epidemiology.

Objective: Nocturnal hypertension and nondipping systolic blood pressure (SBP) are associated with increased cardiovascular disease (CVD) risk. Short and long sleep duration (SSD and LSD) are also associated with increased CVD risk and may be risk factors for nocturnal hypertension and nondipping SBP. We examined the association between SSD and LSD with sleep BP, nocturnal hypertension, and nondipping SBP among 647 white and African American Coronary Artery Risk Development in Young Adults (CARDIA) study participants who completed 24-h ambulatory BP monitoring, wrist actigraphy, and sleep diaries in 2015-2016.

Methods: The times when participants were asleep and awake were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as sleep BP ≥120/70 mmHg and nondipping SBP as mean sleep-to-awake SBP ratio >0.90. Sleep duration was categorized as SSD (<6 h), normal sleep duration (NSD: 6-8.9 h), and LSD (≥9 h).

Results: The prevalence of SSD and LSD were 13.9 and 21.1%, respectively. Compared to participants with NSD, participants with LSD had higher mean sleep SBP (2.1 mmHg, 95% confidence interval [CI] 0.2, 4.1 mmHg) and diastolic BP (1.7 mmHg, 95% CI 0.5, 3.0 mmHg). Participants with LSD had a higher prevalence of nocturnal hypertension (prevalence ratio [PR]: 1.26, 95% CI 1.03-1.54) and nondipping SBP (PR 1.33, 95% CI 1.03-1.72) compared to participants with NSD. There was no evidence of an association between SSD and sleep SBP or DBP, nocturnal hypertension, or nondipping SBP.

Conclusions: These findings suggest that LSD may be associated with nocturnal hypertension and nondipping SBP.
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http://dx.doi.org/10.1097/HJH.0000000000002956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8571489PMC
December 2021

Untreated Hypertension and Subsequent Incidence of Colorectal Cancer: Analysis of a Nationwide Epidemiological Database.

J Am Heart Assoc 2021 Nov 2;10(22):e022479. Epub 2021 Nov 2.

The Department of Cardiovascular Medicine The University of Tokyo Japan.

Background Studies of the association of hypertension with incident colorectal cancer (CRC) may have been confounded by including individuals taking antihypertensive medication, at high risk for CRC (ie, colorectal polyps and inflammatory bowel disease), or with shared risk factors (eg, obesity and diabetes). We assessed whether adults with untreated hypertension are at higher risk for incident CRC compared with those with normal blood pressure (BP), and whether any association is evident among individuals without obesity or metabolic abnormalities. Methods and Results Analyses were conducted using a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2018 (n=2 220 112; mean age, 44.1±11.0 years; 58.4% men). Participants who were taking antihypertensive medications or had a history of CRC, colorectal polyps, or inflammatory bowel disease were excluded. Each participant was categorized as having normal BP (systolic BP [SBP]<120 mm Hg and diastolic BP [DBP] <80 mm Hg, n=1 164 807), elevated BP (SBP 120-129 mm Hg and DBP <80 mm Hg, n=341 273), stage 1 hypertension (SBP 130-139 mm Hg or DBP 80-89 mm Hg, n=466 298), or stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg, n=247 734). Over a mean follow-up of 1112±854 days, 6899 incident CRC diagnoses occurred. After multivariable adjustment, compared with normal BP, hazard ratios for incident CRC were 0.93 (95% CI, 0.85-1.01) for elevated BP, 1.07 (95% CI, 0.99-1.15) for stage 1 hypertension, and 1.17 (95% CI, 1.08-1.28) for stage 2 hypertension. The hazard ratios for incident CRC for each 10-mm Hg-higher SBP or DBP were 1.04 (95% CI, 1.02-1.06) and 1.06 (95% CI, 1.03-1.09), respectively. These associations were present among adults who did not have obesity, high waist circumference, diabetes, or dyslipidemia. Conclusions Higher SBP and DBP, and stage 2 hypertension are associated with a higher risk for incident CRC, even among those without shared risk factors for CRC. BP measurement could identify individuals at increased risk for subsequent CRC.
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http://dx.doi.org/10.1161/JAHA.121.022479DOI Listing
November 2021

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

Hypertension 2021 Dec 1;78(6):1730-1741. Epub 2021 Nov 1.

Department of Epidemiology (S.T.H., L.C., S.S., P.M.), University of Alabama at Birmingham.

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.121.18086DOI Listing
December 2021

Long-term cumulative blood pressure in young adults and incident heart failure, coronary heart disease, stroke, and cardiovascular disease: The CARDIA study.

Eur J Prev Cardiol 2021 Oct;28(13):1445-1451

Johns Hopkins University, USA.

Aims: Cumulative blood pressure (BP) is a measure that incorporates the severity and duration of BP exposure. The prognostic significance of cumulative BP in young adults for cardiovascular diseases (CVDs) in comparison to BP severity alone is, however, unclear.

Methods And Results: We investigated 3667 Coronary Artery Risk Development in Young Adults participants who attended six visits over 15 years (year-0 (1985-1986), year-2, year-5, year-7, year-l0, and year-15 exams). Cumulative BP was calculated as the area under the curve (mmHg × years) from year 0 through year 15. Cox models assessed the association between cumulative BP (year 0 through year 15), current BP (year 15), and BP change (year 0 and year 15) and CVD outcomes. Mean (standard deviation) age at year 15 was 40.2 (3.6) years, 44.1% were men, and 44.1% were African-American. Over a median follow-up of 16 years, there were 47 heart failure (HF), 103 coronary heart disease (CHD), 71 stroke, and 191 CVD events. Cumulative systolic BP (SBP) was associated with HF (hazard ratio (HR) = 2.14 (1.58-2.90)), CHD (HR = 1.49 (1.19-1.87)), stroke (HR = 1.81 (1.38-2.37)), and CVD (HR = 1.73 (1.47-2.05)). For CVD, the C-statistic for SBP (year 15) was 0.69 (0.65-0.73) and change in C-statistic with the inclusion of SBP change and cumulative SBP was 0.60 (0.56-0.65) and 0.72 (0.69-0.76), respectively. For CVD, using year-15 SBP as a reference, the net reclassification index (NRI) for cumulative SBP was 0.40 (p < 0.0001) and the NRI for SBP change was 0.22 (p = 0.001).

Conclusions: Cumulative BP in young adults was associated with the subsequent risk of HF, CHD, stroke, and CVD. Cumulative BP provided incremental prognostic value and improved risk reclassification for CVD, when compared to single BP assessments or changes in BP.
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http://dx.doi.org/10.1177/2047487320915342DOI Listing
October 2021

Atherosclerotic Cardiovascular Disease Events in Adults With CKD Taking a Moderate- or High-Intensity Statin: The Chronic Renal Insufficiency Cohort (CRIC) Study.

Kidney Med 2021 Sep-Oct;3(5):722-731.e1. Epub 2021 Jun 19.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL.

Rationale & Objective: The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline uses risk stratification to guide the decision to initiate nonstatin lipid-lowering medication among adults with atherosclerotic cardiovascular disease (CVD). We determined atherosclerotic CVD (ASCVD) event rates among adults with chronic kidney disease (CKD) taking statin therapy within 2018 AHA/ACC cholesterol guideline risk categories.

Study Design: Observational cohort study.

Setting & Participants: Adults with CKD not on dialysis in the Chronic Renal Insufficiency Cohort (CRIC) study who were taking a moderate/high-intensity statin 1 year after enrollment (baseline for the current analysis, n = 1,753).

Exposure: 2018 AHA/ACC cholesterol guideline risk categories: without a history of ASCVD, a history of 1 major ASCVD event and multiple high-risk conditions, and a history of ≥2 major ASCVD events.

Outcome: Adjudicated ASCVD events after the year 1 study visit.

Analytical Approach: We calculated age-sex standardized rates for ASCVD events and age-sex adjusted hazard ratios for ASCVD events accounting for the competing risk of death.

Results: There were 394 ASCVD events over a median follow-up period of 8 years. The ASCVD event rates (with 95% CI) per 1,000 person-years among participants without a history of ASCVD, with a history of 1 major ASCVD event and multiple high-risk conditions, and with a history of ≥2 major ASCVD events were 21.7 (18.4-25.1), 45.0 (37.8-52.3), and 73.3 (53.3-93.4), respectively. Compared with participants without a history of ASCVD, the HR (95% CI) rates for ASCVD events among those with a history of 1 major ASCVD event and multiple high-risk conditions, and with a history of ≥2 major ASCVD events were 1.89 (1.52-2.36) and 2.50 (1.85-3.39), respectively.

Limitations: Data on whether participants were taking a maximally tolerated statin dosage were unavailable.

Conclusions: The 2018 AHA/ACC cholesterol guideline identifies adults with CKD who have very high ASCVD risk despite taking a moderate/high-intensity statin.
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http://dx.doi.org/10.1016/j.xkme.2021.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8515092PMC
June 2021

Factors associated with antihypertensive monotherapy among US adults with treated hypertension and uncontrolled blood pressure overall and by race/ethnicity, National Health and Nutrition Examination Survey 2013-2018.

Am Heart J 2021 Oct 16. Epub 2021 Oct 16.

Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City, UT.

Background: Treating hypertension with antihypertensive medications combinations, rather than one medication (ie, monotherapy), is underused in the United States, particularly in certain race/ethnic groups. Identifying factors associated with monotherapy use despite uncontrolled blood pressure (BP) overall and within race/ethnic groups may elucidate intervention targets in under-treated populations.

Methods: Cross-sectional analysis of National Health and Nutrition Examination Surveys (NHANES; 2013-2014 through 2017-2018). We included participants age ≥20 years with hypertension, taking at least one antihypertensive medication, and uncontrolled BP (systolic BP [SBP] ≥ 140 mmHg or diastolic BP [DBP] ≥ 90 mmHg). Demographic, clinical, and healthcare-access factors associated with antihypertensive monotherapy were determined using multivariable-adjusted Poisson regression.

Results: Among 1,597 participants with hypertension and uncontrolled BP, age- and sex- adjusted prevalence of monotherapy was 42.6% overall, 45.4% among non-Hispanic White, 31.9% among non-Hispanic Black, 39.6% among Hispanic, and 50.9% among non-Hispanic Asian adults. Overall, higher SBP was associated with higher monotherapy use, while older age, having a healthcare visit in the previous year, higher body mass index, and having heart failure were associated with lower monotherapy use.

Conclusion: Clinical and healthcare-access factors, including a healthcare visit within the previous year and co-morbid conditions were associated with a higher likelihood of combination antihypertensive therapy.
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http://dx.doi.org/10.1016/j.ahj.2021.10.184DOI Listing
October 2021

Risk for ischemic stroke and coronary heart disease associated with migraine and migraine medication among older adults.

J Headache Pain 2021 Oct 13;22(1):124. Epub 2021 Oct 13.

Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada.

Background: Migraine has been associated with cardiovascular disease (CVD) events among middle-aged adults. The objective of this study was to determine the risk for ischemic stroke and coronary heart disease (CHD) events among older adults with versus without migraine.

Methods: This retrospective cohort study was conducted using data from US adults ≥66 years of age with Medicare health insurance between 2008 and 2017. After stratification by history of CVD, patients with a history of migraine were matched 1:4 to those without a history of migraine, based on calendar year, age, and sex. Patients were followed through December 31, 2017 for ischemic stroke and CHD events including myocardial infarction or coronary revascularization. All analyses were done separately for patients with and without a history of CVD.

Results: Among patients without a history of CVD (n = 109,950 including n = 21,990 with migraine and n = 87,960 without migraine), 1789 had an ischemic stroke and 3552 had a CHD event. The adjusted hazard ratio (HR) among patients with versus without migraine was 1.20 (95% confidence interval [95%CI], 1.07-1.35) for ischemic stroke and 1.02 (95%CI, 0.93-1.11) for CHD events. Compared to patients without migraine, those with migraine who were taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.43 [95%CI, 1.20-1.69]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.79 [95%CI, 0.67-0.93]). Among patients with a history of CVD (n = 79,515 including n = 15,903 with migraine and n = 63,612 without migraine), 2960 had an ischemic stroke and 7981 had a CHD event. The adjusted HRs (95%CI) for ischemic stroke and CHD events associated with migraine were 1.27 (1.17-1.39) and 0.99 (0.93-1.05), respectively. Patients with migraine taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.21 [95%CI, 1.07-1.36]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.83 [95%CI, 0.72-0.95]), each versus those without migraine.

Conclusions: Older adults with migraine are at increased risk for ischemic stroke. The risk for ischemic stroke among older adults with migraine may differ by migraine medication classes.
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http://dx.doi.org/10.1186/s10194-021-01338-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8513203PMC
October 2021

Reasons for Uncontrolled Blood Pressure Among US Adults: Data From the US National Health and Nutrition Examination Survey.

Hypertension 2021 Nov 13;78(5):1567-1576. Epub 2021 Oct 13.

Department of Epidemiology (S.S., C.L.C., O.P.A., S.T.H., P.M.), University of Alabama at Birmingham.

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.121.17590DOI Listing
November 2021

A prospective study of multiple sleep dimensions and hypertension risk among white, black and Hispanic/Latina women: findings from the Sister Study.

J Hypertens 2021 11;39(11):2210-2219

Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina.

Background: Poor sleep is associated with increased hypertension risk, but few studies have evaluated multiple sleep dimensions or investigated racial/ethnic disparities in this association among women.

Method: We investigated multiple sleep dimensions (sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping and difficulty falling or staying asleep) and hypertension risk among women, and determined modification by age, race/ethnicity and menopausal status. We used data from the Sister Study, a national cohort of 50 884 women who had sisters diagnosed with breast cancer in the United States enrolled in 2003-2009 and followed through September 2018.

Results: Of 33 497 women without diagnosed hypertension at baseline (mean age ± standard deviation: 53.9 ± 8.8 years; 88.7% White, 6.4% Black and 4.9% Hispanic/Latina), 23% (n = 7686) developed hypertension over a median follow-up of 10.1 years [interquartile range: 8.2-11.9 years]. Very short, short or long sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping, insomnia, insomnia symptoms as well as short sleep and exploratory cumulative poor sleep score were associated with incident hypertension after adjustment for demographics factors. After additional adjustment for lifestyle and clinical factors, insomnia [hazard ratio = 1.09, 95% confidence interval (95% CI): 1.03-1.15] and insomnia symptoms plus short sleep (hazard ratio = 1.13, 95% CI: 1.05-1.21) remained associated with incident hypertension. These associations were stronger in younger (age<54 vs. ≥54 years) and premenopausal vs. postmenopausal women (all P-interaction < 0.05). Associations did not differ by race/ethnicity (all P-interaction > 0.05).

Conclusion: Thus, screening for multiple sleep dimensions and prioritizing younger and premenopausal women may help identify individuals at high risk for hypertension.
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http://dx.doi.org/10.1097/HJH.0000000000002929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8501231PMC
November 2021

Diagnostic Yield of Population-Based Screening for Chronic Kidney Disease in Low-Income, Middle-Income, and High-Income Countries.

JAMA Netw Open 2021 Oct 1;4(10):e2127396. Epub 2021 Oct 1.

Department of Epidemiology, School of Public Health, University of Alabama, Tuscaloosa.

Importance: Population-based screening for chronic kidney disease (CKD) is sometimes recommended based on the assumption that detecting CKD is associated with beneficial changes in treatment. However, the treatment of CKD is often similar to the treatment of hypertension or diabetes, which commonly coexist with CKD.

Objective: To determine the frequency with which population-based screening for CKD is associated with a change in recommended treatment compared with a strategy of measuring blood pressure and assessing glycemia.

Design, Setting, And Participants: This cohort study was conducted using data obtained from studies that evaluated CKD in population-based samples from China (2007-2010), India (2010-2014), Mexico (2007-2008), Senegal (2012), and the United States (2009-2014), including a total of 126 242 adults screened for CKD. Data were analyzed from January 2020 to March 2021.

Main Outcomes And Measures: The primary definition of CKD was estimated glomerular filtration rate less than 60 mL/min/1.73 m2. For individuals with CKD, the need for a treatment change was defined as not taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker or having blood pressure levels of 140/90 mm Hg or greater. For individuals with CKD who also had diabetes, the need for a treatment change was also defined as having hemoglobin A1c levels of 8% or greater or fasting glucose levels of 178.4 mg/dL (9.9 mmol/L) or greater. Case finding was defined as testing for CKD only in adults with hypertension or diabetes.

Results: Among 126 242 adults screened for CKD, there were 47 204 patients in the China cohort, 9817 patients in the India cohort, 51 137 patients in the Mexico cohort, 2441 patients in the Senegal cohort, and 15 643 patients in the US cohort. The mean age of participants was 49.6 years (95% CI, 49.5-49.7 years) in the China cohort, 42.9 years (95% CI, 42.6-43.2 years) in the India cohort, 51.6 years (95% CI, 51.5-51.7 years) in the Mexico cohort, 48.2 years (95% CI, 47.5-48.9 years) in the Senegal cohort, and 47.3 years (95% CI, 46.6-48.0 years) in the US cohort. The proportion of women was 57.3% (95% CI, 56.9%-57.7%) in the China cohort, 53.4% (95% CI, 52.4%-54.4%) in the India cohort, 68.8% (95% CI, 68.4%-69.2%) in the Mexico cohort, 56.0% (95% CI, 54.0%-58.0%) in the Senegal cohort, and 51.9% (51.0%-52.7%) in the US cohort. The prevalence of CKD was 2.5% (95% CI, 2.4%-2.7%) in the China cohort, 2.3% (95% CI, 2.0%-2.6%) in the India cohort, 10.6% (95% CI, 10.3%-10.9%) in the Mexico cohort, 13.1% (95% CI, 11.7%-14.4%) in the Senegal cohort, and 6.8% (95% CI, 6.2%-7.5%) in the US cohort. Screening for CKD was associated with the identification of additional adults whose treatment would change (beyond those identified by measuring blood pressure and glycemia) per 1000 adults: China: 8 adults (95% CI, 8-9 adults); India: 5 adults (95% CI, 4-7 adults); Mexico: 26 adults (95% CI, 24-27 adults); Senegal: 59 adults (95% CI, 50-69 adults); and the US: 19 adults (95% CI, 16-23 adults). Case finding was associated with the identification of 46.2% (95% CI, 45.1%-47.4%) to 86.4% (95% CI, 85.4%-87.3%) of individuals with CKD depending on the country, an increase in the proportion of individuals requiring a treatment change by as much 89.6% (95% CI, 80.4%-99.3%) in the US, and a decrease in the proportion of individuals needing GFR measurements by as much as 57.8% (95% CI, 56.3%-59.3%) in the US.

Conclusions And Relevance: This study found that most additional individuals with CKD identified by population-based screening programs did not need a change in treatment compared with a strategy of measuring blood pressure and assessing glycemia and that case finding was more efficient than screening for early detection of CKD.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.27396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491102PMC
October 2021

Age-specific prevalence and factors associated with normal blood pressure among US adults.

Am J Hypertens 2021 Oct 2. Epub 2021 Oct 2.

Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC.

Background: The mean systolic blood pressure (SBP) for US adults increases with age. Determining characteristics of US adults ≥65 years with normal blood pressure (BP) may inform approaches to prevent this increase.

Methods: We analyzed US National Health and Nutrition Examination Survey 2011-2018 data (n=21,581). BP was measured up to three times and averaged. Normal BP was defined as SBP <120 mmHg and diastolic BP <80 mmHg among participants not taking antihypertensive medication. Those with SBP ≥120 mmHg, diastolic BP ≥80 mmHg, or taking antihypertensive medication were categorized as having elevated BP or hypertension.

Results: The prevalence of normal BP was 57.8%, 25.3%, 11.2% and 5.0% among US adults who were 18-44, 45-64, 65-74 and ≥75 years, respectively. After multivariable adjustment, in US adults ≥65 years of age, normal BP versus elevated BP/hypertension was more common among those with moderate and no versus heavy alcohol consumption (prevalence ratio [PR] 3.03; 95%CI 1.25-7.36 and 2.53; 95%CI 0.96-6.65, respectively), ≥150 versus <150 minutes of physical activity per week (PR=1.44; 95%CI 1.01-2.05), overweight and normal weight versus obesity (PR=1.88; 95%CI 1.22-2.90 and 2.94; 95%CI 1.89-4.59, respectively) and a high Dietary Approaches to Stop Hypertension score (PR=1.43; 95%CI 1.00-2.05). US adults ≥65 years with normal BP versus elevated BP/hypertension were less likely to have good or fair/poor versus excellent/very good self-rated health, diabetes, albuminuria, atherosclerotic cardiovascular disease and heart failure.

Conclusion: Among US adults ≥65 years, normal BP was associated with healthy lifestyle factors and a lower prevalence of adverse health conditions.
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http://dx.doi.org/10.1093/ajh/hpab154DOI Listing
October 2021

Factors associated with not having a healthcare visit in the past year among US adults with hypertension: Data from NHANES 2013-2018.

Am J Hypertens 2021 Oct 2. Epub 2021 Oct 2.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL.

Background: Not having a healthcare visit in the past year has been associated with a higher likelihood of uncontrolled blood pressure (BP) among individuals with hypertension.

Methods: We examined factors associated with not having a healthcare visit in the past year among US adults with hypertension using data from the US National Health and Nutrition Examination Survey 2013-2018 (n=5,985). Hypertension was defined as systolic BP ≥140 mmHg, diastolic BP ≥90 mmHg, or antihypertensive medication use. Having a healthcare visit in the past year was self-reported.

Results: Overall, 7.0% of US adults with hypertension reported not having a healthcare visit in the past year. Those without versus with a healthcare visit in the past year were less likely to be aware they had hypertension (45.0% versus 83.9%), to be taking antihypertensive medication (36.7% versus 91.4%, among those who were aware they had hypertension) and to have controlled BP (systolic/diastolic BP <140/90 mmHg; 9.1% versus 51.7%). After multivariable adjustment, not having a healthcare visit in the past year was more common among US adults without health insurance (prevalence ratio [PR]: 2.22; 95%CI 1.68-2.95), without a usual source of healthcare (PR: 5.65; 95%CI 4.16-7.67), who smoked cigarettes (PR: 1.34; 95%CI 1.02-1.77), and with heavy versus no alcohol consumption (PR: 1.55; 95%CI 1.16-2.08). Also, not having a healthcare visit in the past year was more common among those without diabetes or a history of atherosclerotic cardiovascular disease, and those not taking a statin.

Conclusion: Interventions should be considered to ensure all adults with hypertension have annual healthcare visits.
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http://dx.doi.org/10.1093/ajh/hpab153DOI Listing
October 2021

The Projected Impact of Population-Wide Achievement of LDL Cholesterol <70 mg/dL on the Number of Recurrent Events Among US Adults with ASCVD.

Cardiovasc Drugs Ther 2021 Oct 2. Epub 2021 Oct 2.

Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA.

Purpose: Adults with atherosclerotic cardiovascular disease (ASCVD) are recommended high-intensity statins, with those at very high risk for recurrent events recommended adding ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor if their low-density lipoprotein cholesterol (LDL-C) is ≥70 mg/dL. We estimated the number of recurrent ASCVD events potentially averted if all adults in the United States (US) ≥45 years of age with ASCVD achieved an LDL-C <70 mg/dL.

Methods: The number of US adults with ASCVD and LDL-C ≥70 mg/dL was estimated from the National Health and Nutrition Examination Survey 2009-2016 (n = 596). The 10-year cumulative incidence of recurrent ASCVD events was estimated from the REasons for Geographic And Racial Differences in Stroke study (n = 5390), weighted to the US population by age, race, and sex. The ASCVD risk reduction by achieving an LDL-C <70 mg/dL was estimated from meta-analyses of lipid-lowering treatment trials.

Results: Overall, 14.7 (95% CI, 13.7-15.8) million US adults had ASCVD, of whom 11.6 (95% CI, 10.6-12.5) million had LDL-C ≥70 mg/dL. The 10-year cumulative incidence of ASCVD events was 24.3% (95% CI, 23.2-25.6%). We projected that 2.823 (95% CI, 2.543-3.091) million ASCVD events would occur over 10 years among US adults with ASCVD and LDL-C ≥70 mg/dL. Overall, 0.634 (95% CI, 0.542-0.737) million ASCVD events could potentially be averted if all US adults with ASCVD achieved and maintained LDL-C <70 mg/dL.

Conclusion: A substantial number of recurrent ASCVD events could be averted over 10 years if all US adults with ASCVD achieved, and maintained, an LDL-C <70 mg/dL.
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http://dx.doi.org/10.1007/s10557-021-07268-xDOI Listing
October 2021

Racial Differences in Blood Pressure Control Following Stroke: The REGARDS Study.

Stroke 2021 Dec 2;52(12):3944-3952. Epub 2021 Sep 2.

Department of Epidemiology, School of Public Health (O.P.A., T.L.M., D.H., V.J.H., P.M.), University of Alabama at Birmingham.

Background And Purpose: In the general population, Black adults are less likely than White adults to have controlled blood pressure (BP), and when not controlled, they are at greater risk for stroke compared with White adults. High BP is a major modifiable risk factor for recurrent stroke, but few studies have examined racial differences in BP control among stroke survivors.

Methods: We used data from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) to examine disparities in BP control between Black and White adults, with and without a history of stroke. We studied participants taking antihypertensive medication who did and did not experience an adjudicated stroke (n=306 and 7693 participants, respectively) between baseline (2003-2007) and a second study visit (2013-2016). BP control at the second study visit was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg except for low-risk adults ≥65 years of age (ie, those without diabetes, chronic kidney disease, history of cardiovascular disease, and with a 10-year predicted atherosclerotic cardiovascular disease risk <10%) for whom BP control was defined as systolic BP <130 mm Hg.

Results: Among participants with a history of stroke, 50.3% of White compared with 39.3% of Black participants had controlled BP. Among participants without a history of stroke, 56.0% of White compared with 50.2% of Black participants had controlled BP. After multivariable adjustment, there was a tendency for Black participants to be less likely than White participants to have controlled BP (prevalence ratio, 0.77 [95% CI, 0.59-1.02] for those with a history of stroke and 0.92 [95% CI, 0.88-0.97] for those without a history of stroke).

Conclusions: There was a lower proportion of controlled BP among Black compared with White adults with or without stroke, with no statistically significant differences after multivariable adjustment.
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http://dx.doi.org/10.1161/STROKEAHA.120.033108DOI Listing
December 2021

Race/ethnic and sex differences in the initiation of non-statin lipid-lowering medication following myocardial infarction.

J Clin Lipidol 2021 Aug 10. Epub 2021 Aug 10.

Department of Epidemiology, University of Alabama at Birmingham, 1720 2nd Ave South, RPHB 527C, Birmingham, AL 35294-0013, USA. Electronic address:

Background: Adults with atherosclerotic cardiovascular disease (ASCVD) at very high-risk for recurrent events who have low-density lipoprotein cholesterol ≥ 70 mg/dL despite maximally-tolerated statin therapy are recommended to initiate ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor.

Objective: Compare the initiation of ezetimibe and a PCSK9 inhibitor after a myocardial infarction (MI) among very high-risk ASCVD patients by race/ethnicity and sex.

Methods: We analyzed data from 374,786 adults ≥ 66 years of age with Medicare fee-for-service coverage who had an MI between July 1, 2015 and December 31, 2018, were not taking ezetimibe or a PCSK9 inhibitor, and had very high-risk ASCVD defined by the 2018 American Heart Association/American College of Cardiology multi-society cholesterol guideline. Pharmacy claims through December 31, 2018 were used to determine ezetimibe and PCSK9 inhibitor initiation.

Results: Overall, 6980 (1.9%) beneficiaries initiated ezetimibe, and 1433 (0.4%) initiated a PCSK9 inhibitor. Adjusted hazard ratios (aHR) for ezetimibe initiation among non-Hispanic Black, Hispanic, and Asian versus non-Hispanic White beneficiaries were 0.77 (95% confidence interval [95%CI]: 0.70-0.86), 0.92 (95%CI: 0.76-1.11) and 0.73 (95%CI: 0.59-0.89), respectively. Compared to non-Hispanic White beneficiaries, the aHRs for PCSK9 inhibitor initiation were 0.63 (95%CI: 0.48-0.81) among non-Hispanic Black, 0.70 (95%CI: 0.43-1.13) among Hispanic, and 0.93 (95%CI: 0.62-1.39) among Asian beneficiaries. The aHRs for ezetimibe and PCSK9 inhibitor initiation comparing women to men were 1.11 (95%CI: 1.06-1.17) and 1.13 (95%CI: 1.01-1.25), respectively.

Conclusion: There are race/ethnic and sex disparities in the initiation of ezetimibe and a PCSK9 inhibitor following MI among very high-risk ASCVD patients.
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http://dx.doi.org/10.1016/j.jacl.2021.08.001DOI Listing
August 2021

Predicted cardiovascular risk for United States adults with diabetes, chronic kidney disease, and at least 65 years of age.

J Hypertens 2021 Aug 20. Epub 2021 Aug 20.

Department of Biostatistics Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama Department of Epidemiology, Tulane University, New Orleans, Lousiana, USA.

Background: The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication.

Methods: We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk.

Results: Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively.

Conclusion: Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not.
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http://dx.doi.org/10.1097/HJH.0000000000002982DOI Listing
August 2021

Commentary on the KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD.

Curr Cardiol Rep 2021 08 16;23(9):132. Epub 2021 Aug 16.

University of Utah Health Center, Salt Lake City, UT, USA.

Purpose Of Review: To summarize and explain the new guideline on blood pressure (BP) management in chronic kidney disease (CKD) published by Kidney Disease: Improving Global Outcomes (KDIGO), an independent global nonprofit organization which develops and implements evidence-based clinical practice guidelines in kidney disease. KDIGO issued its first clinical practice guideline for the Management of Blood Pressure (BP) in Chronic Kidney Disease (CKD) for patients not receiving dialysis in 2012 and now updated the guideline in 2021.

Recent Findings: Recommendations in this update were developed based on systematic literature reviews and appraisal of the quality of the evidence and strength of recommendation following the "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) approach. The updated guideline includes five chapters covering BP measurement techniques, lifestyle interventions for lowering BP, and management of BP in three target populations, namely adults (with and without diabetes), kidney transplant recipients, and children. A dedicated chapter on BP measurement emphasizing standardized preparation and measurement protocols for office BP measurement is a new addition, following protocols used in large randomized trials of BP targets with pivotal clinical outcomes. Based on the available evidence, and in particular in the CKD subgroup of the SPRINT trial, the 2021 guideline suggests a systolic BP target of <120 mm Hg, based on standardized measurements, for most individuals with CKD not receiving dialysis, with the exception of kidney transplant recipients and children. This recommendation is strictly contingent on the measurement of BP using standardized office readings and not routine office readings.
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http://dx.doi.org/10.1007/s11886-021-01559-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366157PMC
August 2021

Number and timing of ambulatory blood pressure monitoring measurements.

Hypertens Res 2021 Aug 11. Epub 2021 Aug 11.

Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA.

Ambulatory blood pressure (BP) monitoring (ABPM) may cause sleep disturbances. Some home BP monitoring (HBPM) devices obtain a limited number of BP readings during sleep and may be preferred to ABPM. It is unclear how closely a few BP readings approximate a full night of ABPM. We used data from the Jackson Heart (N = 621) and Coronary Artery Risk Development in Young Adults (N = 458) studies to evaluate 74 sampling approaches to estimate BP during sleep. We sampled two to four BP measurements at specific times from a full night of ABPM and computed chance-corrected agreement (i.e., kappa) of nocturnal hypertension (i.e., mean asleep systolic BP ≥ 120 mmHg or diastolic BP ≥ 70 mmHg) defined using the full night of ABPM and subsets of BP readings. Measuring BP at 2, 3, and 4 h after falling asleep, an approach applied by some HBPM devices obtained a kappa of 0.81 (95% confidence interval [CI]: 0.78, 0.85). The highest kappa was obtained by measuring BP at 1, 2, 4, and 5 h after falling asleep: 0.84 (95% CI: 0.81, 0.87). In conclusion, measuring BP three or four times during sleep may have high agreement with nocturnal hypertension status based on a full night of ABPM.
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http://dx.doi.org/10.1038/s41440-021-00717-yDOI Listing
August 2021

Social Determinants of Health: Past, Current, and Future Threats to Hypertension and Blood Pressure Control.

Am J Hypertens 2021 08;34(7):680-682

Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1093/ajh/hpab023DOI Listing
August 2021

Polypharmacy and mortality association by chronic kidney disease status: The REasons for Geographic And Racial Differences in Stroke Study.

Pharmacol Res Perspect 2021 08;9(4):e00823

Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA.

Many Americans take multiple medications simultaneously (polypharmacy). Polypharmacy's effects on mortality are uncertain. We endeavored to assess the association between polypharmacy and mortality in a large U.S. cohort and examine potential effect modification by chronic kidney disease (CKD) status. The REasons for Geographic And Racial Differences in Stroke cohort data (n = 29 627, comprised of U.S. black and white adults) were used. During a baseline home visit, pill bottle inspections ascertained medications used in the previous 2 weeks. Polypharmacy status (major [≥8 ingredients], minor [6-7 ingredients], and none [0-5 ingredients]) was determined by counting the total number of generic ingredients. Cox models (time-on-study and age-time-scale methods) assessed the association between polypharmacy and mortality. Alternative models examined confounding by indication and possible effect modification by CKD. Over 4.9 years median follow-up, 2538 deaths were observed. Major polypharmacy was associated with increased mortality in all models, with hazard ratios and 95% confidence intervals ranging from 1.22 (1.07-1.40) to 2.35 (2.15-2.56), with weaker associations in more adjusted models. Minor polypharmacy was associated with mortality in some, but not all, models. The polypharmacy-mortality association did not differ by CKD status. While residual confounding by indication cannot be excluded, in this large American cohort, major polypharmacy was consistently associated with mortality.
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http://dx.doi.org/10.1002/prp2.823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328192PMC
August 2021

Higher Serum Urate Levels Are Associated With an Increased Risk for Sudden Cardiac Death.

J Rheumatol 2021 11 15;48(11):1745-1753. Epub 2021 Jun 15.

L.D. Colantonio, MD, PhD, N.S. Chaudhary, MBBS, MPH, N.D. Armstrong, PhD, P. Muntner, PhD, M.R. Irvin, PhD, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Objective: To determine the association of serum urate (SU) levels with sudden cardiac death and incident coronary heart disease (CHD), separately, among adults without a history of CHD.

Methods: We conducted a case-cohort analysis of Black and White participants aged ≥ 45 years enrolled in the REason for Geographic And Racial Differences in Stroke (REGARDS) study without a history of CHD at baseline between 2003 and 2007. Participants were followed for sudden cardiac death or incident CHD (i.e., myocardial infarction [MI] or death from CHD excluding sudden cardiac death) through December 31, 2013. Baseline SU was measured in a random sample of participants (n = 840) and among participants who experienced sudden cardiac death (n = 235) or incident CHD (n = 851) during follow-up.

Results: Participants with higher SU levels were older and more likely to be male or Black. The crude HR (95% CI) per 1 mg/dL higher SU level was 1.26 (1.14-1.40) for sudden cardiac death and 1.17 (1.09-1.26) for incident CHD. After adjustment for age, sex, race, and cardiovascular risk factors, the HR (95% CI) per 1 mg/dL higher SU level was 1.19 (1.03-1.37) for sudden cardiac death and 1.05 (0.96-1.15) for incident CHD. HRs for sudden cardiac death were numerically higher among participants aged 45-64 vs ≥ 65 years, without vs with diabetes, and among those of White vs Black race, although values for effect modification were all ≥ 0.05.

Conclusion: Higher SU levels were associated with an increased risk for sudden cardiac death but not with incident CHD.
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http://dx.doi.org/10.3899/jrheum.210139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8563440PMC
November 2021

Together, We've Got This: The US Surgeon General's Call-to-Action on Hypertension Control.

Am J Hypertens 2021 09;34(9):893-894

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

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http://dx.doi.org/10.1093/ajh/hpaa172DOI Listing
September 2021

Lifestyle behaviors among adults recommended for ambulatory blood pressure monitoring according to the 2017 ACC/AHA blood pressure guideline.

Am J Hypertens 2021 Jul 16. Epub 2021 Jul 16.

Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.

Background: The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends ambulatory BP monitoring (ABPM) to exclude white coat hypertension (WCH) among adults with office systolic BP (SBP)/diastolic BP (DBP) of 130-159/80-99 mmHg, and masked hypertension (MHT) among adults with office SBP/DBP of 120-129/75-79 mmHg after a 3-month trial of lifestyle modification. We estimated the proportion of individuals with ideal lifestyle factors among those who meet these office BP criteria for being recommended ABPM.

Methods: We analyzed data from participants not taking antihypertensive medication in the Coronary Artery Risk Development in Young Adults (CARDIA) and Jackson Heart Study (JHS) who met the office BP criteria for screening for WCH (CARDIA n=490, JHS n=873) and MHT (CARDIA n=486, JHS n=614). We estimated the prevalence of lifestyle factors including ideal body mass index (BMI), physical activity, diet and alcohol use among participants who met office BP criteria for WCH screening and for MHT screening.

Results: Among participants who met office BP criteria for WCH screening, 15.5% in CARDIA and 3.6% in JHS had 3 or more ideal lifestyle factors. Among participants who met office BP criteria for MHT screening, 22.6% in CARDIA and 4.7% in JHS had 3 or more ideal lifestyle factors. Ideal BMI, diet, and physical activity was present in less than half of participants in each sample who met office BP criteria for WCH or MHT screening.

Conclusions: Few participants who met office BP criteria for the screening of WCH or MHT had ideal lifestyle factors.
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http://dx.doi.org/10.1093/ajh/hpab110DOI Listing
July 2021

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension.

J Hypertens 2021 09;39(9):1742-1767

Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.
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http://dx.doi.org/10.1097/HJH.0000000000002922DOI Listing
September 2021

Sustained SBP control and long-term nursing home admission among Medicare beneficiaries.

J Hypertens 2021 11;39(11):2258-2264

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Objectives: Sustaining SBP control reduces the risk for cardiovascular events that impair function but its association with nursing home admission has not been well studied.

Methods: We conducted an analysis of sustained SBP control and long-term nursing home admissions using data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims restricted to participants with fee-for-service coverage, at least eight study visits with SBP measurements, who were not living in a nursing home during a 48-month baseline BP assessment period (n = 6557). Sustained SBP control was defined as less than 140 mmHg at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits. Nursing home admissions were identified using the Medicare Long Term Care Minimum Data Set.

Results: The mean age of participants was 73.8 years and 44.3% were men. Over a median follow-up of 9.2 years, 844 participants (12.8%) had a nursing home admission. Rates of nursing home admission per 100 person-years were 16.3 for participants with SBP control at less than 50%, 14.1 at 50% to less than 75%, 7.8 at 75% to less than 100%, and 5.3 at 100% of visits. Compared with those with sustained SBP control at less than 50% of visits, hazard ratios (95% confidence intervals) for nursing home admission were 0.79 (0.66-0.93), 0.70 (0.58-0.84), and 0.57 (0.44-0.74) among participants with SBP control at 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively.

Conclusion: Among Medicare beneficiaries in ALLHAT, sustained SBP control was associated with a lower risk of long-term nursing home admission.
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http://dx.doi.org/10.1097/HJH.0000000000002926DOI Listing
November 2021

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.

Am J Hypertens 2021 10;34(10):1037-1041

Department of Preventive Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA.

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.
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http://dx.doi.org/10.1093/ajh/hpab099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8557418PMC
October 2021

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline.

Ann Intern Med 2021 09 22;174(9):1270-1281. Epub 2021 Jun 22.

Tufts University, Boston, Massachusetts (M.J.S.).

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline.

Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020.

Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.
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http://dx.doi.org/10.7326/M21-0834DOI Listing
September 2021

Inequities in Hypertension Control in the United States Exposed and Exacerbated by COVID-19 and the Role of Home Blood Pressure and Virtual Health Care During and After the COVID-19 Pandemic.

J Am Heart Assoc 2021 06 19;10(11):e020997. Epub 2021 May 19.

Division of General Internal Medicine, Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.

The COVID-19 pandemic is a public health crisis, having killed more than 514 000 US adults as of March 2, 2021. COVID-19 mitigation strategies have unintended consequences on managing chronic conditions such as hypertension, a leading cause of cardiovascular disease and health disparities in the United States. During the first wave of the pandemic in the United States, the combination of observed racial/ethnic inequities in COVID-19 deaths and social unrest reinvigorated a national conversation about systemic racism in health care and society. The 4th Annual University of Utah Translational Hypertension Symposium gathered frontline clinicians, researchers, and leaders from diverse backgrounds to discuss the intersection of these 2 critical social and public health phenomena and to highlight preexisting disparities in hypertension treatment and control exacerbated by COVID-19. The discussion underscored environmental and socioeconomic factors that are deeply embedded in US health care and research that impact inequities in hypertension. Structural racism plays a central role at both the health system and individual levels. At the same time, virtual healthcare platforms are being accelerated into widespread use by COVID-19, which may widen the divide in healthcare access across levels of wealth, geography, and education. Blood pressure control rates are declining, especially among communities of color and those without health insurance or access to health care. Hypertension awareness, therapeutic lifestyle changes, and evidence-based pharmacotherapy are essential. There is a need to improve the implementation of community-based interventions and blood pressure self-monitoring, which can help build patient trust and increase healthcare engagement.
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http://dx.doi.org/10.1161/JAHA.121.020997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483507PMC
June 2021

Team Science: American Heart Association's Hypertension Strategically Focused Research Network Experience.

Hypertension 2021 Jun 3;77(6):1857-1866. Epub 2021 May 3.

Internal Medicine (T.A.K., S.K.), Medical College of Wisconsin, Milwaukee, WI.

In 2015, the American Heart Association awarded 4-year funding for a Strategically Focused Research Network focused on hypertension composed of 4 Centers: Cincinnati Children's Hospital, Medical College of Wisconsin, University of Alabama at Birmingham, and University of Iowa. Each center proposed 3 integrated (basic, clinical, and population science) projects around a single area of focus relevant to hypertension. Along with scientific progress, the American Heart Association put a significant emphasis on training of next-generation hypertension researchers by sponsoring 3 postdoctoral fellows per center over 4 years. With the center projects being spread across the continuum of basic, clinical, and population sciences, postdoctoral fellows were expected to garner experience in various types of research methodologies. The American Heart Association also provided a number of leadership development opportunities for fellows and investigators in these centers. In addition, collaboration was highly encouraged among the centers (both within and outside the network) with the American Heart Association providing multiple opportunities for meeting and expanding associations. The area of focus for the Cincinnati Children's Hospital Center was hypertension and target organ damage in children utilizing ambulatory blood pressure measurements. The Medical College of Wisconsin Center focused on epigenetic modifications and their role in pathogenesis of hypertension using human and animal studies. The University of Alabama at Birmingham Center's areas of research were diurnal blood pressure patterns and clock genes. The University of Iowa Center evaluated copeptin as a possible early biomarker for preeclampsia and vascular endothelial function during pregnancy. In this review, challenges faced and successes achieved by the investigators of each of the centers are presented.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16296DOI Listing
June 2021
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