Faculty Bibliography

BACKGROUND: The optimal blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg albeit with an increase in serious adverse effects related to low BP. METHODS: PUBMED, EMBASE, and CENTRAL were searched for randomized trials comparing treating to different BP targets. Trial arms were grouped into five systolic BP target categories: 1) <160 mm Hg; 2) <150 mm Hg; 3) <140 mm Hg; 4) <130 mm Hg and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure and safety outcomes of serious adverse effects were evaluated using a network meta-analysis. RESULTS: Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (RR=0.54; 95% CI 0.29-1.00) and myocardial infarction (RR=0.68; 95% CI 0.47-1.00) with systolic BP <120 mm Hg (vs. <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97% and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg and <160 mm respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2 respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs. <150 mm Hg (RR=1.83; 95% CI 1.05-3.20) or vs. <140 mm Hg (RR=2.12; 95% CI 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2 respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety. CONCLUSIONS: In patients with hypertension, a systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.

The metabolic syndrome is associated with higher ambulatory blood pressure. The authors studied the association of metabolic syndrome and masked hypertension (MHT) among African Americans with clinic-measured systolic/diastolic blood pressure (SBP/DBP) <140/90 mm Hg in the Jackson Heart Study. MHT was defined as daytime, nighttime, or 24-hour hypertension on ambulatory blood pressure monitoring. Among 359 participants not taking antihypertensive medication, the metabolic syndrome was associated with MHT (prevalence ratio, 1.38; 95% confidence interval, 1.10-1.74]). When metabolic syndrome components (clinic SBP/DBP 130-139/85-89 mm Hg, abdominal obesity, impaired glucose, low high-density lipoprotein cholesterol, high triglycerides) were analyzed separately, only clinic SBP/DBP 130-139/85-89 mm Hg was associated with MHT (prevalence ratio, 1.90; 95% confidence interval, 1.56-2.32]). The metabolic syndrome was not associated with MHT among participants not taking antihypertensive medication with SBP/DBP 130-139/85-89 and <130/85 mm Hg, separately, or among participants taking antihypertensive medication (n=393). Ambulatory blood pressure monitoring screening for MHT among African Americans should be considered based on clinic BP, not metabolic syndrome.

Blood pressure (BP) can differ substantially when measured in the clinic versus outside of the clinic setting. Few population-based studies with ambulatory blood pressure monitoring (ABPM) include African Americans. We calculated the prevalence of clinic hypertension and ABPM phenotypes among 1016 participants in the population-based Jackson Heart Study, an exclusively African-American cohort. Mean daytime systolic BP was higher than mean clinic systolic BP among participants not taking antihypertensive medication (127.1[standard deviation 12.8] vs. 124.5[15.7] mm Hg, respectively) and taking antihypertensive medication (131.2[13.6] vs. 130.0[15.6] mm Hg, respectively). Mean daytime diastolic BP was higher than clinic diastolic BP among participants not taking antihypertensive medication (78.2[standard deviation 8.9] vs. 74.6[8.4] mm Hg, respectively) and taking antihypertensive medication (77.6[9.4] vs. 74.3[8.5] mm Hg, respectively). The prevalence of daytime hypertension was higher than clinic hypertension for participants not taking antihypertensive medication (31.8% vs. 14.3%) and taking antihypertensive medication (43.0% vs. 23.1%). A high percentage of participants not taking and taking antihypertensive medication had nocturnal hypertension (49.4% and 61.7%, respectively), white-coat hypertension (30.2% and 29.3%, respectively), masked hypertension (25.4% and 34.6%, respectively), and a nondipping BP pattern (62.4% and 69.6%, respectively). In conclusion, these data suggest hypertension may be misdiagnosed among African Americans without using ABPM.

BACKGROUND: Poor medication adherence is a significant public health problem in patients with hypertension. The patient-physician relationship offers an ideal opportunity to address patient non-adherence as physicians' communication skills contribute to as much as 50%of the quality of care patients' receive. Despite this evidence, there is no empirical data on how the informational and relational aspects of patient-physician communication affect patient's actual medication-taking behaviors. The aim of this study was to evaluate the impact of patient-physician communication on medication adherence among a sample of primary care physicians and their Black and White hypertensive patients. METHODS: Cohort study of 92 hypertensive patients (mean age: 60 years) and 27 primary care physicians (mean age: 36 years) in two safety-net primary care practices in New York City. Patient-physician encounters were audiotaped at baseline; medication adherence data were gathered continuously over the 3- month study with an electronic monitoring device. Audiotape analyses of patient physician communication were coded using the Medical Interaction Process System. Six categories of communication were computed: 1) patient centeredness; 2) patient assertiveness; 3) psychosocial focus; 4) information exchange; 5) physician disclosure-promoting; and 6) physician verbal dominance. Frequencies of content codes were also calculated for the proportion of the discussion specific to: hypertension; antihypertensive medications; patient-physician social conversation; and discussions about patient's social circumstances (i.e., patient's living situation, relationship with spouse/partner). Adaptive statistical modeling methods based on likelihood cross validation were used to analyze the adherence data. RESULTS: The majority of patients were Black, 58% women, and most were seeing the same physician for at least 1 year. Approximately half of physicians were White (56%), 67% women, and have been in practice for 6 years. Fifty eight percent of patients exhibited poor adherence to prescribed antihypertensive medications. Two categories of patient-physician communication predicted poor medication adherence in the multivariate adaptive logistic regression model: fewer discussions about patients' social circumstances (OR: 6.03, 95CI:2.15- 17) and about their antihypertensive medications (OR: 5.64, 95CI:1.49-21.3). CONCLUSIONS: The odds of poor medication adherence are nearly six times greater when patient-physician interactions do not address patients' social circumstances or their medication regimen. These findings support the importance of adherence counseling and attending to the social determinants of health in routine care of low-income patients in ambulatory practices

BACKGROUND: The purpose of this study was to explore stakeholders' perception of an on-going evidence-based task-shifting strategy for hypertension (TASSH) in 32 community health centers and district hospitals in Ghana. METHODS: Using focus group discussions and in-depth interviews, qualitative data were obtained from 81 key stakeholders including patients, nurses, and site directors of participating community health centers involved in the TASSH trial. Qualitative data were analyzed using open and axial coding techniques. RESULTS: Analysis of the qualitative data revealed three themes that illustrate stakeholders' perceptions of the ongoing task-shifting strategy for blood pressure control in Ghana and they include: 1) awareness and understanding of the TASSH program; 2) reasons for participation and non-participation in TASSH; and 3) the benefit and drawbacks to the TASSH program. CONCLUSION: The findings support evidence that successful implementation of any task-shifting strategy must focus not only on individual patient characteristics, but also consider the role contextual factors such as organizational and leadership factors play. The findings also demonstrate the importance of understanding stakeholder's perceptions of evidence-based task-shifting interventions for hypertension control as it may ultimately influence the sustainable uptake of these interventions into "real world" settings.

BACKGROUND: Clinical guidelines recommend using predicted atherosclerotic cardiovascular disease (ASCVD) risk to inform treatment decisions. The objective was to compare the contribution of changes in modifiable risk factors versus aging to the development of high 10-year predicted ASCVD risk. METHODS AND RESULTS: A prospective follow-up was done of the Jackson Heart Study, an exclusively black cohort at visit 1 (2000-2004) and visit 3 (2009-2012). Analyses included 1115 black participants without high 10-year predicted ASCVD risk (<7.5%), hypertension, diabetes mellitus, or ASCVD at visit 1. We used the Pooled Cohort equations to calculate the incidence of high (>/=7.5%) 10-year predicted ASCVD risk at visit 3. We recalculated the percentage with high 10-year predicted ASCVD risk at visit 3 assuming each risk factor (age, systolic blood pressure, antihypertensive medication use, diabetes mellitus, smoking, total and high-density lipoprotein cholesterol), one at a time, did not change from visit 1. The mean age at visit 1 was 45.2+/-9.5 years. Overall, 30.9% (95% CI 28.3-33.4%) of participants developed high 10-year predicted ASCVD risk. Aging accounted for 59.7% (95% CI 54.2-65.1%) of the development of high 10-year predicted ASCVD risk compared with 32.8% (95% CI 27.0-38.2%) for increases in systolic blood pressure or antihypertensive medication initiation and 12.8% (95% CI 9.6-16.5%) for incident diabetes mellitus. Among participants <50 years, the contribution of increases in systolic blood pressure or antihypertensive medication initiation was similar to aging. CONCLUSIONS: Increases in systolic blood pressure and antihypertensive medication initiation are major contributors to the development of high 10-year predicted ASCVD risk in blacks, particularly among younger adults.