Faculty Bibliography

BACKGROUND: Clinical trial evidence suggests poorer outcomes in blacks compared with whites when treated with an angiotensin-converting enzyme (ACE) inhibitor-based regimen, but this has not been evaluated in clinical practice. OBJECTIVES: This study evaluated the comparative effectiveness of an ACE inhibitor-based regimen on a composite outcome of all-cause mortality, stroke, and acute myocardial infarction (AMI) in hypertensive blacks compared with whites. METHODS: We conducted a retrospective cohort study of 434,646 patients in a municipal health care system. Four exposure groups (Black-ACE, Black-NoACE, White-ACE, White-NoACE) were created based on race and treatment exposure (ACE or NoACE). Risk of the composite outcome and its components was compared across treatment groups and race using weighted Cox proportional hazard models. RESULTS: Our analysis included 59,316 new users of ACE inhibitors, 47% of whom were black. Baseline characteristics were comparable for all groups after inverse probability weighting adjustment. For the composite outcome, the race treatment interaction was significant (p = 0.04); ACE use in blacks was associated with poorer cardiovascular outcomes (ACE vs. NoACE: 8.69% vs. 7.74%; p = 0.05) but not in whites (6.40% vs. 6.74%; p = 0.37). Similarly, the Black-ACE group had higher rates of AMI (0.46% vs. 0.26%; p = 0.04), stroke (2.43% vs. 1.93%; p = 0.05), and congestive heart failure (3.75% vs. 2.25%; p < 0.0001) than the Black-NoACE group. However, the Black-ACE group was no more likely to develop adverse effects than the White-ACE group. CONCLUSIONS: ACE inhibitor-based therapy was associated with poorer cardiovascular outcomes in hypertensive blacks but not in whites. These findings confirm clinical trial evidence that hypertensive blacks have poorer outcomes than whites when treated with an ACE inhibitor-based regimen.

INTRODUCTION: Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed. METHODS AND ANALYSIS: We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD. ETHICS AND DISSEMINATION: This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations. CONCLUSIONS: IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.

Poor adherence to prescribed medication regimens remains an important challenge preventing successful treatment of cardiovascular diseases such as hypertension. While studies have documented differences in the time of day or weekday vs weekend on medication adherence, no study has examined whether having a medication-taking routine contributes to increased medication adherence. The purpose of this study was to: (1) identify patients' sociodemographic factors associated with consistent medication-taking routine; (2) examine associations between medication-taking consistency, medication adherence, and blood pressure (BP) control. The study included black patients with hypertension (n = 190; 22 men and 168 women; age, mean+/-standard deviation 54 +/- 12.08 years) who completed a practice-based randomized controlled trial. Findings showed that medication-taking consistency was significantly associated with better medication adherence (F = 9.54, P = .002). Associations with the consistency index were not statistically significant for diastolic BP control (odds ratio, 1.319; 95% confidence interval, 0.410-4.246; P = .642) and systolic BP control (odds ratio, 0.621; 95% confidence interval, 0.195-1.974; P = .419).

Cardiovascular disease (CVD) is a major contributor to the growing public health epidemic in chronic diseases. Much of the disease and disability burden from CVDs are in people younger than the age of 70 years in low- and middle-income countries, formerly "the developing world." The risk of CVD is heavily influenced by environmental conditions and lifestyle variables. In this article we review the scope of the CVD problem in low- and middle-income countries, including economic factors, risk factors, at-risk groups, and explanatory frameworks that hypothesize the multifactorial drivers. Finally, we discuss current and potential interventions to reduce the burden of CVD in vulnerable populations including research needed to evaluate and implement promising solutions for those most at risk.

BACKGROUND: This study ascertained whether individuals of the black race/ethnicity are unequally burdened by sleep-related overweight/obesity. METHODS: Analysis was based on data obtained from Americans (ages, 18-85 years) in the National Health Interview Survey (1977-2009). Sleep duration was coded as either very short sleep (VSS) (8 hours), referenced to 7-8-hour sleepers. Overweight was defined as body mass index (BMI) >/=25.0 and /=30 kg/m2, referenced to normal weight (BMI = 18.5-24.9 kg/m2). RESULTS: Multivariate-adjusted regression analyses indicated that, among whites, VSS was associated with a 10% increased likelihood of being overweight and 51% increased likelihood of being obese, relative to 7-8-hour sleepers. Short sleep was associated with a 13% increased likelihood of being overweight and 45% increased likelihood of being obese. Long sleep was associated with 21% increased likelihood of being obese. Among blacks, VSS was associated with a 76% increased likelihood of being overweight and 81% increased likelihood of being obese. Short sleep was associated with a 16% increased likelihood of being overweight and 32% increased likelihood of being obese. As for the white stratum, long sleep was associated with a 25% increased likelihood of being obese. CONCLUSION: Our investigation demonstrates strong linkages between inadequate sleep and overweight/ obesity among black and white Americans. Although it cannot be said that insufficient sleep causes overweight/obesity, individuals of the black race/ethnicity sleeping