Faculty Bibliography

The 2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) raised the systolic blood pressure (SBP) threshold for treatment initiation and goal attainment to 150 mm Hg in adults 60 years and older without a history of diabetes or chronic kidney disease (CKD). Using data from the nationwide Reasons for Geographic and Racial Difference in Stroke (REGARDS) study linked with Medicare claims, we examined the association between SBP levels and coronary heart disease (CHD), stroke, cardiovascular disease (CVD), heart failure, and serious injurious fall events among adults > 65 years of age taking antihypertensive medication. We excluded participants with a history of diabetes, CKD, and diastolic blood pressure > 90 mm Hg. Baseline REGARDS data were collected during telephone interviews and in-home study visits in 2003 through 2007 and included two blood pressure measurements following a standardized protocol. SBP was categorized as < 140 mm Hg, 140-149 mm Hg, and > 150 mm Hg. Outcomes were identified through December 31, 2011 using primary data collection and Medicare claims. Of the 2,279 REGARDS participants taking antihypertensive medications with Medicare linked data (mean age 72.2 years, 54.8% female), 309 (13.6%) had SBP of 140 to 149 mm Hg and 200 (8.8%) had SBP > 150 mm Hg. After multivariable adjustment, SBP of 140 to 149 mm Hg versus SBP < 140 mm Hg was not associated with any of the outcomes (Table 1) whereas SBP > 150 mm Hg was associated with an increased risk for CVD. In summary, SBP levels between 140 and 149 mm Hg were not associated with CVD-related outcomes or falls in comparison to SBP < 140 mm Hg among adults > 65 years taking antihypertensive medication. These data suggest the higher SBP threshold for treatment initiation and goal attainment among individuals > 65 years of age without a history of diabetes or CKD, with

The poor rate of adherence to anti-hypertensive medication is most pervasive and predominant among adult blacks. Unfortunately, patient factors contributing to poor adherence are poorly understood. The present study examined whether patients' expectation of care influenced the relationships of hypertension (HTN) knowledge and perception of social support to medication adherence among hypertensive blacks. Data were analyzed from the Counseling African Americans to Control Hypertension (CAATCH) trial. In this randomized clinical trial, participants (N=1,038; females 70.4%; mean age of 56.57+/-12.18) were hypertensive adult patients from 30 Community Health Centers across the New York City Metropolitan area. Of the trial participants, 56.6% had a high school education or less; 63% were unemployed; 91% had health insurance; and 71% had an income of <$20,000. Of the entire sample, 62.9% were non-adherent. Mixed-effects regression models were used to assess the mediating role of expectation of care on the relationships between HTN knowledge and medication adherence and between perception of social support and medication adherence. Covariates included age, sex, education, income, employment, and insurance. The results showed that greater expectation of care was associated with higher levels of medication adherence (F=6.49; p=0.011; Est. =0.042; S.E. =0.016). Increased perception of social support was associated with medication adherence (F=5.31; p=.021; Est. =0.129; S.E. =0.056). Also, expectation of care mediated the relationship between HTN knowledge and medication adherence (Estimated Indirect Effect= 0.130), (p<0.001). Our study indicated that patients' expectation of care and perceived social support may be important facilitators for developing knowledge-based interventions to increase medication adherence in blacks

Purpose: Blacks are less likely to develop metabolic syndrome (MetS), a known cardiovascular risk factor. These findings should be interpreted cautiously because Blacks may not fit into the gold-standard diagnostic criteria and report lower lipid profiles levels. To resolve this issue, we suggest reclassifying the relative weighted effects of each MetS component in a diagnostic risk model. We argue that uncontrolled blood pressure is the strongest predictor of MetS in Blacks, because it causes obstructive sleep apnea (OSA), a known MetS risk factor. Method: Data were collected from 340 participants from the MetS Outcome study, a NIH-funded cohort study of 1,035 Blacks with MetS (mean age=62+/-13 years, 69% female, and 43% with annual family income <$10K). Patients with a BP <140/80 mm/Hg after several antihypertensive medications had uncontrolled BP and a score >6 on the Apnea Risk Evaluation System (ARES+/-) were considered high OSA risk. Results: 77.1% was at risk for OSA and 16.8% had uncontrolled BP. Mean systolic BP was 134.8+/-18.4; diastolic BP was 75.6+/-11.9; LDL cholesterol was 105.6+/-36.9; HDL cholesterol was 48.0+/-17.3; triglycerides were 135.8+/-81.2; glucose was 138.4+/-68.3; and HbA1c was 7.93+/-1.63. Uncontrolled BP increased the odds of OSA risk (OR=1.94, 95% CI=1.12-3.32, p<0.01) and was the strongest predictor of MetS in Blacks. Conclusion: Uncontrolled BP was associated with a twofold greater risk of OSA and the strongest predictor of MetS in Blacks. Blacks, therefore, with uncontrolled BP should be screened for the presence of OSA and MetS

Purpose: Resistant hypertension (RHTN) is an important condition affecting 3-29% of the US population, albeit more common among blacks. We evaluated associations of RHTN with short sleep among blacks. Method: Data came from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study characterizing metabolic syndrome (MetS) among blacks. Analysis was based on 883 patients (mean age: 62+/-14years; female: 69.2%). MetS was defined according to criteria from the Adult Treatment Panel (ATP III). RHTN was defined as failure to achieve blood pressure goal (BP) of <140/90 mm/Hg or <130/80 mm/Hg among patients with diabetes or kidney disease when on maximal doses of a three-drug regimen. This also includes patients requiring more medications to achieve BP goal. Short sleep, derived from subjective reports, was defined as <7hours nightly referenced to healthy sleep (7-8hours). OSA risk was assessed using the Apnea Risk Evaluation System (ARESTM); patients with a score >6 were considered at high OSA risk, based on validated studies. Results: Most (90.4%) were overweight/obese; 61.4% had diabetes; 74.8%, dyslipidemia; 30.2%, heart disease; and 48% were at OSA risk. Overall, 92.6% had HTN, and 20.8% met criteria for RHTN. Analyses showed no significant difference in HTN prevalence comparing short (93.1%), and healthy sleepers (91.4%) but those with RHTN were more likely to be short sleepers (26.8% vs. 14.9%, p<0.001). Based on logistic regression analysis, adjusting for effects of age, sex and medical comorbidities, patients with RHTN had increased odds of being short sleepers (OR=1.90, 95% CI: 1.27-2.90, p=0.002). Of interest, odds of being short sleepers among those at OSA risk were similar (OR=1.92, 95% CI: 1.38-2.68, p<0.001). Conclusion: Among blacks with metabolic syndrome, patients meeting criteria for RHTN showed a twofold greater likelihood of being short sleepers. Adjusted odds of short sleep were remarkably similar to those observed for patients at OSA risk

Purpose: Despite significant advances in the management of hypertension over the last 40 years, blacks are still disproportionately burdened by this condition. The aim of the present study was to assess the prevalence of hypertension between black and white adults in the United States over a forty-year span. Method: We used data from the National Health Interview Survey (NHIS) dataset beginning in 1983 and ending in 2013. NHIS dataset is an on-going, nationally representative, cross-sectional study of non-institutionalized US adults (> 18 years). This yielded data from 361,024 persons of different birthplaces from 54,612 households. Our sample represented a total of 357,342 adults (Whites = 302,730 and blacks = 58,294). Respondents provided sociodemographic and physician-diagnosed chronic conditions. Results: The average age of black and white adults was 43 years and 45 years, respectively. There were more black (56.0%) than white females (51.2%). Blacks were less likely to complete high school (56.3% vs. 64.4%), be employed in the past 12 months (27.6% vs. 6.1%), or be married (36.3% vs. 58.6%); all p < 0.05. Overall, prevalence of hypertension increased from 24.7% in 1983 to 32.5 in 2013. Over the 40 year period, Blacks consistently reported higher prevalence of hypertension than whites. The difference in adjusted prevalence rates blacks and whites increased from 11.6% in 1985 to 16% in 2010. Age and sex-adjusted logistic regressions showed that US black adults were 1.87 times [OR=1.87, 95% CI=1.76-1.99, p<.001] to report hypertension, compared to white adults. Adjustment for all sociodemographic factors reduced the odds ratio [OR=1.77, 95% CI=1.70-1.84, p<.001]. With further adjustment for health risk and chronic diseases, odds rations were further reduced [OR=1.56, 95% CI=1.50-1.62, p<.001]. Conclusion: Relative to whites, blacks reported higher rates of hypertension over time. The disparity in the prevalence of hypertension between black and white did not decline, and may have increased. More research on the mechanisms of hypertension disparities is needed

Introduction: Growing evidence supports a link of major depressive disorder and anxiety to cardiovascular disease outcome. The study evaluated whether individuals with hypertension are more likely to experience psychological distress. Methods: Data analysis was performed using the National Health Interview Survey (NHIS) dataset data (2004-2013), which applies a stratified multistage sample survey of the resident civilian non-institutionalized population. Respondents provided sociodemographic and physician-diagnosed chronic conditions. Hypertension was self-reported and the Kessler-6 (K6) scale was used to assess psychological distress; a score >13 indicated distress. The hypothesized relationship was tested using a multivariate logistic regression model. Results: Among the participants (N=403,621), 51% were female; overall the mean age (+/-SEM) was 35.3+/-0.02 years) and mean BMI was 27.5+/-0.01 Kg/m2. In the entire sample, the prevalence of hypertension was 28.4%. Hypertension was present among 9.7% of those reporting daily exercise, compared to 18.1% among those who did not (p<0.01). Hypertension was present among 7.5% of alcohol abstainers and 23.3% among current or former alcohol users. The mean age of participants with hypertension was 59.7+/-0.05 years versus 42.5+/-0.05 years for those without the condition. Hypertensives were characterized by a higher prevalence of dyslipidemia (51.4% versus 11.8%, p<0.01), diabetes mellitus (6.7% versus 3.8%, p<0.01), and weak/failing kidney (4.7% versus 0.8%, p<0.01). Multivariate logistic regression, adjusting for cardiovascular risk factors: age, race, BMI, diabetes, physical activity, sleep duration, marital status, educational level, and poverty status, indicated that individuals with hypertension were 30% more likely to experience psychological distress (OR = 1.30, 95% CI=1.16-1.46, p<0.01). There was significant interaction between psychological distress and race (beta=0.09, p<0.01). Conclusion: Results of this study characterized factors associated with the presence of hypertension. Consistent with our hypothesis, individuals with hypertension were more likely to experience psychological distress. Therefore, individuals with hypertension should be screened for the presence of psychological distress

Background: Despite expanding coverage under the Patient Protection and Affordable Care Act (PPACA) of 2010, health utilization and wellness disparities exist across racial and age groups. We hypothesized that rate of wellness assessment indexed by fasting blood sugar and blood lipid levels varied across race and age among individuals with hypertension, regardless of the status of their insurance coverage. Methods: To test our hypotheses, we used the 2010-2013 NHIS dataset. Hypertension was self-reported. Results: Of the sample, 52% were female; mean age (+/-SEM) was 59.5 +/- 0.05 years and mean BMI was 29.5 +/- 0.02 kg/m2. Analysis also showed 74% were white; 20%, black; and 4%, Asian. Ten percent reported no insurance coverage. Chi square analysis showed that there were 9% non-insured whites, 13% non-insured blacks, and 9% non-insured Asians (p<0.01). The rate of non-coverage was 30% for very young adults (18-25 years), 23% for young adults (26-34 years), 15% for middle age adults (35-64 years), and 1% for older adults (> 65 years) (p < 0.01). Among 18-25 years, assessment rates of fasting blood sugar level were 22.1% versus 35.5%, p<0.01; among 25-34 years, they were 25.1% versus 49.7%, p<0.01; among 35-64 years, they were 45.8% versus 68.0%, p<0.01; among those > 65 years, they were 58.6% versus 71.2%, p<0.01. Similarly, lower rates of fasting blood lipid were noted for non-insured hypertensives across the age groups. Among 18-25 years, 32.5% versus 50.1%, p<0.01; among 25-34 years, they were 35.2% versus 66.2%, p<0.01; among 35-64 years, they were 58.1% versus 86.1%, p<0.01; among those > 65 years, they were 73.1% versus 92.2%, p<0.01. Race-based wellness care contrasts between noninsured and insured hypertensives revealed that the rates of annual fasting blood sugar assessment rates were lower among the non-insured. Among Asians rates were (44.1% versus 68.3%, p<0.01); blacks (42.6% versus 66.4%, p<0.01); whites (40.6% versus 72.5%, p<0.01). The non-insured also had fewer assessment rates for fasting lipid. Among Asians rates were (57.2% versus 88.3%, p<0.01); blacks (61.7% versus 88.0%, p<0.01); whites (57.2% versus 87.3%%, p<0.01). Conclusion: Consistent with our hypotheses, individuals with hypertension had varying rates of wellness assessment for blood sugar and blood lipid levels. Results also suggested that the rates of health insurance coverage differed by individuals' age group and race

Background: Short sleep, resulting from sleep disorders or lifestyle choices, is increasingly recognized as an important factor in stroke prevention and management. Recent evidence also suggests that long sleep may also be associated with medical and comorbidities. In a cohort of patients with hypertension, we sought to evaluate whether sleep duration (short or long) is associated with increased stroke risk. Methods: Data from the National Health Interview Survey (2004-2013) were used. NHIS is an on-going nationally representative cross-sectional study of non-institutionalized US adults (> 18 years). Respondents provided sociodemographic and physician-diagnosed chronic conditions. Only those answering "yes" to the question "Have you EVER been told by a doctor or other health professional that you had hypertension, also called high blood pressure?" were included in the analysis. Sleep duration was categorized as very short (<5 hours), short (5-6 hours), healthy (7-8 hours), or long (>8 hours). Self-reported diagnosis of stroke was the main outcome of interest. Result: A total number of 203,794 self-reported hypertensive patients (mean age [+/-SEM] = 59.5 +/- 0.1 years and mean BMI = 29.7 +/- 0.1 kg/m²; 50.2% were female; 15.4%, Black; and 78.6%, White) were studied. Stroke prevalence was 11.2% among very short sleepers, 5.7% among short sleepers, 13.6% among long sleepers and 5.4% among healthy sleepers (p<0.05). Adjusted logistic regressions showed that hypertensive patients reporting very short sleep or long sleep had an increased odds of stroke, relative to healthy sleepers (OR = 1.83; 95% CI = 1.56-2.14), and (OR = 1.74; 95% CI =1.68 - 1.80), respectively. Analysis adjusted for demographic variables, medical comorbidities, smoking history, alcohol intake, and physical activity levels. Conclusion: Hypertensive patients with either very short sleep or long sleep duration had an almost twofold greater likelihood of having a stroke. Healthcare providers caring for hypertensive patients should incorporate a sleep history in their routine examination in order to optimize efforts to prevent or manage stroke