Faculty Bibliography

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

BACKGROUND: Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension. METHODS/DESIGN: A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing. DISCUSSION: The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.

Study Objectives: This study assessed knowledge and attitudes toward obstructive sleep apnea (OSA) among community physicians and explored factors that are associated with referrals for OSA evaluation. Methods: Medical students and residents collected data from a convenience sample of 105 physicians practicing at community-based clinics in a large metropolitan area. Average age was 48 +/- 14 years; 68% were male, 70% black, 24% white, and 6% identified as "other." Physicians completed the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire. Results: The average year in physician practice was 18 +/- 19 years. Of the sample, 90% reported providing care to black patients. The overall OSA referral rate made by physicians was 75%. OSA knowledge and attitudes scores ranged from 5 to 18 (mean = 14 +/- 2) and from 7 to 20 (mean = 13 +/- 3), respectively. OSA knowledge was associated with white race/ethnicity (rp = 0.26, p < 0.05), fewer years in practice (rp = -0.38, p < 0.01), patients inquiring about OSA (rp = 0.31, p < 0.01), and number of OSA referrals made for OSA evaluation (rp = 0.30, p < 0.01). Positive attitude toward OSA was associated with patients inquiring about OSA (rp = 0.20, p < 0.05). Adjusting for OSA knowledge and attitudes showed that physicians whose patients inquired about OSA were nearly 10 times as likely to make a referral for OSA evaluation (OR = 9.38, 95% CI: 2.32 - 38.01, p < 0.01). Conclusion: Independent of physicians' knowledge and attitudes toward obstructive sleep apnea, the likelihood of making a referral for obstructive sleep apnea evaluation was influenced by whether patients inquired about the condition.

Environmental factors, such as noise exposure and air pollution, are associated with hypertension. These environmental factors also affect sleep quality. Given the growing evidence linking sleep quality with hypertension, the purpose of this review is to investigate the role of sleep as a key mediator in the association between hypertension and environmental factors. Through this narrative review of the extant literature, we highlight that poor sleep quality mediates the relationship between environmental factors and hypertension. The conceptual model proposed in this review offers opportunities to address healthcare disparities in hypertension among African Americans by highlighting the disparate impact that the predictors (environmental factors) and mediator (sleep) have on the African-American community. Understanding the impact of these factors is crucial since the main outcome variable (hypertension) severely burdens the African-American community.

Introduction: Previous research has found that long sleep is associated with a myriad of negative outcomes. These studies have been epidemiological, with large samples but without validated measures of sleep-related outcomes. Few studies have examined subjective sleepiness and fatigue levels in the context of long sleep among older adults. The present study examined differences between average and long sleeping older adults on measures of sleepiness and fatigue. We hypothesized that both sleepiness and fatigue would be higher among the long-sleeping compared with the average-sleeping older adults. Methods: Participants were 41 older adults (31 female; mean age 65.0, range 60-77). Exclusion criteria included sleep medication use, excessive napping, severe medical disorders, > 30 mins TIB intentionally awake, TIB < 6 hrs, 7.25-8 hrs, or > 9.25 hrs, and OSA (AHI > 15) as assessed by ambulatory peripheral arterial tonometry. Participants completed two weeks of sleep diaries and actigraphy and were classified as average sleepers (median 2-week TIB: 6-7.25 h, N = 22) or long sleepers (median 2-week TIB: 8-9.25 h, N = 19). Participants then completed the Epworth Sleepiness Scale (ESS) and Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF). Results: On the ESS, average sleepers indicated greater sleepiness (6.2 +/- 3.4) than long sleepers (3.7 +/- 2.8), p < 0.02, d = 0.80. There were no significant group differences on the MFSI-SF, with average sleepers reporting similar levels of fatigue (14.95 +/- 11.7) as long sleepers (12.26 +/- 13.3), p = 0.46. Conclusion: Lower levels of sleepiness among long sleepers is inconsistent with previous research. That we found a difference in sleepiness, but not in fatigue suggests that this may not simply be due to measurement effects. Since all participants were healthy, longer sleep time may leave these long sleepers better rested. Future research should include larger sample sizes and objective measures of sleepiness to clarify the differences between these groups