Faculty Bibliography

Background -Data from before the 2000s indicate the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP)>/=140/90 mmHg. Over the past several decades, BP declined and hypertension control has improved. Methods -We estimated the percentage of incident CVD events that occur at SBP/DBP<140/90 mmHg in a pooled analysis of three contemporary US cohorts: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, the Multi-Ethnic Study of Atherosclerosis (MESA), and the Jackson Heart Study (JHS) (n=31,856; REGARDS=21,208; MESA=6,779; JHS=3,869). Baseline study visits were conducted in 2003-2007 for REGARDS, 2000-2002 for MESA, and 2000-2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or non-fatal stroke, non-fatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. Results -Over a mean follow-up of 7.7 years, 2,584 participants had incident CVD events. Overall, 63.0% (95%CI: 54.9%-71.1%) of events occurred in participants with SBP/DBP<140/90 mmHg; 58.4% (95%CI: 47.7%-69.2%) and 68.1% (95%CI: 60.1%-76.0%) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP<140/90 mmHg among those <65 years (66.7%; 95%CI: 60.5%-73.0%) and >/=65 years (60.3%; 95%CI: 51.0%-69.5%), women (61.4%; 95%CI: 49.9%-72.9%) and men (63.8%; 95%CI: 58.4%-69.1%), and for whites (68.7%; 95%CI: 66.1%-71.3%), blacks (59.0%; 95%CI: 49.5%-68.6%), Hispanics (52.7% 95%CI: 45.1%-60.4%) and Chinese-Americans (58.5%; 95%CI: 45.2%-71.8%). Among participants taking antihypertensive medication with SBP/DBP<140/90 mmHg, 76.6% (95% CI: 75.8%-77.5%) were eligible for statin treatment but only 33.2% (95%CI: 32.1%-34.3%) were taking one and 19.5% (95%CI: 18.5%-20.5%) met the Systolic Blood Pressure Intervention Trial eligibility criteria and may benefit from a SBP target goal of 120 mmHg. Conclusions -While higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP<140/90 mmHg. Although absolute risk and cost-effectiveness should be considered, additional CVD risk reduction measures for adults with SBP/DBP<140/90 mmHg at high risk for CVD may be warranted.

Background -Ambulatory blood pressure (BP) monitoring (ABPM) is the reference standard for out-of-clinic BP measurement. Thresholds for identifying ambulatory hypertension (daytime systolic BP [SBP]/diastolic BP [DBP] >/= 135/85 mmHg, 24-hour SBP/DBP >/= 130/80 mmHg, and nighttime SBP/DBP >/= 120/70 mmHg) have been derived from European, Asian and South American populations. We determined BP thresholds for ambulatory hypertension in a US population-based sample of African Americans. Methods -We analyzed data from the Jackson Heart Study (JHS), a population-based cohort study comprised exclusively of African-American adults (n=5,306). Analyses were restricted to 1,016 participants who completed ABPM at baseline in 2000-2004. Mean systolic BP (SBP) and diastolic BP (DBP) levels were calculated for daytime (10:00am-8:00pm), 24-hour (all available readings) and nighttime (midnight-6:00am) periods, separately. Daytime, 24-hour, and nighttime BP thresholds for ambulatory hypertension were identified using regression- and outcome-derived approaches. The composite of a cardiovascular disease (CVD) or all-cause mortality event was used in the outcome-derived approach. For this latter approach, BP thresholds were identified only for SBP as clinic DBP was not associated with the outcome. Analyses were stratified by antihypertensive medication use. Results -Among participants not taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mmHg were 134/85 mmHg, 130/81 mmHg, and 123/73 mmHg, respectively. The outcome-derived thresholds for daytime, 24-hour, and nighttime SBP corresponding to a clinic SBP >/= 140 mmHg were 138 mmHg, 134 mmHg, and 129 mmHg, respectively. Among participants taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mmHg were 135/85 mmHg, 133/82 mmHg, and 128/76 mmHg, respectively. The corresponding outcome-derived thresholds for daytime, 24-hour, and nighttime SBP were 140 mmHg, 137 mmHg, and 133 mmHg, respectively, among those taking antihypertensive medication. Conclusions -Based on the outcome-derived approach for SBP and regression-derived approach for DBP, the following definitions for daytime hypertension, 24-hour hypertension, and nighttime hypertension corresponding to clinic SBP/DBP >/= 140/90 mmHg are proposed for African Americans: daytime SBP/DBP >/= 140/85 mmHg, 24-hour SBP/DBP >/= 135/80 mmHg, and nighttime SBP/DBP >/= 130/75 mmHg, respectively.

BACKGROUND: Abnormal diurnal blood pressure (BP), including nondipping patterns, assessed using ambulatory BP monitoring, have been associated with increased cardiovascular risk among white and Asian adults. We examined the associations of BP dipping patterns (dipping, nondipping, and reverse dipping) with cardiovascular target organ damage (left ventricular mass index and left ventricular hypertrophy), among participants from the Jackson Heart Study, an exclusively black population-based cohort. METHODS AND RESULTS: Analyses included 1015 participants who completed ambulatory BP monitoring and had echocardiography data from the baseline visit. Participants were categorized based on the nighttime to daytime systolic BP ratio into 3 patterns: dipping pattern (0.90 to 1.00). The prevalence of dipping, nondipping, and reverse dipping patterns was 33.6%, 48.2%, and 18.2%, respectively. In a fully adjusted model, which included antihypertensive medication use and clinic and daytime systolic BP, the mean differences in left ventricular mass index between reverse dipping pattern versus dipping pattern was 8.3+/-2.1 g/m2 (P<0.001) and between nondipping pattern versus dipping pattern was -1.0+/-1.6 g/m2 (P=0.536). Compared with participants with a dipping pattern, the prevalence ratio for having left ventricular hypertrophy was 1.65 (95% CI, 1.05-2.58) and 0.96 (95% CI, 0.63-1.97) for those with a reverse dipping pattern and nondipping pattern, respectively. CONCLUSIONS: In this population-based study of blacks, a reverse dipping pattern was associated with increased left ventricular mass index and a higher prevalence of left ventricular hypertrophy. Identification of a reverse dipping pattern on ambulatory BP monitoring may help identify black at increased risk for cardiovascular target organ damage.

OBJECTIVE: To use novel geographic methods and large-scale claims data to identify the local distribution of pediatric chronic diseases in New York City. METHODS: Using a 2009 all-payer emergency claims database, we identified the proportion of unique children aged 0 to 17 with diagnosis codes for specific medical and psychiatric conditions. As a proof of concept, we compared these prevalence estimates to traditional health surveys and registry data using the most geographically granular data available. In addition, we used home addresses to map local variation in pediatric disease burden. RESULTS: We identified 549,547 New York City children who visited an emergency department at least once in 2009. Though our sample included more publicly insured and uninsured children, we found moderate to strong correlations of prevalence estimates when compared to health surveys and registry data at prespecified geographic levels. Strongest correlations were found for asthma and mental health conditions by county among younger children (0.88, P = .05 and 0.99, P < .01, respectively). Moderate correlations by neighborhood were identified for obesity and cancer (0.53 and 0.54, P < .01). Among adolescents, correlations by health districts were strong for obesity (0.95, P = .05), and depression estimates had a nonsignificant, but strong negative correlation with suicide attempts (-0.88, P = .12). Using SaTScan, we also identified local hot spots of pediatric chronic disease. CONCLUSIONS: For conditions easily identified in claims data, emergency department surveillance may help estimate pediatric chronic disease prevalence with higher geographic resolution. More studies are needed to investigate limitations of these methods and assess reliability of local disease estimates.

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.

Study Objectives: To assess effectiveness of a culturally and linguistically tailored telephone-delivered intervention to increase adherence to physician-recommended evaluation and treatment of obstructive sleep apnea (OSA) among blacks. Methods: In a two-arm randomized controlled trial, we evaluated effectiveness of the tailored intervention among blacks with metabolic syndrome, relative to those in an attention control arm (n = 380; mean age = 58 +/- 13; female = 71%). The intervention was designed to enhance adherence using culturally and linguistically tailored OSA health messages delivered by a trained health educator based on patients' readiness to change and unique barriers preventing desired behavior changes. Results: Analysis showed 69.4% of the patients in the intervention arm attended initial consultation with a sleep specialist, compared to 36.7% in the control arm; 74.7% of those in the intervention arm and 66.7% in the control arm completed diagnostic evaluation; and 86.4% in the intervention arm and 88.9% in the control arm adhered to PAP treatment based on subjective report. Logistic regression analyses adjusting for sociodemographic factors indicated patients in the intervention arm were 3.17 times more likely to attend initial consultation, compared to those in the control arm. Adjusted models revealed no significant differences between the two arms regarding adherence to OSA evaluation or treatment. Conclusion: The intervention was successful in promoting importance of sleep consultation and evaluation of OSA among blacks, while there was no significant group difference in laboratory-based evaluation and treatment adherence rates. It seems that the fundamental barrier to OSA care in that population may be the importance of seeking OSA care.

Introduction: Metabolic syndrome poses an increased burden of disease, warranting heightened public health attention. This study assessed effects of birthplace on cardiometabolic profile among blacks with metabolic syndrome and sleep apnea risk, while exploring potential gender-based effects. Methods: This analysis is based on data from 610 black patients (mean age= 63 +/- 11 years female=65%) with evidence of metabolic syndrome and were at risk for sleep apnea using the ARES. Participants from four community-based clinics in Brooklyn, NY provided sociodemographic, medical, and clinical data. Clinical data included body mass index (BMI), blood pressure (BP), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), and fasting plasma glucose (FPG) or hemoglobin (HbA1c) for those who had a diagnosis of diabetes. General Linear Model (GLM) was used to assess effects of birthplace and gender on cardiometabolic parameters, adjusting for age effects. Results: Of the sample, 61.6 % were foreign-born blacks (FBB) and 38.4 % were US-born blacks (USB). FBB had significantly lower BMI compared with USB (32.76 +/- 0.35 vs. 35.41 +/- 0.44, F=22.57), but had significantly higher systolic blood pressure (136.70 +/- 0.77 vs. 132.83 +/- 0.98; F=9.60) and fasting glucose levels than did USB (146.46 +/- 3.37 vs. 135.02 +/- 4.27; F=4.40). Men had higher diastolic BP (76.67 +/- 0.65 vs. 75.05 +/- 0.45; F=4.20), glucose (146.53 +/- 4.48 vs. 134.95 +/- 3.07; F=4.55) and triglyceride levels (148.10 +/- 4.51 vs. 130.60 +/- 3.09; F=10.25) compared with women, but women had higher LDL-cholesterol (109.24 +/- 1.49 vs. 98.49 +/- 2.18; F=16.60) and HDLcholesterol levels (50.71 +/- 0.66 vs. 42.77 +/- 0.97; F=46.01) than did men. Conclusion: FBB have lower levels of obesity, similar rates of hypertension, dyslipidemia, stroke history, but higher rates of diabetes, history of heart disease, and systolic BP compared with USB. Findings may have implications for addressing effects of birthplace and gender on cardiovascular disease outcomes

Background/UNASSIGNED:Muslims are one of the fastest growing religious groups in the US. However, little is known about their health disparities, and how their unique cultural, religious, and social beliefs and practices affect health behaviors and outcomes. Studies demonstrate Muslim women may have lower rates of breast and cervical cancer screening compared to the overall population. Methods/UNASSIGNED:The purpose of this study was to: 1) conduct key-informant interviews with Muslim community leaders in New York City (NYC), to understand contextual factors that impact Muslim women's beliefs and practices regarding breast and cervical cancer screening; and 2) inform the development and implementation of a research study on breast and cervical cancer screening among Muslims. Twelve key-informant interviews were conducted. The sample included imams, female religious leaders, physicians, community-based organization leaders, and social service representatives. The interview guide assessed: 1) unique healthcare barriers faced by Muslim women; 2) cultural and social considerations in conducting research; 3) potential strategies for increasing screening in this population; and 4) content and venues for culturally tailored programming and messaging. Results/UNASSIGNED:Key informants noted structure and culture as barriers and religion as a facilitator to breast and cervical cancer screening. Themes regarding the development of targeted health campaigns to increase screening included the importance of educational and in-language materials and messaging, and engaging mosques and religious leaders for dissemination. Conclusion/UNASSIGNED:Although Muslim women face a number of barriers to screening, religious beliefs and support structures can be leveraged to facilitate screening and enhance the dissemination and promotion of screening.

Blacks are especially susceptible to hypertension( HTN) and its associated organ damage leading to adverse cardiovascular, cerebrovascular and renal outcomes. Accordingly, HTN is particularly significant in contributing to the black-white racial differences in health outcomes in the US. As such, in order to address these health disparities, practical clinical practice guidelines (CPGs) on how to treat HTN, specifically in blacks, are needed. This review article is a timely addition to the literature because the most recent U.S. CPG more explicitly emphasizes race into the algorithmic management of HTN. However, recent clinical research cautions that use of race as a proxy to determine therapeutic response to pharmaceutical agents may be erroneous. This review will address the implications of the use of race in the hypertension CPGs. We will review the rationale behind the introduction of race into the U.S. CPG and the level of evidence that was available to justify this introduction. Finally, we will conclude with practical considerations in the treatment of HTN in blacks.