Faculty Bibliography

This corrects the article DOI: 10.1038/jhh.2016.100.

Apparent treatment-resistant hypertension (aTRH) is associated with adverse cardiovascular outcomes. aTRH is common and disproportionately affects African Americans. The objective of this study is to explore psychosocial correlates of aTRH in a population-based cohort of African Americans with hypertension. The sample included 1392 participants in the Jackson Heart Study with treated hypertension who reported being adherent to their antihypertensive medications. aTRH was defined as uncontrolled clinic BP (140/90 mm Hg) with 3 classes of antihypertensive medication or treatment with 4 classes of antihypertensive medication, including a diuretic. Self-reported medication adherence was defined as taking all prescribed antihypertensive medication in the 24 h before the study visit. The association of psychosocial factors (chronic stress, depressive symptoms, perceived social support and social network) with aTRH was evaluated using Poisson regression with progressive adjustment for demographic, clinical and behavioural factors. The prevalence of aTRH was 15.1% (n=210). Participants with aTRH had lower social network scores (that is, fewer sources of regular social contact) compared with participants without aTRH (P<0.01). No other psychosocial factors differed between groups. Social network was also the only psychosocial factor that was associated with aTRH prevalence in regression analyses. In age-, sex-adjusted and fully adjusted models, one additional unique source of social contact was associated with a 19% (PR=0.81; 95% confidence interval (CI): 0.68-0.94, P=0.001) and a 13% (PR=0.87; 95% CI 0.74-1.0, P=0.041) lower prevalence of aTRH, respectively. Social network was independently associated with aTRH and warrants further investigation as a potentially modifiable determinant of aTRH in African Americans.Journal of Human Hypertension advance online publication, 26 January 2017; doi:10.1038/jhh.2016.100.

BACKGROUND: Among individuals without hypertension based on clinic blood pressure (BP), it is unclear who should be screened for masked hypertension, defined as having hypertension based on out-of-clinic BP. We hypothesized that individuals with a higher 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the pooled cohort risk equations, have a higher prevalence of masked hypertension. METHODS AND RESULTS: We analyzed data from the Jackson Heart Study-a population-based cohort of blacks-to determine the association of predicted ASCVD risk with masked hypertension. The sample included 644 participants, 40 to 79 years of age, with clinic systolic/diastolic BP <140/90 mm Hg, who completed ambulatory BP monitoring, were free of cardiovascular disease, and had data on factors needed to calculate ASCVD risk. Ten-year predicted ASCVD risk was calculated using the pooled cohort risk equations. Any masked hypertension was defined as masked daytime hypertension (mean daytime systolic/diastolic BP >/=135/85 mm Hg), masked nighttime hypertension (mean nighttime systolic/diastolic BP >/=120/70 mm Hg), or masked 24-hour hypertension (mean 24-hour systolic/diastolic BP >/=130/80 mm Hg). The prevalence of any masked hypertension was 54.0%. Compared with participants in the lowest (<5%) predicted ASCVD risk category, multivariable-adjusted prevalence ratios (95% confidence interval) for any masked hypertension were 1.36 (1.03-1.79), 1.62 (1.22-2.16), and 1.91 (1.47-2.48) for those with ASCVD risk of 5% to <7.5%, 7.5% to <10%, and >/=10%, respectively. The C statistic for discriminating between participants with versus without any masked hypertension was 0.681 (95% confidence interval, 0.640-0.723) for ASCVD risk and 0.703 (95% confidence interval, 0.663-0.744) for clinic systolic BP and diastolic BP. CONCLUSIONS: Higher ASCVD risk was associated with an increased prevalence of masked hypertension. Although the discrimination of ASCVD risk for masked hypertension was not superior to clinic BP, risk prediction equations may be useful for identifying the subgroup of individuals with both masked hypertension and high predicted ASCVD risk.

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.

RATIONALE: Epilepsy is a chronic neurological condition that causes substantial burden on patients and families. Quality of life may be reduced due to the stress of coping with epilepsy. For nearly a decade, the Centers for Disease Control (CDC) Prevention Research Center's Managing Epilepsy Well (MEW) Network has been conducting research on epilepsy self-management to address research and practice gaps. Studies have been conducted by independent centers across the U.S. Recently, the MEW Network sites, collaboratively, began compiling an integrated database to facilitate aggregate secondary analysis of completed and ongoing studies. In this preliminary analysis, correlates of quality of life in people with epilepsy (PWE) were analyzed from pooled baseline data from the MEW Network. METHODS: For this analysis, data originated from 6 epilepsy studies conducted across 4 research sites and comprised 459 PWE. Descriptive comparisons assessed common data elements that included gender, age, ethnicity, race, education, employment, income, seizure frequency, quality of life, and depression. Standardized rating scales were used for quality of life (QOLIE-10) and for depression (Patient Health Questionnaire, PHQ-9). RESULTS: While not all datasets included all common data elements, baseline descriptive analysis found a mean age of 42 (SD 13.22), 289 women (63.0%), 59 African Americans (13.7%), and 58 Hispanics (18.5%). Most, 422 (92.8%), completed at least high school, while 169 (61.7%) were unmarried, divorced/separated, or widowed. Median 30-day seizure frequency was 0.71 (range 0-308). Depression at baseline was common, with a mean PHQ-9 score of 8.32 (SD 6.04); 69 (29.0%) had depression in the mild range (PHQ-9 score 5-9) and 92 (38.7%) had depression in the moderate to severe range (PHQ-9 score >9). Lower baseline quality of life was associated with greater depressive severity (p<.001), more frequent seizures (p<.04) and lower income (p<.05). CONCLUSIONS: The MEW Network Integrated Database offers a unique opportunity for secondary analysis of data from multiple community-based epilepsy research studies. While findings must be tempered by potential sample bias, i.e. a relative under-representation of men and relatively small sample of some racial/ethnic subgroups, results of analyses derived from this first integrated epilepsy self-management database have potential to be useful to the field. Associations between depression severity and lower QOL in PWE are consistent with previous studies derived from clinical samples. Self-management efforts that focus on mental health comorbidity and seizure control may be one way to address modifiable factors that affect quality of life in PWE.

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.

Epilepsy, a complex spectrum of disorders, affects about 2.9 million people in the U.S. Similar to other chronic disorders, people with epilepsy face challenges related to management of the disorder, its treatment, co-occurring depression, disability, social disadvantages, and stigma. Two national conferences on public health and epilepsy (1997, 2003) and a 2012 IOM report on the public health dimensions of epilepsy highlighted important knowledge gaps and emphasized the need for evidence-based, scalable epilepsy self-management programs. The Centers for Disease Control and Prevention translated recommendations on self-management research and dissemination into an applied research program through the Prevention Research Centers Managing Epilepsy Well (MEW) Network. MEW Network objectives are to advance epilepsy self-management research by developing effective interventions that can be broadly disseminated for use in people's homes, healthcare providers' offices, or in community settings. The aim of this report is to provide an update on the MEW Network research pipeline, which spans efficacy, effectiveness, and dissemination. Many of the interventions use e-health strategies to eliminate barriers to care (e.g., lack of transportation, functional limitations, and stigma). Strengths of this mature research network are the culture of collaboration, community-based partnerships, e-health methods, and its portfolio of prevention activities, which range from efficacy studies engaging hard-to-reach groups, to initiatives focused on provider training and knowledge translation. The MEW Network works with organizations across the country to expand its capacity, help leverage funding and other resources, and enhance the development, dissemination, and sustainability of MEW Network programs and tools. Guided by national initiatives targeting chronic disease or epilepsy burden since 2007, the MEW Network has been responsible for more than 43 scientific journal articles, two study reports, seven book chapters, and 62 presentations and posters. To date, two programs have been adopted and disseminated by the national Epilepsy Foundation, state Epilepsy Foundation affiliates, and other stakeholders. Recent expansion of the MEW Network membership will help to extend future reach and public health impact.