Faculty Bibliography

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.

BACKGROUND: African Americans exhibit a lower degree of nocturnal blood pressure (BP) dipping compared with Whites, but the reasons for reduced BP dipping in this group are not fully understood. The aim of this study was to identify psychosocial factors associated with BP dipping in a population-based cohort of African Americans. METHODS: This cross-sectional study included 668 Jackson Heart Study (JHS) participants with valid 24-hour ambulatory BP data and complete data on psychosocial factors of interest including stress, negative emotions, and psychosocial resources (e.g., perceived support). The association of each psychosocial factor with BP dipping percentage and nondipping status (defined as <10% BP dipping) was assessed using linear and Poisson regression models, respectively, with progressive adjustment for demographic, socioeconomic, biomedical, and behavioral factors. RESULTS: The prevalence of nondipping was 64%. Higher depressive symptoms, higher hostility, and lower perceived social support were associated with a lower BP dipping percentage in unadjusted models and after adjustment for age, sex, body mass index, and mean 24-hour systolic BP (P < 0.05). Only perceived support was associated with BP dipping percentage in fully adjusted models. Also, after full multivariable adjustment, the prevalence ratio for nondipping BP associated with 1 SD (7.1 unit) increase in perceived support was 0.93 (95% CI: 0.88-0.99). No other psychosocial factors were associated with nondipping status. CONCLUSIONS: Lower perceived support was associated with reduced BP dipping in this study. The role of social support as a potentially modifiable determinant of nocturnal BP dipping warrants further investigation.

Masked hypertension, defined as nonelevated clinic blood pressure (BP) and elevated out-of-clinic BP may be an intermediary stage in the progression from normotension to hypertension. We examined the associations of out-of-clinic BP and masked hypertension using ambulatory BP monitoring with incident clinic hypertension in the Jackson Heart Study, a prospective cohort of blacks. Analyses included 317 participants with clinic BP <140/90 mm Hg, complete ambulatory BP monitoring, who were not taking antihypertensive medication at baseline in 2000 to 2004. Masked daytime hypertension was defined as mean daytime blood pressure >/=135/85 mm Hg, masked night-time hypertension as mean night-time BP >/=120/70 mm Hg, and masked 24-hour hypertension as mean 24-hour BP >/=130/80 mm Hg. Incident clinic hypertension, assessed at study visits in 2005 to 2008 and 2009 to 2012, was defined as the first visit with clinic systolic/diastolic BP >/=140/90 mm Hg or antihypertensive medication use. During a median follow-up of 8.1 years, there were 187 (59.0%) incident cases of clinic hypertension. Clinic hypertension developed in 79.2% and 42.2% of participants with and without any masked hypertension, 85.7% and 50.4% with and without masked daytime hypertension, 79.9% and 43.7% with and without masked night-time hypertension, and 85.7% and 48.2% with and without masked 24-hour hypertension, respectively. Multivariable-adjusted hazard ratios (95% confidence interval) of incident clinic hypertension for any masked hypertension and masked daytime, night-time, and 24-hour hypertension were 2.13 (1.51-3.02), 1.79 (1.24-2.60), 2.22 (1.58-3.12), and 1.91 (1.32-2.75), respectively. These findings suggest that ambulatory BP monitoring can identify blacks at increased risk for developing clinic hypertension.

BACKGROUND: Factors associated with care concordant with the American College of Rheumatology (ACR) recommendations for the use of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) are unknown. METHODS: We identified a national cohort of biologic-naive patients with RA with visits between December 2008 and February 2013. Treatment acceleration (initiation or dose escalation of biologic and nonbiologic DMARDs) in response to moderate to high disease activity (using the Clinical Disease Activity Index) was assessed. The population was divided into two subcohorts: (1) methotrexate (MTX)-only users and (2) multiple nonbiologic DMARD users. In both subcohorts, we compared the characteristics of patients who received care consistent with the ACR recommendations (e.g., prescriptions for treatment acceleration) and their providers with the characteristics of those who did not at the conclusion of one visit and over two visits, using logistic regression and adjusting for clustering of patients by rheumatologist. RESULTS: Our study included 741 MTX monotherapy and 995 multiple nonbiologic DMARD users cared for by 139 providers. Only 36.2 % of MTX monotherapy users and 39.6 % of multiple nonbiologic DMARD users received care consistent with the recommendations after one visit, which increased over two visits to 78.3 % and 76.2 %, respectively (25-30 % achieved low disease activity by the second visit without DMARD acceleration). Increasing time since the ACR publication on RA treatment recommendations was not associated with improved adherence. CONCLUSIONS: Allowing two encounters for treatment acceleration was associated with an increase in care concordant with the recommendations; however, time since publication was not.

Background: The racial/ethnic differences in post-stroke blood pressure (BP) trajectory and mortality risk are not fully understood. The current paper investigated differences in average systolic BP (SBP) during the 6 months following stroke and effects of average post-stroke BP on mortality risk among Blacks and Hispanics. Hypothesis: Greater post-stroke BP levels will increase risk of mortality Methods:We examined BP measurements in 6,016 stroke survivors within the New York City Health and Hospitals Corporation (NYC HHC) during the 6 months following stroke. Based on the average of all SBP measurements in this period, patients were classified into three groups: (1) SBP =140 mm Hg and =150 mm Hg. We used inverse probability weighting (IPW) to control for group differences in demographic factors, comorbidity, and anti-hypertensive medication use. We examined whether 6 month SBP average was related to mortality following stroke, using Cox regression analysis. The mean duration of follow up after stroke was 2.6+/-1.5 years. Results: The mean age was 57.9+/-13.0 years, 57.4% of patients were female, 49.1% were Black and 37.3% were Hispanic. Blacks were more likely than Hispanics to have an average post-stroke SBP >=150mm Hg (27% versus 17%). Group 1 (SBP <140) and Group 3 (SBP>=150) had higher risks of mortality (Group 1 HR=1.26, 95%CI=1.13-1.41; Group 3 HR=1.29, 95%CI=1.13-1.48) when compared to Group 2 (SBP 140-150). When controlling for ethnicity, these differences are no longer significant. In stratified analyses, the increased hazard in Group 1 was maintained in the sub-sample of Blacks (HR=1.47, 95%CI=1.25-1.72) but not in Hispanics (HR=0.95, 95%CI=0.79-1.15). The difference between Group 2 and Group 3 was not significant in either Black or Hispanic sub-samples. Conclusion: Our findings demonstrate that having a post-stroke SBP below 140 mm Hg or above 150 mm Hg significantly increased individuals' mortality risk, adjusting for demographic factors, comorbidity, number of BP readings, and location of healthcare. Post-stroke BP trajectory differed between Blacks and Hispanics, and had different effects on mortality. These findings have important implications for post-stroke hypertension care

Epilepsy is associated with a high rate of premature mortality from direct and indirect effects of seizures, epilepsy, and antiseizure therapies. Sudden unexpected death in epilepsy (SUDEP) is the second leading neurologic cause of total lost potential life-years after stroke, yet SUDEP may account for less than half of all epilepsy-related deaths. Some epilepsy groups are especially vulnerable: individuals from low socioeconomic status groups and those with comorbid psychiatric illness die more often than controls. Despite clear evidence of an important public health problem, efforts to assess and prevent epilepsy-related deaths remain inadequate. We discuss factors contributing to the underestimation of SUDEP and other epilepsy-related causes of death. We suggest the need for a systematic classification of deaths directly due to epilepsy (e.g., SUDEP, drowning), due to acute symptomatic seizures, and indirectly due to epilepsy (e.g., suicide, chronic effects of antiseizure medications). Accurately estimating the frequency of epilepsy-related mortality is essential to support the development and assessment of preventive interventions. We propose that educational interventions and public health campaigns targeting medication adherence, psychiatric comorbidity, and other modifiable risk factors may reduce epilepsy-related mortality. Educational campaigns regarding sudden infant death syndrome and fires, which kill far fewer Americans than epilepsy, have been widely implemented. We have done too little to prevent epilepsy-related deaths. Everyone with epilepsy and everyone who treats people with epilepsy need to know that controlling seizures will save lives.

The current study examined whether negative illness perceptions help explain the link between depression and quality of life. Seventy patients with epilepsy completed standardized self-report questionnaires measuring depression, illness perception, and quality of life (QOL). Illness perception statistically mediated the relationship between depression and QOL (Indirect effect (CI; confidence interval) = -.72, lower limit = -1.7, upper limit = -.22, p < .05). Results held with and without adjusting for potential confounding variables (age, sex, ethnicity, income, and seizure frequency) and when operationalizing depression as a continuous variable that indexed severity of symptoms or as a dichotomous variable that indexed criteria consistent with a diagnosis of major depressive disorder. This study is the first to suggest that illness perceptions may be a useful target in screening and intervention approaches in order to improve QOL among low-income, racially/ethnically diverse patients with epilepsy.

The current study examined psychosocial correlates of medication adherence in a socioeconomically and racially diverse sample of patients with epilepsy. Fifty-five patients with epilepsy completed standardized self-report questionnaires measuring depression, stress, social support, and medication and illness beliefs. Antiepileptic drug (AED) adherence was measured using the 8-item Morisky Medication Adherence Scale 36% reported poor adherence. We tested which psychosocial factors were independently and most strongly associated with AED adherence. Stress and depression were negatively correlated with adherence, while perceived social support was positively correlated with adherence (Ps<.05). When all three of these variables and relevant covariates in a multiple regression model were included, only perceived social support remained a significant predictor of adherence (P=.015). This study is one of the first to suggest the importance of targeting social support in screening and intervention approaches in order to improve AED adherence among low-income, racially/ethnically diverse patients with epilepsy.

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4(1/2) h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.