Faculty Bibliography

This retrospective cohort study compared blood pressure (BP) control (BP <140/90 mm Hg) and all-cause mortality between US- and foreign-born blacks. We used data from a clinical data warehouse of 41 868 patients with hypertension who received care in a New York City public healthcare system between 2004 and 2009, defining BP control as the last recorded BP measurement and mean BP control. Poisson regression demonstrated that Caribbean-born blacks had lower BP control for the last BP measurement compared with US- and West African-born blacks, respectively (49% vs 54% and 57%; P<.001). This pattern was similar for mean BP control. Caribbean- and West African-born blacks showed reduced hazard ratios of mortality (0.46 [95% CI, 0.42-0.50] and 0.28 [95% CI, 0.18-0.41], respectively) compared with US-born blacks, even after adjustment for BP. BP control rates and mortality were heterogeneous in this sample. Caribbean-born blacks showed worse control than US-born blacks. However, US-born blacks experienced increased hazard of mortality. This suggests the need to account for the variations within blacks in hypertension management.

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.

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

Uncontrolled blood pressure (BP) is linked to increased risk of obstructive sleep apnea (OSA). However, few studies have assessed the impact of this relationship among blacks with metabolic syndrome (MetS). Data for this study were collected from 1035 blacks (mean age=62+/-13 years) enrolled in the Metabolic Syndrome Outcome study. Patients with a score 6 on the Apnea Risk Evaluation System were considered at risk for OSA. Of the sample, 77.1% were low-to-high OSA risk and 92.3% were hypertensive, of which 16.8% had uncontrolled BP levels. Analysis also showed that 60.4% were diabetic, 8.9% had a stroke history, 74.3% had dyslipidemia, 69.8% were obese and 30.9% had a history of heart disease. Logistic regression analyses were employed to investigate associations between uncontrolled BP and OSA risk, while adjusting for known covariates. Findings showed that uncontrolled BP independently increased the odds of OSA risk twofold (odds ratio=2.02, 95% confidence interval=1.18-3.48, P<0.05). In conclusion, our findings show that uncontrolled BP was associated with a twofold greater risk of OSA among blacks, suggesting that those with MetS and who have uncontrolled BP should be screened for the presence of OSA.Journal of Human Hypertension advance online publication, 6 August 2015; doi:10.1038/jhh.2015.78.

INTRODUCTION: Resistant hypertension (RHTN) is an important condition affecting 29% of the hypertensive population in the U.S., especially among blacks. Sleep disturbances, like obstructive sleep apnea, insomnia, and short sleep duration, are increasingly recognized as underlying modifiable factors for RHTN. We evaluated associations of RHTN with short sleep duration among blacks with metabolic syndrome. METHODS: Data from the Metabolic Syndrome Outcome Study (MetSO), a NIH-funded cohort study characterizing metabolic syndrome (MetS) among blacks were analyzed. MetS was defined according to criteria from the Adult Treatment Panel (ATP III). RHTN was defined according to guidelines from the American Heart Association. Short sleep was defined as self-reported sleep duration <7 hrs experienced during a 24-hour period. RESULTS: Analysis was based on 1,035 patients (mean age: 62+/-14years; female: 69.2%). Of the sample, 90.4% were overweight /obese; 61.4% had diabetes; 74.8% had dyslipidemia; 30.2% had a history of heart disease; and 48% were at high risk for obstructive sleep apnea. Overall, 92.6% reported physician-diagnosed hypertension (HTN) and 20.8% met criteria for RHTN. Analyses showed 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 metabolic syndrome and RHTN had increased odds of being short sleepers (OR = 1.95, 95% CI: 1.28-2.97, p = 0.002). CONCLUSION: Among blacks with metabolic syndrome, patients meeting criteria for resistant hypertension showed a twofold greater likelihood of being short sleepers, prompting the need for sleep screening in this vulnerable population.

OBJECTIVES: Epidemiological evidence linking diet, one of the most important modifiable lifestyle factors, and risk of Alzheimer's disease (AD) is rapidly increasing. However, there is little or no evidence for a direct association between dietary nutrients and brain biomarkers of AD. This study identifies nutrient patterns associated with major brain AD biomarkers in a cohort of clinically and cognitively normal (NL) individuals at risk for AD. DESIGN: Cross-sectional study. SETTING: Manhattan (broader area). PARTICIPANTS: Fifty-two NL individuals (age 54+12 y, 70% women, Clinical Dementia Rating=0, MMSE>27, neuropsychological test performance within norms by age and education) with complete dietary information and cross-sectional, 3D T1-weighted Magnetic Resonance Imaging (MRI; gray matter volumes, GMV, a marker of brain atrophy), 11C-Pittsburgh compound-B (PiB; a marker of fibrillar amyloid-beta, Abeta) and 18F-fluorodeoxyglucose (FDG; a marker of glucose metabolism, METglc) Positron Emission Tomography (PET) scans were examined. MEASUREMENTS: Dietary intake of 35 nutrients associated with cognitive function and AD was assessed using the Harvard/Willet Food Frequency Questionnaire. Principal component analysis was used to generate nutrient patterns (NP) from the full nutrient panel. Statistical parametric mapping and voxel based morphometry were used to assess the associations of the identified NPs with AD biomarkers. RESULTS: None of the participants were diabetics, smokers, or met criteria for obesity. Five NPs were identified: NP1 was characterized by most B-vitamins and several minerals [VitB and Minerals]; NP2 by monounsaturated and polyunsaturated fats, including omega-3 and omega-6 PUFA, and vitamin E [VitE and PUFA]; NP3 by vitamin A, vitamin C, carotenoids and dietary fibers [Anti-oxidants and Fibers]; NP4 by vitamin B12, vitamin D and zinc [VitB12 and D]; NP5 by saturated, trans-saturated fats, cholesterol and sodium [Fats]. Voxel-based analysis showed that NP4 scores [VitB12 and D] were positively associated with METglc and GMV, and negatively associated with PiB retention in AD-vulnerable regions (p<0.001). In addition, both METglc and GMV were positively associated with NP2 scores [VitE and PUFA], and negatively associated with NP5 scores [Fats] (p<0.001), and METglc was positively associated with higher NP3 scores [Anti-oxidants and Fibers] (p<0.001). Adjusting for age, gender, ethnicity, education, caloric intake, BMI, alcohol consumption, family history and Apolipoprotein E (APOE) status did not attenuate these relationships. The identified 'AD-protective' nutrient combination was associated with higher intake of fresh fruit and vegetables, whole grains, fish and low-fat dairies, and lower intake of sweets, fried potatoes, high-fat dairies, processed meat and butter. CONCLUSION: Specific dietary NPs are associated with brain biomarkers of AD in NL individuals, suggesting that dietary interventions may play a role in the prevention of AD by modulating AD-risk through its effects on Abeta and associated neuronal impairment.

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

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.