Abstract
Living alone, a key proxy of social isolation, is a risk factor for cardiovascular disease. In addition, Black race is associated with less optimal blood pressure (BP) control than in other racial or ethnic groups. However, it is not clear whether living arrangement status modifies the beneficial effects of intensive BP control on reduction in cardiovascular events among Black individuals. To examine whether the association of intensive BP control with cardiovascular events differs by living arrangement among Black individuals and non-Black individuals (eg, individuals who identified as Alaskan Native, American Indian, Asian, Native Hawaiian, Pacific Islander, White, or other) in the Systolic Blood Pressure Intervention Trial (SPRINT). This secondary analysis incorporated data from SPRINT, a multicenter study of individuals with increased risk for cardiovascular disease and free of diabetes, enrolled at 102 clinical sites in the United States between November 2010 and March 2013. Race and living arrangement (ie, living alone or living with others) were self-reported. Data were collected between November 2010 and March 2013 and analyzed from January 2021 to October 2021. The SPRINT participants were randomized to a systolic BP target of either less than 120 mm Hg (intensive treatment group) or less than 140 mm Hg (standard treatment group). Antihypertensive medications were adjusted to achieve the targets in each group. Cox proportional hazards model was used to investigate the association of intensive treatment with the incident composite cardiovascular outcome (by August 20, 2015) according to living arrangement among Black individuals and other individuals. Transportability formula was applied to generalize the SPRINT findings to hypothetical external populations by varying the proportion of Black race and living arrangement status. Among the 9342 total participants, the mean (SD) age was 67.9 (9.4) years; 2793 participants [30%] were Black, 2714 [29%] lived alone, and 3320 participants (35.5%) were female. Over a median (IQR) follow-up of 3.22 (2.74-3.76) years, the primary composite cardiovascular outcome was observed in 67 of 1001 Black individuals living alone (6.7%), 76 of 1792 Black individuals living with others (4.2%), 108 of 1713 non-Black individuals living alone (6.3%), and 311 of 4836 non-Black individuals living with others (6.4%). The intensive treatment group showed a significantly lower rate of the composite cardiovascular outcome than the standard treatment group among Black individuals living with others (hazard ratio [HR], 0.53 [95% CI, 0.33-0.85]) but not among those living alone (HR, 1.07 [95% CI, 0.66-1.73]; P for interaction = .04). The association was observed among individuals who were not Black regardless of living arrangement status. Using transportability, we found a smaller or null association between intensive control and cardiovascular outcomes among hypothetical populations of 60% Black individuals or more and 60% or more of individuals living alone. Intensive BP control was associated with a lower rate of cardiovascular events among Black individuals living with others and individuals who were not Black but not among Black individuals living alone. ClinicalTrials.gov Identifier: NCT01206062.
Highlights
Hypertension is a leading cause of cardiovascular disease (CVD) and death, affecting nearly half of adults in the United States, and imposing substantial health and economic burden on individuals and society.[1,2] Importantly, the prevalence and control rates of hypertension vary by race or ethnicity, with significantly higher prevalence and lower rates of optimal control among Black patients than White patients.[3,4] the mortality rate related to hypertension was nearly double among Black patients compared with White patients in 2018.5,6 underlying mechanisms of such racial disparities have not been well established because of the complex interaction across biological, environmental, behavioral, genetic, social factors, and systemic racism.[7]
The intensive treatment group showed a significantly lower rate of the composite cardiovascular outcome than the standard treatment group among Black individuals living with others but not among those living alone (HR, 1.07 [95% CI, 0.66-1.73]; P for interaction = .04)
Intensive blood pressure (BP) control was associated with a lower rate of cardiovascular events among Black individuals living with others and individuals who were not Black but not among Black individuals living alone
Summary
Hypertension is a leading cause of cardiovascular disease (CVD) and death, affecting nearly half of adults in the United States, and imposing substantial health and economic burden on individuals and society.[1,2] Importantly, the prevalence and control rates of hypertension vary by race or ethnicity, with significantly higher prevalence and lower rates of optimal control among Black patients than White patients.[3,4] the mortality rate related to hypertension was nearly double among Black patients compared with White patients in 2018.5,6 underlying mechanisms of such racial disparities have not been well established because of the complex interaction across biological, environmental, behavioral, genetic, social factors, and systemic racism.[7]. The mortality rate related to hypertension was nearly double among Black patients compared with White patients in 2018.5,6 underlying mechanisms of such racial disparities have not been well established because of the complex interaction across biological, environmental, behavioral, genetic, social factors, and systemic racism.[7]. This suggests that we need further evidence to build tailored approaches for hypertension prevention and control that consider individual sociodemographic characteristics.[8,9]. Given the possible impact of living alone itself on developing and deteriorating CVD through both social and biological pathways, such as poor adherence to medications and vascular damage,[14-17] it is important to evaluate whether the benefit of blood pressure (BP) control to reduce CVD risks differs by living arrangement status among Black individuals and other individuals
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