Disparities In Hypertension Research Articles

0784 Associations Of Sleep Regularity And Chronotype With Hypertension Among African Americans In The Jackson Heart Sleep Study

Abstract Introduction Emerging evidence suggests that disparities in sleep regularity, a marker of circadian disruption, contributes to hypertension disparities; however, data among African Americans are limited. We examined associations of sleep regularity and chronotype with hypertension among African Americans in the Jackson Heart Sleep Study (JHSS). Methods Participants underwent 7-day actigraphy, completed questionnaires, and had seated blood pressure (BP) measured as part of the JHSS (2012 - 2016). Sleep regularity was defined as the standard deviation (SD) of actigraphy-measured sleep onset timing or sleep duration. Chronotype was assessed by the Morningness-Eveningness Questionnaire. Prevalent hypertension was defined as either a systolic BP ≥ 130 mmHg or diastolic BP ≥ 80mmHg, antihypertensive medication use, or self-report of diagnosed hypertension. Multivariable logistic regression models were fit to estimate the prevalence odds ratio (OR) and 95% confidence intervals for the associations of hypertension with sleep regularity measures (SD of sleep onset timing and sleep duration) and chronotype adjusted for covariates. Results Participants (n=830) on average were 63.4 years (SD:10.7), mostly female (66.3%) and hypertensive (85.8%). Compared to individuals with sleep onset SD < 30 minutes, higher adjusted odds of hypertension was observed with increasing variability: OR:1.87 (CI:0.99-3.56); OR:2.16 (1.06-4.39), and OR:2.41 (1.12-5.20), for SD > 30 & ≤ 60, > 60 & ≤ 90 and > 90 minutes, respectively. Among non-shift workers, definite morning and evening types compared to intermediates had higher adjusted odds of hypertension, OR:1.71 (1.04-2.83) and OR:2.56 (1.12-5.84), respectively. There were no observed associations for the SD of sleep duration with hypertension. Conclusion Increased sleep onset variability and extreme chronotypes were associated with prevalent hypertension, supporting interventions targeting sleep hygiene recommendations promoting regular sleep. Future research is needed to understand sleep patterns and risk of cardiovascular disease according to chronotype. Support NHLBI K01HL138211 and HL110068-03S1

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities

RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months. This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities. Clinicaltrials.govNCT02674464.

Hypertension and race/ethnicity.

United States racial/ethnic minorities may experience disproportionate hypertension (HTN) morbidity and mortality. This review discusses recent literature regarding the differential impact of HTN, especially among African Americans and Hispanics. Although disparities in HTN prevalence, control, and outcomes persist in racial/ethnic minorities relative to non-Hispanic Whites, racial/ethnic minorities are frequently underrepresented in genetic and clinical studies. Genomics have improved our understanding of HTN, but with no clinically useful application, the role of social determinants of health in HTN disparities is increasingly recognized. Team-based approaches with targeted, multilevel interventions may overcome barriers that uniquely impact racial/ethnic minorities. Despite extensive epidemiological research, racial/ethnic minorities remain at higher risk HTN-related morbidity and mortality. Translational efforts may address the differential impact of HTN in racial/ethnic minorities. This review highlights recent research and concepts related to HTN and race/ethnicity.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Building a Multidisciplinary Research Program to Address Hypertension Disparities: Exploring the Neurocognitive Mechanisms of a Self-Management Intervention for African American Women

Building a Multidisciplinary Research Program to Address Hypertension Disparities: Exploring the Neurocognitive Mechanisms of a Self-Management Intervention for African American Women

Scaling Community-Clinical Linage Models to Address Diabetes and Hypertension Disparities in the Southeast United States

Scaling Community-Clinical Linage Models to Address Diabetes and Hypertension Disparities in the Southeast United States

Changes Over Time in Disparities in Health Behaviors and Outcomes by Race in Allegheny County: 2009 to 2015.

Racial/ethnic disparities in health behaviors and disease outcomes on the national level have persisted over time despite overall improvements in public health. To better understand the changes over time in racial/ethnic health disparities at the county level, we examined the Allegheny County Health Survey (ACHS) for Pittsburgh, PA and the surrounding area, which was conducted in 2009/2010 and 2015/2016 using random digit dialing of residents aged 18 and older. The prevalence rates and rate ratios at each time period were calculated using survey weights and general linear models. The change in prevalence over time was calculated using race-time interaction terms. The results showed a significant improvement in asthma, stroke, cholesterol, and fair or poor health disparities as well as persistent disparities in diabetes and hypertension after adjustment for socioeconomic factors. The change over time in the prevalence of fair or poor health in black compared to white respondents was significant, with absolute improvement of approximately 5% versus < 1%, respectively (p = 0.01). These findings demonstrate that some disparities improved while others persist, noting the importance of monitoring the changes over time at the local health department level.

Maternal Race/Ethnicity, Hypertension, and Risk for Stroke During Delivery Admission

BackgroundRacial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes.Methods and ResultsUsing billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy‐induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log‐linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy‐induced hypertension, black and Hispanic women had higher stroke risk compared with non‐Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86–2.30; Hispanics: aRR, 2.19; 95% CI, 1.98–2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30–2.26; Hispanics: aRR, 1.75; 95% CI, 2.32–5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32–5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07–1.28).ConclusionsPregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non‐Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy‐induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.

Ambient air pollution as a mediator in the pathway linking race/ethnicity to blood pressure elevation: The multi-ethnic study of atherosclerosis (MESA)

BackgroundRacial/ethnic disparities in blood pressure and hypertension have been evident in previous studies, as were associations between race/ethnicity with ambient air pollution and those between air pollution with hypertension. The role of air pollution exposure to racial/ethnic differences in hypertension has not been explored. ObjectiveTo assess the potential mediating effects of ambient air pollution on the association between race/ethnicity and blood pressure levels. MethodsWe studied 6,463 White, Black, Hispanic and Chinese adults enrolled across 6 US cities. Systolic (SBP) and diastolic blood pressure (DBP) were measured at Exam 1 (2000–2002) and Exam 2 (2002–2004). Household-level annual average concentrations of fine particulate matter (PM2.5), oxides of nitrogen (NOX), and ozone (O3) for the year 2000 were estimated for participants. ResultsThe difference in SBP levels by race/ethnicity that was related to higher PM2.5 concentrations compared with White men (“indirect associations”) was 0.3 (95% CI: 0.1, 0.6) mmHg for Black men, 0.3 (95% CI: 0.1, 0.6) mmHg for Hispanic men and 1.0 (95% CI: 0.2, 1.8) mmHg for Chinese men. Findings were similar although not statistically significant for women. PM2.5 did not mediate racial/ethnic differences in DBP. Indirect associations were significant for O3 for SBP among women and men and for DBP among men. In contrast, racial/ethnic disparities were attenuated due to exposure to NOX. ConclusionRacial disparities in blood pressure were reduced after accounting for PM2.5 and ozone while increased after accounting for NOX.

Abstract 002: Racial Disparities in Hypertension Among Young, Black and White Women, 1999-2014 National Health and Nutrition Examination Surveys

Black women are at higher risk for cardiovascular disease and its risk factors, including earlier onset compared to their white counterparts. Even with normal blood pressure, Blacks have nearly double the risk of developing hypertension by age 55 years. Despite this increased risk, little attention has been given to racial disparities in hypertension during young adulthood. The objective of this study was to compare prevalence of hypertension among young African American/Black and White women adjusting for other demographic, health behavior, and health status covariates. We used data from the 1999-2014 National Health and Nutrition Examination Survey (NHANES) to perform a cross-sectional analysis of young women aged 18 to 35 years old (n=442; 2,137,064 (weighted)). Compared to White women, Black women in this age group: were less likely to be married; had lower income; were less likely to smoke; and were more likely to report fair or poor self-rated health. In addition, Black women demonstrated higher systolic (116.7(0.88) mm Hg versus 124.3(1.18) mm Hg; p&lt;0.0001) and diastolic (71.7(0.85) mm Hg versus (74.8(1.20) mm Hg; p=0.04) blood pressure on average. In adjusted models, Black women aged 18 to 35 years demonstrated 58% higher likelihood of having hypertension (defined as BP ≥140/90 mm Hg) compared to White women [PR: 1.58 95% CI: 1.29, 1.93]. Adjusting for other factors, race served as the strongest predictor of hypertension among young women aged 18 to 35 years.

Abstract P167: Trends in Hypertension Prevalence, Awareness, and Control Based on the New Definition of Hypertension; A National Health and Nutrition Examination Survey-Based Study

Introduction: Hypertension is a significant risk factor for cardiovascular morbidity and mortality. According to the recent guideline, the criteria for diagnosing hypertension is now 130/80mmhg. This study seeks to gain a better understanding of the prevalence of hypertension, its awareness, and control in the United States population over the last 10 years using the new criteria for hypertension. Methods: NHANES is a stratified multistage probability sampling of the civilian noninstitutionalized population of the United States. We used the last five cycles available (2007-2016) to conduct a prevalence study applying statistical methods to account for the survey technique and non-response. Result: The mean age was 47.33 years (95%CI, 46.82-29.09), females constituted 51.9% of the population(n=28147), non-Hispanic white 66.63%, non-Hispanic black, 11.40%, Mexican American 8.55%. About 39% of the population studied were obese (BMI greater than or equal to 30). The crude ten years prevalence of hypertension was 38.85%, there was an increasing trend from 37.58% in the 2007-2008 cycle to 41.12% in the 2015-2016 cycle; this increase is statistically significant&lt;0.001. In subgroup analysis, 40.12% of non-Hispanic whites were hypertensive compared 48.61% of the black population and 28.65% of Mexican Americans. The age-adjusted prevalence rate of hypertension using the new guideline is 37%, ranging from 12.68% in age 20-39 years to 73.81% in people above 60 years. Non-Hispanic white had an adjusted 10 years prevalence of 35.66%, a minimal trend of 36.02 to 37.14% from 2005-2006 cycle to 2015-2016 cycle while Non-Hispanic black had a trend from 46.88-51.34%,p&lt;0.0001. Awareness of being hypertensive went down from 64.02% in 2005-2006 cycle to 59.90% in the 2015-2016 cycle and control went down from 64.01% to 59.91%. Conclusion: We were able to demonstrate the significant increase in hypertension prevalence with an increasing trend based on the new guidelines. Also, there is a downward trend in awareness and control; we have demonstrated again, the significant racial disparities in hypertension with about half of the black population being hypertensive. Our study showed that there is a need to intensify effort to combat this epidemic.

Abstract 013: Racial Disparities in Maternal Hypertension and Pregnancy Outcomes a Population-Based Study

Objective: Maternal pre-pregnancy hypertension is an established risk factor for preterm births and infant deaths. We sought to investigate the effects of maternal pre-pregnancy hypertension and tobacco use on preterm and infant deaths. Methods: We analyzed National Vital Statistics System’s 2013 and 2015 linked birth/ infant death data from a total sample of 6,629,652 live births. There were 11,782 preterm deaths due to “Newborn affected by maternal factors and by complications.” Maternal factors and complications were defined as deaths at less than 1 year of age with ICD-10 codes P00-P04. Regression model was accounted for tobacco use, cigarette use before and during pregnancy, prenatal care, maternal age and demographics. Results: Disease specific preterm mortality due to pre-pregnancy hypertension was 1.9 per/1000 live births. Preterm risk increased by two folds (adjusted odds ratio (AOR)=2.12; 95% confidence interval (CI) 1.92-2.18) with maternal pre-pregnancy hypertension history. Presence of pre-pregnancy hypertension and tobacco use doubled the risk of preterm (AOR=3.82 (95% CI: 3.67-4.82). African American mothers with pre-pregnancy hypertension were 1.72 time more likely to have preterm mortality than White females. Conclusion: Black race, maternal risk factor pre-pregnancy hypertension and tobacco use during pregnancy were associated with higher risk of preterm mortality. Further investigation is crucial to better understand the risk factors for the disparities in preterm so that women who are at risk pre-pregnancy can be identified and provided risk-specific services.

A Faith-Based Intervention to Reduce Blood Pressure in Underserved Metropolitan New York Immigrant Communities.

Minority populations, including Asian Americans, face disparities in hypertension compared with non-Hispanic whites. This underscores the need for culturally adapted programs in settings that reach Asian American communities, such as faith-based organizations. We worked collaboratively with community partners to culturally adapt and implement an evidence-based community blood pressure monitoring program for Asian Americans (Asian Indians, Koreans, Filipinos, and Bangladeshis) in metropolitan New York during 2015 and 2016. The program included regularly scheduled volunteer-led screening and counseling events with congregants at faith-based organizations. Among participants with complete 6-month data (n = 348), health-related self-efficacy significantly improved after 6 months, and systolic and diastolic blood pressure was significantly reduced in some subgroups; reductions were highest in participants who self-reported a previous diagnosis of hypertension. Among Asian Americans, faith-based programs may be a replicable, low-cost, sustainable way to increase health-related self-efficacy and decrease blood pressure, specifically among individuals with self-reported hypertension.

High blood pressure in Hispanics in the United States: a review.

To provide an overview of the available data on the prevalence of hypertension (HTN) in various groups and segments of the Hispanic population; prevalence of awareness, treatment and control of HTN among Hispanics; and HTN-related disparities, through disproportionate effects on the Hispanic elderly, women, and young adults. Data on HTN in Hispanics has been lacking or aggregated and frequently not inclusive of certain groups of Hispanics but the available data do show a pattern of more prevalent HTN and HTN disparities among Hispanics compared with non-Hispanic whites. Hispanic adults have some of the highest prevalence of poorly controlled blood pressure compared with any other race-ethnic group in the United States. Further, the impact of the most recent iteration of the HTN guidelines among all segments of the Hispanic population has not been well studied. The most recent HTN guidelines will likely only further illuminate worsening HTN-related disparities among Hispanics. These findings suggest significant screening and treatment disparities must be addressed to reduce HTN risk among the Hispanic population.

Comprehensive examination of the multilevel adverse risk and protective factors for cardiovascular disease among hypertensive African Americans.

This paper describes the multilevel factors that contribute to hypertension disparities in 2052 hypertensive African Americans (mean age 52.9±9.9years; 66.3% female) who participated in a clinical trial. At the family level, participants reported average levels of life chaos and high social support. However, at the individual level, participants exhibited several adverse clinical and behavioral factors including poor blood pressure control (45% of population), obesity (61%), medication non-adherence (48%), smoking (32%), physical inactivity (45%), and poor diet (71%). While participants rated their provider as trustworthy, they reported high levels of discrimination in the health care system. Finally, community-level data indicate that participants reside in areas characterized by poor socio-economic and neighborhood conditions (eg, segregation). In the context of our trial, hypertensive African Americans exhibited several adverse risks and protective factors at multiple levels of influence. Future research should evaluate the impact of these factors on cardiovascular outcomes using a longitudinal design.

Sleep and Resistant Hypertension.

The goal of the present review is to describe the current findings on the association of sleep with resistant hypertension (hypertension that remains uncontrolled despite the use of three or more antihypertensive medications from different classes, including a diuretic). Sleep disturbances, particularly obstructive sleep apnea (OSA), are highly prevalent among adults who have resistant hypertension. Randomized controlled trials indicate that treating OSA has modest effects on blood pressure lowering among those with the highest initial blood pressure. There is a paucity of research on the association of habitual sleep and other sleep disturbances with resistant hypertension. Of note, the most recent observational studies describing the association of OSA with resistant hypertension are comprised primarily of non-white race/ethnic groups who are far more likely to have resistant hypertension. OSA is associated with resistant hypertension, but there is limited data on associations between sleep characteristics and resistant hypertension. Future studies should investigate whether treating OSA can reduce disparities in resistant hypertension and whether other aspects of sleep also contribute to resistant hypertension.

Urbanization and Socioeconomic Disparities in Hypertension among Older Adult Women in Sudan.

Background:Evidence from the developed world associates higher prevalence of hypertension with lower socioeconomic status (SES). However, patterns of association are not as clear in Africa and other developing countries, with varying levels of socioeconomic development and epidemiological transition. Using wealth and education as indicators, we investigated association between SES and hypertension among older adult women in Sudan and examined whether urbanicity mediates the relationship.Methods:The sample included women aged 50 years and over participating in the nationally representative population-based second Sudan Health Household Survey (SHHS) conducted in 2010. Principal components analysis was used to assign each household with a wealth score based on assets owned. The score was categorized into quintiles from lowest (poorest) to highest (richest).Findings:The sample included a total of 5218 women, median and mean age 55 and 59 years, respectively, with the majority not have any schooling (81.6%). The overall prevalence of reported hypertension was found to be 10.5%. After adjustment for age, marital status, work status and urban/rural location, better wealth and higher education were independently and positively associated with hypertension prevalence rates. However, when stratified by urbanicity, the relationship between wealth and hypertension lost its significance for women in urban areas but maintained it in rural areas, increasing significantly and consistently with each increase in quintile index (adjusted odds ratio, aOR1 = 1.95 95% CI = 1.08–3.52; aOR2 = 5.25, 95% CI = 3.01–9.15; aOR3 = 8.27, 95% CI = 4.78–14.3; and aOR4 = and 11.4, 95% CI = 6.45–20.0; respectively). By contrast, education played a greater role in increasing the odds of hypertension among women in urban locations but not in rural locations (aOR = 2.14, 95% CI = 1.25–7.90 vs. aOR = 0.79, 95% CI = 0.27–2.30, respectively).Conclusions:Our findings of a socioeconomic gradient in the prevalence of hypertension among women, mediated by urbanization, call for targeted interventions from early stages of economic development in Sudan and similar settings of transitioning countries.

Abstract P177: Hypertension is Considerably More Prevalent, Yet Decreasing Over Time According to the New Guidelines

Introduction: New High Blood Pressure (BP) Guidelines released by the American Heart Association (AHA) and the American College of Cardiology redefined hypertension, imparting implications for monitoring cardiovascular health (CVH). The impact on reclassification of patients according to electronic health record (EHR) data as a result of changes in criteria for BP cut points has not yet been described. Hypothesis: We hypothesized that more stringent cut points for hypertension would increase the prevalence of United States (US) adults with poor CVH for BP. Methods: We analyzed outpatient visit data recorded in The Guideline Advantage©, a repository of EHRs of patients from eight diverse healthcare systems in the US from 2012-2015. For each year, the first non-missing BP measurement for each patient was categorized into poor (hypertensive), intermediate (pre-hypertensive), and ideal (normotensive) for CVH, first in accordance with AHA’s Life Simple 7 guidelines, and then in accordance with the new guidelines. We compared overall trends with trends stratified by race and sex, in distributions of poor and intermediate categories, and in the proportion eligible for pharmacological treatment (BP ≥ 130/80). Results: A total of 172,209 unique patients contributed 348,933 BP measurements, and most were female (58.63%) and white (75.09%). Although the prevalence of poor CVH for BP was consistently 3-fold higher under the new guidelines and the difference in prevalence was significant (p&lt;0.0001), it decreased over time for the both the old (9.4% to 8.7%) and new (27.8% to 26.4%) guidelines. Over time, the proportion classified as hypertensive decreased (12.4% to 10.4 vs. 33.9% to 30.3%) for males and increased for non-whites (10.2% to 13.9% vs. 27.1% to 35.3%) from the old and new guidelines, respectively, but remained stable for females and whites. Similarly, the annual difference in the proportion of intermediate CVH for BP was significant (p&lt;0.0001); however, pre-hypertension prevalence slightly increased under the old (57.9% to 58.5%) and new (39.5% to 40.7%) guidelines. Among untreated adults eligible for pharmacological intervention, the proportion remained relatively unchanged over time; in 2015, patients lacking treatment yet meeting treatment criteria was 23% and 7.3% under the new and old guidelines, respectively, resulting in a difference of 15.7% (p&lt;0.0001). Whites (66.8%) and females (50.6%), compared with non-whites and males, respectively, comprised the majority. Conclusions: Prevalence of poor CVH for BP among US adults substantially increases in the outpatient setting when categorizing measures with the new guidelines. Active participation by clinicians and public health practitioners are needed to address the higher prevalence of and disparities in both hypertension and treatment prescription identified with the old versus new guidelines.

ADDRESSING RACIAL HEALTH DISPARITIES: LOOKING BACK TO POINT THE WAY FORWARD.

This article investigates the influence of family back-ground and neighborhood conditions during childhood on health later in life, with a focus on hypertension. To document the proportion of current adult racial health disparities rooted in early-life factors, I use nationally representative longitudinal data from the PSID spanning four decades. The results indicate that racial differences in early life neighborhood conditions and family background characteristics play a substantial role in explaining racial disparities in hypertension through at least age 50. Contemporaneous socioeconomic factors account for relatively little of the racial disparities in this health condition in adulthood. Second, I match the Panel Study of Income Dynamics data to county-level data on Medicaid expenditures during these cohorts' childhoods, and provide new causal evidence on the long-run returns to childhood Medicaid spending: Medicaid-induced increases in access to public health insurance led to significant reductions in the likelihood of low birth weight, increased educational attainment and adult income, and reduced adult mortality and the annual incidence of health problems.

Southern Diet and Risk for Hypertension Among Black Men and Women

Racial disparities in mortality from cardiovascular disease are driven partly by disparities in hypertension. To explore clinical and social factors