Hypertension Medication Use Research Articles

New Automated Assay of Small Dense Low-Density Lipoprotein Cholesterol Identifies Risk of Coronary Heart Disease

Coronary heart disease (CHD) is the leading cause of death in the United States, yet assessing risk of its development remains challenging. The present study evaluates a new automated assay of small dense low-density lipoprotein cholesterol content (sdLDL-C) and whether sdLDL-C is a risk factor for CHD compared with LDL-C or small LDL particle concentrations derived from nuclear magnetic resonance spectroscopy. sdLDL-C was measured using a new automated enzymatic method, and small LDL concentrations were obtained by nuclear magnetic resonance in 4387 Multi-Ethnic Study of Atherosclerosis participants. Cox regression analysis estimated hazard ratios for developing CHD for 8.5 years after adjustments for age, race, sex, systolic blood pressure, hypertension medication use, high-density lipoprotein cholesterol, and triglycerides. Elevated sdLDL-C was a risk factor for CHD in normoglycemic individuals. Those in the top sdLDL-C quartile showed higher risk of incident CHD (hazard ratio, 2.41; P=0.0037) compared with those in the bottom quartile and indicated greater CHD risk than the corresponding quartile of LDL-C (hazard ratio, 1.75; P=0.019). The association of sdLDL-C with CHD risk remained significant when LDL-C (<2.57 mmol/L) was included in a multivariate model (hazard ratio, 2.37; P=0.012). Nuclear magnetic resonance-derived small LDL concentrations did not convey a significant risk of CHD. Those with impaired fasting glucose or diabetes mellitus showed higher sdLDL-C and small LDL concentrations but neither was associated with higher CHD risk in these individuals. This new automated method for sdLDL-C identifies risk for CHD that would remain undetected using standard lipid measures, but only in normoglycemic, nondiabetic individuals.

Association between underweight and taste sensitivity in middle‐ to old‐aged nursing home residents in Sri Lanka: a cross‐sectional study

Low taste sensitivity may be one factor related to undernutrition, which is a major problem in developing countries. The purpose of this cross-sectional study was to examine the association between underweight, one indicator of undernutrition, and taste sensitivity in middle- to old-aged Sri Lankan nursing home residents. Participants were 946 residents with BMI of <25·0 from 25 nursing homes. Data were obtained on height, weight, taste sensitivity, subjective taste ability, sex, age, ethnicity, number of years in nursing homes, activities of daily living (ADL), frequency of exercise, bowel movements, smoking status, drinking status, current number of chronic diseases, number and kinds of medications used, self-reporting questionnaire 20 (SRQ20), subjective smell ability, number of teeth present, Eichner index and flow rate of saliva. Low sensitivity to bitter taste, being male, old age, low ADL, smoking experience, drinking experience, fewer medications used and no use of medication for hypertension and diabetes were each associated with underweight (P<0·05). In a multilevel Poisson regression model adjusted for sex, age, ADL, smoking status, drinking status, number of medications used, use of medication for hypertension and diabetes and flow rate of saliva, subjects with low sensitivity (>0·003% quinine hydrochloride dihydrate) to bitter taste had a significant 1·70 times higher prevalence ratio (95% confident interval 1·04-2·80) for underweight compared with those with high sensitivity (0·0001% quinine hydrochloride dihydrate). These results suggest that low taste sensitivity to bitter taste may be one factor related to underweight.

Prognostic significance of presenting blood pressure in non–ST-segment elevation acute coronary syndrome in relation to prior history of hypertension

Hypertension is a well-established risk factor for cardiovascular disease, whereas low systolic blood pressure (SBP) is a powerful adverse prognosticator in acute coronary syndrome. However, it is unclear whether the prognostic significance of low SBP differs in patients with versus without prior history of hypertension. We sought to investigate the relationships between presenting SBP, prior hypertension, antihypertensive medication use, and outcomes in non-ST-segment elevation acute coronary syndrome (NSTEACS). Using data from GRACE/GRACE(2) and CANRACE, we stratified 10,337 patients with NSTEACS from 1999 to 2008 into 2 groups: those with and those without prior diagnosis of hypertension. We performed multivariable logistic regression analysis to assess the prognostic significance of prior hypertension on in-hospital mortality and tested for the interactions between prior hypertension, antihypertensive medication use, and presenting SBP. Compared with patients without prior hypertension (n = 3,732), those with prior hypertension (n = 6,605) were older; more likely to be female; and more frequently had diabetes, previous myocardial infarction, heart failure, renal insufficiency, and higher Killip class and GRACE risk scores on presentation. Patients with prior hypertension were more likely to be on antihypertensive medications before admission, to present with higher SBP, and to have heart failure or cardiogenic shock in hospital (6.0% vs 10.1%; P < .001). In-hospital mortality was higher among patients presenting with lower SBP but did not differ between the groups with and without prior hypertension. In multivariable analysis, neither prior hypertension (adjusted odds ratio = 1.15, 95% CI 0.78-1.70, P = .48) nor the number of antihypertensive medications used (P for trend = .84) was independently associated with in-hospital mortality. In contrast, SBP was a strong independent predictor of in-hospital mortality (adjusted odds ratio = 1.21 per 10 mm Hg lower, 1.15-1.27, P < .001). There was no significant interaction between SBP and prior hypertension (P for interaction = .62) or pre-admission antihypertensive medication use (P for interaction = .46) with respect to in-hospital mortality. Low SBP on presentation, but not prior hypertension, was independently associated with in-hospital mortality in NSTEACS. The powerful prognostic value of SBP is similar regardless of a history of hypertension or pre-admission antihypertensive medication use.

Abstract 265: Plasma Lactate and Incident Hypertension in the Atherosclerosis Risk in Communities (ARIC) Study

Insufficient oxidative capacity, or mitochondrial dysfunction, may contribute to the development of high blood pressure by stimulating increased blood flow. To test this hypothesis, we examined the prospective association of lactate, a product of glycolysis and marker of oxidative capacity, with incident hypertension in 5,554 participants from the Atherosclerosis Risk in Communities (ARIC) Study. Participants had no diagnosed hypertension and blood pressures &lt;140/&lt;90 mm Hg at baseline (1996-1998). Incident hypertension was assessed during annual telephone calls and defined as a self-reported physician diagnosis of hypertension or hypertension medication use. Analyses were performed with Cox proportional hazards models. The mean age was 61.9 years, and the mean lactate was 0.08 mmol/L. The population was 45.1% male and 12.8% black. During a median follow-up period of 11.9 years (range: 26.9 days to 13.4 years), there were 3,849 new cases of hypertension. The unadjusted 10-yr cumulative incidences across quartiles 1-4 of lactate were 14.6, 18.3, 21.5, and 32.3%. After adjustment for traditional hypertension risk factors, including baseline systolic and diastolic blood pressure, the highest quartile of baseline lactate was associated with 1.18 times the hazard of the lowest quartile (95% CI: 1.07, 1.31; P-trend = 0.001) (Figure). This association was stronger (HR 1.42; 95% CI: 1.23, 1.63) in participants with blood pressures &lt;120/&lt;80 mm Hg. Mild elevations in lactate precede hypertension even in a normotensive population. These findings have important implications for early detection of hypertension risk in healthy adults.

Posterior Reversible Encephalopathy Syndrome: Incidence and Associated Factors in a Pediatric Critical Care Population

Posterior reversible encephalopathy syndrome may occur frequently and be underrecognized in children and young adults admitted to a pediatric critical care unit. Patients <21 years of age with the diagnosis of posterior reversible encephalopathy syndrome were reviewed in this retrospective cohort study conducted over a 30-month period. There were 2588 admissions to pediatric critical care unit, 226 neurology service consultations, and 10 patients diagnosed with posterior reversible encephalopathy syndrome (incidence of 1 in 259 pediatric critical care unit admissions, 0.4%). The majority of posterior reversible encephalopathy syndrome patients (9/10) presented with generalized tonic and or clonic seizures. Apart from hypertension and cytotoxic medication use, anemia, a previously unreported risk factor, was found in all 10 (100%) patients with posterior reversible encephalopathy syndrome. One-year follow up available in eight patients showed no residual neurological deficits attributable to posterior reversible encephalopathy syndrome with significant resolution of white matter signal abnormalities on neuroimaging. Our case cohort includes an estimation of incidence of posterior reversible encephalopathy syndrome in children and young adults with 1-year follow-up and anemia as a potential previously unreported risk factor.

Hypertension medication use and adherence among adults with developmental disability

Background/objectiveAdults with developmental disability (DD) have high prevalence of coronary artery disease risk factors, as well as impediments to optimal diagnosis and management. We analyzed antihypertensive medication (AM) use and adherence patterns in a Kansas Medicaid cohort. MethodsWe studied adults (18–64 years) with DD and claims for HT from 7/1/05 to 8/31/06, with review of prescription records of AM use and adherence from 9/1/06 to 8/31/07. Adherence was calculated as proportion of days covered (PDC). ResultsOf 3079 eligible people, 280 (9%) had claims for HT: 51% male, mean age 42 ± 13, and 81% Caucasian. Of these, 280 (72%) had claims for at least 1 AM; 57% received ≥2 AM. Angiotensin converting enzyme inhibitor/angiotensin receptor blockers were most commonly prescribed (65%) followed by diuretics (50%), beta blockers (34%), and calcium channel blockers (26%). Mean PDCs by class ranged from 0.622 to 0.693: 55% had a PDC ≥0.80, a common goal for adherence. Younger individuals were more likely to be adherent (p <0.05), but adherence was not significantly associated with comorbid conditions, gender, or race. ConclusionsOf our cohort of adults with DD, 9% had HT of whom 72% submitted claims for AMs. A substantial proportion of subjects had inconsistent AM use suggesting suboptimal therapy. The association between younger ages and higher adherence may reflect better community-based support for younger adults. Further work is needed to identify barriers to optimal care for this vulnerable population.

Validade da hipertensão autorreferida associa-se inversamente com escolaridade em brasileiros

Self-reported hypertension is an important piece of information for public health that is available in epidemiological studies. For proper use of this information, such studies should be validated. To validate self-reported hypertension and associated factors in adults and elderly individuals in São Paulo, Brazil. Participants were selected from the sample of a population-based cross-sectional health survey carried out in São Paulo (ISA Capital-2008). Their age was 20 years or older, they were from both genders, and had their blood pressure measured (n = 535). Hypertension was defined as blood pressure > 140/90 mmHg and/or use of medication for hypertension. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Kappa coefficient were calculated. Poisson regression was used to identify factors associated with sensitivity of self-reported hypertension. Sensitivity of self-reported hypertension was 71.1% (95%CI: 64.8 to 76.9), specificity 80.5% (95%CI: 75.6 to 84.8), PPV 73.7% (95%CI: 67.4 to 79.3), and NPV 78.5% (95%CI: 73.5 to 82.9). There was moderate agreement between self-reported hypertension and hypertension as diagnosed by blood pressure measurement (kappa = 0.52, 95%CI: 0.45 to 0.59). Body mass index and level of education were independently associated with sensitivity (body mass index > 25 kg/m²: PR = 1.42, 95% CI: 1.15 to 1.76; schooling > 9 years: PR = 0.71 95%CI: 0.54-0.94). Self-reported hypertension was shown to be valid in adults and the elderly in the city of São Paulo, and is thus an appropriate indicator for the surveillance of hypertension prevalence in the absence of blood pressure measurement. Overweight was positively associated with validity of self-reported hypertension. Further studies are needed to elucidate the inverse association between the validity of self-reported hypertension and level of education.

Preconception Care: The Perfect Opportunity for Health Care Providers to Advise Lifestyle Changes for Hypertensive Women

To provide estimates for prevalence of health care provider advice offered to reproductive-aged women and to assess their association with behavior change. Cross-sectional study using the 2009 Behavioral Risk Factor Surveillance System. Setting. Nineteen states/areas. Women aged 18 to 44 years with a self-reported history of hypertension or current antihypertensive medication use (n = 2063). Self-reported hypertension; sociodemographic and health care access indicators; and provider advice and corresponding self-reported behavior change to improve diet, limit salt intake, exercise, and reduce alcohol use. We estimated prevalence and prevalence ratios for receipt of provider advice and action to change habits. We calculated 95% confidence interval (CI) and used χ(2) tests to assess associations. Overall, 9.8% of reproductive-aged women had self-reported hypertension; most reported receiving advice to change eating habits (72.9%), reduce salt intake (74.6%), and exercise (82.1%), and most reported making these changes. Only 44.7% reported receiving advice to reduce alcohol intake. Women who received provider advice were more likely to report corresponding behavior change compared to those who did not (prevalence ratios ranged from 1.3 [95% CI, 1.2-1.5, p < .05] for exercise to 1.6 [95% CI, 1.4-1.8, p < .05] for reducing alcohol use. Health care providers should routinely advise hypertensive reproductive-aged women about lifestyle changes to reduce blood pressure and improve pregnancy outcomes.

Differential Effect of Glycemia on the Incidence of Hypertension by Sex

OBJECTIVEDiabetes Control and Complications Trial/Epidemiology of Diabetes Intervention and Complications analyses demonstrated that intensive insulin therapy was inversely associated with incident hypertension. We thus sought to confirm these observations and, given sex differences in other type 1 diabetes complications and risk factors, assessed whether any such associations differ by sex.RESEARCH DESIGN AND METHODSParticipants of a prospective cohort of childhood-onset type 1 diabetes, free of hypertension at study entry (baseline mean age, 28 years; diabetes duration, 19 years), were selected for study (n = 510). Hypertension incidence was defined as blood pressure >140/90 mmHg or use of hypertension medications in two consecutive visits. Intensive insulin therapy was defined as three or more injections (or pump) and four or more glucose tests daily. Baseline predictors of hypertension were examined using Cox proportional hazards models. Models with time-dependent updated means of baseline significant variables were also constructed.RESULTSHypertension incidence over 18 years of follow-up was marginally higher in men than in women (43.2 vs. 35.4%, P = 0.07). A significant interaction was noted between sex and HbA1c, and separate models were constructed by sex. Multivariably, elevated HbA1c was a significant predictor only in men (hazard ratio 1.48 [95% CI 1.28–1.71]). In time-dependent models, although a significant effect of HbA1c was also seen in women (1.21 [1.00–1.46]), the effect of glycemic control on hypertension development remained stronger in men (1.59 [1.29–1.97], P interaction <0.0001).CONCLUSIONSAlthough hyperglycemia is a risk factor for hypertension, its effect is stronger in men compared with women with type 1 diabetes.

472 PREVALENCE, TREATMENT AND CONTROL OF HYPERTENSION IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Background: To investigate the prevalence, treatment and control of hypertension in inpatients with CKD from a nationwide, multicenter study in China. Design and Methods: The present study is a cross-sectional survey among a nationwide investigation based on 61 big hospitals of 31 province, municipalities and autonomous regions in China. All demographic, socioeconomic, clinical data and antihypertensive medications were collected by trained physicians using a standardized protocol. Hypertension was defined as systolic blood pressure ≥140mmHg and/or diastolic blood pressure 90mmHg, and/or reported hypertension and/or antihypertensive medication use. <130/80mmHg was taken as the threshold blood pressure of hypertensive control. Multivariable logistic regression was used to explore the factors associated inadequate control of hypertension in inpatients with CKD. Results: 10582 eligible participants were analyzed. The prevalence of hypertension was 71.4%, and 87.8% were aware of hypertension diagnosis and 83.7% had been treated with antihypertensive drugs before their hospital admission. 13.9% had controlled blood pressure on the day of admission, and 26.0% had controlled blood pressure on the day before leaving hospital. In hospital, 34.9%, 33.5%, 21.0% and 10.6% used 1, 2, 3 and ≥4 antihypertensive drugs. After multivariable adjusted, CKD4 stage, CKD5 stage, obesity, diabetes, high-salt diet history of smoking, existing hypertension >5 years, and proteinuriawere independently associated with inadequate blood pressure control. Conclusions: The prevalence of hypertension was high, but the control of hypertension was poor in Chinese CKD inpatients. Inadequate combined antihypertensive medication and life-style modification might be the major reasons for suboptimal blood pressure control.

Distance Walked and Run as Improved Metrics over Time-Based Energy Estimation in Epidemiological Studies and Prevention; Evidence from Medication Use

PurposeThe guideline physical activity levels are prescribed in terms of time, frequency, and intensity (e.g., 30 minutes brisk walking, five days a week or its energy equivalence) and assume that different activities may be combined to meet targeted goals (exchangeability premise). Habitual runners and walkers may quantify exercise in terms of distance (km/day), and for them, the relationship between activity dose and health benefits may be better assessed in terms of distance rather than time. Analyses were therefore performed to test: 1) whether time-based or distance-based estimates of energy expenditure provide the best metric for relating running and walking to hypertensive, high cholesterol, and diabetes medication use (conditions known to be diminished by exercise), and 2) the exchangeability premise.MethodsLogistic regression analyses of medication use (dependent variable) vs. metabolic equivalent hours per day (METhr/d) of running, walking and other exercise (independent variables) using cross-sectional data from the National Runners' (17,201 male, 16,173 female) and Walkers' Health Studies (3,434 male, 12,384 female).ResultsEstimated METhr/d of running and walking activity were 38% and 31% greater, respectively, when calculated from self-reported time than distance in men, and 43% and 37% greater in women, respectively. Percent reductions in the odds for hypertension and high cholesterol medication use per METhr/d run or per METhr/d walked were ≥2-fold greater when estimated from reported distance (km/wk) than from time (hr/wk). The per METhr/d odds reduction was significantly greater for the distance- than the time-based estimate for hypertension (runners: P<10−5 for males and P = 0.003 for females; walkers: P = 0.03 for males and P<10−4 for females), high cholesterol medication use in runners (P<10−4 for males and P = 0.02 for females) and male walkers (P = 0.01 for males and P = 0.08 for females) and for diabetes medication use in male runners (P<10−3).ConclusionsAlthough causality between greater exercise and lower prevalence of hypertension, high cholesterol and diabetes cannot be inferred from these cross-sectional data, the results do suggest that distance-based estimates of METhr/d run or walked provide superior metrics for epidemiological analyses to their traditional time-based estimates.

Obesity, Type 2 Diabetes Mellitus, and Other Comorbidities

To compare the effect of sleeve gastrectomy vs medical therapy on type 2 diabetes mellitus and other obesity-related comorbidities (obstructive sleep apnea syndrome, hypertension, and dyslipidemia) in prospectively enrolled and matched obese patients with type 2 diabetes. A prospective cohort study. Morbidly obese patients with type 2 diabetes who either underwent sleeve gastrectomy or conventional therapy were followed up and assessed for their diabetic state and other comorbidities every 3 months for 18 months. Centre for the Surgical-Medical Treatment of Morbid Obesity, Policlinico “Umberto I,” University of Rome “Sapienza,” Italy. A total of 30 morbidly obese patients with type 2 diabetes who underwent sleeve gastrectomy (group A) and a total of 30 morbidly obese patients with type 2 diabetes who underwent conventional therapy (group B). In group A, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A1c level were 41.3 (6.0), 166.6 (68.1) mg/dL, and 7.9% (2.1%), respectively, and, at 18 months, these values were 28.3 (5.4), 96.2 (29.4) mg/dL, and 6.0% (1.5%), respectively. For 80% of patients, diabetes was resolved. With regard to other comorbidities, the prevalence of obstructive sleep apnea syndrome dropped from 50% to 10%, and patients reduced significantly their use of medication for hypertension and dyslipidemia. In group B, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A1c level were 39.0 (5.5), 183.7 (63.5) mg/dL, and 8.1% (1.7%), respectively, and, at 18 months, these values were 39.8 (5.0), 150 (48) mg/dL, and 7.1% (1.3%), respectively. All patients remained diabetic and continued or increased their level of hypoglycemic therapy. With regard to other comorbidities, we observed an increase in the use of medication for hypertension and dyslipidemia, and the prevalence of obstructive sleep apnea syndrome did not change. This study confirms the efficacy of sleeve gastrectomy in the treatment of morbidly obese type 2 diabetic patients when compared with conventional medical treatment.

The effects of the combined use of a PDE5 inhibitor and medications for hypertension, lower urinary tract symptoms and dyslipidemia on corporal tissue tone

ED is closely associated with its comorbidities (hypertension, dyslipidemia and lower urinary tract symptoms (LUTS)). Therefore, several drugs have been prescribed simultaneously with PDE5 inhibitors. If a specific medication for ED comorbidities has enhancing effects on PDE5 inhibitors, it offers alternative combination therapy in nonresponders to monotherapy with PDE5 inhibitors and allows clinicians to treat ED and its comorbidities simultaneously. To establish theoretical basis of choosing an appropriate medication for ED and concomitant disease, we examined the effects combining a PDE5 inhibitor with representative drugs for hypertension, dyslipidemia and LUTS on relaxing the corpus cavernosum of rabbits using the organ-bath technique. The effect of mirodenafil on relaxing phenylephrine-induced cavernosal contractions was significantly enhanced by the presence of 10(-4) M losartan, 10(-6) M nifedipine, 10(-6) M amlodipine, 10(-7) M doxazosin and 10(-9) M tamsulosin (P<0.05). The maximum relaxation effects were 47.2±3.8%, 57.6±2.6%, 64.0±3.7%, 76.1±5.7% and 71.7±5.4%, respectively. Enalapril and simvastatin had no enhancing effects. The relaxation induced by sodium nitroprusside alone (39.0±4.0%) was significantly enhanced in the presence of the 10(-4) M losartan (66.0±6.0%, P<0.05). Tetraethylammonium (1 mM) significantly inhibited the enhancement effects of tamsulosin and doxazosin on mirodenafil-induced relaxation (doxazosin: 76.1±5.7% vs 45.3±2.3%; tamsulosin: 71.7±5.4% vs 48.1±3.5%). On the basis of these findings, losartan seemed to induce synergistic effects through an interaction with nitric oxide. In addition, K(+) channel activation could be one of the mechanisms for the synergistic effect of combining mirodenafil with doxazosin or tamsulosin. We believe that the combination of a PDE5 inhibitor with losartan, nifedipine, amlodipine, doxazosin or tamsulosin could be a pharmacologic strategy for simultaneously treating ED and its comorbidities and increasing response rates to PDE5 inhibitors.

Cardiovascular Morbidity and Mortality in Finnish Men and Women Separated Temporarily From Their Parents in Childhood—A Life Course Study

Early-life stress may influence health later in life. We examined morbidity and mortality from cardiovascular disease over 60 years in individuals separated temporarily from their parents in childhood due to World War II. We studied 12,915 members of the Helsinki Birth Cohort Study born from 1934 to 1944, of whom 1726 (13.4%) had been evacuated aboard without their parents to temporary foster families for an average of 1.8 (standard deviation = 1.1) years at an average age of 4.6 (standard deviation = 2.4) years. Data on parental separations were extracted from the Finnish National Archives. Information on use of medication for coronary heart disease and hypertension was derived from the National Register of Medication Reimbursement, and information on coronary events, stroke, and cardiovascular deaths was derived from Finnish Hospital Discharge Register and Causes of Death Register between Years 1971 and 2003. Participants who were separated in childhood used medications for coronary heart disease more frequently than those who were not separated (7.2% versus 4.5%, respectively; hazard ratio [HR] = 1.29, 95% confidence interval [CI] = 1.04-1.59; p = .02). No associations between separation and all-cause mortality (HR = 1.04, 95% CI = 0.90-1.20) or cardiovascular mortality (HR = 0.94, 95% CI = 0.72-1.21) or hospitalizations for cardiovascular disease or stroke were observed. Early-life stress may possibly be a factor predisposing to coronary heart disease decades later, but no evidence was found for increased risk of hospitalizations or mortality.

Effect of the Medicare Part D Coverage Gap on Medication Use Among Patients With Hypertension and Hyperlipidemia

Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope. To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidemia. Quasi-experimental study using pre-post design and contemporaneous control group. Medicare claims files from 2005 and 2006 for 5% random sample of Medicare beneficiaries. Part D plan enrollees with hypertension or hyperlipidemia aged 65 years or older who had no coverage, generic-only coverage, or both brand-name and generic coverage during the gap in 2006. Patients who were fully eligible for the low-income subsidy served as the control group. Monthly 30-day supply prescriptions available, medication adherence, and continuous medication gaps of 30 days or more for antihypertensive or lipid-lowering drugs; monthly 30-day supply prescriptions available for pain relievers, acid suppressants, or antidepressants before and after coverage gap entry. Patients with no gap coverage had a decrease in monthly antihypertensive and lipid-lowering drug prescriptions during the coverage gap. Nonadherence also increased in this group (antihypertensives: odds ratio [OR], 1.60 [95% CI, 1.50 to 1.71]; lipid-lowering drugs: OR, 1.59 [CI, 1.50 to 1.68]). The proportion of patients with no gap coverage who had continuous medication gaps in lipid-lowering medication use and antihypertensive use increased by an absolute 7.3% (OR, 1.38 [CI, 1.29 to 1.46]) and 3.2% (OR, 1.35 [CI, 1.25 to 1.45]), respectively, because of the coverage gap. Decreases in use were smaller for pain relievers and antidepressants and larger for acid suppressants in patients with no gap coverage. Patients with generic-only coverage had decreased use of cardiovascular medications but no change in use of drugs for symptomatic conditions. No measures changed in the brand-name and generic coverage groups. Results of sensitivity analyses were consistent with the main findings. Because this study was nonrandomized, unobserved differences may still exist between study groups. The Part D coverage gap was associated with decreased use of medications for hypertension and hyperlipidemia in patients with no gap coverage and generic-only gap coverage. The proposed phasing out of the gap by 2020 will benefit such patients; however, use of low-value medications may also increase. Penn-Pfizer Alliance and American Heart Association.

A low-fat dietary pattern and risk of metabolic syndrome in postmenopausal women: The Women's Health Initiative

ObjectiveNutrition plays an important role in metabolic syndrome etiology. We examined whether the Women's Health Initiative (WHI) Dietary Modification Trial influenced metabolic syndrome risk. Materials/Methods48,835 postmenopausal women aged 50-79years were randomized to a low-fat (20% energy from fat) diet (intervention) or usual diet (comparison) for a mean of 8.1years. Blood pressure, waist circumference and fasting blood measures of glucose, HDL-cholesterol and triglycerides were measured on a subsample (n=2816) at baseline and years 1, 3 and 6 post-randomization. Logistic regression estimated associations of the intervention with metabolic syndrome risk and use of cholesterol-lowering and hypertension medications. Multivariate linear regression tested associations between the intervention and metabolic syndrome components. ResultsAt year 3, but not years 1 or 6, women in the intervention group (vs. comparison) had a non-statistically significant lower risk of metabolic syndrome (OR=0.83, 95%CI 0.59-1.18). Linear regression models simultaneously modeling the five metabolic syndrome components revealed significant associations of the intervention with metabolic syndrome at year 1 (p<0.0001), but not years 3 (p=0.19) and 6 (p=0.17). Analyses restricted to intervention-adherent participants strengthened associations at years 3 (p=0.05) and 6 (p=0.06). Cholesterol-lowering and hypertension medication use was 19% lower at year 1 for intervention vs. comparison group women (OR=0.81, 95% CI 0.60-1.09).Over the entire trial, fewer intervention vs. comparison participants used these medications (26.0% vs. 29.9%), although results were not statistically significant (p=0.89). ConclusionsThe WHI low-fat diet may influence metabolic syndrome risk and decrease use of hypertension and cholesterol-lowering medications. Findings have potential for meaningful clinical translation.

Outcomes of bariatric surgery in patients >70 years old

BackgroundThe aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States. MethodsA retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities. ResultsOf 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m2, respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m2, respectively. The median length of follow-up was 12 months (range 1–66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively. ConclusionBariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.

Glycated Hemoglobin and Risk of Hypertension in the Atherosclerosis Risk in Communities Study

OBJECTIVEDiabetes and hypertension often co-occur and share risk factors. Hypertension is known to predict diabetes. However, hyperglycemia also may be independently associated with future development of hypertension. We investigated glycated hemoglobin (HbA1c) as a predictor of incident hypertension.RESEARCH DESIGN AND METHODSWe conducted a prospective analysis of 9,603 middle-aged participants in the Atherosclerosis Risk in Communities Study without hypertension at baseline. Using Cox proportional hazards models, we estimated the association between HbA1c at baseline and incident hypertension by two definitions 1) self-reported hypertension during a maximum of 18 years of follow-up and 2) measured blood pressure or hypertension medication use at clinic visits for a maximum of 9 years of follow-up.RESULTSWe observed 4,800 self-reported and 1,670 visit-based hypertension cases among those without diagnosed diabetes at baseline. Among those with diagnosed diabetes at baseline, we observed 377 self-reported and 119 visit-based hypertension cases. Higher baseline HbA1c was associated with an increased risk of hypertension in subjects with and without diabetes. Compared with nondiabetic adults with HbA1c <5.7%, HbA1c in the prediabetic range (5.7–6.4%) was independently associated with incident self-reported hypertension (hazard ratio 1.14 [95% CI 1.06–1.23]) and visit-detected hypertension (1.17 [1.03–1.33]).CONCLUSIONSWe observed that individuals with elevated HbA1c, even without a prior diabetes diagnosis, are at increased risk of hypertension. HbA1c is a known predictor of incident heart disease and stroke. Our results suggest that the association of HbA1c with cardiovascular risk may be partially mediated by the development of hypertension.

Abstract MP021: Glycated Hemoglobin and Risk of Incident Hypertension in the Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Diabetes and hypertension often co-occur and have shared risk factors. While hypertension is known to predict diabetes, hyperglycemia may also be independently associated with incident hypertension. We investigated glycated hemoglobin (HbA1c) as a predictor of incident hypertension in individuals in the Atherosclerosis Risk in Communities (ARIC) cohort. Methods: We conducted a prospective analysis of 9,603 middle-aged participants in the ARIC Study without hypertension at baseline. Using Cox proportional hazards models, we estimated the association between HbA1c at baseline and incident hypertension by two definitions: (1) self-reported hypertension during a maximum of 18 years of follow-up; and (2) measured blood pressure or hypertension medication use recorded at clinic visits for a maximum of 9 years of follow-up. Results: We observed 4,800 self-reported hypertension cases and 1,670 visit-based cases. Higher baseline HbA1c was associated with increased risk of hypertension and was robust to adjustment for a comprehensive list of confounders that included two measures of adiposity (body mass index and waist-hip ratio). Compared to nondiabetic adults with HbA1c &lt;5.7%, HbA1c in the pre-diabetic range (5.7–6.4%) was independently associated with incident self-reported hypertension (HR 1.25, 95% CI: 1.16–1.34) and visit-detected hypertension (HR 1.18, 95% CI: 1.04–1.34). The HR per 1-% point higher HbA1c was 1.11 (1.06–1.16) among those with no history of diabetes and 1.06 (1.01–1.11) among those with diagnosed diabetes; the continuous associations between HbA1c and incidence of self-reported hypertension for individuals without diabetes are illustrated in the Figure. Conclusions: The association of HbA1c with incident hypertension suggests that elevated levels of circulating glucose may independently contribute to cardiovascular risk through higher blood pressure. Persons with elevated HbA1c, even without a prior diabetes diagnosis, are at increased risk of developing hypertension.

Association of Type D personality with unhealthy lifestyle, and estimated risk of coronary events in the general Icelandic population

Type D personality is associated with an increased morbidity and mortality risk in cardiovascular disease patients, but the mechanisms explaining this risk are unclear. We examined whether Type D was associated with coronary artery disease (CAD) risk factors, estimated risk of developing CAD, and previous cardiac events. Cross-sectional study in the general Icelandic population. A random sample of 4753 individuals (mean age 49.1 ± 12.0 years; 49% men) from the REFINE-Reykjavik study completed assessments for Type D personality and conventional CAD risk factors. Ten-year risk of developing CAD was estimated with the Icelandic risk calculator. Type D personality (22% of sample) was associated with a higher prevalence of hypertension (35 vs. 31%, p = 0.009), but less use of hypertension medication (58 vs. 65%, p = 0.013) in hypertensives, more diabetes (6 vs. 4%, p = 0.023), wider waist circumference (p = 0.007), and elevated body mass index (p = 0.025) and blood lipids (p < 0.05). Type D individuals reported less physical exercise (p = 0.000) and more current (26 vs. 21%, p = 0.003) and former smoking (48 vs. 44%, p = 0.036). Estimates of 10-year risk of CAD were higher in Type D individuals (12.4%, 95% CI 1.9 to 23.8%), and Type Ds reported more previous cardiac events than non-Type Ds (5 vs. 3%, p < 0.01; OR 1.71, 95% CI 1.21 to 2.42). In the general Icelandic population, Type D personality was associated with differences in lifestyle-related CAD risk factors, a higher estimated risk of developing CAD, and higher incidence of previous cardiac events. Unhealthy lifestyles may partly explain the adverse cardiovascular effect of Type D personality.