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The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for β-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P =0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P =0.204), although CCB monotherapy increased (29.5% versus 21.0%, P =0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P =0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.

ImportanceAdherence to selected antihypertensive medications (proportion of days covered [PDC]) declined after guidance to shelter in place for COVID-19.ObjectivesTo determine whether PDC for all antihypertensive medications collectively fell from the 6 months before sheltering guidance (September 15, 2019, to March 14, 2020 [baseline]) compared with the first (March 15 to June 14, 2020) and second (June 15 to September 14, 2020) 3 months of sheltering and to assess the usefulness of baseline PDC for identifying individuals at risk for declining PDC during sheltering.Design, Setting, and ParticipantsThis retrospective cohort study included a random sample of US adults obtained from EagleForce Health, a division of EagleForce Associates Inc. Approximately one-half of the adults were aged 40 to 64 years and one-half were aged 65 to 90 years, with prescription drug coverage, hypertension, and at least 1 antihypertensive medication prescription filled at a retail pharmacy during baseline.Main Outcomes and MeasuresPrescription claims were used to assess (1) PDC at baseline and changes in PDC during the first and second 3 months of sheltering and (2) the association of good (PDC ≥ 80), fair (PDC 50-79), and poor (PDC < 50) baseline adherence with adherence during sheltering.ResultsA total of 27 318 adults met inclusion criteria (mean [SD] age, 65.0 [11.7] years; 50.7% women). Mean PDC declined from baseline (65.6 [95% CI, 65.2-65.9]) during the first (63.4 [95% CI, 63.0-63.8]) and second (58.9 [95% CI, 58.5-59.3]) 3 months after sheltering in all adults combined (P P P Conclusions and RelevanceThese findings suggest that individuals with poor baseline adherence are candidates for adherence-promoting interventions irrespective of sheltering guidance. Interventions to prevent poor adherence during sheltering may be more useful for individuals with fair vs good baseline adherence.

[Figure: see text].

Hypertension is often associated with metabolic changes. The sustained increase in sympathetic activity is related to increased blood pressure and metabolic changes. Environmental stimuli may be related to increased sympathetic activity, blood pressure, and metabolic changes, especially in genetically predisposed individuals. The aim of this study was to evaluate the response of fatty acids to physical and mental stress in healthy volunteers and the hemodynamic, hormonal, and metabolic implications of these stimuli. Fifteen healthy individuals with a mean age of 31 ± 7 years, of both sexes, were evaluated. They were assessed at baseline and after combined physical and mental stress (isometric exercise test, Stroop color test). Blood samples were collected at baseline and after stimulation for glucose, insulin, fatty acid, and catecholamine levels. Blood pressure, heart rate, cardiac output, systemic vascular resistance, and distensibility of the large and small arteries were analyzed. The data obtained at baseline and after stimuli were from the same individual, being the control itself. Compared to baseline, after physical and mental stress there was a statistically significant increase (p, Arterial hypertension is highly prevalent worldwide. The real mechanisms of pathophysiology are not well understood. Stress, the sympathetic nervous system, and the release of fatty acids seem to play an important role in the pathophysiology of hypertension.

Objective: This review aims to summarize key facets of the Pro Choice and Pro Life perspectives and outline a resolution pathway that minimizes abortion. Main Results: Approximately 1.3 billion abortions occurred worldwide from 1990 through 2014. In the United States, more than 61 million abortions were performed between 1973 and 2017. The Pro Choice perspective posits that: 1) A fetus is not a person; therefore, a person is not harmed. 2) Forced childbearing includes significant health and psychological risks to the mother and can exacerbate poverty. Since a person is not harmed and the mother is benefited, abortion is a moral good. From a Judeo-Christian, Pro Life perspective: 1) God creates every person in his image and has a pre-conception life plan for them. 2) God commanded us to be fruitful and multiply and identified children as a blessing. Hence, abortion harms a person and is rebellion against God. Conclusion: In working toward a solution, agape love, which is sacrificial and giving, not selfish or condemning, is a good starting point. In that light, the Judeo-Christian community can begin bridging the chasm between the Pro Life and Pro Choice communities by sharing truth in love and helping to meet the material and emotional needs of pregnant women who see no alternative to abortion. Proactive, unconditional love provides the foundation for making the womb a sanctuary for life.

Introduction: Hypertension control is lower among women than men after age 65 years, but it is unknown whether age and sex disparities in hypertension control differ by race and ethnicity. We used data from the Multi-Ethnic Study of Atherosclerosis (MESA), to assess the association of age, sex, and race with hypertension control. Methods: At baseline, MESA enrolled 6814 adults aged 45 to 84 years without clinical CVD during years 2000-2002 followed by 5 follow-up exams. Due to loss of follow-up after exam 5, analysis was limited to participants with use of BP lowering medications at any of the first 5 MESA exams (n=2017). Hypertension control was defined as BP < 140/90 mmHg based on average of second and third BP readings at each exam. Among 873 men and 1144 women with treated hypertension, mean baseline age was 64.1 (9.1 [SD]) years and race/ethnicity was non-Hispanic white in 34.1%, 10.1% Chinese, 35.1% Non-Hispanic Black and 20.7% Hispanic. Results: Figure 1 shows the fully adjusted proportion of participants with hypertension control at any of the first five MESA exams by age group, sex and by race and ethnicity. In all racial and ethnic groups, hypertension control declined with age among women and was lowest at age 75+ years. However, this decline in hypertension control with advancing age was most pronounced among Hispanic women, a group with the lowest adjusted proportion with hypertension control at age 75+ years (45.2%; 95% CI 35.3, 55.1). Hypertension control increased with advancing age among non-Hispanic Black men and stayed stable among Chinese men. Among white and Hispanic men, the adjusted proportion with hypertension control decreased from 81.1% (95% CI 76.7, 85.5) and 70.9% (95% CI 64.1, 77.8), respectively, at age 45-64 years, to 75.4% (95% CI 69.6, 81.3) and 61.5% (95% CI 55.3, 70,8), respectively, at age 75+ years. Conclusion: Age and sex differences in hypertension control are present in these four race and ethnic groups but declines in hypertension control with advancing age appear more prominent among Hispanic women.

Background: Life’s Simple 7 (LS7; nutri­tion, physical activity, cigarette use, body mass index, blood pressure, cholesterol, glucose) predicts cardiovascular health. The principal objective of our study was to define demographic and socioeconomic factors associated with LS7 to better inform programs addressing cardiovascular health and health equity.Methods: National Health and Nutrition Examination Surveys 1999–2016 data were analyzed on non-Hispanic White [NHW], NH Black [NHB], and Hispanic adults aged ≥20 years without cardiovascular disease. Each LS7 variable was assigned 0, 1, or 2 points for poor, intermediate, and ideal lev­els, respectively. Composite LS7 scores were grouped as poor (0–4 points), intermediate (5–9), and ideal (10–14).Results: 32,803 adults were included. Mean composite LS7 scores were below ideal across race/ethnicity groups. After adjusting for confounders, NHBs were less likely to have optimal LS7 scores than NHW (multivariable odds ratios (OR .44; 95% CI .37–.53), whereas Hispanics tended to have better scores (1.18; .96–1.44). Hispan­ics had more ideal LS7 scores than NHBs, although Hispanics had lower incomes and less education, which were independently associated with fewer ideal LS7 scores. Adults aged ≥45 years were less likely to have ideal LS7 scores (.11; .09–.12) than adults aged

Background and aims Within the context of busy clinical settings, health-care providers need practical, evidence-based options to engage smokers in quitting. Sampling of nicotine replacement therapy [i.e. provision of nicotine replacement therapy (NRT starter kits)] is a brief, pragmatic strategy to address this need. We aimed to compare the effects of NRT sampling plus standard care (SC), relative to SC alone, provided by primary care providers during routine clinic visits. Design Cluster-randomized clinical trial. Setting Twenty-two primary care clinics in South Carolina, USA. Participants Adult smokers [n = 1245; 61% female, mean age = 50.7, standard deviation (SD) = 13.5] both motivated and unmotivated to quit, seen during routine clinical visit. Interventions were provider-delivered SC (n = 652, 12 clinics) cessation advice or SC + a 2-week supply of both nicotine patch and lozenge, with minimal instructions on use (n = 593; 10 clinics). Measurements The primary outcome was 7-day point prevalence smoking abstinence at 6-month follow-up, using intent-to-treat. Additional outcomes included NRT use and quit attempts, assessed at 1, 3 and 6 months following baseline. Findings Seven-day point prevalence abstinence rates were significantly higher in the NRT sampling group throughout follow-up, including at 6 months [12 versus 8%, odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.0-2.4]. NRT sampling increased prevalence of any use of NRT (65 versus 25%, OR = 5.8, 95% CI = 4.3-7.7), with higher prevalence of use at 6 months (25 versus 14%, OR = 2.0, 95% CI = 1.5-2.7). NRT sampling increased the rate of quit attempts in the initial month (24 versus 18%, OR = 1.5, 95% CI = 1.0-2.3) but had no significant effect on overall rate of quit attempts (48 versus 45%, OR = 1.2, 95% CI = 0.8-1.7). Conclusion Providing smokers with a free 2-week starter kit of nicotine replacement therapy increased quit attempts, use of stop smoking medications and smoking abstinence compared with standard care in a primary care setting.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as

Hypertension is a major risk factor for cardiovascular and renal diseases in the United States and worldwide. Obesity accounts for much of the risk for primary hypertension through several mechanisms, including neurohormonal activation, inflammation, and kidney dysfunction. As the prevalence of obesity continues to increase, hypertension and associated cardiorenal diseases will also increase unless more effective strategies to prevent and treat obesity are developed. Lifestyle modification, including diet, reduced sedentariness, and increased physical activity, is usually recommended for patients with obesity; however, the long-term success of these strategies for reducing adiposity, maintaining weight loss, and reducing blood pressure has been limited. Effective pharmacotherapeutic and procedural strategies, including metabolic surgeries, are additional options to treat obesity and prevent or attenuate obesity hypertension, target organ damage, and subsequent disease. Medications can be useful for short- and long-term obesity treatment; however, prescription of these drugs is limited. Metabolic surgery is effective for producing sustained weight loss and for treating hypertension and metabolic disorders in many patients with severe obesity. Unanswered questions remain related to the mechanisms of obesity-related diseases, long-term efficacy of different treatment and prevention strategies, and timing of these interventions to prevent obesity and hypertension-mediated target organ damage. Further investigation, including randomized controlled trials, is essential to addressing these questions, and emphasis should be placed on the prevention of obesity to reduce the burden of hypertensive cardiovascular and kidney diseases and subsequent mortality.

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

Highlights • Improving hypertension control will reduce heart disease and mortality. • After age 65 years, women are less likely than men to have controlled hypertension. • Sex differences in hypertension control widen with advancing age. • Sex differences in hypertension control appear independent of obesity and diabetes., Objective Determine sex differences in hypertension control by age group in a diverse cohort of adults age 45–84 years at baseline followed for an average of 12 years. Methods The Multi-Ethnic Study of Atherosclerosis enrolled 3213 men and 3601 women from six communities in the U.S. during years 2000–2002 with follow-up exams completed approximately every two years. At each exam, resting blood pressure (BP) was measured in triplicate, and the last two values were averaged. Hypertension was defined as a BP ≥ 140/90 mmHg and/or use of antihypertensive medications. Hypertension control was defined as a BP < 140/90 mmHg and in separate analyses as < 130/90 mmHg. Generalized linear mixed effects models with a binomial function were used to calculate the odds of hypertension control by age group (45–64,75–74, 75+) at a given exam and by sex, while accounting for the intra-individual correlation, and adjustment for demographics, co-morbidities, smoking, alcohol use, education and site among participants with hypertension at any of the first five exams. Results At baseline, mean age was 64.1 (9.1 [SD]) years, 48.0% were men, and race/ethnicity was Non-Hispanic white in 34.1%, 10.1% Chinese, 35.1% Non-Hispanic Black and 20.7% Hispanic. Average SBP was lower while average DBP was higher among men vs. women at each exam. Adjusted odds ratios of hypertension control defined as BP < 140/90 mmHg among men vs. women was 0.89 (95% CI 0.67, 1.19) for age 45–64 years, 1.37 (95% CI 1.04, 1.81) for age 65–74 years and 2.08 (95% CI 1.43, 3.02) for age 75+ years. When defined as < 130/80 mmHg, adjusted odds of hypertension control among men vs. women was 0.60 (OR 0.60; 95% CI 0.46, 0.79) at age 45–64 years, 1.01 (OR 1.01; 95% CI 0.77, 1.31) at age 65–74 years and 1.71 (95% CI 1.19, 2.45) at age 75+ years. Conclusion Sex disparities in hypertension control increase with advancing age and are greatest among adults age 75+ years.

Hypertension control (United States) increased from 1999 to 2000 to 2009 to 2010, plateaued during 2009 to 2014, then fell during 2015 to 2018. We sought explanatory factors for declining hypertension control and assessed whether specific age (18–39, 40–59, ≥60 years) or race-ethnicity groups (Non-Hispanic White, NH [B]lack, Hispanic) were disproportionately impacted. Adults with hypertension in National Health and Nutrition Examination Surveys during the plateau (2009–2014) and decline (2015–2018) in hypertension control were studied. Definitions: hypertension, blood pressure (mm Hg) ≥140 and/or ≥90 mm Hg or self-reported antihypertensive medications (Treated); Aware, ‘Yes” to, “Have you been told you have hypertension?”; Treatment effectiveness, proportion of treated adults controlled; control, blood pressure P P =0.01), treatment (−4.6%, P =0.004), and treatment effectiveness (−6.0%, P P =0.97]). Antihypertensive monotherapy rose (+4.2%, P =0.04), although treatment resistance factors increased (obesity +4.0%, P =0.02, diabetes +2.3%, P =0.02). Hypertension control fell across age (18–39 [−4.9%, P =0.30]; 40–59 [−9.9%, P =0.0003]; ≥60 years [−6.5%, P =0.005]) and race-ethnicity groups (Non-Hispanic White [−8.5%, P =0.0007]; NHB −7.4%, P =0.002]; Hispanic [−5.2%, P =0.06]). Racial/ethnic disparities in hypertension control versus Non-Hispanic White were attenuated after adjusting for modifiable factors including education, obesity and access to care; NHB (odds ratio, 0.79 unadjusted versus 0.84 adjusted); Hispanic (odds ratio 0.74 unadjusted versus 0.98 adjusted). Improving hypertension control and reducing disparities require greater and more equitable access to high quality health care and healthier lifestyles.

In 2010, 1.4 billion people globally had hypertension, with 14% controlled to systolic blood pressure (SBP, mmHg) below 140, which contributes to 18 million cardiovascular deaths annually. Recent hypertension guidelines endorsed SBP targets below 130 or lower for all or some hypertensive patients to reduce cardiovascular events (CVEs) more than the prior SBP target less than 140. In 2016, the Australian Guideline strongly recommended target SBP below 120 for adults at very high risk for CVE or aged above 75 years. In 2017 and 2018, the Canadian Guideline recommended automated office SBP (AOSBP) below 120 in adults at high risk and aged above 75 years (grade B). In 2017, the US Guideline recommended SBP below 130 for all adults (moderate-to-high risk class I; lower-risk grade IIb). In 2018, the European Guideline recommended SBP below 140 for all adults, and, if tolerated, a SBP range of 120-129 for adults aged below 65 years and 130-139 for adults aged at least 65 years (class I). The guidelines were variably influenced by Systolic blood PRessure INTervention trial and meta-analyses indicating fewer CVE when mean in-trial SBP was below 130 versus above 130. Clinicians considering lower SBP targets should be aware that: AOSBP preceded by 5-min rest is approximately 10-15 mmHg lower than usual office SBP; hypertensive patients with office SBP consistently versus intermittently below 140 have fewer CVE; benefits of mean office SBP or AOSBP below 120 remain unproven and could increase adverse events. Clinicians worldwide will do well to control SBP to below 140 in most hypertensive patients on most visits, which should lead to mean in-clinic SBP of 120-129.

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Better blood pressure (BP; mm Hg) control is a pivotal national strategy for preventing cardiovascular events. Measure accurately, Act rapidly, and Partner with patients (MAP) with practice facilitation improved BP control (P P P =0.01), and systolic BP decreased more per therapeutic intensification (−5.4 to −12.7; P

Background: Non-Hispanic Blacks (NHBs) have a higher prevalence of hypertension and incidence of cardiovascular events than NH(W)hites and Hispanics. To improve hypertension control and outcomes in NHBs, the U.S. High Blood Pressure (BP, mmHg) Guidelines recommended calcium channel blockers (CCBs) and diuretics over other drug classes as initial therapy in 2014 and 2017. Among adults with hypertension, percentages of NHBs who reported taking CCBs and diuretic monotherapy before and after 2014 were assessed and compared to NHWs and Hispanics. Methods: National Health and Nutrition Examination Surveys data in 2-year cycles from 2007-2012 and 2015-2018 were analyzed and included self-identified NHB, NHW, and Hispanic adults ≥18 years with recorded BP values and hypertension defined as self-reported BP medication use in the previous month, which included medication class, e.g., CCBs and diuretics. Multivariable logistic regression was used to assess the independent contribution of NHB race/ethnicity to prevalence of CCB and diuretic use as monotherapy. Results: Self-reported CCB or diuretic monotherapy did not increase significantly from 2007-2012 to 2015-2018 among NHBs (44% vs. 50%, p=0.12) or Hispanics (22% vs 29%, p=0.12) and a non-significant decline in NHWs (26% vs 22%, p=0.14). NHBs were more likely to report taking CCBs or diuretics as monotherapy than NHWs or Hispanics in both time periods (p Conclusions: NHBs had a non-significant increase in self-reported CCB or diuretic as monotherapy from 2007-2012 to 2015-2018, suggesting limited impact for this prescribing recommendation in the 2014 and 2017 High BP Guidelines. NHBs more often reported CCB or diuretic monotherapy than NHWs and Hispanics in both time periods, suggesting some clinicians were aware of evidence prior to the 2014 Guideline. Yet, half of NHBs did not report taking CCBs or diuretics as monotherapy in 2015-2018, indicating further opportunity to prescribe evidence-based initial therapy in NHBs that could improve BP control, cardiovascular outcomes and health equity.

Background: Prior reports show that blood pressure (BP, mmHg) control to Methods: BP control was assessed in adults ≥18 years in NHANES 2009-2018 (age-adjusted to 2010). BP control and its determinants were assessed by age group 18-39, 40-59, and ≥60 years in NHANES 2009-2012 and 2015-2018 (before/after 2014). Terms: Hypertension, BP ≥140 &/or ≥90 or self-reported current BP medication use (Treated); Aware, ‘Yes” to, “Have you been told you have hypertension?”; Treatment efficiency, proportion of treated adults controlled ([Cont]rolled/Treated); BP control, Results: For all adults, BP control peaked in 2013-2014 at 54.5%, declining to 48.0% in 2015-2016 and 43.4% in 2017-2018 (11.1% fall, p Conclusion: Despite the 2017 BP goal

Supplemental Digital Content is available in the text., Better blood pressure (BP; mm Hg) control is a pivotal national strategy for preventing cardiovascular events. Measure accurately, Act rapidly, and Partner with patients (MAP) with practice facilitation improved BP control (

A quantitative survey was completed by 103 primary care physicians (PCPs) and 59 cardiologists who regularly prescribed β-blockers to assess knowledge and use of this heterogeneous drug class for hypertension. More cardiologists than PCPs chose β-blockers as initial antihypertensive therapy (30% vs 17%, P < 0.01). Metoprolol and carvedilol were the most commonly prescribed β-blockers. Cardiologists rated "impact on energy" and "arterial vasodilation" as more important than PCPs (P < 0.05/

Introduction β-Blockers are a heterogenous class of drugs that are no longer recommended for initial antihypertension monotherapy due to unfavorable long-term cardiovascular events observed with non-vasodilatory β-blockers. However, the comparative cardiovascular event risk between the vasodilatory β1-selective antagonist/β3 agonist nebivolol and non-vasodilatory β1-blockers, atenolol and metoprolol, is unknown. Methods Incident nebivolol, atenolol, or metoprolol monotherapy users with hypertension were identified using US claims data (2007–2014). The first β-blocker claim on/after 1/1/2008 defined the index drug/date. Hypertensive patients without pre-index cardiovascular history were followed until index drug discontinuation (> 90 day supply gap), use of other β-blockers, or end of continuous plan enrollment. Patients were pair-wise propensity score-matched using logistic regression, adjusted for baseline demographics, Charlson Comorbidity Index score, comorbid chronic pulmonary disease, rheumatic disease, renal disease, and diabetes, and use of other antihypertensive drugs during baseline. Time to first hospital claim for a cardiovascular event was assessed via Cox proportional hazards regression, adjusted for the variables above. Results Inclusion criteria were met by 81,402 patients (n = 27,134 in each matched treatment cohort), with no between-cohort differences in baseline characteristics, comorbid conditions, or average follow-up duration. Atenolol and metoprolol cohorts had greater risk of hospitalization for a composite event (myocardial infarction, angina, congestive heart failure, stroke) than nebivolol users (adjusted hazard ratios [95% confidence interval] atenolol: 1.68 [1.29, 2.17]; metoprolol: 2.05 [1.59, 2.63]; P

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is an evidence‐based protocol implemented to improve hypertension control in a clinic for underserved patients (49.9% Medicaid and 50.2% black). Patients with hypertension seen during the year before intervention and with at least one visit during the 6‐month intervention (N = 714) were included. If initial attended blood pressure (BP; standard aneroid manometer) was ≥140/≥90 mm Hg, unattended automated office BP was measured in triplicate and averaged (Measure Accurately) using an Omron HEM‐907XL. When automated office BP was ≥140/≥90 mm Hg, Act Rapidly included intensification of antihypertensive medications, assessed by therapeutic inertia. Partner With Patients included BP self‐monitoring, reducing pill burden, and minimizing medication costs, which was assessed by systolic BP change per therapeutic intensification. Between baseline and the last study visit, BP control to

Prehypertension is associated with increased risk for hypertension and cardiovascular disease. Data are limited on the temporal changes in the prevalence of prehypertension and risk factors for hypertension and cardiovascular disease among US adults with prehypertension. We analyzed data from 30 958 US adults ≥20 years of age who participated in the National Health and Nutrition Examination Surveys between 1999 and 2012. Using the mean of 3 blood pressure (BP) measurements from a study examination, prehypertension was defined as systolic BP of 120 to 139 mm Hg and diastolic BP P trend=0.007). During this time period, the prevalence of several risk factors for cardiovascular disease and incident hypertension increased among US adults with prehypertension, including prediabetes (9.6% to 21.6%), diabetes mellitus (6.0% to 8.5%), overweight (33.5% to 37.3%), and obesity (30.6% to 35.2%). There was a nonstatistically significant increase in no weekly leisure-time physical activity (40.0% to 43.9%). Also, the prevalence of adhering to the Dietary Approaches to Stop Hypertension eating pattern decreased (18.4% to 11.9%). In contrast, there was a nonstatistically significant decline in current smoking (25.9% to 23.2%). In conclusion, the prevalence of prehypertension has decreased modestly since 1999–2000. Population-level approaches directed at adults with prehypertension are needed to improve risk factors to prevent hypertension and cardiovascular disease.

Objective:The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study is the first stroke prevention trial to include protocol-driven intensive management of multiple risk factors. In this prespecified analysis, we aimed to investigate the relationship between risk factor control during follow-up and outcome of patients in the medical arm of SAMMPRIS.Methods:Data from SAMMPRIS participants in the medical arm (n = 227) were analyzed. Risk factors were recorded at baseline, 30 days, 4 months, and then every 4 months for a mean follow-up of 32 months. For each patient, values for all risk factor measures were averaged and dichotomized as in or out of target.Results:Participants who were out of target for systolic blood pressure and physical activity, as well as those with higher mean low-density lipoprotein cholesterol and non–high-density lipoprotein, were more likely to have a recurrent vascular event (stroke, myocardial infarction, or vascular death) at 3 years compared to those who had good risk factor control. In the multivariable analysis, greater physical activity decreased the likelihood of a recurrent stroke, myocardial infarction, or vascular death (odds ratio 0.6, confidence interval 0.4–0.8).Conclusions:Raised blood pressure, cholesterol, and physical inactivity should be aggressively treated in patients with intracranial atherosclerosis to prevent future vascular events. Physical activity, which has not received attention in stroke prevention trials, was the strongest predictor of a good outcome in the medical arm in SAMMPRIS.ClinicalTrials.gov identifier:NCT00576693.

Background: Value-based healthcare rewards quality, e.g. 90 th percentile performance, which requires more than 77% of eligible adults 18 - 85 years with hypertension have BP below 140/90 on the last visit of 2019. Systolic (S)BP (mmHg) below140 on most visits leads to fewer cardiovascular events (CVE) than less consistent control. Goal SBP was lowered to below 130 in the 2017 ACC / AHA Hypertension Guideline as treated patient groups with mean SBP 120-124 had fewer CVE than groups with higher mean SBP. Stricter treatment targets and incentives for excellent performance may lead to group mean SBP less than 120, i.e., below the evidence. Methods: SPRINT POP Year 2 data were analyzed given more treatment adjustments in Year 01 and fewer patients active in Year 3 and later. The % of patients controlled on various % of visits and mean SBP on the last visit for each group are provided (Table). SEM for SBP less than 0.5 mmHg. Results: Standard and intensive therapy, respectively, consistently controlled (more than 75% visits) SBP to less than 140 in 29.9% and 78.0% (mean 128.4, 117.6) and SBP to less than 130 in 5.1% and 53.8% (mean 118.5, 114.8) of SPRINT participants. Discussion: Group mean SBP falls as the (% visits and patients at goal rise. Consistent control to SBP less than 140 likely requires group mean SBP 118-128 on the last yearly visit. Consistent control to SBP less than 130 likely requires group mean SBP 115-119, which is below the evidence of 120-124. BP variability, the impact of single point assessment, and incentives for excellent control are items to consider in hypertension guideline and performance metrics as mean SBP below the evidence may be attained.

Background: Life’s Simple 7 (LS7; diet, physical activity, smoking, BMI, BP, cholesterol, glucose) was developed by AHA to track and improve CV risk and outcomes. Individuals with high vs. low LS7 scores have 30%-80% lower incidence rates of hypertension, diabetes, heart disease, stroke, dementia, kidney and lung disease, and cancer. Since LS7 serves as a population health marker, national trends in demographic groups can inform efforts to optimize health and health equity. Methods: LS7 was assessed in 35,562 NHANES 1999-2016 participants 20 years and older, free of CVD with all LS7 data and either non-Hispanic White (NHW), non-Hispanic Black (NHB) or Hispanic. Data were disaggregated by time, age, race / ethnicity and sex. For each LS7 item, 0 points were assigned for poor, 1 point for intermediate, and 2 points for optimal levels; maximum LS7 score = 14. Results: LS7 scores fell with age, were higher in NHWs and Hispanics than NHBs, and higher in women than men (Table). Conclusions: Demographic factors were associated with large differences in LS7 scores. No group had optimal scores or is improving with time. LS7 scores are sharply lower in middle-age and older than younger adults, in NHBs than NHWs and Hispanics, and in men than women. Hispanics had similar LS7 scores to NHWs, despite less income, education and health insurance. Findings highlight the need for culturally tailored and complementary public and population health programs beginning early in life to promote healthy lifestyle patterns and timely access to and adherence with evidence-based care. Successful programs could reduce the age-related rise in cardiometabolic and other chronic diseases and improve health equity.

BackgroundApproximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.Methods and findingsTo determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary.ConclusionsIdentifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Objectives: The aim of this study was to determine if carvedilol improved structural and functional changes in the left ventricle and reduced mortality in patients with hypertensive heart disease. Methods: Blood pressure, heart rate, echocardiographic parameters, and laboratory variables, were assessed pre and post treatment with carvedilol in 98 eligible patients. Results: Carvedilol at a median dose of 50 mg/day during the treatment period in hypertensive heart disease lowered blood pressure 10/10 mmHg, heart rate 10 beats/min, improved left ventricular ejection fraction from baseline to follow-up (median: 6 years) (36%–47%)) and reduced left ventricular end-diastolic and end-systolic dimensions (62 vs 56 mm; 53 vs 42 mm, respectively, all p-values Conclusion: Carvedilol reduced cardiac dimensions and improved left ventricular ejection fraction and cardiac remodeling in patients with hypertensive heart disease. These treatment-related changes had a favorable effect on survival.