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BACKGROUND Blood pressure (BP) measured in the office setting increases from early through later adulthood. However, it is unknown to what extent out-of-office BP derived via ambulatory BP monitoring (ABPM) increases over time, and which participant characteristics and risk factors might contribute to these increases. METHODS We assessed 25-year change in office- and ABPM-derived BP across sex, race, diabetes mellitus (DM), and body mass index (BMI) subgroups in the Coronary Artery Risk Development in Young Adults study using multivariable-adjusted linear mixed effects models. RESULTS We included 288 participants who underwent ABPM at the Year 5 Exam (mean [SD] age, 25.1 [3.7]; 45.8% men) and 455 participants who underwent ABPM at the Year 30 Exam (mean [SD] age, 49.5 [3.7]; 42.0% men). Office, daytime, and nighttime systolic BP (SBP) increased 12.8 (95% confidence interval [CI], 7.6–17.9), 14.7 (95% CI, 9.7–19.8), and 16.6 (95% CI, 11.4–21.8) mm Hg, respectively, over 25 years. Office SBP increased 6.5 (95% CI, 2.3–10.6) mm Hg more among black compared with white participants. Daytime SBP increased 6.3 (95% CI, 0.2–12.4) mm Hg more among participants with a BMI ≥25 vs. CONCLUSIONS Office- and ABPM-derived BP increased more from early through middle adulthood among black adults and participants with DM and BMI ≥25 kg/m2.

Resistant hypertension, defined as blood pressure levels above goal while taking ≥3 classes of antihypertensive medication or ≥4 classes regardless of blood pressure level, is associated with increased cardiovascular disease risk. The 2018 American Heart Association Scientific Statement on Resistant Hypertension recommends healthy lifestyle habits and thiazide-like diuretics and mineralocorticoid receptor antagonists for adults with resistant hypertension. The term apparent treatment-resistant hypertension (aTRH) is used when pseudoresistance cannot be excluded. We estimated the use of healthy lifestyle factors and recommended antihypertensive medication classes among US Black adults with aTRH. Data were pooled for Black participants in the JHS (Jackson Heart Study) in 2009 to 2013 (n=2496) and the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) in 2013 to 2016 (n=3786). Outcomes included lifestyle factors (not smoking, not consuming alcohol, ≥75 minutes of vigorous-intensity or ≥150 minutes of moderate or vigorous physical activity per week, and body mass index 2 ) and recommended antihypertensive medications (thiazide-like diuretics and mineralocorticoid receptor antagonists). Overall, 28.3% of participants who reported taking antihypertensive medication had aTRH. Among participants with aTRH, 14.5% and 1.2% had ideal levels of 3 and 4 of the lifestyle factors, respectively. Also, 5.9% of participants with aTRH reported taking a thiazide-like diuretic, and 9.8% reported taking a mineralocorticoid receptor antagonist. In conclusion, evidence-based lifestyle factors and recommended pharmacological treatment are underutilized in Black adults with aTRH. Increased use of lifestyle recommendations and antihypertensive medication classes specifically recommended for aTRH may improve blood pressure control and reduce cardiovascular disease–related morbidity and mortality among US Black adults. Graphic Abstract A graphic abstract is available for this article.

BACKGROUND Obstructive sleep apnea (OSA), nocturnal hypertension, and nondipping systolic blood pressure (BP) are each highly prevalent among African Americans. However, few data are available on the association between OSA and nighttime BP in this population. METHODS We examined the association of OSA with nighttime BP among African Americans who completed 24-hour ambulatory BP monitoring (ABPM) at Exam 1 (2000–2004) of the Jackson Heart Study (JHS) and subsequently participated in the JHS Sleep Study (2012–2016). Type 3 home sleep apnea testing was used to assess OSA measures, including respiratory event index (REI4%) and percent sleep time RESULTS Among 206 participants who completed ABPM and participated in the Jackson Heart Sleep Study, 50.5% had nocturnal hypertension and 26.2% had moderate to severe OSA (REI4% ≥15 events/hour). After multivariable adjustment, each SD (13.3 events/hour) increase in REI4% was associated with 1.75 mm Hg higher nighttime DBP (95% confidence interval (CI): 0.38, 3.11) and a prevalence ratio of 1.11 (95% CI: 1.00, 1.24) for nocturnal hypertension. Each SD (10.4%) increase in nocturnal hypoxemia was associated with a 1.91 mm Hg higher nighttime SBP (95% CI: 0.15, 3.66). CONCLUSIONS Severity of OSA and nocturnal hypoxemia were associated with high nighttime BP in African American participants in the JHS.

OBJECTIVES: To evaluate the associations of high awake blood pressure (BP), high asleep BP, and non-dipping BP, determined by ambulatory BP monitoring (ABPM), with left ventricular (LV) hypertrophy (LVH) and geometry. METHODS: Black and white participants (n=687) in the Coronary Artery Risk Development in Young Adults (CARDIA) study underwent 24-hour ABPM and echocardiography at the Year 30 Exam in 2015–2016. The prevalence and prevalence ratios (PR) of LVH were calculated for high awake systolic BP (≥ 130 mmHg), high asleep systolic BP (≥ 110 mmHg), the cross-classification of high awake and asleep systolic BP, and non-dipping systolic BP (percentage decline in awake-to-asleep systolic BP < 10%). Odds ratios (ORs) for abnormal LV geometry associated with these phenotypes were calculated. RESULTS: Overall, 46.0% and 49.1% of study participants had high awake and asleep systolic BP, respectively, and 31.1% had non-dipping systolic BP. After adjustment for demographics and clinical characteristics, high awake systolic BP was associated with a PR for LVH of 2.79, (95% confidence interval [95% CI] 1.63–4.79). High asleep systolic BP was also associated with a PR for LVH of 2.19 (95% CI 1.25–3.83). There was no evidence of an association between non-dipping systolic BP and LVH (PR 0.70, 95% CI 0.44–1.12). High awake systolic BP with or without high asleep systolic BP was associated with a higher OR of concentric remodeling and hypertrophy. CONCLUSION: Awake and asleep systolic BP, but not the decline in awake-to-asleep systolic BP, were associated with increased prevalence of cardiac end-organ damage.

Purpose Circular frames have been the gold standard of treatment for complex deformity corrections and bone loss. However, despite the success of frames, patient satisfaction has been low, and complications are frequent. Most recently, lengthening nails have been used to correct leg length discrepancies. In this article, we review the current trends in deformity correction with emphasis on bone lengthening and present our case examples on the use of lengthening nails for management of complex malunions, non-unions, and a novel use in bone transport. Materials and methods A nonsystematic literature review on the topic was performed. Four case examples from our institute, Brighton and Sussex University Hospitals, East Sussex, England, UK, were included. Results New techniques based on intramedullary bone lengthening and deformity correction are replacing the conventional external frames. Introduction of lengthening and then nailing and lengthening over a nail techniques paved the way for popularization of the more recent lengthening nails. Lengthening nails have gone through evolution from the first mechanical nails to motorized nails and more recently the magnetic lengthening nails. Two case examples demonstrate successful use of lengthening nails for management of malunion, and two case examples describe novel use in management of non-unions, including the first report in the literature of plate-assisted bone segment transport for the longest defect successfully treated using this novel technique. Conclusion With the significant advancement of intramedullary lengthening devices with lower complications rates and higher patient satisfaction, the era of the circular frame may be over. How to cite this article Barakat AH, Sayani J, O'Dowd-Booth C, et al. Lengthening Nails for Distraction Osteogenesis: A Review of Current Practice and Presentation of Extended Indications. Strategies Trauma Limb Reconstr 2020;15(1):54–61.

OBJECTIVE: Nocturnal hypertension and non-dipping systolic blood pressure (SBP) are associated with increased cardiovascular disease (CVD) risk. Short and long sleep duration (SSD and LSD) are also associated with increased CVD risk and may be risk factors for nocturnal hypertension and non-dipping SBP. We examined the association between SSD and LSD with sleep BP, nocturnal hypertension, and non-dipping SBP among 647 white and African American Coronary Artery Risk Development in Young Adults (CARDIA) study participants who completed 24-hour ambulatory BP monitoring, wrist actigraphy, and sleep diaries in 2015-2016. METHODS: The times when participants were asleep and awake were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as sleep BP ≥120/70 mmHg and non-dipping SBP as mean sleep-to-awake SBP ratio >0.90. Sleep duration was categorized as SSD (

OBJECTIVE Recent studies have suggested that prediabetes is associated with an increased risk for cardiovascular disease (CVD) only among individuals with concomitant hypertension. RESEARCH DESIGN AND METHODS We analyzed the association between prediabetes and CVD by hypertension status among 3,313 black adults in the Jackson Heart Study (JHS) without diabetes or a history of CVD at baseline (2000–2004). Prediabetes was defined as fasting plasma glucose between 100 and 125 mg/dL or hemoglobin A1c between 5.7 and 6.4% (39 and 46 mmol/mol). Hypertension was defined as systolic/diastolic blood pressure ≥140/90 mmHg and/or self-reported antihypertensive medication use. Participants were followed for incident CVD events and all-cause mortality through 31 December 2014. RESULTS Overall, 35% of JHS participants did not have prediabetes or hypertension, 18% had prediabetes alone, 22% had hypertension alone, and 25% had both prediabetes and hypertension. Compared with participants without either condition, the multivariable-adjusted hazard ratios for CVD events among participants with prediabetes alone, hypertension alone, and both prediabetes and hypertension were 0.86 (95% CI 0.51, 1.45), 2.09 (1.39, 3.14), and 1.93 (1.28, 2.90), respectively. Among participants with and without hypertension, there was no association between prediabetes and an increased risk for CVD (0.78 [0.46, 1.34] and 0.94 [0.70, 1.26], respectively). No association was present between prediabetes and all-cause mortality among participants with or without hypertension. CONCLUSIONS Regardless of hypertension status, prediabetes was not associated with an increased risk for CVD or all-cause mortality in this cohort of black adults.

The 2017 Hypertension Clinical Practice Guidelines recommend out-of-clinic BP monitoring to screen for white coat and masked hypertension among adults not taking antihypertensive medication and white coat effect and masked uncontrolled hypertension among adults taking antihypertensive medication. We estimated the percentage of US adults meeting criteria for out-of-clinic BP monitoring by the American College of Cardiology/American Heart Association guideline using the 2011 to 2014 National Health and Nutrition Examination Survey (n=9623). Among US adults not taking antihypertensive medication, 92.6% (95% CI, 90.7%–94.1%) with systolic/diastolic BP ≥130/80 mm Hg met criteria for out-of-clinic BP monitoring to screen for white coat hypertension and 32.8% (95% CI, 30.4%–35.3%) with systolic/diastolic BP

In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians/American Academy of Family Physicians (ACP/AAFP) published blood pressure guidelines. Adults recommended antihypertensive medication initiation or intensification by the ACP/AAFP guideline receive the same recommendation from the ACC/AHA guideline. However, many adults ≥60 years old are recommended to initiate or intensify antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline. We compared atherosclerotic cardiovascular disease event rates according to antihypertensive treatment recommendations in the ACC/AHA and ACP/AAFP guidelines among adults ≥60 years old with systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) and the JHS (Jackson Heart Study). Among 4311 participants not taking antihypertensive medication at baseline, 11.4%, 61.2%, and 27.4% were recommended antihypertensive medication initiation by neither guideline, the ACC/AHA but not the ACP/AAFP guideline, and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 3.4 (1.6–5.2), 18.0 (16.1–19.8), and 25.3 (21.9–28.6) per 1000 person-years, respectively. Among 7281 participants taking antihypertensive medication at baseline, 57.9% and 42.1% were recommended antihypertensive medication intensification by the ACC/AHA but not the ACP/AAFP guideline and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 18.2 (16.7–19.7) and 33.0 (30.5–35.4) per 1000 person-years, respectively. In conclusion, adults recommended initiation or intensification of antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline have high atherosclerotic cardiovascular disease risk that may be reduced through treatment initiation or intensification.

Background: Over 10 years, achieving and maintaining 2017 ACC/AHA guideline goals could prevent 3.0 million (UR, 1.1–5.1 million), 0.5 million (UR, 0.2–0.7 million), and 1.4 million (UR, 0.6–2.0 million) cardiovascular disease (CVD) events compared with maintaining current blood pressure (BP) levels, achieving 2003 Seventh Joint National Committee Report goals, and achieving 2014 Eighth Joint National Committee goals, respectively. We estimated the number of cardiovascular disease events prevented and treatment-related serious adverse events incurred over 10 years among US adults with hypertension by achieving 2017 ACC/AHA guideline-recommended BP goals compared with (1) current BP levels, (2) achieving 2003 Seventh Joint National Committee Report BP goals, and (3) achieving 2014 Eighth Joint National Committee panel member report BP goals. Methods: US adults aged ≥45 years with an indication for BP treatment were grouped according to recommendations for antihypertensive drug therapy in the 2017 ACC/AHA guideline, 2003 Seventh Joint National Committee Report, and 2014 Eighth Joint National Committee. Population sizes were estimated from the 2011 to 2014 National Health and Nutrition Examination Surveys. Rates for fatal and nonfatal CVD events (stroke, coronary heart disease, or heart failure) were estimated from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, weighted to the US population. CVD risk reductions with treatment to BP goals and risk for serious adverse events were obtained from meta-analyses of BP-lowering trials. CVD events prevented and treatment-related nonfatal serious adverse events over 10 years were calculated. Uncertainty surrounding main data inputs was expressed in uncertainty ranges (UR). Results: Over ten years, achieving and maintaining 2017 ACC/AHA guideline goals compared with current BP levels, achieving 2003 Seventh Joint National Committee Report goals, or achieving 2014 Eighth Joint National Committee goals could prevent 3.0 million (UR, 1.1–5.1 million), 0.5 million (UR, 0.2–0.7 million), or 1.4 million (UR, 0.6–2.0 million) CVD events, respectively. Compared with current BP levels, achieving and maintaining 2017 goals could prevent 71.9 (UR, 26.6–122.3) CVD events per 1000 treated. Achieving 2017 guideline BP goals compared with current BP levels could also lead to nearly 3.3 million more serious adverse events over 10 years (UR, 2.2–4.4 million). Conclusions: Achieving and maintaining 2017 ACC/AHA BP goals could prevent a greater number of CVD events than achieving 2003 Seventh Joint National Committee Report or 2014 Eighth Joint National Committee BP goals but could also lead to more serious adverse events.

Background The American Heart Association created the Life’s Simple 7 (LS7) metrics to promote cardiovascular health (CVH) by achieving optimal levels of blood pressure, cholesterol, blood sugar, physical activity, diet, weight, and smoking status. The degree to which psychosocial factors such as stress and depression impact one’s ability to achieve optimal CVH is unclear, particularly among hypertensive African Americans. Methods Cross-sectional analyses included 1,819 African Americans with hypertension participating in the Jackson Heart Study (2000–2004). Outcomes were LS7 composite and individual component scores (defined as poor, intermediate, ideal). High perceived chronic stress was defined as the top quartile of Weekly Stress Inventory scores. High depressive symptoms were defined as Center for Epidemiologic Studies Depression scale scores of ≥16. We compared 4 groups: high stress alone; high depressive symptoms alone; high stress and high depressive symptoms; low stress and low depressive symptoms (reference) using linear regression for total LS7 scores and logistic regression for LS7 components. Results Participants with both high stress and depressive symptoms had lower composite LS7 scores (B [95% confidence interval] = −0.34 [−0.65 to −0.02]) than those with low stress and depressive symptoms in unadjusted and age/sex-adjusted models. They also had poorer health status for smoking (odds ratio [95% confidence interval] = 0.52 [0.35–0.78]) and physical activity (odds ratio [95% confidence interval] = 0.71 [0.52–0.95]) after full covariate adjustment. Conclusions The combination of high stress and high depressive symptoms was associated with poorer LS7 metrics in hypertensive African Americans. Psychosocial interventions may increase the likelihood of engaging in behaviors that promote optimal CVH.

Background: Social determinants of health (SDH) are individually associated with incident coronary heart disease (CHD) events. Indices reflecting social deprivation have been developed for population management, but are difficult to operationalize during clinical care. We examined whether a simple count of SDH is associated with fatal incident CHD and nonfatal myocardial infarction (MI). Methods: We used data from the prospective longitudinal REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke), a national population-based sample of community-dwelling Black and White adults age ≥45 years recruited from 2003 to 2007. Seven SDH from the 5 Healthy People 2020 domains included social context (Black race, social isolation); education (educational attainment); economic stability (annual household income); neighborhood (living in a zip code with high poverty); and health care (lacking health insurance, living in 1 of the 9 US states with the least public health infrastructure). Outcomes were expert adjudicated fatal incident CHD and nonfatal MI. Results: Of 22 152 participants free of CHD at baseline, 58.8% were women and 42.0% were Black; 20.6% had no SDH, 30.6% had 1, 23.0% had 2, and 25.8% had ≥3. There were 463 fatal incident CHD events and 932 nonfatal MIs over a median of 10.7 years (interquartile range, 6.6 to 12.7). Fewer SDHs were associated with nonfatal MI than with fatal incident CHD. The age-adjusted incidence per 1000 person-years increased with the number of SDH for both fatal incident CHD (0 SDH, 1.30; 1 SDH, 1.44; 2 SDH, 2.05; ≥3 SDH, 2.86) and nonfatal MI (0 SDH, 3.91; 1 SDH, 4.33; ≥2 SDH, 5.44). Compared with those without SDH, crude and fully adjusted hazard ratios for fatal incident CHD among those with ≥3 SDH were 3.00 (95% CI, 2.17 to 4.15) and 1.67 (95% CI, 1.18 to 2.37), respectively; hazard ratios for nonfatal MI among those with ≥2 SDH were 1.57 (95% CI, 1.30 to 1.90) and 1.14 (95% CI, 0.93 to 1.41), respectively. Conclusions: A greater burden of SDH was associated with a graded increase in risk of incident CHD, with greater magnitude and independent associations for fatal incident CHD. Counting the number of SDHs may be a promising approach that could be incorporated into clinical care to identify individuals at high risk of CHD.

Importance High blood pressure (BP) during sleep (asleep blood pressure) is associated with an increased risk of cardiovascular disease, but a national prevalence estimate of masked asleep hypertension (high BP while sleeping but without high BP measured in the clinic [clinic BP]) for the United States is lacking. Objectives To estimate the prevalence of masked asleep hypertension among US adults by using BP thresholds from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) and the 2017 American College of Cardiology-American Heart Association (ACC-AHA) BP guidelines. Design, setting, and participants This cohort analysis pooled data from 3000 participants in 4 US population-based studies that conducted 24-hour ambulatory BP monitoring (ABPM) and 17 969 participants in the 2011-2016 National Health and Nutrition Examination Survey (NHANES) without ABPM. Masked asleep hypertension status in NHANES was imputed using a 2-stage multiple imputation process. Data were collected from 2000 to 2016 and analyzed from March 4, 2019, to June 29, 2020. Main outcomes and measures High clinic BP was defined as clinic systolic BP (SBP)/diastolic BP (DBP) of at least 140/90 mm Hg using JNC7 and at least 130/80 mm Hg using 2017 ACC-AHA guidelines. High asleep BP was defined as mean asleep SBP/DBP of at least 120/70 mm Hg for JNC7 and at least 110/65 mm Hg for the 2017 ACC-AHA guidelines. Masked asleep hypertension was defined as high asleep BP without high clinic BP. Results For the 3000 pooled cohort participants, the mean (SD) age was 52.0 (12.0) years, and 62.6% were women. For the 17 969 NHANES participants, the mean (SD) age was 46.7 (17.5) years, and 51.8% (weighted) were women. The estimated prevalence of masked asleep hypertension among US adults was 18.8% (95% CI, 16.7%-20.8%; 44.4 million US adults) using the JNC7 guideline and 22.7% (95% CI, 20.6%-24.8%; 53.7 million US adults) using the 2017 ACC-AHA guideline criteria. The prevalence of masked asleep hypertension was higher among older adults (aged ≥65 years, 24.4% [95% CI, 20.7%-28.0%]), men (27.0% [95% CI, 24.1%-29.9%]), non-Hispanic Black individuals (28.7% [95% CI, 25.4%-32.0%]), those who were taking antihypertensives (24.4% [95% CI, 21.1%-27.8%]), those who had masked daytime hypertension (44.7% [95% CI, 40.1%-49.3%]), and those with diabetes (27.6% [95% CI, 23.5%-31.8%]), obesity (24.3% [95% CI, 21.8%-26.9%]), or chronic kidney disease (21.5% [95% CI, 17.3%-25.6%]) using the 2017 ACC-AHA guideline. An estimated 11.9% of US adults (28.2 million) had isolated masked asleep hypertension (masked asleep hypertension but without high awake BP) using JNC7 guideline criteria, as did an estimated 13.3% (31.5 million) using 2017 ACC-AHA guideline criteria. Conclusions and relevance These findings suggest that the prevalence of masked asleep hypertension is high among US adults. Data are needed on the cardiovascular risk reduction benefits of treating asleep hypertension.

Background The Life’s Simple 7 (LS7) metric incorporates health behaviors (body mass index, diet, smoking, physical activity) and health factors (blood pressure, cholesterol, glucose) to estimate an individual’s level of cardiovascular health. The association between cardiovascular health and incident hypertension is unresolved. Hypertension’s threshold was recently lowered and it is unclear if better cardiovascular health is associated with lower risk of incident hypertension with the updated threshold or in a multirace cohort. We sought to assess the association between better LS7 score and risk of incident hypertension among Black and White adults using a 130/80 mm Hg hypertension threshold. Methods and Results We determined the association between LS7 metric and incident hypertension in the REGARDS (Reasons for Geographic and Racial Disparities in Stroke) study, including participants free of baseline hypertension (2003–2007) who completed a second visit between 2013 and 2016. Hypertension was defined as systolic/diastolic blood pressure ≥130/80 mm Hg or antihypertensive medication use. Each LS7 component was assigned 0 (poor), 1 (intermediate), or 2 (ideal) points. We generated a 14‐point score by summing points. Among 2930 normotensive participants (20% Black, 80% White), the median (25th–75th percentiles) LS7 total score was 9 (8–10) points. Over a median follow‐up of 9 years, 42% developed hypertension. In the fully adjusted model, each 1‐point higher LS7 score had a 6% lower risk of incident hypertension (risk ratio, 0.94 per 1 point; 95% CI, 0.92–0.96). Conclusions Better cardiovascular health was associated with lower risk of incident hypertension using a 130/80 mm Hg hypertension threshold among Black and White adults.

BACKGROUND Several atherosclerotic cardiovascular disease (ASCVD) risk factors are associated with awake and nocturnal hypertension. METHODS We assessed the association between a composite ASCVD risk score and awake or nocturnal hypertension using data from participants aged 40–79 years who completed ambulatory blood pressure monitoring at the Year 30 Coronary Artery Risk Development in Young Adults study exam in 2015–2016 (n = 716) and the baseline Jackson Heart Study exam in 2000–2004 (n = 770). Ten-year predicted ASCVD risk was calculated using the Pooled Cohort risk equations. Awake hypertension was defined as mean awake systolic blood pressure (SBP) ≥135 mm Hg or diastolic blood pressure (DBP) ≥85 mm Hg and nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or DBP ≥70 mm Hg. RESULTS Among participants with a 10-year predicted ASCVD risk CONCLUSIONS Using 10-year predicted ASCVD risk in conjunction with clinic BP improves discrimination between individuals with and without awake or nocturnal hypertension.

Background Among US Hispanics/Latinos, the largest ethnic minority population in the United States, hypertension incidence has not been thoroughly reported. The goal of this study was to describe the incidence of hypertension among US Hispanic/Latino men and women of diverse Hispanic/Latino background. Methods and Results We studied 6171 participants of the Hispanic Community Health Study/Study of Latinos, a diverse group of self‐identified Hispanics/Latinos from 4 US urban communities, aged 18 to 74 years, and free from hypertension in 2008 to 2011 and re‐examined in 2014 to 2017. Hypertension was defined as self‐reported use of anti‐hypertension medication, or measured systolic blood pressure ≥130 mm Hg, or diastolic blood pressure ≥80 mm Hg. Results were weighted given the complex survey design to reflect the target population. Among men, the 6‐year age‐adjusted probability of developing hypertension was 21.7% (95% CI , 19.5–24.1) and differed by Hispanic/Latino background. Specifically, the probability was significantly higher among men of Cuban (27.1%; 95% CI , 20.2–35.2) and Dominican (28.1%; 95% CI , 19.5–38.8) backgrounds compared with Mexican Americans (17.6%; 95% CI : 14.5–21.2). Among women, the 6‐year age‐adjusted probability of developing hypertension was 19.7% (95% CI , 18.1–21.5) and also differed by Hispanic/Latino background. Specifically, the probability was significantly higher among women of Cuban (22.6%; 95% CI , 18.3–27.5), Dominican (23.3%; 95% CI , 18.0–29.5), and Puerto Rican (28.2%; 95% CI , 22.7–34.4) backgrounds compared with Mexican Americans (16.0%; 95% CI , 13.9–18.4). Conclusions Hypertension incidence varies by Hispanic/Latino background, with highest incidence among those of Caribbean background.

BACKGROUND: Suboptimal sleep, including insufficient/long sleep duration and poor sleep quality, is a risk factor for cardiovascular disease (CVD) common but there is little information among African Americans, a group with a disproportionate CVD burden. The current study examined the association between suboptimal sleep and incident CVD among African Americans. METHODS: This study included 4,522 African Americans without CVD at baseline (2000–2004) of the Jackson Heart Study (JHS). Self-reported sleep duration was defined as very short (

Background Sleep characteristics and disorders are associated with higher blood pressure ( BP ) when measured in the clinic setting. Methods and Results We tested whether self‐reported sleep characteristics and likelihood of obstructive sleep apnea ( OSA ) were associated with nocturnal hypertension and nondipping systolic BP ( SBP ) among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who completed 24‐hour ambulatory BP monitoring during the year 30 examination. Likelihood of OSA was determined using the STOP ‐Bang questionnaire. Global sleep quality, habitual sleep duration, sleep efficiency, and midsleep time were obtained from the Pittsburgh Sleep Quality Index. Nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping SBP was defined as a decline in awake‐to‐asleep SBP SBP was 41.3% and 32.5%, respectively. After multivariable adjustment including cardiovascular risk factors, the prevalence ratios (PRs) for nocturnal hypertension and nondipping SBP associated with high versus low likelihood of OSA were 1.32 (95% CI, 1.00–1.75) and 1.31 (95% CI, 1.02–1.68), respectively. The association between likelihood of OSA and nocturnal hypertension was stronger for white participants (PR: 2.09; 95% CI, 1.23–3.48) compared with black participants (PR: 1.11; 95% CI, 0.79–1.56). The PR for nondipping SBP associated with a 1‐hour later midsleep time was 0.92 (95% CI, 0.85–0.99). Global sleep quality, habitual sleep duration, and sleep efficiency were not associated with either nocturnal hypertension or nondipping SBP . Conclusions These findings suggest that addressing OSA risk and sleep timing in a clinical trial may improve BP during sleep.

The cardiovascular disease (CVD) and mortality risk associated with morning blood pressure (BP) surge and its components among black adults, a population with high BP during the asleep period, is unknown. We studied Jackson Heart Study participants who completed 24-hour ambulatory BP monitoring at the baseline exam in 2000 to 2004 (n=761). The sleep-trough morning surge was calculated as the mean 2-hour postawakening systolic BP (SBP) minus the lowest nighttime SBP, preawakening morning surge as mean 2-hour postawakening SBP minus mean 2-hour preawakening SBP, and rising morning surge as the first postawakening SBP minus the last preawakening SBP. The primary outcome was the occurrence of CVD events including the composite of coronary heart disease or stroke. Over a median follow-up of 14.0 years, there were 74 CVD (coronary heart disease or stroke) events and 144 deaths. Higher tertiles of sleep-trough, preawakening, and rising SBP surge were not associated with CVD risk after multivariable adjustment. In contrast, the highest tertile of the individual components of morning surge, including postawakening SBP (tertiles 2 and 3 versus 1: hazard ratio [95% CI]: 1.58 [0.71–3.53] and 4.04 [1.91–8.52], respectively), lowest nighttime SBP (1.29 [0.59–2.84] and 2.87 [1.41–5.83]), preawakening SBP (1.26 [0.57–2.80] and 2.79 [1.32–5.93]), first postawakening SBP (1.60 [0.73–3.51] and 2.93 [1.40–6.16]), and last preawakening SBP (1.23 [0.57–2.68] and 2.99 [1.46–6.12]), was associated with increased CVD risk after multivariable adjustment. Among black adults, the components of morning SBP surge, but not morning SBP surge itself, were associated with increased CVD risk.

Background Nocturnal hypertension, defined by a mean asleep systolic blood pressure (SBP)/diastolic blood pressure (BP) ≥120/70 mm Hg, and nondipping SBP , defined by an awake‐to‐asleep decline in SBP Methods and Results We developed predictive equations to identify adults with a high probability of having nocturnal hypertension or nondipping SBP using data from the CARDIA (Coronary Artery Risk Development in Young Adults) study (n=787), JHS (Jackson Heart Study) (n=1063), IDH (Improving the Detection of Hypertension) study (n=395), and MHT (Masked Hypertension) study (n=772) who underwent 24‐hour ambulatory BP monitoring. Participants were randomized to derivation (n=2511) or validation (n=506) data sets. The prevalence rates of nocturnal hypertension and nondipping SBP were 39.7% and 44.9% in the derivation data set, respectively, and 36.6% and 44.5% in the validation data set, respectively. The predictive equation for nocturnal hypertension included age, race/ethnicity, smoking status, neck circumference, height, high‐density lipoprotein cholesterol, albumin/creatinine ratio, and clinic SBP and diastolic BP. The predictive equation for nondipping SBP included age, sex, race/ethnicity, waist circumference, height, alcohol use, high‐density lipoprotein cholesterol, and albumin/creatinine ratio. Concordance statistics (95% CI) for nocturnal hypertension and nondipping SBP predictive equations in the validation data set were 0.84 (0.80–0.87) and 0.73 (0.69–0.78), respectively. Compared with reference models including antihypertensive medication use and clinic SBP and diastolic BP as predictors, the continuous net reclassification improvement (95% CI) values for the nocturnal hypertension and nondipping SBP predictive equations were 0.52 (0.35–0.69) and 0.51 (0.34–0.69), respectively. Conclusions These predictive equations can direct ambulatory BP monitoring toward adults with high probability of having nocturnal hypertension and nondipping SBP .

Coups d’état, once a common end for democracies in the Americas, have declined sharply in recent years. This article investigates whether overall public support for coups is also in decline. Examining 21 countries in Latin America and the Caribbean from 2004 to 2014 helps to evaluate two alternative theses on democratization: Mainwaring and Pérez-Liñán’s 2013 normative regime preferences theory, which inquires (but does not test) whether public opinion can signal to elites a reluctance or willingness to support a coup; and classic modernization theory (Inglehart 1988; Inglehart and Welzel 2005). We find a substantively meaningful effect of democratic attitudes on coup support and a weak effect for national wealth, from which we infer that evolving elite values and preferences are paralleled at the mass level and that together, those two trends play a stronger role in the consolidation of democratic regimes than does modernization.

Background The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline provides updated recommendations for antihypertensive medication initiation and intensification. Objectives Determine the risk for cardiovascular disease (CVD) events among adults recommended and not recommended antihypertensive medication initiation or intensification by the 2017 ACC/AHA BP guideline. Methods The authors analyzed data for black and white REGARDS (REasons for Geographic And Racial Differences in Stroke) study participants (age ≥45 years). Systolic BP (SBP) and diastolic BP (DBP) were measured twice at baseline (2003 to 2007) and averaged. Participants not taking (n = 14,039) and taking (n = 15,179) antihypertensive medication were categorized according to their recommendations for antihypertensive medication initiation and intensification by the 2017 ACC/AHA guideline. Overall, 4,094 CVD events (stroke, coronary heart disease, and heart failure) occurred by December 31, 2014. Results Among participants not taking antihypertensive medication, 34.4% were recommended pharmacological antihypertensive treatment initiation. The CVD event rate per 1,000 person-years among participants recommended antihypertensive medication initiation with SBP/DBP ≥140/90 mm Hg was 22.7 (95% confidence interval [CI]: 20.3 to 25.0). Among participants with SBP/DBP 130 to 139/80 to 89 mm Hg, the CVD event rate was 20.5 (95% CI: 18.5 to 22.6) and 3.4 (95% CI: 2.4 to 4.4) for those recommended and not recommended antihypertensive medication initiation, respectively. Among participants taking antihypertensive medication, 62.8% were recommended treatment intensification. The CVD event rate per 1,000 person-years among participants recommended treatment intensification was 33.6 (95% CI: 31.5 to 35.6) and 22.4 (95% CI: 20.8 to 23.9) for those with SBP/DBP ≥140/90 mm Hg and 130 to 139/80 to 89 mm Hg, respectively. Conclusions Implementing the 2017 ACC/AHA guideline would direct antihypertensive medication initiation and intensification to adults with high CVD risk.

BACKGROUND Higher dietary phosphorus is associated with left ventricular hypertrophy and mortality, which are blood pressure (BP)-related outcomes. For this reason, we hypothesized that dietary phosphorus may be associated with adverse clinic and ambulatory BP patterns. METHODS Our study included 973 African American adults enrolled in the Jackson Heart Study (2000–2004) with 24-hour ambulatory BP monitoring (ABPM) data at baseline. We quantified dietary phosphorus from a validated Food Frequency Questionnaire as follows: (i) absolute daily intake, (ii) ratio of phosphorus-to-protein intake, (iii) phosphorus density, and (iv) energy-adjusted phosphorus intake. Using multivariable linear regression, we determined associations between dietary phosphorus intake and systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure in clinic and over daytime, nighttime, and 24-hour periods from ABPM. Extent of nocturnal BP dipping was also assessed. Using logistic regression, we modeled relationships between dietary phosphorus intake and clinically relevant qualitative BP phenotypes, such as masked, sustained, or white-coat hypertension and normotension. RESULTS There were no statistically significant associations between phosphorus intake and SBP or pulse pressure in adjusted models. Most metrics of higher phosphorus intake were associated with lower daytime, nighttime, and clinic DBP. Higher phosphorus intake was not associated with clinic or ABPM-defined hypertension overall, but most metrics of higher phosphorus intake were associated with lower odds of sustained hypertension compared to sustained normotension, white-coat hypertension, and masked hypertension. There were no associations between dietary phosphorus and nocturnal BP dipping. CONCLUSIONS These data do not support a role for higher phosphorus intake and higher BP in African Americans.

Background Hypertension diagnosed by blood pressure (BP) measured in the clinic is associated with rapid kidney function decline (RKFD) and incident chronic kidney disease (CKD). The extent to which hypertension defined using out-of-clinic BP measurements is associated with these outcomes is unclear. Methods We evaluated the association of any masked hypertension (daytime SBP/DBP ≥ 135/85 mmHg, night-time SBP/DBP ≥ 120/70 mmHg or 24-h SBP/DBP ≥ 130/80 mmHg) with RKFD and incident CKD among 676 African-Americans in the Jackson Heart Study with clinic-measured SBP/DBP less than 140/90 mmHg who completed ambulatory BP monitoring in 2000-2004. RKFD was defined as a decline in estimated glomerular filtration rate (eGFR) at least 30% and incident CKD was defined as development of eGFR less than 60 ml/min per 1.73 m with an at least 25% decline in eGFR between 2000-2004 and 2009-2013. Results The mean age of participants was 57.6 years, 28.8% were men and 52.7% had any masked hypertension. After a median follow-up of 8 years, 13.8 and 8.6% of participants had RKFD and incident CKD, respectively. In unadjusted analyses, masked hypertension was associated with an increased odds for incident CKD [odds ratio (OR) 2.20, 95% confidence interval (CI) 1.22, 3.97]. This association remained statistically significant after adjustment for demographic characteristics, baseline eGFR and albumin-to-creatinine ratio (OR 1.95, 95% CI 1.04, 3.67) but was eliminated after propensity score adjustment (OR 1.62, 95% CI 0.87, 3.00). There was no association between masked hypertension and RKFD. Conclusion Masked hypertension may be associated with the development of CKD in African-Americans.

Objective We determined differences in the prevalence of blood pressure (BP) phenotypes and the association of these phenotypes with left ventricular hypertrophy (LVH) for individuals who fulfilled and did not fulfill various criteria used for defining a complete ambulatory blood pressure monitoring (ABPM) recording. Methods We analyzed data for 1141 participants from the Jackson Heart Study. Criteria evaluated included having greater than or equal to 80% of planned readings with more than or equal to one reading per hour (Spanish ABPM Registry criteria), more than or equal to 70% of planned readings with a minimum of 20 daytime and seven nighttime readings (2013 European Society of Hypertension criteria), greater than or equal to 14 daytime and greater than or equal to seven nighttime readings (2003 European Society of Hypertension criteria), more than or equal to 10 daytime and more than or equal to 5 nighttime readings (International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome criteria), and greater than or equal to 14 daytime readings (UK National Institute of Health and Clinical Excellence criteria). Results Between 45.0% (Spanish ABPM Registry) and 91.8% (UK National Institute of Health and Clinical Excellence) of the participants fulfilled the different criteria for a complete ABPM recording. Across the various criteria evaluated, 55.5-57.8% of participants had nocturnal hypertension and 62.8-66.8% had nondipping systolic BP. Among participants with clinic-measured systolic/diastolic BP of more than or equal to 140/90 mmHg, 22.9-26.5% had white-coat hypertension. The prevalence of daytime, 24-h, sustained, and masked hypertension differed by up to 2% for participants fulfilling each criterion. The association of BP phenotypes with LVH was similar for participants who fulfilled versus those who did not fulfill different criteria (each P>0.05). Conclusion Irrespective of the criteria used for defining a complete ABPM recording, the prevalence of BP phenotypes and their association with LVH were similar.

BACKGROUND: African Americans have a higher prevalence of nocturnal hypertension and nondipping blood pressure than European Americans, but the genetic contribution to these racial differences remains unclear. We assessed the association of the percentage West African genetic ancestry with nocturnal hypertension and nondipping blood pressure in 932 African Americans from the Jackson Heart Study. METHODS: Using percentage West African ancestry determined from 389 ancestry informative markers, participants were categorized into tertiles (tertile 1 [low]: 86.3%). Nocturnal hypertension was defined as mean nighttime (midnight–6 am) systolic (SBP)/diastolic blood pressure ≥120/70 mm Hg. Nondipping blood pressure was defined as mean nighttime-to-daytime (10 am–8 pm) SBP ratio >0.90. RESULTS: Nocturnal hypertension was present in 57.9% of participants; 66.6% had nondipping blood pressure. The mean age was 59.4 years, 32.8% were male, and 56.0% were taking antihypertensive medication. The prevalence ratios (95% confidence interval) adjusted for age, sex, cardiovascular disease risk factors, and socioeconomic and psychosocial factors comparing participants with moderate and high to those with low percentage West African ancestry for nocturnal hypertension were 0.98 (0.87–1.10) and 0.95 (0.84–1.08), respectively, and for nondipping blood pressure was 0.96 (0.86–1.07) and 0.98 (0.88–1.09), respectively. CONCLUSIONS: West African ancestry was not associated with nocturnal hypertension and nondipping blood pressure among African Americans. While rare genetic variants cannot be ruled out, these data highlight the need to better understand how environmental and behavioral factors contribute to differences in nocturnal blood pressure among African Americans compared with European Americans.

Apparent treatment-resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03-1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09-1.43). Over a median 7.3 years of follow-up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.

Background: Data from before the 2000s indicate that the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP) ≥140/90 mm Hg. Over the past several decades, BP has declined and hypertension control has improved. Methods: We estimated the percentage of incident CVD events that occur at SBP/DBP Results: Over a mean follow-up of 7.7 years, 2584 participants had incident CVD events. Overall, 63.0% (95% confidence interval [CI], 54.9−71.1) of events occurred in participants with SBP/DBP Conclusions: Although higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP

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.

Background Left ventricular hypertrophy ( LVH ) is associated with an increased risk for cardiovascular disease ( CVD ) events and all‐cause mortality. Many individuals without LVH have a left ventricular mass that exceeds the level predicted by their sex, body size, and cardiac workload, a condition called inappropriate left ventricular mass ( iLVM ). We investigated the association of iLVM with CVD events and all‐cause mortality among blacks. Methods and Results We analyzed data from the Jackson Heart Study, a community‐based cohort of blacks. The current analysis included 4424 participants without CVD and with an echocardiogram at baseline. Among this cohort, the prevalence of iLVM was 13.8%. There were 262 CVD events and 419 deaths over a median follow‐up of 9.7 years (maximum, 12 years). Compared with participants without iLVM , participants with iLVM had a higher rate of CVD events and all‐cause mortality. After multivariable adjustment, including for the presence of LVH , iLVM was associated with an increased risk of CVD events (hazard ratio, 1.87; 95% CI , 1.33–2.62). The multivariable‐adjusted hazard ratio for all‐cause mortality was 1.29 (95% CI , 0.98–1.70). Among participants without and with LVH , the multivariable‐adjusted hazard ratios of iLVM for CVD events were 2.53 (95% CI , 1.68–3.81) and 1.21 (95% CI , 0.74–2.00), respectively ( P interaction =0.029); and for all‐cause mortality, the hazard ratios were 1.24 (95% CI , 0.81–1.89) and 1.26 (95% CI , 0.86–1.85), respectively ( P interaction =0.664). Conclusions iLVM is associated with an increased risk for CVD events among blacks without LVH .

Background Previous cross‐sectional studies have shown conflicting results regarding the effects of television viewing and occupational sitting on cardiovascular disease ( CVD ) risk factors. The purpose of this study was to compare the association of both television viewing and occupational sitting with CVD events and all‐cause mortality in blacks. Methods and Results Participants included 3592 individuals enrolled in the Jackson Heart Study, a community‐based study of blacks residing in Jackson, Mississippi. Television viewing (4 h/day) and occupational sitting (never/seldom, sometimes, often/always) were self‐reported. Over a median follow‐up of 8.4 years, there were 129 CVD events and 205 deaths. The highest category of television viewing (>4 h/day) was associated with a greater risk for a composite CVD events/all‐cause mortality end point compared with the lowest category (CI , 1.13–1.97). In contrast, the highest category of occupational sitting (often/always) was not associated with risk for a composite CVD events/all‐cause mortality end point compared with the lowest category (never/seldom; hazard ratio, 0.90; 95% CI , 0.69–1.18). Moderate‐to‐vigorous physical activity moderated the association of television viewing with CVD events/all‐cause mortality such that television viewing was not associated with greater risk among those with high moderate‐to‐vigorous physical activity levels. Conclusions Television viewing was associated with greater risk of CVD events and all‐cause mortality, while occupational sitting had no association with these outcomes. These findings suggest that minimizing television viewing may be more effective for reducing CVD and mortality risk in blacks compared with reducing occupational sedentary behavior.

Background The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline lowered the BP thresholds for defining hypertension compared with the Seventh Report of the Joint National Committee (JNC7) guideline. Methods We analyzed clinic and ambulatory BP monitoring data from 717 Coronary Artery Risk Development in Young Adults study participants and compared the prevalence of clinic and out-of-clinic BP phenotypes using thresholds from the 2017 ACC/AHA and JNC7 guidelines. Results Among participants not taking antihypertensive medication and according to the JNC7 and 2017 ACC/AHA guidelines, 11.1 and 30.1% of participants had clinic hypertension, 37.5 and 57.9% had awake hypertension, 35.7 and 58.1% had asleep hypertension, and 35.7 and 58.6% had 24-h hypertension, respectively. According to the JNC7 and 2017 ACC/AHA guideline definitions, 1.9 and 3.2% had white-coat hypertension, 28.2 and 31.0% had masked hypertension and 9.3 and 26.9% had sustained hypertension, respectively. Among participants taking antihypertensive medication and when defined using the JNC7 and 2017 ACC/AHA guideline BP thresholds, 18.6 and 45.3% had uncontrolled clinic BP, 48.1 and 62.5% had uncontrolled awake BP, 48.1 and 70.2% had uncontrolled asleep BP and, 47.7 and 65.3% had uncontrolled 24-h BP, respectively. Using JNC7 and 2017 ACC/AHA guideline BP thresholds, the prevalence was 1.4 and 5.2% for white-coat effect, 30.9 and 22.5% for masked uncontrolled hypertension, and 17.2 and 40.0% for sustained uncontrolled BP, respectively. Conclusion The 2017 ACC/AHA guideline results in a substantially higher prevalence of awake, asleep, 24-h, and sustained hypertension.

Introduction: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline uses lower clinic and out-of-clinic BP thresholds to define hypertension compared to previous US guidelines. Using these thresholds, we determined the associations between white coat hypertension (WCH) and masked hypertension with cardiovascular disease (CVD) events and mortality. Methods: We included 993 African Americans participating in the Jackson Heart Study who had clinic BP measured during their baseline study visit between 2000 and 2004 and underwent ambulatory blood pressure monitoring (ABPM). We defined normotension, WCH/white coat effect (WCE), masked/masked uncontrolled hypertension, and sustained hypertension using clinic BP and mean awake BP on ABPM (Table). CVD events (i.e., coronary heart disease and stroke; n=107), and all-cause mortality (n=185) were adjudicated from baseline through December 2014 and December 2016, respectively. Results: The mean age of participants was 59 years and 68% were female. Among those not taking antihypertensive medication, 38% had normotension, 27% had WCH, 33% had masked hypertension, and 31% had sustained hypertension. WCH, masked hypertension, and sustained hypertension were each associated with an increased risk for CVD and mortality compared to normotension (Table). Among those taking antihypertensive medication, 26% had controlled normotension, 25% had a WCE, 45% had masked uncontrolled hypertension, and 39% had treated sustained hypertension. Masked uncontrolled hypertension was associated with a higher risk for CVD and a lower risk for mortality compared to controlled normotension. WCE was not associated with CVD events or all-cause mortality. Conclusions: According to the ACC/AHA BP guideline, WCH and masked hypertension are common among African American adults. ABPM could have an important role in guiding antihypertensive medication initiation and intensification to reduce CVD and mortality risk among African Americans.

Introduction: The American Heart Association created the Life’s Simple 7 (LS7) metric to promote optimal cardiovascular health (CVH) via managing blood pressure (BP), controlling cholesterol, reducing blood sugar, getting active, eating better, losing weight, and quitting smoking. The degree to which psychosocial factors impact one’s ability to achieve LS7 recommendations is unclear. We hypothesized that hypertensive African Americans with high stress levels and high depressive symptoms would have poorer CVH compared to those with low stress and low depressive symptoms. Methods: Cross-sectional analyses included 1,845 participants with hypertension from the Jackson Heart Study, a community-based cohort of African Americans. Hypertension was defined as clinic BP ≥140/90 mm Hg or self-reported use of antihypertensive medication at the baseline exam (2000-2004). Outcomes were the continuous LS7 composite score and individual components (each defined as poor, intermediate or ideal). The Weekly Stress Inventory was used to identify high stress (top quartile vs. all others). The Center for Epidemiologic Studies Depression (CES-D) scale was used to identify high depressive symptoms (CES-D ≥16 vs. Results: The mean age was 58.9 ± 10.8 years, 31% of participants were male, and 9.6% had both high stress and high depressive symptoms. Participants with both high stress and high depressive symptoms had a lower composite LS7 score than those with low stress and low depressive symptoms (6.0 vs. 6.5, p=0.004). The association was present after adjusting for demographic and socioeconomic factors (p=.029) but not in fully adjusted models (p>0.05). Neither high stress alone nor high depressive symptoms alone were associated with LS7 score in any model (p>0.05). Other key findings included significant associations between high stress and depressive symptoms and poorer levels of health for smoking (OR [95% CI]= 0.53 [0.34-0.81]) and physical activity (OR [95% CI]= 0.68 [0.50-0.94]) in fully adjusted models. Conclusion: African Americans with the combination of high stress and high depressive symptoms had poorer overall CVH compared with those reporting low stress and low depressive symptoms, and were less likely to have ideal smoking and physical activity. Future studies should evaluate prospective effects of this psychosocial risk profile on CVH, which may inform behavioral approaches to improving CVH.

Introduction: Although treating hypertension (HTN) reduces the risk of cardiovascular disease, being aware of a HTN diagnosis may have unintended consequences, including psychological distress and poorer perceived health. We hypothesized that African Americans meeting criteria for HTN, who are aware of a HTN diagnosis, would report higher levels of stress and depressive symptoms and poorer perceived health than those who are unaware. Methods: Our sample included 2,815 participants with HTN from the Jackson Heart Study, a community-based cohort of African Americans. HTN was defined as blood pressure ≥140/90 mm Hg or taking antihypertensive medication. Awareness of HTN was defined based on participants’ self-report of having been told by a health care provider that they had HTN or high blood pressure. Outcomes included depressive symptoms (Center for Epidemiologic Studies Depression score ≥16 vs. 3 years). Results: The majority of participants (2,572, 91.4%) were aware of having HTN while 243 (8.6%) were unaware. Among the aware participants, 15.5% were diagnosed ≤3 years ago and 84.5% were diagnosed >3 years ago. Aware participants were older (60.2 vs. 57.9, p=.002) and more likely to be female (68.4% vs. 47.7%, p3 years ago. Conclusions: In a community-based sample of African Americans with HTN, participants who were aware of having a HTN diagnosis reported higher levels of stress and depressive symptoms and lower self-reported health compared to participants who were unaware. Prospective studies of the potential psychosocial consequences of diagnosing HTN are warranted, particularly in light of recent changes to BP treatment guidelines that result in an increased prevalence of HTN.

INTRODUCTION: Earlier development of cardiovascular disease risk factors in blacks versus whites may result from differences in maintaining health behaviors. Age-specific racial differences in maintaining health behaviors from ages 18 to 50 years were determined. METHODS: In 1985–1986, the population-based Coronary Artery Risk Development in Young Adults study enrolled 5,115 participants aged 18–30 years. In 2017, a total of 2,485 blacks and 2,407 whites with one or more optimal health behaviors at baseline who attended one or more of seven follow-up exams over 25 years (i.e., through 2010–2011) were analyzed. The primary outcome, maintaining four or more optimal health behaviors, included BMI

Background and Purpose— In previous observational studies, hemoglobin concentrations have been associated with an increased risk of stroke. However, these studies were limited by a relatively low number of stroke events, making it difficult to determine whether the association of hemoglobin and stroke differed by demographic or clinical factors. Methods— Using Cox proportional hazards analysis and Kaplan–Meier plots, we examined the association of baseline hemoglobin concentrations with incident stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of black and white adults aged ≥45 years. Results— A total of 518 participants developed stroke over a mean 7±2 years of follow-up. There was a statistically significant interaction between hemoglobin and sex ( P =0.05) on the risk of incident stroke. In Cox regression models adjusted for demographic and clinical variables, there was no association of baseline hemoglobin concentration with incident stroke in men, whereas in women, the lowest (14.0 g/dL) quartiles of hemoglobin were associated with higher risk of stroke when compared with the second quartile (12.4–13.2 g/dL; quartile 1: hazard ratio, 1.59; 95% confidence interval, 1.09–2.31; quartile 2: referent; quartile 3: hazard ratio, 0.91; 95% confidence interval, 0.59–1.38; quartile 4: hazard ratio, 1.59; 95% confidence interval, 1.08–2.35). Similar results were observed in models stratified by hemoglobin and sex and when hemoglobin was modeled as a continuous variable using restricted quadratic spline regression. Conclusions— Lower and higher hemoglobin concentrations were associated with a higher risk of incident stroke in women. No such associations were found in men.

The prevalence of masked hypertension (out-of-clinic daytime systolic/diastolic blood pressure (SBP/DBP) ≥135/85 mm Hg on ambulatory blood pressure monitoring [ABPM] among adults with clinic SBP/DBP

Objective Prescription sleep medication use is most prevalent among women and older adults. Morning drowsiness and impaired coordination are side effects of sleep medications that may affect driving safety. The association between current use of zolpidem-containing medications and motor vehicle collisions (MVCs) was evaluated among drivers of advanced age. Methods Participants were current drivers aged ≥70 years residing in north-central Alabama, spoke English, had a valid driver's license, and had driven within the past three months (n = 2000). Current zolpidem use was determined by pill bottle review. The participant's five-year MVC history was determined from Alabama Department of Public Safety accident reports. The five-year MVC and at-fault MVC rate ratios (RR) were estimated comparing zolpidem users with nonusers in the overall sample and a priori–defined age and sex subgroups. Results The unadjusted RR (95% confidence interval [CI]) of MVCs comparing zolpidem users with nonusers was attenuated after adjustment (1.46 [1.02–2.08] and 1.38 [0.97–1.98], respectively). Among women, the unadjusted and adjusted RRs (95% CI) were 1.65 (1.03–2.66) and 1.61 (1.00–2.60), respectively. The unadjusted and adjusted RRs (95% CI) among those aged 80 years or more were 2.24 (1.19–4.57) and 2.35 (1.20–4.61), respectively. There were no statistically significant associations among men or participants less than 80 years old. Similar patterns were present for at-fault MVCs. Conclusion Current zolpidem users, specifically women and individuals aged 80 years or more, had higher MVC rates than nonusers. Practitioners should consider behavioral treatment before initiating low doses of zolpidem and increasing it as needed to achieve restorative sleep in women and individuals aged 80 years or more to reduce the risk of zolpidem-associated MVCs.

BACKGROUND Several health behaviors have been associated with hypertension based on clinic blood pressure (BP). Data on the association of health behaviors with nocturnal hypertension and non-dipping systolic BP (SBP) are limited. METHODS We analyzed data for participants with ambulatory BP monitoring at the Year 30 Coronary Artery Risk Development in Young Adults (CARDIA) study exam in 2015–2016 (n = 781) and the baseline Jackson Heart Study (JHS) exam in 2000–2004 (n = 1,046). Health behaviors (i.e., body mass index, physical activity, smoking, and alcohol intake) were categorized as good, fair, and poor and assigned scores of 2, 1, and 0, respectively. A composite health behavior score was calculated as their sum and categorized as very good (score range = 6–8), good (5), fair (4), and poor (0–3). Nocturnal hypertension was defined as mean asleep SBP ≥ 120 mm Hg or mean asleep diastolic BP ≥ 70 mm Hg and non-dipping SBP as < 10% awake-to-asleep decline in SBP. RESULTS Among CARDIA study and JHS participants, 41.1% and 56.9% had nocturnal hypertension, respectively, and 32.4% and 72.8% had non-dipping SBP, respectively. The multivariable-adjusted prevalence ratios (95% confidence interval) for nocturnal hypertension associated with good, fair, and poor vs. very good health behavior scores were 1.03 (0.82–1.29), 0.98 (0.79–1.22), and 0.96 (0.77–1.20), respectively in CARDIA study and 0.98 (0.87–1.10), 0.96 (0.86–1.09), and 0.86 (0.74–1.00), respectively in JHS. The health behavior score was not associated non-dipping SBP in CARDIA study or JHS after multivariable adjustment. CONCLUSIONS A health behavior score was not associated with nocturnal hypertension or non-dipping SBP.

Introduction: A larger sleep-trough morning surge, defined as the mean two-hour post-awakening blood pressure (BP) minus the lowest asleep BP, has been associated with cardiovascular disease (CVD) events in Asians and Europeans. High asleep BP in African Americans (AA) may preclude a morning surge and an association with CVD due to a smaller BP change upon awakening. Objective: Determine the association of morning surge with CVD events in AAs. Methods: We analyzed participants from the Jackson Heart Study, a community-based cohort of AAs, with a complete 24-hour ambulatory BP monitoring recording and self-report asleep and awake times at baseline in 2000-2004 (n=767). Participants were grouped into tertiles of sleep-trough morning surge, two-hour post-awakening BP and lowest sleep BP. CVD events (nonfatal/fatal stroke, nonfatal myocardial infarction or fatal coronary heart disease; n=61) through December 2012 were adjudicated. Results: Participants’ mean age was 59.2 years and 32.1% were male. Multivariable adjusted hazard ratios (95% CI) for CVD events associated with Tertile 2 and 3 versus Tertile 1 of morning systolic BP (SBP) surge were 1.45 (0.71 – 2.97) and 2.03 (0.98 – 4.23), respectively; of post-awakening SBP were 2.01 (0.81 – 4.99) and 4.41 (1.85 – 10.50), respectively; and of lowest asleep SBP were 1.55 (0.68 – 3.52) and 2.22 (0.96 – 5.14), respectively ( Table ). Also, there was a graded increasing risk for CVD associated with Tertile 2 and 3 versus Tertile 1 of post-awakening diastolic BP (DBP), but not morning DBP surge and lowest asleep DBP. Conclusion: Higher morning SBP surge, post-awakening SBP and lowest asleep SBP and DBP were associated increased CVD risk in AAs.

Background Blacks have higher blood pressure levels compared with whites beginning in childhood. Few data are available on racial differences in the incidence of hypertension from young adulthood through middle age. Methods and Results We calculated the cumulative incidence of hypertension from age 18 to 55 years among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study. Incident hypertension was defined by the first visit with mean systolic blood pressure ≥130 mm Hg, mean diastolic blood pressure ≥80 mm Hg, or self‐reported use of antihypertensive medication. Among 3890 participants without hypertension at baseline (aged 18–30 years), cumulative incidence of hypertension by age 55 years was 75.5%, 75.7%, 54.5%, and 40.0% in black men, black women, white men, and white women, respectively. Among participants with systolic blood pressure/diastolic blood pressure Conclusions Regardless of blood pressure level in young adulthood, blacks have a substantially higher risk for hypertension compared with whites through 55 years of age.

Astronomical instrumentation development used to be much simpler than it is today. The quest for new discoveries and more light has driven the design and construction of new generations of ever-larger telescopes, which in turn created the need for correspondingly larger and more complex instruments. Large instrument teams composed of scientists and engineers from many technical disciplines have been brought together to design and build these instruments. Engineers trained in these disciplines have become key members of instrument development teams, taking responsibility for these areas of instrument design. With the engineers came an engineering culture and way of thinking that is often at odds with the scientific culture of astronomers. Project management techniques can help organize such an effort, but they have important limitations in a research environment and cannot ensure success. Training in the so-called “soft skills” can improve how a diverse team functions, but this, too, is not the complete answer. Only by immersing the engineer in an observing environment can one hope to overcome the cultural differences and inherent conflicts between scientists and engineers that can cause instrument projects to fail.

Learning curves graphically represent the relationship between learning effort and learning outcome. Learning curves are increasingly used in research, the design of randomised controlled trials, the assessment of competency, healthcare education and training programme design. In this review we have outlined the principles behind plotting learning curves, described the common methods used to analyse learning curves, how to interpret learning curves, the multitude of learning models, their applications and potential pitfalls, and the importance of a mathematically rigorous approach to learning curve analytics.

We calculated the prevalence of white coat hypertension (WCH) using out-of-clinic blood pressure (BP) in the daytime period; daytime and 24-hour periods; and daytime, 24-hour, and nighttime periods among 199 African Americans with clinic-measured systolic/diastolic BP ≥140/90 mm Hg in the Jackson Heart Study. Left ventricular mass index (LVMI) was measured among participants with WCH and 374 participants with sustained normotension (ie, non-hypertensive clinic, daytime, 24-hour, and nighttime BP). The prevalence of WCH was 29.6%, 21.1%, and 10.6% using daytime BP; daytime and 24-hour BP; and daytime, 24-hour, and nighttime BP, respectively. Compared with sustained normotension, LVMI was higher when WCH was defined using daytime BP (adjusted mean difference [95% CI] 5.0 [-0.2, 10.1] g/m2 ), but not when defined using daytime and 24-hour BP or daytime, 24-hour, and nighttime BP (adjusted mean difference [95% CI] 3.9 [-1.9, 9.7] and 0.4 [-7.3,8.2] g/m2 , respectively). Using only daytime BP overestimates the prevalence of WCH among African Americans.

To describe the spectrum of renal tubular disease (RTD) in HIV-positive patients and its association with exposure to antiretroviral therapy (ART).Review of 265 consecutive renal biopsies from HIV-positive patients attending eight clinics in the United Kingdom between 2000 and 2012.We described the clinical characteristics of patients with RTD and compared current/recent exposure (at the time of, or up to 3 months prior to the date of biopsy) to potentially nephrotoxic ART [tenofovir (TDF), atazanavir (ATV), indinavir (IDV) and lopinavir/ritonavir (LPV/r)]. We also analysed the incidence of RTD in the UK CHIC cohort. Kruskall-Wallis, analysis of variance and Fisher's exact tests were used to evaluate between-group differences.Of the 60 RTD cases, 54 (90%) were included in the analyses. RTD comprised of three distinct patterns: acute tubular injury (ATI, n = 22), tubulo-interstitial nephritis (TIN, n = 20) and interstitial fibrosis and tubular atrophy (IFTA, n = 12). Compared with TIN and IFTA, ATI cases were less likely to be of black ethnicity (10 vs. 42-55%; P = 0.006), more likely to be on ART (100 vs. 55-68%; P = 0.001), with HIV-RNA below 200 copies/ml (100 vs. 54-58%; P 0.001), and more likely to have current/recent exposure to TDF (P 0.001). We did not find evidence for an association between exposure to TDF, ATV/r or LPV/r and either TIN or IFTA.RTD was present in approximately 20% of renal biopsies and comprised three distinct injury patterns with considerable clinical overlap. ATI was associated with TDF exposure, although the overall incidence of biopsy-defined ATI was low.

Background— Although the benefits of statins accrue over time, treatment discontinuation is common. Examining the patterns of statin discontinuation, reinitiation, and persistence after reinitiation among Medicare beneficiaries after hospital discharge for a myocardial infarction may help increase statin use in high-risk patients. Methods and Results— Medicare beneficiaries with a statin fill claim within 30 days after hospital discharge for myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days post-discharge to identify discontinuation, defined as 60 continuous days without statins available. Reinitiation, defined by a statin fill, was identified in the 365 days post-discontinuation. High persistence was defined as proportion of days covered ≥80% with ≥1 day of statin supply 182 days after reinitiation. Follow-up ended on December 31, 2014. In the 182 days after myocardial infarction hospital discharge, 15.4% of beneficiaries discontinued statins. Of this group, 53.7% reinitiated statins. On reinitiation, 27.1% changed statin type, 6.9% up-titrated intensity, 14.4% down-titrated intensity, and 66.0% had the same statin and intensity. In the 182 days after reinitiation, 45.8% had high persistence. Moderate- and high- versus low-intensity statins were associated with a lower risk for statin discontinuation (moderate intensity: relative risk [RR], 0.93; 95% confidence interval [CI], 0.89–0.96; high-intensity: RR, 0.95; 95% CI, 0.91–0.99). High persistence was less common after reinitiating high- versus low-intensity statins (RR, 0.80; 95% CI, 0.75–0.86), but no association was present for those reinitiating a moderate- versus low-intensity statin (RR, 0.95; 95% CI, 0.90–1.01). Down-titrating versus reinitiating the same statin intensity (RR, 1.10; 95% CI, 1.05–1.16) and reinitiating a different versus the same statin (RR, 1.10; 95% CI, 1.06–1.14) were associated with high persistence after treatment reinitiation. Conclusions— Although many people who discontinue a statin reinitiate treatment, statin persistence after reinitiation was low. Reinitiating therapy with moderate-intensity statins, down-titration, and using a different statin may promote persistence.