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African Americans, other minorities and underserved populations are consistently under- represented in clinical trials. Such underrepresentation results in a gap in the evidence base, and health disparities. The ABC Cardiovascular Implementation Study (CVIS) is a comprehensive prospective cohort registry that integrates social determinants of health. ABC CVIS uses real world clinical practice data to address critical gaps in care by facilitating robust participation of African Americans and other minorities in clinical trials. ABC CVIS will include diverse patients from collaborating ABC member private practices, as well as patients from academic health centers and Federally Qualified Health Centers (FQHCs). This paper describes the rationale and design of the ABC CVIS Registry. The registry will: (1) prospectively collect socio-demographic, clinical and biospecimen data from enrolled adults, adolescents and children with prioritized cardiovascular diseases, (2) Evaluate the safety and clinical outcomes of new therapeutic agents, including post marketing surveillance and pharmacovigilance, (3) Support National Institutes of Health (NIH) and industry sponsored research, (4) Support Quality Measures standards from the Center for Medicare and Medicaid Services (CMS) and Commercial Health Plans. The registry will utilize novel data and technology tools to facilitate mobile health technology application programming interface (API) to health system or practice electronic health records (EHR). Long term, CVIS will become the most comprehensive patient registry for underserved diverse patients with cardiovascular disease (CVD) and co morbid conditions, providing real world data to address health disparities. At least 10,000 patients will be enrolled from 50 sites across the United States.

The prevalence of hypertension dictates that blood pressure must be managed effectively in primary care. The American Society of Hypertension (ASH) regional chapters and clinical hypertension specialists represent a positive response by ASH to the growing problems of hypertension and metabolic syndrome-related risks and disease. To have a significant public health effect, the impact of clinical hypertension specialists must be leveraged. Key activities in the community include educating other providers locally, delivering care for complex referral patients, and fostering growth of a practice network with a central database in collaboration with academic partners. The database supports practice audit and feedback reports to enhance quality improvement, identify continuing medical education topics, and facilitate clinical trials to test new therapeutic and best-practice approaches to risk factor management. The ASH regional chapters serve as a forum for community and academic hypertension specialists to collaborate with like-minded individuals and organizations. The collaboration among the ASH Carolinas-Georgia chapter, the Hypertension Initiative, and the Community Physicians' Network provides a model for other ASH chapters and health delivery groups to partner in delivering continuing medical education programs focused on cardiovascular risk factor management, recruiting practices into the network, and developing and maintaining a centralized patient database. Evidence suggests that this collaboration is facilitating application of evidence-based medicine and risk factor control.

Background: The role of eNOS gene polymorphisms on plasma nitrite or nitrate (NOx) level, endothelial function, and blood pressure (BP) remains unclear. Methods: We estimated the relationship of eNOS polymorphisms (the T 786 C in the 5-flanking promoter region, T 786 C; 27-bp repeat in intron 4, eNOS4; and Glu298Asp in exon 7, G894T) with plasma NOx level, brachial endothelial function assessed by ultrasound measure of brachial artery flow-mediated dilation (FMD), and BP in 60 healthy African Americans, 30 men and 30 women aged 18 to 73 years. Results: Among them, 73.1%, 23.9%, and 3.0% carried TT, TC, and CC of T 786 C, respectively, 14.5%, 27.5%, 53.6%, and 1.4% carried aa, ab, bb, and bc of eNOS4 polymorphism, respectively, and 70.4%, 23.9%, and 5.6% carried GG, GT, and TT of G894T, respectively. G894T and eNOS4 were observed in linkage disequilibrium. Mean values of age, plasma NOx, FMD, systolic and diastolic BPs were not significantly different (P .05) by eNOS polymorphisms. Plasma NOx level was found to be associated with systolic BP (r 0.51, P .03), and diastolic BP (r 0.41, P .08), but not with FMD, in individuals with “a” allele of eNOS4 polymorphism after adjustment for age, body mass index, serum glucose, and smoking status. Conclusions: We reveal a positive association between plasma NOx level and BP in normotensive African Americans who carry the “a” allele of eNOS4. Because the frequency of the rare allele “a” is significantly higher in African Americans than in other ethnic groups, this finding may provide a clue to understanding the genetic susceptibility to hypertension in African Americans. Am J Hypertens 2004;17:560 ‐567 © 2004 American Journal of Hypertension, Ltd.

Heart failure (HF) remains a significant cardiovascular problem, with increasing incidence and prevalence rates: Adult Americans over 40 years of age have a 20 % lifetime risk of developing heart failure. Approximately five million people in the USA have HF, and over 650,000 new cases of HF are diagnosed each year. HF incidence increases with age: from 20 per 1,000 among individuals 65–69 years of age to greater than 80 per 1,000 for individuals who are over 85 years of age.

Association between angiographic coronary artery disease and cardiac troponin T levels has been observed in patients with normal kidney function; however, this association remains unsettled in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Over a 12-month period we retrospectively reviewed coronary angiograms (CAs) performed in 194 hospitalized patients with presumed acute myocardial injury. About 50% of the ESRD and 30% of the CKD patients had normal CAs. Troponin T levels significantly correlated with CAs in patients with normal kidney function (r = 0.4, p = 0.005) but not in ESRD and CKD patients (r = 0.2, p = NS, respectively).

Objective: There are conflicting data on the influence of race and gender on the outcome of patients undergoing coronary artery bypass graft surgery (CABG), with blacks and females showing higher operative mortality (OM) in some series and not others. Materials and Methods: The medical records of 176 black patients undergoing isolated CABG by a single surgeon from 2000 to 2014 were retrospectively reviewed. The mean age was 61.9 ± 11.2 years and majority 93 (52.8%) were males. Identified risk profiles were peripheral vascular disease 53 (30.1%) patients, insulin-dependent diabetes mellitus 49 (27.8%), end-stage renal disease (ESRD) 27 (15.3%), chronic obstructive pulmonary disease 27 (15.3%), cerebrovascular disease 24 (13.6%), and HIV/AIDS 5 (2.8%). One hundred and forty (79.5%) had severe triple vessel disease, 30 (17.0%) left main disease, and ejection fraction mean 43.0 ± 14.3. Results: One hundred and twenty-eight patients (72.7%) underwent on-pump and 48 patients (27.3%) off-pump coronary artery bypass graft (OPCAB), with 150 (85.2%) urgent surgeries. EuroSCORE-II (ES-II) score was 3.86 ± 3.18 while observed OM was 6.81% (12/176). There was no difference in OM between males and females 6.45% versus 7.22% ( P = 0.924) and on-pump and OPCAB 7.81% versus 4.16% ( P = 0.604). Univariate analysis identified ESRD and ES as predictors but on multivariate analysis only ESRD with odds ratio 4.630 (95% CI: 1.321-16.229, P = 0.017). The society of thoracic surgeons (STS) quality measurement task force major complications were acute kidney injury 6.81%, prolonged ventilation 6.81%, stroke 3.40%, deep sternal wound infection 2.27%, and reoperation 1.70%. Overall 1 and 5 years survival was 90.0% and 73.9%, respectively, with no significant difference between males and females 92.4% and 75.0% versus 86.4% and 70.9%, respectively, when P = 0.764. Conclusion: The observed/expected 1.76 ratio may partly be due to higher number of urgent and ESRD patients of 85.2% and 15.3% compared to 27.9% and 2.36-7.90%, respectively, in the STS database. Our ESRD patients had 4΍ times odds of death than non-ESRD. Despite males having slightly higher risk profiles, long-term survival was similar with females and overall 1 and 5 years survival comparable to blacks in other series.

Objective: Some earlier studies have suggested that cocaine use in African-Americans (AAs) results in higher defibrillation thresholds. We are therefore reviewing our own experience with this racial group for comparison. Materials and Methods: We retrospectively reviewed the medical records of AA patients who had placement by a single operator of implantable cardioverter defibrillator (ICD) at an inner city hospital from January 2006 to December 2015. Results: Seventy-four patients, mean age 59.2 ± 12.9 years, comprising 37 (50.0%) males, underwent ICD implantation of which 67.6% were single chamber and 32.4% dual chamber devices. Diagnosis was nonischemic cardiomyopathy in 68.9% and indication for device therapy was primary prevention in 87.8%. Sixty-six (89.2%) patients were noncocaine users, whereas 8 (10.8%) were cocaine abusers. The mean age, ejection fraction, and defibrillation threshold between the noncocaine and cocaine users were 60.2 ± 12.8 versus 51.3 ± 12.4 ( P = 0.642), 21.6 ± 8.3 versus 16.1 ± 4.6 ( P = 0.0704), and 23.5 ± 5.0 versus 25.0 ± 8.4 ( P = 0.447), respectively. Biotronik device patients had complete follow-up and they had an all-cause mortality of 28.8% (15/52), while 27.0% (10/37) of the survivors had at least one or more antitachycardia pacing or high voltage shock therapies. Conclusion: There was no statistically significant difference in defibrillation threshold testing observed in AA patients in our series between noncocaine and cocaine users as previously seen in some earlier small reviews. Larger studies or meta-analysis of several studies to accumulate a substantial number of AAs using cocaine may be required for a definitive answer to the question.

Objective: Off-pump coronary artery bypass (OPCAB) has been demonstrated to be a safe technique with similar outcomes to on-pump coronary artery bypass (ONCAB) in low-risk patients, while its role and benefits in high-risk patients are the subject of ongoing clinical trials. This review compares our high-risk patients aided by intra-aortic balloon pump (IABP) with low-risk patients undergoing OPCAB to identify any differences in outcomes. Materials and Methods: One hundred and twenty-four patients who underwent OPCAB surgery between January 2004 and December 2013 were retrospectively reviewed. 61.3% were males, 57.3% were African Americans, mean age was 62.7 ± 13.3, and range was 30-90 years. Patients were divided into Group 1, 26 (21.0%) patients with IABP and Group 2, 98 (79.0%) patients without IABP. Group 1 patients had higher risk profile with mean ejection fraction (EF) 26.0 ± 10.8 and EF ≤20 present in 46.1% compared to 45.2 ± 11.9 and 5.1%, respectively, in Group 2 (P < 0.001). Results: 92.35% of Group 1 and 82.7% of Group 2 patients had multivessel disease with a mean number of bypass grafts 2.9 ± 0.97 versus 2.75 ± 0.8, respectively (P < 0.364). Left internal mammary artery (LIMA) to left anterior descending (LAD) was performed in all Group 1 and 97.9% of Group 2 patients, with saphenous vein graft (SVG) to the left circumflex and right coronary arteries in 73.1% versus 62.2% and 57.7% versus 52.0% of Groups 1 and 2, respectively. Complete revascularization occurred in 88.5% and 90.8% of Groups 1 and 2, respectively (P < 0.990). 4.0% were converted to ONCAB for either hemodynamic instability or intramyocardial coronary artery. Major morbidities were re-exploration for bleeding 3.8% versus 1.0%, stroke 3.8% versus 2.0%, acute kidney injury 11.5% versus 0%, and prolonged intubation 15.4% versus 2.0% in Groups 1 and 2, respectively. Euroscore II predicted (P) versus observed (O) mortality was 4.56% versus 4.03%, for Group 1, 7.82% versus 7.69% and Group 2, 3.64% versus 3.06%, and O/P ratios 0.88, 0.98 and 0.84 respectively. Two (2.0%) females in Group 2 with single LIMA to LAD underwent repeat revascularization with SVG to the LAD within 90 days. Conclusion: IABP helps stabilize hemodynamics during OPCAB in high-risk patients with moderate to severe left ventricular dysfunction. Mean number of bypass grafts and predicted versus observed mortality were similar between the low- and high-risk groups.

Provider-focused strategies for improving outcomes in hypertension have produced mixed results. Studies suggest that the effectiveness of a chosen strategy increases when it is tailored to the specific situation. The hypertension registry includes data on African-American hypertensives who receive care in community-based primary care settings. We examined the registry to identify patterns of care and opportunities for provider-focused interventions to improve patient outcomes.The registry will include all records of hypertensive patients from 50 community-based primary care practices at full enrollment. Data from nine practices were manually abstracted into an electronic database and analyzed. Seven hundred and ten records were included in this report. Approximately 70% are female, average age 47 +/- 13 years, 5.3% are uninsured, and more than 60% have at least a high school education. Registry patients have multiple co-morbid conditions: 28% are diabetic, 8% have left ventricular hypertrophy, 5% have congestive heart failure, 6.5% have renal insufficiency, 5% have cerebrovascular disease, 3.5% have previous myocardial infarction and 2% have peripheral vascular disease. Among those with diabetes, mean glycosylated hemoglobin was 7.4 +/- 2. Pattern of antihypertensive use showed 43% on diuretics, 28% on calcium channel blockers, 24% on angiotensin converting enzyme inhibitors, 20% on beta blockers and 16% on angiotensin receptor blockers. Overall, 37% were at goal blood pressure and among those with diabetes, only 16% reached goal blood pressure.We conclude that the blood pressure control rates of African Americans in the registry trail those of the general population. This provides a unique opportunity to study the underlying factors and design tailored interventions to address this disparity in health outcome.

Disparities in health care are maintained by three primary factors: 1) patient factors which include multiple risk factors and comorbidities; 2) healthcare practitioner factors comprising inconsistent application of practice guidelines due to a limited database of clinical trials of effective therapies in African Americans and other underrepresented minorities; and 3) barriers in the healthcare delivery system resulting in poor access to care. The Morehouse School of Medicine Community Physicians' Network (CPN) was established to address disparities in health care by focusing on provider-specific strategies.To: 1) use disease-specific registries to identify treatment gaps and facilitate quality improvement processes among CPN practices; 2) develop practice-specific and guideline-based educational messages to promote quality care; 3) engage and train CPN-physicians for participation in approved NIH, other government, and industry-supported clinical protocols; and 4) develop a data repository of all CPN-sponsored clinical trials that include significant numbers of African Americans and other underrepresented minorities.The disease-specific outpatient registries will have the following features: 1) data structures and data elements will use standard database codes and a data dictionary; 2) HIPPA-compliant data abstraction and data transfer tool; 3) baseline chart review to establish practice patterns and provide practice-specific feedback; 4) annual update of registry; 5) data registry and repository maintained on Morehouse School of Medicine's secure servers; 6) registry publications will include only aggregate data, without identification of contributing practices; 7) an electronic medical records platform will be encouraged as the ultimate data management tool for CPN practices. In addition, up to three continuing medical education (CME) programs each year will feature national speakers and promote evidence-based practice guidelines.Eighty-five primary care and subspecialty practices are actively enrolled in CPN with a total of 385,000 annual outpatient visits. The makeup of insurance status is: HMO/PPO (45%); Medicare only (19%); Medicare HMO (11%); Medicare plus (8%); Medicaid (6%); Uninsured (11%).The Community Physicians' Network will address specific gaps in the health care of African-American and other minority patients by promoting quality care among its members and by facilitating participation in approved clinical trial protocols. The unique academic community partnership is consistent with the NIH roadmap goal of eliminating healthcare disparities.

This cross-sectional study sought to determine the prevalence of cognitive impairment among African-American patients with congestive heart failure (CHF). We studied 100 African-American CHF patients (aged 55-87 years) in New York Heart Association classes II-IV, who are enrolled in an ongoing, randomized, controlled trial, evaluating the effectiveness of a telemonitoring intervention to improve access to ambulatory care for heart failure patients. These CHF patients were recruited from an inner-city practice, rural physician practices and an urban physician practice in Atlanta. The Mini-Mental Status Examination (MMSE) was used to measure cognition. Cognitive impairment was defined as a MMSE score of less than 24. The crude prevalence of cognitive impairment was 10% in this population of African Americans with CHF. The results of multivariate logistic regression analysis indicated an increase in odds of cognitive impairment with increasing age [odds ratio (OR) = 1.10 and 95% confidence interval, 1.00-1.20; p=0.042]. There was no significant relationship between cognitive impairment and gender, education status, depression and severity of CHF. This study indicates that cognitive impairment is relatively prevalent among African Americans with CHF, but lower than previously reported among Caucasians with CHF.

BACKGROUND AND OBJECTIVES: The 894T allele in exon 7 of the endothelial nitric oxide synthase (eNOS) gene has been inconsistently associated with hypertension in different racial groups. Because high-normal blood pressure (BP) confers an increased risk for the development of hypertension and other cardiovascular disorders, including left ventricular hypertrophy (LVH), we tested the hypothesis that the allelic variation (894T) in the eNOS gene would directly correlate with alterations in LV mass (LVM) in individuals with high-normal BP. METHODS: Genotype distribution of G894T was compared between 20 African Americans (10 females/10 males) with high-normal BP (systolic BP of 130-139 and/or diastolic BP of 85-89 mmHg) and 64 counterparts (37 females/27 males) with normal BP (134/110 g/m2 for men/women). RESULTS: For the entire group, the 894T allelic frequencies (15, 48%) and G894T genotype distributions were consistent with the Hardy-Weinberg equilibrium expectations (estimated disequilibrium coefficient = 0.0118, P=0.40). LVMI was significantly higher in homozygous carriers (TT) of the rare 894T allele (n = 3 females/0 males) than in heterozygous GT (n = 13 females/7 males) and individuals bearing the GG (n=34 females/27 males) variant (124 +/- 70 vs. 82 +/- 24 and 82 +/- 19 g/m2, respectively, P < 0.05). The observed relationship between eNOS 894T allele and LVMI was restricted to individuals with high-normal BP (r = 0.94, P = 0.03) but not in those with normal BP (r = 0.39, P =0.64), by analysis of variance (ANOVA) after adjusting for age, gender, body mass index, smoking and systolic BP. CONCLUSION: These findings, not previously described, provide important preliminary evidence to suggest an increased susceptibility to LVH in African Americans who carry the 894T variant of the eNOS gene and have high-normal blood pressure.

The role of eNOS gene polymorphisms on plasma nitrite or nitrate (NOx) level, endothelial function, and blood pressure (BP) remains unclear.We estimated the relationship of eNOS polymorphisms (the T(-786)C in the 5'-flanking promoter region, T(-786)C; 27-bp repeat in intron 4, eNOS4; and Glu298Asp in exon 7, G894T) with plasma NOx level, brachial endothelial function assessed by ultrasound measure of brachial artery flow-mediated dilation (FMD), and BP in 60 healthy African Americans, 30 men and 30 women aged 18 to 73 years.Among them, 73.1%, 23.9%, and 3.0% carried TT, TC, and CC of T(-786)C, respectively, 14.5%, 27.5%, 53.6%, and 1.4% carried aa, ab, bb, and bc of eNOS4 polymorphism, respectively, and 70.4%, 23.9%, and 5.6% carried GG, GT, and TT of G894T, respectively. G894T and eNOS4 were observed in linkage disequilibrium. Mean values of age, plasma NOx, FMD, systolic and diastolic BPs were not significantly different (P.05) by eNOS polymorphisms. Plasma NO(x) level was found to be associated with systolic BP (r = 0.51, P =.03), and diastolic BP (r = 0.41, P =.08), but not with FMD, in individuals with "a" allele of eNOS4 polymorphism after adjustment for age, body mass index, serum glucose, and smoking status.We reveal a positive association between plasma NOx level and BP in normotensive African Americans who carry the "a" allele of eNOS4. Because the frequency of the rare allele "a" is significantly higher in African Americans than in other ethnic groups, this finding may provide a clue to understanding the genetic susceptibility to hypertension in African Americans.

RAS inhibitors (RASIs/ACE inhibitors & ARBs) have reduced mortality in SHF (EF 45p) in randomized controlled trials. Since, AAs are underrepresented in these trials, whether these results are applicable to AAs with HFPEF is uncertain All cause mortality was