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

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

Objectives: The Quality and Care Model Committee for a clinically integrated network requested a comparative analysis on the projected cardiovascular benefits of implementing either the 2013 and 2014 cholesterol guideline in a South Carolina patient population. A secondary request was to assess the relative risk of the two guidelines based on the literature. Methods: Electronic health data were obtained on 1,580,860 adults aged 21–80 years who had had one or more visits from January 2013 to June 2015; 566,688 had data to calculate 10-year atherosclerotic cardiovascular disease (ASCVD10) risk. Adults with end-stage renal disease ( n = 7852), congestive heart failure ( n = 19,818), alcohol or drug abuse ( n = 68,547), or currently on statins ( n = 154,964) were excluded leaving 315,508 for analysis. Estimated reduction in ASCVD10 assumed that: (a) moderate-intensity statins lowered low-density lipoprotein cholesterol (LDL-C) by 35% and high-intensity statins by 50%; (b) ASCVD events declined 22% for each 1 mmol/l fall in LDL-C. Results: Among the 315,508 adults in the analysis, 131,289 (41.6%) were eligible for statins according to the 2013 guideline and 137,375 (43.5%) to the 2014 guideline. The 2013 and 2014 guidelines were estimated to prevent 6780 and 5915 ASCVD events over 10 years with: (a) relative risk reductions of 29.0% and 21.8%; (b) absolute risk reductions of 5.2% and 4.3%; (c) number needed-to-treat (NNT) of 19 and 23, respectively. The greater projected cardiovascular protection with the 2013 guideline was largely related to greater use of high-dose statins, which carry a greater risk for adverse events. The literature indicates that the NNT for benefit with high-intensity versus moderate-intensity statins is 31 in high-risk patients with a number needed-to-harm of 47. Conclusions: The 2013 guideline is projected to prevent more clinical ASCVD events and with lower NNTs than the 2014 guideline, yet both have substantial benefit. The 2013 guideline is also expected to generate more adverse events, but the risk-benefit profile appears favor .

The US Preventive Services Task Force cholesterol guideline recommended statins for fewer adults than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline by setting a higher 10-year atherosclerotic cardiovascular disease threshold (≥10.0% vs ≥7.5%) and requiring concomitant diabetes mellitus, hypertension, dyslipidemia, or cigarette smoking. The 2017 ACC/AHA hypertension guideline lowered the hypertension threshold, increasing 2016 guideline statin-eligible adults. Cross-sectional data on US adults aged 40 to 75 years enabled estimated numbers for the 2013 guideline and 2016 guideline with hypertension thresholds of ≥140/≥90 mm Hg and ≥130/80 mm Hg, respectively, on: (1) untreated, statin-eligible adults for primary atherosclerotic cardiovascular disease prevention (25.40, 14.72, 15.35 million); (2) atherosclerotic cardiovascular disease events prevented annually (124 000, 70 852, 73 199); (3) number needed to treat (21, 21, 21); and (4) number needed to harm (38, 143, 143) per 1000 patient-years for incident diabetes mellitus (42 800, 6700, 7100 cases per year). Despite the lower hypertension threshold, the 2013 cholesterol guideline qualifies approximately 10 million more adults for statins and prevents approximately 50 600 more primary atherosclerotic cardiovascular disease events but induces approximately 35 700 more diabetes mellitus cases annually than the 2016 guideline.

Background Low‐density lipoprotein cholesterol (LDL‐C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity. Methods and Results Awareness, treatment, and control of elevated LDL‐C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel‐3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL‐C ( P P P P P P Conclusions LDL‐C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL‐C management, yet poverty retains an independent adverse effect.

Background: Multiple chronic conditions ([M]CCs), including hypertension (HTN) and clinical CVD, increase sharply with age and account for most U.S. healthcare costs. In 2001, the Institute of Medicine recommended integrated clinical guidelines for MCC. The dearth of integrated guidelines reflects limited inclusion of complex patients in clinical trials and continued focus on individual diseases. Methods: To explore implications of MCC for clinical trials and HTN guidelines in older adults, hierarchical clustering was used to segregate beneficiaries in one large Medicare Shared Savings Program into clusters with similar groups of MCC. Clusters were named for the most prevalent CC and described by number of CCs, prevalent HTN, CVD, behavioral health diagnoses and paid claims. Results: The 50,627 beneficiaries (mean 72 yrs) segregated into 12 clusters; 36,533 (72.2%) had HTN. A total of 33,262 beneficiaries (65.7%) segregated into 6 complex clusters (CHF, CKD, Diabetes, Cancer, COPD, Vascular) with a high prevalence of CVD; 27,324 (82.1%) had HTN. The CHF and CKD clusters had the highest mean number of CCs (9.8, 7.5, respectively), HTN prevalence (94.3%, 91.9%), and yearly costs ($37,700, $26,700/beneficiary). Diabetes, cancer, COPD and vascular disease clusters also had a large burden of CCs (5.9, 5.8, 5.1, 5.4) and HTN (88.3%, 73.6%, 70.7%, 83.9%) with annual healthcare costs from $19,500 (cancer) to $12,900 (COPD); more than 1/3 of patients in the CHF, CKD, diabetes and vascular clusters had a behavioral health diagnosis, most often depression. Of 17,365 (34.3%) beneficiaries in less complex clusters, 9,209 (54%) had HTN, 90+% were candidates for primary CVD prevention, less than 10% had behavioral health diagnoses, and costs were lower. Conclusions: HTN impacts ~82% of older adults with a higher burden of MCC, and ~75% (27,324/36,533) of Medicare beneficiaries with HTN have a large burden of MCCs. Behavioral health diagnosis, associated with adverse outcomes and costs, are common with MCCs. Clinical care, outcomes and costs for older adults with HTN and MCCs could improve with more representative inclusion in clinical trials and translation through integrated clinical guidelines developed by multi-specialty/disciplinary teams.

Disparate vascular outcomes in diabetes by race and/or ethnicity may reflect differential risk factor control, especially pre-Medicare. Assess concurrent target attainment for glycohemoglobin7%, non-high density lipoprotein-cholesterol130 mg/dL, and blood pressure140/90 mm Hg in white, black, and Hispanic diabetics65 years and ≥65 years of age. The National Health and Nutrition Examination Surveys 1999-2010 data were analyzed on diagnosed and undiagnosed diabetics ≥18 years old. Concurrent target attainment was higher in whites (18.7%) than blacks (13.4% [P = .02] and Hispanics [10.3%, P.001]65 years but not ≥65 years of age; 20.0% vs. 15.9% [P = .13], 19.5% [P = .88]). Disparities in health care insurance among younger whites, blacks, and Hispanics, respectively, (87.4% vs. 81.1%, P.01; 68.0%, P.001) and infrequent health care (0-1 visits/y; 14.3% vs. 15.0%, P = not significant; 32.0%, P.001) declined with age. Cholesterol treatment predicted concurrent control in both age groups (multivariable odds ratio2, P.001). Risk factor awareness and treatment were lower in Hispanics than whites. When treated, diabetes and hypertension control were greater in whites than blacks or Hispanics. Concurrent risk factor control is low in all diabetics and could improve with greater statin use. Insuring younger adults, especially Hispanic, could raise risk factor awareness and treatment. Improving treatment effectiveness in younger black and Hispanic diabetics could promote equitable risk factor control.

The impact of age, race/ethnicity, healthcare insurance, and selected clinical variables on statin-preventable ASCVD were quantified in adults aged 21 to 79 years from National Health and Nutrition Examination Surveys 2007–2012 using the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol. Among ≈42.4 million statin-eligible, untreated adults, 52.6% were hypertensive and 71% were younger than 65 years. Of ≈232 000 statin-preventable ASCVD events annually, most occur in individuals younger than 65 years, with higher proportions in blacks and Hispanics than whites (73.0% and 69.2% vs 56.9%, respectively; P

Background Healthy People 2020 aim to reduce fatal atherosclerotic cardiovascular disease ( ASCVD ) by 20%, which translates into 310 000 fewer events annually assuming proportional reduction in fatal and nonfatal ASCVD . We estimated preventable ASCVD events by implementing the American College of Cardiology/American Heart Association ( ACC / AHA ) 2013 Cholesterol Guideline in all statin‐eligible adults. Absolute risk reduction ( ARR ) and number needed‐to‐treat ( NNT ) were calculated. Methods and Results National Health and Nutrition Examination Survey data for 2007–2012 were analyzed for adults aged 21 to 79 years and extrapolated to the US population. Literature‐guided assumptions were used including (1) low‐density lipoprotein cholesterol falls 33% with moderate‐intensity statins and 51% with high‐intensity statins; (2) for each 39 mg/dL decline in low‐density lipoprotein cholesterol, 10‐year ASCVD 10 risk would fall 21% when ASCVD 10 risk was ≥20% and 33% when ASCVD 10 risk was ASCVD 10 risk ≥7.5% would receive statins. Of 175.9 million adults aged 21 to 79 years not taking statins, 44.8 million (25.5%) were statin eligible. Treating all statin‐eligible adults would prevent an estimated 243 589 ASCVD events annually ( ARR 5.4%, 10‐year NNT 18). Treating all statin‐eligible adults with ASCVD 10 risk ≥7.5% reduces the number treated to 32.2 million (28.2% fewer), whereas ASCVD events prevented annually fall only 10.5% to 217 974 (6.8% ARR , NNT 15). Conclusions Implementing the ACC / AHA 2013 Cholesterol Guideline in all untreated, statin‐eligible adults could achieve ≈78% of the Healthy People 2020 ASCVD prevention goal. Most of the benefit is attained by individuals with 10‐year ASCVD risk ≥7.5%.

Hypertension control may offer less protection from incident cardiovascular disease (CVDi ) in adults with than without apparent treatment-resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to

Electronic health record data were analyzed to estimate the number of statin‐eligible adults with the 2013 American College of Cardiology/American Heart Association cholesterol guidelines not taking statin therapy and the impact of recommended statin therapy on 10‐year atherosclerotic cardiovascular disease (ASCVD(10)) events. Adults aged 21 to 80 years in an outpatient network with ≥1 clinic visit(s) from January 2011 to June 2014 with data to calculate ASCVD(10) were eligible. Moderate‐intensity statin therapy was assumed to lower low‐density lipoprotein cholesterol by 30% and high‐intensity therapy was assumed to reduce low‐density lipoprotein cholesterol by 50%. ASCVD events were assumed to decline 22% for each 39 mg/dL decline in low‐density lipoprotein cholesterol. Among 411,768 adults, 260,434 (63.2%) were not taking statins and 103,478 (39.7%) were eligible for a statin, including 79,069 (76.4%) patients with hypertension. Estimated ASCVD(10) events were 18,781 without and 13,328 with statin therapy, a 29.0% relative and 5.3% absolute risk reduction with a number needed to treat of 19. The 2013 cholesterol guidelines are a relatively efficient approach to reducing ASCVD in untreated, statin‐eligible adults who often have concomitant hypertension.

Hypertension awareness, treatment, and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 data in adults aged 18 to 64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988 to 1994 to 17.4% in 2005 to 2010. In 1988 to 1994, hypertension awareness, treatment, and control to P =0.27) were similar in insured and uninsured adults. By 2005 to 2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%; P P

Background— Joint National Committee goal blood pressure for all adults was Methods and Results— National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to P P P P =0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P P Conclusions— The age gap in hypertension control to

Physical exam; 2. ECG; 3. Chest X-Ray; 4. Full blood test; 5. Full urine test; 6. Retina exam. We also include patient education and follow-up immediately after 24h the acute presentation. We identified 2 HU populations: High-risk HU (patients with TO initially compromised that will probably evolve to HE), and low-risk HU (patiens without compromise of TO). The latter would rest for 1 h until reach BP values below 160/ 100 mmHg. High-risk HU typically present 4 sound, ventricular hypertrophy, creatinine>1.5 mg/dL or ‘‘arterial-venous’’ crosses in the retinal exam, and will receive pharmacological treatment. The antihypertensive treatment administered was labetalol 200 mg. We monitored patients for 2 h after the drug was administered, and if the goal of treatment was reached (BP 160/100 mmHg patients will receive a second dose of labetalol. The new guideline revealed that 33 pacients (24%) were not diagnosed with high BP before. It also allowed us to diagnose high BP in 13 of these 33 previously undiagnosed patients. From the total patients with high BP (115) only 27 (23%) were adequately managed and treated. The most frequent cause that triggered HU was the dietary transgression (excessive salt ingestion). In conclusion, these guideline for HU revealed that a high percentage of patients with high BP lack adequate diagnosis and/or management. Implementation of resting before drug administration allowed us to achieve the goal of BP

To determine the relationship between prehypertension (PH) and socioeconomic factors in a Hispanic population, it was carried out this communitybase study, in Venezuela, that included 2109 adult subjects -males (n1⁄4570) and females (n1⁄41539)mean-age1⁄437 13 years, who were chosen from a random selection of households. Information about age, gender, educational level (EL) and blood pressure was collected at a single household visit. Pre-hypertension was defined as blood pressure values of 120-139/ 80-89 mmHg. Socioeconomic level was estimated using the educational level (EL) of each subject. The EL was classified in 4 categories: elementary, high and technical school and university degree. The Odds Ratio (OR) and 95% Confidence Interval (CI) were calculated through the Logistic Regression Analysis to know the relationship between PH and EL. The PH prevalence was 38.9% (n1⁄4821) in all subjects, 57.0% (n1⁄4325) in males and 32.2% (n1⁄4496) in females (p