Clinical Outcomes in Hypertensive Emergency: A Systematic Review and Meta-Analysis.

Background To study the prevalence and types of hypertension-mediated organ damage and the prognosis of patients presenting to the emergency department (ED) with hypertensive emergencies. Methods and Results PubMed was queried from inception through November 30, 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Studies reporting data on hypertensive emergencies in other departments were excluded. The extracted data were arcsine transformed and pooled using a random-effects model. Fifteen studies (n=4370 patients) were included. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI, 0.40%-0.70%) in all patients presenting to ED and 35.9% (95% CI, 26.7%-45.5%) among patients presenting in ED with hypertensive crisis. Ischemic stroke (28.1% [95% CI, 18.7%-38.6%]) was the most prevalent hypertension-mediated organ damage, followed by pulmonary edema/acute heart failure (24.1% [95% CI, 19.0%-29.7%]), hemorrhagic stroke (14.6% [95% CI, 9.9%-20.0%]), acute coronary syndrome (10.8% [95% CI, 7.3%-14.8%]), renal failure (8.0% [95% CI, 2.9%-15.5%]), subarachnoid hemorrhage (6.9% [95% CI, 3.9%-10.7%]), encephalopathy (6.1% [95% CI, 1.9%-12.4%]), and the least prevalent was aortic dissection (1.8% [95% CI, 1.1%-2.8%]). Prevalence of in-hospital mortality among patients with hypertensive emergency was 9.9% (95% CI, 1.4%-24.6%). Conclusions Our findings demonstrate a pattern of hypertension-mediated organ damage primarily affecting the brain and heart, substantial cardiovascular renal morbidity and mortality, as well as subsequent hospitalization in patients with hypertensive emergencies presenting to the ED.

Managing Atherosclerotic Cardiovascular Risk in Young Adults: JACC State-of-the-Art Review.

There is a need to identify high-risk features that predict early-onset atherosclerotic cardiovascular disease (ASCVD). The authors provide insights to help clinicians identify and address high-risk conditions in the 20- to 39-year age range (young adults). These include tobacco use, elevated blood pressure/hypertension, family history of premature ASCVD, primary severe hypercholesterolemia such as familial hypercholesterolemia, diabetes with diabetes-specific risk-enhancing factors, or the presence of multiple other risk-enhancing factors, including in females, a history of pre-eclampsia or menopause under age 40. The authors update current thinking on lipid risk factors such as triglycerides, non-high-density lipoprotein cholesterol, apolipoprotein B, or lipoprotein (a) that are useful in understanding an individual's long-term ASCVD risk. The authors review emerging strategies, such as coronary artery calcium and polygenic risk scores in this age group, that have potential clinical utility, but whose best use remains uncertain. Finally, the authors discuss both the obstacles and opportunities for addressing prevention in early adulthood.

Sociodemographic Determinants of Life's Simple 7: Implications for Achieving Cardiovascular Health and Health Equity Goals.

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

Differences in primary cardiovascular disease prevention between the 2013 and 2016 cholesterol guidelines and impact of the 2017 hypertension guideline in the United States.

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.

Opportunities for improving cardiovascular health outcomes in adults younger than 65 years with guideline-recommended statin therapy.

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<.01). Among adults younger than 65 years, the ratio of statin-eligible but untreated to statin-treated adults was higher in blacks and Hispanics than whites (3.0 and 2.9 vs 1.3, respectively; P<.01), and blacks, men, hypertensives, and cigarette smokers were more likely to be statin eligible than their statin-ineligible counterparts by multivariable logistic regression. Two thirds of untreated statin-eligible adults had two or more healthcare visits per year. Identifying and treating more statin-eligible adults in the healthcare system could improve cardiovascular health equity.

Prehypertension: an opportunity for a new public health paradigm.

From 2005 to 2006, approximately 3 of 8 adults in the United States had blood pressure (BP) in the prehypertensive range of 120 to 139/80 to 89 mm Hg and roughly 1 in 8 adults had BP in the range of 130 to 139/85 to 89 mm Hg, which is referred to as high normal BP or stage 2 prehypertension. Adults with stage 2 prehypertension are also roughly twice as likely as adults with normotension to suffer cardiovascular disease. The Seventh Report of the Joint National Committee on Hypertension recommended only lifestyle changes for most prehypertensive patients. BP in the range of 120 to 129/80 to 84 mm Hg is also associated with increased risk but roughly half of that of stage 2 prehypertension.

Prevalence, awareness, treatment, and control of hypertension in the Jackson Heart Study.

African Americans have higher reported hypertension prevalence and lower control rates than other ethnic groups in the United States. Hypertension prevalence, awareness, treatment, and control (outcomes) and potentially associated demographic, lifestyle, comorbidity, and health care access factors were examined in 5249 adult participants (3362 women and 1887 men) aged 21 to 94 years enrolled in the Jackson Heart Study. Hypertension prevalence (62.9%), awareness (87.3%), treatment (83.2%), and control (66.4%) were high. Control declined with advancing age; estimates for all of the outcomes were higher for women compared with men. Lower socioeconomic status was associated with prevalence and control. Smoking was negatively associated with awareness and treatment, particularly among men. Comorbidities (diabetes, chronic kidney disease, and cardiovascular disease), likely driven by the high rates of obesity, correlated with hypertension prevalence, awareness, treatment, and control. Lack of health insurance was marginally associated with poorer control, whereas use of preventive care was positively associated with prevalence, awareness, and treatment, particularly among men. In comparisons with the 1994-2004 National Health and Nutrition Examination Survey data adjusted to Jackson Heart Study sex, age, and socioeconomic status distribution, control rates among Jackson Heart Study participants appeared to be higher than in their national counterparts and similar to that of whites. These results suggest that public health efforts to increase awareness and treatment among African Americans have been relatively effective. The Jackson Heart Study data indicate that better control rates can be achieved in this high-risk population.

Metabolic syndrome and echocardiographic left ventricular mass in blacks: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: The metabolic syndrome has been associated with cardiovascular disease, but few studies have examined its relationship with subclinical measures such as echocardiographic left ventricular (LV) mass. This relationship is likely to be of particular importance in blacks, in whom both the metabolic syndrome and LV hypertrophy are common. METHODS AND RESULTS: Echocardiography, performed at 1 of 4 sites in the Atherosclerosis Risk in Communities (ARIC) Study, was used to assess LV dimensions in 1572 black women and men aged 49 to 75 years in 1993-1996. Participants were categorized by number of metabolic syndrome characteristics (hypertension, dyslipidemia [low HDL cholesterol or high triglycerides], and glucose intolerance). Age-adjusted mean LV mass indexed by height (g/m) increased in a stepwise gradient with increasing number of metabolic syndrome disorders (none, any 1, any 2, all 3) in both women and men (125.1, 143.9, 153.7, 169.3 and 130.5, 148.7, 160.8, 170.2, respectively; P<0.001, tests for trend). Associations were diminished slightly by adjustment for smoking, alcohol intake, and education; additional adjustment for waist circumference resulted in some attenuation, but associations remained statistically significant. Analyses focusing on components of LV mass revealed that posterior wall and interventricular septal thickness, but not LV chamber size, were significantly and independently associated in general with the number of metabolic syndrome disorders. Consistent with these findings, relative wall thickness was also associated with number of disorders. Associations were similar across age and central adiposity. Hypertension had a strong influence on LV mass with additional contributions from dyslipidemia and glucose intolerance; strong synergistic effects of the syndrome beyond its individual components were not observed. CONCLUSIONS: In this cross-sectional population-based study of black women and men, the degree of metabolic syndrome clustering was strongly related to LV mass and its wall thickness components. These associations are consistent with a possible influence of underlying factors such as insulin resistance or other vascular processes on myocardial thickening and not on chamber size.

Capsaicin pepper, cancer and ethnicity.

The 'hot' sensation produced by exposure to pepper is apparently due to two natural carcinogens: capsaicin in chili type peppers and safrole in black/white pepper. There are four cookeries in the United States that are noted for their high pepper content: Mexican-American, Cajun, white Creole, and black Creole. Each is largely confined to a single ethnic-cultural group which is concentrated in some counties. By use of county population and mortality data, significantly higher rates for stomach and liver cancer were found in counties inhabited by these four ethnic-cultural groups than in matched control counties. This involved both sexes. The cancer increase was dependent on the concentration of these groups in a county. These results strengthen and extend an earlier case-control study which found odds ratios above 5 for the stomach cancer association with capsaicin pepper. It is further evidence that capsaicin is a human carcinogen.

The effect of decision rules on the choice of a body mass index cutoff for obesity: examples from African American and white women.

BACKGROUND: Ethnic differences in the relation of body mass index (BMI; in kg/m2) to morbidity and mortality have led investigators to question whether a single cutoff for obesity should be applied to all ethnic groups. OBJECTIVE: The effects of using 4 different outcomes and 3 different measures of effect as criteria for comparing BMI cutoffs were shown with the use of data from 45- to 64-y-old African American and white women. DESIGN: Data were from the Cancer Prevention Study I (CPS-I) and the Atherosclerosis Risk in Communities (ARIC) Study. The outcomes were mortality (9211 deaths), diabetes (757 cases), hypertension (1518 cases), and hypertriglyceridemia (1264 cases). The measures of effect were incidence rate, rate ratio, and rate difference. The BMI in African American women that was associated with a risk equivalent to that of white women with a BMI of 30 was estimated. RESULTS: There was no significant association between BMI and mortality in African American women. The BMI in African American women that was associated with a risk of diabetes equivalent to that of white women with a BMI of 30 was 28.0-34.5, depending on the measure of effect. For hypertension, the equivalent risk in African American women occurred at a BMI of <18-38, depending on the measure of effect. There was no BMI at which African American women had an incidence rate or rate ratio for hypertriglyceridemia that was as high as that of white women with a BMI of 30. CONCLUSION: BMI cutoffs associated with equivalent risk across ethnic groups differ widely depending on the outcome and the risk estimate.

Secondary Hypertension: Detection and Management for the Primary Care Provider.

Of hypertensive patients, 95% have primary (essential) hypertension. The remaining 5% of adults with hypertension have an identifiable or "secondary" disorder responsible for the elevated blood pressure. Although relatively rare, the diagnosis of secondary hypertension is important as these forms require specific treatments based on the underlying pathophysiology and are potentially curable. Secondary causes of hypertension include renal disease, such as chronic parenchymal disease and renovascular hypertension, a number of endocrinopathies, such as primary aldosteronism, pheochromocytoma, or thyroid disease, as well as a variety of miscellaneous causes including obstructive sleep apnea and substance abuse. An evaluation for secondary causes in all hypertensive patients is not necessary or cost effective. Clinical clues obtained from a careful history, physical examination, and laboratory assessment guide the clinician through an appropriate evaluation for identifiable causes. A combination of the clinician's index of suspicion and interpretation of data provide guidance in the choice of diagnostic tests and therapies to target the mechanisms contributing to poor blood pressure control. (c)2000 by Le Jacq Communications, Inc.