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BACKGROUND: Adherence to study medications is crucial to evaluating treatment effects in clinical trials. To assess whether in the SPRINT trial, adherence and cardiovascular outcomes are associated regardless of intervention assignment. METHODS: This study included 9,361 participants aged ≥50 years, recruited from 102 clinics. Participants were randomized to a Standard Treatment Group (targeted systolic blood pressure [SBP] <140 mm Hg) or an Intensive Treatment Group (targeted SBP <120 mm Hg) and followed for incident cardiovascular events until the study was halted early for benefit. The 8-item Morisky Medication Adherence Scale (MMAS-8) was administered at baseline, and at the 12- and 48-month (or close out) visit. RESULTS: Adjusting for covariates, there was no association between the baseline 8-item MMAS-8 and the likelihood of the primary composite endpoint, any of the secondary endpoints, or blood pressure (BP) control. Low adherence was associated with a higher body mass index, SBP, diastolic BP, and Patient Health Questionnaire, and high adherence was associated with a higher Montreal Cognitive Assessment. There was no difference in the MMAS-8 over time by treatment arm assignment. For the primary outcome (a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes), baseline odds ratios (95% confidence intervals) for the Low vs. Medium and vs. High; and, for Medium vs. High MMAS-8 were 1.02 (0.82-1.28), 1.07 (0.85-1.34), and 1.05 (0.88-1.250). CONCLUSIONS: In SPRINT, medication adherence as measured using the MMAS-8 was not associated with outcomes or BP control.
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Hipertensión , Infarto del Miocardio , Antihipertensivos/farmacología , Antihipertensivos/uso terapéutico , Presión Sanguínea , Humanos , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Cumplimiento de la Medicación , Infarto del Miocardio/tratamiento farmacológicoRESUMEN
Markers of systemic inflammation are associated with increased risk of cognitive impairment, but it is unclear if they are associated with a faster rate of cognitive decline and whether this relationship differs by race. Our objective was to examine the association of baseline C-reaction protein (CRP) with cognitive decline among a large racially diverse cohort of older adults. Participants included 21,782 adults aged 45 and older (36% were Black, Mean age at baseline 64) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. CRP was measured at baseline and used as a continuous variable or a dichotomous grouping based on race-specific 90th percentile cutoffs. Cognitive measures of memory and verbal fluency were administered every 2 years for up to 12 years. Latent growth curve models evaluated the association of CRP on cognitive trajectories, adjusting for relevant demographic and health factors. We found that higher CRP was associated with worse memory (B = -.039, 95% CI [-.065,-.014]) and verbal fluency at baseline (B = -.195, 95% CI [-.219,-.170]), but not with rate of cognitive decline. After covariate adjustment, the association of CRP on memory was attenuated (B = -.005, 95% CI [-.031,-.021]). The association with verbal fluency at baseline, but not over time, remained (B = -.042, 95% CI [-.067,-.017]). Race did not modify the association between CRP and cognition. Findings suggest that levels of CRP at age 45+, are a marker of cognitive impairment but may not be suitable for risk prediction for cognitive decline.
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Proteína C-Reactiva/metabolismo , Disfunción Cognitiva/psicología , Negro o Afroamericano/estadística & datos numéricos , Anciano , Disfunción Cognitiva/etnología , Disfunción Cognitiva/metabolismo , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos/etnología , Población Blanca/estadística & datos numéricosRESUMEN
BACKGROUND: Patients with stage 1 systolic hypertension have increased risk of cardiovascular disease (CVD) events. METHODS: Using Cox models, we assess the effect of targeting an intensive SBP goal of less than 120âmmHg compared with standard SBP goal of less than 140âmmHg on the risk of CVD events in adults with stage 1 systolic hypertension with diabetes mellitus enrolled in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) (nâ=â1901) and without diabetes mellitus enrolled in Systolic Blood Pressure Intervention Trial (SPRINT) (nâ=â3484) that used identical SBP goal interventions. OUTCOMES: In ACCORD BP, the primary composite CVD outcome was the first occurrence of myocardial infarction, stroke, or CVD mortality. In SPRINT, the primary composite CVD outcome was the first occurrence of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or CVD mortality. RESULTS: In SPRINT, targeting an intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.75 (95% confidence interval, 0.58-0.98); events 1.78 vs. 2.37%/year]. In ACCORD BP, the relationships of SBP goal with the primary CVD outcome was modified by the glycemia goal intervention (interaction Pâ=â0.039). In the standard glycemia subgroup (A1c target 7-7.9%), intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.61 (0.40-0.94); events 1.63 vs. 2.56%/year]. In the intensive glycemia subgroup (A1c target <6%), the risk of the primary CVD outcome was not significantly different between groups [hazard ratio 1.20 (0.76-1.89); events 1.91 vs. 1.60%/year]. CONCLUSION: Targeting an intensive SBP goal significantly reduced the risk of CVD events in patients with stage 1 systolic hypertension without diabetes and with diabetes on standard glycemia goal.
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Presión Sanguínea/fisiología , Enfermedades Cardiovasculares , Complicaciones de la Diabetes , Adulto , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/fisiopatología , Complicaciones de la Diabetes/complicaciones , Complicaciones de la Diabetes/epidemiología , Humanos , Factores de Riesgo , Sístole/fisiologíaRESUMEN
OBJECTIVE: To examine the effects of an intensive lifestyle intervention (ILI) on cardiovascular disease (CVD), the Action for Health in Diabetes (Look AHEAD) trial randomized 5,145 participants with type 2 diabetes and overweight/obesity to a ILI or diabetes support and education. Although the primary outcome did not differ between the groups, there was suggestive evidence of heterogeneity for prespecified baseline CVD history subgroups (interaction P = 0.063). Event rates were higher in the ILI group among those with a CVD history (hazard ratio 1.13 [95% CI: 0.90-1.41]) and lower among those without CVD (hazard ratio 0.86 [95% CI: 0.72-1.02]). METHODS: This study conducted post hoc analyses of the rates of the primary composite outcome and components, adjudicated cardiovascular death, nonfatal myocardial infarction (MI), stroke, and hospitalization for angina, as well as three secondary composite cardiovascular outcomes. RESULTS: Interaction P values for the primary and two secondary composites were similar (0.060-0.064). Of components, the interaction was significant for nonfatal MI (P = 0.035). This interaction was not due to confounding by baseline variables, different intervention responses for weight loss and physical fitness, or hypoglycemic events. In those with a CVD history, statin use was high and similar by group. In those without a CVD history, low-density lipoprotein cholesterol levels were higher (P = 0.003) and statin use was lower (P ≤ 0.001) in the ILI group. CONCLUSIONS: Intervention response heterogeneity was significant for nonfatal MI. Response heterogeneity may need consideration in a CVD-outcome trial design.
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Enfermedades Cardiovasculares/epidemiología , Estilo de Vida , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Background Blood pressure ( BP ) varies over time within individual patients and across different BP measurement techniques. The effect of different BP targets on concordance between BP measurements is unknown. The goals of this analysis are to evaluate concordance between (1) clinic and ambulatory BP , (2) clinic visit-to-visit variability and ambulatory BP variability, and (3) first and second ambulatory BP and to evaluate whether different clinic targets affect these relationships. Methods and Results The SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP monitoring ancillary study obtained ambulatory BP readings in 897 participants at the 27-month follow-up visit and obtained a second reading in 203 participants 293±84 days afterward. There was considerable lack of agreement between clinic and daytime ambulatory systolic BP with wide limits of agreement in Bland-Altman plots of -21 to 34 mm Hg in the intensive-treatment group and -26 to 32 mm Hg in the standard-treatment group. Overall, there was poor agreement between clinic visit-to-visit variability and ambulatory BP variability with correlation coefficients for systolic and diastolic BP all <0.16. We observed a high correlation between first and second ambulatory BP ; however, the limits of agreement were wide in both the intensive group (-27 to 21 mm Hg) and the standard group (-23 to 20 mm Hg). Conclusions We found low concordance in BP and BP variability between clinic and ambulatory BP and second ambulatory BP . Results did not differ by treatment arm. These results reinforce the need for multiple BP measurements before clinical decision making.
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Determinación de la Presión Sanguínea/métodos , Hipertensión/diagnóstico , Hipertensión Enmascarada/diagnóstico , Hipertensión de la Bata Blanca/diagnóstico , Anciano , Anciano de 80 o más Años , Antihipertensivos/uso terapéutico , Monitoreo Ambulatorio de la Presión Arterial/métodos , Humanos , Hipertensión/tratamiento farmacológico , Persona de Mediana Edad , Planificación de Atención al PacienteRESUMEN
BACKGROUND: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) previously reported increased mortality in patients who sustained a periprocedural stroke or cardiac event (myocardial infarction [MI] or biomarker only) in follow-up to 4 years. We now extend these observations to 10 years. METHODS AND RESULTS: CREST is a randomized controlled trial designed to compare the outcomes of carotid stenting versus carotid endarterectomy. Proportional hazards models were used to assess the association between mortality and periprocedural stroke, MI, or biomarker-only events. For 10-year follow-up, patients with periprocedural stroke were at 1.74× the risk of death compared with those without stroke (adjusted hazard ratio [HR]=1.74; 95% CI, 1.21-2.50; P<0.003). This increased risk was driven by increased early (between 0 and 90 days) mortality (adjusted HR=14.41; 95% CI, 5.33-38.94; P<0.0001), with no significant increase in late (between 91 days and 10 years) mortality (adjusted HR=1.40; 95% CI, 0.93-2.10; P=0.11). Patients with a protocol MI were at 3.61× increased risk of death compared with those without MI (adjusted HR=3.61; 95% CI, 2.28-5.73; P<0.0001), with an increased hazard both early (adjusted HR=8.20; 95% CI, 1.86-36.2; P=0.006) and late (adjusted HR=3.40; 95% CI, 2.09-5.53; P<0.0001). Patients with a biomarker-only event were at 2.04× increased risk overall (adjusted HR=2.04; 95% CI, 1.09-3.84; P=0.03) than those without MI, with an increased early hazard (adjusted HR=8.44; 95% CI, 1.09-65.5; P=0.04) and a suggestive but nonsignificant association toward higher 91-day to 10-year risk (1.88; 95% CI, 0.97-3.64; P=0.062) contributing to the increased risk. CONCLUSIONS: In the CREST trial, patients with periprocedural events demonstrate a substantial increase in future mortality to 10 years. For stroke, this risk is largely confined to an early time frame while periprocedural MI or biomarker-only events confer a continuous increased mortality for 10 years. Strategies to reduce periprocedural events and to optimize the evaluation and management of patients with cardiac events should be considered in efforts to reduce not only early but also long-term mortality. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00004732.
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Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Infarto del Miocardio/epidemiología , Implantación de Prótesis , Accidente Cerebrovascular/epidemiología , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Estenosis Carotídea/epidemiología , Estenosis Carotídea/mortalidad , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Factores de Riesgo , Stents , Accidente Cerebrovascular/mortalidad , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Antihipertensivos , Hipertensión , Femenino , Humanos , Masculino , Caracteres Sexuales , Encuestas y CuestionariosRESUMEN
STUDY OBJECTIVES: To examine the cross-sectional association between obstructive sleep apnea (OSA) risk and atrial fibrillation (AF) in the REasons for Geographic And Racial Differences in Stroke (REGARDS), a cohort of black and white adults. METHODS: Using REGARDS data from subjects recruited between 2003-2007, we assessed 20,351 participants for OSA status. High OSA risk was determined if the participant met at least two criteria from the Berlin Sleep Questionnaire (persistent snoring, frequent sleepiness, high blood pressure, or obesity). AF was defined as a self-reported history of a previous physician diagnosis or presence of AF on electrocardiogram. Logistic regression was used to determine odds ratio and 95% confidence interval for the association between OSA status and AF with subgroup analysis to examine effect modification by age, race, sex, and geographical region. RESULTS: The prevalence of AF was 7% (n = 1,079/14,992) and 9% (n = 482/5,359) in participants at low and high risk of OSA, respectively (P < .0001). Persons at high risk of OSA had greater prevalence of diabetes and stroke history, and were more likely to be obese and taking sleep medications. In a multivariable analysis adjusted for demographics, cardiovascular risk factors, and potential confounders, high risk for OSA was associated with an increased odds of AF compared to low risk for OSA (odds ratio = 1.27, 95% confidence interval = 1.13, 1.44). This association differed significantly only by race (P for interaction = .0003). For blacks, there was a significant 58% increase in odds of AF in participants at high risk versus low risk of OSA, compared to a nonsignificant 12% increase in odds in whites. We were limited by self-reported variables, inability to adjust for obesity, and the cross-sectional nature of our study. CONCLUSIONS: High risk of OSA is associated with prevalent AF among blacks but not whites. COMMENTARY: A commentary on this article appears in this issue on page 1459.
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Fibrilación Atrial/epidemiología , Negro o Afroamericano/estadística & datos numéricos , Apnea Obstructiva del Sueño/epidemiología , Población Blanca/estadística & datos numéricos , Factores de Edad , Estudios de Cohortes , Comorbilidad , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Factores de Riesgo , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
The functional implications of serum tumor necrosis factor-alpha (TNF-α), a marker of oxidative stress, on hemodynamic parameters at rest and during physical exertion are unclear. The aims of this investigation were to examine the independent associations of TNF-α on myocardial oxygen demand at rest and during submaximal exercise, while also evaluating the association of TNF-α on exercise tolerance. Forty, postmenopausal women, provided blood samples and completed a modified-Balke protocol to measure maximal oxygen uptake (VO2max). Large artery compliance was measured by pulse contour analyses while rate-pressure product (RPP), an index of myocardial oxygen demand, was measured at rest and during two submaximal workloads (i.e., ≈55% and ≈75% VO2max). RPP was calculated by dividing the product of heart rate and systolic blood pressure (via auscultation) by 100. Exercise tolerance corresponded with the cessation of the graded exercise test. During higher-intensity exertion, ≈75% VO2max, multiple linear regression revealed a positive association (r = 0.43; p = 0.015) between TNF-α and RPP while adjusting for maximal heart rate, VO2max, large artery compliance, and percent body fat. Path analyses revealed a significant indirect effect of large artery compliance on exercise tolerance through TNF-α, ß = 0.13, CI [0.03, 0.35], indicating greater levels of TNF-α associated with poorer exercise tolerance. These data suggest TNF-α independently associates with myocardial oxygen demand during physical exertion, thus highlighting the utility of higher-intensity efforts to expose important phenomena not apparent at rest. TNF-α also appears to be indirectly associated with the link between large artery compliance and exercise tolerance.
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BACKGROUND: N-terminal pro B-type peptide (NT-proBNP) has been associated with risk of myocardial infarction (MI), but less is known about the relationship between NT-proBNP and very small non ST-elevation MI, also known as microsize MI. These events are now routinely detectable with modern troponin assays and are emerging as a large proportion of all MI. Here, we sought to compare the association of NT-proBNP with risk of incident typical MI and microsize MI in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. METHODS: The REGARDS Study is a national cohort of 30,239 US community-dwelling black and white adults aged ≥ 45 years recruited from 2003 to 2007. Expert-adjudicated outcomes included incident typical MI (definite/probable MI with peak troponin ≥ 0.5 µg/L), incident microsize MI (definite/probable MI with peak troponin < 0.5 µg/L), and incident fatal CHD. Using a case-cohort design, we estimated the hazard ratio of the outcomes as a function of baseline NT-proBNP. Competing risk analyses tested whether the associations of NT-proBNP differed between the risk of incident microsize MI and incident typical MI as well as if the association of NT-proBNP differed between incident non-fatal microsize MI and incident non-fatal typical MI, while accounting for incident fatal coronary heart disease (CHD) as well as heart failure (HF). RESULTS: Over a median of 5 years of follow-up, there were 315 typical MI, 139 microsize MI, and 195 incident fatal CHD. NT-proBNP was independently and strongly associated with all CHD endpoints, with significantly greater risk observed for incident microsize MI, even after removing individuals with suspected HF prior to or coincident with their incident CHD event. CONCLUSION: NT-proBNP is associated with all MIs, but is a more powerful risk factor for microsize than typical MI.
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Negro o Afroamericano , Péptido Natriurético Encefálico/sangre , Infarto del Miocardio sin Elevación del ST/sangre , Infarto del Miocardio sin Elevación del ST/etnología , Fragmentos de Péptidos/sangre , Población Blanca , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Femenino , Insuficiencia Cardíaca/etnología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/mortalidad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: To determine if the effects of intensive lowering of systolic blood pressure (goal of less than 120âmmHg) versus standard lowering (goal of less than 140âmmHg) upon cardiovascular, renal, and safety outcomes differed by gender. METHODS: Nine thousand three hundred and sixty-one men and women aged 50 years or older with systolic blood pressure of 130âmmHg or greater, taking 0-4 antihypertensive medications, and with increased risk of cardiovascular disease, but free of diabetes, were randomly assigned to either a systolic blood pressure target of less than 120âmmHg (intensive treatment) or a target of less than 140âmmHg (standard treatment). The primary composite outcome encompassed incident myocardial infarction, heart failure, other acute coronary syndromes, stroke, or cardiovascular-related death. All-cause mortality, renal outcomes, and serious adverse events were also assessed. RESULTS: Compared with the standard treatment group, the primary composite outcome in the intensive treatment group was reduced by 16% [hazard ratio 0.84 (0.61-1.13)] in women, and by 27% in men [hazard ratio 0.73 (0.59-0.89), P value for interaction between treatment and gender is 0.45]. Similarly, the effect of the intensive treatment on individual components of the primary composite outcome, renal outcomes, and overall serious adverse events was not significantly different according to gender. CONCLUSION: In adults with hypertension but not with diabetes, treatment to a systolic blood pressure goal of less than 120âmmHg, compared with a goal of less than 140âmmHg, resulted in no heterogeneity of effect between men and women on cardiovascular or renal outcomes, or on rates of serious adverse events.ClinicalTrials.gov number, NCT01206062.
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Antihipertensivos/uso terapéutico , Presión Sanguínea , Enfermedades Cardiovasculares/epidemiología , Síndrome Coronario Agudo/epidemiología , Anciano , Enfermedades Cardiovasculares/mortalidad , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Incidencia , Enfermedades Renales/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Planificación de Atención al Paciente , Modelos de Riesgos Proporcionales , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Sístole , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Left ventricular hypertrophy assessed by electrocardiography (ECG-LVH) is a marker of subclinical cardiac damage and a strong predictor of cardiovascular disease (CVD) events. The prevalence of ECG-LVH is increased in obesity and type 2 diabetes; however, there are no data on the long-term effects of weight loss on ECG-LVH. The purpose of this study was to determine whether an intensive lifestyle intervention (ILI) reduces ECG-LVH in overweight and obese adults with type 2 diabetes. METHODS: Data from 4,790 Look AHEAD participants (mean age: 58.8 ± 6.8 years, 63.2% White) who were randomized to a 10-year ILI (n = 2,406) or diabetes support and education (DSE, n = 2,384) were included. ECG-LVH defined by Cornell voltage criteria was assessed every 2 years. Longitudinal logistic regression analysis with generalized estimation equations and linear mixed models were used to compare the prevalence of ECG-LVH and changes in absolute Cornell voltage over time between intervention groups, with tests of interactions by sex, race/ethnicity, and baseline CVD status. RESULTS: The prevalence of ECG-LVH at baseline was 5.2% in the DSE group and 5.0% in the ILI group (P = 0.74). Over a median 9.5 years of follow-up, prevalent ECG-LVH increased similarly in both groups (odds ratio: 1.02, 95% confidence interval: 0.83-1.25; group × time interaction, P = 0.49). Increases in Cornell voltage during follow-up were also similar between intervention groups (group × time interaction, P = 0.57). Intervention effects were generally similar between subgroups of interest. CONCLUSIONS: The Look AHEAD long-term lifestyle intervention does not significantly lower ECG-LVH in overweight and obese adults with type 2 diabetes. CLINICAL TRIALS REGISTRATION: Trial Number NCT00017953 (ClinicalTrials.gov).
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Electrocardiografía , Hipertrofia Ventricular Izquierda/fisiopatología , Estilo de Vida , Anciano , Diabetes Mellitus Tipo 2/complicaciones , Humanos , Hipertrofia Ventricular Izquierda/epidemiología , Modelos Logísticos , Persona de Mediana Edad , Obesidad/complicacionesRESUMEN
It is unclear whether metabolic syndrome (MetS) is associated with atrial fibrillation (AF) in an older population with greater cardiovascular risk, including those with chronic kidney disease. The authors investigated the association between MetS and AF in participants in SPRINT (Systolic Blood Pressure Intervention Trial). MetS was defined based on the Modified Third National Cholesterol Education Program. The baseline prevalence rate for MetS was 55%, while 8.2% of the participants had AF. In multivariate regression analyses, AF was not associated with presence of MetS in either chronic kidney disease or non-chronic kidney disease subgroups. Age, race, history of cardiovascular diseases, decreased triglycerides, decreased pulse pressure, and albuminuria remained significantly associated with AF risk. In contrast to the general population, MetS was not associated with AF in the older population with increased cardiovascular risk studied in SPRINT.
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Albuminuria/epidemiología , Fibrilación Atrial , Presión Sanguínea , Hipertensión , Resistencia a la Insulina , Síndrome Metabólico , Insuficiencia Renal Crónica , Triglicéridos/análisis , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Femenino , Humanos , Hipertensión/epidemiología , Hipertensión/metabolismo , Hipertensión/fisiopatología , Hipertensión/terapia , Masculino , Síndrome Metabólico/diagnóstico , Síndrome Metabólico/epidemiología , Prevalencia , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/epidemiología , Factores de Riesgo , Estadística como AsuntoRESUMEN
BACKGROUND: The National Death Index (NDI) is widely used to detect coronary heart disease (CHD) and cardiovascular disease (CVD) deaths, but its reliability has not been examined recently. METHODS AND RESULTS: We compared CHD and CVD deaths detected by NDI with expert adjudication of 4010 deaths that occurred between 2003 and 2013 among participants in the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort of black and white adults in the United States. NDI derived CHD mortality had sensitivity 53.6%, specificity 90.3%, positive predictive value 54.2%, and negative predictive value 90.1%. NDI-derived CVD mortality had sensitivity 73.4%, specificity 84.5%, positive predictive value 70.6%, and negative predictive value 86.2%. Among NDI-derived CHD and CVD deaths, older age (odds ratios, 1.06 and 1.04 per 1-year increase) was associated with a higher probability of disagreement with the adjudicated cause of death, whereas among REGARDS adjudicated CHD and CVD deaths a history of CHD or CVD was associated with a lower probability of disagreement with the NDI-derived causes of death (odds ratios, 0.59 and 0.67, respectively). CONCLUSIONS: The modest accuracy and differential performance of NDI-derived cause of death may impact CHD and CVD mortality statistics.
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Negro o Afroamericano , Enfermedad Coronaria/etnología , Enfermedad Coronaria/mortalidad , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/mortalidad , Población Blanca , Anciano , Causas de Muerte , Enfermedad Coronaria/diagnóstico , Femenino , Disparidades en el Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Reproducibilidad de los Resultados , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
Importance: High-intensity statins are recommended following myocardial infarction. However, patients may not continue taking this medication with high adherence. Objective: To estimate the proportion of patients filling high-intensity statin prescriptions following myocardial infarction who continue taking this medication with high adherence and to analyze factors associated with continuing a high-intensity statin with high adherence after myocardial infarction. Design, Setting, and Participants: Retrospective cohort study of Medicare patients following hospitalization for myocardial infarction. Medicare beneficiaries aged 66 to 75 years (n = 29â¯932) and older than 75 years (n = 27â¯956) hospitalized for myocardial infarction between 2007 and 2012 who filled a high-intensity statin prescription (atorvastatin, 40-80 mg, and rosuvastatin, 20-40 mg) within 30 days of discharge. Beneficiaries had Medicare fee-for-service coverage including pharmacy benefits. Exposures: Sociodemographic, dual Medicare/Medicaid coverage, comorbidities, not filling high-intensity statin prescriptions before their myocardial infarction (ie, new users), and cardiac rehabilitation and outpatient cardiologist visits after discharge. Main Outcomes and Measures: High adherence to high-intensity statins at 6 months and 2 years after discharge was defined by a proportion of days covered of at least 80%, down-titration was defined by switching to a low/moderate-intensity statin with a proportion of days covered of at least 80%, and low adherence was defined by a proportion of days covered less than 80% for any statin intensity without discontinuation. Discontinuation was defined by not having a statin available to take in the last 60 days of each follow-up period. Results: Approximately half of the beneficiaries were women and fourth-fifths were white. At 6 months and 2 years after discharge among beneficiaries 66 to 75 years of age, 17â¯633 (58.9%) and 10â¯308 (41.6%) were taking high-intensity statins with high adherence, 2605 (8.7%) and 3315 (13.4%) down-titrated, 5182 (17.3%) and 4727 (19.1%) had low adherence, and 3705 (12.4%) and 4648 (18.8%) discontinued their statin, respectively. The proportion taking high-intensity statins with high adherence increased between 2007 and 2012. African American patients, Hispanic patients, and new high-intensity statin users were less likely to take high-intensity statins with high adherence, and those with dual Medicare/Medicaid coverage and more cardiologist visits after discharge and who participated in cardiac rehabilitation were more likely to take high-intensity statins with high adherence. Results were similar among beneficiaries older than 75 years of age. Conclusions and Relevance: Many patients filling high-intensity statins following a myocardial infarction do not continue taking this medication with high adherence for 2 years postdischarge. Interventions are needed to increase high-intensity statin use and adherence after myocardial infarction.
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Atorvastatina/administración & dosificación , Hospitalización , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Cumplimiento de la Medicación/estadística & datos numéricos , Infarto del Miocardio/tratamiento farmacológico , Rosuvastatina Cálcica/administración & dosificación , Negro o Afroamericano/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Atorvastatina/uso terapéutico , Estudios de Cohortes , Femenino , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Medicare , Cumplimiento de la Medicación/etnología , Estudios Retrospectivos , Rosuvastatina Cálcica/uso terapéutico , Prevención Secundaria , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
Orthostatic changes in systolic blood pressure (SBP) impact cardiovascular outcomes. In this study, we aimed to determine the pattern of orthostatic systolic pressure changes in participants enrolled in the SBP Intervention Trial (SPRINT) at their baseline visit before randomization and sought to understand clinical factors predictive of these changes. Of the 9323 participants enrolled in SPRINT, 8662 had complete data for these analyses. The SBP after 1 minute of standing was subtracted from the mean value of the three preceding seated SBP values. At the baseline visit, medical history, medications, anthropometric measures, and standard laboratory testing were undertaken. The mean age of SPRINT participants was 68 years, two-thirds were male, with 30% black, 11% Hispanic, and 55% Caucasian. The spectrum of SBP changes on standing demonstrated that increases in SBP were as common as declines, and about 5% of participants had an increase, and 5% had a decrease of >20 mm Hg in SBP upon standing. Female sex, taller height, more advanced kidney disease, current smoking, and several drug classes were associated with larger declines in BP upon standing, while black race, higher blood levels of glucose and sodium, and heavier weight were associated with more positive values of the change in BP upon standing. Our cross-sectional results show a significant spectrum of orthostatic SBP changes, reflecting known (eg, age) and less well-known (eg, kidney function) relationships that may be important considerations in determining the optimal target blood pressure in long-term outcomes of older hypertensive patients.
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Presión Sanguínea/fisiología , Tasa de Filtración Glomerular , Hipertensión/complicaciones , Hipotensión Ortostática/fisiopatología , Postura/fisiología , Insuficiencia Renal Crónica/complicaciones , Factores de Edad , Anciano , Anciano de 80 o más Años , Antihipertensivos/uso terapéutico , Determinación de la Presión Sanguínea , Estatura , Estudios Transversales , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatología , Hipotensión Ortostática/complicaciones , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores Sexuales , SístoleRESUMEN
BACKGROUND: The association between lipid levels and stroke rates is less than lipid levels and coronary heart disease (CHD). OBJECTIVE: To assess if there are geographic, racial, and ethnic differences in total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and triglyceride levels with incident stroke. METHODS: From the REasons for Geographic And Racial Differences in Stroke (REGARDS) study we evaluated baseline levels of LDL-C, HCL-C, TC, Non-HDL-C (Total-HDL-C) and triglycerides in participants free of prevalent stroke at baseline. Cox Proportional-Hazard models were the main analytical tool used to examine the association between incident stroke and lipids. For each adjusted lipid measure (LDL-C, HDL-C, triglycerides, TC, and non-HDL-C) we calculated a series of incremental models. RESULTS: The analysis cohort was 23,867 participants with a mean follow-up time of 7.5±2.9years, and 1031 centrally adjudicated strokes (874 ischemic and 77 hemorrhagic strokes). HDL-C baseline level was associated with an overall unadjusted 13% risk reduction (HR 0.87, 95% confidence interval [CI]: 0.81-0.93; p<0.05; 14% for ischemic and 16% for hemorrhagic strokes), and TC with an 8% (HR 0.92, 95%CI: 0.87-0.99; p<0.05) risk reduction of all strokes. When the results were fully adjusted a significant association was observed only for LDL-C and non-HDL-C and ischemic stroke. There were no significant differences in these associations when adjusted for age, race, age∗race, gender, education, region, or income. CONCLUSION: In a disease free population, LDL-C and non-HDL-C baseline levels are significantly associated with the risk of ischemic stroke.
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HDL-Colesterol/sangre , LDL-Colesterol/sangre , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/epidemiología , Triglicéridos/sangre , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnósticoRESUMEN
We evaluated the prevalence of major and minor electrocardiographic (ECG) abnormalities based on blood pressure (BP) control and hypertension (HTN) treatment resistance. We analyzed data from the Reasons for Geographic and Racial Differences in Stroke study of 20,932 participants who were divided into presence of major (n = 3782), only minor (n = 8944), or no (n = 8206) ECG abnormalities. The cohort was stratified into normotension (n = 3373), pre-HTN (n = 4142), controlled HTN (n = 8619), uncontrolled HTN (n = 3544), controlled apparent treatment-resistant HTN (aTRH, n = 400), and uncontrolled aTRH (n = 854) groups, and the prevalence ratios (PRs) of major and minor ECG abnormalities were assessed separately for each BP group. The full multivariable adjustment included demographics, risk factors, and HTN duration. Compared with normotension, the PRs of major ECG abnormalities for pre-HTN, controlled HTN, uncontrolled HTN, controlled aTRH, and uncontrolled aTRH groups were 1.01 (0.90-1.14), 1.30 (1.16-1.45), 1.37 (1.23-1.54), 1.42 (1.22-1.64), and 1.44 (1.26-1.65), respectively (P < .001), whereas the PRs of minor ECG abnormalities among each of the above BP groups were similar. Detection of major ECG abnormalities among hypertensive persons with poor control and treatment resistance may help improve their cardiovascular risk stratification and early intervention.
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Antihipertensivos/uso terapéutico , Enfermedades Cardiovasculares/epidemiología , Vasoespasmo Coronario/complicaciones , Hipertensión/complicaciones , Factores de Edad , Anciano , Determinación de la Presión Sanguínea , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/etiología , Vasoespasmo Coronario/tratamiento farmacológico , Estudios Transversales , Electrocardiografía , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores SexualesRESUMEN
The association of atrial fibrillation (AF) with the severity and control of hypertension (HTN) remains unclear. We analyzed data from the national biracial cohort of REasons for Geographic And Racial Differences in Stroke study. The AF prevalence ratios were estimated and full multivariable adjustment included demographics, risk factors, medication adherence, HTN duration, and antihypertensive medication classes. Of the 30,018 study participants (8.6% with AF), 4386 had normotension (4.3% with AF), 5916 had prehypertension (4.3 with AF%), 12,294 had controlled HTN (11.2% with AF), 5587 had uncontrolled HTN (8.1% with AF), 547 had controlled apparent treatment-resistant hypertension (aTRH) (19.2% with AF), and 1288 had uncontrolled aTRH (15.5% with AF). Compared with normotension, the AF prevalence ratios for prehypertension, controlled HTN, uncontrolled HTN, controlled aTRH, and uncontrolled aTRH groups in fully adjusted model were 1.01 (95% confidence interval: 0.84, 1.21), 1.42 (1.18, 1.71), 1.37 (1.14, 1.65), 1.17 (0.86, 1.58), and 1.42 (1.10, 1.84), respectively (P < .001). The prevalence of AF was similar among persons with HTN regardless of blood pressure level and antihypertensive treatment resistance.
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Fibrilación Atrial/epidemiología , Hipertensión/epidemiología , Prehipertensión/epidemiología , Factores de Edad , Anciano , Antihipertensivos/uso terapéutico , Fibrilación Atrial/complicaciones , Población Negra , Determinación de la Presión Sanguínea , Estudios de Cohortes , Estudios Transversales , Femenino , Humanos , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Prehipertensión/complicaciones , Prevalencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Población BlancaRESUMEN
Pulse pressure (PP) has been associated with atrial fibrillation (AF) independent of other measures of arterial pressure and other AF risk factors. However, the impact of gender, race, age, and geographic region on the association between PP and AF is unclear. A cross-sectional study of data from 25,109 participants (65 ± 9 years, 54% women, 40% black) from the Reasons for Geographic and Racial Differences in Stroke study recruited between 2003 and 2007 were analyzed. AF was defined as a self-reported history of a previous physician diagnosis or presence of AF on ECG. Multivariable logistic regression models were used to calculate the odds ratio for AF. Interactions for age (<75 years and ≥75 years), gender, race, and region were examined in the multivariable adjusted model. The prevalence of AF increased with widening PP (7.9%, 7.9%, 8.4%, and 11.6%, for PP < 45, 45-54.9, 55-64.9, and ≥65 mm Hg, respectively, [P for trend <.001]) but attenuated with adjustment. No differences by gender, race, and region were observed. However, there was evidence of significant effect modification by age (interaction P = .0002). For those <75 years, PP ≥ 65 mm Hg compared to PP < 45 mm Hg was significantly associated with higher risk of AF in both the unadjusted and multivariable adjusted models (odds ratio = 1.66 [95% CI = 1.42-1.94] and 1.32 [95% CI = 1.03-1.70], respectively). In contrast, higher PP (55-64.9 mm Hg) among those ≥75 years was significantly associated with a lower risk of AF. The relationship between PP and AF may differ for older versus younger individuals.