Association of blood pressure variability with Endothelin-1 by menopause status among Black women: findings from the Jackson Heart Study.

TO THE EDITOR: Postmenopausal women have a higher risk of hypertension compared with premenopausal women possibly related to increased endothelial dysfunction in the setting of lower levels of circulating estrogen. Using data from 660 women in the Jackson Heart Study (JHS), postmenopausal women had higher daytime, nighttime and 24 h systolic blood pressure variability (BPV) compared with premenopausal women, and higher nighttime systolic BPV was associated with higher endothlin-1 (a marker of endothelial dysfunction) in postmenopausal women (ß = 0.27 [0.05, 0.50], p = 0.019), even after adjustment for possible confounders including age. These findings highlight the relevance of menopause status to blood pressure variability and the potential role of blood pressure variability in the development of high endothelin-1 in postmenopausal women.

Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018.

BACKGROUND: Multisociety guidelines recommend a goal systolic blood pressure (BP) <130 mm Hg and a hemoglobin A1c (HbA1c) <8% in patients with heart failure (HF), regardless of ejection fraction. Few studies have described BP and glycemic control in ambulatory patients with HF and racial and ethnic disparities in this subset of the population. METHODS: We evaluated prevalence of uncontrolled BP and HbA1c in non-Hispanic Black, non-Hispanic White, and Mexican American adults aged ≥20 years with self-reported HF (National Health and Nutrition Examination Surveys: 2001-2018). Prevalence ratios (95% CI) for uncontrolled BP and HbA1c were calculated by race and ethnicity and adjusted for sex, age, treatment, and socioeconomic status. In secondary analyses, we examined trends in the prevalence of uncontrolled BP and HbA1c. RESULTS: Uncontrolled BP was present in 48% (95% CI, 49%-56%) of adults with HF (representing 2.3 million people). Non-Hispanic Black participants had a higher prevalence of uncontrolled BP compared with non-Hispanic White participants (53% [48%-58%] compared with 47% [43%-51%], P<0.05). In adjusted models, non-Hispanic Black participants were 1.19 (1.02-1.39) times more likely to have uncontrolled BP than non-Hispanic White participants. Overall, uncontrolled HbA1c was found in 8% (6%, 10%) with no differences by race and ethnicity. Prevalence of uncontrolled BP improved over time but uncontrolled risk factors remained high-2017 to 2018: 41% (36%, 47%) and 7% (5%, 12%) had uncontrolled BP and HbA1c, respectively. CONCLUSIONS: We document an unacceptably high prevalence of uncontrolled BP and HbA1c in a nationally representative, ambulatory HF sample with significant differences in BP control by race and ethnicity.

Risk-Based Intensive Blood Pressure Lowering and Prevention of Heart Failure: A SPRINT Post Hoc Analysis.

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Neighborhood Poverty and Incident Heart Failure: an Analysis of Electronic Health Records from 2005 to 2018.

BACKGROUND: Neighborhood-level characteristics, such as poverty, have been associated with risk factors for heart failure (HF), including hypertension and diabetes mellitus. However, the independent association between neighborhood poverty and incident HF remains understudied. OBJECTIVE: To evaluate the association between neighborhood poverty and incident HF using a "real-world" clinical cohort. DESIGN: Retrospective cohort study of electronic health records from a large healthcare network. Individuals' residential addresses were geocoded at the census-tract level and categorized by poverty tertiles based on American Community Survey data (2007-2011). PARTICIPANTS: Patients from Northwestern Medicine who were 30-80 years, free of cardiovascular disease at index visit (January 1, 2005-December 1, 2013), and followed for at least 5 years. MAIN MEASURES: The association of neighborhood-level poverty tertile (low, intermediate, and high) and incident HF was analyzed using generalized linear mixed effect models adjusting for demographics (age, sex, race/ethnicity) and HF risk factors (body mass index, diabetes mellitus, hypertension, smoking status). KEY RESULTS: Of 28,858 patients included, 75% were non-Hispanic (NH) White, 43% were men, 15% lived in a high-poverty neighborhood, and 522 (1.8%) were diagnosed with incident HF. High-poverty neighborhoods were associated with a 1.80 (1.35, 2.39) times higher risk of incident HF compared with low-poverty neighborhoods after adjustment for demographics and HF risk factors. CONCLUSIONS: In a large healthcare network, incident HF was associated with neighborhood poverty independent of demographic and clinical risk factors. Neighborhood-level interventions may be needed to complement individual-level strategies to prevent and curb the growing burden of HF.

Antihypertensive Class and Cardiovascular Outcomes in Patients With HIV and Hypertension.

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Application of Guideline-Based Echocardiographic Assessment of Left Atrial Pressure to Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Early, noninvasive identification of patients with heart failure with preserved ejection fraction (HFpEF) with congestion may allow timely tailoring of decongestive therapies. The 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines provide an algorithm to assess for elevated left atrial pressure (LAP); the associations of echocardiographic LAP with clinical status and disease progression in patients with HFpEF are unclear. METHODS: Participants in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF trial were categorized into one of four prespecified guideline-based echocardiographic LAP categories: (1) normal, (2) elevated, (3) atrial fibrillation (AF) at the time of echocardiography, or (4) indeterminate. Associations of echocardiographic LAP categories with baseline exercise capacity, change in exercise capacity, and change in N-terminal pro-B-type natriuretic peptide over 24 weeks were evaluated. RESULTS: Of 216 participants, 199 underwent mitral inflow Doppler echocardiography for LAP categorization. Participants with elevated echocardiographic LAP (n = 81) or AF (n = 57) were older and had a higher prevalence of kidney dysfunction. Compared with the normal echocardiographic LAP group (n = 28), elevated echocardiographic LAP and AF were each independently associated with a greater reduction in peak oxygen consumption over 24 weeks after adjusting for baseline values and clinical covariates (ß for elevated echocardiographic LAP = -1.55 [95% CI, -2.59 to -0.51], P = .004; ß for AF = -1.33 [95% CI, -2.49 to -0.17], P = .03). Indeterminate echocardiographic LAP (n = 33) was also independently associated with a reduction in exercise capacity at 24 weeks compared with normal echocardiographic LAP (ß = -1.35; 95% CI, -2.51 to -0.19; P = .02). Finally, elevated echocardiographic LAP and AF were significantly associated with increases in N-terminal pro-B-type natriuretic peptide over 24 weeks compared with normal echocardiographic LAP. CONCLUSIONS: In patients with chronic HFpEF, elevated echocardiographic LAP and indeterminate echocardiographic LAP, as defined by contemporary guidelines, and AF were each independently associated with a reduction in exercise capacity compared with normal echocardiographic LAP. These findings suggest the potential utility of noninvasive LAP assessment in patients with HFpEF for tailoring treatments that decrease congestion.

Trends in the Prevalence of Self-reported Heart Failure by Race/Ethnicity and Age From 2001 to 2016.

Importance: Despite recent advances in therapies for heart failure (HF), deaths from HF are increasing, with persistent disparities between Black and White adults. Recent national trends in the prevalence of HF need to be clarified to appropriately allocate resources and develop effective preventive interventions. Objectives: To examine the prevalence of ambulatory HF overall and by race/ethnicity and age and the temporal changes in HF prevalence between 2001 and 2016. Design, Setting, and Participants: This cross-sectional study of nationally representative data collected biennially through the National Health and Nutrition Examination Survey (NHANES) from January 1, 2001, to December 31, 2016, assessed nonpregnant adults 35 years and older who self-identified as non-Hispanic Black, non-Hispanic White, or Mexican American. Data analysis was performed from November 16, 2019, to April 12, 2020. Exposures: Survey period, race/ethnicity, and age group. Main Outcomes and Measures: Age-standardized prevalence was calculated within 4-year survey periods (2001-2004, 2005-2008, 2009-2012, and 2013-2016) based on self-report of ambulatory HF overall and by race/ethnicity and age group (35-64 and ≥65 years). Weighted multivariable logistic regression was used to examine trends in ambulatory HF prevalence over time by race/ethnicity and age group. Results: A total of 26 097 participants (mean [SD] age, 55.9 [10.7] years; 13 192 [52%] female; 6519 [12%] non-Hispanic Black; and 4906 [7%] Mexican American) were studied. Overall age-standardized prevalence (per 100 000 population) of ambulatory HF was 3184 (95% CI, 2641-3728) from 2001 to 2005 and 3045 (95% CI, 2651-3438) from 2013 to 2016. The prevalence of ambulatory HF was highest among non-Hispanic Black adults: from 2013 to 2016, HF prevalence (per 100 000 population) was 5017 (95% CI, 3755-6279) among non-Hispanic Black adults, 2746 (95% CI, 2313-3179) among non-Hispanic White adults, and 2508 (95% CI, 1154-3862) among Mexican American adults. Differences between White and Black adults in HF prevalence were also present in younger and middle-aged adults (eg, 35-64 years of age in 2013-2016: 3864 [95% CI, 2369-5359] for non-Hispanic Black adults vs 1297 [95% CI, 878-1716] for non-Hispanic White adults). Conclusions and Relevance: This study found that a high burden of ambulatory HF persisted between 2001 and 2016 in the US. Disparities were most prominent by age group. Alongside prevention and aggressive management of risk factors, targeted efforts aimed at mitigating racial disparities are needed.

The "difficult" cadaver: weight bias in the gross anatomy lab.

Background: The prevalence of overweight and obesity continues to rise and is associated with increased morbidity and mortality. Weight bias is common among physicians and medical students and limits the therapeutic alliance between providers and patients with overweight and obesity.Objective: The authors sought to explore the relationship between the gross anatomy course and medical student attitudes towards weight and obesity.Design: The authors employed a mixed-methods approach consisting of semi-structured interviews and anonymous web-based surveys of first-year medical students taking gross anatomy at one USA medical school. They analyzed transcripts of interviews and free-text survey responses using a grounded theory approach and performed tests of association to investigate the relationship between demographic information, responses to multiple-choice survey questions and weight bias.Results: A total of 319 (52%) first-year medical students (2015-2018) completed the survey and 33 participated in interviews. Of survey respondents, 71 (22%) responded that the course had changed how they felt about people with overweight/obesity. These respondents were also more likely to affirm that the course had affected their views toward their own bodies (p < 0.001). Qualitative data analysis identified three overarching themes within students' descriptions of the effects of the gross anatomy lab on attitudes toward bodies perceived to have excess weight: these bodies were described as 1) difficult, 2) unhealthy, and 3) evoking disgust. Students extrapolated from their experiences with cadavers to imagined interactions with future patients, relying heavily on the narrative of the difficult patient.Conclusions: At one USA medical school, students perceived their experiences in gross anatomy as shaping their attitudes toward individuals with overweight or obesity. Efforts to reduce medical student weight bias ought to target this previously unexplored potential site of weight bias.