Racial/ethnic heterogeneity in associations of blood pressure and incident cardiovascular disease by functional status in a prospective cohort: the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVES:Research has demonstrated that the association between high blood pressure and outcomes is attenuated among older adults with functional limitations, compared with healthier elders. However, it is not known whether these patterns vary by racial/ethnic group. We evaluated race/ethnicity-specific patterns of effect modification in the association between blood pressure and incident cardiovascular disease (CVD) by functional status. SETTING:We used data from the Multi-Ethnic Study of Atherosclerosis (2002-2004, with an average of 8.8 years of follow-up for incident CVD). We assessed effect modification of systolic blood pressure and cardiovascular outcomes by self-reported physical limitations and by age. PARTICIPANTS:The study included 6117 participants (aged 46 to 87; 40% white, 27% black, 22% Hispanic and 12% Chinese) who did not have CVD at the second study examination (when self-reported physical limitations were assessed). OUTCOME MEASURES:Incident CVD was defined as an incident myocardial infarction, coronary revascularisation, resuscitated cardiac arrest, angina, stroke (fatal or non-fatal) or death from CVD. RESULTS:We observed weaker associations between systolic blood pressure (SBP) and CVD among white adults with physical limitations (incident rate ratio (IRR) per 10 mm Hg higher SBP: 1.09 (95% CI 0.99 to 1.20)) than those without physical limitations (IRR 1.29 (1.19, 1.40); P value for interaction <0.01). We found a similar pattern among black adults. Poor precision among the estimates for Hispanic or Chinese participants limited the findings in these groups. The attenuated associations were consistent across both multiplicative and additive scales, though physical limitations showed clearer patterns than age on an additive scale. CONCLUSION:Attenuated associations between high blood pressure and incident CVD were observed for blacks and whites with poor function, though small sample sizes remain a limitation for identifying differences among Hispanic or Chinese participants. Identifying the characteristics that distinguish those in whom higher SBP is associated with less risk of morbidity or mortality may inform our understanding of the consequences of hypertension among older adults

Intersectional Discrimination and Change in Blood Pressure Control among Older Adults: The Health and Retirement Study

BACKGROUND: Associations between multiple forms of discrimination and blood pressure control in older populations remain unestablished. METHODS: Participants were 14582 non-institutionalized individuals (59% women) in the Health and Retirement Study aged at least 51 years (76% Non-Hispanic White, 15% Non-Hispanic Black, 9% Hispanic/Latino). Primary exposures included the mean frequency of discrimination in everyday life, intersectional discrimination (defined as marginalization ascribed to more than one reason), and the sum of discrimination over the lifespan. We assessed whether discrimination was associated with change in measured hypertension status (N=14582) and concurrent medication use among reported hypertensives (N=9086) over four years (2008-2014). RESULTS: There was no association between the frequency of everyday discrimination and change in measured hypertension. Lifetime discrimination was associated with higher odds of hypertension four years later among men (OR: 1.21, 95% CI: 1.08, 1.36) but not women (OR: 0.98, 95% CI: 0.86, 1.13). Only among men, everyday discrimination due at least two reasons was associated with a 1.44 (95% CI: 1.03, 2.01)-fold odds of hypertension than reporting no everyday discrimination; reporting intersectional discrimination was not associated with developing hypertension among women (OR: 0.91, 95% CI: 0.70, 1.20). All three discriminatory measures were inversely related to time-averaged antihypertensive medication use, without apparent gender differences (e.g., OR for everyday discrimination-antihypertensive use associations: 0.85, 95% CI: 0.77, 0.94)). CONCLUSIONS: Gender differences in marginalization may more acutely elevate hypertensive risk among older men than similarly aged women. Experiences of discrimination appear to decrease the likelihood of antihypertensive medication use among older adults overall

Blood Pressure in Older Adults: the Importance of Frailty

The importance of high blood pressure (BP) and the effect of BP lowering in older adults remain controversial due to the mixed evidence in this population. Frailty status may resolve the apparently conflicting findings and identify subpopulations who share common risk. Emerging evidence demonstrates that low BP is associated with poor outcomes in older frail adults or those with poor functional status. In contrast, in non-frail older adults, low BP appears beneficial. Frail older adults may be at increased risk of hypotension, serious fall injuries, and polypharmacy. Additionally, peripheral BP may not be the best prognostic measure in this population. The majority of clinical practice guidelines give little recommendation for frail older adults, which is likely due to their systematic underrepresentation in randomized controlled trials. Future studies need to consider modifications to safely include frail older adults, and guidelines should consider inclusion of evidence beyond randomized controlled trials.This article is part of the Topical Collection on Resistant Hypertension. This is an author's peer-reviewed final manuscript, as accepted by the publisher. The published article is copyrighted by Springer and can be found at: http://www.springer.com/medicine/internal/journal/11906Keywords: Antihypertensive medications, Cognitive function, Aged, Physical function, Falls, Frailt

Gender Differences in the Combined Effects of Cardiovascular Disease and Osteoarthritis on Progression to Functional Impairment in Older Mexican Americans

Comorbidity (COM) is an important issue in aging. Cardiovascular disease (CVD) and osteoarthritis separately and together may modify the trajectories of functional decline. This analysis examines whether specific and unrelated COMs influence functional change differently and vary by gender

Health Benefits of Reducing Sugar-Sweetened Beverage Intake in High Risk Populations of California: Results from the Cardiovascular Disease (CVD) Policy Model

Background Consumption of sugar-sweetened beverage (SSB) has risen over the past two decades, with over 10 million Californians drinking one or more SSB per day. High SSB intake is associated with risk of type 2 diabetes, obesity, hypertension, and coronary heart disease (CHD). Reduction of SSB intake and the potential impact on health outcomes in California and among racial, ethnic, and low-income sub-groups has not been quantified. Methods We projected the impact of reduced SSB consumption on health outcomes among all Californians and California subpopulations from 2013 to 2022. We used the CVD Policy Model – CA, an established computer simulation of diabetes and heart disease adapted to California. We modeled a reduction in SSB intake by 10–20% as has been projected to result from proposed penny-per-ounce excise tax on SSB and modeled varying effects of this reduction on health parameters including body mass index, blood pressure, and diabetes risk. We projected avoided cases of diabetes and CHD, and associated health care cost savings in 2012 US dollars. Results Over the next decade, a 10–20% SSB consumption reduction is projected to result in a 1.8–3.4% decline in the new cases of diabetes and an additional drop of 0.5–1% in incident CHD cases and 0.5–0.9% in total myocardial infarctions. The greatest reductions are expected in African Americans, Mexican Americans, and those with limited income regardless of race and ethnicity. This reduction in SSB consumption is projected to yield $320–620 million in medical cost savings associated with diabetes cases averted and an additional savings of$14–27 million in diabetes-related CHD costs avoided. Conclusions A reduction of SSB consumption could yield substantial population health benefits and cost savings for California. In particular, racial, ethnic, and low-income subgroups of California could reap the greatest health benefits

Neighborhood Characteristics and Elevated Blood Pressure in Older Adults

IMPORTANCE: The local environment remains an understudied contributor to elevated blood pressure among older adults. Untargeted approaches can identify neighborhood conditions interrelated with racial segregation that drive hypertension disparities. OBJECTIVE: To evaluate independent associations of sociodemographic, economic, and housing neighborhood factors with elevated blood pressure. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, the sample included Health and Retirement Study participants who had between 1 and 3 sets of biennial sphygmomanometer readings from 2006 to 2014 or 2008 to 2016. Statistical analyses were conducted from February 5 to November 30, 2021. EXPOSURES: Fifty-one standardized American Community Survey census tract variables (2005-2009). MAIN OUTCOMES AND MEASURES: Elevated sphygmomanometer readings over the study period (6-year period prevalence): a value of at least 140 mm Hg for systolic blood pressure and/or at least 90 mm Hg for diastolic blood pressure. Participants were divided 50:50 into training and test data sets. Generalized estimating equations were used to summarize multivariable associations between each neighborhood variable and the period prevalence of elevated blood pressure, adjusting for individual-level covariates. Any neighborhood factor associated (Simes-adjusted for multiple comparisons P ≤ .05) with elevated blood pressure in the training data set was rerun in the test data set to gauge model performance. Lastly, in the full cohort, race- and ethnicity-stratified associations were evaluated for each identified neighborhood factor on the likelihood of elevated blood pressure. RESULTS: Of 12 946 participants, 4565 (35%) had elevated sphygmomanometer readings (median [IQR] age, 68 [63-73] years; 2283 [50%] male; 228 [5%] Hispanic or Latino, 502 [11%] non-Hispanic Black, and 3761 [82%] non-Hispanic White). Between 2006 and 2016, a lower likelihood of elevated blood pressure was observed (relative risk for highest vs lowest tertile, 0.91; 95% CI, 0.86-0.96) among participants residing in a neighborhood with recent (post-1999) in-migration of homeowners. This association was precise among participants with non-Hispanic White and other race and ethnicity (relative risk, 0.91; 95% CI, 0.85-0.97) but not non-Hispanic Black participants (relative risk, 0.97; 95% CI, 0.85-1.11; P = .48 for interaction) or Hispanic or Latino participants (relative risk, 0.84; 95% CI, 0.65-1.09; P = .78 for interaction). CONCLUSIONS AND RELEVANCE: In this cohort study of older adults, recent relocation of homeowners to a neighborhood was robustly associated with reduced likelihood of elevated blood pressure among White participants but not their racially and ethnically marginalized counterparts. Our findings indicate that gentrification may influence later-life blood pressure control

Uric Acid Levels, Kidney Function, and Cardiovascular Mortality in US Adults: NHANES 1988-1994 and 1999-2002

BACKGROUND: Chronic kidney disease (CKD) and hyperuricemia often coexist and both conditions are increasing in prevalence in the U.S., although their shared role on cardiovascular risk remains highly debated. STUDY DESIGN: Cross-sectional and longitudinal SETTING AND PARTICIPANTS: Participants in the National Health and Nutrition Examination Survey (NHANES) from 1988 to 2002 (n = 10,956); data were linked to mortality data from the National Death Index through December 31st, 2006. PREDICTORS: Serum uric acid concentration, categorized as the sex-specific lowest 25th percentile, 25th-75th, and 75th percentile and higher; and kidney function measured by estimated glomerular filtration rate (eGFR) based on the combined creatinine and cystatin C estimating equation developed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and urinary albumin to creatinine ratio (ACR) OUTCOMES: Cardiovascular death and all-cause mortality RESULTS: Uric acid levels were correlated with eGFR[Cr-Cys (r = -0.29, p<0.001), and were only slightly correlated with ACR (r = 0.04, p<0.001). There were 2,203 deaths up until December 31st, 2006, of which 981 were due to cardiovascular causes. Overall, there was a U-shaped association between uric acid levels and cardiovascular mortality in both women and men, although the lowest risk of cardiovascular mortality occurred at a lower level of uric acid for women compared with men. There was an association between the highest quartile of uric acid and cardiovascular mortality even after adjustment for potential confounders (1.48, 95% CI: 1.13, 1.96), although this association was attenuated after adjustment for ACR and eGFRCr-Cys (HR = 1.25, 95% CI: 0.89, 1.75). The pattern of association between uric acid levels and all-cause mortality was similar. LIMITATIONS: GFR not measured; mediating events were not observed. CONCLUSIONS: High uric acid is associated with cardiovascular and all-cause mortality, although this relationship was no longer statistically significant after accounting for kidney function.Keywords: Hyperuricemia, Risk factor, Chronic kidney disease (CKD), Albuminuria, Kidney function, Cardiovascular mortality, Uric acidKeywords: Hyperuricemia, Risk factor, Chronic kidney disease (CKD), Albuminuria, Kidney function, Cardiovascular mortality, Uric aci

Predicting Future Years of Life, Health, and Functional Ability: A Healthy Life Calculator for Older Adults

Introduction Planning for the future would be easier if we knew how long we will live and, more importantly, how many years we will be healthy and able to enjoy it. There are few well-documented aids for predicting our future health. We attempted to meet this need for persons 65 years of age and older. Methods Data came from the Cardiovascular Health Study, a large longitudinal study of older adults that began in 1990. Years of life (YOL) were defined by measuring time to death. Years of healthy life (YHL) were defined by an annual question about self-rated health, and years of able life (YABL) by questions about activities of daily living. Years of healthy and able life (YHABL) were the number of years the person was both Healthy and Able. We created prediction equations for YOL, YHL, YABL, and YHABL based on the demographic and health characteristics that best predicted outcomes. Internal and external validity were assessed. The resulting CHS Healthy Life Calculator (CHSHLC) was created and underwent three waves of beta testing. Findings A regression equation based on 11 variables accounted for about 40% of the variability for each outcome. Internal validity was excellent, and external validity was satisfactory. As an example, a very healthy 70-year-old woman might expect an additional 20 YOL, 16.8 YHL, 16.5 YABL, and 14.2 YHABL. The CHSHLC also provides the percent in the sample who differed by more than 5 years from the estimate, to remind the user of variability. Discussion The CHSHLC is currently the only available calculator for YHL, YABL, and YHABL. It may have limitations if today’s users have better prospects for health than persons in 1990. But the external validity results were encouraging. The remaining variability is substantial, but this is one of the few calculators that describes the possible accuracy of the estimates. Conclusion The CHSHLC, currently at http://diehr.com/paula/healthspan, meets the need for a straightforward and well-documented estimate of future years of healthy and able life that older adults can use in planning for the future

The Association of Intensive Blood Pressure Treatment and Non-Fatal Cardiovascular or Serious Adverse Events in Older Adults With Mortality: Mediation Analysis in Sprint

AIMS: Randomized clinical trials of hypertension treatment intensity evaluate the effects on incident major adverse cardiovascular events (MACEs) and serious adverse events (SAEs). Occurrences after a non-fatal index event have not been rigorously evaluated. The aim of this study was to evaluate the association of intensive (\u3c120 \u3emmHg) to standard (\u3c140 \u3emmHg) blood pressure (BP) treatment with mortality mediated through a non-fatal MACE or non-fatal SAE in 9361 participants in the Systolic Blood Pressure Intervention Trial. METHODS AND RESULTS: Logistic regression and causal mediation modelling to obtain direct and mediated effects of intensive BP treatment. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cardiovascular (CVM) and non-CV mortality (non-CVM). The direct effect of intensive treatment was a lowering of ACM [odds ratio (OR) 0.75, 95% confidence interval (CI): 0.60-0.94]. The MACE-mediated effect substantially attenuated (OR 0.96, 95% CI: 0.92-0.99) ACM, while the SAE-mediated effect was associated with increased (OR 1.03, 95% CI: 1.01-1.05) ACM. Similar patterns were noted for intensive BP treatment on CVM and non-CVM. We also noted that SAE incidence was 3.9-fold higher than MACE incidence (13.7 vs. 3.5%), and there were a total of 365 (3.9%) ACM cases, with non-CVM being 2.6-fold higher than CVM [2.81% (263/9361) vs. 1.09% (102/9361)]. The SAE to MACE and non-CVM to CVM preponderance was found across all age groups, with the ≥80-year age group having the highest differences. CONCLUSION: The current analytic techniques demonstrated that intensive BP treatment was associated with an attenuated mortality benefit when it was MACE-mediated and possibly harmful when it was SAE-mediated. Current cardiovascular trial reporting of treatment effects does not allow expansion of the lens to focus on important occurrences after the index event

Kidney Function and Cognitive Health in Older Adults: The Cardiovascular Health Study

Recent evidence has demonstrated the importance of kidney function in healthy aging. We examined the association between kidney function and change in cognitive function in 3,907 participants in the Cardiovascular Health Study, recruited from 4 U.S. communities, and studied from 1992 - 1999. Kidney function was measured by cystatin C-based estimated glomerular filtration rate (eGFR[subscript cys]). Cognitive function was assessed using the Modified Mini-Mental State Exam and the Digit Symbol Substitution Test administered up to 7 times during annual visits. There was an association between eGFR[subscript cys] and change in cognitive function after adjustment for confounders; persons with eGFR[subscript cys] < 60 ml/min/1.73m² had a 0.64 (95% confidence interval: 0.51, 0.77) point/year faster decline in Modified Mini-Mental State Exam score and a 0.42 (95% confidence interval: 0.28, 0.56) point/year faster decline in Digit Symbol Substitution Test score compared with persons with eGFR[subscript cys] ≥ 90 ml/min/1.73m². Additional adjustment for intermediate cardiovascular events modestly impacted these associations. Participants with eGFR[subscript cys] < 60 ml/min/1.73m² had fewer cognitive impairment-free life-years on average compared with those with eGFR[subscript cys] ≥ 90 ml/min/1.73m², independent of confounders and mediating cardiovascular events (-0.44, 95% confidence interval: -0.62, -0.26). Older adults with reduced kidney function are at increased risk of worsening cognitive function.This is an author's peer-reviewed final manuscript, as accepted by the publisher. The published article is copyrighted by the author(s) and published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. It can be found at: http://aje.oxfordjournals.org/Keywords: stroke, aging, myocardial infarction, successful aging, chronic kidney disease, cognitive function, prospective study, congestive heart failur