Background: Hypertension (HTN) continues to pose a considerable challenge to the health system. Suboptimal rates of screening, awareness, treatment and control, reported at national and local levels, reflect an urgent need for a coordinated and collective approach to action. Methods: On May 20, 2017 (World HTN day), we convened a one-day HTN summit in response to an expressed need from stakeholders across the health system (healthcare, public health, community organizations) in the Bi-State Greater Kansas City Area. To help formulate an action plan, we administered a pre-and post-survey to document stakeholder engagement in HTN programs, their awareness of existing key initiates and resources, and perceived needs to address HTN. Results: Overall, 24 individuals from 16 organizations registered for the event and completed a pre-event survey - healthcare system (46%), Public health or Government organizations (17%), Community organizations (29%), Academic entity (8.3). Thirteen (54%) attendees completed the post-event survey - 29% delivered healthcare services, 57% conducted community activities, 21% were patients or caregivers. Only 32% of the attendees reported a current program on blood pressure. Less than 10% of participants reported satisfaction with the availability of regularly scheduled learning opportunities or tools for healthcare professionals or patients to improve HTN. Only 21% of participants reported monitoring of performance on metrics related to high blood pressure programs. All attendees expressed interest in continued meetings, patient engagement resources, and an in-depth exploration of the underlying factors contributing to the burden of uncontrolled HTN. Findings also reflected a significant need to improve the awareness of resources like the Missouri Million Hearts initiative and Target BP™. Conclusion: In spite of temporal advancements in cardiovascular medicine, there exist significant gaps in the awareness and use of resources and tools to support HTN management among stakeholders in the health system. Planned strategies include a dedicated working group to proactively identify and support coordinated, multi-stakeholder efforts to reduce the HTN burden and improve cardiovascular health in our communities.
OBJECTIVE To evaluate the association of successive percutaneous coronary intervention (PCI) modalities with balloon angioplasty (BA), bare-metal stent (BMS), drug-eluting stents (DES), and pharmacotherapy over the last 3 decades with outcomes among patients with diabetes in routine clinical practice. RESEARCH DESIGN AND METHODS We examined outcomes in 1,846 patients with diabetes undergoing de novo PCI in the multicenter, National Heart, Lung, and Blood Institute–sponsored 1985–1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry and 1997–2006 Dynamic Registry. Multivariable Cox regression models were used to estimate the adjusted risk of events (death/myocardial infarction [MI], repeat revascularization) over 1 year. RESULTS Cumulative event rates for postdischarge (31–365 days) death/MI were 8% by BA, 7% by BMS, and 7% by DES use (P = 0.76) and for repeat revascularization were 19, 13, and 9% (P < 0.001), respectively. Multivariable analysis showed a significantly lower risk of repeat revascularization with DES use when compared with the use of BA (hazard ratio [HR] 0.41 [95% CI 0.29–0.58]) and BMS (HR 0.55 [95% CI 0.39–0.76]). After further adjustment for discharge medications, the lower risk for death/MI was not statistically significant for DES when compared with BA. CONCLUSIONS In patients with diabetes undergoing PCI, the use of DES is associated with a reduced need for repeat revascularization when compared with BA or BMS use. The associated death/MI benefit observed with the DES versus the BA group may well be due to greater use of pharmacotherapy.
Abstract Background Cardiovascular disease presents an increasing health burden to low- and middle-income countries. Although ample therapeutic options and care improvement frameworks exist to address its prime risk factor, hypertension, blood pressure control rates remain poor. We describe the results of an effectiveness study of a multisector urban population health initiative that targets hypertension in a real-world implementation setting in cities across three continents. The initiative followed the “CARDIO4Cities” approach (quality of Care, early Access, policy Reform, Data and digital technology, Intersectoral collaboration, and local Ownership). Method The approach was applied in Ulaanbaatar in Mongolia, Dakar in Senegal, and São Paulo in Brazil. In each city, a portfolio of evidence-based practices was implemented, tailored to local priorities and available data. Outcomes were measured by extracting hypertension diagnosis, treatment and control rates from primary health records. Data from 18,997 patients with hypertension in primary health facilities were analyzed. Results Over one to two years of implementation, blood pressure control rates among enrolled patients receiving medication tripled in São Paulo (from 12·3% to 31·2%) and Dakar (from 6·7% to 19·4%) and increased six-fold in Ulaanbaatar (from 3·1% to 19·7%). Conclusions This study provides first evidence that a multisectoral population health approach to implement known best-practices, supported by data and digital technologies, and relying on local buy-in and ownership, can improve hypertension control in high-burden urban primary care settings in low-and middle-income countries.
Background— Aging results in vascular stiffening and an increase in the velocity of the pressure wave as it travels down the aorta. Increased aortic pulse wave velocity (aPWV) has been associated with mortality in clinical but not general populations. The objective of this investigation was to determine whether aPWV is associated with total and cardiovascular (CV) mortality and CV events in a community-dwelling sample of older adults. Methods and Results— aPWV was measured at baseline in 2488 participants from the Health, Aging and Body Composition (Health ABC) study. Vital status, cause of death and coronary heart disease (CHD), stroke, and congestive heart failure were determined from medical records. Over 4.6 years, 265 deaths occurred, 111 as a result of cardiovascular causes. There were 341 CHD events, 94 stroke events, and 181 cases of congestive heart failure. Results are presented by quartiles because of a threshold effect between the first and second aPWV quartiles. Higher aPWV was associated with both total mortality (relative risk, 1.5, 1.6, and 1.7 for aPWV quartiles 2, 3, and 4 versus 1; P =0.019) and cardiovascular mortality (relative risk, 2.1, 3.0, and 2.3 for quartiles 2, 3, and 4 versus 1; P =0.004). aPWV quartile was also significantly associated with CHD ( P =0.007) and stroke ( P =0.001). These associations remained after adjustment for age, gender, race, systolic blood pressure, known CV disease, and other variables related to events. Conclusions— Among generally healthy, community-dwelling older adults, aPWV, a marker of arterial stiffness, is associated with higher CV mortality, CHD, and stroke.
Hypertension is one of the most common diagnoses carried by adults yet is often difficult to manage. A combination of medical therapy, patient engagement, and self-care is required to achieve blood pressure control. We, therefore, sought to elicit patient views on lifestyle factors that are known to influence optimal management of hypertension. From outpatient clinics, we identified patients with documented hypertension and taking at least one antihypertensive medication. Patients with secondary causes of hypertension or end-organ damage were excluded. Following informed consent, patient views were elicited using the Kear Hypertension Management Instrument (KHMI), the Motivators of and Barriers to Health-Smart Behaviors Inventory (MB-HSBI), and the Stages of Change questionnaire (SOC). Participants were also provided with a 10-point Likert scale (10-very highly motivated/confident) to rate their level of motivation and confidence to maintain heart-healthy behaviors. Data are summarized using descriptive statistics for continuous and categorical variables. Between 12/02/17 and 01/16/18, 19 eligible individuals of at least age 18 provided data; 95% (n=18) were African-American and 68% (n=13) were female. On the KHMI, 63% (n=12) reported either seldom or never forgetting to take medication. 84% (n=16) reported following a low salt diet a good bit of the time or more frequently. Only 32% (n=6) reported exercising as prescribed and 47% (n=9) reported participating in stress-reducing activities with similar frequency. 58% (n=11), reported never experiencing medication side effects. Only 1 in 3 patients reported financial barriers in obtaining medication. Interestingly, the relationship between motivators and barriers to adopt a healthy lifestyle varied by type of behavior. On the MB-HSBI, 53% (n=10) patients shared being highly motivated to eat a healthy breakfast while only 21% (n=4) reported having the least barriers to do so. However, only 26% (n=5) reported being highly motivated to increase physical activity and 37% (n=7) reported having the least barriers to do so. The SOC revealed 74% (n=14) of patients saying they have been maintaining heart-healthy behaviors for 6+ months. When asked to rate motivation to maintain behaviors on the 10-point scale, the median=8 and IQR=5. For confidence in maintaining these behaviors, the median=8 and IQR=4. In our setting of safety-net outpatient care, patients with documented hypertension were highly motivated to pursue healthy lifestyle behaviors with a low prevalence of financial barriers to medication access. However, self-reported access to and awareness of physical activity and stress management options is less encouraging and warrant attention. Further analyses are planned to continue study and elucidate the relationship of these patient reported outcomes with temporal change in clinical outcomes including blood pressure.
Percutaneous coronary intervention (PCI) has witnessed rapid technological advancements, resulting in improved safety and effectiveness over time. Little, however, is known about the temporal impact on patient-reported symptoms and quality of life after PCI.Temporal trends in post-PCI symptoms were analyzed using 8879 consecutive patients enrolled in the National Heart, Lung, and Blood Institute-sponsored Dynamic Registry (wave 1: 1997 [bare metal stents], wave 2: 1999 [uniform use of stents], wave 3: 2001 [brachytherapy], wave 4, 5: 2004, 2006 [drug eluting stents]). Patients undergoing PCI in the recent waves were older and more often reported comorbidities. However, fewer patients across the waves reported post-PCI angina at one year (wave 1 to 5: 24%, 23%, 18%, 20%, 20%; P(trend)<0.001). The lower risk of angina in recent waves was explained by patient characteristics including use of antianginal medications at discharge (relative risk [95% CI] for waves 2, 3, 4 versus 1: 1.0 [0.9 to 1.2], 0.9 [0.7 to 1.1], 1.0 [0.8 to 1.3], 0.9 [0.7 to 1.1]). Similar trend was seen in the average quality of life scores over time (adjusted mean score for waves 1 to 5: 6.2, 6.5, 6.6 and 6.6; P(trend)=0.01). Other factors associated with angina at 1 year included younger age, female gender, prior revascularization, need for repeat PCI, and hospitalization for myocardial infarction over 1 year.Favorable temporal trends are seen in patient-reported symptoms after PCI in routine clinical practice. Specific subgroups, however, remain at risk for symptoms at 1 year and thus warrant closer attention.
Mean blood glucose (BG) during acute myocardial infarction (AMI) is an important predictor of inpatient mortality but does not capture glucose variability (GV), which has been shown to be independently associated with mortality in critically ill patients. Whether GV is associated with in-hospital mortality during AMI, after accounting for mean BG, is unknown.We analyzed 18 563 consecutive patients with AMI with ≥3 BGs in the first 48 hours admitted to 61 US hospitals from 2000 to 2008. Five different GV metrics were compared for their ability to predict in-hospital mortality (range, standard deviation, mean amplitude of glycemic excursions, mean absolute glucose change, and average daily risk range) using hierarchical logistic regression models that sequentially adjusted for mean BG, hypoglycemia (<70 mg/dL), and multiple patient characteristics. In unadjusted analyses, range and average daily risk range had the highest C-indices (0.620 for range, 0.635 for average daily risk range; both P<0.0001). Greater GV was associated with higher mortality for all metrics (eg, mortality was 3.8%, 5.5%, 7.1%, and 11.3% for increasing quartiles of range, P<0.0001); however, the association between GV and mortality for each metric was no longer significant after multivariable adjustment. In contrast, mean BG remained an important predictor of survival (P<0.001, all models).Although greater GV is associated with increased risk of in-hospital mortality in patients with AMI in unadjusted analyses, GV is no longer independently predictive after controlling for multiple patient factors, including mean BG. These findings suggest that GV does not provide additional prognostic value above and beyond already recognized risk factors for mortality during AMI.
