International Society on Hypertension in Blacks (ISHIB): Annual Meeting (ISHIB 2012)

MIAMI BEACH – Results of a comprehensive study looking at almost 1.6 million women suggest a small but real elevated risk of thrombotic stroke and myocardial infarction associated with use of hormonal contraception among women who have hypertension.

Even hypertensive women who do not smoke were at increased risk, which suggests that there needs to be a shift in how physicians counsel women regarding use of oral contraception, according to Dr. Keith C. Ferdinand, professor of clinical medicine at Tulane University, New Orleans, and a cardiologist at the Tulane Heart and Vascular Institute in that city.

"Clearly this does suggest that if a patient is on oral contraceptives, you cannot tell them they won’t have a stroke or MI just because they don’t smoke," Dr. Ferdinand said at the meeting, which was sponsored by the International Society on Hypertension in Blacks.

"I was a little surprised by the Danish study," Dr. Ferdinand said (N. Engl. J. Med. 2012;366:2257-66). "The rule of thumb is – if you look at the package insert and at what most clinicians believe – if you’re not over 35 and you don’t smoke, you’re [essentially] okay. That is what we tell patients."

"The Danish registry suggests that although the attributable risk was low (41.5 cases out of 10,000 person-years), it’s really there."

World Health Organization guidelines state that OCs are absolutely contraindicated in women with blood pressure greater than 160 mm Hg/100 mm Hg. "You may say to the patient that if their blood pressure is significantly elevated, they may need another form of contraception." Dr. Ferdinand urged additional caution because even milder blood pressure elevations could be associated with increased risks. The good news, he added, is that the increased risk for MI and stroke does reverse with cessation of OC use.

In the Danish study, researchers assessed 1,626,158 nonpregnant women with no previous cardiovascular disease. This represented essentially the entire Danish female population aged 15-49 years, Dr. Ferdinand said. A total 3,311 thrombotic strokes and 1,725 first MIs occurred out of more than 14 million total person-years of observation in this historical cohort study.

Relative risks increased with hormonal contraceptive use. "Using contraceptive pills with estrogen and progestin did indeed increase the risk of stroke and MI," Dr. Ferdinand said, but the variation by dosage was modest. For example, higher doses of estrogen did appear to increase the relative risk of stroke, but dosing of progestin had little effect, he added.

Specifically, the absolute risks for MI and stroke were increased by a factor of 0.9 to 1.7 with oral contraceptives that included ethinyl estradiol at a dose of 20 mcg, and by a factor of 1.3 to 2.3 with OCs that included ethinyl estradiol at a dose of 30-40 mcg.

Another finding was that if a woman had diabetes, her relative risk of thrombotic stroke was 2.73 and her relative risk for an MI was 4.66. If a woman had hypertension, there was almost an equivalent increased risk of stroke (RR, 2.3), Dr. Ferdinand said. The relative risk of MI associated with hypertension was 2.17.

Dr. Ferdinand is a consultant to Astra Zeneca, Daiichi Sankyo, Forest, and Novartis. He is on the speakers bureau for Astra Zeneca, Forest, Takeda, and Novartis. He also receives grant research support from Eli Lilly, Daiichi Sankyo, Forest, and Novartis.

MIAMI BEACH – Results of a comprehensive study looking at almost 1.6 million women suggest a small but real elevated risk of thrombotic stroke and myocardial infarction associated with use of hormonal contraception among women who have hypertension.

Even hypertensive women who do not smoke were at increased risk, which suggests that there needs to be a shift in how physicians counsel women regarding use of oral contraception, according to Dr. Keith C. Ferdinand, professor of clinical medicine at Tulane University, New Orleans, and a cardiologist at the Tulane Heart and Vascular Institute in that city.

"Clearly this does suggest that if a patient is on oral contraceptives, you cannot tell them they won’t have a stroke or MI just because they don’t smoke," Dr. Ferdinand said at the meeting, which was sponsored by the International Society on Hypertension in Blacks.

"I was a little surprised by the Danish study," Dr. Ferdinand said (N. Engl. J. Med. 2012;366:2257-66). "The rule of thumb is – if you look at the package insert and at what most clinicians believe – if you’re not over 35 and you don’t smoke, you’re [essentially] okay. That is what we tell patients."

"The Danish registry suggests that although the attributable risk was low (41.5 cases out of 10,000 person-years), it’s really there."

World Health Organization guidelines state that OCs are absolutely contraindicated in women with blood pressure greater than 160 mm Hg/100 mm Hg. "You may say to the patient that if their blood pressure is significantly elevated, they may need another form of contraception." Dr. Ferdinand urged additional caution because even milder blood pressure elevations could be associated with increased risks. The good news, he added, is that the increased risk for MI and stroke does reverse with cessation of OC use.

In the Danish study, researchers assessed 1,626,158 nonpregnant women with no previous cardiovascular disease. This represented essentially the entire Danish female population aged 15-49 years, Dr. Ferdinand said. A total 3,311 thrombotic strokes and 1,725 first MIs occurred out of more than 14 million total person-years of observation in this historical cohort study.

Relative risks increased with hormonal contraceptive use. "Using contraceptive pills with estrogen and progestin did indeed increase the risk of stroke and MI," Dr. Ferdinand said, but the variation by dosage was modest. For example, higher doses of estrogen did appear to increase the relative risk of stroke, but dosing of progestin had little effect, he added.

Specifically, the absolute risks for MI and stroke were increased by a factor of 0.9 to 1.7 with oral contraceptives that included ethinyl estradiol at a dose of 20 mcg, and by a factor of 1.3 to 2.3 with OCs that included ethinyl estradiol at a dose of 30-40 mcg.

Another finding was that if a woman had diabetes, her relative risk of thrombotic stroke was 2.73 and her relative risk for an MI was 4.66. If a woman had hypertension, there was almost an equivalent increased risk of stroke (RR, 2.3), Dr. Ferdinand said. The relative risk of MI associated with hypertension was 2.17.

Dr. Ferdinand is a consultant to Astra Zeneca, Daiichi Sankyo, Forest, and Novartis. He is on the speakers bureau for Astra Zeneca, Forest, Takeda, and Novartis. He also receives grant research support from Eli Lilly, Daiichi Sankyo, Forest, and Novartis.

MIAMI BEACH – Results of a comprehensive study looking at almost 1.6 million women suggest a small but real elevated risk of thrombotic stroke and myocardial infarction associated with use of hormonal contraception among women who have hypertension.

Even hypertensive women who do not smoke were at increased risk, which suggests that there needs to be a shift in how physicians counsel women regarding use of oral contraception, according to Dr. Keith C. Ferdinand, professor of clinical medicine at Tulane University, New Orleans, and a cardiologist at the Tulane Heart and Vascular Institute in that city.

"Clearly this does suggest that if a patient is on oral contraceptives, you cannot tell them they won’t have a stroke or MI just because they don’t smoke," Dr. Ferdinand said at the meeting, which was sponsored by the International Society on Hypertension in Blacks.

"I was a little surprised by the Danish study," Dr. Ferdinand said (N. Engl. J. Med. 2012;366:2257-66). "The rule of thumb is – if you look at the package insert and at what most clinicians believe – if you’re not over 35 and you don’t smoke, you’re [essentially] okay. That is what we tell patients."

"The Danish registry suggests that although the attributable risk was low (41.5 cases out of 10,000 person-years), it’s really there."

World Health Organization guidelines state that OCs are absolutely contraindicated in women with blood pressure greater than 160 mm Hg/100 mm Hg. "You may say to the patient that if their blood pressure is significantly elevated, they may need another form of contraception." Dr. Ferdinand urged additional caution because even milder blood pressure elevations could be associated with increased risks. The good news, he added, is that the increased risk for MI and stroke does reverse with cessation of OC use.

In the Danish study, researchers assessed 1,626,158 nonpregnant women with no previous cardiovascular disease. This represented essentially the entire Danish female population aged 15-49 years, Dr. Ferdinand said. A total 3,311 thrombotic strokes and 1,725 first MIs occurred out of more than 14 million total person-years of observation in this historical cohort study.

Relative risks increased with hormonal contraceptive use. "Using contraceptive pills with estrogen and progestin did indeed increase the risk of stroke and MI," Dr. Ferdinand said, but the variation by dosage was modest. For example, higher doses of estrogen did appear to increase the relative risk of stroke, but dosing of progestin had little effect, he added.

Specifically, the absolute risks for MI and stroke were increased by a factor of 0.9 to 1.7 with oral contraceptives that included ethinyl estradiol at a dose of 20 mcg, and by a factor of 1.3 to 2.3 with OCs that included ethinyl estradiol at a dose of 30-40 mcg.

Another finding was that if a woman had diabetes, her relative risk of thrombotic stroke was 2.73 and her relative risk for an MI was 4.66. If a woman had hypertension, there was almost an equivalent increased risk of stroke (RR, 2.3), Dr. Ferdinand said. The relative risk of MI associated with hypertension was 2.17.

Dr. Ferdinand is a consultant to Astra Zeneca, Daiichi Sankyo, Forest, and Novartis. He is on the speakers bureau for Astra Zeneca, Forest, Takeda, and Novartis. He also receives grant research support from Eli Lilly, Daiichi Sankyo, Forest, and Novartis.

MIAMI BEACH – Just slightly more than half of black patients with hypertension attained their systolic and diastolic blood pressure goals at 1 year in a large, cross-sectional study, which suggests that more aggressive intervention is needed.

"There is a perception among some ... that hypertension is not an issue, that patients are well controlled. The ultimate goal of this research is to vet that," Michael Hagan, Dr.P.H., said at a meeting sponsored by the International Society on Hypertension in Blacks.

Damian McNamara/IMNG Medical Media

Another prominent finding is that combination drug therapy outperformed the use of only one agent at a time, according to this General Electric electronic medical record database study of 9,251 hypertensive blacks. In addition, notable differences in efficacy emerged among 16 different treatment strategies, Dr. Hagan reported.

Despite at least 1 year of treatment, only 53% of the study subjects achieved a blood pressure goal below 140/90 mm Hg (or below 130/80 mmHg if they had diabetes or chronic kidney disease). "So far, we’ve found a large, unmet need in terms of getting patients to goal."

Goal attainment varied by therapy, with combination therapy outshining monotherapy in general. Goals were met by 67% of patients taking a beta-blocker plus diuretic, by 65% of those taking a thiazide or thiazidelike diuretic, by 57% of those taking an ACE inhibitor plus hydrochlorothiazide, by 54% of those taking a calcium channel blocker, by 51% of patients taking an angiotensin receptor blocker plus hydrochlorothiazide, by 46% of those on ACE inhibitor monotherapy, and by 45% of those prescribed an angiotensin receptor blocker alone.

The study also reveals differences in systolic and diastolic blood pressure decreases after 6 months and 1 year. "The combination of beta-blocker plus diuretic had the largest effect," said Dr. Hagan, director of global health economics and outcomes research at Takeda Pharmaceuticals North America.

At both 6 months and 1 year, patients taking a beta-blocker and diuretic experienced the greatest decrease in systolic blood pressure (about 13%) compared with baseline measures. This combination also was associated with the greatest decrease in diastolic blood pressure at 6 months (12%). Patients taking an ACE inhibitor plus hydrochlorothiazide experienced the greatest drop in diastolic pressure at 1 year (11%).

Interestingly, only 1% of the study population was prescribed the most effective combination. In contrast, 21% were prescribed the most common treatment: an ACE inhibitor. Next most common were calcium channel blockers (17%); thiazide or thiazidelike diuretics (15%); an ACE inhibitor plus hydrochlorothiazide (15%); an ARB plus hydrochlorothiazide; and an ARB alone (7%).

Overall mean baseline blood pressure was 146/87 mm Hg. A significant decrease to 132/79 mm Hg was observed at 1 year, Dr. Hagan reported.

This potential limitation stems from the retrospective, cross-sectional design of the study, which limits investigating why patients were prescribed a certain regimen, for example. Additional findings are forthcoming, Dr. Hagan added, and could include assessment of antihypertensive use and efficacy in the general hypertensive population, as well as the treatment profile of certain higher risk subgroups.

Mean patient age in the study was 58 years and 68% were women. The most prevalent risk factors for hypertension were obesity (65%), stage 2 hypertension (50%), and diabetes (43%).

Takeda Pharmaceuticals sponsored this study.

MIAMI BEACH – Just slightly more than half of black patients with hypertension attained their systolic and diastolic blood pressure goals at 1 year in a large, cross-sectional study, which suggests that more aggressive intervention is needed.

"There is a perception among some ... that hypertension is not an issue, that patients are well controlled. The ultimate goal of this research is to vet that," Michael Hagan, Dr.P.H., said at a meeting sponsored by the International Society on Hypertension in Blacks.

Damian McNamara/IMNG Medical Media

Another prominent finding is that combination drug therapy outperformed the use of only one agent at a time, according to this General Electric electronic medical record database study of 9,251 hypertensive blacks. In addition, notable differences in efficacy emerged among 16 different treatment strategies, Dr. Hagan reported.

Despite at least 1 year of treatment, only 53% of the study subjects achieved a blood pressure goal below 140/90 mm Hg (or below 130/80 mmHg if they had diabetes or chronic kidney disease). "So far, we’ve found a large, unmet need in terms of getting patients to goal."

Goal attainment varied by therapy, with combination therapy outshining monotherapy in general. Goals were met by 67% of patients taking a beta-blocker plus diuretic, by 65% of those taking a thiazide or thiazidelike diuretic, by 57% of those taking an ACE inhibitor plus hydrochlorothiazide, by 54% of those taking a calcium channel blocker, by 51% of patients taking an angiotensin receptor blocker plus hydrochlorothiazide, by 46% of those on ACE inhibitor monotherapy, and by 45% of those prescribed an angiotensin receptor blocker alone.

The study also reveals differences in systolic and diastolic blood pressure decreases after 6 months and 1 year. "The combination of beta-blocker plus diuretic had the largest effect," said Dr. Hagan, director of global health economics and outcomes research at Takeda Pharmaceuticals North America.

At both 6 months and 1 year, patients taking a beta-blocker and diuretic experienced the greatest decrease in systolic blood pressure (about 13%) compared with baseline measures. This combination also was associated with the greatest decrease in diastolic blood pressure at 6 months (12%). Patients taking an ACE inhibitor plus hydrochlorothiazide experienced the greatest drop in diastolic pressure at 1 year (11%).

Interestingly, only 1% of the study population was prescribed the most effective combination. In contrast, 21% were prescribed the most common treatment: an ACE inhibitor. Next most common were calcium channel blockers (17%); thiazide or thiazidelike diuretics (15%); an ACE inhibitor plus hydrochlorothiazide (15%); an ARB plus hydrochlorothiazide; and an ARB alone (7%).

Overall mean baseline blood pressure was 146/87 mm Hg. A significant decrease to 132/79 mm Hg was observed at 1 year, Dr. Hagan reported.

This potential limitation stems from the retrospective, cross-sectional design of the study, which limits investigating why patients were prescribed a certain regimen, for example. Additional findings are forthcoming, Dr. Hagan added, and could include assessment of antihypertensive use and efficacy in the general hypertensive population, as well as the treatment profile of certain higher risk subgroups.

Mean patient age in the study was 58 years and 68% were women. The most prevalent risk factors for hypertension were obesity (65%), stage 2 hypertension (50%), and diabetes (43%).

Takeda Pharmaceuticals sponsored this study.

MIAMI BEACH – Just slightly more than half of black patients with hypertension attained their systolic and diastolic blood pressure goals at 1 year in a large, cross-sectional study, which suggests that more aggressive intervention is needed.

"There is a perception among some ... that hypertension is not an issue, that patients are well controlled. The ultimate goal of this research is to vet that," Michael Hagan, Dr.P.H., said at a meeting sponsored by the International Society on Hypertension in Blacks.

Damian McNamara/IMNG Medical Media

Another prominent finding is that combination drug therapy outperformed the use of only one agent at a time, according to this General Electric electronic medical record database study of 9,251 hypertensive blacks. In addition, notable differences in efficacy emerged among 16 different treatment strategies, Dr. Hagan reported.

Despite at least 1 year of treatment, only 53% of the study subjects achieved a blood pressure goal below 140/90 mm Hg (or below 130/80 mmHg if they had diabetes or chronic kidney disease). "So far, we’ve found a large, unmet need in terms of getting patients to goal."

Goal attainment varied by therapy, with combination therapy outshining monotherapy in general. Goals were met by 67% of patients taking a beta-blocker plus diuretic, by 65% of those taking a thiazide or thiazidelike diuretic, by 57% of those taking an ACE inhibitor plus hydrochlorothiazide, by 54% of those taking a calcium channel blocker, by 51% of patients taking an angiotensin receptor blocker plus hydrochlorothiazide, by 46% of those on ACE inhibitor monotherapy, and by 45% of those prescribed an angiotensin receptor blocker alone.

The study also reveals differences in systolic and diastolic blood pressure decreases after 6 months and 1 year. "The combination of beta-blocker plus diuretic had the largest effect," said Dr. Hagan, director of global health economics and outcomes research at Takeda Pharmaceuticals North America.

At both 6 months and 1 year, patients taking a beta-blocker and diuretic experienced the greatest decrease in systolic blood pressure (about 13%) compared with baseline measures. This combination also was associated with the greatest decrease in diastolic blood pressure at 6 months (12%). Patients taking an ACE inhibitor plus hydrochlorothiazide experienced the greatest drop in diastolic pressure at 1 year (11%).

Interestingly, only 1% of the study population was prescribed the most effective combination. In contrast, 21% were prescribed the most common treatment: an ACE inhibitor. Next most common were calcium channel blockers (17%); thiazide or thiazidelike diuretics (15%); an ACE inhibitor plus hydrochlorothiazide (15%); an ARB plus hydrochlorothiazide; and an ARB alone (7%).

Overall mean baseline blood pressure was 146/87 mm Hg. A significant decrease to 132/79 mm Hg was observed at 1 year, Dr. Hagan reported.

This potential limitation stems from the retrospective, cross-sectional design of the study, which limits investigating why patients were prescribed a certain regimen, for example. Additional findings are forthcoming, Dr. Hagan added, and could include assessment of antihypertensive use and efficacy in the general hypertensive population, as well as the treatment profile of certain higher risk subgroups.

Mean patient age in the study was 58 years and 68% were women. The most prevalent risk factors for hypertension were obesity (65%), stage 2 hypertension (50%), and diabetes (43%).

Takeda Pharmaceuticals sponsored this study.

One day, when Dr. George E. Kikano was taking care of a patient he’d known for years, the unexpected occurred – 25 million unexpecteds, to be exact.

The patient was Albert J. Weatherhead, a major philanthropist. Through their foundation, Mr. Weatherhead and his wife Celia have given more than $100 million to Harvard University, pledged another $100 million to Tulane University, and supported many other institutions nationwide.

Courtesy University Hospitals Cleveland

They also happen to live in the Cleveland area, where family physician Dr. Kikano had launched a number of innovative community health outreach programs in recent years.

"Mr. Weatherhead came in one day when he was sick," Dr. Kikano recalls. "He said: ‘George, I appreciate all the good programs you are doing to help in the community. This is something my wife and I have decided to support with $25 million.’

"This was not money to name a building or put a billboard out there," Dr. Kikano said. "This is just going to go to develop programs to help the community."

The Weatherheads’ gift will bolster existing health care and disease prevention outreach programs. A multidisciplinary house-calls program, now in its seventh year and run by family physician Dr. Peter DeGolia, is an example. The money also will allow Dr. Kikano and his colleagues to devise new ways to address the needs of underserved residents in Cleveland.

Prior to the Weatherheads’ gift, outreach services were funded through smaller grants from other individuals and foundations. "This is completely mission driven. You don’t make money doing this, but you do it for people," Dr. Kikano said in an interview.

Courtesy University Hospitals Cleveland

No one would fault Dr. Kikano if he chose to focus solely on inpatient care. He is the Dorothy Jones Weatherhead Professor of Family Medicine & Community Health at Case Western Reserve University School of Medicine. However, Dr. Kikano saw a great need outside the walls of the institution as well.

"We have great hospitals [in Cleveland], but health care is not the best in our county in Ohio, Cuyahoga County," Dr. Kikano said during a presentation at the annual meeting of the International Society on Hypertension in Blacks in Miami Beach. "I see two different populations. There is more than 20 years’ difference in life expectancy [in communities] 6 miles apart. It’s amazing."

The $25 million grant establishes the Weatherhead Institute for Family Medicine & Community Health. The institute’s priorities include fighting the childhood obesity epidemic; supplying fresh fruit and other healthy foods to residents who can shop only at inner-city grocery stores; and targeting the high rates of hypertension, diabetes, and other chronic health conditions.

Mapping of seniors in the local communities around university hospitals is another project. "I have 20,000 seniors living in poverty with no primary care," Dr. Kikano said. "When they get sick, they go to the ER or they see me for an appointment, with the next available appointment at 2-3 months."

Nearly one-third of noninstitutionalized seniors in the community live alone. Many are medically complex. The typical house-call patient is an older woman with five or more comorbid chronic conditions and eight or more prescribed medications.

"Most of what we see is hypertension, heart failure, diabetes, osteoarthritis, and dementia," Dr. Kikano said. He described ‘Jamie,’ a 97-year-old woman with all five of these conditions who "lives, essentially, across the street from the Cleveland Clinic." Taking her two blocks by ambulance to the emergency department costs the county $1,000 each time.

In contrast, Medicare reimburses the house call program $85 for each monthly visit to her home.

In addition to identifying challenges in the community, Dr. Kikano and his colleagues devise solutions as well. For example, after they discovered a lack of pharmacies in Cleveland’s inner-city neighborhoods, they found a local pharmacy willing to deliver with no extra fee or kickback. "This made a huge difference."

Although you may not count major philanthropists among your patients, Dr. Kikano has a message for other physicians: "The message is do the right things for the right reasons, and the money will follow."

In September 2011, shortly after surprising Dr. Kikano with his $25 million gift, Albert Weatherhead died from cancer and pneumonia. He was 86 years old.

Mr. McNamara is Miami Bureau Chief. Follow him on Twitter@MedReporter on Twitter.

Courtesy University Hospitals Cleveland

Courtesy University Hospitals Cleveland

One day, when Dr. George E. Kikano was taking care of a patient he’d known for years, the unexpected occurred – 25 million unexpecteds, to be exact.

The patient was Albert J. Weatherhead, a major philanthropist. Through their foundation, Mr. Weatherhead and his wife Celia have given more than $100 million to Harvard University, pledged another $100 million to Tulane University, and supported many other institutions nationwide.

Courtesy University Hospitals Cleveland

They also happen to live in the Cleveland area, where family physician Dr. Kikano had launched a number of innovative community health outreach programs in recent years.

"Mr. Weatherhead came in one day when he was sick," Dr. Kikano recalls. "He said: ‘George, I appreciate all the good programs you are doing to help in the community. This is something my wife and I have decided to support with $25 million.’

"This was not money to name a building or put a billboard out there," Dr. Kikano said. "This is just going to go to develop programs to help the community."

The Weatherheads’ gift will bolster existing health care and disease prevention outreach programs. A multidisciplinary house-calls program, now in its seventh year and run by family physician Dr. Peter DeGolia, is an example. The money also will allow Dr. Kikano and his colleagues to devise new ways to address the needs of underserved residents in Cleveland.

Prior to the Weatherheads’ gift, outreach services were funded through smaller grants from other individuals and foundations. "This is completely mission driven. You don’t make money doing this, but you do it for people," Dr. Kikano said in an interview.

Courtesy University Hospitals Cleveland

No one would fault Dr. Kikano if he chose to focus solely on inpatient care. He is the Dorothy Jones Weatherhead Professor of Family Medicine & Community Health at Case Western Reserve University School of Medicine. However, Dr. Kikano saw a great need outside the walls of the institution as well.

"We have great hospitals [in Cleveland], but health care is not the best in our county in Ohio, Cuyahoga County," Dr. Kikano said during a presentation at the annual meeting of the International Society on Hypertension in Blacks in Miami Beach. "I see two different populations. There is more than 20 years’ difference in life expectancy [in communities] 6 miles apart. It’s amazing."

The $25 million grant establishes the Weatherhead Institute for Family Medicine & Community Health. The institute’s priorities include fighting the childhood obesity epidemic; supplying fresh fruit and other healthy foods to residents who can shop only at inner-city grocery stores; and targeting the high rates of hypertension, diabetes, and other chronic health conditions.

Mapping of seniors in the local communities around university hospitals is another project. "I have 20,000 seniors living in poverty with no primary care," Dr. Kikano said. "When they get sick, they go to the ER or they see me for an appointment, with the next available appointment at 2-3 months."

Nearly one-third of noninstitutionalized seniors in the community live alone. Many are medically complex. The typical house-call patient is an older woman with five or more comorbid chronic conditions and eight or more prescribed medications.

"Most of what we see is hypertension, heart failure, diabetes, osteoarthritis, and dementia," Dr. Kikano said. He described ‘Jamie,’ a 97-year-old woman with all five of these conditions who "lives, essentially, across the street from the Cleveland Clinic." Taking her two blocks by ambulance to the emergency department costs the county $1,000 each time.

In contrast, Medicare reimburses the house call program $85 for each monthly visit to her home.

In addition to identifying challenges in the community, Dr. Kikano and his colleagues devise solutions as well. For example, after they discovered a lack of pharmacies in Cleveland’s inner-city neighborhoods, they found a local pharmacy willing to deliver with no extra fee or kickback. "This made a huge difference."

Although you may not count major philanthropists among your patients, Dr. Kikano has a message for other physicians: "The message is do the right things for the right reasons, and the money will follow."

In September 2011, shortly after surprising Dr. Kikano with his $25 million gift, Albert Weatherhead died from cancer and pneumonia. He was 86 years old.

Mr. McNamara is Miami Bureau Chief. Follow him on Twitter@MedReporter on Twitter.

Courtesy University Hospitals Cleveland

Courtesy University Hospitals Cleveland

One day, when Dr. George E. Kikano was taking care of a patient he’d known for years, the unexpected occurred – 25 million unexpecteds, to be exact.

The patient was Albert J. Weatherhead, a major philanthropist. Through their foundation, Mr. Weatherhead and his wife Celia have given more than $100 million to Harvard University, pledged another $100 million to Tulane University, and supported many other institutions nationwide.

Courtesy University Hospitals Cleveland

They also happen to live in the Cleveland area, where family physician Dr. Kikano had launched a number of innovative community health outreach programs in recent years.

"Mr. Weatherhead came in one day when he was sick," Dr. Kikano recalls. "He said: ‘George, I appreciate all the good programs you are doing to help in the community. This is something my wife and I have decided to support with $25 million.’

"This was not money to name a building or put a billboard out there," Dr. Kikano said. "This is just going to go to develop programs to help the community."

The Weatherheads’ gift will bolster existing health care and disease prevention outreach programs. A multidisciplinary house-calls program, now in its seventh year and run by family physician Dr. Peter DeGolia, is an example. The money also will allow Dr. Kikano and his colleagues to devise new ways to address the needs of underserved residents in Cleveland.

Prior to the Weatherheads’ gift, outreach services were funded through smaller grants from other individuals and foundations. "This is completely mission driven. You don’t make money doing this, but you do it for people," Dr. Kikano said in an interview.

Courtesy University Hospitals Cleveland

No one would fault Dr. Kikano if he chose to focus solely on inpatient care. He is the Dorothy Jones Weatherhead Professor of Family Medicine & Community Health at Case Western Reserve University School of Medicine. However, Dr. Kikano saw a great need outside the walls of the institution as well.

"We have great hospitals [in Cleveland], but health care is not the best in our county in Ohio, Cuyahoga County," Dr. Kikano said during a presentation at the annual meeting of the International Society on Hypertension in Blacks in Miami Beach. "I see two different populations. There is more than 20 years’ difference in life expectancy [in communities] 6 miles apart. It’s amazing."

The $25 million grant establishes the Weatherhead Institute for Family Medicine & Community Health. The institute’s priorities include fighting the childhood obesity epidemic; supplying fresh fruit and other healthy foods to residents who can shop only at inner-city grocery stores; and targeting the high rates of hypertension, diabetes, and other chronic health conditions.

Mapping of seniors in the local communities around university hospitals is another project. "I have 20,000 seniors living in poverty with no primary care," Dr. Kikano said. "When they get sick, they go to the ER or they see me for an appointment, with the next available appointment at 2-3 months."

Nearly one-third of noninstitutionalized seniors in the community live alone. Many are medically complex. The typical house-call patient is an older woman with five or more comorbid chronic conditions and eight or more prescribed medications.

"Most of what we see is hypertension, heart failure, diabetes, osteoarthritis, and dementia," Dr. Kikano said. He described ‘Jamie,’ a 97-year-old woman with all five of these conditions who "lives, essentially, across the street from the Cleveland Clinic." Taking her two blocks by ambulance to the emergency department costs the county $1,000 each time.

In contrast, Medicare reimburses the house call program $85 for each monthly visit to her home.

In addition to identifying challenges in the community, Dr. Kikano and his colleagues devise solutions as well. For example, after they discovered a lack of pharmacies in Cleveland’s inner-city neighborhoods, they found a local pharmacy willing to deliver with no extra fee or kickback. "This made a huge difference."

Although you may not count major philanthropists among your patients, Dr. Kikano has a message for other physicians: "The message is do the right things for the right reasons, and the money will follow."

In September 2011, shortly after surprising Dr. Kikano with his $25 million gift, Albert Weatherhead died from cancer and pneumonia. He was 86 years old.

Mr. McNamara is Miami Bureau Chief. Follow him on Twitter@MedReporter on Twitter.

Courtesy University Hospitals Cleveland

Courtesy University Hospitals Cleveland

MIAMI BEACH – When it comes to heart failure, women tend to respond better to cardiac resynchronization therapy than do men, but for a long time no one knew why.

Turns out women have some distinct physiologic advantages, specifically more left bundle branch block and more nonischemic cardiomyopathy. Each drives a better response to cardiac resynchronization therapy (CRT), said Dr. David G. Strauss, a medical officer at the Food and Drug Administration’s Center for Devices and Radiologic Health in Silver Spring, Md.

In addition, timing of a specific electrical component within the heart triggers a third important distinction. Women benefit significantly from CRT even when their QRS duration is shorter than 150 msec. This supports the need for new gender-specific criteria for left bundle branch block and, ultimately, better identification of patients most likely to benefit from CRT device placement, Dr. Strauss said at the annual meeting of the International Society on Hypertension in Blacks.

"This is important because different professional societies recently have recommended that CRT be given to patients with QRS duration of 150 msec or more, and primarily in class II heart failure," he said. However, this cutoff "would exclude women with left bundle branch block and QRS duration 130-149 msec that derived significant benefit in MADIT-CRT" (Circulation 2011;123:1061-72).

In MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy), 1,820 patients were randomly assigned to receive CRT with an implantable cardioverter-defibrillator (ICD) or an ICD alone. In men with QRS duration of 130-140 msec in the study, there was no benefit from CRT and a trend toward harm associated with the device (hazard ratio, 1.69), Dr. Strauss said.

In contrast, women with QRS durations of 130-140 msec "had very significant benefit from CRT with a hazard ratio of 0.20, indicating 80% decrease in heart failure hospitalization or death," Dr. Strauss said.

More nonischemic cardiomyopathy among women translates to less myocardial scar and, ultimately, to a better CRT response. Scar tissue, no matter how it is electrically activated, does not contract, Dr. Strauss said.

Presence of left bundle branch block conferred a significant benefit in terms of reduced heart failure hospitalizations and deaths with use of CRT in the MADIT-CRT research. Conversely, participants without left bundle branch block realized no clinical advantage with CRT.

Be careful, however, to correctly identify left bundle branch block, Dr. Strauss said. Research suggests that one third of patients diagnosed with left bundle branch block by conventional electrocardiographic criteria are misdiagnosed (Am. J. Cardiol. 2011;107:927-34). Patients with intraventricular conduction delays, such as those caused by left ventricular hypertrophy and left ventricular dilation who do not have a blocked left bundle branch, can still display a prolonged QRS duration. This duration can be in the range generally considered diagnostic of left bundle branch block.

New criteria could parlay into better patient selection in the future, Dr. Strauss said. "CRT has been shown to improve heart failure symptoms, reduce heart failure hospitalization, and reduce mortality. However, not all patients benefit and significant risks exist." For example, addition of a CRT device with a left ventricular lead is associated with more complications, compared with ICD alone. "Thus there is a need for better patient risk stratification and patient identification criteria."

Based on results of electrical activation mapping and simulation studies, "My colleagues and I proposed stricter left bundle branch block criteria," he said. For example, they propose QRS duration of 130 msec or greater in women and 140 msec greater in men to replace the conventional 120 msec definition of left bundle branch block in either gender.

Another proposed new requirement is mid-QRS notching in at least two of the electrocardiographic leads of I, aVL, V1, V2, V5, or V6. This is important for diagnosing left bundle branch block because it reflects two events, Dr. Strauss said. There is an initial notch when electrical activation reaches the endocardium of the left ventricle and a second notch when activation reaches the lateral wall opposite the septum.

Other researchers support changing the current criteria for left bundle branch block. In a study of 111 patients, researchers found meeting what they termed "false" criteria was associated with a fourfold higher rate of heart failure hospitalization or death, compared with those meeting strict criteria (Pacing Clin. Electrophysiol. 2012;35:927-34).

CRT is FDA approved for class 3 or 4 heart failure, both of ischemic and nonischemic etiology, with a left ventricular ejection fraction less than 35% and a QRS duration over 120 msec. The FDA also approved CRT for class I ischemic or class II (ischemic or nonischemic) heart failure with an ejection fraction less than 30%, a QRS duration over 130 msec, and left bundle branch block.

Dr. Strauss reported no relevant financial disclosures.

MIAMI BEACH – When it comes to heart failure, women tend to respond better to cardiac resynchronization therapy than do men, but for a long time no one knew why.

Turns out women have some distinct physiologic advantages, specifically more left bundle branch block and more nonischemic cardiomyopathy. Each drives a better response to cardiac resynchronization therapy (CRT), said Dr. David G. Strauss, a medical officer at the Food and Drug Administration’s Center for Devices and Radiologic Health in Silver Spring, Md.

In addition, timing of a specific electrical component within the heart triggers a third important distinction. Women benefit significantly from CRT even when their QRS duration is shorter than 150 msec. This supports the need for new gender-specific criteria for left bundle branch block and, ultimately, better identification of patients most likely to benefit from CRT device placement, Dr. Strauss said at the annual meeting of the International Society on Hypertension in Blacks.

"This is important because different professional societies recently have recommended that CRT be given to patients with QRS duration of 150 msec or more, and primarily in class II heart failure," he said. However, this cutoff "would exclude women with left bundle branch block and QRS duration 130-149 msec that derived significant benefit in MADIT-CRT" (Circulation 2011;123:1061-72).

In MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy), 1,820 patients were randomly assigned to receive CRT with an implantable cardioverter-defibrillator (ICD) or an ICD alone. In men with QRS duration of 130-140 msec in the study, there was no benefit from CRT and a trend toward harm associated with the device (hazard ratio, 1.69), Dr. Strauss said.

In contrast, women with QRS durations of 130-140 msec "had very significant benefit from CRT with a hazard ratio of 0.20, indicating 80% decrease in heart failure hospitalization or death," Dr. Strauss said.

More nonischemic cardiomyopathy among women translates to less myocardial scar and, ultimately, to a better CRT response. Scar tissue, no matter how it is electrically activated, does not contract, Dr. Strauss said.

Presence of left bundle branch block conferred a significant benefit in terms of reduced heart failure hospitalizations and deaths with use of CRT in the MADIT-CRT research. Conversely, participants without left bundle branch block realized no clinical advantage with CRT.

Be careful, however, to correctly identify left bundle branch block, Dr. Strauss said. Research suggests that one third of patients diagnosed with left bundle branch block by conventional electrocardiographic criteria are misdiagnosed (Am. J. Cardiol. 2011;107:927-34). Patients with intraventricular conduction delays, such as those caused by left ventricular hypertrophy and left ventricular dilation who do not have a blocked left bundle branch, can still display a prolonged QRS duration. This duration can be in the range generally considered diagnostic of left bundle branch block.

New criteria could parlay into better patient selection in the future, Dr. Strauss said. "CRT has been shown to improve heart failure symptoms, reduce heart failure hospitalization, and reduce mortality. However, not all patients benefit and significant risks exist." For example, addition of a CRT device with a left ventricular lead is associated with more complications, compared with ICD alone. "Thus there is a need for better patient risk stratification and patient identification criteria."

Based on results of electrical activation mapping and simulation studies, "My colleagues and I proposed stricter left bundle branch block criteria," he said. For example, they propose QRS duration of 130 msec or greater in women and 140 msec greater in men to replace the conventional 120 msec definition of left bundle branch block in either gender.

Another proposed new requirement is mid-QRS notching in at least two of the electrocardiographic leads of I, aVL, V1, V2, V5, or V6. This is important for diagnosing left bundle branch block because it reflects two events, Dr. Strauss said. There is an initial notch when electrical activation reaches the endocardium of the left ventricle and a second notch when activation reaches the lateral wall opposite the septum.

Other researchers support changing the current criteria for left bundle branch block. In a study of 111 patients, researchers found meeting what they termed "false" criteria was associated with a fourfold higher rate of heart failure hospitalization or death, compared with those meeting strict criteria (Pacing Clin. Electrophysiol. 2012;35:927-34).

CRT is FDA approved for class 3 or 4 heart failure, both of ischemic and nonischemic etiology, with a left ventricular ejection fraction less than 35% and a QRS duration over 120 msec. The FDA also approved CRT for class I ischemic or class II (ischemic or nonischemic) heart failure with an ejection fraction less than 30%, a QRS duration over 130 msec, and left bundle branch block.

Dr. Strauss reported no relevant financial disclosures.

MIAMI BEACH – When it comes to heart failure, women tend to respond better to cardiac resynchronization therapy than do men, but for a long time no one knew why.

Turns out women have some distinct physiologic advantages, specifically more left bundle branch block and more nonischemic cardiomyopathy. Each drives a better response to cardiac resynchronization therapy (CRT), said Dr. David G. Strauss, a medical officer at the Food and Drug Administration’s Center for Devices and Radiologic Health in Silver Spring, Md.

In addition, timing of a specific electrical component within the heart triggers a third important distinction. Women benefit significantly from CRT even when their QRS duration is shorter than 150 msec. This supports the need for new gender-specific criteria for left bundle branch block and, ultimately, better identification of patients most likely to benefit from CRT device placement, Dr. Strauss said at the annual meeting of the International Society on Hypertension in Blacks.

"This is important because different professional societies recently have recommended that CRT be given to patients with QRS duration of 150 msec or more, and primarily in class II heart failure," he said. However, this cutoff "would exclude women with left bundle branch block and QRS duration 130-149 msec that derived significant benefit in MADIT-CRT" (Circulation 2011;123:1061-72).

In MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy), 1,820 patients were randomly assigned to receive CRT with an implantable cardioverter-defibrillator (ICD) or an ICD alone. In men with QRS duration of 130-140 msec in the study, there was no benefit from CRT and a trend toward harm associated with the device (hazard ratio, 1.69), Dr. Strauss said.

In contrast, women with QRS durations of 130-140 msec "had very significant benefit from CRT with a hazard ratio of 0.20, indicating 80% decrease in heart failure hospitalization or death," Dr. Strauss said.

More nonischemic cardiomyopathy among women translates to less myocardial scar and, ultimately, to a better CRT response. Scar tissue, no matter how it is electrically activated, does not contract, Dr. Strauss said.

Presence of left bundle branch block conferred a significant benefit in terms of reduced heart failure hospitalizations and deaths with use of CRT in the MADIT-CRT research. Conversely, participants without left bundle branch block realized no clinical advantage with CRT.

Be careful, however, to correctly identify left bundle branch block, Dr. Strauss said. Research suggests that one third of patients diagnosed with left bundle branch block by conventional electrocardiographic criteria are misdiagnosed (Am. J. Cardiol. 2011;107:927-34). Patients with intraventricular conduction delays, such as those caused by left ventricular hypertrophy and left ventricular dilation who do not have a blocked left bundle branch, can still display a prolonged QRS duration. This duration can be in the range generally considered diagnostic of left bundle branch block.

New criteria could parlay into better patient selection in the future, Dr. Strauss said. "CRT has been shown to improve heart failure symptoms, reduce heart failure hospitalization, and reduce mortality. However, not all patients benefit and significant risks exist." For example, addition of a CRT device with a left ventricular lead is associated with more complications, compared with ICD alone. "Thus there is a need for better patient risk stratification and patient identification criteria."

Based on results of electrical activation mapping and simulation studies, "My colleagues and I proposed stricter left bundle branch block criteria," he said. For example, they propose QRS duration of 130 msec or greater in women and 140 msec greater in men to replace the conventional 120 msec definition of left bundle branch block in either gender.

Another proposed new requirement is mid-QRS notching in at least two of the electrocardiographic leads of I, aVL, V1, V2, V5, or V6. This is important for diagnosing left bundle branch block because it reflects two events, Dr. Strauss said. There is an initial notch when electrical activation reaches the endocardium of the left ventricle and a second notch when activation reaches the lateral wall opposite the septum.

Other researchers support changing the current criteria for left bundle branch block. In a study of 111 patients, researchers found meeting what they termed "false" criteria was associated with a fourfold higher rate of heart failure hospitalization or death, compared with those meeting strict criteria (Pacing Clin. Electrophysiol. 2012;35:927-34).

CRT is FDA approved for class 3 or 4 heart failure, both of ischemic and nonischemic etiology, with a left ventricular ejection fraction less than 35% and a QRS duration over 120 msec. The FDA also approved CRT for class I ischemic or class II (ischemic or nonischemic) heart failure with an ejection fraction less than 30%, a QRS duration over 130 msec, and left bundle branch block.

Dr. Strauss reported no relevant financial disclosures.

MIAMI BEACH  – Metabolic syndrome drives the cardiovascular disease risk disparity for young and middle-age Hispanics more than for other women, according to a large community-based study of 6,843 women.

Hispanic women deserve additional attention to mitigate risk factors and intervention to ultimately lessen their cardiometabolic risk, Dr. Fatima Rodriguez said.

Overall, increasing age was associated with a higher prevalence of metabolic syndrome. However, compared with white and black women, Hispanics had the highest rates across all ages in the cross-sectional study. The Hispanic women aged 30-65 years had the greatest disparity in metabolic syndrome rates, suggesting this age group is at particular risk, Dr. Rodriguez said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Rodriguez and her colleagues assessed data from Sister to Sister: The Women’s Heart Health Foundation collected through free health screenings in 17 U.S. cities. In 2008 and 2009, 18,892 women were screened for obesity (using both body mass index and waist circumference), hypertension, hyperglycemia, and dyslipidemia. These women also completed cardiovascular risk questionnaires. Nearly 7,000 women had complete clinical and demographic data and were studied further.

"This was a very diverse sample," Dr. Rodriguez said. A total 42% self-identified as non-Hispanic white, 37% as black, 13% as Hispanic, and 8% as "other" race or ethnicity. 

Overall prevalence of metabolic syndrome in the study was high, at 35%. In addition, "there was a disproportionate burden for Hispanic women and black women," said Dr. Rodriguez, an internal medicine resident at Brigham and Women’s Hospital in Boston. A total 40% of Hispanic women met the criteria for metabolic syndrome, as did 39% of black women, 31% of non-Hispanic white women, and 29% of women who identified as "other."

For Hispanic woman, much of the disparity is driven by abnormal lipid levels. "Many of these women have high triglyceride levels and low HDL levels ... and this disparity was most pronounced in young women," Dr. Rodriguez said. "It is a different pattern than the metabolic syndrome in black women, where it’s largely driven by waist circumference and hypertension."

In addition to assessment of race/ethnicity and age, a third objective of the study was to identify risk-adjusted predictors of metabolic syndrome. The No.1 predictor was Hispanic ethnicity (odds ratio, 1.65), followed by being black (OR, 1.39), compared with non-Hispanic whites. Smoking also was an independent predictor for the syndrome (OR, 1.30), as was increasing age (OR, 1.13).

Dr. Rodriguez and her colleagues used the National Cholesterol Education Program definition (NCEP ATP III) for metabolic syndrome. Women had to meet at least three of the following criteria: waist circumference of at least 35 inches; triglyceride level of at least 150 mg/dL; HDL cholesterol below 50 mg/dL; systolic blood pressure at least 130 mm Hg, or diastolic blood pressure at least 85mm Hg; or pharmacologic treatment for hypertension; or a fasting glucose of at least 110 mg/dL.

Use of cross-sectional data in the current study limits assessment of any causality. Other potential limitations include aggregating all Hispanic women into one group (even though there is a great deal of heterogeneity among Hispanics) and an inability to account for lifestyle or patient level factors (for example, diet or exercise).

A disparity in insurance status was another finding. "One thing that was very interesting in this study was the high rates of lack of insurance for Hispanic women. Alarmingly, almost 65% of these women were uninsured had no insurance whatsoever," Dr. Rodriguez said. "This suggests these women have little access to the health care setting and a population-based approach would be best for primary prevention."

Dr. Rodriguez said that she had no financial disclosures.

MIAMI BEACH  – Metabolic syndrome drives the cardiovascular disease risk disparity for young and middle-age Hispanics more than for other women, according to a large community-based study of 6,843 women.

Hispanic women deserve additional attention to mitigate risk factors and intervention to ultimately lessen their cardiometabolic risk, Dr. Fatima Rodriguez said.

Overall, increasing age was associated with a higher prevalence of metabolic syndrome. However, compared with white and black women, Hispanics had the highest rates across all ages in the cross-sectional study. The Hispanic women aged 30-65 years had the greatest disparity in metabolic syndrome rates, suggesting this age group is at particular risk, Dr. Rodriguez said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Rodriguez and her colleagues assessed data from Sister to Sister: The Women’s Heart Health Foundation collected through free health screenings in 17 U.S. cities. In 2008 and 2009, 18,892 women were screened for obesity (using both body mass index and waist circumference), hypertension, hyperglycemia, and dyslipidemia. These women also completed cardiovascular risk questionnaires. Nearly 7,000 women had complete clinical and demographic data and were studied further.

"This was a very diverse sample," Dr. Rodriguez said. A total 42% self-identified as non-Hispanic white, 37% as black, 13% as Hispanic, and 8% as "other" race or ethnicity. 

Overall prevalence of metabolic syndrome in the study was high, at 35%. In addition, "there was a disproportionate burden for Hispanic women and black women," said Dr. Rodriguez, an internal medicine resident at Brigham and Women’s Hospital in Boston. A total 40% of Hispanic women met the criteria for metabolic syndrome, as did 39% of black women, 31% of non-Hispanic white women, and 29% of women who identified as "other."

For Hispanic woman, much of the disparity is driven by abnormal lipid levels. "Many of these women have high triglyceride levels and low HDL levels ... and this disparity was most pronounced in young women," Dr. Rodriguez said. "It is a different pattern than the metabolic syndrome in black women, where it’s largely driven by waist circumference and hypertension."

In addition to assessment of race/ethnicity and age, a third objective of the study was to identify risk-adjusted predictors of metabolic syndrome. The No.1 predictor was Hispanic ethnicity (odds ratio, 1.65), followed by being black (OR, 1.39), compared with non-Hispanic whites. Smoking also was an independent predictor for the syndrome (OR, 1.30), as was increasing age (OR, 1.13).

Dr. Rodriguez and her colleagues used the National Cholesterol Education Program definition (NCEP ATP III) for metabolic syndrome. Women had to meet at least three of the following criteria: waist circumference of at least 35 inches; triglyceride level of at least 150 mg/dL; HDL cholesterol below 50 mg/dL; systolic blood pressure at least 130 mm Hg, or diastolic blood pressure at least 85mm Hg; or pharmacologic treatment for hypertension; or a fasting glucose of at least 110 mg/dL.

Use of cross-sectional data in the current study limits assessment of any causality. Other potential limitations include aggregating all Hispanic women into one group (even though there is a great deal of heterogeneity among Hispanics) and an inability to account for lifestyle or patient level factors (for example, diet or exercise).

A disparity in insurance status was another finding. "One thing that was very interesting in this study was the high rates of lack of insurance for Hispanic women. Alarmingly, almost 65% of these women were uninsured had no insurance whatsoever," Dr. Rodriguez said. "This suggests these women have little access to the health care setting and a population-based approach would be best for primary prevention."

Dr. Rodriguez said that she had no financial disclosures.

MIAMI BEACH  – Metabolic syndrome drives the cardiovascular disease risk disparity for young and middle-age Hispanics more than for other women, according to a large community-based study of 6,843 women.

Hispanic women deserve additional attention to mitigate risk factors and intervention to ultimately lessen their cardiometabolic risk, Dr. Fatima Rodriguez said.

Overall, increasing age was associated with a higher prevalence of metabolic syndrome. However, compared with white and black women, Hispanics had the highest rates across all ages in the cross-sectional study. The Hispanic women aged 30-65 years had the greatest disparity in metabolic syndrome rates, suggesting this age group is at particular risk, Dr. Rodriguez said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Rodriguez and her colleagues assessed data from Sister to Sister: The Women’s Heart Health Foundation collected through free health screenings in 17 U.S. cities. In 2008 and 2009, 18,892 women were screened for obesity (using both body mass index and waist circumference), hypertension, hyperglycemia, and dyslipidemia. These women also completed cardiovascular risk questionnaires. Nearly 7,000 women had complete clinical and demographic data and were studied further.

"This was a very diverse sample," Dr. Rodriguez said. A total 42% self-identified as non-Hispanic white, 37% as black, 13% as Hispanic, and 8% as "other" race or ethnicity. 

Overall prevalence of metabolic syndrome in the study was high, at 35%. In addition, "there was a disproportionate burden for Hispanic women and black women," said Dr. Rodriguez, an internal medicine resident at Brigham and Women’s Hospital in Boston. A total 40% of Hispanic women met the criteria for metabolic syndrome, as did 39% of black women, 31% of non-Hispanic white women, and 29% of women who identified as "other."

For Hispanic woman, much of the disparity is driven by abnormal lipid levels. "Many of these women have high triglyceride levels and low HDL levels ... and this disparity was most pronounced in young women," Dr. Rodriguez said. "It is a different pattern than the metabolic syndrome in black women, where it’s largely driven by waist circumference and hypertension."

In addition to assessment of race/ethnicity and age, a third objective of the study was to identify risk-adjusted predictors of metabolic syndrome. The No.1 predictor was Hispanic ethnicity (odds ratio, 1.65), followed by being black (OR, 1.39), compared with non-Hispanic whites. Smoking also was an independent predictor for the syndrome (OR, 1.30), as was increasing age (OR, 1.13).

Dr. Rodriguez and her colleagues used the National Cholesterol Education Program definition (NCEP ATP III) for metabolic syndrome. Women had to meet at least three of the following criteria: waist circumference of at least 35 inches; triglyceride level of at least 150 mg/dL; HDL cholesterol below 50 mg/dL; systolic blood pressure at least 130 mm Hg, or diastolic blood pressure at least 85mm Hg; or pharmacologic treatment for hypertension; or a fasting glucose of at least 110 mg/dL.

Use of cross-sectional data in the current study limits assessment of any causality. Other potential limitations include aggregating all Hispanic women into one group (even though there is a great deal of heterogeneity among Hispanics) and an inability to account for lifestyle or patient level factors (for example, diet or exercise).

A disparity in insurance status was another finding. "One thing that was very interesting in this study was the high rates of lack of insurance for Hispanic women. Alarmingly, almost 65% of these women were uninsured had no insurance whatsoever," Dr. Rodriguez said. "This suggests these women have little access to the health care setting and a population-based approach would be best for primary prevention."

Dr. Rodriguez said that she had no financial disclosures.

MIAMI BEACH  – Nondipping of nighttime blood pressure – a recognized risk factor for hypertension – emerges as early as adolescence, preferentially affects blacks, and is associated with lower socioeconomic status, according to a study.

In addition, negative psychological attributes such as trait anger and interpersonal conflict by day were independent factors for blood pressure nondipping at night, Tanisha I. Burford, Ph.D., said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Burford recommended asking potentially at-risk adolescent patients about their sleep quality, because those with fragmented or interrupted sleep are less likely to experience a normal, nocturnal restorative decline in blood pressure.

She also suggested that clinicians consider asking at-risk adolescents to wear an ambulatory blood pressure monitor for more-comprehensive, real-time feedback on circadian blood pressures, compared with conventional intermittent clinical readings.

Dr. Burford and her colleagues did just that – they asked 139 black and 106 white healthy adolescents to wear ambulatory blood pressure monitors for 48 consecutive hours.

"Most of what we know about nondipping blood pressure is [from studies] in adults." There is some evidence that blunting of blood pressure decreases at night "emerges early in the life course, during adolescence, and even in some children 9-11 years old," said Dr. Burford, a postdoctoral scholar in the cardiovascular behavioral medicine research program at the University of Pittsburgh.

Study participants used electronic diaries to rate social interactions and any conflict (on a 6-point scale) in the 10 minutes preceding each blood pressure reading. They also completed standard measures of depression (Center for Epidemiologic Studies Depression scale or CES-D); trait anger (State Trait Anxiety Inventory or STAI), and negative affect (Positive and Negative Aspect Schedule or PANAS).

The researchers found a higher ratio of average night to day blood pressures (both systolic and diastolic) among black teenagers who reported higher rates of negative emotions and/or conflict compared to white teenagers in a regression analysis that adjusted for age, sex, and body mass index.

"Most of this is a systolic effect – which makes sense for hypertension – [where] systolic changes are more detrimental in early stages," Dr. Burford said.

Among blacks, the beta value (the interaction between average systolic blood pressure night/day ratio and race) was a significant 0.43 for trait anger; a significant 0.52 for negative affect; and a significant 0.59 for depression.

The interaction between interpersonal stress and race had a nonsignificant trend for an adverse effect on the systolic blood pressure ratio (beta value, 0.38).

"The most fascinating thing is that these negative psychological attributes did [interact with] race," Dr. Burford said. Trait anger, depression, and conflict were only associated with nighttime nondipping of blood pressure among black teens, even though white teens reported higher levels of trait anger. A possible explanation, she added, was that positive attributes were less protective for black teenagers.

Some blacks have a "lower resource capacity," Dr. Burford said, which could include lower levels of self-esteem and less social support, particularly if they live in a stressful environment.

Participants were 14-19 years old (median, 16 years) and part of the Pittsburgh Project Pressure II.

Typically, blood pressure is low during the morning, increases during the day, and then drops at nighttime. Nondipping nighttime blood pressure was defined as less than a 10% decrease vs. daytime pressures. Although blood pressure readings can be highly variable and influenced by multiple factors, this 10% or less cutoff is a reliable predictor of risk, Dr. Burford said.

Dr. Burford had no relevant financial disclosures.

MIAMI BEACH  – Nondipping of nighttime blood pressure – a recognized risk factor for hypertension – emerges as early as adolescence, preferentially affects blacks, and is associated with lower socioeconomic status, according to a study.

In addition, negative psychological attributes such as trait anger and interpersonal conflict by day were independent factors for blood pressure nondipping at night, Tanisha I. Burford, Ph.D., said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Burford recommended asking potentially at-risk adolescent patients about their sleep quality, because those with fragmented or interrupted sleep are less likely to experience a normal, nocturnal restorative decline in blood pressure.

She also suggested that clinicians consider asking at-risk adolescents to wear an ambulatory blood pressure monitor for more-comprehensive, real-time feedback on circadian blood pressures, compared with conventional intermittent clinical readings.

Dr. Burford and her colleagues did just that – they asked 139 black and 106 white healthy adolescents to wear ambulatory blood pressure monitors for 48 consecutive hours.

"Most of what we know about nondipping blood pressure is [from studies] in adults." There is some evidence that blunting of blood pressure decreases at night "emerges early in the life course, during adolescence, and even in some children 9-11 years old," said Dr. Burford, a postdoctoral scholar in the cardiovascular behavioral medicine research program at the University of Pittsburgh.

Study participants used electronic diaries to rate social interactions and any conflict (on a 6-point scale) in the 10 minutes preceding each blood pressure reading. They also completed standard measures of depression (Center for Epidemiologic Studies Depression scale or CES-D); trait anger (State Trait Anxiety Inventory or STAI), and negative affect (Positive and Negative Aspect Schedule or PANAS).

The researchers found a higher ratio of average night to day blood pressures (both systolic and diastolic) among black teenagers who reported higher rates of negative emotions and/or conflict compared to white teenagers in a regression analysis that adjusted for age, sex, and body mass index.

"Most of this is a systolic effect – which makes sense for hypertension – [where] systolic changes are more detrimental in early stages," Dr. Burford said.

Among blacks, the beta value (the interaction between average systolic blood pressure night/day ratio and race) was a significant 0.43 for trait anger; a significant 0.52 for negative affect; and a significant 0.59 for depression.

The interaction between interpersonal stress and race had a nonsignificant trend for an adverse effect on the systolic blood pressure ratio (beta value, 0.38).

"The most fascinating thing is that these negative psychological attributes did [interact with] race," Dr. Burford said. Trait anger, depression, and conflict were only associated with nighttime nondipping of blood pressure among black teens, even though white teens reported higher levels of trait anger. A possible explanation, she added, was that positive attributes were less protective for black teenagers.

Some blacks have a "lower resource capacity," Dr. Burford said, which could include lower levels of self-esteem and less social support, particularly if they live in a stressful environment.

Participants were 14-19 years old (median, 16 years) and part of the Pittsburgh Project Pressure II.

Typically, blood pressure is low during the morning, increases during the day, and then drops at nighttime. Nondipping nighttime blood pressure was defined as less than a 10% decrease vs. daytime pressures. Although blood pressure readings can be highly variable and influenced by multiple factors, this 10% or less cutoff is a reliable predictor of risk, Dr. Burford said.

Dr. Burford had no relevant financial disclosures.

MIAMI BEACH  – Nondipping of nighttime blood pressure – a recognized risk factor for hypertension – emerges as early as adolescence, preferentially affects blacks, and is associated with lower socioeconomic status, according to a study.

In addition, negative psychological attributes such as trait anger and interpersonal conflict by day were independent factors for blood pressure nondipping at night, Tanisha I. Burford, Ph.D., said at the annual meeting of the International Society on Hypertension in Blacks.

Dr. Burford recommended asking potentially at-risk adolescent patients about their sleep quality, because those with fragmented or interrupted sleep are less likely to experience a normal, nocturnal restorative decline in blood pressure.

She also suggested that clinicians consider asking at-risk adolescents to wear an ambulatory blood pressure monitor for more-comprehensive, real-time feedback on circadian blood pressures, compared with conventional intermittent clinical readings.

Dr. Burford and her colleagues did just that – they asked 139 black and 106 white healthy adolescents to wear ambulatory blood pressure monitors for 48 consecutive hours.

"Most of what we know about nondipping blood pressure is [from studies] in adults." There is some evidence that blunting of blood pressure decreases at night "emerges early in the life course, during adolescence, and even in some children 9-11 years old," said Dr. Burford, a postdoctoral scholar in the cardiovascular behavioral medicine research program at the University of Pittsburgh.

Study participants used electronic diaries to rate social interactions and any conflict (on a 6-point scale) in the 10 minutes preceding each blood pressure reading. They also completed standard measures of depression (Center for Epidemiologic Studies Depression scale or CES-D); trait anger (State Trait Anxiety Inventory or STAI), and negative affect (Positive and Negative Aspect Schedule or PANAS).

The researchers found a higher ratio of average night to day blood pressures (both systolic and diastolic) among black teenagers who reported higher rates of negative emotions and/or conflict compared to white teenagers in a regression analysis that adjusted for age, sex, and body mass index.

"Most of this is a systolic effect – which makes sense for hypertension – [where] systolic changes are more detrimental in early stages," Dr. Burford said.

Among blacks, the beta value (the interaction between average systolic blood pressure night/day ratio and race) was a significant 0.43 for trait anger; a significant 0.52 for negative affect; and a significant 0.59 for depression.

The interaction between interpersonal stress and race had a nonsignificant trend for an adverse effect on the systolic blood pressure ratio (beta value, 0.38).

"The most fascinating thing is that these negative psychological attributes did [interact with] race," Dr. Burford said. Trait anger, depression, and conflict were only associated with nighttime nondipping of blood pressure among black teens, even though white teens reported higher levels of trait anger. A possible explanation, she added, was that positive attributes were less protective for black teenagers.

Some blacks have a "lower resource capacity," Dr. Burford said, which could include lower levels of self-esteem and less social support, particularly if they live in a stressful environment.

Participants were 14-19 years old (median, 16 years) and part of the Pittsburgh Project Pressure II.

Typically, blood pressure is low during the morning, increases during the day, and then drops at nighttime. Nondipping nighttime blood pressure was defined as less than a 10% decrease vs. daytime pressures. Although blood pressure readings can be highly variable and influenced by multiple factors, this 10% or less cutoff is a reliable predictor of risk, Dr. Burford said.

Dr. Burford had no relevant financial disclosures.