ethnicity in a large integrated health care system, 2008-2012

Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e81–e91

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Summary of Baroreceptor Dysfunction Patients Age

Gender

Follow-up (months)

Cause of baroreceptor dysfunction

Pharmacologic interventions

Non-pharmacologic interventions (high salt intake, compression stockings, head of the bed elevation

Mean home BPs/HR at Baseline (supine/standing)

Mean home BPs/HR at last follow-up (sitting/standing)

84

M

1

Neck radiation therapy for laryngeal Canceradvanced bilateral carotid stenosis NHL of neck

atenolol 50 mg bedtime and isradipine 5 mg at bedtime

yes

167/67/65 94/62/61

145/65/60 117/55/58

69

M

1

Atenolol, decrease Flomax, decrease fluronef atenolol 25 mg and isradipine 5 mg at bedtime midodrine stopped Guanfacine at bedtime

yes

125/78/113 87/64/132 146/91/57 97/63/60

149/85/66 112/70/84 136/86/58 104/84/62

63

M

14

59

M

1

Oral cancer with radiotherapy

170/100/84 110/80/85 180/80/75 80/50/80

146/97/83 124/88/94 160/92/68 120/70/67

84

M

1

Advanced bilateral carotid stenosis

30

F

1

63

M

12

65

M

36

Carotid body tumors s/p resection Neck radiation therapy for tongue Cancer Neck radiation therapy for Head and Neck Cancer

96/60/88 80/56/88 185/105/62 155/76/68 156/80/84 128/60/82

129/100/98 110/80/120 152/82/58 146/80/60 145/77/56 123/67/60

50

M

5

136/86/85 110/75/95

134/63/102 117/60/101

Neck radiation therapy for tongue Cancer

Carotid stenosis/unknown

atenolol 100 mg at night and nicardipine 40 mg at bedtime Diltiazem 240 Qpm Stopped fluronef atenolol 50 mg at bedtime atenolol 50 mg at bedtime and guanfacine 2mg at bedtime Nebivolol 10 mg qam and 5 mg qpm with ramipril 5 mg bid

P-155 Treatment resistant hypertension and the incidence of cardiovascular disease and end-stage renal disease: results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Paul Muntner,7 Barry R. Davis,5 William C. Cushman,2 Sripal Bangalore,3 David A. Calhoun,7 Sara Pressel,5 Henry R. Black,3 John B. Kostis,4 Jeff Probstfield,8 Paul K. Whelton,6 Mahboob Rahman,.1, the ALLHAT Collaborative Research Group 1Case Western Reserve University, Cleveland, OH, United States; 2Memphis Veterans Affairs Medical CenterUniversity of Alabama at Birmingham, Memphis, TN, United States; 3New York University, New York, NY, United States; 4 Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States; 5The University of Texas School of Public Health, Houston, TX, United States; 6Tulane University, New Orleans, LA, United States; 7 University of Alabama at Birmingham, Birmingham, AL, United States; 8 University of Washington, Seattle, WA, United States Patients who require
4 classes of antihypertensive medication to control their blood pressure (BP) are considered to have apparent treatment resistant hypertension (aTRH). While this definition is useful for guiding the clinical management of difficult to control hypertension, few data are available on the association between aTRH and cardiovascular (CV) and renal outcomes. We analyzed data on 14,684 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial to determine the association between aTRH (n¼1,870) with coronary heart disease (CHD), stroke, all-cause mortality, heart failure (HF), peripheral artery disease (PAD) and end-stage renal disease (ESRD). We defined aTRH as BP not at goal (systolic/diastolic BP
140/90 mmHg) while taking
3 classes of antihypertensive medication or taking
4 classes of antihypertensive medication with BP at goal during the Year 2 follow-up study visit in 1996 - 2000. Use of a diuretic was not required to meet the definition of aTRH. Follow-up occurred through 2002. The multivariable adjusted hazard ratios (HR) (95% confidence intervals) for clinical

yes

yes yes-no bed elevation

yes yes yes

yes

outcomes comparing participants with versus without aTRH were: CHD [1.43 (1.17 - 1.74)], stroke [1.56 (1.18 - 2.07)], all-cause mortality [1.29 (1.10 - 1.51)], HF [1.88 (1.51 - 2.33)], PAD [1.23 (0.85 - 1.79)] and ESRD [1.95 (1.11 - 3.41)]. aTRH was also associated with increased HR for the pooled outcomes of combined CHD (1.46, 95% CI: 1.25 1.70) and combined CV (1.45, 95% CI: 1.28 - 1.63). The magnitude of the risk estimates in our study underscores the importance of achieving goal BP during treatment of patients with resistant hypertension. Keywords: Treatment resistant hypertension; coronary heart disease; endstage renal disease

P-156 Trends in hypertension control by race/ethnicity in a large integrated health care system, 2008-2012 Joseph D. Young,2 Marc Jaffe,2 Sharon T. Platt,3 Alan S. Go,2 Stephen Sidney.2 1Kaiser Permanente Northern California, Oakland, CA, United States; 2Kaiser Permanente Northern California, South San Francisco, CA, United States; 3Kaiser Permanente Program Offices, Oakland, CA, United States Objectives: To describe trends and disparities in blood pressure control in hypertensive patients by race/ethnicity in Kaiser Permanente Northern California (KPNC) between 2008 and 2012. Methods: KPNC is an integrated health care delivery system providing comprehensive medical care to > 3.3 million members in the greater San Francisco Bay Area. Hypertension (HTN) control rates for the 4th quarter of each of the years, 2008-2012, were ascertained by examination of electronic health records in patients who met criteria for the NCQA HEDIS HTN control measure. Results: Between 2008-2102, the number of eligible HTN patients ranged from 330,087 to 355,401, with small changes in the racial/ethnic distributions, with the percentage increasing for Asian/Pacific Islanders (A/PI, 16.2% to 17.6%) and decreasing for Whites (W, 58.7% to 57.3%), while

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Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e81–e91

remaining nearly identical for Blacks (B, 10.7% to 10.6%), Hispanics (H, 13.2% to 13.4%), and all others (1.2% to 1.1%). Overall HTN control rate increased from 76.2% to 85.2% from 2008 to 2012, and increased in all race/ethnicity groups (76.9% to 85.7% in W, 69.2% to 80.1% in B, 79.5% to 87.1% in A/PI, 74.9% to 84.6% in H). A/PI had the highest HTN control rates, followed by W, H, and B. The difference in the HTN control rates between W and B patients decreased from 7.6% to 5.0% between 2008 and 2010 but has remained essentially stable since then. Discussion: Recent data from the NHANES study shows that blood pressure control rate among adults with HTN was 51.8% in 2011-12 and ranged from 46.0% in non-Hispanic (NH) Asians to 53.9% in NH Whites. In KPNC, a high functioning, integrated system in which all members have access to care, HTN control rates have steadily increased for all racial/ ethnic groups, but racial differences in HTN control persist, particularly among Blacks compared with other groups. Understanding the specific reasons explaining these remaining differences and development of innovative strategies to address them is needed.

urinary metanephrines and normetanephrines levels were 84  43 ng/ml and 290  168 ng/ml respectively. Significant associations were observed between the urinary cotinine levels and 24-hour diastolic BP (p ¼ 0.02), heart rate (p ¼ 0.03) and rate-pressure product (p ¼ 0.008) but not with clinic measurements. Additionally, urinary cotinine (p ¼ 0.004) and normetanephrines (p ¼ 0.03) were both related to the RPP while awake. On step-wise linear regression controlling for nicotine, cotinine, exhaled carbon monoxide, BMI, catecholamines and the average daily cigarettes smoked during the last 7 days, urinary cotinine and normetanephrines remained significantly correlated with 24-hour RPP (p ¼ 0.02 and 0.003 respectively) and awake RPP (p ¼ 0.01 and 0.002 respectively). (Figure) Ambulatory but not clinic BP, HR, and the RPP is related to parameters of smoking burden in individuals with pre- and stage 1 hypertension.

Keywords: Ambulatory Blood Pressure Monitoring; Smoking; Catecholamine; Rate Pressure Product

P-158 Keywords: Hypertension control; Disparities

P-157 Urinary cotinine and normetanephrine levels predict the ambulatory rate-pressure product in cigarette smokers Vinay Gulati, Ravi Marfatia, Karen Gilliam, Dorothy Wakefield, Carla Rash, Sheila Alessi, Nancy M. Petry, William B. White. University of Connecticut Health Center, Farmington, CT, United States Several epidemiological studies report conflicting data on the changes in blood pressure (BP) in subjects who smoke cigarettes. Nicotine may transiently increase the BP and heart rate (HR) but due to its short half-life, little is known on the effects of smoking on 24-hr BP, HR, or the rate-pressure product (RPP). We evaluated participants who smoked > 10 cigarettes/day with clinic BPs between 120-160/80-100 mmHg with seven day point prevalence cigarette smoking rates, 24 hour urinary nicotine, cotinine, and catecholamine values as well as clinic and 24-hour BP and HR. Subjects with an absence of urinary cotinine concentrations were excluded. The associations between urinary cotinine and 24-hour urinary catecholamines with clinic BP, 24-hour ambulatory BP and RPP were determined. Complete data were available for 187 participants at baseline. The mean age of the cohort was 47  11 years, with 66% males and 83% non-black. The mean clinic and 24-hour BPs were 134  11 / 83  8 and 137  13 / 81  8 mmHg, respectively. The average number of cigarettes smoked daily was 19.5  7.8 and mean urinary cotinine and nicotine levels were 1695  976 ng/ml and 5162  9966 ng/ml, respectively. The 24-hour

Visit-to-visit blood pressure variability is a marker of both diastolic dysfunction and carotid artery stenosis Rieko Okada,2 Akira Okada,3 Takashi Okada,3 Mamoru Nanasato,1 Kenji Wakai.2 1Nagoya Daini Red Cross Hospital, Nagoya, Japan; 2 Nagoya University Graduate School of Medicine, Nagoya, Japan; 3Okada Medical Clinic, Nagoya, Japan Visit-to-visit systolic blood pressure variability (BPV), which reflects longterm BPV, has recently been demonstrated to be a strong predictor of cardiovascular events. However, there are limited data about the association between BPV and cardiac function measures. This study was to investigate the association between BPV and cardiac (diastolic/systolic) function, left ventricular hypertrophy, and carotid artery stenosis. The study subjects were 144 patients (83 females, aged 73  9 years) who underwent both cervical ultrasonography and echocardiography at the same time. Blood pressure was measured at an outpatient clinic every 1 or 2 months. Diastolic function was assessed by the ratio of early ventricular filling velocity (E) and early diastolic mitral annular velocity (e’). The E/e’, ejection fraction, left ventricular mass index (LVMI), and max intima-media thickness (IMT) of carotid artery, were compared between the highest tertile (high BPV, SD >10.99 mm Hg) and the lowest tertile (low BPV, SD <8.29 mm Hg) of the standard deviation of the systolic blood pressure. Both the mean E/e’ and the mean IMT were higher in subjects with high BPV compared to those with low BPV (E/e’, 13.03  5.33 vs. 10.66  3.30, p ¼ 0.005; and IMT, 1.65  0.43 mm vs. 1.42  0.46 mm, p ¼ 0.001, respectively). These differences remained statistically significant after adjustment for age, sex, mean systolic blood pressure, use of calcium-channel blockers, renin-angiotensin antagonists, or beta-blockers,