Publications

The 2025 AHA/ACC blood pressure (BP) management guidelines recommend BP treatment for 10-year cardiovascular disease (CVD) ≥7.5% from the PREVENT equation, replacing the prior pooled cohort equations (PCE). We examined associations between risk in PCE and PREVENT and a composite of CVD or cardiovascular death in SPRINT. Among 1794 participants, 477 (26.6%) were at low risk in both, 119 (6.6%) were high-risk in PREVENT only, 89 (5.0%) were high-risk in PCE only, and 1109 (61.8%) were high-risk in both. Those at high risk in both equations receiving intensive treatment had a lower risk of the primary outcome [hazard ratio (HR): 0.46, 95% confidence interval (CI): 0.24, 0.89]. Intensive treatment did not affect the risk of any outcomes for those at high-risk in PREVENT only or PCE only due to low event rates. These findings confirm the neutrality of the change from PCE to PREVENT for BP treatment recommendations.

BACKGROUND: Assessment and treatment of orthostatic hypotension (OH) are recommended to prevent falls in older adults. However, the optimal timing of standing blood pressure (BP) assessments to identify clinically relevant OH remains unclear.

METHODS: We measured 3 supine BP readings after 5 minutes of rest at 30-second intervals and 6 standing BP readings (timed at 0, 1, 2, 3, 4, and 5 minutes after standing) during the ARIC study (Atherosclerosis Risk in Communities) visit 10. OH was defined as a drop in BP (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) on standing from the supine position. We quantified the prevalence and predictors of initial OH (immediately after standing), early OH (within 3 minutes), late OH (after 3 minutes), and sustained OH (all 6 minutes). We examined their associations with orthostatic symptoms and falls using logistic regression and negative binomial models, respectively.

RESULTS: Of the 863 participants (mean age, 83.7 years), 41.3% had initial OH. Participants on antihypertensive medications had higher odds of all types of OH irrespective of controlled (<130/80 mm Hg) or uncontrolled (≥130/80 mm Hg) hypertension compared with those without hypertension (<130/80 mm Hg) and no antihypertensive use. Initial and early OH were strongly associated with orthostatic symptoms in the process of standing from the supine position (odds ratio, 2.34 [95% CI, 1.42-3.86]; odds ratio, 1.82 [95% CI, 1.11-2.98], respectively). Finally, participants with initial OH had higher fall rates (rate ratio, 1.45 [95% CI, 1.02-2.06]) than those without OH.

CONCLUSIONS: Measuring BP within 3 minutes of standing, particularly the first BP measurement immediately after standing, may provide clinicians with important information on falls risk and orthostatic symptoms.

INTRODUCTION: Previous research has shown narrowing racial disparities in self-reported health. However, these disparities may have worsened in recent years, particularly during and after the COVID-19 pandemic. Less is known regarding the current state of disparities in self-reported health.

METHODS: Participants are from the 2023 and 2024 U.S. National Health Interview Survey. Using survey-weighted, age- and sex-adjusted modified Poisson regression models, we examined associations of race, ethnicity, and socioeconomic status with fair or poor self-reported health, both overall and stratified by levels of education, income, and health insurance status.

RESULTS: Among 251,930,438 adults aged ≥ 18 years (unweighted N = 60,449), 14.9% (95% CI: 14.5, 15.3) reported fair or poor health. Compared to those with a bachelor's degree or higher, those who had not completed high school had a higher prevalence of fair or poor health (prevalence ratio [PR] = 3.79, 95% CI: 3.52, 4.08). Additionally, compared to people with household income ≥ 4 times the federal poverty line, those with household incomes below the federal poverty line had a higher prevalence of fair or poor health (PR = 3.94, 95% CI: 3.70, 4.19). Non-Hispanic Black (PR = 1.56, 95% CI: 1.46, 1.67) and Hispanic (PR = 1.49, 95% CI: 1.39, 1.59) adults were more likely than non-Hispanic White adults to report fair or poor health.

CONCLUSION: In this U.S. nationally representative study, fair or poor self-reported health was more prevalent among adults with lower socioeconomic status and among non-Hispanic Black and Hispanic adults. These findings underscore the need for policy interventions that simultaneously address socioeconomic inequality and structural racism to improve population health outcomes.

BACKGROUND: Successful trial recruitment depends on balancing initial interest with participants' commitment and eligibility. It is uncertain how different motivational advertisement themes affect recruitment of interested and eligible trial participants.

METHODS: The GoFresh trials examined how healthy groceries affect blood pressure among Black adults from Boston healthy food priority areas. Using Facebook's "A/B testing" feature, users 18 years and older in eligible ZIP codes were randomly shown one of four digital advertisement themes-science volunteerism, study incentives, blood pressure reduction, or wellness in the Black community-between November 2023 and December 2024. We tracked Facebook and website analytics by theme. 'Interest' was defined as submission of an online interest form. 'Commitment' as visit no-show rates, and 'Eligibility' as qualification following the in-person visit. The 'number needed to screen' was calculated as 1 divided by the proportion of inquiries who were eligible.

RESULTS: Advertisements reached 603,418 Facebook users and generated 32,168 clicks, 264 inquiries, 73 scheduled visits, and 23 eligible participants. The community theme generated the highest inquiry engagement rate (54%) but lower commitment (8 no-shows) and the highest number needed to screen (17). The blood pressure theme had the lowest inquiry engagement rate (32%) but yielded the highest commitment (2 no-shows) and the lowest number needed to screen (8).

CONCLUSION: Beyond generating study interest, motivational themes may select for participants with varying degrees of commitment and eligibility, which could affect the cost-effectiveness of recruitment and long-term retention. These findings have important implications for timely and representative recruitment for cardiovascular trials.

REGISTRATION: URL: https://clinicaltrials.gov/; Unique Identifier: NCT05121337 &NCT05393232.

BACKGROUND: Current clinical guidelines recommend home blood pressure monitoring (HBPM) to confirm hypertension diagnosis, guide therapy, and support long-term control. However, the optimal number of HBPM measurements needed for valid assessment is not established.

METHODS: At ARIC Visit 10 (2023), participants completed an eight-day HBPM protocol with morning and evening measurements and three readings per session. We evaluated the validity between the eight-day mean (reference) and streamlined protocols (fewer days, less than three readings per session, or only morning or evening measurements). In secondary analyses, we assessed the validity of these HBPM protocols relative to ambulatory BP.

RESULTS: Among 812 participants (median age 83 years, 24% Black adults, 40% male, 84% using anti-hypertensive medications), median BP varied by less than 3 mmHg across the eight-day protocol. The greatest improvement in HBPM validity occurred when extending the averaging window from one to two days. By three days, concordance correlation coefficients exceeded 0.95, and ≥97% of participants were within 10 mmHg of the reference for both systolic and diastolic BP. Averaging ≥2 readings per session, including both morning and evening measurements, yielded greater validity than a single reading or timepoint.

CONCLUSIONS: In this community-based cohort of older adults, HBPM provided stable BP estimates within three days (can be non-consecutive within an 8-day period) using morning and evening sessions with ≥2 readings each. While further studies are required to validate generalizability beyond this engaged cohort, these findings support shorter, less burdensome HBPM protocols in clinical guidelines for hypertension management in older adults.

Per- and polyfluoroalkyl substances (PFAS) and metals are ubiquitous environmental contaminants that have been individually linked to childhood adiposity, but their combined effects remain understudied. In the Project Viva cohort (n = 845), we evaluated joint associations of six first-trimester PFAS in plasma and five essential and six nonessential metals in erythrocytes with child and adolescent body mass index (BMI) z-scores and dual-energy X-ray absorptiometry (DXA) total and truncal fat mass indices. We used Bayesian kernel machine regression to evaluate joint associations of PFAS and metals with adiposity. Higher prenatal PFAS and nonessential metal mixture levels were significantly associated with higher mid-childhood and early adolescent BMI z-scores (75th vs 50th percentile: 0.17 [95% Credible Interval (CrI): 0.06, 0.28]; 0.14 [95% CrI: 0.02, 0.25]) and DXA total fat mass (0.17 kg/m2 [0.05, 0.30]; 0.20 kg/m2 [0.07, 0.32]), but not adiposity in late adolescence. Children with lower levels of the prenatal essential metal mixture had higher early and late adolescent DXA total fat mass (25th vs 50th percentile: 0.13 [0.04, 0.22]; 0.08 [0.01, 0.16]). Our findings underscore the importance of considering concurrent prenatal exposures across multiple chemical classes when evaluating environmental influences on child adiposity.

BACKGROUND: Orthostatic hypotension is thought to be associated with coronary heart disease, falls, and syncope due to low blood pressure (BP) upon standing.

METHODS: The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing BP among adult participants aged 45 to 64 years once at baseline and followed them for over 35 years. We evaluated higher and lower supine and standing systolic BP, diastolic BP, mean arterial pressure, pulse pressure, absolute and relative orthostatic changes in BP after standing, and mean BP across positions. Associations with adjudicated coronary heart disease and mortality events, as well as hospitalizations and medical claims-based falls and syncope, were assessed via adjusted Cox models in strata of antihypertensive treatment.

RESULTS: Among 11 386 participants (mean age, 54 years [SD, 5.7 years]; 56% female; 25% Black adults), drops in systolic BP upon standing (absolute or relative) were associated with coronary heart disease, syncope, and mortality. Higher supine systolic BP and mean arterial pressure were associated with syncope among untreated participants. Increases in systolic BP ≥20 mm Hg upon standing were associated with falls (hazard ratio, 1.52 [95% CI, 1.14-2.02]) and syncope (hazard ratio, 1.40 [95% CI, 1.03-1.92]), particularly among untreated participants. Lower standing systolic BP was associated with a higher risk of syncope among treated participants (hazard ratio, 1.55 [95% CI, 1.14-2.12]). Regardless of treatment status, a higher pulse pressure was associated with coronary heart disease and mortality, but this was not observed for falls or syncope.

CONCLUSIONS: Higher BP, rather than lower standing BP alone, may be an important risk factor for both cardiovascular and hypotension-related events, especially among untreated adults.

BACKGROUND: Home blood pressure (BP) monitoring (HBPM) is increasingly used as an alternative to office BP. However, factors influencing agreement between office and home BP among very old adults remain unclear.

METHODS: During ARIC (Atherosclerosis Risk in Communities) visit 10, participants underwent 3 automated office BP (AOBP) measurements using an Omron HEM-907XL and performed HBPM twice daily for 8 days using an Omron BP7450. Discordance was defined as a systolic BP difference of ±10 mm Hg between mean AOBP and HBPM. Multivariable regression models evaluated demographic, anthropometric, and clinical factors associated with discordance.

RESULTS: Among 792 participants (58% female; mean age, 84±3.7 years), mean systolic BP was 130.6 mm Hg (AOBP) and 129.6 mm Hg (HBPM). Despite a minimal average difference (1.0±15.7 mm Hg), 49% had ≥10 mm Hg systolic BP discordance. Higher AOBP was associated with greater discordance. Compared with females, males had lower AOBP relative to HBPM (-4.69 mm Hg [95% CI, -6.86 to -2.51]). Smaller arm circumference was associated with higher discordance (β=14.4 mm Hg [95% CI, 4.78-24.04]). Frail adults had lower AOBP relative to HBPM (β, -5.1 mm Hg [95% CI, -11.0 to 0.9]). Baseline AOBP systolic BP ≥140 mm Hg strongly predicted discordance ≥+10 mm Hg (odds ratio, 8.27 [95% CI, 5.52-12.40]). Participants aged 91 to 100 years had lower AOBP than those aged 78 to 80 years (β, -5.0 mm Hg [95% CI, -10.06 to 0.001]).

CONCLUSIONS: Among very old adults, substantial BP discordance between AOBP and HBPM was common and influenced by higher BP, age, male sex, arm circumference, and frailty.

BACKGROUND: Higher relative risk for cardiovascular disease (CVD) events at lower blood pressure (BP) thresholds in female versus male adults suggest that hypertension thresholds should be sex-specific.

METHODS: We used the ARIC study (Atherosclerosis Risk in Communities) visit 1 (1987-1989) to compare the BP distribution, estimated risk (via the 10-year Predicting Risk of Cardiovascular Disease Events score), absolute risk, and relative risk of CVD according to BP thresholds, stratified by sex and hypertension treatment status, in participants without prior CVD.

RESULTS: Of 13 418 participants (56% women, mean age [54±5.7 years]), 25% were treated for hypertension. Males had higher average 10-year CVD risk scores regardless of treatment. The distribution of BP and prevalence of CVD risk factors was similar for male and female adults. Incidence rates (per 10 000 person-years) comparing a systolic BP threshold of ≥140 versus <140 mm Hg for coronary heart disease were 30.9 and 12.0 among untreated male and female adults (P=0.07) and 27.4 versus 16.5 among treated male and female adults (P=0.63). HRs comparing a systolic BP threshold of ≥140 versus <140 mm Hg for coronary heart disease were 1.49 and 1.72 among untreated male and female adults (P=0.16) and 1.30 versus 1.40 among treated male and female adults (P=0.93).

CONCLUSIONS: In this middle-aged population, there were no consistent differences in BP distribution, risk factor burden, absolute risk, or relative risk of CVD between male and female adults. These findings do not support a sex-specific threshold for hypertension.