Hypertension - References

Mt Sinai J Med 1999 Sep;66(4):273-276

'Tis Better to Receive than to Give: The Relative Failure of the African American Community to Provide Organs for Transplantation.

Rozon-Solomon M, Burrows L

Department of Surgery, Mount Sinai School of Medicine, New York, NY.

[Record supplied by publisher]

There is a serious, continuous and increasing shortfall of organs, especially kidneys, for the purpose of transplantation. This shortfall is especially remarkable in African American populations. Because the incidence of hypertension (HTN) and associated end-stage renal diseases (ESRD) is 17 times greater in African Americans, this minority group, which comprises only 12% of the U.S. population, represents 34% of the dialysis population and 30% of the national kidney waiting list. Furthermore, while black individuals comprise 22-24% of kidney recipients, they comprise only 8-11% of donors. Because of the histocompatibility differences between the races and because tissue matching is part of the United Network for Organ Sharing (UNOS) allocation formula, African Americans wait twice as long for kidneys as Caucasians. Also, because they get more poorly matched organs, their kidney transplant graft survival is 10-20% lower than that for other racial groups. The African American community is unaware of the special needs in members of their own race. Steps must be taken to increase minority awareness of the need for well-matched transplant organs and their involvement in the donation process.

PMID: 10477483

Ann Epidemiol 1999 Aug;9(6):374-82

Women, employment status, and hypertension: cross-sectional and prospective findings from the Atherosclerosis Risk in Communities (ARIC) Study.

Rose KM, Newman B, Tyroler HA, Szklo M, Arnett D, Srivastava N

Department of Epidemiology, University of North Carolina at Chapel Hill, School of Public Health, 27514, USA.

[Medline record in process]

PURPOSE: This study examined the cross-sectional and prospective associations between employment status and hypertension among middle-aged, African-American (AA) and European-American (EA) women participating in the Atherosclerosis Risk in Communities Study. METHODS: Employed women and homemakers from the baseline examination (1987-89) were included in the cross-sectional study (n = 7351). Associations between employment and the incidence of hypertension ascertained at visit 2 (1990-92) were determined among those who at baseline, had low-normal blood pressure (not hypertensive and systolic blood pressure (SBP) < or = 120 mm Hg systolic and diastolic blood pressure (DBP) < or =80 mm Hg (n = 3194). Logistic regression analysis was used to examine the association between employment status and hypertension by ethnicity, taking into account covariates. RESULTS: At baseline, employed women were less likely to be hypertensive (SBP > or =140 mm Hg or DBP > or =90 mm Hg or current use of antihypertensive drugs) than were homemakers (prevalence odds ratio) (POR) = 0.70; 95% confidence interval (CI) = 0.62-0.79), controlling for age, body mass index, and education. Among the subgroup who had low-normal blood pressure at baseline, employed women were less likely to develop hypertension during the three-year time period than were homemakers (odds ratio (OR) = 0.68; 95% CI = 0.44-1.05). The inverse association was stronger among AA (RR = 0.37; 95% CI = 0.16-0.88) than EA (OR = 0.83; 95% CI = 0.50-1.38) women. CONCLUSIONS: These findings suggest that the inverse association between hypertension and employment status is not due to a healthy worker effect, and that employment may confer protection against incident hypertension in women.

PMID: 10475537, UI: 99402522

Am J Public Health 1999 Sep;89(9):1418-21

Prevalence of self-reported nutrition-related health problems in the Lower Mississippi Delta.

Smith J, Lensing S, Horton JA, Lovejoy J, Zaghloul S, Forrester I, McGee BB, Bogle ML

Arkansas Children's Hospital Research Institute, Little Rock, USA.

[Medline record in process]

OBJECTIVES: The purpose of this study was to assess demographic and geographic differences in prevalence of self-reported nutrition-related health problems in Arkansas, Louisiana, and Mississippi. METHODS: The authors analyzed 1991 and 1993 Behavioral Risk Factor Surveillance System data for adults 18 years or older. RESULTS: Less educated African American women and women of other minority groups who were aged 35 to 64 years reported the highest prevalence of health problems. Geographic differences involved prevalence of hypertension, health status, and insurance status. CONCLUSIONS: Specific demographic subgroups and geographic areas with a high risk of health problems are in particular need of targeted interventions.

PMID: 10474563, UI: 99403811

J Toxicol Clin Toxicol 1999;37(4):485-9

Hypersensitivity myocarditis associated with ephedra use.

Zaacks SM, Klein L, Tan CD, Rodriguez ER, Leikin JB

Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois 60612, USA.

[Medline record in process]

BACKGROUND: Ephedrine has previously been described as a causative factor of vasculitis but myocarditis has not yet been associated with either ephedrine or its plant derivative ephedra. CASE REPORT: A 39-year-old African American male with hypertension presented to Rush Presbyterian St. Luke's Medical Center with a 1-month history of progressive dyspnea on exertion, orthopnea, and dependent edema. He was taking Ma Huang (Herbalife) 1-3 tablets twice daily for 3 months along with other vitamin supplements, pravastatin, and furosemide. Physical examination revealed a male in mild respiratory distress. The lung fields had rales at both bases without audible wheezes. Internal jugular venous pulsations were 5 cm above the sternal notch. Medical therapy with intravenous furosemide and oral enalapril was initiated upon admission. Cardiac catheterization with coronary angiography revealed normal coronary arteries, a dilated left ventricle, moderate pulmonary hypertension, and a pulmonary capillary wedge pressure of 34 mm Hg. The patient had right ventricular biopsy performed demonstrating mild myocyte hypertrophy and an infiltrate consisting predominantly of lymphocytes with eosinophils present in significantly increased numbers. Treatment for myocarditis was initiated with azothioprine 200 mg daily and prednisone 60 mg per day with a tapering course over 6 months. Anticoagulation with warfarin and diuretics was initiated and angiotensin-converting enzyme inhibition was continued. Hydralazine was added later. One month into therapy, an echocardiogram demonstrated improved left ventricular function with only mild global hypokinesis. A repeat right ventricular biopsy 2 months after the first admission showed no evidence of myocarditis. At 6 months, left ventricular ejection fraction was normal (EFN 50%) and the patient asymptomatic. CONCLUSION: Ephedra (Ma Huang) is the suspected cause of hypersensitivity myocarditis in this patient due to the temporal course of disease and its propensity to induce vasculitis.

PMID: 10465246, UI: 99392915

Clin Excell Nurse Pract 1998 Jul;2(4):225-31

Hypertension in African-American males.

Wagner L

University of Wisconsin-Madison, School of Nursing, USA.

Hypertension is more prevalent in African-Americans than in Caucasians, and African-Americans experience more rapid progression of end-organ damage from this often "silent" disease than do whites. African-American males are particularly at risk because they often are unaware of the disease, do not receive treatment, and/or do not adhere to a treatment regimen if one is prescribed. Management of hypertension in African-American men is complex and requires consideration of the unique aspects of this special-need population. This article outlines some of the special concerns related to hypertension management in African-American men, including differences in pathophysiology, lifestyle, education, and socioeconomic status. Advanced practice nurses, with their additional knowledge and their strong emphasis on patient education and holistic care, possess the skills to competently, caringly, and creatively manage hypertension with African-American clients.

Publication Types:

• Review
• Review, tutorial

PMID: 10455566, UI: 99384478

J Am Diet Assoc 1999 Aug;99(8 Suppl):S69-75

Recruitment and baseline characteristics of participants in the Dietary Approaches to Stop Hypertension trial. DASH Collaborative Research Group.

Appel LJ, Vollmer WM, Obarzanek E, Aicher KM, Conlin PR, Kennedy BM, Charleston JB, Reams PM

Johns Hopkins University, Baltimore, Md., USA.

Dietary Approaches to Stop Hypertension (DASH) was a randomized, multicenter feeding study designed to assess the effects of modifying dietary patterns on blood pressure. Among the most challenging aspects of conducting the DASH trial was the recruitment of participants at the 4 clinical centers. As part of the recruitment drive, 347,500 brochures were mailed, 250,500 coupons were distributed in coupon packs, 114 advertisements were published in newspapers or bulletins, 140 radio and 74 television advertisements were broadcast, and 68 screening events and presentations were conducted. These efforts yielded a total of 459 enrolled participants, ahead of schedule. The most common source of participants was mass mailing of individual brochures (n = 194, 42.3%), followed by word-of-mouth (n = 82, 17.8%), and then other types of mass mailing (n = 44, 9.6%). Recruitment of minority participants followed a similar pattern. Among the 3,192 persons attending the first in-person screening visit, the major reason for nonenrollment was low blood pressure (56%) rather than a diet-related factor. The study population was demographically heterogeneous (49% women, 60% African American, 48% married, and 77% employed full-time). On average, the diet of participants before the DASH feeding study was more similar to the trial control diet than to the combination diet, which reduced blood pressure more effectively. In summary, recruitment of a heterogeneous study population that includes a substantial number of minority participants is a feasible undertaking. However, the effort is considerable and requires a major commitment of resources.

PMID: 10450297, UI: 99378791

J Am Diet Assoc 1999 Aug;99(8 Suppl):S28-34

Pre-enrollment diets of Dietary Approaches to Stop Hypertension trial participants. DASH Collaborative Research Group.

Karanja NM, McCullough ML, Kumanyika SK, Pedula KL, Windhauser MM, Obarzanek E, Lin PH, Champagne CM, Swain JF

Kaiser Permanente Center for Health Research, Portland, Ore. 97227, USA.

A large body of evidence suggests that several nutrients are related to blood pressure. Less is known about the eating patterns of special populations, such as those at risk for hypertension, or how demographic factors affect the diets of these populations. This article characterizes the usual diets of participants before they enrolled in the Dietary Approaches to Stop Hypertension (DASH) trial. During screening for DASH, 380 participants completed the National Cancer Institute food frequency questionnaire. Nutrient and food group intake, the Keys score (a measure of a diet's atherogenicity), and the Diet Quality Index were estimated from the food frequency questionnaire. The effects of age, sex, race, baseline weight, and education on these dietary factors were assessed among DASH participants and compared with similar data from the Third National Health and Nutrition Examination Survey and other published reports. Among DASH participants, African-Americans reported lower intakes of dairy products (P < .001), calcium (P < .001), and magnesium (P < .05) than did whites. Older women reported greater intakes of calcium, magnesium, and potassium (all P < .05) and less fat (P < .05) than did younger women. Older men consumed fewer servings of fruits (P < .03), less vitamin C (P < .05), and had a higher Keys score (P < .05) than did younger men. Heavier (body mass index > or = 25) participants reported lower intakes of protein and potassium, but higher fat and energy intakes (all P < .05). Taken together, these data show that younger, overweight African-American women have the least healthful diets, because they consume more atherogenic foods and fewer of the nutrients related to decreased blood pressure. Overall Diet Quality Index scores did not differ between African-American and white participants. Despite differences in dietary assessment methods between the population samples of DASH and the Third National Health and Nutrition Examination Survey, within each population sample patterns of micronutrient intake were similar between African-American and white participants.

PMID: 10450291, UI: 99378785

Neurology 1999 Aug 11;53(3):517-21

APOE genotype, plasma lipids, lipoproteins, and AD in community elderly.

Romas SN, Tang MX, Berglund L, Mayeux R

Taub Center for Alzheimer's Disease Research, Columbia University, New York, NY 10032, USA.

[Medline record in process]

BACKGROUND: Genetic variation at the APOE locus has a major influence on both plasma lipid levels and the risk of AD. The relationship between APOE genotype and plasma lipids may influence the risk of AD. OBJECTIVE: In a community-based study of white, African American, and Caribbean Hispanic elderly in New York City, we investigated the relationship between plasma lipids and AD as well as the possible influence of APOE genotype on this relationship. METHODS: Total plasma cholesterol (TC), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride levels were investigated in a cross-sectional study of nondemented elderly and patients with AD and in a prospective study of incident AD. Analyses included APOE genotype, gender, ethnicity, body mass index, and other potential confounders such as a history of hypertension, smoking, aspirin use, previous stroke, or ischemic heart disease. RESULTS: Compared with nondemented elderly, decreased TC level had a weak but significant inverse association with incident AD, independent of APOE genotype. No other lipoprotein fragment was associated with either prevalent or incident AD. CONCLUSION: Our results suggest that no consistent relationship exists between APOE genotype, plasma lipoproteins, and AD.

PMID: 10449113, UI: 99376353

Psychosom Med 1999 Jul-Aug;61(4):525-31

Acute effects of transcendental meditation on hemodynamic functioning in middle-aged adults.

Barnes VA, Treiber FA, Turner JR, Davis H, Strong WB

Georgia Institute for Prevention of Human Diseases and Accidents, Medical College of Georgia, Augusta 30912, USA.

[Medline record in process]

OBJECTIVE: Increased peripheral vasoconstriction (ie, total peripheral resistance, or TPR) has been implicated as playing an important role in the early development of essential hypertension. Some studies have demonstrated that Transcendental Meditation (TM) reduces high blood pressure, but the hemodynamic adjustments behind these blood pressure reductions have not been elucidated. The aim of this study was to provide a preliminary investigation of the acute effects of TM on TPR. METHODS: Subjects were 32 healthy adults (16 women and 16 men; 30 white and two African American; mean age, 46.4 +/- 3.9 years). Subjects were divided into a TM group of long-term TM practitioners (eight white women, nine white men, and one African American man; mean years of twice-daily TM practice, 22.4 +/- 6.7) and a control group (eight white women, five white men, and one African American man). Hemodynamic functioning was assessed immediately before and during three conditions: 20 minutes of rest with eyes open (all subjects), 20 minutes of TM (TM group), and 20 minutes of eyes-closed relaxation (control group). RESULTS: During eyes-open rest, the TM group had decreases in systolic blood pressure (SBP) and TPR, compared with increases in the control group (SBP: -2.5 vs. +2.4 mm Hg, p < .01; TPR: -0.7 vs. +0.5 mm Hg/liter per minute, p < .004). During TM, there was a greater decrease in SBP due to a concomitantly greater decrease in TPR compared with the control group during eyes-closed relaxation (SBP: -3.0 vs. +2.1 mm Hg, p < .04; TPR: -1.0 vs. +0.3 mm Hg/liter per minute, p < .03). CONCLUSIONS: TPR decreased significantly during TM. Decreases in vasoconstrictive tone during TM may be the hemodynamic mechanism responsible for reduction of high blood pressure over time. The results of this study provide a preliminary contribution to the understanding of the underlying hemodynamic mechanisms responsible for the beneficial influence of TM on cardiovascular risk factors.

PMID: 10443761, UI: 99371361

Stroke 1999 Aug;30(8):1506-9

Mechanisms of retinal arterial occlusive disease in African American and Caucasian patients.

Ahuja RM, Chaturvedi S, Eliott D, Joshi N, Puklin JE, Abrams GW

Kresge Eye Institute, Department of Ophthalmology, Wayne State University, Detroit, Michigan, USA.

BACKGROUND AND PURPOSE: The aim of our study was to evaluate the causes of retinal arterial occlusive disease in African American patients and to compare these etiologies with those observed in Caucasian patients with retinal ischemic symptoms. METHODS: We performed a retrospective analysis of a series of consecutive patients evaluated by both the ophthalmology department and the neurology/stroke clinic. Patients had a diagnosis of amaurosis fugax, branch retinal artery occlusion, central retinal artery occlusion, or intra-arterial retinal plaques. RESULTS: Twenty-nine African American patients and 17 Caucasian patients were evaluated. African American patients had a mean age of 61 years (range, 30 to 77 years) and Caucasian patients a mean age of 73 years (range, 56 to 94 years) (P=0.003). There was no statistically significant difference between the 2 groups with respect to visible emboli on funduscopy (P=0.462). After adjusting for age, there was also no difference between the 2 groups with regards to risk factors for arterial occlusive disease such as hypertension, coronary artery disease, hypercholesterolemia, tobacco use, and history of stroke or transient ischemic attacks. Caucasian patients had a 41% incidence (7/17) of high-grade ipsilateral internal carotid artery stenosis, measured by carotid duplex, compared with 3.4% incidence (1/29) in African American patients (P=0.002). CONCLUSIONS: There are racial differences in the causes of retinal arterial occlusion. African American patients have a low prevalence of moderate to severe extracranial carotid stenosis, and a high proportion of African American patients have cryptogenic retinal ischemia. In Caucasian patients there is a stronger association between extracranial carotid artery disease and retinal arterial occlusion.

PMID: 10436091, UI: 99365433

Am J Kidney Dis 1999 Aug;34(2):254-8

Familial clustering of end-stage renal disease in blacks with HIV-associated nephropathy.

Freedman BI, Soucie JM, Stone SM, Pegram S

Internal Medicine/Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA. bfreedma@wfubmc.edu

Human immunodeficiency virus-associated nephropathy (HIVAN) develops more often in HIV-infected blacks than whites. Blacks also show marked familial clustering of other causes of end-stage renal disease (ESRD), particularly diabetes mellitus-, hypertension-, and systemic lupus erythematosus-associated ESRD. We compared the family history of ESRD in 201 blacks with ESRD caused by HIVAN (cases) to that of 50 HIV-infected blacks without renal disease (controls) to determine whether HIV-associated ESRD shows familial aggregation. Cases were identified using the Southeastern Kidney Council/ESRD Network 6 Family History of ESRD database. Cases initiated dialysis between September 1993 and October 1998. Controls were consecutively identified, HIV-infected blacks with serum creatinine concentrations of 1.3 mg/dL or less and no proteinuria, treated in an infectious disease clinic during September 1998. Cases and controls had similar mean ages and family sizes. First- or second-degree relatives with ESRD were reported by 24.4% of the cases compared with 6% of the controls (P = 0.004). Logistic regression analysis, controlling for sex, family size, and age, showed cases were 5.4 times more likely than controls to have close relatives with ESRD (P = 0.007). The 49 HIVAN cases who reported a positive family history had a mean of 1.2 additional relatives with ESRD per case (60 total relatives with ESRD). HIVAN was not listed as the cause of ESRD in any of the 27 relatives who underwent dialysis in Network 6 facilities. We conclude that ESRD clusters in the families of nearly 25% of blacks initiating renal replacement therapy for HIVAN. This familial aggregation of ESRD appears to be independent of HIV infection. Although environmental factors cannot be excluded, it is possible an inherited susceptibility to renal failure is present in many blacks with HIV infection who subsequently develop nephropathy.

PMID: 10430971, UI: 99362889

Am J Ther 1999 Jan 1;6(1):19-24

Clinical Experience With Transdermal Clonidine in African-American and Hispanic-American Patients With Hypertension: Evaluation From a 12-Week Prospective, Open-Label Clinical Trial in Community-Based Clinics.

Dias VC, Tendler B, Oparil S, Reilly PA, Snarr P, White WB

Department of Clinical Research, Boehringer Ingelheim, Ridgefield, Connecticut.

[Record supplied by publisher]

The objective of this study was to assess the efficacy and tolerability of transdermal clonidine in inner-city African-American and Hispanic-American patients with essential hypertension. A multiclinic open-label, prospective trial for 12 weeks was used. Dose titration was based on office blood pressure (BP) measurements of > 140/90 mm Hg. Clinical sites were community-based primary care centers. Untreated and treated hypertensive patients whose diastolic BP exceeded 90 mm Hg were administered transdermal clonidine at 0.1 mg or 0.2 mg delivery daily. The drug was titrated after 1 month if diastolic BP was greater than 90 mm Hg. At 12 weeks of treatment, change in blood pressure from baseline as well as adverse effects and patient satisfaction were assessed. A total of 357 patients entered the treatment phase of the study, and 315 patients (244 African-Americans, 67 Hispanic-Americans) had evaluable data. Transdermal clonidine significantly (P <.001) lowered BP in all patients by 15.7/12.8 +/- 18.1/9.6 mm Hg, and heart rate was reduced by 3 +/- 9 beats/min (P <.001). There were no differences in BP reduction according to race and ethnicity, gender, or age. The most common adverse effects were pruritus or discomfort at the patch site, dizziness, dry mouth, and fatigue. Eleven percent of the patients discontinued treatment because of one of these adverse effects. A large proportion of patients (67%) reported that transdermal clonidine was more convenient to use than oral therapy. Transdermal clonidine, alone or in combination with other antihypertensive therapies, significantly lowered BP and heart rate in inner-city hypertensive patients. The drug was generally well tolerated, with 89% of the patients remaining in the trial. Patient acceptability was high with the once-weekly treatment, which is an important feature for this particular hypertensive population.

PMID: 10423643

Am Fam Physician 1999 Jul;60(1):156-62

A rational approach to the treatment of hypertension in special populations.

Hall WD

Emory University School of Medicine, Atlanta, Georgia, USA.

Hypertension in blacks is usually characterized by low renin, expanded volume and sensitivity to salt. Diuretics are the preferred initial therapy, but response to calcium channel antagonists is also good. The blood pressure response to monotherapy with beta blockers or angiotensin-converting enzyme (ACE) inhibitors is blunted, but this effect is abolished with concomitant use of diuretics. The two major types of hypertension in older persons are isolated systolic hypertension and combined systolic and diastolic hypertension. Strong data support the treatment of combined hypertension in patients 60 to 79 years of age and isolated systolic hypertension in patients 60 to 96 years of age. Diuretics and long-acting dihydropyridine calcium channel antagonists are the recommended initial therapies for isolated systolic hypertension. More studies are necessary before recommendations can be made about the treatment of combined hypertension in patients 80 years of age and older.

Publication Types:

• Review
• Review, tutorial

PMID: 10414635, UI: 99341585

Am J Obstet Gynecol 1999 Jul;181(1):S22-7

Racial patterns in the effects of tobacco use on fetal growth.

Sprauve ME, Lindsay MK, Drews-Botsch CD, Graves W

Emory University School of Medicine and Emory University School of Public Health, Department of Gynecology and Obstetrics, Atlanta, GA, USA.

OBJECTIVE: The aim of this study was to characterize the interaction between the effects on fetal growth of maternal smoking and race by means of race-specific growth normograms. STUDY DESIGN: A case-control study was performed on white and African American mothers who were delivered at 2 hospitals in metropolitan Atlanta between February 1993 and December 1994. The study population consisted of 621 small for gestational age infants and their mothers and 324 appropriate for gestational age infants and their mothers. Face-to-face interviews with mothers and detailed anthropometric measurements of neonates were performed. Relationships among tobacco use, race, and fetal growth were evaluated by means of multiple logistic regression. The chi(2) test of trend was performed to assess a dose-response relationship between smoking and fetal growth. RESULTS: Mothers of small for gestational age neonates were significantly more likely than control mothers to be single (52% versus 40%), to be primiparous (47% versus 37%), to have a low body mass index (26% versus 17%), to have hypertension (22% versus 15%), and to use alcohol (15% versus 9%). Mothers of small for gestational age infants were significantly more likely than control mothers to smoke (26% versus 12%) and to smoke more cigarettes (P <.05). After controlling for potential confounders cigarette smoking in the second trimester was significantly associated with small for gestational age infants in both races (whites <1 pack/d adjusted odds ratio 3.82, 1-2 packs/d adjusted odds ratio 4.86, >2 packs/d crude odds ratio; African Americans <1 pack/d adjusted odds ratio 2. 35, 1-2 packs/d adjusted odds ratio 2.52). The chi(2) test of trend results were consistent with a dose-response relationship between smoking and small for gestational age infants (whites chi(2) = 14.06, P <.0001, African Americans chi(2) = 7.99). Comparison between the 2 races of the adverse effects of smoking on fetal growth showed no significant difference. CONCLUSION: Self-reported maternal smoking during the second trimester is associated with fetal growth restriction in a dose-response manner. According to race-specific growth normograms no significant difference in the effects of tobacco use on fetal growth was found between white and African American women.

PMID: 10411787, UI: 99339752

J Epidemiol Community Health 1999 May;53(5):264-8

An inverse relation between blood pressure and birth weight among 5 year old children from Soweto, South Africa.

Levitt NS, Steyn K, De Wet T, Morrell C, Edwards R, Ellison GT, Cameron N

Department of Medicine, University of Cape Town, South Africa.

STUDY OBJECTIVE: To examine the relation between birth weight and blood pressure at 5 years in a cohort of South African children. DESIGN: Prospective cohort study. PARTICIPANTS: 849 five year old children. SETTING: Soweto, a sprawling urban area close to Johannesburg, South Africa, which was a designated residential area for people classified as "black" under apartheid legislation. MAIN RESULTS: Systolic blood pressure at 5 years was inversely related to birthweight (r = -0.05, p = 0.0007), independent of current weight, height, gestational age, maternal age or socioeconomic status at 5 years. There was no relation between birth weight and diastolic blood pressure. After adjusting for current weight and height, there was a mean decline in systolic blood pressure of 3.4 mm Hg (95% confidence intervals 1.4, 5.3 mm Hg) for every 1000 g increase in birth weight. CONCLUSIONS: These data from a disadvantaged urbanised community in Southern Africa extend the reported observations of an inverse relation between birth weight and systolic blood pressure. The study adds to the evidence that influences in fetal life and early childhood influence systolic blood pressure. Further research is required to assess whether efforts to reduce the incidence of low birthweight babies will attenuate the prevalence of hypertension in future generations.

PMID: 10396531, UI: 99324853

Am J Hypertens 1999 Jun;12(6):548-54

A clinical trial to improve high blood pressure care in young urban black men: recruitment, follow-up, and outcomes.

Hill MN, Bone LR, Hilton SC, Roary MC, Kelen GD, Levine DM

The Johns Hopkins University School of Nursing, Baltimore, Maryland 21205-2110, USA. mnhill@son.jhmi.edu

This randomized trial recruited and followed underserved, inner-city, hypertensive (HTN), young black men and investigated whether a nurse-community health worker team in combination with usual medical care (SI) increased entry into care and reduced high blood pressure (HBP), in comparison to usual medical care (UC) alone. Emergency department records, advertising, and BP screenings identified potential participants with HBP. Telephone calls and personal contacts tracked enrollees. Of 1391 potential participants, 803 (58%) responded to an invitation to be screened and scheduled a visit. Of these, 528 (66%) kept an appointment, 207 (35%) were BP eligible, and 204 (99%) consented to enroll. At 12 months 91% of men were accounted for and 85.8% (adjusted for death, in jail, or moved away) were seen. Mean BP changed from 153(16)/98(10) to 152(19)/94(11) mm Hg in the SI group and 151(18)/98(11) to 147(21)/92(14) mm Hg in the UC group (P = NS). High rates of participation are attainable in this population; however, culturally acceptable ways of delivering HBP care are needed.

PMID: 10371363, UI: 99297773

Ethn Dis 1999 Winter;9(1):104-10

Aerobic exercise attenuates blood pressure reactivity to cold pressor test in normotensive, young adult African-American women.

Bond V, Mills RM, Caprarola M, Vaccaro P, Adams RG, Blakely R, Roltsch M, Hatfield B, Davis GC, Franks BD, Fairfax J, Banks M

Department of Kinesiology, University of Maryland, College Park, USA. vbond@fac.howard.edu

Exaggerated blood pressure reactivity to behavioral stress has been observed in the African-American population, and such a pressor response is believed to play a role in hypertension. Regular aerobic exercise has been shown to exert an anti-hypertensive effect, and this may alter the blood pressure hyperreactivity observed in African Americans. To test the hypothesis that aerobic exercise attenuates pressor reactivity in African Americans, we studied eight healthy aerobically-trained normotensive African-American females and five similar sedentary females. The stress stimuli consisted of the cold pressor test with the foot immersed in ice water for two minutes. The aerobic exercise training protocol consisted of six weeks of jogging at 60-70% of peak oxygen uptake (VO2peak), three days/week for 35 min/exercise session. Systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, heart rate, cardiac output, total peripheral resistance, and forearm blood flow were measured. Manifestation of a training effect was illustrated by a 24.1 +/- 0.2% increase in VO2peak (26.9 +/- 1.2 mL x kg(-1) min(-1) vs 35.4 +/- 1.6 mL x kg(-1) min(-1)) (P<.05). Within the exercise-trained group there was a 6.3 +/- .15% decrease in systolic pressure (129 +/- 4.6 mm Hg vs. 121 +/- 5.4 mm Hg) (P<.05), and a 5.0 +/- .05% decrement in mean arterial blood pressure (99 +/- 3.3 mm Hg vs 94 +/- 3.6 mm Hg) (P<.05) during the cold pressor test. Pressor reactivity to cold stress did not change in the untrained group. Measures of heart rate, cardiac output, total peripheral resistance, and forearm blood flow were unaltered during conditions of the cold pressor test. We conclude that aerobic exercise attenuates the blood pressure reactivity to behavioral stress in young, adult normotensive African-American females. A lifestyle change such as exercising may play a role in reducing the risk of hypertension in African-American women.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 10355479, UI: 99281610

Ethn Dis 1999 Winter;9(1):33-47

Examination of factor structure of the cognitive representations of hypertension scale for ethnic equivalence.

Scisney-Matlock M, Watkins K

School of Nursing, The University of Michigan, Ann Arbor 48109-0482, USA.

The major purpose of this analysis was to examine the factor structure of separate interpretive dimensions of the Cognitive Representation of Hypertension Scales (CRHTN) for ethnic equivalence. The CRHTN is a theoretically derived measurement of individualized experience of hypertension assessed along three cognitive interpretive dimensions: perceptions, preferences and possibilities. The sample for this study was recruited from a university-based hypertension clinic, a Veterans Administration ambulatory service, and a large urban-based HMO. Analysis of data through confirmatory factor analysis techniques across both samples provided evidence for construct validity of a five-factor model along three dimensions: perceptions, preferences and possibilities. However, multigroup analyses suggest the model may not equally describe cognitive representations of hypertension for different ethnic groups. Differences in fit of the theoretical model to data from two different ethnic groups is discussed. Findings from this study provide a basis for development of culturally sensitive and appropriate cognitive strengthening strategies to influence behavioral outcomes for hypertension management.

PMID: 10355473, UI: 99281604

Ethn Dis 1999 Winter;9(1):22-32

Ethnic variation in the health burden of self-reported diabetes in adults aged 75 and older.

Black SA, Jakobi PL, Rush RD, DiNuzzo AR, Garcia D

Center on Aging, Department of Internal Medicine, University of Texas Medical Branch, Galveston 77555-0860, USA. sblack@utmb.edu

OBJECTIVE: The health burden of self-reported diabetes was compared across three ethnic groups of older adults. METHODS: Analysis of variance and logistic regression were used to compare ethnic differences in the rates of co-morbid chronic health conditions, complications, and disability for older diabetics vs non-diabetics, in a sample of 173 Mexican Americans, 201 African Americans, and 181 non-Hispanic whites, all aged 75 and older. RESULTS: The prevalence of self-reported diabetes was significantly higher in older Mexican Americans (17.6%) and African Americans (16.4%) than in non-Hispanic whites (8.5%). In all three ethnic groups, and after controlling for sociodemographic characteristics, diabetics were found to be generally at higher risk for chronic conditions such as heart disease, stroke, and hypertension, circulation and foot problems, obesity, and impaired vision and activities of daily living. Multivariate analyses indicated that the burden of diabetes appeared to be greatest among non-Hispanic white diabetics. We suggest that this is the result of higher diabetes-mortality rates among minority diabetics at earlier ages. CONCLUSIONS: Diabetes is known to be increasing in prevalence and incidence, particularly among the elderly, the fastest growing segment of the population. Our findings indicate that regardless of ethnicity, diabetes carries an increased burden that affects both the functioning and the quality of life of older adults.

PMID: 10355472, UI: 99281603

Ethn Dis 1999 Winter;9(1):3-9

Abnormal urinary protein excretion in African Americans with type 2 diabetes mellitus.

Konen JC, Summerson JH, Bell RA

Department of Family Medicine, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA. jkonen@carolinas.org

The purpose of this investigation was to determine the prevalence and correlates of abnormal urinary albumin excretion and to examine the possible additive effects of cardiovascular risk factors on urinary albumin excretion in African Americans with type 2 diabetes mellitus. One hundred fifty-one African-American subjects who met WHO criteria for type 2 diabetes were included in this cross-sectional analysis. Subjects were identified through computerized medical records from a family medicine clinic and a community health center. Urinary albumin excretion ratios (UAER) were determined from overnight samples. The prevalence of abnormal urinary protein excretion was 51%. Of those with abnormal protein excretion, 36% had microalbuminuria and 15% had macroalbuminuria. Diabetes duration, waist to hip ratio, blood pressure, and total- and LDL cholesterol were significantly higher in subjects with macroalbuminuria. Regression analysis indicated that mean arterial blood pressure, diabetes duration and total cholesterol were independently associated with UAER. Mean UAER significantly increased with the addition of one or more syndrome X risk factors to pure diabetes. Our results indicate that African Americans with type 2 diabetes mellitus have a high prevalence of abnormal urinary protein excretion, which is associated with a clustering of additional cardiovascular risk factors. The fact that this increased risk was associated with hypertension indicates that screening for albuminuria in this population is essential and that a majority of African Americans with diabetes may be at risk for developing cardiovascular complications.

PMID: 10355470, UI: 99281601

J Hypertens Suppl 1999 Feb;17(1):S19-24

Difficult-to-treat hypertensive populations: focus on African-Americans and people with type 2 diabetes.

Flack JM, Hamaty M

Department of Internal Medicine, Wayne State University School of Medicine, John D. Dingell VA Medical Center, and the Detroit Medical Center, Michigan 48201, USA. jflack@oncgate.roc.wayne.edu

The awareness, treatment, and control of hypertension has risen steadily over the past three decades, until the early 1990s. However, blood pressure control to < 140/90 mmHg is attained in fewer than 25% of all hypertensive patients and fewer than 50% of drug-treated hypertensive patients, except for white women. Two special populations, African-Americans and diabetics, share several important attributes. First, they both have a high prevalence of hypertension, including stage 3 hypertension (as defined by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension VI: > or =180/110 mmHg), relative to other subgroups. African-Americans have an approximate 8% prevalence of stage 3 hypertension, and elevated systolic blood pressure is highly prevalent among diabetic people, particularly older African-American women. Second, both groups have high levels of blood-pressure-related target-organ damage, which contributes to their inordinately high absolute risk for cardiovascular disease complications (i.e. stroke, congestive heart failure, renal failure) at a given level of blood pressure. Moreover, the reduced natriuretic capacity common to each group contributes to the attenuated efficacy of antihypertensive drug monotherapy, particularly for drug classes other than diuretics and calcium antagonists. These two special populations are also typically salt-sensitive, an intermediate blood pressure phenotype that raises blood pressure medication requirements. This phenomenon has been associated with an attenuation in the normal nocturnal fall in blood pressure. The high absolute risk for cardiovascular disease among diabetics led to the formulation of more aggressive treatment recommendations for antihypertensive drug therapy. In diabetics, blood pressure therapy is initiated at blood pressures > or = 130/85 mmHg, and treatment goals are at least to this level, unless proteinuria is > or = 1g/day (in which case the goals are < 125/75 mmHg). The more aggressive treatment targets for diabetics will not be reached with most currently available single antihypertensive agents in many African-Americans. While at best only 50-60% of hypertensive patients can be controlled with single drug therapy, that percentage falls dramatically in persons with stage 3 hypertension and renal insufficiency, thereby necessitating the use of combination drug therapy. Treatment alone is not enough; treatment to goal blood pressure is an essential first step towards optimal target-organ protection. While circulating levels of renin are suppressed, in general, in these special populations, each group manifests an inordinate burden of blood-pressure-related target-organ damage that has been linked to excessive levels of angiotensin II or a reduced bradykinin and nitric oxide tissue effect. The renin-angiotensin-aldo-sterone-kinin system is therefore an attractive therapeutic target that might conceivably provide target-organ protection over and above that attributable solely to lowering the blood pressure.

Publication Types:

• Review
• Review, tutorial

PMID: 10340840, UI: 99270688

Nurs Res 1999 May-Jun;48(3):150-61

Mood and blood pressure responses in black female caregivers and noncaregivers.

Picot SJ, Zauszniewski JA, Debanne SM, Holston EC

Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, USA. sjp8@po.cwru.edu

BACKGROUND: Substantial interaction between mood and blood pressure, especially in the context of caregiving for a dependent elder, could increase the risk in the already at-risk population of black women for either higher blood pressure or the onset of hypertension. OBJECTIVES: To examine the relationship between mood symptoms and daytime ambulatory blood pressures during a 12-hour period in Black female caregivers and noncaregivers. METHOD: A prospective cohort design was employed to study black females 18 years of age or older identified by randomly selected elders as the provider or potential provider of 5 or more hours of care per week to the elder. Mood symptoms were measured on visual analogue scales by the subjects in a diary attached to a retractable clip key ring worn by the subject. Blood pressure responses were measured with automated portable blood pressure monitors every 30 minutes. Additional risk and treatment factors were considered for descriptive purposes. RESULTS: The two groups were equivalent on all hypertension risk and treatment factors except alcohol use (more noncaregivers consumed alcohol). Among caregivers, anger and mean diastolic blood pressure (DBP) were negatively related (parameter = -0.64, SE = .23, p = .01) and the negative relationship between anger and systolic blood pressure approached significance (parameter = -0.81, SE = 0.65, p = 0.10). Anxiety and sadness were not significant predictors. CONCLUSION: Among black caregivers, elevated anger was associated with significant decreases in DBP, while lowered anger was associated with significant increases in DBP. Whether lower anger scores reflect a low level of perceived anger or suppressed anger among black caregivers should be explored in future studies.

PMID: 10337846, UI: 99268168

Hypertension 1999 May;33(5):1099-104

Race and diurnal blood pressure patterns. A review and meta-analysis.

Profant J, Dimsdale JE

Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, USA.

Investigators have reported variable findings regarding the role of race in diurnal blood pressure patterns. We performed a review and meta-analysis of this literature to identify the overall effect of race on circadian blood pressure patterns. Eighteen studies involving 2852 participants were reviewed. Meta-analyses were conducted using effect sizes calculated from the data provided directly in the study reports. Separate meta-analyses were conducted on effect sizes for differences between blacks and whites in daytime and nighttime systolic and diastolic blood pressure and nocturnal dip in systolic and diastolic blood pressure. To evaluate discrepancies in findings from studies involving American versus non-American blacks, overall meta-analyses as well as within-subset meta-analyses of black/white differences were conducted for comparisons involving American and non-American blacks. Results of overall meta-analyses indicate that blacks experience higher levels of systolic and diastolic blood pressure, both at night and during the day. These differences were significantly greater at night than during the day (P<0.05). Results of within-subset analyses involving American blacks mirrored those for all black/white comparisons, except that the effect of race on nocturnal dip, ie, that American blacks experienced less of a dip in both systolic and diastolic blood pressure at night, was significant (P<0.05). In contrast, the effect of race on nocturnal dip was not significant for comparisons involving non-American blacks. These results suggest a consistent difference in the chronobiology of blood pressure, particularly in American blacks.

Publication Types:

• Meta-analysis

PMID: 10334794, UI: 99267477

J Hum Hypertens 1999 Apr;13(4):237-41

Obesity and hypertension among college-educated black women in the United States.

Rosenberg L, Palmer JR, Adams-Campbell LL, Rao RS

Slone Epidemiology Unit, Boston University School of Medicine, Brookline, MA 02446, USA.

It is established that obesity is an important risk factor for hypertension, but there is little information on this relationship among highly educated black women. We assessed the relationship of body mass index (weight (kg)/height2 (m)) to prevalent hypertension among US black women who had completed college, and among less educated women as well. The data were collected in 1995 in the Black Women's Health Study: 64530 African-American women aged 21 to 69 years enrolled by completing mailed health questionnaires; 44% of the participants had completed college. We compared the 9394 participants who reported a diagnosis of hypertension treated with a diuretic or antihypertensive drug (cases) with 9259 participants of similar ages who did not have hypertension (controls). Multivariate odds ratios were estimated by logistic regression. The odds ratio for treated hypertension increased with increasing body mass index at every educational level. Among college-educated women, the odds ratio for hypertension was 2.7 for overweight women (index 27.3-32.3) and 4.9 for severely overweight women (index > or =32.3), relative to women with a body mass index <22.8. The prevalences of obesity and hypertension were high among the college-educated women, although not as high as among women with fewer years of education. About a quarter of the difference in the prevalence of hypertension across educational levels was explained by the difference in the proportions who were overweight or severely overweight. These results document a high prevalence of obesity and hypertension, and a strong association of obesity with hypertension, among highly educated US black women.

PMID: 10333341, UI: 99264136

Arch Ophthalmol 1999 May;117(5):573-83

The Ocular Hypertension Treatment Study: design and baseline description of the participants.

Gordon MO, Kass MA

Department of Ophthalmology and Visual Sciences, Washington University, St Louis, MO 63110, USA.

BACKGROUND: The Ocular Hypertension Treatment Study (OHTS) seeks to evaluate the safety and efficacy of topical ocular hypotensive medication in preventing or delaying the onset of visual field loss and/or optic nerve damage in subjects with ocular hypertension at moderate risk for developing primary open angle glaucoma. OBJECTIVE: To describe the study protocol, the questions to be answered, and the baseline characteristics of the subjects. DESIGN: Multicenter randomized clinical trial with 2 groups: topical ocular hypotensive medication and close observation. SETTING: Subjects were enrolled and evaluated at 22 participating clinical centers. Visual fields and stereoscopic optic disc photographs were read in masked fashion. METHODS: We determined eligibility from a comprehensive eye examination, medical and ocular history, visual field testing, and stereoscopic optic disc photography. RESULTS: We describe the baseline characteristics of 1637 subjects randomized between February 28, 1994, and October 31, 1996. The mean age was 55 years; 56.9% of the subjects were women; and 25% were African American. The baseline intraocular pressure was 24.9 +/- 2.7 mm Hg (mean +/- SD). Systemic diseases and conditions reported by subjects included previous use of medication for ocular hypertension, 37%; systemic hypertension, 38%; cardiovascular disease, 6%; diabetes mellitus, 12%; and family history of glaucoma, 44%. The mean horizontal cup-disc ratio by contour estimated from stereophotography was 0.36 +/- 0.18. Qualifying Humphrey 30-2 visual fields had to be normal and reliable for entry into the study. Health-related quality of life (36-item short form health survey) scores in the OHTS sample were better than the age- and sex-matched population norms. African American subjects had larger baseline cup-disc ratios and higher reported rates of elevated blood pressure and diabetes than the rest of the subjects. CONCLUSIONS: The intraocular pressure among enrolled subjects was sufficiently high to provide an adequate test of the potential benefit of ocular hypotensive medication in preventing or delaying glaucomatous damage. The large number of African American subjects enrolled should provide a good estimate of the African American response to topical medication.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 10326953, UI: 99256885

Am J Cardiol 1999 May 1;83(9):1350-5

Gender differences and practice implications of risk factors for frequent hospitalization for heart failure in an urban center serving predominantly African-American patients.

Ofili EO, Mayberry R, Alema-Mensah E, Saleem S, Hamirani K, Jones C, Salih S, Lankford B, Oduwole A, Igho-Pemu P

Department of Medicine and the Medical Treatment Effectiveness Center, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.

To identify the clinical correlates of recurrent heart failure hospitalization in a large urban hospital serving predominately African-American patients, and to provide further insight into modifiable risks for heart failure readmissions, a retrospective period prevalence review of the records of all adult patients admitted with a primary diagnosis of heart failure (International Classification of Diseases-9 code 428.0) between January and December 1995 was performed.The main outcome was the number of heart failure hospitalizations over 12 months. Twelve hundred patients were identified. Mean age was 64 +/- 16 years, 94% were black, 57% were women, and 40% were > or = 65 years old. Ninety-eight percent had a history of systemic hypertension and 55% had uncontrolled hypertension. Other comorbidities were left ventricular (LV) hypertrophy (64%), coronary artery disease (52%), and tobacco abuse (28%). Sixty-five percent of patients were on angiotensin-converting enzyme (ACE) inhibitors, 51% on calcium antagonists, and 8% on beta blockers. Most patients had suboptimal dosing of ACE inhibitors and there was inappropriate use of calcium antagonists in 56% of patients with moderate or severe systolic dysfunction. Diabetes mellitus and echocardiographic wall motion abnormality were independently associated with frequent admissions for women but not for men. Medication-related increase in heart failure hospitalization was seen for calcium antagonists in patients with severe LV dysfunction (odds ratio 2.24, 95% confidence intervals 1.0 to 5.03; p <0.03). Uncontrolled hypertension, underdosing of ACE inhibitors, and overuse of calcium antagonists in patients with significant LV dysfunction are potential targets for intervention.

PMID: 10235094, UI: 99249173

Ann Behav Med 1998 Fall;20(4):326-32

Anger inhibition, cardiovascular recovery, and vagal function: a model of the link between hostility and cardiovascular disease.

Brosschot JF, Thayer JF

University of Amsterdam.

A model of the association between hostility and cardiovascular disease (CVD) is proposed based upon anger inhibition, slow cardiovascular recovery, and low parasympathetic activity (vagal tone). This model is opposed to the more conventional model that emphasizes anger expression, cardiovascular reactivity, and high sympathetic tone. We argue that in social reality, incidences of anger inhibition outnumber incidences of anger expression to a great extent, irrespective of preferred expression style. Moreover, slow cardiovascular recovery, rather than high reactivity, may be the mechanism underlying the CVD risk associated with anger inhibition. Both anger inhibition and slow cardiovascular recovery are associated with a persistently low vagal tone. Thus, the anger inhibition/vagal inhibition model seems more consistent with the actual nature of anger in daily life and with the known cardiovascular control mechanisms. The model may better account for the chronic pathophysiological state that is believed to lead to CVD. Importantly, an experimental inhibition/recovery paradigm might also allow to test potential behavioral and cognitive accelerators of cardiovascular recovery. As an example of an important socially-mediated health risk that may be elucidated using the anger inhibition/vagal inhibition model, we discuss Black-White differences that have been found in CVD.

PMID: 10234427, UI: 99250686

J S C Med Assoc 1999 Mar;95(3):116-8

Race and health care.

Bryan CS

Publication Types:

• Editorial

PMID: 10204332, UI: 99220543

J Am Geriatr Soc 1999 Apr;47(4):482-6

Alzheimer's disease symptom severity in blacks and whites.

Shadlen MF, Larson EB, Gibbons L, McCormick WC, Teri L

Department of Medicine, Alzheimer's Disease Research Center, University of Washington, Seattle, USA.

OBJECTIVE: In order to determine whether there are racial differences in Alzheimer's Disease (AD) symptom severity and vascular comorbidities, we compared African-American (black) and Caucasian (white) patients with AD from similar socioeconomic backgrounds at the time the disease was first recognized. DESIGN: Cross-sectional observational study from a population-based dementia registry. PARTICIPANTS: Patients were enrolled from an HMO base population of 23,000 persons more than age 60 in Seattle, Washington. This study examines 453 subjects with probable AD (38 blacks (mean age 76.5, SD 6.4), and 415 whites (mean age 79.7, SD 6.7)). MEASUREMENTS: Measured were patient demographics, age at onset of AD, AD symptom duration, Mini-Mental State Exam (MMSE) score, Blessed Dementia Rating Scale, presence of psychiatric symptoms, and vascular comorbidities. RESULTS: Blacks had significantly lower mean cognitive scores (MMSE = 17.2, SD 5.6) compared with whites (MMSE = 20.2, SD 5.2, unpaired t test P < .01). The significant racial difference in MMSE scores persisted after controlling for education, duration of AD symptoms, age, and ADL impairment. Blacks and whites did not differ significantly regarding gender distribution, education level, income, or percent with early age of onset of AD. No statistically significant race-related differences were found in impairments in activities of daily living or symptoms of paranoia, hallucinations, or agitation. Blacks had significantly higher rates of hypertension (56%) compared with whites (34%) (Fisher's exact test, P = .013), but the rates of stroke and ischemic heart disease were similar. CONCLUSIONS: Despite uniform detection methods and controlling for reported duration of dementia symptoms, measured cognitive impairment is significantly more severe when AD is recognized in blacks compared with whites. The significantly higher prevalence of hypertension among black AD cases was not associated with excess cerebrovascular disease comorbidity. This study highlights a need for normative measurements of cognitive function in minority AD groups in order to distinguish differential cognitive symptom severity from possible measurement bias.

PMID: 10203126, UI: 99217776

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Health Serv Res 1999 Apr;34(1 Pt 1):145-70

The role of medical problems and behavioral risks in explaining patterns of prenatal care use among high-risk women.

Clarke LL, Miller MK, Albrecht SL, Frentzen B, Cruz A

Department of Health Policy and Epidemiology, College of Medicine, University of Florida, Gainesville 32610-0177, USA.

OBJECTIVE: To examine the associations between maternal medical conditions and behavioral risks and the patterns of prenatal care use among high-risk women. DATA SOURCE/STUDY DESIGN: Data on over 25,000 high-risk deliveries to African American and white women using multinomial logistic regression to predict the odds of adequate-plus care relative to three other categories of care. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from records maintained by the University of Florida/Shands Hospital maternity clinic on all deliveries between 1987 and 1994; records for white and for African American women were subset to examine racial differences in medical conditions, health behaviors, and patterns of prenatal care use. PRINCIPAL FINDINGS: Net of sociodemographic and fertility-related characteristics, African American and white women with late antepartum conditions and hypertension problems had significantly higher odds of receiving adequate-plus care, as well as no care or inadequate care, relative to adequate care. White women with gynecological disease and medical/surgical problems were significantly less likely to receive no care or inadequate care, as were African American women with gynecological disease. CONCLUSIONS: Maternal medical conditions explain much but not all of the adequate-plus prenatal care use. More than 13 percent of African American women and 20 percent of white women with no reported medical problems or behavioral risks used adequate-plus care. Additional research is needed to understand this excess use and its possibilities in mediating birth outcomes.

PMID: 10201856, UI: 99216039

Int J Aging Hum Dev 1998;47(4):279-97

The relationship between perceptions of social support and adherence to dietary recommendations among African-American elders with hypertension.

Schoenberg NE

Department of Behavioral Science, University of Kentucky, Lexington 40536-0086, USA. nesch@pop.uky.edu

Social support is generally thought to facilitate adherence to recommended treatment regimens. Despite a well-documented tradition of social support among African Americans, much of the existing research indicates a very limited level of adherence, especially to dietary modification. To account for this seeming contradiction, forty-one rural-dwelling African Americans with hypertension age 65+ participated in a series of structured and semi-structured interviews. Results indicate that 1) informants perceived themselves to be well-supported by family and friends; 2) most informants have achieved a moderate to high level of dietary adherence; and 3) no statistically significant relationship existed between perceived social support and dietary adherence. The discussion focuses on three reasons for this lack of association, including: 1) modest sample size; 2) informants' identification of helpful others who defied standard evaluations of support; and 3) incremental and gradual dietary changes that required little need for social support.

PMID: 10198806, UI: 99215019

Am J Cardiol 1999 Apr 1;83(7):1144-5, A10

Risk factors for new atherothrombotic brain infarction in older African-American men and women.

Aronow WS, Ahn C, Gutstein H

Hebrew Hospital Home, Bronx, New York 10475, USA.

Independent risk factors for new atherothrombotic brain infarction (ABI) in older African-American men were hypertension (risk ratio 4.381), diabetes mellitus (risk ratio 2.872), and previous ABI (risk ratio 1.904). Independent risk factors for new coronary events in older African-American women were cigarette smoking (risk ratio 2.754), hypertension (risk ratio 5.914), diabetes mellitus (risk ratio 3.464), serum total cholesterol (risk ratio 1.008), serum high-density lipoprotein cholesterol (inverse association) (risk ratio 0.958), age (risk ratio 1.026), and previous ABI (risk ratio 2.601).

PMID: 10190539, UI: 99204814

Diabetes Care 1999 Apr;22(4):562-8

Insulin sensitivity in subjects with type 2 diabetes. Relationship to cardiovascular risk factors: the Insulin Resistance Atherosclerosis Study.

Haffner SM, D'Agostino R Jr, Mykkanen L, Tracy R, Howard B, Rewers M, Selby J, Savage PJ, Saad MF

Department of Medicine, University of Texas Health Science Center at San Antonio 78284-7873, USA.

OBJECTIVE: Among nondiabetic subjects, insulin resistance has been associated with increased cardiovascular risk factors, including dyslipidemia, hypertension, impaired fibrinolysis, and coagulation. Less is known about the relationship between insulin resistance and cardiovascular risk factors in subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS: To examine this issue, we determined insulin sensitivity (SI) in 479 type 2 diabetic subjects by minimal model analyses of frequently sampled intravenous glucose tolerance tests in the Insulin Resistance Atherosclerosis Study (IRAS), a large multicenter study of insulin sensitivity and cardiovascular disease in African-Americans, Hispanics, and non-Hispanic whites. We defined insulin-sensitive subjects as having SI > or = 1.61 x 10(-4) min-1.microU-1.ml-1 (above median in nondiabetic subjects of all ethnic groups in the IRAS). Using this definition, only 37 type 2 diabetic subjects were insulin sensitive, and the remaining 442 were insulin resistant. RESULTS: After adjustment for age, sex, ethnicity, and clinic, insulin resistance was significantly correlated with total triglycerides, VLDL cholesterol, VLDL triglyceride, fibrinogen, PAI-1, and fasting glucose, and was inversely correlated with HDL cholesterol level and LDL size. Carotid intimal-medial thickness was greater in insulin-resistant than in insulin-sensitive subjects, but this difference was not statistically significant. After further adjustment for waist circumference (marker of visceral adiposity), insulin-resistant subjects continued to have higher plasminogen activator inhibitor 1 and VLDL triglyceride levels, lower HDL cholesterol levels, and smaller LDL particle size than did insulin-sensitive subjects. After further adjustment for fasting glucose levels, these results were very similar. CONCLUSIONS: We conclude that insulin-resistant type 2 diabetic subjects have more atherogenic cardiovascular risk factor profiles than insulin-sensitive type 2 diabetic subjects and that this is only partially related to increased obesity and an adverse body fat distribution.

Publication Types:

• Multicenter study

PMID: 10189532, UI: 99205530

Am Demogr 1998 May;20(5):26-9

Strokes and the South.

Braus R

PMID: 10182485, UI: 98618687

Am J Med Sci 1999 Mar;317(3):189-92

Traditional coronary risk factors in African Americans.

Potts JL, Thomas J

Department of Medicine, Meharry Medical College, Nashville, Tennessee 37208, USA.

The importance of traditional coronary artery disease risk factors in the development of coronary heart disease is well known. African Americans have a higher prevalence of such risk factors as hypertension, diabetes mellitus, obesity, cigarette smoking, and left ventricular hypertrophy, which might account for the disproportionate rate of coronary heart disease mortality in African Americans. Compelling data from randomized lipid-lowering trials show conclusively that lowering cholesterol levels, specifically low-density lipoprotein cholesterol, lowers coronary heart disease morbidity and mortality. Recent data has also demonstrated the beneficial effects of lowering blood pressure on cardiovascular mortality. Left ventricular hypertrophy, which results from elevated blood pressure, seems to raise coronary heart disease risks independently. Diabetes mellitus, cigarette use, physical inactivity, stress, and obesity play critical roles collectively and individually in increasing coronary heart disease, morbidity, and mortality. Clustering of coronary heart disease risk factors in African Americans must be strongly considered to play a critical role in the excess mortality from coronary heart disease seen in African Americans. New innovative approaches are required if the course of coronary heart disease is to be altered.

Publication Types:

• Review
• Review, tutorial

PMID: 10100693, UI: 99198792

Am J Med Sci 1999 Mar;317(3):183-8

The role of hypertension, obesity, and diabetes in causing renal vascular disease.

Crook ED

Department of Medicine/Division of Nephrology, University of Mississippi Medical Center, Jackson 39216, USA.

The Jackson Heart Study will be an epidemiological study of African Americans in Jackson, Mississippi, to identify risk factors for development and progression of cardiovascular disease. One of the potential risk factors to be assessed in this study is renal vascular disease. Atherosclerotic renal vascular disease is a disease of the elderly, is predominantly seen in white people, and is strongly associated with diffuse atherosclerotic disease and high-grade hypertensive retinopathy. Patients with ischemic nephropathy may constitute up to 16% of new dialysis patients and die more quickly while on renal replacement therapy. Although often not present, hypertension is a commonly observed consequence (but probably not a cause) of renal vascular disease, and the control of blood pressure may not halt the progression of the disease. Approximately 20-25% of patients with moderate to severe renal artery stenosis will be diabetic. Diabetic patients fair less well with intervention and have a higher progression to end-stage renal disease or death. Obesity is not commonly seen in patients with renal vascular disease. The Jackson Heart Study may be able to assess the true incidence of atherosclerotic renal vascular disease in African Americans and its impact of cardiovascular morbidity and mortality.

Publication Types:

• Review
• Review, tutorial

PMID: 10100692, UI: 99198791

Am J Med Sci 1999 Mar;317(3):168-75

Why is left ventricular hypertrophy so predictive of morbidity and mortality?

Benjamin EJ, Levy D

National Heart, Lung, and Blood Institute's Framingham Heart Study, MA 01702, USA. emelia@fram.nhlbi.nih.gov

The prevalence, prognosis, and predictors of left ventricular hypertrophy (LVH) are reviewed, and theories of the pathogenesis of the relation between LVH and poor prognosis are summarized to highlight controversies in the field. In the Framingham Heart Study, which consists largely of white people, echocardiographic LVH has a prevalence of 14% in men and 18% in women. The prevalence of LVH is reported to be elevated in African Americans compared with whites, although the higher prevalence has been attributed to the increased prevalence of hypertension and obesity. Echocardiographic LVH is independently associated with a variety of cardiovascular endpoints, including coronary heart disease and stroke. Furthermore, after adjusting for other cardiovascular disease risk factors, LVH is associated with a doubling in mortality in both white and African American cohorts. Despite the intensive investigation of LVH, there remain many unanswered questions: To what extent do genetic or other factors account for the large portion of the variance in LVH that remains unexplained? What is the prognosis of LVH and left ventricular geometry in a population-based African American cohort? How does the development and progression of LVH relate to other risk factors and their treatment? What is the relation of LVH to poor prognosis? The proposed Jackson Heart Study will help address many important unanswered questions regarding LVH.

Publication Types:

• Review
• Review, tutorial

PMID: 10100690, UI: 99198789

Am J Med Sci 1999 Mar;317(3):152-9

What is the role of dietary sodium and potassium in hypertension and target organ injury?

He J, Whelton PK

Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA. jhe@mailhost.tcs.tulane.edu

There is substantial evidence from both observational epidemiology studies and randomized controlled trials that dietary intake of sodium and potassium is important in the etiology of hypertension. However, the direct evidence for a direct link between dietary sodium and potassium and risk of cardiovascular and renovascular events is limited. Epidemiological studies should be designed to examine the relationship between dietary intake of sodium and potassium and risk of stroke, coronary heart disease, left ventricular hypertrophy, and renal disease in a prospective manner. In these studies, dietary intake of sodium and potassium should be estimated using multiple 24-hour urine collections. These studies should be focused on African Americans because they are at a disproportionately high risk of developing hypertension and blood pressure-related vascular disease. Moreover, this group has been underrepresented in most previous epidemiological studies.

Publication Types:

• Review
• Review, tutorial

PMID: 10100688, UI: 99198787

Am J Med Sci 1999 Mar;317(3):147-51

What is the role of obesity in hypertension and target organ injury in African Americans?

Jones DW

Center for Excellence in Cardiovascular-Renal Research, University of Mississippi Medical Center, Jackson 39216-4505, USA.

Hypertension is the most common reversible risk factor for cardiovascular disease. It is especially common in African Americans. One of the factors that may contribute to the high rates of hypertension and target organ injury in African Americans is obesity. Hypertension and obesity are common among African Americans. Obesity is particularly common in African American women. About 75% of African American women are obese. Regulation of both body weight and blood pressure are complex, involving an interaction of genetic and environmental factors. Most research thus far has focused on blood pressure control systems studied in other forms of hypertension, including the sympathetic nervous system, the renin angiotensin system, and metabolic factors-primarily insulin resistance. Proposed mechanisms that are unique to obesity-associated hypertension include: 1) intrarenal physical forces associated with obesity-induced changes in the renal medulla; 2) genetic/metabolic factors; and 3) metabolic effects of abdominal visceral fat. The Jackson Heart Study provides a unique opportunity to address unresolved questions in the relationship of body weight, blood pressure, and cardiovascular disease.

Publication Types:

• Review
• Review, tutorial

PMID: 10100687, UI: 99198786

Am J Med Sci 1999 Mar;317(3):142-6

Overview of the Jackson Heart Study: a study of cardiovascular diseases in African American men and women.

Sempos CT, Bild DE, Manolio TA

Epidemiology and Biometry Program, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA. semposc@od.nih.gov

The Jackson Heart Study is a partnership among Jackson State University, Tougaloo College, the University of Mississippi Medical Center and the National Institutes of Health's National Heart, Lung, and Blood Institute (NHLBI) and Office of Research on Minority Health. The purposes of the study are to: (1) establish a single-site cohort study to identify the risk factors for the development of cardiovascular diseases, especially those related to hypertension, in African American men and women; (2) build research capabilities in minority institutions by building partnerships; (3) attract minority students to careers in public health and epidemiology; and (4) establish an NHLBI Field Site in Jackson, Mississippi, similar to those established for the Framingham Heart Study and the Honolulu Heart Program. The study will consist of participants from the Jackson site of the Atherosclerosis Risk in Communities (ARIC) Study and a sample of residents from the Jackson metropolitan area. The study will have a sample size of approximately 6,500 men and women aged 35-84 years and will include approximately 400 families. Exam 1 is scheduled to take place in the spring of the year 2000.

PMID: 10100686, UI: 99198785

Ned Tijdschr Geneeskd 1999 Jan 30;143(5):229-34

[Hypertension in the Negro patient].

Timmers GJ, Schouten JA, ter Wee PM, Gans RO

Academisch Ziekenhuis Vrije Universiteit, Amsterdam.

Essential hypertension appears to be more prevalent among blacks than among whites and has an earlier onset in blacks. Many data in this field come from studies in the African-American population. Hypertension-related complications, e.g. ischaemic heart disease, (end stage) renal failure and cerebrovascular disease, are encountered more often among blacks and frequently run a more severe course. Factors that might explain the racial difference in prevalence of hypertension and hypertensive complications include both genetic and environmental variables. Hypertension in blacks is characterized by salt sensitivity, a tendency towards expanded plasma volume and low plasma renin levels. Socioeconomic factors, the higher prevalence of obesity and insulin resistance may contribute to the high prevalence of hypertension in blacks. Aggressive antihypertensive therapy appears mandatory in the black hypertensive, possibly with lower goal blood pressures than the 140/90 mmHg generally recommended. Diuretic monotherapy proves to be the first-line therapy, calcium channel blockers are an attractive alternative. Black patients are frequently less responsive to monotherapy with angiotensin-converting enzyme (ACE) inhibitors and beta-blocking agents. This black/white difference in therapeutic response can, however, be eliminated by addition of a diuretic.

Publication Types:

• Review
• Review, tutorial

PMID: 10086150, UI: 99186069

Am J Public Health 1999 Mar;89(3):302-7

Prevalence and social correlates of cardiovascular disease risk factors in Harlem.

Diez-Roux AV, Northridge ME, Morabia A, Bassett MT, Shea S

Division of General Medicine, Columbia College of Physicians and Surgeons, USA. diezrou@medicine1.cpmc.columbia.edu

OBJECTIVES: This study examined the prevalence, social correlates, and clustering of cardiovascular disease risk factors in a predominantly Black, poor, urban community. METHODS: Associations of risk factor prevalences with sociodemographic variables were examined in a population-based sample of 695 men and women aged 18 to 65 years living in Central Harlem. RESULTS: One third of the men and women were hypertensive, 48% of the men and 41% of the women were smokers, 25% of the men and 49% of the women were overweight, and 23% of the men and 35% of the women reported no leisure-time physical activity over the past month. More than 80% of the men and women had at least 1 of these risk factors, and 9% of the men and 19% of the women had 3 or more risk factors. Income and education were inversely related to hypertension, smoking, and physical inactivity. Having 3 or more risk factors was associated with low income and low education (extreme odds ratio [OR] = 10.2, 95% confidence interval [CI] = 3.0, 34.5 for education; OR = 3.7, CI = 1.6, 8.9 for income) and with a history of unstable work or of homelessness. CONCLUSIONS: Disadvantaged, urban communities are at high risk for cardiovascular disease. These results highlight the importance of socioenvironmental factors in shaping cardiovascular risk.

PMID: 10076477, UI: 99175773

Arch Intern Med 1999 Mar 8;159(5):505-10

Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population.

Croft JB, Giles WH, Pollard RA, Keenan NL, Casper ML, Anda RF

Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724, USA. jbc0@cdc.gov

OBJECTIVE: To describe the 6-year probability of survival for older adults after their first hospitalization for heart failure. SETTING: National Medicare hospital claims records for 1984 through 1986 and Medicare enrollment records from 1986 through 1992. DESIGN: We identified a national cohort of 170 239 (9% black patients) Medicare patients, 67 years or older, with no evidence of heart failure in 1984 or 1985, who were hospitalized and discharged for the first time in 1986 with a principal diagnosis of heart failure. For groups defined by race, sex, age, Medicaid eligibility, and comorbid conditions, we compared the probability of survival with Cox proportional hazards regression. RESULTS: Only 19% of black men, 16% of white men, 25% of black women, and 23% of white women survived 6 years. One third died within the first year. Men had lower median survival and 38% greater risk of mortality than did women (P<.05). White men had 10% greater risk of mortality than did black men (P<.05). Medicaid eligibility (white adults only) and diabetes were associated with increased mortality (P<.05). CONCLUSIONS: The prognosis for older adults with heart failure underscores the importance of prevention strategies and early detection and treatment modalities that can prevent, improve, or reverse myocardial dysfunction, particularly for the growing number of adults who are at increased risk for developing heart failure because of hypertension, diabetes, or myocardial infarction.

PMID: 10074960, UI: 99173255

Arch Intern Med 1999 Mar 8;159(5):498-503

Plasma insulin levels and incidence of hypertension in African Americans and whites.

He J, Klag MJ, Caballero B, Appel LJ, Charleston J, Whelton PK

Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA. jhe@mailhost.tcs.tulane.edu

BACKGROUND: Hyperinsulinemia may play an important role in the pathogenesis of hypertension in whites but the role of hyperinsulinemia in hypertension in African Americans is controversial. SUBJECTS AND METHODS: We studied the relationship between insulin levels and subsequent incidence of hypertension in 140 African Americans and 237 whites who were initially screened for possible participation in the Trials of Hypertension Prevention, phase 1. Plasma insulin and serum glucose were measured at baseline and at a follow-up examination 7 years later. Blood pressure was measured by trained observers using a random-zero sphygmomanometer. Incident hypertension was defined as an average systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 95 mm Hg or higher at a single visit and/or use of antihypertensive medication during follow-up. RESULTS: Over the 7 years of follow-up, the incidence of hypertension was 25.7% in the African Americans and 25.3% in the whites. Baseline plasma insulin and insulin-to-glucose ratio were associated with an increased risk of hypertension in both the African Americans and the whites. After adjustment for age, sex, race, body mass, heart rate, and alcohol consumption at baseline as well as intervention assignment in the Trials of Hypertension Prevention, phase 1, a 1-SD (21 pmol/mmol) difference in baseline insulin-to-glucose ratio was associated with a 2.77 (95% confidence interval, 1.48-5.19) odds ratio of hypertension in the African Americans and a 1.69 (95% confidence interval, 1.08-2.64) odds ratio in the whites. CONCLUSION: These results suggest that higher plasma insulin levels are associated with an increased risk of hypertension in both African Americans and whites.

PMID: 10074959, UI: 99173254

J Health Care Poor Underserved 1998 Feb;9(1):62-75

Hypertension in community-dwelling elders from a statewide study: implications for nonpharmacologic therapy.

Ciesla JR, Piane G, Rubens AJ

School of Allied Health Professions, Northern Illinois University, DeKalb 60115-2854, USA.

This study used multivariate analysis to determine the sociodemographic variables that predict whether hypertensive elders who are aware of their disease deliberately make lifestyle modifications aimed at controlling their hypertension. The data are from the 1990 Panel Study of Older South Carolinians (n = 6,473). The researchers performed five separate logistic regressions, each to predict the odds that the elders made specific lifestyle changes to reduce their hypertension. The dependent variable in the first regression was 1 = quite smoking to reduce hypertension and 0 = did not quite smoking to reduce hypertension. Changing diet, exercising, taking medication, and using stress management techniques were the dependent variables in the second, third, fourth, and fifth regressions, respectively. Significant determinants included age, gender, marital status, socioeconomic status, previous medical history, and social participation. This paper discussed implications for prevention programs.

PMID: 10073194, UI: 99172849

Prev Med 1999 Mar;28(3):304-12

Physical activity and incident hypertension in black and white adults: the Atherosclerosis Risk in Communities Study.

Pereira MA, Folsom AR, McGovern PG, Carpenter M, Arnett DK, Liao D, Szklo M, Hutchinson RG

Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota 55455-1015, USA. pereira@epivax.epi.umn.edu

BACKGROUND: The epidemiologic observation that physical activity reduces the risk for hypertension has only been made for white men who self-reported hypertension. This study examined physical activity and clinically determined incident hypertension in black and white men and women of the Atherosclerosis Risk in Communities (ARIC) Study. METHODS: ARIC is a population-based prospective study with four U.S. clinic centers. The present analyses included 7,459 black and white adults 45-65 years of age. Hypertension (systolic/diastolic blood pressure >/= 140/90 mm Hg) was defined by blood pressure measured by a random-zero device or medication use. Physical activity was assessed with the Baecke questionnaire. RESULTS: After adjustment for age, baseline blood pressure, ARIC center, education, body mass index, waist-hip ratio, parental history of hypertension, cigarette smoking, alcohol consumption, and diet, white men in the highest quartile of leisure activity (primarily cycling and walking) had a 34% lower odds of developing hypertension over 6 years compared to the least active (OR = 0.66, 95% CI = 0.47-0.94; P for quartile trend = 0.01). Baseline activity was not associated with incident hypertension in white women or blacks. CONCLUSIONS: Leisure-time physical activity reduces the odds of hypertension in middle-aged white men. Additional studies in women and blacks are needed. Copyright 1999 American Health Foundation and Academic Press.

PMID: 10072750, UI: 99174179

Am J Crit Care 1999 Mar;8(2):101-4

Differences in African American and white women with myocardial infarction: history, presentation, diagnostic methods, and infarction type.

Griffiths DH, Pokorny ME, Bowman JM

Nursing Program, Nash Community College, Rocky Mount, NC, USA.

BACKGROUND: Despite overall declining death rates from cardiovascular disease, the number of women dying of cardiovascular disease increases each year, with substantially higher rates in African American women than in white women. OBJECTIVE: To investigate differences in presentation, diagnostic method, and type of infarction between African American and white women with myocardial infarction. METHODS: Chart review of all women with discharge diagnosis of myocardial infarction. RESULTS: No significant differences were found between African American and white women in admitting diagnosis, diagnostic methods, or type of infarction. At the time of admission, 2 medical history variables, stroke and hypertension, differed significantly between African American and white women (P = .027 and P = .002, respectively). CONCLUSIONS: Healthcare professionals must be aware of possible racial differences in medical history, signs and symptoms, and prognosis when assessing patients and planning interventions. Studies with larger samples are needed to confirm these findings on African American and white women with myocardial infarction.

PMID: 10071700, UI: 99171094

Arch Med Res 1999 Jan-Feb;30(1):40-8

Renovasculopathies of hypertension in Hispanic residents of Dallas, Texas.

Tracy RE, Guileyardo JM

Department of Pathology, Louisana State University Medical Center, New Orleans, USA.

BACKGROUND: Mean blood pressure levels (MBP) appear to rise with age slowly in the population of Mexico City and more swiftly in the U.S. in the black and white population, judging from published survey data. Some evidence suggests that MBP rises at intermediate rates in Hispanics in the U.S. METHOD: This question is explored here in two ways, by review of published survey data and by a novel approach that uses renal tissues obtained from forensic autopsies to estimate MBP. Past studies have revealed good agreement between the two methods of estimating MBP. RESULTS: Good agreement is again observed from the results of this study. Results from both methods agree that MBP is much lower at all ages in Mexican men and women than in blacks and whites in the U.S. Both methods also agree that Hispanics in the U.S. demonstrate an intermediate rise in MBP. A speculative first look at a small sample of U.S. Hispanics suggest that MBP rates of recent immigrants tend to resemble those of Mexico, while MBP levels of migrants of long-term residence resemble the native-born U.S. populations. CONCLUSIONS: The findings underscore the need for definitive testing to confirm if Mexicans who relocate to the U.S. may acquire an acceleration of the renovasculopathies, and of the lifelong progression toward hypertension that this implies.

PMID: 10071424, UI: 99170818

Arch Intern Med 1999 Feb 8;159(3):285-93

Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial.

Svetkey LP, Simons-Morton D, Vollmer WM, Appel LJ, Conlin PR, Ryan DH, Ard J, Kennedy BM

Duke University Medical Center, Department of Medicine, Durham, NC, USA.

OBJECTIVE: To determine the effects of dietary patterns on blood pressure in subgroups. METHODS: Dietary Approaches to Stop Hypertension (DASH) was a randomized controlled feeding study conducted at 4 academic medical centers. Participants were 459 adults with untreated systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg. For 3 weeks, participants were fed a "control" diet. They were then randomized to 8 weeks of (1) control diet; (2) a diet rich in fruits and vegetables; or (3) a combination diet rich in fruits, vegetables, and low-fat dairy foods, and reduced in saturated fat, total fat, and cholesterol (the DASH combination diet). Weight and salt intake were held constant. Change in diastolic blood pressure was the primary outcome variable, and systolic blood pressure a secondary outcome. Subgroups analyzed included race, sex, age, body mass index, years of education, income, physical activity, alcohol intake, and hypertension status. RESULTS: The combination diet significantly lowered systolic blood pressure in all subgroups (P<.008), and significantly lowered diastolic blood pressure (P<.01) in all but 2 subgroups. The fruits-and-vegetables diet also reduced blood pressure in the same subgroups, but to a lesser extent. The combination diet lowered systolic blood pressure significantly more in African Americans (6.8 mm Hg) than in whites (3.0 mm Hg), and in hypertensive subjects (11.4 mm Hg) than in nonhypertensive subjects (3.4 mm Hg) (P<.05 for both interactions). CONCLUSIONS: The DASH combination diet, without sodium reduction or weight loss, significantly lowered blood pressure in virtually all subgroups examined, and was particularly effective in African Americans and those with hypertension. The DASH combination diet may be an effective strategy for preventing and treating hypertension in a broad cross section of the population, including segments of the population at highest risk for blood pressure-related cardiovascular disease.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 9989541, UI: 99142647

J Vasc Surg 1999 Feb;29(2):352-9

Diabetes mellitus is the major risk factor for African Americans who undergo peripheral bypass graft operation.

Brothers TE, Robison JG, Elliott BM

Department of Surgery, Section of Vascular Surgery, Medical University of South Carolina, USA.

OBJECTIVE: African Americans, especially African American women, have a greater risk of lower extremity ischemia that necessitates an infrainguinal bypass graft operation and amputation. Because the prevalence of diabetes mellitus is proportionally greater in this ethnic/racial group, the relative contribution of diabetes was compared with other potential risk factors. METHODS: This study was designed as a retrospective case control study at the University and Veterans Hospitals. In a 5-year period, 764 consecutive patients who required infrainguinal revascularizations were compared with a statewide population that was described by the 1995 Behavior Risk Factor Surveillance System database. The main outcome measure was the requirement for infrainguinal revascularization. RESULTS: Diabetes mellitus was more common among African American women who underwent bypass graft operation (70%; odds ratio [OR], 24.9; 95% confidence interval [CI], 20.3 to 30.4) than African American men (46%; OR, 11.6; 95% CI, 8.9 to 15.2), white women (49%; OR, 15.9; 95% CI, 13.0 to 19.5), or white men (42%; OR, 14.8; 95% CI, 12.5 to 17.4). Overall, bypass graft operation was associated more strongly with diabetes mellitus for all groups (OR, 15.7; 95% CI, 13.5 to 18. 3) than with smoking (OR, 4.5; 95% CI, 3.8 to 5.2) or hypertension (OR, 4.6; 95% CI, 4.0 to 5.3). Life-table analysis revealed limb salvage to be worse at 3 years among African American patients (64% vs 75%; P <.005) despite similar primary and cumulative secondary graft patency rates. CONCLUSION: Diabetes mellitus is the dominant risk factor that contributes to the need for bypass graft operation, especially among African American women. A greater prevalence of diabetes mellitus may account for the higher incidence of tissue necrosis and the increased requirement for distal bypass grafting and may contribute to the reduction in long-term limb salvage that was observed with these women.

PMID: 9950993, UI: 99137875

J Hum Hypertens 1999 Jan;13(1):13-21

Ten-year incidence of elevated blood pressure and its predictors: the CARDIA study. Coronary Artery Risk Development in (Young) Adults.

Dyer AR, Liu K, Walsh M, Kiefe C, Jacobs DR Jr, Bild DE

Department of Preventive Medicine, Northwestern University Medical School, Chicago, IL 60611-4402, USA.

Few prospective studies have examined associations of lifestyle factors or variables in the insulin resistance syndrome (syndrome X) with incidence of elevated blood pressure (BP) in black subjects and women. This report estimates the 10-year incidence of high blood pressure (HBP) and high normal blood pressure (HNBP) in the biracial cohort of the Coronary Artery Risk Development in (Young) Adults Study (CARDIA), and examines lifestyle factors and four syndrome X variables, measured at baseline, as predictors. CARDIA examined 5115 black and white men and women aged 18-30 years in 1985-1986, and re-examined them at 2, 5, 7, and 10 years. The 10-year incidence of HBP was 16.4% in black men, 7.8% in white men, 13.1% in black women, and 3.2% in white women, while the 10-year incidence of HBP or HNBP was 29.5%, 16.2%, 19.2%, and 6.3%, respectively, in the four sex-race subgroups. Predictors included body mass index, waist circumference, physical activity, alcohol intake, pulse rate, cigarette smoking, education, fasting insulin, triglycerides, uric acid, and high-density lipoprotein cholesterol, as well as age and systolic BP. In univariate analyses, each of these variables was significantly related to incidence in at least one of the four sex-race groups. In multivariate analyses that included control for age and systolic pressure, independent predictors included fasting insulin in white men and women, triglycerides in white men, uric acid and pulse rate in black men, waist circumference in white men and black women, and education (inverse) in white men and black and white women. These results suggest that lower socioeconomic status, as assessed by education level, and one or more syndrome X variables, ie, fasting insulin, triglycerides, uric acid, may be associated with development of elevated BP in young adults.

PMID: 9928747, UI: 99125827

Ethn Dis 1998 Autumn;8(3):312-8

Renin and hemodynamic responses to exercise in borderline hypertensives.

Headley SA, Keenan TG, Manos TM, Phillips K, Lachowetz T, Keenan HA, Mahar MT

Department of Exercise Science & Sport Studies; Springfield College, Mass 01109, USA. Sheadley@spfldcol.edu

OBJECTIVE: In this study, we examined the relationship between baseline plasma renin (REN) and hemodynamic variables during recovery from aerobic exercise in 10 Caucasian (C) and 10 African-American (AA) borderline hypertensive females. METHODS: Subjects attended three preliminary sessions and an experimental session in which treadmill walking was performed for 40 minutes at a moderate intensity. During this session, blood was drawn at baseline prior to exercise and immediately following. Blood pressure and other hemodynamic variables were recorded at rest before exercise and for 2 hours afterwards. The average difference from baseline during the two hour recovery period was calculated for each variable and used as the dependent variable in a multiple regression analysis. RESULTS: For mean arterial pressure and cardiac output, the regression slopes did not differ between AA and C. However, during recovery, the average difference from baseline for systemic vascular resistance (SVR) increased in AA but decreased in C. CONCLUSION: In conclusion, REN had a significant effect on SVR but no effect on the other hemodynamic variables during recovery from aerobic exercise. It appears as if the peripheral vasculature in AA may be more sensitive than in C to the vasoconstrictive effects of the renin angiotensin system.

PMID: 9926901, UI: 99124091

Ethn Dis 1998 Autumn;8(3):296-8

A perspective on the calcium antagonists in blacks (CAB) trial.

Hall WD

Publication Types:

• Clinical trial
• Editorial
• Multicenter study
• Randomized controlled trial

PMID: 9926898, UI: 99124088

Metabolism 1999 Jan;48(1):107-12

Hyperinsulinism and sex hormones in young adult African Americans.

Falkner B, Sherif K, Sumner A, Kushner H

Institute for Women's Health and the Department of Medicine, Allegheny University for the Health Sciences, Philadelphia, PA 19129, USA.

Hyperinsulinemia is a risk factor for cardiovascular disease, and is linked with non-insulin-dependent diabetes mellitus (NIDDM), hyperlipidemia, obesity, and hypertension. Sex hormones also play a role in the metabolic alterations associated with the risk for cardiovascular disease. A reduction in sex hormone-binding globulin (SHBG) may be predictive of future NIDDM particularly in women. The postmenopausal decline in estrogen is also associated with an increase in risk factor expression in women. Since African Americans experience a greater prevalence of NIDDM, obesity, and hypertension, conditions associated with hyperinsulinemia, the purpose of this study was to determine if alterations in sex hormone levels are associated with the plasma insulin concentration in young adult African Americans, and to determine if there are sex differences in the effect of insulin on lipids and sex hormones. In a sample of 221 nondiabetic African American men (n = 105) and women (n = 116) with a mean age of 31 years, we examined the relationship of the plasma insulin concentration with the body mass index (BMI), blood pressure, plasma lipids, and sex hormones, including free testosterone, estradiol, and SHBG. Plasma insulin increased with the BMI and other measures of adiposity (P<.001) in men and women. Significant correlations of insulin with plasma lipids were also present in both sexes. There was a significant inverse correlation of insulin with SHBG in both men (r = .28, P = .007) and women (r = .27, P = .02). There was a significant direct correlation of insulin with free testosterone in women (r = .032, P<.001). Stepwise multiple regression analyses with insulin as the dependent variable detected the BMI, triglyceride, and apolipoprotein A1 as significant contributors to the plasma insulin concentration in men. In women, the multiple regression model detected percent body fat, low-density lipoprotein (LDL) cholesterol, and free testosterone as significant contributors to plasma insulin. These data on young African Americans demonstrate a significant relationship between hyperinsulinemia and obesity, atherogenic lipid status, and lower SHBG. In the premenopausal women, the lower SHBG is linked with higher free testosterone, favoring a condition of relative androgen excess.

PMID: 9920153, UI: 99116881

Clin Transpl 1997;:305-14

Impact of new variables reported to the UNOS registry.

Cho YW, Terasaki PI

1. Donor age is now a predominant factor influencing graft outcome. 2. A new finding here is that recipient peripheral vascular disease, PVD is also a major factor. This factor was independent of whether the patient had diabetes or not. Presensitization, as shown by a high PRA is additive to PVD. 3. Hypertension in the donor was important only when a history of more than 10 years was noted in the older donors over age 50. 4. Angina and cardiovascular disease in the patient resulted in a slightly higher death rate, but was only of importance in patients over age 50. 5. Cadaver donor pretreatment was of importance only in donors over age 30. 6. White patients with private insurance had a slightly higher graft survival rate than those on Medicare or Medicaid. Black patients with private insurance had almost the same graft survival as White patients with private insurance. The lowest graft survival was noted for Black patients on Medicaid.

PMID: 9919414, UI: 99118058

J Am Diet Assoc 1999 Jan;99(1):66-71

Participants' evaluation of a weight-loss program.

Mattfeldt-Beman MK, Corrigan SA, Stevens VJ, Sugars CP, Dalcin AT, Givi MJ, Copeland KC

Department of Nutrition and Dietetics, Saint Louis University, MO 63104, USA.

OBJECTIVE: The purpose of this study was to evaluate participants' perceptions of the weight-loss intervention used in a hypertension prevention clinical trial. DESIGN: A total of 308 overweight and moderately obese subjects participated in the weight-management intervention. After the 18-month program, 281 participants completed a questionnaire designed to evaluate their perceptions of the program's effectiveness. SUBJECTS/SETTING: Adult participants (224 men and 84 women) in the weight-loss modality of the Trials of Hypertension Prevention Phase I, surveyed in 1991. STATISTICAL ANALYSES PERFORMED: chi 2 Analyses were used to test for statistical significance of group differences. RESULTS: Intervention components that were most useful are presented. Older participants (older than 50 years) were most likely to attend sessions and women were most likely to identify stress and frustration because of disappointing results. Successful participants were more likely to incorporate exercise into their daily activities, exercise regularly, and use self-monitoring strategies. Few participants found group exercise to be useful. CONCLUSION: These findings suggest that interventionists in weight-loss programs need to find flexible and creative ways to maintain contact with participants, continue to develop better methods of self-monitoring, obtain the skills needed to recognize frustration and provide timely support, continue to couple the message of diet and exercise, and emphasize helping participants develop their problem-solving skills. This may require training outside the traditional field of dietetics.

Publication Types:

• Multicenter study

PMID: 9917734, UI: 99116259

JAMA 1999 Jan 6;281(1):53-60

The protective effect of moderate alcohol consumption on ischemic stroke.

Sacco RL, Elkind M, Boden-Albala B, Lin IF, Kargman DE, Hauser WA, Shea S, Paik MC

Department of Neurology, Sergievsky Center, Columbia University College of Physicians and Surgeons, New York, NY, USA. rls1@columbia.edu

CONTEXT: Moderate alcohol consumption has been shown to be protective for coronary heart disease, but the relationship between moderate alcohol consumption and ischemic stroke is more controversial. OBJECTIVE: To determine the association between alcohol consumption and risk of ischemic stroke. DESIGN: Population-based case-control study conducted between July 1993 and June 1997. SETTING: Multiethnic population in northern Manhattan, New York, NY, aged 40 years or older. PATIENTS AND OTHER PARTICIPANTS: Cases (n = 677) had first ischemic stroke and were matched to community controls (n = 1139) derived through random digit dialing by age, sex, and race/ethnicity. Mean +/- SD age of cases was 70.0+/-12.7 years; 55.8% were women; 19.5% were white, 28.4% black, and 50.7% Hispanic. MAIN OUTCOME MEASURE: First ischemic stroke (fatal or nonfatal). RESULTS: Moderate alcohol consumption, up to 2 drinks per day, was significantly protective for ischemic stroke after adjustment for cardiac disease, hypertension, diabetes, current smoking, body mass index, and education (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.39-0.67). This protective effect of alcohol consumption was detected in both younger and older groups, in men and women, and in whites, blacks, and Hispanics. In a quadratic model of stroke risk, increased risk of ischemic stroke was statistically significant among those consuming 7 or more drinks per day (OR, 2.96; 95% CI, 1.05-8.29). CONCLUSIONS: Moderate alcohol consumption was independently associated with a decreased risk of ischemic stroke in our elderly, multiethnic, urban subjects, while heavy alcohol consumption had deleterious effects. Our data support the National Stroke Association Stroke Prevention Guidelines regarding the beneficial effects of moderate alcohol consumption.

PMID: 9892451, UI: 99107469

J Behav Med 1998 Dec;21(6):527-44

Culture, socioeconomic status, and coronary heart disease risk factors in an African American community.

Dressler WW, Bindon JR, Neggers YH

Department of Anthropology, University of Alabama, Tuscaloosa 35487-0210, USA.

In this paper, cultural influences are examined in the relationship between socioeconomic status and health. Cultural definitions of material lifestyles are investigated as a correlate of disease risk in an African American community in the rural South. A new technique--called "cultural consensus analysis"--is used to test for a cultural model of lifestyles indicative of success. Survey data are then used to operationalize the degree to which individuals adhere in their own behavior to that cultural model; this measure is referred to as "cultural consonance in lifestyle." Cultural consonance in lifestyle is more strongly associated with hypertension and smoking (but not serum lipids) than are conventional measures of socioeconomic status (occupation, income, and education). These results suggest that the extent to which individuals are unable to live in accordance with cultural norms regarding lifestyles may contribute to the risk of coronary heart disease in the African American community.

PMID: 9891253, UI: 99108402

Mo Med 1998 Dec;95(12):654-62

Prevalence changes in modifiable cardiovascular disease risk factors in three Missouri regions, 1990-1996.

Dietz MJ, Simoes EJ, Waterman B, Jackson-Thompson J, Murayi T

OBJECTIVES: To determine the prevalence and prevalence trend of modifiable cardiovascular disease (CVD) risk factors among African Americans and whites/others from 1990-1996. We also examined differential changes between African Americans and whites/others during the same time period. METHODS: This study used data from two special Behavioral Risk Factor Surveillance System (BRFSS) based surveys in 1990 (N = 3,000+) and one in 1996 (N = 2,095) that targeted two metropolitan and one rural region in Missouri with substantial minority populations. Risk factors included physical inactivity, obesity, hypertension, unmonitored cholesterol and smoking. The percent change in prevalence estimates and corresponding confidence intervals between survey years were calculated for each of the above risk factors. RESULTS: When compared with Missouri BRFSS data, overall prevalence of smoking, obesity, hypertension and unmonitored cholesterol was higher in the three-region study population than the state as a whole. African-American males did not experience any statistically significant reductions in CVD risk factor prevalence rates between 1990 and 1996, while the increase in obesity was driven mostly by the African-American female subgroup. The least amount of reduction in CVD risk factors was seen in individuals aged 55 or older, with a high school education or less and/or without health insurance. CONCLUSIONS: Individuals of African-American ethnicity, aged 55 or older, with a high school education or less and/or without health insurance need to be the focus of future public health initiatives designed to reduce the prevalence of CVD risk factors.

PMID: 9863342, UI: 99080710

Mor Mortal Wkly Rep CDC Surveill Summ 1998 Dec 11;47(5):35-69

Cardiovascular disease risk factors and preventive practices among adults--United States, 1994: a behavioral risk factor atlas. Behavioral Risk Factor Surveillance System State Coordinators.

Hahn RA, Heath GW, Chang MH

Division of Prevention Research and Analytic Methods, Epidemiology Program Office, National Center for Chronic Disease Prevention and Health Promotion, USA.

PROBLEM/CONDITIONS: Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death in the United States, and state rates of CVD vary by state and by region of the country. Several behavioral risk factors (i.e., overweight, physical inactivity, smoking, hypertension, and diabetes mellitus) and preventive practices (i.e., weight loss and smoking cessation) are associated with the development of CVD and also vary geographically. This summary displays and analyzes geographic variation in the prevalences of selected CVD risk factors. REPORTING PERIOD: 1994 (1992 for prevalence of hypertension). DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based random-digit-dialing telephone survey of noninstitutionalized adults aged > or =18 years; 50 states and the District of Columbia participated in BRFSS in 1994, and 48 states and the District of Columbia participated in 1992. METHODS: Several different analyses were conducted: a) analysis of state risk factor and preventive practice prevalences by sex and race (i.e., black and white); b) mapping; c) cluster analysis; d) correlations of state prevalence rates by sex and race; and e) regression of state risk factor prevalences on state CHD and stroke mortality rates. RESULTS: Mapping the prevalence of selected CVD risk factors and preventive health practices indicates substantial geographic variation for black and white men and women, as confirmed by cluster analysis. Data for blacks are limited by small sample size, especially in western states. Geographic clustering is found for physical inactivity, smoking, and risk factor combinations. Risk factor prevalences are generally lower in the West and higher in the East. White men and white women are more similar in state risk factor rates than other race-sex pairs; white women and black women ranked second in similarity. State prevalences of physical inactivity and hypertension are strongly associated with state mortality rates of CVD. INTERPRETATION: Geographic patterns of risk factor prevalence suggest the presence (or absence) of sociocultural environments that promote (or inhibit) the given risk factor or preventive behavior. Because the risk factors examined in this summary are associated with CVD, further exploration of the reasons underlying observed geographic patterns might be useful. The BRFSS will continue to provide geographic data about cardiovascular health behaviors with a possible emphasis on more data-based small- area analyses and mapping. This will permit states to more adequately monitor trends that affect the burden of CVD in their regions and the United States. Mapping also facilitates the exploration of patterns of morbidity, health-care use, and mortality, as well as the epidemiology of risk factors. Finally, by identifying those segments of the population with high levels of these risk factors and lower levels of the preventive health practices, public health personnel can better allocate resources and target intervention efforts for the prevention of CVD.

PMID: 9859955, UI: 99075298

Circulation 1998 Nov 10;98(19 Suppl):II46-9; discussion II49-50

Effect of payer status on outcomes of coronary artery bypass surgery in blacks.

Higgins RS, Paone G, Borzak S, Jacobsen G, Peterson E, Silverman NA

Division of Cardiac and Thoracic Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.

BACKGROUND: Black patients with coronary artery disease have a higher mortality rate than white Americans. They also have a higher prevalence of hypertension, diabetes mellitus, and renal disease, which may have an effect on mortality rates. The deleterious effect of these comorbidities may be exacerbated by impaired access to secondary prevention strategies and longitudinal care. Therefore, the presence or absence of comprehensive care as indicated by payer status may then affect survival on surgically treated patients. In this study we examined the role of cardiovascular risk factors and insurance carrier status on early outcomes of coronary artery bypass grafting (CABG) surgery in blacks versus white Americans. METHODS AND RESULTS: From January 1990 to December 1996, 2776 patients (2003 men, 773 women; mean age 63 +/- 10 years), underwent isolated CABG in a multispecialty practice serving a major metropolitan population. There were 494 (17.8%) black patients and 2282 (82.2%) white patients. The proportion of black patients in each payer category was 17.8% commercial, 14.1% managed care, 52.9% Medicaid, and 19.5% Medicare. The effect of preoperative risk factors, including status of operation (elective, urgent, or emergent), sex, race, redo CABG, presence of renal disease, diabetes mellitus, congestive heart failure, myocardial infarction, the completeness of revascularization, age, and left ventricular ejection fraction were analyzed with the chi 2 test for categorical variables and the Student t test for age and ejection fraction. A multiple logistic regression analysis was performed to assess the effect of all variables on mortality rates simultaneously. Black patients had a higher incidence of diabetes mellitus, hypertension, and renal disease than white patients (P < 0.001). Overall, 30-day mortality rate was 2.5% (58 of 2282) in white patients versus 5.5% (25 of 494) for black patients (P < 0.003). Multivariate analysis showed that only emergency surgery status (OR 3.59, P < 0.01), redo CABG (OR 3.78, P < 0.001), hypertension (OR 2.32, P < 0.03), history of congestive heart failure (OR 2.1, P < 0.004), older age (OR 1.07, P < 0.001), and low ejection fraction (OR 0.98, P < 0.003) correlated with mortality rates. Race and payer status were not significant predictors of death. CONCLUSIONS: These data on CABG surgery in black patients suggest that early death is due to associated risk factors and not due to race or insurance payer status.

PMID: 9852879, UI: 99069981

J Natl Med Assoc 1998 Nov;90(11):658-64

The relationship between health status and blood pressure in urban African Americans.

DeForge BR, Stewart DL, DeVoe-Weston M, Graham L, Charleston J

Department of Family Medicine, University of Maryland, Baltimore, USA.

African Americans have higher rates of hypertension and poorer health status than their white counterparts. This study assessed the relationship between health status, cardiovascular risk factors, and measured blood pressure. Free blood pressure screenings were performed at businesses and organizations located in west Baltimore. All individuals with cardiovascular risk factors were offered health education. Also, participants with a measured blood pressure of > or = 140/90 mm Hg were referred for free medical treatment. Participants completed a questionnaire that included demographics, cardiovascular risk factors, the Medical Outcomes Study SF 36, and two tests on cholesterol and heart disease knowledge. A total of 1389 African-American men and women were screened; 20% were found to have high normal blood pressure and 31% had stage 1 hypertension or higher. Those with hypertension reported lower physical functioning and poorer general health than those without high blood pressure. When compared with US normative data, participants reported higher levels in vitality and physical and emotional role functioning, more bodily pain, and poorer general health, but they were similar in physical functioning, social functioning, and mental health. Preliminary data suggest that hypertension does have an effect on health function.

PMID: 9828580, UI: 99046020

Curr Opin Cardiol 1998 Sep;13(5):298-303

Diabetic vascular disease and hypertension.

Hamaty M, Lamberti M, Sowers JR

Division of Endocrinology, Metabolism and Hypertension, Wayne State University School of Medicine, Detroit, MI 48201, USA.

There is increasing evidence that essential hypertension is associated with a panoply of metabolic abnormalities. Included in these abnormalities are insulin resistance, dyslipidemia, enhanced coagulation, and decreased fibrinolytic activity, microalbuminuria, and platelet abnormalities and endothelial dysfunction. Visceral obesity appears to be the most common and predictive underlying factor for all of these metabolic abnormalities accompanying hypertension as well as increased cardiovascular disease (CVD) risk. As the prevalence of obesity is increasing, there is cause for concern that CVD increases will parallel this risk factor, particularly in especially high-risk populations, such as African-American women. Other important risk factors, such as increased oxidative stress, may require special therapeutic strategies, including the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin blockers as cornerstones of antihypertensive drug therapy.

Publication Types:

• Review
• Review, tutorial

PMID: 9823785, UI: 99039391

Int J Obes Relat Metab Disord 1998 Nov;22(11):1079-83

Published erratum appears in Int J Obes Relat Metab Disorder 1999 Feb;23(2):220

Central adiposity and hemodynamic functioning at rest and during stress in adolescents.

Barnes VA, Treiber FA, Davis H, Kelley TR, Strong WB

Georgia Institute for Prevention of Human Disease and Accidents, Medical College of Georgia, Augusta 30912, USA.

OBJECTIVE: To examine the impact of central adiposity upon hemodynamic functioning at rest and during stress in adolescents. DESIGN: Cross-sectional, correlational study. SUBJECTS: 46 White and 49 Black normotensive adolescents with family histories of essential hypertension. MEASUREMENTS: Systolic and diastolic blood pressure (SBP, DBP), cardiac output and total peripheral resistance responses were assessed at rest, during postural change, video game challenge and forehead cold stimulation. Specific lower and higher waist-to-hip ratio (WHR) tertiles were created for each gender and then integrated for analyses. This resulted in a lower WHR tertile of 11 Whites and 21 Blacks and an upper WHR tertile of 15 Whites and 17 Blacks. RESULTS: No differences in age, gender or ethnicity proportions were found between tertile groups (all P > 0.21). The upper WHR group showed greater body weight, waist and hip circumferences, body mass index (BMI), triceps skinfold and body surface area (all P < 0.001). Controlling for peripheral (that is, triceps skinfold) and overall (that is, BMI) adiposity, the upper WHR group exhibited greater SBP (that is, peak response minus mean pre-stressor level) to all three stressors and greater DBP reactivity to postural change and cold pressor (all P < 0.05). CONCLUSION: Central adiposity appears to adversely influence hemodynamic functioning during adolescence. Underlying mechanisms responsible for these associations require exploration.

PMID: 9822945, UI: 99040279

Am J Cardiol 1998 Nov 1;82(9):1046-51

Markedly high prevalence of coronary risk factors in apparently healthy African-American and white siblings of persons with premature coronary heart disease.

Becker DM, Yook RM, Moy TF, Blumenthal RS, Becker LC

Center for Health Promotion and Division of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA.

Among persons with a family history of premature coronary heart disease (CHD), siblings bear an excess risk of CHD that is as high as 12 times that of the general population. Aggressive, new, national guidelines for CHD risk reduction have focused on high-risk families, yet little is known about actual remediable risk factors in siblings of persons with premature CHD. To determine the magnitude of the problem relative to the general population, we screened 846 unaffected siblings (ages 30 to 59 years) of persons with documented CHD before age 60 years and compared their risk factor values with population reference norms obtained in the Third National Health and Nutrition Examination Survey (NHANES III) and the National Health Interview Survey (NHIS). Mean levels of low-density lipoprotein cholesterol were 0.52 mmol/L (20 mg/dl) higher in siblings; the prevalence of low-density lipoprotein cholesterol > or =4.14 mmol/L (160 mg/dl) was nearly twice that of race, sex, and age-specific values from NHANES III. Levels of high-density lipoprotein cholesterol <0.91 mmol/L (35 mg/dl) were similar between siblings and NHANES III (11% and 12%, respectively). Only 4% of all siblings had triglyceride levels > or =4.52 mmol/L (400 mg/dl). Hypertension prevalence was twice as high among siblings as among the NHANES III. Current smoking was 33.9% in white siblings and 25.5% in the NHIS, whereas smoking in African-Americans was similar to that in the NHIS (31.1% vs 29.2%). A mere 13% to 29% of siblings were without any major remediable risk factors. The overwhelming need for risk factor modification in this easily identifiable high-risk population supports aggressive national guidelines and demonstrates the lack of adequate treatment of apparently healthy siblings of persons with premature CHD.

PMID: 9817479, UI: 99032417

J Hypertens Suppl 1998 Sep;16(4):S13-5

Does essential hypertension cause progressive renal disease?

Fliser D, Ritz E

Department of Internal Medicine, Ruperto-Carola University, Heidelberg, Germany.

In the distant past, terminal renal failure occurred mainly as a result of malignant hypertension. The introduction of effective antihypertensive therapy has made malignant hypertension rare, and researchers have stopped focusing on the kidney's role in their hypertension research. However, recent long-term observational studies have documented an impressive relationship between hypertension and impaired renal function in patients without primary chronic renal disease; elderly and African American individuals with hypertension have the worst prognoses. The hallmark of hypertensive renal injury is thought to be a progressive increase in intrarenal vascular resistance, which may precede changes in renal structure. Because we lack evidence from renal biopsy studies, it is unclear whether an increase in albumin (protein) excretion correlates with these disturbances of renal function and structure. Nevertheless, because urinary excretion of albumin in patients with essential hypertension is related to the risk of cardiovascular complications, its measurement provides important clinical information.

Publication Types:

• Review
• Review, tutorial

PMID: 9817187, UI: 99032099

Am J Public Health 1998 Nov;88(11):1696-9

Hypertension control and access to medical care in the inner city.

Kotchen JM, Shakoor-Abdullah B, Walker WE, Chelius TH, Hoffmann RG, Kotchen TA

Division of Epidemiology, Medical College of Wisconsin, Milwaukee 53226, USA. jkotchen@post.its.mcw.edu

OBJECTIVES: This study assessed hypertension control among high-risk African Americans. METHODS: We interviewed 583 African Americans aged 18 years and older residing in 438 randomly selected inner-city households. RESULTS: Forty-two percent of the respondents were hypertensive. Blood pressure was uncontrolled in 74% of hypertensive persons, although 64% of hypertensive persons reported having seen a physician within the previous 3 months. Hypertension control was associated with female gender and higher socioeconomic strata but not with public versus private sources of medical care. CONCLUSIONS: Hypertension control is inadequate in this population, although health care services are used frequently. Hypertension control efforts should focus on the effectiveness of health care delivery.

PMID: 9807539, UI: 99024671

East Afr Med J 1998 Jul;75(7):388-91

Perinatal outcome of babies born to black South African women with hypertension.

Rankhethoa NM, Moodley J, Adhikari M, Gouws E

Department of Paediatrics and Child Health and MRC Biostatistics, Faculty of Medicine, University of Natal, Durban.

BACKGROUND: Perinatal mortality rates (PMR) associated with hypertension are known to be high but there have been isolated reports that primigravidae who develop hypertension late in pregnancy have a better PMR than normotensive gravid women. OBJECTIVE: To verify this report and compare the perinatal outcome in differing categories of hypertensive disorders of pregnancy. DESIGN: Maternal and neonatal data were recorded for all hypertensive patients admitted to King Edward VIII Hospital over a six month period from January to June 1995. In addition, similar data from normotensive women matched for age, parity and gestational age were also recorded. The latter formed the control group. RESULTS: Three hundred and thirty seven women were entered into the study. Group A consisted of 189 patients with hypertension, while group B consisted of 148 normotensive pregnant women. There were no significant differences between the groups in relation to maternal age and parity. More women in the hypertensive group had Caesarean sections than in the control group (study group 115 versus control 35: p = 0.001). The perinatal outcome (SBs + NNDs) was significantly greater in the control group than in the hypertensive group (p = 0.031). More importantly, the number of perinatal deaths in the aproteinuric group was significantly different from the control group (aproteinuric group = 2; control group = 26, p = 0.007). Furthermore, the hypertensive group had greater foetal weights than the control groups (controls 1.65 kg versus 2.3 kg hypertensives: p = 0.0001). CONCLUSION: This study shows that babies born to hypertensive mothers have a significantly greater birthweight than a control group of normotensive women. Further, although there are no statistically significant differences in perinatal outcome between moderate and severe categories of hypertension and control patients, there were significantly fewer perinatal deaths in women with aproteinuric hypertension.

PMID: 9803628, UI: 99020469

Diabetes Care 1998 Nov;21(11):1836-42

Association of waist circumference with risk of hypertension and type 2 diabetes in Nigerians, Jamaicans, and African-Americans.

Okosun IS, Cooper RS, Rotimi CN, Osotimehin B, Forrester T

Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Maywood, Illinois 60153, USA. iokosun@wpo.it.luc.edu

OBJECTIVE: Prior studies have supported that waist circumference correlates better with visceral adipose tissue and is a better predictor of cardiovascular disease than are BMI and waist-to-hip ratio. In this study, we reexamine the role of waist size on the risk of hypertension and type 2 diabetes in African-origin populations from three contrasting environments. RESEARCH DESIGN AND METHODS: A cross-sectional survey was conducted of 5,042 men and women 25-74 years of age from Nigeria, Jamaica, and the U.S. The relationship between waist, blood pressure, and fasting blood glucose was assessed using multiple linear regression analyses. Logistic regression analyses using sex-specific empirical waist cut-points were used to determine the risks of hypertension and type 2 diabetes. RESULTS: Waist circumference was positively correlated with blood pressure and fasting blood glucose (P < 0.05). Increasing waist quartiles were significantly associated with higher risks of hypertension in the three populations, as estimated from age-adjusted odds ratios obtained from sex-specific logistic regression models. A highly elevated risk of type 2 diabetes-10-fold for Jamaican men and 23-fold for African-American women-was observed in the comparison of lowest to highest quartiles of waist circumference. CONCLUSIONS: Substantial reduction in hypertension and diabetes in men and women is achievable if the waist size is decreased in these populations. Intervention programs designed to reduce waist circumference through lifestyle modification, including exercise and diet, may have significant public health significance in reducing the incidence of hypertension and adult-onset diabetes in these populations.

Comments:

• Comment in: Diabetes Care 1999 May;22(5):876-7

PMID: 9802730, UI: 99017730

Diabetes Care 1998 Nov;21(11):1790-6

Association of hormone replacement therapy and carotid wall thickness in women with and without diabetes.

Dubuisson JT, Wagenknecht LE, D'Agostino RB Jr, Haffner SM, Rewers M, Saad MF, Laws A, Herrington DM

Physician Assistant Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

OBJECTIVE: Atherosclerosis is the major underlying cause of death for women with type 2 diabetes. We examined the relationship between use of postmenopausal hormone replacement therapy(HRT) and subclinical atherosclerosis among women with type 2 diabetes, impaired glucose tolerance (IGT), and normal glucose tolerance. RESEARCH DESIGN AND METHODS: A cross-sectional analysis was conducted among 623 postmenopausal women in the Insulin Resistance Atherosclerosis Study (IRAS). Current users of HRT, n = 200, were compared with 104 former users and 319 never users. Intimal-medial wall thicknesses (IMTs) of the common carotid (CCA) and internal carotid (ICA) arteries were used as measures of atherosclerosis. RESULTS: Significant differences between HRT user groups were noted for certain demographic, socioeconomic, and lifestyle factors. After adjustment for these and other coronary heart disease risk factors, current users had a 69 microm thinner ICA IMT than never users (P = 0.06). Former users had a 96 pm thinner ICA IMT than never users (P = 0.03). No significant difference was observed for the CCA. Although women with type 2 diabetes had thicker carotid IMT than women without diabetes, the association between HRT use and thinner IMT was similar in both groups. The difference between current and never users was attenuated by adjustment for HDL and LDL cholesterol. Neither duration of HRT use nor HRT regimen was associated with IMT in either artery. CONCLUSIONS: This analysis suggests that current and former use of HRT is associated with reduced atherosclerosis and that women with type 2 diabetes may receive the same benefit from HRI as women without diabetes.

Publication Types:

• Multicenter study

PMID: 9802722, UI: 99017722

Ann Epidemiol 1998 Nov;8(8):497-503

The contribution of baseline weight and weight gain to blood pressure change in African Americans: the Pitt County Study.

Curtis AB, Strogatz DS, James SA, Raghunathan TE

Department of Epidemiology, School of Public Health, University of Michigan, USA.

PURPOSE: The positive association between obesity and blood pressure has been less consistent in African Americans than whites. This is especially true for African American men. This study investigated the sex-specific associations between baseline body mass index (BMI), weight change (kilograms), and five-year hypertension incidence and changes in blood pressure in a cohort of African Americans ages 25-50 years at baseline. METHODS: The Pitt County Study is a longitudinal investigation of anthropometric, psychosocial, and behavioral predictors of hypertension in African Americans. Data were obtained through household interviews and physical examinations in 1988 and 1993. RESULTS: Baseline BMI was positively and independently associated with changes in blood pressure after controlling for weight change and other covariates. When participants were stratified by sex-specific overweight vs. nonoverweight status at baseline, weight gain was significantly associated with increases in blood pressure only among the initially nonoverweight. CONCLUSIONS: Baseline weight for all respondents, and weight gain among the nonoverweight at baseline, were independent predictors of blood pressure increases in this cohort of African Americans.

PMID: 9802594, UI: 99017580

Am J Cardiol 1998 Oct 1;82(7):902-4

Risk factors for new coronary events in older African-American men and women.

Aronow WS, Ahn C

Hebrew Hospital Home, Bronx, New York 10475, USA.

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).

PMID: 9781976, UI: 98453237

Arch Intern Med 1998 Oct 12;158(18):2029-34

Comparison of the efficacy of dihydropyridine calcium channel blockers in African American patients with hypertension. ISHIB Investigators Group. International Society on Hypertension in Blacks.

Hall WD, Reed JW, Flack JM, Yunis C, Preisser J

Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.

BACKGROUND: Hypertension is a prevalent disease among African Americans, and successful treatment rates are low. Since calcium channel blockers are well-tolerated and efficacious in African Americans, we undertook this study to compare the efficacy, safety, and tolerability of 3 commonly prescribed calcium channel blockers: amlodipine besylate (Norvasc), nifedipine coat core (CC) (Adalat CC), and nifedipine gastrointestinal therapeutic system (GITS) (Procardia XL). METHODS: One hundred ninety-two hypertensive patients across 10 study centers were randomly assigned to double-blind monotherapy with amlodipine besylate (5 mg/d), nifedipine CC (30 mg/d), or nifedipine GITS (30 mg/d) for 8 weeks. Patients not achieving therapeutic response after 4 weeks had their dose doubled for the next 4 weeks. The primary end point was a comparison of the average reduction (week 8 minus baseline) in 24-hour ambulatory diastolic blood pressure (DBP). Secondary end points included a comparison of average 24-hour ambulatory systolic blood pressure (SBP), office SBP or DBP reduction, responder rates, safety, and tolerability. RESULTS: One hundred sixty-three patients were evaluable for efficacy after 8 weeks. There was no significant difference in the average 24-hour ambulatory DBP (-8.5, -9.0, and -6.1 mm Hg, respectively) or SBP (-14.3, -15.7, and -11.8 mm Hg, respectively) reduction. Average office SBP and DBP were reduced to a comparable degree (19-22 mm Hg [P =.50] and 12-14 mm Hg [P =.51], respectively). Responder rates (DBP <90 or reduced by > or = 10 mm Hg) were similar (P = .38). Discontinuation rates and adverse event frequency were distributed similarly across the 3 treatment groups. CONCLUSION: The efficacy, safety, and tolerability of the 3 dihydropyridine calcium channel blockers are equivalent in African Americans with stages 1 and 2 hypertension.

Publication Types:

• Clinical trial
• Clinical trial, phase iv
• Randomized controlled trial

PMID: 9778203, UI: 98449652

Psychosom Med 1998 Sep-Oct;60(5):620-4

John Henryism, gender, and arterial blood pressure in an African American community.

Dressler WW, Bindon JR, Neggers YH

Department of Anthropology, The University of Alabama, Tuscaloosa 35487-0210, USA.

OBJECTIVE: To examine the interaction between gender and John Henryism in relationship to arterial blood pressure in an African American community in the Southern United States. It was hypothesized that, within this specific social and cultural context, John Henryism would be associated with blood pressure differently for men and women. METHODS: A cross-sectional survey of 600 persons, aged 25 to 65, was conducted in the African American community of a small Southern city. John Henryism was assessed using the 12-item John Henryism Scale for Active Coping. Blood pressure was assessed by conventional methods. RESULTS: The interaction effect between gender and John Henryism was assessed as a cross-product term in ordinary least squares regression analysis using arterial blood pressure as the dependent variable, and with logistic regression using hypertension as the dependent variable. This interaction effect was significant (p < .05) in relation to systolic blood pressure and hypertension, with the effect evident (p < .07) in relation to diastolic blood pressure. For men, as John Henryism increases, blood pressure and the risk of hypertension increases. For women, as John Henryism increases, blood pressure and the risk of hypertension decreases. CONCLUSIONS: The association of the behavioral disposition of John Henryism with blood pressure is dependent on the gender of the individual. Men and women face differing cultural expectations and social structural constraints in this community. The sociocultural context modifies the meaning of the behavioral disposition, and hence its effects.

PMID: 9773768, UI: 98444752

West J Med 1998 Sep;169(3):139-45

Ischemic heart disease and stroke mortality in African-American, Hispanic, and non-Hispanic white men and women, 1985 to 1991.

Karter AJ, Gazzaniga JM, Cohen RD, Casper ML, Davis BD, Kaplan GA

Division of Research, Kaiser Permanente, Northern California Region, Oakland. ajk@dor.kaiser.org

We compare recent trends in ischemic heart disease (IHD) and stroke mortality in California among the 6 major sex-racial or -ethnic groups. Rates of age-specific and -adjusted mortality were calculated for persons aged 35 and older during the years 1985 to 1991. Log-linear regression modeling was performed to estimate the average annual percentage change in mortality. During 1985 through 1991, the mortality for IHD and stroke was generally highest for African Americans, intermediate for non-Hispanic whites, and lowest for Hispanics. Age-adjusted mortality for IHD declined significantly in all sex-racial or -ethnic groups except African-American women, and stroke rates declined significantly in all groups except African-American and Hispanic men. African Americans had excess IHD mortality relative to non-Hispanic whites until late in life, after which mortality of non-Hispanic whites was higher. Similarly, African Americans and Hispanics had excess stroke mortality relative to non-Hispanic whites early in life, whereas stroke mortality in non-Hispanic whites was higher at older ages. The lower IHD and stroke mortality among Hispanics was paradoxical, given the generally adverse risk profile and socioeconomic status observed among Hispanics. An alarmingly high prevalence of self-reported cardiovascular disease risk factors in 1994 to 1996, particularly hypertension, leisure-time sedentary lifestyle, and obesity, is a serious public health concern, with implications for future trends in cardiovascular disease mortality. Of particular concern was the growing disparities in stroke and IHD mortality among younger-aged African Americans relative to Hispanics and non-Hispanic whites.

PMID: 9771151, UI: 98444090

J Perinatol 1998 Sep-Oct;18(5):372-6

Frequency, timing, and diagnoses of antenatal hospitalizations in women with high-risk pregnancies.

Brooten D, Kaye J, Poutasse SM, Nixon-Jensen A, McLean H, Brooks LM, Groden S, Polis NS, Youngblut JM

Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106-4904, USA.

OBJECTIVE: To examine the frequency, time of gestation, and reasons for antenatal hospitalizations in women with medically high-risk pregnancies. STUDY DESIGN: This secondary analysis reports all antenatal hospitalizations from a clinical trial testing transitional care to women with high-risk pregnancies. Data were collected from 1992 to 1996. Pregnant women with pregestational (n = 16) or gestational diabetes (n = 21), hypertension (n = 29), and diagnosed (n = 47) or at high risk for preterm labor (n = 37) were included. Diagnoses for each hospitalization and lengths of stay were collected from chart review and validated by attending physicians. Gestation was determined via ultrasonography. The sample (N = 150) consisted of predominantly African-American women, never married, between the ages of 15 and 40 with Medicaid insurance. RESULTS: Eighty-three percent (n = 125) of the women had one or more antenatal hospitalization with a mean length of stay of 123 hours. All women with diabetes were hospitalized at least once. Women with pregestational diabetes had the greatest number of hospitalizations whereas those with gestational diabetes had the least. Major reasons for hospitalizations were preterm labor, glucose control, premature cervical dilation, and preeclampsia. CONCLUSION: Some hospitalizations could potentially be avoided or reduced through expanded patient education, improved screening, and more aggressive monitoring for early signs and symptoms of impending complications.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9766414, UI: 98437804

Mt Sinai J Med 1998 Sep;65(4):304-7

Unexpected factors predict control of hypertension in a hospital-based homeless clinic.

Child J, Bierer M, Eagle K

Mount Sinai School of Medicine, New York, NY, USA.

BACKGROUND: Boston Health Care for the Homeless Program (BHCHP) physicians conduct a primary care clinic twice a week at Massachusetts General Hospital (MGH). The MGH clinic is part of a city-wide network of BHCHP clinics providing primary care services to indigent patients. Despite this network, long term control of chronic illnesses such as hypertension (HTN) continues to challenge the clinic staff. METHODS: In an effort to better understand the factors obstructing long term treatment of chronic illness, we conducted a chart review of hypertensive patients seen over a three-year period (January 1991 to March 1994) at the MGH clinic. Frequency of visits, total number of visits and physicians' notes on concomitant diagnoses were analyzed for their correlation to control of hypertension. RESULTS: Overall control of hypertension was poor (42%). A greater proportion of patients with a diagnosis of psychiatric illness responded to treatment intended to lower their blood pressure below 140/90 mm Hg than those without such a diagnosis (odds ratio: 10.2). While there was no difference in the total number of clinic visits during the study period, those with a diagnosis of psychiatric illness had a lower average number of days between their first and third visits (52 days vs 108 p = 0.002). CONCLUSIONS: A greater proportion of patients with concomitant psychiatric diagnoses exhibited blood pressures < or = 140/90 mm Hg than patients without mental illness. The increased frequency of visits at the onset of treatment may confer a positive effect on long term control of HTN among homeless patients attending outpatient hospital-based clinics.

PMID: 9757754, UI: 98430320

Am J Epidemiol 1998 Sep 15;148(6):528-38

Systolic blood pressure trends in US adults between 1960 and 1980: influence of antihypertensive drug therapy.

Kumanyika SK, Landis JR, Matthews-Cook YL, Almy SL, Boehmer SJ

Center for Biostatistics and Epidemiology, The Pennsylvania State University College of Medicine, Hershey, USA.

Recent blood pressure trends reflect progress in hypertension control, but prevalent drug therapy precludes direct estimation of the component due to primary prevention. In data gathered on persons aged 35-74 years in three successive US health examination surveys (1960-1980), systolic blood pressure levels assuming no drug therapy were imputed by reassigning blood pressure to the upper end of the distribution for respondents reporting use of antihypertensive medication. Blood pressure was partitioned into four ordinal categories based on weighted percentiles of the 1960-1962 distributions for 35- to 44-year-old males and females who reported no use of antihypertensive medication. Cumulative logit models (alpha = 0.01) were used to estimate age- and sex-specific trends for blacks and whites within two strata (<25 or > or =25) of body mass index (BMI) (weight (kg)/height (m)2). Before imputation, systolic blood pressure decreased between 1960 and 1980; after imputation, significant decreases remained only in 35- to 44-year-olds. Strong associations of black race and BMI > or =25 with higher blood pressures were present in models with and without drug therapy. Thus, according to the models, there has been little progress in decreasing racial or BMI-related blood pressure differentials. Above the age of 44 years, blood pressure trends were largely attributable to medication use. In contrast, data for 35- to 44-year-olds suggest progress in primary prevention.

PMID: 9753007, UI: 98423929

J Assoc Acad Minor Phys 1998;9(3):48-52

Prevention and control of hypertension and diabetes in an underserved population through community outreach and disease management: a plan of action.

Gerber JC, Stewart DL

Hoechst Marion Roussel Pharmaceuticals, Inc., Kansas City, Missouri, USA.

Hypertension and diabetes are overrepresented in the African-American population and can be particularly devastating in this population. These diseases share genetic predisposition, medical risk factors, and environmental influences as etiologic factors, and they may be interrelated, at least in part, by obesity and accompanying hyperinsulinemia. Noncompliance with treatment plans is a significant barrier to health improvement in both diseases, but increased attention to patient involvement in care is a potential solution to this long-standing problem. The Baltimore Alliance for the Prevention and Control of Hypertension and Diabetes was established in January 1998 to promote care to the underserved community of West Baltimore, Maryland, and to improve outcomes of hypertension and diabetes. Based at the University of Maryland School of Medicine, the Baltimore Alliance comprises a community health worker program, a church-based education and screening effort, managed care and pharmaceutical company (Hoechst Marion Roussel) partners, a health policy and services research group, and inpatient/outpatient clinical care sites in the health system. Mobilization, cultural relevance, and partnership are employed to ensure that the Alliance's goals of increased patient enrollment and retention in treatment programs will be achieved. Thereby, improved outcomes--clinical, humanistic, and economic--will result. Novel as well as classic approaches to patient education, compliance, and goal achievement are being pursued. Complete expert systems for hypertension and diabetes disease management are being created and will be implemented in the near future. Baseline practices and current outcomes are being identified to act as historical controls. The organization and administration of the Alliance will serve as a prototype that others may follow.

PMID: 9747058, UI: 98419195

East Afr Med J 1998 May;75(5):300-3

Hypertension in east Africans and others of African descent: a review.

Mbaya VB

Department of Biochemistry, Faculty of Medicine, University of Nairobi.

As the number of fatalities from cardiovascular diseases declines in western industrial nations, an opposite trend is observed in the East African region. Inter-regional variations in the prevalence of vascular disorders have been attributed to socioeconomic, psychosocial and heritable physiological parameters. Although faulty mineralocorticoid metabolism and the dysfunctional kidney are prominent features of circulatory problems, many current studies are focused on membrane receptors, transmembrane ion transport mechanisms, ion channels and the possible genetic polymorphisms that determine the characteristics of those molecular structures in the vascular system of normal or hypertensive persons. In this review, a composite of the data available on each of the above parameters and its significance in the pathogenesis of hypertension in the industrial West and transforming economies of East Africa is presented.

Publication Types:

• Review
• Review, tutorial

PMID: 9747003, UI: 98419140

East Afr Med J 1998 Apr;75(4):197-8

Salt and hypertension: a race-related phenomenon?

Yonga GO

Publication Types:

• Comment
• Editorial
• Review
• Review, tutorial

Comments:

• Comment on: East Afr Med J 1998 Apr;75(4):199-203

PMID: 9745832, UI: 98418354

Arch Intern Med 1998 Sep 14;158(16):1761-8

Time trends in the use of cholesterol-lowering agents in older adults: the Cardiovascular Health Study.

Lemaitre RN, Furberg CD, Newman AB, Hulley SB, Gordon DJ, Gottdiener JS, McDonald RH Jr, Psaty BM

Department of Medicine, University of Washington, Seattle, USA.

OBJECTIVES: To describe recent temporal patterns of cholesterol-lowering medication use and the characteristics that may have influenced the initiation of cholesterol-lowering therapy among those aged 65 years or older. SUBJECTS AND METHODS: A cohort of 5201 adults 65 years or older were examined annually between June 1989 and May 1996. We added 687 African American adults to the cohort in 1992-1993. We measured blood lipid levels at baseline and for the original cohort in the third year of follow-up. We assessed the use of cholesterol-lowering drugs at each visit. RESULTS: The prevalence of cholesterol-lowering drug use in 1989-1990 was 4.5% among the men and 5.9% among the women; these figures increased over the next 6 years to 8.1% and 10.0%, respectively, in 1995-1996. There was a 4-fold increase in the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors during the 6 years of follow-up, from 1.9% of all participants in 1989-1990 to 7.5% in 1995-1996. The use of bile acid sequestrants, nicotinic acid, and probucol declined from initial levels of less than 1% each. Among the participants who were untreated in 1989-1990, but eligible for cholesterol-lowering therapy after a trial of dietary therapy according to the 1993 guidelines of the National Cholesterol Education Panel, less than 20% initiated drug therapy in the 6 years of follow-up, even among subjects with a history of coronary heart disease. Among participants untreated at baseline but eligible for either cholesterol-lowering therapy or dietary therapy, initiation of cholesterol-lowering drug therapy was directly associated with total cholesterol levels, hypertension, and a history of coronary heart disease, and was inversely related to age, high-density lipoprotein cholesterol levels, and difficulties with activities of daily living. Other characteristics that form the basis of the 1993 National Cholesterol Education Panel guidelines-diabetes, smoking, family history of premature coronary heart disease, and total number of risk factors-were not associated with the initiation of cholesterol-lowering drug therapy. CONCLUSIONS: Given the clinical trial evidence for benefit, those aged 65 to 75 years and with prior coronary heart disease appeared undertreated with cholesterol-lowering drug therapy.

PMID: 9738605, UI: 98408985

Am J Clin Nutr 1998 Sep;68(3):517-8

Mineral intake and blood pressure in African Americans.

McCarron DA, Metz JA, Hatton DC

Publication Types:

• Comment
• Editorial

Comments:

• Comment on: Am J Clin Nutr 1998 Sep;68(3):648-55

PMID: 9734722, UI: 98403791

Pediatr Ann 1998 Aug;27(8):491-4

Ambulatory blood pressure monitoring in the evaluation of pediatric disorders.

Harshfield GA, Hanevold CD

Department of Pediatrics, Georgia Prevention Institute, Medical College of Georgia, Augusta 30912-4534, USA.

PMID: 9713867, UI: 98379494

Clin Chem 1998 Aug;44(8 Pt 2):1821-5

Obesity and cardiovascular disease.

Sowers JR

Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA. sowers@oncgate.roc.wayne.edu

Obesity, diabetes mellitus, and hypertension are common, interrelated medical problems in Westernized, industrialized societies. These interrelated medical conditions are associated with an increased risk of cardiovascular disease and are more prevalent in several minority groups, including African-American and Hispanic populations. The associated cardiovascular risks of these problems are more thoroughly addressed in another review in this supplement. Obesity markedly enhances the development of Type 2 diabetes. Moreover, it enhances the cardiovascular risk associated with other risk factors, such as hypertension and dyslipidemia. Weight reduction in association with an aerobic exercise program improves metabolic abnormalities and reduces blood pressure in individuals with diabetes and hypertension.

Publication Types:

• Review
• Review, tutorial

PMID: 9702991, UI: 98366551

Ethn Dis 1998;8(2):249-53

African American Study of Kidney Disease and hypertension (AASK)--clinical trial update.

Agodoa L

Division of Kidney, Urologic, and Hematologic Diseases, NIDDK, National Institutes of Health, Bethesda, Maryland, USA. agodoa@ep.niddk.nih.gov

African Americans are disproportionately afflicted with end-stage kidney failure (ESRD). Whereas they constitute approximately 12 percent of the US population, they comprise 32 percent of the prevalent ESRD population. Diabetes mellitus is the predominant cause of ESRD in the U.S. population. However, hypertension is the most frequently reported cause of ESRD in African Americans. In 1990, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health launched an initiative to investigate the underlying cause, and to study mechanisms that could slow progression of hypertensive kidney disease in African Americans. An important component of this initiative is the clinical trial African American Study of Kidney Disease and Hypertension (AASK). This report provides an update on the Institute's initiative on hypertensive kidney disease in African Americans and, specifically, on the clinical trial.

PMID: 9681290, UI: 98346268

Ethn Dis 1998;8(2):198-208

Recruitment and retention of minority participants in the DASH controlled feeding trial. DASH Collaborative Research Group. Dietary Approaches to Stop Hypertension.

Vollmer WM, Svetkey LP, Appel LJ, Obarzanek E, Reams P, Kennedy B, Aicher K, Charleston J, Conlin PR, Evans M, Harsha D, Hertert S

Kaiser Permanente Center For Health Research. vollmerwi@chr.mts.kpnw.org

The Dietary Approaches to Stop Hypertension (DASH) study was a National Heart, Lung, and Blood Institute multicenter trial that compared the impact of three dietary patterns on blood pressure (BP) among adults with high normal blood pressure or mild (Stage I) hypertension. DASH's high minority representation (two-thirds of the 459 randomized participants came from minority populations, and 60% of the cohort were African American) offered a valuable opportunity to assess factors affecting minority enrollment and retention in clinical trials of lifestyle modification. Recruitment strategies included targeted mailings to specific groups, mass mailings, community and worksite screenings, and mass media advertising; the four DASH clinical centers also reimbursed participants from $150 to $160. The most productive recruitment strategies tended to be mass mailings directed at a broad audience that was weighted toward, but not limited to, minority participants. DASH's African-American participants overwhelmingly (89%) cited health and dietary factors, such as learning more about blood pressure and healthy eating habits, as their primary reason for participating, while only six percent listed the financial incentives as their primary reason for participating. Eighty-eight percent of African-American respondents reported they would participate again in a similar study. The insights from DASH should help inform future efforts to recruit minority participants.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 9681285, UI: 98346263

Ethn Dis 1998;8(2):184-97

Knowledge of diet and blood pressure among African Americans: use of focus groups for questionnaire development.

Carter-Edwards L, Bynoe MJ, Svetkey LP

Department of Epidemiology, University of North Carolina at Chapel Hill 27599, USA.

Though focus groups are widely used for development of interventions, little is known about their utility in questionnaire construction, particularly for health surveys in a south-eastern African-American population. In this study, focus groups aided in the development of questions, question sub-components, and response options identifying factors that may influence dietary behavior. Information was used for a survey of dietary knowledge, blood pressure knowledge, and measured blood pressure in a church-based, stratified random sample of middle-class African Americans in North Carolina. Each session, conducted in six churches, lasted 1-1 1/2 hours and had four to nine participants; thirty-four individuals participated. Recorded responses were reviewed and summarized by trained personnel. Results indicate that participants had a general understanding of hypertension, its risk factors, and modes of prevention. However, some misconceptions existed regarding blood pressure and sources of sodium. Television was the most common source of health information. Cost and Southern cultural traditions were deemed the major influences on dietary behavior. Many believed stress was strongly related to blood pressure. The focus group process generated useful information for developing questions about nutrition knowledge, blood pressure knowledge, and health attitudes and beliefs of the target population for the epidemiologic survey that followed.

PMID: 9681284, UI: 98346262

Hypertension 1998 Jul;32(1):123-8

Hypertension among siblings of persons with premature coronary heart disease.

Yanek LR, Moy TF, Blumenthal RS, Raqueno JV, Yook RM, Hill MN, Becker LC, Becker DM

Center for Health Promotion, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA. lryanek@welchlink.welch.jhu.edu

To determine the extent to which the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) guidelines were implemented in high-risk families with premature coronary heart disease, we examined the prevalence of hypertension and associated coronary risk factors in asymptomatic siblings of persons with documented premature coronary disease (<60 years of age). A total of 859 apparently healthy siblings (51% male, 19% African American) were screened for coronary risk factors. Siblings were classified as normotensive or hypertensive (BP > or = 140/90 and/or current antihypertensive pharmacotherapy). The prevalence of hypertension, awareness, treatment, and control among siblings was compared with published national estimates from the third National Health and Nutrition Examination Survey. The prevalence of hypertension in siblings was 44%. Among all hypertensives, only 60% were aware of being hypertensive, 45% were being treated, and 16% were under control. A high prevalence of other coronary risk factors was found among hypertensive siblings: 72% were hypercholesterolemic; 61% were obese; 29% were current smokers; 82% were consuming >30% of calories from fat; and only 14% were participating in vigorous physical activity three or more times per week. Comparisons with the national reference population revealed siblings to have a significantly higher prevalence of hypertension, along with significantly lower levels of awareness, treatment, and control. These findings demonstrate the intersection of multiple risk factors among hypertensive siblings and emphasize the need for more aggressive screening and treatment in this easily identifiable high-risk population.

PMID: 9674648, UI: 98337405

Am J Kidney Dis 1998 Jul;32(1):32-42

Creatinine clearance as a measure of GFR in screenees for the African-American Study of Kidney Disease and Hypertension pilot study.

Coresh J, Toto RD, Kirk KA, Whelton PK, Massry S, Jones C, Agodoa L, Van Lente F

Department of Epidemiology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA. coresh@jhu.edu

Serum creatinine and endogenous creatinine clearance (CrCl) are widely used measures of renal function. This study compares the precision, bias, and sources of error in using different CrCl measures to estimate the glomerular filtration rate (GFR) in 118 men and women screened for the African-American Study of Kidney Disease and Hypertension (AASK) pilot study. We measured serum creatinine, 24-hour CrCl, and CrCl during timed clearance periods conducted simultaneously with an 125I-iothalamate GFR study. Serum creatinine was measured using two different kinetic rate Jaffe methods (CX3 and Hitachi). After standardization for body surface area, the different measures of renal function available for each individual were compared with the 125I-iothalamate GFR simultaneous to the CrCl. In a subset of 50 participants, the CrCl measures were compared with a follow-up GFR (fGFR). The mean 125I-iothalamate GFR was 65.2 (SD, 26.4), with a range of 11 to 122 mL/min/1.73 m2. The mean +/- SD percentage differences from the GFR were -9%+/-22% for the Cockcroft-Gault estimated CrCl, 1%+/-29% for the 24-hour CrCl, and 8%+/-16% for the CX3 simultaneous CrCl. The Hitachi method overestimated serum creatinine and underestimated GFR. Compared with an fGFR, the mean +/- SD differences were 2%+/-19% for the first GFR, -6%+/-20% for the Cockcroft-Gault estimated CrCl, 10%+/-28% for the 24-hour CrCl, and 14%+/-29% for the CX3 simultaneous CrCl. Thus, the increased precision with which the timed CrCl predicted its simultaneous GFR did not extend to improved ability to predict a future GFR. The fractional excretion of creatinine, measured as the ratio of the CX3 simultaneous CrCl to 125I-iothalamate clearance, increased with decreasing GFR but was lower than expected (mean +/- SD of 1.21+/-0.16 for GFRs between 20 and 40 mL/min/1.73 m2). The lower fractional excretion explains why the 24-hour and Cockcroft-Gault CrCls did not overestimate GFR, but the reasons for this lower excretion are uncertain. Creatinine assay specificity and calibration are important sources of variability that must be examined in any CrCl measure of GFR. We conclude that despite requiring substantially more time and effort, neither the outpatient 24-hour urine nor the timed CrCl offered increased precision over a calculation based on serum creatinine, sex, age, and weight in predicting GFR.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

PMID: 9669421, UI: 98332084

Neurology 1998 Jun;50(6):1688-93

Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study.

Sloan MA, Kittner SJ, Feeser BR, Gardner J, Epstein A, Wozniak MA, Wityk RJ, Stern BJ, Price TR, Macko RF, Johnson CJ, Earley CJ, Buchholz D

Department of Neurology, University of Maryland School of Medicine, Baltimore, USA.

BACKGROUND: Limited information exists on the frequency, trends in occurrence, risk factors, mechanisms, and outcome of ischemic stroke associated with illicit drug use among young adults in a geographically defined population. METHODS: We reviewed ischemic stroke in young adults (aged 15 to 44 years) in 46 regional hospitals for 1988 and 1991. We examined stroke mechanisms and outcome in patients with recent drug use. RESULTS: Recent illicit drug use was noted in 51/422 (12.1%) stroke patients. Patients with drug use were more likely than other stroke patients to be black (p=0.01), aged 25 to 39 years (p=0.004), and smokers (p=0.006), and were less likely to have hypertension (p=0.004) or diabetes mellitus (p=0.004). Drug use was the probable cause of stroke in 20 (4.7%) patients. Among 31 (7.3%) patients with drug use as a possible stroke mechanism, more likely diagnoses included cardioembolic stroke in 18, hematologic/collagen vascular in 6, nonatherosclerotic vasculopathy in 5, and atherosclerosis in 3. There was no difference in outcome between drug-associated and non-drug associated stroke. CONCLUSIONS: Recent illicit drug use occurs in 12.1% of young adult stroke patients. Drug-associated young adult stroke seems to relate to vascular mechanisms other than those related to hypertension or diabetes. Case-control studies are needed.

PMID: 9633712, UI: 98295469

Psychosom Med 1998 May-Jun;60(3):319-26

Inverse relationship of urinary cyclic GMP to blood pressure reactivity in the CARDIA study: vasodilatory regulation of sympathetic vasoconstriction. Coronary Artery Risk Development in Young Adults.

Markovitz JH, Tucker D, Lewis CE, Sanders PW, Warnock DG

Department of Medicine, University of Alabama at Birmingham, 35205, USA. jmarkovitz@cardia.dopm.uab.edu

OBJECTIVE: To determine whether urinary cyclic GMP (cGMP), which mediates the actions of the vasodilators nitric oxide and atrial natriuretic factor, is inversely related to blood pressure (BP) reactivity. In previous work, we found that urinary cGMP was inversely related to diastolic BP, but cGMP levels were higher among individuals presumed to have increased adrenergic activity, increased reactivity, and increased risk of hypertension (blacks, individuals with a family history of hypertension). METHOD: We measured 24-hour urinary cGMP levels in a substudy of 529 individuals in the Coronary Artery Risk Development in Young Adults (CARDIA) study; the sample was 23 to 35 years of age and approximately balanced for race (black/white) and gender. BP reactivity to stressors (video game, star-tracing, cold pressor) was tested 3 years earlier. Baseline BP was included as a covariate in all analyses. RESULTS: Diastolic BP reactivity to cold pressor was inversely related to cGMP excretion (p < .05); the relationship was strongest among black women with a family history of hypertension (partial r = -.33, p < .01). Systolic BP reactivity to star-tracing was also inversely related to cGMP (p < .01); the relationship for both star-tracing and video game stressors was strongest among black men (partial r values = -.25 and -.24, respectively; p values < .01). CONCLUSIONS: The results indicate that vasodilatory activity may impact the BP response to stress through modulation of adrenergic activation, particularly among blacks.

PMID: 9625219, UI: 98286883

Hypertension 1998 Jun;31(6):1230-4

Genetic markers at the leptin (OB) locus are not significantly linked to hypertension in African Americans.

Rutkowski MP, Klanke CA, Su YR, Reif M, Menon AG

Department of Molecular Genetics, University of Cincinnati Medical Center, Ohio 45267-0524, USA.

Increased body mass index (BMI) has been correlated with increased blood pressure in human populations. To examine the role of the leptin gene (OB) in essential hypertension in African Americans, we performed affected sib pair analysis on a set of 103 hypertensive African American sibships using four highly polymorphic markers at the human leptin locus. No evidence of linkage was detected between these markers and the phenotype of essential hypertension either in these sibships or in a severely obese subset of 46 sibships in which each sibling had a BMI > or = 85th percentile for the US population. Using BMI rather than hypertension as a quantitative trait, we found significant linkage for the marker D7S504 (P=0.029) but not for the other markers. Significance strengthened in the overweight subset of sibships for this marker (P=0.001), and there was a trend of lower P values for the other three markers. However, multipoint analysis with the use of all four markers simultaneously to estimate linkage between BMI and the leptin locus did not demonstrate a statistically significant relationship. Analysis of the coding region of the leptin gene (exons 2 and 3) by single-strand conformational polymorphism revealed a rare Ile-Val polymorphism at amino acid 45 but revealed no other alterations. These results suggest that the OB gene is not a major contributor to the phenotype of essential hypertension in African Americans, although a minor contribution to the phenotype of extreme obesity in this group cannot be ruled out.

PMID: 9622134, UI: 98283453

Hypertension 1998 Jun;31(6):1206-15

Conference report on stroke mortality in the southeastern United States.

Perry HM, Roccella EJ

Department of Veterans Affairs and Washington University School of Medicine, St Louis, MO, USA. perry.h mitchell jr@st-louis.va.gov

A workshop to describe and then seek possible causes for the increased stroke mortality in the southeastern United States briefly considered 30 suspected correlates and discussed in more detail the 10 thought to be most likely. Recent age-adjusted stroke mortality rates in adults from industrialized countries reveal marked geographic differences. Age-adjusted statewide stroke mortality rates also differ, and they are higher in the Southeast than elsewhere in the United States. For five southeastern coastal states in the heart of the "Stroke Belt," excess stroke mortality has been present at least since 1930. In a 20-year follow-up of 10,000 veterans, the Stroke Belt had a 25% increase in all-cause mortality and congestive heart failure. A potential cause of increased fatal stroke included hypertension, which was more frequent in the Stroke Belt. No consistent patterns of lifestyle differences or of differences in potassium or calcium intake seemed to explain the higher rates of fatal strokes in the Stroke Belt; however, detailed investigations of smaller populations in localized areas seem warranted. Some data suggest a relationship between socioeconomic status and the Stroke Belt effect. Other differences in the Southeast that could explain, at least partially, the Stroke Belt effect include presence of soft water throughout most of the area, decreased antioxidant intake, and differences in the use of medical care and in the response to antihypertensive drugs. On the basis of available information, the three most likely explanations or partial explanations for the Stroke Belt are increased levels of blood pressure, localized differences in socioeconomic status, and toxic environmental factor(s). Two major recommendations were made: (1) to encourage both patient and caregiver to use all currently available means of decreasing morbidity and mortality by controlling blood pressures at or below normal levels and by reducing other risk factors and (2) to seek precise information about relationships of identified possible causes of increased morbidity and mortality in the Stroke Belt.

PMID: 9622131, UI: 98283450

Am J Epidemiol 1998 Jun 1;147(11):1053-61

Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants.

Kieffer EC, Alexander GR, Kogan MD, Himes JH, Herman WH, Mor JM, Hayashi R

Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, USA.

This study examined the impact of maternal diabetes on birth weight for gestational age patterns of all term black infants and white infants in the United States using data derived from the 1990-1991 US Live Birth File of the National Center for Health Statistics. Infants of both black mothers and white mothers exhibited the expected fetal overgrowth associated with maternal diabetes. However, the increase in birth weight was much greater in infants of black than white diabetic mothers in comparison with their nondiabetic counterparts, as measured by the discrepancy in birth weight between infants of diabetic and nondiabetic mothers at each gestational week, the incidence of large for gestational age, high birth weight, small for gestational age, and low birth weight. After adjustment for maternal hypertension, prenatal care use, and sociodemographic factors, the disparity in mean birth weight associated with diabetes was 211.67 g in black infants and 115.74 g in white infants. The adjusted odds ratios of birth weight > or = 4,000 g were 2.98 (95% confidence interval 2.89-3.12) for black infants and 1.83 (95% confidence interval 1.78-1.89) for white infants. Given the potential risks for mothers and infants consequent to maternal diabetes and fetal hyperinsulinemia, further investigation of the prevalence, characteristics, and outcomes of diabetes during pregnancy among black mothers and infants is warranted.

PMID: 9620049, UI: 98281348

Am J Public Health 1998 Jun;88(6):949-51

Effects of school-based aerobic exercise on blood pressure in adolescent girls at risk for hypertension.

Ewart CK, Young DR, Hagberg JM

Department of Psychology, Syracuse University, NY 13244-2340, USA.

OBJECTIVES: This study evaluated the effects of aerobic exercise physical education on blood pressure in high-risk, predominantly African-American, adolescent girls. METHODS: Ninth-grade girls (n = 99) with blood pressure above the 67th percentile were randomized to 1 semester of aerobic exercise classes or standard physical education classes. RESULT: The study was completed by 88 girls. At posttest, only members of the aerobic exercise group increased their estimated cardiorespiratory fitness. The aerobic exercise group had a greater decrease in systolic blood pressure than the standard physical education group (P < .03). CONCLUSIONS: Aerobic exercise physical education is a feasible and effective health promotion strategy for high-risk adolescent girls.

PMID: 9618627, UI: 98282326

Stroke 1998 May;29(5):908-12

Cigarette smoking as a determinant of high-grade carotid artery stenosis in Hispanic, black, and white patients with stroke or transient ischemic attack.

Mast H, Thompson JL, Lin IF, Hofmeister C, Hartmann A, Marx P, Mohr JP, Sacco RL

Stroke Unit, The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY 10032, USA. ah267@columbia.edu

BACKGROUND AND PURPOSE: We sought to investigate the association of cigarette smoking with high-grade carotid artery stenosis in Hispanic, black, and white patients with cerebral ischemia in two independent samples. METHODS: Prospectively collected data from the Northern Manhattan Stroke Study (NOMASS) (n=431) and the Berlin Cerebral Ischemia Databank (BCID) (n=483) were used separately for a cross-sectional study estimating the association between cigarette smoking and high-grade carotid stenosis (defined as a luminal narrowing of > or =60%, diagnosed by duplex and/or Doppler ultrasound). In both studies, cerebral ischemia patients with normal sonographic findings or nonstenosing plaques of their carotid arteries served as a comparison group. Multivariate logistic regression models were used for statistical tests to determine the association between smoking and the dependent variable for high-grade carotid stenosis. Age, sex, hypertension, diabetes, hypercholesterolemia, and race/ethnicity were considered potential confounders. Further analyses of the NOMASS data estimated the effect of the amount of cigarette use and the impact of race/ethnicity. RESULTS: High-grade carotid stenoses were found in 14% of the NOMASS and in 21% of the Berlin patients. In Berlin the entire sample was white, whereas in New York only 19% of the cohort were white. In both samples, smoking was independently associated with severe carotid stenosis (NOMASS: odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0; BCID: OR, 3.9; 95% CI, 2.4 to 6.4). Patients smoking 20 pack-years or more showed a significant association (OR, 2.0; 95% CI, 1.1 to 3.9), whereas no significant effect was found for lower amounts of cigarette use. In NOMASS, white smokers displayed a significant (OR, 3.2; 95% CI, 1.1 to 8.9) association with high-grade carotid stenosis, the association for black smokers was less strong, and no association was found among Hispanics. CONCLUSIONS: Smoking is an independent determinant of severe carotid artery stenosis in patients with focal cerebral ischemia. The association differs by race/ethnicity, with the greatest effect observed among whites.

Publication Types:

• Multicenter study

PMID: 9596233, UI: 98255672

Neurology 1998 May;50(5):1238-45

Cognitive test performance among nondemented elderly African Americans and whites.

Manly JJ, Jacobs DM, Sano M, Bell K, Merchant CA, Small SA, Stern Y

Department of Neurology, the Gertrude H. Sergievsky Center, Columbia University College of Physicians and Surgeons, New York, NY 10032-3702, USA.

We examined the neuropsychological test performance of a randomly selected community sample of English-speaking non-Hispanic African American and white elders in northern Manhattan. All participants were diagnosed as nondemented by a neurologist, whose assessment was made independent of neuropsychological test scores. African American elders obtained significantly lower scores on measures of verbal and nonverbal learning and memory, abstract reasoning, language, and visuospatial skill than whites. After using a stratified random sampling technique to match groups on years of education, many of the discrepancies became nonsignificant; however, significant ethnic group differences on measures of figure memory, verbal abstraction, category fluency, and visuospatial skill remained. Discrepancies in test performance of education-matched African Americans and whites could not be accounted for by occupational attainment or history of medical conditions such as hypertension and diabetes. These findings emphasize the importance of using culturally appropriate norms when evaluating ethnically diverse elderly for dementia.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9595969, UI: 98255408

Vital Health Stat 13 1998 Apr;(136):iii-vi, 1-99

National Ambulatory Medical Care Survey: 1993 summary.

Nelson C, Woodwell D

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, USA.

OBJECTIVE: This report describes ambulatory care visits made to private office-based settings in the United States during 1993. Ambulatory medical care services are described in terms of physician, patient, and visit characteristics. METHODS: The data presented in this report are from the 1993 National Ambulatory Medical Care Survey (NAMCS). This survey is part of the ambulatory care component of the National Health Care Survey (NHCS), which measures health care utilization across a variety of providers. The NAMCS is a national probability sample survey of visits to office-based physicians in the United States. Sample data were weighted to produce annual estimates. RESULTS: During 1993, an estimated 717.2 million visits were made to physician offices in the United States, resulting in an average of 2.8 visits per person per year. This rate did not differ significantly from the overall visit rate of 3.0 in 1992. Females made 60 percent of the visits. White persons had a significantly higher rate of visits to physicians than black persons (3.0 visits per person per year and 1.8 visits per person per year, respectively). Over one-quarter (27.6 percent) of the visits were to general and family physicians. About 84 million, or 12 percent, of the visits were injury related. The annual rate of injury-related office visits was 33.0 visits per 100 persons. Essential hypertension was the most common diagnosis made by physicians in 1993 as it has been since the survey began in 1973. Two-thirds of the visits resulted in another scheduled appointment and the mean duration was 18 minutes.

PMID: 9595958, UI: 98258322

Ethn Dis 1998 Winter;8(1):124-7

Calcium antagonists--clinical considerations.

Prisant LM

Hypertension Unit, Medical College of Georgia, Augusta, USA.

Calcium antagonists are useful for treating hypertension, stable exertional and vasospastic angina, and supraventricular arrhythmias. Recent studies have proven their ability to decrease the rate of nonfatal strokes. Short-acting calcium antagonists should be avoided with hypertensive emergencies and urgencies, unstable angina, and acute myocardial infarction. The use of calcium antagonists in systolic heart failure should not be as the primary therapy. Care must be taken in using non-dihydropyridines because of multiple drug-drug interactions. Prospective trials are in progress through the next decade that will compare traditional drugs such as diuretics and beta-blockers to calcium antagonists, converting enzyme inhibitors, and angiotensin II receptor blockers.

Publication Types:

• Review
• Review, tutorial

PMID: 9595257, UI: 98257613

Ethn Dis 1998 Winter;8(1):120-3

Calcium antagonists in African-American patients.

Jamerson K

University of Michigan, Ann Arbor, USA.

When initiating monotherapy for the treatment of essential hypertension, multiple determinants factor into the decision. The goal of treatment is to lower blood pressure and lessen the likelihood of progression to target organ failure. Physicians frequently prioritize these determinants and make decisions to initiate monotherapy based on the race of an individual. All too often, however, the black/white issue is overstated and given too much consideration. The overall goal of this review is to suggest the appropriate "role" for racial profiling in the initial selection of an antihypertensive agent.

Publication Types:

• Review
• Review, tutorial

PMID: 9595256, UI: 98257612

Ethn Dis 1998 Winter;8(1):60-72

Lipoprotein(A) and coronary heart disease risk factors in a racially mixed population: the Johns Hopkins Sibling Study.

Weiss SR, Bachorik PS, Becker LC, Moy TF, Becker DM

Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA.

OBJECTIVES: To determine if heart disease risk factors differentially affect lipoprotein(a) concentration by race, we assessed the association of lipoprotein(a) with heart disease risk factors in healthy Caucasians and African Americans with family histories of premature heart disease. METHODS: Participants (403 Caucasian and 148 African American), all less than 60 years old and free of heart disease, were recruited through a brother or sister diagnosed with coronary heart disease before age 60. Risk factor information was elicited through an interview and medical examination. RESULTS: As expected, lipoprotein(a) was significantly higher among African Americans than among Caucasians. Mean lipoprotein(a) concentrations were positively associated with smoking status and age, and negatively associated with hypertension in African Americans. Smokers had lipoprotein(a) levels 38% higher than nonsmokers. Conversely, lipoprotein(a) concentrations were unrelated to heart disease risk factors among Caucasians. CONCLUSION: While this study confirms that lipoprotein(a) concentration is independent of CHD risk factors in Caucasians, lipoprotein(a) appears to be related to several CHD risk factors in African Americans at high risk for premature heart disease. Given the high levels of lipoprotein(a) in people of African descent and lipoprotein(a)'s link to cardiovascular diseases, more research is needed to understand the relationship of lipoprotein(a) to heart disease risk factors and the subsequent disease in African-American populations.

Publication Types:

• Clinical trial

PMID: 9595249, UI: 98257605

Ethn Dis 1998 Winter;8(1):10-20

Race, education, and dietary cations: findings from the Third National Health And Nutrition Examination Survey.

Ford ES

Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. esf2@cdc.gov

Hypertension, which has been associated with high intake of sodium and low intake of calcium, magnesium, and potassium, is highly prevalent among African Americans. To examine differences in dietary intakes of calcium, magnesium, and potassium between whites and African Americans, and the effect of education on these differences, the author analyzed data from a nationally representative sample that participated in the first phase of the National Health and Examination Survey III from 1988-1991. The analytic sample included 6,046 white participants and 2,226 African-American participants with complete information for age, race, education, and diet. Dietary information was collected from a single 24-hour dietary recall. African Americans consumed less calcium, magnesium, and potassium than whites regardless of educational achievement. Sodium intakes from diet were similar between the two groups. Among whites, intakes of calcium, magnesium, and potassium were positively related to educational attainment. Among African Americans, only magnesium intake was positively related to educational attainment. Because the prevalence of hypertension among African Americans exceeds that among whites, increases in the consumption of calcium, magnesium, and potassium could help to prevent and control excess hypertension among African Americans.

PMID: 9595243, UI: 98257599

Chin Med J (Engl) 1997 Jul;110(7):502-7

The prognosis of biopsy-proven lupus nephritis in chinese patients: long term follow-up of 86 cases.

Shen K, Yu Y, Tang Z, Liu Z, Li L

Research Institute of Nephrology, Jinling Hospital, Nanjing, China.

OBJECTIVE: To investigate the prognosis of lupus nephritis (LN) and its influencing factors in patients with lupus nephritis in China. METHODS: A retrospective study was carried out in 86 patients followed up for at least 5 years. Clinical features, serological and immunological tests were investigated. Renal biopsies were performed at the beginning of the study and repeated in some cases during the follow-up period. All the 86 patients had serum creatinine (Scr) level less than 132.6 mumol/L at the initial presentation and were divided into three groups according to the level of Scr at the end of the study. Group I: the patients with normal renal function (Scr < 132.6 mumol/L); Group II: the patients with mild-moderate renal insufficiency (132.6 mumol/L < or = SCR < or = 530.4 mumol/L); Group III: the patients with end stage renal failure (ESRF) (Scr > or = 530.4 mumol/L). RESULTS: Forty-seven patients reached clinical remission with normal renal function, 11 had with stabilization of renal function, although the systemic lupus erythematosis (SLE) activity relapsed repeatedly, while 28 subjects developed renal insufficiency after 60-170 (mean 88.12 +/- 28.23) months of observation. ESRF rate was 11.6% in this group of patients. Eight patients died (2 died of infections and 6 died of ESRF) during the follow-up period. At the beginning of the study the rates of hypertension, persistent anemia and hematuria in Group II were 50%, 70%, and 70% respectively, being much higher than those in Group I. The calculation of AI and CI in 60 patients revealed that there were 65% of patients with AI > or = 7 and 70% of patients with CI > or = 3 in Groups II and III, while in Group I there were only 32% of patients with AI > or = 7 and 19% of patients with CI > or = 3. Sixteen cases had pathologic class changed in 48 repeated biopsies. Seven cases changed to Class IV, 5 to Class II, 3 to Class V from other classes and one to class III from Class II. CONCLUSIONS: Factors associated with the development of renal insufficiency in these lupus patients included hypertension, anemia and hematuria. Renal biopsy evaluation offered additional prognostic information and showed that patients with severe active and chronic histologic changes were at risk for developing renal insufficiency. During the clinical course, the renal classification of LN changed in certain patients, thus the histologic classification of renal morphology at initial presentation did not fully predict the outcome. Renal involvement is very common in systemic lupus erythematosis (SLE) patients. Lupus nephritis (LN) is the most common form of secondary renal disease in China. It has various and unpredictable clinical features. The risks associated with its treatment have challenged investigators to detect the factors which may influence the survival rate of patients with LN and to develop the rational approaches to therapy. Decades of intensive investigation at many centers around the world had underscored the predictive value of demographic, clinical and laboratory data prior to treatment. Controversies still existed due to the difference in environment, race and the selection criteria of patients as well as the method used to evaluate the outcome. There are still some factors which are thought to have an impact on the prognosis of LN. Most of the articles on the prognosis of patients with LN were reported from Europe and America either about Caucasian or African-American patients. The prognosis of LN and its influence in Chinese patients need more elucidation.

PMID: 9594205, UI: 98256561

J Pediatr Adolesc Gynecol 1998 May;11(2):79-84

Employment and health-risk behaviors among pregnant adolescents.

Rickert VI, Wiemann CM, Goodrum LA, Berenson AB

Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, USA.

STUDY OBJECTIVE: To compare health-risk behaviors, maternal, and neonatal outcomes of pregnant adolescents less than 18 years old who reported employment more than 15 hours per week with those who did not report working. We hypothesized that working teens compared with nonworking adolescents would report higher rates of health-risk behaviors. METHODS: A structured interview was conducted at the first prenatal visit and the medical chart was reviewed to extract pregnancy (pregnancy-induced hypertension, preterm labor with hospitalization, and preterm delivery) and neonatal outcomes (low birthweight, small for gestational age, and admission to the neonatal intensive care unit). The study was conducted at an outpatient maternal and child health clinic at a university teaching hospital. A total of 384 white (n=111), African American (n=151), and Mexican American (n=99) adolescents, aged 12 to 17 years, who initiated care between January 2, 1992, and December 31, 1994, and delivered an infant at our institution were consecutively sampled. A structured interview assessed various health-risk behaviors including age at first intercourse, substance use (tobacco, alcohol, and other illicit drug use), and number of sexual partners. Medical records were reviewed to obtain information on pregnancy complications (pregnancy-induced hypertension, preterm delivery, and preterm labor with hospitalization) and negative birth outcomes (infant birthweight and neonatal intensive care admission). RESULTS: Controlling for chronological age, logistic regression analyses found that adolescents reporting employment at their first prenatal visit (n=40) compared with those not employed at this visit (n=331) were more likely to be characterized by school enrollment, higher economic status, partner employment, partner alcohol use, and a longer relationship with the father of their baby. Multivariate logistic regression found that employed females were 4.6 times more likely to deliver a small-for-gestational-age infant. CONCLUSIONS: Employment reported at the time of the first prenatal visit does not appear to be associated with an increase in health-risk behaviors or obstetric complications, but a relationship between working more than 15 hours and small-for-gestational-age delivery was detected.

PMID: 9593606, UI: 98254438

J Hum Hypertens 1998 Mar;12(3):189-94

Renin status does not predict the anti-hypertensive response to angiotensin-converting enzyme inhibition in African-Americans. Trandolapril Multicenter Study Group.

Weir MR, Saunders E

Department of Medicine, University of Maryland School of Medicine, Baltimore 21201, USA.

The angiotensin-converting enzyme (ACE) inhibitor trandolapril, a non-sulfhydryl prodrug which is hydrolysed into trandolaprilat, was studied in 322 hypertensives of African-American descent using a double-blind, randomised, placebo-controlled, parallel study design. Following 6 weeks of double-blind treatment with placebo or 0.25 to 16 mg/day trandolapril, an analysis of drug effect on trough blood pressure (BP) stratified by age, gender, weight, pre-treatment plasma renin activity, and trandolaprilat concentration was performed. Two mg was the lowest effective trandolapril dose, whereas doses above 4 mg did not significantly reduce trough BP. Reduction in BP did not correlate with trough plasma trandolaprilat concentration. Pre-treatment plasma renin activity was not a reliable indicator of anti-hypertensive response, as similar reductions in BP occurred even in patients with the lowest renin levels. There were no observable differences based on age, gender or measurements of the renin-angiotensin-aldosterone axis. In conclusion, neither age, gender or plasma renin activity influenced anti-hypertensive response to angiotensin-converting enzyme inhibition in African-Americans.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9579769, UI: 98239372

Hypertension 1998 May;31(5):1130-5

Seven-year incidence of hypertension in a cohort of middle-aged African Americans and whites.

He J, Klag MJ, Appel LJ, Charleston J, Whelton PK

Department of Biostatistics and Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112-2699, USA. jhe@mailhost.tcs.tulane.edu

Many studies have suggested that African Americans have a higher prevalence of hypertension than whites. The authors conducted a prospective study of hypertension incidence from 1987-1988 to 1994-1995 in 140 African American and 237 white adults aged 30 to 54 years at baseline. The study participants were screened for participation in the Trials of Hypertension Prevention, phase 1, an 18-month lifestyle modification intervention trial aimed at lowering blood pressure, at the Baltimore Clinical Center. Baseline age, blood pressure, body mass index, and heart rate were similar in the two groups. Compared with whites, however, African Americans had a lower percentage of men, college graduates, and households with an income > or = $40,000 per year. African Americans also had lower mean urinary sodium to creatinine ratio and potassium to creatinine ratio, but a similar sodium to potassium ratio. The incidence of hypertension (blood pressure > or = 160/95 mm Hg and/or taking antihypertensive medication) over 7 years of follow-up was nearly identical: 25.7% in African Americans and 25.3% in whites. Baseline age, gender, blood pressure, and heart rate were all associated with the incidence of hypertension. Even after adjustment for these covariables, the risk of hypertension was not higher in African Americans compared with whites. These results indicate that middle-aged African Americans and whites have a similar risk of developing hypertension given the same age, initial blood pressure, and body mass index at baseline.

PMID: 9576125, UI: 98235658

J Thorac Imaging 1998 Apr;13(2):128-34

Thoracic manifestations of sickle cell disease.

Leong CS, Stark P

Department of Radiology, Veterans Affairs Palo Alto Health Care System, California 94304, USA.

Sickle cell disease is the most common inherited disease in the African American population. Multiorgan pathologic features with a predilection for thoracic organs predominate. Acute cardiopulmonary diseases include acute chest syndrome, pneumonia, and left ventricular failure. Cardiomegaly, pleural effusions, pulmonary consolidation, pulmonary edema on chest radiographs, and ground-glass opacities on computed tomographs are characteristic. Chronic changes include sickle cell lung disease with lung fibrosis, pulmonary arterial hypertension, hyperkinetic circulation related to severe anemia, and thoracic skeletal abnormalities; the latter are H-shaped vertebrae, rib infarction, and extramedullary hematopoesis.

Publication Types:

• Review
• Review, tutorial

PMID: 9556290, UI: 98215577

Arch Intern Med 1998 Apr 13;158(7):793-800

End-stage renal disease in specific ethnic and racial groups: risk factors and benefits of antihypertensive therapy.

Powers DR, Wallin JD

Section of Nephrology, Louisiana State University School of Medicine, New Orleans 70112, USA.

During the past few years, it has become apparent that there are factors that place a person at greater risk for the development and progression of renal failure. This has been documented since the early 1980s by the United States Renal Data System that has collected data confirming that end-stage renal disease occurs at a greater rate in certain subpopulations of Americans. It is evident from an examination of the data that African Americans and American Indians have an incidence of end-stage renal disease that is not proportional to their percentage of the total population. In fact, African Americans and American Indians are reported to have at least a 4-fold greater incidence of end-stage renal disease than white Americans. There have been 5 factors identified: hypertension, glucose intolerance, insulin resistance, salt sensitivity, and hyperlipidemia, which may play a greater role in these subpopulations. In addition, as with other populations, lifestyle issues may serve to alter these primary risk factors or may act as direct modulators of renal disease progression. There is also a possibility that interactions between risk factors frequently occur that may modify the development or progression of the disease. This article reviews these risk factors and emphasizes the interaction between hypertension and the other factors. In addition, the effects of antihypertensive agents on risk factors and on renal outcome are emphasized. Where possible, issues specific to African Americans and American Indians are underscored; however, one must accept that the database on these populations is only now developing. This review should help the clinician make appropriate choices when prescribing antihypertensive therapy for patients who may be at risk of developing progressive renal failure.

Publication Types:

• Review
• Review, tutorial

PMID: 9554686, UI: 98213407

J Natl Med Assoc 1998 Mar;90(3):147-56

Diabetes mellitus and its complications in an African-American community: project DIRECT.

Herman WH, Thompson TJ, Visscher W, Aubert RE, Engelgau MM, Liburd L, Watson DJ, Hartwell T

Program Development Branches, National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, Atlanta, Georgia, USA.

Project DIRECT (Diabetes Intervention Reaching and Educating Communities Together) is a multilevel community-based intervention project designed to address diabetes and its complications in an African-American community. This article presents results of the Project DIRECT pilot study and describes risk factors for diabetes, diabetes prevalence, complications, and care practices. During 1993, a pilot study was conducted among persons 20 to 74 years of age in Wake County, North Carolina. The study involved household interviews and examinations, and more extensive health center interviews and examinations based on the race of the head of the household, previous diagnosis of diabetes, and results of capillary glucose tests done in the household. Of the black population aged 20 to 74 years, 52 +/- 3% reported being inactive and 51 +/- 3% were overweight; the prevalence of diagnosed diabetes was 5.2 +/- 0.9%; the prevalence of undiagnosed diabetes was 5.7 +/- 2.7%; and the prevalence of impaired glucose tolerance was 11.4 +/- 7.5%. Blacks with diabetes were significantly more likely than nonblacks with diabetes to have uncontrolled hypertension and to smoke cigarettes. Blacks with diabetes were significantly less likely to report having health insurance or to have a private health-care provider. Diabetes mellitus is a major public health problem in the African-American community of Wake County. Modifiable risk factors for diabetes and undiagnosed diabetes are common. Project DIRECT is attempting to improve the health-related quality of life of this population by reducing the burden of diabetes and its complications through a multilevel, community-based intervention.

PMID: 9549978, UI: 98211148

Nephron 1998;78(3):332-3

Does hypertension cause end-stage renal disease in older white patients?

Appel RG, Bleyer AJ, Burkart JM

Publication Types:

• Letter

PMID: 9546696, UI: 98206773

Int J Psychophysiol 1998 Mar;28(2):131-42

Sociotropic cognition moderates blood pressure response to interpersonal stress in high-risk adolescent girls.

Ewart CK, Jorgensen RS, Kolodner KB

Department of Psychology, Syracuse University, NY 13244-2340, USA. cewart@psych.syr.edu

This article tests the hypothesis that 'sociotropic cognition'--heightened preoccupation with being accepted by others--increase vulnerability to cardiovascular stress in females. Adolescent girls (55 African-American; 23 Caucasian) at increased risk of developing essential hypertension due to persisting high normal blood pressure, completed measures of sociotropic cognition, social competence, trait affect and social support. Later, their blood pressure and heart rate were measured during non-social stress (mirror image tracing) and interpersonal stress [Social Competence Interview (SCI)]. Comparisons of blood pressure responses to the tasks disclosed a significant Task main effect, replicating a previous finding that blood pressure is elevated more by SCI than by non-social stress. When Sociotropy was introduced as a moderator, however, a significant Task by Sociotropy interaction indicated that the comparatively greater reactivity to SCI occurred mainly in girls who exhibited high levels of sociotropic thinking. Cognitive sociotropy was associated with a profile of social emotional and environmental deficits suggesting increased susceptibility to chronic stress and impaired coping.

PMID: 9545651, UI: 98207261

Diabetes Care 1998 Feb;21(2):291-5

The association between diabetic complications and exercise capacity in NIDDM patients.

Estacio RO, Regensteiner JG, Wolfel EE, Jeffers B, Dickenson M, Schrier RW

Department of Medicine, Denver Health and University of Colorado Health Sciences Center, Colorado 80262, USA.

OBJECTIVE: Exercise capacity has been used as a noninvasive parameter for predicting cardiovascular events. It has been demonstrated previously in NIDDM patients that several risk factors (i.e., obesity, smoking, hypertension, and African-American race) are associated with an impaired exercise capacity. We studied 265 male and 154 female NIDDM patients who underwent graded exercise testing with expired gas analyses to determine the possible influences of diabetic neuropathy, nephropathy, and retinopathy on exercise capacity. RESEARCH DESIGN AND METHODS: Univariate and multiple linear regression analyses were performed to determine the relationship between diabetic neuropathy, urinary albumin excretion (UAE), and retinopathy with respect to peak oxygen consumption (VO2). Neuropathy was assessed by neurological symptom and disability scores, autonomic function testing, and quantitative sensory exams involving thermal and vibratory sensation. Three categories of UAE were used: normal albuminuria (< 20 micrograms/min), microalbuminuria (20-200 micrograms/min), and overt albuminuria (> 200 micrograms/min). Retinopathy was assessed by stereoscopic fundus photographs. Multiple linear regression analyses were then performed controlling for age, sex, length of diagnosed diabetes, duration of hypertension, race and ethnicity, GHb, BMI, and smoking to determine whether there was an independent effect of these diabetic complications on exercise capacity. RESULTS: Univariate analyses revealed that the presence of diabetic retinopathy (P = 0.03), neuropathy (P = 0.002), microalbuminuria (P = 0.04), and overt albuminuria (P = 0.06) were associated with a lower peak VO2. Multiple linear regression analyses were performed to determine independent relationships with peak VO2. The results revealed that increasing retinopathy stage (Parameter estimate [PE] = -0.59 +/- 0.3 ml.kg-1.min-1; P = 0.026) and increasing UAE stage (PE = -0.62 +/- 0.3 ml.kg-1.min-1; P = 0.04) were associated with a decrease in peak VO2. CONCLUSIONS: In the present study of NIDDM subjects, a significant independent association was demonstrated between diabetic nephropathy and retinopathy with exercise capacity. These results were obtained controlling for age, sex, length of diagnosed diabetes, hypertension, race, and BMI. Thus the findings in this large NIDDM population without a history of coronary artery disease indicate a potential pathogenic relationship between microvascular disease and exercise capacity.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9539998, UI: 98200819

Hypertension 1998 Apr;31(4):906-11

Identification of human plasma kallikrein gene polymorphisms and evaluation of their role in end-stage renal disease.

Yu H, Bowden DW, Spray BJ, Rich SS, Freedman BI

Department of Biochemistry, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157-1053, USA.

Kallikreins are serine proteases that release kinins from kininogens. Kinins, via their effects on cardiovascular and renal function, may be involved in the pathogenesis of hypertension and renal failure. Two groups of kallikreins exist, glandular or tissue kallikrein and plasma kallikrein. In this study, we examined the human plasma kallikrein gene KLK3 to determine whether it contributed to end-stage renal disease (ESRD) susceptibility. We identified two novel polymorphic sequences closely linked to the KLK3 gene, designated KLK3b and KLK3c (heterozygosities: 0.64 to 0.68 and 0.48 to 0.52, respectively). We mapped the KLK3 gene and the marker KLK3c to the long arm of human chromosome 4 between F11 and D4S426 using a radiation hybrid panel. The study population consisted of 142 sibling pairs concordant for ESRD from 121 African American families. The 142 sibling pairs were stratified into 78 pairs with hypertension- and chronic glomerulonephritis-associated ESRD and 64 with non-insulin-dependent diabetes mellitus-associated ESRD. Linkage analyses, using SIBPAL of SAGE, and exclusion analysis, using MAPMAKERS/SIBS, were performed. Linkage analysis of affected sibling pairs did not reveal any evidence of linkage of KLK3 to ESRD in all 142 sib-pairs or in the two stratified subsets. Exclusion analysis indicated that the KLK3 gene could be excluded from contributing to ESRD at a relative risk of 3 when the maximum log of the odds score of -2 was used as the criterion for exclusion. However, an association analysis using the relative predispositional effect technique showed that alleles 7 and 9 of KLK3b were consistently associated with ESRD. Alleles 7 and 9 were present in 11.2% and 10.8% of the 113 unrelated ESRD probands and in 6.6% and 6.6% of the 204 race-matched control subjects without renal disease (allele P=.0041 and .0016, respectively). Alleles 7 and 9 were also present in 13% and 10.4% of the proband's first siblings (allele P=.00014 and .0087, respectively). The association of KLK3b alleles with ESRD raises the possibility that polymorphisms in KLK3 may play a role in ESRD susceptibility. The lack of linkage might reflect our relatively small family set.

PMID: 9535413, UI: 98195090

Am J Cardiol 1998 Mar 15;81(6):732-5

Effects of moderate intensity exercise on serum lipids in African-American men with severe systemic hypertension.

Kokkinos PF, Narayan P, Colleran J, Fletcher RD, Lakshman R, Papademetriou V

Cardiology Division, Veterans Affairs Medical Center, Washington, DC 20422, USA.

The prevalence of systemic hypertension and its cardiovascular consequences is higher in African-Americans than in whites. Low to moderate intensity aerobic exercise lowers blood pressure (BP) in African-American patients with severe hypertension. It is not known whether such exercise can improve lipid metabolism in these patients. Thirty-six African-American men with established essential hypertension, aged 35 to 76 years, were randomly assigned to an exercise (n = 17) or no exercise (n = 19) group. The exercise group exercised for 16 weeks, 3 times/week, at 60% to 80% of maximum heart rate. After 16 weeks, peak oxygen uptake in the exercise group improved (21+/-4 vs 23+/-3 ml/kg/min; p <0.001). Body weight did not change. Exercise intensity correlated with high-density lipoprotein (HDL) cholesterol changes from baseline to 16 weeks (r = 0.65; p <0.01) and was the strongest predictor of these changes (R2 = 0.4; p = 0.009). Lipoprotein-lipid changes in the 2 randomized groups did not differ significantly. A 10% increase in HDL cholesterol--42+/-19 versus 46+/-19 mg/dl; p = 0.003--noted in 10 patients who exercised > or = 75% of maximal heart rate suggested the existence of an exercise intensity threshold. Thus low to moderate intensity aerobic exercise may not be adequate to modify lipid profiles favorably in patients with severe hypertension. However, substantial changes in HDL cholesterol were noted in patients exercising at intensities > or = 75% of age-predicted maximum heart rate, suggesting an exercise-intensity threshold.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9527083, UI: 98186312

J Natl Med Assoc 1998 Feb;90(2):78-84

Clinical aspects of Alzheimer's disease in black and white patients.

Hargrave R, Stoeklin M, Haan M, Reed B

University of California at Davis, Oakland.

This article examines the association between ethnicity and psychiatric symptoms in patients with Alzheimer's disease. Data from a cross-sectional study of patients evaluated at nine California Department of Health Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs) were used. Using the ADDTC patient database, sociodemographic and clinical variables in 207 black patients and 1818 white patients with probable and possible Alzheimer's disease were compared. Logistic and linear regression analysis indicated the following results: 1) black patients had fewer years of education and more often had hypertension, 2) black patients reported shorter duration of illness at the time of initial diagnosis of dementia, 3) black patients had lower Mini-Mental State Examination scores and higher Blessed Roth Dementia Rating Scale scores at the time of initial diagnosis, and 4) black patients more frequently reported insomnia and less frequently reported anxiety. Additional studies are needed to validate these findings and to generate hypotheses about the role of cardiovascular disease and pathophysiology of psychiatric symptoms in ethnic populations with Alzheimer's disease.

PMID: 9510621, UI: 98171610

Kidney Int 1998 Mar;53(3):639-44

Transforming growth factor-beta 1 hyperexpression in African American end-stage renal disease patients.

Suthanthiran M, Khanna A, Cukran D, Adhikarla R, Sharma VK, Singh T, August P

Department of Transplantation Medicine and Extracorporeal Therapy, New York City Department of Health, New York, USA. msuthan@mail.med.cornell.edu

End-stage renal disease (ESRD) is more frequent in African Americans (blacks) compared to Caucasian Americans (whites). Identification of remediable causes of the increased prevalence has the potential to reduce the excess burden of ESRD. Because renal fibrosis is a correlate of progressive renal failure and a dominant feature of ESRD, and because transforming growth factor-beta 1 (TGF-beta 1) can induce fibrosis and renal insufficiency, we explored the hypothesis that TGF-beta 1 hyperexpression is more frequent in black ESRD patients compared to white ESRD patients. Our postulate was tested by determining circulating levels of TGF-beta 1 protein in the sera of 56 black and 42 white ESRD patients treated by chronic hemodialysis. A solid-phase sandwich enzyme-linked immunosorbent assay, specific for TGF-beta 1, was used to quantify TGF-beta 1 levels in the ESRD cohort. Additional cytokines implicated in tissue repair/remodeling, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), were also measured. Our investigation demonstrated a significantly higher concentration of TGF-beta 1 protein but not that of IL-6 or TNF-alpha in blacks compared to whites. Our observation that TGF-beta 1 is hyperexpressed in black ESRD patients suggests a mechanism for the increased prevalence of renal failure (since TGF-beta 1 hyperexpression can result in renal insufficiency in experimental models) among the black population.

Comments:

• Comment in: Kidney Int 1998 Mar;53(3):792-3

PMID: 9507209, UI: 98168050

J Subst Abuse 1997;9:111-25

The effects of substance use during gestation on birth outcome, infant and maternal health.

Hanna EZ, Faden VB, Dufour MC

National Institute of Alcohol Abuse and Alcoholism, Division of Biometry and Epidemiology, Bethesda, MD 20892-7003, USA.

This study examines the relationship of substance use to birth outcome, infant, and maternal health in a large, nationally representative sample. Multiple regression analyses, accommodating the nature of the survey data using the SUDAAN software package, indicated that drinking and smoking independently and/or interactively with depression account for poor health and serious medical conditions among pregnant women as well as negative birth outcomes or adverse health consequences in those infants who are live births. In addition, African American women and their infants are more likely than those of other racial groups to suffer these adverse outcomes. Given the risk profiles of individual illnesses, this study suggests the need for developing and targeting health education and preventive efforts specific to those groups that are clearly at greater risk.

PMID: 9494943, UI: 98156047

Am J Public Health 1998 Feb;88(2):292-4

Blood pressure measurement and antihypertensive treatment in a low-income African-American population.

Hyman DJ, Pavlik VN, Vallbona C, Dunn JK, Louis K, Dewey CM, Wieck L

Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA.

OBJECTIVES: The purpose of this study was to describe blood pressure measurement and hypertension treatment in an inner-city African-American community. METHODS: A random-digit dialing telephone survey of adults more than 18 years of age was carried out in 12 predominantly African-American zip code areas in Houston, Texas. RESULTS: More than 90% of subjects reported a blood pressure measurement within the past 2 years, and 87% of known hypertensives reported current medication use. CONCLUSIONS: Further improvements in hypertension control among African Americans in this country are likely to depend primarily on changes in diagnosis and management practices of health care providers and on maintaining primary care access for all socioeconomic groups.

PMID: 9491026, UI: 98151726

East Afr Med J 1997 Aug;74(8):478-86

Macronutrient intake and cardiovascular risk factors in older coloured South Africans.

Charlton KE, Wolmarans P, Marais AD, Lombard CJ

HSRC/UCT Centre for Gerontology, Braemar, Medical School, University of Cape Town, Observatory, South Africa.

A cross-sectional analytical study was undertaken to investigate the macronutrient intake and cardiovascular risk factor profile of community-dwelling older coloured (mixed descent) South Africans. A sample of 200 subjects aged 65 years and above in Cape Town was randomly drawn using a two-stage cluster design. Trained field workers interviewed subjects to obtain demographic, dietary and life-style data, to draw fasting blood samples for the analysis of plasma lipids, and to take anthropometric measurements. Nutrient intake was assessed using a validated quantified food frequency questionnaire. Blood pressure was measured according to the guidelines of the American Heart Association. The mean daily energy intake was 7984 (3245) kJ and 6979 (2219) kJ for men and women, respectively. Twenty-nine per cent of the subjects had energy intakes less than two-thirds of the RDA. Dietary fat intake comprised 32.4% of total energy intake, which is in line with the prudent dietary guidelines. The inadequate fibre intake (mean = 17(8) g/day) was attributed to the low consumption of fruit and vegetables. Anthropometric assessment indicated that the women tended towards overnutrition, while the men appeared to be undernourished. Lipid profiles fell within the lower end of the moderate risk band for cardiovascular disease and a high prevalence of hypertension (71.7%) was identified. The survey findings indicate a need for health promotion activities to encourage increased physical activity levels and an increased consumption of vegetables, fruit, wholegrain cereals and low fat dairy products in this population.

PMID: 9487411, UI: 98148391

JAMA 1998 Feb 25;279(8):585-92

Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study.

Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, Robbins JA, Gardin JM

Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md, USA.

CONTEXT: Multiple factors contribute to mortality in older adults, but the extent to which subclinical disease and other factors contribute independently to mortality risk is not known. OBJECTIVE: To determine the disease, functional, and personal characteristics that jointly predict mortality in community-dwelling men and women aged 65 years or older. DESIGN: Prospective population-based cohort study with 5 years of follow-up and a validation cohort of African Americans with 4.25-year follow-up. SETTING: Four US communities. PARTICIPANTS: A total of 5201 and 685 men and women aged 65 years or older in the original and African American cohorts, respectively. MAIN OUTCOME MEASURES: Five-year mortality. RESULTS: In the main cohort, 646 deaths (12%) occurred within 5 years. Using Cox proportional hazards models, 20 characteristics (of 78 assessed) were each significantly (P<.05) and independently associated with mortality: increasing age, male sex, income less than $50000 per year, low weight, lack of moderate or vigorous exercise, smoking for more than 50 pack-years, high brachial (>169 mm Hg) and low tibial (< or = 127 mm Hg) systolic blood pressure, diuretic use by those without hypertension or congestive heart failure, elevated fasting glucose level (>7.2 mmol/L [130 mg/dL]), low albumin level (< or = 37 g/L), elevated creatinine level (> or = 106 micromol/L [1.2 mg/dL]), low forced vital capacity (< or = 2.06 mL), aortic stenosis (moderate or severe) and abnormal left ventricular ejection fraction (by echocardiography), major electrocardiographic abnormality, stenosis of internal carotid artery (by ultrasound), congestive heart failure, difficulty in any instrumental activity of daily living, and low cognitive function by Digit Symbol Substitution test score. Neither high-density lipoprotein cholesterol nor low-density lipoprotein cholesterol was associated with mortality. After adjustment for other factors, the association between age and mortality diminished, but the reduction in mortality with female sex persisted. Finally, the risk of mortality was validated in the second cohort; quintiles of risk ranged from 2% to 39% and 0% to 26% for the 2 cohorts. CONCLUSIONS: Objective measures of subclinical disease and disease severity were independent and joint predictors of 5-year mortality in older adults, along with male sex, relative poverty, physical activity, smoking, indicators of frailty, and disability. Except for history of congestive heart failure, objective, quantitative measures of disease were better predictors of mortality than was clinical history of disease.

Comments:

• Comment in: JAMA 1998 Feb 25;279(8):622-3
• Comment in: ACP J Club 1998 Jul-Aug;129(1):23

PMID: 9486752, UI: 98146157

Am J Cardiol 1998 Feb 15;81(4):453-9

Electrocardiographic findings in a healthy biracial population. Atherosclerosis Risk in Communities (ARIC) Study Investigators.

Vitelli LL, Crow RS, Shahar E, Hutchinson RG, Rautaharju PM, Folsom AR

Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55454, USA.

It has been well documented that the prevalence of certain electrocardiographic (ECG) findings among individuals free of coronary heart disease (CHD) differs by race. However, it is not known whether these differences exist independently of CHD risk factors (e.g., hypertension). We examined the ECG tracings of 2,686 apparently healthy, middle-aged African-American and white men and women who participated in the Atherosclerosis Risk in Communities Study and were at low risk of CHD. Using the Minnesota Code, among men, 46% of African-Americans, but only 25% of whites, had a minor ECG finding (p < 0.001). In women, 32% of African-Americans and 23% of whites had a minor ECG finding (p < 0.01). Specifically, the age-adjusted prevalences of high-amplitude R wave, ST elevation, T-wave findings, and prolonged P-R interval were statistically significantly higher in African-Americans. As for continuous ECG measurements, the R wave in leads V5 and V6, the S wave in V1, the J-point amplitude in leads V2 and V5, the P-R interval, and the Cornell voltage (S V3 + R aVL) for left ventricular hypertrophy were all significantly greater in African-Americans than in whites. However, in both men and women, the heart rate corrected QT interval was shorter in African-Americans than in whites. All of these findings remained statistically significant after further adjustment for traditional CHD risk factors. These results suggest that racial differences in electrocardiograms may not be explained entirely by differences in established CHD risk factors, and because current diagnostic ECG criteria are largely based on data from middle-aged white men and women, race should be considered in the interpretation of ECG findings.

Publication Types:

• Multicenter study

PMID: 9485136, UI: 98143670

J Pediatr 1998 Jan;132(1):90-7

Can cardiovascular risk be predicted by newborn, childhood, and adolescent body size? An examination of longitudinal data in urban African Americans.

Hulman S, Kushner H, Katz S, Falkner B

Albert Einstein Medical Center, Biomedical Computer Research Institute, Krogman Growth Center, University of Pennsylvania, Allegheny University, Philadelphia 19141-3098, USA.

OBJECTIVE: Recent retrospective studies of older adults have demonstrated a correlation between lower birth weight and hypertension and insulin resistance. We tested this finding in our sample of urban African Americans with prospective data on growth and blood pressure and also tested other variables (in addition to birth weight) for their relationship to adult cardiovascular risk. STUDY DESIGN: A prospective study of birth weight, growth, and blood pressure (Philadelphia Perinatal Collaborative Project) followed a sample of 137 African Americans, with nine examinations from birth through 28.0 +/- 2.7 years. Metabolic measurements (oral glucose tolerance testing, euglycemic hyperinsulinemic clamp, and plasma lipid concentration) were performed on the subjects as adults. Bivariate correlations among parameters were computed using the Pearson r. The chi-squared statistic was used to determine associations of outcomes with birth weight. Stepwise multiple linear regressions were computed using newborn, early childhood, adolescent, and young adult parameters to predict adult outcomes. RESULTS: Birth weight and blood pressure at age 28 years are not correlated (Pearson r = 0.06). Birth weight is also unrelated to adult obesity. However, weight at 0.3 years and after and body mass index at 7 years and after are correlated with adult weight. Furthermore, weight at age 14 years is significantly negatively correlated with measures of insulin-stimulated glucose use, indicating that obese adolescents may be at greater risk than nonobese adolescents for development of non-insulin dependent diabetes in adulthood. CONCLUSIONS: We found no relationship between birth weight and adult outcomes pertaining to cardiovascular risk in this sample of adult African Americans. However, we did find evidence that somatic growth (body weight and body mass index) is significantly related to obesity and attenuated insulin-stimulated glucose utilization in adulthood. These findings indicate that the origins of adult cardiovascular disease are related to somatic growth, but not intrauterine growth, and are evident during childhood.

PMID: 9470007, UI: 98130783

Ethn Dis 1997 Autumn;7(3):250-8

Body fat distribution and race differences in apolipoprotein A1.

Ferguson JE, Croft JB, Thompson SJ, Addy CL, Sheridan DP, Wheeler FC, Macera CA

South Carolina Department of Health and Environmental Control, Columbia, USA.

OBJECTIVE: This is the first study to assess the role of waist-to-hip ratio in explaining race differences in levels of serum apolipoprotein A1, a protective risk factor for atherosclerosis. METHODS: Linear regression analyses were used in a community-based survey of 3,043 adults (23.5% African-American) to assess associations of race, age, anthropometric measures, education, diabetes, blood pressure medication use, cigarette smoking, and leisure-time physical activity with apolipoprotein A1 levels. RESULTS: Higher apolipoprotein A1 levels were observed among African-American than among white adults (African-American men: +15.6 mg/dl than white men, African-American women: +3.1 mg/dl more than white women; p < 0.05). Waist-to-hip ratio and other variables did not account for race differences among men. African-American women had +8.6 mg/dl higher levels than white women after adjustment for differing distributions of waist-to-hip ratio, age, body mass index and education. Cigarette smoking, physical activity, and medical history accounted for no further differences among women. CONCLUSIONS: Higher levels of obesity indicators and lower educational attainment among African-American women reduced a potentially greater beneficial race difference in apolipoprotein A1. These findings also suggest that other environmental and biochemical factors may play roles in explaining the higher protective levels of apolipoprotein A1 observed among African-American children and adults.

PMID: 9467708, UI: 98128889

Ethn Dis 1997 Autumn;7(3):191-9

A hypertension control program tailored to unskilled and minority workers.

Fouad MN, Kiefe CI, Bartolucci AA, Burst NM, Ulene V, Harvey MR

Department of Medicine, University of Alabama at Birmingham 35205-4785, USA. mfouad@dopm.uab.edu

PURPOSE: A comprehensive worksite health promotion program designed to reduce risk factors for cardiovascular disease among 4000 city of Birmingham employees was used to develop and implement a tailored antihypertensive educational intervention. The mean age of the underlying population was 36 years, 89% were blue-collar or unskilled workers, 50% were African Americans and 20% were female. METHODS: First, we identified barriers to hypertension control: low literacy, difficulty understanding the need for treatment of asymptomatic disease, and wide variability of health beliefs and priorities. We then tailored an educational program, which offered employees health education sessions on a variety of different topics, including heart disease, cancer, sleep disorders and back injury. All program materials focused on lifestyle changes and the need to seek medical care. This program was offered to all hypertensive workers; 130 chose to enroll, and 81 completed the program. These 81 participants were matched by age, sex, race and baseline BP with nonparticipating hypertensive workers (controls). Changes in SBP and DBP from before to after the educational program were used to evaluate the program. RESULTS: Overall, intervention participants had a decrease of 4.5 mm Hg in mean SBP (different from zero, [p = 0.03]). African American participants showed a significant decrease (7.4 mm Hg, [p = 0.004]), as did unskilled intervention participants (SBP changes = 7.7 mm Hg, [p = 0.004]). Although not statistically significant, controls showed decreases in BP in the same direction. CONCLUSION: An educational intervention tailored to the specific health perceptions and working conditions of a low literacy population is feasible, and may have a significant effect on hypertension control.

Publication Types:

• Clinical trial
• Controlled clinical trial

PMID: 9467701, UI: 98128882

Ethn Dis 1997 Autumn;7(3):175-83

Incorporating socio-economic and risk factor diversity into the development of an African-American community blood pressure control program.

Shakoor-Abdullah B, Kotchen JM, Walker WE, Chelius TH, Hoffmann RG

Division of Epidemiology, Medical College of Wisconsin, Milwaukee, USA.

OBJECTIVE: To develop culturally competent community based blood pressure control programs for inner-city African Americans. DESIGN: Cross sectional study of randomly selected households from three experimental and three control communities. SETTING: Very low, moderately low and moderate socio-economic status (SES) inner-city communities in Chicago, Illinois. PARTICIPANTS: 957 African Americans adults, aged 18 and over from target communities. MAIN OUTCOME MEASURE: Household health assessments included employment, education and other demographic information, history of hypertension, disease prevalence, health behaviors, risk factor prevalence, stress, coping/John Henryism, social support, health care utilization and standardized assessments of blood pressure, height, and weight. RESULTS: There were no significant gender differences in blood pressure levels. Men had more hypertension than women, and women in the very low SES community had significantly more hypertension than women in the moderately low SES community. There was significantly more hypertension overall in the moderately low SES community. Age, education and BMI were the only factors significantly associated with systolic and diastolic blood pressure in all three communities. The very low SES community had significantly more obesity and more uninsured persons than the other communities. CONCLUSIONS: Intraracial diversity is an important factor to be considered in the development of community blood pressure control programs for African Americans. Age, gender, educational background and SES play a major role in influencing health behaviors and access to health care.

PMID: 9467699, UI: 98128880

Ann Epidemiol 1998 Jan;8(1):22-30

Differences in cardiovascular disease risk factors in black and white young adults: comparisons among five communities of the CARDIA and the Bogalusa heart studies. Coronary Artery Risk Development In Young Adults.

Greenlund KJ, Kiefe CI, Gidding SS, Lewis CE, Srinivasan SR, Williams OD, Berenson GS

Tulane Center for Cardiovascular Health, Tulane School of Public Health & Tropical Medicine, New Orleans, LA, USA.

PURPOSE: To examine community differences in cardiovascular disease (CVD) risk factors among black and white young adults by combining data from two large epidemiologic studies. METHODS: Data are from participants aged 20-31 years in the Coronary Artery Risk Development In Young Adults (CARDIA) study (1987-1988; N = 4129) and the Bogalusa Heart study (1988-1991; N = 1884), adjusting for data collection differences prior to analysis. CARDIA includes four urban sites: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Bogalusa is a semi-rural town in Southeastern Louisiana. CVD risk factors examined were smoking status, body habitus, and blood pressure. RESULTS: In Birmingham and Bogalusa, more white than black women were current smokers; no ethnic differences were observed among men. In Chicago, Minneapolis, and Oakland, more blacks were current smokers than were whites. For all sites, educational level was strongly inversely related to current smoking status; ethnic differences were more apparent among those with up to a high school education. Among white men and women, prevalence of obesity (body mass index > 31.1 kg/m2 in men and 32.3 kg/m2 in women) was greater in Birmingham and Bogalusa than in Chicago. Minneapolis, and Oakland. Mean systolic blood pressures were highest in Bogalusa, and the proportion of black men with elevated blood pressure (> or = 130/85 mmHg) was higher in Bogalusa and Birmingham. CONCLUSIONS: Community and ethnic differences in CVD risk factors were observed among young adults in two large epidemiologic studies. Further studies may enhance our understanding of the relationship of geographic differences in CVD risk to subsequent disease.

PMID: 9465990, UI: 98127138

Adv Nurse Pract 1997 Apr;5(4):49-52

High pressure. Treating hypertension in African Americans.

Peters S

Publication Types:

• Review
• Review, tutorial

PMID: 9459897, UI: 98116297

Mt Sinai J Med 1998 Jan;65(1):27-32

HIV-associated nephropathy.

Winston J, Klotman PE

Mount Sinai School of Medicine, New York, NY 10029, USA.

BACKGROUND: Patients with HIV-1 infection are at risk for developing renal diseases with diverse etiologies. Acute renal failure occurs in up to 20% of hospitalized patients with HIV infection, and chronic renal disease of diverse etiology has been reported. The single most common cause of chronic renal insufficiency in HIV-1+ patients is HIV-associated nephropathy (HIVAN). Typical morphologic features include enlarged kidneys, microcystic tubule dilatation, tubulointerstitial inflammation, and focal and segmental glomerulosclerosis. METHODS: The pathogenesis, epidemiology, and treatment options for HIVAN are discussed. In studying the epidemiology of the disease, we reviewed several renal disease databases, including the United States Renal Data Systems and New York State End Stage Renal Disease Network. We have previously reported our experience with HIVAN at Mount Sinai Medical Center. RESULTS: The exact cause of the renal disease remains unknown. The importance of a direct effect of HIV-1 viral protein(s) or renal HIV-1 gene expression in disease pathogenesis is supported in the murine model of HIVAN, but definitive proof of renal cell infection in humans is lacking. Further study is required to clarify this issue. We estimate that HIVAN is the fourth leading cause of end-stage renal disease (ESRD) among Blacks between the ages of 20 and 64 years, only slightly behind hypertension, diabetes, and chronic glomerulonephritis. At Mount Sinai Hospital HIVAN accounts for 20% of newly diagnosed ESRD in young black adults. It has become the third leading cause of ESRD in this group, after hypertension and diabetes. CONCLUSIONS: In seropositive patients with renal disease, renal biopsies should be performed to confirm the diagnosis and determine the true incidence. Special attention should be directed toward understanding the underlying cause(s) of HIVAN. A multicenter trial to explore the potential for antiviral therapy in this disease should be initiated.

Publication Types:

• Review
• Review, tutorial

PMID: 9458681, UI: 98120264

Am J Epidemiol 1998 Jan 15;147(2):95-9; discussion 100-2

Secular trends in the United States black/white hypertension prevalence ratio: potential impact of diminishing response rates.

Gorey KM, Trevisan M

School of Social Work, University of Windsor, Ontario, Canada.

In this integrative review, the authors analyzed 25 studies on hypertension prevalence among black and white adults (1960-1991). The authors made the following inferences: 1) both female (2.59 vs. 1.77) and male (2.20 vs. 1.38) black/white hypertension prevalence ratios have diminished by approximately a third over the past three decades; 2) response rates were significantly lower among the more recent surveys (i.e., 1976 or later, mean 69.2 percent (standard deviation (SD) 6.9) vs. 1960 to 1975, mean 86.1 percent (SD 9.1)); and 3) these two trends are directly associated--response rates may account for a third (women, R2 = 0.362) to nearly a half (men, R2 = 0.469) of the variability in black-white hypertension differentials. These findings suggest that although respondent-based research has found black and white adults in the United States to be increasingly similar in hypertension prevalence, the same may not be true of the entire adult population (responders and nonresponders). The apparent diminishment over time in the black-white hypertension gap is as likely to be a methodological artifact allied with declining response rates as a true parametric phenomenon resultant from substantive factors such as enhanced treatment effectiveness among blacks.

Publication Types:

• Review
• Review, tutorial

PMID: 9456997, UI: 98118113

Diabet Med 1997 Dec;14(12):1073-7

Audit of public sector primary diabetes care in Cape Town, South Africa: high prevalence of complications, uncontrolled hyperglycaemia, and hypertension.

Levitt NS, Bradshaw D, Zwarenstein MF, Bawa AA, Maphumolo S

Department of Medicine, University of Cape Town, South Africa.

This study was undertaken to investigate the prevalence of diabetes complications and level of glycaemic and blood pressure control in Black African patients at the primary care level in the public sector Cape Town, South Africa. A stratified random sample of 300 patients attending the three largest ambulatory diabetes clinics in community health centres in Black African residential areas of Cape Town (100 patients from each) during the last 6 months of 1992 was selected. Each patient had a clinical examination, interview, and 1 year retrospective record review. Eighty-one per cent of the sampled patients were reviewed, 90% were non-insulin-dependent (NIDDM) and 10% were treated with insulin. The mean duration of diabetes was 8 (range 0-28) years. Acceptable glycaemic control was present in 49.4% (95% Confidence Intervals 45.6-53.5) of patients while 38.5% (CI 24.8-52.2) of hypertensive patients had acceptable blood pressure control. The prevalence of any grade of retinopathy was 55.4% (CI 48.90-62.9), proliferative and preproliferative retinopathy 15.6% (CI 8.5-22.8), cataracts 7.9% (CI 4.4-11.4), peripheral neuropathy 27.6% (CI 15.2-39.4), absent foot pulses 8.2% (CI 5.2-12.6), amputations 1.4% (CI 0.4-2.4), persistent proteinuria 5.3% (CI 2.5-8.1) and an elevated albumin-creatinine ratio 36.7% (CI 29.0-44.4). The complications were not documented in the clinic records of the preceding year with the exception of 1 patient with absent foot pulses and the 12 patients with proteinuria. The high prevalence of suboptimal glycaemic and blood pressure control as well as complications of diabetes, largely unrecorded in the preceding years' clinic notes, demonstrates the deficiency of and need for preventative diabetes care at the primary care level. The design, institution, and evaluation of effective intervention programmes are a priority to improve the quality of care provided and the health of diabetic patients.

PMID: 9455936, UI: 98115471

Adv Pract Nurs Q 1996 Fall;2(2):31-8

Bridging cultural boundaries: the African American and transcultural caring.

Morris RI

School of Nursing, San Diego State University, California, USA.

This article discusses how to bridge cultural boundaries in the African-American culture. It also explains the influences of cultural trends in America and Africa on health care. The importance of cultural assessment in clinical practice is discussed, including the preparation of graduate nurses to acquire cultural assessment skills. A cultural assessment interview, using a modified cultural assessment tool, is provided.

PMID: 9447071, UI: 98108311

Muscle Nerve 1998 Jan;21(1):72-80

Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM).

Cohen JA, Jeffers BW, Faldut D, Marcoux M, Schrier RW

Department of Neurology, Kaiser Permanente, Denver, Colorado 80262, USA.

Identification of risk factors for development of diabetic sensorimotor peripheral neuropathy (DSPN) and diabetic autonomic neuropathy (DNA) may help to prevent or modify these complications. The ABCD Trial, a prospective study of diabetic complications, has identified risk factors of the presence and staging of peripheral neuropathy based on neurological symptom scores, neurological disability scores, autonomic function testing and quantitative sensory examination. DSPN is independently associated with diabetes duration [odds ratio (OR) = 1.5 per 10 years], body weight (OR = 1.1 per 5 kg), age (OR = 1.8 per 10 years), retinopathy (OR = 2.3), overt albuminuria (OR = 2.5), height (OR = 1.2 per 10 cm), duration of hypertension (OR = 1.1 per 10 years), insulin use (OR = 1.4), and race/ethnicity [African American vs. non-Hispanic white (OR = 0.4) and Hispanic vs. non-Hispanic white (OR = 0.8)]. DAN is independently associated with diabetes duration (OR = 1.2 per 10 years), body weight (OR = 1.1 per 5 kg), glycosylated hemoglobin (OR = 1.1 per 2.5%), overt albuminuria (OR = 1.6), and retinopathy (OR = 1.8).

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 9427226, UI: 98087098

Ethn Health 1997 Aug;2(3):243-53

Church-based education: an outreach program for African Americans with hypertension.

Smith ED, Merritt SL, Patel MK

University of Illinois at Chicago College of Nursing 60612, USA.

The goals of this education outreach demonstration study were to prepare a cadre of registered nurses (RN) as Church Health Educators (CHE), and to test the efficacy of a hypertension (HBP) education and support program in African American (AA) churches for persons with HBP in managing blood pressure (BP). In this two-phase study, RNs were prepared as CHEs in phase 1 and a convenience sample of 97 subjects with HBP was taught by the CHEs in phase 2. The intervention's content included the bases of HBP and HBP management strategies, and was taught in eight 1-hour sessions. Using a pre-test-post-test design, data on knowledge, social support and BP were collected at baseline (pre), post-intervention (post1) and 3 months post-intervention (post2). Major findings include: (1) there was a significant increase in knowledge scores from pre to post1 and post2 (P < or = 0.0001; F = 95.08; df = 1.79); (2) education, age and number of years with HBP explained 49% of the variance associated with HBP knowledge; (3) systolic BP (SBP) and mean arterial BP (MAP) significantly decreased from pre to post1 and post2 (SBP-p < or = 0.0001, F = 18.35, df = 1.91; MAP-p < or = 0.0001, F = 17.80, df = 1.86); (4) DBP significantly decreased from pre to post1 only (p < or = 0.008, F = 17.48, df = 1.91); and (5) relationships were found between social support and DBP, and social support and MAP. Issues that emerged from this study with implications for outreach programming include recruitment and retention, randomization, selective sampling, intervention design and use of volunteers.

Publication Types:

• Clinical trial
• Multicenter study

PMID: 9426988, UI: 98088427

Transplant Proc 1997 Dec;29(8):3718

Hypertension does not contribute to end-stage renal disease in black recipients of kidney/pancreas transplants.

Froelich J, Posner M, Beck R, Tesi RJ

Sangstat Medical Company, Menlo Park, California 94025, USA.

PMID: 9414899, UI: 98076579

Transplant Proc 1997 Dec;29(8):3710-2

Genes within and flanking the major histocompatibility region are risk factors for diabetes, insulin resistance, hypertension, and microalbuminuria in African-American women.

Acton RT, Bell DS, Collins J, Giger JN, Go RC, Harrison R, McDonald R, Rivers C, Roseman JM, Taylor HA Jr, Vanichanan C

Department of Microbiology, University of Alabama at Birmingham 35294-4400, USA.

PMID: 9414895, UI: 98076575

Transplant Proc 1997 Dec;29(8):3695

The Fourth international Samuel L. Kountz Symposium on renal disease and transplantation in African Americans: foreword.

Rapaport FT

State University of New York at Stony Brook, Department of Surgery, New York, USA.

Publication Types:

• Biography
• Historical article

Personal Name as Subject:

• Kountz SL

Clin Neurol Neurosurg 1997 Oct;99 Suppl 2:S45-8

Risk factors of moyamoya disease in Canada and the USA.

Peerless SJ

Mercy Neuroscience Institute, Miami, FL, USA. neurodpt@icanect.net

Over the past 28 years, 39 patients with Moyamoya disease or syndrome defined as spontaneous occlusion of the circle of Willis with extensive basal collateral vessels have been treated by the author in Canada and the USA. All patients presented with clinical or radiologic evidence of hemorrhage (23) or ischemia and infarction (16). A total of 12 patients had associated cerebral aneurysms and seven of these patients with aneurysms presented with subarachnoid hemorrhage. The patients ages ranged from 5 to 47 years. Of these 58% were female. The patients racial origin included North American Indian, Innuit, East Indian/Pakistani, Japanese, Chinese, Filipino, Korean, Malayasian, Hispanic, African American and Caucasian. Familial clustering was seen in North American Indian, Innuit and Caucasian patients. Associated disorders (tuberculosis, pharyngitis, thalassemia, fibromuscular hyperplasia, polycystic kidney, sickle cell trait and hypertension) were common in these patients, as was the use of tobacco, alcohol and in the adult females, oral contraceptives. It may be concluded from this series that the etiology of Moyamoya disease or syndrome is probably multifactorial, but that some racial and familial groups are more susceptible. Furthermore, in that the clinical and angiographic features are identical, the separation between Moyamoya disease and syndrome may not be helpful in understanding the etiology and pathophysiology of this disorder.

PMID: 9409404, UI: 98073869

J Natl Black Nurses Assoc 1997 Spring-Summer;9(1):22-8

A research review: involving the African American family in anti-hypertensive medication management.

Boutain DM

University of Washington, Seattle, USA.

Research about the role of the family in helping hypertensive individuals manage hypertension using medications is limited. The African American family should be included in whatever future hypertension management research takes place. This review focuses on research conducted using adults and minors as study participants. Theoretical issues about the use of anti-hypertensive medications among hypertensive individuals are presented. Definitions about adherence are critiqued, and future research directions are explored.

Publication Types:

• Review
• Review literature

PMID: 9384099, UI: 98045407

Hypertension 1997 Dec;30(6):1549-53

Improvement of insulin sensitivity by short-term exercise training in hypertensive African American women.

Brown MD, Moore GE, Korytkowski MT, McCole SD, Hagberg JM

Preventive Cardiology, Cardiology Division, University of Pittsburgh Medical Center, Penn, USA. mb@umail.umd.edu

African American women have a high prevalence of insulin resistance, non-insulin-dependent diabetes mellitus, obesity, and hypertension that may be linked to low levels of physical activity. We sought to determine whether 7 days of aerobic exercise improved glucose and insulin metabolism in 12 obese (body fat >35%), hypertensive (systolic blood pressure > or =140 and/or diastolic blood pressure > or =90 mmHg) African American women (mean age 51+/-8 years). Insulin-assisted frequently-sampled intravenous glucose tolerance tests were performed at baseline and 14 to 18 hours after the 7th exercise session. There was no significant change in maximal oxygen consumption, body composition, or body weight after the 7 days of aerobic exercise. The insulin sensitivity index increased (2.68+/-0.45 x 10[-5] to 4.23+/-0.10 x 10[-5] [min(-1)/pmol/L], P=.02). Fasting (73+/-9 to 50+/-9 pmol/L, P=.02) and glucose-stimulated (332+/-58 to 261+/-45 pmol/L, P=.05) plasma insulin levels decreased. Additional measures related to the insulin resistance syndrome also changed with the 7 days of exercise: basal plasma norepinephrine concentrations were reduced (2.46+/-0.27 to 1.81+/-0.27 nmol/L, P=.02) and sodium excretion rate increased from 100+/-13 to 137+/-7 mmol/d (P=.03); however, there was no change in potassium excretion or 24-hour ambulatory blood pressure. We conclude that a short-term aerobic exercise program improves insulin sensitivity in African American hypertensive women independent of changes in fitness levels, body composition, or body weight. The present study indicates that short-term exercise can improve insulin resistance in hypertensive, obese, sedentary African American women and confirms previous reports that a portion of the exercise-induced improvements in glucose and insulin metabolism may be the result of recent exercise.

PMID: 9403581, UI: 98065839

Ann Neurol 1997 Dec;42(6):919-23

A triethnic comparison of intracerebral hemorrhage mortality in Texas.

Morgenstern LB, Spears WD

Department of Neurology, University of Texas Medical School, Houston 77030, USA.

Intracerebral hemorrhage (ICH) is a significant cause of stroke death. Little is known about the relative risk of Hispanic Americans (HAs), African Americans (AAs), and non-Hispanic whites (NHWs) for ICH mortality. Based on the high prevalence of hypertension in AAs and the low prevalence of hypertension in HAs, we expected AAs to have the highest ICH mortality rates and HAs the lowest. Race/ethnic age-specific ICH mortality rates were calculated from Texas vital statistics for the years 1980 through 1995. Rate ratios (RRs) are reported with NHWs as the referent group. There were 15,042 deaths due to ICH in Texas during this time. In the 45- to 59-year age group, AAs had an RR of 4. The RR for HAs was 1.9. In the 60- to 74-year age range, AAs had an RR of 1.7 and HAs had an RR of 1.3. In the 75+ age group, the rates were similar among all three race/ethnic groups. We conclude that there is a significant interaction of age and race/ethnicity for ICH. At younger ages, AAs and HAs have the highest ICH mortality rates. Access to care and socioeconomic status may play a role in the unexpectedly high ICH mortality rates in HAs.

PMID: 9403485, UI: 98065743

J Am Soc Nephrol 1997 Dec;8(12):1942-5

Family history of end-stage renal disease among incident dialysis patients.

Freedman BI, Soucie JM, McClellan WM

Department of Internal Medicine/Nephrology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27157-1053, USA.

As part of a larger study of genetic risk factors for the occurrence of renal failure, the prevalence of a family history of end-stage renal disease (ESRD) in first- and second-degree relatives of all incident dialysis patients treated in Georgia, North Carolina, and South Carolina (ESRD Network 6) in 1994 was ascertained. Family histories were obtained from 4365 dialysis patients (83% of those eligible), and 856 (20%) reported having a family history of ESRD. Among race-sex groups, 14.1% of Caucasian men, 14.6% of Caucasian women, 22.9% of African-American men, and 23.9% of African-American women reported a first- or second-degree relative with ESRD (P = 0.001). The prevalence of relatives with ESRD varied by the reported etiology: 22.2% in diabetes mellitus; 18.9% in hypertension, 22.7% in glomerulonephritis; and 13.0% of other etiologies (P = 0.001). Patient characteristics independently associated with family history of ESRD included race, younger age, higher levels of education, and etiology of ESRD. In this report, it is concluded that a large proportion of incident ESRD cases have close relatives with ESRD in whom preventive actions might be directed. Genetic analyses in multiply affected families may identify the inherited factors contributing to progressive renal failure.

PMID: 9402097, UI: 98063689

Acta Physiol Scand Suppl 1997;640:129-32

Stress hypertension: the "wrong" genes in the "wrong" environment.

Harshfield GA, Grim CE

Medical College of Georgia, Augusta, Georgia, USA.

Jim Henry demonstrated an animal's society can induce an increase in blood pressure and its cardiovascular sequale. He recognized that the stress required to elevate blood pressure was a function of the genetically determined behavioral traits of the mice used. He termed some strains aggressive, others peaceable. Being highly inbred (indeed isogenic strains) it was intriguing to find that the behavior of these genetically identical individuals could differ markedly once placed in a society that decreased territory. A dominant or "king" mouse emerged. Other non-dominant males were aggressive and striving to be king. Adrenal medullary systems were activated and renins high. Others huddled in one cage and appeared to have given up. Jim called them depressed. Their adrenal cortex was hyperplastic suggesting pituitary adrenal axis activation as in depression, their renin was low and corticosterone high. In rats, careful selection of a strain genetically aggressive had to be combined with titration of societal stress to reliably induce hypertension. Its likely that humans retain some, if not all, of these variations, i.e. some respond to stress with an increase in blood pressure and others do not, some respond via the sympathetic pathway and others by adrenal cortical activation. The suggestion that African American's high blood pressures is due to stress is relevant to the Henry paradigm and the known genetic influences on sodium retention in blacks. The integration of this paradigm with the genetically increased sensitivity to the blood pressure raising effects of dietary sodium in blacks is proposed and discussed.

Publication Types:

• Review
• Review, tutorial

PMID: 9401624, UI: 98065146

Am J Obstet Gynecol 1997 Nov;177(5):1003-10

Risk factors associated with preeclampsia in healthy nulliparous women. The Calcium for Preeclampsia Prevention (CPEP) Study Group.

Sibai BM, Ewell M, Levine RJ, Klebanoff MA, Esterlitz J, Catalano PM, Goldenberg RL, Joffe G

Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Memphis, USA.

OBJECTIVE: Our goal was to identify risk factors for the development of preeclampsia in nulliparous women enrolled in a multicenter trial comparing calcium supplementation to a placebo. STUDY DESIGN: A total of 4589 women from five centers was studied. Analysis of risk factors for preeclampsia was performed in 4314 who carried the pregnancy to > 20 weeks. Baseline systolic and diastolic blood pressure, demographic characteristics, and findings after randomization were examined for the prediction of preeclampsia. Preeclampsia was defined as hypertension (diastolic blood pressure > or = 90 mm Hg on two occasions 4 hours to 1 week apart) and proteinuria (> or = 300 mg/24 hours, a protein/creatinine ratio > or = 0.35, one dipstick measurement > or = 2+ or two dipstick measurements > or = 1+ at an interval as specified for diastolic blood pressure). RESULTS: Preeclampsia developed in 326 women (7.6%). The first analysis treated each risk factor as a categoric variable in a univariate regression. Maternal age, blood group and Rh factor, alcohol use, previous abortion or miscarriage, private insurance, and calcium supplementation were not statistically significant. Risk factors initially found to be significant were body mass index, systolic blood pressure, diastolic blood pressure, non-white race (African-American and other), clinical center, and smoking. Adjusted odds ratios computed with a logistic regression model revealed that body mass index (odds ratio 3.22 for > or = 35 kg/m2 vs < 19.8 kg/m2), systolic blood pressure (odds ratio 2.66 for > or = 120 vs < 101 mm Hg), diastolic blood pressure (odds ratio 1.72 for > or = 61 mm Hg vs < 60 mm Hg), and clinical center (odds ratio 1.85 for Memphis vs the other clinical centers) were statistically significant predictors of preeclampsia. Results of the final model fit revealed that preeclampsia risk increases significantly (p < 0.0001) with increased body mass index at randomization, as well as with increased systolic and diastolic blood pressure at randomization. Calcium supplementation had no effect on the risks posed by body mass index and blood pressure. Among risk factors developing after randomization, an abnormal results of a glucose screen (plasma glucose > or = 140 mg/dl 1 hour after a 50 gm glucose challenge) was not found to be associated with a significant risk of preeclampsia. CONCLUSION: These risk factors should be of value in counseling women regarding preeclampsia and should aid in understanding the pathophysiologic characteristics of this syndrome.

Publication Types:

• Clinical trial
• Multicenter study
• Randomized controlled trial

Comments:

• Comment in: Am J Obstet Gynecol 1998 Apr;178(4):870-1

PMID: 9396883, UI: 98059016

Ethn Health 1996 May;1(2):117-28

Hereditary intermediate phenotypes in African American hypertension.

Kailasam MT, O'Connor DT, Parmer RJ

Department of Medicine, University of California, San Diego 92161, USA.

OBJECTIVE: Essential hypertension is a heterogeneous and multifactorial disorder and is at least twice as frequent among African Americans as in the general population. Inheritance of high blood pressure is complex, with the gene(s) responsible for hypertension still remaining elusive. A useful strategy for investigating the heritability of hypertension is to evaluate 'intermediate phenotypes'--simple Mendelian or monogenic traits that are associated with hypertension. These intermediate steps may identify potential pathophysiological factors that antedate the development of high blood pressure and suggest candidate genes. We are attempting to identify and characterize several such intermediate phenotypes, in particular as these might apply to hypertension in African Americans. METHODS: We studied several physiological and biochemical candidate intermediate phenotypes in untreated black and white patients with essential hypertension and in their normotensive counterparts stratified by genetic risk of hypertension. RESULTS AND CONCLUSIONS: Promising intermediate phenotypes, which may be useful for studies in African American families, include baroreceptor sensitivity to low and high pressure stimuli, cold pressor test responses, and biochemical markers such as plasma chromogranin A, dopamine-beta-hydroxylase and urinary kallikrein excretion. Identification of genes involved in complex traits such as hypertension may be facilitated by the intermediate phenotype approach, combined with recent advances in quantitative genetics and linkage mapping. Further studies are needed to pinpoint the nature of genes in African American hypertension.

Publication Types:

• Review
• Review, tutorial

PMID: 9395555, UI: 98051737

Ethn Dis 1997 Spring-Summer;7(2):150-64

Regional and ethnic differences in stroke in the southeastern United States population.

Gaines K

Field Neurosciences Institute, Michigan State University, College of Human Medicine, Saginaw 48604, USA.

The Stroke Belt in the United States lies in the Southeastern region where stroke mortality has been higher than in other geographic regions. The U.S. (African-American) black population has a higher stroke incidence and mortality rate than the US white population. This article reviews the English-language literature relating to observed regional and ethnic differences in stroke mortality, incidence, and risk factors. In addition, possible explanations for regional and ethnic differentials are explored. The significance of these regional and ethnic differences, and directions for future research, are examined.

Publication Types:

• Review
• Review, academic

PMID: 9386955, UI: 98048196

Am J Epidemiol 1997 Nov 1;146(9):727-33

Alcohol consumption and changes in blood pressure among African Americans. The Pitt County Study.

Curtis AB, James SA, Strogatz DS, Raghunathan TE, Harlow S

Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA.

The Pitt County Study is a longitudinal investigation of anthropometric, psychosocial, and behavioral predictors of hypertension in African Americans who were aged 25-50 years at baseline in 1988. At baseline, a strong dose-response gradient was observed for alcohol consumption and blood pressure for both sexes. The current study investigated whether baseline alcohol consumption or, alternatively, changes in drinking status predicted 5-year changes in blood pressure among the 652 women and 318 men who satisfied all inclusion criteria for the longitudinal analyses. In multivariate regression analyses, baseline alcohol consumption was not significantly associated with changes in blood pressure or hypertension incidence (systolic/diastolic blood pressure > or = 160/95 mmHg) by 1993. Change in drinking status, however, was significantly associated with changes in systolic pressure. The systolic pressure increase among individuals who initiated alcohol consumption was 6.2 mmHg (95% confidence interval (CI) 1.1-6.4) greater than abstainers, while that for individuals who reported drinking at both time points was 3.8 mmHg (95% CI 1.3-11.1) greater. Blood pressure increases for persons who discontinued drinking were comparable to those of abstainers. Results were independent of baseline age, body mass index, blood pressure, and sex. Social and economic disadvantage in 1988 was significantly associated with continuation and initiation of alcohol consumption by 1993.

PMID: 9366620, UI: 98033415

Hum Hered 1997 Sep-Oct;47(5):250-3

Angiotensin-converting enzyme deletion polymorphism is associated with hypertension in a Sikh population.

Mastana S, Nunn J

Human Genetics Laboratory, Department of Human Sciences, Loughborough University, UK. S.S.Mastana@LBORO.AC.UK

The deletion polymorphism, situated in intron 16, of angiotensin-converting enzyme (ACE) gene (17q23) has been observed to be associated with an increased risk for myocardial infarction and left ventricular hypertrophy in Caucasian populations. The homozygous genotype for the deletion allele (DD) has additionally been observed at greater frequencies in hypertensive individuals of African-American and Japanese origin. In a population-based study of a Sikh population, we compared the occurrence of the insertion/deletion polymorphism at the ACE gene in subjects with hypertension to those with normal blood pressure. The ACE deletion allele was observed with a greater frequency in hypertensive subjects than in the normotensive subjects (p < 0.0001). These findings raise the possibility that in some ethnic subgroups, variation in or near the ACE gene may contribute to the development, and severity, of hypertension.

PMID: 9358012, UI: 98019044

Am J Clin Nutr 1997 Nov;66(5):1224-31

Insulin sensitivity and intake of vitamins E and C in African American, Hispanic, and non-Hispanic white men and women: the Insulin Resistance and Atherosclerosis Study (IRAS).

Sanchez-Lugo L, Mayer-Davis EJ, Howard G, Selby JV, Ayad MF, Rewers M, Haffner S

Department of Public Health Sciences, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC, USA.

Elevated fasting insulin concentrations and insulin resistance have been associated with non-insulin-dependent diabetes mellitus (NIDDM), obesity, atherosclerosis, and hypertension. Vitamin E supplementation in persons with and without NIDDM may be related to greater insulin sensitivity (SI). The cross-sectional associations of the intake of vitamins E and C with SI and insulin concentrations were evaluated among African American, Hispanic, and non-Hispanic white men and women with a wide spectrum of glucose tolerance included in the Insulin Resistance and Atherosclerosis Study (IRAS) (n = 1151). Insulin sensitivity was measured by minimal model analysis of a 12-sample, insulin-modified, frequently sampled intravenous glucose tolerance test. Nutrient intake (including vitamin supplement use) was assessed with a food-frequency questionnaire modified to include foods consumed by the three ethnic groups. Linear-regression models were used, including rank of SI and the log of fasting insulin as the outcome variables. Pearson correlation coefficients for vitamins E and C in relation to rank SI were r = 0.07 (P = 0.01) and r = 0.07 (P = 0.02), respectively. After adjustment for total energy and BMI these associations were no longer statistically significant and did not differ between ethnic groups. Results were similar when vitamins E and C were combined in categories of low and high antioxidant intake. Models replicated with log of fasting insulin as the outcome variable also did not produce significant associations with vitamins E or C. Thus, these cross-sectional analyses do not support the hypothesis of improved SI with increased intake of vitamins E and C.

Publication Types:

• Multicenter study

PMID: 9356542, UI: 98019355

Ann Epidemiol 1997 Oct;7(7):479-85

Do ethnic differences in dietary cation intake explain ethnic differences in hypertension prevalence? Results from a cross-sectional analysis.

Bauer UE, Mayne ST

Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA.

PURPOSE: To better understand how the magnitude of the association between ethnicity and hypertension is affected by ethnic differences in dietary cation intake, we describe differences in dietary cation intakes and prevalence of hypertension across four ethnic groups (African-Americans, European-Americans, Mexican-Americans, and Puerto Ricans). We also assess the cross-sectional association between: (i) hypertension and self-reported dietary intakes of sodium, potassium, and calcium for each ethnic group; and (ii) ethnicity and hypertension before and after adjustment for dietary cation intakes. METHODS: Data from the Second National Health and Nutrition Examination Survey (1976-1980) and the Hispanic Health and Nutrition Examination Survey (1982-1984) were analyzed. Multiple logistic regression was used to estimate odds ratio (OR) for hypertension for each ethnic group, with adjustment for age, body mass index (BMI), and diabetes status. Comparisons were made to assess whether the magnitude for the ethnicity ORs changed when the three nutrient variables were entered into the model. RESULTS: Mexican-American and Puerto Rican men and women showed clinically and statistically significantly higher mean intakes of the three cations than did African-American men and women, who reported clinically and statistically significantly lower mean intakes of sodium, potassium, and calcium than did European-American men and women. Mean dietary intakes of potassium and calcium were higher for normotensives than for hypertensives among all ethnic groups, except African-American and Mexican-American women. In multivariate modeling, stark differences in ORs for hypertension persisted across ethnic groups despite inclusion of the nutrient variables. CONCLUSION: In this cross-sectional study, adjustment for dietary cation intakes did not alter the magnitude of the ethnic differences in prevalence of hypertension.

PMID: 9349915, UI: 98010757

J Natl Med Assoc 1997 Oct;89(10):665-71

Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: a multicenter study.

Maynard C, Beshansky JR, Griffith JL, Selker HP

Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.

This study examines whether race is a significant determinant of the diagnoses of acute myocardial infarction or angina pectoris in patients with symptoms suggestive of acute cardiac ischemia. The study population was comprised of 3401 (34%) African-American and 6600 (66%) white patients who presented to emergency departments with symptoms suggestive of acute cardiac ischemia. The main outcome measure was a diagnosis of acute myocardial infarction or angina pectoris. African Americans were younger, predominantly female, and more often had hypertension, diabetes mellitus, or smoked. The diagnosis of acute myocardial infarction was confirmed in 6% of African-American and 12% of white men, and in 4% of African-American and 8% of white women. After adjusting for age, gender, medical history, signs and symptoms, and hospital, African Americans were half as likely to develop acute myocardial infarction and were 60% as likely to have acute cardiac ischemia. Despite having less acute cardiac ischemia, African Americans in this study had high risk levels for coronary artery disease.

Publication Types:

• Multicenter study

PMID: 9347680, UI: 98007272

Angiology 1997 Oct;48(10):883-91

Physical activity is related to ankle/brachial index in subjects without peripheral arterial occlusive disease.

Gardner AW, Sieminski DJ, Montgomery PS

Claude D. Pepper Older Americans Independence Center, Department of Medicine, University of Maryland, Baltimore, USA.

The purpose of this study was to determine whether physical activity level was directly and independently related to the ankle/brachial systolic blood pressure index (ABI) in subjects without peripheral arterial occlusive disease (PAOD). A total of 353 subjects between the age of 38 and 88 years (63.7 +/- 9.1 years; mean +/- standard deviation) who had ABI values > or = 1.00 were studied. The sample consisted of 230 men and 123 women, of whom 274 were caucasian and 79 were African-American. Subjects were characterized on blood pressure, physical activity level from validated questionnaires, anthropometry, plasma lipoprotein lipids, and smoking history. The ABI (1.16 +/- 0.13) was related to physical activity obtained from the Minnesota Leisure Time Physical Activity (LTPA) questionnaire (r = 0.413, P < 0.001). Multiple regression analysis identified race, hypertension, current smoking status, and body mass index (BMI) as cardiovascular risk factors that were independently related to ABI. After controlling for these variables, the relationship between ABI and physical activity persisted (partial r = 0.329, P < 0.001). Thus, physical activity was positively related to ABI in subjects free of PAOD, and the relationship between physical activity and ABI persisted after controlling for race, hypertension, current smoking status, and BMI. It is concluded that adopting a physically active lifestyle is associated with a reduced risk of developing PAOD.

PMID: 9342967, UI: 98002483

Stroke 1997 Oct;28(10):1908-12

Familial history of stroke and stroke risk. The Family Heart Study.

Liao D, Myers R, Hunt S, Shahar E, Paton C, Burke G, Province M, Heiss G

Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill 27514, USA. duanping_liao@unc.edu

BACKGROUND AND PURPOSE: Although familial history of stroke is generally perceived to be an important marker of stroke risk, very few epidemiological studies have been published to address this hypothesis. We sought to examine whether familial history of stroke is associated with the prevalence of stroke in the Family Heart Study, a National Heart, Lung, and Blood Institute-supported multicenter study of the familial, genetic, and nongenetic determinants of cardiovascular disease in populations. METHODS: The personal and familial histories of stroke were assessed in 3168 individuals (probands) who were at least 45 years old and 29,325 of their first-degree relatives with the use of a standardized questionnaire. RESULTS: The age-, ethnicity-, and sex-adjusted stroke prevalences were 4.8%, 4.9%, and 3.9% in probands with a positive familial, paternal, and maternal history of stroke, respectively, in comparison with 2.0% in probands without any positive familial history (P < .01). The age-, ethnicity-, and sex-adjusted odds ratios (95% confidence interval) of stroke were 2.00 (1.13, 3.54) for a positive paternal and 1.41 (0.80, 2.50) for a positive maternal history of stroke. Additional statistical adjustment for the proband's history of elevated cholesterol level, cigarette smoking status, history of coronary heart disease, hypertension, and diabetes did not alter the associations. A similar pattern was seen for African Americans and European Americans. CONCLUSIONS: The increased risk of stroke among persons with a positive familial history of stroke compared with those without a familial history of stroke is consistent with the expression of genetic susceptibility, a shared environment, or both in the etiology of stroke.

Publication Types:

• Multicenter study

PMID: 9341694, UI: 98000901

ABNF J 1997 Jul-Aug;8(4):82-5

Managing clinical experiences for minority students with physical disabilities and impairments.

Watkins MP, Kurz JM

Department of Nursing, Delaware State University, Dover 19901, USA.

According to the Americans with Disabilities Act of 1990, clinical training programs cannot refuse admission to individuals with certain physical limitations. That is, an otherwise qualified person who meets program requirements in spite of a handicap must not be discriminated against. Since hypertension and renal disease affect a disproportionately higher number of African Americans than others, the numbers of students with physical disabilities as well as students of color who are also adult learners are likely to increase in clinical nursing programs. This article discusses a planning model developed and implemented by nursing faculty in a baccalaureate degree nursing program at a historically Black university which was used as a guide for the inclusion in clinical practice of students experiencing physical disabilities. A case study is presented to illustrate how the model was implemented with an immunosupressed student secondary to a renal transplantation.

PMID: 9341335, UI: 98000481

J Health Care Poor Underserved 1997 Nov;8(4):409-15

Community-based hypertension control programs that work.

Kong BW

Hypertension is the number one public health problem in the United States, particularly among African Americans. Although the National High Blood Pressure Education Program, started in 1972, led the way to a substantial decrease in morbidity and mortality from this disease, the percentage of African American hypertensives whose conditions are detected, treated, and controlled continues to lag behind that of white hypertensives. Community-based programs at locations where people congregate-for example, churches, barbershops, beauty salons, firehouses, housing projects, and worksites-can play a valuable role in increasing the number of African American hypertensives who receive treatment. Physicians can be a potent force for the development of these programs by acting as consultants to define the scope and function of lay volunteers and by promoting these programs in a variety of other ways.

PMID: 9334533, UI: 97474912

Biochem Mol Biol Int 1997 Sep;43(1):227-31

Angiotensin II type I receptor polymorphism in African Americans lower frequency of the C1166 variant.

Gainer JV, Hunley TE, Kon V, Nadeau JH, Muldowney JA 3rd, Brown NJ

Vanderbilt University Medical Center, Division of Clinical Pharmacology, Nashville, TN, USA. jay.gainer@mcmail.vanderbilt.edu

The C1166 variant, an A to C substitution polymorphism at the 1166 position of the angiotensin II type I (AT1) receptor, has been previously associated with hypertension in Caucasians. This study determines the frequency of the C1166 variant in an African American population. Normotensive African American (n = 99) and Caucasian (n = 100) subjects were genotyped to determine the frequency of the C1166 variant. This study establishes the frequency of the C1166 variant in African Americans (0.05 +/- 0.01) and demonstrates a significantly lower frequency in African Americans compared with Caucasians (0.05 vs. 0.25, respectively, chi 2 = 30.7, p < < 0.001, 1 df).

PMID: 9315301, UI: 97460934

J Vasc Surg 1997 Sep;26(3):465-72; discussion 473

Renal artery repair in African-Americans.

Deitch JS, Hansen KJ, Craven TE, Flack JM, Appel RG, Dean RH

Department of General Surgery, Wake Forest University Medical Center, Winston-Salem, North Carolina 27157-1095, USA.

PURPOSE: This retrospective review examines the results of atherosclerotic renal artery (RA) repair in consecutive hypertensive African-Americans treated at our center and compares these results with Caucasians treated during the same period. METHODS: From Jan. 1987 through Sep. 1996, a total of 485 patients underwent operative RA repair. Of these, 28 African-Americans and 370 Caucasians were managed for atherosclerotic renovascular disease. These cohorts were compared on the basis of preoperative blood pressure and renal function, extent of renal disease, extrarenal atherosclerosis, response to operation, and estimated survival. RESULTS: The African-American cohort included nine men and 19 women (mean age, 62 years) with hypertension (mean blood pressure, 204 +/- 31/109 +/- 20 mm Hg) for an average of 10.2 +/- 7.5 years. Ischemic nephropathy (serum creatinine level, > 1.3 mg/dl) was present in 82% (n = 23) of the African-American group. RA reconstructions were unilateral in nine patients and bilateral in 19 patients (including repair to two solitary kidneys), for a total of 45 RA reconstructions (30 RA bypass procedures; eight transrenal/transaortic RA endarterectomy procedures; two RA reimplantations; five nephrectomies). Nine patients underwent combined aortic procedures (four abdominal aortic aneurysm; five occlusive disease). There was one perioperative death in the African-American group as a result of sepsis and multiple organ failure. Among surgical survivors, 20 African-American patients (74%) had a beneficial hypertension response (7% cured, 67% improved). Mean estimated glomerular filtration rate improved significantly from 34 to 42 ml/min/1.73 m2 (p < 0.001). In the 23 patients with ischemic nephropathy, 13 (57%) demonstrated greater than 20% decrease in serum creatinine level. In comparison with the 370 Caucasians (191 men, 179 women), the African-American cohort had significantly more preoperative heart disease (congestive heart failure or left ventricular hypertrophy; 68% vs 46%; p = 0.03) and tended toward more severe renal dysfunction (mean serum creatinine level, 2.5 vs 2.1 mg/dl; p = 0.25). However, African-Americans demonstrated a beneficial blood pressure and renal function response after operation, similar to Caucasians. CONCLUSIONS: Our results indicate that the majority of selected African-Americans have a favorable blood pressure and renal function response to operative renal artery repair. This beneficial clinical response appears equivalent to the response observed in Caucasian patients and supports the search for RA disease in hypertensive African-Americans.

PMID: 9308592, UI: 97453972

J Cardiovasc Risk 1997 Apr;4(2):135-42

Urbanization and the risk for chronic diseases of lifestyle in the black population of the Cape Peninsula, South Africa.

Steyn K, Kazenellenbogen JM, Lombard CJ, Bourne LT

Programme for Chronic Disease of Lifestyle, Medical Research Council, Parowvallei, South Africa.

BACKGROUND: Men and women have experienced differing patterns of urbanization. Men spent more time in the city as migrant labourers, which could be attributed to the influx control legislation during the apartheid years. OBJECTIVE: To investigate urban exposure among black people of the Cape Peninsula, South Africa, in relation to unhealthy lifestyles and the risk factors for chronic diseases of lifestyle. METHODS: Blood pressure, height, weight and serum cholesterol were measured in a random sample of 986 persons, aged 15-64 years. Sociodemographic details, urban exposure, dietary intake patterns and personal habits were elicited by questionnaire. An urbanization index (percentage of life spent in a city), the dietary Keys score and body mass index were calculated. Linear regression modelling for cholesterol and hypertension, and multiple correspondence analysis for risk factors and demographic characteristics were performed. RESULTS: The degree of urbanization had no effect on total serum cholesterol concentrations, which were very low compared with other groups in South Africa. Hypertension was independently related to age, obesity and the degree of urbanization. Smoking patterns were influenced by the degree of urbanization in women only. Correspondence analysis identified groups with clusters of risk factors: formal housing-westernized diet-highly urbanized; male-normal weight-increased exercise-alcohol-smoking; female-obesity-non-smoking; and hypertension-ageing. CONCLUSIONS: Those who spent larger proportions of their lives in an urban setting tended to have unhealthier lifestyles and higher risk for chronic diseases lifestyle compared with their less urbanized counterparts. Groups to whom intervention should be targeted were also identified.

PMID: 9304495, UI: 97449479

Stroke 1997 Sep;28(9):1693-701

Does the association of risk factors and atherosclerosis change with age? An analysis of the combined ARIC and CHS cohorts. The Atherosclerosis Risk in Communities (ARIC) and Cardiovascular Health Study (CHS) investigators.

Howard G, Manolio TA, Burke GL, Wolfson SK, O'Leary DH

Department of Public Health Sciences, Bowman Gray School of Medicine of Wake Forest University, Winston Salem, NC 27157-1063, USA. GHOWARD@PHS.BGSM.EDU

INTRODUCTION: A decrease in the estimated relative risk of cerebrovascular and cardiovascular diseases associated with known disease risk factors has been observed among elderly cohorts, perhaps suggesting that continued risk factor management in the elderly may not be as efficacious as with younger age groups. In this paper, the differential magnitude of the association of risk factors with atherosclerosis across the age spectrum from 45 years to older than 75 years is presented. METHODS: Subclinical atherosclerosis as measured by carotid ultrasonography and risk factor prevalence were assessed using similar methods among participants aged 45 to 64 years in the Atherosclerosis Risk in Communities (ARIC) study and among participants 65 years and older in the Cardiovascular Health Study (CHS). Pooling these two cohorts provided data on the relationship of risk factors and atherosclerosis on nearly 19,000 participants over a broad age range. Regression analyses were used to assess the consistency of the magnitude of the association of risk factors with atherosclerosis across the age spectrum separately for black and white participants in cross-sectional analyses. RESULTS: As expected, each of the risk factors was globally (across all ages) associated with increased atherosclerosis. However, the magnitude of the association did not differ across the age spectrum for hypertension, low density lipoprotein cholesterol (LDL-c), fibrinogen, or body mass index (BMI). For whites, there was a significantly greater impact of smoking and HDL-C among older age strata but a smaller impact of diabetes. For black women, the impact of HDL-C decreased among the older age strata. CONCLUSIONS: These data suggest that most risk factors continue to be associated with increased atherosclerosis at older ages, possibly suggesting a continued value in investigation of strategies to reduce atherosclerosis by controlling risk factors at older ages.

PMID: 9303011, UI: 97448686

J Fam Pract 1997 Sep;45(3):237-42

Blood pressure response to orthostatic and mental challenge in African-American women taking oral contraceptives.

McDermott DS, Ernst FA, Nevels H, Robertson RM

Department of Family and Preventive Medicine, Meharry Medical College, Nashville, TN 37208, USA.

BACKGROUND: Contraceptive use among women with an elevated risk of cardiovascular disease and stroke has generated little concern among primary care physicians. African Americans in the southeastern region of the United States are particularly vulnerable to hypertension but are often neglected in research studies of cardiovascular disease. The current study examines the effect of oral contraceptive use by African-American women on blood pressure response to orthostatic and mental challenges. METHODS: One hundred African-American women between the ages of 19 and 29 years were recruited from the student populations of Meharry Medical College and Flask University in Tennessee for a study of oral contraceptive use and blood pressure. Of 95 subjects on whom complete data were collected, 31 were taking oral contraceptives (OCs). As a measure of orthostatic challenge, each subject's blood pressure was monitored by a Dinamap automated instrument while she moved from a supine to sitting to standing position. To test blood pressure reactivity to mental challenge, a subset of 34 subjects (10 OC users and 24 nonusers) were monitored while they attempted to perform a frustrating cognitive task on a computer. RESULTS: There were no differences between users and nonusers of oral contraceptives with respect to the amount of change in blood pressure associated with either the orthostatic or mental challenge. Levels of systolic blood pressure and mean arterial pressure, however, were consistently higher in subjects using oral contraceptives (P < .05) under both testing conditions. Systolic blood pressure levels were 6.7 mm Hg to 9.7 mm Hg higher in OC users during each of the three conditions of orthostatic challenge and 4.4 mm Hg to 7.4 mm Hg higher during each of the four periods of mental challenge. Among OC users, mean arterial pressure levels were 2.9 mm Hg to 4.7 mm Hg higher during orthostatic challenge and 5.0 mm Hg to 8.3 mm Hg higher during mental challenge. CONCLUSIONS: While absolute levels of systolic blood pressure never exceeded 126 mm Hg under either testing condition, the difference in blood pressure levels between the OC users and nonusers warrants concern about the long-term effects of oral contraceptive use among African-American women. Although all OC users in this study were taking low-dose formulations, OC use did not eliminate the risk of elevated blood pressure in this population. Our findings suggest that caution is warranted and that alternative birth control methods should be advised for African-American women who have additional risk factors for cardiovascular disease.

PMID: 9300003, UI: 97445014

Am J Obstet Gynecol 1997 Aug;177(2):425-8

Women with sickle cell trait are at increased risk for preeclampsia.

Larrabee KD, Monga M

University of Texas Health Science Center, Houston 77030, USA.

OBJECTIVE: Our purpose was to determine the rate of preeclampsia in women who are positive for sickle cell trait. STUDY DESIGN: All African-American women were tested for sickle cell trait with the "sickledex" screen at the fist prenatal visit and prospectively enrolled in this study from March 1994 to June 1995. "Sickledex" screens were confirmed with hemoglobin electrophoresis. Demographic data were collected at the time of enrollment. Outcome data, including preeclampsia (as defined by The American College of Obstetricians and Gynecologists criteria), gestational age at delivery, birth weight, and postpartum endometritis were collected immediately post partum. Assuming a 10% rate of positive sickle cell trait, 1100 patients were required to demonstrate a doubling in the rate of preeclampsia with 80% power and p < 0.05. The Student t test, the Mann-Whitney U test, chi 2 analysis, and Fisher's exact tests were used for statistical analysis. RESULTS: Of 1584 women enrolled in the study, 162 were positive for sickle cell trait. Sickle cell trait-positive women were older than the sickle cell trait-negative women (24.4 +/- 4.6 vs 23.0 +/- 4.4 years, p < 0.001), but there was no significant difference in parity. The rate of preeclampsia was significantly increased in sickle cell-positive women (24.7% vs 10.3%, p < 0.0001). There was no significant difference in the rate of chronic hypertension, diabetes, or smoking. Parous sickle cell-positive women more frequently gave a history of preeclampsia in a previous pregnancy (21.4% vs 9.3%, p < 0.0001). There was a statistically significant decrease in gestational age at delivery and birth weight in sickle cell trait-positive women (36.7 +/- 2.7 vs 37.7 +/- 3.0 weeks, p < 0.0001; and 3082 +/- 591 vs 3369 +/- 573 gm, p < 0.0001). The rate of postpartum endometritis was significantly increased in the women positive for sickle cell trait (12.3% vs 5.1%, p < 0.001), although both groups had a similar cesarean section rate (14.8% vs 12.6%, not significant). CONCLUSION: This is the first prospective study to demonstrate that sickle cell trait-positive women are at significantly higher risk for development of perinatal complications that have traditionally been associated with sickle disease.

PMID: 9290462, UI: 97435795