Guidelines recommend lifestyle modification for individuals with coronary heart disease (CHD). Few data demonstrate which lifestyle modifications, if sustained, reduce recurrent CHD and mortality risk among cardiac patients after the post-acute rehabilitation phase. We determined the association between ideal lifestyle factors and recurrent CHD and all-cause mortality among REasons for Geographic and Racial Differences in Stroke study participants with CHD (n=4,174). Ideal lifestyle factors (physical activity ≥4 times/week, non-smoking, highest quartile of Mediterranean diet score, waist circumference <88/<102 cm for women/men) were assessed through questionnaires and an in-home study visit. There were 447 recurrent CHD events and 745 deaths over a median 4.3 and 4.5 years, respectively. After multivariable adjustment, physical activity ≥4 versus no times/week and non-smoking versus current smoking were associated with reduced hazard ratios (HR) [95% confidence interval] for recurrent CHD (0.69 [0.54–0.89] and 0.50 [0.39–0.64], respectively) and death (0.71 [0.59–0.86] and 0.53 [0.44–0.65], respectively). The multivariable adjusted HR (95% CI) for recurrent CHD and death comparing the highest versus lowest quartile of Mediterranean diet adherence were 0.77 (0.55–1.06) and 0.84 (0.67–1.07), respectively. Neither outcome was associated with waist circumference. Comparing participants with 1, 2, and 3 versus 0 ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, highest quartile of Mediterranean diet score), the HR (95% CI) were 0.60 (0.44–0.81), 0.49 (0.36–0.67) and 0.38 (0.21–0.67), respectively, for recurrent CHD and 0.65 (0.51–0.83), 0.57 (0.43–0.74) and 0.41 (0.26–0.64), respectively, for death. In conclusion, maintaining smoking cessation, physical activity and Mediterranean diet adherence is important for secondary CHD prevention.

Refractory hypertension is an extreme phenotype of antihypertensive treatment failure. Participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a large (n=30,239), population-based cohort were evaluated to determine the prevalence of refractory hypertension and associated cardiovascular risk factors and comorbidities. Refractory hypertension was defined as uncontrolled blood pressure (systolic/diastolic ≥ 140/90 mm Hg) on ≥ 5 antihypertensive drug classes. Participants with resistant hypertension (systolic/diastolic ≥140/90 mm Hg on ≥ 3 or<140/90 mm Hg on ≥ 4 antihypertensive classes) and all treated hypertensive participants served as comparator groups. Of 14,809 REGARDS participants receiving antihypertensive treatment, 78 (0.5%) had refractory hypertension. The prevalence of refractory hypertension was 3.6% among participants with resistant hypertension(n=2,144) and 41.7% among participants on 5 or more antihypertensive drug classes. Among all hypertensive participants, African American race, male gender, living in the stroke belt or buckle, higher body mass index, lower heart rate, reduced estimated glomerular filtration rate, albuminuria, diabetes and history of stroke and coronary heart disease were associated with refractory hypertension. Compared to resistant hypertension, prevalence ratios for refractory hypertension were increased for African Americans (3.00, 95% CI 1.68 – 5.37) and those with albuminuria (2.22, 95% CI 1.40 – 3.52) and diabetes (2.09, 95% CI 1.32 – 3.31). The median 10-year Framingham risk for coronary heart disease and stroke was higher among participants with refractory hypertension compared to either comparator group. These data indicate that while resistant hypertension is relatively common among treated hypertensive patients, true antihypertensive treatment failure is rare.

Background Apparent treatment resistant hypertension (aTRH) is defined as uncontrolled hypertension despite the use of ≥3 antihypertensive medication classes or controlled hypertension while treated with ≥ 4 antihypertensive medication classes. We evaluated the association of aTRH with incident stroke, coronary heart disease (CHD) and all-cause mortality. Methods Participants from the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) Study treated for hypertension with aTRH (n=2,043) and without aTRH (n=12,479) were included. aTRH was further categorized as controlled aTRH (≥ 4 medication classes and controlled hypertension) and uncontrolled aTRH (≥ 3 medication classes and uncontrolled hypertension). Results Over a median of 5.9, 4.4, and 6.0 years of follow-up the multivariable adjusted hazard ratio for stroke, CHD, and all-cause mortality associated with aTRH versus no aTRH was 1.25 (0.94 – 1.65), 1.69 (1.27 – 2.24), and 1.29 (1.14 – 1.46), respectively. Compared to controlled aTRH, uncontrolled aTRH was associated with CHD (HR=2.33; 95% CI 1.21 – 4.48), but not stroke or mortality. Comparing controlled aTRH to no aTRH, risk of stroke, CHD and all-cause mortality was not elevated. Conclusion aTRH was associated with an increased risk for coronary heart disease and all-cause mortality.

Prehypertension is associated with increased risk for hypertension and cardiovascular disease. Data are limited on the temporal changes in the prevalence of prehypertension and risk factors for hypertension and cardiovascular disease among United States adults with prehypertension. We analyzed data from 30,958 United States adults aged ≥20 years who participated in the National Health and Nutrition Examination Surveys between 1999 and 2012. Using the mean of three blood pressure measurements from a study examination, prehypertension was defined as systolic blood pressure of 120 to 139 mmHg and diastolic blood pressure <90 mmHg or diastolic blood pressure of 80 to 89 mmHg and systolic blood pressure <140 mmHg among participants not taking antihypertensive medication. Between 1999–2000 and 2011–2012, the percentage of United States adults with prehypertension decreased from 31.2% to 28.2% (p-trend=0.007). During this time period, the prevalence of several risk factors for cardiovascular disease and incident hypertension increased among United States adults with prehypertension including prediabetes (9.6% to 21.6%) and diabetes (6.0% to 8.5%) and overweight (33.5% to 37.3%) and obesity (30.6% to 35.2%). There was a non-statistically significant increase in no weekly leisure-time physical activity (40.0% to 43.9%). Also, the prevalence of adhering to the Dietary Approaches to Stop Hypertension eating pattern decreased (18.4% to 11.9%). In contrast, there was a non-statistically significant decline in current smoking (25.9% to 23.2%). In conclusion, the prevalence of prehypertension has decreased modestly since 1999–2000. Population-level approaches directed at adults with prehypertension are needed to improve risk factors to prevent hypertension and cardiovascular disease.

Experimental sleep restriction results in decreased amount and intensity of physical activity in adults at risk for type 2 diabetes.

Masked hypertension, defined as non-elevated clinic blood pressure (BP) with elevated out-of-clinic BP, has been associated with increased cardiovascular disease (CVD) risk in Europeans and Asians. Few data are available on masked hypertension and CVD and mortality risk among African Americans (AAs). We analyzed data from the Jackson Heart Study, a prospective cohort study of AAs. Analyses included participants with clinic-measured systolic/diastolic BP (SBP/DBP)<140/90mmHg who completed ambulatory BP monitoring (ABPM) following the baseline exam in 2000–2004 (n=738). Masked daytime (10:00am–8:00pm) hypertension was defined as mean ambulatory SBP/DBP≥135/85mmHg. Masked nighttime (midnight-6:00am) hypertension was defined as mean ambulatory SBP/DBP≥120/70mmHg. Masked 24-hour hypertension was defined as mean SBP/DBP≥130/80mmHg. CVD events (nonfatal/fatal stroke, nonfatal myocardial infarction or fatal coronary heart disease) and deaths identified through December 2010 were adjudicated. Any masked hypertension (masked daytime, nighttime or 24-hour hypertension) was present in 52.2% of participants; 28.2%, 48.2% and 31.7% had masked daytime, nighttime and 24-hour hypertension, respectively. There were 51 CVD events and 44 deaths over a median follow-up of 8.2 and 8.5 years, respectively. CVD rates per 1,000 person-years (95% CI) in participants with and without any masked hypertension were 13.5 (9.9–18.4) and 3.9 (2.2–7.1), respectively. The multivariable adjusted hazard ratio (95% CI) for CVD was 2.49 (1.26–4.93) for any masked hypertension and 2.86 (1.59–5.13), 2.35 (1.23–4.50) and 2.52 (1.39–4.58) for masked daytime, nighttime and 24-hour hypertension, respectively. Masked hypertension was not associated with all-cause mortality. Masked hypertension is common and associated with increased risk for CVD events in AAs.

Background and Purpose In prior observational studies, hemoglobin concentrations have been associated with an increased risk of stroke. However, these studies were limited by a relatively low number of stroke events, making it difficult to determine whether the association of hemoglobin and stroke differed by demographic or clinical factors. Methods Using Cox proportional hazards analysis and Kaplan-Meier plots, we examined the association of baseline hemoglobin concentrations with incident stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of black and white adults ≥45 years of age. Results A total of 518 participants developed stroke over a mean 7±2 years of follow-up. There was a statistically significant interaction between hemoglobin and sex (P=0.05) on the risk of incident stroke. In Cox regression models adjusted for demographic and clinical variables, there was no association of baseline hemoglobin concentration with incident stroke in men, whereas in women, the lowest (<12.4 g/dL) and highest (>14.0 g/dL) quartiles of hemoglobin were associated with higher risk of stroke as compared to the second quartile (12.4 – 13.2 g/dL) (Quartile 1, HR 1.59, 95%CI 1.09,2.31; Quartile 2 referent; Quartile 3, HR 0.91, 95%CI 0.59,1.38; Quartile 4, HR 1.59, 95%CI 1.08,2.35). Similar results were observed in models stratified by hemoglobin and sex and when hemoglobin was modeled as a continuous variable using restricted quadratic spline regression. Conclusions Lower and higher hemoglobin concentrations were associated with a higher risk of incident stroke in women. No such associations were found in men.

There is limited empirical evidence to support the protective effects of physical activity in the prevention of hypertension among African Americans. The purpose of this study was to examine the association of physical activity with incident hypertension among African Americans. We studied 1,311 participants without hypertension at baseline enrolled in the Jackson Heart Study, a community-based study of African Americans residing in Jackson, MS. Overall physical activity, moderate-vigorous physical activity (MVPA), and domain-specific physical activity (work, active living, household, and sport/exercise) were assessed by self-report during the baseline exam (2000–2004). Incident hypertension, assessed at exam 2 (2005–2008) and exam 3 (2009–2013), was defined as the first visit with systolic/diastolic blood pressure ≥140/90mmHg or self-reported antihypertensive medication use. Over a median follow-up of 8.0 years, there were 650 (49.6%) incident hypertension cases. The multivariable-adjusted hazard ratios (95% CI) for incident hypertension comparing participants with intermediate and ideal versus poor levels of MVPA were 0.84 (0.67–1.05) and 0.76 (0.58–0.99), respectively (P-trend=0.038). A graded, dose-response association was also present for sport/exercise-related physical activity (Quartiles 2, 3, and 4 vs. Quartile 1: 0.92 [0.68–1.25], 0.87 [0.67–1.13], 0.75 [0.58–0.97], respectively; P-trend=0.032). There were no statistically significant associations observed for overall physical activity, or work, active living, and household-related physical activities. In conclusion, the results of the current study suggest that regular MVPA or sport/exercise-related physical activity may reduce the risk of developing hypertension in African Americans.