Visit-to-visit variability (VVV) of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between VVV of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014 for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease (CHD), stroke, or mortality outcomes; events confirmed via database, death certificate, and/or event ascertainment committee; and adjustment for confounders. Data were extracted by two reviewers and pooled using a random-effects model. Overall, 8,870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, VVV of systolic BP (SBP) and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mmHg higher SD of SBP, the pooled hazard ratios for stroke across seven cohorts was 1.17 (95% CI:1.07–1.28), for CHD across four cohorts was 1.27 (95% CI:1.07–1.51), for CVD across five cohorts was 1.12 (95% CI:0.98–1.28), for CVD mortality across five cohorts was 1.22 (95% CI:1.09–1.35), and for all-cause mortality across four cohorts was 1.20 (95% CI:1.05–1.36). In summary, modest associations between VVV of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.

SummaryBackground and objectives Apparent treatment-resistant hypertension is defined as systolic/diastolic BP$140/ 90 mmHg with concurrent use of three or more antihypertensive medication classes or use of four or more antihypertensive medication classes regardless of BP level.Design, setting, participants, & measurements The prevalence of apparent treatment-resistant hypertension among Reasons for Geographic and Racial Differences in Stroke study participants treated for hypertension (n=10,700) was determined by level of estimated GFR and albumin-to-creatinine ratio, and correlates of apparent treatment-resistant hypertension among those participants with CKD were evaluated. CKD was defined as an albumin-to-creatinine ratio$30 mg/g or estimated GFR,60 ml/min per 1.73 m 2 .Results The prevalence of apparent treatment-resistant hypertension was 15.8%, 24.9%, and 33.4% for those participants with estimated GFR$60, 45-59, and ,45 ml/min per 1.73 m 2 , respectively, and 12.1%, 20.8%, 27.7%, and 48.3% for albumin-to-creatinine ratio,10, 10-29, 30-299, and $300 mg/g, respectively. The multivariableadjusted prevalence ratios (95% confidence intervals) for apparent treatment-resistant hypertension were 1.25 (1.11 to 1.41) and 1.20 (1.04 to 1.37) for estimated GFR levels of 45-59 and ,45 ml/min per 1.73 m 2 , respectively, versus $60 ml/min per 1.73 m 2 and 1.54 (1.39 to 1.71), 1.76 (1.57 to 1.97), and 2.44 (2.12 to 2.81) for albumin-tocreatinine ratio levels of 10-29, 30-299, and $300 mg/g, respectively, versus albumin-to-creatinine ratio,10 mg/g. After multivariable adjustment, men, black race, larger waist circumference, diabetes, history of myocardial infarction or stroke, statin use, and lower estimated GFR and higher albumin-to-creatinine ratio levels were associated with apparent treatment-resistant hypertension among individuals with CKD.Conclusions This study highlights the high prevalence of apparent treatment-resistant hypertension among individuals with CKD.

BACKGROUND In SPRINT (Systolic Blood Pressure Intervention Trial), a systolic blood pressure (SBP) goal of <120 mm Hg resulted in lower cardiovascular disease (CVD) risk compared with an SBP goal of <140 mm Hg. OBJECTIVES The purpose of this study was to estimate the prevalence, number, and characteristics of U.S. adults meeting SPRINT eligibility criteria and determine the broader population to whom SPRINT could be generalized. METHODS We conducted a cross-sectional, population-based study using data from the National Health and Nutrition Examination Survey, 2007 to 2012. The SPRINT inclusion criteria were age ≥50 years, SBP 130 to 180 mm Hg depending on the number of antihypertensive medication classes being taken, and high CVD risk (history of coronary heart disease, estimated glomerular filtration rate of 20 to 59 ml/min/1.73 m2, 10-year CVD risk ≥15%, or age ≥75 years). Exclusion criteria were diabetes, history of stroke, >1 g in 24 h of proteinuria daily, heart failure, estimated glomerular filtration rate <20 ml/min/1.73 m2, or receiving dialysis. Treated hypertension was defined by self-reported use of medication to lower blood pressure with ≥1 class of antihypertensive medication identified through a pill bottle review. RESULTS Overall, 7.6% (95% confidence interval [CI]: 7.0% to 8.3%) or 16.8 million (95% CI: 15.7 to 17.8 million) U.S. adults, and 16.7% (95% CI: 15.2% to 18.3%) or 8.2 million (95% CI: 7.6 to 8.8 million) adults with treated hypertension met the SPRINT eligibility criteria. Among both the overall U.S. population and adults with treated hypertension, the percentage meeting SPRINT eligibility criteria increased with older age, was higher among males than females, and was higher among non-Hispanic whites compared with non-Hispanic blacks or Hispanics. Of U.S. adults eligible for SPRINT, 51.0% (95% CI: 47.8% to 54.1%) or 8.6 million (95% CI: 8.0 to 9.1 million) were not treated for hypertension. CONCLUSIONS A substantial percentage of U.S. adults meet the eligibility criteria for SPRINT.

Background Obesity may be an important risk factor for end-stage renal disease (ESRD) but the association between the obesity measure waist circumference (WC) and ESRD remains poorly explored. Study Design Longitudinal population-based cohort Setting and Participants Participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study (n=30, 239) with body mass index (BMI), WC, spot urine albumin-to-creatinine ratio (ACR), and estimated glomerular filtration rate (eGFR) measured at baseline (n=26, 960). Predictor Obesity as defined by an elevated WC or BMI Outcomes and Measurements Incident cases of ESRD were identified through linkage of REGARDS study participants with the United States Renal Data System. Results The mean baseline age was 64.8 years, 45.8% were male, 40.3% were black and 12.1% reported less than a high school education. Overall, 297 individuals developed ESRD (1.1%) during a median of 6.3 years. After adjustment for all covariates including WC, no significant association was noted between any BMI category and ESRD incidence compared to the referent group (BMI 18.5–24.9 kg/m2). Higher WC categories showed significantly increased hazard rates of ESRD with WC ≥ 108 cm in women and ≥ 122 cm in men (highest category) showing a 2.81-fold higher hazard rate (95% CI 1.89, 4.17) for ESRD after adjusting for age, sex, race, region, income and education compared to the referent group (< 80 cm in women and < 94 cm in men),. Further adjustment for BMI strengthened the associations between WC categories and ESRD incidence (HR 3.79; 95% CI 2.10, 6.86 for the highest WC category compared to referent group). However, no significant association was noted between any WC category and ESRD incidence after adjustment for obesity associated co-morbidities, baseline ACR and eGFR. Limitations The median follow-up period (6.3 years) may have been too short to adequately assess ESRD risk among adults with an eGFR > 60 ml/min/1.73 m2. Conclusion In this older cohort of adults followed for 6 years, obesity as measured by WC is associated with higher ESRD risk even with adjustment for BMI while obesity as measured by BMI is not associated with higher ESRD risk after adjustment for WC. However, the association between increased WC and ESRD risk is markedly attenuated and no longer statistically significant after adjustment for obesity related co-morbidities, eGFR and ACR.

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Obesity is associated with chronic kidney disease progression. Whether metabolic risk factors modify this association is unclear. Here we examined associations of body mass index (BMI) and metabolic health with risk of end-stage renal disease (ESRD) in the Reason for Geographic and Racial Differences in Stroke (REGARDS) study. Among 21,840 participants eligible for analysis, 247 developed ESRD (mean follow-up of 6.3 years). Metabolic health significantly modified the association of BMI with ESRD. In models stratified by presence or absence of metabolic syndrome and adjusted for demographic, lifestyle and clinical factors, higher BMI was associated with lower risk of ESRD in those without (hazard ratio per 5 kg/m2 increase in BMI 0.70, 95%CI 0.52,0.95), but not those with (hazard ratio, 1.06) metabolic syndrome. In models stratified by weight and metabolic health, compared to normal weight (BMI 18.5–24.9 kg/m2) participants without metabolic syndrome the overweight individuals (BMI 25–29.9) and obese individuals (BMI of 30 or more) with metabolic syndrome had greater risk of ESRD (hazard ratios of 2.03 and 2.29, respectively), whereas obesity without the metabolic syndrome was associated with lower risk of ESRD (hazard ratio 0.47). Thus, higher BMI is associated with lower ESRD risk in those without but not those with metabolic syndrome.

The authors examined trends in systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the prevalence, awareness, treatment, and control of hypertension in 1988–1994 (n=1164), 1999–2004 (n=1,026), and 2005–2010 (n=1048) among US adults 80 years and older in serial National Health and Nutrition Examination Surveys. Hypertension was defined as SBP ≥140 mm Hg, DBP ≥90 mm Hg, or use of antihypertensive medication. Awareness and treatment were defined by self‐report and control as SBP/DBP<140/90 mm Hg. Mean SBP decreased from 147.3 mm Hg to 140.1 mm Hg and mean DBP from 70.2 mm Hg to 59.4 mm Hg between 1988–1994 and 2005–2010. The prevalence, awareness, and treatment of hypertension each increased over time. Controlled hypertension increased from 30.4% in 1988–1994 to 53.1% in 2005–2010. The proportion of patients taking 3 classes of antihypertensive medication increased from 7.0% to 30.9% between 1988–1994 and 2005–2010. Increases in awareness, treatment, and control of hypertension and antihypertensive polypharmacy have been observed among very old US adults.

Background Previous research has indicated that women and Blacks have worse outcomes following acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis and functional outcome after AIS. Methods AIS patients who presented to two academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2 point increase in NIHSS), and functional outcome at discharge, measured by the modified Rankin Scale (mRS), were investigated. These outcomes were compared across race/gender groups. A sub-analysis was conducted to assess race/gender differences in exclusion criteria for tPA. Results Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS on admission (8) with White men had the lowest median NIHSS on admission (6). There were no differences in outcomes between Black men and White men. A smaller percentage of Black women than White women were treated with tPA (27.6% vs. 36.6%, p<0.0001), partially due to a greater proportion of White women presenting within 3 hours (51% vs. 45.5%, p =0.0005). Black women had decreased odds of poor functional outcome relative to White women (OR=0.85, 95%CI 0.72-1.00), but after adjustment for baseline differences in age, NIHSS and tPA use this association was no longer significant (OR=1.2, 95%CI 0.92-1.46, p=0.22). Black women with a NIHSS on admission of less than 7 were at lower odds of receiving tPA than the other race gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR 0.66, 95%CI 0.44-0.99, p=0.0433). Conclusion Race and gender were not significantly associated with short-term outcome, although Black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to Black women not arriving to the ED in time is of great importance.