Background: The COVID-19 pandemic may have negatively affected medical care for and self-management of chronic hypertension. We sought to examine the impact of the pandemic on blood pressure (BP) among individuals with hypertension. Methods: Using an interrupted time series analysis, we compared the level and trend (slope) of BP outcomes before the public health emergency declaration (prepandemic period: August 2018 through January 2020) versus after the stay-at-home orders (pandemic period: April 2020 through November 2020) among adults with hypertension followed at 3 large health systems (n=137 593). Outcomes include systolic and diastolic BP recorded in electronic health records and the proportion of individuals with BP <140/90 mm Hg. Results: The number of BP measurements substantially dropped early in the pandemic and then gradually increased. During the pandemic period, systolic and diastolic BP increased by 1.79 mm Hg (95% CI, 1.57–2.01; P <0.001) and 1.30 mm Hg (95% CI, 1.18–1.42; P <0.001), respectively, compared with the prepandemic period. Similarly, the proportion of patients with controlled BP decreased by 3.43 percentage points (95% CI, −3.97 to −2.90; P <0.001). A trend showing increasing control in the prepandemic period (+3.19 percentage points per year [95% CI, +2.96 to +3.42]; P <0.001) flattened during the pandemic period (+0.27 percentage points per year [95% CI, −0.81 to −1.37]; P =0.62). Conclusions: The first 8 months of the pandemic were associated with worsening BP outcomes among individuals with hypertension. Opportunities to ensure ongoing access to health care with telemedicine and home BP monitoring may mitigate adverse impacts on BP control for future disasters/emergencies.

Background: Team-based care (TBC), a team of ≥2 healthcare professionals working collaboratively toward a shared clinical goal, is a recommended strategy to manage blood pressure (BP). However, the most effective and cost-effective TBC strategy is unknown. Methods: A meta-analysis of clinical trials in US adults (aged ≥20 years) with uncontrolled hypertension (≥140/90 mm Hg) was performed to estimate the systolic BP reduction for TBC strategies versus usual care at 12 months. TBC strategies were stratified by the inclusion of a nonphysician team member who could titrate antihypertensive medications. The validated BP Control Model-Cardiovascular Disease Policy Model was used to project the expected BP reductions out to 10 years and simulate cardiovascular disease events, direct healthcare costs, quality-adjusted life years, and cost-effectiveness of TBC with physician and nonphysician titration. Results: Among 19 studies comprising 5993 participants, the 12-month systolic BP change versus usual care was −5.0 (95% CI, −7.9 to −2.2) mm Hg for TBC with physician titration and −10.5 (−16.2 to −4.8) mm Hg for TBC with nonphysician titration. Relative to usual care at 10 years, TBC with nonphysician titration was estimated to cost $95 (95% uncertainty interval, −$563 to $664) more per patient and gain 0.022 (0.003–0.042) quality-adjusted life years, costing $4400/quality-adjusted life year gained. TBC with physician titration was estimated to cost more and gain fewer quality-adjusted life years than TBC with nonphysician titration. Conclusions: TBC with nonphysician titration yields superior hypertension outcomes compared with other strategies and is a cost-effective way to reduce hypertension-related morbidity and mortality in the United States.

Background Implantable cardioverter defibrillator (ICD) implantation is contraindicated in those with <1 year life expectancy. Objective To develop a risk prediction score for 1-year mortality in patients with primary prevention ICDs and to determine the incremental improvement in discrimination when incorporating serum-based biomarkers to traditional clinical variables. Methods We analyzed data from the PROSE-ICD study, a large prospective observational study of patients undergoing primary prevention ICD implantation who were extensively phenotyped for clinical and serum markers. We identified variables predicting 1-year mortality and synthesized them into a comprehensive risk scoring construct using backward selection. Results Among 1,189 patients deemed by their treating physicians as having reasonable 1 year life expectancy, 62 patients died within 1 year of ICD implantation. The risk score, comprised of 6 clinical factors (age ≥75 years, New York Heart Association class III/IV, atrial fibrillation, eGFR <30mL/min/1.73m2, diabetes, and use of diuretics), had good discrimination (AUC=0.77) for 1-year mortality. Addition of 3 biomarkers (TNF-αRII, pro-BNP, and cTnT) further improved model discrimination to 0.82. Patients with 0-1, 2-3, 4-6, or 7-9 risk factors had 1-year mortality rates of 0.8%, 2.7%, 16.1% and 46.2%, respectively. Conclusions Individuals with more co-morbidities and elevations of specific serum biomarkers were at increased risk for all-cause mortality despite being deemed as having reasonable 1 year life expectancy. A simple risk score comprised of readily available clinical data and serum biomarkers may better identify patients at high risk of early mortality and improve patient selection and counseling for primary prevention ICD therapy.

BACKGROUND Left ventricular ejection fraction (LVEF) improves over time in 25%–40% of cardiomyopathy patients with primary prevention implantable cardioverter-defibrillators (ICD). The determinants of LVEF improvement, however, are not well characterized. OBJECTIVES We sought to examine the associations of clinical risk factors and cardiac imaging markers with changes in LVEF following ICD implantation. METHODS We conducted a retrospective analysis of cardiac magnetic resonance (CMR) images in 202 patients who underwent primary prevention ICD implantation to quantify the amount of heterogeneous myocardial tissue (gray zone [GZ]), dense core and total scar. LVEF was reassessed at least once after ICD implantation. RESULTS Over a mean follow-up of 3 years, LVEF decreased in 21.3%, improved in 43.6%, and was unchanged in 35.1% of the patients. Baseline LVEF and myocardial scar characteristics were the strongest determinants of LVEF trajectory with high scar burden and increasing lack of myocardial viability associated with a greater decline in LVEF. There was a trend toward an association between both changes in LVEF and scar extent with subsequent appropriate ICD shock. Changes in LVEF were also strongly associated with heart failure (HF) hospitalizations. CONCLUSIONS Scar burden and characteristics were strong determinants, independent of baseline LVEF and other traditional cardiovascular risk factors, of changes in LVEF. Both worsened LVEF and high scar extent were associated with a trend toward increased risk of appropriate shock. These findings suggest that baseline CMR imaging of the myocardial substrate may provide important prognostic information regarding subsequent LV remodeling and adverse events.

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Background Heterozygous familial hypercholesterolemia (FH) is a common genetic disorder causing premature cardiovascular disease. Despite this, there is no national screening program in the United States to identify individuals with FH or likely pathogenic FH genetic variants. Methods and Results The clinical characteristics and FH variant status of 49 738 UK Biobank participants were used to develop a regression model to predict the probability of having any FH variants. The regression model and modified Dutch Lipid Clinic Network criteria were applied to 39 790 adult participants (aged ≥20 years) in the National Health and Nutrition Examination Survey to estimate the yield of FH screening programs using Dutch Lipid Clinic Network clinical criteria alone (excluding genetic variant status), genetic testing alone, or combining clinical criteria with genetic testing. The regression model accurately predicted FH variant status in UK Biobank participants (observed prevalence, 0.27%; predicted, 0.26%; area under the receiver‐operator characteristic curve, 0.88). In the National Health and Nutrition Examination Survey, the estimated yield per 1000 individuals screened (95% CI) was 3.7 (3.0–4.6) FH cases with the Dutch Lipid Clinic Network clinical criteria alone, 3.8 (2.7–5.1) cases with genetic testing alone, and 6.6 (5.3–8.0) cases by combining clinical criteria with genetic testing. In young adults aged 20 to 39 years, using clinical criteria alone was estimated to yield 1.3 (95% CI, 0.6–2.5) FH cases per 1000 individuals screened, which was estimated to increase to 4.2 (95% CI, 2.6–6.4) FH cases when combining clinical criteria with genetic testing. Conclusions Screening for FH using a combination of clinical criteria with genetic testing may increase identification and the opportunity for early treatment of individuals with FH.