Apparent Treatment-Resistant Hypertension Among Stroke Survivors: A Transcontinental Study Assessing Impact of Race and Geography

Abstract

Background Race and geographic differences in the prevalence and predictors of hypertension in stroke survivors have been reported, but apparent treatment-resistant hypertension (aTRH) among stroke survivors by race (African ancestry vs Non-Hispanic Caucasians) and by geography (continental Africa versus the United States) are under studied. Methods This is a cross-sectional study using ethically approved stroke registries from the University of Florida and the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Univariate and multivariate regression was used to evaluate for differences in prevalence of aTRH and associations with clinical covariates. Results Harmonized data were available for 3,365 stroke survivors of which 943 (28.0%) were indigenous Africans, 558 (16.6%) African Americans and 1864 (55.4%) Non-Hispanic Caucasians with median ages (IQR) of 59 (49 - 68) years, 61 (55-72) years and 70 (62-78) years, p<0.0001. The overall frequency of aTRH was 18.5% (95% CI: 17.2-19.8%) with 42.7% (95% CI: 39.6–46.0%) among indigenous Africans, 16.1% (95% CI: 13.2-19.5%) among African Americans and 6.9% (95% CI: 5.8–8.2%) among non-Hispanic Caucasians, p<0.0001. Five factors associated with aTRH: age, adjusted odds-ratio (95% CI) of 0.99 (0.98-0.99), female sex 0.70 (0.56-0.87), cigarette smoking 1.98 (1.36–2.90), intracerebral hemorrhage 1.98 (1.57-2.48) and Black race namely indigenous Africans 4.42 (3.41-5.73)and African Americans 2.44 (1.81 – 3.29). Conclusions Future studies are needed to investigate the contribution of socioeconomic disparities in the prevalence aTRH in those with African Ancestry to explore the long-term impact, and evaluate effective therapeutic interventions in this subpopulation.

Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps

“…9 This is critical information for clinicians because hypertension is common (prevalence of 70%-80%) in patients with a history of stroke, and 16% to 40% of patients have apparent treatment-resistant hypertension (defined as BP greater than target despite use of 3+ antihypertensive medications), which varies by race and geography. 10,11 The recommended target systolic BP has been <140 mm Hg for decades, in part because of the potential for poor outcomes with over-treating. 12 However, in the primary prevention settings, the goal has now changed with the most recent hypertension guidelines (published in 2017) recommending a BP goal of <130/80 mm Hg.…”

“…9 This is critical information for clinicians because hypertension is common (prevalence of 70%–80%) in patients with a history of stroke, and 16% to 40% of patients have apparent treatment-resistant hypertension (defined as BP greater than target despite use of 3+ antihypertensive medications), which varies by race and geography. 10,11…”