Abstract
BACKGROUND
2014 hypertension guidelines raised treatment goals in older adults. The objective was to examine changes in blood pressure (BP) control (<140/90 mm Hg) from 2011–2013 to 2016–2017 among Black and white older adults with treated hypertension.
METHODS
Participants were 1,600 white and 650 Black adults aged 71–90 years in the Atherosclerosis Risk in Communities (ARIC) Study with treated hypertension in 2011–2013 (baseline) who had BP measured in 2016–2017 (follow-up). Predictors of changes in BP control were examined by race.
RESULTS
BP was controlled among 75.3% of white and 65.7% of Black participants at baseline and 59.0% of white and 56.5% of Black participants at follow-up. Among those with baseline BP control, risk factors for incident uncontrolled BP included age (relative risk [RR] 1.15 per 5 years, 95% confidence interval [CI] 1.07–1.25), female sex (RR 1.36, 95% CI 1.16–1.60), and chronic kidney disease (RR 1.19, 95% CI 1.01–1.40) among white participants, and hypertension duration (RR 1.14 per 5 years, 95% CI 1.03–1.27) and diabetes (RR 1.48, 95% CI 1.15–1.91) among Black participants. Among those with uncontrolled BP at baseline, white females vs. males (RR 0.60, 95% CI 0.46–0.78) and Black participants with chronic kidney disease vs. without (RR 0.58, 95% CI 0.36–0.93) were less likely to have incident controlled BP.
CONCLUSIONS
BP control decreased among white and Black older adults. Black individuals with diabetes or chronic kidney disease were less likely to have controlled BP at follow-up. Higher treatment goals may have contributed to these findings and unintended differences by race.
Keywords: blood pressure, clinical practice guidelines, cohort study, health disparities, hypertension, older adults
Graphical Abstract
Graphical Abstract.
Hypertension is common in older persons, but treatment goals are debated. Clinical practice guidelines seek to balance the benefits of blood pressure (BP)-lowering therapy with the potential for adverse events. However, recent recommendations from leading professional societies for treatment targets in older adults are conflicting.1–4
The JNC7 guideline published in 2003 recommended treating hypertension to a BP goal of <140/90 mm Hg among the general population and to <130/80 mm Hg for those with diabetes or chronic kidney disease.1 In 2014, panel members of the JNC8 committee recommended treatment to BP <150/90 mm Hg for adults aged ≥60 years without diabetes or chronic kidney disease and to <140/90 mm Hg for all other patients.2 However, several panel members expressed concern raising the systolic blood pressure (SBP) threshold for older adults could undo progress reducing cardiovascular disease and have a disproportionate negative impact on patients at highest cardiovascular risk, such as African Americans, those with a history of cardiovascular disease, and those with multiple risk factors.2,5 The Association of Black Cardiologists echoed these concerns and cautioned an unintended consequence may be to worsen Black–white disparities in cardiovascular outcomes and life expectancy.6
In the context of changes in guideline recommendations in 2014, it is critical to characterize factors that influence BP control and changes in control, as these may contribute to cardiovascular health disparities.7 There are few community-based cohorts of older adults with contemporary, repeat BP measurements to evaluate, longitudinally, the impact of changes in hypertension guidelines. The Atherosclerosis Risk in Communities (ARIC) Study, which enrolled Black and white adults from 4 US communities, conducted examination visits in 2011–2013 and 2016–2017 when participants were aged 71–90 and 75–94 years, respectively. The objectives of the present analysis were to examine and compare changes in BP control in older Black and white adults in ARIC, and associations with sociodemographic and clinical characteristics.
METHODS
Study population
The ARIC Study included 15,792 participants from Forsyth County, North Carolina, Jackson, Mississippi, Minneapolis, Minnesota, and Washington County, Maryland aged 45–64 at the first study visit in 1987–1989.8 Follow-up visits have been conducted in 1990–1992, 1993–1995, 1996–1998, 2011–2013, and 2016–2017. An institutional review board at all study sites and the University of North Carolina (ARIC coordinating center) approved all procedures. All participants provided written informed consent.
In this analysis, the 2011–2013 study visit (visit 5) served as the baseline. The primary analysis included participants with hypertension taking antihypertensive medication (ie, treated hypertension) in 2011–2013 who also attended the 2016–2017 study visit (visit 6) (Supplementary Figure S1 online). A total of 6,538 participants attended visit 5. Participants were excluded if they were nonwhite or nonblack (n = 18); missing hypertension status, BP measurements, or self-reported antihypertensive medication use (additional n = 146); or missing covariates of interest (additional n = 837). Among this population at visit 5, participants were identified who had a doctor’s diagnosis of hypertension and self-reported antihypertensive medication use in the past 4 weeks. Of 3,752 participants with hypertension taking antihypertensive medication in 2011–2013, 2,250 were present in 2016–2017 and had BP measured; these participants comprised the study sample.
In secondary analyses, antihypertensive medication use was examined among those who brought their medications to the 2011–2013 and 2016–2017 study visits (N = 2,213; 37 participants without medications at both visits).
Outcome
At the 2011–2013 and 2016–2017 study visits, BP measurements were obtained using the same, standardized procedures. BP was measured using an automated sphygmomanometer (Omron HEM 907 XL) with an appropriately sized cuff. After 5 minutes rest, the device took 3 serial measurements. The mean of the second and third SBP and diastolic blood pressure (DBP) readings were used for all analyses. BP control was defined as SBP <140 and DBP <90 mm Hg.
Those with BP <140/90 mm Hg at baseline were classified as having controlled (<140/90 mm Hg) or incident uncontrolled BP (≥140/90 mm Hg) at follow-up. Similarly, those with BP ≥140/90 mm Hg at baseline were classified as having uncontrolled (≥140/90 mm Hg) or incident controlled BP (<140/90 mm Hg) at follow-up.
In secondary analyses, antihypertensive medication use was assessed based on medications brought to the visits and corresponding scanned UPC codes. For each participant, the total numbers of antihypertensive medications used at baseline and follow-up were calculated. For combination therapies, each drug in the combination was counted as a unique medication (i.e., 2-drug single pill combinations were counted as 2 medications).
Participant characteristics of interest
Participant characteristics were assessed in 2011–2013 unless otherwise noted and included factors associated with BP control or which could influence BP treatment goals. Date of birth, sex, and race were self-reported. Education was self-reported at the 1987–1989 ARIC visit.
The Short Physical Performance Battery (SPPB) was used to assess physical functioning. Poor physical function was defined using an established cutoff.9 Frailty was assessed using a previously validated measure.10 In all analyses, participants who were frail or pre-frail were compared with those who were not frail.
Cognitive status was determined by expert committee review according to procedures established by the ARIC Neurocognitive Study.11 Participants were categorized as having normal cognition, mild cognitive impairment, or dementia. Participants with mild cognitive impairment or dementia were combined into 1 category due to the low prevalence of dementia and compared with individuals with normal cognition. Depressive symptoms were defined as a score ≥9 on the 11-item Center for Epidemiologic Studies Depression (CES-D) scale.12,13
Medication adherence was assessed using the Morisky Green Levine Medication Adherence Scale and categorized as “low,” “intermediate,” or “high” based on established cut points.14 Questions on the scale were not asked in the context of antihypertensive medications specifically, rather about adherence to all medications. Hypertension duration was determined based on the time between the date of doctor’s diagnosis, medication use, or BP in the hypertensive range and the 2016–2017 study visit date. For those with prevalent hypertension at the 1987–1989 study visit, the visit date was used as the date of hypertension onset.
Body mass index was calculated as weight in kilograms (kg) divided by height in meters squared (m2) and categorized as <25 kg/m2 (normal), 25 to <30 kg/m2 (overweight), or ≥30 kg/m2 (obese). Diabetes was defined as hemoglobin A1c ≥6.5 %, medication use, or self-reported diagnosis. Chronic kidney disease was defined as creatinine-based estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 using the CKD-EPI equation.15 Prevalent coronary heart disease, stroke, and heart failure were determined based on a self-reported event prior to the first ARIC Study visit or an adjudicated event prior to the 2011–2013 visit.
Statistical analysis
Baseline characteristics of participants with treated hypertension were compared by race using t-tests for continuous variables and chi-square tests for categorical variables. In a supplemental analysis, characteristics of those who were present and absent in 2016–2017 were compared.
The proportion of individuals with BP <140/90 mm Hg at baseline was compared among white and Black participants using chi-square tests. The proportion of white and Black participants with BP controlled to <130/80 mm Hg at baseline was also compared; this target reflects the JNC7 treatment goal among adults with diabetes or chronic kidney disease and is similar to the ACC/AHA 2017 treatment goal (SBP <130 mm Hg) for all adults aged ≥65 years.1,8 Prevalence ratios for participant characteristics associated with BP <140/90 and <130/80 mm Hg at baseline, stratified by race and adjusted for age and sex, were calculated using Poisson regression with robust variance estimates. A priori, regression models were stratified by race as it was hypothesized there would be differences in factors associated with BP control. Differences in associations by race were tested using models with an interaction term between race and the characteristic of interest.
Poisson regression with robust variance estimates was used to evaluate the associations of participant characteristics with change in BP control status from baseline. For those with BP <140/90 mm Hg at baseline, the relative risk of incident uncontrolled BP was calculated. For those with BP ≥140/90 mm Hg at baseline, the relative risk of incident controlled BP was calculated. Models were stratified by race and controlled for age, sex, and baseline SBP. Differences in associations by race were tested using interaction terms. Finally, changes in the mean and distribution of antihypertensive medications were evaluated among white and Black participants.
Analyses were conducted using Stata version 15.1 (College Station, TX). P values <0.05 were considered statistically significant.
RESULTS
At baseline, Black participants with treated hypertension were younger, but had longer hypertension duration than white participants (Table 1). Black participants were more likely to be female, have lower education, poor physical functioning, depressive symptoms, lower medication adherence, and generally had a higher prevalence of cardiovascular disease and its risk factors. Characteristics of participants who did and did not attend the 2016–2017 visit are in Supplementary Table S1 online.
Table 1.
Characteristics of older adults with treated hypertension in 2011–2013, by race
| White | Black | P value | |
|---|---|---|---|
| N (%) | 1600 (71.1%) | 650 (28.9%) | |
| Age, mean years (SD) | 75.1 (4.7) | 74.0 (4.7) | <0.001 |
| Female sex | 54.4% | 71.4% | <0.001 |
| Education | <0.001 | ||
| Less than high school | 9.5% | 22.8% | |
| High school or vocational school | 45.6% | 32.2% | |
| College or higher | 44.9% | 45.1% | |
| Poor physical function | 7.4% | 22.3% | <0.001 |
| Pre-frail or frail | 50.2% | 53.8% | 0.12 |
| Mild cognitive impairment or dementia | 19.1% | 17.7% | 0.45 |
| Depressive symptoms | 5.1% | 9.4% | <0.001 |
| Medication adherence | <0.001 | ||
| High | 61.1% | 56.2% | |
| Intermediate | 37.6% | 39.2% | |
| Low | 1.3% | 4.6% | |
| Hypertension duration, mean years (SD) | 16.3 (7.3) | 19.2 (6.5) | <0.001 |
| BMI category (kg/m2) | <0.001 | ||
| <25 | 20.1% | 11.7% | |
| 25 to <30 | 41.2% | 37.1% | |
| ≥30 | 38.7% | 51.2% | |
| Diabetes | 27.8% | 42.9% | <0.001 |
| eGFR <60 ml/min/ 1.73 m2 | 30.1% | 24.9% | 0.013 |
| Prevalent coronary heart disease | 18.9% | 9.2% | <0.001 |
| Prevalent stroke | 3.1% | 5.2% | 0.017 |
| Prevalent heart failure | 11.6% | 18.2% | <0.001 |
Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration rate; SD, standard deviation.
Baseline results
At baseline, 75.4% of whites and 66.0% of Blacks had BP <140/90 mm Hg (P < 0.001), while 53.3% and 43.4% of whites and Blacks, respectively, had BP <130/80 mm Hg (P < 0.001). Black participants were, on average, taking more antihypertensive medications than whites (2.53 vs. 2.18, P < 0.001). More Black than white participants with hypertension were taking 2 or more antihypertensive medications (83.3% vs. 69.6%, P < 0.001) (Supplementary Table S2 online).
Among white participants, those who were older, women, and those with a longer duration of hypertension were less likely to have BP controlled to <140/90 mm Hg (Table 2). Among Black participants, women and those with longer hypertension duration were less likely to have BP <140/90 mm Hg. Among white participants, those with coronary heart disease and heart failure were more likely to have BP controlled to <130/80 mm Hg, while women, those who were older, and had low medication adherence were less likely to have BP <130/80 mm Hg. Among Black participants, those who were pre-frail or frail were more likely to have BP <130/80 mm Hg, while women and those who were older we less likely to have BP <130/80 mm Hg.
Table 2.
Characteristics associated with blood pressure <140/90 and <130/80 mm Hg among older adults with treated hypertension in 2011–2013, by race
| Prevalence ratio (95% CI)* | <140/90 mm Hg | <130/80 mm Hg | ||||
|---|---|---|---|---|---|---|
| White | Black | P value for interaction | White | Black | P value for interaction | |
| Age, per 5 years | 0.95 (0.92–0.98) | 0.95 (0.89–1.01) | 0.95 | 0.89 (0.84–0.94) | 0.87 (0.78–0.96) | 0.70 |
| Female (vs. male) | 0.91 (0.86–0.96) | 0.86 (0.77–0.96) | 0.39 | 0.88 (0.80–0.96) | 0.81 (0.67–0.98) | 0.47 |
| Education (vs. less than high school) | 0.75 | 0.19 | ||||
| High school or vocational school | 0.99 (0.90–1.09) | 1.00 (0.86–1.18) | 0.91 (0.77–1.07) | 1.17 (0.90–1.51) | ||
| College or higher | 0.99 (0.90–1.09) | 1.04 (0.90–1.21) | 1.00 (0.85–1.17) | 1.07 (0.84–1.38) | ||
| Poor physical function (vs. normal) | 0.97 (0.85–1.09) | 1.03 (0.90–1.18) | 0.55 | 0.87 (0.70–1.08) | 1.12 (0.90–1.40) | 0.15 |
| Pre-frail or frail (vs. not frail) | 1.01 (0.95–1.07) | 1.04 (0.93–1.16) | 0.74 | 1.01 (0.92–1.11) | 1.23 (1.03–1.48) | 0.07 |
| Mild cognitive impairment or dementia (vs. normal) | 0.94 (0.87–1.02) | 0.98 (0.84–1.14) | 0.64 | 0.96 (0.85–1.08) | 0.96 (0.74–1.23) | 0.97 |
| Depressive symptoms (vs. no) | 1.02 (0.90–1.15) | 0.84 (0.67–1.06) | 0.15 | 1.06 (0.87–1.30) | 0.78 (0.54–1.23) | 0.14 |
| Medication adherence (vs. high) | 0.60 | 0.31 | ||||
| Intermediate | 1.01 (0.95–1.07) | 0.95 (0.85–1.07) | 0.99 (0.96–1.03) | 0.94 (0.78–1.14) | ||
| Low | 0.93 (0.71–1.22) | 0.98 (0.76–1.27) | 0.43 (0.20–0.93) | 0.82 (0.50–1.33) | ||
| Hypertension duration, per 5 years | 0.97 (0.95–0.98) | 0.94 (0.91–0.97) | 0.18 | 0.99 (0.96–1.03) | 0.99 (0.92–1.05) | 0.83 |
| BMI category, kg/m2 (vs. <25) | 0.41 | 0.67 | ||||
| 25 to <30 | 1.02 (0.94–1.11) | 1.20 (0.97–1.49) | 1.00 (0.87–1.14) | 1.17 (0.84–1.62) | ||
| ≥30 | 1.05 (0.96–1.14) | 1.23 (0.99–1.52) | 1.06 (0.93–1.20) | 1.17 (0.84–1.62) | ||
| Diabetes (vs. no) | 1.02 (0.96–1.08) | 1.02 (0.91–1.14) | 0.93 | 1.02 (0.93–1.13) | 1.04 (0.87–1.25) | 0.83 |
| eGFR <60 ml/min/1.73 m2 (vs. ≥60) | 0.96 (0.90–1.03) | 1.00 (0.88–1.13) | 0.61 | 1.04 (0.94–1.15) | 1.11 (0.91–1.36) | 0.58 |
| Prevalent coronary heart disease (vs. no) | 1.02 (0.95–1.10) | 0.92 (0.75–1.13) | 0.39 | 1.18 (1.05–1.32) | 1.09 (0.81–1.46) | 0.70 |
| Prevalent stroke (vs. no) | 0.99 (0.84–1.16) | 0.98 (0.77–1.26) | 0.99 | 0.93 (0.69–1.24) | 0.78 (0.48–1.26) | 0.56 |
| Prevalent heart failure (vs. no) | 0.98 (0.89–1.07) | 0.97 (0.85–1.13) | 0.98 | 1.18 (1.04–1.35) | 1.01 (0.80–1.27) | 0.24 |
Abbreviations: BMI, body mass index; CI, confidence interval; eGFR, estimated glomerular filtration rate.
*Prevalence ratios adjusted for age and sex. A prevalence ratio >1.00 indicates a higher prevalence of hypertension control as compared with the reference group. Bold indicates the prevalence ratio is significant at P < 0.05. A P value for interaction < 0.05 indicates a statistically significant difference in the association by race.
Follow-up results
At follow-up, 59.0% of white and 56.5% of Black participants had BP <140/90 mm Hg (P = 0.27). Among those with controlled BP at baseline, 33.4% white and 34.6% Black participants had uncontrolled BP at follow-up (Figure 1). Among those with uncontrolled BP at baseline, 35.9% of white and 39.5% of Black participants had controlled BP at follow-up.
Figure 1.
Blood pressure control in 2011–2013 and 2016–2017, by race. Abbreviation: BP, blood pressure. The figure shows the percent of white and Black participants with BP <140/90 and ≥140/90 mm Hg at baseline in 2011–2013. Within categories of baseline BP control, the figure shows the percent of individuals with controlled and uncontrolled BP in 2016–2017. The values in parentheses refer to the percent of the total population in each of the 4 possible categories at follow-up. .
Among white participants with controlled BP at baseline, those who had uncontrolled BP at follow-up were older and more likely to be female, have lower education, pre-frail or frail, and eGFR <60 ml/min/1.73 m2 (Supplementary Table S3 online). Among Black participants with controlled BP at baseline, those with uncontrolled BP at follow-up had a longer mean duration of hypertension. After adjusting for age, sex, and baseline SBP, characteristics associated with having uncontrolled BP at follow-up among white participants included older age, female sex, and eGFR <60 ml/min/1.73 m2 (relative risks >1; Table 3). Among Black participants, characteristics associated with having uncontrolled BP at follow-up included longer hypertension duration and diabetes. There was a significant interaction between diabetes and race; Black individuals with diabetes were significantly more likely than whites to have uncontrolled BP at follow-up (P value for interaction = 0.01).
Table 3.
Relative risk for uncontrolled blood pressure in 2016–2017 among white and Black participants with controlled blood pressure in 2011–2013
| White | Black | P value for interaction | |
|---|---|---|---|
| RR (95% CI)* | RR (95% CI)* | ||
| Age, per 5 years | 1.15 (1.07–1.25) | 1.08 (0.94–1.23) | 0.37 |
| Female (vs. male) | 1.36 (1.16–1.60) | 1.11 (0.84–1.48) | 0.22 |
| Education (vs. less than high school graduate) | 0.28 | ||
| High school or vocational school | 1.07 (0.81–1.40) | 0.91 (0.63–1.30) | |
| College or higher | 0.87 (0.65–1.15) | 0.97 (0.70–1.33) | |
| Poor physical function (vs. normal) | 1.12 (0.86–1.45) | 0.93 (0.67–1.29) | 0.26 |
| Pre-frail or frail (vs. not frail) | 1.15 (0.98–1.35) | 1.20 (0.92–1.57) | 0.94 |
| Mild cognitive impairment or dementia (vs. normal) | 1.15 (0.95–1.39) | 1.28 (0.96–1.73) | 0.65 |
| Depressive symptoms (vs. no) | 1.05 (0.76–1.46) | 1.24 (0.84–1.83) | 0.55 |
| Medication adherence (vs. high) | 0.38 | ||
| Intermediate | 0.93 (0.79–1.09) | 1.15 (0.88–1.51) | |
| Low | 1.46 (1.00–2.14) | 1.37 (0.83–2.25) | |
| Hypertension duration, per 5 years | 1.02 (0.97–1.07) | 1.14 (1.03–1.27) | 0.06 |
| BMI category, kg/m2 (vs. <25) | 0.23 | ||
| 25 to <30 | 0.92 (0.76–1.11) | 0.95 (0.64–1.40) | |
| ≥30 | 0.89 (0.73–1.09) | 0.70 (0.47–1.04) | |
| Diabetes (vs. no) | 1.02 (0.86–1.21) | 1.48 (1.15–1.91) | 0.01 |
| eGFR <60 ml/min/1.73 m2 (vs. ≥60) | 1.19 (1.01–1.40) | 1.25 (0.95–1.66) | 0.79 |
| Prevalent coronary heart disease (vs. no) | 1.21 (1.00–1.48) | 0.96 (0.59–1.56) | 0.46 |
| Prevalent stroke (vs. no) | 1.24 (0.87–1.76) | 1.36 (0.86–2.13) | 0.78 |
| Prevalent heart failure (vs. no) | 0.95 (0.73–1.25) | 1.00 (0.72–1.38) | 0.80 |
| Systolic blood pressure at visit 5, mm Hg | 1.03 (1.02–1.04) | 1.03 (1.01–1.04) | 0.92 |
Abbreviations: BMI, body mass index; CI, confidence interval; eGFR, estimated glomerular filtration rate; RR, relative risk.
*Relative risk adjusted for age, sex, and systolic blood pressure at visit 5 (2011–2013). A relative risk >1.00 indicates higher risk of uncontrolled blood pressure in 2016–2017. Bold indicates statistically significant at P < 0.05. A P value for interaction <0.05 indicates a statistically significant difference in the association by race.
In bivariate analyses among those with uncontrolled BP at baseline, those with controlled BP at follow-up were less likely to be female among white participants and less likely to have eGFR <60 ml/min/1.73 m2 among Black participants (Supplementary Table S4 online). In multivariable analyses, these associations remained statistically significant (relative risks <1; Table 4). Black participants with eGFR <60 ml/min/1.73 m2 were significantly less likely than white participants to have controlled BP at follow-up (P value for interaction = 0.006).
Table 4.
Relative risk for controlled blood pressure in 2016–2017 among white and Black participants with uncontrolled blood pressure in 2011–2013
| White | Black | P value for interaction | |
|---|---|---|---|
| RR (95% CI)* | RR (95% CI)* | ||
| Age, per 5 years | 1.05 (0.92–1.21) | 1.06 (0.90–1.25) | 0.96 |
| Female (vs. male) | 0.60 (0.46–0.78) | 0.88 (0.61–1.27) | 0.08 |
| Education (vs. <less than high school) | 0.57 | ||
| High school or vocational school | 0.89 (0.55–1.44) | 0.72 (0.45–1.15) | |
| College or higher | 0.97 (0.60–1.56) | 1.06 (0.72–1.57) | |
| Poor physical function (vs. normal) | 1.27 (0.86–1.86) | 1.36 (0.96–1.94) | 0.69 |
| Pre-frail or frail (vs. not frail) | 1.01 (0.78–1.32) | 0.90 (0.64–1.24) | 0.64 |
| Mild cognitive impairment or dementia (vs. normal) | 1.11 (0.81–1.51) | 0.68 (0.41–1.12) | 0.12 |
| Depressive symptoms (vs. no) | 0.81 (0.45–1.48) | 0.64 (0.33–1.25) | 0.71 |
| Medication adherence (vs. high) | 0.49 | ||
| Intermediate | 0.94 (0.72–1.23) | 0.84 (0.60–1.19) | |
| Low | 0.52 (0.08–3.24) | 1.32 (0.71–2.45) | |
| Hypertension, duration per 5 years | 1.05 (0.95–1.17) | 0.92 (0.81–1.05) | 0.12 |
| BMI category, kg/m2 (vs. <25) | 0.83 | ||
| 25 to <30 | 1.25 (0.87–1.82) | 1.00 (0.59–1.67) | |
| ≥30 | 1.27 (0.86–1.86) | 1.09 (0.66–1.82) | |
| Diabetes (vs. no) | 1.11 (0.84–1.47) | 0.86 (0.61–1.21) | 0.31 |
| eGFR <60 ml/min/1.73 m2 (vs. ≥60) | 1.23 (0.93–1.62) | 0.58 (0.36–0.93) | 0.006 |
| Prevalent coronary heart disease (vs. no) | 0.97 (0.70–1.34) | 1.29 (0.81–2.06) | 0.57 |
| Prevalent stroke (vs. no) | 0.60 (0.25–1.42) | 0.78 (0.34–1.80) | 0.71 |
| Prevalent heart failure (vs. no) | 1.16 (0.81–1.64) | 0.84 (0.52–1.36) | 0.26 |
| Systolic blood pressure at visit 5, mm Hg | 0.99 (0.97–1.00) | 0.99 (0.98–1.01) | 0.46 |
Abbreviations: BMI, body mass index; CI, confidence interval; eGFR, estimated glomerular filtration rate; RR, relative risk.
*Relative risk adjusted for age, sex, and systolic blood pressure at visit 5 (2011–2013). A relative risk >1.00 indicates higher risk of controlled blood pressure in 2016–2017. Bold indicates statistically significant at P < 0.05. A P value for interaction <0.05 indicates a statistically significant difference in the association by race.
From 2011–2013 to 2016–2017, the mean number of antihypertensive medications per participant decreased from 2.18 to 2.11 (P = 0.004) among whites; there was no change among Black participants (2.53 vs. 2.55; P = 0.64). Among white participants, 22.4% were taking fewer, 57.2% were taking the same number, and 20.4% were taking more medications at follow-up. Among Black participants, 25.3% were taking fewer, 48.6% were taking the same number, and 26.1% were taking more medications at follow-up.
DISCUSSION
Among older adults with treated hypertension in 2011–2013, a greater proportion of white than Black adults had BP controlled to <140/90 mm Hg. Consistent with serial cross-sectional data nationally,16 BP control among white and Black adults with treated hypertension decreased from 2011–2013 to 2016–2017. Approximately one-third of both white and Black participants with controlled BP at baseline developed uncontrolled BP at follow-up, and nearly 40% with uncontrolled BP at baseline had controlled BP at follow-up.
Factors associated with changes in BP control differed among white and Black participants, highlighting potential differences in the underlying reasons for changes in BP control and targets for intervention to maintain BP control. There were several important differences in associations of clinical characteristics which may contribute to racial disparities in cardiovascular outcomes. Among those with controlled BP at baseline, Black participants with diabetes were more likely to have incident uncontrolled BP compared with those without diabetes; meanwhile, there was no association among white participants. White and Black participants with chronic kidney disease were more likely to have uncontrolled hypertension at follow-up, though the association was not statistically significant among Black participants. Among those with uncontrolled BP at baseline, Black participants with chronic kidney disease were less likely to have incident controlled BP compared with those without and there was a significant interaction by race. Given the burden of diabetes and chronic kidney disease among older Black adults in the population, combined with less favorable changes in hypertension management among Black adults with these conditions documented in this study, inadequate BP control is an important and potentially increasing source of cardiovascular health disparities.
During the time between the 2 study visits, a new clinical guideline was issued by members of the JNC8 panel recommending higher BP goals for adults aged ≥60 without diabetes or chronic kidney disease (an increase from <140/90 to <150/90 mm Hg) and for those with diabetes or chronic kidney disease (an increase from <130/80 to <140/90 mm Hg). Of note, the guideline included a corollary recommendation for patients on pharmacologic treatment with lower BP (e.g., <140/90 mm Hg in individuals without diabetes or chronic kidney disease) without adverse effects, that treatment did not necessarily need to be adjusted. It is unclear whether the overall reduction in BP control or changes in BP control among those with diabetes or chronic kidney disease can be attributed to changes in guidelines or patient and provider preferences regarding treatment goals with age. For some patients with a high burden of comorbidities or limited life expectancy, higher BP goals may be appropriate.3 However, the less favorable changes in BP control among Black individuals with diabetes and chronic kidney disease are concerning.
In 2017, the American College of Cardiology (ACC), American Heart Association (AHA), and 9 other professional societies recommended adults aged ≥65 be treated to SBP <130 mm Hg.3 In 2011–2013, more than half of white participants had BP <130/80 mm Hg compared with ~40% of Black participants. While these data illustrate BP can be managed to lower levels among older adults, and population BP has decreased with previous guidelines recommending lower BP goals,17 it will be important to ensure lower treatment goals are implemented equitably. This will require targeted efforts to address barriers to BP control among Black adults, including those which occur in health care (e.g., provider mistrust, cultural competence) and as a result of historical, social, and economic factors that perpetuate systemic racism.18,19 Additionally, it will be important for patients at increased cardiovascular risk, such as those with diabetes or chronic kidney disease, to discuss treatment goals with their physicians.
We found Black older adults were using more antihypertensive medications than whites at baseline. Among both white and Black participants, many had no change in the number of antihypertensive medications used or were taking fewer medications at follow-up. It is difficult to determine whether there were medication intensifications that would have been clinically appropriate, especially if the BP goal remained <140/90 mm Hg. Further research is warranted to understand reasons for medication deintensification.
This study has several limitations. First, research BP measurements obtained with standardized measurement protocols may differ from those in clinical settings used to guide treatment decisions.20 Second, ARIC does not have information from clinical encounters which may have influenced BP treatment goals. Third, the majority of Black participants in our study are from 1 study site in Jackson, Mississippi. Differences by race may reflect geographic differences in care practices or social determinants of health. Fourth, changes in BP control may reflect heterogeneous processes. Some decreases in BP could be due to worsening health status as opposed to improved control. Fourth, it was not possible to assess whether participants received or adhered to lifestyle modifications to reduce BP. Fifth, measures of racism and discrimination were not included in the study. Finally, because of the age of participants, there is substantial loss to follow-up between the 2 study visits. However, study retention is considered high for a cohort of older adults and the aim was to describe changes in BP control in participants who were followed.
The study has multiple strengths. ARIC is a large, community-based cohort which includes both Black and white older adults whose health status is well characterized. Risk factors were assessed by trained personnel using rigorous, standardized measurements including a consistent, high-quality BP measurement protocol across the 2 study visits. Additionally, this analysis leverages study visits before and after the publication of a major hypertension guideline in 2014.
This analysis highlights Black older adults have a higher cumulative burden of uncontrolled BP as compared with whites. While prevention at younger ages is critical, improving hypertension management in older age is also important for reducing cardiovascular disease. Black individuals with diabetes or chronic kidney disease were less likely to have improvements in BP control from 2011–2013 to 2016–2017. Higher treatment goals recommended in 2014 may have contributed to these findings and unintended differences by race. Reducing racial disparities in BP control will require efforts to address clinical and societal factors which influence BP control. The lower level of BP recommended by the 2017 ACC/AHA guideline affords an opportunity to focus on reducing BP for populations at high risk and reduce disparities in cardiovascular health.
Supplementary Material
ACKNOWLEDGMENTS
The authors thank the staff and participants of the ARIC Study for their important contributions.
FUNDING
The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under contract nos. (HHSN268201700001I, HHSN268 201700002I, HHSN268201700003I, HHSN268201700005I, HHSN268201700004I). Kathryn Foti is supported by grant number T32 HL007024 from the National Heart, Lung, and Blood Institute, National Institutes of Health. Dr Selvin was supported by grant number K24 HL152440 from the National Heart, Lung, and Blood Institute, National Institutes of Health and grant number R01DK089174 from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
DISCLOSURE
The authors declared no conflict of interest.
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