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PURPOSE OF REVIEW: Elevated blood pressure is the leading modifiable risk factor for cardiovascular morbidity and mortality in the US. Older individuals, Black adults, and those with comorbidities such as chronic kidney disease, have higher levels of uncontrolled and resistant hypertension. This review focuses on resistant hypertension, specifically in the US Black population, including potential benefits and limitations of current and investigational agents to address the disparate toll. RECENT FINDINGS: There is a necessity to implement public health measures, including early screening, detection, and evidence-based hypertension treatment with lifestyle, approved and investigational agents. The evidence highlights the importance of implementing feasible and cost-effective public health measures to advocate for early screening, detection, and appropriate treatment of hypertension. A team-based approach involving physicians, advanced practice nurses, physician assistants, pharmacists, social workers, and clinic staff to implement proven approaches and the delivery of care within trusted community settings may mitigate existing disparities.

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The need for diverse representation in clinical trials has recently been reinforced by the Food and Drug Administration's (FDA) guidance for industry entitled, "Diversity Plans to Improve Enrollment of Participants from Underrepresented Racial and Ethnic Populations in Clinical Trials." By ensuring inclusion of underrepresented racial and ethnic minority populations in clinical trials, results can be more generalizable and the safety and efficacy can be accurately assessed within the diverse U.S. population. Limitations exist in the interpretation and implementation of clinical trial results reported using the current racial and ethnic categories, as these standards do not reflect the true diversity of the U.S. population. This is particularly true for the Middle Eastern and North African (MENA) population, which is usually overlooked given the lack of an established category. Although the international MENA region demonstrates the highest prevalence of diabetes in the world at 12.2%, the actual prevalence among MENA individuals living in the U.S. may be "hidden" within the White category. Therefore, data on the MENA population should be disaggregated from data within the White category to not only unmask health disparities, but also to ensure adequate representation in clinical trials. This paper discusses the importance of appropriate representation and inclusion of the MENA population in diabetes clinical trials, which is a critical public health issue domestically and globally.

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The racial/ethnic disparities in cardiometabolic risk factors and cardiovascular diseases (CVD) are prominent in non-Hispanic Black adults and other United States (U.S.) sub-populations, with evidence of differential access and quality of health care. High blood pressure (BP) is the most potent and prevalent risk factor for adverse cardiovascular (CV) outcomes across all populations globally, but especially in the non-Hispanic Black adults in the U.S. The use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) demonstrate favorable effects in patients with and without type 2 diabetes (T2DM) in CVD especially for heart failure (HF), as the contemporary clinical practice recommendations and standards of care advocate. The beneficial effects of SGLT2is have been most profoundly documented with HF, including reduced (HFrEF) or preserved ejection fraction (HFpEF), and chronic kidney disease (CKD) with T2DM. Given that hypertension (HTN), CVD, HF, and CKD are significantly greater in certain racial/ethnic populations, the potential impact of SGLT2is will be more significant on the excess cardiometabolic and renal disease, especially in the Black patients. Moreover, there is a need for increased diverse representation in clinical trials. Inclusion of larger members of various racial/ethnic populations may assure that new and emerging data accurately reflect the diversity of the U.S. population. This review highlights potential benefits of SGLT2is, as noted in the most recent literature, and their BP-lowering impact on potentially reducing CV disparities, especially in Black adults. Furthermore, this commentary emphasizes the need to increase diversity in clinical trials to reduce the disparity gaps.

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Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

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Following decades of decline, maternal mortality began to rise in the United States around 1990-a significant departure from the world's other affluent countries. By 2018, the same could be seen with the maternal mortality rate in the United States at 17.4 maternal deaths per 100 000 live births. When factoring in race/ethnicity, this number was more than double among non-Hispanic Black women who experienced 37.1 maternal deaths per 100 000 live births. More than half of these deaths and near deaths were from preventable causes, with cardiovascular disease being the leading one. In an effort to amplify the magnitude of this epidemic in the United States that disproportionately plagues Black women, on June 13, 2020, the Association of Black Cardiologists hosted the Black Maternal Heart Health Roundtable-a collaborative task force to tackle the maternal health crisis in the Black community. The roundtable brought together diverse stakeholders and champions of maternal health equity to discuss how innovative ideas, solutions and opportunities could be implemented, while exploring additional ways attendees could address maternal health concerns within the health care system. The discussions were intended to lead the charge in reducing maternal morbidity and mortality through advocacy, education, research, and collaborative efforts. The goal of this roundtable was to identify current barriers at the community, patient, and clinician level and expand on the efforts required to coordinate an effective approach to reducing these statistics in the highest risk populations. Collectively, preventable maternal mortality can result from or reflect violations of a variety of human rights-the right to life, the right to freedom from discrimination, and the right to the highest attainable standard of health. This is the first comprehensive statement on this important topic. This position paper will generate further research in disparities of care and promote the interest of others to pursue strategies to mitigate maternal mortality.

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BACKGROUND: Subclinical hypertensive heart disease (SHHD) is a precursor to heart failure. Blood pressure (BP) reduction is an important component of secondary disease prevention in patients with SHHD. Treating patients with SHHD utilizing a more intensive BP target (120/80 mm Hg), may lead to improved cardiac function but there has been limited study of this, particularly in African Americans (AAs). METHODS: We conducted a single center, randomized controlled trial where subjects with uncontrolled, asymptomatic hypertension, and SHHD not managed by a primary care physician were randomized to standard (<140/90 mm Hg) or intensive (<120/80 mm Hg) BP therapy groups with quarterly follow-up for 12 months. The primary outcome was the differences of BP reduction between these 2 groups and the secondary outcome was the improvement in echocardiographic measures at 12 months. RESULTS: Patients (95% AAs, 65% male, mean age 49.4) were randomized to the standard (n = 65) or the intensive (n = 58) BP therapy groups. Despite significant reductions in systolic BP (sBP) from baseline (-10.9 vs. -19.1 mm Hg, respectively) (P < 0.05), no significant differences were noted between intention-to-treat groups (P = 0.33) or the proportion with resolution of SHHD (P = 0.31). However, on post hoc analysis, achievement of a sBP <130 mm Hg was associated with significant reduction in indexed left ventricular mass (-6.91 gm/m2.7; P = 0.008) which remained significant on mixed effect modeling (P = 0.031). CONCLUSIONS: In post hoc analysis, sBP <130 mm Hg in predominantly AA patients with SHHD was associated with improved cardiac function and reverse remodeling and may help to explain preventative effects of lower BP goals. CLINICAL TRIALS REGISTRATION: Trial Number NCT00689819.

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PURPOSE OF REVIEW: The purpose of this review is to examine the impact and effectiveness of community interventions for controlling hypertension in African-Americans. The questions addressed are as follows: Which salient prior and current community efforts focus on African-Americans and are most effective in controlling hypertension and patient-related outcomes? How are these efforts implemented and possibly sustained? RECENT FINDINGS: The integration of out-of-office blood pressure measurements, novel hypertension control centers (i.e., barbershops), and community health workers improve hypertension control and may reduce the excess hypertension-related complications in African-Americans. Several community-based interventions may assist effectiveness of clinical care teams, decrease care barriers, and improve adherence. A multifaceted, tailored, multidisciplinary community-based approach may effectively reduce barriers to blood pressure control among African-Americans. Future research should evaluate the long-term benefits of community health workers, barbershops as control centers, and out-of-office blood pressure monitoring upon control and eventually on morbidity and mortality.

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Blacks are two to three times as likely as whites to die of preventable heart disease and stroke. Declines in mortality from heart disease have not eliminated racial disparities. Control and effective treatment of hypertension, a leading cause of cardiovascular disease, among blacks is less than in whites and remains a challenge. One of the driving forces behind this racial/ethnic disparity is medication nonadherence whose cause is embedded in social determinants. Eight practical approaches to addressing medication adherence with the potential to attenuate disparities were identified and include: (1) patient engagement strategies, (2) consumer-directed health care, (3) patient portals, (4) smart apps and text messages, (5) digital pillboxes, (6) pharmacist-led engagement, (7) cardiac rehabilitation, and (8) cognitive-based behavior. However, while data suggest that these strategies may improve medication adherence, the effect on ameliorating racial/ethnic disparities is not certain. This review describes the relationship between disparities and medication adherence, which likely plays a role in persistent disparities in cardiovascular morbidity and mortality.

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The treatment of essential hypertension is one of the most critical interventions to decrease cardiovascular morbidity and mortality. The prevalence of hypertension in the US varies across race/ethnicity with African Americans having the highest prevalence and overall less control among racial/ethnic minorities compared with non-Hispanic whites. Therapeutic lifestyle modifications are the bedrock of essential hypertension control, but most patients with hypertension will require pharmacotherapy, usually with multiple medications often in combination. Overall, the principal drug classes recommended as initial pharmacotherapy are thiazide-type diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

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Medication nonadherence, a major problem in cardiovascular disease (CVD), contributes yearly to approximately 125,000 preventable deaths, which is partly attributable to only about one-half of CVD patients consistently taking prescribed life-saving medications. Current interest has focused on how labeling and education influence adherence. This paper summarizes the scope of CVD nonadherence, describes key U.S. Food and Drug Administration initiatives, and identifies potential targets for improvement. We describe key adherence factors, methods, and technological applications for simplifying regimens and enhancing adherence, and 4 areas where additional collaborative research and implementation involving the regulatory system and clinical community could substantially reduce nonadherence: 1) identifying monitoring methods; 2) improving the evidence base to better understand adherence; 3) developing patient/health provider team-based engagement strategies; and 4) alleviating health disparities. Alignment of U.S. Food and Drug Administration approaches to dissemination of information about appropriate use with clinical practice could improve adherence, and thereby reduce CVD death and disability.

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OBJECTIVES: Poorly controlled hypertension (HTN) is extremely prevalent and, if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure. To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost-effectiveness of our program. METHODS: Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single-center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of 1 year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life-year (QALY) less than $50,000 was defined as cost-effective. RESULTS: Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost-effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control. CONCLUSIONS: In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost-effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost-effective mechanism to mitigate the cardiovascular consequences of HTN in emergency department patients with uncontrolled BP.

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Predicting blood pressure (BP) response to antihypertensive therapy is challenging. The therapeutic intensity score (TIS) is a summary measure that accounts for the number of medications and the relative doses a patient received, but its relationship to BP change and its utility as a method to project dosing equivalence has not been reported. We conducted a prospective, single center, randomized controlled trial to compare the effects of Joint National Committee (JNC) 7 compliant treatment with more intensive (<120/80 mm Hg) BP goals on left ventricular structure and function in hypertensive patients with echocardiographically determined subclinical heart disease who were treated over a 12-month period. For this preplanned subanalysis, we sought to compare changes in BP over time with changes in TIS. Antihypertensive therapy was open label. TIS and BP were determined at 3-month intervals with titration of medication doses as needed to achieve targeted BP. Mixed linear models defined antihypertensive medication TIS as an independent variable and change in systolic BP as an outcome measure, while controlling for gender, age, baseline BP, and treatment group. A total of 123 patients (mean age 49.4 ± 8.2 years; 66% female; 95.1% African-American) were enrolled and 88 completed the protocol. For each single point increase in total antihypertensive TIS, a 14.5 (95% confidence interval: 11.5, 17.4) mm Hg decrease in systolic BP was noted (15.5 [95% confidence interval: 13.0, 18.0] mm Hg for those who completed the trial). Total TIS is a viable indicator of the anticipated BP-lowering effect associated with antihypertensive therapy.

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Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a serine protease that binds to low-density lipoprotein receptors (LDL-Rs), leading to their accelerated degradation and increased low-density lipoprotein cholesterol (LDL-C) levels. Therefore, PCSK9 levels play a critical role in cholesterol metabolism by reducing LDL-R levels and thus increasing levels of plasma LDL-C. Recently, investigational agents inhibiting PCSK9 have been shown to lower LDL-C and also, potentially, an important secondary target, lipoprotein(a). Therefore, several pharmaceutical companies have initiated drug-development programs that target PCSK9 and are built on a solid foundation of basic science, genetic studies, and epidemiological observations. PCSK9 inhibition with monoclonal antibodies demonstrated LDL-C lowering of up to 57% when the PCSK9 antibodies are used as monotherapy and up to 73% when added to background lipid-lowering therapy. In addition, long-term cardiovascular outcome studies are currently under way to confirm the longer term safety and efficacy of PCSK9 inhibitors and to determine whether PCSK9 inhibition lowers the incidence of major cardiovascular events. PCSK9 inhibitors may provide safe and effective lipid-lowering therapy, especially for patients with inadequate LDL-C lowering on lipid-lowering treatments, those who are statin intolerant or have contraindications to statin therapy, and those with hereditary hypercholesterolemia/familial hypercholesterolemia and severely elevated LDL-C.

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Although several risk factors contribute to cardiovascular disease (CVD) overall, hypertension (HTN) is the major controllable risk factor. Hypertension is disproportionately more prevalent among Blacks or African-Americans compared with other race/ethnic populations, and the control rates among this disparate population are alarming. Several pathophysiologic mechanisms have been demonstrated and evaluated among hypertensives and the conglomeration of genetics, environmental, and personal lifestyle activities concurrently impact the progression of hypertension-related comorbidities (i.e., chronic renal disease, CVD, stroke, etc.). Specific pharmacotherapeutic choices are discussed and the most up-to-date data is presented to optimize the care of hypertensives. National and international guidelines for the treatment of HTN are reviewed and analyzed, presenting the most appropriate approach to the care of hypertensive patients overall. Additionally, national efforts supporting the goal of early HTN screening and treatment, as well as the variety of evidence-based pharmacotherapy, are summarized, applying to the public health impact overall.

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BACKGROUND: As of 2012, nearly 10% of Americans had diabetes mellitus. People with diabetes are at approximately double the risk of premature death compared with those in the same age groups without the condition. While the prevalence of diabetes has risen across all racial/ethnic groups over the past 30 years, rates are higher in minority populations. The objective of this review article is to evaluate the prevalence of diabetes and disease-related comorbidities as well as the primary endpoints of clinical studies assessing glucose-lowering treatments in African Americans, Hispanics, and Asians. METHODS: As part of our examination of this topic, we reviewed epidemiologic and outcome publications. Additionally, we performed a comprehensive literature search of clinical trials that evaluated glucose-lowering drugs in racial minority populations. For race/ethnicity, we used the terms African American, African, Hispanic, and Asian. We searched PubMed for clinical trial results from 1996 to 2015 using these terms by drug class and specific drug. Search results were filtered qualitatively. RESULTS: Overall, the majority of publications that fit our search criteria pertained to native Asian patient populations (i.e., Asian patients in Asian countries). Sulfonylureas; the α-glucosidase inhibitor, miglitol; the biguanide, metformin; and the thiazolidinedione, rosiglitazone have been evaluated in African American and Hispanic populations, as well as in Asians. The literature on other glucose-lowering drugs in non-white races/ethnicities is more limited. CONCLUSIONS: Clinical data are needed for guiding diabetes treatment among racial minority populations. A multi-faceted approach, including vigilant screening in at-risk populations, aggressive treatment, and culturally sensitive patient education, could help reduce the burden of diabetes on minority populations. To ensure optimal outcomes, educational programs that integrate culturally relevant approaches should highlight the importance of risk-factor control in minority patients.

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Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of death in the USA, regardless of self-determined race/ethnicity, and largely driven by cardiometabolic risk (CMR) and cardiorenal metabolic syndrome (CRS). The primary drivers of increased CMR include obesity, hypertension, insulin resistance, hyperglycemia, dyslipidemia, chronic kidney disease as well as associated adverse behaviors of physical inactivity, smoking, and unhealthy eating habits. Given the importance of CRS for public health, multiple stakeholders, including the National Minority Quality Forum (the Forum), the American Association of Clinical Endocrinologists (AACE), the American College of Cardiology (ACC), and the Association of Black Cardiologists (ABC), have developed this review to inform clinicians and other health professionals of the unique aspects of CMR in racial/ethnic minorities and of potential means to improve CMR factor control, to reduce CRS and CVD in diverse populations, and to provide more effective, coordinated care. This paper highlights CRS and CMR as sources of significant morbidity and mortality (particularly in racial/ethnic minorities), associated health-care costs, and an evolving index tool for cardiometabolic disease to determine geographical and environmental factors. Finally, this work provides a few examples of interventions potentially successful at reducing disparities in cardiometabolic health.