Carma Ayala

Hypertensive disorders and severe obstetric morbidity in the United States.

OBJECTIVE: To examine trends in the rates of hypertensive disorders in pregnancy and compare the rates of severe obstetric complications for delivery hospitalizations with and without hypertensive disorders. METHODS: We performed a cross-sectional study using the 1998–2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regressions and population-attributable fractions were used to examine the effect of hypertensive disorders on severe complications. RESULTS: The overall prevalence of hypertensive disorders among delivery hospitalizations increased significantly from 67.2 per 1,000 deliveries in 1998 to 81.4 per 1,000 deliveries in 2006. Compared with hospitalizations without any hypertensive disorders, the risk of severe obstetric complications ranged from 3.3 to 34.8 for hospitalizations with eclampsia/severe preeclampsia and from 1.4 to 2.2 for gestational hypertension. The prevalence of hospitalizations with eclampsia/severe preeclampsia increased moderately from 9.4 to 12.4 per 1,000 deliveries (P for linear trend <0.001) during the period of study. However, these hospitalizations were associated with 38% of hospitalizations with acute renal failure and 19% or more of hospitalizations with ventilation, disseminated intravascular coagulation syndrome, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. Overall, hospitalizations with hypertensive disorders were associated with 57% of hospitalizations with acute renal failure, 27% of hospitalizations with disseminated intravascular coagulation syndrome, and 30% or more of hospitalizations with ventilation, pulmonary edema, puerperal cerebrovascular disorders, and respiratory distress syndrome. CONCLUSION: The number of delivery hospitalizations in the United States with hypertensive disorders in pregnancy is increasing, and these hospitalizations are associated with a substantial burden of severe obstetric morbidity. LEVEL OF EVIDENCE: III

Sex Differences in US Mortality Rates for Stroke and Stroke Subtypes by Race/Ethnicity and Age, 1995–1998

Background and Purpose— Ischemic stroke accounts for 70% to 80% of all strokes, but intracerebral and subarachnoid hemorrhagic strokes have greater fatality. Age-standardized death rates from overall stroke are higher among men than women, but little is known about sex differences in stroke subtype mortality by race/ethnicity. Methods— We analyzed 1995 to 1998 national death certificate data to compare sex-specific age-standardized death rates (per 100 000) for ischemic stroke (n=507 256), intracerebral hemorrhagic stroke (n=98 709), and subarachnoid hemorrhagic stroke (n=27 334) among whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics. We calculated rate ratios and 95% CIs comparing women with men within age and racial/ethnic groups. Results— Age-specific rates of ischemic and intracerebral hemorrhagic stroke deaths were lower for women than for men aged 25 to 44 and 45 to 64 years but were higher for ischemic stroke among older women, aged ≥65 years. Only among whites did women have higher age-standardized rates of ischemic stroke. Age-standardized death rates for intracerebral hemorrhagic stroke among women were lower than or similar to those among men in all racial/ethnic groups. Women had higher risk of death from subarachnoid hemorrhagic; this sex differential increased with age. Conclusions— The female-to-male mortality ratio differs for stroke subtypes by race/ethnicity and age. A primary public health effort should focus on increasing the awareness of stroke symptoms, particularly among people at high risk, to decrease delay in early detection and effective stroke treatment.

Sodium Intake and Blood Pressure Among US Children and Adolescents

OBJECTIVE: To assess the association between usual dietary sodium intake and blood pressure among US children and adolescents, overall and by weight status. METHODS: Children and adolescents aged 8 to 18 years (n = 6235) who participated in NHANES 2003–2008 comprised the sample. Subjects’ usual sodium intake was estimated by using multiple 24-hour dietary recalls. Linear or logistic regression was used to examine association between sodium intake and blood pressure or risk for pre-high blood pressure and high blood pressure (pre-HBP/HPB). RESULTS: Study subjects consumed an average of 3387 mg/day of sodium, and 37% were overweight/obese. Each 1000 mg per day sodium intake was associated with an increased SD score of 0.097 (95% confidence interval [CI] 0.006–0.188, ∼1.0 mm Hg) in systolic blood pressure (SBP) among all subjects and 0.141 (95% CI: –0.010 to 0.298, ∼1.5 mm Hg) increase among overweight/obese subjects. Mean adjusted SBP increased progressively with sodium intake quartile, from 106.2 mm Hg (95% CI: 105.1–107.3) to 108.8 mm Hg (95% CI: 107.5–110.1) overall (P = .010) and from 109.0 mm Hg (95% CI: 107.2–110.8) to 112.8 mm Hg (95% CI: 110.7–114.9; P = .037) among those overweight/obese. Adjusted odds ratios comparing risk for pre-HBP/HPB among subjects in the highest versus lowest sodium intake quartile were 2.0 (95% CI: 0.95–4.1, P = .062) overall and 3.5 (95% CI: 1.3–9.2, P = .013) among those overweight/obese. Sodium intake and weight status appeared to have synergistic effects on risk for pre-HBP/HPB (relative excess risk for interaction = 0.29 (95% CI: 0.01–0.90, P < .05). CONCLUSIONS: Sodium intake is positively associated with SBP and risk for pre-HBP/HPB among US children and adolescents, and this association may be stronger among those who are overweight/obese.

Low public recognition of major stroke symptoms

BACKGROUND A Healthy People 2010 objective includes increasing public awareness of the warning signs of stroke, yet few data exist about the level of awareness. Recognition of stroke symptoms and awareness of the need to call 911 for acute stroke events were examined among the general population. METHODS Data are from 61,019 adults participating in the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Respondents indicated whether the following were symptoms of stroke: confusion/trouble speaking; numbness/weakness of face, arm, or leg; trouble seeing; chest pain (false symptom); trouble walking, dizziness, or loss of balance; and severe headache with no known cause. Persons also reported the first action they would take if they thought someone was having a stroke. RESULTS Only 17.2% of respondents overall (5.9% to 21.7% by state) correctly classified all stroke symptoms and indicated that they would call 911 if they thought someone was having a stroke. Recognition of all symptoms and knowledge of when to call 911 were comparable by gender but lower among ethnic minorities, younger and older people, those with less education, and current smokers compared to whites, middle-aged people, those with more education, and nonsmokers, respectively. There were no substantive differences by history of hypertension, diabetes, heart disease, or stroke. CONCLUSIONS Public recognition of major stroke symptoms is low. Educational campaigns to increase awareness among the general population and targeted messages to those at high-risk persons and their families may help to improve time to treatment for adults suffering acute strokes.

Acute Myocardial Infarction Hospitalization in the United States, 1979 to 2005

BACKGROUND We reported earlier that there was no decline of acute myocardial infarction hospitalization from 1988 to 1997. We now extend these observations to document trends in acute myocardial infarction hospitalization rates and in-hospital case-fatality rates for 27 years from 1979 to 2005. METHODS We determined hospitalization rates for acute myocardial infarction by age and gender using data from the National Hospital Discharge Survey and US civilian population from 1979 to 2005, aggregated by 3-year groupings. We also assessed comorbid, complications, cardiac procedure use, and in-hospital case-fatality rates. RESULTS Age-adjusted hospitalization rate for acute myocardial infarction identified by primary International Classification of Diseases code was 215 per 100,000 people in 1979-1981 and increased to 342 in 1985-1987. Thereafter, the rate stabilized for the next decade and then declined slowly after 1996 to 242 in 2003-2005. Trends were similar for men and women, although rates for men were almost twice that of women. Hospitalization rates increased substantially with age and were the highest among those aged 85 years or more. Although median hospital stay decreased from 12 to 4 days, intensity of hospital care increased, including use of coronary angioplasty, coronary bypass, and thrombolytics therapy. During the period, reported comorbidity from diabetes and hypertension increased. Acute myocardial infarction complicated by heart failure increased, and cardiogenic shock decreased. Altogether, the in-hospital case-fatality rate declined. CONCLUSION During the past quarter century, hospitalization for acute myocardial infarction increased until the mid-1990s, but has declined since then. At the same time, in-hospital case-fatality rates declined steadily. This decline has been associated with more aggressive therapeutic intervention.

Nondrug interventions in hypertension prevention and control

This review was undertaken to address the relation of various factors to HBP and their potential for preventing and controlling this widespread problem. With respect to salt intake and BP, the 1999 Workshop on Sodium and Blood Pressure of the (US) National Heart, Lung, and Blood Institute [5] will serve the reader well as a point of departure. The body of the present review provides more detailed discussion especially of recent epidemiologic research, including the DASH-Sodium trial, published more recently than the proceedings of that workshop. The DASH-Sodium trial demonstrates significant increases in SBP and DBP, with sodium intake greater than 65 mmol/d (= 3.7 g NaCl--see equivalencies in Appendix A) and with the usual American diet (versus the DASH diet). These results provide substantial evidence against current dietary practices in many populations where daily intakes of salt are much higher than recommended. We also have addressed alcohol consumption, micronutrients/macronutrients, physical activity and inactivity, obesity, cigarette smoking, and alternative approaches to treatment such as stress reduction/biofeedback, yoga/meditation, and acupuncture. Evidence for the efficacy of certain nonpharmacologic approaches to preventing and controlling HBP is strong. This evidence offers a basis for public health policies and clinical approaches that can greatly affect the incidence and consequences of HBP in the population at large. What is needed now is implementation of the policies and practices addressed here. Unless such action is taken on a large scale, we will have made poor use of the knowledge accrued over decades of research. The clinician is referred to the National Heart, Lung and Blood Institute Web site at www.nhlbi.gov/health/prof/heart/index.htm for resource and guideline information for hypertension. Patients and the general public are referred to the sister web page at www.nhlbi.gov\health\public\heart\index.htm for educational fact sheets and general information on hypertension.

Pulmonary Hypertension Surveillance: United States, 2001 to 2010

Pulmonary hypertension (PH) is an uncommon but progressive condition, and much of what we know about it comes from specialized disease registries. With expanding research into the diagnosis and treatment of PH, it is important to provide updated surveillance on the impact of this disease on hospitalizations and mortality. This study, which builds on previous PH surveillance of mortality and hospitalization, analyzed mortality data from the National Vital Statistics System and data from the National Hospital Discharge Survey between 2001 and 2010. PH deaths were identified using International Classification of Diseases, Tenth Revision codes I27.0, I27.2, I27.8, or I27.9 as any contributing cause of death on the death certificate. Hospital discharges associated with PH were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 416.0, 416.8, or 416.9 as one of up to seven listed medical diagnoses. The decline in death rates associated with PH among men from 1980 to 2005 has reversed and now shows a significant increasing trend. Similarly, the death rates for women with PH have continued to increase significantly during the past decade. PH-associated mortality rates for those aged 85 years and older have accelerated compared with rates for younger age groups. There have been significant declines in PH-associated mortality rates for those with pulmonary embolism and emphysema. Rates of hospitalization for PH have increased significantly for both men and women during the past decade; for those aged 85 years and older, hospitalization rates have nearly doubled. Continued surveillance helps us understand and address the evolving trends in hospitalization and mortality associated with PH and PH-associated conditions, especially regarding sex, age, and race/ethnicity disparities.

Prevalence of Self-Reported Hypertension, Advice Received From Health Care Professionals, and Actions Taken to Reduce Blood Pressure Among US Adults—HealthStyles, 2008

J Clin Hypertens (Greenwich). 2010;12:784‐792.

Trends and Disparities in Heart Disease Mortality Among American Indians/Alaska Natives, 1990–2009

OBJECTIVES We evaluated heart disease death rates among American Indians and Alaska Natives (AI/ANs) and Whites after improving identification of AI/AN populations. METHODS Indian Health Service (IHS) registration data were linked to the National Death Index for 1990 to 2009 to identify deaths among AI/AN persons aged 35 years and older with heart disease listed as the underlying cause of death (UCOD) or 1 of multiple causes of death (MCOD). We restricted analyses to IHS Contract Health Service Delivery Areas and to non-Hispanic populations. RESULTS Heart disease death rates were higher among AI/AN persons than Whites from 1999 to 2009 (1.21 times for UCOD, 1.30 times for MCOD). Disparities were highest in younger age groups and in the Northern Plains, but lowest in the East and Southwest. In AI/AN persons, MCOD rates were 84% higher than UCOD rates. From 1990 to 2009, UCOD rates declined among Whites, but only declined significantly among AI/AN persons after 2003. CONCLUSIONS Analysis with improved race identification indicated that AI/AN populations experienced higher heart disease death rates than Whites. Better prevention and more effective care of heart disease is needed for AI/AN populations.

Sleep duration and history of stroke among adults from the USA

Although short sleep duration is related to chronic conditions, such as hypertension, diabetes and obesity, the association with stroke is less well known. Using 2006–2011 National Health Interview Surveys, we assessed the association between self‐reported duration of sleep and prevalence of stroke stratifying by age and sex. Of the 154 599 participants aged 18 years or older, 29.2%, 61.8% and 9.0% reported they sleep ≤6, 7–8 and ≥9 h per day, respectively. Corresponding age‐standardized prevalence of stroke were 2.78%, 1.99% and 5.21% (P < 0.001). Logistic regression models showed a higher prevalence of stroke among those who slept ≤6 or ≥9 h a day compared with those who slept 7–8 h, after adjusting for sociodemographic, behavioural and health characteristics. Further stratifying by age and sex showed that the association of duration of sleep and stroke differed among different age or sex groups. Among young adults (18–44 years), a higher prevalence of stroke was found among women with short sleep. Higher prevalence of stroke was found among middle‐aged men and women reporting short or long sleep duration. Among older adults (≥65 years), higher prevalence of stroke was found only among those who slept ≥9 h. In this national sample of adults, the association between duration of sleep and stroke varied by sex and age. Although there was an association of short sleep duration with stroke, we also observed the association of long sleep duration with stroke, especially among those aged 65 years or older.