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BP control poorer in low-income vs. high-income populations
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Patients with the lowest socioeconomic status had poorer BP control and worse outcomes compared with those with higher socioeconomic status, according to a secondary analysis of the ALLHAT trial published in the Journal of the American Heart Association.
“We know racial and socioeconomic disparities exist in this country, and other research by our group shows that they are worsening, but in a clinical trial where all participants have access to the doctor with study protocols that are standardized and medication algorithms with specific guidance to give blood pressure medications, we would expect for the intervention to, on average, result in similar blood pressure control across all groups, but this wasn’t the case; there were systematic differences by socioeconomic region,” Andi Shahu, MD, MHS, medical student at Yale School of Medicine at the time of the study and now a resident physician at Johns Hopkins Hospital, told Cardiology Today.
Hypertension control
Researchers analyzed data from 27,862 patients from the ALLHAT trial aged 55 years or older with untreated or treated systolic and/or diastolic hypertension. The patients also had established CVD or at least one additional CV risk factor. Patients were assigned one of four antihypertensive medications. Data assessed throughout the study included BP measurements and socioeconomic context. Visits were periodically scheduled for a mean follow-up of 4.9 years.
The primary outcome was CHD, defined as nonfatal MI and fatal CHD combined. Secondary outcomes included stroke, all-cause mortality, combined CHD and combined CVD. Individual components of the outcomes were also assessed and included hospitalized/fatal HF, angina, HF, coronary revascularization, end-stage renal disease and PAD. The cohort was divided into quintiles based on socioeconomic status.
Of the patients in the study, 7.8% were from the lowest-income sites, or quintile 1, and 37.6% were from the highest-income sites, or quintile 5. Patients in quintile 1 were more likely to be black or Hispanic, were more likely to be women, had lower levels of education and lived in the South compared with those in quintile 5. Patients in quintile 1 were less likely to have a history of atherosclerotic CVD, to take aspirin or to have ever smoked compared with those in quintile 5.
Patients from the lowest-income sites were less likely to achieve BP control compared with those from the highest-income sites after adjusting for baseline clinical and demographic characteristics (50% vs. 69.3%; OR = 0.48; 95% CI, 0.37-0.63). Patients from quintile 1 had higher rates of HF hospitalizations/mortality (HR = 1.26; 95% CI, 1.03-1.55), all-cause mortality (HR = 1.25; 95% CI, 1.1-1.41) and end-stage renal disease (HR = 1.86; 95% CI, 1.26-2.73) compared with patients from quintile 5. The lowest-income group also had lower rates of coronary revascularizations (HR = 0.71; 95% CI, 0.57-0.89) and angina hospitalizations (HR = 0.7; 95% CI, 0.59-0.83) compared with the highest-income group.
“People living in these low-income communities may experience more stressors or have unhealthy lifestyle behaviors that can increase blood pressure and counteract the effects of medication,” Shahu said in an interview. “Our study found that these participants were less likely to attend all study visits, so there may have been less of an opportunity to adjust the medication or promote other cardiovascular prevention strategies.”
Future considerations
“As we implement strategies to improve blood pressure control, it is essential that we actively account for the potential harms to health associated with low [socioeconomic status] to ensure that the care we deliver improves outcomes for all populations,” D. Edmund Anstey, MD, MPH, instructor and cardiology fellow at Columbia University Irving Medical Center, and colleagues wrote in a related editorial. – by Darlene Dobkowski
For more information:
Andi Shahu, MD, MHS, can be reached at ashahu1@jhmi.edu; Twitter: @andishahu.
Disclosures:Shahu and Anstey report no relevant financial disclosures. Please see the study and editorial for all other authors’ relevant financial disclosures.
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