Department of Medicine Johns Hopkins Hospital Baltimore MD.
Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.
J Am Heart Assoc. 2019 Aug 6;8(15):e012277. doi: 10.1161/JAHA.119.012277. Epub 2019 Jul 31.
Background Observational studies demonstrate that communities of low socioeconomic status have higher blood pressure and worse cardiovascular outcomes. Yet, whether the clinical outcomes resulting from antihypertensive therapy vary by socioeconomic context in a randomized clinical trial, in which participants are treated under a standard protocol, is unknown. Methods and Results We used data from ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) to study the effect of socioeconomic context, defined as the county-level median household income, of study sites. We stratified sites into income quintiles and compared characteristics, blood pressure control, and cardiovascular outcomes among ALLHAT participants in the lowest- and highest-income quintiles. Among 27 862 qualifying participants, 2169 (7.8%) received care in the lowest-income sites (quintile 1) and 10 458 (37.6%) received care in the highest-income sites (quintile 5). Participants in quintile 1 were more likely to be women, to be black, to be Hispanic, to have fewer years of education, to live in the South, and to have fewer cardiovascular risk factors. After adjusting for baseline demographic and clinical characteristics, quintile 1 participants were less likely to achieve blood pressure control (<140/90 mm Hg) (odds ratio, 0.48; 95% CI, 0.37-0.63) and had greater all-cause mortality (hazard ratio [HR], 1.25; 95% CI, 1.10-1.41), heart failure hospitalizations/mortality (HR, 1.26; 95% CI, 1.03-1.55), and end-stage renal disease (HR, 1.86; 95% CI, 1.26-2.73), but lower angina hospitalizations (HR, 0.70; 95% CI, 0.59-0.83) and coronary revascularizations (HR, 0.71; 95% CI, 0.57-0.89). Conclusions Despite standardized treatment protocols, ALLHAT participants in the lowest-income sites experienced poorer blood pressure control and worse outcomes for some adverse cardiovascular events, emphasizing the importance of measuring and addressing socioeconomic context. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
背景 观察性研究表明，社会经济地位较低的社区血压较高，心血管结局较差。然而，在一项参与者根据标准方案接受治疗的随机临床试验中，降压治疗的临床结果是否因社会经济背景而有所不同尚不清楚。
方法和结果 我们使用 ALLHAT（抗高血压和降脂治疗预防心脏病试验）的数据来研究社会经济背景（定义为研究地点的县一级家庭收入中位数）对临床结局的影响。我们将地点分层为收入五分位数，并比较了 ALLHAT 参与者中收入最低和最高五分位数组的特征、血压控制和心血管结局。在 27862 名符合条件的参与者中，2169 名（7.8%）在收入最低的地点（五分位数 1）接受治疗，10458 名（37.6%）在收入最高的地点（五分位数 5）接受治疗。五分位数 1 组的参与者更有可能是女性、黑人、西班牙裔、受教育程度较低、居住在南部，且心血管危险因素较少。在调整了基线人口统计学和临床特征后，五分位数 1 组的参与者更不可能达到血压控制目标（<140/90mmHg）（比值比，0.48；95%CI，0.37-0.63），且全因死亡率更高（危险比[HR]，1.25；95%CI，1.10-1.41）、心力衰竭住院/死亡率（HR，1.26；95%CI，1.03-1.55）和终末期肾病（HR，1.86；95%CI，1.26-2.73），但心绞痛住院率较低（HR，0.70；95%CI，0.59-0.83）和冠状动脉血运重建率较低（HR，0.71；95%CI，0.57-0.89）。
结论 尽管采用了标准化的治疗方案，但来自收入最低地点的 ALLHAT 参与者的血压控制较差，某些不良心血管事件的结局较差，这强调了测量和解决社会经济背景的重要性。
http://www.clinicaltrials.gov。
NCT00000542。
