Adam P. Bress

Aims: To determine whether menopausal status, menopausal hormone therapy (MHT), or oral contraceptive (OCP) use modifies the association between elevated Lp(a) and prevalent coronary artery disease (CAD). Methods: We conducted a cross-sectional study of 6,314 U.S. Women Veterans with Lp(a) testing from 1999-2025 to evaluate whether menopausal status, MHT use, or OCP use modify the association between elevated Lp(a) (≥ 125 nmol/L) and prevalent CAD. Logistic regression was used to estimate adjusted odds ratios (aOR), with interaction terms evaluated by likelihood ratio tests. Restricted cubic splines were used to model the continuous association between Lp(a) and prevalent CAD. Results: Elevated Lp(a) was present in 31.6% of Women Veterans and was independently associated with increased odds of prevalent CAD (aOR 1.24, 95% confidence interval 1.06-1.44, p = 0.0079). We observed a continuous increase in prevalent CAD with rising Lp(a) levels (aOR 1.023 per 25 nmol/L increase, 95% confidence interval 1.010-1.040, p = 0.0033). No effect modification was detected for menopausal status (p-value for interaction = 1.0), MHT use in postmenopausal women (p-value for interaction = 0.20), or OCP use in premenopausal women (p-value for interaction = 0.32). Conclusion: Elevated Lp(a) is common and associated with prevalent CAD in Women Veterans. We did not detect modification of the association between elevated Lp(a) and prevalent CAD based on menopausal status or hormonal therapy. These findings support systematic Lp(a) screening across the full female reproductive spectrum.

Background and ObjectivesAngiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) may differentially affect dementia risk by targeting distinct components of the re...

BACKGROUND: Amid persistently low blood pressure (BP) control rates and pervasive therapeutic inertia, we evaluated trends in pre- and posttreatment BP before and after 2 major disruptions (the 2017 target‑lowering guideline and the COVID‑19 pandemic) to assess their impact on early hypertension management. METHODS: This retrospective cohort study of national Veterans Health Administration data included outpatient adults newly diagnosed with hypertension and starting antihypertensive medication between November 13, 2014, and May 31, 2023 (index date). Patients were stratified into 3 periods corresponding to preguideline/prepandemic (Period 1), postguideline/prepandemic (Period 2), and postguideline/postpandemic (Period 3), and into 3 pretreatment systolic BP (SBP) groups based on the average of ≥2 measurements in the 90-day preindex period (<140, 140–160, or ≥160 mm Hg). Across periods, multivariable analyses evaluated: (1) mean posttreatment SBP (mean of measurements from days 180–365 postindex); and (2) posttreatment BP control (<140/90 or <130/80 mm Hg). RESULTS: Among 271 496 Veterans (mean age, 62 years; 92% male; 66% non-Hispanic White), 39%, 32%, and 29% were in Periods 1, 2, and 3, respectively. Adjusted posttreatment SBP across periods was 128, 135, and 142 mm Hg for the <140, 140 to 160, and ≥160 groups, respectively. Rates of posttreatment BP control <140/90 mm Hg across Periods 1, 2, and 3, respectively, were 82.3%, 83.3%, and 84.2% (SBP <140 group); 64.1%, 66.1%, and 67.3% (140–160 group); and 46.4%, 47.0%, and 48.6% (≥160 group). For BP control <130/80 mm Hg, rates were 38.2%, 40.0%, and 39.9% (SBP <140 group); 20.7%, 22.0%, and 22.6% (140–160 group); and 15.1%, 15.4%, and 15.2% (≥160 group). CONCLUSIONS: Despite the target-lowering guideline and the care-disrupting pandemic, BP levels and control among Veterans remained largely unchanged. At 1 year, only half to two-thirds achieved BP <140/90 mm Hg, and few reached <130/80 mm Hg, underscoring persistent clinical inertia and the need to improve early hypertension management in the Veterans Health Administration.

In this cross-sectional study of 5.8 million US adults with hypertension taking antihypertensive single-pill combination (SPC) products in the Medical Expenditure Panel Survey (2016-2022), the median out-of-pocket cost was $5.53 per SPC fill (interquartile range [IQR] $0.00-$12.70). A hypothetical small (e.g., $4/30 days) cost cap could reduce annual out-of-pocket spending by $152.9 million overall (median savings $5.35 (IQR $1.06-$12.81) per fill). A hypothetical large cost cap (e.g., $11/30 days) could reduce annual out-of-pocket spending by $61.2 million overall (median savings $2.27 (IQR $0.00-$11.28) per fill). Despite relatively low out-of-pocket costs, these spending reductions may lower patient financial burdens associated with antihypertensive SPC therapy.

Background: Blood pressure (BP) control remains suboptimal in the United States despite available low‐cost antihypertensive medications. Even small out‐of‐pocket medication costs may contribute to adherence. We determined whether $0 versus >$0 out‐of‐pocket costs for antihypertensive medications is associated with differences in adherence, discontinuation, BP control, and cardiovascular outcomes. Methods: We included veterans with newly diagnosed hypertension who initiated antihypertensive medication in the Veterans Health Administration from 2004 to 2022. A fuzzy regression discontinuity design with 2‐stage residual inclusion leveraged differences in medication copay policy at a 50% service‐connected disability threshold (≥50% service‐connected disability: $0 out‐of‐pocket cost versus <50%: $8 monthly cost). Outcomes included 1‐year medication nonadherence (proportion of days covered <80%), 1‐year medication discontinuation (no medication in the final 90 days of the study year), 1‐year BP control (systolic BP/diastolic BP <140/90 mm Hg and <130/80 mm Hg) and cardiovascular disease events (myocardial infarction, coronary revascularization, peripheral artery disease, or stroke). Results: Among 417 705 veterans (mean±SD age, 56 [13] years; 92% male; 61% non‐Hispanic White), 296 432 (71%) had $0 out‐of‐pocket costs. Accounting for changes in eligibility for $0 copays at the 50% service‐related disability threshold, $0 out‐of‐pocket costs were associated with lower odds of nonadherence (odds ratio [OR], 0.87 [95% CI, 0.81–0.94]) and medication discontinuation (OR, 0.77 [95% CI, 0.71–0.84]). One‐year BP control <140/90 mm Hg or <130/80 mm Hg and cardiovascular disease events events were similar between groups. Conclusions: Among veterans with newly diagnosed hypertension, modest out‐of‐pocket medication costs were associated with lower adherence and discontinuation. These findings can inform ongoing discussions regarding policy levers for improving hypertension outcomes.

Hypertension is a leading cause of cardiovascular disease and disproportionately affects African American (AA) adults. Apparent treatment-resistant hypertension (aTRH) is highly prevalent in this population. Sodium intake is associated with blood pressure (BP) levels, yet the relationship between sodium and the risk of developing aTRH in AA adults remains unclear. This study examined the association between 24-hour urinary sodium excretion and incident aTRH among AA adults with hypertension, using data from the Jackson Heart Study (JHS). The JHS included 5306 self-identified AA adults from Jackson, Mississippi, with data collected from 2000 to 2013. This analysis included 452 participants with baseline hypertension and complete urinary excretion and medication data. Sodium excretion was categorized into quartiles: Q1 (253 to 2530 mg/day), Q2 (2553 to 3657 mg/day), Q3 (3680 to 4692 mg/day), and Q4 (4715 to 9775 mg/day). A semi-parametric proportional hazards model was used to determine the association between sodium excretion and incident aTRH. Participants had a mean age of 63 years, and 27.7% were men. Over a median follow-up of 7.5 years, 123 participants (27.2%) developed aTRH. The incidence of aTRH was 25.7%, 24.8%, 29.2%, and 29.2% in Q1, Q2, Q3, and Q4 of urinary sodium excretion, respectively. In adjusted models, there was no significant association between urinary sodium excretion and incident aTRH [HRs (95% CIs): Q2 = 0.71 (0.34, 1.46), Q3 = 1.02 (0.50, 2.06), Q4 = 0.95 (0.46, 2.00); P = 0.166]. Among AA adults with treated hypertension, sodium intake, as measured by 24-hour urinary sodium excretion, was not significantly associated with incident resistant hypertension.

To determine population attributable fractions (PAFs) of modifiable dementia risk factors by income, and independent and interactive associations of race-ethnicity and income with each risk factor and cumulative number of midlife risk factors. This nationally representative cross-sectional study of the 1999-2008, 2011-2014, and primarily the 2015-2018 National Health and Nutrition Examination Surveys comprised of individuals aged 18-44, 45-64, and 65+ years for early-life, midlife, and late-life analyses, respectively. Income was operationalized using the poverty-income ratio. The primary outcomes were PAFs and prevalence ratios (PR) of the 13 individual-level dementia risk factors and cumulative number of midlife risk factors. There were 13,145 individuals with risk factor data between 2015 and 2018 (51.1% aged 18-44, 31.0% aged 45-64, and 17.9% aged ≥65 years; 51.5% female after survey-weighting). Higher income was associated with lower prevalence of each dementia risk factor except obesity, high LDL, and TBI. The highest PAF for those with incomes <100% of the federal poverty level was late-life vision loss (20.9%, 95% CI 16.8%-25.2%). Higher income was associated with lower number of midlife risk factors (PR: 0.91, 95% CI 0.89-0.94). Race-ethnicity categories historically-underrepresented in dementia studies were associated with midlife diabetes, obesity, physical inactivity, and late-life vision loss. Lower income and historically underrepresented race-ethnicity categories are associated with many dementia risk factors. Dementia prevention efforts may be more successful by targeting modifiable risk factors in these higher-risk populations.