Neighborhood Deprivation and Race Synergistically Contribute to Undiagnosed Hypertension Leading to Acute Ischemic Stroke: Results from the All of Us Research Program
Victor Torres-Lopez1, Daniela Renedo1, Julian Acosta2, Thomas Gill1, Kevin Sheth3, Guido Falcone4, Cyprien Rivier1
1Yale University, 2Yale, 3Yale UniversityDivision of Neuro and Critical Care, 4Yale School of Medicine
Objective:
We hypothesize that hypertension goes undiagnosed more frequently in highly deprived neighborhoods and in people from Black race. We also hypothesize that undiagnosed hypertension is associated with a higher risk of incident stroke.
Background:
Neighborhood deprivation is one of the leading social determinants of health and is associated with lower access to clinical care.
Design/Methods:
We conducted a longitudinal study analyzing participants from the All of Us study (AoU). We identified people who met the criteria for hypertension based on blood pressure measurements at the time of enrollment but were not known to have the condition according to EHR or survey data. We evaluated neighborhood deprivation using the Deprivation Index (DI), an aggregate variable derived from six American Community Survey metrics. We used multivariable logistic regression to test for interaction between race and tertiles of DI in a model predicting undiagnosed hypertension adjusting for age, sex, income, and education.
Results:
Of the 372,397 participants enrolled in AoU, 269,063 had data for DI and blood pressure; of these, 6,690(2.5%) sustained a stroke. Compared to low deprivation, intermediate and high deprivation were associated with 3.4%(OR:1.034;95%CI:1.00-1.07) and 17.4%(OR:1.174;95%CI:1.14-1.21) higher risk of undiagnosed hypertension (test-for-trend p<0.0001). Compared to White participants, Black participants had a 67.4%(OR:1.674;95%CI:1.62-1.73;p<0.001) higher risk of undiagnosed hypertension. There was a significant synergy between DI and race (interaction p<0.001): compared to White participants living in areas of low deprivation, Black participants living in highly deprived neighborhoods had 106%(OR:2.06;95%CI:1.96-2.16;p<0.001) higher risk of undiagnosed hypertension. In the whole cohort, undiagnosed hypertension was associated with a 34%(OR:1.34;95%CI:1.12-1.62;p=0.002) higher incident stroke risk when adjusting for prevalent hypertension and the aforementioned socioeconomic factors.
Conclusions:
High neighborhood deprivation and Black race are associated with a higher risk of undiagnosed hypertension, and these effects are synergistic. Undiagnosed hypertension is associated with a higher ischemic stroke risk after accounting for medically diagnosed hypertension.