Dissertation Defense: Josh Garfein

"Addressing disparities in the development and management of hypertension: the role of education", School of Public Health Department of Epidemiology. Commitee: Akira Sekikawa (advisor, chair), EPIJared Magnani (co-advisor), Department of Medicine, Division of Cardiology, EPIMaria Brooks, EPI and BiostatisticsAnthony Fabio, EPISamar El Khoudary, Department of Epidemiology, Virginia Commonwealth UniversityAbstract Hypertension affects most individuals by midlife, yet only about a quarter of those with hypertension have their blood pressure controlled. The burden of hypertension, which includes both increased cardiovascular risk and substantial societal cost, is expected to increase in the absence of intensive prevention and treatment efforts. Educational attainment is a critical determinant of health outcomes, as emphasized in recent clinical guidelines, but it remains under-studied. This dissertation examines whether educational attainment influences the prevention and management of hypertension, as well as associated cardiovascular outcomes, through the following complementary aims: Aim 1: In a prospective cohort study of 3,302 midlife women, higher educational attainment was associated with a significantly lower systolic blood pressure at baseline, but a similar rate of change in systolic blood pressure over time. BMI, income, and physical activity mediated the largest percentage of the association between education and baseline blood pressure. Aim 2: In the same cohort, higher educational attainment was associated with a marginally lower use of antihypertensive medications over time. At initial diagnosis, fewer than 50% of hypertensive participants were receiving antihypertensive medications, rising to about 60% in the most recent follow-up visit. Use of all classes of antihypertensive medications increased over time across education groups. Aim 3: In a secondary analysis of a landmark clinical trial, intensive blood pressure reduction resulted in a 49% l