Download Body Mass Index and Blood Pressure Influences on Left Ventricular

Body Mass Index and Blood Pressure Influences on Left
Ventricular Mass and Geometry in African Americans
The Atherosclerotic Risk In Communities (ARIC) Study
Ervin Fox, Herman Taylor, Michael Andrew, Hui Han, Emad Mohamed,
Robert Garrison, Thomas Skelton
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Abstract—A unique interaction between the influences of body mass index and blood pressure on left ventricular mass
index and geometry may contribute to the higher prevalence of left ventricular hypertrophy in African Americans. This
cross-sectional study assessed separate and joint influences of body mass index and blood pressure on left ventricular
mass index and geometry in 1729 African American participants of the Atherosclerotic Risk in Communities Study. The
association between both left ventricular mass index and relative wall thickness and body mass index in each blood
pressure category and between these variables and blood pressure in each body mass index category was assessed
adjusting for age, diabetes status, hypertension medication, and smoking status. We found that left ventricular
hypertrophy and concentric geometry were highly prevalent and that body mass index and blood pressure were
independently associated with left ventricular mass index. The adjusted association between blood pressure and left
ventricular mass index was stronger with higher body mass index categories; however, there was no significant
interaction suggesting merely an additive relationship (not synergistic/multiplicative as tested for in the interaction
analysis). Although relative wall thickness was greater with higher categories of body mass index and blood pressure,
the mean difference in relative wall thickness between body mass index and blood pressure categories was not
statistically significant. The effect on left ventricular geometry as measured by relative wall thickness supports the
theory that there is a pathophysiological component in the mechanism of hypertrophy. (Hypertension. 2004;44:55-60.)
Key Words: hypertrophy 䡲 body mass index 䡲 blood pressure
I
ncreased left ventricular mass (LVM) as determined by
2-dimensional M-mode echocardiography is a predictor of
cardiovascular morbidity and mortality.1,2 In the few earlier
studies comparing LVM in African Americans to that in
whites, results suggest that in African Americans, LVM is
increased compared with other ethnic groups at a given blood
pressure, representing a potential racial disparity in cardiac
adaptation to hypertension.3,4 Recent studies have indexed
LVM by height and/or body surface area and have not
reproduced this racial disparity in LVM severity.5,6 Disparities in left ventricular (LV) wall thickness still persisted in a
number of these studies, and LV wall thickness in itself has
been associated with cardiovascular mortality. Despite the
question of racial differences in the prevalence of left
ventricular hypertrophy (LVH) and in the patterns of LV
remodeling, risk factors contributing to increased LVM and
changes in LV geometry have not been extensively investigated in African Americans but mostly in large, predominantly white population-based cohorts such as Framingham
Heart Study. Generalizability of these studies to the black
population has not been well defined.7
This report focuses on an analysis of the independent and
combined effects of body mass index (BMI) and blood
pressure (BP) on left ventricular mass index (LVMI) and
geometry in African Americans. Although there is a high
prevalence of individuals with both of these risk factors in
this population,2,8 –16 their joint influences on LVMI (unlike
their independent effects) have not been studied in a
population-based middle-aged African American cohort.17–20
We are particularly interested in the question of whether the
racial disparity in the prevalence of LVH is merely caused by
the increased prevalence of risk factors in the African
American community or is a component of the ethnic
difference caused by a significant interaction between the
effects of BMI and BP on LVMI and geometry in African
Americans, which has been shown not to be present in white,
non-Hispanic populations.19
Methods
Study Population
The base population consisted of participants in the Jackson Cohort
of the Atherosclerotic Risk in Communities (ARIC) Study. Partici-
Received January 16, 2004; first decision February 5, 2004; revision accepted May 4, 2004.
From the Department of Medicine, University of Mississippi Medical Center, Jackson.
This paper was sent to Ernesto L. Schiffrin, associate editor, for review by expert referees, editorial decision, and final disposition.
Correspondence to Ervin R. Fox, MD, Assistant Professor of Medicine, Division of Cardiovascular Diseases, University of Mississippi Medical Center,
2500 North State Street, Jackson, MS 39216-4505. E-mail [email protected]
© 2004 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org
DOI: 10.1161/01.HYP.0000132373.26489.58
55
56
Hypertension
July 2004
pants were selected by probability sampling of eligible resident
adults, aged 45 to 64. The Jackson Cohort was the only site of ARIC
receiving echocardiograms and was 100% African American. The
echocardiograms were performed between 1993 and 1995. Subjects
with significant valvular heart disease (moderate or severe mitral
regurgitation, moderate or severe aortic regurgitation, moderate or
severe mitral stenosis or any degree of aortic stenosis) and those with
missing M-mode measurements were excluded. Detailed study
procedures, including study sampling, study design, and examination
protocol, for the ARIC study have been reported previously.21
Echocardiographic Methods
Downloaded from http://hyper.ahajournals.org/ by guest on May 6, 2017
Left ventricular internal diastolic diameter (LVIDD), LV posterior
wall thickness (PWT), and interventricular septal thickness (IVST)
were measured in diastole on 2-dimensional echocardiogram using
the American Society of Echocardiography (ASE) criteria. Relative
wall thickness (RWT), the ratio of the sum of PWT and IVST to the
LVIDD, was derived from these measurements. To calculate LVM,
individual dimensions determined by ASE criteria were applied
to the formula of Troy.22 The LVM calculated from the formula
of Troy was then corrected for overestimation as described by
Devereux et al.23
LVG(g)⫽0.8{1.04[(LVIDd⫹IVSTd⫹PWTd)3⫺(LVIDd)3]}⫹0.60
To correct for influences caused by body size, LVM was indexed
by height2.7 (g/ht2.7).24 LVIDD, PWT, and IVST were indexed to
height (LVIDDI, PWTI, and IVSTI, respectively).
TABLE 1. Gender-Specific Demographics for Jackson (All
African American) Cohort of ARIC
Demographics
Men
(n⫽611)
Women
(n⫽1119)
Age, y
58.8⫾6.0
58.7⫾5.6
Weight, kg
87.9⫾16.3
Height, m
76.3⫾6.8
BMI, kg/m2
83.9⫾18.1
163.3⫾6.1
28.2⫾4.8
31.4⫾6.5
Total cholesterol, mg/dL
197.4⫾37.5
208.5⫾38.6
LDL cholesterol, mg/dL
124.1⫾34.1
126.6⫾37.8
HDL cholesterol, mg/dL
49.8⫾16.7
59.5⫾18.2
LVM, g (ASE-corrected)
226.9⫾71.1
188.2⫾58.3
LVMI, g/m2.7
128.8⫾40.
115.2⫾35.4
Posterior wall thickness, cm
1.2⫾0.23
1.1⫾0.21
Interventricular wall thickness, cm
1.21⫾0.26
1.13⫾0.23
Left ventricular internal diastolic diameter, cm
4.82⫾0.60
4.54⫾0.55
37.3
40.9
LVH, %
Current smoker, %
26.6
14.7
Diabetes, %
17.9
21.3
Hypertension, %
57.3
61.8
Antihypertensive medications, %
43.7
51.4
Values represents mean⫾SD.
Statistical Analysis
All analyses were sex-specific. Main factors of interest, the BMI and
BP, were placed into categories with clinical relevant cut-points.
There are 3 levels of BMI groups generated: normal (ⱕ25 kg/m2),
overweight (25 to ⱕ30 kg/m2), and obese (⬎30 kg/m2). Participants
were also categorized into 3 BP groups according to the Joint
National Committee VI guidelines: normal (⬍130 mm Hg systolic
and ⬍85 mm Hg diastolic), high normal/borderline (130 to
139 mm Hg systolic or 85 to 89 mm Hg diastolic), and hypertensive
(⬎140 mm Hg systolic or ⬎90 mm Hg diastolic).
Two-way ANCOVA was used to evaluate the strength of association between the aforementioned factors with the LVM and geometry. Possible synergistic (multiplicative) effects between independent variables were first analyzed by putting an interaction term
between the BMI group and BP group into the model, in the presence
of both factors.
To assess the independent association of each factor to LVM or its
geometry, a new subgroup variable was generated by crossing the 3
levels of BMI group and the 3 levels of BP group. Subsequently, the
subgroup variable was used in the multivariable ANCOVA analysis
in place of the 2 original factors to address joint influence of BMI
and BP on the dependent variables with the presence of each other.
The study protocol was approved by the Institutional Review
Board at the University of Mississippi Medical Center. The study
was performed with the participants’ written informed consent.
Results
Characteristics of Participants
Of the 3728 African American participants, 2445 subjects
presented for the third visit or early phase of the fourth visit
and received echocardiograms. Of the 2445 receiving echocardiograms, 716 (29.2%) were excluded from the study (687
caused by inadequate echocardiographic studies, 27 caused
by valvular heart disease, and 2 caused by missing BMI). The
study population therefore consisted of 1729 subjects; 611
(35%) of the participants were men and 1119 (65%) were
women. The mean age of the study population was 58.7⫾5.7
years (range 49 to 75 years).
Sex-specific demographics for the study population are
shown in Table 1. Using the criteria of 51 g/m2.7, 37.3% of
men and 40.9% of women met criteria for LVH.25 Men had
slightly larger LV dimensions on average.
Assessment for an Interaction Between BMI and
BP Effects on LVMI and Geometry
The analysis of the joint influences of BMI and BP on LVMI
and LV geometry showed there was no significant interaction
(multiplicative relationship) between effects of BMI and BP
(P interaction for the population⫽0.69). After stratifying the
study population by gender, there was no significant interaction between BMI and BP on LVMI in men (P⫽0.3614) or in
women (P⫽0.7321). The adjusted association between BP
and LVMI was stronger with higher BMI categories. These
findings suggest that the joint influences of BMI and BP on
LVM and LVMI for both genders were merely additive.
Similarly, the joint impact of BMI and BP on RWT and
each of the 3 LV dimensions was merely additive. There was
no significant interaction between BMI and BP on any of the
individual LV dimensions, although the association between
BP and individual dimensions was stronger with higher BMI
categories.
Influence of BMI on LVMI
BMI was an independent predictor of LVMI. Horizontal rows
in Table 2 show the relationship between BMI and mean
LVMI within each category of BP after adjusting for covariates. In both men and women, mean LVMI was greater in
higher BMI categories in normotensive, high normal, and
hypertensive subjects. For lean normotensive men, mean
LVMI was 37.8 g/m2.7 compared with 48.1 g/m2.7 for obese
normotensive men (27% mean difference). For lean men with
Fox et al
TABLE 2.
BMI and BP Influences on LV Mass and Geometry
57
Effect of BMI and BP on Left Ventricular Mass Index
Left Ventricular Mass Index
2
Women, BMI Categories (kg/m2)
Men, BMI Categories (kg/m )
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
†P
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
†P
Normal
37.8
43.2
48.1
High normal
44.8
48.3
51.7
0.0001
Normal
38.1
44.5
51.6
0.0001
0.1275
High normal
38.8
46.9
55.2
Hypertensive
45.4
54.6
60.7
0.0001
0.0001 Hypertensive
44.1
53.8
61.6
0.0001
*P
0.007
0.0001
0.0001
0.087
0.0001
0.0001
*P
Normal refers to category of subjects with SBP ⬍130 mm Hg and DBP⬍85 mm Hg. Hypertensive refers to category
of subjects with SBP ⬎140 mm Hg or DBP ⬎90 mm Hg. High normal refers to category of subjects with BP between
normal and hypertensive.
All means are adjusted for age, diabetes status, hypertension medication, smoking status, and physical activity.
P Interaction⫽0.69. *P is for the linear trend; †P value is for the linear trend.
Downloaded from http://hyper.ahajournals.org/ by guest on May 6, 2017
high normal BP, mean LVMI was 44.8 g/m2.7 compared with
51.7 g/m2.7 in obese men with high normal BP (15% mean
difference). In lean hypertensive men, mean LVMI was 45.4
g/m2.7 versus 60.7 g/m2.7 in obese hypertensive men (34%
mean difference). BMI was highly predictive of LVMI for
both normotensive (P⫽0.0001) and hypertensive men
(P⫽0.0001).
Similarly for women, there was a significant relationship
between BMI and LVMI (P⫽0.0001 in each BP category). For
a given BP, mean LVMI was greater in higher BMI categories.
In normotensive women, mean LVMI was 38.1 g/m2.7 in lean
subjects versus 51.6 g/m2.7 in obese subjects (35% mean difference). In women with high normal BP, mean LVMI was 38.8
g/m2.7 in lean subjects versus 55.2 g/m2.7 in obese subjects (42%
mean difference). Finally, for hypertensive women, mean LVMI
was 44.1 g/m2.7 in lean subjects versus 61.6 g/m2.7 in obese
subjects (40% mean difference). Similar gender-specific results
were seen with LVM.
37.8 g/m2.7 versus 45.4 g/m2.7 in lean hypertensive men (20%
mean difference). In overweight normotensive men, the mean
adjusted LVMI was 43.2 g/m2.7 versus 54.6 g/m2.7 in overweight hypertensive men (26% mean difference). Finally, in
obese normotensive men, the mean LVMI was 48.1 g/m2.7
compared with 60.7 g/m2.7 in obese hypertensive (26% mean
difference). BP was highly predictive of the LVMI in men for
all BMI categories (P⫽0.007 in lean subjects and P⫽0.0001
in overweight and obese subjects).
For overweight and obese women the relationship between
BP and LVMI was highly significant (P⫽0.0001 for both). In
women, there was no significant relationship between BP and
LVMI in lean subjects (P⫽0.087); however, for overweight and
obese subjects, LVMI was greater with higher categories of BP.
For lean normotensive women, the mean LVMI was 38.1 g/m2.7
compared with 44.1 g/m2.7 in lean hypertensive women (16%
mean difference). In overweight normotensive women, the mean
LVMI was 44.5 g/m2.7 compared with 53.8 g/m2.7 in overweight
hypertensive women (21% mean difference). In obese normotensive women, the mean LVMI was 51.6 g/m2.7 compared with
61.6 g/m2.7 (19% mean difference) in obese hypertensives.
Similar gender-specific results were seen with LVM.
Influence of BP on LVMI
BP was also an independent predictor of LVMI. Vertical
columns in Table 2 show the relationship between LVMI and
BP within various categories of BMI after adjusting for
covariates. In both men and women, mean LVMI was greater
for higher BP categories in lean, overweight, and obese
subjects. For lean normotensive men, the mean LVMI was
TABLE 3.
Influence of BMI and BP on LV Geometry
Tables 3 to 6 show the influences of BMI and BP on RWT,
LVIDDI, PWTI, and IVSTI. In both men and women, RWT
Effect of BMI and BP on Relative Wall Thickness
Relative Wall Thickness
Men, BMI Categories (kg/m2)
Women, BMI Categories (kg/m2)
Lean
⬍25
Overweight
25–30
Obese
⬎30
†P
Normal
0.478
0.474
0.509
High normal
0.487
0.495
0.515
Hypertensive
0.522
0.511
*P
0.2014
0.1485
BP Categories
BP
Categories
Lean
25
0.1472
Normal
0.482
0.513
0.504
0.1195
0.6177
High normal
0.475
0.533
0.509
0.0456
0.541
0.4353 Hypertensive 0.530
0.539
0.526
0.7036
0.3488
*P
0.1615
0.1166
0.0669
Overweight Obese
25–30
⬎30
†P
Normal refers to category of subjects with SBP ⬍130 mm Hg and DBP⬍85 mm Hg. Hypertensive refers to category
of subjects with SBP ⬎140 mm Hg or DBP ⬎90 mm Hg. High normal refers to category of subjects with BP between
normal and hypertensive.
All means are adjusted for age, diabetes status, hypertension medication, smoking status, and physical activity.
P Interaction⫽0.69. *P is for the linear trend; †P value is for the linear trend.
58
Hypertension
July 2004
TABLE 4.
Effect of BMI and BP on Indexed Posterior Wall Thickness
Indexed Posterior Wall Thickness
2
Women, BMI Categories (kg/m2)
Men, BMI Categories (kg/m )
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
P
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
†P
Normal
0.607
0.638
0.687
0.0003
Normal
0.618
0.674
0.700
0.0001
High normal
0.656
0.679
0.703
0.2736
High normal
0.617
0.694
0.727
0.0001
Hypertensive 0.676
0.714
0.771
0.0002
Hypertensive
0.672
0.727
0.756
0.0001
*P
0.0001
0.0001
*P
0.0472
0.0016
0.0001
0.0073
Normal refers to category of subjects with SBP ⬍130 mm Hg and DBP⬍85 mm Hg. Hypertensive refers to category
of subjects with SBP ⬎140 mm Hg or DBP ⬎90 mm Hg. High normal refers to category of subjects with BP between
normal and hypertensive.
All means are adjusted for age, diabetes status, hypertension medication, smoking status, and physical activity.
P Interaction⫽0.69. *P is for the linear trend; †P value is for the linear trend.
Downloaded from http://hyper.ahajournals.org/ by guest on May 6, 2017
was greater for higher BMI and BP categories. However the
differences in RWT between the categories of BMI and
between the categories of BP were not statistically
significant.
Conversely, in both men and women, indexed PWT and
IVST were significantly associated with both BMI and BP
after adjusting for covariates. The mean PWTI and IVST
were greater with higher BMI and BP categories. LVIDDI
was significantly associated with BMI in both genders,
showing greater values with higher BMI categories. LVIDDI,
however, was not strongly associated with the categories of
BP for either gender.
Discussion
In this study of a population-based cohort of middle-aged
African Americans, there is a high prevalence of LVH and
concentric LV geometry. Compared with findings in young
African Americans from the Coronary Artery Risk Development In young Adults (CARDIA) study (in which ⬍5% of
African American men and women had LVH and a RWT
⬎4.5), our data suggest there is an apparent shift toward
higher LVMI and a more concentric LV geometry as the
African American population ages.26,27
Joint Impact of BMI and BP on LVMI
A number of individual studies have shown that both BMI
and BP have significant independent effects on LVMI.4 –9,11,12
TABLE 5.
Fewer studies have assessed the joint influences of BMI and
BP on LVMI and other variables of LV geometry.13,14,28,29
Gottdiener et al studied a hospital-based population of
white American and African American men at 14 VA
medical centers nationwide and found a significant association between both obesity and hypertension and cardiac
structure and function.20 In this study, obesity was found to be
the strongest clinical predictor of LVM and LVH, even in
those with mild to moderate hypertension. There was a
significant synergistic interaction between systolic blood
pressure and obesity, resulting in conclusion that in men the
effects of systolic blood pressure on LVM were amplified by
obesity. Among the limitations of this study, the randomized
trial was multicenter, hospital-based, and did not include
women.
Investigators at the Framingham Heart Study looked at the
joint influences of BMI and BP on LVMI in their cohort of
predominantly white American men and women.19 They found
that there was an association between both BMI and BP on
LVMI. The effects of obesity and BP on echocardiographic LV
variables were additive; however, there was no significant
interaction seen. As with the study by Gottdiener, obesity was
found to be a stronger predictor of LVMI than BP.
In the current study, both BMI and BP were found to be
independent predictors for increased LVMI for African
American men and women. Unlike Framingham, BMI and
Effect of BMI and BP on Indexed Interventricular Septal Thickness
Indexed Interventricular Septal Wall Thickness
Men, BMI Categories (kg/m2)
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
Women, BMI Categories (kg/m2)
†P
BP
Categories
Lean
⬍25
Overweight
25–30
Obese
⬎30
†P
Normal
0.610
0.634
0.678
0.0123
Normal
0.618
0.674
0.700
0.0001
High normal
0.648
0.670
0.707
0.1863
High Normal
0.617
0.694
0.727
0.0001
Hypertensive 0.667
0.710
0.746
0.0174
Hypertensive
0.672
0.727
0.756
0.0002
*P
0.0013
0.0017
*P
0.0472
0.0016
0.0001
0.0847
Normal refers to category of subjects with SBP ⬍130 mm Hg and DBP⬍85 mm Hg. Hypertensive refers to category
of subjects with SBP ⬎140 mm Hg or DBP ⬎90 mm Hg. High normal refers to category of subjects with BP between
normal and hypertensive.
All means are adjusted for age, diabetes status, hypertension medication, smoking status, and physical activity.
P Interaction⫽0.69. *P is for the linear trend; †P value is for the linear trend.
Fox et al
TABLE 6.
BMI and BP Influences on LV Mass and Geometry
59
Effect of BMI and BP on Indexed Left Ventricular Internal Diastolic Diameter
Indexed Left Ventricular Diastolic Diameter
Men, BMI Categories (kg/m2)
BP
Categories
Lean
⬍25
Women, BMI Categories (kg/m2)
Overweight
25–30
Obese
⬎30
†P
BP
Categories
Overweight
25–30
Obese
⬎30
†P
Normal
2.575
2.706
2.717
0.0147
2.601
2.656
2.819
0.0001
High normal
2.692
2.738
2.765
0.6815
High normal 2.633
2.656
2.875
0.0001
Hypertensive 2.665
2.810
2.847
0.0212
Hypertensive 2.625
2.764
2.934
0.0001
*P
0.1306
0.0841
0.0237
0.0001
0.1946
Normal
Lean
⬍25
*P
0.8631
Normal refers to category of subjects with SBP ⬍130 mm Hg and DBP⬍85 mm Hg. Hypertensive refers to category
of subjects with SBP ⬎140 mm Hg or DBP ⬎90 mm Hg. High normal refers to category of subjects with BP between
normal and hypertensive.
P Interaction⫽0.69. *P is for the linear trend; †P value is for the linear trend.
Downloaded from http://hyper.ahajournals.org/ by guest on May 6, 2017
BP effects on LVMI were similar in both genders. Unlike
Gottdiener’s study but similar to the Framingham study, BMI
and BP effects on LVMI were merely additive in African
American men and women; there was no significant interaction between the influences of these risk factors on LVMI.
Similar relationships and trends among known determinants
of LVH strengthens the argument that racial disparity in LVH
prevalence is related to the higher prevalence of these risk
factors in the African American population. These data do not
support the notion that the high prevalence of LVH in this
population is a result of a synergistic or multiplicative
relationship between these risk factors on LVMI in the
African American population.
Effect of BMI and BP on LV Geometry
Hypertension creates a state of LV pressure overload. Obesity
is associated with volume overload.28 Grossman et al found
that RWT tends to increase significantly with pressure overload and remains unchanged with volume overload and
hypothesized that hypertrophy occurs to normalize peak
systolic wall stress.29
In this study, RWT values were elevated (RWT ⬎0.45
being the standard cutoff value distinguishing normal LV
geometry from concentric LV geometry) regardless of gender, BMI, or BP, reflecting a population with mostly concentric hearts. RWT tended to be greater with higher categories
of BMI and BP; however, there was not a statistically
significant relationship between RWT and BMI or between
RWT and BP. The differences in our findings compared with
Grossman’s findings suggest that geometric patterns seen in
LVH may be caused by reasons other than merely normalizing peak systolic wall stress; there may also be a pathophysiologic component to LV remodeling. Potential mechanisms
that have undergone recent investigation include possible
neurologic, endocrinologic, and genetic pathways. Although
it is if sample size may have contributed to the negative
findings with RWT, similar results with LV geometry were
found in both the Framingham cohort and Gottdiener’s VA
population.
Perspectives
We have shown that LVH and concentric geometry are highly
prevalent in the middle-aged African American population.
Compared with the CARDIA study, which looked at a young
population of African Americans, the findings in ARIC
suggests that there is an apparent shift in LVM and geometry
in African Americans with aging. BMI and BP are independent risk factors for LVH in this group and their joint
influences on LVMI are merely additive (not synergistic or
multiplicative as tested for in an analysis for an interaction).
The effect of BMI and BP on LV geometry as measured by
RWT suggests a potential pathophysiologic component (not
merely compensatory hypertrophy as defined by Grossman).
These joint influences are similar to those seen in the
Framingham cohort. Although comparisons to other ethnic
groups are inferential because they are made using previous
publications, our findings support the theory that racial
differences in the prevalence of LVH are more so caused by
the higher prevalence of risk factors such as BMI and BP in
the African American population. Future investigations
should focus on uncovering pathophysiologic mechanisms
that may also contribute to the racial difference in LVH
prevalence and explain the increased cardiovascular morbidity and mortality seen in all subjects with LVH.
Acknowledgments
The ARIC Study is a collaborative study supported by National
Institutes of Health–National Heart, Lung, and Blood Institute
contracts NO1-HC-55015, NO1-HC-55016, NO1-HC-55018, NO1HC-55019, NO1-HC-55020, NO1-HC-55021, and NO1-HC-55022.
The authors thank the staff and participants in the ARIC Study for
their important contributions.
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Body Mass Index and Blood Pressure Influences on Left Ventricular Mass and Geometry
in African Americans: The Atherosclerotic Risk In Communities (ARIC) Study
Ervin Fox, Herman Taylor, Michael Andrew, Hui Han, Emad Mohamed, Robert Garrison and
Thomas Skelton
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Hypertension. 2004;44:55-60; originally published online June 7, 2004;
doi: 10.1161/01.HYP.0000132373.26489.58
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