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CME / ABIM MOC / CE

Do "Forever Chemicals" Contribute to Hypertension in Women?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 7/15/2022
  • Valid for credit through: 7/15/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, diabetologists/endocrinologists, nurses, nephrologists, family medicine and primary care clinicians, pharmacists, internists, neurologists, physician assistants, and other members of the health care team for women with exposure to "forever chemicals" (per- and polyfluoroalkyl substances) who may be at increased risk for hypertension.

The goal of this activity is for learners to be better able to describe the association between serum concentrations of perfluoroalkyl and polyfluoroalkyl substances and risks of developing hypertension, based on a prospective cohort study among middle-aged women enrolled in the Study of Women's Health Across the Nation-Multi-Pollutant Study.

Upon completion of this activity, participants will:

  • Assess the association between serum concentrations of perfluoroalkyl and polyfluoroalkyl substances and risks of developing hypertension, based on a prospective cohort study among middle-aged women enrolled in the Study of Women's Health Across the Nation-Multi-Pollutant Study
  • Evaluate the clinical and public health implications of the association between serum concentrations of perfluoroalkyl and polyfluoroalkyl substances and risks of developing hypertension, based on a prospective cohort study among middle-aged women enrolled in the Study of Women's Health Across the Nation-Multi-Pollutant Study
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.

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    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-22-231-H01-P).

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  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 7/15/2023. PAs should only claim credit commensurate with the extent of their participation.

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There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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  1. Read the target audience, learning objectives, and author disclosures.
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  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

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CME / ABIM MOC / CE

Do "Forever Chemicals" Contribute to Hypertension in Women?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/15/2022

Valid for credit through: 7/15/2023

processing....

Clinical Context

Global prevalence of hypertension is more than 1 billion. It is a leading risk factor for cardiovascular disease (CVD) and cause of death and disability-adjusted life-years globally. Studies of associations between PFAS exposure and incident hypertension have yielded conflicting results.

During menopausal transition, hormone levels fluctuate and risk for hypertension and CVD increases. The present study tested the hypothesis that higher serum PFAS concentrations would be linked to higher risks for incident hypertension among middle-aged women.

Study Synopsis and Perspective

Exposure to per- and polyfluoroalkyl substances (PFAS), a class of widely used synthetic chemicals dubbed "forever chemicals," may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk for hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

"Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous," Sung Kyun Park, ScD, MPH, from the University of Michigan School of Public Health, Ann Arbor, told theheart.org | Medscape Cardiology.

The study was published online June 13 in Hypertension.[1]

Everywhere and Forever

"PFAS are forever chemicals as well as everywhere chemicals," Dr Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

"A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension," Dr Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks for incident hypertension in 1058 initially normotensive women participating in the Study of Women's Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). The women were followed-up annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension compared with their peers in the lowest tertile (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [CI], 1.19-1.68; trend<0.0001).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; trend<0.0001) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend=0.0003) higher risks for incident hypertension, respectively, comparing the highest with the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS "mixture" analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend=.008).

"These findings suggest that PFAS might be an underappreciated contributing factor to women's cardiovascular disease [CVD] risk," the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

"This is an important question, but the answer is that we do not know," Dr Park told theheart.org | Medscape Cardiology.

"Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage," Dr Park said.

The researchers say that more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

"If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD," the researchers write.

"The More We Learn, the Worse It Gets"

This is an "interesting" study and shows that "the more we learn about PFAS, the worse it seems to get," Ankur Shah, MD, from the Division of Kidney Disease and Hypertension, Warren Alpert Medical School of Brown University, Providence, Rhode Island, told theheart.org | Medscape Cardiology.

"This multisite, multiracial, and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension," said Dr Shah, who was not involved in the study.

"This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension," he noted.

Dr Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status "and still found a strong association."

"Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted-for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction," Dr Shah added.

The study had no sources of funding. Dr Park and Dr Shah have disclosed no relevant financial relationships.

Hypertension. Published online June 13, 2022.[1]

Study Highlights

  • 1058 women in midlife (median age, 49.2 years, 54.5% White, 30% postmenopausal) who were initially free of hypertension and who were enrolled in SWAN had annual follow-ups between 1999 and 2017.
  • During 11,722 person-years of follow-up, 470 participants developed incident hypertension (blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic or receiving antihypertensive treatment; 40.1 cases per 1000 person-years).
  • HRs were adjusted for race, study site, education, financial strain, smoking status, alcohol use, calorie intake, and menopausal status.
  • For women in the highest vs the lowest tertile of baseline serum concentrations, aHR was 1.42 (95% CI, 1.19-1.68) for PFOS (Ptrend<0.0001), 1.47 (95% CI, 1.24-1.75; P trend= <0.0001 for linear PFOA, and 1.42 (95% CI, 1.19-1.70) for EtFOSAA (P trend= trend=.0003).
  • There were no significant associations for perfluorononanoate and perfluorohexane sulfonate.
  • In the mixture analysis, for women in the highest vs the lowest tertile of overall PFAS concentrations, aHR was 1.71 (95% CI, 1.15-2.54; P=.008).
  • Multivariable-adjusted HRs for a doubling in serum concentrations were 1.18 (95% CI, 1.09-1.28) for total PFOS, 1.17 (95% CI, 1.08-1.27) for linear PFOS, 1.16 (95% CI, 1.08-1.25) for sum of branched isomers of PFOS, 1.17 (95% CI, 1.07-1.27) for linear PFOA, 1.09 (95% CI, 1.04-1.15) for EtFOSAA, and 1.10 (95% CI, 1.03-1.19) for 2-(N-methyl-perfluorooctane sulfonamido) acetate (MeFOSAA).
  • Despite significant associations of PFOS, linear PFOA, and EtFOSAA with hypertension, there were no interactions of these chemicals with menopausal status, except for MeFOSAA.
  • In sensitivity analyses, effect estimates remained similar after further adjustment for weight change over time.
  • The investigators concluded that several PFAS had positive associations with incident hypertension, even after adjustment for multiple variables, suggesting that PFAS might be an underappreciated contributor to women's CVD risk.
  • PFAS are potentially modifiable risk factors for hypertension and CVD.
  • As PFAS are ubiquitous in the blood of most humans and in the environment, the findings create significant public health concern.
  • Potential sources of PFAS exposure include nonstick cookware, food wrappers, waterproof fabrics, cosmetics, and drinking water.
  • If confirmed in future studies, the results suggest that understanding human exposure to PFAS and developing effective strategies to lower PFAS exposure might hinder development of hypertension and thereby lower global CVD burden.
  • The findings add to accumulating evidence of associations of PFAS with cancer, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, pregnancy-induced hypertension, and other disorders.
  • Potential biological mechanisms relating exposure to PFAS to hypertension may include disturbances of fatty acid metabolism, likely through activation of multiple nuclear receptors including peroxisome proliferator-activated receptors, disruption of thyroid hormone homeostasis, and/or oxidative stress and endothelial dysfunction.
  • Lower estrogen levels during menopausal transition may increase risks for hypertension and CVD, whereas PFAS as endocrine-disrupting chemicals may accelerate ovarian aging.
  • PFAS mixtures conferred greater risk for incident hypertension than individual PFAS, which is consistent with previous toxicological studies.
  • Study limitations include that the sample was limited to middle-aged women, precluding generalizability to men or women of other ages.
  • It is still unknown whether PFAS cause hypertension or whether an unmeasured confounder results in increased PFAS exposure and hypertension, as well as whether PFAS are causative, and if so, whether lowering PFAS exposure would reduce blood pressure.

Clinical Implications

  • PFAS had positive associations with incident hypertension, even after adjustment for multiple variables, suggesting that PFAS might be an underappreciated contributor to women's CVD risk.
  • As PFAS are ubiquitous in most humans and the environment, the findings create significant public health concern.
  • Implications for the Health Care Team: The heathcare team should be aware that PFAS are potentially modifiable risk factors for hypertension and CVD.

 

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