Severity of Hypertension Mediates the Association of Hyperuricemia With Stroke in the REGARDS Case Cohort Study

Previous studies do not widely support hyperuricemia as a risk factor for stroke and other cardiovascular diseases. We assessed the relationship between hyperuricemia and ischemic stroke (≈900 cases) using a large data set from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). We employed a case-cohort design (incident stroke cases and randomly selected cohort participants) and weighted Cox-proportional hazard models to estimate the association of serum urate level ≥6.8 mg/dL (ie, hyperuricemia) and 6.0 to <6.8 mg/dL versus <6.0 mg/dL (reference) with incident stroke. Analyses were stratified by race, gender, and age. Mediation of cardiovascular disease comorbidities on the serum urate-stroke association was tested. Hyperuricemia was associated with stroke (hazard ratio, 1.40 [95% CI, 1.10-1.78]) after adjustment for demographic variables and systolic and diastolic blood pressure. This association was substantially attenuated (hazard ratio, 1.17 [95% CI, 0.90-1.51]) by additional covariate adjustment. In particular, apparent treatment-resistant hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on 3 antihypertensive medications or use of ≥4 antihypertensive medications) and the count of antihypertensive medication classes significantly reduced the effect of hyperuricemia on ischemic stroke. Specifically, apparent treatment-resistant hypertension and number of antihypertensive, respectively, mediate 45% and 43% of the association. There was no effect modification in the association between hyperuricemia and stroke by age, race, or gender. We conclude that hyperuricemia may be a risk factor for stroke. The substantial attenuation of this association by apparent treatment-resistant hypertension and number of antihypertensive suggests that severe hypertension may be a mediator.

Prescribing Patterns of Heart Failure-Exacerbating Medications Following a Heart Failure Hospitalization

OBJECTIVES

This study sought to describe the patterns of heart failure (HF)-exacerbating medications used among older adults hospitalized for HF and to examine determinants of HF-exacerbating medication use.

BACKGROUND

HF-exacerbating medications can potentially contribute to adverse outcomes and could represent an important target for future strategies to improve post-hospitalization outcomes.

METHODS

Medicare beneficiaries ≥65 years of age with an adjudicated HF hospitalization between 2003 and 2014 were derived from the geographically diverse REGARDS (Reasons for Geographic and Racial Difference in Stroke) cohort study. Major HF-exacerbating medications, defined as those listed on the 2016 American Heart Association Scientific Statement listing medications that can precipitate or induce HF, were examined. Patterns of prescribing medications at hospital admission and at discharge were examined, as well as changes that occurred between admission and discharge; and a multivariable logistic regression analysis was conducted to identify determinants of harmful prescribing practices following HF hospitalization (defined as either the continuation of an HF-exacerbating medications or an increase in the number of HF-exacerbating medications between hospital admission and discharge).

RESULTS

Among 558 unique individuals, 18% experienced a decrease in the number of HF-exacerbating medications between admission and discharge, 19% remained at the same number, and 12% experienced an increase. Multivariable logistic regression analysis revealed that diabetes (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.18 to 2.75]) and small hospital size (OR: 1.93; 95% CI: 1.18 to 3.16) were the strongest, independently associated determinants of harmful prescribing practices.

CONCLUSIONS

HF-exacerbating medication regimens are often continued or started following an HF hospitalization. These findings highlight an ongoing need to develop strategies to improve safe prescribing practices in this vulnerable population.

Association of Neighborhood Socioeconomic Status With Risk of Infection and Sepsis

Background

Prior studies suggest disparities in sepsis risk and outcomes based on place of residence. We sought to examine the association between neighborhood socioeconomic status (nSES) and hospitalization for infection and sepsis.

Methods

We conducted a prospective cohort study using data from 30239 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. nSES was defined using a score derived from census data and classified into quartiles. Infection and sepsis hospitalizations were identified over the period 2003-2012. We fit Cox proportional hazards models, reporting hazard ratios (HRs) with 95% confidence intervals (CIs) and examining mediation by participant characteristics.

Results

Over a median follow-up of 6.5 years, there were 3054 hospitalizations for serious infection. Infection incidence was lower for participants in the highest nSES quartile compared with the lowest quartile (11.7 vs 15.6 per 1000 person-years). After adjustment for demographics, comorbidities, and functional status, infection hazards were also lower for the highest quartile (HR, 0.84 [95% CI, .73-.97]), with a linear trend (P = .011). However, there was no association between nSES and sepsis at presentation among those hospitalized with infection. Physical weakness, income, and diabetes had modest mediating effects on the association of nSES with infection.

Conclusions

Our study shows that differential infection risk may explain nSES disparities in sepsis incidence, as higher nSES is associated with lower infection hospitalization rates, but there is no association with sepsis among those hospitalized. Mediation analysis showed that nSES may influence infection hospitalization risk at least partially through physical weakness, individual income, and comorbid diabetes.

Characteristics and Healthcare Utilization Among Veterans Treated for Heart Failure With Reduced Ejection Fraction Who Switched to Sacubitril/Valsartan

Background:

US guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF), who tolerate an ACEI (angiotensin-converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), be switched to sacubitril/valsartan to reduce morbidity and mortality. We compared characteristics and healthcare utilization between Veterans with HFrEF who were switched to sacubitril/valsartan versus maintained on an ACEI or ARB.

Methods:

retrospective cohort study of treated HFrEF (July 2015–June 2017) using Veterans Affairs data. The index date was the first fill for sacubitril/valsartan and if none, for an ACEI or ARB. Treated HFrEF was defined by (1) left ventricular ejection fraction ≤40%, (2) ≥1 in/outpatient HF encounter, and (3) ≥1 ACEI or ARB fill, all within 1-year preindex. Poisson regression models were used to compare baseline characteristics and 1:1 propensity score-matched adjusted 4-month follow-up healthcare utilization between sacubitril/valsartan switchers and ACEI or ARB maintainers.

Results:

Switchers (1612; 4.2%) were less likely than maintainers (37 065; 95.8%) to have a history of myocardial infarction or hypertension, and more likely to be black, have a lower left ventricular ejection fraction, and higher preindex healthcare utilization. Switchers were less likely to experience follow-up all-cause hospitalizations (11.2% versus 14.0%; risk ratio 0.80 [95% CI, 0.65–0.98], P value 0.035).

Conclusions:

Few Veterans with treated HFrEF were switched to sacubitril/valsartan within the first 2 years of Food and Drug Administration approval. Sacubitril/valsartan use was associated with a lower risk for all-cause hospitalizations at 4 months follow-up. Reasons for lack of guideline-recommended sacubitril/valsartan initiation warrant investigation and may reveal opportunities for HFrEF care optimization.

Potential Cardiovascular Disease Events Prevented with Adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline

BACKGROUND

Over 10 years, achieving and maintaining 2017 ACC/AHA guideline goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), and 1.4 million (UR, 0.6-2.0 million) cardiovascular disease (CVD) events compared with maintaining current blood pressure (BP) levels, achieving 2003 Seventh Joint National Committee Report goals, and achieving 2014 Eighth Joint National Committee goals, respectively. We estimated the number of cardiovascular disease events prevented and treatment-related serious adverse events incurred over 10 years among US adults with hypertension by achieving 2017 ACC/AHA guideline-recommended BP goals compared with (1) current BP levels, (2) achieving 2003 Seventh Joint National Committee Report BP goals, and (3) achieving 2014 Eighth Joint National Committee panel member report BP goals.

METHODS

US adults aged ≥45 years with an indication for BP treatment were grouped according to recommendations for antihypertensive drug therapy in the 2017 ACC/AHA guideline, 2003 Seventh Joint National Committee Report, and 2014 Eighth Joint National Committee. Population sizes were estimated from the 2011 to 2014 National Health and Nutrition Examination Surveys. Rates for fatal and nonfatal CVD events (stroke, coronary heart disease, or heart failure) were estimated from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study, weighted to the US population. CVD risk reductions with treatment to BP goals and risk for serious adverse events were obtained from meta-analyses of BP-lowering trials. CVD events prevented and treatment-related nonfatal serious adverse events over 10 years were calculated. Uncertainty surrounding main data inputs was expressed in uncertainty ranges (UR).

RESULTS

Over ten years, achieving and maintaining 2017 ACC/AHA guideline goals compared with current BP levels, achieving 2003 Seventh Joint National Committee Report goals, or achieving 2014 Eighth Joint National Committee goals could prevent 3.0 million (UR, 1.1-5.1 million), 0.5 million (UR, 0.2-0.7 million), or 1.4 million (UR, 0.6-2.0 million) CVD events, respectively. Compared with current BP levels, achieving and maintaining 2017 goals could prevent 71.9 (UR, 26.6-122.3) CVD events per 1000 treated. Achieving 2017 guideline BP goals compared with current BP levels could also lead to nearly 3.3 million more serious adverse events over 10 years (UR, 2.2-4.4 million).

CONCLUSIONS

Achieving and maintaining 2017 ACC/AHA BP goals could prevent a greater number of CVD events than achieving 2003 Seventh Joint National Committee Report or 2014 Eighth Joint National Committee BP goals but could also lead to more serious adverse events.

2017 ACC/AHA Blood Pressure Treatment Guideline Recommendations and Cardiovascular Risk

BACKGROUND

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline provides updated recommendations for antihypertensive medication initiation and intensification.

OBJECTIVES

Determine the risk for cardiovascular disease (CVD) events among adults recommended and not recommended antihypertensive medication initiation or intensification by the 2017 ACC/AHA BP guideline.

METHODS

The authors analyzed data for black and white REGARDS (REasons for Geographic And Racial Differences in Stroke) study participants (age ≥45 years). Systolic BP (SBP) and diastolic BP (DBP) were measured twice at baseline (2003 to 2007) and averaged. Participants not taking (n = 14,039) and taking (n = 15,179) antihypertensive medication were categorized according to their recommendations for antihypertensive medication initiation and intensification by the 2017 ACC/AHA guideline. Overall, 4,094 CVD events (stroke, coronary heart disease, and heart failure) occurred by December 31, 2014.

RESULTS

Among participants not taking antihypertensive medication, 34.4% were recommended pharmacological antihypertensive treatment initiation. The CVD event rate per 1,000 person-years among participants recommended antihypertensive medication initiation with SBP/DBP ≥140/90 mm Hg was 22.7 (95% confidence interval [CI]: 20.3 to 25.0). Among participants with SBP/DBP 130 to 139/80 to 89 mm Hg, the CVD event rate was 20.5 (95% CI: 18.5 to 22.6) and 3.4 (95% CI: 2.4 to 4.4) for those recommended and not recommended antihypertensive medication initiation, respectively. Among participants taking antihypertensive medication, 62.8% were recommended treatment intensification. The CVD event rate per 1,000 person-years among participants recommended treatment intensification was 33.6 (95% CI: 31.5 to 35.6) and 22.4 (95% CI: 20.8 to 23.9) for those with SBP/DBP ≥140/90 mm Hg and 130 to 139/80 to 89 mm Hg, respectively.

CONCLUSIONS

Implementing the 2017 ACC/AHA guideline would direct antihypertensive medication initiation and intensification to adults with high CVD risk.

Body image and dissatisfaction among rural Deep South African American women in a weight loss intervention

Body image perception may impact health-promoting behaviors as well as knowledge regarding health risks associated with obesity. Our cross-sectional analysis evaluated body image and its association with body mass index among overweight and obese treatment-seeking African American women (N = 409). Differences between current and desired body image were captured using the Pulvers scale. Results indicated the presence of body image dissatisfaction among participants (median = 2.00, interquartile range: 2.00-3.00), with greater dissatisfaction observed at higher categories of body mass index. Additionally, receiver operating curves demonstrated the ability of the Pulvers scale to correctly identify participants classified by body mass index. Further research is needed to identify factors that influence body image perception.

Is Rheumatoid Arthritis a Cardiovascular Risk-Equivalent to Diabetes Mellitus?

OBJECTIVE

The 2013 American College of Cardiology/American Heart Association cholesterol treatment guidelines recommend statins for patients with diabetes mellitus ages 40-75 years due to their elevated cardiovascular disease (CVD) risk. We compared the incidence of hospitalized acute myocardial infarction (MI), stroke, and coronary revascularization according to whether patients had diabetes mellitus, rheumatoid arthritis (RA), both, or neither.

METHODS

Using 2006-2010 private and public health plan claims, we identified 4 mutually exclusive retrospective cohorts ages >40 years: patients with RA and diabetes mellitus, RA only, diabetes mellitus only, or neither condition. Patients with prevalent CVD were excluded. Outcomes included acute MI and stroke, identified from inpatient discharge diagnosis codes, and coronary revascularization from procedure codes. Across the 4 cohorts, we calculated incidence rates (IRs) of the outcomes, standardized to the 2010 US census age and sex distribution.

RESULTS

We identified 920,772 eligible participants. The age- and sex-standardized IRs (per 1,000 person-years) for MI were highest among patients with RA and diabetes mellitus (IR 12.6 [95% confidence interval (95% CI) 10.7-14.7]), followed by patients with diabetes mellitus only (IR 10.7 [95% CI 10.3-11.0]), RA only (IR 5.7 [95% CI 5.2-6.3]), and with neither condition (IR 4.2 [95% CI 4.1-4.3]).

CONCLUSION

Findings from the present study suggest that while CVD risk in RA is elevated, it is lower in magnitude compared to the CVD risk associated with diabetes mellitus. Therefore, considering RA a diabetes mellitus risk-equivalent with respect to hyperlipidemia management may not be appropriate.

Racial differences in the association of NT-proBNP with risk of incident heart failure in REGARDS

BACKGROUND

Black individuals have lower natriuretic peptide levels and greater risk of heart failure (HF) than white individuals. Higher N-terminal-pro-B-type natriuretic peptide (NT-proBNP) is associated with increased risk of incident HF, but little information is available in black individuals. We examined race-specific differences in 1) the association of NT-proBNP with incident HF and 2) the predictive ability of NT-proBNP for incident HF across body mass index (BMI) and estimated glomerular filtration rate (eGFR) categories.

METHODS

In a prospective case-cohort study, baseline NT-proBNP was measured among 687 participants with incident HF and 2,923 (weighted 20,075) non-case randomly selected participants. Multivariable Cox proportional hazard modeling was used to assess the objectives of our study. Global Wald Chi-square score estimated from multivariable Cox models was used to assess predictive ability of NT-proBNP across BMI and eGFR categories.

RESULTS

In the multivariable model, a doubling of NT-proBNP concentration was associated with greater risk of incident HF among white individuals [hazard ratio (HR): 1.73; 95% CI: 1.55-1.94] than black individuals (HR: 1.51; 95% CI: 1.34-1.70); Pinteraction by race = 0.024. Higher NT-proBNP was the strongest predictor of incident HF across all BMI and eGFR categories among white individuals. By contrast, among black individuals with obesity (BMI ≥ 30 kg/m2) or eGFR < 60 mL/min/1.73 m2, the predictive ability of NT-proBNP for incident HF was attenuated.

CONCLUSIONS

The magnitude of the association of higher NT-proBNP with incident HF risk was greater among white individuals than black individuals. The diminished ability of NT-proBNP to predict the risk of HF in black population with obesity or impaired kidney function highlights the need of further investigations.

Indications for β-Blocker Prescriptions in Heart Failure with Preserved Ejection Fraction

OBJECTIVES

To better understand indications for β-blocker (BB) prescriptions among older adults hospitalized with heart failure with preserved ejection fraction (HFpEF).

DESIGN/SETTING

Retrospective observational study of hospitalizations derived from the geographically diverse Reasons for Geographic and Racial Differences in Stroke cohort.

PARTICIPANTS

We examined Medicare beneficiaries aged 65 years or older with an expert-adjudicated hospitalization for HFpEF (left ventricular ejection fraction = 50% or greater).

MEASUREMENTS

Discharge medications and indications for BBs were abstracted from medical records.

RESULTS

Of 306 hospitalizations for HFpEF, BBs were prescribed at discharge in 68%. Among hospitalizations resulting in BB prescriptions, 60% had a compelling indication for BB-44% had arrhythmias, and 29% had myocardial infarction (MI) history. Among the 40% with neither indication, 57% had coronary artery disease (CAD) without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD), both clinical scenarios with little supportive evidence of benefit of BBs. Among hospitalizations resulting in BB prescription at discharge, 69% had geriatric conditions (functional limitation, cognitive impairment, hypoalbuminemia, or history of falls). There were no significant differences in the prevalence of geriatric conditions between hospitalizations of individuals with compelling indications for BBs and hospitalizations of individuals with noncompelling indications.

CONCLUSIONS

BBs are commonly prescribed following a hospitalization for HFpEF, even in the absence of compelling indications. This occurs even for hospitalizations of individuals with geriatric conditions, a subpopulation who may be at elevated risk for experiencing harm from BBs.

Medication-Taking Behaviors and Perceptions Among Adults With Heart Failure (from the REasons for Geographic And Racial Differences in Stroke Study)

Medication regimens in adults with heart failure (HF) are complex which can complicate patient adherence. Individuals with HF frequently use beta blockers (BBs) for multiple indications, including hypertension and HF, but BBs can have significant side effects that may affect their use. We examined medication-taking behaviors and perceptions in individuals with HF with a particular focus on BBs. A mailed survey on medication use was administered to US adults with HF enrolled in the REasons for Geographic And Racial Differences in Stroke study. Among 518 respondents, 357 (69%) reported taking a BB. Nearly half (42%) reported taking ≥10 medications per day. However, 45% indicated that they did not miss any days taking medications, and over 85% reported willingness to take additional medications to prevent further healthcare encounters. Participants' perceptions of BB symptoms varied, but 56% of those who reported experiencing symptoms did not discuss this with their healthcare providers. Adults who experienced HF hospitalization had higher odds of reporting taking BBs to treat HF (odds ratio 1.51, 95% confidence interval 1.19, 1.91). Adults with hypertension were also likely to report taking BBs to treat high blood pressure (odds ratio 2.42, 95% confidence interval 1.79, 3.26). In conclusion, despite extensive medication regimens, individuals with HF were willing to take additional medications for their disease. Participant recognition of BB use for treating HF and co-morbidities was high, yet many do not report side effects to healthcare providers. In conclusion, better understanding of patients' medication-taking behaviors and perceptions may facilitate optimization of HF treatments.

Abstract 284: Social Determinants of Health and 90 Day Mortality after Hospitalization for Heart Failure in the REasons for Geographic and Racial differences in Stroke (REGARDS) Study

Background: Mortality after heart failure (HF) hospitalizations is high, with 15-20% of patients dying within 90 days. Prior studies have found that individual social determinants of health (SDOH) are associated with mortality after discharge, heightening interest in SDOH as risk factors for 90-day mortality. However, little is known about how the burden of SDOH within individuals affects 90-day mortality. We examined associations between multiple within-person SDOH and 90-day mortality among adults hospitalized for HF.

Methods: We used data from the REGARDS study, a large prospective cohort of 30,239 US black and white adults recruited in 2003-7, with ongoing follow-up. We studied participants 65 years of age and older who were discharged alive after an expert-adjudicated HF hospitalization, with continuous Medicare Part A for 6 months before and 90 days after hospitalization. The primary outcome was 90-day mortality. Informed by the HealthyPeople 2020 framework for SDOH, we examined 8 SDOH: 1) black race; 2) low educational attainment; 3) low annual household income; 4) social isolation; and living in a: 5) zip code with high poverty; 6) Health Professional Shortage Area (HPSA); 7) rural area; and 8) state with poor public health infrastructure. Using cox proportional hazards models, we first examined the age-adjusted association between each SDOH and 90-day mortality; those associated with p<0.20 were retained to create groups of participants with 0, 1, and 2+ SDOH. We then determined hazard ratios (HR) for SDOH groups and 90-day mortality, adjusting for demographics, medical conditions, cognition, functional status, and hospitalization characteristics.

Results: Over 10 years, a total of 690 individuals were hospitalized for HF at 440 unique hospitals across the US. They had a mean age of 76 years and 44% were female. We observed 79 deaths within 90 days of hospitalization. Of 8 candidate SDOH, black race (HR: 1.56 [95% CI: 0.99-2.43]), HPSA (1.56 [1.00-2.42]), social isolation (1.71 [0.99-2.97]), and living in a rural area (1.68 [.88- 3.19]) were associated with increased risk of age-adjusted 90-day mortality. Overall, 37% had no SDOH, 40% had 1, and 23% had 2+ SDOH. Compared to those with fewer SDOH, participants with 2+ vulnerabilities were younger, female, had less education and income, worse overall health, and were more often discharged to a nursing home. In a fully adjusted model, compared to those with 0 or 1 SDOH, the HR for 90-day mortality among those with 2+ SDOH was 1.24 (95% CI: 0.72 -2.14).

Discussion: Four SDOH were individually associated with increased risk of 90-day mortality, but a greater number of SDOH within individuals was not independently associated.Larger studies that can operationalize a greater number of SDOH may shed more light on the relationship between the burden of SDOH and 90-day mortality following hospitalization for HF.

Race-based demographic, anthropometric and clinical correlates of N-terminal-pro B-type natriuretic peptide

BACKGROUND

Population studies have shown that black race is a natriuretic peptide (NP) deficiency state. We sought to assess whether the effects of age, sex, body mass index (BMI) and estimated glomerular filtration rate (eGFR) on N-terminal-pro-B-type NP (NT-proBNP) levels differ in white and black individuals.

METHODS

The study population consisted of a stratified random cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. The study outcomes were the effects of age, sex, BMI and eGFR on NT-proBNP levels independent of socioeconomic and cardiovascular disease factors. Multivariable regression analyses were used to assess the effects of age, sex, BMI and eGFR on NT-proBNP levels in blacks and whites.

RESULTS

Of the 27,679 participants in the weighted sample, 54.7% were females, 40.6% were black, and the median age was 64 years. Every 10-year higher age was associated with 38% [95% confidence interval (CI): 30%-45%] and 34% (95% CI: 22%-43%) higher NT-proBNP levels in whites and blacks, respectively. Female sex was associated with 31% (95% CI: 20%-43%) higher NT-proBNP levels in whites and 28% (95% CI: 15%-45%) higher in blacks. There was a significant linear inverse relationship between BMI and NT-proBNP in whites and a non-linear inverse relationship in blacks. Whites and blacks had a non-linear inverse relationship between eGFR and NT-proBNP. However, the non-linear relationship between NT-proBNP and eGFR differed by race (p = 0.01 for interaction).

CONCLUSIONS

The association of age and sex with NT-proBNP levels was similar in blacks and whites but the form of the BMI and eGFR relationship differed by race.

Abstract 188: Association Between Uric Acid and Stroke in the REgards Case-cohort Study

Introduction: The association between hyperuricemia and stroke has been inconsistent especially after adjustment for cardiovascular risk factors. Previous studies were limited in the number of events and did not measure these associations in subgroups.

Methods: We used a stratified case-cohort design within the REasons for Geographic and Racial Differences in Stroke study. Clinically adjudicated stroke events (n=903) were defined as focal neurologic deficit lasting >24 hours or non-focal neurological symptoms with brain imaging consistent with stroke. Controls (n=951) were a random stratified sample selected from baseline to ensure representation of high-risk groups. Uric acid was assayed using the baseline sample and categorized into three groups: < 6 (referent), 6-6.8, ≥ 6.8 mg/dl (hyperuricemia). Cox-proportional-hazard-models adjusted for demographic and clinical variables were fit to examine the association between uric acid levels and stroke. We repeated the analysis stratified by race, gender, and age (</≥ 65years) and finally, since uric acid is associated with hypertension, explored the count of antihypertensive treatment classes (nHTN) as a potential mediator.

Results: Hyperuricemic individuals were more likely to be male and black. Hyperuricemia versus the referent category was significantly associated with stroke after adjustment for race, sex, age, and age*race interaction [model 1 HR(95%CI)= 1.42(1.12-1.80)], and after further adjustment for systolic and diastolic blood pressure [HR (95%CI)= 1.42(1.12-1.80)]. The associations was attenuated after full adjustment [HR (95%CI)= 1.22(0.91-1.63)]. Incremental adjustment by clinical variables suggested nHTN attenuated the association between hyperuricemia and stroke. Results were similar for hyperuricemia within subgroups defined by age, gender and race, except among men <65 years [HR (95%CI)= 2.72(1.25-5.93)]. Mediation analysis estimated that nHTN accounted for 43%(95%CI: 15 to 158%) of the relationship.

Conclusion: We observed a significant association between hyperuricemia and stroke that was partially dependent upon hypertension severity (count of antihypertensive treatment classes). The association was strongest among males aged <65 years.

Abstract WMP56: Risk of Atrial Fibrillation in Black versus White Medicare Beneficiaries With Implanted Cardiac Devices

Introduction: Black individuals in the U.S. have a higher risk of ischemic stroke than whites but a lower risk of clinically apparent atrial fibrillation (AF), a strong stroke risk factor. It is unclear whether blacks truly have less AF or simply more undiagnosed AF.

Methods: We conducted a retrospective cohort study using inpatient and outpatient claims from 2008-2015 in a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥66 years old with black or white race and at least one documented Current Procedural Terminology code for interrogation of an implantable pacemaker, cardioverter-defibrillator, or loop recorder. The primary outcome was a composite of AF or atrial flutter (AFL). Secondary outcomes were AF, AFL, and ischemic stroke. All variables were ascertained using validated ICD-9-CM codes. Those diagnosed with AF, AFL, or stroke before their first recorded device interrogation were excluded. Patients were censored at their last recorded device interrogation, end of Medicare coverage, or death. Kaplan-Meier statistics and Cox proportional hazards models were used to examine the association between black race and outcomes while adjusting for age, sex, and vascular risk factors.

Results: Among 45,615 eligible beneficiaries, the 3,192 black patients (7.0%) had more vascular risk factors than white patients. The annual incidence of AF/AFL was 12.2 (95% confidence interval [CI], 11.5-13.1) per 100 person-years among blacks and 17.8 (95% CI, 17.6-18.1) per 100 person-years among whites. After adjustment for confounders, black beneficiaries faced a lower hazard of AF/AFL than white beneficiaries (hazard ratio [HR], 0.74; 95% CI, 0.70-0.79). This reflected a lower risk of AF (HR, 0.73; 95% CI, 0.68-0.78), not AFL (HR, 1.10; 95% CI, 0.89-1.36). Despite the lower risk of AF, black patients faced a higher hazard of ischemic stroke (HR, 1.36; 95% CI, 1.22-1.53).

Conclusions and Relevance: Among Medicare beneficiaries with implanted cardiac devices capable of detecting atrial rhythm, black patients had a lower incidence of AF despite a higher burden of vascular risk factors and a higher risk of stroke.

Unmet Patient Need in Statin Intolerance: the Clinical Characteristics and Management

PURPOSE

A substantial percentage of patients report intolerance or side effects of statin treatment leading to treatment changes or discontinuation. The purpose of this study was to examine statin therapy changes and subsequent effects on low-density lipoprotein cholesterol (LDL-C) among patients with statin intolerance (SI).

METHODS

We identified 45,037 adults from Kaiser Permanente Southern California with SI documented between 2006 and 2012. Changes in statin therapy in the year before and after the SI index date were examined. We categorized patients into those who initiated statin therapy, discontinued, up-titrated, down-titrated, or did not switch therapy. We calculated the percentage change in LDL-C from the year before to the year after SI, and the percentage of patients attaining LDL-C < 100 and < 70 mg/dL.

RESULTS

In the year prior to the SI date, 77.8% of patients filled a statin prescription. Following SI, 44.6% had no treatment change, 25.5% discontinued, and 30.0% altered their statin therapy. Of those who altered statin therapy, 52.6% down-titrated and 17.2% up-titrated their dose. Rhabdomyolysis was documented in < 1% of the cohort. The largest changes in LDL-C were experienced by patients who were on a high-intensity statin then discontinued treatment (35.6% increase) and those who initiated a high-intensity statin (25.5% decrease). The proportion of patients achieving LDL-C < 100 mg/dL and LDL-C < 70 mg/dL was the lowest among those who discontinued therapy.

CONCLUSIONS

Although adjustments to the statin dosage may be appropriate upon documentation of SI, many of these patients will have high LDL-C. Strategies for LDL-C reduction in patients with SI may be necessary.

Patient Perspectives on Factors Influencing Medication Adherence Among People with Coronary Heart Disease (CHD) and CHD Risk Factors

BACKGROUND

Few qualitative studies have explored factors influencing medication adherence among people with coronary heart disease (CHD) or CHD risk factors. We explored how factors related to the patient (e.g. self-efficacy), social/economic conditions (e.g. social support and cost of medications), therapy (e.g. side effects), health condition (e.g. comorbidities), and the healthcare system/healthcare team (e.g. support from healthcare providers and pharmacy access) influence medication adherence, based on the World Health Organization Multidimensional Adherence Model (WHO-MAM).

METHODS

We conducted 18 in-depth qualitative interviews from April to July 2018 with ambulatory care patients aged ≥45 years (8 black men, 5 black women, 2 white men, and 3 white women) who were using medications for diabetes, hypertension, dyslipidemia and/or CHD. We used thematic analysis to analyze the data, and sub-themes emerged within each WHO-MAM dimension.

FINDINGS

Patient-related factors included beliefs about medications as important for self and faith; the desire to follow the advice of family, friends, and influential others; and self-efficacy. Social/economic factors included observations of social network members and information received from them; social support for medication adherence and pharmacy utilization; and economic influences. Therapy-related barriers included side effects and medicine schedules. Only a few participants mentioned condition-related factors. Healthcare system/healthcare team-related factors included support from doctors and pharmacists; and ease of pharmacy access and utilization.

CONCLUSION

These results underscore the need for multidimensional interventions aimed at improving medication adherence and overall health of patients with CHD and CHD risk factors.

The Prevalence of Cognitive Impairment Among Adults With Incident Heart Failure: The "Reasons for Geographic and Racial Differences in Stroke" (REGARDS) Study

BACKGROUND

Cognitive impairment (CI) is estimated to be present in 25%-80% of heart failure (HF) patients, but its prevalence at diagnosis is unclear. To improve our understanding of cognition in HF, we determined the prevalence of CI among adults with incident HF in the REGARDS study.

METHODS AND RESULTS

REGARDS is a longitudinal cohort study of adults ≥45 years of age recruited in the years 2003-2007. Incident HF was expert adjudicated. Cognitive function was assessed with the Six-Item Screener. The prevalence of CI among those with incident HF was compared with the prevalence of CI among an age-, sex-, and race-matched cohort without HF. The 436 participants with incident HF had a mean age of 70.3 years (SD 8.9), 47% were female, and 39% were black. Old age, black race, female sex, less education, and anticoagulation use were associated with CI. The prevalence of CI among participants with incident HF (14.9% [95% CI 11.7%-18.6%]) was similar to the non-HF matched cohort (13.4% [11.6%-15.4%]; P < .43).

CONCLUSIONS

A total of 14.9% of the adults with incident HF had CI, suggesting that the majority of cognitive decline occurs after HF diagnosis. Increased awareness of CI among newly diagnosed patients and ways to mitigate it in the context of HF management are warranted.

Use of Medicare Claims Data for the Identification of Myocardial Infarction: The Reasons for Geographic And Racial Differences in Stroke Study

OBJECTIVES

Assess the validity of Medicare claims for identifying myocardial infarction (MI).

METHODS

We used data from 9951 Medicare beneficiaries 65 years and above in the Reasons for Geographic And Racial Differences in Stroke study. Between 2003 and 2012, 669 participants had an MI identified and adjudicated through study procedures (ie, the gold standard), and 552 had an overnight inpatient claim with a code for MI (ICD-9 code 410.x0 or 410.x1) in any discharge diagnosis position.

RESULTS

Using Medicare claims with a discharge diagnosis code for MI in any position, the positive predictive value (PPV) was 84.3% [95% confidence interval (CI), 80.9%-87.3%] and the sensitivity was 49.0% (95% CI, 44.9%-53.1%). Sensitivity was lower for men (45.8%) versus women (55.1%), microsize MIs (13.7%) versus other MIs (64.7%), type 2 (30.9%), and 4-5 MIs (11.1%) versus type 1 MIs (76.6%), and MIs occurring in-hospital (28.8%) versus out-of-hospital (66.7%). Using Medicare claims with a code for MI in the primary discharge diagnosis position, the PPV was 89.7% (95% CI, 86.3%-92.5%) and sensitivity was 40.1% (95% CI, 36.1%-44.2%). The sensitivity of claims with a code for MI in the primary discharge diagnosis position was lower for microsize versus other MIs, type 2 and 4-5 MIs versus type 1 MIs and MIs occurring in-hospital versus out-of-hospital. Hazard ratios for MI associated with participant characteristics were similar using adjudicated MIs identified through study procedures or claims for MI without further adjudication.

CONCLUSIONS

Medicare claims have a high PPV but low sensitivity for identifying MI and can be used to investigate individual-level characteristics associated with MI.

A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure

INTRODUCTION

Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure.

METHODS

National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models.

RESULTS

More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037).

CONCLUSIONS

These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Low Utilization of Beta-Blockers Among Medicare Beneficiaries Hospitalized for Heart Failure With Reduced Ejection Fraction

BACKGROUND

The evidence-based beta-blockers carvedilol, bisoprolol, and metoprolol succinate reduce mortality and hospitalizations among patients with heart failure with reduced ejection fraction (HFrEF). Use of these medications is not well described in the general population of patients with HFrEF, especially among patients with potential contraindications.

OBJECTIVES

Our goal was to describe the patterns of prescription fills for carvedilol, bisoprolol, and metoprolol succinate among Medicare beneficiaries hospitalized for HFrEF, as well as to estimate the associations between specific contraindications for beta-blocker therapy and those patterns.

METHODS AND RESULTS

With the use of the cohort of 15,205 Medicare beneficiaries hospitalized for HFrEF from 2007 to 2013 in the 5% Medicare random sample, we described prescription fills (30 days after discharge) and dosage patterns (1 year after discharge) for beta-blockers. By means of of Fine and Gray competing risk models, we estimated the associations between potential contraindications (hypotension, chronic obstructive pulmonary disease [COPD], asthma, and syncope) and prescription fill and dosing patterns while adjusting for demographics, comorbidities, and health care utilization. For beneficiaries who did not die or readmitted to the hospital, 38% of hospitalizations were followed by a prescription fill for an evidence-based beta-blocker within 30 days, 12% were followed by prescription fills for at least 50% of the recommended dose of an evidence-based beta-blocker within 1 year, and 9% were followed by a prescription fill for an up-titrated dose of an evidence-based beta-blocker within 1 year. The prevalence of the contraindications were 21% for hypotension, 48% for COPD, 15% for asthma, and 12% for syncope. Among beneficiaries who did not fill a prescription for an evidence-based beta-blocker within 30 days, 67% had at least 1 of these contraindications. Hypotension, COPD, and syncope were each associated with a ∼10% lower risk of filling a prescription for an evidence-based beta-blocker.

CONCLUSIONS

Prescription fill and up-titration rates for evidence-based beta-blockers are low among Medicare beneficiaries with HFrEF, but contraindications explain only a minor part of these low rates.

Development of algorithms for identifying fatal cardiovascular disease in Medicare claims

BACKGROUND

Cause of death is often not available in administrative claims data.

OBJECTIVE

To develop claims-based algorithms to identify deaths due to fatal cardiovascular disease (CVD; ie, fatal coronary heart disease [CHD] or stroke), CHD, and stroke.

METHODS

Reasons for Geographic and Racial Differences in Stroke (REGARDS) study data were linked with Medicare claims to develop the algorithms. Events adjudicated by REGARDS study investigators were used as the gold standard. Stepwise selection was used to choose predictors from Medicare data for inclusion in the algorithms. C-index, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to assess algorithm performance. Net reclassification index (NRI) was used to compare the algorithms with an approach of classifying all deaths within 28 days following hospitalization for myocardial infarction and stroke to be fatal CVD.

RESULTS

Data from 2,685 REGARDS participants with linkage to Medicare, who died between 2003 and 2013, were analyzed. The C-index for discriminating fatal CVD from other causes of death was 0.87. Using a cut-point that provided the closest observed-to-predicted number of fatal CVD events, the sensitivity was 0.64, specificity 0.90, PPV 0.65, and NPV 0.90. The algorithms resulted in positive NRIs compared with using deaths within 28 days following hospitalization for myocardial infarction and stroke. Claims-based algorithms for discriminating fatal CHD and fatal stroke performed similarly to fatal CVD.

CONCLUSION

The claims-based algorithms developed to discriminate fatal CVD events from other causes of death performed better than the method of using hospital discharge diagnosis codes.

Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Background

Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined.

Methods

We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003–2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence.

Results

Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates.

Conclusions

Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

Statin Discontinuation, Reinitiation, and Persistence Patterns Among Medicare Beneficiaries After Myocardial Infarction: A Cohort Study

BACKGROUND

Although the benefits of statins accrue over time, treatment discontinuation is common. Examining the patterns of statin discontinuation, reinitiation, and persistence after reinitiation among Medicare beneficiaries after hospital discharge for a myocardial infarction may help increase statin use in high-risk patients.

METHODS AND RESULTS

Medicare beneficiaries with a statin fill claim within 30 days after hospital discharge for myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days post-discharge to identify discontinuation, defined as 60 continuous days without statins available. Reinitiation, defined by a statin fill, was identified in the 365 days post-discontinuation. High persistence was defined as proportion of days covered ≥80% with ≥1 day of statin supply 182 days after reinitiation. Follow-up ended on December 31, 2014. In the 182 days after myocardial infarction hospital discharge, 15.4% of beneficiaries discontinued statins. Of this group, 53.7% reinitiated statins. On reinitiation, 27.1% changed statin type, 6.9% up-titrated intensity, 14.4% down-titrated intensity, and 66.0% had the same statin and intensity. In the 182 days after reinitiation, 45.8% had high persistence. Moderate- and high- versus low-intensity statins were associated with a lower risk for statin discontinuation (moderate intensity: relative risk [RR], 0.93; 95% confidence interval [CI], 0.89-0.96; high-intensity: RR, 0.95; 95% CI, 0.91-0.99). High persistence was less common after reinitiating high- versus low-intensity statins (RR, 0.80; 95% CI, 0.75-0.86), but no association was present for those reinitiating a moderate- versus low-intensity statin (RR, 0.95; 95% CI, 0.90-1.01). Down-titrating versus reinitiating the same statin intensity (RR, 1.10; 95% CI, 1.05-1.16) and reinitiating a different versus the same statin (RR, 1.10; 95% CI, 1.06-1.14) were associated with high persistence after treatment reinitiation.

CONCLUSIONS

Although many people who discontinue a statin reinitiate treatment, statin persistence after reinitiation was low. Reinitiating therapy with moderate-intensity statins, down-titration, and using a different statin may promote persistence.

Healthcare Utilization and Statin Re-Initiation Among Medicare Beneficiaries With a History of Myocardial Infarction

Background

Contact with the healthcare system represents an opportunity for individuals who discontinue statins to re‐initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk‐lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re‐initiation among patients with history of a myocardial infarction.

Methods and Results

Medicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re‐initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case‐crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re‐initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re‐initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with lipid panel testing was 2.65 (1.93–3.65), outpatient primary care was 1.31 (1.23–1.40), and outpatient cardiologist care was 1.38 (1.28–1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with emergency department visits was 1.77 (1.31–2.40), coronary heart disease (CHD) hospitalizations was 3.16 (2.41–4.14) and non–coronary heart disease hospitalizations was 1.73 (1.49–2.01).

Conclusions

The weaker association of routine versus acute healthcare utilization with statin re‐initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.

Causes and Temporal Patterns of 30-Day Readmission Among Older Adults Hospitalized With Heart Failure With Preserved or Reduced Ejection Fraction

Background

It is unknown whether causes and temporal patterns of 30‐day readmission vary between heart failure (HF) with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). We sought to address this question by examining a 5% national sample of Medicare beneficiaries.

Methods and Results

We included individuals who experienced a hospitalization for HFpEF or HFrEF between 2007 and 2013. We identified causes of 30‐day readmission based on primary discharge diagnosis and further classified causes of readmission as HF‐related, non–HF cardiovascular‐related, and non–cardiovascular‐related. We calculated the cumulative incidence of these classifications for HFpEF and HFrEF in a competing risks model and calculated subdistribution hazard ratios of these classifications by comparing those with HFpEF and those with HFrEF. Among 60 640 Medicare beneficiaries, we identified 13 785 unique older adults hospitalized with HFpEF and 15 205 who were hospitalized with HFrEF. Noncardiovascular diagnoses represented the most common causes of 30‐day readmission (HFpEF: 59%; HFrEF: 47%), a pattern that was observed for each week of the 30‐day study period for both HFpEF and HFrEF participants. In comparing readmission diagnoses in an adjusted model, non–cardiovascular‐related diagnoses were more common and HF‐related diagnoses were less common in HFpEF participants.

Conclusions

Non–cardiovascular‐related diagnoses represented the most common causes of 30‐day readmission following HF hospitalization for each week of the 30‐day postdischarge period. HF diagnoses were less common among those with HFpEF compared with HFrEF. Future interventions aimed at reducing 30‐day readmissions following an HF hospitalization would benefit from an increased focus on noncardiovascular comorbidity and interventions that target HFpEF and HFrEF separately.

N-terminal pro-B-type natriuretic peptide and microsize myocardial infarction risk in the reasons for geographic and racial differences in stroke study

Background

N-terminal pro B-type peptide (NT-proBNP) has been associated with risk of myocardial infarction (MI), but less is known about the relationship between NT-proBNP and very small non ST-elevation MI, also known as microsize MI. These events are now routinely detectable with modern troponin assays and are emerging as a large proportion of all MI. Here, we sought to compare the association of NT-proBNP with risk of incident typical MI and microsize MI in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Methods

The REGARDS Study is a national cohort of 30,239 US community-dwelling black and white adults aged ≥ 45 years recruited from 2003 to 2007. Expert-adjudicated outcomes included incident typical MI (definite/probable MI with peak troponin ≥ 0.5 μg/L), incident microsize MI (definite/probable MI with peak troponin < 0.5 μg/L), and incident fatal CHD. Using a case-cohort design, we estimated the hazard ratio of the outcomes as a function of baseline NT-proBNP. Competing risk analyses tested whether the associations of NT-proBNP differed between the risk of incident microsize MI and incident typical MI as well as if the association of NT-proBNP differed between incident non-fatal microsize MI and incident non-fatal typical MI, while accounting for incident fatal coronary heart disease (CHD) as well as heart failure (HF).

Results

Over a median of 5 years of follow-up, there were 315 typical MI, 139 microsize MI, and 195 incident fatal CHD. NT-proBNP was independently and strongly associated with all CHD endpoints, with significantly greater risk observed for incident microsize MI, even after removing individuals with suspected HF prior to or coincident with their incident CHD event.

Conclusion

NT-proBNP is associated with all MIs, but is a more powerful risk factor for microsize than typical MI.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0806-4) contains supplementary material, which is available to authorized users.

Abstract 211: Long-Term Participant Engagement in Weight Management Programs

Lifestyle interventions must be effective at engaging participants beyond the initial intervention period in order to be successful in reducing long-term cardiovascular risks. Unfortunately, there is a lack of evidence for improvement in long-term cardiovascular outcomes following participation in lifestyle interventions. Participant engagement has been shown to wane after the first 12 months of participation. This gradual reduction in engagement may be responsible for the limited evidence for an effect on long-term cardiovascular risk. The objective of this study is to assess patient, program and community characteristics associated with better participant engagement after 2 years in a weight management program. This is an observational study of 330,522 participants enrolled in MOVE! programs within the Veterans Healthcare Administration (VHA) from 2008 to 2013. The MOVE! program is a nationwide weight management intervention integrated into primary care within the VHA and provided free to Veterans. Participant engagement is defined as the number of MOVE! program visits per year for each participant. Engagement is assessed at 6 months, 12 months, and 24 months following the first program visit. Bivariate statistics and multivariate generalized linear models were used to assess factors associated with patient engagement at each time point. At the first MOVE! visit, the average participant age was 56.3 years old (SD=12.0) with a body mass index of 36.9 [Standard Deviation (SD)=5.4). Most participants were male (87.9 and lived in an urban area (69.7%) an average of 38.6 miles from the MOVE! program (SD=48.5). Eight percent (7.5%) of participants had a Charlson Comorbidity Index of 4 or more at the time of their first visit. Engagement decreased as time from the first visit increased. Patients had a median of 4.0 visits per year at 6 months [Interquartile Range (IQR)=2.0-8.0], 2.0 visits per year at 12 months (IQR=1.0-5.0), and 1.0 visit per year at 24 months (IQR=0.5-3.0). In adjusted models of 24-month engagement, older age (beta=0.03, p<0.01), greater body mass index (beta=0.06, p<0.01), and female gender (beta=0.46, p<0.01) were associated with better engagement. Factors predicting better engagement at each time period were similar with the exception of comorbidities. More comorbidities at the time of first visit was the only factor associated with a small improvement in 24-month engagement (beta=0.01, p=0.04) but no difference in 6-month (p=0.35) or 12-month (p=0.10) engagement. In conclusion, in this large observational study, female gender, greater BMI, older age, and more comorbidities are associated with better 24-month engagement in a weight management program. Few factors stood out as predictors of better 24-month engagement as compared to 6- and 12-month engagement.

Fine particulate matter and incident coronary heart disease in the REGARDS cohort

Chronic exposure to fine particulate matter (PM_2.5) is accepted as a causal risk factor for coronary heart disease (CHD). However, most of the evidence for this hypothesis is based upon cohort studies in whites, comprised of either only males or females who live in urban areas. It is possible that many estimates of the effect of chronic exposure to PM_2.5 on risk for CHD do not generalize to more diverse samples.

METHODS

Therefore, we estimated the relationship between chronic exposure to PM_2.5 and risk for CHD in among participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort who were free from CHD at baseline (n=17,126). REGARDS is a sample of whites and blacks of both genders living across the continental United States. We fit Cox proportional hazards models for time to CHD to estimate the hazard ratio for baseline 1-year mean PM_2.5 exposure, adjusting for environmental variables, demographics, and other risk factors for CHD including the Framingham Risk Score.

RESULTS

The hazard ratio (95% CI) for a 2.7-μg/m³ increase (interquartile range) 1-year mean concentration of PM_2.5 was 0.94 (0.83-1.06) for combined CHD death and nonfatal MI, 1.13 (0.92-1.40) for CHD death, and 0.85 (0.73-0.99) for nonfatal MI. We also did not find evidence that these associations depended upon overall CHD risk factor burden.

CONCLUSIONS

Our results do not provide strong evidence for an association between PM_2.5 and incident CHD in a heterogeneous cohort, and we conclude that the effects of chronic exposure to fine particulate matter on CHD require further evaluation.

PCSK9 Variants, Low-Density Lipoprotein Cholesterol, and Neurocognitive Impairment: Reasons for Geographic and Racial Differences in Stroke Study (REGARDS)

BACKGROUND

Despite concerns about adverse neurocognitive events raised by prior trials, pharmacological PCSK9 (proprotein convertase subtilisin/kexin type-9) inhibition was not associated with neurocognitive effects in a recent phase 3 randomized trial. PCSK9 loss-of-function (LOF) variants that result in lifelong exposure to lower levels of low-density lipoprotein cholesterol can provide information on the potential long-term effects of lower low-density lipoprotein cholesterol on neurocognitive impairment and decline.

METHODS

We investigated the association between PCSK9 LOF variants and neurocognitive impairment and decline among black REGARDS study (Reasons for Geographic and Racial Differences in Stroke) participants with (n=241) and without (n=10 454) C697X or Y142X LOF variants. Neurocognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (Word List Learning, World List Delayed Recall, Semantic Animal Fluency) and Six-Item Screener (SIS) assessments, administered longitudinally during follow-up. Neurocognitive impairment was defined as a score ≥1.5 SD below age, sex, and education-based stratum-specific means on 2 or 3 CERAD assessments or, separately, a score <5 on any SIS assessment at baseline or during follow-up. Neurocognitive decline was assessed using standardized continuous scores on individual neurocognitive tests.

RESULTS

The mean sample age was 64 years (SD, 9), 62% were women, and the prevalence of neurocognitive impairment at any assessment was 6.3% by CERAD and 15.4% by SIS definitions. Adjusted odds ratios for neurocognitive impairment for participants with versus without PCSK9 LOF variants were 1.11 (95% confidence interval [CI], 0.58-2.13) using the CERAD battery and 0.89 (95% CI, 0.61-1.30) using the SIS assessment. Standardized average differences in individual neurocognitive assessment scores over the 5.6-year (range, 0.1-9.1) study period ranged between 0.07 (95% CI, -0.06 to 0.20) and -0.07 (95% CI, -0.18 to 0.05) among participants with versus without PCSK9 LOF variants. Patterns of neurocognitive decline were similar between participants with and without PCSK9 LOF variants (all P>0.10). Odds ratios for neurocognitive impairment per 20 mg/dL low-density lipoprotein cholesterol decrements were 1.02 (95% CI, 0.96-1.08) and 0.99 (95% CI, 0.95-1.02) for the CERAD and SIS definitions of impairment, respectively.

CONCLUSIONS

These results suggest that lifelong exposure to low PCSK9 levels and cumulative exposure to lower levels of low-density lipoprotein cholesterol are not associated with neurocognitive effects in blacks.

WIC Cash Value Voucher Redemption Behavior in Jefferson County, Alabama, and Its Association With Fruit and Vegetable Consumption

PURPOSE

To examine cash value voucher (CVV) redemption behavior and its association with fruit and vegetable (FV) consumption among women who participate in the Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Cross-sectional.

SETTING

Jefferson County, Alabama.

PARTICIPANTS

Between October 2014 and January 2015, 300 women (mean age: 27.6 years; 66.8% non-Hispanic black; 45.1% obese) who participated in the Birmingham WIC program were surveyed.

MEASURES

Self-reported information on demographics, produce shopping behaviors, and residential access to fresh produce retailers (eg, supermarkets and farmers markets) was examined. Fruit and vegetable intake was collected via the Block Fruit-Vegetable-Fiber screener. Participants who self-reported redeeming the WIC CVV in each of the 3 prior months were classified as regular redeemers.

ANALYSIS

Multivariable-adjusted regression models were used to examine associations between variables of interest and regular WIC CVV redemption.

RESULTS

There were 189 (63.0%) study participants classified as regular WIC CVV redeemers. Regular redeemers and other participants (ie, irregular redeemers and nonredeemers) were similar with respect to demographics. Regular redeemers were more likely to use grocery stores to purchase FVs ( P = .003) and consumed significantly more servings of FVs per day (β = .67; standard error = 0.24; P = .007).

CONCLUSION

Regular WIC CVV redemption was associated with some produce shopping behaviors and increased FV consumption and among WIC participants in Jefferson County, Alabama.

Medical therapy following hospitalization for heart failure with reduced ejection fraction and association with discharge to long-term care: a cross-sectional analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) population

BACKGROUND

Less intensive treatment for heart failure with reduced ejection fraction (HFrEF) may be appropriate for patients in long-term care settings because of limited life expectancy, frailty, comorbidities, and emphasis on quality of life.

METHODS

We compared treatment patterns between REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants discharged to long-term care versus home following HFrEF hospitalizations. We examined medical records and Medicare pharmacy claims for 147 HFrEF hospitalizations among 80 participants to obtain information about discharge disposition and medication prescriptions and fills.

RESULTS

Discharge to long-term care followed 22 of 147 HFrEF hospitalizations (15%). Participants discharged to long-term care were more likely to be prescribed beta-blockers and less likely to be prescribed aldosterone receptor antagonists and hydralazine/isosorbide dinitrate (96%, 14%, and 5%, respectively) compared to participants discharged home (81%, 22%, and 23%, respectively). The percentages of participants discharged to long-term care and home who had claims for filled prescriptions were similar for beta-blockers (68% versus 66%) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs) (45% versus 47%) after 1 year. Smaller percentages of participants discharged to long-term care had claims for filled prescriptions of other medications compared to participants discharged home (diuretics: long-term care-50%, home-72%; hydralazine/isosorbide dinitrate: long-term care-5%, home-23%; aldosterone receptor antagonists: long-term care-5%, home-23%).

CONCLUSIONS

Differences in medication prescriptions and fills among individuals with HFrEF discharged to long-term care versus home may reflect prioritization of some medical therapies over others for patients in long-term care.

Black-White Differences in Incident Fatal, Nonfatal, and Total Coronary Heart Disease

BACKGROUND

Blacks have higher coronary heart disease (CHD) mortality compared with whites. However, a previous study suggests that nonfatal CHD risk may be lower for black versus white men.

METHODS

We compared fatal and nonfatal CHD incidence and CHD case-fatality among blacks and whites in the Atherosclerosis Risk in Communities study (ARIC), the Cardiovascular Health Study (CHS), and the Reasons for Geographic and Racial Differences in Stroke study (REGARDS) by sex. Participants 45 to 64 years of age in ARIC (men=6479, women=8488) and REGARDS (men=5296, women=7822), and ≥65 years of age in CHS (men=1836, women=2790) and REGARDS (men=3381, women=4112), all without a history of CHD, were analyzed. Fatal and nonfatal CHD incidence was assessed from baseline (ARIC=1987-1989, CHS=1989-1990, REGARDS=2003-2007) through up to 11 years of follow-up.

RESULTS

Age-adjusted hazard ratios comparing black versus white men 45 to 64 years of age in ARIC and REGARDS were 2.09 (95% confidence interval, 1.42-3.06) and 2.11 (1.32-3.38), respectively, for fatal CHD, and 0.82 (0.64-1.05) and 0.94 (0.69-1.28), respectively, for nonfatal CHD. After adjustment for social determinants of health and cardiovascular risk factors, hazard ratios in ARIC and REGARDS were 1.19 (95% confidence interval, 0.74-1.92) and 1.09 (0.62-1.93), respectively, for fatal CHD, and 0.64 (0.47-0.86) and 0.67 (0.48-0.95), respectively, for nonfatal CHD. Similar patterns were present among men ≥65 years of age in CHS and REGARDS. Among women 45 to 64 years of age in ARIC and REGARDS, age-adjusted hazard ratios comparing blacks versus whites were 2.61 (95% confidence interval, 1.57-4.34) and 1.79 (1.06-3.03), respectively, for fatal CHD, and 1.47 (1.13-1.91) and 1.29 (0.91-1.83), respectively, for nonfatal CHD. After multivariable adjustment, hazard ratios in ARIC and REGARDS were 0.67 (95% confidence interval, 0.36-1.24) and 1.00 (0.54-1.85), respectively, for fatal CHD, and 0.70 (0.51-0.97) and 0.70 (0.46-1.06), respectively, for nonfatal CHD. Racial differences in CHD incidence were attenuated among older women. CHD case fatality was higher among black versus white men and women, and the difference remained similar after multivariable adjustment.

CONCLUSIONS

After accounting for social determinants of health and risk factors, black men and women have similar risk for fatal CHD compared with white men and women, respectively. However, the risk for nonfatal CHD is consistently lower for black versus white men and women.

PCSK9 Loss-of-Function Variants, Low-Density Lipoprotein Cholesterol, and Risk of Coronary Heart Disease and Stroke: Data From 9 Studies of Blacks and Whites

BACKGROUND

PCSK9 loss-of-function (LOF) variants allow for the examination of the effects of lifetime reduced low-density lipoprotein cholesterol (LDL-C) on cardiovascular events. We examined the association of PCSK9 LOF variants with LDL-C and incident coronary heart disease and stroke through a meta-analysis of data from 8 observational cohorts and 1 randomized trial of statin therapy.

METHODS AND RESULTS

These 9 studies together included 17 459 blacks with 403 (2.3%) having at least 1 Y142X or C679X variant and 31 306 whites with 955 (3.1%) having at least 1 R46L variant. Unadjusted odds ratios for associations between PCSK9 LOF variants and incident coronary heart disease (851 events in blacks and 2662 events in whites) and stroke (523 events in blacks and 1660 events in whites) were calculated using pooled Mantel-Haenszel estimates with continuity correction factors. Pooling results across studies using fixed-effects inverse-variance-weighted models, PCSK9 LOF variants were associated with 35 mg/dL (95% confidence interval [CI], 32-39) lower LDL-C in blacks and 13 mg/dL (95% CI, 11-16) lower LDL-C in whites. PCSK9 LOF variants were associated with a pooled odds ratio for coronary heart disease of 0.51 (95% CI, 0.28-0.92) in blacks and 0.82 (95% CI, 0.63-1.06) in whites. PCSK9 LOF variants were not associated with incident stroke (odds ratio, 0.84; 95% CI, 0.48-1.47 in blacks and odds ratio, 1.06; 95% CI, 0.80-1.41 in whites).

CONCLUSIONS

PCSK9 LOF variants were associated with lower LDL-C and coronary heart disease incidence. PCSK9 LOF variants were not associated with stroke risk.

Visual Sensory and Visual-Cognitive Function and Rate of Crash and Near-Crash Involvement Among Older Drivers Using Naturalistic Driving Data

Purpose

An innovative methodology using naturalistic driving data was used to examine the association between visual sensory and visual-cognitive function and rates of future crash or near-crash involvement among older drivers.

Methods

The Strategic Highway Research Program (SHRP2) Naturalistic Driving Study was used for this prospective analysis. The sample consisted of N = 659 drivers aged ≥70 years and study participation lasted 1 or 2 years for most participants. Distance and near visual acuity, contrast sensitivity, peripheral vision, visual processing speed, and visuospatial skills were assessed at baseline. Crash and near-crash involvement were based on video recordings and vehicle sensors. Poisson regression models were used to generate crude and adjusted rate ratios (RRs) and 95% confidence intervals, while accounting for person-miles of travel.

Results

After adjustment, severe impairment of the useful field of view (RR = 1.33) was associated with an increased rate of near-crash involvement. Crash, severe crash, and at-fault crash involvement were associated with impaired contrast sensitivity in the worse eye (RRs = 1.38, 1.54, and 1.44, respectively) and far peripheral field loss in both eyes (RRs = 1.74, 2.32, and 1.73, respectively).

Conclusions

Naturalistic driving data suggest that contrast sensitivity in the worse eye and far peripheral field loss in both eyes elevate the rates of crash involvement, and impaired visual processing speed elevates rates of near-crash involvement among older drivers. Naturalistic driving data may ultimately be critical for understanding the relationship between vision and driving safety.

Risk of Acute Coronary Heart Disease After Sepsis Hospitalization in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort

Background

Sepsis is associated with long-term health consequences. We sought to determine the long-term risks of acute and fatal coronary heart disease (CHD) events after sepsis hospitalizations among community-dwelling adults.

Methods

We analyzed data from 30329 participants in the population-based REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Sepsis events included hospitalizations for a serious infection with ≥2 systemic inflammatory response syndrome criteria. Acute CHD events included myocardial infarctions (MIs; nonfatal and fatal) and acute CHD deaths. Fatal CHD included deaths ≤28 days of an acute MI and acute CHD deaths. We age- and time-matched each sepsis participant with 5 nonsepsis participants. We assessed the associations between sepsis hospitalizations and future acute and fatal CHD events using Cox regression, Gray's model, and competing risks analysis, adjusting for comorbidities.

Results

The matched cohort contained 1070 sepsis and 5350 nonsepsis participants. Risk of acute CHD was higher for sepsis than nonsepsis controls after adjusting for sex, race, education, income, region, tobacco use, and select chronic medical conditions (0-1 year adjusted hazard ratio [HR], 4.38 [95% confidence interval (CI), 2.03-9.45]; 1-4 years, 1.78 [1.09-2.88]; and 4+ years, 1.18 [0.52-2.67]). Risk of fatal CHD was similarly higher for sepsis than nonsepsis individuals (0-1 year adjusted HR, 3.12 [95% CI, 1.35-7.23]; 1-4 years, 3.29 [1.89-5.74]; and 4+ years HR, 1.15 [0.34-3.94]).

Conclusions

The long-term risks of acute and fatal CHD are elevated after sepsis hospitalization. Management of acute CHD risk may be important for individuals surviving a sepsis event.

Comparison of Expert Adjudicated Coronary Heart Disease and Cardiovascular Disease Mortality With the National Death Index: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

BACKGROUND

The National Death Index (NDI) is widely used to detect coronary heart disease (CHD) and cardiovascular disease (CVD) deaths, but its reliability has not been examined recently.

METHODS AND RESULTS

We compared CHD and CVD deaths detected by NDI with expert adjudication of 4010 deaths that occurred between 2003 and 2013 among participants in the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort of black and white adults in the United States. NDI derived CHD mortality had sensitivity 53.6%, specificity 90.3%, positive predictive value 54.2%, and negative predictive value 90.1%. NDI-derived CVD mortality had sensitivity 73.4%, specificity 84.5%, positive predictive value 70.6%, and negative predictive value 86.2%. Among NDI-derived CHD and CVD deaths, older age (odds ratios, 1.06 and 1.04 per 1-year increase) was associated with a higher probability of disagreement with the adjudicated cause of death, whereas among REGARDS adjudicated CHD and CVD deaths a history of CHD or CVD was associated with a lower probability of disagreement with the NDI-derived causes of death (odds ratios, 0.59 and 0.67, respectively).

CONCLUSIONS

The modest accuracy and differential performance of NDI-derived cause of death may impact CHD and CVD mortality statistics.

Abstract 188: Hospital and Regional Variation in Use of High-intensity Statins Following Myocardial Infarction Among Medicare Beneficiaries

Background: American College of Cardiology/American Heart Association guidelines published in 2013 recommend high-intensity statins (atorvastatin 40 or 80 mg or rosuvastatin 20 or 40 mg) for most adults ≤75 years of age with atherosclerotic cardiovascular disease (ASCVD). For adults >75 years of age with ASCVD, the guidelines recommend continuation of tolerated statins or initiation of moderate intensity statins for most patients.

Objective: To examine whether guideline concordant use of high-intensity statins following myocardial infarction (MI) among Medicare beneficiaries differed by hospital size, medical school affiliation, and region of the US in 2014 (after publication of the guidelines).

Methods: We identified 28,086 Medicare beneficiaries with fee-for-service and pharmacy coverage who filled a statin within 30 days following hospital discharge for MI in 2014. The analyses were restricted to 731 hospitals with at least 20 beneficiaries discharged for MI in 2014. Hospital size and medical school affiliation were determined from the American Hospital Association survey. In subgroups ≤75 and >75 years of age, we calculated the proportion of beneficiaries whose first statin fill after MI was a high-intensity statin by hospital, hospital size, medical school affiliation, and region.

Results: Among statin users ≤75 years of age, 10,696 (55%) beneficiaries filled a prescription for a high-intensity statin following MI. The percentage filling high-intensity statins range from 0-100% (25 th percentile 39%, 75 th percentile 69%) across hospitals. High-intensity statin use was more common following hospitalization at larger hospitals, hospitals with medical school affiliations, and those in New England ( Figure ). A lower percentage of Medicare beneficiaries >75 years of age filled high-intensity statins (n = 8,441, 44%), but patterns were similar across hospital characteristics and region.

Conclusions: Similar patterns of high-intensity statin use were present among individuals ≤75 years of age, in whom high-intensity statin use is guideline concordant, and individuals >75 years of age, in whom high-intensity statin use is not necessarily guideline concordant, suggesting that variation in high-intensity statin prescriptions may not be directly related to close adherence to guidelines.

Insurance, self-reported medication adherence and LDL cholesterol: The REasons for Geographic And Racial Differences in Stroke study

BACKGROUND

Lack of health insurance may adversely impact medication adherence and the control of cardiovascular risk factors. We examined if the association between insurance and LDL-C is due to self-reported low medication adherence.

METHODS

This cross-sectional study included 8685 black and white men and women aged 45 and older who participated in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort and used statins. Medication adherence was assessed using the 4-item Morisky Medication Adherence Scale (MMAS-4). Mean differences in LDL-C between participants with and without insurance were calculated using generalized linear models before and after adjustment for MMAS-4. Subgroups stratified by age, annual household income, diabetes, and CHD were compared. Separately, individual MMAS-4 questions were examined for mediation effects.

RESULTS

After multivariable adjustment but without MMAS-4, LDL-C was 2.5mg/dL (95% CI -0.6, 5.6) higher among uninsured versus insured participants. After further adjustment for MMAS-4, LDL-C was 2.6mg/dL (95% CI -0.5, 5.6) higher. Stratified analyses produced similar results. No mediating effect was observed when each MMAS-4 question was examined separately.

CONCLUSION

High medication adherence does not mediate the association between having health insurance and lower LDL-C.

Heat Maps of Hypertension, Diabetes Mellitus, and Smoking in the Continental United States

BACKGROUND

Geographic variations in cardiovascular mortality are substantial, but descriptions of geographic variations in major cardiovascular risk factors have relied on data aggregated to counties. Herein, we provide the first description of geographic variation in the prevalence of hypertension, diabetes mellitus, and smoking within and across US counties.

METHODS AND RESULTS

We conducted a cross-sectional analysis of baseline risk factor measurements and latitude/longitude of participant residence collected from 2003 to 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Of the 30 239 participants, all risk factor measurements and location data were available for 28 887 (96%). The mean (±SD) age of these participants was 64.8(±9.4) years; 41% were black; 55% were female; 59% were hypertensive; 22% were diabetic; and 15% were current smokers. In logistic regression models stratified by race, the median(range) predicted prevalence of the risk factors were as follows: for hypertension, 49% (45%-58%) among whites and 72% (68%-78%) among blacks; for diabetes mellitus, 14% (10%-20%) among whites and 31% (28%-41%) among blacks; and for current smoking, 12% (7%-16%) among whites and 18% (11%-22%) among blacks. Hypertension was most prevalent in the central Southeast among whites, but in the west Southeast among blacks. Diabetes mellitus was most prevalent in the west and central Southeast among whites but in south Florida among blacks. Current smoking was most prevalent in the west Southeast and Midwest among whites and in the north among blacks.

CONCLUSIONS

Geographic disparities in prevalent hypertension, diabetes mellitus, and smoking exist within states and within counties in the continental United States, and the patterns differ by race.

Cholesterol levels and long-term rates of community-acquired sepsis

Background

Dyslipidemia is a risk factor for cardiovascular disease, with elevated low-density lipoprotein cholesterol (LDL-C) and decreased high-density lipoprotein cholesterol (HDL-C) recognized as risk factors for acute coronary events. Studies suggest an association between low cholesterol levels and poor outcomes in acute sepsis. We sought to determine the relationship between baseline cholesterol levels and long-term rates of sepsis.

Methods

We used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, a population-based cohort of 30,239 community-dwelling adults. The primary outcome was first sepsis event, defined as hospitalization for an infection with the presence of ≥2 systemic inflammatory response syndrome criteria (abnormal temperature, heart rate, respiratory rate, white blood cell count) during the first 28 hours of hospitalization. Cox models assessed the association between quartiles of HDL-C or LDL-C and first sepsis event, adjusted for participant demographics, health behaviors, chronic medical conditions, and biomarkers.

Results

We included 29,690 subjects with available baseline HDL-C and LDL-C. There were 3423 hospitalizations for serious infections, with 1845 total sepsis events among 1526 individuals. Serum HDL-C quartile was not associated with long-term rates of sepsis (hazard ratio (HR) (95% CI): Q1 (HDL-C 5–40 mg/dl), 1.08 (0.91–1.28); Q2 (HDL-C 41–49 mg/dl), 1.06 (0.90–1.26); Q3 (HDL-C 50–61 mg/dl), 1.04 (0.89–1.23); Q4, reference). However, compared with the highest quartile of LDL-C, low LDL-C was associated with higher rates of sepsis (Q1 (LDL-C 3–89 mg/dl), 1.30 (1.10–1.52); Q2 (LDL-C 90–111 mg/dl), 1.24 (1.06–1.47); Q3 (LDL-C 112–135 mg/dl), 1.07 (0.91–1.26); Q4, reference).

Conclusion

Low LDL-C was associated with higher long-terms rates of community-acquired sepsis. HDL-C level was not associated with long-term sepsis rates.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1579-8) contains supplementary material, which is available to authorized users.

Diabetes, diabetes severity, and coronary heart disease risk equivalence: REasons for Geographic and Racial Differences in Stroke (REGARDS)

BACKGROUND

Evidence is mixed regarding whether diabetes confers equivalent risk of coronary heart disease (CHD) as prevalent CHD. We investigated whether diabetes and severe diabetes are CHD risk equivalents.

METHODS

At baseline, participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study (black and white US adults ≥45 years old recruited in 2003-2007) were categorized as having prevalent CHD only (self-reported or electrocardiogram evidence; n = 3,043), diabetes only (self-reported or elevated glucose; n = 4,012), diabetes and prevalent CHD (n = 1,529), and neither diabetes nor prevalent CHD (n = 17,155). Participants with diabetes using insulin and/or with albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g) were categorized as having severe diabetes. Participants were followed up through 2011 for CHD events (myocardial infarction or fatal CHD).

RESULTS

During a mean follow-up of 5 years, 1,385 CHD events occurred. The hazard ratios of CHD events comparing participants with diabetes only, diabetes, and prevalent CHD and neither diabetes nor prevalent CHD with those with prevalent CHD were 0.65 (95% CI 0.54-0.77), 1.54 (95% CI 1.30-1.83), and 0.41 (95% CI 0.35-0.47), respectively, after adjustment for demographics and risk factors. Compared with participants with prevalent CHD, the hazard ratio of CHD events for participants with severe diabetes was 0.88 (95% CI 0.72-1.09).

CONCLUSIONS

Participants with diabetes had lower risk of CHD events than did those with prevalent CHD. However, participants with severe diabetes had similar risk to those with prevalent CHD. Diabetes severity may need consideration when deciding whether diabetes is a CHD risk equivalent.

Linkage of a Population-Based Cohort With Primary Data Collection to Medicare Claims: The Reasons for Geographic and Racial Differences in Stroke Study

We described the linkage of primary data with administrative claims using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and Medicare. REGARDS study data were linked with Medicare claims by use of Social Security numbers. We compared REGARDS participants by Medicare linkage status, having fee-for-service (FFS) coverage or not, and with a 5% sample of Medicare beneficiaries who had FFS coverage in 2005, overall, by age (45-64 and ≥65 years), and by race. Among REGARDS participants who were ≥65 years of age, 80% had data linked to Medicare on their study-visit date (64% with FFS coverage). No differences except race and sex were present between REGARDS participants without Medicare linkage and those with data linked to Medicare with and without FFS coverage. After the age-sex-race adjustment, comorbid conditions and health-care utilization were similar for those with FFS coverage in the REGARDS study and the 5% sample of Medicare beneficiaries. Among REGARDS participants aged 45-64 years, 11% had FFS coverage on their study-visit date. In this age group, differences were present between participants with and without FFS coverage and the Medicare 5% sample with FFS coverage. In conclusion, REGARDS participants aged ≥65 years with FFS coverage are representative of the study cohort and the US population aged ≥65 years with FFS coverage.

Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study

Background

Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.

Methods

Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000–2012.

Results

Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.

Conclusions

Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0357-5) contains supplementary material, which is available to authorized users.

Mediterranean diet score and left ventricular structure and function: the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Data are limited on the relation between dietary patterns and left ventricular (LV) structure and function.

OBJECTIVE

We examined cross-sectional associations of a diet-score assessment of a Mediterranean dietary pattern with LV mass, volume, mass-to-volume ratio, stroke volume, and ejection fraction.

DESIGN

We measured LV variables with the use of cardiac MRI in 4497 participants in the Multi-Ethnic Study of Atherosclerosis study who were aged 45-84 y and without clinical cardiovascular disease. We calculated a Mediterranean diet score from intakes of fruit, vegetables, nuts, legumes, whole grains, fish, red meat, the monounsaturated fat:saturated fat ratio, and alcohol that were self-reported with the use of a food-frequency questionnaire. We used linear regression with adjustment for body size, physical activity, and cardiovascular disease risk factors to model associations and assess the shape of these associations (linear or quadratic).

RESULTS

The Mediterranean diet score had a slight U-shaped association with LV mass (adjusted means: 146, 145, 146, and 147 g across quartiles of diet score, respectively; P-quadratic trend = 0.04). The score was linearly associated with LV volume, stroke volume, and ejection fraction: for each +1-U difference in score, LV volume was 0.4 mL higher (95% CI: 0.0, 0.8 mL higher), the stroke volume was 0.5 mL higher (95% CI: 0.2, 0.8 mL higher), and the ejection fraction was 0.2 percentage points higher (95% CI: 0.1, 0.3 percentage points higher). The score was not associated with the mass-to-volume ratio.

CONCLUSIONS

A higher Mediterranean diet score is cross-sectionally associated with a higher LV mass, which is balanced by a higher LV volume as well as a higher ejection fraction and stroke volume. Participants in this healthy, multiethnic sample whose dietary patterns most closely conformed to a Mediterranean-type pattern had a modestly better LV structure and function than did participants with less-Mediterranean-like dietary patterns. This trial was registered at clinicaltrials.gov as NCT00005487.

Comparison of Length of Stay, 30-Day Mortality, and 30-Day Readmission Rates in Medicare Patients With Heart Failure and With Reduced Versus Preserved Ejection Fraction

Length of stay (LOS), 30-day mortality, and 30-day readmission rates have not been compared between Medicare beneficiaries with heart failure (HF) with reduced ejection fraction (HFrEF) and beneficiaries with heart failure with preserved ejection fraction (HFpEF), although HFpEF is common in patients with HF. To determine whether type of HF (HFrEF or HFpEF) was associated with LOS, 30-day mortality, and 30-day readmission, we used a cohort of 19,477 Medicare beneficiaries admitted to the hospital and discharged alive with a primary discharge diagnosis of HF between 2007 and 2011. Gamma regression, Poisson regression, and Cox proportional hazards with a competing risk for death were used to model LOS, 30-day mortality, and 30-day readmission rate, respectively. All models were adjusted for HF severity, co-morbidities, demographics, nursing home residence, and calendar year of admission. Beneficiaries with HFpEF had an LOS 0.02 days shorter than beneficiaries with HFrEF and a nearly identical 30-day readmission rate. Thirty-day mortality was 10% lower in beneficiaries with HFpEF versus HFrEF. In conclusion, readmission rates were as high in those with HFpEF as they are in those with HFrEF, with comparable LOS in the hospital.

Farm-to-Consumer Retail Outlet Use, Fruit and Vegetable Intake, and Obesity Status among WIC Program Participants in Alabama

OBJECTIVES

We studied whether use of farm-to-consumer (FTC) retail outlets (eg, farmers market, farm/roadside stand) was associated with daily fruit and vegetable (F&V) intake or obesity status among women who participate in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Birmingham, AL.

METHODS

We used a cross-sectional study design and recruited a convenience sample of 312 women (mean age = 27.6; 67.0% non-Hispanic black; 45.6% obese) participating in Birmingham's WIC Program. Participants were recruited between October 2014 and January 2015. Participants who self-reported purchasing produce from a FTC outlet during the 2014 farmers' market season were classified as FTC outlet users. Multivariable-adjusted regression models were used to examine associations between FTC outlet use, daily F&V intake, and obesity status (ie, body mass index ≥ 30).

RESULTS

Approximately 26.1% of participants were classified as FTC outlet users. After adjusting for socio-demographic factors and WIC Cash Value Voucher redemption, FTC outlet use was associated with increased odds of consuming ≥ 5 servings of F&Vs per day (OR: 2.01; 95%: 1.15 - 3.50), but not obesity status (OR: 0.68; 95% CI: 0.39 - 1.20).

CONCLUSIONS

FTC retail outlet use was associated with F&V intake among program participants but not obesity status.