Family Environment and the Metabolic Syndrome: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (SCAS)

BACKGROUND

Metabolic syndrome (MetS) is a risk factor for cardiovascular disease. Very limited work has evaluated associations of sociocultural processes with prevalence of the MetS.

PURPOSE

The purpose of the present study was to evaluate associations between family environment (cohesion/conflict) and the MetS, in a multi-site sample of US Hispanics/Latinos.

METHODS

A total of 3278 participants from the Hispanic Community Health Study/Study of Latinos underwent a clinical exam and completed psychosocial measures including family environment (cohesion and conflict) as part of the Sociocultural Ancillary Study.

RESULTS

The association between family environment and the MetS was moderated by sex. Among all women, higher family conflict was associated with MetS prevalence. Results by ancestry group showed that only among Cuban women, higher conflict was associated with the MetS, whereas only among Dominican men, greater cohesion was associated with the MetS.

CONCLUSIONS

The family context may be a sociocultural protective or risk factor among Hispanics/Latinos in terms of MetS risk, but these associations may vary by sex and Hispanic background.

Baseline characteristics of African Americans in the Systolic Blood Pressure Intervention Trial

The Systolic Blood Pressure Intervention Trial (SPRINT) will compare treatment to a systolic blood pressure goal of <120 mm Hg to treatment to the currently recommended goal of <140 mm Hg for effects on incident cardiovascular, renal, and neurologic outcomes including cognitive decline. The objectives of this analysis are to compare baseline characteristics of African American (AA) and non-AA SPRINT participants and explore factors associated with uncontrolled blood pressure (BP) by race. SPRINT enrolled 9361 hypertensive participants aged older than 50 years. This cross-sectional analysis examines sociodemographics, baseline characteristics, and study measures among AAs compared with non-AAs. AAs made up 31% of participants. AAs (compared with non-AAs) were younger and less frequently male, had less education, and were more likely uninsured or covered by Medicaid. In addition, AAs scored lower on the cognitive screening test when compared with non-AAs. Multivariate logistic regression analysis found BP control rates to <140/90 mm Hg were higher for AAs who were male, had higher number of chronic diseases, were on diuretic treatment, and had better medication adherence. SPRINT is well poised to examine the effects of systolic blood pressure targets on clinical outcomes as well as predictors influencing BP control in AAs.

Serum Inflammatory Cytokine Markers of Invasive Fungal Infection in Previously Immunocompetent Battle Casualties

BACKGROUND

Invasive fungal infection (IFI) is described increasingly in individuals experiencing high-energy military trauma. Hallmarks of successful treatment involve aggressive surgical debridement and early initiation of systemic antimicrobial therapy. Currently, intravenous anti-fungal therapy commences based on appearance of wounds and patient's clinical course. Whereas some clinical protocols exist to predict which critically injured patients should receive anti-fungal therapies, there are no established serum markers associated with IFI. Our hypothesis is that serum inflammatory cytokines exist that can assist in identifying individuals at risk for IFI.

METHODS

This is a retrospective case control study at a single institution. Nine patients with IFI (Saksenaea vasiformis, Fusarium sp., Graphium sp., Scedosporium sp., Aspergillus sp., Mucor sp., and Alternaria sp.) after battlefield trauma were matched to nine individuals with similar injury patterns whose laboratory results were negative for IFI. The combination of serum inflammatory cytokines from the first and second debridements was examined with multiplex platform proteomic analysis. We defined statistical significance as a two-tailed α<0.05 after adjusting for multiple comparisons using the false discovery rate method. This model was refined further with correlation-based filter selection and the area under the curve of the receiver operating characteristics (AUROC) was tested.

RESULTS

Both groups had similar Injury Severity Scores (ISS) (mean±standard deviation [SD]) (26.8±15.5 vs. 29.2±16.8, p=0.766). Elevated RANTES (regulated on activation, normal T cell expressed and secreted) alone (10,492.8±4,450.1 vs. 5,333.3±4,162.2, p=0.006) correlated with IFI. Also, the combination of persistent elevations in RANTES, interleukin (IL)-2R, and IL-15 was a robust model for predicting IFI with the AUROC being 0.9.

CONCLUSIONS

Elevation in serum cytokines, particularly RANTES, correlated with IFI in this small group of patients. This demonstrates the potential of future rapid serum testing for early initiation and guidance of anti-fungal therapies.

High Cholesterol Awareness, Treatment, and Control Among Hispanic/Latinos: Results From the Hispanic Community Health Study/Study of Latinos

BACKGROUND

We assessed high cholesterol (HC) awareness, treatment, and control rates among US Hispanic/Latino adults and describe factors associated with HC awareness and management.

METHODS AND RESULTS

Baseline data (collected 2008-2011) from a multisite probability sample of Hispanic/Latino adults in the Hispanic Community Health Study/Study of Latinos (18 to 74 years old; N=16 207) were analyzed. HC was defined as low-density lipoprotein-cholesterol ≥130 mg/dL and/or total cholesterol ≥240 mg/dL or use of cholesterol-lowering medication. Among Hispanic/Latino adults with HC, almost half (49.3%) were not aware of their condition and only 29.5% were receiving treatment. Men had a higher HC prevalence than women (44.0% versus 40.5%) but a lower rate of treatment (28.1% versus 30.6%). Younger adults were significantly less likely to be HC aware compared to those who were older. Those with hypertension, diabetes, and high socioeconomic position were more likely to be HC aware. US-born Hispanic/Latino were more likely to be HC unaware than foreign-born Hispanics/Latinos, but longer US residency was significantly associated with being HC aware, treated, and controlled. Cholesterol control was achieved among 64.3% of those who were HC treated. However, younger adults, women, those with lower income, those uninsured, and more recent immigrants were less likely to be HC controlled. Individuals of Puerto Rican or Dominican background were most likely to be HC aware and treated, whereas those of Mexican or Central American background were least likely to be HC treated. Individuals of Cuban and South American background had the lowest rates of HC control, whereas Puerto Ricans had the highest.

CONCLUSIONS

Understanding gaps in HC awareness, treatment, and control among US Hispanic/Latino adults can help inform physicians and policymakers to improve disease management and patient education programs.

Psychosocial Predictors of Metabolic Syndrome among Latino Groups in the Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE

We sought to determine the contribution of psychological variables to risk for metabolic syndrome (MetS) among Latinos enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA), and to investigate whether social support moderates these associations, and whether inflammatory markers mediate the association between psychological variables and MetS.

RESEARCH DESIGN AND METHODS

Cross-sectional analyses at study baseline were conducted with a national Latino cohort (n = 1,388) that included Mexican Americans, Dominican Americans, Puerto Rican Americans and Central/South Americans. Hierarchical logistic regression analyses were conducted to test the effects of psychosocial variables (chronic stress, depressive symptoms, and social support) on MetS. In addition, separate subgroup-specific models, controlling for nationality, age, gender, socioeconomic position, language spoken at home, exercise, smoking and drinking status, and testing for the effects of chronic stress, depressive symptoms and inflammation (IL-6, CRP, fibrinogen) in predicting risk for MetS were conducted.

RESULTS

In the overall sample, high chronic stress independently predicted risk for MetS, however this association was found to be significant only in Mexican Americans and Puerto Rican Americans. Social support did not moderate the associations between chronic stress and MetS for any group. Chronic stress was not associated with inflammatory markers in either the overall sample or in each group.

CONCLUSIONS

Our results suggest a differential contribution of chronic stress to the prevalence of MetS by national groups.

The Role of Hypertension in Race-Ethnic Disparities in Cardiovascular Disease

Race-ethnic disparities in cardiovascular disease (CVD) have persisted in the USA over the past few decades. Hypertension (HTN) is a significant contributor to CVD, including coronary heart disease, stroke, end-stage kidney disease and overall mortality and race-ethnic disparities in longevity. Additionally, both non-Hispanic blacks (NHBs) and Hispanic adults have been known to have higher prevalence of poorly controlled blood pressure compared to non-Hispanic whites (NHWs). Addressing these disparities has been a focus of programs such as the Million Hearts initiative. This review will provide an update of available data on HTN in various race-ethnic groups, including awareness, treatment, and control and note the recent progress in HTN control across all race/ethnic groups. We will also discuss the recent 2014 U.S. HTN guideline that has led to debate regarding the potential impact of BP goals in older persons on worsening CVD disparities, with disproportionate effects on women and NHBs.

Prevalence and trends of isolated systolic hypertension among untreated adults in the United States

The prevalence and long-term trends of isolated systolic hypertension (ISH) among untreated adults have not been reported. Data from 24,653 participants aged ≥18 years were selected from the National Health and Nutrition Examination Survey 1999-2010. The prevalence and 95% confidence intervals (CIs) of untreated ISH were estimated by conducting the independent survey t-test. The prevalence of untreated ISH was 9.4% and decreased from 10.3% in 1999-2004 to 8.5% in 2005-2010 (P = .00248). Old persons, females, and non-Hispanic blacks had higher prevalence of untreated ISH. Compared with 1999-2004, the prevalence of untreated ISH in 2005-2010 decreased among older (33.6%; 95% CI, 30.9%-36.3% vs. 25.1%; 95% CI, 22.7%-27.5%) and female individuals (8.3%; 95% CI, 7.5-9.2% vs. 11.4%; 95% CI, 10.4-12.3%). The stratified prevalence of untreated ISH declined in 2005-2010 (vs. 1999-2004) for older non-Hispanic whites (24.6% vs. 32.8%; P < .0001) and blacks (27.7% vs. 40.8%; P = .0013), non-Hispanic white females (7.5% vs. 10.8%; P < .0001), older individuals with higher education (21.0% vs. 30.6%; P = .0024), and females with lower education (10.1% vs. 13.1%; P = .006). Untreated ISH is more prevalent in older adults and females. Significant decreases in untreated ISH prevalence over time among these groups suggest that public health measures and/or treatment patterns are trending in the right direction.

Rationale and Design of the Echocardiographic Study of Hispanics/Latinos (ECHO-SOL)

BACKGROUND

Information regarding the prevalence and determinants of cardiac structure and function (systolic and diastolic) among the various Hispanic background groups in the United States is limited.

METHODS AND RESULTS

The Echocardiographic Study of Latinos (ECHO-SOL) ancillary study recruited 1,824 participants through a stratified-sampling process representative of the population-based Hispanic Communities Health Study - Study of Latinos (HCHS-SOL) across four sites (Bronx, NY; Chicago, Ill; San Diego, Calif; Miami, Fla). The HCHS-SOL baseline cohort did not include an echo exam. ECHO-SOL added the echocardiographic assessment of cardiac structure and function to an array of existing HCHS-SOL baseline clinical, psychosocial, and socioeconomic data and provides sufficient statistical power for comparisons among the Hispanic subgroups. Standard two-dimensional (2D) echocardiography protocol, including M-mode, spectral, color and tissue Doppler study was performed. The main objectives were to: 1) characterize cardiac structure and function and its determinants among Hispanics and Hispanic subgroups; and 2) determine the contributions of specific psychosocial factors (acculturation and familismo) to cardiac structure and function among Hispanics.

CONCLUSION

We describe the design, methods and rationale of currently the largest and most comprehensive study of cardiac structure and function exclusively among US Hispanics. ECHO-SOL aims to enhance our understanding of Hispanic cardiovascular health as well as help untangle the relative importance of Hispanic subgroup heterogeneity and sociocultural factors on cardiac structure and function.

Dyslipidemia patterns among Hispanics/Latinos of diverse background in the United States

BACKGROUND

The prevalence and determinants of dyslipidemia patterns among Hispanics/Latinos are not well known.

METHODS

Lipid and lipoprotein data were used from the Hispanic Community Health Study/Study of Latinos—a population-based cohort of 16,415 US Hispanic/Latinos ages 18-74 years. National Cholesterol Education Program cutoffs were employed. Differences in demographics, lifestyle factors, and biological and acculturation characteristics were compared among those with and without dyslipidemia.

RESULTS

Mean age was 41.1 years, and 47.9% were male. The overall prevalence of any dyslipidemia was 65.0%. The prevalence of elevated low-density lipoprotein cholesterol was 36.0%, and highest among Cubans (44.5%; P < .001). Low high-density lipoprotein cholesterol (HDL-C) was present in 41.4% and did not significantly differ across Hispanic background groups (P = .09). High triglycerides were seen in 14.8% of Hispanics/Latinos, most commonly among Central Americans (18.3%; P < .001). Elevated non-HDL-C was seen in 34.7%, with the highest prevalence among Cubans (43.3%; P < .001). Dominicans consistently had a lower prevalence of most types of dyslipidemia. In multivariate analyses, the presence of any dyslipidemia was associated with increasing age, body mass index, and low physical activity. Older age, female sex, diabetes, low physical activity, and alcohol use were associated with specific dyslipidemia types. Spanish-language preference and lower educational status were associated with higher dyslipidemia prevalence.

CONCLUSION

Dyslipidemia is highly prevalent among US Hispanics/Latinos; Cubans seem particularly at risk. Determinants of dyslipidemia varied across Hispanic backgrounds, with socioeconomic status and acculturation having a significant effect on dyslipidemia prevalence. This information can help guide public health measures to prevent disparities among the US Hispanic/Latino population.

Atrial fibrillation incidence and risk factors in relation to race-ethnicity and the population attributable fraction of atrial fibrillation risk factors: the Multi-Ethnic Study of Atherosclerosis

PURPOSE

We studied incident atrial fibrillation (AF) in the prospective community-based Multi-Ethnic Study of Atherosclerosis (MESA). Reportedly, non-Hispanic blacks (NHBs) have a lower AF burden compared with their non-Hispanic white (NHW) counterparts. Information on the epidemiology of AF in Hispanic and Asian populations is much more limited.

METHODS

We excluded participants with a history of AF at enrollment. A total of 6721 MESA participants were monitored for the first AF event ascertained according to hospital discharge International Classification of Diseases, Ninth Revision, codes. Age- and sex-adjusted incidence rates (IRs) of AF were calculated per 1000 person-years of observation. IR ratios were calculated using NHWs as the reference group. Age- and sex-adjusted population attributable fractions (PAFs) of established modifiable AF risk factors were ascertained.

RESULTS

In the MESA cohort, 47.2% was male; at baseline, 25.7% had hypertension; 12.5% had diabetes. Three hundred five incident hospitalized AF events occurred over a mean follow-up of 7.3 years. Age- and sex-adjusted IRs and IR ratios showed that overall AF incidence was significantly lower among Hispanics, NHBs and Chinese compared with NHWs (all P < .001). Among participants 65 years of age or greater, Hispanics, Chinese, and blacks had significantly lower AF incidence than NHWs (all P ≤ .01), but IRs were similar among participants under age 65 years. The PAF for smoking was 27% among NHBs but lower among other race-ethnic groups. Among NHWs, the PAF for hypertension was 22.2%, but this was higher among NHBs (33.1%), Chinese (46.3%), and Hispanics (43.9%).

CONCLUSIONS

Overall, the incidence of hospitalized AF was significantly lower in Hispanics, NHBs, and Chinese than in NHWs. A larger proportion of AF events appear to be attributable to hypertension among nonwhite populations compared with NHWs.

Population attributable risks of hypertension and diabetes for cardiovascular disease and stroke in the northern Manhattan study

BACKGROUND

Understanding the population-level risk factor contribution to disease incidence is critical for effective allocation of resources for prevention. There are little data on the contribution of cardiovascular disease (CVD) risk factors in multiethnic elderly populations.

METHODS AND RESULTS

The Northern Manhattan Study (n=3298) is a population-based prospective cohort study of CVD outcomes in a multiethnic urban population. Multivariable Cox's models were used to calculate hazard ratios, population attributable risk (PAR), and 95% confidence intervals (CIs) for (1) combined vascular event (VE) endpoint of stroke/myocardial infarction/vascular death (n=835) and (2) stroke (n=347). The PAR resulting from hypertension (HTN) was 24.3% (95% CI, 13.2 to 35.4) for VE and 29.9% (95% CI, 12.5 to 47.4) for stroke; PAR resulting from diabetes was 12.7% (95% CI, 8.2 to 17.2) for VE and 19.5% (95% CI, 12.4 to 26.5) for stroke. The PAR resulting from HTN and diabetes for stroke differed by race-ethnicity and age (P for differences <0.05). PAR for stroke reslting from HTN was greater among Hispanics (50.6%; 95% CI, 29.2 to 71.9) than non-Hispanic whites (2.6%; 95% CI, -33.2 to 38.6) and in those <80 years of age (35.6%; 95% CI, 18.9 to 52.3) than in those ≥80 (-0.3%; 95% CI, -34.2 to 33.6). Similarly, the PAR for stroke resulting from diabetes was 23.6% among those <80 years of age (95% CI, 15.7 to 31.5) and 2.3% among those ≥80 (95% CI, -8.2 to 12.7; P for difference=0.001). The PAR for VE did not differ by age/sex/race-ethnicity.

CONCLUSIONS

HTN and diabetes have important effects on the burden of stroke, particularly among those younger than age 80 and Hispanics. Public health campaigns targeted at specific risk factors in specific populations can lead to a greater reduction in CVD.

Left ventricular dilation and incident congestive heart failure in asymptomatic adults without cardiovascular disease: multi-ethnic study of atherosclerosis (MESA)

BACKGROUND

Limited data exist on the association between left ventricular (LV) dilation/remodeling and incident heart failure (HF), especially in adults without prior myocardial infarction (MI) and valvular heart disease. We assessed the association between LV dilation and remodeling and incident HF in a multiethnic cohort.

METHODS AND RESULTS

A total of 4,974 of 6,814 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) had cardiac magnetic resonance imaging and complete data. Kaplan-Meier and Cox proportional hazard analyses were used to assess the association between LV end-diastolic diameter (LVEDD) and adjudicated HF. During the 12 years of follow-up (mean 9.4 y), 177 (3.6%) HF events occurred, 126 (71.2%) in HF with reduced ejection fraction (EF) and 51 (28.8%) in HF with preserved EF. LV dilation (LVEDD >52 mm or >95th percentile) was associated with HF in univariate (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.08-1.46; P = .007) and multivariable Cox models (HR 1.28, 95% CI 1.09-1.57; P = .01) adjusting for traditional risk factors, medication use, LV EF, and interim MI. We found a significant multiplicative interaction between LVEDD and LV EF in our full multivariable models. Participants with dilated LV and preserved EF had increased risk [HR 2.22, 95% CI 1.46-3.37; P = .006) and those with dilated LV and reduced EF had worse prognosis (HR 7.35, 95% CI 2.36-22.85; P = .0006) compared with normal-size LV and preserved EF. A high proportion of participants with LV dilation had eccentric remodeling, a risk factor for HF. Concentric hypertrophy, also a risk factor for HF, was common in the normal-size LV group.

CONCLUSIONS

LV dilation predicts incident HF independently from risk factors, LV EF, and interim MI.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Blood pressure and cardiovascular effects of new and emerging antidiabetic agents

Despite remarkable declines in US cardiovascular disease morbidity and mortality over the last several decades, the prevalence of risk factors such as type 2 diabetes and hypertension remains high, associated with increasing obesity rates. Although optimal glycemic control remains a primary focus to decrease the disease burden, the FDA has issued guidance recommendations for documenting cardiovascular disease-related safety with research trials on new antidiabetic agents with more demanding requirements compared to past approval of existing therapies. This review will discuss the public health impact of type 2 diabetes, specifically with comorbid hypertension; mechanisms of action of the newest antidiabetic drug classes; and preliminary findings and potential clinical significance of the favorable blood pressure and body weight effects of the sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists; and additionally discuss two recent large cardiovascular outcome trials with dipeptidyl peptidase-4 inhibitors.

Systolic blood pressure levels among adults with hypertension and incident cardiovascular events: the atherosclerosis risk in communities study

IMPORTANCE

Studies document a progressive increase in heart disease risk as systolic blood pressure (SBP) rises above 115 mm Hg, but it is unknown whether an SBP lower than 120 mm Hg among adults with hypertension (HTN) lowers heart failure, stroke, and myocardial infarction risk.

OBJECTIVE

To examine the risk of incident cardiovascular (CV) events among adults with HTN according to 3 SBP levels: 140 mm Hg or higher; 120 to 139 mm Hg; and a reference level of lower than 120 mm Hg.

DESIGN, SETTING, AND PARTICIPANTS

A total of 4480 participants with HTN but without prevalent CV disease at baseline (years 1987-1989) from the Atherosclerosis Risk in Communities Study were included. Measurements of SBP were taken at baseline and at 3 triennial visits; SBP was treated as a time-dependent variable and categorized as elevated (≥140 mm Hg), standard (120-139 mm Hg), and low (<120 mm Hg). Multivariable Cox regression models included baseline age, sex, diabetes status, BMI, high cholesterol level, smoking status, and alcohol intake.

MAIN OUTCOMES AND MEASURES

Incident composite CV events (heart failure, ischemic stroke, myocardial infarction, or death related to coronary heart disease).

RESULTS

After a median follow-up of 21.8 years, a total of 1622 incident CV events had occurred. Participants with elevated SBP developed incident CV events at a significantly higher rate than those in the low BP group (adjusted hazard ratio [HR], 1.46; 95% CI, 1.26-1.69). However, there was no difference in incident CV event-free survival among those in the standard vs low SBP group (adjusted HR, 1.00; 95% CI, 0.85-1.17). Further adjustment for BP medication use or diastolic BP did not significantly affect the results.

CONCLUSIONS AND RELEVANCE

Among patients with HTN, having an elevated SBP carries the highest risk for cardiovascular events, but in this categorical analysis, once SBP was below 140 mm Hg, an SBP lower than 120 mm Hg did not appear to lessen the risk of incident CV events.

Risk factors associated with invasive fungal infections in combat trauma

BACKGROUND

In recent years, invasive fungal infections (IFI) have complicated the clinical course of patients with combat-related injuries. Commonalities in injury patterns and characteristics among patients with IFI led to the development of a Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management. We performed a case-control study to confirm and further delineate risk factors associated with IFI development in combat casualties with the objective of generating data to refine the CPG and promote timelier initiation of treatment.

METHODS

Data were collected retrospectively for United States (U.S.) military personnel injured during deployment in Afghanistan from June 2009 through August 2011. Cases were identified as IFI based upon wound cultures with fungal growth and/or fungal elements seen on histology, in addition to the presence of recurrent wound necrosis. Controls were matched using date of injury (±3 mo) and injury severity score (±10). Risk factor parameters analyzed included injury circumstances, blood transfusion requirements, amputations after first operative intervention, and associated injuries. Data are expressed as multivariate odds ratios (OR; 95% confidence interval [CI]).

RESULTS

Seventy-six IFI cases were identified from 1,133 U.S. military personnel wounded in Afghanistan and matched to 150 controls. Parameters associated significantly with the development of IFI multivariate analysis were blast injuries (OR: 5.7; CI: 1.1-29.6), dismounted at time of injury (OR: 8.5; CI: 1.2-59.8); above the knee amputations (OR: 4.1; CI: 1.3-12.7), and large-volume packed red blood cell (PRBC; >20 U) transfusions within first 24 h (OR: 7.0; CI: 2.5-19.7).

CONCLUSIONS

Our analysis indicates that dismounted blast injuries, resulting in above the knee amputations, and requirement of large volume PRBC transfusions are independent predictors of IFI development. These data confirm all the preliminary risk factors, except for genitalia/perineal injuries, utilized by JTS in their IFI CPG. Model validation is necessary for further risk factor specification.

Carotid intima-media thickness is associated with incident heart failure among middle-aged whites and blacks: the Atherosclerosis Risk in Communities study

Background

Increased carotid intima‐media thickness (IMT) is associated with subclinical left ventricular myocardial dysfunction, suggesting a possible role of carotid IMT in heart failure (HF) risk determination.

Methods and Results

Mean far wall carotid IMT, measured by B‐mode ultrasound, was available for 13 590 Atherosclerosis Risk in Communities study participants aged 45 to 64 years and free of HF at baseline. HF was defined using ICD‐9 428 and ICD‐10 I‐50 codes from hospitalization records and death certificates. The association between carotid IMT and incident HF was assessed using Cox proportional hazards analysis with models adjusted for demographic variables, major CVD risk factors, and interim CHD. There were 2008 incident HF cases over a median follow‐up of 20.6 years (8.1 cases per 1000 person‐years). Mean IMT was higher in those with HF than in those without (0.81 mm±0.23 versus 0.71 mm±0.17, P<0.001). Unadjusted rate of HF for the fourth compared with the first quartile of IMT was 15.4 versus 3.9 per 1000 person‐years; P<0.001. In multivariable analysis, after adjustment, each standard deviation increase in IMT was associated with incident HF (HR 1.20 [95% CI: 1.16 to 1.25]). After adjustment, the top quartile of IMT was associated with HF (HR 1.60 [95% CI: 1.37 to 1.87]). Results were similar across race and gender groups.

Conclusions

Increasing carotid IMT is associated with incident HF in middle‐aged whites and blacks, beyond risks explained by major CVD risk factors and CHD. This suggests that carotid IMT may be associated with HF through mechanisms different from myocardial ischemia or infarction.

The relationship between measures of obesity and incident heart failure: the multi-ethnic study of atherosclerosis

OBJECTIVE

To evaluate the strength of association of body mass index (BMI) and waist circumference (WC) with incident heart failure (HF), exploring our associations by ethnicity and age.

DESIGN AND METHODS

6,809 participants, aged 45-84 years old, without clinical cardiovascular disease (2000-2002), from the Multi-Ethnic Study of Atherosclerosis were included. Cox-Proportional hazards models were used to examine associations of BMI and WC with incident HF. The predictive abilities of BMI and WC were compared using receiver operating characteristic curves.

RESULTS

Over a median follow-up of 7.6 years, there were 176 cases. BMI and WC were associated with incident HF in men (1.33 [1.10-1.61] and 1.38 [1.18-1.62], respectively] and women (1.70 [1.33-2.17] and 1.64 [1.29-2.08], respectively). These associations became non-significant after adjusting for obesity-related conditions (hypertension, dysglycemia, hypercholesterolemia, left ventricular hypertrophy, kidney disease, and inflammation). The associations of BMI and WC did not vary significantly by ethnicity or age-group, but were inverse in Hispanic men. The area under the curve for BMI and WC was 0.749 and 0.750, respectively, in men and 0.782 and 0.777, respectively, in women.

CONCLUSIONS

The association between obesity and incident HF is largely mediated by obesity-related conditions. BMI and WC have similar predictive abilities for incident HF.

Socioeconomic status, psychosocial factors, race and nocturnal blood pressure dipping in a Hispanic cohort

BACKGROUND

Little information is available about the relationship of socioeconomic status (SES) to blunted nocturnal ambulatory blood pressure (ABP) dipping among Hispanics and whether this relationship differs by race. We sought to characterize ABP nondipping and its determinants in a sample of Hispanics.

METHODS

We enrolled 180 Hispanic participants not on antihypertensive medications. SES was defined by years of educational attainment. All participants underwent 24-hour ABP monitoring. A decrease of <10% in the ratio between average awake and average asleep systolic BP was considered nondipping.

RESULTS

The mean age of the cohort was 67.1 ± 8.7, mean educational level was 9.4 ± 4.4 years, and 58.9% of the cohort was female. The cohort was comprised of 78.3% Caribbean Hispanics with the rest from Mexico and Central/South America; 41.4% self-identified as white Hispanic, 34.4% self-identified as black Hispanic, and 24.4% did not racially self- identify. The percentage of nondippers was 57.8%. Educational attainment (10.5 years vs. 8.6 years; P <0.01) was significantly higher among dippers than nondippers. In multivariable analyses, each 1-year increase in education was associated with a 9% reduction in the likelihood of being a nondipper (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84-0.98; P = 0.01). There were significantly greater odds of being a nondipper for black Hispanics than for white Hispanics (OR, 2.83, 95% CI, 1.29-6.23; P = 0.005). Higher SES was significantly protective of nondipping in white Hispanics but not black Hispanics.

CONCLUSIONS

These results document a substantial prevalence of nondipping in a cohort of predominantly normotensive Hispanics. Dipping status varied significantly by race. Lower SES is significantly associated with nondipping status, and race potentially impacts on this relation.

Association of lipids with incident heart failure among adults with and without diabetes mellitus: Multiethnic Study of Atherosclerosis

BACKGROUND

Dyslipidemia is a known risk factor for coronary disease, but its role in heart failure (HF) development is less well-defined.

METHODS AND RESULTS

We included 5688 participants, aged 45 to 84 years, without clinical cardiovascular disease, and not receiving lipid-lowering medications at baseline, from the Multiethnic Study of Atherosclerosis. Cox-proportional hazards models were used to evaluate associations of triglyceride, total cholesterol/high-density lipoprotein-cholesterol (HDL-C) ratio, HDL-C, and non HDL-C with incident HF. We investigated for effect-modification by diabetes mellitus status and sex. During a median follow-up of 8.5 years, there were 152 incident HF cases. There were no interactions by sex. We observed significant interactions between triglyceride and diabetes mellitus (P(interaction)<0.05). We stratified our analyses by diabetes mellitus status. In participants with diabetes, the hazard ratios were 2.03 (0.97-4.27) and 1.68 (1.18-2.38) for high triglyceride and log of triglyceride, respectively, after adjusting for confounders, comorbidities, and diabetes mellitus severity/treatment. The association of high triglyceride with incident HF was attenuated by interim myocardial infarction. The hazard ratios were greatest in participants with diabetes who also had high triglyceride, low HDL-C, or high total cholesterol/HDL-C ratio (3.59 [2.03-6.33], 3.62 [2.06-6.36], and 3.54 [1.87-6.70], respectively). Lipid measures were not associated with incident HF in individuals without diabetes.

CONCLUSIONS

The risk of incident HF is greater in individuals with diabetes mellitus who also have high triglyceride, low HDL-C, or high total cholesterol/HDL-C ratio. The association of high triglyceride with incident HF is partly mediated by myocardial infarction.

Salt sensitivity: a review with a focus on non-Hispanic blacks and Hispanics

The purpose of this review is to summarize the available information regarding salt sensitivity particularly as it relates to non-Hispanic blacks and Hispanics and to clarify possible etiologies, especially those that might shed light on potential treatment options. In non-Hispanic blacks, there is evidence that endothelial dysfunction, reduced potassium intake, decreased urinary kallikrein excretion, upregulation of sodium channel activity, dysfunction in atrial natriuretic peptide (ANP) production, and APOL1 gene nephropathy risk variants may cause or contribute to salt sensitivity. Supported treatment avenues include diets high in potassium and soybean protein, the components of which stimulate nitric oxide production. Racial heterogeneity complicates the study of salt sensitivity in Hispanic populations. Caribbean Hispanics, who have a higher proportion of African ancestry, may respond to commonly prescribed anti-hypertensive agents in a way that is characteristic of non-Hispanic black hypertensives. The low-renin hypertensive phenotype commonly seen in non-Hispanic blacks has been linked to salt sensitivity and may indicate an increased risk for salt sensitivity in a portion of the Hispanic population. In conclusion, increased morbidity and mortality associated with salt sensitivity mandates further studies evaluating the efficacy of tailored dietary and pharmacologic treatment in non-Hispanic blacks and determining the prevalence of low renin hypertension and salt sensitivity within the various subgroups of Hispanic Americans.

Prognosis of individuals with asymptomatic left ventricular systolic dysfunction in the multi-ethnic study of atherosclerosis (MESA)

BACKGROUND

Limited data exist on the prevalence, associations, and prognosis of individuals with asymptomatic left ventricular systolic dysfunction (ALVSD), especially in populations without previous clinical cardiovascular disease (CVD).

METHODS AND RESULTS

Kaplan-Meier and Cox proportional hazard analyses were used to assess the association between ALVSD, defined as left ventricular ejection fraction <50%, and adjudicated incident congestive heart failure (CHF), all-cause mortality, and CVD events. Of 5004 participants, 112 participants had CHF, 321 had a CVD event, and 278 died after 9 years of follow-up. The overall prevalence of ALVSD was 1.7%, with a higher prevalence in blacks (2.6%). ALVSD had a worse cardiovascular risk profile and was also associated with increased risk in unadjusted and adjusted models for incident CHF (HR [hazard ratio] [95% CI {confidence interval}]: 12.0 [7.04-20.3], P<0.0001 and 8.69 [4.89-15.45], P<0.001 respectively), CVD (HR [95% CI]: 3.32 [1.98-5.58], P<0.001 and 2.21 [1.30-3.73], P=0.003 respectively), and all-cause mortality (HR [95% CI]: 3.47 [2.03-5.94], P<0.0001 and 2.00 [1.13-3.54], P=0.017, respectively). A 10% decrement in left ventricular ejection fraction at baseline was associated with an increase in risk in unadjusted and adjusted models for clinical CHF (HR [95% CI]: 2.17 [1.82-2.63], P<0.0001 and 2.13 [1.73-2.51], P<0.001, respectively) and all-cause mortality (HR [95% CI]: 1.22 [1.05-1.41], P=0.009 and 1.17 [1.00-1.36], P=0.047, respectively). Among the subset of participants with ALVSD, the left ventricular mass index was particularly informative about risk for incident CHF (c-index=0.74).

CONCLUSIONS

ALVSD is uncommon in individuals without previous clinical CVD, but it is associated with high risk for CHF, CVD, and all-cause mortality. The left ventricular mass index had good discrimination for incident CHF in Multi-Ethnic Study of Atherosclerosis (MESA) participants with ALVSD.

Dedicated Tracking of Patients with Retrievable Inferior Vena Cava Filters Improves Retrieval Rates

Retrievable IVC filters (R-IVCF) are associated with multiple complications, including filter migration and deep venous thrombosis. Unfortunately, most series of R-IVCF show low retrieval rates, often due to loss to follow-up. This study demonstrates that actively tracking R-IVCF improves retrieval. Trauma patients at one institution with R-IVCF placed between January 2007 and January 2011 were tracked in a registry with a goal of retrieval. These were compared to a control group who had R-IVCF placed previously (December 2005 to December 2006). Outcome measures include filter retrieval, retrieval attempts, loss to follow-up, and time to filter retrieval. We compared 93 tracked patients with R-IVCF with 20 controls. The baseline characteristics of the groups were similar. Tracked patients had significantly higher rates of filter retrieval (60% vs 30%, P = 0.02) and filter retrieval attempts (70% vs 30%, P = 0.002) and were significantly less likely to be lost to follow-up (5% vs 65%, P < 0.0001). Time to retrieval attempt was 84 days in the registry versus 210 days in the control group, which trended towards significance ( P = 0.23). Tracking patients with R-IVCF leads to improved retrieval rates, more retrieval attempts, and decreased loss to follow up. Institutions should consider tracking R-IVCF to maximize retrieval rates.

Population structure of Hispanics in the United States: the multi-ethnic study of atherosclerosis

Using ∼60,000 SNPs selected for minimal linkage disequilibrium, we perform population structure analysis of 1,374 unrelated Hispanic individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with self-identification corresponding to Central America (n = 93), Cuba (n = 50), the Dominican Republic (n = 203), Mexico (n = 708), Puerto Rico (n = 192), and South America (n = 111). By projection of principal components (PCs) of ancestry to samples from the HapMap phase III and the Human Genome Diversity Panel (HGDP), we show the first two PCs quantify the Caucasian, African, and Native American origins, while the third and fourth PCs bring out an axis that aligns with known South-to-North geographic location of HGDP Native American samples and further separates MESA Mexican versus Central/South American samples along the same axis. Using k-means clustering computed from the first four PCs, we define four subgroups of the MESA Hispanic cohort that show close agreement with self-identification, labeling the clusters as primarily Dominican/Cuban, Mexican, Central/South American, and Puerto Rican. To demonstrate our recommendations for genetic analysis in the MESA Hispanic cohort, we present pooled and stratified association analysis of triglycerides for selected SNPs in the LPL and TRIB1 gene regions, previously reported in GWAS of triglycerides in Caucasians but as yet unconfirmed in Hispanic populations. We report statistically significant evidence for genetic association in both genes, and we further demonstrate the importance of considering population substructure and genetic heterogeneity in genetic association studies performed in the United States Hispanic population.

Using genotype data from about 60,000 distinct genetic markers, we examined population structure in 1,374 unrelated Hispanic individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with self-identification corresponding to Central America (n = 93), Cuba (n = 50), the Dominican Republic (n = 203), Mexico (n = 708), Puerto Rico (n = 192), and South America (n = 111). By comparing genetic ancestry of MESA Hispanic participants to reference samples representing worldwide diversity, we show major differences in ancestry of MESA Hispanics reflecting their Caucasian, African, and Native American origins, with finer differences corresponding to North-South geographic origins that separate MESA Mexican versus Central/South American samples. Based on our analysis, we define four subgroups of the MESA Hispanic cohort that show close agreement with the following self-identified regions of origin: Dominican/Cuban, Mexican, Central/South American, and Puerto Rican. We examine association of triglycerides with selected genetic markers, and we further demonstrate the importance of considering differences in genetic ancestry (or factors associated with genetic ancestry) when performing genetic studies of the United States Hispanic population.

Coronary death and myocardial infarction among Hispanics in the Northern Manhattan Study: exploring the Hispanic paradox

PURPOSE

Prior studies have reported that Hispanics have lower cardiovascular disease (CVD) mortality despite a higher burden of risk factors. We examined whether Hispanic ethnicity was associated with a lower risk of nonfatal myocardial infarction (MI) coronary death (CD) and vascular death.

METHODS

A total of 2671 participants in the Northern Manhattan Study without clinical CVD were prospectively evaluated. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the association of race-ethnicity with nonfatal MI, CD, and vascular death after adjusting for demographic and CVD risk factors.

RESULTS

Mean age was 68.8 (10.4) years; 52.8% were Hispanic (88% Caribbean-Hispanic). Hispanics were more likely to have hypertension (73.1% vs. 62.2%, p < .001) and diabetes (22.0% vs. 13.3%, p < .001), and less likely to perform any physical activity (50.1% vs. 69.2%, p < .001) compared to non-Hispanic whites (NHW). During a mean 10 years of follow-up there were 154 nonfatal MIs, 186 CD, and 386 vascular deaths. In fully adjusted models, Hispanics had a lower risk of CD (adjusted HR = 0.36, 95% CI: 0.21-0.60), and vascular death (adjusted HR = 0.62, 95% CI: 0.43-0.89), but not nonfatal MI (adjusted HR = 0.95, 95% CI: 0.56-1.60) when compared to NHW.

CONCLUSIONS

We found a "Hispanic paradox" for coronary and vascular deaths, but not nonfatal MI.

Association of annular calcification and aortic valve sclerosis with brain findings on magnetic resonance imaging in community dwelling older adults: the cardiovascular health study

OBJECTIVES

The objective of this study was to investigate the associations of mitral annular calcification, aortic annular calcification, and aortic valve sclerosis with covert magnetic resonance imaging (MRI)-defined brain infarcts.

BACKGROUND

Clinically silent brain infarcts defined by MRI are associated with increased risk for cognitive decline, dementia, and future overt stroke. Left-sided cardiac valvular and annular calcifications are suspected as risk factors for clinical ischemic stroke.

METHODS

A total of 2,680 CHS (Cardiovascular Health Study) participants without clinical histories of stroke or transient ischemic attack underwent brain MRI in 1992 and 1993, 1 to 2 years before echocardiographic exams (1994 to 1995).

RESULTS

The mean age of the participants was 74.5 ± 4.8 years, and 39.3% were men. The presence of any annular or valvular calcification (mitral annular calcification, aortic annular calcification, or aortic valve sclerosis), mitral annular calcification alone, or aortic annular calcification alone was significantly associated with a higher prevalence of covert brain infarcts in unadjusted analyses (p < 0.01 for all). In models adjusted for age, sex, race, body mass index, physical activity, creatinine, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking, diabetes, coronary heart disease, and congestive heart failure, the presence of any annular or valve calcification remained associated with covert brain infarcts (risk ratio: 1.24; 95% confidence interval: 1.05 to 1.47). The degree of annular or valvular calcification severity showed a direct relation with the presence of covert MRI findings.

CONCLUSIONS

Left-sided cardiac annular and valvular calcifications are associated with covert MRI-defined brain infarcts. Further study is warranted to identify mechanisms and determine whether intervening in the progression of annular and valvular calcification could reduce the incidence of covert brain infarcts as well as the associated risk for cognitive impairment and future stroke.

Association of sodium and potassium intake with left ventricular mass: coronary artery risk development in young adults

High salt intake may affect left ventricular mass (LVM). We hypothesized that urinary sodium (UNa) and sodium/potassium ratio (UNa/K) are associated with LVM in a predominantly normotensive cohort of young adults. The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a multicenter cohort of black and white men and women aged 30±3.6 years at the time of baseline echocardiographic examination (1990-1991). 2D guided M-mode LVM indexed to body size (grams per meter(2.7)) was calculated, and UNa and potassium excretion assessed (average of three 24-hour urinary samples, n=1042). Linear and logistic regression analysis was used. Participants were 57% women and 55% black. Only 4% were hypertensive. UNa, urinary potassium, and UNa/K ratios were (mean±SD) 175.6±131.0, 56.4±46.3, and 3.4±1.4 mmol/24 h, respectively. Participants in the highest versus the lowest UNa excretion quartile had the greatest LVM (37.5 versus 34.0 g/m(2.7); P<0.001). Adjusted for age, sex, education, and race, LVM averaged 0.945 g/m(2.7) higher per SD of UNa/K (P=0.001). The relationship between UNa/K and LVM persisted among 399 participants with repeat echocardiographic measures 5 years later. In logistic regression analysis adjusted for age, sex, education, and race, each SD higher baseline UNa/K was associated with 23% and 38% greater chances of being in the highest quartile of LVM at baseline (odds ratio: 1.23; P=0.005) and 5 years later (odds ratio: 1.38; P=0.02). A higher sodium/potassium excretion ratio is significantly related to cardiac structure, even among healthy young adults.

Race-ethnic differences in the association between lipid profile components and risk of myocardial infarction: The Northern Manhattan Study

OBJECTIVE

The aim of this study was to explore race-ethnic differences in the association between plasma lipid components and risk of incident myocardial infarction (MI).

DESIGN/METHODS

As part of the Northern Manhattan Study, 2,738 community residents without cardiovascular disease were prospectively evaluated. Baseline fasting blood samples were collected, and lipid panel components were analyzed as continuous and categorical variables. Cox proportional hazards models were used to calculate HRs and 95% CIs for incident MI after adjusting for demographic and cardiovascular risk factors.

RESULTS

The mean age was 68.8 ± 10.4 years; 36.7% were men. Of the participants, 19.9% were non-Hispanic white; 24.9%, non-Hispanic black; and 52.8%, Hispanic (>80% from the Caribbean). Hispanics had lower mean high-density lipoprotein cholesterol (HDL-C) and higher triglycerides (TG)/HDL-C. During a mean 8.9 years of follow-up, there were 163 incident MIs. In the whole cohort, all lipid profile components were associated with risk of MI in the expected directions. However, HDL-C (adjusted HR per 10 mg/dL increase 0.93, 95% CI 0.76-1.12) and TG/HDL-C >2 (adjusted HR 0.89, 95% CI 0.51-1.55) were not predictive of MI among Hispanics but were predictive among non-Hispanic blacks and whites. Triglycerides/HDL-C per unit increase was associated with an 8% higher risk of MI among Hispanics (adjusted HR 1.08, 95% CI 1.04-1.12).

CONCLUSIONS

In Hispanics, low HDL-C and TG/HDL-C >2 were not associated with MI risk. Our data suggest that a different TG/HDL ratio cutoff may be needed among Hispanics to predict MI risk.

Association between social isolation and left ventricular mass

BACKGROUND

Social isolation is associated with progression of cardiovascular disease, with the most socially isolated patients being at increased risk. Increased left ventricular mass is a predictor of cardiovascular morbidity and mortality. It is not yet clear whether social isolation is a determinant of increased left ventricular mass.

METHODS

We performed a cross-sectional study of Northern Manhattan Study participants who were free of clinical cardiovascular disease and had obtained transthoracic echocardiograms (n=2021) and a baseline questionnaire on social habits. Social isolation was defined as the lack of friendship networks (knowing fewer than 3 people well enough to visit within their homes). Echocardiographic left ventricular mass was indexed to height(2.7), analyzed as a continuous variable and compared between exposure groups.

RESULTS

The prevalence of social isolation was 13.5%. The average left ventricular mass was significantly higher (50.2 gm/m(2.7)) in those who were, as compared with those who were not (47.6 gm/m(2.7)), socially isolated (P<.05). Higher prevalence of social isolation was found among those less educated, uninsured, or unemployed. There were no significant race-ethnic differences in the prevalence of social isolation. In multivariate analysis, there was a trend toward an association between social isolation and increased left ventricular mass in the total cohort (P=.09). Among Hispanics, social isolation was significantly associated with greater left ventricular mass. Hispanics who were socially isolated averaged 3.9 gm/ht(2.7) higher left ventricular mass compared with those not socially isolated (P=.002). This relationship was not present among non-Hispanic blacks or whites.

CONCLUSION

In this urban tri-ethnic cohort, social isolation was prevalent and associated with indices of low socioeconomic status. Hispanics who were socially isolated had a greater risk for increased left ventricular mass.

Ethnic differences in aortic valve thickness and related clinical factors

BACKGROUND

Prior studies suggest that the causes of calcific aortic valve (AV) disease involve chronic inflammation, lipoprotein levels, and calcium metabolism, all of which may differ among race-ethnic groups. We sought to determine whether AV thickness differs by race-ethnicity in a large multiethnic population-based cohort.

METHODS

The Northern Manhattan Study includes stroke-free community-based Hispanic (57%), non-Hispanic black (22%), and non-Hispanic white (21%) participants. The relation between AV thickness on transthoracic echocardiography and clinical risk factors for atherosclerosis was evaluated among 2,085 participants using polytomous logistic regression models. Aortic valve thickness was graded in 3 categories (normal, mild, and moderate/severe) based on leaflet thickening and calcification.

RESULTS

Mild AV thickness was present in 44.4% and moderate/severe thickness in 5.7% of the cohort, with the lowest frequency of moderate/severe thickness seen particularly among Hispanic women. In multivariate models adjusting for age, sex, race-ethnicity, body mass index, hypertension, coronary artery disease, blood glucose, and high-density lipoprotein cholesterol, Hispanics had significantly less moderate/severe AV thickness (odds ratio 0.43, 95% CI 0.25-0.73) than non-Hispanic whites. Men were almost 2-fold as likely to have moderate/severe AV thickness compared with women (odds ratio 1.96, 95% CI 1.24-3.10).

CONCLUSIONS

In this large multiethnic population-based cohort, there were ethnic differences in the degree of AV thickness. Hispanic ethnicity was strongly protective against AV thickness. This effect was not related to traditional risk factors, suggesting that unmeasured factors related to Hispanic ethnicity and AV thickness may be responsible.

Left ventricular mass and ventricular remodeling among Hispanic subgroups compared with non-Hispanic blacks and whites: MESA (Multi-ethnic Study of Atherosclerosis)

OBJECTIVES

The purpose of this study was to examine the prevalence of left ventricular hypertrophy (LVH) and left ventricular (LV) remodeling patterns within Hispanic subgroups compared with non-Hispanic whites in the MESA (Multi-Ethnic Study of Atherosclerosis).

BACKGROUND

Hispanics are the largest and fastest-growing ethnic minority in the U.S., but there are no data on LVH and LV geometry among Hispanic subgroups.

METHODS

Cardiac magnetic resonance imaging was performed in 4,309 men and women age 45 to 84 years without clinical cardiovascular disease. Hispanics were categorized into subgroups based on self-reported ancestry. LVH was defined as the upper 95th percentile of indexed LV mass in a reference normotensive, nondiabetic, nonobese population, and LV remodeling according to the presence/absence of LVH and abnormal/normal LV mass to LV end-diastolic volume ratio.

RESULTS

Among Hispanic participants, 574 were of Mexican origin, 329 were of Caribbean origin, and 161 were of Central/South American origin. On unadjusted analysis, only Caribbean-origin Hispanics (prevalence ratio = 1.2; 95% confidence interval [CI]: 1.03 to 1.4) had greater prevalence of hypertension than non-Hispanic whites. Hispanic subgroups were more likely to have LVH than non-Hispanic whites after adjustment for hypertension and other covariates (Caribbean-origin Hispanics = odds ratio [OR]: 1.8, 95% CI: 1.1 to 3.0; Mexican-origin Hispanics = OR: 2.2, 95% CI: 1.4 to 3.3; Central/South Americans = OR: 1.5, 95% CI: 0.7 to 3.1). All Hispanic subgroups also had a higher prevalence of concentric and eccentric hypertrophy compared with non-Hispanic whites (p < 0.001).

CONCLUSIONS

Caribbean-origin Hispanics had a higher prevalence of LVH and abnormal LV remodeling compared with non-Hispanic whites. A higher prevalence of LVH and abnormal LV remodeling was also observed among Mexican-origin Hispanics, despite a lower prevalence of hypertension. Differences among Hispanic subgroups regarding LVH and LV remodeling should be taken into account when evaluating cardiovascular risk in this population.

Prevalence and determinants of isolated systolic hypertension among young adults: the 1999-2004 US National Health And Nutrition Examination Survey

BACKGROUND

Little is known about isolated systolic hypertension (ISH) in younger adults. We examined the prevalence and determinants of ISH in this age group using the 1999-2004 National Health and Nutrition Examination Surveys (NHANES) and made comparisons using data from NHANES III (1988-1994).

METHODS

A total of 5685 adults aged 18-39 years and not on antihypertensive medications were analyzed. Prevalence estimates of ISH and potential risk factors were estimated by age and sex. For comparison of prevalence estimates with published reports of NHANES III data, age cutoffs (18-24, 25-34, and 35-44 year) by sex were also employed. A multivariate logistic regression model tested independent determinants of ISH.

RESULTS

ISH in young adults had a higher prevalence than systolic/diastolic hypertension (1.57 +/- 0.23% vs. 0.93 +/- 0.18%). ISH prevalence increased within the last decade particularly for men for each respective age category [men (0.8 vs. 2.2%, 1.3 vs. 2.4%, 1.3 vs. 2.4%), women (0.0 vs. 0.3%, 0.1 vs. 0.7%, 1.7 vs. 1.8%)]. On multivariate analysis, obesity [odds ratio (OR): 2.68, 95% confidence interval (CI): 1.06, 6.77], male sex (OR: 2.19, 95% CI: 1.10, 4.37), education level less than high school (OR: 2.98, 95% CI: 1.10, 8.06), and current smoking (OR: 2.06, 95% CI: 1.03, 4.11) were characteristics independently associated with higher odds of ISH among young adults. Relative increases in prevalence between the surveys were noted for current smoking (24.3 vs. 51.5%), obesity (33.9 vs. 42.7%) and low educational level (18.4 vs. 38.6%).

CONCLUSION

ISH among young adults is increasing in prevalence, and is more common than systolic/diastolic hypertension. Obesity, smoking, and low socioeconomic status appear to be important determinants of ISH among young adults and have all increased over the last decade.

Prognostic Implications of Left Ventricular Mass Among Hispanics

Hispanics may carry a similar burden of increased left ventricular mass (LVM) as non-Hispanic blacks but whether LVM portends a worse outcome among Hispanics is largely unknown. We prospectively evaluated 1081 Hispanics enrolled in the Northern Manhattan Study during the period of 1993 to 2001. Subjects were aged ≥40 years and free of prior myocardial infarction or stroke. LVM was defined echocardiographically and indexed for height 2.7 . Cox proportional hazards models were used to assess the risk of vascular events with adjustments for age, gender, systolic blood pressure, diabetes, and smoking. LVM averaged 48.4±15 gm/ht 2.7 and on multivariate analysis was significantly associated with the combined end point of myocardial infarction, stroke, or vascular death (adjusted hazard ratio 1.34 per SD change in LVM [95% CI 1.10 to 1.63]). During a mean of 57 months of follow-up, 74 vascular events occurred. The annual rate of vascular events was 21.8 per 1000 patient-years in the highest quartile of LVM and 8.6 per 1000 patient-years in the lowest quartile ( P =0.007). These data demonstrate in a large population-based sample that increased LVM yields independent prognostic information among Hispanics, predicting a higher incidence of events attributable to vascular disease in this understudied population. Our findings identify the Hispanic population with increased LVM as a high-risk subgroup.

Classical positioning decreases the cross-sectional area of the subclavian vein

BACKGROUND

The classic position for subclavian venipuncture is the Trendelenberg position, with the head turned away and placement of a shoulder roll (SR). The purpose of this study was to determine whether this position results in the largest cross-sectional area (CSA) of the subclavian vein (SV).

METHODS

Adult volunteers underwent ultrasound imaging of the right SV in supine and Trendelenberg positioning in the following four head and shoulder positions: head neutral with the chin midline (NL), head turned away (TA), head neutral with an SR, and head TA with an SR (TA/SR). The mean CSA of the SV in each position was calculated. Statistical significance was determined using Student's t, Wilcoxon signed rank, and Bonferroni test.

RESULTS

Eighteen adults participated in the study. Trendelenberg positioning significantly increased the CSA of the SV in all positions except NL compared to supine positioning (P < .03). An SR significantly decreased SV CSA in all positions. The largest SV CSA was obtained in the TA/Trendelenberg position (1.41 +/- .06 cm(2)). The classic positioning for subclavian cannulation, TA/SR/Trendelenberg, resulted in a significantly smaller CSA than TA/Trendelenberg position (1.27 +/- .06 cm(2), 15% reduction, P < .01).

CONCLUSIONS

The classic recommended maneuvers of turning the head and placing an SR significantly reduce the CSA of the SV. Positioning patients in Trendelenberg with the head turned away without an SR optimizes SV size. Positioning patients in this manner may serve to reduce the morbidity associated with percutaneous access of the SV.

Association of increased body mass index and impaired endothelial function among Hispanic women

We tested the hypothesis that an increased body mass index was similarly associated with impaired endothelial function as measured by flow-mediated dilation in a high-risk, Hispanic population of men and women living in northern Manhattan. The association of flow-mediated dilation and body mass index was significant in women (beta -0.16 +/- 0.04, p <0.0001) but not in men (beta -0.02 +/- 0.06, p = 0.72). This is the first study to demonstrate a gender-specific difference in endothelial function associated with body mass index.

Relation of plasma glucose and endothelial function in a population-based multiethnic sample of subjects without diabetes mellitus

To determine whether endothelial dysfunction precedes the clinical diagnosis of diabetes mellitus, we investigated the relation of endothelial flow-mediated dilation (FMD) with fasting plasma glucose among a multiethnic population-based cohort of 579 nondiabetic subjects without previous myocardial infarction or stroke enrolled in the Northern Manhattan Study (age 66 +/- 9 years; 41% men, 16% white, 15% black, and 68% Hispanic). Impaired fasting glucose or prediabetic status, defined as a fasting glucose level of 100 to 125 mg/dl, was present in 95 subjects (16%). Endothelial function was determined using FMD during reactive hyperemia. Multiple linear regression analyses were used to assess the relation between plasma glucose and endothelial function after adjustment for potential confounders. FMD was significantly lower (4.9 +/- 3.8% vs 6.1 +/- 3.7%, p = 0.003) in those with impaired fasting glucose than in subjects with normal fasting glucose. Prediabetic status was significantly associated with impaired FMD (odds ratio 1.9, 95% confidence interval 1.1 to 3.1, p = 0.02). After adjustment for age, gender, body mass index, and hypertensive status, a higher fasting glucose was significantly associated with a lower FMD (beta = -0.024 +/- 0.012, p = 0.04) in a continuous linear relation. Thus, for each 10-mg/dl increase in plasma glucose, a 0.24% decrease occurred in FMD. Impaired FMD was present among prediabetics. An elevated fasting plasma glucose level is associated with impaired endothelial function among nondiabetics. These results further support the role of hyperglycemia in the pathogenesis of vascular dysfunction at different stages of diabetes development and the role of impaired fasting glucose as a risk factor for macrovascular disease.

Relation between socioeconomic status, race-ethnicity, and left ventricular mass: the Northern Manhattan study

Increased left ventricular mass (LVM) and lower socioeconomic status (SES) are predictors of cardiovascular morbidity and mortality. Blacks and Hispanics are more likely to have higher LVM and lower SES. The relation between SES, race-ethnicity, and LVM has not been fully explored. Data were used from the NOMAS population-based sample of 1916 subjects living in Northern Manhattan. SES was characterized on the basis of educational attainment and divided into 4 categories. Echocardiography-defined LVM was indexed according to height at the allometric power of 2.7 and analyzed as a continuous variable. LVM varied by race in our cohort (blacks 48.9 g/m2.7, Hispanics 48.4 g/m2.7, whites 45.6 g/m2.7; P=0.004). Using ANCOVA, there was a significant inverse and graded association between mean LVM and SES for the total cohort. Mean LVM was 48.4 g/m2.7, 48.6 g/m2.7, 47.1 g/m2.7, and 45.3 g/m2.7 for the lowest to the highest educational level category (P trend=0.0004). This relationship remained among normotensives (P trend=0.0005) and was present for blacks (P trend=0.009), but not for whites (P trend=0.86) or Hispanics (P trend=0.47). The difference in mean LVM between the highest and lowest categories of education was 5.3 g/m2.7 for blacks, 0.0 g/m2.7 for whites, and 1.0 g/m2.7 for Hispanics. Lower SES is an independent predictor of increased LVM among hypertensive and normotensive blacks.

Management of patients with stroke and a patent foramen ovale

Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

Management of patients with stroke and a patent foramen ovale

Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

Hypercoagulable States in patients with patent foramen ovale

A patent foramen ovale (PFO) is a risk factor for stroke with the presumed mechanism being paradoxical embolism. Hypercoagulable states have been associated with the propensity to develop venous thromboses and have been separately associated with the risk for ischemic stroke. A PFO could provide the missing link. Having a PFO and a hypercoagulable state may place a person at an increased risk for paradoxical embolism. However, the prevalence of PFO in patients with hypercoagulable states and vice versa is unknown, and the best therapeutic strategy for these patients is unelucidated. This review assesses the literature, provides some insight on these topics, and identifies areas for further investigation.

Race-ethnic differences in patent foramen ovale, atrial septal aneurysm, and right atrial anatomy among ischemic stroke patients

BACKGROUND AND PURPOSE

Stroke remains a substantial cause of mortality and morbidity in the United States. Racial differences in stroke incidence and mortality persist with well-known excesses among blacks. Information on stroke among Hispanics is limited. In particular, little is known about whether patent foramen ovale (PFO), atrial septal aneurysm (ASA), and other atrial anomalies associated with cryptogenic stroke differ among minority populations.

METHODS

As a part of the PFO in Cryptogenic Stroke Study, transesophageal echocardiography was performed in a cohort of 630 ischemic stroke patients (mean age, 59+/-12 years; 44% women; 45% whites, 35% blacks, 17% Hispanics, 3% other). The prevalences of PFO, ASA, and right atrial (RA) anatomy favoring paradoxical embolization were compared among race-ethnic groups. Statistical analyses used analysis of variance for continuous variables and logistic regression for dichotomous variables with adjustments for age and sex.

RESULTS

Age- and sex-adjusted prevalences of PFO and ASA were similar across race-ethnic subgroups. However, large PFO was significantly less prevalent among blacks than among whites (odds ratio, 0.47; 95% confidence interval, 0.24 to 0.91; P=0.02). RA anatomy favoring paradoxical embolization was also significantly less prevalent among blacks compared with whites (odds ratio, 0.62; 95% confidence interval, 0.43 to 0.91; P=0.01). There were no significant differences in prevalence between whites and Hispanics.

CONCLUSIONS

Although the frequency of PFO did not vary among race-ethnic groups, a large PFO and RA anatomy favoring paradoxical embolization were significantly more prevalent among whites and Hispanics compared with blacks. These may be relatively more important risk factors for stroke among whites and Hispanics than among blacks.

Patent Foramen Ovale and Stroke

Observational data from prospective and retrospective trials indicate that a patent foramen ovale (PFO) is associated with the risk of ischemic stroke. The mechanism involved is presumed to be paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation causing an ischemic stroke. Primary stroke prevention data for patients with a PFO are nonexistent. Given the substantial prevalence of PFO in the total population (~ 25% to 30%), a primary prevention study may not be feasible. However, whether targeted primary prevention for patients with PFOs of certain morphologic characteristics (eg, larger size, greater degree of shunt) would be possible remains undefined. Given the large number of asymptomatic subjects, no therapy is currently recommended. The best treatment modality to prevent recurrent stroke in patients with PFO has not been defined. There are four major treatment choices: surgical closure, percutaneous device closure, medical therapy with anticoagulants, and medical therapy with antiplatelet agents. Regarding medical therapy, the Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent adverse events. Although closure of the PFO, either surgical or percutaneous, may further reduce the event rates, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.