The Burden of Cardiovascular Diseases Among US States, 1990-2016

Divergences and gaps in life expectancy and health-adjusted life expectancy in Mexico: Contribution analysis of the Global Burden of Disease Study 2019

INTRODUCTION

Life expectancy (LE) and Health-adjusted life expectancy (HALE) are summary indicators that reflect a population's general life conditions and measure inequities in health outcomes. The objective of this study was to identify the differences in LE and HALE by sex, age group, and state in Mexico from 1990 to 2019. Also, to evaluate whether the changes in HALE are related to sociodemographic indicators and indicators of access to and quality of health services.

METHODS

A secondary analysis was performed based on the Global Burden of Disease, Injuries, and Risk Factors Study (GBD). Data were obtained for LE (by sex and state) and HALE (by sex, age group, and state) for the years 1990, 2010, and 2019. The correlations between HALE with the Socio-Demographic Index (SDI) and with the Healthcare Access and Quality (HAQ) Index were estimated for 1990 and 2019 (by total population and sex).

RESULTS

LE and HALE had an absolute increase of 6.7% and 6.4% from 1990 to 2019, mainly among women, although they spent more years in poor health (11.8 years) than men. The patterns of LE and HALE were heterogeneous and divergent by state. In 2019, the difference in HALE (for both sex) between the states with the highest (Hidalgo) and the lowest (Chiapas) value was 4.6 years.

CONCLUSIONS

Progress in LE and HALE has slowed in recent years; HALE has even had setbacks in some states. Gaps between men and women, as well as between states, are persistent. Public and population policymaking should seek to lengthen LE and focus on ensuring that such years are spent in good health and with good quality of life.

Geographic Variation in the Quality of Heart Failure Care Among U.S. Veterans

BACKGROUND

The burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described.

OBJECTIVES

This study evaluated variation nationally for prescription of GDMT within the Veterans Health Administration.

METHODS

A cohort of Veterans with HFrEF had their address linked to hospital referral regions (HRRs). GDMT prescription was defined using pharmacy data between July 1, 2020, and July 1, 2021. Within HRRs, we calculated the percentage of Veterans prescribed GDMT and a composite GDMT z-score. National choropleth maps were created to evaluate prescription variation. Associations between GDMT performance and demographic characteristics were evaluated using linear regression.

RESULTS

Maps demonstrated significant variation in the HRR composite score and GDMT prescriptions. Within HRRs, the prescription of beta-blockers to Veterans was highest with a median of 80% (IQR: 77.3%-82.2%) followed by angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitors (69.3%; IQR: 66.4%-72.1%), sodium-glucose cotransporter-2 inhibitors (10.3%; IQR: 7.7%-12.8%), mineralocorticoid receptor antagonists (29.2%; IQR: 25.8%-33.9%), and angiotensin receptor-neprilysin inhibitors (12.2%; IQR: 8.6%-15.3%). HRR composite GDMT z-scores were inversely associated with the HRR median Gini coefficient (R = -0.13; P = 0.0218) and the percentage of low-income residents (R = -0.117; P = 0.0413).

CONCLUSIONS

Wide geographic differences exist for HFrEF care. Targeted strategies may be required to increase GDMT prescription for Veterans in lower-performing regions, including those affected by income inequality and poverty.

Development and User Testing of a Dynamic Tool for Rheumatic Heart Disease Management

OBJECTIVE

Most rheumatic heart disease (RHD) registries are static and centralized, collecting epidemiological and clinical data without providing tools to improve care. We developed a dynamic cloud-based RHD case management application with the goal of improving care for patients with RHD in Uganda.

METHODS

The Active Community Case Management Tool (ACT) was designed to improve community-based case management for chronic disease, with RHD as the first test case. Global and local partner consultation informed selection of critical data fields and prioritization of application functionality. Multiple stages of review and revision culminated in user testing of the application at the Uganda Heart Institute.

RESULTS

Global and local partners provided feedback of the application via survey and interview. The application was well received, and top considerations included avenues to import existing patient data, considering a minimum data entry form, and performing a situation assessment to tailor ACT to the health system setup for each new country. Test users completed a postuse survey. Responses were favorable regarding ease of use, desire to use the application in regular practice, and ability of the application to improve RHD care in Uganda. Concerns included appropriate technical skills and supports and potential disruption of workflow.

CONCLUSION

Creating the ACT application was a dynamic process, incorporating iterative feedback from local and global partners. Results of the user testing will help refine and optimize the application. The ACT application showed potential for utility and integration into existing care models in Uganda.

Genotype-by-socioeconomic status interaction influences heart disease risk scores and carotid artery thickness in Mexican Americans: the predominant role of education in comparison to household income and socioeconomic index

Background: Socioeconomic status (SES) is a potent environmental determinant of health. To our knowledge, no assessment of genotype-environment interaction has been conducted to consider the joint effects of socioeconomic status and genetics on risk for cardiovascular disease (CVD). We analyzed Mexican American Family Studies (MAFS) data to evaluate the hypothesis that genotype-by-environment interaction (GxE) is an important determinant of variation in CVD risk factors. Methods: We employed a linear mixed model to investigate GxE in Mexican American extended families. We studied two proxies for CVD [Pooled Cohort Equation Risk Scores/Framingham Risk Scores (FRS/PCRS) and carotid artery intima-media thickness (CA-IMT)] in relation to socioeconomic status as determined by Duncan's Socioeconomic Index (SEI), years of education, and household income. Results: We calculated heritability for FRS/PCRS and carotid artery intima-media thickness. There was evidence of GxE due to additive genetic variance heterogeneity and genetic correlation for FRS, PCRS, and CA-IMT measures for education (environment) but not for household income or SEI. Conclusion: The genetic effects underlying CVD are dynamically modulated at the lower end of the SES spectrum. There is a significant change in the genetic architecture underlying the major components of CVD in response to changes in education.

The Impact of Metabolic Syndrome Risk Factors on Lung Function Impairment: Cross-Sectional Study

BACKGROUND

Metabolic syndrome (MetS) is a constellation of risk factors increasingly present in the world's population. People with this syndrome are at an increased risk of cardiovascular disease and type 2 diabetes mellitus. Moreover, evidence has shown that it affects different organs. MetS and its risk factors are independently associated with impaired lung function, which can be quantified through spirometric variables.

OBJECTIVE

This study aims to determine whether a high number of MetS criteria is associated with increased lung function decline.

METHODS

We conducted a descriptive cross-sectional study with a random sample of 1980 workers. Workers with acute respiratory pathology (eg, influenza), chronic respiratory pathology (eg, chronic bronchitis), or exposure to substances harmful to the lungs (eg, organic and inorganic dust) were not included. MetS was established based on harmonized criteria, and lung function was assessed according to spirometric variables. On the basis of these, classification into restrictive lung disease (RLD), obstructive lung disease, and mixed lung disease (MLD) was performed. In addition, the association between MetS and lung function was established based on analysis of covariance, linear trend analysis, and multiple linear regression.

RESULTS

MetS was associated with worse lung function according to all the spirometric parameters analyzed (percentage of predicted forced expiratory volume in 1 second: mean 83, SD 13.8 vs mean 89.2, SD 12.8; P<.001 and percentage of predicted forced vital capacity: mean 85.9, SD 11.6 vs mean 92, SD 11.3; P<.001). Moreover, those diagnosed with MetS had a higher prevalence of lung dysfunction (41% vs 21.9%; P<.001), RLD (23.4% vs 11.2%; P<.001), and MLD (7.3% vs 2.2%; P<.001). Furthermore, an increasing number of MetS criteria was associated with a greater impairment of pulmonary mechanics (P<.001). Similarly, with an increasing number of MetS criteria, there was a significant linear trend (P<.001) in the growth of the prevalence ratio of RLD (0 criteria: 1, 1: 1.46, 2: 1.52, 3: 2.53, 4: 2.97, and 5: 5.34) and MLD (0 criteria: 1, 1: 2.68, 2: 6.18, 3: 9.69, and 4: 11.37). Regression analysis showed that the alteration of all MetS risk factors, adjusted for various explanatory variables, was significantly associated with a worsening of spirometric parameters, except for forced expiratory volume in 1 second/forced vital capacity.

CONCLUSIONS

The findings have shown that an increase in cardiometabolic risk factors is associated with a more significant worsening of spirometric variables and a higher prevalence of RLD and MLD. As spirometry could be a crucial tool for monitoring patients at risk of developing chronic pathologies, we conclude that this inexpensive and easily accessible test could help detect changes in lung function in patients with cardiometabolic disorders. This highlights the need to consider the importance of cardiometabolic health in lung function when formulating public health policies.

Unveiling Spatial Associations between COVID-19 Severe Health Index, Racial/Ethnic Composition, and Community Factors in the United States

There are limited efforts to incorporate different predisposing factors into prediction models that account for population racial/ethnic composition in exploring the burden of high COVID-19 Severe Health Risk Index (COVID-19 SHRI) scores. This index quantifies the risk of severe COVID-19 symptoms among a county's population depending on the presence of some chronic conditions. These conditions, as identified by the Centers for Disease Control and Prevention (CDC), include Chronic Obstructive Pulmonary Disease (COPD), heart disease, high blood pressure, diabetes, and obesity. Therefore, the objectives of this study were (1) to investigate potential population risk factors preceding the COVID-19 pandemic that are associated with the COVID-19 SHRI utilizing non-spatial regression models and (2) to evaluate the performance of spatial regression models in comparison to non-spatial regression models. The study used county-level data for 3107 United States counties, utilizing publicly available datasets. Analyses were carried out by constructing spatial and non-spatial regression models. Majority White and majority Hispanic counties showed lower COVID-19 SHRI scores when compared to majority Black counties. Counties with an older population, low income, high smoking, high reported insufficient sleep, and a high percentage of preventable hospitalizations had higher COVID-19 SHRI scores. Counties with better health access and internet coverage had lower COVID-19 SHRI scores. This study helped to identify the county-level characteristics of risk populations to help guide resource allocation efforts. Also, the study showed that the spatial regression models outperformed the non-spatial regression models. Racial/ethnic inequalities were associated with disparities in the burden of high COVID-19 SHRI scores. Therefore, addressing these factors is essential to decrease inequalities in health outcomes. This work provides the baseline typology to further explore many social, health, economic, and political factors that contribute to different health outcomes.

Effect of proprotein convertase subtilisin/kexin type 9 inhibition on cancer events: A pooled, post hoc, competing risk analysis of alirocumab clinical trials

OBJECTIVE

Assess the risk of new and worsening cancer events among participants who received the lipid-lowering therapy alirocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor.

DESIGN

Pooled post hoc analysis.

SETTING

Six phase 3 or phase 4 placebo-controlled randomised trials with alirocumab.

PARTICIPANTS

A total of 24,070 patients from the safety population with complete dosing data (alirocumab, n = 12,533; placebo, n = 11,537).

INTERVENTION

Alirocumab 75 mg, alirocumab 150 mg, alirocumab 75 mg increasing to 150 mg if low-density lipoprotein cholesterol <50 mg/dL not achieved, or placebo, all every 2 weeks. All participants received background high-intensity or maximum-tolerated statin therapy.

OUTCOMES AND MEASURES

The first new or worsening incident cancer events were assessed during the treatment-emergent adverse event period. Four outcomes were evaluated: any-neoplasm, malignant neoplasms, broad definition of hormone-sensitive cancers, and stricter definition of hormone-sensitive cancers. Sub-distribution hazard ratios and 95% confidence intervals (CIs) were estimated using a competing risk framework, with death as a competing risk.

RESULTS

Considering both treatment arms in aggregate, 969 (4.03%), 779 (3.24%), 178 (0.74%) and 167 (0.69%) patients developed any neoplasm, malignant neoplasms, broad definition of hormone-sensitive cancer and strict definition of hormone-sensitive cancer events, respectively. There was no significant difference in the risk of having any neoplasm in the alirocumab versus the placebo group (sub-distribution hazards ratio [95% CI], 0.93 [0.82-1.1]; p = 0.28). A nominally lower risk of having any neoplasms with alirocumab was observed among subjects aged ≥64 years (sub-distribution hazards ratio 0.83; 95% CI, 0.70-0.99).

CONCLUSIONS

Intensive low-density lipoprotein cholesterol lowering with a proprotein convertase subtilisin/kexin type 9 inhibitor combined with statin does not appear to increase the risk of new or worsening cancer events.

Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents

BACKGROUND

Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications.

METHODS

Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications).

RESULTS

More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group).

CONCLUSIONS

The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

In vivo PAR-CLIP (viP-CLIP) of liver TIAL1 unveils targets regulating cholesterol synthesis and secretion

System-wide cross-linking and immunoprecipitation (CLIP) approaches have unveiled regulatory mechanisms of RNA-binding proteins (RBPs) mainly in cultured cells due to limitations in the cross-linking efficiency of tissues. Here, we describe viP-CLIP (in vivo PAR-CLIP), a method capable of identifying RBP targets in mammalian tissues, thereby facilitating the functional analysis of RBP-regulatory networks in vivo. We applied viP-CLIP to mouse livers and identified Insig2 and ApoB as prominent TIAL1 target transcripts, indicating an important role of TIAL1 in cholesterol synthesis and secretion. The functional relevance of these targets was confirmed by showing that TIAL1 influences their translation in hepatocytes. Mutant Tial1 mice exhibit altered cholesterol synthesis, APOB secretion and plasma cholesterol levels. Our results demonstrate that viP-CLIP can identify physiologically relevant RBP targets by finding a factor implicated in the negative feedback regulation of cholesterol biosynthesis.

An overview of the Together Everyone Achieves More Physical Activity (TEAM-PA) trial to increase physical activity among African American women

BACKGROUND

The Together Everyone Achieves More Physical Activity (TEAM-PA) trial is a randomized controlled trial testing the efficacy of a group-based intervention for increasing physical activity (PA) among insufficiently active African American women.

DESIGN

The TEAM-PA trial uses a group cohort design, is implemented at community sites, and will involve 360 African American women. The trial compares a 10-week group-based intervention vs. a standard group-delivered PA comparison program. Measures include minutes of total PA/day using 7-day accelerometer estimates (primary outcome), and body mass index, blood pressure, waist circumference, walking speed, sedentary behavior, light physical activity, and the percentage achieving ≥150 min of moderate to vigorous PA/week (secondary outcomes) at baseline, post-intervention, and 6-months post-intervention.

INTERVENTION

The intervention integrates elements from Social Cognitive Theory, Self-Determination Theory, Group Dynamics Theory, and a focus on collectivism to evaluate different components of social affiliation (relatedness, reciprocal support, group cohesion, and collective efficacy). The intervention integrates shared goal-setting via Fitbits, group-based problem-solving, peer-to-peer positive communication, friendly competition, and cultural topics related to collectivism. Compared to the standard group-delivered PA program, participants in the intervention are expected to show greater improvements from baseline to post- and 6-month follow-up on minutes of total PA/day and secondary outcomes. Social affiliation variables (vs. individual-level factors) will be evaluated as mediators of the treatment effect.

IMPLICATIONS

The results of the TEAM-PA trial will determine the efficacy of the intervention and identify which aspects of social affiliation are most strongly related to increased PA among African American women.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (# NCT05519696) in August 2022 prior to initial participant enrollment.

State-Level Cardiovascular Mortality Rates Among Hispanic, Non-Hispanic Black, and Non-Hispanic White Populations, 1990 to 2019

Importance

Cardiovascular disease (CVD) is the leading cause of death in the US, with considerable variation by both state and race and ethnicity group. Consistent, comparable measures of mortality by specific CVD cause at the state level and by race and ethnicity have not previously been available and are necessary for supporting policy decisions aimed at reducing health inequities.

Objective

To quantify and describe levels and trends of mortality due to overall CVD and its component causes for 3 mutually exclusive race and ethnicity groups and by state.

Design, Setting, and Participants

This cross-sectional study used Census data, population surveys, and US vital registration records to estimate cause-specific cardiovascular mortality by state and by the following race and ethnicity groups, defined by the US Office of Management and Budget: Hispanic of any race, non-Hispanic Black (hereafter, Black), and non-Hispanic White (hereafter, White). Data were analyzed from January 2020 to September 2022.

Exposures

State of residence at time of death; Hispanic ethnicity and Black or White race.

Main Outcomes and Measures

CVD death counts and mortality rates.

Results

An estimated 25 397 029 persons died of cardiovascular diseases from 1990 to 2019. The mean (SD) age of individuals was 78.20 (14.01); 13 087 290 individuals (51.53%) were female and 12 309 739 (48.47%) were male; 2 921 650 (11.50%) were Black, 1 159 498 (4.57%) were Hispanic, and 21 315 880 (83.93%) were White. Age-standardized CVD mortality per 100 000 persons in 2019 was 194.4 (95% uncertainty interval [UI], 172.7 to 207.4), 107.7 (95% UI, 92.9 to 121.4), and 153.8 (95% UI, 133.8 to 163.8) among Black, Hispanic, and White populations, respectively. The median (IQR) percentage change across states was smaller for 2010 to 2019 compared with 1990 to 2000 for both White female and White male populations (-6.8 [-10.1 to -4.3] vs -10.2 [-12.9 to -5.9] and -4.6 [-8.6 to -2.5] vs -16.5 [-19.3 to -15.4]). For the Black and Hispanic groups, the percentage change (IQR) was larger for the female populations for the latter time period (-15.1 [-18.9 to -11.7] vs -12.6 [-19.6 to -7.8] and -23.5 [-29.2 to -18.5] vs -8.2 [-17.8 to 5.96]). The converse was observed among male individuals in both groups, with smaller percentage change (IQR) values in 2010 to 2019 compared with 1990 to 2000 (-13.1 [-18.7 to -8.6] vs -18.6 [-25.5 to -14.7] among the Black male population and -20.4 [-25.6 to -15.6] vs -21.5 [-31.1 to -5.7] among the Hispanic male population). There was substantial variability at the state level for death due to total CVD and component causes in 2019 and changes in CVD mortality from 1990 through 2019.

Conclusions and Relevance

The findings of this study indicate that CVD mortality varied widely by state and race and ethnicity group. Changes over the time period were not consistent for all groups and varied by cardiovascular subcause. These results highlight ongoing health disparities in cardiovascular mortality.

A Qualitative Study of Patients' Experiences, Enablers and Barriers of Rheumatic Heart Disease Care in Uganda

Introduction

Rheumatic heart disease (RHD) remains a significant public health problem in countries with limited health resources. People living with RHD face numerous social challenges and have difficulty navigating ill-equipped health systems. This study sought to understand the impact of RHD on PLWRHD and their households and families in Uganda.

Methods

In this qualitative study, we conducted in-depth interviews with 36 people living with RHD sampled purposively from Uganda's national RHD research registry, stratifying the sample by geography and severity of disease. Our interview guides and data analysis used a combination of inductive and deductive methods, with the latter informed by the socio-ecological model. We ran thematic content analysis to identify codes that were then collapsed into themes. Coding was done independently by three analysts, who compared their results and iteratively updated the codebook.

Results

The inductive portion of our analysis, which focused on the patient experience, revealed a significant impact of RHD on work and school. Participants often lived in fear of the future, faced limited childbirth choices, experienced domestic conflict, and suffered stigmatization and low self-esteem. The deductive portion of our analysis focused on barriers and enablers to care. Major barriers included the high out-of-pocket cost of medicines and travel to health facilities, as well as poor access to RHD diagnostics and medications. Major enablers included family and social support, financial support within the community, and good relationships with health workers, though this varied considerably by location.

Conclusion

Despite several personal and community factors that support resilience, PLWRHD in Uganda experience a range of negative physical, emotional, and social consequences from their condition. Greater investment is needed in primary healthcare systems to support decentralized, patient-centered care for RHD. Implementing evidence-based interventions that prevent RHD at district level could greatly reduce the scale of human suffering. There is need to increase investment in primary prevention and tackling social determinants, to reduce the incidence of RHD in communities where the condition remains endemic.

Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data

AIM

We aimed to combine Global Burden of Disease (GBD) Study data and local data to identify the highest priority intervention domains for preventing cardiovascular disease (CVD) in the case study country of Aotearoa New Zealand (NZ).

METHODS

Risk factor data for CVD in NZ were extracted from the GBD using the "GBD Results Tool." We prioritized risk factor domains based on consideration of the size of the health burden (disability-adjusted life years [DALYs]) and then by the domain-specific interventions that delivered the highest health gains and cost-savings.

RESULTS

Based on the size of the CVD health burden in DALYs, the five top prioritized risk factor domains were: high systolic blood pressure (84,800 DALYs; 5400 deaths in 2019), then dietary risk factors, then high LDL cholesterol, then high BMI and then tobacco (30,400 DALYs; 1400 deaths). But if policy-makers aimed to maximize health gain and cost-savings from specific interventions that have been studied, then they would favor the dietary risk domain (e.g., a combined fruit and vegetable subsidy plus a sugar tax produced estimated lifetime savings of 894,000 health-adjusted life years and health system cost-savings of US$11.0 billion; both 3% discount rate). Other potential considerations for prioritization included the potential for total health gain that includes non-CVD health loss and potential for achieving relatively greater per capita health gain for Māori (Indigenous) to reduce health inequities.

CONCLUSIONS

We were able to show how CVD risk factor domains could be systematically prioritized using a mix of GBD and country-level data. Addressing high systolic blood pressure would be the top ranked domain if policy-makers focused just on the size of the health loss. But if policy-makers wished to maximize health gain and cost-savings using evaluated interventions, dietary interventions would be prioritized, e.g., food taxes and subsidies.

Utilization Trends In Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor and Cost Among Medicare Beneficiaries

Recent guidelines regarding acute coronary syndrome (ACS) have advocated for use of prasugrel and ticagrelor over clopidogrel for acute coronary syndrome. However, analyses from multiple databases have shown that clopidogrel continues to be the most commonly prescribed P2Y12 inhibitor. We aimed to evaluate the trends in utilization and cost of P2Y12 inhibitors for Medicare beneficiaries using data from Medicare Part D Prescription Drug Data Event set from 2011 to 2018 for P2Y12 inhibitors. Medicare part D total beneficiaries for P2Y12 receptor inhibitors increased from 2011 to 2018 by 34.8% from 2.45 million to 3.31 million. The total cost for P2Y12 antiplatelets decreased from $ 3.72 billion in 2011 to $ 0.72 billion in 2018 by 80.4%. The availability of generic clopidogrel drove the considerable total cost reduction. Clopidogrel was the most prescribed P2Y12 inhibitor since its introduction accounting for more than 90% of the Medicare beneficiaries from 2013 to 2018. Overall, the number of beneficiaries on newer P2Y12 inhibitors showed a steady increase with 5.9% beneficiaries on brilinta in 2018 and 2.1 % on prasugrel. The total cost of brilinta beneficiaries grew exponentially accounting for 59.2% of total cost in 2018 and average cost per beneficiary increased by 465% in study period. Despite the availability of generic version clopidogrel and prasugrel, 2,161,175 beneficiaries were on brand plavix and 87,174 on effient which contributed to the increased total expenditure. Earlier introduction and transition to generic versions of medication may help to reduce the drug cost and potentially enhance medication compliance.

Epigenetic Regulation of Macrophage Polarization in Cardiovascular Diseases

Cardiovascular diseases (CVDs) are the leading cause of hospitalization and death worldwide, especially in developing countries. The increased prevalence rate and mortality due to CVDs, despite the development of several approaches for prevention and treatment, are alarming trends in global health. Chronic inflammation and macrophage infiltration are key regulators of the initiation and progression of CVDs. Recent data suggest that epigenetic modifications, such as DNA methylation, posttranslational histone modifications, and RNA modifications, regulate cell development, DNA damage repair, apoptosis, immunity, calcium signaling, and aging in cardiomyocytes; and are involved in macrophage polarization and contribute significantly to cardiac disease development. Cardiac macrophages not only trigger damaging inflammatory responses during atherosclerotic plaque formation, myocardial injury, and heart failure but are also involved in tissue repair, remodeling, and regeneration. In this review, we summarize the key epigenetic modifications that influence macrophage polarization and contribute to the pathophysiology of CVDs, and highlight their potential for the development of advanced epigenetic therapies.

Adolescent Psychological Assets and Cardiometabolic Health Maintenance in Adulthood: Implications for Health Equity

Background Positive cardiometabolic health (CMH) is defined as meeting recommended levels of multiple cardiometabolic risk factors in the absence of manifest disease. Prior work finds that few individuals-particularly members of minoritized racial and ethnic groups-meet these criteria. This study investigated whether psychological assets help adolescents sustain CMH in adulthood and explored interactions by race and ethnicity. Methods and Results Participants were 3478 individuals in the National Longitudinal Study of Adolescent Health (49% female; 67% White, 15% Black, 11% Latinx, 6% other [Native American, Asian, or not specified]). In Wave 1 (1994-1995; mean age=16 years), data on 5 psychological assets (optimism, happiness, self-esteem, belongingness, and feeling loved) were used to create a composite asset index (range=0-5). In Waves 4 (2008; mean age=28 years) and 5 (2016-2018; mean age=38 years), CMH was defined using 7 clinically assessed biomarkers. Participants with healthy levels of ≥6 biomarkers at Waves 4 and 5 were classified as maintaining CMH over time. The prevalence of CMH maintenance was 12%. Having more psychological assets was associated with better health in adulthood (odds ratio [OR]_{linear trend}, 1.12 [95% CI, 1.01-1.25]). Subgroup analyses found substantive associations only among Black participants (OR, 1.35 [95% CI, 1.00-1.82]). Additionally, there was some evidence that racial and ethnic disparities in CMH maintenance may be less pronounced among participants with more assets. Conclusions Youth with more psychological assets were more likely to experience favorable CMH patterns 2 decades later. The strongest associations were observed among Black individuals. Fostering psychological assets in adolescence may help prevent cardiovascular disease and play an underappreciated role in shaping health inequities.

Differences in county-level cardiovascular disease mortality rates due to damage caused by hurricane Matthew and the moderating effect of social capital: a natural experiment

BACKGROUND

As the climate continues to warm, hurricanes will continue to increase in both severity and frequency. Hurricane damage is associated with cardiovascular events, but social capital may moderate this relationship. Social capital is a multidimensional concept with a rich theoretical tradition. Simply put, social capital refers to the social relationships and structures that provide individuals with material, financial, and emotional resources throughout their lives. Previous research has found an association between high levels of social capital and lower rates of cardiovascular (CVD) mortality. In post-disaster settings, social capital may protect against CVD mortality by improving access to life-saving resources. We examined the association between county-level hurricane damage and CVD mortality rates after Hurricane Matthew, and the moderating effect of several aspects of social capital and hurricane damage on this relationship. We hypothesized that (1) higher (vs. lower) levels of hurricane damage would be associated with increased CVD mortality rates and (2) in highly damaged counties, higher (vs. lower) levels of social capital would be associated with lower CVD mortality.

METHODS

Analysis used yearly (2013-2018) county-level sociodemographic and epidemiological data (n = 183). Sociodemographic data were compiled from federal surveys before and after Hurricane Matthew to construct, per prior literature, a social capital index based on four dimensions of social capital (sub-indices): family unity, informal civil society, institutional confidence, and collective efficacy. Epidemiological data comprised monthly CVD mortality rates constructed from monthly county-level CVD death counts from the CDC WONDER database and the US Census population estimates. Changes in CVD mortality based on level of hurricane damage were assessed using regression adjustment. We used cluster robust Poisson population average models to determine the moderating effect of social capital on CVD mortality rates in both high and low-damage counties.

RESULTS

We found that mean levels of CVD mortality increased (before and after adjustment for sociodemographic controls) in both low-damage counties (unadjusted. Mean = 2.50, 95% CI [2.41, 2.59], adjusted mean = 2.50, 95% CI [2.40, 2.72]) and high-damage counties (mean = 2.44, CI [2.29, 2.46], adj. Mean = 2.51, 95% CI [2.49, 2.84]). Among the different social capital dimensions, institutional confidence was associated with reduced initial CVD mortality in low-damage counties (unadj. IRR 1.00, 95% CI [0.90, 1.11], adj. IRR 0.91 CI [0.87, 0.94]), but its association with CVD mortality trends was null. The overall effects of social capital and its sub-indices were largely nonsignificant.

CONCLUSION

Hurricane damage is associated with increased CVD mortality for 18 months after Hurricane Matthew. The role of social capital remains unclear. Future research should focus on improving measurement of social capital and quality of hurricane damage and CVD mortality data.

Low-Volume and High-Intensity Aerobic Interval Training May Attenuate Dysfunctional Ventricular Remodeling after Myocardial Infarction: Data from the INTERFARCT Study

Background

Aerobic high-intensity interval training (HIIT) has demonstrated benefits for ventricular remodeling after myocardial infarction (MI) through various mechanisms. Despite this, the optimal training volume is not well known. The present study aimed to assess the effects of different (low vs. high volume) aerobic HIIT compared to an attentional control (AC) group on echocardiographic and biochemical indicators of left ventricular (LV) remodeling in adults after MI.

Methods

Randomized clinical trial conducted on post-MI patients with preserved ventricular function. Participants were assigned to three study groups. Two groups performed HIIT 2 d/week, one group with low-volume HIIT (20 min, n = 28) and another with high-volume HIIT (40 min, n = 28). A third group was assigned to AC (n = 24) with recommendations for unsupervised aerobic training. Left ventricular echocardiographic parameters and cardiac biomarker levels (N-terminal pro-b-type natriuretic peptide, NT-proBNP; soluble growth stimulation expressed gene 2, ST2; troponin T; and creatine kinase) were assessed at baseline and after the intervention (16 weeks).

Results

Eighty participants (58.4 ± 8.3 yrs, 82.5% male) were included. Both low- and high-volume HIIT showed increases (p < 0.05) in left ventricular end-diastolic diameter (1.2%, 2.6%), and volume (1.1%, 1.3%), respectively. Interventricular septal and posterior walls maintained their thickness (p = 0.36) concerning the AC. Significant (p < 0.05) gain in diastolic function was shown with the improvements in E (-2.1%, -3.3%), e' waves (2.2%, 5.5%), and the deceleration time (2.1%, 2.9%), and in systolic function with a reduction in global longitudinal strain (-3.2%, -4.7%), respectively. Significant (p < 0.05) reductions of N-terminal pro-B-type natriuretic peptide (NT-proBNP) (-4.8%, -11.1%) and of ST2 (-21.7%, -16.7%)were found in both HIIT groups respectively compared to the AC group. Creatine kinase elevation was shown only in high-volume HIIT (19.3%, p < 0.01).

Conclusions

Low-volume HIIT is proposed as a clinically time-efficient and safer strategy to attenuate dysfunctional remodeling by preventing wall thinning and improving LV function in post-MI patients.

Hypertrophic Cardiomyopathy in Saudi Arabia: A Systematic Review of the Epidemiological, Clinical, and Imaging Features

BACKGROUND

A systematic review was performed to deliver a critical view of clinical and research practice on hypertrophic cardiomyopathy (HCM) in Saudi Arabia. Scopus, PubMed, and Google Scholar databases were searched for original articles reporting clinical and/or imaging findings among HCM patients in Saudi Arabia. Of 559 records identified, 3 studies and 1 abstract were included, involving 169 patients.

METHODS

The mean age ranged between 40and 56 years, up to 93.3% were males. A family history of HCM was reported in one study (5%), and sudden cardiac death was investigated in two studies (9% and 13%). Dyspnea was the most frequent symptom (60-68.7%) reported, followed by chest pain (12.5%-73.3%).

RESULTS

Regarding complications, atrial fibrillation was reported among 0-25% of the patients, mitral regurgitations among 13.3-50%, and ventricular tachycardia among 5-12.5%. Imaging parameters were inadequately documented and suggested a high prevalence of left atrial enlargement, SVI + RV5 > 35 mm, blocks, and asymmetric septal hypertrophy.

CONCLUSION

The ejection fraction was reported by two studies with a mean±SD of 68±13% and 77.2±8.07%. The researchers stress the paucity, low quality, and disparity in time of original studies about HCM in Saudi Arabia and recommend conducting national multicenter studies, with appropriate design, notably using screening-based recruitment methods.

Cardiovascular Nursing Workforce Challenges: Transforming the Model of Care for the Future

The complexities of acute and critical care cardiovascular management demand specialty trained and experienced nurses to ensure quality patient outcomes. An ongoing nurse labor shortage threatens to destabilize the healthcare system and presents a twofold challenge: a decreasing supply of registered nurses and increasing demand for nursing services. This article describes the numerous forces driving the current nursing shortage as well as the impact of the coronavirus-19 pandemic on nurse job satisfaction and turnover. We present a reinvented model of nursing care as a framework for healthcare organizations to address nurse staffing challenges.

Association of Parental Cardiovascular Health With Disability-Adjusted Life Years in the Offspring: Results From the Framingham Heart Study

BACKGROUND

Disability-adjusted life years (DALYs) are used to evaluate the relative burden of diseases in populations to help set prevention or treatment priorities. The impact of parental cardiovascular health (CVH) on healthy life years lost from cardiovascular disease (CVD) in adult offspring is unknown. We compared parent-offspring CVD DALYs trends over the life course and examined the association of parental CVH with offspring CVD DALYs.

METHODS

Using data from the Framingham Heart Study, 4814 offspring-mother-father trios were matched for age at selected baseline exams. CVH score was computed from the number of CVH metrics attained at recommended levels: poor (0-2), intermediate (3-4), and ideal (5-7). CVD DALYs were defined as the sum of years of life lost and years lived with CVD. Age-sex-standardized life expectancy and disability weights were derived from the actuarial life tables and Global Burden of Disease study, respectively. Multivariable-adjusted linear regression was used to investigate the association of parental CVH with offspring CVD DALYs.

RESULTS

Over an equal 47-year follow-up, parents lost nearly twice the number of CVD DALYs compared to their offspring (23 234 versus 12 217). However, age-adjusted CVD DALYs were higher at younger ages and similar along the life course for parents and offspring. One-unit increase in parental CVH was associated with 5 healthy life months saved in offspring. Offspring of mothers with ideal versus poor CVH had 3 healthy life years saved (β=-3.0 DALYs [95% CI, -5.6 to -0.3]). No statistically significant association was found between paternal CVH categories and offspring CVD DALYs.

CONCLUSIONS

Higher maternal and paternal CVH were associated with increased healthy life years in offspring; however, the association was strongest between mothers and offspring. Investment in CVH promotion along the life course has the potential to reduce the burden of CVD in the current and future generation of adults.

State-level disparities in burden of ischemic heart diseases mortality attributable to ambient fine particulate matter in the United States, 1990-2019: Observational analysis for the Global Burden of Disease (2019) study

BACKGROUND

ambient fine particulate air pollution (PM2.5) is an important yet often overlooked risk factor for cardiovascular disease in the United States. However, epidemiologic evidence suggests that current knowledge does not comprehensively capture state-level disparities in mortality for ambient PM2.5-related ischemic heart diseases.

METHODS

I performed serial cross sectional analysis with ambient PM2.5-attributable ischemic heart diseases decedents between 1990 and 2019. I used the Global Health Data Exchange to extract age adjusted mortality rates in each state, and used Joinpoint software to calculate average annual percentage change.

RESULTS

the average age adjusted mortality rates (AAMR) for ischemic heart diseases attributable to ambient PM2.5 for both sex ranged from 1.5 (1.3-1.8) per 100,000 in Hawaii to 1.1 (0.9-1.3) per 100,000 in Mississippi, respectively. The rate of change in AAMR varied widely across states. Compared with the national level, the number of states with smaller decline has increased from 3 before 2002 to 10 after 2011. Oregon, Idaho, and Montana showed an upward trend in AAMR, which was independent of sex after 2011. Between 1990 and 2019, average AAMR for ischemic heart diseases attributable to ambient PM2.5 was higher for male than female in all states. But the number of states with sex disparities in the rate of change has decreased, from 13 in 1990-2002 to 5 after 2011.

CONCLUSIONS

wide state-level disparities exist in burden of ischemic heart diseases attributable to ambient PM2.5. After 2011, the association between rate of AAMR decline and sex weakened across states. State-level policies and programs are needed to address the avoidable burden of ischemic heart diseases deaths attributable to ambient particulate pollution, with priority for states with a higher burden.

Internet of Things-Based ECG and Vitals Healthcare Monitoring System

Health monitoring and its associated technologies have gained enormous importance over the past few years. The electrocardiogram (ECG) has long been a popular tool for assessing and diagnosing cardiovascular diseases (CVDs). Since the literature on ECG monitoring devices is growing at an exponential rate, it is becoming difficult for researchers and healthcare professionals to select, compare, and assess the systems that meet their demands while also meeting the monitoring standards. This emphasizes the necessity for a reliable reference to guide the design, categorization, and analysis of ECG monitoring systems, which will benefit both academics and practitioners. We present a complete ECG monitoring system in this work, describing the design stages and implementation of an end-to-end solution for capturing and displaying the patient's heart signals, heart rate, blood oxygen levels, and body temperature. The data will be presented on an OLED display, a developed Android application as well as in MATLAB via serial communication. The Internet of Things (IoT) approaches have a clear advantage in tackling the problem of heart disease patient care as they can transform the service mode into a widespread one and alert the healthcare services based on the patient's physical condition. Keeping this in mind, there is also the addition of a web server for monitoring the patient's status via WiFi. The prototype, which is compliant with the electrical safety regulations and medical equipment design, was further benchmarked against a commercially available off-the-shelf device, and showed an excellent accuracy of 99.56%.

Emphasis on Icosapent Ethyl for Cardiovascular Risk Reduction: A Systematic Review

Despite the widespread use of lipid-lowering agents such as statins, cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Icosapent ethyl (IPE) (Vascepa), an ethyl ester of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA), has gained widespread popularity as an adjunctive agent that targets multiple and additional mechanisms linked to the incidence of cardiovascular (CV) events and the causative pathway of atherosclerosis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 standards were used to conduct this systematic review. In this review, we assessed various studies from PubMed, PubMed Central (PMC), and Google Scholar to evaluate the mechanisms of action and beneficial effects of IPE in the reduction of CVD outcomes. The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) has demonstrated a significant reduction in CV mortality with 4 g/day IPE as compared to placebo. All other trials and observational studies have supported the role of Vascepa in hypertriglyceridemia and CV risk reduction. In conclusion, the use of IPE has been shown to significantly reduce triglyceride levels and reduce CV risks in patients receiving optimal statin therapy.

Social support, psychosocial risks, and cardiovascular health: Using harmonized data from the Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America Study, and Multi-Ethnic Study of Atherosclerosis

Purpose

Social support may have benefits on cardiovascular health (CVH). CVH is evaluated using seven important metrics (Life's Simple 7; LS7) established by the American Heart Association (e.g., smoking, diet). However, evidence from longitudinal studies is limited and inconsistent. The objective of this study is to examine the longitudinal relationship between social support and CVH, and assess whether psychosocial risks (e.g., anger and stress) modify the relationship in a racially/ethnically diverse population.

Methods

Participants from three harmonized cohort studies - Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America, and Multi-Ethnic Study of Atherosclerosis - were included. Repeated-measures modified Poisson regression models were used to examine the overall relationship between social support (in tertiles) and CVH (LS7 metric), and to assess for effect modification by psychosocial risk.

Results

Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96-1.03). For medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98-1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95% CI) of 1.04 (0.99-1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94-1.03) and 0.97 (0.91-1.03), respectively.

Conclusion

Overall, we observed no strong evidence for an association between social support and CVH. However, some psychosocial risks may be modifiers. Prospective studies are needed to assess the social support-CVH relationship by psychosocial risks in racially/ethnically diverse populations.

Spatiotemporal trends and ecological determinants of cardiovascular mortality among 2844 counties in mainland China, 2006-2020: a Bayesian modeling study of national mortality registries

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in China. No previous study has reported CVD mortality at county-level, and little was known about the nonmedical ecological factors of CVD mortality at such small scale in mainland China. Understanding the spatiotemporal variations of CVD mortality and examining its nonmedical ecological factors would be of great importance to tailor local public health policies.

METHODS

By using national mortality registration data in China, this study used hierarchical spatiotemporal Bayesian model to demonstrate spatiotemporal distribution of CVD mortality in 2844 counties during 2006 to 2020 and investigate how nonmedical ecological determinants have affected CVD mortality inequities from the spatial perspectives.

RESULTS

During 2006-2020, the age-standardized mortality rate (ASMR) of CVD decreased from 284.77 per 100,000 in 2006 to 241.34 per 100,000 in 2020. Among 2844 counties, 1144 (40.22%) were hot spots counties with a higher CVD mortality risk compared to the national average and located mostly in northeast, north central, and westernmost regions; on the contrary, 1551 (54.53%) were cold spots counties and located mostly in south and southeast coastal counties. CVD mortality risk decreased from 2006 to 2020 was larger in counties where CVD mortality rate had been higher in 2006 in most of the counties, vice versa. Nationwide, nighttime light intensity (NTL) was the major influencing factor of CVD mortality, a higher NTL appeared to be negatively associated with a lower CVD mortality, with one unit increase in NTL, and the CVD mortality risk will decrease 11% (relative risk of NTL was estimated as 0.89 with 95% confidence interval of 0.83-0.94).

CONCLUSIONS

Substantial between-county discrepancies of CVD mortality distribution were observed during past 15 years in mainland China. Nonmedical ecological determinants were estimated to significantly explain the overall and local spatiotemporal patterns of this CVD mortality risk. Targeted considerations are needed to integrate primary care with clinical care through intensifying further strategies to narrow unequally distribution of CVD mortality at local scale. The approach to county-level analysis with small area models has the potential to provide novel insights into Chinese disease-specific mortality burden.

Circadian Variations and Associated Factors in Patients with Ischaemic Heart Disease

Circadian rhythms have been identified in cardiovascular diseases, and cardiovascular risk factors can modify the circadian rhythm. The purpose of this study was to describe the onset of ischaemic heart disease symptomatology in relation to the date and time, the day of the week of presentation, the season, AMI location and severity and the level of influence of individual patient characteristics in a retrospective cross-sectional study involving 244 ischaemic heart disease patients from the intensive care unit of La Ribera Hospital (Spain). The onset of pain was more frequent in the morning, the season with the highest frequency of ischaemic events was winter, and the lowest incidence was during weekends. Regarding the severity of ischaemic heart disease, the circadian rhythm variables of weekdays vs. weekends and seasons did not show a significant association. The length of hospital stay was associated with the onset of pain in the afternoon. The onset of pain at night was associated with the subendocardial location of the infarction. In conclusion, living in a Mediterranean country, the Spanish population showed a circadian pattern of AMI, where the onset of pain has an influence on AMI location and on the length of hospital stay and is the same in patients with different individual risk factors.

Multifactorial Effects of Outpatient Cardiac Rehabilitation in Patients with Heart Failure: A Nationwide Retrospective Cohort Study

AIM

Although cardiac rehabilitation (CR) is a strongly recommended therapy, no large study has assessed the effects of outpatient CR in patients with heart failure (HF) in real-world settings. Therefore, this study aimed to investigate the multifactorial effects of outpatient CR in patients with HF using a nationwide database.

METHODS AND RESULTS

This nationwide retrospective cohort study was performed using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with acute HF who underwent inpatient CR between April 2014 and March 2020 were included. The association between outpatient CR participation and all-cause mortality, rehospitalisation for HF, use of medical resources, and medical costs was analysed using propensity score matching analysis. Of 250,528 patients, 17,884 (7.1%) underwent outpatient CR. After propensity score matching, the CR (+) group was associated with a reduction in the risk of all-cause mortality (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.60-0.68, p < 0.001) and rehospitalisation for HF compared to the CR (-) group (HR: 0.87, 95% CI: 0.82-0.92, p < 0.001). The proportion of guideline-based medication use for HF at 1 year was higher in the CR (+) group than in the CR (-) group. The total medical costs from the index hospitalisation to 1.5 years after admission were similar between the groups.

CONCLUSION

Outpatient CR participation after discharge from HF was associated with reduced mortality and rehospitalisation for HF without increasing medical costs.

Gastrointestinal prophylaxis for COVID-19: an illustration of severe bias arising from inappropriate comparators in observational studies

OBJECTIVES

We aimed to use setting-appropriate comparisons to estimate the effects of different gastrointestinal (GI) prophylaxis pharmacotherapies for patients hospitalized with COVID-19 and setting-inappropriate comparisons to illustrate how improper design choices could result in biased results.

STUDY DESIGN AND SETTING

We identified 3,804 hospitalized patients aged ≥ 18 years with COVID-19 from March to November 2020. We compared the effects of different gastroprotective agents on clinical improvement of COVID-19, as measured by a published severity scale. We used propensity score-based fine-stratification for confounding adjustment. Based on guidelines, we prespecified comparisons between agents with clinical equipoise and inappropriate comparisons of users vs. nonusers of GI prophylaxis in the intensive care unit (ICU).

RESULTS

No benefit was detected when comparing oral famotidine to omeprazole in patients treated in the general ward or ICUs. We also found no associations when comparing intravenous famotidine to intravenous pantoprazole. For inappropriate comparisons of users vs. nonusers in the ICU, the probability of improvement was reduced by 32%-45% in famotidine users and 21%-48% in omeprazole or pantoprazole users.

CONCLUSION

We found no evidence that GI prophylaxis improved outcomes for patients hospitalized with COVID-19 in setting-appropriate comparisons. An improper comparator choice can lead to spurious associations in critically ill patients.

Socioeconomic inequalities in molecular risk for chronic diseases observed in young adulthood

Many common chronic diseases of aging are negatively associated with socioeconomic status (SES). This study examines whether inequalities can already be observed in the molecular underpinnings of such diseases in the 30s, before many of them become prevalent. Data come from the National Longitudinal Study of Adolescent to Adult Health (Add Health), a large, nationally representative sample of US subjects who were followed for over two decades beginning in adolescence. We now have transcriptomic data (mRNA-seq) from a random subset of 4,543 of these young adults. SES in the household-of-origin and in young adulthood were examined as covariates of a priori-defined mRNA-based disease signatures and of specific gene transcripts identified de novo. An SES composite from young adulthood predicted many disease signatures, as did income and subjective status. Analyses highlighted SES-based inequalities in immune, inflammatory, ribosomal, and metabolic pathways, several of which play central roles in senescence. Many genes are also involved in transcription, translation, and diverse signaling mechanisms. Average causal-mediated effect models suggest that body mass index plays a key role in accounting for these relationships. Overall, the results reveal inequalities in molecular risk factors for chronic diseases often decades before diagnoses and suggest future directions for social signal transduction models that trace how social circumstances regulate the human genome.

Synergistic Effects of Particle Radioactivity (Gross β Activity) and Particulate Matter ≤2.5 μm Aerodynamic Diameter on Cardiovascular Disease Mortality

Background Although the effects of fine particulate matter (particulate matter ≤2.5 μm aerodynamic diameter [PM2.5]) on cardiovascular disease (CVD) morbidity and mortality are well established, little is known about the CVD health effects of particle radioactivity. In addition, there are still questions about which of the PM2.5 physical, chemical, or biological properties are mostly responsible for its toxicity. Methods and Results We investigated the association between particle radioactivity, measured as gross β activity from highly resolved spatiotemporal predictions, and mortality for CVD, myocardial infarction, stroke, and all-cause nonaccidental mortality in Massachusetts (2001-2015). Within both difference-in-differences model and generalized linear mixed model frameworks, we fit both single-exposure and 2-exposure models adjusting for PM2.5 and examined the interaction between PM2.5 and gross β activity. We found significant associations between gross β activity and PM2.5 and each mortality cause. Using difference-in-differences and adjusting for PM2.5, we found the highest associations with myocardial infarction (rate ratio, 1.16 [95% CI, 1.08-1.24]) and stroke (rate ratio, 1.11 [95% CI, 1.04-1.18]) for an interquartile range increase (0.055 millibecquerels per cubic meter) in gross β activity. We found a significant positive interaction between PM2.5 and gross β activity, with higher associations between PM2.5 and mortality at a higher level of gross β activity. We also observed that the associations varied across age groups. The results were comparable between the 2 statistical methods also with and without adjusting for PM2.5. Conclusions This is the first study that, using highly spatiotemporal predictions of gross β-activity, provides evidence that particle radioactivity increases CVD mortality and enhances PM2.5 CVD mortality. Therefore, particle radioactivity can be an important property of PM2.5 that must be further investigated. Addressing this important question can lead to cost-effective air-quality regulations.

Sex Differences in Cardiovascular Disease Mortality in Brazil between 1996 and 2019

BACKGROUND

cardiovascular diseases (CVD) are Brazil's leading causes of death in women and men. This study analyzed age-adjusted death rate (DRaj) trends from all causes of death (ACD), CVD, ischemic heart disease (IHD), and stroke in women and men aged 35 to 74 years from 1996 to 2019.

METHODS

We analyzed DRaj trends for all causes of death (ACD), CVD, IHD, and stroke. Data were from the Ministry of Health mortality database. Joinpoint Regression Program™ performed trend analysis and adjustments in death rates. Average annual percentage change (AAPC) determined the intensity of changes.

RESULTS

In women, DRaj reduced for ACD (AAPC = -1.6%); CVD (AAPC = -2.6%); IHD (AAPC = -1.9%); and stroke (AAPC = -4.6%) (p < 0.001 for all). In men, ACD reduced from 1996 to 2004 (AAPC = -0.9%; p < 0.001), from 2012 to 2019 (AAPC = -1.9%; p < 0.001), and unchanged from 2004 to 2012; CVD (AAPC = -2.1%); IHD (AAPC = -1.5%); stroke (AAPC = -4.9%) (p < 0.001 for all) reduced from 1996 to 2019. From 1996 to 2019, the male/female ratio for ACD remained unchanged. CVD increased from 1.58 to 1.83, IHD from 1.99 to 2.30, and stroke from 1.52 to 1.83.

CONCLUSION

ACD, CVD, IHD, and stroke were reduced more significantly in women, and the ratio of CVD, IHD, and CVD in men and women increased more in men. Future studies will be needed to determine the main factors responsible for a better outcome in women.

Flavan-3-ols and Cardiometabolic Health: First Ever Dietary Bioactive Guideline

Guideline recommendation for a plant bioactive such as flavan-3-ols is a departure from previous recommendations because it is not based on deficiencies but rather improvement in health outcomes. Nevertheless, there is a rapidly growing body of clinical data reflecting benefits of flavan-3-ol intake that outweigh potential harms. Thus, the objective of the Expert Panel was to develop an intake recommendation for flavan-3-ols and cardiometabolic outcomes to inform multiple stakeholders including clinicians, policymakers, public health entities, and consumers. Guideline development followed the process set forth by the Academy of Nutrition and Dietetics, which includes use of the Evidence to Decision Framework. Studies informing this guideline (157 randomized controlled trials and 15 cohort studies) were previously reviewed in a recently published systematic review and meta-analysis. Quality and strength-of-evidence along with risk-of-bias in reporting was reviewed. In drafting the guideline, data assessments and opinions by authoritative scientific bodies providing guidance on the safety of flavan-3-ols were considered. Moderate evidence supporting cardiometabolic protection resulting from flavan-3-ol intake in the range of 400-600 mg/d was supported in the literature. Further, increasing consumption of dietary flavan-3-ols can help improve blood pressure, cholesterol concentrations, and blood sugar. Strength of evidence was strongest for some biomarkers (i.e., systolic blood pressure, total cholesterol, HDL cholesterol, and insulin/glucose dynamics). It should be noted that this is a food-based guideline and not a recommendation for flavan-3-ol supplements. This guideline was based on beneficial effects observed across a range of disease biomarkers and endpoints. Although a comprehensive assessment of available data has been reviewed, evidence gaps identified herein can inform scientists in guiding future randomized clinical trials.

Prevalence and risk factors of high cholesterol and triglycerides among people with HIV in Texas

Background

People with HIV (PWH) commonly have elevated cholesterol and triglycerides levels that have been linked to medications. However, healthy behaviors including lifestyle changes can lower high cholesterol (CHOL) or high triglycerides (TG), thereby reducing individual risk for cardiovascular diseases. This study aimed to determine the prevalence and risk factors associated with high CHOL or TG among PWH in Texas.

Methods

Cross-sectional data of 981 PWH from the 2015–2017 Texas and Houston Medical Monitoring Projects were examined. High CHOL or TG was identified by medical chart diagnosis, CHOL or TG medication use, or most recent fasting lab ≥ 200 mg/dl (total CHOL) or ≥ 150 mg/dl (TG). High CHOL or TG associations with sociodemographic and clinical characteristics were assessed using Rao-Scott chi-square tests. Prevalence of high CHOL or TG development was calculated using multivariable logistic regression model.

Results

High CHOL or TG prevalence was 41% with participants being mostly male (73%), ≥ 40 years (68%), with overweight (31%) or obesity (28%), and virally suppressed (62%). Compared with PWH < 40 years of age, PWH in their 40s, 50s, and ≥ 60s were 57%, 64%, and 62% more likely to have high CHOL or TG, respectively. Participants with overweight and obesity were 41% and 30% more likely to have high CHOL or TG than those with normal weight (BMI: 18.5– < 25), respectively.

Conclusion

Since high CHOL and TG are modifiable CVD risk factors, increased education and lifestyle modification interventions are warranted to prevent the development of high CHOL or TG among PWH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00467-y.

Carotenoids in Drug Discovery and Medicine: Pathways and Molecular Targets Implicated in Human Diseases

Carotenoids are isoprenoid-derived natural products produced in plants, algae, fungi, and photosynthetic bacteria. Most animals cannot synthesize carotenoids because the biosynthetic machinery to create carotenoids de novo is absent in animals, except arthropods. Carotenoids are biosynthesized from two C20 geranylgeranyl pyrophosphate (GGPP) molecules made from isopentenyl pyrophosphate (IPP) and dimethylallyl pyrophosphate (DMAPP) via the methylerythritol 4-phosphate (MEP) route. Carotenoids can be extracted by a variety of methods, including maceration, Soxhlet extraction, supercritical fluid extraction (SFE), microwave-assisted extraction (MAE), accelerated solvent extraction (ASE), ultrasound-assisted extraction (UAE), pulsed electric field (PEF)-assisted extraction, and enzyme-assisted extraction (EAE). Carotenoids have been reported to exert various biochemical actions, including the inhibition of the Akt/mTOR, Bcl-2, SAPK/JNK, JAK/STAT, MAPK, Nrf2/Keap1, and NF-κB signaling pathways and the ability to increase cholesterol efflux to HDL. Carotenoids are absorbed in the intestine. A handful of carotenoids and carotenoid-based compounds are in clinical trials, while some are currently used as medicines. The application of metabolic engineering techniques for carotenoid production, whole-genome sequencing, and the use of plants as cell factories to produce specialty carotenoids presents a promising future for carotenoid research. In this review, we discussed the biosynthesis and extraction of carotenoids, the roles of carotenoids in human health, the metabolism of carotenoids, and carotenoids as a source of drugs and supplements.

Prevalence of cardiovascular diseases in COVID-19 related mortality in the United States

BACKGROUND

Several cardiovascular disease (CVD) risk factors and sequelae have been associated with COVID-19. Little is known about the distribution of CVD conditions in COVID-19 related deaths in the US population.

METHODS

The public-use dataset by CDC, "Conditions Contributing to COVID-19 Deaths, by State and Age, Provisional 2020-2021", was abstracted as of August 1, 2021. A descriptive analysis was conducted to explore the overall and age-specific prevalence of various CVD and risk factors grouped by pre-specified ICD-10 codes amongst COVID-19 patient deaths. Respective trends over the duration of the pandemic were analyzed using the Mann-Kendall method, including time-periods before and after the introduction of vaccines in January 2021. All time-related analysis was conducted between March 2020 and June 2021.

RESULTS

A total of 600,241 COVID-19 related deaths were reported between March 2020 and June 2021. Hypertensive diseases were the most prevalent (19.6%), followed by diabetes (15.9%), ischemic heart disease (IHD;10.9%), heart failure (7.7%), cardiac arrhythmias (7.5%), other diseases of the circulatory system (6.6%), cerebrovascular diseases (5%), and obesity (4.1%). While a significant downward trend was noted for hypertensive diseases over the course of the pandemic, cardiac arrhythmias, heart failure (HF), obesity, and other circulatory system diseases demonstrated a significant upward trend. Since the introduction of vaccines, the trends for heart failure and cardiac arrhythmias remained steady while having demonstrated a significant rise in the pre-vaccination time-period. While obesity and other diseases of the circulatory system predominated (>50%) amongst the CVD burden in the younger population (0-24 years and 25-34 years), the percentage occurrence of cardiac arrhythmias, hypertensive diseases, HF, and IHD increased with age.

CONCLUSION

Hypertensive diseases, diabetes, and IHD were the most prevalent cardiovascular conditions amongst COVID-19 related deaths. These patterns varied by age. While the trend for hypertensive diseases declined over the course of the pandemic, cardiac arrhythmias, HF, obesity, and other diseases of the circulatory system demonstrated an upward trend. An important limitation is the source of the data being limited to death certificates.

C-Reactive Protein, Subjective Aging, and Incident Cardiovascular Disease: A Mediation Model

OBJECTIVES

Negative self-perceptions of aging (SPA) and an older subjective age are associated with a greater likelihood of cardiovascular disease. We predicted that C-reactive protein (CRP), a marker of stress-related inflammation, would mediate this relation.

METHOD

Data from up to 6 602 participants ages 50-101 in the Health and Retirement Study (2008-2018) were analyzed using logistic regressions with mediation. Subjective aging was assessed in 2008 or 2010, CRP was assessed 2 years later, and diagnosis of heart disease or stroke was assessed in the years from CRP measurement to 2018.

RESULTS

Significant indirect effects occurred in all models, indicating that negative SPA and older subjective age are associated with a greater likelihood of heart disease and stroke through elevated levels of the inflammatory marker CRP.

DISCUSSION

These findings suggest that psychological factors such as subjective aging impact cardiovascular health through physiological mechanisms, specifically markers of inflammation.

Association of an evolutionary-concordance lifestyle pattern score with incident CVD among Black and White men and women

Dietary and lifestyle evolutionary discordance is hypothesised to play a role in the aetiology of CVD, including CHD and stroke. We aimed to investigate associations of a previously reported, total (dietary plus lifestyle) evolutionary-concordance (EC) pattern score with incident CVD, CHD and stroke. We used multivariable Cox proportional hazards regression to investigate associations of the EC score with CVD, CHD and stroke incidence among USA Black and White men and women ≥45 years old in the prospective REasons for Geographic and Racial Differences in Stroke study (2003-2017). The EC score comprised seven equally weighted components: a previously reported dietary EC score (using Block 98 FFQ data) and six lifestyle characteristics (alcohol intake, physical activity, sedentary behaviour, waist circumference, smoking history and social network size). A higher score indicates a more evolutionary-concordant dietary/lifestyle pattern. Of the 15 467 participants in the analytic cohort without a CVD diagnosis at baseline, 1563 were diagnosed with CVD (967 with CHD and 596 with stroke) during follow-up (median 11·0 years). Among participants in the highest relative to the lowest EC score quintile, the multivariable-adjusted hazards ratios and their 95 % CI for CVD, CHD and stroke were, respectively, 0·73 (0·62, 0·86; Ptrend < 0·001), 0·72 (0·59, 0·89; Ptrend < 0·001) and 0·76 (0·59, 0·98; Ptrend = 0·01). The results were similar by sex and race. Our findings support that a more evolutionary-concordant diet and lifestyle pattern may be associated with lower risk of CVD, CHD and stroke.

The Global Burden of Type 2 Diabetes Attributable to Tobacco: A Secondary Analysis From the Global Burden of Disease Study 2019

Objectives

Growing epidemiological studies have reported the relationship between tobacco and health loss among patients with type 2 diabetes (T2D). This study aimed to explore the secular trend and spatial distribution of the T2D burden attributable to tobacco on a global scale to better understand regional disparities and judge the gap between current conditions and expectations.

Methods

As a secondary analysis, we extracted data of tobacco-attributable T2D burden from the 2019 Global Burden of Disease Study (GBD). Joinpoint regression was adopted to determine the secular trend of age-standardized rates (ASR), with average annual percentage change (AAPC). Gaussian process regression (GPR) was used to explore the average expected relationship between ASRs and the socio-demographic index (SDI). Spatial autocorrelation was used to indicate if there is clustering of age-standardized DALY rate (ASDR) with Moran's I value. Multi-scale geographically weighted regression (MGWR) was to investigate the spatial distribution and scales of influencing factors in ASDR attributable to tobacco, with the regression coefficients for each influencing factor among 204 countries.

Results

Tobacco posed a challenge to global T2D health, particularly for the elderly and men from lower SDI regions. For women, mortality attributable to secondhand smoke was higher than smoking. A downward trend in age-standardized mortality rate (ASMR) of T2D attributable to tobacco was observed (AAPCs= -0.24; 95% CI -0.30 to -0.18), while the ASDR increased globally since 1990 (AAPCs= 0.19; 0.11 to 0.27). Oceania, Southern Sub-Saharan Africa, and Southeast Asia had the highest ASMRs and ASDRs, exceeding expectations based on the SDI. Also, "high-high" clusters were mainly observed in South Africa and Southeast Asian countries, which means a high-ASDR country is surrounded by high-ASDR neighborhoods in the above areas. According to MGWR model, smoking prevalence was the most sensitive influencing factor, with regression coefficients from 0.15 to 1.80.

Conclusion

The tobacco-attributable burden of T2D should be considered as an important health issue, especially in low-middle and middle-SDI regions. Meanwhile, secondhand smoke posed a greater risk to women. Regional disparities existed, with hot spots mainly concentrated in South Africa and Southeast Asian countries.

Association of Sleep Duration With All-Cause and Cardiovascular Mortality: A Prospective Cohort Study

To clarify the association of sleep duration with all-cause and cardiovascular mortality, and further estimate the population attributable fraction (PAF) for the 10-year risk of cardiovascular disease (CVD) due to inappropriate sleep duration among US adults, we included data of the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2014 by linkage to the National Death Index until December 31, 2015 in a prospective design. Cox proportional hazards models were used for multivariate longitudinal analyses. The Pooled Cohort Equations methods was adopted to calculate the predicted 10-year CVD risk. In the current study, sleep <5 h or longer than 9 h per day were significantly associated with elevated risks of all-cause mortality, and the multivariable-adjusted HRs across categories were 1.40 (95% CI, 1.14–1.71), 1.12 (95% CI, 0.91–1.38), 1 (reference), 1.35 (95% CI, 1.12–1.63), and 1.74 (95% CI, 1.42–2.12). Similarly, the HRs of cardiovascular mortality across categories were 1.66 (95% CI, 1.02–2.72), 1.15 (95% CI, 0.77–1.73), 1 (reference), 1.55 (95% CI, 1.05–2.29), and 1.81 (95% CI, 1.09–3.02). Under a causal–effect assumption, we estimated that 187 000 CVD events (PAF 1.8%, 0.9% to 2.3%) were attributable to short sleep duration and 947 000 CVD events (PAF 9.2%, 6.4% to 11.6%) were attributable to long sleep duration from 2018 to 2028. This study informed the potential benefit of optimizing the sleep duration for the primary prevention of CVD in a contemporary population.

Relationship between blood cadmium and abdominal aortic calcification: NHANES 2013-2014

BACKGROUND

Cadmium is a common toxic heavy metal in the environment and can cause irreversible damage to the human body. It is well established that cadmium has direct cardiovascular toxicity, but the relationship between cadmium exposure and abdominal aortic calcification (AAC) is not clear.

METHODS

This was a cross-sectional study that aimed to assess the relationship between blood cadmium (B-Cd) and AAC in U.S. adults ≥ 40 years old. We obtained data from the 2013-2014 National Health and Nutrition Examination Survey. The AAC score was quantified by the Kauppila score system, whereas severe AAC was defined as an AAC score ≥ 6. We performed multivariate regressions, correlated subgroup analyses, and interaction terms to evaluate the relationship between B-Cd and AAC score and severe AAC.

RESULTS

For 1530 enrolled participants, the mean AAC score was 1.52 ± 3.32, and the prevalence of severe AAC was 8.95%. Participants with higher B-Cd levels showed higher AAC scores (β = 0.36, 95% CI: 0.03, 0.70, P = 0.0323) and an increased risk of severe AAC (OR=1.61, 95% CI: 1.01, 2.56, P = 0.0432). However, these associations were weakened after adjusting for serum cotinine to define smoking exposure. Subgroup analyses and correlated interaction terms indicated that the relationship between B-Cd and AAC was generally similar in different population settings, except for males, nonsmokers, and participants with a normal body mass index (BMI). The interaction terms indicated that smoking exposure status defined by serum cotinine interacted with the relationship between B-Cd and AAC condition (P for interaction=0.0413).

CONCLUSIONS

There might be positive associations between B-Cd levels and AAC scores and the risk of severe AAC, while these associations were partially explained by smoking exposure. However, more well-designed studies are still needed to validate this relationship.

Association of epicardial adipose tissue with different stages of coronary artery disease: A cross-sectional UK Biobank cardiovascular magnetic resonance imaging substudy

Objective

Increased epicardial adipose tissue (EAT) has been identified as a risk factor for the development of coronary artery disease (CAD). However, the exact role of EAT in the development of CAD is unclear. This study aims to compare EAT volumes between healthy controls and individuals with stable CAD and a history of myocardial infarction (MI). Furthermore, associations between clinical and biochemical parameters with EAT volumes are examined.

Methods

This retrospective cross-sectional study included 171 participants from the United Kingdom Biobank (56 healthy controls; 60 stable CAD; 55 post MI), whom were balanced for age, sex and body mass index (BMI). EAT volumes were quantified on end-diastolic cardiac magnetic resonance (CMR) imaging short-axis slices along the left and right ventricle and indexed for body surface area (iEAT) and iEAT volumes were compared between groups.

Results

iEAT volumes were comparable between control, CAD and MI cases (median [IQR]: 66.1[54.4-77.0] vs. 70.9[55.8-85.5] vs. 67.6[58.6-82.3] mL/m2, respectively (p > 0.005 for all). Increased HDL-cholesterol was associated with decreased iEAT volume (β = -14.8, CI = -24.6 to -4.97, p = 0.003) and suggestive associations (P-value < 0.05 and ≥ 0.005) were observed between iEAT and triglycerides (β = 3.26, CI = 0.42 to 6.09, p = 0.02), Apo-lipoprotein A (β = -16.3, CI = -30.3 to -2.24, p = 0.02) and LDL-cholesterol (β = 3.99, CI = -7.15 to -0.84, p = 0.01).

Conclusions

No significant differences in iEAT volumes were observed between patients with CAD, MI and healthy controls. Our results indicate the importance of correcting for confounding by CVD risk factors, including circulating lipid levels, when studying the relationship between EAT volume and CAD. Further mechanistic studies on causal pathways and the role of EAT composition are warranted.

Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status

Importance

Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown.

Objective

To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states.

Design, Setting, and Participants

This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019.

Exposures

State Medicaid expansion and insurance status.

Main Outcomes and Measures

The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states.

Results

The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states.

Conclusions and Relevance

In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.

Socioeconomic Deprivation and Premature Cardiovascular Mortality in the United States

OBJECTIVE

To determine the variability in county cardiovascular (CV) premature mortality explained by integrated metrics of socioeconomic deprivation and to explore temporal trends in CV mortality by county socioeconomic deprivation.

METHODS

This is a cross-sectional analysis of US county-level death certificate data from 1999 to 2018 of age-adjusted premature (25 to 64 years) CV mortality. Integrated metrics of socioeconomic deprivation (Social Deprivation Index [SDI] and county Area Deprivation Index [ADI]) were associated with mortality using linear regression analysis. Relative change in county CV mortality from 1999 to 2018 was associated with indices using linear regression analysis.

RESULTS

Counties with higher quartile SDI and ADI had significantly higher total, non-Hispanic Black/African American, and female premature CV mortality (P<.001). Both SDI and ADI were significantly associated with CV mortality by linear regression (P<.001) explaining 40% and 44% of county variability in CV mortality, respectively. Counties with lower deprivation indices experienced a larger decreased in premature CV mortality (P<.001).

CONCLUSION

This study demonstrates an association between multiple integrated metrics of socioeconomic deprivation and premature cardiovascular mortality and shows potentially worsening disparities.