Cardiovascular mortality in Hispanics compared to non-Hispanic whites: a systematic review and meta-analysis of the Hispanic paradox

Racial/ethnic differences in the clinical presentation and survival of breast cancer by subtype

Background

Breast cancer (BC) affects racial and ethnic groups differently, leading to disparities in clinical presentation and outcomes. It is unclear how Hispanic ethnicity affects BC outcomes based on geographic location and proximity to the United States (U.S.)/Mexico border. We hypothesized that the impact of race/ethnicity on BC outcomes depends on geographic location and country of origin within each BC subtype.

Methods

We analyzed BC data from the Texas Cancer Registry by race/ethnicity/birthplace according to BC subtype (luminal A/luminal B/human epidermal growth factor receptor 2 [HER2]/triple-negative breast cancer[TNBC]). Other covariates included age, geographic location (U.S., Mexico), residency (border, non-border), treatments, and comorbidities. Crude and adjusted effects of race/ethnicity and birthplace on overall survival (OS) were analyzed using Cox regression methods.

Results

Our analysis of 76,310 patient records with specific BC subtypes revealed that Hispanic and non-Hispanic Black (NHB) patients were diagnosed at a younger age compared with non-Hispanic White (NHW) patients for all BC subtypes. For the 19,748 BC patients with complete data on race/ethnicity/birthplace/residency, Hispanic patients had a higher mortality risk in the Luminal A subtype, regardless of birthplace, whereas U.S.-born Hispanics had a higher risk of death in the TNBC subtype. In contrast, NHB patients had a higher mortality risk in the Luminal A and HER2 subtypes. Residence along the U.S./Mexico border had little impact on OS, with better outcomes in Luminal A patients and worse outcomes in Luminal B patients aged 60-74 years.

Conclusion

Race/ethnicity, geographic birth location, and residency were significant predictors of survival in BC. Migration, acculturation, and reduced healthcare access may contribute to outcome differences.

Racial and Ethnic Composition of Populations Served by Freestanding Children's Hospitals and Disparities in Outcomes of Pediatric Lupus

OBJECTIVE

Health disparities may be driven by hospital-level factors. We assessed whether racial and ethnic composition of populations hospitals serve explain or modify disparities in hospital outcomes of children with systemic lupus erythematosus (SLE).

METHODS

In this retrospective cohort study of patients 5 to 26 years old with SLE at 47 children's hospitals in the Pediatric Health Information System (2006-2021), race and ethnicity were assessed at the patient level and hospital level (proportion of total admissions composed of Black or Hispanic patients, respectively). Outcomes included intensive care unit (ICU) admission or adverse renal outcome (end-stage renal disease, dialysis, or transplant) during follow-up. We estimated racial and ethnic disparities, adjusted or stratified by hospital racial or ethnic composition.

RESULTS

Of 8,125 patients with SLE, 2,293 (28%) required ICU admission, and 698 (9%) had an adverse renal outcome. Black and non-Hispanic White disparities in ICU admission were observed only at hospitals serving higher proportions of Black patients (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.04-1.59 vs OR 1.07, 95% CI 0.83-1.38). Larger Black and non-Hispanic White disparities in adverse renal outcomes were observed at hospitals with higher Black racial composition (OR 2.0, 95% CI 1.4-2.8 vs OR 1.7, 95% CI 1.1-2.4). Conversely, Hispanic versus non-Hispanic disparities in renal outcomes persisted after adjustment for hospital-reported Hispanic ethnic composition but were observed only at hospitals with lower proportions of Hispanic patients.

CONCLUSION

Worse Black and White disparities in SLE outcomes are observed at children's hospitals serving more Black children, whereas distinct patterns are observed for Hispanic and non-Hispanic disparities. Reporting of hospital characteristics related to populations served is needed to identify modifiable drivers of hospital-level variation.

Low income and education are associated with greater ASCVD risk scores among adults in the US

Introduction

Social determinants of health (SDOH) are fundamental causes of poor cardiovascular health, yet cardiovascular disease (CVD) risk assessment tools exclude SDOH. Our objective was to determine whether SDOH are independently associated with CVD risk in US adults.

Methods

Utilizing the National Health and Nutrition Examination Survey (NHANES), we combined years 1999-2018 and included participants aged 40-79 without history of CVD and with information to calculate CVD risk (n = 21,694). Ten-year risk of atherosclerotic CVD (ASCVD) was calculated using the American Heart Association/American College of Cardiology (AHA/ACC) pooled cohort equations. We used linear regression models to estimate the association between SDOH and ASCVD risk, after adjusting for demographic factors. All analyses accounted for the complex survey design.

Results

Mean age was 54.7 years, with 52.7 % female, 73.8 % non-Hispanic White, 9.4 % non-Hispanic Black, and 10.7 % Hispanic. From adjusted models, compared with an income of ≥ $75 K, ASCVD risk was greater by 3.06 (95 % CI: 2.65, 3.47) among those with income < $25 K, by 1.55 (95 % CI: 1.21, 1.89) among those with income $25 K-<$55 K, and by 1.20 (95 % CI: 0.84, 1.56) among those with income $55 K-<$75 K. Compared to college graduates, ASCVD risk was greater by 3.09 (95 % CI: 2.56, 3.62) among those with less than a high school education, by 1.65 (95 % CI: 1.31, 200) among those who were high school graduates, and by 1.41 (95 % CI: 1.11, 1.72) among those with some college education.

Conclusion

We found strong graded associations between lower income and lower educational attainment with greater CVD risk.

Cardiovascular Disease in Hispanic Women: JACC Review Topic of the Week

Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.

Increasing Racial and Ethnic Disparities in Ambient Air Pollution-Attributable Morbidity and Mortality in the United States

BACKGROUND

Ambient nitrogen dioxide (NO 2 ) and fine particulate matter with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) threaten public health in the US, and systemic racism has led to modern-day disparities in the distribution and associated health impacts of these pollutants.

OBJECTIVES

Many studies on environmental injustices related to ambient air pollution focus only on disparities in pollutant concentrations or provide only an assessment of pollution or health disparities at a snapshot in time. In this study, we compare injustices in NO 2 - and PM 2.5 -attributable health burdens, considering NO 2 -attributable health impacts across the entire US; document changing disparities in these health burdens over time (2010-2019); and evaluate how more stringent air quality standards would reduce disparities in health impacts associated with these pollutants.

METHODS

Through a health impact assessment, we quantified census tract-level variations in health outcomes attributable to NO 2 and PM 2.5 using health impact functions that combine demographic data from the US Census Bureau; two spatially resolved pollutant datasets, which fuse satellite data with physical and statistical models; and epidemiologically derived relative risk estimates and incidence rates from the Global Burden of Disease study.

RESULTS

Despite overall decreases in the public health damages associated with NO 2 and PM 2.5 , racial and ethnic relative disparities in NO 2 -attributable pediatric asthma and PM 2.5 -attributable premature mortality have widened in the US during the last decade. Racial relative disparities in PM 2.5 -attributable premature mortality and NO 2 -attributable pediatric asthma have increased by 16% and 19%, respectively, between 2010 and 2019. Similarly, ethnic relative disparities in PM 2.5 -attributable premature mortality have increased by 40% and NO 2 -attributable pediatric asthma by 10%.

DISCUSSION

Enacting and attaining more stringent air quality standards for both pollutants could preferentially benefit the most marginalized and minoritized communities by greatly reducing racial and ethnic relative disparities in pollution-attributable health burdens in the US. Our methods provide a semi-observational approach to track changes in disparities in air pollution and associated health burdens across the US. https://doi.org/10.1289/EHP11900.

Social Vulnerability and Cardiovascular-Related Mortality Among Older Adults in the United States

PURPOSE

The association of social vulnerability and cardiovascular disease-related mortality in older adults has not been well characterized.

METHODS

The Centers for Disease Control and Prevention database was evaluated to examine the relationship between county-level Social Vulnerability Index (SVI) and age-adjusted cardiovascular disease-related mortality rates (AAMRs) in adults aged 65 and above in the United States between 2016 and 2020.

RESULTS

A total of 3139 counties in the United States were analyzed. Cardiovascular disease-related AAMRs increased in a stepwise manner from first (least vulnerable) to fourth SVI quartiles; (AAMR of 2423, 95% CI [confidence interval] 2417-2428; 2433, 95% CI 2429-2437; 2516, 95% CI 2513-2520; 2660, 95% CI 2657-2664). Similar trends among AAMRs were noted based on sex, all race and ethnicity categories, and among urban and rural regions. Higher AAMR ratios between the highest and lowest SVI quartiles, implying greater relative associations of SVI on mortality rates, were seen among Hispanic individuals (1.52, 95% CI 1.49-1.55), Non-Hispanic-Asian and Pacific Islander individuals (1.32, 95% CI 1.29-1.52), Non-Hispanic- American Indian or Alaskan Native individuals (1.43, 95% CI 1.37-1.50), and rural counties (1.21, 95% CI 1.20-1.21).

CONCLUSION

Social vulnerability as measures by the SVI was associated with cardiovascular disease-related mortality in older adults, with the association being particularly prominent in ethnic minority patients and rural counties.

US Initiative to Eliminate Racial and Ethnic Disparities in Health: The Impact on the Outcomes of ST-Segment-Elevation Myocardial Infarction in New Jersey

Background In 1998, President Clinton launched a federal initiative to eliminate racial and ethnic health disparities. The impact on the outcomes of ST-segment-elevation myocardial infarction has not been well studied. Methods and Results ST-segment-elevation myocardial infarction outcomes from 1994 to 2015 were studied in 7942 Black, 27 665 Hispanic, and 88 727 White patients with first admission of ST-segment-elevation myocardial infarction using the Myocardial Infarction Data Acquisition System. Logistic regressions were used to assess mortality adjusting for demographics, comorbidities, and interventional procedures. There was an overall rise from 1994 to 2015 in the use of percutaneous coronary interventions in all 3 groups. Before 1998, White patients received more percutaneous coronary interventions compared with Black and Hispanic patients (P<0.05). After 1998, the disparity in use of percutaneous coronary interventions in Black and Hispanic patients was greatly reduced compared with White patients, and the difference reversed in favor of Hispanic patients after 2005 (P<0.05). There was an overall downward trend of in-hospital mortality without evidence of disparity among Black, Hispanic, and White patients. A linear regression model was used with a change point in 1998. Before 1998, the slope of 1-year all-cause and cardiovascular mortality was not statistically significant. After 1998, the mortality showed negative slopes for all 3 groups, however, with lower overall crude mortality for Hispanic patients compared with Black and White patients (P<0.0001). Conclusions The initiative launched in 1998 may have contributed to a reduction in percutaneous coronary intervention usage disparity in patients with ST-segment-elevation myocardial infarction. Short- and long-term mortality decreased in all 3 groups, but more in the Hispanic population.

Nonalcoholic Fatty Liver Disease in Latin America and Australia

The epidemiologic and demographical features of nonalcoholic fatty liver disease (NAFLD) vary significantly across countries and continents. In this review, we analyze current data regarding prevalence of NAFLD in Latin America and Caribbean and Australia and review some peculiarities found in these regions. We stress the need of greater awareness of NAFLD and the development of cost-effective risk stratification strategies and clinical care pathways of the disease. Finally, we highlight the need of effective public health policies to control the main risk factors for NAFLD.

Intersectional Approaches to Minority Aging Research

Purpose of Review

Growing racial/ethnic diversity among America's older adults necessitates additional research specifically focused on health and well-being among aging minoritized populations. Although Black and Latinx adults in the USA tend to face worse health outcomes as they age, substantial evidence points to unexpected health patterns (e.g., the race paradox in mental health, the Latino health paradox) that challenge our understanding of health and aging among these populations. In this review, we demonstrate the value of intersectionality theory for clarifying these health patterns and highlight the ways that intersectionality has been applied to minority aging research. To advance the field, we also make several recommendations for incorporating intersectional approaches in future scholarship on minority aging.

Recent Findings

Scholars have applied intersectional approaches to health and aging to unravel how social statuses and social conditions, such as race, ethnicity, gender, nativity, incarceration history, geographic region, and age, produce distinct shared experiences that shape health trajectories through multiple mechanisms.

Summary

We highlight common intersectional approaches used in minority aging research and underscore the value of this perspective for elucidating the complex, and often unexpected, health patterns of aging minoritized populations. We identify several key lessons and propose recommendations to advance scholarship on minority aging.

Effect of cognitive impairment on risk of death in Hispanic/Latino adults over the age of 50 residing in the United States with and without diabetes: Data from the Health and Retirement Study 1995-2014

OBJECTIVE

To understand the relationship between mortality and cognitive function among older US Hispanic adults with and without diabetes.

METHODS

Data from the Health and Retirement Study (1995-2014) were analyzed. Cox proportional hazard models were used to estimate the association between mortality and cognitive function. Models were stratified by diabetes.

RESULTS

Four thousand thirteen older US Hispanic adults were included. Fully adjusted models for individuals with diabetes showed those with mild cognitive impairment (MCI; hazard ratio [HR]: 1.61; 95% confidence interval [CI]: 1.06, 2.45; P = .025) and dementia (HR: 2.14; 95% CI: 1.25, 3.67; P = .006) had increased mortality compared to normal cognition. Fully adjusted models for individuals without diabetes showed those with MCI (HR: 1.87; 95% CI: 1.28, 2.74; P = .001) and dementia (HR: 3.25; 95% CI: 1.91, 5.55; P < .001) had increased mortality compared to normal cognition.

CONCLUSIONS

Cognitive impairment is associated with increased mortality in older US Hispanic adults with and without diabetes. Clinicians should regularly assess cognitive function in this group to quickly identify declines and make appropriate referrals for support to optimize health and reduce mortality.

Unique Cardiovascular Disease Risk Factors in Hispanic Individuals

Purpose of Review

This review summarizes contemporary data on unique cardiovascular disease (CVD) risk factors in Hispanic individuals in the USA, and how addressing these factors is important in addressing health equity.

Recent Findings

Recent studies have shown high rates of traditional CVD risk factors in Hispanic individuals such as obesity, hypertension, diabetes, hyperlipidemia, and emerging CVD risk factors like hypertensive disorders of pregnancy, psychological stress, and occupational exposures. However, most studies fail to consider the significant heterogeneity in risk factor burden and outcomes in atherosclerotic CVD by Hispanic subgroup. Heart failure and rhythm disorders are less well studied in Hispanic adults, making risk assessment for these conditions difficult. High levels of CVD risk factors in Hispanic youth given an aging Hispanic population overall highlight the importance of risk mitigation among these individuals.

Summary

In brief, these data highlight the significant, unique burden of CVD risk among Hispanic individuals in the USA and predict a rising burden of disease among this growing and aging population. Future CVD research should focus on including robust, diverse Hispanic cohorts as well as specifically delineating results for disaggregated Hispanic groups across CVDs. This will allow for better risk assessment, prevention, and treatment decisions to promote health equity for Hispanic patients.

Air pollution and metabolic disorders: Dynamic versus static measures of exposure among Hispanics/Latinos and non-Hispanics

INTRODUCTION

Exposure to air pollution disproportionately affects racial/ethnic minorities that could contribute to health inequalities including metabolic disorders. However, most existing studies used a static assessment of air pollution exposure (mostly using the residential address) and do not account for activity space when modelling exposure to air pollution. The aim of this study is to understand how exposure to air pollution impacts metabolic disorders biomarkers, how this effect differs according to ethnicity, and for the first time compare these findings with two methods of exposure assessment: dynamic and static measures.

METHODS

Among the Community of Mine study, a cross-sectional study conducted in San Diego County, insulin resistance, diabetes, hypertension, obesity, dyslipidemia, and metabolic syndrome (MetS) were assessed. Exposure to air pollution (PM_2.5, NO₂, traffic) was calculated using static measures around the home, and dynamic measures of mobility derived from Global Positioning Systems (GPS) traces using kernel density estimators to account for exposure variability across space and time. Associations of air pollution with metabolic disorders were quantified using generalized estimating equation models to account for the clustered nature of the data.

RESULTS

Among 552 participants (mean age 58.7 years, 42% Hispanic/Latino), Hispanics/Latinos had a higher exposure to PM_2.5 compared to non-Hispanics using static measures. In contrast, Hispanics/Latinos had less exposure to PM_2.5 using dynamic measures. For all participants, higher dynamic exposure to PM_2.5 and NO₂ was associated with increased insulin resistance and cholesterol levels, and increased risk of obesity, dyslipidemia and MetS (RR 1.17, 95% CI: 1.07-1.28; RR 1.21, 95% CI: 1.12-1.30, respectively). The association between dynamic PM_2.5 exposure and MetS differed by Hispanic/Latino ethnicity.

CONCLUSION

These results highlight the importance of considering people's daily mobility in assessing the impact of air pollution on health.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Impact of Race/Ethnicity on Long Term Outcomes After Percutaneous Coronary Intervention with Drug-Eluting Stents

Cardiovascular disease constitutes the leading cause of mortality worldwide, irrespective of race/ethnicity. Previous studies have shown that minority patients with acute coronary syndrome have distinct clinical, anatomic, and socioeconomic characteristics which may affect clinical outcomes. We included patients who underwent percutaneous coronary intervention with drug-eluting stents for ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina in a single center. Patients were stratified into Caucasian, African-American, Hispanic, and Asian. Caucasians were the reference group. The primary end point was major adverse cardiac and cerebrovascular events, composite of death, spontaneous myocardial infarction, or stroke at 1 year. Of 6,800 patients included, 49.7% were Caucasian, 20.7% Hispanic, 17.0% Asian and 12.6% African-American. Caucasians were the oldest, Hispanics and Asians had the highest prevalence of diabetes mellitus whereas African-Americans had more chronic kidney disease. Hispanics and African-Americans had the highest STEMI rates, whereas Asians were more likely to present with unstable angina. Compared with Caucasians, Asians had a lower rate of major adverse cardiac and cerebrovascular events at 1 year (3.9% vs 7.1%; p <0.01) whereas Hispanics (6.2% vs 7.1%; p = 0.17) and African-Americans (8.0% vs 7.1%; p = 0.38) had comparable outcomes. Differences were driven by mortality. Findings remained unchanged after adjustment. In conclusion, in acute coronary syndrome patients who underwent percutaneous coronary intervention, Asian race/ethnicity was associated with favorable cardiovascular outcomes compared with Caucasians. No significant differences were observed for Hispanics and African-Americans.

Comprehensive evaluation of disparities in cardiometabolic and reproductive risk between Hispanic and White women with polycystic ovary syndrome in the United States: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to comprehensively compare cardiometabolic and reproductive health risk between Hispanic and White women with polycystic ovary syndrome in the United States in response to the call by the international guideline for polycystic ovary syndrome to delineate health disparities.

DATA SOURCES

Databases of MEDLINE, Web of Science, and Scopus were initially searched through October 25, 2020, and confirmed on February 1, 2021.

STUDY ELIGIBILITY CRITERIA

Observational studies comparing glucoregulatory, lipid profile, anthropometric, blood pressure, androgen, ovarian morphology, oligoanovulation, and infertility status between Hispanic and White women with polycystic ovary syndrome were included. The primary outcome was metabolic syndrome risk. Furthermore, major cardiovascular events (stroke, coronary heart disease, and heart failure) and mortality rate (cardiovascular death and total mortality) data were evaluated. Studies on adolescents (<2 years after menarche), pregnant, or menopausal-aged women (>50 years) were excluded.

METHODS

Data were pooled by random-effects models and expressed as mean differences and 95% confidence intervals. Risk of bias was assessed by the Newcastle-Ottawa Scale.

RESULTS

A total of 11 studies (n=2267; 589 Hispanic and 1678 White women) were eligible. All studies, including both White and Hispanic women, had high-quality assessment (Newcastle-Ottawa Scale score of ≥8). Hispanic women exhibited comparable metabolic syndrome prevalence (7% [95% confidence interval, -1 to 14]; P=.06; I2=0%); however, Hispanic women exhibited higher modified Ferriman-Gallwey score (0.60 [95% confidence interval, -0.01 to 1.21]; P=.05; I2=0%), fasting insulin (5.48 μIU/mL [95% confidence interval, 3.11-7.85]; P≤.01; I2=40.0%), and homeostatic model assessment of insulin resistance (1.20 [95% confidence interval, 0.50-1.89]; P≤.01; I2=43.0%) than White women. The 2 groups had comparable glucose, lipid profile, waist circumference, blood pressure, and androgen status (all P≥.08). Findings about group differences in certain reproductive outcomes (ie, ovarian dysmorphology and infertility) were contradictory and described only narratively as inclusion in the meta-analyses was not possible. No study reported on cardiovascular events or mortality.

CONCLUSION

Hispanic women with polycystic ovary syndrome exhibited greater impairments in glucoregulatory status than White women. Disparities in reproductive risks could not be concluded. The degree to which glucoregulatory aberrations translate into patient-pressing diseases (diabetes mellitus and infertility) remains a major roadblock given the paucity of available evidence. Our observations have supported the consideration of these disparities in the diagnostic, monitoring, and management practices for polycystic ovary syndrome and reinforced the need to elucidate mechanisms that account for the observed disparities to foster equity in polycystic ovary syndrome care.

Estimating the joint effect of diabetes and subsequent depressive symptoms on mortality among older latinos

PURPOSE

Diabetes and depression are risk factors for cardiovascular disease, but the evidence about their interaction effect on long-term health outcomes among Latinos is lacking. We aimed to investigate the joint association of diabetes and subsequent depressive symptoms with mortality among older Latinos, an understudied racial/ethnic group with high prevalence of diabetes.

METHODS

This study included 1,495 adults from the Sacramento Area Latino Study on Aging. We employed Cox proportional-hazards models to estimate the adjusted hazard ratios [aHRs] for cardiovascular and all-cause mortality according to diabetes status at enrollment and depressive symptoms a year after the enrollment. We used marginal structural models to adjust for time-varying confounders.

RESULTS

The mean age (standard deviation) of participants was 70 (6.6) years. Over follow-up (median 7.7 years), diabetes and depressive symptoms were individually associated with increased risk of cardiovascular mortality (diabetes, aHR[95% CI]=2.13[1.60-2.84]; depressive symptoms, aHR[95% CI]=1.62[1.09-2.39]) and all-cause mortality (diabetes, aHR[95% CI]=1.92[1.53-2.41]; depressive symptoms, aHR[95% CI]=1.41[1.02-1.94]). After adjusting for time-varying confounders, we found a multiplicative interaction between diabetes and subsequent depressive symptoms for cardiovascular mortality (aHR[95% CI]=2.94[1.07-8.39]), but not all-cause mortality (aHR[95% CI]=1.80[0.81-4.35]).

CONCLUSIONS

Using a longitudinal cohort of community-dwelling older Latinos, we found that diabetes and subsequent depressive symptoms were jointly associated with increased risk of cardiovascular mortality.

Socioeconomic Determinants of Health and Cardiovascular Outcomes in Women: JACC Review Topic of the Week

Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women.

Central Blood Pressure and Subclinical Atherosclerotic Risk in Young Hispanic American Women

Background

The incidence of younger women being hospitalized from cardiovascular disease (CVD) events is on the rise. Hispanic women are generally thought to have higher CVD risk factor burden than non-Hispanic White (NHW) women yet Hispanic Americans have lower mortality from CVD. Traditional measures of CVD may not accurately capture CVD risk in Hispanic Americans. Hence, the purpose of this study was to assess the impact of ethnicity on vascular reactivity and central hemodynamic load to gain insight into subclinical CVD risk in young women.

Methods

Brachial flow-mediated dilation (FMD), low-flow mediated constriction (L-FMC), carotid-femoral pulse wave velocity (cfPWV), and pulse wave analysis (from synthesized aortic pressure waveforms) were measured in 25 Hispanic women and 31 NHW women aged between 18-35 years. FMD and L-FMC were combined to provide an index of total vessel reactivity.

Results

NHW and Hispanic women did not differ in age or traditional CVD risk factors (P>.05 for all). Compared with NHW women, Hispanic women had greater vascular reactivity (8.7±4.1 vs 11.7±4.1 %, P=.011), lower central pulse pressure (28±5 vs 24±3 mm Hg, P=.001) and lower pressure from wave reflections (12±2 vs 10±1 mm Hg, P=.001). There were no differences in cfPWV between NHW women and Hispanic women (5.4±0.7 vs 5.3±0.7 m/s, P=.73).

Conclusion

Young Hispanic women have greater vascular reactivity and lower central pulsatile hemodynamic load compared with NHW women, suggesting lower subclinical CVD risk.

Demographic characteristics associated with circadian rest-activity rhythm patterns: a cross-sectional study

BACKGROUND

Rest-activity rhythm (RAR), a manifestation of circadian rhythms, has been associated with morbidity and mortality risk. However, RAR patterns in the general population and specifically the role of demographic characteristics in RAR pattern have not been comprehensively assessed. Therefore, we aimed to describe RAR patterns among non-institutionalized US adults and age, sex, and race/ethnicity variation using accelerometry data from a nationally representative population.

METHODS

This cross-sectional study was conducted using the US National Health and Nutrition Examination Survey (NHANES) 2011-2014. Participants aged ≥20 years who were enrolled in the physical activity monitoring examination and had at least four 24-h periods of valid wrist accelerometer data were included in the present analysis. 24-h RAR metrics were generated using both extended cosinor model (amplitude, mesor, acrophase and pseudo-F statistic) and nonparametric methods (interdaily stability [IS] and intradaily variability [IV]). Multivariable linear regression was used to assess the association between RAR and age, sex, and race/ethnicity.

RESULTS

Eight thousand two hundred participants (mean [SE] age, 49.1 [0.5] years) were included, of whom 52.2% were women and 67.3% Whites. Women had higher RAR amplitude and mesor, and also more robust (pseudo-F statistic), more stable (higher IS) and less fragmented (lower IV) RAR (all P trend < 0.001) than men. Compared with younger adults (20-39 years), older adults (≥ 60 years) exhibited reduced RAR amplitude and mesor, but more stable and less fragmented RAR, and also reached their peak activity earlier (advanced acrophase) (all P trend < 0.001). Relative to other racial/ethnic groups, Hispanics had the highest amplitude and mesor level, and most stable (highest IS) and least fragmented (lowest IV) RAR pattern (P trend < 0.001). Conversely, non-Hispanic blacks had the lowest peak activity level (lowest amplitude) and least stable (lowest IS) RAR pattern (all P trend < 0.001).

CONCLUSIONS

In the general adult population, RAR patterns vary significantly according to sex, age and race/ethnicity. These results may reflect demographic-dependent differences in intrinsic circadian rhythms and may have important implications for understanding racial, ethnic, sex and other disparities in morbidity and mortality risk.

Association of Hispanic ethnicity and linguistic acculturation with cardiovascular medication adherence in patients with suspected acute coronary syndrome

Despite a higher prevalence of cardiovascular disease (CVD) risk factors, Hispanic-Americans have lower rates of CVD-related and all-cause mortality, as well as higher life expectancy than non-Hispanic whites – a phenomenon known as the Hispanic health paradox. However, this survival benefit attenuates with increased acculturation to Western lifestyles, potentially due to adoption of unhealthy behaviors. Accordingly, we assessed whether Hispanic ethnicity and linguistic acculturation, as measured by English proficiency, were associated with nonadherence to cardiovascular medications. We enrolled patients presenting to an academic medical center emergency department with suspected acute coronary syndrome between May 2014 and November 2017. Ethnicity, native language, and English proficiency were self-reported. Cardiovascular medication adherence was assessed using an electronic pill bottle that recorded the date and time of each bottle opening. Generalized linear models with a logit link were used to examine the association of Hispanic ethnicity and English proficiency with daily cardiovascular medication adherence, adjusting for demographics, comorbidities, and dosing frequency of the electronically-monitored medication. Among 332 included patients, mean age was 61.68 ± 12.05 years, 43.07% were women, and 62.95% were Hispanic, of whom 80.38% were native Spanish-speakers. Overall, Hispanics had higher odds of medication adherence than non-Hispanics (adjusted OR 1.31, 95% CI 1.16–1.49, p < 0.001). However, among native Spanish-speaking Hispanics, greater English proficiency was associated with lower odds of medication adherence (adjusted OR 0.80 per 1-point increase in English proficiency, 95% CI 0.75–0.86, p < 0.001). Although Hispanics had better medication adherence than non-Hispanics overall, increased linguistic acculturation among native Spanish-speakers was associated with worse adherence behaviors.

US Obesity Mortality Trends and Associated Noncommunicable Diseases Contributing Conditions Among White, Black, and Hispanic Individuals by Age from 1999 to 2017

This study aims to assess the effect of obesity as an underlying cause of death in association with four main noncommunicable diseases (NCDs) as contributing causes of mortality on the age of death in White, Black, and Hispanic individuals in the USA. To estimate mortality hazard ratios, we ran a Cox regression on the US National Center for Health Statistics mortality integrated datasets from 1999 to 2017, which included almost 48 million cases. The variable in the model was the age of death in years as a proxy for time to death. The cause-of-death variable allowed for the derivation of predictor variables of obesity and the four main NCDs. The overall highest obesity mortality HR when associated with NCD contributing conditions for the year 1999-2017 was diabetes (2.15; 95% CI: 2.11-2.18), while Whites had the highest HR (2.46; 95% CI: 2.41-2.51) when compared with Black (1.32; 95% CI: 1.27-1.38) and Hispanics (1.25; 95% CI: 1.18-1.33). Hispanics had lower mortality HR for CVD (1.21; 95% CI: 1.15-1.27) and diabetes (1.25; 95% CI: 1.18-1.33) of the three studied groups. The obesity death mean was 57.3 years for all groups. People who die from obesity are, on average, 15.4 years younger than those without obesity. Although Hispanics in the USA have a higher prevalence of diabetes and cardiovascular disease (CVD), they also have the lowest mortality HR for obesity as an underlying cause of death when associated with CVD and cancer. While there is no obvious solution for obesity and its complications, continued efforts to address obesity are needed.

Clinical outcomes of a community clinic-based lifestyle change program for prevention and management of metabolic syndrome: Results of the 'Vida Sana/Healthy Life' program

Introduction

As US Hispanic populations are at higher risk than non-Hispanics for cardiovascular disease and Type 2 diabetes targeted interventions are clearly needed. This paper presents the four years results of the Vida Sana Program (VSP), which was developed and is implemented by a small clinic serving mostly Spanish-speaking, limited literacy population.

Methods

The eight-week course of interactive two-hour sessions taught by Navegantes, bilingual/cultural community health workers, was delivered to participants with hypertension, or high lipids, BMI, waist circumference, glucose or hemoglobin A1C (A1C). Measures, collected by Navegantes and clinic nurses, included blood chemistries, blood pressure, anthropometry, and an assessment of healthy food knowledge.

Results

Most participants (67%) were female, Hispanic (95%), and all were 18 to 70 years of age. At baseline, close to half of participants were obese (48%), had high waist circumference (53%), or elevated A1C (52%), or fasting blood glucose (57%). About one third had high blood pressure (29%) or serum cholesterol (35%), and 22% scored low on the knowledge assessment. After the intervention, participants decreased in weight (-1.0 lb), BMI (-0.2 kg/m2), WC (-0.4 inches), and cholesterol (-3.5 mg/dl, all p<0.001). Systolic blood pressure decreased (-1.7 mm Hg, p<0.001), and the knowledge score increased (6.8 percent, p<0.001).

Discussion

VSP shows promising improvements in metabolic outcomes, similar to other programs with longer duration or higher intensity interventions. VSP demonstrates an important model for successful community-connected interventions.

Ten things to know about ten cardiovascular disease risk factors

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Race and ethnicity, gender, and age on perceived threats and fear of COVID-19: Evidence from two national data sources

Previous studies find preventative behaviors designed to reduce the number of infections during emerging disease outbreaks are associated with perceived risk of disease susceptibility. Few studies have attempted to identify underlying factors that explain differences in perceptions of risk during an infectious disease outbreak. Drawing from two early waves of American Trends Panel (n=7,441), as well as a National Science Foundation funded, Qualtrics national panel survey from the early stages of the pandemic (n=10,368), we test whether race and ethnicity, gender, and age were associated with six perceived threat and fear outcomes related to COVID-19. Results demonstrate race and ethnicity, gender, and age play a significant role in shaping threat and fear perceptions of COVID-19, but depending on the outcome, relationships vary in direction and magnitude. In some cases, historically marginalized racial and ethnic groups were more likely to report high fear and perceive coronavirus as a major threat to population and individual health, whereas, in others cases, the same marginalized racial and ethnic groups were less likely to perceive coronavirus to be a serious threat to the immune-comprised and the elderly population. We also find women were generally more likely to report high levels of threat and fear of COVID-19. Finally, we observe a clear age difference, whereby adults in older age groups report high-risk perceptions of COVID-19. Findings can inform public health programs designed to educate communities on the benefits of engaging in effective preventative practices during emerging infectious disease outbreaks.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

Cardiovascular Risk Assessment Varies Widely by Calculator and Race/Ethnicity in a Majority Latinx Cohort Living with HIV

Comparison of cardiovascular disease (CVD) risk calculators in Latinx majority populations living with HIV can assist clinicians in selecting a calculator and interpreting results. 10-year CVD risks were estimated for 652 patients seen ≥ 2 times over 12 months in a public clinic using three risk calculators: Atherosclerotic CVD risk Calculator (ASCVD), Framingham Risk Calculator (FRC), and Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) Calculator. Median estimated 10-year CVD risk in this population was highest using FRC (11%), followed by D:A:D (10%), and lowest with ASCVD (5%; p < 0.001). However, D:A:D classified 44.3% in a high/very high risk category compared to FRC (20.7%) and ASCVD (33.4%) (all p < 0.001). ASCVD risk estimates differed significantly by race/ethnicity (p < 0.001). Risk varied widely across three risk calculators and by race/ethnicity, and providers should be aware of these differences when choosing a calculator for use in majority minority populations.

Linking Mediterranean Diet and Lifestyle with Cardio Metabolic Disease and Depressive Symptoms: A Study on the Elderly in Europe

Against a backdrop of an aging population in Europe, promoting health in older adults becomes a pressing issue. This study aimed to explore if correlations exist between the adherence to the Mediterranean diet and specific health outcomes such as the incidence of chronic cardio metabolic illnesses and experiencing depressive symptoms for elderly individuals. We also looked into probable links between regularly engaging in vigorous physical activities and these health outcomes. Our goal was to clearly demonstrate these relationships while controlling for several individual characteristics and socio-demographic factors on a cross-national scale within Europe. Using the Survey of Health, Aging and Retirement in Europe (SHARE) data for adults aged 50 years and above, we found that following the Mediterranean diet was negatively correlated with the incidence of chronic illnesses, as well as with levels of depressive symptoms. These results were robust to the inclusion of a number of individual and socio-demographic controls. We also showed that regular participation in sports and other strenuous physical activities were associated with lesser chronic disorders and lower levels of depressive symptoms. These findings may have important implications in formulating preventive interventions on ensuring the quality of life of the older population.

Ten things to know about ten cardiovascular disease risk factors ("ASPC Top Ten - 2020")

Preventive cardiology involves understanding and managing multiple cardiovascular disease (CVD) risk factors. Given the rapid advancements in medical science, it may be challenging for the busy clinician to remain up-to-date on the multifaceted and fundamental aspects of CVD prevention, and maintain awareness of the newest applicable guidelines. The "American Society for Preventive Cardiology (ASPC) Top Ten 2020" summarizes ten essential things to know about ten important CVD risk factors, listed in tabular formats. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and gender), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten 2020" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

The Hispanic Paradox in Patients With Liver Cirrhosis: Current Evidence From a Large Regional Retrospective Cohort Study

BACKGROUND

Despite lower socioeconomic status, Hispanics in the United States paradoxically maintain equal or higher average survival rates compared to non-Hispanic Whites (NHW).

METHODS

We used multivariable Cox regression to assess whether this "Hispanic paradox" applies to patients with liver cirrhosis using a retrospective cohort of twenty 121 patients in a Chicago-wide electronic health record database.

RESULTS

Our study population included 3279 (16%) Hispanics, 9150 (45%) NHW, 4432 (22%) African Americans, 529 (3%) Asians, and 2731 (14%) of other races/ethnic groups. Compared to Hispanics, NHW (hazard ratio [HR] 1.26; 95% confidence interval [CI], 1.16-1.37), African American (HR 1.26; 95% CI, 1.15-1.39), and other races/ethnic groups (HR 1.55; 95% CI, 1.40-1.71) had an increased risk of death despite adjustment for age, sex, insurance status, etiology of cirrhosis, and comorbidities. On stratified analyses, a mortality advantage for Hispanics compared to NHW was seen for alcohol cirrhosis (HR for NHW 1.35; 95% CI, 1.19-1.52), hepatitis B (HR for NHW 1.35; 95% CI, 0.98-1.87), hepatitis C (HR for NHW 1.21; 95% CI, 1.06-1.38), and nonalcoholic steatohepatitis (HR for NHW 1.14; 95% CI, 0.94-1.39). There was no advantage associated with Hispanic race over NHW in cases of hepatocellular carcinoma or cholestatic liver disease.

CONCLUSIONS

Hispanic patients with cirrhosis experience a survival advantage over many other racial groups despite adjustment for multiple covariates.

Racial differences and mortality risk in patients with heart failure and hyponatremia

BACKGROUND

Hyponatremia is a well-established poor prognostic marker in patients with heart failure. Whether the mortality risk is comparable among different races of patients with heart failure and hyponatremia is unknown.

MATERIALS AND METHODS

Consecutive patients admitted with acute decompensated heart failure and an admission sodium level<135 mEq/L from 1/1/2001 through 12/31/10 were identified. Patients were divided into four groups based on self-reported race: white, African American, Hispanic and other. African Americans were used as the reference group for statistical analysis. The primary outcome was all-cause mortality.

RESULTS

We included 4,343 patients, from which 1,356 (31%) identified as white, 1,248 (29%) as African American, 780 (18%) as Hispanic and 959 (22%) as other. During a median follow-up of 23 months, a total of 2,384 patients died: 678 were African American, 820 were white, 298 were Hispanic and 588 were other. After adjusting for baseline demographics, comorbidities and medication use, Hispanic patients had a 45% less risk of death as compared to African Americans (HR .55, CI .48-.64, p<0.05). There was no difference in mortality between white and African American patients (HR 1.04, CI .92-1.2, p = 0.79).

CONCLUSION

Hispanic patients admitted for heart failure and who were hyponatremic on admission had an independent lower risk of mortality compared to other groups. These findings may be due to the disparate activity of the renin-angiotensin-aldosterone system among various racial groups. This observational study is hypothesis generating and suggests that treatment of patients with heart failure and hyponatremia should perhaps be focused more on renin-angiotensin-aldosterone system reduction in certain racial groups, yet less in others.

Disaggregation of Cause-Specific Cardiovascular Disease Mortality Among Hispanic Subgroups

Importance

Hispanics are the largest minority group in the United States and face a disproportionate burden of risk factors for cardiovascular disease (CVD) and low socioeconomic position. However, Hispanics paradoxically experience lower all-cause mortality rates compared with their non-Hispanic white (NHW) counterparts. This phenomenon has been largely observed in Mexicans, and whether this holds true for other Hispanic subgroups or whether these favorable trends persist over time remains unknown.

Objective

To disaggregate a decade of national CVD mortality data for the 3 largest US Hispanic subgroups.

Design, Setting, and Participants

Deaths from CVD for the 3 largest US Hispanic subgroups-Mexicans, Puerto Ricans, and Cubans-compared with NHWs were extracted from the US National Center for Health Statistics mortality records using the underlying cause of death based on coding from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (I00-II69). Mortality data were evaluated from January 1, 2003, to December 31, 2012. Population estimates were calculated using linear interpolation from the 2000 and 2010 US Census reports. Data were analyzed from November 2015 to July 2016.

Main Outcomes and Measures

Mortality due to CVD.

Results

Participants included 688 074 Mexican, 163 335 Puerto Rican, 130 397 Cuban, and 19 357 160 NHW individuals (49.0% men and 51.0% women; mean [SD] age, 75 [15] years). At the time of CVD death, Mexicans (age, 67 [18] years) and Puerto Ricans (age, 68 [17] years) were younger compared with NHWs (age, 76 [15] years). Mortality rates due to CVD decreased from a mean of 414.2 per 100 000 in 2003 to 303.3 per 100 000 in 2012. Estimated decreases in mortality rate for CVD from 2003 to 2012 ranged from 85 per 100 000 for all Hispanic women to 144 per 100 000 for Cuban men, but rate differences between groups vary substantially, with Puerto Ricans exhibiting similar mortality patterns to NHWs, and Mexicans experiencing lower mortality. Puerto Ricans experienced higher mortality rates for ischemic and hypertensive heart disease compared with other subgroups, whereas Mexicans experienced higher rates of cerebrovascular disease deaths.

Conclusions and Relevance

Significant differences in CVD mortality rates and changes over time were found among the 3 largest Hispanic subgroups in the United States. Findings suggest that the current aggregate classification of Hispanics masks heterogeneity in CVD mortality reporting, leading to an incomplete understanding of health risks and outcomes in this population.

Racial and Ethnic Disparities in the Burden and Cost of Diabetes for US Medicare Beneficiaries

Purpose: To examine the burden and cost of diabetes among fee-for-service Medicare beneficiaries. Methods: Medicare 5% File data for type 1 diabetes (T1D) and type 2 diabetes (T2D) consisting of 1,397,933 enrollees in fee-for-service without Medicare Advantage during the period 2012-2013 were analyzed by race and ethnicity. Results: Although non-Hispanic whites (nHWs) comprised most of this population (86%), prevalence of T1D and T2D was higher for Hispanics than nHWs (3.4% vs. 1.8%, p=0.0006, for T1D and 33.4% vs. 21.9%, p<0.0001, for T2D). Hispanics also had more acute hospital admissions (p=0.0235 for T1D and p=0.0009 for T2D) and longer lengths of stay (7.5 vs. 6.9 days for T1D, p=0.0105, and 6.7 vs. 6.2 days for T2D, p<0.0001) compared with nHWs. Allowed and paid costs per member per month adjusted for confounding were higher for Hispanics than nHWs for T2D (both p<0.0001) and lower for those with T1D (both p<0.0001). Mean number of chronic diseases in patients with diabetes was higher in Hispanics than nHWs (both T1D and T2D, p<0.0000). For T2D, Hispanics were more likely to have glycated hemoglobin (HbA_1c) and lipid testing as well as nephropathy screening (all p<0.0001). Hispanics with T1D were also more likely to have HbA_1c and lipid tests (p=0.0014 and p=0.0011, respectively); retinopathy and nephropathy screening rates did not differ significantly from rates among nHWs. Conclusion: Diabetes disproportionately impacts US seniors, with Hispanics almost twice as likely as nHWs to be diagnosed. Racial and ethnic disparities exist in the burden and cost of diabetes care for Medicare recipients.

Association of Educational Attainment and Cardiovascular Risk in Hispanic Individuals: Findings From the Cooper Center Longitudinal Study

Importance

Hispanic individuals are the fastest growing ethnic group in the United States and face lower socioeconomic status compared with non-Hispanic white (NHW) individuals. However, Hispanic individuals tend to experience better health outcomes than expected, a phenomenon known as the Hispanic paradox. Little is known about how higher socioeconomic status is associated with Hispanic cardiovascular risk factor burden and outcomes.

Objective

To determine cardiovascular risk and outcomes among highly educated Hispanic vs NHW individuals in a preventive medicine clinic.

Design, Settings, and Participants

Retrospective cohort analysis of participants from the Cooper Center Longitudinal Study who underwent preventive medical examinations at the Cooper Clinic in Dallas, Texas, from October 1972 to November 2017. Analysis began April 2018.

Exposure

Ethnicity, self-defined as Hispanic or NHW.

Main Outcomes and Measures

Prevalence of major metabolic risk factors and cardiorespiratory fitness were compared, as were changes among participants with at least 2 visits. Ethnic differences adjusted for age, examination year, and educational attainment were estimated using regression models. Age-matched comparisons of coronary artery calcium scores were performed. All-cause mortality was summarized using the Kaplan-Meier method.

Results

This study included 1351 Hispanic and 43 736 NHW participants aged 20 to 80 years, body mass index between 18.5 and 50.0, and were not missing key cardiometabolic or fitness variables. Both Hispanic and NHW participants had high educational attainment, with a mean of more than 15 years of total education. Hispanic women and men had a higher prevalence of metabolic syndrome (71 of 518 [13.1%] vs 1477 of 13 732 [10.8%] for women and 255 of 833 [30.6%] vs 7902 of 30 004 [26.3%] for men, respectively). Although Hispanic individuals were twice as likely to have diabetes, there was no difference in calculated 10-year atherosclerotic cardiovascular disease risk scores by ethnicity. Both Hispanic and NWH individuals experienced a statistically significant worsening in cardiometabolic parameters during follow-up, although this was not statistically significantly different between groups. In age-matched analyses, there were no significant differences in the prevalence of coronary artery calcium scores between Hispanic and NWH individuals. During a mean (SD) follow-up of 12.9 (7.5) years, there was no difference in mortality between Hispanic and NHW individuals.

Conclusions and Relevance

Hispanic and NHW men and women with high educational attainment had similar atherosclerotic cardiovascular disease risk, subclinical coronary atherosclerosis, and mortality during follow-up. These findings do not support the Hispanic paradox in a highly educated Hispanic population.

Community clinic-based lifestyle change for prevention of metabolic syndrome: Rationale, design and methods of the 'Vida Sana/healthy life' program

Purpose

and Objectives: The risk of diseases associated with Metabolic Syndrome (MetS) is higher for Hispanics living in the northeastern United States than for other racial and ethnic groups. Higher risk of diabetes, high blood lipids, obesity and limited access to continuity of care are all factors that also contribute to disproportionately poorer chronic disease outcomes for Hispanics.

Intervention approach

This article describes the planning and implementation of, and evaluation plans for the Vida Sana Program (VSP), a community-based group intervention created to address the identified MetS risks by encouraging healthier diet and physical activity behaviors among a low-income, largely Spanish speaking, and literacy limited uninsured population. Developed in response to recent calls for culturally-tailored interventions, VSP is conducted by trained bicultural/bilingual Navegantes, who deliver a culturally sensitive, fun and engaging eight-week, in-person educational series through group meetings. The intervention also includes a 40-page colorful, picture and graphic enhanced booklet to be used in the group setting and at home. The intervention focused on screening for MetS-associated disease risk factors, understanding chronic disease management, encouraging medication adherence, increasing physical activity, and healthful dietary changes such as limiting alcohol, sodium, unhealthy fats and excess carbohydrate intake, while emphasizing portion control, whole grains and healthy fats.

Conclusions

This creative, community-based approach fills an important gap in the community and in the public health literature, is well liked by health literacy limited patients, and will provide an important model of successfully engaging the Hispanic community on these important health issues.

Body Composition and Mortality in Mexican American Adults: Results from the National Health and Nutrition Examination Survey

OBJECTIVE

Epidemiologic analyses indicate a lack of association between BMI (kg/m² ) and mortality among Hispanic adults. Because BMI provides only a surrogate for the real variable of interest, adiposity, this study evaluated associations between measures of body composition and mortality.

METHODS

Using data from US-residing Mexican Americans in the National Health and Nutrition Examination Survey (NHANES) III (n = 4,480) and NHANES 1999-2010 (n = 5,849), the association between seven measures of body composition measured via anthropometry and bio-electrical impedance analysis (i.e., waist circumference, waist-to-height ratios [WHtR], skinfolds, lean mass, fat mass, percent body fat, and BMI) and all-cause and cardiovascular and diabetes mortality were examined. Additional analyses were stratified by gender.

RESULTS

Waist circumference (hazard ratio [HR]: 1.04, 95% CI: 1.01-1.07) and WHtR (HR: 1.08, 95% CI: 1.03-1.14) were weakly associated with an increased all-cause mortality, while WHtR was associated with an increased risk of diabetes-related death (HR: 1.26, 95% CI: 1.07-1.49). In gender-stratified analyses, there was an increased risk of mortality in females who had increases in WHtR and waist circumference for all-cause mortality and cardiovascular deaths.

CONCLUSIONS

Waist circumference and WHtR were associated with increased risk of all-cause and diabetes-related mortality in US-residing Mexican American adults.

Trends in the prevalence of type 2 diabetes and its association with mortality rates in Asians vs. Whites: Results from the United States National Health Interview Survey from 2000 to 2014

AIMS

To identify the prevalence and mortality of type 2 diabetes in Asian Americans (Asians) vs. non-Hispanic whites (Whites).

METHODS

We analyzed a nationally representative sample of 237,354 U.S. adults aged ≥30 years using National Health Interview Survey data from 2000 to 2014 to estimate the prevalence and trends of type 2 diabetes. Additionally, 144,638 Asians and Whites represented in surveys from 2000 to 2009 were included in the mortality analysis with follow-up to 2011.

RESULTS

Type 2 diabetes was higher in Asians than Whites (7.0-11.2 vs. 5.6-8.3%) and increased over time. Prevalence rates increased from 8.1 (2000-2002) to 9.6% (2012-2014) in Asians and from 6.0 (2000-2002) to 7.9% (2012-2014) in Whites (both P < 0.05). The age-standardized mortality rates were 72.7 and 138.8 per 1000 person-years in Asians and Whites with diabetes, respectively, and 58.1 and 77.8 per 1000 person-years, respectively, in those without diabetes. Among Asians and Whites with diabetes, hazard ratios for total and CVD mortality were 0.7 (95% CI: 0.5-0.9) and 0.3 (95% CI: 0.1-0.6), respectively, with no difference in cancer mortality. Asians and Whites without diabetes exhibited no differences in total or cause-specific mortality.

CONCLUSIONS

Type 2 diabetes was more prevalent in Asians, with a significant upward trend since 2000, but overall mortality was lower in Asians than Whites with diabetes. Asians are susceptible to type 2 diabetes; thus, prevention programs are still needed.

Impact of Ethnicity, Sex, and Socio-Economic Status on the Risk for Heart Failure Readmission: The Importance of Context

Background

Hispanics are a fast-growing minority in the United States and have a high risk for the development of heart failure (HF). Hispanics have higher HF-related hospital readmission rates compared with non-Hispanics. However, the risk of readmission in a largely disadvantaged and majority Hispanic population has not been evaluated.

Methods

We analyzed data for patients discharged with a principal discharge diagnosis of HF from the University of New Mexico Hospital from 2010-2014. Student t-test and chi-square analysis were used to assess the unadjusted associations between baseline characteristics and 30-day readmission rate. Multivariable logistic regression modeling evaluated the associations between 30-day hospital readmission rate, socio-demographic characteristics, and clinical variables.

Results

A total of 1,594 patients were included in our analysis. Mean age (SD) was 63.1 ± 14 and 62.9 ±13.8 (P=.07) for Hispanics and non-Hispanics, respectively. Sixty percent of Hispanics had HF with reduced ejection fraction compared with 53.9% of non-Hispanics (P=.012). In unadjusted analysis, Hispanic ethnicity was associated with a two-fold increase in HF readmission rate compared with non-Hispanic ethnicity (OR 2.0, 95% CI 1.5-2.7). In fully adjusted models, Hispanic ethnicity showed an 80% increase in HF readmission rate compared with non-Hispanic ethnicity (OR 1.8, 95% CI 1.2-2.6).

Conclusion

Among patients from a socioeconomically disadvantaged background living in a Hispanic-majority area, being Hispanic is associated with higher odds of 30-day hospital re-admission after adjusting for demographic, clinical and socioeconomic covariates. Our findings show that further research is needed to understand disparities in Hispanic's heart failure-related outcomes.

The Association of Fasting Glucose, Insulin, and C-Peptide, with 19-Year Incidence of Coronary Heart Disease in Older Japanese-American Men; the Honolulu Heart Program

The role of fasting glucose, insulin levels, and C-peptide in coronary heart disease (CHD) in non-diabetic individuals remains uncertain. We examined the association between fasting glucose, insulin and C-peptide with the long-term incidence of CHD in Japanese-American men. In 1980–1982, from a random sample of the Honolulu Heart Program men (n = 1378), aged 61–81 years, data on several CHD and metabolic risk factors were obtained to examine the relation of fasting glucose, insulin and C-peptide to 19-year CHD incidence. Age-adjusted incidence of CHD increased with increasing quintiles of glucose, insulin and C-peptide. Age-adjusted CHD rates in the glucose quintiles were 11.9, 11.6, 14.4, 18.1 and 24.1 per 1000 person-years (trend p < 0.001). In individual Cox models (lowest quintiles of glucose, insulin and C-peptide as reference) the relative risks (95% confidence interval) of CHD incidence for the glucose quintiles adjusting for age, smoking, hypertension, cholesterol, physical activity, and body mass index, were 0.9 (0.6–1.4), 1.2 (0.8–1.8), 1.4 (0.9–2.2), and 1.7 (1.1–2.6), respectively (trend p = 0.004). Insulin and C-peptide were not significantly associated with CHD on multivariate analysis. Fasting glucose remained the only significant predictor of increased CHD risk (p = 0.003) in a model combining all 3 metabolic variables. In this cohort, only fasting glucose independently predicts long-term incidence of CHD. Age-adjusted insulin and C-peptide levels were associated with CHD incidence, but after adjustment for other risk factors, do not independently predict CHD.

Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery

OBJECTIVES

Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival.

METHODS

All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed.

RESULTS

Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO.

CONCLUSIONS

Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.

Evidence for reduced susceptibility to cardiac bradycardias in South Asians compared with Caucasians

Objectives

To investigate ethnic differences in susceptibility to bradycardias in South Asian and white European patients in the UK by determining rates of permanent pacemaker (PPM) implantation for sinus node dysfunction (SND) and atrioventricular block (AVB) in each ethnic group.

Methods

We carried out a retrospective cohort study into new PPM implantation during the period from 1 May 2006 to 31 March 2014, in patients of South Asian and Caucasian ethnicity resident in Leicestershire, UK. Numbers of individuals at risk in each ethnic group were derived from UK National Census data of 2011. Crude, and age-standardised incidence rates and risk ratios per 1000 population of PPM implantation were calculated for Caucasians and South Asians.

Results

During the study period, 4883 individuals from the Leicestershire population of 980 328 underwent PPM implantation, a cumulative implantation rate of 4.98/1000 population. The population cumulative PPM implantation rate for SND was 1.74/1000, AVB 2.83/1000 and other indications 0.38/1000 population. The crude incidence in Caucasians (6.15/1000 population) was higher than in South Asians (1.07/1000 population) and remained higher after age standardisation (5.60/1000 vs 2.03/1000, P<0.001). The age-standardised cumulative PPM implantation rates were lower in South Asians for both SND (0.53/1000 in South Asians; 1.97/1000 in Caucasians, P<0.001) and AVB (1.30/1000 in South Asians; 3.17/1000 in Caucasians, P<0.001). Standardised risk ratios (95% CI) for PPM implantation in South Asians compared with Caucasians for all pacing indications, SND and AVB were 0.36 (95% CI 0.36 to 0.37), 0.27 (95% CI 0.27 to 0.28) and 0.41 (95% CI 0.41 to 0.42), respectively.

Conclusions

Rates of PPM implantation are lower in South Asians residing in the UK, compared with Caucasians. This observation raises the possibility of lower inherent susceptibility to bradycardias in South Asians compared with Caucasians. Studies aimed at identifying underlying mechanisms, including possible genetic differences, are warranted.

Clinical Outcomes by Race and Ethnicity in the Systolic Blood Pressure Intervention Trial (SPRINT): A Randomized Clinical Trial

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) showed that targeting a systolic blood pressure (SBP) of ≤ 120 mm Hg (intensive treatment) reduced cardiovascular disease (CVD) events compared to SBP of ≤ 140 mm Hg (standard treatment); however, it is unclear if this effect is similar in all racial/ethnic groups.

METHODS

We analyzed SPRINT data within non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic subgroups to address this question. High-risk nondiabetic hypertensive patients (N = 9,361; 30% NHB; 11% Hispanic) 50 years and older were randomly assigned to intensive or standard treatment. Primary outcome was a composite of the first occurrence of a myocardial infarction, acute coronary syndrome, stroke, decompensated heart failure, or CVD death.

RESULTS

Average postbaseline SBP was similar among NHW, NHB, and Hispanics in both treatment arms. Hazard ratios (HRs) (95% confidence interval) (intensive vs. standard treatment groups) for primary outcome were 0.70 (0.57-0.86), 0.71 (0.51-0.98), 0.62 (0.33-1.15) (interaction P value = 0.85) in NHW, NHB, and Hispanics. CVD mortality HRs were 0.49 (0.29-0.81), 0.77 (0.37-1.57), and 0.17 (0.01-1.08). All-cause mortality HRs were 0.61 (0.47-0.80), 0.92 (0.63-1.35), and 1.58 (0.73-3.62), respectively. A test for differences among racial/ethnic groups in the effect of treatment assignment on all-cause mortality was not significant (Hommel-adjusted P value = 0.062) after adjustment for multiple comparisons.

CONCLUSION

Targeting a SBP goal of ≤ 120 mm Hg compared to ≤ 140 mm Hg led to similar SBP control and was associated with similar benefits and risks among all racial ethnic groups, though NHBs required an average of ~0.3 more medications.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01206062, ClinicalTrials.gov Identifier at https://clinicaltrials.gov/ct2/show/NCT01206062.

Examining Race and Ethnicity Information in Medicare Administrative Data

Racial and ethnic disparities are observed in the health status and health outcomes of Medicare beneficiaries. Reducing these disparities is a national priority, and having high-quality data on individuals' race and ethnicity is critical for researchers working to do so. However, using Medicare data to identify race and ethnicity is not straightforward. Currently, Medicare largely relies on Social Security Administration data for information about Medicare beneficiary race and ethnicity. Directly self-reported race and ethnicity information is collected for subsets of Medicare beneficiaries but is not explicitly collected for the purpose of populating race/ethnicity information in the Medicare administrative record. As a consequence of historical data collection practices, the quality of Medicare's administrative data on race and ethnicity varies substantially by racial/ethnic group; the data are generally much more accurate for whites and blacks than for other racial/ethnic groups. Identification of Hispanic and Asian/Pacific Islander beneficiaries has improved through use of an imputation algorithm recently applied to the Medicare administrative database. To improve the accuracy of race/ethnicity data for Medicare beneficiaries, researchers have developed techniques such as geocoding and surname analysis that indirectly assign Medicare beneficiary race and ethnicity. However, these techniques are relatively new and data may not be widely available. Understanding the strengths and limitations of different approaches to identifying race and ethnicity will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using these measures.