Predictive Validity of the American College of Cardiology/American Heart Association Pooled Cohort Equations in Predicting All-Cause and Cardiovascular Disease-Specific Mortality in a National Prospective Cohort Study of Adults in the United States

Association of atherogenic index of plasma with cardiovascular disease mortality and all-cause mortality in the general US adult population: results from NHANES 2005-2018

BACKGROUND

The atherogenic index of plasma (AIP) is a critical metric for predicting cardiovascular outcomes. However, its associations with cardiovascular disease mortality (CVM) and all-cause mortality (ACM) remain unclear. This study aims to elucidate the relationship between baseline AIP levels and CVM and ACM among a broad cohort of US adults.

METHODS

Utilizing data from the National Health and Nutrition Examination Survey (2005-2018), we analyzed 18,133 adults aged ≥ 18. Baseline triglycerides and high-density lipoprotein cholesterol levels were measured to calculate the AIP. Mortality outcomes were determined through linkage with the National Death Index database, with follow-up through December 31, 2019. Multivariable Cox proportional hazard models examined the associations between baseline AIP and mortality risks. Additionally, restricted cubic splines were utilized to investigate potential non-linear relationships, with subgroup analyses conducted across strata defined by age, gender, body mass index, diabetes, hypertension, and metabolic syndrome to assess variability in these associations.

RESULTS

Over a median 95.0-month follow-up, there were 1870 all-cause deaths and 579 cardiovascular disease-related deaths. Our findings indicate a J-shaped association between the AIP and ACM (threshold = 0.0905); specifically, when baseline AIP exceeded 0.0905, a significant positive association with ACM emerged (hazard ratio, HR (95% confidence interval, CI): 1.61(1.08-2.37)). However, after adjusting for confounders, the relationship between AIP and CVM was not statistically significant (HR 1.31, 95% CI 0.93-1.86). Notably, in the 40-60-year age group, AIP was significantly positively associated with ACM and CVM, with HRs and 95% CIs of 1.51 (1.08v2.10) and 2.63 (1.39-4.98), respectively.

CONCLUSIONS

A J-shaped relationship was observed between baseline AIP levels and ACM within the general US population, with a threshold of 0.0905. Moreover, AIP could potentially be an effective predictor for future ACM or CVM, particularly among individuals aged 40-60. Further investigation is warranted to corroborate these findings.

Association of diabetic retinopathy on all-cause and cause-specific mortality in older adults with diabetes: National Health and Nutrition Examination Survey, 2005-2008

To evaluate the effect of diabetic retinopathy (DR) status or severity on all-cause and cause-specific mortality among diabetic older adults in the United States using the most recent National Health and Nutrition Examination Survey (NHANES) follow-up mortality data. The severity of DR was graded according to the Early Treatment Diabetic Retinopathy Study (ETDRS) grading scale. Multiple covariate-adjusted Cox proportional hazards regression models, Fine and Gray competing risk regression models, and propensity score matching (PSM) methods were used to assess the risk of all-cause and cause-specific mortality in individuals with diabetes. All analyses adopted the weighted data and complex stratified design approach proposed by the NHANES guidelines. Time to death was calculated based on the time between baseline and date of death or December 31, 2019, whichever came first. Ultimately 1077 participants, representing 3,025,316 US non-hospitalized individuals with diabetes, were included in the final analysis. After a median follow-up of 12.24 years (IQR, 11.16-13.49), 379 participants were considered deceased from all-causes, with 43.90% suffering from DR, including mild DR (41.50%), moderate to severe DR (46.77%), and proliferative DR (PDR) (67.21%). DR was associated with increased all-cause, cardiovascular disease (CVD) and diabetes mellitus (DM)-specific mortality, which remained consistent after propensity score matching (PSM). Results of DR grading assessment suggested that the presence of mild, moderate to severe NPDR was significantly associated with increased risk of all-cause and CVD-specific mortality, while the presence and severity of any DR was associated with increased DM-specific mortality, with a positive trend. The presence of DR in elderly individuals with diabetes is significantly associated with the elevated all-cause and CVD mortality. The grading or severity of DR may reflect the severity of cardiovascular disease status and overall mortality risk in patients with diabetes.

Association between dietary flavonol intake and mortality risk in the U.S. adults from NHANES database

Using updated National Health and Nutrition Examination Survey (NHANES) follow-up data, and a large nationwide representative sample of adult U.S. citizens, the aim of this study was to explore the relationship between dietary flavonol intake, all-cause and cause-specific mortality risks. In this prospective cohort study based on NHANES (2007-2008, 2009-2010, and 2017-2018), a total of 11,679 participants aged 20 years and above were evaluated. The amount and type of food taken during a 24-h dietary recall were used to estimate dietary flavonol intake, which includes total flavonol, isorhamnetin, kaempferol, myricetin, and quercetin. Each analysis of the weighted data was dealt with in accordance with the NHANES reporting requirements' intricate stratification design. The Cox proportional risk regression model or Fine and Gray competing risks regression model were applied to evaluate all-cause and cause-specific mortality risks, respectively. The follow-up period was calculated using the time interval between the baseline and the death date or December 31, 2019 (whichever occurs first). Each data analysis was performed between October 1, 2023, and October 22, 2023. Dietary flavonol intake included total flavonol, isorhamnetin, kaempferol, myricetin, and quercetin. Up to December 31, 2019, National Death Index (NDI) mortality data were used to calculate mortality from all causes as well as cause-specific causes. A total of 11,679 individuals, which represents 44,189,487 U.S. non-hospitalized citizens, were included in the study; of these participants, 49.78% were male (n = 5816), 50.22% were female (n = 5, 863); 47.56% were Non-Hispanic White (n = 5554), 18.91% were Non-Hispanic Black (n = 2209), 16.23% were Mexican American (n = 1895), and 17.30% were other ethnicity (n = 2021); The mean [SE] age of the sample was 46.93 [0.36] years, with a median follow-up of 7.80 years (interquartile range, 7.55-8.07 years). After adjusting covariates, Cox proportional hazards models and fine and gray competing risks regression models for specific-cause mortality demonstrated that total flavonol intake was associated with all-cause (HR 0.64, 95% CI 0.54-0.75), cancer-specific (HR 0.45, 95% CI 0.28-0.70) and CVD-specific (HR 0.67, 95% CI 0.47-0.96) mortality risks; isorhamnetin intake was associated with all-cause (HR 0.72, 95% CI 0.60-0.86), and cancer-specific (HR 0.62, 95% CI 0.46-0.83) mortality risks; kaempferol intake was associated with all-cause (HR 0.74, 95% CI 0.63-0.86), and cancer-specific (HR 0.62, 95% CI 0.40-0.97) mortality risks; myricetin intake was associated with all-cause (HR 0.77, 95% CI 0.67-0.88), AD-specific (HR 0.34, 95% CI 0.14-0.85), and CVD-specific (HR 0.61, 95% CI 0.47-0.80) mortality risks; quercetin intake was associated with all-cause (HR 0.66, 95% CI 0.54-0.81), cancer-specific (HR 0.54, 95% CI 0.35-0.84), and CVD-specific (HR 0.61, 95% CI 0.40-0.93) mortality risks; there was no correlation observed between dietary flavonol intake and DM-specific mortality. According to the current study, all-cause, AD, cancer, and CVD mortality risks declined with increased dietary flavonoid intake in the U.S. adults. This finding may be related to the anti-tumor, anti-inflammatory, and anti-oxidative stress properties of flavonol.

Retinal Vascular Measurements and Mortality Risk: Evidence From the UK Biobank Study

Purpose

This study aimed to investigate the association between quantitative retinal vascular measurements and the risk of all-cause and premature mortality.

Methods

In this population-based cohort study using the UK Biobank data, we employed the Retina-based Microvascular Health Assessment System to assess fundus images for image quality and extracted 392 retinal vascular measurements per fundus image. These measurements encompass six categories of vascular features: caliber, density, length, tortuosity, branching angle, and complexity. Univariate Cox regression models were used to identify potential indicators of mortality risk using data on all-cause and premature mortality from death registries. Multivariate Cox regression models were then used to test these associations while controlling for confounding factors.

Results

The final analysis included 66,415 participants. After adjusting for demographic, health, and lifestyle factors and genetic risk score, 18 and 10 retinal vascular measurements were significantly associated with all-cause mortality and premature mortality, respectively. In the fully adjusted model, the following measurements of different vascular features were significantly associated with all-cause mortality and premature mortality: arterial bifurcation density (branching angle), number of arterial segments (complexity), interquartile range and median absolute deviation of arterial curve angle (tortuosity), mean and median values of mean pixel widths of all arterial segments in each image (caliber), skeleton density of arteries in macular area (density), and minimum venular arc length (length).

Conclusions

The study revealed 18 retinal vascular measurements significantly associated with all-cause mortality and 10 associated with premature mortality. Those identified parameters should be further studied for biological mechanisms connecting them to increased mortality risk.

Translational Relevance

This study identifies retinal biomarkers for increased mortality risk and provides novel targets for investigating the underlying biological mechanisms.

Association of retinopathy with risk of all-cause and specific-cause mortality in the National Health and Nutrition Examination Survey, 2005 to 2008

Objective

This study aimed to elucidate the relationship between retinopathy status or severity and the all-cause and specific-cause mortality risk based on the updated National Health and Nutrition Examination Survey (NHANES) database and 2019 Public Access Link mortality file.

Methods

In this prospective cohort study, a total of 6,797 participants aged over 40 years based on NHANES 2005-2008 were analyzed. The severity of retinopathy was classified into 4 grades-no retinopathy, mild non-proliferative retinopathy (NPR), moderate to severe NPR, and proliferative retinopathy (PR). Multiple covariate-adjusted Cox proportional hazards regression models and Fine and Gray competing risk regression models were used to assess the all-cause and cause-specific mortality risks, respectively. The propensity score matching (PSM) approach was also applied additionally to adequately balance between-group covariates to validate our findings.

Results

A final total of 4,808 participants representing 18,282,772 United States (US) non-hospitalized participants were included for analysis, 50.27% were male (n = 2,417), 55.32% were non-hispanic white (n = 2,660), and mean [SE] age, 56.10 [0.40] years. After a median follow-up of 12.24 years (interquartile range, 11.16-13.49 years), 1,164 participants died of all-cause mortality, of which 941 (80.84%) died without retinopathy and 223 (19.16%) died with retinopathy at baseline. The presence of retinopathy was associated with increased all-cause mortality, cardiovascular disease (CVD), and diabetes mellitus (DM)-specific mortality, and the results remain consistent after PSM. Severity analysis showed that only mild NPR was associated with an increased all-cause mortality risk (hazard ratio (HR) = 2.01; 95% confidence interval (CI), 1.00-4.03), while increased CVD and DM-specific mortality risk were associated with all grades of retinopathy and were exponentially greater with increasing retinopathy severity, and the trend test was also significant (P for trend 0.004 and 0.04, respectively).

Discussion

Our findings suggest that the diagnosis of retinopathy is an independent risk factor for all-cause mortality in people over 40 years old. Retinopathy grading is significantly associated with the survival risk of patients with CVD or DM, it can be a valuable predictor in the stratified management and risk warning of CVD or DM patients, as well as in the monitoring of systemic vasculopathy status.

Temporal trends in atherosclerotic cardiovascular disease risk among U.S. adults. Analysis of the National Health and Nutrition Examination Survey, 1999-2018

BACKGROUND

Atherosclerotic cardiovascular diseases are a significant cause of disability and mortality. Study of trends in cardiovascular risk at a population level helps understand the overall cardiovascular health and the impact of primary prevention efforts.

AIMS

To assess trends in the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among U.S. adults from 1999-2000 to 2017-18 with no established cardiovascular disease (CVD).

METHODS AND RESULTS

Serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 (10 cycles), including 24 022 US adults aged 40-79 years with no reported ASCVD. ASCVD risk was assessed using the pooled cohort equations (PCEs). There was a significant temporal decline in the mean 10-year ASCVD risk from 13.5% (95% CI, 12.5-14.4) in 1999-2000 to 11.1% (10.5-11.7) in 2011-12 (Ptrend < 0.001) and to 12.0% (11.3-12.7) in 2017-2018 (overall Ptrend = 0.001), with the mean ASCVD risk score remaining stable from 2013-14 through 2017-2018 (Ptrend = 0.056). A declining trend in ASCVD risk was noted in females, non-Hispanic Blacks and those with income <3 times the poverty threshold with Ptrend of <0.001, 0.002, and 0.007, respectively. Mean total cholesterol and prevalence of smokers showed a downward trend (Ptrend <0.001 for both), whereas type 2 diabetes and mean BMI showed an upward trend (Ptrend < 0.001 for both).

CONCLUSIONS

The 20-year trend of ASCVD risk among NHANES participants 40-79 years, as assessed by the use of PCE, showed a non-linear downward trend from 1999-2000 to 2017-18. The initial and significant decline in estimated ASCVD risk from 1999-2000 to 2011-12 subsequently stabilized, with no significant change from 2013-14 to 2017-18. Mean BMI and prevalence of diabetes mellitus increased while mean serum cholesterol levels and prevalence of smoking declined during the study period. Our findings support invigoration of efforts aimed at prevention of CVD, including primordial prevention of CVD risk factors.

Importance of NT-proBNP and conventional risk factors for prediction of death in older adults with and without diabetes mellitus- A report from the Atherosclerosis Risk in Communities (ARIC) study

In this community-based cohort of 5861 individuals followed for median 7.2 years, the discriminatory ability of NT-proBNP alone in predicting mortality was similar to that of multiple conventional markers of risk in people without diabetes. In people with diabetes, NT-proBNP alone discriminated risk of mortality better than conventional risk factors.

Cardiovascular Risk Assessment by SCORE2 Predicts Risk for Colorectal Neoplasia and Tumor-Related Mortality

Objectives: The European Society of Cardiology endorsed SCORE2 to assess cardiovascular risk. The aim of this observational, retrospective study was to assess whether SCORE2 is associated with colorectal neoplasia in an asymptomatic screening population. Further, we evaluated if SCORE2 predicts tumor-related mortality. Methods: We included 3408 asymptomatic patients who underwent a screening colonoscopy. We calculated SCORE2 for each participant and stratified patients according to their predicted 10-year risk of cardiovascular disease: SCORE2 0−4.9%, SCORE2 5−9.9%, and SCORE2 ≥ 10%. We assessed the association between SCORE2 as a continuous variable, the presence of colorectal neoplasia using multilevel logistic regression, and SCORE2 and mortality using Cox regression. Results: In total, 1537 patients had a SCORE2 of 0−4.9%, 1235 a SCORE2 of 5−9.9%, and 636 a SCORE2 ≥ 10%. The respective rates of colorectal neoplasia were 20%, 37%, and 44%. SCORE2 was associated with the presence of any (OR 1.11 95%CI 1.09−1.12; p < 0.001) and advanced colorectal neoplasia (OR 1.06 95%CI 1.08−1.13; p < 0.001) in univariate analysis. After multivariable adjustment (age, sex, family history, and metabolic syndrome) a higher SCORE2 remained associated with higher odds for any (aOR 1.04 95%CI 1.02−1.06; p = 0.001) and advanced (aOR 1.06 95%CI 1.03−1.10; p < 0.001) colorectal neoplasia. SCORE2 was associated with both all-cause (HR 1.11 95%CI 1.09−1.14; p < 0.001) and tumor-related mortality (HR 1.10 95%CI 1.05−1.14; p < 0.001). Conclusions: We found that SCORE2 is associated with the presence of colorectal neoplasia. Clinicians could kill two birds with one stone calculating SCORE2. In patients with a high SCORE2, screening colonoscopy aside from cardiovascular risk mitigation could improve outcomes.

Serum Total Testosterone and Premature Mortality Among Men in the USA

The relationship between testosterone and premature mortality has caused recent controversy. While previous studies have demonstrated mixed results, this is partly because of variable patient populations, different testosterone thresholds, and the use of antiquated techniques to measure serum testosterone. Using the National Health and Nutrition Examination Survey we analyzed a cohort representative of men in the USA to explore the relationship between serum testosterone and premature mortality using contemporary guidelines and testosterone measurements. We found that men with low testosterone (<300 ng/dl) were at higher risk (odds ratio 2.07, 95% confidence interval 1.30–3.32; p < 0.01) of premature death compared to men with normal testosterone. Furthermore, men with low testosterone were also more likely to have treatable comorbid conditions that were independently predictive of premature mortality. Both testosterone and these comorbid conditions are also modulated by lifestyle modifications, rendering this an important therapeutic approach in men with either or both conditions.

Patient summary

We explored the relationship between testosterone levels and premature death in a large US population. We found that low testosterone is associated with both premature death and related disease processes such as obesity, both of which can be initially treated with diet and exercise.

Impact of Retinopathy and Systemic Vascular Comorbidities on All-Cause Mortality

PURPOSE

To assess the impact of retinopathy and systemic vascular comorbidities on the all-cause mortality in a representative U.S. sample.

METHODS

A total of 5703 participants (≥40 years old) from the 2005-2008 National Health and Nutrition Examination Survey. The Early Treatment Diabetic Retinopathy Study grading scale was used to evaluate the retinopathy status. Systemic vascular comorbidities included diabetes mellitus (DM), high blood pressure (HBP), chronic kidney disease (CKD) and cardiovascular disease (CVD). Time to death was calculated as the time from baseline to either the date of death or censoring (December 31^st, 2015), whichever came first. Risks of mortality were estimated using Cox proportional hazards models after adjusting for confounders and vascular comorbidities.

RESULTS

After a median follow-up of 8.33 years (IQR: 7.50-9.67 years), there were 949 (11.8%) deaths from all causes. After adjusting for confounders, the presence of retinopathy predicted higher all-cause mortality (hazard ratio (HR), 1.41; 95% confidence interval (CI), 1.08-1.83). The all-cause mortality among participants with both retinopathy and systemic vascular comorbidities including DM (HR, 1.72; 95% CI, 1.21-2.43), HBP (HR, 1.47; 95% CI, 1.03-2.10), CKD (HR, 1.73; 95% CI, 1.26-2.39) and CVD (HR, 1.92; 95% CI, 1.21-3.04) was significantly higher than that among those without either condition. When stratified by diabetic or hypertension status, the co-occurrence of retinopathy and CKD or CVD further increased the all-cause mortality compared to those without either condition.

CONCLUSIONS

The co-occurrence of retinopathy and systemic vascular conditions predicted a further increase in the risk of mortality. More extensive vascular risk factor assessment and management are needed to detect the burden of vascular pathologies and improve long-term survival in individuals with retinopathy.

Relationships Between Personal Satisfaction, Cardiovascular Disease Risk, and Health Promoting Behavior Among Arab American Middle-Aged Women

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death among middle-aged women. Health-promoting behavior is essential to the prevention of CVD. During middle adulthood, women experience biopsychosocial changes that may reduce personal satisfaction and affect health-promoting behavior and CVD risk.

OBJECTIVE

This study aimed to examine the impact of personal satisfaction on health-promoting behavior and CVD risk in middle-aged Arab American women.

METHODS

A convenience sample of 114 middle-aged Arab American women was recruited from 2 clinical sites in Michigan in the United States. Participants completed a demographic questionnaire, the Health-Promoting Lifestyle Profile-II, the Multidimensional Scale of Perceived Social Support, the Satisfaction With Life Scale, the Rosenberg Self-esteem Scale, and a single item assessing health satisfaction. Risk for CVD was calculated using the 10-year atherosclerotic CVD Risk Estimator.

RESULTS

Health-promoting behavior was significantly correlated with self-satisfaction (r = 0.54, P < .0001), health satisfaction (r = 0.45, P < .0001), and life satisfaction (r = 0.41, P < .0001). Risk for CVD was significantly negatively correlated with self-satisfaction (r = -0.17, P = .039), health satisfaction (r = -0.18, P = .029), and life satisfaction (r = -0.27, P = .002). Self-satisfaction and health satisfaction accounted for 32% of the variance in health-promoting behavior (F = 7.568, P < .0001). Age and life satisfaction accounted for 50% of the variance in CVD risk score (F = 58.28, P < .0001).

CONCLUSIONS

Personal satisfaction was associated with health-promoting behavior and CVD risk. Future research would benefit from the inclusion of longitudinal data and comparative groups.

Association of Age-Related Macular Degeneration With Risk of All-Cause and Specific-Cause Mortality in the National Health and Nutrition Examination Survey, 2005 to 2008

Question

What is the association of age-related macular degeneration with mortality outcomes among older adults?

Findings

In this cohort study of 5603 participants 40 years or older, only late age-related macular degeneration was associated with more than a doubling of all-cause mortality and more than 3-fold higher risk of mortality not due to cardiovascular disease and cancer.

Meaning

The association of late age-related macular degeneration and poor survival may shed light on mechanisms underlying the disease, indicating that late age-related macular degeneration may be a marker of frailty and aging or may be due to residual confounding factors indicative of aging.

Importance

Age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment and blindness in the United States if subretinal neovascularization is left untreated. Knowledge of the association between AMD and survival is informative for underlying mechanisms of AMD.

Objective

To examine the association between AMD and risk of all-cause and specific-cause mortality in a representative US sample.

Design, Setting, and Participants

This population-based prospective cohort study included 5603 participants 40 years or older who responded to the National Health and Nutrition Examination Survey (NHANES) in the 2005-2008 phase. Retinal photographs were graded as early, late, or no AMD. All analyses accounted for the complex and stratified design of NHANES with weighted data. Risks of all-cause mortality were assessed with Cox proportional hazards regression models; risks of specific-cause mortality, with Fine and Gray competing risks regression models. Time to death was counted from baseline to date of death or December 31, 2011, whichever came first. Data analysis was conducted from April 1 through 30, 2018.

Exposures

Age-related macular degeneration status as determined by digital fundus images.

Main Outcomes and Measures

Mortality resulting from all causes and specific causes until December 31, 2011.

Results

Among the 5603 participants (52.6% female [n = 2793] and 77.1% white [n = 3017]; mean [SE] age, 56.4 [0.4] years), weighted prevalence of any AMD was 6.6%, with 386 (5.8%) having early AMD and 55 (0.8%) having late AMD. After a median follow-up of 4.5 years (interquartile range, 3.6-5.6 years), 433 (5.3%) died of all causes, of whom 361 (83.1%) had no AMD, 54 (11.5%) had signs of early AMD, 18 (5.4%) had signs of late AMD, and 72 (16.9%) had any AMD at baseline. Overall, unadjusted all-cause and specific-cause mortality rates were higher for those participants who had early, late, or any AMD compared with no AMD. However, after adjusting confounding factors, only late AMD was associated with more than a doubling of all-cause mortality (hazard ratio [HR], 2.01; 95% CI, 1.00-4.03) and more than a 3-fold higher risk of mortality due to causes other than cardiovascular disease and cancer (HR, 3.42; 95% CI, 1.38-8.49). No association was identified between AMD presence or early AMD and all-cause or specific-cause mortality.

Conclusions and Relevance

In this study’s findings, only late AMD was independently associated with all-cause mortality and mortality due to causes other than cardiovascular disease and cancer, indicating that late AMD may be a marker of biological aging. Alternatively, this association may be due to unmeasured or inadequately assessed confounding factors for late AMD.

Unique cardiovascular risk factors in women

Despite an overall reduction in cardiovascular disease (CVD) mortality in the USA, the rate of coronary heart disease and CVD mortality is on the rise in younger women aged 35 to 54 years. This has been attributed to an increasing prevalence of CVD risk factors, which can portend disparate outcomes in women versus men. Women with diabetes and those who smoke have an excess relative risk of CVD when compared with their male counterparts. In addition to these discrepancies in traditional risk factors, a number of clinical conditions unique to women have been shown to increase CVD risks such as pre-eclampsia, gestational diabetes, polycystic ovary syndrome, early menopause and autoimmune diseases. The majority of these sex-specific risk factors can be identified at an early age, allowing for aggressive risk factor modification through lifestyle changes and, in certain patients, medications. The recently published 2018 American College of Cardiology and American Heart Association (ACC/AHA) hypercholesterolaemia and 2019 ACC/AHA primary prevention guidelines reflect this, citing pre-eclampsia, early menopause and autoimmune diseases as 'risk enhancers' that if present may favour initiation of statin therapy in borderline or intermediate risk patients. This comprehensive review addresses both traditional and unique risk factors of CVD in women, as well as sex-specific risk stratification and management options.

Cognitive Performance Concomitant With Vision Acuity Predicts 13-Year Risk for Mortality

Objective: To assess the joint impact of cognitive performance and visual acuity on mortality over 13-year follow-up in a representative US sample.

Methods: Data from National Health and Nutrition Examination Survey (NHANES) participants (≥18 years old) were linked with the death record data of the National Death Index (NDI) with mortality follow-up through December 31, 2011. Cognitive performance was evaluated by the Digit Symbol Substitution Test (DSST) and cognitive performance impairment was defined as the DSST score equal to or less than the median value in the study population. Visual impairment (VI) was defined as presenting visual acuity worse than 20/40 in the better-seeing eye. Risks of all-cause and specific-cause mortality were estimated with Cox proportional hazards models after adjusting for confounders.

Results: A total of 2,550 participants 60 years and older from two waves of (NHANES, 1999–2000, 2001–2002) were included in the current analysis. Over a median follow-up period of 9.92 years, 952 (35.2%) died of all causes, of whom 239 (23.1%), 224 (24.0%), and 489 (52.9%) died from cardiovascular disease (CVD), cancer, and non-CVD/non-cancer mortality, respectively. Cognitive performance impairment and VI increased the odds for mortality. Co-presence of VI among cognitive impaired elderly persons predicted nearly a threefold increased risk of all-cause mortality [hazard ratios (HRs), 2.74; 95% confidence interval (CI), 2.02–3.70; P < 0.001) and almost a fourfold higher risk of non-CVD/non-cancer mortality (HR, 3.72; 95% CI, 2.30–6.00; P < 0.001) compared to having neither impairment.

Conclusion: People aged 60 years and over with poorer cognitive performance were at higher risk of long-term mortality, and were especially vulnerable to further mortality when concomitant with VI. It is informative for clinical implication in terms of early preventive interventions.

Behavioral Strategies to Lower Postprandial Glucose in Those with Type 2 Diabetes May Also Lower Risk of Coronary Heart Disease

INTRODUCTION

Efforts to lower glycosylated hemoglobin (A1c) in patients with type 2 diabetes (T2D) are intended to reduce the risk of diabetic complications, but A1c is not the only factor contributing to this risk. Consequently, we re-analyzed published data from a broad-spectrum lifestyle intervention that lowered A1c to assess its effectiveness in lowering the overall risk of two complications of T2D, namely, coronary heart disease (CHD) and stroke.

METHODS

Data from 37 adults who participated in a randomized clinical trial of a lifestyle intervention intended to reduce postprandial glucose (PPG) were re-analyzed for their pre- and post-treatment risk of CHD and stroke using the T2D-specific UK Prospective Diabetes Study (UKPDS) v2.0 risk algorithm.

RESULTS

Compared to participants who received routine care, those using the lifestyle intervention had a significantly greater reduction in 10-year risk for CHD, but not for stroke.

CONCLUSION

These secondary analyses suggest that broad-spectrum lifestyle interventions that focus on lowering PPG may lower the risk of future CHD, which could guide future research.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02432391.

Cardiovascular risk algorithms in primary care: Results from the DETECT study

Guidelines for prevention of cardiovascular diseases use risk scores to guide the intensity of treatment. A comparison of these scores in a German population has not been performed. We have evaluated the correlation, discrimination and calibration of ten commonly used risk equations in primary care in 4044 participants of the DETECT (Diabetes and Cardiovascular Risk Evaluation: Targets and Essential Data for Commitment of Treatment) study. The risk equations correlate well with each other. All risk equations have a similar discriminatory power. Absolute risks differ widely, in part due to the components of clinical endpoints predicted: The risk equations produced median risks between 8.4% and 2.0%. With three out of 10 risk scores calculated and observed risks well coincided. At a risk threshold of 10 percent in 10 years, the ACC/AHA atherosclerotic cardiovascular disease (ASCVD) equation has a sensitivity to identify future CVD events of approximately 80%, with the highest specificity (69%) and positive predictive value (17%) among all the equations. Due to the most precise calibration over a wide range of risks, the large age range covered and the combined endpoint including non-fatal and fatal events, the ASCVD equation provides valid risk prediction for primary prevention in Germany.

Geographic disparities persist despite decline in mortality from IHD in California's Central Valley 1999-2014

BACKGROUND

Nationally, ischemic heart disease mortality has declined significantly due to advancements in managing traditional risk factors of hypertension, diabetes, hyperlipidemia, smoking, and obesity and acute intervention. However geographic disparities persist that may, in part, be attributed to environmental effects.

METHODS

Ischemic heart disease age-adjusted mortality were obtained from the CDC database for years 1999 through 2014 by county, gender, race, and Hispanic origin for the Central Valley of California.

RESULTS

There was an increase in mortality from north to south of 14.9 (95% CI: 8.0-21.9, p value <0.0001) in time period 1, 7.9 (95% CI: 0.8-15, p value <0.05) in time period 2, and 9.2 (95% CI: 4.0-14.3, p value <0.001) in time period 3. In time period 1, the ambient particulate matter ≤2.5 micrometers (PM2.5) level increased from north to south by 0.84 µg/m³ (95% CI: 0.71-0.96), in time period 2 there was a 0.87 µg/m³ increase (95% CI: 0.74-1.0), and a 1.0 µg/m³ increase in time period 3 (95% CI: 0.87-1.1). PM2.5 level was correlated to IHD mortality in all time periods (Period 1 r2 = 0.46, p = 0.0001; Period 2, r2 = 0.34, p = 0.008; Period 3 r2 = 0.51, p value <0.0001).

CONCLUSION

Continued declines in ischemic heart disease mortality will depend on the concerted efforts of clinicians in continuing management of the traditional risk factors with appropriate medication use, acute interventions for coronary syndromes, the necessity of patient self-management of high risk behaviors associated with smoking and obesity, and the development of coordinated actions with policy makers to reduce environmental exposure in their respective communities.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current US prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general US clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (eg, family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current U.S. prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (e.g., family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.

Impact of 2017 ACC/AHA guidelines on prevalence of hypertension and eligibility for antihypertensive treatment in United States and China: nationally representative cross sectional study

OBJECTIVE

To examine the effect of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines on the prevalence of hypertension and eligibility for initiation and intensification of treatment in nationally representative populations from the United States and China.

DESIGN

Observational assessment of nationally representative data.

SETTING

US National Health and Nutrition Examination Survey (NHANES) for the most recent two cycles (2013-14, 2015-16) and China Health and Retirement Longitudinal Study (CHARLS) (2011-12).

PARTICIPANTS

All 45-75 year old adults who would have a diagnosis of hypertension and be candidates for treatment on the basis of the ACC/AHA guidelines, compared with current guidelines.

MAIN OUTCOME MEASURES

Diagnosis of hypertension and candidacy for initiation and intensification of antihypertensive treatment.

RESULTS

Adoption of the 2017 ACC/AHA hypertension guidelines in the US would label 70.1 (95% confidence interval 64.9 to 75.3) million people in the 45-75 year age group as having hypertension, representing 63% (60.6% to 65.4%) of the population in this age group. Their adoption in China would lead to labeling of 266.9 (252.9 to 280.8) million people or 55% (53.4% to 56.7%) of the same age group as having hypertension. This would represent an increase in prevalence of 26.8% (23.2% to 30.9%) in the US and 45.1% (41.3% to 48.9%) in China. Furthermore, on the basis of treatment patterns and current guidelines, 8.1 (6.5 to 9.7) million Americans with hypertension are untreated, which would be expected to increase to 15.6 (13.6 to 17.7) million after the implementation of the ACC/AHA guidelines. In China, on the basis of current treatment patterns, 74.5 (64.1 to 84.8) million patients with hypertension are untreated, estimated to increase to 129.8 (118.7 to 140.9 million. In addition, the ACC/AHA guidelines would label 8.7 (6.0 to 11.5) million adults in the US and 51 (40.3 to 61.6) million in China as having hypertension that would not require antihypertensive treatment, compared with 1.5 (1.2 to 2.1) million and 23.4 (12.1 to 35.1) million with the current guidelines. Finally, even among people receiving treatment, the proportion that are candidates for intensification of treatment is estimated to increase by 13.9 (12.2 to 15.6) million (from 24.0% to 54.4% of treated patients) in the US, and 30 (24.3 to 35.7) million (41.4% to 76.2% of treated patients) in China, if the ACC/AHA treatment targets are adopted.

CONCLUSIONS

If adopted, the 2017 ACC/AHA hypertension guidelines will markedly increase the number of people labeled as having hypertension and treated with drugs in both the US and China, leading to more than half of those aged 45-75 years in both countries being considered hypertensive.

Individual and Combined Associations of Cognitive and Mobility Limitations on Mortality Risk in Older Adults

OBJECTIVE

To evaluate the potential independent and combined associations of cognitive and mobility limitations on risk of all-cause mortality in a representative sample of the US older adult population who, at baseline, were free of cardiovascular and cerebrovascular disease.

PATIENTS AND METHODS

Data from the 1999 to 2002 National Health and Nutrition Examination Survey were used to identify 1852 adults (age, 60-85 years) with and without mobility and/or cognitive limitations. Hazard ratios (HRs) for mortality risk were calculated for 4 mutually exclusive groups: no limitation (group 1 as reference), mobility limitation only (group 2), cognitive limitation only (group 3), both cognitive and mobility limitations (group 4).

RESULTS

Compared with group 1, the adjusted HRs (95% CI) for groups 2, 3, and 4 were 1.72 (1.24-2.38), 2.00 (1.37-2.91), and 2.18 (1.57-3.02), respectively. The mortality risk when comparing group 4 (HR, 2.18) with group 3 (HR, 2.00), however, was not statistically significant (P=.65). Similarly, the mortality risk when comparing group 4 (HR, 2.18) with group 2 (HR, 1.72) was not statistically significant (P=.16).

CONCLUSION

Although the highest mortality risk occurred in those with both limitations (group 4), this point estimate was not statistically significantly different when compared with those with cognitive or mobility limitations alone.

Psycho-Socioeconomic bio-behavioral influences on health-related quality of life

Background: The cumulative effects of psychological, socioeconomic, biological and behavioral parameters on health-related quality of life (HRQOL) has not been thoroughly evaluated, which was this study’s purpose.

Methods: Data from the 2005-2006 National Health and Nutrition Examination Survey were used (N = 2524 adults 20-85 years). HRQOL assessed from the Centers for Disease Control and Prevention HRQOL survey, with a higher score indicating worse HRQOL. Evaluated parameters included psychological function, socioeconomic risk, biological function and behavioral parameters. Ultimately, 14 psycho-socioeconomic bio-behavioral (PSBB) parameters were evaluated.

Results: For every 1 unit increase in the PSBB index, participants had a corresponding -0.35 lower HRQOL score (β =-0.35; 95% CI: -0.44, -0.25; P<0.001). All individual components of PSBB were inversely associated with PSBB.

Conclusion: PSBB was both individually and cumulatively associated with HRQOL.

Convergent validity of the ACC/AHA pooled cohort equations in associating with health-related quality of life among adults in the United States

Background: The potential convergent validity of the pooled cohort risk (PCR) equations in predicting health-related quality of life (HRQOL) has yet to be evaluated, which was this study's purpose. Methods: Data from the 2001-2011 National Health and Nutrition Examination Survey (NHANES) were used (N = 8978 adults, 40-79 years, free of cardiovascular disease at baseline). Calculation of an individual's 10-year risk of a first atherosclerotic cardiovascular disease (ASCVD) event was determined via the PCR equation. The Centers for Disease Control and Prevention (CDC) HRQOL measure was assessed utilizing 4 questions regarding participants' perceived mental and physical health status from the past 30 days. Results: When adjusting for moderate-to-vigorous physical activity (MVPA), obesity, age, gender and race-ethnicity, an ASCVD score of >20% (vs. <20%) was associated with a 0.53-unit (95% CI: 0.34-0.71) higher HRQOL score. A higher HRQOL score indicates a poorer patient perception of their mental and physical health. Conclusion: The observed association between PCR-determined ASCVD-risk scores and HRQOL provides evidence for the convergent validity of the PCR algorithms, indicating that individuals with a higher risk for a first time ASCVD-event may also have an overall worse HRQOL. As such, employing ASCVD risk reduction efforts may be an important strategy in improving an individual's HRQOL.

Elevated serum interleukin-6 is predictive of coronary artery disease in intermediate risk overweight patients referred for coronary angiography

BACKGROUND

Interleukin-6 (IL-6) plays a central role in atherosclerosis and inflammation. It may improve risk prediction in patients at intermediate cardiovascular risk.

OBJECTIVE

To analyze the impact of serum IL-6 in predicting early angiographic coronary artery disease in patients at intermediate cardiovascular risk with chest pain.

METHODS

In a cross-sectional study, patients referred for coronary angiography due to suspected coronary artery disease (CAD) were included. Coronary artery disease was defined as the presence of at least 30% stenosis in one or more coronary artery. Severity of CAD was classified by the anatomic burden score. Performance of serum IL-6 assay was compared with ACC/AHA atherosclerotic cardiovascular disease (ASCVD) risk score and hs-CRP through receiver operating characteristic (ROC) curves.

RESULTS

We have included 48 patients with a mean 10-year ASCVD risk of 10.0 ± 6.8%. The prevalence of CAD was 72.9%. The presence of CAD was associated with higher mean levels of IL-6 (p = 0.025). Patients with CAD had significantly more overweight than subjects without CAD. In 27% of patients, IL-6 was >1.0 pg/mL and 100% of these patients had CAD, while only 64% in those with IL-6 <1.0 pg/mL, corresponding to a positive predictive value of 100% (p = 0.015). The area under the receiver operating characteristic (ROC) curve of IL-6, hs-CRP and ASCVD were respectively 0.72, 0.60 and 0.54. Intermediate risk patients with IL-6 >1.0 pg/mL were further reclassified into ASCVD high risk due to the presence of coronary lesions.

CONCLUSION

In intermediate risk patients referred for coronary angiography, a serum IL-6 level above 1 pg/mL is predictive of significant CAD. IL-6 determination may be useful to reclassify ASCVD intermediate risk patients into higher risk categories.

Dietary Behavior and Predicted 10-Year Risk for a First Atherosclerotic Cardiovascular Disease Event Using the Pooled Cohort Risk Equations Among US Adults

PURPOSE

The pooled cohort equations were developed in 2013 by the American College of Cardiology/American Heart Association Task Force to predict an individual's 10-year risk of an atherosclerotic cardiovascular disease (ASCVD) event. The purpose of the present study was to evaluate how predicted 10-year ASCVD event risk varies as a function of daily dietary behavior.

DESIGN

Cross-sectional.

SETTING

National Health and Nutrition Examination Survey 2003 to 2006.

PARTICIPANTS

A total of 2362 adults aged 40 to 79 years.

MEASURES

The ASCVD was assessed via the pooled cohort equations, with the Healthy Eating Index calculated from self-reported dietary behavior.

ANALYSIS

Multivariable linear and logistic regression.

RESULTS

Adults in the United States consuming a healthy diet (vs those not consuming a healthy diet) had an 88% increased odds of being at low risk for a future ASCVD event within the next 10 years (odds ratio [OR] = 1.88; 95% confidence interval [CI]: 1.35-2.68; P < .001). Similarly, those eating a healthy diet had a 44% reduced odds of being at high risk for a future ASCVD event within the next 10 years (OR = 0.56; 95% CI: 0.34-0.93; P = .02).

CONCLUSION

Among adults who were free of cardiovascular disease, those with a healthy diet had reduced odds of being at high risk for a 10-year ASCVD event.

All-cause mortality risk as a function of sedentary behavior, moderate-to-vigorous physical activity and cardiorespiratory fitness

OBJECTIVE

Emerging work demonstrates individual associations of sedentary behavior, moderate-to-vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF) on mortality risk. Limited research has evaluated all three of these parameters in a model when considering mortality risk, and their potential additive association on mortality risk has not been fully evaluated, which was the purpose of this study.

METHODS

Data from the 2003-2006 National Health and Nutrition Examination Survey were used (N = 2,295 adults 20-85 yrs), with follow-up through 2011. Sedentary behavior and MVPA were objectively assessed (accelerometry) with cardiorespiratory estimated from a prediction equation taking into consideration participant demographic, anthropometric and behavioral characteristics. Using the median values, a PACS (Physical Activity Cardiorespiratory Sedentary) score was created that ranged from 0-3, indicating the number of these three positive characteristics.

RESULTS

Those with below median sedentary behavior did not have a reduced all-cause mortality risk (HR = 0.59; 95% CI: 0.34-1.04; P = 0.07), but those with above median MVPA (HR = 0.35; 95% CI: 0.15-0.82; P = 0.02) and above median CRF did (HR = 0.20; 95% CI: 0.09-0.43; P < 0.001). Compared to those with a PACS score of 0, those with a PACS score of 1, 2, and 3, respectively, had a 67% (HR = 0.33; 95% CI: 0.17-0.63, P = 0.002), 82% (HR = 0.12; 95% CI: 0.05-0.30; P < 0.001) and 96% (HR = 0.04; 95% CI: 0.02-0.11; P < 0.001) reduced risk of all-cause mortality.

CONCLUSION

Cardiorespiratory fitness and MVPA, but not sedentary behavior, were independently associated with reduced mortality risk. Adults with all three characteristics (below median sedentary and above median MVPA and CRF), however, had the lowest mortality risk.