Blood Pressure Levels in Young Adulthood and Midlife Stroke Incidence in a Diverse Cohort

Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050-Prevalence of Risk Factors and Disease: A Presidential Advisory From the American Heart Association

BACKGROUND

Cardiovascular disease and stroke are common and costly, and their prevalence is rising. Forecasts on the prevalence of risk factors and clinical events are crucial.

METHODS

Using the 2015 to March 2020 National Health and Nutrition Examination Survey and 2015 to 2019 Medical Expenditure Panel Survey, we estimated trends in prevalence for cardiovascular risk factors based on adverse levels of Life's Essential 8 and clinical cardiovascular disease and stroke. We projected through 2050, overall and by age and race and ethnicity, accounting for changes in disease prevalence and demographics.

RESULTS

We estimate that among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050. Diabetes (16.3% to 26.8%) and obesity (43.1% to 60.6%) will increase, whereas hypercholesterolemia will decline (45.8% to 24.0%). The prevalences of poor diet, inadequate physical activity, and smoking are estimated to improve over time, whereas inadequate sleep will worsen. Prevalences of coronary disease (7.8% to 9.2%), heart failure (2.7% to 3.8%), stroke (3.9% to 6.4%), atrial fibrillation (1.7% to 2.4%), and total cardiovascular disease (11.3% to 15.0%) will rise. Clinical CVD will affect 45 million adults, and CVD including hypertension will affect more than 184 million adults by 2050 (>61%). Similar trends are projected in children. Most adverse trends are projected to be worse among people identifying as American Indian/Alaska Native or multiracial, Black, or Hispanic.

CONCLUSIONS

The prevalence of many cardiovascular risk factors and most established diseases will increase over the next 30 years. Clinical and public health interventions are needed to effectively manage, stem, and even reverse these adverse trends.

Financial responsibility, financial context, and ambulatory blood pressure in early middle-aged African-American women

BACKGROUND

African-American women have excess rates of elevated blood pressure (BP) and hypertension compared to women of all other racial/ethnic backgrounds. Several researchers have speculated that race and gender-related socioeconomic status (SES) stressors might play a role.

OBJECTIVE

To examine the association between a novel SES-related stressor highly salient among African-American women, financial responsibility for one's household, and 48-h ambulatory BP. We further examined whether aspects related to African-American women's financial context (e.g., single parenthood, household income, marital status) played a role.

METHODS

Participants were N = 345 employed, healthy African-American women aged 30-46 from diverse SES backgrounds who underwent 48-h ambulatory BP monitoring. Linear regression analyses were conducted to examine associations between self-reported financial responsibility and daytime and nighttime BP, adjusting for age, SES and other sociodemographics, cardiovascular risk factors, financial strain and depressive symptoms. Interactions between financial responsibility and single parenthood, household income, and marital/partnered status were tested.

RESULTS

In age-adjusted analyses, reporting financial responsibility was associated with higher daytime systolic (β = 4.42, S.E. = 1.36, p = 0.0013), and diastolic (β = 2.82, S.E. = 0.98, p = 0.004) BP. Associations persisted in fully adjusted models. Significant associations were also observed for nighttime systolic and diastolic BP. There were no significant interactions with single parenthood, household income, nor marital/partnered status.

CONCLUSION

Having primary responsibility for one's household may be an important driver of BP in early middle-aged African-American women, independent of SES, financial strain, and across a range of financial contexts. Future studies examining prospective associations are needed, and policy interventions targeting structural factors contributing to financial responsibility in African-American women may be warranted.

Cumulative blood pressure predicts risk of stroke in individuals with type 2 diabetes

AIMS

To determine whether cumulative blood pressure (BP) could predict stroke in individuals with type 2 diabetes (T2D).

METHODS

BP levels at baseline and the initial three visits were obtained from individuals participating in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial who had not experienced a stroke. Cumulative elevations in BP were assessed by adding the weighted mean BP values at various time intervals. The association of cumulative BP with stroke was evaluated by a multivariate-adjusted Cox proportional hazard model analysis.

RESULTS

Overall, 8282 participants were included (62.10% males and 37.90% females; mean age, 62.73 years). With a median follow-up period of 6.36 years, 324 (3.91%) and 305 (3.68%) patients had any and nonfatal stroke events, respectively. Only baseline systolic BP (SBP) independently predicted any stroke after adjustment for potential confounders, whereas cumulative SBP and pulse pressure independently predicted elevated stroke events. A strong dose-response relationship between cumulative BP and stroke was identified, and conventional risk factors combined with cumulative SBP improved prediction efficiency.

CONCLUSION

Cumulative SBP independently predicts stroke in individuals with T2D and provides an incremental predictive value for stroke compared with baseline BP assessments.

TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT00000620).

Cerebrovascular pathology mediates associations between hypoxemia during rapid eye movement sleep and medial temporal lobe structure and function in older adults

Obstructive sleep apnea (OSA) is common in older adults and is associated with medial temporal lobe (MTL) degeneration and memory decline in aging and Alzheimer's disease (AD). However, the underlying mechanisms linking OSA to MTL degeneration and impaired memory remains unclear. By combining magnetic resonance imaging (MRI) assessments of cerebrovascular pathology and MTL structure with clinical polysomnography and assessment of overnight emotional memory retention in older adults at risk for AD, cerebrovascular pathology in fronto-parietal brain regions was shown to statistically mediate the relationship between OSA-related hypoxemia, particularly during rapid eye movement (REM) sleep, and entorhinal cortical thickness. Reduced entorhinal cortical thickness was, in turn, associated with impaired overnight retention in mnemonic discrimination ability across emotional valences for high similarity lures. These findings identify cerebrovascular pathology as a contributing mechanism linking hypoxemia to MTL degeneration and impaired sleep-dependent memory in older adults.

Disparities in transitions of acute stroke care: The transitions of care stroke disparities study methodological report

OBJECTIVE

The Transitions of Stroke Care Disparities Study (TCSD-S) is an observational study designed to determine race-ethnic and sex disparities in post-hospital discharge transitions of stroke care and stroke outcomes and to develop hospital-level initiatives to reduce these disparities to improve stroke outcomes.

MATERIALS AND METHODS

Here, we present the study rationale, describe the methodology, report preliminary outcomes, and discuss a critical need for the development, implementation, and dissemination of interventions for successful post-hospital transition of stroke care. The preliminary outcomes describe the demographic, stroke risk factor, socioeconomic, and acute care characteristics of eligible participants by race-ethnicity and sex. We also report on all-cause and vascular-related death, readmissions, and hospital/emergency room representations at 30- and 90-days after hospital discharge.

RESULTS

The preliminary sample included data from 1048 ischemic stroke and intracerebral hemorrhage discharged from 10 comprehensive stroke centers across the state of Florida. The overall sample was 45% female, 22% Non-Hispanic Black and 21% Hispanic participants, with an average age of 64 ± 14 years. All cause death, readmissions, or hospital/emergency room representations are 10% and 19% at 30 and 90 days, respectively. One in 5 outcomes was vascular-related.

CONCLUSIONS

This study highlights the transition from stroke hospitalization as an area in need for considerable improvement in systems of care for stroke patients discharged from hospital. Results from our preliminary analysis highlight the importance of investigating race-ethnic and sex differences in post-stroke outcomes.

Relationship between early-onset stroke and triglyceride-glucose index among young Chinese adults

BACKGROUND

The triglyceride-glucose index (TyG index), an alternative indicator of peripheral insulin resistance (IR), is associated with cardiovascular disease (CVD) in the general population. The aim of this research was to determine the correlation between early-onset stroke and the TyG index among young Chinese adults.

METHODS

Participants (age ≤ 40 years) who attended their first physical examination in Kailuan General Hospital or its 11 subsidiary hospitals between 2006 and 2012 were enrolled. The subjects were divided into four equal points according to the quartile of the TyG index, with the lowest quartile (Q1) as the reference group. A Cox proportional hazard model was employed to assess the correlation between early-onset stroke incidence and the TyG index. Restricted cubic spline analysis was further conducted to examine nonlinear associations. The TyG index was calculated as Ln [Triglyceride (TG, mg/dL) × Fasting Blood Glucose (FBG, mg/dL)/2].

RESULTS

Overall, 35,999 subjects met the inclusion criteria. Their mean age was 30.8 ±  5.7 years, and 77.1% of subjects were males. During a median observation period of 11 years, 281 stroke events occurred (62 hemorrhagic strokes and 219 ischemic strokes). Compared to the Q1 group (as the lowest group), subjects in groups Q2-Q4 had significantly higher risks of early-onset stroke (P < 0.05) after adjustment for relevant confounders in the Cox proportional hazards model. Similar results were consistent with ischemic stroke. However, no significant associations were observed between the risk of hemorrhage and the baseline TyG index. The restricted cubic splines revealed that the risk of stroke progressively increased with a high TyG index ≥ 8.41.

CONCLUSIONS

The TyG index may be a major risk factor for early-onset stroke among young Chinese adults. A TyG index ≥ 8.41 can be used as an indicator for screening high-risk stroke groups.

Physical activity from young adulthood to middle age and premature cardiovascular disease events: a 30-year population-based cohort study

Background

Although physical activity is generally protective of cardiovascular disease (CVD), less is known about how young adult physical activity relates to premature CVD events. The objective of this study was to determine the association between level and change in physical activity from young adulthood to middle age and incidence of premature CVD events before age 60.

Methods

We analyzed data collected across four urban sites from nine visits over 30 years of follow-up (1985–2016) from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective community-based cohort study of 5115 Black and White women and men aged 18–30 years at baseline (1985–1986). Linear mixed models were used to develop individualized moderate-to-vigorous intensity self-reported physical activity trajectories per participant. Fatal and nonfatal coronary heart disease (CHD), heart failure, and stroke outcomes were analyzed separately and as a combined CVD event outcome.

Results

Overall, physical activity declined in young adults as they progressed through middle age. Lower physical activity scores (per 100 exercise units) in 18 year-olds were associated with higher odds of premature CHD (AOR 1.14, 95% CI 1.02–1.28), heart failure (AOR 1.21, 95% CI 1.05–1.38), stroke (AOR 1.20, 95% CI 1.04–1.39), and any CVD (AOR 1.15, 95% CI 1.06–1.24) events. Each additional annual 1-unit reduction in the physical activity score was associated with a higher annual odds of incident heart failure (1.07, 95% CI 1.02–1.13), stroke (1.06, 95% CI 1.00–1.13), and CVD (1.04, 95% CI 1.01–1.07) events. Meeting the minimum (AOR 0.74, 95% CI 0.0.57–0.96) and twice the minimum (AOR 0.55, 95% CI 0.34–0.91) Department of Health and Human Services physical activity guidelines through follow up was protective of premature CVD events.

Conclusions

Given recent trends in declining physical activity with age and associated premature CVD events, the transition from young adult to midlife is an important time period to promote physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01357-2.

Prevalence of Atherosclerotic Risk Factors Among Children and Young Adults With Arterial Ischemic Stroke

Importance

Arterial ischemic stroke (AIS) incidence has decreased overall in recent decades yet has increased in young adults. The potential associations with atherosclerotic risk factors (ARFs) remain unknown.

Objective

To assess the ages at which ARFs may be risk factors associated with AIS.

Design, Setting, and Participants

A nested case-control study was conducted within Kaiser Permanente Northern California (KPNC) from January 1, 2000, through December 31, 2014. Data were analyzed from 2019 to 2022. Cases were identified using diagnostic codes and radiology reports. A total of 2 to 3 controls per case, matched on age and enrollment dates, were randomly identified and confirmed as stroke-free by medical record review. Only ARFs documented prior to stroke diagnosis (or the same date in controls) were considered to ensure the same period of observation. Comparisons were stratified by decade of life. Cases and controls were selected from the KPNC population (4.7 million children and 7.5 million young adults). Medical record review was conducted of all children (aged 29 days to 19 years) and a sample of young adults (aged 20-49 years) with International Classification of Diseases, Ninth Revision code or radiology text string search suggestive of AIS. Stroke-free controls were randomly selected.

Exposures

Hypertension, hyperlipidemia, diabetes, obesity, and smoking history.

Main Outcomes and Measures

Odds of AIS. In all analyses, cases and controls were compared using logistic regression.

Results

A total of 141 pediatric cases (69 [48.9%] aged 29 days to 9 years; 72 [51.1%] aged 10-19 years) and 364 pediatric controls (168 [46.2%] aged 0-9 years; 196 [53.8%] aged 10-19 years) and 455 young adult cases (71 [15.6%] aged 20-29 years; 144 [31.6%] aged 30-39 years; and 240 [52.7%] aged 40-49 years) and 1018 young adult controls (121 [11.9%] aged 20-29 years; 298 [29.3%] aged 30-39 years; and 599 [58.8%] aged 40-49 years) were identified. The percent of the cases that were male or female did not differ from the percent in the control group. The odds ratio (OR) of having any ARFs on AIS was 1.87 (95% CI, 0.72-4.88) for age range 0 to 9 years; OR, 1.00 (95% CI, 0.51-1.99) for age range 10 to 19 years; OR, 2.3 (95% CI, 1.17- 4.51) for age range 20 to 29 years; OR, 3.57 (95% CI, 2.34-5.45) for age range 30 to 39 years; and OR, 4.91 (95% CI, 3.52-6.86) for age range 40 to 49 years. The risk associated with multiple ARFs was OR, 5.29 (95% CI, 0.47-59.4) for age range 0 to 9 years; OR, 2.75 (95% CI, 0.77-9.87) for age range 10 to 19 years; OR, 7.33 (95% CI, 1.92-27.9) for age range 20 to 29 years; OR, 9.86 (95% CI, 4.96-19.6) for age range 30 to 39 years; and OR, 9.35 (95% CI, 6.31-13.8) for age range 40 to 49 years. The ARF findings by both definitions were significant in all young adult groups. Atherosclerosis was the presumed etiology in 0% of cases in the age group 0 to 9 years, 1.4% in the age group 10 to 19 years, 8.5% in the age group 20 to 29 years, 21.5% in the age group 30 to 39 years, and 42.5% in the age group 40 to 49 years.

Conclusions and Relevance

Although atherosclerosis may not be a common cause of AIS in children or in early young adulthood, findings of this study suggest that ARFs associated with stroke in older adults are present in childhood and increase with age. Efforts to reduce these risk factors should begin as early as possible.

Community-based culturally tailored education programmes for black adults with cardiovascular disease, diabetes, hypertension and stroke: a systematic review protocol of primary empirical studies

INTRODUCTION

Chronic conditions and stroke disproportionately affect black adults in communities all around the world partly due to patterns of systemic racism, disparities in care, and lack of resources. Culturally tailored programmes can potentially meet the needs of the communities they serve, including black adults who may experience reduced access to postacute services. To address unequal care received by black communities, a shift to community-based programmes that deliver culturally tailored programmes may give an alternative to a healthcare model which reinforces health inequities. The objectives of this review are to: (1) synthesise key programme characteristics and outcomes of culturally tailored community-based (CBCT) programmes that are designed to improve health outcomes in black adults with cardiovascular disease, hypertension, diabetes, or stroke and (2) identify which of the five categories of culturally appropriate programmes from Kreuter and colleagues have been used to implement CBCT programmes.

METHODS AND ANALYSIS

This is a protocol for a systematic review that will search Medline, Embase and Cumulative Index to Nursing and Allied Health Literature databases to identify studies of CBCT programmes for black adults with cardiovascular disease, hypertension, diabetes, or stroke between 2000 and 2021. Two reviewers will assess each study based on the inclusion criteria and any disagreements will be resolved by a third reviewer. Data will be extracted using a customised data extraction form to identify programme characteristics and the strategies used to develop culturally appropriate programmes. AMSTAR will be used to evaluate the articles included in the study. The aggregated data will be presented through textual descriptions of programme characteristics and outcomes.

ETHICS AND DISSEMINATION

This systematic review protocol does not require ethics approval without the inclusion of human participants and will use studies that have previously obtained informed consent. The systematic review findings will be disseminated in a peer-reviewed journal and used to inform future research led by JF and HS.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021245772.

Health Disparities: Research That Matters

Health advances have not benefited all people equally. Health equity remains an aspirational goal, but research that enhances health equity is the highest priority at the National Institutes of Health. Here, we propose a call to action and outline current National Institutes of Health programs that aim to eliminate health disparities both broadly and in high priority areas. Discussed topics include stroke as an indicator of broad health inequity, challenges, and opportunities in health disparities research, the need to diversify the research workforce, and the ongoing efforts and struggles to establish trust with disadvantaged communities during the COVID-19 pandemic.

Epidemiology and risk factors for stroke in young individuals: implications for prevention

PURPOSE OF REVIEW

Summarize and examine the epidemiology, etiologies, risk factors, and treatment of stroke among young adults and highlight the importance of early recognition, treatment, and primordial prevention of risk factors that lead to stroke.

RECENT FINDINGS

Incidence of stroke, predominantly ischemic, among young adults has increased over the past two decades. This parallels an increase in traditional risk factors such as hypertension, diabetes, and use of tobacco, and use of illicit substances among young stroke patients. Compared to older patients, there is a much higher proportion of intracerebral and subarachnoid hemorrhage in young adults. The cause of ischemic stroke in young adults is also more diverse compared to older adults with 1/3rd classified as stroke of undetermined etiology due to inadequate effort or time spent on investigating these diverse and rare etiologies. Young premature Atherosclerotic Cardiovascular Disease patients have suboptimal secondary prevention care compared to older patients with lower use of antiplatelets and statin therapy and lower adherence to statins.

SUMMARY

Among young patients, time-critical diagnosis and management remain challenging, due to atypical stroke presentations, vast etiologies, statin hesitancy, and provider clinical inertia. Early recognition and aggressive risk profile modification along with primary and secondary prevention therapy optimization are imperative to reduce the burden of stroke among young adults and save potential disability-adjusted life years.

The Coronary Artery Risk Development In Young Adults (CARDIA) Study: JACC Focus Seminar 8/8

The CARDIA (Coronary Artery Risk Development in Young Adults) study began in 1985 to 1986 with enrollment of 5,115 Black or White men and women ages 18 to 30 years from 4 US communities. Over 35 years, CARDIA has contributed fundamentally to our understanding of the contemporary epidemiology and life course of cardiovascular health and disease, as well as pulmonary, renal, neurological, and other manifestations of aging. CARDIA has established associations between the neighborhood environment and the evolution of lifestyle behaviors with biological risk factors, subclinical disease, and early clinical events. CARDIA has also identified the nature and major determinants of Black-White differences in the development of cardiovascular risk. CARDIA will continue to be a unique resource for understanding determinants, mechanisms, and outcomes of cardiovascular health and disease across the life course, leveraging ongoing pan-omics work from genomics to metabolomics that will define mechanistic pathways involved in cardiometabolic aging.

Non-alcoholic fatty liver disease and cognitive function in middle-aged adults: the CARDIA study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is associated with cardiovascular disease (CVD) risk factors that have been linked to cognitive decline. Whether NAFLD is associated with cognitive performance in midlife remains uncertain.

METHODS

Coronary Artery Risk Development in Young Adults study participants with CT examination and cognitive assessment at Y25 (2010-2011; n = 2809) were included. Cognitive function was reassessed at Y30. NAFLD was defined according to liver attenuation and treated both continuously and categorically (using ≤ 40 and ≤ 51 Hounsfield units to define severity) after exclusion for other causes of liver fat. Cognitive tests including the Digit Symbol Substitution (processing speed), Rey Auditory Verbal Learning (verbal memory), and Stroop (executive function) were analyzed with standardized z-scores. Linear models were constructed to (a) examine the cross-sectional associations of NAFLD with cognitive scores and (b) evaluate its predictive role in 5-year change in cognitive performance.

RESULTS

Participants' mean age (Y25) was 50.1 (SD 3.6) years (57% female; 48% black), with 392 (14%) having mild NAFLD and 281 (10%) having severe NAFLD. NAFLD was positively associated with CVD risk factors and inversely associated with cognitive scores. However, after adjustment for CVD risk factors, no associations were shown between NAFLD and cognitive scores (all βs ≈ 0). Similarly, no associations were observed with 5-year cognitive decline. CVD history, hypertension, smoking, diabetes and hypertriglyceridemia showed stronger associations with baseline cognitive scores and were predictive of subsequent cognitive decline (all P ≤ .05).

CONCLUSION

Among middle-aged adults, inverse associations between NAFLD and cognitive scores were attenuated after adjustment for CVD risk factors, with the latter predictive of poorer cognitive performance both at baseline and follow-up.