Race/ethnicity, income, major risk factors, and cardiovascular disease mortality

Circadian disruptions and their role in the development of hypertension

Circadian fluctuations in physiological setpoints are determined by the suprachiasmatic nucleus (SCN) which exerts control over many target structures within and beyond the hypothalamus via projections. The SCN, or central pacemaker, orchestrates synchrony between the external environment and the internal circadian mechanism. The resulting cycles in hormone levels and autonomic nervous system (ANS) activity provide precise messages to specific organs, adjusting, for example, their sensitivity to approaching hormones or metabolites. The SCN responds to both photic (light) and non-photic input. Circadian patterns are found in both heart rate and blood pressure, which are linked to daily variations in activity and autonomic nervous system activity. Variations in blood pressure are of great interest as several cardiovascular diseases such as stroke, arrhythmias, and hypertension are linked to circadian rhythm dysregulation. The disruption of normal day-night cycles, such as in shift work, social jetlag, or eating outside of normal hours leads to desynchronization of the central and peripheral clocks. This desynchronization leads to disorganization of the cellular processes that are normally driven by the interactions of the SCN and photic input. Here, we review autonomic system function and dysfunction due to regulation and interaction between different cardiorespiratory brain centers and the SCN, as well as social, lifestyle, and external factors that may impact the circadian control of blood pressure.

Relationship between race, income-level, and Cardiovascular Disease

AIM

To study the prevalence of cardiovascular disease (CVD) and associated risk factors among different races/ethnicities across different income groups.

METHODS

This retrospective analysis included data from the National Health and Nutrition Examination Survey from 2005-2018. Adults >20 years who identified as non-Hispanic (NH) White, NH Black, or Hispanic were included. Family income-to-poverty ratio (PIR) was calculated by dividing family income by poverty guidelines specific to the survey year and divided into four quartiles. Weighted logistic regression was performed to estimate adjusted odds ratios to determine association of race/ethnicity and CVD in each PIR quartile. Models were adjusted for age, sex, race, health insurance, marital status, citizenship status, education level, and PIR.

RESULTS

We included 31,884 adults that corresponded to ∼191.3 million weighted, nationally representative participants. Of these, 8,009, 7,967, 7,944, and 7,964 participants belonged to 1st, 2nd, 3rd, and 4th quartiles, respectively. The prevalence of diabetes mellitus (DM), hypertension, coronary artery disease (CAD), congestive heart failure (CHF), and stroke decreased with each successive PIR quartile. NH Black participants had higher prevalence odds of DM, hypertension, obesity, CHF, and stroke compared to NH White participants. The difference in prevalence odds between NH White adults and NH Black adults was greater for obesity (p-interaction=0.002), DM (p-interaction=0.027), and stroke (p-interaction=0.053) in the 4th PIR quartile (highest income) compared to the 1st PIR quartile (lowest income).

CONCLUSION

Racial and ethnic disparities in the risk of CVD persists across income levels, with a greater difference in prevalence of select CVD and risk factors between NH Black and NH White participants in the highest income quartile compared to the lowest income quartile.

Race, Social Determinants of Health, and Risk of All-Cause and Cardiovascular Mortality in the United States

OBJECTIVE

To examine the independent and interdependent effects of race and social determinants of health (SDoH) and risk of all-cause and cardiovascular disease (CVD) mortality in the US.

DATA SOURCE/STUDY DESIGN

Secondary analysis of pooled data for 252,218 participants of the 2006-2018 National Health Interview Survey, linked to the National Death Index.

METHODS

Age-adjusted mortality rates (AAMR) were reported for non-Hispanic White (NHW) and non-Hispanic Black (NHB) individuals overall, and by quintiles of SDoH burden, with higher quintiles representing higher cumulative social disadvantage (SDoH-Qx). Survival analysis was used to examine the association between race, SDoH-Qx, and all-cause and CVD mortality.

FINDINGS

AAMRs for all-cause and CVD mortality were higher for NHB and considerably higher at higher levels of SDoH-Qx, however, with similar mortality rates at any given level of SDoH-Qx. In multivariable models, NHB experienced 20-25% higher mortality risk relative to NHW (aHR = 1.20-1.26); however, no association was observed after adjusting for SDoH. In contrast, higher SDoH burden was associated with up to nearly threefold increased risk of all-cause (aHR, Q5 vs Q1 = 2.81) and CVD mortality (aHR, Q5 vs Q1 = 2.90); the SDoH effect was observed similarly for NHB (aHR, Q5:all-cause mortality = 2.38; CVD mortality = 2.58) and NHW (aHR, Q5:all-cause mortality = 2.87; CVD mortality = 2.93) subgroups. SDoH burden mediated 40-60% of the association between NHB race and mortality.

CONCLUSIONS

These findings highlight the critical role of SDoH as upstream drivers of racial inequities in all-cause and CVD mortality. Population level interventions focused on addressing adverse SDoH experienced by NHB individuals may help mitigate persistent disparities in mortality in the US.

Race and Ethnicity Disparities in Cardiovascular and Cancer Mortality: the Role of Socioeconomic Status-a Systematic Review and Meta-analysis

To clarify the role of socioeconomic status (SES) in cardiovascular and cancer mortality disparities observed between Black, Hispanic, and Asian compared to White adults, we conducted a meta-analysis of the longitudinal research in the USA. A PubMed, Ovid Medline, Web of Science, and EBSCO search was performed from January 1995 to May 2023. Two authors independently screened the studies and conducted risk assessments, with conflicts resolved via consensus. Studies were required to analyze mortality data using Cox proportional hazard regression. Random-effects models were used to pool hazard ratios (HR) and reporting followed PRISMA guidelines. Twenty-two studies with cardiovascular mortality (White and Black (n = 22), Hispanic (n = 7), and Asian (n = 3) adults) and twenty-three with cancer mortality endpoints (White and Black (n = 23), Hispanic (n = 11), and Asian (n = 10) adults) were included. The meta-analytic sample for cardiovascular mortality endpoints was 6,199,049 adults (White = 4,891,735; Black = 935,002; Hispanic = 295,623; Asian = 76,689), while for cancer-specific mortality endpoints was 7,745,180 adults (White = 5,988,392; Black= 1,070,447; Hispanic= 484,848; Asian = 201,493). Median follow-up was 10 and 11 years in cohorts with cardiovascular and cancer mortality endpoints, respectively. Adjustments for SES attenuated the higher risk for cardiovascular (HR, 1.46; 95% CI, 1.30-1.64) and cancer mortality (HR, 1.35; 95% CI, 1.32-1.38) of Black compared to White adults by 25% (HR, 1.21; 95% CI, 1.15-1.28) and 19% (HR, 1.16; 95% CI, 1.13-1.18), respectively. However, the Hispanic cardiovascular (HR, 0.79; 95% CI, 0.73-0.85) and Asian cancer mortality (HR, 0.81; 95% CI, 0.76-0.86) advantage were independent of SES. These findings emphasize the need to develop strategies focused on SES to reduce cardiovascular and cancer mortality in Black adults.

Shiftwork, long working hours and markers of inflammation in a national US population-based sample of employed black and white men and women aged ≥45 years

OBJECTIVES

Work schedule demands contribute to circadian disruption and may influence health via an inflammatory response. We examined the impact of shiftwork and long work hours on inflammation in a national US sample.

METHODS

Participants included 12 487 employed black and white men and women aged ≥45 years enrolled in the REasons for Geographic and Racial Differences in Stroke Study who completed an occupational questionnaire (2011-2013) and clinical examination (2013-2016). Cross-sectional associations between shiftwork and work hours with log-transformed high-sensitivity C reactive protein (CRP) and white blood cell (WBC) count were examined by multiple linear regression analysis, overall and by race-sex subgroups.

RESULTS

Overall, rotating shift workers had higher log-CRP concentration compared with day workers (β=0.09, 95% CI:0.02 to 0.16) and findings for WBC were null. Black women had the highest geometric mean CRP (2.82 mg/L), while white men had the highest WBC (6.35×109/L). White men who worked afternoons had higher log-CRP compared with those who worked days (β=0.20, 95% CI: 0.08 to 0.33). Black men engaged in shiftwork <10 years working ≥55 hours/week had higher log-CRP and log-WBC compared with those working days <55 hours/week (β=0.33, 95% CI: 0.02 to 0.64 and β=0.10, 95% CI: 0.003 to 0.19). Among shift workers, non-retired white women working forward and backward shift rotations had higher log-CRP compared with those working forward only (β=0.49, 95% CI: 0.02 to 0.96).

CONCLUSIONS

Shift workers had higher inflammatory markers compared with day workers and race-sex disparities should be examined further. These findings highlight a potential biological pathway linking work schedule demands and chronic disease.

Race-based reporting and participation of Black individuals in registered pain clinical trials, United States, 2000 to 2019

ABSTRACT

There are numerous, well-established racial disparities in the management of pain. The degree to which these are evident at the stage of conducting clinical trials is unknown. To address this knowledge gap, we examined race-based reporting, participation of Black individuals, and the factors associated with reporting and participation in pain clinical trials in the United States. Data were extracted from Clinicaltrials.gov and published articles. One thousand two hundred trials met our inclusion criteria; 482 (40.2%) reported participant race. More recent, publicly funded, and larger trials were more likely to report race. Of 82,468 participants included in pain clinical trials that reported race, 15,101 were Black individuals (18.3%). Participation of Black individuals was significantly associated with pain type (ß = +27% in cardiovascular disease pain compared with acute pain, P < 0.05), study population (ß = +33% and +7% in pain in minoritized populations and women, respectively, compared with general population, P < 0.05), pain intervention (ß = +7.5% for trials of opioid interventions compared with nonopioid interventions, P < 0.05), and a diverse team of investigators (ß = +8.0% for studies incorporating a visible non-White investigator compared with those that did not, P < 0.05). Our results indicate that representation of Black participants in pain clinical trials generally aligns with national demographics in the United States. Increased representation corresponds with health conditions more prevalent among Black individuals (eg, cardiovascular disease) and with a diverse study team composition. Despite these encouraging results, less than half of pain trials reported race, which introduces potential publication bias and limits external validity.

Long-term risks of cardiovascular death in a population-based cohort of 1,141,675 older patients with cancer

BACKGROUND

previous studies have focused on the risk of cardiovascular disease (CVD)-related death in individual cancers, adolescents or all cancers.

OBJECTIVE

to evaluate the risk of CVD-related death in older patients with cancer.

METHODS

older patients with cancer (over 65 years) of 16 cancers diagnosed between 1975 and 2018 were screened out from the Surveillance, Epidemiology and End Results program. The proportion of deaths, competing risk regression models, standardized mortality ratios (SMRs) and absolute excess risks (AERs) were used to assess the risk of CVD-related death.

RESULTS

this study included 1,141,675 older patients (median follow-up: 13.5 years). Of the 16 individual cancers, the risk of CVD death exceeded primary neoplasm death in older patients with cancers of the breast, endometrium, vulva, prostate gland, penis and melanoma of the skin over time (high competing risk group). Compared to the general older population, older patients with cancer had higher SMR and AER of CVD-related death (SMR: 1.58-4.23; AER: 21.16-365.89), heart disease-related death (SMR: 1.14-4.16; AER: 16.29-301.68) and cerebrovascular disease-related death (SMR: 1.11-4.66; AER: 3.02-72.43), with the SMR trend varying with CVD-related death competing risk classifications. The risk of CVD-related death in the high-competing risk group was higher than in the low-competing risk group.

CONCLUSIONS

for older patients with cancer, six of 16 individual cancers, including breast, endometrium, vulva, prostate gland, penis and melanoma of the skin was at high risk of CVD-related death. Management for long-term cardiovascular risk in older patients with cancer is needed.

Cardiovascular disease risk factors in autistic adults: The impact of sleep quality and antipsychotic medication use

Approximately 40% of American adults are affected by cardiovascular disease (CVD) risk factors (e.g., high blood pressure, high cholesterol, diabetes, and overweight or obesity), and risk among autistic adults may be even higher. Mechanisms underlying the high prevalence of CVD risk factors in autistic people may include known correlates of CVD risk factors in other groups, including high levels of perceived stress, poor sleep quality, and antipsychotic medication use. A sample of 545 autistic adults without intellectual disability aged 18+ were recruited through the Simons Foundation Powering Autism Research, Research Match. Multiple linear regression models examined the association between key independent variables (self-reported perceived stress, sleep quality, and antipsychotic medication use) and CVD risk factors, controlling for demographic variables (age, sex assigned at birth, race, low-income status, autistic traits). Overall, 73.2% of autistic adults in our sample had an overweight/obesity classification, 45.3% had high cholesterol, 39.4% had high blood pressure, and 10.3% had diabetes. Older age, male sex assigned at birth, and poorer sleep quality were associated with a higher number of CVD risk factors. Using antipsychotic medications was associated with an increased likelihood of having diabetes. Poorer sleep quality was associated with an increased likelihood of having an overweight/obesity classification. Self-reported CVD risk factors are highly prevalent among autistic adults. Both improving sleep quality and closely monitoring CVD risk factors among autistic adults who use antipsychotic medications have the potential to reduce risk for CVD.

An analysis of sex differences and socioeconomic deprivation among Canadian children with high blood pressure: a retrospective, cross-sectional study

BACKGROUND

Understanding which children are at highest risk for high blood pressure (HBP) can inform surveillance and treatment. This study evaluated sex differences in childhood HBP and its associations with socioeconomic status.

METHODS

This retrospective cross-sectional study assessed 74,233 children with data from a national primary care electronic medical record database. Differences between sex and material and social deprivation scores for children with and without HBP were examined. Covariates included age, BMI z-score, diabetes, hyperlipidemia, and depression. HBP was defined as > 90^th percentile for < 13-year-olds, and ≥ 120/80 for age ≥ 13 years on 2 separate occasions between 2010 and 2017.

RESULTS

The prevalence of HBP was 10.2% in males and 7.6% in females (p < 0.0001). Children with HBP had higher BMI z-scores (0.66 vs. 0.18, p < 0.0001), and higher rates of diabetes (1.31 vs. 0.54%, p < 0.0001), depression (9.89 vs. 7.11%, p < 0.0001), and hyperlipidemia (2.82 vs. 0.86%, p < 0.0001). In univariate regression analyses, boys in the most materially deprived quintile had increased odds of HBP (OR 1.24 (95% CI 1.08-1.43)), whereas females did not (OR 1.11 (95% CI 0.95-1.29)). In multivariate regression, male sex was associated with HBP with adjusted OR of 1.39 (95% CI 1.24-1.55). After statistical adjustment, material deprivation was no longer significant (aOR 1.05, 95% CI 0.94-1.17).

CONCLUSIONS

Male sex is associated with HBP in Canadian children. This study also suggests a possible association between material deprivation and HBP, particularly in boys. Further study is required to better understand this relationship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Racial and Ethnic Cardiometabolic Risk Disparities in the Type 1 Diabetes Exchange Clinic Registry Cohort

OBJECTIVE

To determine whether individuals from a historically underrepresented racial group have a higher cardiometabolic risk than historically represented individuals with type 1 diabetes (T1D) considering socioeconomic deprivation.

METHODS

We used the multivariable logistic and linear regression models to examine socioeconomic deprivation (upper 10th percentile) by race/ethnicity interaction for each cardiometabolic risk factor and cardiometabolic risk burden score, respectively, across 6320 zip code tabulation areas. We also determined the age-adjusted prevalence of low, moderate, and high cardiometabolic risks defined as 0, 1 to 2, and 3 or more risk factors for hypertension, obesity, dyslipidemia, and off-target glycemia for non-Hispanic White (n = 15 746), non-Hispanic Black (n = 1019), Hispanic (n = 1115), and other (n = 887), respectively.

RESULTS

The sample comprised 18 767 adolescents and adults with T1D. Those identifying as non-Hispanic Black were more likely to have a high cardiometabolic risk profile, including a 4.5-fold increase in the odds of off-target glycemia, a twofold increase in the odds of systolic hypertension, and 0.29 (unadjusted) and 0.46 (adjusted) increases in a higher cardiometabolic risk burden compared with non-Hispanic White individuals (P < .01). Those identifying as Hispanic had a 3.4-fold increase in the odds of off-target glycemia but were less likely to be overweight/obese or have systolic hypertension compared with non-Hispanic White. However, the lower likelihood of overweight/obesity and hypertension did not persist after considering covariates.

CONCLUSION

There is a need to investigate additional determinants of racially/ethnically underrepresented cardiometabolic health, including structural racism and implicit bias in cardiometabolic care for individuals with T1D.

Gender-affirming estrogen therapy route of administration and cardiovascular risk: a systematic review and narrative synthesis

Transgender women (individuals assigned male sex at birth who identify as women) and nonbinary and gender-diverse individuals receiving gender-affirming estrogen therapy (GAET) are at increased cardiovascular risk. Nonoral (i.e., patch, injectable) compared with oral estrogen exposure in cisgender women (individuals assigned female sex at birth who identify as women) may be associated with lower cardiovascular risk, though whether this applies to transgender women and/or gender-diverse individuals is unknown. We sought to determine the association between the route of estrogen exposure (nonoral compared with oral) and cardiovascular risk in transgender women and gender diverse individuals. Bibliographic databases (MEDLINE, Embase, PsycINFO) and supporting relevant literature were searched from inception to January 2022. Randomized controlled trials and observational studies reporting cardiovascular outcomes, such as all-cause and cardiovascular mortality, adverse cardiovascular events, and cardiovascular risk factors in individuals using nonoral compared with oral gender-affirming estrogen therapy were included. The search strategy identified 3,113 studies, 5 of which met inclusion criteria (3 prospective cohort studies, 1 retrospective cohort study, and 1 cross-sectional study; n = 259 participants, range of duration of exposure of 2 to 60 mo). One out of five studies reported on all-cause and cardiovascular mortality or adverse cardiovascular events. All five studies reported lipid levels [low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), and total cholesterol (TC)], whereas only two studies reported systolic blood pressure (SBP) and diastolic blood pressure (DBP). Limited studies have examined the effect of the route of GAET on all-cause cardiovascular mortality, morbidity, and risk factors. In addition, there is significant heterogeneity in studies examining the cardiovascular effects of GAET.NEW & NOTEWORTHY This study is the first to summarize the potential effect of nonoral versus oral gender-affirming estrogen therapy use on cardiovascular risk factors in transgender women or nonbinary or gender-diverse individuals. Heterogeneity of studies in reporting gender-affirming estrogen therapy formulation, dose, and duration of exposure limits quantification of the effect of gender-affirming estrogen therapy on all-cause and cardiovascular mortality, adverse cardiovascular events, and cardiovascular risk factors. This systematic review highlights the needs for large prospective cohort studies with appropriate stratification of gender-affirming estrogen therapy by dose, formulation, administration route, and sufficient follow-up and analyses to limit selection bias to optimize the cardiovascular care of transgender, nonbinary, and gender-diverse individuals.

The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status

Disparities in cardiovascular outcomes are persistent in our society. The objective was to track the trends before and after the passage of the Affordable Care Act in socioeconomic status (SES) disparities in utilization of cardiovascular disease (CVD) preventive services among nonelderly adults aged 18-64 years. This study used the National Health Interview Survey (2011-2017) to compare utilization of blood pressure, cholesterol, glycemic screening, and diet and smoking cessation advice over time between groups stratified by SES and race using difference-in-difference analysis. This study also measured the differences over time in specific vulnerable population subgroups (Hispanic, low-income and uninsured vs. White, middle-high-income, and insured). The study population included 176,961 surveyed individuals (mean age 40 [±13] years; 51% female; 67.7% non-Hispanic White) between 2011 and 2017, translating to 194.8 million nonelderly US adults per year. Most individuals were from high-income SES (40.0%), followed by middle-income (28.1%), low-income (13.6%), and lowest income SES (18.3%). The proportion of CVD preventive services increased over all SES categories through the study period. The biggest relative changes were seen among low-income individuals. The difference in blood pressure checks, cholesterol checks, and smoking cessation advise between high- and lowest income groups showed a statistically significant decrease at 5.2%, 4.8%, and 11.2%, respectively, between 2011 and 2017. The findings demonstrate a trend in reduction of CVD preventive care disparities between SES groups. However, a gap still exists, and this study highlights the need for continuous improvement to eliminate SES disparities.

Warfarin Monitoring in Safety-Net Health Systems: Analysis by Race/Ethnicity and Language Preference

BACKGROUND

Racial/ethnic disparities in anticoagulation management are well established. Differences in warfarin monitoring can contribute to these disparities and should be measured.

OBJECTIVE

We assessed for differences in international normalized ratio (INR) monitoring by race/ethnicity and language preference across safety-net care systems serving predominantly low-income, ethnically diverse populations.

DESIGN

Cross-sectional analysis of process and safety data shared from the Safety Promotion Action Research and Knowledge Network (SPARK-Net) initiative, a consortium of five California safety-net hospital systems.

PARTICIPANTS

Eligible patients were at least 18 years old, received warfarin for at least 56 days during the measurement period from July 2015 to June 2017, and had INR testing in an ambulatory care setting at a participating healthcare system.

MAIN MEASURES

We conducted a scaled Poisson regression for adjusted rate ratio of having at least one INR checked per 56-day time period for which a patient had a warfarin prescription. Adjusting for age, sex, healthcare system, and insurance status/type, we assessed for racial/ethnic and language disparities in INR monitoring.

KEY RESULTS

Of 8129 patients, 3615 (44%) were female; 1470 (18%), Black/African American; 3354 (41%), Hispanic/Latinx; 1210 (15%), Asian; 1643 (20%), White; and 452 (6%), other. Three thousand five hundred forty-nine (45%) were non-English preferring. We did not observe statistically significant disparities in the rate of appropriate INR monitoring by race/ethnicity or language; the primary source of variation was by healthcare network. Older age, female gender, and uninsured patients had a slightly higher rate of appropriate INR monitoring, but differences were not clinically significant.

CONCLUSIONS

We did not find a race/ethnicity nor language disparity in INR monitoring; safety-net site was the main source of variation.

Race and Ethnicity and Cardiometabolic Risk Profile: Disparities Across Income and Health Insurance in a National Sample of US Adults

CONTEXT

Income and health insurance are important social determinants of cardiovascular disease (CVD) and may explain much racial/ethnic variation in CVD burden. However, racial/ethnic disparities in cumulative cardiometabolic (CMB) risk profile by insurance type and income level have not been studied on a national scale.

OBJECTIVES

To test the hypothesis that racial/ethnic minorities experience greater CMB burden at each income level and insurance type than non-Hispanic Whites (NHW).

SETTING

This study used nationally representative data from the National Health Interview Survey (NHIS).

DESIGN

Observational (cross-sectional).

PARTICIPANTS

In total, 134661 (weighted N = 197780611) adults, 18 years or older, from the 2013-2017 NHIS.

PRIMARY OUTCOME

CMB risk profile.

INTERVENTION/ANALYSIS

Age-adjusted prevalence of optimal, average, and poor CMB risk profile-defined respectively as self-report of 0, 1-2, and 3 or more risk factors of diabetes, hypertension, obesity, or hypercholesterolemia-was examined for NHW, non-Hispanic Blacks (NHB), and Hispanics. Multivariable ordinal logistic regression models were used to test the association between race and ethnicity and CMB profile overall and separately by household income level and insurance type.

RESULTS

Overall, 15% of NHB and 11% of Hispanics experienced poor CMB risk profile, compared with 9% for NHW. In fully adjusted models, NHB and Hispanics, respectively had nearly 25%-90% and 10%-30% increased odds of poor CMB profile across insurance types and 45%-60% and 15%-30% increased odds of poor CMB profile across income levels, relative to NHW. The observed disparities were widest for the Medicare group (NHB: OR = 1.90; Hispanics: OR = 1.31) and highest-income level (NHB: OR = 1.62).

CONCLUSIONS

Racial/ethnic minorities experience poor CMB profile at each level of income and insurance. These findings point to the need for greater investigation of unmeasured determinants of minority cardiovascular (CV) health, including structural racism and implicit bias in CV care.

Classical Risk Factors for Ischemic Stroke are not Associated with Inpatient Post-Stroke Mortality in Sickle Cell Disease

OBJECTIVES

Sickle cell disease is a common haemoglobinopathy that significantly increases the risk of ischemic stroke. Because the risk factors for ischemic stroke onset and mortality in non-sickle cell disease patients have been largely elucidated, this paper aims to analyze risk factors for ischemic stroke mortality in sickle cell disease patients, which remain largely unknown.

MATERIALS/METHODS

The National Inpatient Sample database (2016-2017) was used to develop a multivariable regression model for risk quantification of known ischemic stroke risk factors for in-hospital mortality in ischemic stroke patients with and without sickle cell disease.

RESULTS

Classical risk factors for ischemic stroke onset, including ischemic heart disease, carotid artery disease, lipidemias, hypertension, obesity, tobacco use, atrial fibrillation, personal or family history of stroke, congenital heart defects, congestive heart failure, cardiac valve disorder, peripheral vascular disease, and diabetes mellitus are associated with in-hospital mortality in non-sickle cell patients (p < 0.05). However, no significant association was found between these stroke risk factors and in-hospital mortality in sickle cell disease patients presenting with ischemic stroke (p > 0.05).

CONCLUSIONS

While the classical risk factors for stroke onset are associated with in-hospital mortality in non-sickle cell stroke patients, they are not associated with in-hospital mortality in sickle cell stroke patients.

Trends in mortality among Black and White men with prostate cancer in Massachusetts and Pennsylvania: Race and neighborhood socioeconomic position

BACKGROUND

Reducing disparities in men with prostate cancer (PCa) that may be caused by racial and socioeconomic differences is a major public health priority. Few reports have studied whether these disparities have changed over time.

METHODS

Men diagnosed with PCa from January 1, 2000 to December 31, 2015 were identified from the Massachusetts and Pennsylvania cancer registries. All-cause mortality and PCa and cardiovascular cause-specific mortality were assessed. To estimate neighborhood socioeconomic position (nSEP), a summary score was generated using census tract-level measures of income, wealth, educational attainment, and racial and income segregation. Participants were grouped by diagnosis year (2000-2003, 2004-2007, 2008-2011, or 2012-2015), and changing trends in the mortality rate ratio by race and nSEP were estimated using covariate-adjusted Cox models with follow-up for up to 10 years, until death, or until censoring on January 1, 2018.

RESULTS

There were 193,883 patients with PCa and 43,661 deaths over 1,404,131 person-years of follow-up. The Black-White adjusted hazard ratio (aHR) from 2000 to 2003 through 2012 to 2015 was stable for all-cause mortality (aHR, 1.14 to 0.97; P for heterogeneity = .42), decreased for PCa-specific mortality (aHR, 1.38 to 0.93; P for heterogeneity = .005), and increased for cardiovascular mortality (aHR, 1.09 to 1.28; P for heterogeneity = .034). The aHR comparing those in the lowest versus the highest nSEP quintile increased significantly for all-cause mortality (aHR, 1.54 to 1.79; P for heterogeneity = .008), but not for PCa-specific mortality (aHR, 1.60 to 1.72; P for heterogeneity = .40) or cardiovascular mortality (aHR, 1.72 to 1.89; P for heterogeneity = .085).

CONCLUSIONS

Although Black-White disparities in prostate mortality declined in Massachusetts and Pennsylvania over the study period, nSEP mortality disparity trends were stagnant or increased, warranting further attention.

LAY SUMMARY

Few reports have examined whether racial and socioeconomic disparities in prostate cancer mortality have widened or narrowed in recent years. Using data from 2 state registries (Massachusetts and Pennsylvania) with differing intensities of government-mandated health insurance, trends in racial and neighborhood socioeconomic disparities were studied among Black and White men diagnosed from 2000 to 2015. Overall, trends in racial disparities were stagnant for all-cause mortality, shrank for prostate mortality, and widened for cardiovascular mortality. Disparities associated with neighborhood socioeconomic status either were stagnant or widened across all mortality end points. In general, disparities were more pronounced in Pennsylvania than in Massachusetts.

Impact of Cardiovascular Risk Factors in Adolescence, Young Adulthood, and Midlife on Late-Life Cognition: Study of Healthy Aging in African Americans

BACKGROUND

Midlife cardiovascular risk factors (CVRFs) increase risk of dementia. Black Americans experience an elevated prevalence of CVRFs and dementia. However, little is known of how CVRFs prior to midlife affect late-life cognition. We examined CVRFs in adolescence, young adulthood, and midlife with late-life cognition in the Study of Healthy Aging in African Americans (STAR).

METHOD

STAR assesses cognitive aging among 764 Black Americans aged ≥50 (mean age = 69; SD = 9; range = 53-95). Participants' body mass index, blood pressure, glucose, and total cholesterol were collected during Multiphasic Health Checkups (MHC; 1964-1985). At STAR baseline (2018-2019), executive function, verbal episodic memory, and semantic memory were measured using the Spanish and English Neuropsychological Assessment Scales. Linear regression models examined associations between CVRFs and cognition adjusting for demographics and years since MHC.

RESULTS

At MHC, 36% of participants had 1 CVRF and 26% had ≥2. Twenty-two percent of participants were adolescents (age 12-20), 62% young adults (age 21-34), and 16% midlife adults (age 35-56). Overweight/obesity was not associated with cognition. Hypertension was associated with worse executive function (β [95% CI]: -0.14 [-0.28, -0.0003]) and verbal episodic memory (β [95% CI]: -0.22 [-0.37, -0.07]) compared to normotension. Diabetes was associated with worse executive function (β [95% CI]: -0.43 [-0.83, -0.03]). Having ≥2 CVRFs (vs 0) was associated with worse executive function (β [95% CI]: -0.19 [-0.34, -0.03]) and verbal episodic memory (β [95% CI]: -0.25 [-0.41, -0.08]). Adolescents with hypertension had lower late-life executive function compared to normotensive adolescents (β [95% CI]: -0.39 [-0.67, -0.11]). Young adulthood hypertension (β [95% CI]: -0.29 [-0.49, -0.09]) and midlife hyperlipidemia (β [95% CI]: -0.386 [-0.70, -0.02]) were associated with lower verbal episodic memory.

CONCLUSIONS

Among Black Americans, life-course CVRFs were associated with poorer executive function and verbal episodic memory emphasizing the importance of cardiovascular health on the aging brain.

Nationwide Study of Short-term Exposure to Fine Particulate Matter and Cardiovascular Hospitalizations Among Medicaid Enrollees

BACKGROUND

Fine particulate matter (PM2.5) has been consistently linked to cardiovascular disease (CVD). Although studies have reported modification by income, to our knowledge, no study to date has examined this relationship among adults in Medicaid, which provides health coverage to low-income and/or disabled Americans.

METHODS

We estimated the association between short-term PM2.5 exposure (average of PM2.5 on the day of hospitalization and the preceding day) and CVD admissions rates among adult Medicaid enrollees in the continental United States (2000-2012) using a time-stratified case-crossover design. We repeated this analysis at PM2.5 concentrations below the World Health Organization daily guideline of 25 μg/m. We compared the PM2.5-CVD association in the Medicaid ≥65 years old versus non-Medicaid-eligible Medicare enrollees (≥65 years old).

RESULTS

Using information on 3,666,657 CVD hospitalizations among Medicaid adults, we observed a 0.9% (95% CI = 0.6%, 1.1%) increase in CVD admission rates per 10 μg/m PM2.5 increase. The association was stronger at low PM2.5 levels (1.3%; 95% CI = 0.9%, 1.6%). Among Medicaid enrollees ≥65 years old, the association was 0.9% (95% CI = 0.6%, 1.3%) vs. 0.8% (95% CI = 0.6%, 0.9%) among non-Medicaid-eligible Medicare enrollees ≥65 years old.

CONCLUSION

We found robust evidence of an association between short-term PM2.5 and CVD hospitalizations among the vulnerable subpopulation of adult Medicaid enrollees. Importantly, this association persisted even at PM2.5 levels below the current national standards.

It's Time for a Haircut: a Perspective on Barbershop Health Interventions Serving Black Men

Black men in the USA experience disproportionate cardiovascular disease mortality compared to their white counterparts, in part due to an excess of uncontrolled hypertension. A promising intervention to address these disparities involves the direct pharmacologic management of hypertension by clinical pharmacists in Black male patrons of barbershops, as demonstrated in the Los Angeles Barbershop Blood Pressure Study (LABBPS). Despite the observed reduction in systolic blood pressure of > 20 mmHg after 1 year, the feasibility of scaling up such an intervention to a regional or national platform remains uncertain. Here we explore the success of LABBPS in the context of prior barbershop interventions and theorize the most important aspects driving the observed reductions. We further make a case for prioritizing preventive care in nontraditional settings in an effort to reduce health disparities.

Attitudinal, regional and sex related vulnerabilities to COVID-19: Considerations for early flattening of curve in Nigeria

Background: In Nigeria, the policies and interventions due to the COVID-19 pandemic are majorly directed at businesses and relief. There are no clear plans to identify individuals with comorbidities associated with high morbidity and fatality rates. This paper identifies comorbidities associated with high morbidity and fatalities of COVID-19 across countries and vulnerable groups in Nigeria. Methods: Peer-reviewed articles published between 2010 and 2020 retrieved from Google scholar, African Journal Online, EMBASE, Scopus, and MEDLINE/PubMed (central) were systematically reviewed. Results: The pooled prevalence of hypertension is the lowest in North Central Nigeria (22.0%) and the highest in South-Eastern Nigeria (33.6%) while the pooled prevalence of diabetes mellitus (DM) is lowest in North-Western Nigeria (3.0%) and highest in South-Southern Nigeria (9.8%). Significant differences in the frequency of comorbidities (hypertension, DM, cardiovascular disease, cancer, and chronic kidney disease; CKD) and complications (cardiac injury and acute respiratory disease syndrome; ARDS) were observed between fatal and non-fatal cases of COVID-19 (p<0.0001). There were significant correlations between hypertension and ARDS (p=0.002), DM and ARDS (p=0.010), hypertension and (p<0.0001), DM and CKD (p=0.033), and hypertension and DM (p=0.001). Conclusion: High prevalence of comorbidity may be predictive of high COVID-19 morbidity and mortality. Thus, to flatten the curve early intervention funds should be appropriately allocated based on the prevalence of comorbidities in the geopolitical zones. Such high-risk groups should be identified, stratified and actively monitored during treatment to prevent the development or progression of complications such as cardiac injury and ARDS.

Invited Commentary: Learning From Our Past to Build on Our Future- Lessons Learned From MRFIT and JUMBO

We propose that Blackburn (Am J Epidemiol. 2020;189(6):491-498) ignores several important issues that need to be considered in the context of a historical reflection of the National Heart Institute's landmark study, the Multiple Risk Factor Intervention Trial (MRFIT), and the alternative proposal, the "JUMBO" trial, submitted to the National Heart Institute by an experienced team of extramural investigators but never funded. A key focus of this commentary is to offer an alternative perspective on both studies using our current understanding of the impact of social and structural determinants of health; evidence that policy, systems, and environmental interventions are needed to support behavior change at the individual level; and the significance of examining research from a racial/socioeconomic equity lens. While we strongly agree with Blackburn's conclusion urging the National Institutes of Health to invest in prevention research at a level consistent with its social and economic impact, we encourage the author to move beyond simply underscoring the methodological limitations and failure of the findings of MRFIT compared with the potential of the proposed JUMBO trial to consider the contribution of MRFIT to our current understanding of chronic disease prevention and treatment.

Immune cell phenotyping in low blood volumes for assessment of cardiovascular disease risk, development, and progression: a pilot study

Background

Cardiovascular disease (CVD) is the leading cause of death in the world. Given the role of immune cells in atherosclerosis development and progression, effective methods for characterizing immune cell populations are needed, particularly among populations disproportionately at risk for CVD.

Results

By using a variety of antibodies combined in one staining protocol, we were able to identify granulocyte, lymphocyte, and monocyte sub-populations by CD-antigen expression from 500 µl of whole blood, enabling a more extensive comparison than what is possible with a complete blood count and differential (CBC). The flow cytometry panel was established and tested in a total of 29 healthy men and women. As a proof of principle, these 29 samples were split by their race/ethnicity: African-Americans (AA) (N = 14) and Caucasians (N = 15). We found in accordance with the literature that AA had fewer granulocytes and more lymphocytes when compared to Caucasians, though the proportion of total monocytes was similar in both groups. Several new differences between AA and Caucasians were noted that had not been previously described. For example, AA had a greater proportion of platelet adhesion on non-classical monocytes when compared to Caucasians, a cell-to-cell interaction described as crucially important in CVD. We also examined our flow panel in a clinical population of AA women with known CVD risk factors (N = 20). Several of the flow cytometry parameters that cannot be measured with the CBC displayed correlations with clinical CVD risk markers. For instance, Framingham Risk Score (FRS) calculated for each participant correlated with immune cell platelet aggregates (PA) (e.g. T cell PA β = 0.59, p = 0.03 or non-classical monocyte PA β = 0.54, p = 0.02) after adjustment for body mass index (BMI).

Conclusion

A flow cytometry panel identified differences in granulocytes, monocytes, and lymphocytes between AA and Caucasians which may contribute to increased CVD risk in AA. Moreover, this flow panel identifies immune cell sub-populations and platelet aggregates associated with CVD risk. This flow cytometry panel may serve as an effective method for phenotyping immune cell populations involved in the development and progression of CVD.

Effects of Race on Statin Prescribing for Primary Prevention With High Atherosclerotic Cardiovascular Disease Risk in a Large Healthcare System

Background

Although guidelines recommend statins with a high level of evidence for 4 primary prevention benefit groups, prescribing disparities still exist. The objective of this study was to evaluate the effects of race on statin prescribing for primary prevention.

Methods and Results

A retrospective cohort analysis of patients within a large academic health system was performed to investigate statin prescribing among primary prevention groups. The statin benefits groups were patients diagnosed with diabetes mellitus, with an low‐density lipoprotein ≥190 mg/dL, or with an atherosclerotic cardiovascular disease (ASCVD) 10‐year risk ≥7.5%. Statin prescribing was 20% in the ASCVD ≥7.5% group, followed by 37.8% in the low‐density lipoprotein ≥190 mg/dL group and 40.5% in the diabetes mellitus group. Blacks were less likely to be prescribed a statin compared with whites in the diabetes mellitus (odds ratio, 0.64; 95% CI, 0.49–0.82; P=0.001) and ASCVD ≥7.5% groups (odds ratio, 0.38; 95% CI, 0.26–0.54; P<0.0001). Blacks 60 to 69 years of age (odds ratio, 7.97; 95% CI, 3.14–20.2; P=0.003) and 70 to 79 years of age (odds ratio, 4.21; 95% CI, 1.81–9.79; P=0.008) were more likely to be prescribed a statin compared with blacks <60 years of age in the ASCVD ≥7.5% group.

Conclusions

Blacks are less likely to be prescribed statins in diabetes mellitus and ASCVD ≥7.5% groups compared with whites. Younger blacks with ASCVD risk ≥7.5% are less likely to be prescribed statins compared with older blacks. Future research should focus on tailored interventions to address statin prescribing disparities in blacks.

Long-Term Association of Low-Density Lipoprotein Cholesterol With Cardiovascular Mortality in Individuals at Low 10-Year Risk of Atherosclerotic Cardiovascular Disease

BACKGROUND

The associations of low-density lipoprotein cholesterol (LDL-C) with cardiovascular disease (CVD) and coronary heart disease mortality in an exclusively low estimated 10-year risk group are not well delineated. We sought to determine the long-term associations of various LDL-C and non-high-density lipoprotein cholesterol (HDL-C) thresholds and CVD and coronary heart disease mortality in a large, low 10-year risk cohort.

METHODS

The study sample included participants of the CCLS (Cooper Center Longitudinal Study) without a history of CVD or diabetes mellitus and defined as low risk (<7.5%) for 10-year atherosclerotic CVD events at baseline based on Pooled Cohort Risk Assessment Equations. The associations of fasting LDL-C and non-HDL-C with CVD mortality were tested with Cox proportional hazards models.

RESULTS

In 36 375 participants (72% men, median age 42) followed for a median of 26.8 years, 1086 CVD and 598 coronary heart disease deaths occurred. Compared with LDL-C <100 mg/dL, LDL-C categories 100 to 129 mg/dL, 130 to 159 mg/dL, 160 to 189.9 mg/dL, and ≥190 mg/dL were associated with a significantly higher risk of CVD death, with hazard ratios of 1.4 (95% CI, 1.1-1.7), 1.3 (95% CI, 1.1-1.6), 1.9 (95% CI, 1.5-2.4), and 1.7 (95% CI, 1.3-2.3), and mean reductions in years free of CVD death of 1.8, 1.1, 4.3, and 3.9, respectively. After adjustment for atherosclerotic CVD risk factors, LDL-C categories 160 to 189 mg/dL and ≥190 mg/dL remained independently associated with CVD mortality, with hazard ratios of 1.7 (95% CI, 1.4-2.2) and 1.5 (95% CI, 1.2-2.1), respectively. In multivariable-adjusted models using non-HDL-C <130 mg/dL as the reference, non-HDL-C 160 to 189 mg/dL, 190 to 219 mg/dL, and ≥220 mg/dL were significantly associated with CVD death, with hazard ratios of 1.3 (95% CI, 1.1-1.6), 1.8 (95% CI, 1.4-2.2), and 1.5 (95% CI, 1.2-2.0), respectively. Restricting the cohort to those with 10-year risk <5% did not diminish the associations of LDL-C and non-HDL-C with CVD mortality.

CONCLUSIONS

In a low 10-year risk cohort with long-term follow-up, LDL-C and non-HDL-C ≥160 mg/dL were independently associated with a 50% to 80% increased relative risk of CVD mortality. These findings may have implications for future cholesterol treatment paradigms.

Association between access to social service resources and cardiometabolic risk factors: a machine learning and multilevel modeling analysis

OBJECTIVES

Interest in linking patients with unmet social needs to area-level resources, such as food pantries and employment centres in one's ZIP code, is growing. However, whether the presence of these resources is associated with better health outcomes is unclear. We sought to determine if area-level resources, defined as organisations that assist individuals with meeting health-related social needs, are associated with lower levels of cardiometabolic risk factors.

DESIGN

Cross-sectional.

SETTING

Data were collected in a primary care network in eastern Massachusetts in 2015.

PARTICIPANTS AND PRIMARY AND SECONDARY OUTCOME MEASURES

123 355 participants were included. The primary outcome was body mass index (BMI). The secondary outcomes were systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol and haemoglobin A1c (HbA1c). All participants were included in BMI analyses. Participants with hypertension were included in SBP analyses. Participants with an indication for cholesterol lowering were included in LDL analyses and participants with diabetes mellitus were included in HbA1c analyses. We used a random forest-based machine-learning algorithm to identify types of resources associated with study outcomes. We then tested the association of ZIP-level selected resource types (three for BMI, two each for SBP and HbA1c analyses and one for LDL analyses) with these outcomes, using multilevel models to account for individual-level, clinic-level and other area-level factors.

RESULTS

Resources associated with lower BMI included more food resources (-0.08 kg/m² per additional resource, 95% CI -0.13 to -0.03 kg/m²), employment resources (-0.05 kg/m², 95% CI -0.11 to -0.002 kg/m²) and nutrition resources (-0.07 kg/m², 95% CI -0.13 to -0.01 kg/m²). No area resources were associated with differences in SBP, LDL or HbA1c.

CONCLUSIONS

Access to specific local resources is associated with better BMI. Efforts to link patients to area resources, and to improve the resources landscape within communities, may help reduce BMI and improve population health.

Biological embedding of neighborhood disadvantage and collective efficacy: Influences on chronic illness via accelerated cardiometabolic age

The present study extends prior research on the link between neighborhood disadvantage and chronic illness by testing an integrated model in which neighborhood characteristics exert effects on health conditions through accelerated cardiometabolic aging. Hypotheses were tested using a sample of 408 African Americans from the Family and Community Health Study. Using four waves of data spanning young adulthood (ages 18-29), we first found durable effects of neighborhood disadvantage on accelerated cardiometabolic aging and chronic illness. Then, we used marginal structural modeling to adjust for potential neighborhood selection effects. As expected, accelerated cardiometabolic aging was the biopsychosocial mechanism that mediated much of the association between neighborhood disadvantage and chronic illness. This finding provides additional support for the view that neighborhood disadvantage can influence morbidity and mortality by creating social contexts that becomes biologically embedded. Perceived neighborhood collective efficacy served to buffer the relationship between neighborhood disadvantage and biological aging, identifying neighborhood-level resilience factor. Overall, our results indicate that neighborhood context serves as a fundamental cause of weathering and accelerated biological aging. Residing in a disadvantaged neighborhood increases biological wear and tear that ultimately leads to onset of chronic illness, but access to perceived collective efficacy buffers the impact of these neighborhood effects. From an intervention standpoint, identifying such an integrated model may help inform future health-promoting interventions.

Hypertensive emergencies in diabetic patients from predominantly African American urban communities

Aim: The aim of this study was to identify risk factors for hypertensive emergencies in diabetic patients presenting with severely elevated blood pressure. Methods: Using electronic medical records, this study identified diabetic patients with hypertensive crisis who presented to the emergency department of Newark Beth Israel Medical Center, Newark, NJ from June 2013 to May 2016. Diabetic patients with hypertensive emergencies were compared with non-diabetic patients based on important demographic and clinical characteristics. Results: Patients with diabetes accounted for 52.27% of all hypertensive emergencies during the study period. There were 264 diabetic patients with hypertensive emergencies and 519 diabetic patients with hypertensive urgencies. The majority of patients were African Americans (88.6%). The odds of hypertensive emergencies were strikingly higher in diabetic patients with hyperlipidemia (OR 1.66, 95% CI 1.23-2.24), coronary artery disease (OR 2.95, 95% CI 2.15-4.05), congestive heart failure (OR 6.28, 95% CI 4.49-8.80), renal insufficiency (OR 2.84, 95% CI 2.10-3.86) and low hemoglobin (OR 0.9, 95% CI 0.84-0.97). Acute or worsening heart failure was the most frequent acute target organ injury (49.6%) followed by non-ST elevation myocardial infarction (41.7%). Diabetic and non-diabetic patients had similar rates of target organ injuries. Conclusion: The development of hypertensive emergencies in patients with diabetes was not because of diabetes per se but because of coexisting highly elevated blood pressure. Tight blood pressure control may decrease the risk of hypertensive emergencies in this patient population.

Heart Matters: a study protocol for a community based randomized trial aimed at reducing cardiovascular risk in a rural, African American community

BACKGROUND

African Americans living in the rural south have the highest prevalence of cardiovascular disease (CVD) risk in the United States. Given this geographic and racial disparity, intervention implementation needs to be evaluated for effectiveness and feasibility with African Americans in the rural south.

METHODS

The trial developed out of a community-based participatory research partnership, Project GRACE, and community partners who are collaborators throughout the study. Heart Matters is a randomized stepped wedge trial that will assess the effectiveness of a 12-month behavioral change intervention adapted from PREMIER, an evidence-based treatment targeting multiple CVD risk factors. 140 participants will be recruited through 8 community- or faith-based organizations to participate in the intervention. Through matched pair randomization, organizations will be randomized to begin immediately after baseline data collection (Arm 1) or delayed 6 months (Arm 2). Data collection will occur at baseline, 6, 12, and 18 months. The primary outcome is change in body weight. In addition to assessing effectiveness, the study will also evaluate process and feasibility outcomes through quantitative and qualitative data collection.

DISCUSSION

This study will contribute to CVD prevention research and likely have a positive impact on the rural, African American community where the trial occurs. Our study is unique in its use of community partnerships to develop, implement, and evaluate the intervention. We expect that this approach will enhance the feasibility of the trial, as well as future dissemination and sustainability of the intervention.

TRIAL REGISTRATION

Clinical Trials, NCT02707432 . Registered 13 March 2016.

Childhood trauma, pubertal timing, and cardiovascular risk in adulthood

OBJECTIVE

An association between childhood trauma and adult health outcomes has been widely reported, but little is known about the developmental pathways through which childhood trauma influences adult cardiovascular disease (CVD).

METHOD

Hypotheses were tested with a sample of 405 African Americans from the Family and Community Health Study (FACHS). Path modeling was used to test our theoretical model.

RESULTS

Replicating prior research, exposure to childhood trauma was associated positively with increases in symptoms of CVD risk across young adulthood even after controlling for a variety of health-related and health behavior covariates. Further, the association of childhood trauma with CVD risk was mediated by early pubertal maturation. There were no gender differences in the magnitude of this effect.

CONCLUSION

Our findings support an evolutionary-development perspective (Belsky & Shalev, 2016) suggesting that early adverse life experiences lead to early biologically embedded changes reflected in early physical maturation and that these early changes predict later negative adult health outcomes. The results imply that early pubertal maturation is a precursor to vulnerability to long term health problems. From an intervention standpoint, identifying such developmental pathways may help inform future health-promoting interventions. (PsycINFO Database Record

Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association

The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.

Racial Differences in Heart Age and Impact on Mortality

BACKGROUND

Heart age is an estimate of the age of a person's cardiovascular system given their cardiovascular disease (CVD) risk factors. The difference between a person's chronological age and heart age (excess heart age) represents their added CVD risk.

OBJECTIVE

To examine racial differences in excess heart age and whether race impacts the association between excess heart age and CVD mortality.

METHODS

This analysis included 5110 participants (2449 non-Hispanic white, 1287 non-Hispanic black, and 1374 Mexican-American) from the NHANES III who were free of CVD. Heart age was calculated using the sex-specific non-laboratory-based Framingham risk prediction functions. Multivariable Cox proportional-hazards regression models were used to evaluate the relationship (overall and by race) between excess heart age and CVD mortality.

RESULTS

Mean excess heart age was greatest in non-Hispanic blacks (13.0 years), followed by Mexican-Americans (10.5 years), and non-Hispanic whites (8.5 years); p < 0.001 for pairwise differences. Over a mean follow-up of 13.0 years, 394 CVD deaths occurred. Each 10 years of excess heart age was associated with 65% increased risk of CVD mortality (HR, 95% CI: 1.65, 1.53-1.78). This association was stronger in non-Hispanic whites (1.83, 1.63-2.02) compared to non-Hispanic blacks (1.50, 1.29-1.72) and Mexican American (1.60, 1.33-1.87), interaction p = 0.065.

CONCLUSIONS

Compared to non-Hispanic whites, non-Hispanic blacks and Mexican Americans have more excess heart age, but the risk of CVD death for the same level of excess heart age appears more pronounced in non-Hispanic whites. Further investigation is needed to show the usefulness of these findings in directing future efforts and resource allocation for reduction of health disparities between ethnic groups.

Quality and Equitable Health Care Gaps for Women: Attributions to Sex Differences in Cardiovascular Medicine

The present review synthesizes evidence and discusses issues related to health care quality and equity for women, including minority population subgroups. The principle of "sameness" or women and men receiving equitable, high-quality care is a near-term target, but optimal population health cannot be achieved without consideration of the unique, gendered structural determinants of health and the development of unique care pathways optimized for women. The aim of this review is to promote enhanced awareness, develop critical thinking in sex and gender science, and identify strategic pathways to improve the cardiovascular health of women. Delineation of the components of high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for or living with cardiovascular disease.

Longitudinal study of cardiometabolic risk from early adolescence to early adulthood in an ethnically diverse cohort

OBJECTIVE

To examine influences of adiposity from early adolescence to early 20s on cardiovascular disease (CVD) risk in the multiethnic Determinants of young Adult Social well-being and Health (DASH) longitudinal study.

METHODS

In 2002-2003, 6643 11-13-year-olds from 51 London schools participated at baseline, and 4785 were seen again at 14-16 years. Recently, 665 (97% of invited) participated in pilot follow-up at 21-23 years, with biological and psychosocial measures and blood biomarkers (only at 21-23 years). Regression models examined interplay between ethnicity, adiposity and CVD.

RESULTS

At 21-23 years, ∼30-40% were overweight. About half of the sample had completed a degree with little ethnic variation despite more socioeconomic disadvantage in adolescence among ethnic minorities. Regardless of ethnicity, overweight increased more steeply between 14-16 years and 21-23 years than between 11-13 years and 14-16 years. More overweight among Black Caribbean and Black African females, lower systolic blood pressure (sBP) among Indian females and Pakistani/Bangladeshi males compared with White UK peers, persisted from 11-13 years. At 21-23 years, glycated haemoglobin (HbA1c) was higher among Black Caribbean females, total cholesterol higher and high-density lipoprotein (HDL) cholesterol lower among Pakistani/Bangladeshis. Overweight was associated with a ∼+2 mm Hg rise in sBP between 11-13 years and 21-23 years. Adiposity measures at 11-13 years were related to allostatic load (a cluster of several risk markers), HbA1c and HDL cholesterol at 21-23 years. Ethnic patterns in CVD biomarkers remained after adjustments.

CONCLUSIONS

Adolescent adiposity posed significant risks at 21-23 years, a period in the lifespan generally ignored in cardiovascular studies, when ethnic/gender variations in CVD are already apparent.

Racial disparities in adult all-cause and cause-specific mortality among us adults: mediating and moderating factors

BACKGROUND

Studies uncovering factors beyond socio-economic status (SES) that would explain racial and ethnic disparities in mortality are scarce.

METHODS

Using prospective cohort data from the Third National Health and Nutrition Examination Survey (NHANES III), we examined all-cause and cause-specific mortality disparities by race, mediation through key factors and moderation by age (20-49 vs. 50+), sex and poverty status. Cox proportional hazards, discrete-time hazards and competing risk regression models were conducted (N = 16,573 participants, n = 4207 deaths, Median time = 170 months (1-217 months)).

RESULTS

Age, sex and poverty income ratio-adjusted hazard rates were higher among Non-Hispanic Blacks (NHBs) vs. Non-Hispanic Whites (NHW). Within the above-poverty young men stratum where this association was the strongest, the socio-demographic-adjusted HR = 2.59, p < 0.001 was only partially attenuated by SES and other factors (full model HR = 2.08, p = 0.003). Income, education, diet quality, allostatic load and self-rated health, were among key mediators explaining NHB vs. NHW disparity in mortality. The Hispanic paradox was observed consistently among women above poverty (young and old). NHBs had higher CVD-related mortality risk compared to NHW which was explained by factors beyond SES. Those factors did not explain excess risk among NHB for neoplasm-related death (fully adjusted HR = 1.41, 95 % CI: 1.02-2.75, p = 0.044). Moreover, those factors explained the lower risk of neoplasm-related death among MA compared to NHW, while CVD-related mortality risk became lower among MA compared to NHW upon multivariate adjustment.

CONCLUSIONS

In sum, racial/ethnic disparities in all-cause and cause-specific mortality (particularly cardiovascular and neoplasms) were partly explained by socio-demographic, SES, health-related and dietary factors, and differentially by age, sex and poverty strata.

Racial Differences in the Incidence of Cardiovascular Risk Factors in Older Black and White Adults

OBJECTIVES

To describe the incidence of cardiovascular risk factors, or race-related disparities in incidence, across the age spectrum in adults.

DESIGN

Longitudinal cohort.

SETTING

National sample.

PARTICIPANTS

Community-dwelling black and white adults recruited between 2003 and 2007.

MEASUREMENTS

Incident hypertension, diabetes mellitus, dyslipidemia and atrial fibrillation over 10 years of follow-up in 10,801 adults, stratified according to age (45-54, 55-64, 65-74, ≥75).

RESULTS

There was no evidence (P ≥ .68) of an age-related difference in the incidence of hypertension for white men (average incidence 38%), black men (48%), or black women (54%), although for white women incidence increased with age (45-54, 27%; ≥75, 40%). Incidence of diabetes mellitus was lower at older ages for white men (45-54, 15%; ≥75, 8%), black men (45-54, 29%; ≥75, 13%), and white women (45-54, 11%; ≥75, 4%), although there was no evidence (P = .11) of age-related changes for black women (average incidence 21%). For dyslipidemia, incidence for all race-sex groups was approximately 20% for aged 45 to 54 but approximately 30% for aged 54 to 64 and 65 to 74 and approximately 22% for aged 75 and older. Incidence of atrial fibrillation was low at age 45 to 54 (<5%) but for aged 75 and older was approximately 20% for whites and 11% for blacks. The incidence of hypertension, diabetes mellitus, and dyslipidemia was higher in blacks across the age spectrum but lower for atrial fibrillation.

CONCLUSION

Incidence of risk factors remains high in older adults. Blacks have a higher incidence of hypertension, diabetes mellitus, and dyslipidemia after age 45, underscoring the ongoing importance of prevention of all three conditions in mid- to later life.

Elucidating the Association Between Depressive Symptoms, Coronary Heart Disease, and Stroke in Black and White Adults: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background

Depression is a relapsing and remitting disease. Prior studies on the association between depressive symptoms and incident cardiovascular disease (CVD) have been limited by single measurements, and few if any have examined both incident coronary heart disease and stroke in a large biracial national cohort. We aimed to assess whether time‐dependent depressive symptoms conferred increased risk of incident CVD.

Methods and Results

Between 2003 to 2007, 22 666 black and white participants (aged ≥45 years) without baseline CVD in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were recruited. Cox proportional hazards regression analyses assessed the association between up to 3 measurements of elevated depressive symptoms (4‐item Center for Epidemiologic Studies Depression Scale score ≥4) and incident coronary heart disease, stroke, and CVD death adjusting for age, sex, region, income, health insurance, education, blood pressure, cholesterol, medication, obesity, diabetes mellitus, kidney disease, C‐reactive protein, corrected QT interval, atrial fibrillation, left ventricular hypertrophy, smoking, alcohol, physical inactivity, medication adherence, and antidepressant use. The participants’ average age was 63.4 years, 58.8% were female, and 41.7% black. Time‐varying depressive symptoms were significantly associated with CVD death (adjusted hazard ratio 1.30, 95% CI 1.04–1.63), with a trend toward significance for fatal and nonfatal stroke (adjusted hazard ratio 1.26, 95% CI 0.99–1.60) but not fatal and nonfatal coronary heart disease (adjusted hazard ratio 1.11, 95% CI 0.89–1.38). Race did not moderate the association between depressive symptoms and CVD.

Conclusions

Proximal depressive symptoms were associated with incident fatal and nonfatal stroke and CVD death even after controlling for multiple explanatory factors, further supporting the urgent need for timely management of depressive symptoms.

Exploring the Spatial Association between Social Deprivation and Cardiovascular Disease Mortality at the Neighborhood Level

Cardiovascular disease (CVD), the leading cause of death in the United States, is impacted by neighborhood-level factors including social deprivation. To measure the association between social deprivation and CVD mortality in Harris County, Texas, global (Ordinary Least Squares (OLS) and local (Geographically Weighted Regression (GWR)) models were built. The models explored the spatial variation in the relationship at a census-tract level while controlling for age, income by race, and education. A significant and spatially varying association (p < .01) was found between social deprivation and CVD mortality, when controlling for all other factors in the model. The GWR model provided a better model fit over the analogous OLS model (R² = .65 vs. .57), reinforcing the importance of geography and neighborhood of residence in the relationship between social deprivation and CVD mortality. Findings from the GWR model can be used to identify neighborhoods at greatest risk for poor health outcomes and to inform the placement of community-based interventions.

Access to Care, Treatment Ambivalence, Medication Nonadherence, and Long-Term Mortality Among Severely Hypertensive African Americans: A Prospective Cohort Study

African Americans living in poor neighborhoods bear a high burden of illness and early mortality. Nonadherence may contribute to this burden. In a prospective cohort study of urban African Americans with poorly controlled hypertension, mortality was 47.6% over a median follow-up of 6.1 years. Patients with pill-taking nonadherence were more likely to die (hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.76) after adjustment for potential confounders. With regard to factors related to nonadherence, poor access to care such as difficulty paying for medications was associated with prescription refill nonadherence (odds ratio [OR], 4.12; 95% CI, 1.88-9.03). Pill-taking nonadherence was not associated with poor access to care; however, it was associated with factors related to treatment ambivalence including lower hypertension knowledge (OR, 2.97; 95% CI, 1.39-6.32), side effects (OR, 3.44; 95% CI, 1.47-8.03), forgetfulness (OR, 3.62; 95% CI, 1.78-7.34), and feeling that the medications do not help (OR, 2.78; 95% CI, 1.09-7.09). These data suggest that greater access to care is a necessary but insufficient remedy to the disparities experienced by urban African Americans with hypertension. To achieve its full promise, health reform must also address treatment ambivalence.

Early origins of ethnic disparities in cardiovascular risk factors

BACKGROUND

Not much is known about the ethnic differences in cardiovascular risk factors during childhood in European countries. We examined the ethnic differences in childhood cardiovascular risk factors in the Netherlands.

METHODS

In a multi-ethnic population-based prospective cohort study, we measured blood pressure, left ventricular mass, and levels of cholesterol, triglyceride and insulin at the median age of 6.2years.

RESULTS

As compared to Dutch children, Cape Verdean and Turkish children had a higher blood pressure, whereas Cape Verdean, Surinamese-Creole and Turkish children had higher total-cholesterol levels (p-values<0.05). Turkish children had higher triglyceride levels, but lower insulin levels than Dutch children (p-values<0.05). As compared to Dutch children, only Turkish children had an increased risk of clustering of cardiovascular risk factors (odds ratio: 2.45 (95% confidence interval 1.18, 3.37)). Parental pre-pregnancy factors explained up to 50% of the ethnic differences in childhood risk factors. In addition to these factors, pregnancy and childhood factors and childhood BMI explained up to 50%, 12.5% and 61.1%, respectively.

CONCLUSIONS

Our results suggest that compared to Dutch children, Cape Verdean, Surinamese-Creole and Turkish children have an adverse cardiovascular profile. These differences are largely explained by parental pre-pregnancy factors, pregnancy factors and childhood BMI.

Race-ethnic differences in subclinical left ventricular systolic dysfunction by global longitudinal strain: A community-based cohort study

BACKGROUND

Race-ethnic differences exist in the epidemiology of heart failure, with blacks experiencing higher incidence and worse prognosis. Left ventricular (LV) systolic dysfunction (LVSD) detected by speckle-tracking global longitudinal strain (GLS) is a predictor of cardiovascular events including heart failure. It is not known whether race-ethnic differences in GLS-LVSD exist in subjects without overt LV dysfunction.

METHODS

Participants from a triethnic community-based study underwent 2-dimensional echocardiography with assessment of LV ejection fraction (LVEF) and GLS by speckle-tracking. Participants with LVEF <50% were excluded. Left ventricular systolic dysfunction by GLS was defined as GLS >95% percentile in a healthy sample (-14.7%).

RESULTS

Of the 678 study participants (mean age 71 ± 9 years, 61% women), 114 were blacks; 464, Hispanics; and 100, whites. Global longitudinal strain was significantly lower in blacks (-16.5% ± 3.5%) than in whites (-17.5% ± 3.0%) and Hispanics (-17.3% ± 2.9%) in both univariate (P = .015) and multivariate analyses (P = .011), whereas LVEF was not significantly different between the 3 groups (64.3% ± 4.6%, 63.4% ± 4.9%, 64.7% ± 4.9%, respectively, univariate P = .064, multivariate P = .291). Left ventricular systolic dysfunction by GLS was more frequent in blacks (27.2%) than in whites (19.0%) and Hispanics (14.9%, P = .008). In multivariate analysis adjusted for confounders and cardiovascular risk factors, blacks were significantly more likely to have GLS-LVSD (adjusted odds ratio 2.6, 95% CIs 1.4-4.7, P = .002) compared to the other groups.

CONCLUSIONS

Among participants from a triethnic community cohort, black race was associated with greater degree of subclinical LVSD by GLS than other race-ethnic groups. This difference was independent of confounders and cardiovascular risk factors.

What Is Fitness Training? Definitions and Implications: A Systematic Review Article

BACKGROUND

This review based upon studies searched from the major scientific libraries has the objective of clarifying what is fitness training in modern days, the implications that it has on health in both youth and elderly and finally discuss fitness training practical implications.

METHODS

The PRISMA statement was partially adopted and a number of 92 items were selected, according to the inclusion criteria. Results were discussed in 4 main sections: 1. Children and adolescents fitness levels; 2. Fitness training in the elderly; 3. Pathology prevention through fitness training; 4. Training through Fitness activities.

RESULTS

This review pointed out the fact that nowadays there is a large variety of fitness activities available within gyms and fitness centers. Even though they significantly differ with each other, the common aim they have is the wellbeing of the people through the improvement of the physical fitness components and the psychological balance.

CONCLUSION

Fitness instructors' recommendations should be followed in gym context and should be contingent upon an individual's objectives, physical capacity, physical characteristics and experience.

Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial

Background

Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension.

Methods/Design

A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing.

Discussion

The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence.

Trial registration

ClinicalTrials.gov NCT02011685. Registered 10 December 2013.

Metabolic diseases and sex hormone levels affect differently in the development of cardiovascular and cerebrovascular diseases in elderly males

OBJECTIVE

This single-centre cross-sectional study aimed to investigate the metabolic and gonadal risk factors of vascular diseases in elderly males.

METHODS

After screening, 337 subjects aged 60-90 were found to be qualified. Odds ratios (ORs) in cross-table analyses and exp(B) in logistic regression analyses were used to evaluate the vascular risk of dependent factors. R(2) of logistic regression equation was used to estimate the goodness-of-fit of vascular diseases logistic regression models.

RESULTS

Hypertension increased the risk of cardiovascular disease (CAVD) in elderly men approximately 3-fold. The number of metabolic diseases also correlated with incremental risks of CAVD; presence of one abnormality approximately increases the risk approximately 62%. Cerebrovascular disease (CEVD) development was closely associated with both metabolic syndrome and sex hormone levels; their explanation effects of single action and combined action were 13.2%, 12.55% and 28.5%. C-peptide might be the underlying mechanism of the metabolic syndrome's effect on CEVD. C-peptide = 2.43 U/L and FE(2) = 0.66 were the tangent points in receiver operating characteristic (ROC) analyses.

CONCLUSIONS

Metabolic diseases and sex hormones play different roles in the development of CAVD and CEVD, the methods for vascular protection in elderly men should be promoted differently according to the their risks of CAVD and CEVD.

Predicted long-term cardiovascular risk among young adults in the national longitudinal study of adolescent health

OBJECTIVES

We estimated the distribution of predicted long-term cardiovascular disease (CVD) risk among young adults in the United States.

METHODS

Our data were derived from National Longitudinal Study of Adolescent Health participants (n = 14 333; average age: 28.9 years). We used a Framingham-derived risk prediction function to calculate 30-year risks of "hard" and "general" CVD by gender and race/ethnicity.

RESULTS

Average 30-year risks for hard and general CVD were 10.4% (95% confidence interval [CI] = 10.1%, 10.7%) and 17.3% (95% CI = 17.0%, 17.7%) among men and 4.4% (95% CI = 4.3%, 4.6%) and 9.2% (95% CI = 8.9%, 9.5%) among women. Average age-adjusted risks of hard and general CVD were higher among Blacks and American Indians than among Whites and lower among Asian/Pacific Islander women than White women. American Indian men continued to have a higher risk of general CVD after adjustment for socioeconomic status. Four percent of women (95% CI = 3.6%, 5.0%) and 26.2% of men (95% CI = 24.7%, 27.8%) had a 20% or higher risk of general CVD. Racial differences were detected but were not significant after adjustment for socioeconomic status.

CONCLUSIONS

Average CVD risk among young adults is high. Population-based prevention strategies and improved detection and treatment of high-risk individuals are needed to reduce the future burden of CVD.

Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

The extent to which the relative contributions of traditional cardiovascular risk factors to incident cardiovascular disease (CVD) may have changed over time remains unclear.

METHODS AND RESULTS

We studied 13 541 participants (56% women, 26% black) in the Atherosclerosis Risk in Communities Study, aged 52 to 66 years and free of CVD at exams in 1987 through 1989, 1990 through 1992, 1993 through 1995, or 1996 through 1998. At each examination, we estimated the population attributable risks (PAR) of traditional risk factors (hypertension, diabetes mellitus, obesity, hypercholesterolemia, and smoking) for the 10-year incidence of CVD. Overall, the PAR of all risk factors combined appeared to decrease from the late 1980s to the late 1990s (0.58 to 0.53). The combined PAR was higher in women than men in 1987 through 1989 (0.68 versus 0.51, P<0.001) but not by the late 1990s (0.58 versus 0.48, P=0.08). The combined PAR was higher in blacks than whites in the late 1980s (0.67 versus 0.57, P=0.049), and this difference was more pronounced by the late 1990s (0.67 versus 0.48, P=0.002). By the late 1990s, the PAR of hypertension had become higher in women than men (P=0.02) and also appeared higher in blacks than whites (P=0.08). By the late 1990s, the PAR of diabetes mellitus remained higher in women than men (P<0.0001) and in blacks than whites (P<0.0001).

CONCLUSIONS

The contribution to CVD of all traditional risk factors combined is greater in blacks than whites, and this difference may be increasing. The contributions of hypertension and diabetes mellitus remain especially high, in women as well as blacks. These findings underscore the continued need for individual as well as population approaches to CVD risk factor modification.

Role of vitamin D receptor activation in racial disparities in kidney disease outcomes

African Americans have lower 25-hydroxyvitamin D (25(OH)D) levels compared with whites. African Americans also have a higher risk of developing albuminuria and end-stage renal disease but a lower risk of death once they commence hemodialysis compared with whites. Vitamin D levels have been associated with multiple outcomes including albuminuria, progression to end-stage renal disease, and all-cause and cardiovascular mortality. In this review, we examine the evidence linking 25(OH)D to outcomes and the possibility that differential 25(OH)D may explain certain racial differences in outcomes.