Perspectives and experiences of Māori and Pasifika peoples living with cardiac inherited disease: a qualitative study

OBJECTIVE

Cardiac inherited diseases can have considerable psychosocial effects, including lifestyle limitations, anxiety and depression. Most research to date on patient experiences of CID has been conducted with people from Western cultures, yet culture can shape patient views and experiences of health. The aim of this research was to explore the experiences and perspectives of Māori and Pasifika living with a cardiac inherited disease (CID).

METHODS AND MEASURES

Semi-structured interviews were conducted with 14 Māori and 14 Pasifika patients living with a cardiac inherited disease and seven of their family members, using Talanoa and Kaupapa Māori methodologies. Themes from the interviews were identified using interpretative phenomenological analysis.

RESULTS

Three common themes were identified as important in shaping participants' perceptions and experiences of CID: (1) difficulty in understanding the disease as separate from symptoms, (2) considering ancestors and future generations and (3) the role of spirituality and religion.

CONCLUSION

This study highlights a gap between indigenous patients' understanding of CID and the western biomedical approach. Patients' understanding and treatment behaviours depend on symptoms, familial ties and spirituality. The findings support the need for transparency and culturally appropriate practices in healthcare. Considering these aspects may help to reduce health inequities for these populations.

Prevalence of cardiac pathology and relation to mortality in a multiethnic population hospitalised with COVID-19

OBJECTIVE

To determine the prevalence of cardiac abnormalities and their relationship to markers of myocardial injury and mortality in patients admitted to hospital with COVID-19.

METHODS

A retrospective and prospective observational study of inpatients referred for transthoracic echocardiography for suspected cardiac pathology due to COVID-19 within a London NHS Trust. Echocardiograms were performed to assess left ventricular (LV), right ventricular (RV) and pulmonary variables along with collection of patient demographics, comorbid conditions, blood biomarkers and outcomes.

RESULT

In the predominant non-white (72%) population, RV dysfunction was the primary cardiac abnormality noted in 50% of patients, with RV fractional area change <35% being the most common marker of this RV dysfunction. By comparison, LV systolic dysfunction occurred in 18% of patients. RV dysfunction was associated with LV systolic dysfunction and the presence of a D-shaped LV throughout the cardiac cycle (marker of significant pulmonary artery hypertension). LV systolic dysfunction (p=0.002, HR 3.82, 95% CI 1.624 to 8.982), pulmonary valve acceleration time (p=0.024, HR 0.98, 95% CI 0.964 to 0.997)-marker of increased pulmonary vascular resistance, age (p=0.047, HR 1.027, 95% CI 1.000 to 1.055) and an episode of tachycardia measured from admission to time of echo (p=0.004, HR 6.183, 95% CI 1.772 to 21.575) were independently associated with mortality.

CONCLUSIONS

In this predominantly non-white population hospitalised with COVID-19, the most common cardiac pathology was RV dysfunction which is associated with both LV systolic dysfunction and elevated pulmonary artery pressure. The latter two, not RV dysfunction, were associated with mortality.

Heart Disease, Advanced Age, Minority Race, and Hispanic Ethnicity Are Associated With Mortality in COVID-19 Patients

BACKGROUND

The objective of this study was to determine the associations between heart disease, obesity, and demographic factors and increased COVID-19 mortality.

METHODS

We extracted deidentified patient-level data from the Froedtert Health System and Children's Hospital of Wisconsin and used descriptive statistics and multivariable logistic regression to characterize relationships between heart disease, obesity, age group, sex, race and ethnicity and mortality following COVID-19 diagnosis.

RESULTS

We found heart disease (adjusted odds ratio [AOR] 2.85; 95% CI, 2.11-8.83) and other demographic factors are significant predictors of increased mortality in COVID-19 patients. However, obesity was not a significant predictor of mortality (AOR 1.04; 95% CI, 0.53- 3.10).

DISCUSSION

These unique results indicate some comorbid conditions and patient demographics contribute more strongly to mortality in COVID-19 patients.

Comparison of 20-Year Obesity-Associated Cancer Mortality Trends With Heart Disease Mortality Trends in the US

IMPORTANCE

Heart disease and cancer are the 2 major diseases associated with mortality risk in the United States. Four decades of improvements in heart disease mortality slowed after 2011; this slowing has been associated with the obesity epidemic. The same pattern has not been observed for total cancer mortality. However, trends in total cancer mortality may obscure patterns specific to obesity-associated cancers.

OBJECTIVE

To investigate whether trends in obesity-associated cancer mortality mirror the slowed mortality improvements observed for heart disease associated with the obesity epidemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared US mortality trends for International Statistical Classification of Diseases and Related Health Problems, Tenth Revision-defined cancer (total cancer, obesity-associated cancer, and cancer not associated with obesity) and heart disease deaths from January 1, 1999, to December 31, 2018. Data were included on decedents with complete information on the underlying cause of death, age, sex, race, and ethnicity.

EXPOSURES

Changes in age-adjusted cause-specific mortality rates between 1999-2011 and 2011-2018 were compared.

MAIN OUTCOMES AND MEASURES

Annual relative rates of change in age-adjusted mortality rates (AAMRs) in the overall population and stratified by sex, race, and ethnicity were estimated using Poisson regression. Differences in AAMR annual relative rates of change before and after 2011 were evaluated using Wald tests.

RESULTS

A total of 50 163 483 decedents met the inclusion criteria (50.1% female decedents, 79.9% non-Hispanic White decedents, and 11.7% non-Hispanic Black decedents; mean [SD] age, 72.8 [18.5] years). In contrast with heart disease mortality, for which improvements slowed between 1999-2011 and 2011-2018, decreases in total cancer AAMR relative change accelerated between 1999-2011 (-1.48 [95% CI, -1.43 to -1.52]) and 2011-2018 (-1.77 [95% CI, -1.67 to -1.86]) (P < .001). For obesity-associated cancer mortality, which accounted for approximately 33% of total cancer deaths annually, decreases in annual AAMR relative change decelerated from -1.19 (95% CI, -1.13 to -1.26) in 1999-2011 to -0.83 (95% CI, -0.70 to -0.96) in 2011-2018 (P < .001). The largest decelerations in obesity-associated cancer mortality were observed for female decedents (-1.45 [95% CI, -1.36 to -1.53] in 1999-2011 and -0.91 [95% CI, -0.75 to -1.07] in 2011-2018; P < .001) and non-Hispanic White individuals (-1.16 [95% CI, -1.09 to -1.22] in 1999-2011 and -0.68 [95% CI, -0.55 to -0.81] in 2011-2018; P < .001).

CONCLUSIONS AND RELEVANCE

Slowing improvements in obesity-associated cancer mortality were obscured when considering total cancer mortality. These findings potentially signal a changing profile of cancer-associated mortality that may parallel trends previously observed for heart disease as the consequences of the obesity epidemic are understood.

Adverse Trends in Premature Cardiometabolic Mortality in the United States, 1999 to 2018

Background Life expectancy in the United States has recently declined, in part attributable to premature cardiometabolic mortality. We characterized national trends in premature cardiometabolic mortality, overall, and by race-sex groups. Methods and Results Using death certificates from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research, we quantified premature deaths (<65 years of age) from heart disease, cerebrovascular disease, and diabetes mellitus from 1999 to 2018. We calculated age-adjusted mortality rates (AAMRs) and years of potential life lost (YPLL) from each cardiometabolic cause occurring at <65 years of age. We used Joinpoint regression to identify an inflection point in overall cardiometabolic AAMR trends. Average annual percent change in AAMRs and YPLL was quantified before and after the identified inflection point. From 1999 to 2018, annual premature deaths from heart disease (117 880 to 128 832), cerebrovascular disease (18 765 to 20 565), and diabetes mellitus (16 553 to 24 758) as an underlying cause of death increased. By 2018, 19.7% of all heart disease deaths, 13.9% of all cerebrovascular disease deaths, and 29.1% of all diabetes mellitus deaths were premature. AAMRs and YPLL from heart disease and cerebrovascular disease declined until the inflection point identified in 2011, then remained unchanged through 2018. Conversely, AAMRs and YPLL from diabetes mellitus did not change through 2011, then increased through 2018. Black men and women had higher AAMRs and greater YPLL for each cardiometabolic cause compared with White men and women, respectively. Conclusions Over one-fifth of cardiometabolic deaths occurred at <65 years of age. Recent stagnation in cardiometabolic AAMRs and YPLL are compounded by persistent racial disparities.

Effect of An Online Physical Activity Promotion Program and Cardiovascular Symptoms Among Asian American Women at Midlife

Despite an increasing number of online programs to promote physical activity, they have rarely been evaluated for their effects on cardiovascular symptoms of racial/ethnic minority women at midlife. This study aimed to determine the preliminary efficacy of a newly developed online program for physical activity promotion on cardiovascular symptoms of Asian American midlife women. This study was a pilot repeated-measures randomized controlled trial (pretest/posttest) among 26 Asian American midlife women. The variables were measured using multiple instruments on background features, physical activity, and cardiovascular symptoms at three points of time (baseline, after 1 month, and after 3 months). Linear mixed models were used to analyze the data. The prevalence and severity of cardiovascular symptoms did not show a statistically significant group-time interaction. However, the increase in lifestyle physical activity over time was significant only among the intervention group (Δ = 0.49, P = .016). The results supported the program's preliminary efficacy on lifestyle physical activity for Asian American women at midlife, but not on cardiovascular symptoms.

Dose-dependent Cardiac Dysfunction and Structural Damage in Rats after Shortwave Radiation

OBJECTIVE

To detect the effects of shortwave radiation on dose-dependent cardiac structure and function in rats after radiation and to elucidate the mechanism of shortwave radiation induced cardiac injury to identify sensitive indicators and prophylactic treatment.

METHODS

One hundred Wistar rats were either exposed to 27 MHz continuous shortwave at a power density of 5, 10, and 30 mW/cm ² for 6 min or undergone sham exposure for the control (the rats had to be placed in the exposure system with the same schedules as the exposed animals, but with an inactive antenna). The Ca ²⁺, glutamic oxaloacetic transaminase (AST), creatine kinase (CK) and lactate dehydrogenase (LDH) content in the peripheral serum of the rats were detected by an automatic blood biochemical analyser. The electrocardiogram (ECG) of standard lead II was recorded by a multi-channel physiological recording and analysis system. The cardiac structure of rats was observed by light and electron microscopy.

RESULTS

The results showed that the 5, 10, and 30 mW/cm ² shortwave radiation caused a significant increased in the levels of Ca ²⁺, AST, CK, and LDH in the peripheral serum of rats. The cardiac structure was damaged by radiation and showed a disordered arrangement of myocardial fibres, the cavitation and swelling of myocardial mitochondria. These injuries were most significant 7 d after radiation and were not restored until 28 d after radiation.

CONCLUSION

Shortwave radiation of 5, 10, and 30 mW/cm ² can damage rat cardiac function, including damage to the tissue structure and ultrastructure, especially at the level of the myocardial fibres and mitochondria. Shortwave radiation at 5, 10, and 30 mW/cm ² induced damage to rat heart function and structure with a dose-effect relationship, i.e., the greater the radiation dose was, the more significant the damage was.

Heterogeneous trends in burden of heart disease mortality by subtypes in the United States, 1999-2018: observational analysis of vital statistics

OBJECTIVE

To describe trends in the burden of mortality due to subtypes of heart disease from 1999 to 2018 to inform targeted prevention strategies and reduce disparities.

DESIGN

Serial cross sectional analysis of cause specific heart disease mortality rates using national death certificate data in the overall population as well as stratified by race-sex, age, and geography.

SETTING

United States, 1999-2018.

PARTICIPANTS

12.9 million decedents from total heart disease (49% women, 12% black, and 19% <65 years old).

MAIN OUTCOME MEASURES

Age adjusted mortality rates (AAMR) and years of potential life lost (YPLL) for each heart disease subtype, and respective mean annual percentage change.

RESULTS

Deaths from total heart disease fell from 752 192 to 596 577 between 1999 and 2011, and then increased to 655 381 in 2018. From 1999 to 2018, the proportion of total deaths from heart disease attributed to ischemic heart disease decreased from 73% to 56%, while the proportion attributed to heart failure increased from 8% to 13% and the proportion attributed to hypertensive heart disease increased from 4% to 9%. Among heart disease subtypes, AAMR was consistently highest for ischemic heart disease in all subgroups (race-sex, age, and region). After 2011, AAMR for heart failure and hypertensive heart disease increased at a faster rate than for other subtypes. The fastest increases in heart failure mortality were in black men (mean annual percentage change 4.9%, 95% confidence interval 4.0% to 5.8%), whereas the fastest increases in hypertensive heart disease occurred in white men (6.3%, 4.9% to 9.4%). The burden of years of potential life lost was greatest from ischemic heart disease, but black-white disparities were driven by heart failure and hypertensive heart disease. Deaths from heart disease in 2018 resulted in approximately 3.8 million potential years of life lost.

CONCLUSIONS

Trends in AAMR and years of potential life lost for ischemic heart disease have decelerated since 2011. For almost all other subtypes of heart disease, AAMR and years of potential life lost became stagnant or increased. Heart failure and hypertensive heart disease account for the greatest increases in premature deaths and the largest black-white disparities and have offset declines in ischemic heart disease. Early and targeted primary and secondary prevention and control of risk factors for heart disease, with a focus on groups at high risk, are needed to avoid these suboptimal trends beginning earlier in life.

US trends in premature heart disease mortality over the past 50 years: Where do we go from here?

Despite the premature heart disease mortality rate among adults aged 25-64 decreasing by 70% since 1968, the rate has remained stagnant from 2011 on and, in 2017, still accounted for almost 1-in-5 of all deaths among this age group. Moreover, these overall findings mask important differences and continued disparities observed by demographic characteristics and geography. For example, in 2017, rates were 134% higher among men compared to women and 87% higher among blacks compared to whites, and, while the greatest burden remained in the southeastern US, almost two-thirds of all US counties experienced increasing rates among adults aged 35-64 during 2010-2017. Continued high rates of uncontrolled blood pressure and increasing prevalence of diabetes and obesity pose obstacles for re-establishing a downward trajectory for premature heart disease mortality; however, proven public health and clinical interventions exist that can be used to address these conditions.

Change in quality of life over eight years in a nationally representative sample of US adults with heart disease and type 2 diabetes:minority race and toxic stress as keysocial determinants

BACKGROUND

Toxic stress (TS), minority race and their interaction are evaluated as determinants of change in quality of life (QOL) over 8 years follow-up in a nationally representative sample of United States (US) adults (≥50 years old) with heart disease (HD) and/or type-2 diabetes (T2DM) diagnosed by 2006 as part of the Health and Retirement Study (HRS).

METHODS

Recent and life-course stress plus experiences of lifetime discrimination were measured every 2 years using the stressful life experiences questionnaire. QOL was assessed by participant self-rated health (SRH) and operationally defined as improved, unchanged or declined in current year versus two years prior. Repeated measures multinomial logistic regressionusing generalized estimating equations (GEEs) was implemented to estimate race-, TS and their interaction- related odds of worse SRH from2006-2014. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated with adjustment for time, age, sex and socio-economic status.

RESULTS

Three thousand nine hundred four adults with HD/T2DM, mean age 71.1 ± 9.3 years old, 80.9, 14.7 and 4.4% that respectively self-identified as Caucasian, African-American and Other race, were included. Over the eight-year follow-up, the odds of worse SRH for African-American and Other race were respectively 1.46 (95% CI: 1.25-1.70) and 1.43 (95% CI, 1.10-1.86) times higher relative to Caucasians. Relative to older Americans that reported ≥2 lifetime discrimination events, the odds of poor SRH was respectively 33% (OR = 0.67, 95%CI: 0.50-0.89) and 17% (OR = 0.83, 95%CI: 0.59-1.17) lower for those that reported none vs one lifetime discrimination experience. Furthermore, the relationship of life-course stress to SRH decline over 8 years varied by race (time*stress*race, p = 0.1173). Specifically, increasing life-course stress predicted worse QOL among Caucasians (p = 0.0063) and among African-American (p = 0.0820) but not among Other race (p = 0.9943).

CONCLUSION

Toxic stress and minority race are social determinants of deterioration in QOL among older Americans with chronic diseases (HD/T2DM). The types and prevalence of toxic stressors varied by race/ethnicity. Policy interventions to address root causes of TS while targeted at proximate drivers of TS by race/ethnicity represent a viable strategy for mitigating racial disparities in overall wellbeing and improving QOL in all aging Americans regardless of race.

Pathogenic and Uncertain Genetic Variants Have Clinical Cardiac Correlates in Diverse Biobank Participants

Background

Genome sequencing coupled with electronic heath record data can uncover medically important genetic variation. Interpretation of rare genetic variation and its role in mediating cardiovascular phenotypes is confounded by variants of uncertain significance.

Methods and Results

We analyzed the whole genome sequence of 900 racially and ethnically diverse biobank participants selected from a single US center. Participants were equally divided among European, African, Hispanic, and mixed races/ethnicities. We evaluated the American College of Medical Genetics and Genomics medically actionable list of 59 genes, focusing on the cardiac genes. Variation was interpreted using the most recent reports in ClinVar, a database of medically relevant human variation. We identified 19 individuals with pathogenic or likely pathogenic variants in cardiac actionable genes (2%) and found evidence of related clinical correlates in the electronic health record. Participants of African ancestry, compared with those of European ancestry, had more variants of uncertain significance in the medically actionable genes including the 30 cardiac actionable genes, even when normalized to total variant count per person. Longitudinal measures of left ventricle size from ≈400 biobank participants (1723 patient‐years) were correlated with genetic findings. The presence of ≥1 uncertain variant in the actionable cardiac genes and a cardiomyopathy diagnosis correlated with increased left ventricular internal diameter in diastole and in systole. In particular, MYBPC3 was identified as a gene with excess variants of uncertain significance.

Conclusions

These data indicate that a subset of uncertain genetic variants may confer risk and should not be considered benign.

Racial Disparity in Cardiac Surgery Risk and Outcome: Report From a Statewide Quality Initiative

BACKGROUND

Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland.

METHODS

A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality.

RESULTS

The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P < .001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93).

CONCLUSIONS

African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients.

Impact of diabetes on outcomes of cardiac surgery in a multiethnic Southeast Asian population

Although diabetes is rapidly increasing in Asia and has been shown to be associated with worse cardiac surgery outcomes, no research has been done to study the impact of diabetes on cardiac surgery outcomes in a Southeast Asian cohort. Hence, this study aims to delineate the predictors and impact of diabetes after cardiac surgery in a multi-ethnic Southeast Asian cohort. We analysed data from 2831 adult patients undergoing elective cardiac surgery, from 2008 to 2010 in Singapore. Diabetes was found to significantly increase the odds of intensive care unit readmission by 1.70 (95% confidence interval 1.171-2.480, p = 0.005), postoperative infection by 1.73 (95% confidence interval 1.003-2.976, p = 0.049), acute kidney injury by 1.36 (95% confidence interval 1.137-1.626, p = 0.001), postoperative hyperglycaemia by 6.00 (95% confidence interval 4.893-7.348, p < 0.001), and new need for dialysis by 1.71 (95% 1.086-5.360, p = 0.021). In conclusion, diabetes is associated with increased risk for renal dysfunction, hyperglycaemia, and infection after cardiac surgery, similar to the relative risks of diabetes patients observed in Western populations.

Trends in Cancer and Heart Disease Death Rates Among Adults Aged 45-64: United States, 1999-2017

Objectives-This report presents death rates for cancer and heart disease among adults aged 45-64 in the United States for 1999-2017. Rates for 1999-2017 are presented by sex and race and ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). Methods-Mortality statistics in this report are based on information from death certificates filed in all 50 states and the District of Columbia. Cancer deaths are classified by the International Classification of Diseases, 10th Revision (ICD-10) underlying cause-of-death codes C00-C97; heart disease deaths are classified with ICD-10 underlying cause-of-death codes I00-I09, I11, I13, and I20-I51. Death rates are calculated per 100,000 population. Trends were evaluated using the National Cancer Institute's Joinpoint Regression Program. Results-Cancer death rates for middle-aged adults aged 45-64 declined by 19% from 1999 to 2017 (224.9 deaths per 100,000 to 182.6), whereas heart disease death rates declined by 22% from 1999 (164.3) to 2011 (127.9) and then increased 4% from 2011 to 2017 (133.6). The same trend patterns were observed for both men and women. The cancer death rate was always higher than the heart disease death rate from 1999 to 2017, and was 37% higher in 2017. For non-Hispanic white and non-Hispanic black men and women, cancer death rates declined over the 1999-2017 period, whereas heart disease death rates declined and then increased since 2009 for non-Hispanic white men and women, and since 2011 for non-Hispanic black men and women. Hispanic men and women experienced different trends than their non-Hispanic white and black counterparts-both cancer and heart disease death rates for this group had periods of decline and stability.

Prospective associations between cardiac stress, glucose dysregulation and executive cognitive function in Black men: The Sympathetic activity and Ambulatory Blood Pressure in Africans study

OBJECTIVE

Glucose dysregulation is an independent risk factor for cardiovascular and neurodegenerative disease development through synaptic dysfunction resulting in cognitive decline. The aim of this study was to study the interplay between impaired glycaemic metabolism (hyperglycaemia and insulin resistance), cardiac stress (cardiac troponin T and N-terminal brain natriuretic peptide) and executive cognitive function prospectively, in a bi-ethnic sex cohort.

METHODS

Black and White teachers (N = 338, aged 20-63 years) from the Sympathetic activity and Ambulatory Blood Pressure in Africans study were monitored over a 3-year period. Fasting blood samples were obtained for cardiac troponin T, N-terminal brain natriuretic peptide, glycated haemoglobin and the homeostatic model assessment-insulin resistance for insulin resistance. The Stroop colour-word conflict test was applied to assess executive cognitive function at baseline.

RESULTS

Over the 3-year period, Black men revealed constant high levels of cardiac troponin T (⩾4.2 ng/L), pre-diabetes (glycated haemoglobin > 5.7%) and insulin resistance (homeostatic model assessment-insulin resistance >3). %Δ Glycated haemoglobin was associated with %Δ insulin resistance (p < 0.001) and increases in %ΔN-terminal brain natriuretic peptide (p = 0.02) in Black men only. In the latter, baseline Stroop colour-word conflict test was inversely associated with %Δ cardiac troponin T (p = 0.001) and %Δ insulin resistance levels (p = 0.01).

CONCLUSION

Progressive myocyte stretch and chronic myocyte injury, coupled with glucose dysregulation, may interfere with processes related to interference control in Black men.

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.

Low health literacy: Implications for managing cardiac patients in practice

There are limited data on racial and ethnic disparities related to quality of life (QoL) and health literacy in adults with multiple cardiac conditions. This article evaluates the relationship between health literacy and QoL among patients with cardiac conditions in a multiethnic community in New York City.

Particulate Matter Air Pollution Exposure and Heart Disease Mortality Risks by Race and Ethnicity in the United States: 1997 to 2009 National Health Interview Survey With Mortality Follow-Up Through 2011

BACKGROUND

Most US studies of mortality and air pollution have been conducted on largely non-Hispanic white study populations. However, many health and mortality outcomes differ by race and ethnicity, and non-Hispanic white persons experience lower air pollution exposure than those who are non-Hispanic black or Hispanic. This study examines whether associations between air pollution and heart disease mortality differ by race/ethnicity.

METHODS

We used data from the 1997 to 2009 National Health Interview Survey linked to mortality records through December 2011 and annual estimates of fine particulate matter (PM2.5) by census tract. Proportional hazards models were used to estimate hazard ratios and 95% confidence intervals between PM2.5 (per 10 µg/m3) and heart disease mortality using the full sample and the sample adults, which have information on additional health variables. Interaction terms were used to examine differences in the PM2.5-mortality association by race/ethnicity.

RESULTS

Overall, 65 936 of the full sample died during follow-up, and 22 152 died from heart disease. After adjustment for several factors, we found a significant positive association between PM2.5 and heart disease mortality (hazard ratio, 1.16; 95% confidence interval, 1.08-1.25). This association was similar in sample adults with adjustment for smoking and body mass index (hazard ratio, 1.18; 95% confidence interval, 1.06-1.31). Interaction terms for non-Hispanic black and Hispanic groups compared with the non-Hispanic white group were not statistically significant.

CONCLUSIONS

Using a nationally representative sample, the association between PM2.5 and heart disease mortality was elevated and similar to previous estimates. Associations for non-Hispanic black and Hispanic adults were not statistically significantly different from those for non-Hispanic white adults.

Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia

BACKGROUND

Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10-30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations.

METHODS

CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance.

RESULTS

Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators.

CONCLUSION

Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed.

Heart disease risk information, encouragement, and physical activity among Mexican-origin couples: Self- or spouse-driven change?

Family health history is an accessible, clinically-recommended genomic tool that improves health risk evaluation. It captures both genetic and modifiable risk factors that cluster within families. Thus, families represent a salient context for family health history-based interventions that motivate engagement in risk-reducing behaviors. While previous research has explored how individuals respond to their personal risk information, we extend this inquiry to consider how individuals respond to their spouse's risk information among a sample of Mexican-Americans. One hundred and sixty spouse-dyads within Mexican-heritage households received a pedigree or a pedigree and personalized risk assessments, with or without behavioral recommendations. Analyses of Covariance (ANCOVAs) were conducted to assess the relationship between risk feedback, both personal and spouse, and self-reported physical activity levels at 3-month and 10-month assessments, controlling for baseline levels. The effect of being identified as an encourager of spouse's healthy weight was also evaluated. Personal feedback had no effect on participants' physical activity at either 3- or 10-month assessments. However, husbands' risk information was associated with wives' physical activity levels at 3-month assessment, with women whose husbands received both increased risk feedback and behavioral recommendations engaging in significantly higher physical activity levels than all other women. At 10-month follow-up, physical activity levels for both husbands and wives differed depending on whether they encouraged their spouse's healthy weight. Spousal risk information may be a stronger source of motivation to improve physical activity patterns than personal risk information, particularly for women. Interventions that activate interpersonal encouragement among spouses may more successfully extend intervention effects.

Heart Disease in Syrian Refugee Children: Experience at Jordan University Hospital

BACKGROUND

Since March 2011, an estimated 600,000 Syrian refugees crossed into Jordan, of which 52% were children. Demand for health care is overwhelming. The burden of heart disease in Syrian refugee children is not known. The aim of this study WAS to describe heart disease in Syrian refugee children in terms of diagnoses, presentation, outcome, and funding sources for treatment.

METHODS

From April 1, 2012 to April 30, 2014, data on Syrian refugee children who were referred to the Pediatric Cardiology Department at Jordan University Hospital and were found to have heart disease was recorded. In this study, we describe diagnoses, presentations, complications, and mortality. We discuss therapeutic procedures and their funding sources. Patients were followed until July 31, 2014.

FINDINGS

In all, 119 children, median age 2 years (6 days to 16 years), were diagnosed with heart disease. At presentation, 37% had failure to thrive, 13% had severe complications, and 32% of cyanotic patients had severe hypoxia with oxygen saturation of <70%. Mortality rate was 14% by end of follow up. Of 73 surgical procedures recommended, only 28 were funded and performed; others have been waiting for a median of 223 days (35-534 days). Funding for procedures came from multiple sources; including the United Nations, governmental and nongovernmental organizations, and individual donations.

CONCLUSION

Heart disease in Syrian refugee children constitutes a major problem for both patients and health systems of host countries. Late presentation and diagnosis, high rate of complications, suboptimal living conditions, lack of funding, shortage of specialized centers and personnel, and high mortality rates are among the major challenges facing this patient population.

Cohort Profile: The Mexican American Mano a Mano Cohort

Hispanic Americans comprise the largest and fastest-growing ethnic minority in the USA. In Houston, Texas, 44% of the population is of Hispanic descent, with the majority being Mexican Americans (78%). This population is under-represented in health-related research despite their high prevalence of obesity and diabetes, which may predispose them to cancer and other chronic conditions. Recognizing the need for a greater research effort into the health risks of Hispanic Americans, the population-based Mexican American (Mano a Mano) Cohort study was launched in 2001. This is an open cohort with enrolment ongoing to 2019, and as of 30 June 2014, 23 606 adult participants from over 16 600 households were enrolled. Bilingual interviewers elicit information in person on demographics, acculturation, lifestyle, occupation, medical history, family cancer history, self-reported and measured height and weight, and other exposures. Urine, blood and saliva samples have been collected at baseline from 43%, 56% and 63% of participants, respectively. DNA samples are available for about 90% of participants. Incident cancers and other chronic diseases are ascertained through annual telephone re-contact and linkage to the Texas Cancer Registry and/or medical records. Molecular data such as genetic ancestry markers, blood telomere length and HbA1c, a marker of impaired glucose tolerance, are available for a substantial proportion of the participants. Data access is provided on request [manoamano@mdanderson.org]. For further information please visit [www.mano-mano.us].

Indicators of abdominal size relative to height associated with sex, age, socioeconomic position and ancestry among US adults

BACKGROUND/OBJECTIVES

The supine sagittal abdominal diameter (SAD) and standing waist circumference (WC) describe abdominal size. The SAD/height ratio (SADHtR) or WC/height ratio (WHtR) may better identify cardiometabolic disorders than BMI (weight/height2), but population-based distributions of SADHtR and WHtR are not widely available. Abdominal adiposity may differ by sociodemographic characteristics.

SUBJECTS/METHODS

Anthropometry, including SAD by sliding-beam caliper, was performed on 9894 non-pregnant adults ≥20 years in the US National Health and Nutrition Examination Surveys of 2011-2014. Applying survey design factors and sampling weights, we estimated nationally representative SADHtR and WHtR distributions by sex, age, educational attainment, and four ancestral groups.

RESULTS

The median (10th percentile, 90th percentile) for men's SADHtR was 0.130 (0.103, 0.165) and WHtR 0.569 (0.467, 0.690). For women, median SADHtR was 0.132 (0.102, 0.175) and WHtR 0.586 (0.473, 0.738). Medians for SADHtR and WHtR increased steadily through age 79. The median BMI, however, reached maximum values at ages 40-49 (men) or 60-69 (women) and then declined. Low educational attainment, adjusted for age and ancestry, was associated with elevated SADHtR more strongly than elevated BMI. While non-Hispanic Asians had substantially lower BMI compared to all other ancestral groups (adjusted for sex, age and education), their relative reductions in SADHtR and WHtR, were less marked.

CONCLUSIONS

These cross-sectional data are consistent with monotonically increasing abdominal adipose tissue through the years of adulthood but decreasing mass in non-abdominal regions beyond middle age. They suggest also that visceral adipose tissue, estimated by SADHtR, expands differentially in association with low socioeconomic position. Insofar as Asians have lower BMIs than other populations, employing abdominal indicators may attenuate the adiposity differences reported between ancestral groups. Documenting the distribution and sociodemographic features of SADHtR and WHtR supports the clinical and epidemiologic adoption of these adiposity indicators.

Changes in heavy drinking following onset of health problems in a U.S. general population sample

Heavy episodic drinking is a well-established risk factor for heart disease, diabetes, certain cancers, stroke, hypertension and injuries, however, little is known about whether health problems precipitate changes in subsequent drinking patterns. Retrospective cohort analyses of heavy drinking by decade were conducted using data from the 2010 U.S. National Alcohol Survey (n=5240). Generalized estimating equations models were used to predict any, monthly, and weekly heavy (5+) drinking occasions across decades of life following a diagnosis of hypertension, heart problems, diabetes, stroke, cancer, or serious injury. Experiencing heart problems was associated with higher odds of reduced weekly heavy drinking (adjusted odds ratio (ORadj)=3.5; 95% confidence interval (CI); 1.7-7.4). The onset of diabetes was also associated with higher odds of reducing any heavy drinking over the decade (ORadj=1.7; 95% CI; 1.1-2.6). Cancer survivors were less likely to report no heavy drinking (ORadj=0.5; 95% CI; 0.3-0.8) or no weekly heavy drinking (ORadj=0.3; 95% CI; 0.2-0.7). Hypertension, stroke and injury were not found to have any significant associations. Reduced heavy drinking was more likely to be reported by Black drinkers following heart problems and Whites following a diabetes diagnosis. Increased heavy drinking following a cancer diagnosis was significant among women and Whites. Future studies on alcohol's heath and mortality risks should take into consideration effects of health problems on drinking patterns. Additionally, study results support increased prevention efforts targeting heavy drinking among cancer survivors, especially White women, and individuals with or being treated for hypertension.

Left Atrial Structure in Relationship to Age, Sex, Ethnicity, and Cardiovascular Risk Factors: MESA (Multi-Ethnic Study of Atherosclerosis)

BACKGROUND

Left atrial (LA) size is a marker of diastolic function and is associated with atrial fibrillation and cardiovascular outcomes. However, there are no large population studies measuring LA structure. The relationship of demographics and cardiovascular risk factors to LA size is largely unknown. This study aimed to determine associations of LA size with demographic factors, cardiac structure and function, and cardiovascular risk factors.

METHODS AND RESULTS

LA volume indexed to body surface area was measured by cardiovascular magnetic resonance steady-state free precession and fast gradient echo cine long- and short-axis images in 2576 asymptomatic participants of MESA ([Multi-Ethnic Study of Atherosclerosis] 68.7 years, 53.0% women, white 42.2%, Chinese American 12.0%, black 24.5%, and Hispanic 21.2%) using biplane and short-axis images. The mean LA volume index was 36.5±11.4 mL/m2 in the entire cohort and 35.5±10.1 mL/m2 in subjects free of cardiovascular risk factors (n=283). Multivariable analysis included adjustment for demographics, ethnicity, cardiovascular risk factors, serological studies, socioeconomic status, left ventricular structure, and medications. In the adjusted analysis, age (β=0.2 mL/m2 per year, P<0.0001), male sex (β=-4.2 mL/m2, P<0.0001), obesity (β=1.3 mL/m2, P<0.01), end-diastolic volume index (β=0.4 mL/m2, P<0.0001), Chinese American (β=-2.6 mL/m2, P<0.0001), and Hispanic (β=1.1 mL/m2, P<0.05) ethnicities were associated with LA volume index. Diabetes mellitus and smoking were not associated with LA volume index. LA volumes measured by steady-state free precession were 3% larger than by fast gradient echo cine cardiovascular magnetic resonance (P<0.001).

CONCLUSIONS

Age, sex, ethnicity and left ventricular structural parameters were associated with LA size. Importantly, the study provides reference values of normal LA volume index.

Changes in the Leading Cause of Death: Recent Patterns in Heart Disease and Cancer Mortality

Data from the National Vital Statistics System •Heart disease has consistently been the leading cause of death in the United States and remained so in 2014. •The gap between the number of heart disease and cancer deaths generally widened from 1950 through 1968, narrowed from 1968 through 2012, and then slightly widened again from 2012 through 2014. •The mortality burden of cancer has surpassed that of heart disease in several states. In 2000, there were only 2 states where cancer was the leading cause of death; in 2014, there were 22. •Heart disease remained the leading cause of death for the non-Hispanic white and non-Hispanic black populations in 2014. •Cancer is now the leading cause of death for the non-Hispanic Asian or Pacific Islander and Hispanic populations. The timing of the leading-cause crossover varied by group. For the total U.S. population, heart disease has been the leading cause of death for decades, with cancer the second leading cause (1). However, the ranking of these causes has varied across demographic group and geographic unit over time. Rankings are based on the number of deaths and reflect mortality burden rather than risk of death (2). This report highlights changes in the mortality burden of heart disease and cancer and presents findings by state, race, and Hispanic origin.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Perceptions and Motivations to Prevent Heart Disease among Puerto Ricans

OBJECTIVES

We performed a qualitative assessment of Puerto Ricans' knowledge and perceptions of cardiovascular disease (CVD), and motivations/barriers and preferences to participate in community/ clinical programs for CVD-prevention.

METHODS

Four guided focus group discussions were conducted on a total of 24 Puerto Ricans, aged 40-60 years in Boston, MA.

RESULTS

Participants were aware of CVD, but less knowledgeable about its prevention. They perceived it as serious, and either had CVD or knew someone who had it. They favored education and activities on nutrition, exercise, clinical advice, and social interaction, in weekly/ biweekly small-group sessions with other Latinos, led in Spanish by a familiar health professional, in a convenient community location. Age- and culture-specific program content and educational materials were preferred. A theme emerged on 'personal or family motivations' such as to become healthier and live longer so they would feel better and support their families, or to learn about CVD-prevention. Main barriers included family obligations, weather, safety concerns, transportation, and depressive mood.

CONCLUSIONS

Culturally-tailored CVD-prevention programs for Puerto Ricans should include multiple behavioral and social approaches, and draw on intrinsic motivators while reducing barriers to help enhance efficacy and sustainability.

Leading Causes of Death Contributing to Decrease in Life Expectancy Gap Between Black and White Populations: United States, 1999-2013

Life expectancy at birth has increased steadily since 1900 to a record 78.8 years in 2013. But differences in life expectancy between the white and black populations still exist, despite a decrease in the life expectancy gap from 5.9 years in 1999 to 3.6 years in 2013. Differences in the change over time in the leading causes of death for the black and white populations have contributed to this decrease in the gap in life expectancy. Between 1999 and 2013, the decrease in the life expectancy gap between the black and white populations was mostly due to greater decreases in mortality from heart disease, cancer, HIV disease, unintentional injuries, and perinatal conditions among the black population. Similarly, the decrease in the gap between black and white male life expectancy was due to greater decreases in death rates for HIV disease, cancer, unintentional injuries, heart disease, and perinatal conditions in black males. For black females, greater decreases in diabetes death rates, combined with decreased rates for heart disease and HIV disease, were the major causes contributing to the decrease in the life expectancy gap with white females. The decrease in the gap in life expectancy between the white and black populations would have been larger than 3.6 years if not for increases in death rates for the black population for aortic aneurysm, Alzheimer’s disease, and maternal conditions. For black males, the causes that showed increases in death rates over white males were hypertension, aortic aneurysm, diabetes, Alzheimer’s disease, and kidney disease, while the causes that showed increases in death rates for black females were Alzheimer’s disease, maternal conditions, and atherosclerosis. This NCHS Data Brief is the second in a series of data briefs that explore the causes of death contributing to differences in life expectancy between detailed ethnic and racial populations in the United States. The first data brief focused on the racial differences in life expectancy for a single year, 2010 (3).

Medication adherence and healthcare disparities: impact of statin co-payment reduction

OBJECTIVES

Minority patients have lower rates of cardiovascular medication adherence, which may be amenable to co-payment reductions. Our objective was to evaluate the effect of race on adherence changes following a statin co-payment reduction intervention.

STUDY DESIGN

Retrospective analysis.

METHODS

The intervention was implemented by a large self-insured employer. Eligible individuals in the intervention cohort (n = 1961) were compared with a control group of employees of other companies without such a policy (n = 37,320). As a proxy for race, we categorized patients into tertiles based on the proportion of black residents living in their zip code of residence. Analyses were performed using difference-in-differences design with generalized estimating equations.

RESULTS

Prior to the new co-payment policy, adherence rates were higher for individuals living in areas with fewer black residents. In multivariable models adjusting for demographic factors, clinical covariates and baseline trends, the co-payment reduction increased adherence by 2.0% (P = .14), 2.1% (P = .15) and 6% (P < .0001) for intervention patients living in areas with the bottom, middle and top tertiles of the proportion of black residents. These results persisted after adjusting for income.

CONCLUSIONS

Co-payment reduction for statins preferentially improved adherence among patients living in communities with a higher proportion of black residents. Further research is needed on the impact of value-based insurance design programs on reducing racial disparities in cardiovascular care.

Invited Commentary: A-P-C... It's Easy as 1-2-3!

Investigations of age, period, and cohort effects are difficult because the 3 factors are linearly dependent. In a novel application, Kramer et al. (Am J Epidemiol. 2015;182(4):302-312) have used graphical analysis and statistical models to estimate the impact that age, period, and cohort effects have had on trends in black-white inequalities in heart disease mortality. Using a constrained regression approach (with the first 2 periods' effects constrained to zero), Kramer et al. find evidence that age and cohort effects figure more prominently than do period effects in contributing to relative black-white mortality differences, and they argue that early-life exposures should be given greater consideration for mitigation of racial differences in heart disease. In this invited commentary, I argue that the utility of age-period-cohort models for understanding health inequalities depends on the plausibility of the assumptions used to break the link between the 3 factors. Based on the existing age-period-cohort literature, alternative assumptions seem likely to produce substantially different results. I also argue that interpretations of the impacts of age, period, and cohort effects on racial inequalities in heart disease mortality may depend on whether inequalities are assessed on the absolute scale or the relative scale.

Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

Left atrial structure and functional quantitation using cardiovascular magnetic resonance and multimodality tissue tracking: validation and reproducibility assessment

BACKGROUND

Left atrium (LA) strain, volume and function are important markers of cardiovascular disease and myocardial impairment. We aimed to assess the accuracy of LA biplane volume and function measured by Multimodality Tissue Tracking (MTT). Also we assessed the inter-study reproducibility for cardiovascular magnetic resonance (CMR) derived LA volume and function parameters.

METHODS

Thirty subjects (mean age: 71.3 ± 8.7, 87% male) including twenty subjects with cardiovascular events and ten healthy subjects, with CMR were evaluated in the Multi-Ethnic Study of Atherosclerosis (MESA). LA volumes were computed by the modified biplane method from 2- and 4-chamber projections and the Simpson's method from short-axis slices using both methods - manual and semi-automated delineation using MTT. LA total, active and passive ejection fractions were calculated. Pearson's correlation and Bland-Altman analysis were used to compare the measurements. In a second sample of 25 subjects (age: 65.7 ± 7.1, 72% males) inter study, intra and inter reader reliability analysis was performed. The intra-class correlation coefficient (ICC) was evaluated.

RESULTS

Left atrial MTT structural and functional parameters were not different from manual delineation, yet image analysis was only half as time consuming on average with MTT. Maximal volume MTT was not different between the Simpson's and Biplane methods, functional parameters, however were different. MTT allowed us to measure multiple LA parameters with good-excellent (ICC; 0.88- 0.98, p < 0.001) intra-and inter reader reproducibility and fair-good (ICC; 0.44-0.82, p < 0.05-0.001) inter study reproducibility.

CONCLUSIONS

MTT derived LA biplane volume and function is accurate and reproducible and is suited for use in longitudinal studies.

Hypertension-related Mortality in the United States, 2000-2013

Hypertension is a chronic condition that can lead to heart disease, stroke, and other diseases that can result in premature death. Reducing the number of persons in the population with hypertension is one of the objectives of Healthy People 2020. Using national multiple cause-of-death data files from the National Vital Statistics System, this report presents trends in hypertension-related mortality for 2000–2013 by selected demographic characteristics and the underlying causes of hypertension-related death. Hypertension-related mortality is defined by any mention of hypertension on the death certificate. Because about 2% of all decedents with hypertension reported on the death certificate were under age 45, only decedents aged 45 and over were included in this analysis.

The association between cardiovascular risk and cardiovascular magnetic resonance measures of fibrosis: the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Risk scores for cardiovascular disease (CVD) are in common use to integrate multiple cardiovascular risk factors in order to identify individuals at greatest risk for disease. The purpose of this study was to determine if individuals at greater cardiovascular risk have T1 mapping indices by cardiovascular magnetic resonance (CMR) indicative of greater myocardial fibrosis.

METHODS

CVD risk scores for 1208 subjects (men, 50.8%) ages 55-94 years old were evaluated in the Multiethnic Study of Atherosclerosis (MESA) at six centers. T1 times were determined at 1.5Tesla before and after gadolinium administration (0.15 mmol/kg) using a modified Look-Locker pulse sequence. The relationship between CMR measures (native T1, 12 and 25 minute post-gadolinium T1, partition coefficient and extracellular volume fraction) and 14 established different cardiovascular risk scores were determined using regression analysis. Bootstrapping analysis with analysis of variance was used to compare different CMR measures. CVD risk scores were significantly different for men and women (p < 0.001).

RESULTS

25 minute post gadolinium T1 time showed more statistically significant associations with risk scores (10/14 scores, 71%) compared to other CMR indices (e.g. native T1 (7/14 scores, 50%) and partition coefficient (7/14, 50%) in men. Risk scores, particularly the new 2013 AHA/ASCVD risk score, did not correlate with any CMR fibrosis index.

CONCLUSIONS

Men with greater CVD risk had greater CMR indices of myocardial fibrosis. T1 times at greater delay time (25 minutes) showed better agreement with commonly used risk score indices compared to ECV and native T1 time.

CLINICAL TRIAL REGISTRATION

http://www.mesa-nhlbi.org/, NCT00005487.

Rationale and Design of the Echocardiographic Study of Hispanics/Latinos (ECHO-SOL)

BACKGROUND

Information regarding the prevalence and determinants of cardiac structure and function (systolic and diastolic) among the various Hispanic background groups in the United States is limited.

METHODS AND RESULTS

The Echocardiographic Study of Latinos (ECHO-SOL) ancillary study recruited 1,824 participants through a stratified-sampling process representative of the population-based Hispanic Communities Health Study - Study of Latinos (HCHS-SOL) across four sites (Bronx, NY; Chicago, Ill; San Diego, Calif; Miami, Fla). The HCHS-SOL baseline cohort did not include an echo exam. ECHO-SOL added the echocardiographic assessment of cardiac structure and function to an array of existing HCHS-SOL baseline clinical, psychosocial, and socioeconomic data and provides sufficient statistical power for comparisons among the Hispanic subgroups. Standard two-dimensional (2D) echocardiography protocol, including M-mode, spectral, color and tissue Doppler study was performed. The main objectives were to: 1) characterize cardiac structure and function and its determinants among Hispanics and Hispanic subgroups; and 2) determine the contributions of specific psychosocial factors (acculturation and familismo) to cardiac structure and function among Hispanics.

CONCLUSION

We describe the design, methods and rationale of currently the largest and most comprehensive study of cardiac structure and function exclusively among US Hispanics. ECHO-SOL aims to enhance our understanding of Hispanic cardiovascular health as well as help untangle the relative importance of Hispanic subgroup heterogeneity and sociocultural factors on cardiac structure and function.

Australian women and heart disease: Trends, epidemiological perspectives and the need for a culturally competent research agenda

Heart disease commonly manifests as acute coronary syndromes (unstable angina pectoris, or myocardial infarction) and heart failure (HF). These conditions are major causes of morbidity and mortality in Australia and internationally. Australian faces particular challenges in health care delivery given the cultural and ethnic diversity of society and unique issues related to rurality. These factors have significant implications for health care delivery. Following an acute cardiac event women have poorer outcomes: higher mortality rates, higher incidence of complications and greater psychological morbidity compared with men. Language barriers, socioeconomic factors, psychological trauma related to migration and alternate health seeking behaviors and varying perceptions of risk are likely to impact adversely on health outcomes. Self-management in chronic cardiovascular disease underscores the importance of models of care that incorporate aspects related to self-care and promotion of adherence to primary and secondary prevention initiatives. Implicit in this statement is the inclusion of the individual in negotiating and developing their care plan. Therefore health professionals need to be aware of the patient's needs, values, beliefs and health seeking behaviours. These factors are strongly influenced by culture and ethnicity. The cultural diversity of Australian society mandates cultural competence in health care. This paper presents an overview of nursing science related to women and heart disease in Australia and suggests directions for culturally-competent research and development and evaluation of models of care to improve health outcomes for all Australians.

Race and ancestry in the age of inclusion: technique and meaning in post-genomic science

This article examines how race and ancestry are taken up in gene-environment interaction (GEI) research on complex diseases such as heart disease, diabetes, and cancer. Using 54 in-depth interviews of 33 scientists and over 200 hours of observation at scientific conferences, we explore how GEI researchers use and interpret race, ethnicity, and ancestry in their work. We find that the use of self-identified race and ethnicity (SIRE) exists alongside ancestry informative markers (AIMs) to ascertain genetic ancestry. Our participants assess the utility of these two techniques in relative terms, downplaying the accuracy and value of SIRE compared to the precision and necessity of AIMs. In doing so, we argue that post-genomic scientists seeking to understand the interactions of genetic and environmental disease determinants actually undermine their ability to do so by valorizing precise characterizations of individuals' genetic ancestry over measurement of the social processes and relations that differentiate social groups.

Kidney disease and cognitive function: African American-diabetes heart study MIND

AIMS

Albuminuria and reduced estimated glomerular filtration rate (eGFR) are linked with poorer cognitive performance in European-ancestry populations with advanced nephropathy; relationships in African Americans (AAs) with type 2 diabetes (T2D) are less clear. Tests of cognitive performance, urine albumin:creatinine ratio (UACR), and CKD-EPI eGFR were performed in unrelated AAs with T2D to determine relationships.

METHODS

Cross-sectional analysis of 263 unrelated AAs with T2D recruited in the African American-Diabetes Heart Study (AA-DHS) MIND. Global cognitive function (mini-mental state exam [3MSE] and Montreal Cognitive Assessment [MoCA]), memory (Rey Auditory Verbal Learning Test [RAVLT]), executive function (Stroop, verbal fluency for animals, and Digit Symbol Copy [DSC]), UACR, and eGFR were determined. Relationships between cognitive tests and renal parameters were assessed using multivariate models, adjusted for age, gender, body mass index, hemoglobin A1c, level of education, hypertension, and LDL cholesterol.

RESULTS

Participants had a mean ± SD age of 60.2 ± 9.7 years, 62.7% were female, T2D duration was 14.3 ± 8.9 years, eGFR 86.0 ± 23.2 ml/min/1.73 m(2), and UACR 155.8 ± 542.1 (median 8.1) mg/g. In adjusted models, higher UACR was associated with worse 3MSE (p = 0.014), MoCA (p = 0.0089), DSC (p = 0.0004), Stroop performance time (p = 0.003), Stroop errors (p = 0.032), and Stroop interference (p = 0.026). Higher eGFR was associated with better performance on DSC (p = 0.0071).

CONCLUSIONS

In AAs with T2D, albuminuria and eGFR were associated with cognitive function, even in mild kidney disease. These data stress the need for interventions to prevent cognitive decline well before the late stages of kidney disease.

Trends and disparities in heart disease mortality among American Indians/Alaska Natives, 1990-2009

OBJECTIVES

We evaluated heart disease death rates among American Indians and Alaska Natives (AI/ANs) and Whites after improving identification of AI/AN populations.

METHODS

Indian Health Service (IHS) registration data were linked to the National Death Index for 1990 to 2009 to identify deaths among AI/AN persons aged 35 years and older with heart disease listed as the underlying cause of death (UCOD) or 1 of multiple causes of death (MCOD). We restricted analyses to IHS Contract Health Service Delivery Areas and to non-Hispanic populations.

RESULTS

Heart disease death rates were higher among AI/AN persons than Whites from 1999 to 2009 (1.21 times for UCOD, 1.30 times for MCOD). Disparities were highest in younger age groups and in the Northern Plains, but lowest in the East and Southwest. In AI/AN persons, MCOD rates were 84% higher than UCOD rates. From 1990 to 2009, UCOD rates declined among Whites, but only declined significantly among AI/AN persons after 2003.

CONCLUSIONS

Analysis with improved race identification indicated that AI/AN populations experienced higher heart disease death rates than Whites. Better prevention and more effective care of heart disease is needed for AI/AN populations.

The impact of personalized risk feedback on Mexican Americans' perceived risk for heart disease and diabetes

Little is known about the effect of personalized risk information on risk perceptions over time, particularly among ethnically diverse subpopulations. The present study examines Mexican American's (MAs) risk perceptions for heart disease and diabetes at baseline and following receipt of risk feedback based on family health history. Participants comprising 162 households received a pedigree or personalized risk feedback, with or without behavioral risk reduction recommendations. Multiple logistic regression analyses were used to assess lifetime perceived risk (LPR) at baseline, 3 months and 10 months following the receipt of risk feedback. Having an elevated familial risk of heart disease or diabetes increased the odds of an elevated LPR for both diseases at baseline. At 3 months, compared with receipt of a pedigree only, MAs receiving elevated risk feedback for both diseases were more likely to have an elevated LPR for both diseases. At 10 months, participants receiving weak risk feedback for both diseases indicated an adjustment to a lower LPR for heart disease only. Results suggest that communicating risk for multiple diseases may be more effective than a single disease, with responses to increased risk feedback more immediate than to weak risk feedback.

The biracial Asian population in California: an examination of health profiles and chronic conditions

OBJECTIVES

To examine health outcomes and chronic conditions for the biracial Asian population in California. We hypothesized that the biracial population will display intermediate (or an average of) outcomes in comparison to their monoracial counterparts.

DESIGN

The study was cross-sectional. After adjusting for sociodemographic variables, multivariable regression models predicted health outcomes (ie, diabetes, heart disease, high blood pressure, disability status, BMI, and general health) and compared health outcomes among various (mono- and bi-) racial and ethnic groups.

PARTICIPANTS

Data were collected from 238,897 adult (aged ≥ 18 years) respondents after merging iterations of the California Health Interview Survey (CHIS) administered in 2001, 2003, 2005, 2007, and 2009.

RESULTS

Multivariate results revealed that Whites reported better health overall than biracial Asians and other monoracial groups. Biracial Asians displayed BMI ranges that were intermediate between their monoracial constituents.

CONCLUSIONS

BMI is a more proximal health outcome and is more sensitive to lifestyles and behaviors. As a result, BMI may be a better indicator than chronic diseases in showing that biracial Asians have adopted health behaviors and practices that fall between their mono-racial counterparts. Future epidemiological research should examine the prevalence of more proximal health outcomes among biracial Asians and assess how it differs by developmental age.

Risk and preventive factors for type 2 diabetes and heart disease among foreign-born older Vietnamese Americans

The 2009 California Health Interview Survey (CHIS) data was used to examine associations of bodyweight, lifestyles, and demographic variables with type 2 diabetes (T2DM) and heart disease among foreign-born older Vietnamese adults. CHIS consisted of 709 Vietnamese Americans aged 50 to 85. Thirteen percent reported T2DM and 11% had heart disease. Using logistic regression, body mass index ≥ 24, age ≥ 65, and female were significantly associated with T2DM. There was significant interaction effect of alcohol consumption and psychological distress with T2DM. The interaction of vegetable consumption, poverty, and length of living in the U.S. was significantly associated with heart disease.