Ambar Kulshreshtha

Life’s Simple 7 and Risk of Incident Stroke The Reasons for Geographic and Racial Differences in Stroke Study

Background and Purpose— The American Heart Association developed Life’s Simple 7 (LS7) as a metric defining cardiovascular health. We investigated the association between LS7 and incident stroke in black and white Americans. Methods— The Reasons for Geographic And Racial Differences in Stroke (REGARDS) is a national population-based cohort of 30 239 blacks and whites, aged ≥45 years, sampled from the US population from 2003 to 2007. Data were collected by telephone, self-administered questionnaires, and an in-home examination. Incident strokes were identified through biannual participant contact followed by adjudication of medical records. Levels of the LS7 components (blood pressure, cholesterol, glucose, body mass index, smoking, physical activity, and diet) were each coded as poor (0 point), intermediate (1 point), or ideal (2 points) health. An overall LS7 score was categorized as inadequate (0–4), average (5–9), or optimum (10–14) cardiovascular health. Results— Among 22 914 subjects with LS7 data and no previous cardiovascular disease, there were 432 incident strokes over 4.9 years of follow-up. After adjusting for demographics, socioeconomic status, and region of residence, each better health category of the LS7 score was associated with a 25% lower risk of stroke (hazard ratios, 0.75; 95% confidence interval, 0.63–0.90). The association was similar for blacks and whites (interaction P value=0.55). A 1-point higher LS7 score was associated with an 8% lower risk of stroke (hazard ratios, 0.92; 95% confidence interval, 0.88–0.95). Conclusions— In both blacks and whites, better cardiovascular health, on the basis of the LS7 score, is associated with lower risk of stroke, and a small difference in scores was an important stroke determinant.

Life’s Simple 7 and Risk of Incident Stroke: REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background and Purpose— The American Heart Association developed Life’s Simple 7 (LS7) as a metric defining cardiovascular health. We investigated the association between LS7 and incident stroke in black and white Americans. Methods— The Reasons for Geographic And Racial Differences in Stroke (REGARDS) is a national population-based cohort of 30 239 blacks and whites, aged ≥45 years, sampled from the US population from 2003 to 2007. Data were collected by telephone, self-administered questionnaires, and an in-home examination. Incident strokes were identified through biannual participant contact followed by adjudication of medical records. Levels of the LS7 components (blood pressure, cholesterol, glucose, body mass index, smoking, physical activity, and diet) were each coded as poor (0 point), intermediate (1 point), or ideal (2 points) health. An overall LS7 score was categorized as inadequate (0–4), average (5–9), or optimum (10–14) cardiovascular health. Results— Among 22 914 subjects with LS7 data and no previous cardiovascular disease, there were 432 incident strokes over 4.9 years of follow-up. After adjusting for demographics, socioeconomic status, and region of residence, each better health category of the LS7 score was associated with a 25% lower risk of stroke (hazard ratios, 0.75; 95% confidence interval, 0.63–0.90). The association was similar for blacks and whites (interaction P value=0.55). A 1-point higher LS7 score was associated with an 8% lower risk of stroke (hazard ratios, 0.92; 95% confidence interval, 0.88–0.95). Conclusions— In both blacks and whites, better cardiovascular health, on the basis of the LS7 score, is associated with lower risk of stroke, and a small difference in scores was an important stroke determinant.

An Internet-Based Virtual Coach to Promote Physical Activity Adherence in Overweight Adults: Randomized Controlled Trial

Background Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching. Objectives We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone. Methods We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m2 from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants’ satisfaction. Results The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs –12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures. Conclusions The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study. Trial Registration ClinicalTrials.gov NCT00792207; http://clinicaltrials.gov/ct2/show/NCT00792207 (Archived by WebCite at http://www.webcitation.org/63sm9mXUD)

Urban-Rural Differences in Coronary Heart Disease Mortality in the United States: 1999–2009

Objective. Coronary heart disease (CHD) mortality has declined in the past few decades; however, it is unclear whether the reduction in CHD deaths has been similar across urbanization levels and in specific racial groups. We describe the pattern and magnitude of urban-rural variations in CHD mortality in the U.S. Methods. Using data from the National Center for Health Statistics, we examined trends in death rates from CHD from 1999 to 2009 among people aged 35–84 years, in each geographic region (Northeast, Midwest, West, and South) and in specific racial-urbanization groups, including black and white people in large and medium metropolitan (urban) areas and in non-metropolitan (rural) areas. We also examined deaths from early-onset CHD in females aged <65 years and males aged <55 years. Results. From 1999 to 2009, there was a 40% decline in age-adjusted CHD mortality. The trend was similar in black and white people but was more pronounced in urban than in rural areas, resulting in a crossover in 2007, when rural areas began showing a higher CHD mortality than urban areas. White people in large metropolitan areas had the largest decline (43%). Throughout the study period, CHD mortality remained higher in black people than in white people, and, in the South, it remained higher in rural than in urban areas. For early-onset CHD, the mortality decline was more modest (30%), but overall trends by urbanization and region were similar. Conclusion. Favorable national trends in CHD mortality conceal persisting disparities for some regions and population subgroups (e.g., rural areas and black people).

Use of remote monitoring to improve outcomes in patients with heart failure: a pilot trial

Remote monitoring (RM) of homebound heart failure (HF) patients has previously been shown to reduce hospital admissions. We conducted a pilot trial of ambulatory, non-homebound patients recently hospitalized for HF to determine whether RM could be successfully implemented in the ambulatory setting. Eligible patients from Massachusetts General Hospital (n = 150) were randomized to a control group (n = 68) or to a group that was offered RM (n = 82). The participants transmitted vital signs data to a nurse who coordinated care with the physician over the course of the 6-month study. Participants in the RM program had a lower all-cause per person readmission rate (mean = 0.64, SD ± 0.87) compared to the usual care group (mean = 0.73, SD ± 1.51; P-value = .75) although the difference was not statistically significant. HF-related readmission rate was similarly reduced in participants. This pilot study demonstrates that RM can be successfully implemented in non-homebound HF patients and may reduce readmission rates.

Association Between Ideal Cardiovascular Health and Carotid Intima-Media Thickness: A Twin Study

Background The American Heart Association (AHA) recently developed the Cardiovascular Health Index (CVHI), a health metric consisting of 7 modifiable risk factors. The relationship of the CVHI with preclinical markers, such as carotid intima‐media thickness (CIMT) has not been assessed. Methods We examined 490 male monozygotic and dizygotic twins without overt cardiovascular disease. CIMT was measured using B‐mode ultrasonography. Each of the 7 CVHI components (blood pressure, fasting glucose, total cholesterol, body mass index, physical activity, healthy diet, and smoking) was given a point score of 0, 1, or 2 to represent poor, intermediate, or ideal health, respectively. A CVHI summation score was computed (range 0 to 14) and categorized as inadequate (0 to 4), average (5 to 9), or optimum (10 to 14) cardiovascular health. Mixed‐model regression was used to examine the association of the CVHI with CIMT. Results The mean age of the twins was 55.4 years, and 61% were monozygotic. The mean CIMT was 0.75 (±0.11) mm and the mean CVHI score was 7.7 (±2.1). There was an inverse correlation between CVHI and CIMT (Spearman r=−0.22, P<0.01). For every 5‐unit increase in overall CVHI score (indicating better cardiovascular health category), CIMT decreased by 0.045 mm (P<0.001) after adjusting for demographic variables and other confounders. Within monozygotic twin pairs, a 5‐unit increment in CVHI score was associated with a 0.05 mm lower CIMT (P<0.001). Conclusions The CVHI is independently associated with CIMT and the association is not confounded by shared genetic and other familial factors.

Stroke in South Asia: A Systematic Review of Epidemiologic Literature from 1980 to 2010

Background: Globally 15 million people have an acute stroke every year and one third of them die secondary to stroke events. Most research on stroke prevention and treatment is done in developed countries, yet more than 85% of strokes occur in developing countries. In particular, stroke remains an underrecognized cause of death and disability in South Asia. Methods: We conducted a systematic review to identify reliable and comparable epidemiological evidence on stroke in South Asia from 1980 to 2010. Publications were screened for eligibility to identify only population-based stroke studies. Results: Of the 71 studies retrieved, only 6 studies from South Asia gave us acceptable estimates of the burden of stroke. Population-based studies from South Asia have stroke prevalence in the range of 45–471 per 100,000. The age-adjusted incidence rate varied from approximately 145 per 100,000 to 262 per 100,000. Rural parts of South Asia have a lower stroke prevalence compared with urban areas. Conclusions: Our review highlights the paucity of research data in South Asia. This must be addressed in order to accurately determine the burden of stroke in South Asia, so that specific policy recommendations can be formulated to combat the stroke epidemic in this region.

Prospects for a Cardiovascular Disease Prevention Polypill

Cardiovascular diseases (CVD) account for one-third of annual global mortality. The aggregated benefits of concurrently controlling common CVD risk factors, such as dyslipidemia and hypertension, in people at overall risk for CVD is postulated to be more efficient than treating each individual risk factor to target. Administration of a polypill consisting of cholesterol-lowering (statins), antihypertensive, and antiplatelet agents together would simultaneously lower multiple risk factors, and applying such a population risk-reduction strategy would drastically reduce CVD incidence. This idea has generated much controversy and debate over the past decade. A few studies have emerged providing early evidence about the safety and efficacy of such a pill, and the results of ongoing and planned studies of outcome are eagerly anticipated. In this article, we review and interpret the existing evidence as well as explore the potential of a polypill for primary and secondary prevention of CVD.

Association of JNC-8 and SPRINT Systolic Blood Pressure Levels With Cognitive Function and Related Racial Disparity

Importance The Eighth Joint National Committee (JNC-8) recommended treating systolic blood pressure (SBP) to a target below 150 mm Hg in older adults, whereas data from the Systolic Blood Pressure Intervention Trial (SPRINT) suggested that a SBP level of lower than 120 mm Hg decreases cardiovascular event rates. Target SBP guidelines have not addressed the potential that black patients may have greater morbidity and mortality from hypertension, especially with regard to cognitive outcomes. The association of these discordant SBP targets with cognition and differences by race have not been systematically evaluated in the same population. Objectives To assess the long-term outcomes of the various recommended SBP levels and to determine if racial differences exist based on long-term cognitive trajectories. Design, Setting, and Participants A total of 1657 cognitively intact older adults receiving treatment for hypertension were studied from 1997 to 2007 in the Health Aging and Body Composition study. Data analysis was conducted from October 1, 2016, to January 1, 2017. Main Outcomes and Measures Cognition was assessed using the Modified Mini-Mental State Examination (3MSE) 4 times and the Digit Symbol Substitution Test (DSST) 5 times. At each visit, participants were classified as having an SBP level of 120 mm Hg or lower, 121 to 139 mm Hg, 140 to 149 mm Hg, or 150 mm Hg or higher based on the mean SBP level of 2 seated readings. Mixed models assessed the association of SBP levels with 10-year cognitive trajectories. The impact of race was tested using a race interaction term. Results During the 10-year study period, among the 1657 individuals (908 women and 784 black patients; mean [SE] age, 73.7 [0.1] years), there was a differential decrease in 3MSE and DSST scores by the SBP levels, with the greatest decrease in the group with SBP levels of 150 mm Hg or higher (adjusted decrease was 3.7 for 3MSE and 6.2 for DSST) and the lowest decrease in the group with SBP levels of 120 mm Hg or lower (adjusted decrease was 3.0 for 3MSE and 5.0 for DSST) (P < .001 for both). Compared with white patients, black patients had a greater difference between the higher and lower SBP levels in the decrease in cognition; adjusted differences between the group with SBP levels of 150 mm Hg or higher and the group with SBP levels of 120 mm Hg or lower were –0.05 in white patients and –0.08 in black patients for 3MSE (P = .03) and –0.07 in white patients and –0.13 in black patients for DSST (P = .05). Conclusions and Relevance For patients 70 years of age or older receiving treatment for hypertension, a SPRINT SBP level of 120 mm Hg or lower was not associated with worsening cognitive outcome and may be superior to the JNC-8 target for cognition. Lower SBP treatment levels may result in improved cognition in black patients.

Family history of stroke and cardiovascular health in a national cohort.

BACKGROUND We investigated the association between family history of stroke (FHS) and Lifes Simple 7 (LS7), a public health metric defined by the American Heart Association. METHODS Reasons for Geographic and Racial Differences in Stroke is a national population-based cohort of 30,239 blacks and whites, aged 45 years or older, sampled from the US population between 2003 and 2007. Data were collected by telephone, mail questionnaires, and in-home examinations. FHS was defined as any first-degree relative with stroke. Levels of the LS7 components (total cholesterol, blood pressure, fasting glucose, physical activity, diet, smoking, and body mass index) were each coded as poor (0 points), intermediate (1 point), or ideal (2 points) health. Ordinal logistic regression was used to model the data. RESULTS Among 20,567 subjects with complete LS7 and FHS data, there were 7702 (37%) participants with an FHS. The mean age of the participants was 64 years. The mean (± standard deviation) overall LS7 score was lower for blacks (6.5 ± 2.0) than that of whites (7.6 ± 2.1). FHS was associated with poorer levels of physiological factors, particularly high blood pressure (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19) and inversely associated with behaviors such as smoking (OR, .92; 95% CI, .85-.99). CONCLUSIONS Our results suggest that screening for FHS can provide an opportunity for earlier detection and management of modifiable risk factors.