Aryan N. Aiyer

Low Prevalence of “Ideal Cardiovascular Health” in a Community-Based Population The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study

Background— Cardiovascular health is a new construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal definition. The applicability of this construct to community-based populations and the distributions of its components by race and sex have not been reported. Methods and Results— The AHA construct of cardiovascular health and the AHA ideal health behaviors index and ideal health factors index were evaluated among 1933 participants (mean age 59 years; 44% blacks; 66% women) in the community-based Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study. One of 1933 participants (0.1%) met all 7 components of the AHAs definition of ideal cardiovascular health. Less than 10% of participants met ≥5 components of ideal cardiovascular health in all subgroups (by race, sex, age, and income level). Thirty-nine subjects (2.0%) had all 4 components of the ideal health behaviors index and 27 (1.4%) had all 3 components of the ideal health factors index. Blacks had significantly fewer ideal cardiovascular health components than whites (2.0±1.2 versus 2.6±1.4; P <0.001). After adjustment by sex, age, and income level, blacks had 82% lower odds of having ≥5 components of ideal cardiovascular health (odds ratio 0.18, 95% confidence interval, 0.10 to 0.34; P <0.001). No interaction was found between race and sex. Conclusion— The prevalence of ideal cardiovascular health is extremely low in a middle-aged community-based study population. Comprehensive individual and population-based interventions must be developed to support the attainment of the AHA′s 2020 Impact Goal for cardiovascular health. # Clinical Perspective {#article-title-31}Background— Cardiovascular health is a new construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal definition. The applicability of this construct to community-based populations and the distributions of its components by race and sex have not been reported. Methods and Results— The AHA construct of cardiovascular health and the AHA ideal health behaviors index and ideal health factors index were evaluated among 1933 participants (mean age 59 years; 44% blacks; 66% women) in the community-based Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study. One of 1933 participants (0.1%) met all 7 components of the AHAs definition of ideal cardiovascular health. Less than 10% of participants met ≥5 components of ideal cardiovascular health in all subgroups (by race, sex, age, and income level). Thirty-nine subjects (2.0%) had all 4 components of the ideal health behaviors index and 27 (1.4%) had all 3 components of the ideal health factors index. Blacks had significantly fewer ideal cardiovascular health components than whites (2.0±1.2 versus 2.6±1.4; P<0.001). After adjustment by sex, age, and income level, blacks had 82% lower odds of having ≥5 components of ideal cardiovascular health (odds ratio 0.18, 95% confidence interval, 0.10 to 0.34; P<0.001). No interaction was found between race and sex. Conclusion— The prevalence of ideal cardiovascular health is extremely low in a middle-aged community-based study population. Comprehensive individual and population-based interventions must be developed to support the attainment of the AHA′s 2020 Impact Goal for cardiovascular health.

Black race is associated with digital artery endothelial dysfunction: results from the Heart SCORE study

AIMS We evaluated whether black race is independently associated with arterial endothelial dysfunction. The pathophysiological basis for race-related differences in cardiovascular disease (CVD) risk has not been established. Endothelial dysfunction, which precedes obstructive atherosclerotic disease, may contribute to CVD disparities. Accordingly, we evaluated race-related differences in digital pulse amplitude tonometry (PAT) response to an endothelium-dependent vasodilatory stimulus. METHODS AND RESULTS A total of 1377 subjects (41% black; mean age 58.5 ± 7.5 years; 67% female) enrolled in the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study underwent assessment of digital pulse amplitude response to forearm occlusion-induced hyperaemia. The response was measured as a PAT ratio of hyperaemia:baseline pulse amplitude in a finger that was subject to hyperaemic stimulus divided by this same ratio in a control finger on the contralateral arm which did not undergo forearm occlusion, expressed as the natural logarithm. The average PAT ratio was significantly lower in blacks compared with whites (0.67 ± 0.44 vs. 0.80 ± 0.46, P < 0.001), signifying greater endothelial dysfunction in blacks. Black race was independently correlated with lower PAT ratio. This finding was consistent across all Framingham risk strata. Adjusted analyses showed significant gender-race interactions. With white women serving as the referent group, parameter estimates for lower PAT ratio in ascending order were as follows: black males (t = -6.93, P < 0.0001); white males (t = -3.31, P = 0.001); and black females (t = -1.12, P = 0.26). CONCLUSION Our findings indicate that black race is independently associated with arterial endothelial dysfunction. Racial differences in CVD risk may be related, in part, to race-related differences in endothelial dysfunction.

Biogeographic Ancestry, Self-Identified Race, and Admixture-Phenotype Associations in the Heart SCORE Study

Large epidemiologic studies examining differences in cardiovascular disease (CVD) risk factor profiles between European Americans and African Americans have exclusively used self-identified race (SIR) to classify individuals. Recent genetic epidemiology studies of some CVD risk factors have suggested that biogeographic ancestry (BGA) may be a better predictor of CVD risk than SIR. This hypothesis was investigated in 464 African Americans and 771 European Americans enrolled in the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study in March and April 2010. Individual West African and European BGA were ascertained by means of a panel of 1,595 genetic ancestry informative markers. Individual BGA varied significantly among African Americans and to a lesser extent among European Americans. In the total cohort, BGA was not found to be a better predictor of CVD risk factors than SIR. Both measures predicted differences in the presence of the metabolic syndrome, waist circumference, triglycerides, body mass index, very low density lipoprotein cholesterol, lipoprotein A, and systolic and diastolic blood pressure between European Americans and African Americans. These results suggest that for most nongenetic cardiovascular epidemiology studies, SIR is sufficient for predicting CVD risk factor differences between European Americans and African Americans. However, higher body mass index and diastolic blood pressure were significantly associated with West African BGA among African Americans, suggesting that BGA should be considered in genetic cardiovascular epidemiology studies carried out among African Americans.

Traditional and Nontraditional Cardiovascular Risk Factors in Comorbid Insomnia and Sleep Apnea

OBJECTIVES Insomnia and sleep apnea frequently co-occur and are independently associated with an increased risk of cardiovascular disease, but little is known about cardiovascular disease risk among individuals with comorbid insomnia and sleep apnea. The current study examined traditional risk factors and a physiologic biomarker of cardiovascular risk in comorbid insomnia and sleep apnea. DESIGN Community-based participatory research study. PARTICIPANTS The sample comprised 795 participants without preexisting cardiovascular disease from the Heart Strategies Concentrating On Risk Evaluation (Heart SCORE) study. MEASUREMENTS AND RESULTS Participants were assessed for symptoms of insomnia and sleep apnea risk, as well as for presence of obesity, smoking, a sedentary lifestyle, hypertension, dyslipidemia, and diabetes. Baseline resting brachial artery diameter was measured by B-mode ultrasonography. A total of 138 participants (17.4%) met criteria for insomnia syndrome alone, 179 (22.5%) were at high risk for sleep apnea alone, 95 (11.9%) reported both insomnia syndrome and high sleep apnea risk, and 383 (48.2%) reported having neither insomnia nor sleep apnea symptoms Both high sleep apnea risk alone and comorbid insomnia and high sleep apnea risk groups had greater frequencies of obesity, sedentary lifestyle, hypertension, and three or more traditional cardiovascular risk factors and significantly larger brachial artery diameters than the insomnia alone group and those without insomnia or sleep apnea symptoms. No differences in traditional cardiovascular risk factors or brachial artery diameter were found between the high sleep apnea risk and comorbid groups. CONCLUSIONS These findings suggest that sleep apnea is a major contributor to cardiovascular risk and co-occurring insomnia does not appear to add to this risk.

Relation of Obstructive Sleep Apnea to Coronary Artery Calcium in Non-Obese Versus Obese Men and Women Aged 45–75 Years

Sleep apnea and obesity are strongly associated, and both increase the risk for coronary artery disease. Several cross-sectional studies have reported discrepant results regarding the role obesity plays in the relation between sleep apnea and coronary artery calcium (CAC), a marker of subclinical coronary disease. The aim of the present study was to investigate the association between sleep apnea and the presence of CAC in a community cohort of middle-aged men and women without preexisting cardiovascular disease, stratified by body mass index (<30 vs ≥30 kg/m(2)). Participants underwent electron-beam computed tomography to measure CAC and underwent home sleep testing for sleep apnea. The presence of CAC was defined as an Agatston score >0. Sleep apnea was analyzed categorically using the apnea-hypopnea index. The sample was composed of primarily men (61%) and Caucasians (56%), with a mean age of 61 years. The prevalence of CAC was 76%. In participants with body mass indexes <30 kg/m(2) (n = 139), apnea-hypopnea index ≥15 (vs <5) was associated with 2.7-fold odds of having CAC, but the effect only approached significance. Conversely, in participants with body mass indexes ≥30 kg/m(2), sleep apnea was not independently associated with CAC. In conclusion, sleep apnea is independently associated with early atherosclerotic plaque burden in nonobese patients.

Low Prevalence of “Ideal Cardiovascular Health” in a Community-Based Population

Background— Cardiovascular health is a new construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal definition. The applicability of this construct to community-based populations and the distributions of its components by race and sex have not been reported. Methods and Results— The AHA construct of cardiovascular health and the AHA ideal health behaviors index and ideal health factors index were evaluated among 1933 participants (mean age 59 years; 44% blacks; 66% women) in the community-based Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study. One of 1933 participants (0.1%) met all 7 components of the AHAs definition of ideal cardiovascular health. Less than 10% of participants met ≥5 components of ideal cardiovascular health in all subgroups (by race, sex, age, and income level). Thirty-nine subjects (2.0%) had all 4 components of the ideal health behaviors index and 27 (1.4%) had all 3 components of the ideal health factors index. Blacks had significantly fewer ideal cardiovascular health components than whites (2.0±1.2 versus 2.6±1.4; P <0.001). After adjustment by sex, age, and income level, blacks had 82% lower odds of having ≥5 components of ideal cardiovascular health (odds ratio 0.18, 95% confidence interval, 0.10 to 0.34; P <0.001). No interaction was found between race and sex. Conclusion— The prevalence of ideal cardiovascular health is extremely low in a middle-aged community-based study population. Comprehensive individual and population-based interventions must be developed to support the attainment of the AHA′s 2020 Impact Goal for cardiovascular health. # Clinical Perspective {#article-title-31}Background— Cardiovascular health is a new construct defined by the American Heart Association (AHA) as part of its 2020 Impact Goal definition. The applicability of this construct to community-based populations and the distributions of its components by race and sex have not been reported. Methods and Results— The AHA construct of cardiovascular health and the AHA ideal health behaviors index and ideal health factors index were evaluated among 1933 participants (mean age 59 years; 44% blacks; 66% women) in the community-based Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study. One of 1933 participants (0.1%) met all 7 components of the AHAs definition of ideal cardiovascular health. Less than 10% of participants met ≥5 components of ideal cardiovascular health in all subgroups (by race, sex, age, and income level). Thirty-nine subjects (2.0%) had all 4 components of the ideal health behaviors index and 27 (1.4%) had all 3 components of the ideal health factors index. Blacks had significantly fewer ideal cardiovascular health components than whites (2.0±1.2 versus 2.6±1.4; P<0.001). After adjustment by sex, age, and income level, blacks had 82% lower odds of having ≥5 components of ideal cardiovascular health (odds ratio 0.18, 95% confidence interval, 0.10 to 0.34; P<0.001). No interaction was found between race and sex. Conclusion— The prevalence of ideal cardiovascular health is extremely low in a middle-aged community-based study population. Comprehensive individual and population-based interventions must be developed to support the attainment of the AHA′s 2020 Impact Goal for cardiovascular health.

Population variations in atherogenic dyslipidemia: A report from the HeartSCORE and IndiaSCORE Studies

BACKGROUND Asian Indians and blacks have a higher risk for cardiovascular disease (CVD) events compared to whites. Atherogenic dyslipidemia, comprised of small-dense low-density lipoprotein (LDL), low high-density lipoprotein (HDL) levels, and high triglyceride (TG) levels, constitutes an important risk factor for CVD often seen in the presence of obesity. The contribution of atherogenic dyslipidemia to CVD risk across diverse racial populations is not well established. OBJECTIVE Our primary aim was to investigate the relationship between race and atherogenic dyslipidemia among whites, blacks, and Asian Indians. A secondary aim was to evaluate the association between obesity and atherogenic dyslipidemia across populations. METHODS From community-based sampling, 720 whites and 373 blacks underwent evaluation of CVD risk factors, including fasting lipoproteins. An identical protocol was administered to 205 Asian Indians from Chennai, India. Lipid profiles, including those comprising atherogenic dyslipidemia, were compared among populations. RESULTS The prevalence of small-dense LDL (pattern B) and of TG/HDL ratio >3 was greatest among Asian Indians and smallest among blacks. Compared to whites, the adjusted odds for Indians having a LDL pattern B was 2.06 (P < .001) and TG/HDL ratio >3 was 9.42 (P < .001). The adjusted odds of having LDL pattern B (odds ratio 0.39, P < 0.001) or TG/HDL ratio >3 (odds ratio 0.41, P < .001) was lower in blacks compared to whites. Among Indians, obesity had a weak association with atherogenic dyslipidemia, in contrast to the strong association among whites. CONCLUSIONS Significant population variations in atherogenic dyslipidemia exist. This may be an important component to explain population differences in cardiovascular risk.

Endothelial Dysfunction and Racial Disparities in Mortality and Adverse Cardiovascular Disease Outcomes

The contribution of arterial endothelial dysfunction (ED) to increased cardiovascular disease (CVD) risk among Blacks is not known.

Particulate Matter Air Pollution and Racial Differences in Cardiovascular Disease Risk

Objective— We aimed to assess racial differences in air pollution exposures to ambient fine particulate matter (particles with median aerodynamic diameter <2.5 µm [PM2.5]) and black carbon (BC) and their association with cardiovascular disease (CVD) risk factors, arterial endothelial function, incident CVD events, and all-cause mortality. Approach and Results— Data from the HeartSCORE study (Heart Strategies Concentrating on Risk Evaluation) were used to estimate 1-year average air pollution exposure to PM2.5 and BC using land use regression models. Correlates of PM2.5 and BC were assessed using linear regression models. Associations with clinical outcomes were determined using Cox proportional hazards models, adjusting for traditional CVD risk factors. Data were available on 1717 participants (66% women; 45% blacks; 59±8 years). Blacks had significantly higher exposure to PM2.5 (mean 16.1±0.75 versus 15.7±0.73µg/m3; P=0.001) and BC (1.19±0.11 versus 1.16±0.13abs; P=0.001) compared with whites. Exposure to PM2.5, but not BC, was independently associated with higher blood glucose and worse arterial endothelial function. PM2.5 was associated with a higher risk of incident CVD events and all-cause mortality combined for median follow-up of 8.3 years. Blacks had 1.45 (95% CI, 1.00–2.09) higher risk of combined CVD events and all-cause mortality than whites in models adjusted for relevant covariates. This association was modestly attenuated with adjustment for PM2.5. Conclusions— PM2.5 exposure was associated with elevated blood glucose, worse endothelial function, and incident CVD events and all-cause mortality. Blacks had a higher rate of incident CVD events and all-cause mortality than whites that was only partly explained by higher exposure to PM2.5.

Assessing Longitudinal Invariance of the Center for Epidemiologic Studies-Depression Scale Among Middle-Aged and Older Adults.

Background and Purpose: The longitudinal invariance of the Center for Epidemiologic Studies-Depression (CES-D) scale among middle-aged and older adults is unknown. This study examined the factorial invariance of the CES-D scale in a large cohort of community-based adults longitudinally. Methods: 1,204 participants completed the 20-item CES-D scale at 4 time points 1 year apart. Structural equation modeling was used to identify best fitting model using longitudinal data at baseline and at 1-, 2-, and 3-year follow-up. Results: The 4-factor model showed partial invariance over 3 years. Two of the 6 noninvariant items were consistently noninvariant at the 3 follow-up points. Conclusion: Special consideration should be given to these 2 items when using the CES-D scale in healthy adults (45–75 years old).