Eileen M. Stuart-Shor

Behavioral Strategies for Cardiovascular Risk Reduction in Diverse and Underserved Racial/Ethnic Groups

Cardiovascular disease (CVD) is the leading cause of death and disability in the United States across all racial/ethnic groups.1 Much of the burden of CVD morbidity and mortality is associated with modifiable lifestyle risk factors. A disproportionate share of the burden of CVD and metabolic/vascular risk factors falls on racial and ethnic communities as a result of a constellation of social, environmental, biological, and systems factors.1,2 Disparities are most clearly evident for black compared with white Americans.1 Available data for other racial/ethnic minority populations indicate disparities for certain CVD risk factors or outcomes.1,3 Despite widespread awareness among clinicians of primary and secondary CVD prevention goals and the potential for improving clinical outcomes by integrating lifestyle risk reduction interventions into practice, the application of these interventions is far from optimal.4 Therapeutic goals for primary and secondary prevention have been well established over the last 3 decades.5,6 Table 1, derived from the American Heart Association (AHA) scientific statements on primordial,4 primary,5 and secondary6 risk reduction and diet and lifestyle recommendations,7 delineates targeted goals and risk reduction strategies across the spectrum of prevention. Primary prevention seeks to avoid a first occurrence of CVD among individuals at risk through smoking cessation; management of blood pressure (BP), lipids, and glucose; weight control; and dietary and physical activity counseling.5 Secondary prevention aims for intensive and comprehensive management of risk factors in those with established CVD and is associated with improved survival and a reduction in recurrent events.6 Secondary prevention benchmarks for lipid management are lower than for primary prevention, but BP, smoking, dietary, and physical activity goals are the same. As a result of a growing recognition that subclinical disease develops over many years and with various …

Gender Differences in Presenting and Prodromal Stroke Symptoms

Background and Purpose— Prompt recognition of stroke symptoms is critical to timely treatment and women have increased delay to treatment. Women may be more likely to present with atypical symptoms, but this hypothesis has not been extensively evaluated. Methods— We examined gender differences in the prevalence of presenting and prodromal stroke symptoms among 1107 consecutive patients hospitalized with neurologist-confirmed acute ischemic stroke. Patient demographics, clinical variables, and stroke symptoms were abstracted from medical records by trained abstractors using standardized forms. Estimates were age-standardized to the age distribution of men and women combined. Presenting symptoms occurred within 24 hours of incident stroke admission; prodromal symptoms occurred ≥24 hours of admission. Results— Women were significantly older (P<0.001), more likely to have cardioembolic stroke (P<0.01), and less likely to receive aspirin (P=0.014) or statins (P<0.001). Thirty-five percent of the sample (n=389) reported prodromal symptoms. Women were more likely to have ≥1 somatic prodromal and presenting symptoms (P=0.03; P=0.008), but did not differ from men on specific somatic symptoms. Women did not differ from men in classic presenting stroke symptoms (P=0.89). Conclusion— Women did not differ significantly in the prevalence of traditional stroke symptoms but were more likely to have somatic presenting and prodromal symptoms. We found no differences in specific prodromal symptoms, making it difficult to craft a public health message about gender differences in early warning signs of stroke. These results suggest that the focus of stroke prevention education for women should continue to emphasize traditional stroke risk factors.

Are psychosocial factors associated with the pathogenesis and consequences of cardiovascular disease in the elderly

It is well known that older individuals are at higher risk of developing cardiovascular disease (CVD). In addition, evidence exists for the relationship between psychosocial factors and the pathogenesis and cognitive consequences of CVD. However, less is known about the effect of psychosocial factors on the development and consequences of CVD in older individuals. Using a biopsychosocial framework, this article examines the influence of psychosocial factors, specifically depression, anxiety, and social isolation on older persons with CVD as well as the influence of CVD on psychosocial factors. The effectiveness of interventions for modifying adverse psychosocial factors is also discussed.

Evaluation of the performance of existing non-laboratory based cardiovascular risk assessment algorithms

BackgroundThe high burden and rising incidence of cardiovascular disease (CVD) in resource constrained countries necessitates implementation of robust and pragmatic primary and secondary prevention strategies. Many current CVD management guidelines recommend absolute cardiovascular (CV) risk assessment as a clinically sound guide to preventive and treatment strategies. Development of non-laboratory based cardiovascular risk assessment algorithms enable absolute risk assessment in resource constrained countries.The objective of this review is to evaluate the performance of existing non-laboratory based CV risk assessment algorithms using the benchmarks for clinically useful CV risk assessment algorithms outlined by Cooney and colleagues.MethodsA literature search to identify non-laboratory based risk prediction algorithms was performed in MEDLINE, CINAHL, Ovid Premier Nursing Journals Plus, and PubMed databases. The identified algorithms were evaluated using the benchmarks for clinically useful cardiovascular risk assessment algorithms outlined by Cooney and colleagues.ResultsFive non-laboratory based CV risk assessment algorithms were identified. The Gaziano and Framingham algorithms met the criteria for appropriateness of statistical methods used to derive the algorithms and endpoints. The Swedish Consultation, Framingham and Gaziano algorithms demonstrated good discrimination in derivation datasets. Only the Gaziano algorithm was externally validated where it had optimal discrimination. The Gaziano and WHO algorithms had chart formats which made them simple and user friendly for clinical application.ConclusionBoth the Gaziano and Framingham non-laboratory based algorithms met most of the criteria outlined by Cooney and colleagues. External validation of the algorithms in diverse samples is needed to ascertain their performance and applicability to different populations and to enhance clinicians’ confidence in them.

Methodological Challenges in Estimating Trends and Burden of Cardiovascular Disease in Sub-Saharan Africa

Background. Although 80% of the burden of cardiovascular disease (CVD) is in developing countries, the 2010 global burden of disease (GBD) estimates have been cited to support a premise that sub-Saharan Africa (SSA) is exempt from the CVD epidemic sweeping across developing countries. The widely publicized perspective influences research priorities and resource allocation at a time when secular trends indicate a rapid increase in prevalence of CVD in SSA by 2030. Purpose. To explore methodological challenges in estimating trends and burden of CVD in SSA via appraisal of the current CVD statistics and literature. Methods. This review was guided by the Critical review methodology described by Grant and Booth. The review traces the origins and evolution of GBD metrics and then explores the methodological limitations inherent in the current GBD statistics. Articles were included based on their conceptual contribution to the existing body of knowledge on the burden of CVD in SSA. Results/Conclusion. Cognizant of the methodological challenges discussed, we caution against extrapolation of the global burden of CVD statistics in a way that underrates the actual but uncertain impact of CVD in SSA. We conclude by making a case for optimal but cost-effective surveillance and prevention of CVD in SSA.

A public health action plan to prevent heart disease and stroke: the mandate for prevention across the continuum of care and across the lifespan.

We at the U.S. Department of Health and Human Services are committed to improving the health of America. With the release of A Public Health Action Plan to Prevent Heart Disease and Stroke, we will tackle one of the most formidable public health challenges of this century—reducing the burden of heart disease and stroke. Heart disease and stroke are among the nations leading causes of death and disability, projected to cost more than

Validation of the nonlaboratory-based Framingham cardiovascular disease risk assessment algorithm in the Atherosclerosis Risk in Communities dataset

351 billion in 2003. Heart disease and stroke can affect anyone without regard to age, race, ethnicity, sex, or income level. And as our population ages, these largely preventable conditions are projected to increase. This nation has the tools to substantially reduce the devastating impact that heart disease and stroke have on individuals, their families, and the nations economy. We can take significant steps toward a heart-healthy and stroke-free America through several actions. These include early and continuous health education that focuses on prevention and healthy lifestyle choices; medical services that provide the most effective drugs and therapies without disparity; and environmental policies in schools, work sites, and communities that promote good nutrition, regular physical activity, and abstinence from smoking. The Action Plan offers a new promise of success. Quite simply, this plan gives health practitioners and policy makers a framework for developing a health care system that equally supports treatment and prevention. This plan is a collaborative effort designed to guide the nation in taking action, strengthening capacity, evaluating impact, advancing policy, and engaging in partnerships to reverse the epidemic of heart disease and stroke. I thank the many public and private health, social service, faith, and community professionals who pooled their talents to develop the Action Plan—our landmark, long-term guide for improving the nations heart and stroke health. But a plan is not enough. Your personal commitment is essential to accomplishing this massive national effort. I call on all Americans to join me and to learn what you can do to make a difference. A Public Health Action Plan to Prevent Heart Disease and Stroke is a call to action for tackling one of our nations foremost challenges—to prevent and control chronic diseases. To meet the challenge, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) are charged with providing leadership to reduce heart disease and stroke, using Healthy People 2010 objectives as their guide. The CDC and the …

Using Noninvasive Tools to Screen for Prediabetes and Undiagnosed Diabetes: Value Added to Cardiovascular Disease Prevention

Background Nonlaboratory-based (non-LB) algorithms have been developed to facilitate absolute cardiovascular risk assessment in resource-constrained settings. The non-LB Framingham algorithm, which substitute BMI for lipids in laboratory-based Framingham, exhibits best performance among non-LB algorithms. However, its external validity has not been evaluated. Aim To examine the validity of non-LB Framingham algorithm in Atherosclerosis Risk in Communities dataset, and contrast performance with the laboratory-based Framingham algorithm. Methods We developed Cox regression models including non-LB and laboratory-based Framingham covariates in Atherosclerosis Risk in Communities dataset. Discrimination was assessed via C-statistic, calibration via goodness-of-fit, and marginal discrimination value of BMI vis-à-vis lipids vis-à-vis waist–hip ratio via net reclassification improvement (NRI). Both models were compared via area under receiver operating characteristic. Results Among 11 601 participants (mean age 54 years, 55% women, 23% black), non-LB vs. laboratory-based Framingham performed as follows: C-statistic 0.75 vs. 0.76 among women and 0.67 vs. 0.68 among men; goodness-of-fit 14.2 vs. 10.5 among women and 25.8 vs. 21.8 among men. Overall area under receiver operating characteristic was 0.706 vs. 0.710, respectively, with no racial differences in discrimination or calibration. BMI and total cholesterol had no impact on NRI. Incremental predictive value of HDL was comparable with waist–hip ratio (category-less NRI = 0.34 vs. 0.31; categorical NRI7.5 = 0.06 vs. 0.05, P < 0.01). Conclusion These results demonstrate the validity and limitations of the non-LB Framingham algorithm in a biracial cohort. Substituting BMI with a central adiposity metric such as waist–hip ratio or waist circumference could make the algorithm better or at par with the laboratory-based Framingham algorithm.

Cost-effectiveness of the non-laboratory based Framingham algorithm in primary prevention of cardiovascular disease: A simulated analysis of a cohort of African American adults

Globally, there has been a steep rise in diabetes between 1980 and 2014, with the prevalence among adults over this time period nearly doubling from 108 million (4.7%) to 422 million (8.5%). Type 2 diabetes mellitus (T2DM) accounts for most diabetes cases reported and is a major public health concern in the United States, affecting approximately 28 million adults and costing

The concept of risk as applied to cardiovascular disease.

245 billion annually. To place this number in context, every 17 seconds, an American is diagnosed with this chronic condition, a sobering and alarming fact of American life today. The high prevalence of T2DM is partially attributable to increases in the prevalence of obesity, and estimates predict that by 2050, 1 in 3 Americans will have diabetes if no measures are taken. A similar high prevalence and rapid rise in rates of diabetes have been reported in middleand low-income countries. Diabetes is a major risk factor for cardiovascular disease (CVD) and stroke, increasing the risk of developing CVD or cerebrovascular disease (stroke) 2to 4-fold. Among adults 65 years or older who have diabetes, current estimates are that 68% will die of CVD and 16% will die of stroke. Early detection, diagnosis, and management of diabetes are important in the prevention of CVD; however, many cases of diabetes go undetected and undiagnosed. Globally, the prevalence of undiagnosed diabetes and prediabetes (impaired glucose tolerance) continues to rise, with resource-limited settings reporting the highest rates of undetected diabetes (65%). Of particular concern, estimates indicate that 90% of individuals with prediabetes are unaware of their condition. This is important because without prevention efforts, 15% to 30% of individuals with prediabetes will progress to T2DM within 5 years. These worrisome trends in the high prevalence of undetected/ undiagnosed T2DM and prediabetes prompted the American Heart Association (AHA) and American Diabetes Association (ADA) to revise the current screening recommendations for diabetes to add glycated hemoglobin (A1c) as a diagnostic criterion. Previously, A1c had been a guide to management but the addition of this common clinical measure to screening was deemed important to identify more new cases of diabetes and to treat individuals with diabetes earlier in the course of the disease. Early screening and detection has been shown to be effective. In a randomized control trial-The AngloDanish-Dutch Study of Intensive Treatment in People With ScreenDetected Diabetes in Primary Care (ADDITION-Europe)-screening followed by treatment of T2DM led to a significant reduction in the development of CVD or death in a 5-year follow-up study. However, screening for T2DM and prediabetes using traditional serum-based methods such as fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), or A1c is not always feasible in low-income settings because of lack of access and the costs associated with testing. Alternatively, the use of simple, noninvasive, and cost-effective screening tools has been proposed as an effective strategy for detecting undiagnosed diabetes and glucose intolerance.