Elizabeth A. Jackson

Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events

Objective: To assess whether sex differences exist in the angiographic severity, management and outcomes of acute coronary syndromes (ACS). Methods: The study comprised 7638 women and 19 117 men with ACS who underwent coronary angiography and were included in GRACE (Global Registry of Acute Coronary Events) from 1999–2006. Normal vessels/mild disease was defined as <50% stenosis in all epicardial vessels; advanced disease was defined as ⩾one vessel with ⩾50% stenosis. Results: Women were older than men and had higher rates of cardiovascular risk factors. Men and women presented equally with chest pain; however, jaw pain and nausea were more frequent among women. Women were more likely to have normal/mild disease (12% vs 6%, p<0.001) and less likely to have left-main and three-vessel disease (27% vs 32%, p<0.001) or undergo percutaneous coronary intervention (65% vs 68%, p<0.001). Women and men with normal and mild disease were treated less aggressively than those with advanced disease. Women with advanced disease had a higher risk of death (4% vs 3%, p<0.01). After adjustment for age and extent of disease, women were more likely to have adverse outcomes (death, myocardial infarction, stroke and rehospitalisation) at six months compared to men (odds ratio 1.24, 95% confidence interval 1.14 to 1.34); however, sex differences in mortality were no longer statistically significant. Conclusions: Women with ACS were more likely to have cardiovascular disease risk factors and atypical symptoms such as nausea compared with men, but were more likely to have normal/mild angiographic coronary artery disease. Further study regarding sex differences related to disease severity is warranted.

The association of sex with outcomes among patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction in the contemporary era: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

BACKGROUND historically, women with ST elevation myocardial infarction (STEMI) have had a higher mortality compared with men. It is unclear if these differences persist among patients undergoing contemporary primary percutaneous coronary intervention (PCI) with focus on early reperfusion. METHODS we assessed the impact of sex on the outcome of 8,771 patients with acute STEMI who underwent primary PCI from 2003 to 2008 at 32 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry. A propensity-matched analysis was performed to adjust for differences in baseline characteristics and comorbidities between men and women. RESULTS twenty-nine percent of the cohort was female. Compared with men, women were older and had more comorbidity. Female sex was associated with a higher unadjusted in-hospital mortality (6.02% vs 3.45%, odds ratio [OR] 1.79, 95% CI 1.45-2.22, P < .0001) and higher risk of contrast-induced nephropathy (OR 1.75, P < .0001), vascular complications (OR 2.13, P < .0001), and postprocedure transfusion (OR 2.84, P < .0001). The gap in sex-specific mortality narrowed over time. In a propensity-matched analysis, female sex was associated with a higher rate of transfusion (OR 1.88, 95% CI 1.57-2.24, P < .0001) and vascular complications (OR 1.65, 95% CI 1.26-2.14, P < .0002); but there was no difference in mortality (OR 1.30, 95% CI 0.98-1.72, P = .07). CONCLUSIONS women make up approximately one third of patients undergoing primary PCI for STEMI. Female sex is associated with an apparent hazard of increased mortality among patients undergoing primary PCI for STEMI, but this difference is likely explained by older age and worse baseline comorbidities among women.

Understanding childhood obesity in America: Linkages between household income, community resources, and children's behaviors

BACKGROUND Understanding childhood obesitys root causes is critical to the creation of strategies to improve our childrens health. We sought to define the association between childhood obesity and household income and how household income and childhood behaviors promote childhood obesity. METHODS We assessed body mass index in 109,634 Massachusetts children, identifying the percentage of children who were overweight/obese versus the percentage of children in each community residing in low-income homes. We compared activity patterns and diet in 999 sixth graders residing in 4 Michigan communities with varying annual household income. RESULTS In Massachusetts, percentage of overweight/obese by community varied from 9.6% to 42.8%. As household income dropped, percentage of overweight/obese children rose. In Michigan sixth graders, as household income goes down, frequency of fried food consumption per day doubles from 0.23 to 0.54 (P < .002), and daily TV/video time triples from 0.55 to 2.00 hours (P < .001), whereas vegetable consumption and moderate/vigorous exercise go down. CONCLUSIONS The prevalence of overweight/obese children rises in communities with lower household income. Children residing in lower income communities exhibit poorer dietary and physical activity behaviors, which affect obesity.

Constipation and Risk of Cardiovascular Disease among Postmenopausal Women

BACKGROUND Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events. METHODS We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Womens Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years). RESULTS The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events. CONCLUSION In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.

Sex differences in survival after acute myocardial infarction in patients with diabetes mellitus (Worcester Heart Attack Study)

BACKGROUND Women with diabetes mellitus are at particularly high risk for coronary heart disease-related morbidity and mortality compared with men with diabetes mellitus. However, recent data comparing hospital and long-term outcomes in women with diabetes mellitus and men hospitalized with acute myocardial infarction (AMI) are scarce. The objectives of our multi-hospital observational study were to examine sex differences and temporal trends (1975-99) in hospital and long-term case-fatality rates (CFRs) in patients with diabetes mellitus and AMI from a population-based perspective. METHODS A community-wide study of residents of the Worcester, Mass, metropolitan area who were hospitalized with confirmed AMI was conducted. Data were collected in 12 1-year periods between 1975 and 1999. The study sample consisted of 1354 men and 1280 women with diabetes mellitus. RESULTS Overall hospital CFRs were significantly greater for women with diabetes mellitus (21.3%) than for men with diabetes mellitus (14.9%). Between 1975 and 1999, hospital CFRs declined from 39.2% to 17.5% for women and from 18.9% to 9.5% in men. In examining long-term survival patterns for as long as 10 years after hospital discharge, there were no significant sex differences in long-term survival rates after adjustment for a limited number of known potentially confounding factors. CONCLUSIONS Hospital death rates after AMI in men and women with diabetes mellitus have declined in the last 2 decades. The gap in hospital CFRs between men and women with diabetes mellitus has decreased considerably with time, although women have a higher risk of dying after AMI than men. Patients with diabetes mellitus continue to represent a high-risk group who will benefit from enhanced surveillance efforts and increased use of effective cardiac treatments.

Chronic PM2.5 exposure and inflammation: determining sensitive subgroups in mid-life women.

BACKGROUND Several cohort studies report associations between chronic exposure to ambient fine particles (PM2.5) and cardiovascular mortality. Uncertainty exists about biological mechanisms responsible for this observation, but systemic inflammation has been postulated. In addition, the subgroups susceptible to inflammation have not been fully elucidated. METHODS We investigated whether certain subgroups are susceptible to the effects of long-term exposure to PM2.5 on C-reactive protein (CRP), a marker of inflammation directly linked to subsequent cardiovascular disease. We used data from the SWAN cohort of 1923 mid-life women with up to five annual repeated measures of CRP. Linear mixed and GEE models accounting for repeated measurements within an individual were used to estimate the effects of prior-year PM2.5 exposure on CRP. We examined CRP as a continuous and as binary outcome for CRP greater than 3mg/l, a level of clinical significance. RESULTS We found strong associations between PM2.5 and CRP among several subgroups. For example a 10 µg/m(3) increase in annual PM2.5 more than doubled the risk of CRP greater than 3mg/l in older diabetics, smokers and the unmarried. Larger effects were also observed among those with low income, high blood pressure, or who were using hormone therapy, with indications of a protective effects for those using statins or consuming moderate amounts of alcohol. CONCLUSIONS In this study, we observed significant associations between long-term exposure to PM2.5 and CRP in several susceptible subgroups. This suggests a plausible pathway by which exposure to particulate matter may be associated with increased risk of cardiovascular disease.

Health status and behavior among middle-school children in a midwest community: What are the underpinnings of childhood obesity?

BACKGROUND Childhood obesity is one of the nations foremost health challenges. How much of this is due to lifestyle choices? The objective of the study was to determine health behaviors that contribute to obesity in sixth-grade children. METHODS To assess which health habits contribute to childhood obesity, we studied body mass index, blood pressure, lipid profile, glucose, and heart rate recovery after a 3-minute step test among sixth-grade children enrolled in a school-based intervention study from 2004 to 2009, comparing health behaviors and physiologic markers in obese versus nonobese children. Univariate associations with obesity (P values≤.10) were entered into a stepwise logistic regression to identify independent predictors. RESULTS Among 1,003 sixth graders (55% white, 15% African American; average age 11.5 years), 150 (15%) were obese. Obese students had higher levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, blood pressure, and recovery heart rates. They consumed more regular soda and school lunches but were less likely to engage in physical activities. Obese students were more likely to watch TV≥2 hours per day. Independent predictors were watching TV or video games (odds ratio [OR] 1.19, 95% CI 1.06-1.33) and school lunch consumption (OR 1.29, 95% CI 1.02-1.64); moderate exercise was protective (OR 0.89, 95% CI 0.82-0.98). CONCLUSIONS Obesity is present in 15% of our sixth graders and is associated with major differences in cardiovascular risk factors. Opportunities to improve childhood health should emphasize programs that increase physical activity, reduce recreational screen time, and improve nutritional value of school lunches. Whether genetic or not, childhood obesity can be attacked.

Trends (1986 to 1999) in the incidence and outcomes of in-hospital stroke complicating acute myocardial infarction (The Worcester Heart Attack Study)

Although stroke is an infrequent hospital complication of acute myocardial infarction (AMI), limited contemporary data are available about the incidence and death rates associated with this serious complication. The objective of this population-based study was to examine temporal trends (1986 to 1999) in the risk of stroke and associated hospital outcomes in patients hospitalized with AMI. This was an observational study of 6,325 metropolitan Worcester, Massachusetts, residents hospitalized with validated AMI and without prior stroke at all greater Worcester hospitals during 8 one-year periods between 1986 and 1999. Overall, 1.5% of patients (n = 92) with confirmed AMI developed an acute stroke during their index hospitalization. Decreases, followed by increases, in the risk of acute stroke were observed between 1986 and 1999. The highest risk for stroke was observed in the most recent study year of 1999 (3.0%). Several demographic, medical history, and clinical characteristics were associated with an increased risk of stroke overall and separately in younger and older patients hospitalized with AMI. Patients developing an acute stroke had a significantly increased risk of dying during hospitalization even after controlling for other factors of prognostic importance (adjusted odds ratio 4.26, 95% confidence interval 2.49 to 7.31). The results of this community-wide study provide insights into recent trends in the development of acute stroke after AMI and into the profile of high-risk patients.

Gender Differences in Physiologic Markers and Health Behaviors Associated With Childhood Obesity

BACKGROUND: Previous studies have demonstrated gender-related differences in body composition, physical activity, and diet. This observational study assesses gender variance in independent predictors for obesity to determine targeted areas for intervention. METHODS: Data from 1714 sixth-grade students enrolled in Project Healthy Schools were compared by using health behaviors and physiologic markers (lipids, random glucose, blood pressure, and resting and recovery heart rates). Students were stratified by gender and obesity (BMI ≥95th percentile by age and gender). Physiologic markers and behaviors were compared by using χ2 analysis. Univariate associations with P < .10 were included in a stepwise logistic regression model to determine independent predictors for obesity by gender. RESULTS: Nonobese students (both boys and girls) showed significantly healthier physiologic parameters compared with their obese counterparts. Two behaviors independently correlated with obesity in both boys and girls: regularly eating school lunches (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01–1.64; OR 1.27, 95% CI 1.00–1.62, respectively) and watching ≥2 hours of television per day (OR 1.19, 95% CI 1.07–1.32; OR 1.19, 95% CI 1.06–1.34, respectively). Vigorous physical activity and involvement in school sports teams appeared to be protective against obesity in boys (OR 0.90, 95% CI 0.82–0.98; OR 0.77, 95% CI 0.64–0.94, respectively), whereas milk consumption appeared protective in girls (OR 0.81, 95% CI 0.67–0.98). CONCLUSIONS: Among middle-school children, we observed gender-related differences in factors associated with obesity. Additional research is warranted to determine the beneficial impact of improving school lunches and decreasing screen time, while improving our understanding of gender-related differences in milk consumption and physical activities in relation to BMI.

Effect of Use of Combination Evidence-Based Medical Therapy After Acute Coronary Syndromes on Long-Term Outcomes

Several medications have individually been shown to reduce mortality in patients with acute coronary syndromes (ACS), but data on long-term outcomes related to the use of combinations of these medications are limited. For 2,684 consecutive patients admitted with ACS from January 1999 and January 2007, a composite score was calculated correlating with the use upon discharge of indicated evidence-based medications (EBMs): aspirin, β blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents. Multivariate models were used to examine the impact of EBM score on 2-year events with adjustment for components of the Global Registry of Acute Coronary Events (GRACE) risk score, thienopyridine use, and year of discharge. Women were older, had more co-morbidities, and were less likely to receive all 4 EBMs (53% vs 64%, p < 0.0001) than men. Patients who received all 4 indicated EBMs had a significant 2-year survival benefit compared to patients who received ≤1 EBM (odds ratio 0.25, 95% confidence interval 0.15 to 0.41), which was observed when men and women were examined separately (for men, odds ratio 0.22, 95% confidence interval 0.11 to 0.44; for women, odds ratio 0.3, 95% confidence interval 0.15 to 0.63). A modest benefit, in terms of cardiovascular disease events (myocardial infarction, rehospitalization, stroke, and death), was observed only for men who received all 4 EBMs. In conclusion, a combination of cardiac medications at the time of ACS discharge is strongly associated with 2-year survival in men and women, suggesting that discharge is an important time to prescribe secondary preventative medications.