Janet B. Croft

State of Disparities in Cardiovascular Health in the United States

Background—Reducing health disparities remains a major public health challenge in the United States. Having timely access to current data on disparities is important for policy and program development. Accordingly, we assessed the current magnitude of disparities in cardiovascular disease (CVD) and its risk factors in the United States. Methods and Results—Using national surveys, we determined CVD and risk factor prevalence and indexes of morbidity, mortality, and overall quality of life in adults ≥18 years of age by race/ethnicity, sex, education level, socioeconomic status, and geographic location. Disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.2%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (47.3%). Hypertension prevalence was high among blacks (39.8%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women in both groups of educational status. Ischemic heart disease and stroke were inversely related to education, income, and poverty status. Hospitalization was greater in men for total heart disease and acute myocardial infarction but greater in women for congestive heart failure and stroke. Among Medicare enrollees, congestive heart failure hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for congestive heart failure and stroke were highest in the southeastern United States. Life expectancy remains higher in women than men and higher in whites than blacks by ≈5 years. CVD mortality at all ages tended to be highest in blacks. Conclusions—Disparities in CVD and related risk factors remain pervasive. The data presented here can be invaluable for policy development and in the planning, implementation, and evaluation of interventions designed to eliminate health disparities.

Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: A scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Heart Failure-Related Hospitalization in the U.S., 1979 to 2004

OBJECTIVES The purpose of this study was to determine hospitalizations for heart failure in the U.S. during the past 26 years. BACKGROUND Heart failure increased in the U.S.; however, little is known about the long-term trends in diseases leading to hospitalizations among patients with heart failure. METHODS Using National Hospital Discharge Survey data from 1979 to 2004, we assessed trends in hospitalizations for heart failure as either a first-listed or additional (2nd to 7th) diagnosis. Among hospitalizations with any mention of heart failure, we assessed the distribution of first-listed diagnoses. RESULTS The number of hospitalizations with any mention of heart failure tripled from 1,274,000 in 1979 to 3,860,000 in 2004; 65% to 70% of admissions were patients with additional diagnoses of heart failure. Heart failure hospitalization rates increased sharply with age. More than 80% of hospitalizations were among patients of at least 65 years and were paid by Medicare/Medicaid. Age-adjusted hospitalization rates between 1979 and 2004 increased for heart failure as either the first-listed or additional diagnosis. Whereas heart failure was the first-listed diagnosis for 30% to 35% of these hospitalizations, the proportion with respiratory diseases and noncardiovascular, nonrespiratory diseases as the first-listed diagnoses increased. Heart failure hospitalizations that resulted in transfers to long-term care facilities increased, and in-hospital mortality and length of hospital stay declined. CONCLUSIONS With the increased aging of the U.S. population and advanced therapeutic interventions that improve survival, it is expected that heart failure hospitalizations at older ages and the associated economic burden to Medicare will continue to increase in the future.

Adverse childhood experiences and personal alcohol abuse as an adult.

Adult alcohol abuse has been linked to childhood abuse and family dysfunction. However, little information is available about the contribution of multiple adverse childhood experiences (ACEs) in combination with parental alcohol abuse, to the risk of later alcohol abuse. A questionnaire about childhood abuse, parental alcoholism and family dysfunction while growing up was completed by adult HMO members in order to retrospectively assess the independent relationship of eight ACEs to the risk of adult alcohol abuse. The number of ACEs was used in stratified logistic regression models to assess their impact on several adult alcohol problems in the presence or absence of parental alcoholism. Each of the eight individual ACEs was associated with a higher risk alcohol abuse as an adult. Compared to persons with no ACEs, the risk of heavy drinking, self-reported alcoholism, and marrying an alcoholic were increased twofold to fourfold by the presence of multiple ACEs, regardless of parental alcoholism. Prevention of ACEs and treatment of persons affected by them may reduce the occurrence of adult alcohol problems.

Adverse childhood experiences and the risk of premature mortality.

BACKGROUND Strong, graded relationships between exposure to childhood traumatic stressors and numerous negative health behaviors and outcomes, healthcare utilization, and overall health status inspired the question of whether these adverse childhood experiences (ACEs) are associated with premature death during adulthood. PURPOSE This study aims to determine whether ACEs are associated with an increased risk of premature death during adulthood. METHODS Baseline survey data on health behaviors, health status, and exposure to ACEs were collected from 17,337 adults aged >18 years during 1995-1997. The ACEs included abuse (emotional, physical, sexual); witnessing domestic violence; parental separation or divorce; and growing up in a household where members were mentally ill, substance abusers, or sent to prison. The ACE score (an integer count of the eight categories of ACEs) was used as a measure of cumulative exposure to traumatic stress during childhood. Deaths were identified during follow-up assessments (between baseline appointment date and December 31, 2006) using mortality records obtained from a search of the National Death Index. Expected years of life lost (YLL) and years of potential life lost (YPLL) were computed using standard methods. The relative risk of death from all causes at age < or =65 years and at age < or =75 years was estimated across the number of categories of ACEs using multivariable-adjusted Cox proportional hazards regression. Analysis was conducted during January-February 2009. RESULTS Overall, 1539 people died during follow-up; the crude death rate was 91.0 per 1000; the age-adjusted rate was 54.7 per 1000. People with six or more ACEs died nearly 20 years earlier on average than those without ACEs (60.6 years, 95% CI=56.2, 65.1, vs 79.1 years, 95% CI=78.4, 79.9). Average YLL per death was nearly three times greater among people with six or more ACEs (25.2 years) than those without ACEs (9.2 years). Roughly one third (n=526) of those who died during follow-up were aged < or =75 years at the time of death, accounting for 4792 YPLL. After multivariable adjustment, adults with six or more ACEs were 1.7 (95% CI=1.06, 2.83) times more likely to die when aged < or =75 years and 2.4 (95% CI=1.30, 4.39) times more likely to die when aged < or =65 years. CONCLUSIONS ACEs are associated with an increased risk of premature death, although a graded increase in the risk of premature death was not observed across the number of categories of ACEs. The increase in risk was only partly explained by documented ACE-related health and social problems, suggesting other possible mechanisms by which ACEs may contribute to premature death.

Cumulative Childhood Stress and Autoimmune Diseases in Adults

Objective: To examine whether childhood traumatic stress increased the risk of developing autoimmune diseases as an adult. Methods: Retrospective cohort study of 15,357 adult health maintenance organization members enrolled in the Adverse Childhood Experiences (ACEs) Study from 1995 to 1997 in San Diego, California, and eligible for follow-up through 2005. ACEs included childhood physical, emotional, or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce, and/or an incarcerated household member. The total number of ACEs (ACE Score range = 0-8) was used as a measure of cumulative childhood stress. The outcome was hospitalizations for any of 21 selected autoimmune diseases and 4 immunopathology groupings: T- helper 1 (Th1) (e.g., idiopathic myocarditis); T-helper 2 (Th2) (e.g., myasthenia gravis); Th2 rheumatic (e.g., rheumatoid arthritis); and mixed Th1/Th2 (e.g., autoimmune hemolytic anemia). Results: Sixty-four percent reported at least one ACE. The event rate (per 10,000 person-years) for a first hospitalization with any autoimmune disease was 31.4 in women and 34.4 in men. First hospitalizations for any autoimmune disease increased with increasing number of ACEs (p < .05). Compared with persons with no ACEs, persons with ≥2 ACEs were at a 70% increased risk for hospitalizations with Th1, 80% increased risk for Th2, and 100% increased risk for rheumatic diseases (p < .05). Conclusions: Childhood traumatic stress increased the likelihood of hospitalization with a diagnosed autoimmune disease decades into adulthood. These findings are consistent with recent biological studies on the impact of early life stress on subsequent inflammatory responses. ACE = adverse childhood experience; AD = autoimmune disease; Th1 = T-helper 1; Th2 = T-helper 2; CRP = C-reactive protein; CRH = corticoid releasing hormone.

Growing up with Parental Alcohol Abuse: Exposure to Childhood Abuse, Neglect, and Household Dysfunction.

OBJECTIVE This study is a detailed examination of the association between parental alcohol abuse (mother only, father only, or both parents) and multiple forms of childhood abuse, neglect, and other household dysfunction, known as adverse childhood experiences (ACEs). METHOD A questionnaire about ACEs including child abuse, neglect, household dysfunction, and exposure to parental alcohol abuse was completed by 8629 adult HMO members to retrospectively assess the relationship of growing up with parental alcohol abuse to 10 ACEs and multiple ACEs (ACE score). RESULTS Compared to persons who grew up with no parental alcohol abuse, the adjusted odds ratio for each category of ACE was approximately 2 to 13 times higher if either the mother, father, or both parents abused alcohol (p < 0.05). For example, the likelihood of having a battered mother was increased 13-fold for men who grew up with both parents who abused alcohol (OR, 12.7; 95% CI: 8.4-19.1). For almost every ACE, those who grew up with both an alcohol-abusing mother and father had the highest likelihood of ACEs. The mean number of ACEs for persons with no parental alcohol abuse, father only, mother only, or both parents was 1.4, 2.6, 3.2, and 3.8, respectively (p < .001). CONCLUSION Although the retrospective reporting of these experiences cannot establish a causal association with certainty, exposure to parental alcohol abuse is highly associated with experiencing adverse childhood experiences. Improved coordination of adult and pediatric health care along with related social and substance abuse services may lead to earlier recognition, treatment, and prevention of both adult alcohol abuse and adverse childhood experiences, reducing the negative sequelae of ACEs in adolescents and adults.

White blood cell count: an independent predictor of coronary heart disease mortality among a national cohort.

An association between elevated white blood cell (WBC) count and coronary heart disease (CHD) mortality has been previously observed. However, the relationship between WBC count and CHD mortality independent of cigarette smoking and the possible interaction between WBC count and smoking remains unclear. We examined the association between WBC count and CHD mortality with Cox regression analyses of data from 8914 adults, aged 30-75, in the NHANES II Mortality Study (1976-1992). Covariates included age, sex, race, education, physical activity, smoking status, hypertensive status, total serum cholesterol, body mass index, hematocrit, and history of cardiovascular disease, stroke, and diabetes. During 17 follow-up years, there were 548 deaths from CHD (ICD-9 410-414) and 782 deaths from diseases of the heart (ICD-9 390-398, 402, 404, 410-414, 415-417, 420-429). Mean WBC count (x10(9) cells/L) was greater among persons who died from CHD (7.6 vs 7.2, P <.001). Compared to persons with a WBC count <6.1, persons with a WBC count > 7.6 were at increased risk of death from CHD (relative risk = 1.4, 95% confidence interval = 1.1-1.8) after adjustment for smoking status and other CVD risk factors. Similar results were observed among nonsmokers (RR = 1.4, 95% CI = 0.9-2.0). These results suggest that higher WBC counts are a predictor of CHD mortality independent of the effects of smoking and other traditional CVD risk factors, which may indicate a role for inflammation in the pathogenesis of CHD. Additional studies are needed to determine whether interventions to decrease inflammation can reduce the risk for CHD associated with elevated WBC.

Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study

BackgroundStrong relationships between exposure to childhood traumatic stressors and smoking behaviours inspire the question whether these adverse childhood experiences (ACEs) are associated with an increased risk of lung cancer during adulthood.MethodsBaseline survey data on health behaviours, health status and exposure to adverse childhood experiences (ACEs) were collected from 17,337 adults during 1995-1997. ACEs included abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members with mentally ill, substance abusers, or sent to prison. We used the ACE score (an integer count of the 8 categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. Two methods of case ascertainment were used to identify incident lung cancer through 2005 follow-up: 1) hospital discharge records and 2) mortality records obtained from the National Death Index.ResultsThe ACE score showed a graded relationship to smoking behaviors. We identified 64 cases of lung cancer through hospital discharge records (age-standardized risk = 201 × 100,000-1 population) and 111 cases of lung cancer through mortality records (age-standardized mortality rate = 31.1 × 100,000-1 person-years). The ACE score also showed a graded relationship to the incidence of lung cancer for cases identified through hospital discharge (P = 0.0004), mortality (P = 0.025), and both methods combined (P = 0.001). Compared to persons without ACEs, the risk of lung cancer for those with ≥ 6 ACEs was increased approximately 3-fold (hospital records: RR = 3.18, 95%CI = 0.71-14.15; mortality records: RR = 3.55, 95%CI = 1.25-10.09; hospital or mortality records: RR = 2.70, 95%CI = 0.94-7.72). After a priori consideration of a causal pathway (i.e., ACEs → smoking → lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with ≥ 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs.ConclusionsAdverse childhood experiences may be associated with an increased risk of lung cancer, particularly premature death from lung cancer. The increase in risk may only be partly explained by smoking suggesting other possible mechanisms by which ACEs may contribute to the occurrence of lung cancer.