Norrina B. Allen

Status of Cardiovascular Health in US Adults Prevalence Estimates From the National Health and Nutrition Examination Surveys (NHANES) 2003–2008

Background— The American Heart Associations 2020 Strategic Impact Goals define a new concept, cardiovascular (CV) health; however, current prevalence estimates of the status of CV health in US adults according to age, sex, and race/ethnicity have not been published. Methods and Results— We included 14 515 adults (≥20 years of age) from the 2003 to 2008 National Health and Nutrition Examination Surveys. Participants were stratified by young (20–39 years), middle (40–64 years), and older (≥65 years) ages. CV health behaviors (diet, physical activity, body mass index, smoking) and CV health factors (blood pressure, total cholesterol, fasting blood glucose, smoking) were defined as poor, intermediate, or ideal. Fewer than 1% of adults exhibited ideal CV health for all 7 metrics. For CV health behaviors, nonsmoking was most prevalent (range, 60.2%–90.4%), whereas ideal Healthy Diet Score was least prevalent (range, 0.2%–2.6%) across groups. Prevalences of ideal body mass index (range, 36.5%–45.3%) and ideal physical activity levels (range, 50.2%–58.8%) were higher in young adults compared with middle or older ages. Ideal total cholesterol (range, 23.7%–36.2%), blood pressure (range, 11.9%–16.3%), and fasting blood glucose (range, 31.2%–42.9%) were lower in older adults compared with young and middle-aged adults. Prevalence of poor CV health factors was lowest in young age but higher at middle and older ages. Prevalence estimates by age and sex were consistent across race/ethnic groups. Conclusions— These prevalence estimates of CV health represent a starting point from which effectiveness of efforts to promote CV health and prevent CV disease can be monitored and compared in US adult populations.

Blood Pressure Trajectories in Early Adulthood and Subclinical Atherosclerosis in Middle Age

IMPORTANCE Single measures of blood pressure (BP) levels are associated with the development of atherosclerosis; however, long-term patterns in BP and their effect on cardiovascular disease risk are poorly characterized. OBJECTIVES To identify common BP trajectories throughout early adulthood and to determine their association with presence of coronary artery calcification (CAC) during middle age. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort data from 4681 participants in the CARDIA study, who were black and white men and women aged 18 to 30 years at baseline in 1985-1986 at 4 urban US sites, collected through 25 years of follow-up (2010-2011). We examined systolic BP, diastolic BP, and mid-BP (calculated as [SBP+DBP]/2, an important marker of coronary heart disease risk among younger populations) at baseline and years 2, 5, 7, 10, 15, 20, and 25. Latent mixture modeling was used to identify trajectories in systolic, diastolic, and mid-BP over time. MAIN OUTCOMES AND MEASURES Coronary artery calcification greater than or equal to Agatston score of 100 Hounsfield units (HU) at year 25. RESULTS We identified 5 distinct mid-BP trajectories: low-stable (21.8%; 95% CI, 19.9%-23.7%; n=987), moderate-stable (42.3%; 40.3%-44.3%; n=2085), moderate-increasing (12.2%; 10.4%-14.0%; n=489), elevated-stable (19.0%; 17.1%-20.0%; n=903), and elevated-increasing (4.8%; 4.0%-5.5%; n=217). Compared with the low-stable group, trajectories with elevated BP levels had greater odds of having a CAC score of 100 HU or greater. Adjusted odds ratios were 1.44 (95% CI, 0.83-2.49) for moderate-stable, 1.86 (95% CI, 0.91-3.82) for moderate-increasing, 2.28 (95% CI, 1.24-4.18), for elevated-stable, and 3.70 (95% CI, 1.66-8.20) for elevated-increasing groups. The adjusted prevalence of a CAC score of 100 HU or higher was 5.8% in the low-stable group. These odds ratios represent an absolute increase of 2.7%, 5%, 6.3%, and 12.9% for the prevalence of a CAC score of 100 HU or higher for the moderate-stable, moderate-increasing, elevated-stable and elevated-increasing groups, respectively, compared with the low-stable group. Associations were not altered after adjustment for baseline and year 25 BP. Findings were similar for trajectories of isolated systolic BP trajectories but were attenuated for diastolic BP trajectories. CONCLUSIONS AND RELEVANCE Blood pressure trajectories throughout young adulthood vary, and higher BP trajectories were associated with an increased risk of CAC in middle age. Long-term trajectories in BP may assist in more accurate identification of individuals with subclinical atherosclerosis.

Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: the cardiovascular lifetime risk pooling project.

Background— Prior estimates of lifetime risk (LTR) for cardiovascular disease (CVD) examined the impact of blood pressure (BP) at the index age and did not account for changes in BP over time. We examined how changes in BP during middle age affect LTR for CVD, coronary heart disease, and stroke. Methods and Results— Data from 7 diverse US cohort studies were pooled. Remaining LTRs for CVD, coronary heart disease, and stroke were estimated for white and black men and women with death free of CVD as a competing event. LTRs for CVD by BP strata and by changes in BP over an average of 14 years were estimated. Starting at 55 years of age, we followed up 61 585 men and women for 700 000 person-years. LTR for CVD was 52.5% (95% confidence interval, 51.3–53.7) for men and 39.9% (95% confidence interval, 38.7–41.0) for women. LTR for CVD was higher for blacks and increased with increasing BP at index age. Individuals who maintained or decreased their BP to normal levels had the lowest remaining LTR for CVD, 22% to 41%, compared with individuals who had or developed hypertension by 55 years of age, 42% to 69%, suggesting a dose-response effect for the length of time at high BP levels. Conclusions— Individuals who experience increases or decreases in BP in middle age have associated higher and lower remaining LTR for CVD. Prevention efforts should continue to emphasize the importance of lowering BP and avoiding or delaying the incidence of hypertension to reduce the LTR for CVD.

Symptom Recognition and Healthcare Experiences of Young Women With Acute Myocardial Infarction

Background—Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ⩽55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population. Methods and Results—We conducted a qualitative study using in-depth interviews with 30 women (aged 30–55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease. Conclusions—Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women’s elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

Association of Neighborhood Characteristics With Cardiovascular Health in the Multi-Ethnic Study of Atherosclerosis

Background—The concept of cardiovascular health (CVH) was introduced as a global measure of ones burden of cardiovsacular risk factors. Previous studies established the relationship between neighborhood characteristics and individual cardiovascular risk factors. However, the relationship between neighborhood environment and overall CVH remains unknown. Methods and Results—We analyzed data from the Multi-Ethnic Study of Atherosclerosis baseline examination (2000–2002). Mean age was 61.6 years, and 52% were women. Ideal, intermediate, and poor categories of cholesterol, body mass index, diet, physical activity, fasting glucose, blood pressure, and smoking were defined according to the American Heart Association 2020 Strategic Goals, assigned an individual score, and summed to create an overall score. CVH scores were categorized into ideal (11–14 points), intermediate (9–10), and poor (0–8). Neighborhood exposures included favorable food store and physical activity resources densities (by 1-mile buffer), reported healthy food availability, walking/physical activity environment, safety, and social cohesion (by census tract). Multinomial logistic regression was used to determine the association of each characteristic with ideal and intermediate CVH, adjusted for demographics and neighborhood socioeconomic status. Over 20% of Multi-Ethnic Study of Atherosclerosis participants had an ideal CVH score at baseline. In fully adjusted models, favorable food stores (odds ratio=1.22; 1.06–1.40), physical activity resources (odds ratio=1.19; 1.08–1.31), walking/physical activity environment (odds ratio=1.20; 1.05–1.37), and neighborhood socioeconomic status (odds ratio=1.22; 1.11–1.33) were associated with higher odds of having an ideal CVH score. Conclusions—Neighborhood environment including favorable food stores, physical activity resources, walking/physical activity environment, and neighborhood socioeconomic status are associated with ideal CVH. Further research is needed to investigate the longitudinal associations between neighborhood environment and CVH.

Long-Term Blood Pressure Variability Throughout Young Adulthood and Cognitive Function in Midlife The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Whether long-term blood pressure (BP) variability throughout young adulthood is associated with cognitive function in midlife remains uncertain. Using data from the Coronary Artery Risk Development in Young Adults (CARDIA), which recruited healthy young adults aged 18 to 30 years (mean age, 25 years) at baseline (Y0), we assessed BP variability by SD and average real variability (ARV) for 25 years (8 visits). Cognitive function was assessed with the Digit Symbol Substitution Test (psychomotor speed test), the Rey Auditory Verbal Learning Test (verbal memory test), and the modified Stroop test (executive function test) at follow-up (Y25). At the Y25 examination, participants (n=2326) had a mean age of 50.4 years, 43% were men, and 40% were black. In multivariable-adjusted linear regression models, higher ARVSBP, ARVDBP, and SDDBP were significantly associated with lower scores of Digit Symbol Substitution Test (&bgr; [SE]: −0.025 [0.006], −0.029 [0.007], and −0.029 [0.007], respectively; all P<0.001) and Rey Auditory Verbal Learning Test (&bgr; [SE]: −0.016 [0.006], −0.021 [0.007], and −0.019 [0.007], respectively; all P<0.05) after adjustment for demographic and clinical characteristics and with cumulative exposure to BP through Y0 to Y25. Neither SDBP nor ARVBP was associated with the Stroop score. The associations between ARVBP or SDBP and each cognitive function test were similar between blacks and whites except for 1 significant interaction between race and SDSBP on the Digit Symbol Substitution Test (P<0.05). Long-term BP variability for 25 years beginning in young adulthood was associated with worse psychomotor speed and verbal memory tests in midlife, independent of cumulative exposure to BP during follow-up.Whether long-term blood pressure (BP) variability throughout young adulthood is associated with cognitive function in midlife remains uncertain. Using data from the Coronary Artery Risk Development in Young Adults (CARDIA), which recruited healthy young adults aged 18 to 30 years (mean age, 25 years) at baseline (Y), we assessed BP variability by SD and average real variability (ARV) for 25 years (8 visits). Cognitive function was assessed with the Digit Symbol Substitution Test (psychomotor speed test), the Rey Auditory Verbal Learning Test (verbal memory test), and the modified Stroop test (executive function test) at follow-up (Y25). At the Y25 examination, participants (n=2326) had a mean age of 50.4 years, 43% were men, and 40% were black. In multivariable-adjusted linear regression models, higher ARVSBP, ARVDBP, and SDDBP were significantly associated with lower scores of Digit Symbol Substitution Test (β [SE]: −0.025 [0.006], −0.029 [0.007], and −0.029 [0.007], respectively; all P <0.001) and Rey Auditory Verbal Learning Test (β [SE]: −0.016 [0.006], −0.021 [0.007], and −0.019 [0.007], respectively; all P <0.05) after adjustment for demographic and clinical characteristics and with cumulative exposure to BP through Y to Y25. Neither SDBP nor ARVBP was associated with the Stroop score. The associations between ARVBP or SDBP and each cognitive function test were similar between blacks and whites except for 1 significant interaction between race and SDSBP on the Digit Symbol Substitution Test ( P <0.05). Long-term BP variability for 25 years beginning in young adulthood was associated with worse psychomotor speed and verbal memory tests in midlife, independent of cumulative exposure to BP during follow-up. # Novelty and Significance {#article-title-25}

Regional Variation in Recommended Treatments for Ischemic Stroke and TIA Get With the Guidelines-Stroke 2003–2010

Background and Purpose— Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get With The Guidelines-Stroke. Methods— Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics. Results— Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%–67.8%), lipid-lowering medications (72.5%–75.7%), antihypertensives (80.1%–83.6%), antithrombotics (95.6%–96.8%), deep vein thrombosis prophylaxis (88.0%–91.4%), weight loss education (49.3%–54.7%), and defect-free care (72.1%–76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69–0.97]), antihypertensives (0.82 [0.67–0.99]), and defect-free care (0.83 [0.75–0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05–1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68–0.99]) and defect-free care (0.81 [0.72–0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67–0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03–1.53]). Conclusions— Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.

Geographic variation in one-year recurrent ischemic stroke rates for elderly Medicare beneficiaries in the USA.

Background: While geographic disparities in stroke mortality are well documented, there are no data describing geographic variation in recurrent stroke. Accordingly, we evaluated geographic variations in 1-year recurrent ischemic stroke rates in the USA with adjustment for patient characteristics. Methods: One-year recurrent stroke rates for ischemic stroke (International Classification of Diseases, 9th Revision codes 433, 434 and 436) following hospital discharge were calculated by county for all fee-for-service Medicare beneficiaries from 2000 to 2002. The rates were standardized and smoothed using a bayesian conditional autoregressive model that was risk-standardized for patients’ age, gender, race/ethnicity, prior hospitalizations, Deyo comorbidity score, acute myocardial infarction, congestive heart failure, diabetes, hypertension, dementia, cancer, chronic obstructive pulmonary disease and obesity. Results: The overall 1-year recurrent stroke rate was 9.4% among 895,916 ischemic stroke patients (mean age: 78 years; 56.6% women; 86.6% White, 9.7% Black and 1.2% Latino/Hispanic). The rates varied by geographic region and were highest in the South and in parts of the West and Midwest. Regional variation was present for all racial/ethnic subgroups and persisted after adjustment for individual patient characteristics. Conclusions: Almost 1 in 10 hospitalized ischemic stroke patients was readmitted for an ischemic stroke within 1 year. There was heterogeneity in recurrence patterns by geographic region. Further work is needed to understand the reasons for this regional variability.

Comparison of Medicare Claims Versus Physician Adjudication for Identifying Stroke Outcomes in the Women’s Health Initiative

Background and Purpose— Many studies use medical record review for ascertaining outcomes. One large, longitudinal study, the Women’s Health Initiative (WHI), ascertains strokes using participant self-report and subsequent physician review of medical records. This is resource-intensive. Herein, we assess whether Medicare data can reliably assess stroke events in the WHI. Methods— Subjects were WHI participants with fee-for-service Medicare. Four stroke definitions were created for Medicare data using discharge diagnoses in hospitalization claims: definition 1, stroke codes in any position; definition 2, primary position stroke codes; and definitions 3 and 4, hemorrhagic and ischemic stroke codes, respectively. WHI data were randomly split into training (50%) and test sets. A concordance matrix was used to examine the agreement between WHI and Medicare stroke diagnosis. A WHI stroke and a Medicare stroke were considered a match if they occurred within ±7 days of each other. Refined analyses excluded Medicare events when medical records were unavailable for comparison. Results— Training data consisted of 24 428 randomly selected participants. There were 577 WHI strokes and 557 Medicare strokes using definition 1. Of these, 478 were a match. With regard to algorithm performance, specificity was 99.7%, negative predictive value was 99.7%, sensitivity was 82.8%, positive predictive value was 85.8%, and &kgr;=0.84. Performance was similar for test data. Whereas specificity and negative predictive value exceeded 99%, sensitivity ranged from 75% to 88% and positive predictive value ranged from 80% to 90% across stroke definitions. Conclusions— Medicare data seem useful for population-based stroke research; however, performance characteristics depend on the definition selected.

Association between urinary cadmium levels and prediabetes in the NHANES 2005–2010 population

Evidence suggests an association between exposure to cadmium and dysglycemia. To investigate this matter, we examined the relationship between urinary cadmium and prediabetes in the cross sectional National Health and Nutrition Examination Survey (NHANES). NHANES participants for the years 2005 through 2010 aged ≥ 40 years were included in the analysis. Participants with nephropathy, overt diabetes, or missing required data were excluded. To assess the non-linear relationship between cadmium and Prediabetes, non-parametric logistic regression with B spline expansion of urinary cadmium/creatinine ratio was performed. This analysis revealed a complex non-linear association between higher cadmium levels and prediabetes. This relationship persisted, though with varying magnitudes across smoking groups (never smokers, moderate smokers, heavy smokers). In a conventional logistic regression analysis, this relationship was less evident with significantly increased OR for prediabetes was found in the highest quintile of urine cadmium compared to the lowest quintile in the overall population and in moderate smokers. In an age stratified analysis, a significant linear association was found only in the age groups 60-69 and ≥ 70. We conclude that there is a significant non-linear, complex relationship between urinary Cd levels, age, smoking habits and odds of prediabetes.