Feasibility of a healthcare system-based tetralogy of Fallot patient registry

Background Patient-reported outcomes and epidemiological studies in adults with tetralogy of Fallot are lacking. Recruitment and longitudinal follow-up investigation across institutions is particularly challenging. Objectives of this study were to assess the feasibility of recruiting adult patients with tetralogy of Fallot for a patient-reported outcomes study, describe challenges for recruitment, and create an interactive, online tetralogy of Fallot registry. Methods Adult patients living with tetralogy of Fallot, aged 18-58 years, at the University of North Carolina were identified using diagnosis code query. A survey was designed to collect demographics, symptoms, history, and birth mother information. Recruitment was attempted by phone (Part I, n=20) or by email (Part II, n=20). Data analysis included thematic grouping of recruitment challenges and descriptive statistics. Feasibility threshold was 75% for recruitment and for data fields completed per patient. Results In Part I, 60% (12/20) were successfully contacted and eight (40%) were enrolled. Demographics and birth mother information were obtained for all enrolled patients. In Part II, 70% (14/20) were successfully contacted; 30% (6/20) enrolled and completed all data fields linked to REDCap database; the median time for survey completion was 8 minutes. Half of the patients had cardiac operations/procedures performed at more than one hospital. Automatic electronic data entry from the online survey was uncomplicated. Conclusions Although recruitment (54%) fell below our feasibility threshold, enrolled individuals were willing to complete phone or online surveys. Incorrect contact information, privacy concerns, and patient-reported time constraints were challenges for recruitment. Creating an online survey and linked database is technically feasible and efficient for patient-reported outcomes research

The Association between Parity and Subsequent Cardiovascular Disease in Women: The Atherosclerosis Risk in Communities Study

Background: Previous studies are inconclusive on the relationship between parity and cardiovascular disease (CVD), with few evaluating multiple cardiovascular outcomes. It is also unclear if any relationship between parity and CVD is independent of breastfeeding. We examined the associations between parity and cardiovascular outcomes, including breastfeeding adjustment. Materials and Methods: Data were from 8,583 White and African American women, 45-64 years of age, in the Atherosclerosis Risk in Communities Study. Coronary heart disease (CHD), myocardial infarction (MI), heart failure, and strokes were ascertained from 1987 to 2016 by annual interviews and hospital surveillance. Parity and breastfeeding were self-reported. Cox proportional hazards regression estimated hazard ratios (HR) for the association between parity and cardiovascular outcomes, adjusting for baseline sociodemographic, clinical and lifestyle factors, and breastfeeding. Results: Women reported no pregnancies (6.0%), or having 0 (1.6%), 1-2 (36.2%), 3-4 (36.4%), or 5+ (19.7%) live births. During 30 years follow-up, there were 1,352 CHDs, 843 MIs, 750 strokes, and 1,618 heart failure events. Compared with women with 1-2 prior births, those with prior pregnancies and no live births had greater incident CHD (HR=1.64, 95% confidence interval 1.14-2.42) and heart failure risk (1.46, 1.04-2.05), after adjustment for baseline characteristics. Women with 5+ births had greater risk of CHD (1.29, 1.10-1.52) and hospitalized MI (1.38, 1.13-1.69), after adjustment for baseline characteristics and breastfeeding. Conclusions: In a diverse U.S. cohort, a history of 5+ live births is associated with CHD risk, specifically, MI, independent of breastfeeding. Having a prior pregnancy and no live birth is associated with greater CHD and heart failure risk

Association of Sleep Apnea, Diagnosed by Self-Reported Physician Diagnosis or Hospital Discharge Codes, With Atrial Fibrillation and Ectopy Using Ambulatory Electrocardiogram in the ARIC Study

Sleep apnea is associated with cardiac arrhythmias1 such as atrial fibrillation (AF), premature ventricular contractions (PVC), and premature atrial contractions (PAC). Mechanisms that may explain this association include autonomic imbalance, hypertension, intermittent hypoxia, and atrial remodeling. However, prior studies of sleep apnea and cardiac arrhythmias relied on a single ten second,12-lead electrocardiogram, and/or hospital medical records, which would miss paroxysmal, asymptomatic, and intermittent arrhythmias. The Reveal XT-SA study reported that using a medically implanted device for cardiac monitoring in patients with severe obstructive SA may help to identify newly detected AF, however application of this study’s findings to our work was limited as the Reveal XT-SA study used a small sample size in a clinical population.4 Our study overcomes these limitations by adding standardized 48-hour continuous ambulatory ECG (aECG) monitoring to the population-based Atherosclerosis Risk in Communities (ARIC) study to examine the association between sleep apnea and AF, PACs, and PVCs

American Heart Association's Life Simple 7 and risk of atrial fibrillation in a population without known cardiovascular disease: The ARIC (Atherosclerosis risk in communities) study

Background-The American Heart Association has defined metrics of ideal cardiovascular health known as Life's Simple 7 (LS7) to prevent cardiovascular disease. We examined the association between LS7 and incident atrial fibrillation (AF) in a biracial cohort of middle- and older-aged adults without known cardiovascular disease. Methods and Results-This analysis included 13 182 ARIC (Atherosclerosis Risk in Communities) study participants (mean baseline age=54±5.7 years; 56% women; 25% black) free of AF and cardiovascular disease. An overall LS7 score was calculated as the sum of the LS7 component scores and classified as inadequate (0-4), average (5-9), or optimal (10-14) cardiovascular health. The primary outcome was incident AF, identified primarily by ECG and hospital discharge coding of AF through December 31, 2014. A total of 2266 (17%) incident AF cases were detected over a median follow-up of 25.1 years. Compared with the inadequate category (n=1057), participants in the average (n=8629) and optimal (n=3496) categories each had a lower risk of developing AF in a multivariable Cox proportional hazards model (hazard ratio 0.59, 95% confidence interval 0.51, 0.67 for average; and hazard ratio 0.38, 95% confidence interval 0.32, 0.44 for optimal). In a similar model, a 1-point-higher LS7 score was associated with a 12% lower risk of incident AF (hazard ratio 0.88, 95% confidence interval 0.86, 0.89). Conclusions-A higher LS7 score is strongly associated with a lower risk of AF in individuals without baseline cardiovascular disease. Determining whether interventions that improve the population's cardiovascular health also reduce AF incidence is needed

Antihypertensive Adherence Trajectories among Older Adults in the First Year after Initiation of Therapy

BACKGROUND Adherence to antihypertensives is suboptimal, but previous methods of quantifying adherence fail to account for varying patterns of use over time. We sought to improve classification of antihypertensive adherence using group-based trajectory models, and to determine whether individual factors predict adherence trajectories. METHODS We identified older adults initiating antihypertensive therapy during 2008-2011 using a 20% sample of Medicare (federal health insurance available to US residents over the age of 65) beneficiaries enrolled in parts A (inpatient services), B (outpatient services), and D (prescription medication). We developed monthly adherence indicators using prescription fill dates and days supply data in the 12 months following initiation. Adherence was defined as having at least 80% of days covered. Logistic models were used to identify trajectory groups. Bayesian information criterion and trajectory group size were used to select the optimal trajectory model. We compared the distribution of covariates across trajectory groups using multivariable logistic regression. RESULTS During 2008-2011, 282,520 Medicare beneficiaries initiated antihypertensive therapy (mean age 75 years, 60% women, 84% White). Six trajectories were identified ranging from perfect adherence (12-month adherence of 0.97, 40% of beneficiaries) to immediate stopping (12-month adherence of 0.10, 18% of beneficiaries). The strongest predictors of nonadherence were initiation with a single antihypertensive class (adjusted odds ratio = 2.08 (95% confidence interval: 2.00-2.13)), Hispanic (2.93 (2.75-3.11)) or Black race/ethnicity (2.04 (1.95-2.13)), and no prior history of hypertension (2.04 (2.00-2.08)) (Area under the receiving operating characteristic curve: 0.53). CONCLUSIONS There is substantial variation in antihypertensive adherence among older adults. Certain patient characteristics are likely determinants of antihypertensive adherence trajectories

Goal-striving stress and incident cardiovascular disease in blacks: The jackson heart study

BACKGROUND: Goal-striving stress (GSS), the stress from striving for goals, is associated with poor health. Less is known about its association with cardiovascular disease (CVD). METHODS AND RESULTS: We used data from the JHS (Jackson Heart Study), a study of CVD among blacks (21–95 years old) from 2000 to 2015. Participants free of CVD at baseline (2000–2004) were included in this analysis (n=4648). GSS was examined in categories (low, moderate, high) and in SD units. Incident CVD was defined as fatal or nonfatal stroke, coronary heart disease (CHD), and/or heart failure. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of incident CVD by levels of GSS, adjusting for demographics, socioeconomic status, health behaviors, risk factors, and perceived stress. The distribution of GSS categories was as follows: 40.77% low, 33.97% moderate, and 25.26% high. Over an average of 12 years, there were 140 incident stroke events, 164 CHD events, and 194 heart failure events. After full adjustment, high (versus low) GSS was associated with a lower risk of stroke (HR, 0.38; 95% CI, 0.17–0.83) and a higher risk of CHD (HR, 1.91; 95% CI, 1.10–3.33) among women. A 1-standard deviation unit increase in GSS was associated with a 31% increased risk of CHD (HR, 1.31; 95% CI, 1.10–1.56) among women. CONCLUSIONS: Higher GSS may be a risk factor for developing CHD among women; however, it appears to be protective of stroke among women. These analyses should be replicated in other samples of black individuals

Lifetime Risk of Atrial Fibrillation by Race and Socioeconomic Status: ARIC Study (Atherosclerosis Risk in Communities)

Background: Limited information exists on the lifetime risk of atrial fibrillation (AF) in African Americans and by socioeconomic status. Methods: We studied 15 343 participants without AF at baseline from the ARIC (Atherosclerosis Risk in Communities) cohort recruited in 1987 to 1989 from 4 communities in the United States when they were 45 to 64 years of age. Participants have been followed through 2014. Incidence rates of AF were calculated dividing the number of new cases by person-years of follow-up. Lifetime risk of AF was estimated by a modified Kaplan-Meier method considering death as a competing risk. Participants' family income and education were obtained at baseline. Results: We identified 2760 AF cases during a mean follow-up of 21 years. Lifetime risk of AF was 36% (95% confidence interval, 32%-38%) in white men, 30% (95% confidence interval, 26%-32%) in white women, 21% (95% confidence interval, 13%-24%) in African American men, and 22% (95% confidence interval, 16%-25%) in African American women. Regardless of race and sex, incidence rates of AF decreased from the lowest to the highest categories of income and education. In contrast, lifetime risk of AF increased in individuals with higher income and education in most sex-race groups. Cumulative incidence of AF was lower in those with higher income and education compared with their low socioeconomic status counterparts through earlier life but was reversed after age 80. Conclusions: Lifetime risk of AF in the ARIC cohort was ≈1 in 3 among whites and 1 in 5 among African Americans. Socioeconomic status was inversely associated with cumulative incidence of AF before the last decades of life

Serum Metabolomics and Incidence of Atrial Fibrillation (from the Atherosclerosis Risk in Communities Study)

We have previously identified associations of 2 circulating secondary bile acids (glycocholenate and glycolithocolate sulfate) with atrial fibrillation (AF) risk in 1,919 blacks in the Atherosclerosis Risk in Communities cohort. We aimed to replicate these findings in an independent sample of 2,003 white and black Atherosclerosis Risk in Communities participants, and performed a new metabolomic analysis in the combined sample of 3,922 participants, followed between 1987 and 2013. Metabolomic profiling was done in baseline serum samples using gas and liquid chromatography mass spectrometry. AF was ascertained from electrocardiograms, hospitalizations, and death certificates. We used multivariable Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (95%CI) of AF by 1 standard deviation difference of metabolite levels. Over a mean follow-up of 20 years, 608 participants developed AF. Glycocholenate sulfate was associated with AF in the replication and combined samples (HR 1.10, 95% CI 1.00, 1.21 and HR 1.13, 95% CI 1.04, 1.22, respectively). Glycolithocolate sulfate was not related to AF risk in the replication sample (HR 1.02, 95% CI 0.92, 1.13). An analysis of 245 metabolites in the combined cohort identified 3 additional metabolites associated with AF after multiple-comparison correction: pseudouridine (HR 1.18, 95% CI 1.10, 1.28), uridine (HR 0.86, 95% CI 0.79, 0.93) and acisoga (HR 1.17, 95% CI 1.09, 1.26). In conclusion, we replicated a prospective association among a previously identified secondary bile acid, glycocholenate sulfate, and AF incidence, and identified new metabolites involved in nucleoside and polyamine metabolism as markers of AF risk

Polycystic Ovary Syndrome Signs and Metabolic Syndrome in Premenopausal Hispanic/Latina Women: the HCHS/SOL Study

Context: Polycystic ovary syndrome (PCOS), a condition of androgen excess in women, is associated with cardiometabolic risk factors; however, this association is not fully characterized in a population-based sample of premenopausal women and high-risk groups such as Hispanics/Latinas. Objective: We examined the association of PCOS signs and metabolic syndrome (MetS) in premenopausal Hispanic/Latina women. Methods: This cross-sectional analysis includes 1427 women age 24 to 44 years from the Hispanic Community Health Study/Study of Latinos. PCOS signs included menstrual cycle greater than 35 days or irregular, self-reported PCOS, and oral contraceptive use to regulate periods or acne, and a composite of 1 or more PCOS signs. We calculated odds ratios (OR) and 95% CI for MetS, accounting for sociodemographic factors and the complex survey design; an additional model included body mass index (BMI). Results: The mean age was 34 years and 30% reported any PCOS sign. The odds of MetS were higher in women reporting cycles greater than 35 days or irregular (OR 1.63; CI: 1.07-2.49) vs cycles 24 to 35 days, self-reported PCOS (OR 2.49; CI: 1.38-4.50) vs no PCOS, and any PCOS sign (OR 1.58; CI: 1.10-2.26) vs none. We found no association between OC use to regulate periods or acne and MetS (OR 1.1; CI: 0.6-1.8). When adjusting for BMI, only the association of self-reported PCOS and MetS was attenuated (OR 1.78; CI: 0.92-3.44). Conclusions: In Hispanic/Latina women, irregular menstrual cycles, self-reported PCOS, and any PCOS sign were associated with MetS and could indicate women at metabolic disease risk

Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005–2014) ARIC study community surveillance

BACKGROUND: Community trends of acute decompensated heart failure (ADHF) in diverse populations may differ by race and sex. METHODS: The ARIC study (Atherosclerosis Risk in Communities) sampled heart failure-related hospitalizations (≥55 years of age) in 4 US communities from 2005 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification codes. ADHF hospitalizations were validated by standardized physician review and computer algorithm, yielding 40173 events after accounting for sampling design (unweighted n=8746). RESULTS: Of the ADHF hospitalizations, 50% had reduced ejection fraction, and 39% had preserved EF (HFpEF). HF with reduced ejection fraction was more common in black men and white men, whereas HFpEF was most common in white women. Average age-adjusted rates of ADHF were highest in blacks (38.1 per 1000 black men, 30.5 per 1000 black women), with rates differing by HF type and sex. ADHF rates increased over the 10 years (average annual percentage change: black women +4.3%, black men +3.7%, white women +1.9%, white men +2.6%), mostly reflecting more acute HFpEF. Age-adjusted 28-day and 1-year case fatality proportions were ≈10% and 30%, respectively, similar across race-sex groups and HF types. Only blacks showed decreased 1-year mortality over time (average annual percentage change: black women –5.4%, black men –4.6%), with rates differing by HF type (average annual percentage change: black women HFpEF –7.1%, black men HF with reduced ejection fraction –4.7%). CONCLUSIONS: Between 2005 and 2014, trends in ADHF hospitalizations increased in 4 US communities, primarily driven by acute HFpEF. Survival at 1 year was poor regardless of EF but improved over time for black women and black men