Childhood Psychosocial Determinants of Cardiovascular Health

Understanding risk and protective factors that impact cardiovascular health is of utmost importance. There is ample evidence that cardiovascular health begins in childhood, tracks over time, and is subject to adverse social influences. This paper reviews key studies examining the relations of psychosocial factors in childhood to cardiovascular health in adulthood. The existing literature provides evidence for both individual and cumulative effects of childhood psychosocial factors on adult cardiovascular health across the population, although the specific mechanisms underlying these relationships are not yet fully understood. This paper also includes a discussion of evidence-based strategies for prevention and treatment of childhood psychosocial problems. The extent to which these programs lead to improved cardiovascular health in high-risk groups or across the population by impacting psychosocial factors has not yet been studied, but is a clear future direction for research and policy

Causes and Mechanisms, an Interview with Dr. Jeremiah Stamler

Dr. Jeremiah Stamler began his career in New York City and moved to Chicago in 1947 with his wife Rose, to accept a basic research position with Dr. Louis N. Katz. Early animal studies convinced him of the role of dietary factors, particularly cholesterol and salt, in the etiology of atherosclerotic vascular disease. Because of a strong interest in public health, he began the first of many population based cohort studies in the 1950s that subsequently defined the role of health behaviors (adverse nutrition choices, tobacco use, low physical activity) and associated measurable biologic traits, now called risk factors, in the causation of the cardiovascular disease epidemic then at its peak in the United States. He began his professional work in preventive medicine with the City of Chicago Health Department and subsequently developed the Department of Preventive Medicine at Northwestern University Medical School where he now serves as professor emeritus. His research, leadership, and teaching have been critical in defining the contemporary roles of both the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute. He remains an active investigator at age 85. I interviewed Dr. Stamler at his home

Familial Hypercholesterolemia: A Decade of Progress

Natural history studies of familial hypercholesterolemia (FH), a genetic disorder associated with elevated cholesterol and premature coronary artery disease, and with a frequency of about 1:500 in the general population, were first conducted in the 1970s. 1 Homozygotes, with cholesterol levels in excess of 500 mg/dl experience coronary events as early as adolescence and heterozygotes (with one normal and one abnormal gene) are affected prematurely in middle age. The first major breakthrough in understanding the disease came with the discovery of the low density lipoprotein (LDL) receptor by Brown and Goldstein, work that won the Nobel prize

Adolescent and adult African Americans have similar metabolic dyslipidemia.

BACKGROUND: African Americans (AAs) have lower triglyceride (TG) and higher high-density lipoprotein cholesterol (HDL-C) than other ethnic groups; yet, they also have higher risk for developing diabetes mellitus despite the strong relationship of dyslipidemia with insulin resistance. No studies directly compare adolescents and adults with regard to relationships among dyslipidemia, high-sensitivity C-reactive protein (hs-CRP), and insulin resistance. Here, we compare AA adolescents to adults with regard to the relationships of adiposity-related lipid risk markers (TG-to-HDL ratio and non-HDL-C) with body mass index (BMI), waist circumference (WC), homeostasis model of insulin resistance (HOMA), and hs-CRP. METHODS: Two cohorts of healthy AA were recruited from the same urban community. Participants in each cohort were stratified by TG-to-HDL ratio (based on adult tertiles) and non-HDL-C levels. BMI, WC, HOMA, and hs-CRP were compared in adolescents and adults in the low-, middle-, and high-lipid strata. RESULTS: Prevalence of TG-to-HDL ratio greater than 2.028 (high group) was 16% (44 of 283) in adolescents and 33% (161 of 484) in adults; prevalence of non-HDL-C above 145 and 160, respectively, was 8% (22 of 283) in adolescents and 12% (60 of 484) in adults. Values of hs-CRP were lower, and HOMA values were higher in adolescents (both P \u3c .01). As both TG-to-HDL ratio and non-HDL-C strata increased, BMI, WC, HOMA, and hs-CRP increased in both adolescents and adults. In the high TG-to-HDL ratio and non-HDL-C groups, BMI and WC were similar in adolescents vs adults (BMI, 34 kg/m(2) vs 32 kg/m(2); WC, 101 cm vs 101 cm). After adjusting for non-HDL-C and other covariates, a 2-fold increase in TG-to-HDL ratio was associated with increases of 10.4% in hs-CRP (95% CI, 1.1%-20.5%) and 24.2% in HOMA (95% CI, 16.4%-32.6%). Non-HDL-C was not significant in models having TG-to-HDL ratio. CONCLUSION: The elevated TG-to-HDL ratio is associated with similar inflammation and metabolic risk relationships in adolescent and adult AAs

Associations of cardiac structure with obesity, blood pressure, inflammation, and insulin resistance in African-American adolescents.

To determine if obesity, blood pressure (BP), markers of inflammation, and insulin resistance are associated with cardiac structure in African-American adolescents, a cross-sectional study was performed on a cohort oversampled for high BP and obesity. Measurements included the following: anthropometrics, BP, homeostasis model assessment (HOMA) to assess insulin resistance, high-sensitivity C-reactive protein, and plasma adipokines (adiponectin, interleukin-6, plasminogen activator inhibitor-1). Echocardiogram measurements were left-ventricular mass index (LVMI) (g/m(2.7)), LV relative wall thickness (LVRWT), left-atrial diameter index [LADI (mm/m)], and LV diastolic time intervals. LADI (r (2) = 0.25) was associated with body mass index (BMI) systolic BP (SBP) and female sex. LVMI (r (2) = 0.35) variation was associated with BMI SBP, heart rate, age, and male sex. LVRWT (r (2) = 0.05) was associated with HOMA. Tissue diastolic intervals were not associated with any risk factor. Inflammatory markers and adipokines were associated with BMI but were not independently associated with any echocardiographic measures. In African-American adolescents, BMI and SBP, but not inflammatory markers or adipokines, are important correlates of LA size and LVM

Serum Non-high-density lipoprotein cholesterol concentration and risk of death from cardiovascular diseases among U.S. adults with diagnosed diabetes: the Third National Health and Nutrition Examination Survey linked mortality study

<p>Abstract</p> <p>Background</p> <p>Non-high-density lipoprotein cholesterol (non-HDL-C) measures all atherogenic apolipoprotein B-containing lipoproteins and predicts risk of cardiovascular diseases (CVD). The association of non-HDL-C with risk of death from CVD in diabetes is not well understood. This study assessed the hypothesis that, among adults with diabetes, non-HDL-C may be related to the risk of death from CVD.</p> <p>Methods</p> <p>We analyzed data from 1,122 adults aged 20 years and older with diagnosed diabetes who participated in the Third National Health and Nutrition Examination Survey linked mortality study (299 deaths from CVD according to underlying cause of death; median follow-up length, 12.4 years).</p> <p>Results</p> <p>Compared to participants with serum non-HDL-C concentrations of 35 to 129 mg/dL, those with higher serum levels had a higher risk of death from total CVD: the RRs were 1.34 (95% CI: 0.75-2.39) and 2.25 (95% CI: 1.30-3.91) for non-HDL-C concentrations of 130-189 mg/dL and 190-403 mg/dL, respectively (<it>P </it>= 0.003 for linear trend) after adjustment for demographic characteristics and selected risk factors. In subgroup analyses, significant linear trends were identified for the risk of death from ischemic heart disease: the RRs were 1.59 (95% CI: 0.76-3.32) and 2.50 (95% CI: 1.28-4.89) (<it>P </it>= 0.006 for linear trend), and stroke: the RRs were 3.37 (95% CI: 0.95-11.90) and 5.81 (95% CI: 1.96-17.25) (<it>P </it>= 0.001 for linear trend).</p> <p>Conclusions</p> <p>In diabetics, higher serum non-HDL-C concentrations were significantly associated with increased risk of death from CVD. Our prospective data support the notion that reducing serum non-HDL-C concentrations may be beneficial in the prevention of excess death from CVD among affected adults.</p

A double-blind randomized trial of fish oil to lower triglycerides and improve cardiometabolic risk in adolescents.

OBJECTIVES: To determine the efficacy of 4 g/day fish oil to lower triglycerides and impact lipoprotein particles, inflammation, insulin resistance, coagulation, and thrombosis. STUDY DESIGN: Participants (n = 42, age 14 ± 2 years) with hypertriglyceridemia and low-density lipoprotein (LDL) cholesterol/dL were enrolled in a randomized, double-blind, crossover trial comparing 4 g of fish oil daily with placebo. Treatment interval was 8 weeks with a 4-week washout. Lipid profile, lipoprotein particle distribution and size, glucose, insulin, high-sensitivity C-reactive protein, interleukin-6, fibrinogen, plasminogen activator inhibitor-1, and thrombin generation were measured. RESULTS: Baseline lipid profile was total cholesterol 194 (5.4) mg/dL (mean [SE]), triglycerides 272 (21) mg/dL, high-density lipoprotein cholesterol 39 (1) mg/dL, and LDL cholesterol 112 (3.7) mg/dl. LDL particle number was 1614 (60) nmol/L, LDL size was 19.9 (1.4) nm, and large very low-density lipoprotein/chylomicron particle number was 9.6 (1.4) nmol/L. Triglycerides decreased on fish oil treatment but the difference was not significant compared with placebo (-52 ± 16 mg/dL vs -16 ± 16 mg/dL). Large very low-density lipoprotein particle number was reduced (-5.83 ± 1.29 nmol/L vs -0.96 ± 1.31 nmol/L; P \u3c .0001). There was no change in LDL particle number or size. There was a trend towards a lower prothrombotic state (lower fibrinogen and plasminogen activator inhibitor-1; .10 \u3e P \u3e .05); no other group differences were seen. CONCLUSIONS: In children, fish oil (4 g/day) lowers triglycerides slightly and may have an antithrombotic effect but has no effect on LDL particles

Response to the valsalva maneuver after the fontan procedure for tricuspid valve atresia, single ventricle or pulmonic valve atresia

The Valsalva maneuver was performed during cardiac catheterization in 9 patients who had undergone a Fontan operation (Fontan group) and in 10 control subjects. The Fontan group had higher right atrial (RA) pressure (16 +/- 1 vs 4 +/- 0.5 mm Hg, p 2, p 2, p 2, p 2, p 2 and stroke index greater than 31 ml/beat/m2.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/25501/1/0000042.pd

Evaluation of a multidisciplinary lipid clinic to improve the care of individuals with severe lipid conditions: A RE-AIM framework analysis

BACKGROUND: Individuals with complex dyslipidemia, or those with medication intolerance, are often difficult to manage in primary care. They require the additional attention, expertise, and adherence counseling that occurs in multidisciplinary lipid clinics (MDLCs). We conducted a program evaluation of the first year of a newly implemented MDLC utilizing the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to provide empirical data not only on program effectiveness, but also on components important to local sustainability and future generalizability. METHODS: The purpose of the MDLC is to increase the uptake of guideline-based care for lipid conditions. Established in 2019, the MDLC provides care via a centralized clinic location within the healthcare system. Primary care providers and cardiologists were invited to refer individuals with lipid conditions. Using a pre/post-study design, we evaluated the implementation outcomes from the MDLC using the RE-AIM framework. RESULTS: In 2019, 420 referrals were made to the MDLC (reach). Referrals were made by 19% (148) of the 796 active cardiology and primary care providers, with an average of 35 patient referrals per month in 2019 (SD 12) (adoption). The MDLC saw 83 patients in 2019 (reach). Additionally, 50% (41/82) had at least one follow-up MDLC visit, and 12% (10/82) had two or more follow-up visits in 2019 (implementation). In patients seen by the MDLC, we found an improved diagnosis of specific lipid conditions (FH (familial hypercholesterolemia), hypertriglyceridemia, and dyslipidemia), increased prescribing of evidence-based therapies, high rates of medication prior authorization approvals, and significant reductions in lipid levels by lipid condition subgroup (effectiveness). Over time, the operations team decided to transition from in-person follow-up to telehealth appointments to increase capacity and sustain the clinic (maintenance). CONCLUSIONS: Despite limited reach and adoption of the MDLC, we found a large intervention effect that included improved diagnosis, increased prescribing of guideline-recommended treatments, and clinically significant reduction of lipid levels. Attention to factors including solutions to decrease the large burden of unseen referrals, discussion of the appropriate number and duration of visits, and sustainability of the clinic model could aid in enhancing the success of the MDLC and improving outcomes for more patients throughout the system

Natural History of Atherosclerosis and Abdominal Aortic Intima-Media Thickness: Rationale, Evidence, and Best Practice for Detection of Atherosclerosis in the Young

Atherosclerosis underlies most myocardial infarctions and ischemic strokes. The timing of onset and the rate of progression of atherosclerosis differ between individuals and among arterial sites. Physical manifestations of atherosclerosis may begin in early life, particularly in the abdominal aorta. Measurement of the abdominal aortic intima-media thickness by external ultrasound is a non-invasive methodology for quantifying the extent and severity of early atherosclerosis in children, adolescents, and young adults. This review provides an evidence-based rationale for the assessment of abdominal aortic intima-media thickness-particularly as an age-appropriate methodology for studying the natural history of atherosclerosis in the young in comparison to other methodologies-establishes best practice methods for assessing abdominal aortic intima-media thickness, and identifies key gaps in the literature, including those that will identify the clinical relevance of this measure