Geographic variation in cardiovascular disease burden clues and questions

In October 1978, a conference was convened by the National Institutes of Health to discuss the decline in coronary heart disease (CHD) mortality rates in the United States during the previous decade. The purpose of the conference was to consider whether the decline was real, discuss the possible causes, and recommend further studies to elucidate these causes. The conference was a watershed event that launched several major population-based, observational studies in the United States and internationally, including the Atherosclerosis Risk in Communities Study in the United States and the World Health Organization–Monitoring Trends and Determinants in Cardiovascular Disease Project in 21 countries in the mid-1980s. A focus of studies prompted by the conference was to better understand the abrupt decrease in CHD mortality rates as well as investigating geographic variation in CHD trends. In 1986, Wing et al4 reported that the onset of the decline in CHD mortality in the United States began in metropolitan areas before nonmetropolitan areas. They also reported that the timing of the onset of the decline was independent of a region’s absolute CHD morality rate; mid-Atlantic regions (with high rates) and Pacific regions (with low rates) experienced early onset of the decline, while much of the south (with high rates) and mountain regions (with low rates) had later onset of the decline

Trends in Heart Failure Incidence in the Community: A Gathering Storm

In populations around the world, a gathering storm of cardiovascular disease occurrence is building on the horizon, the likes of which we have not seen in decades. Between 1970 and 2010, age-adjusted cardiovascular mortality rates declined dramatically in almost all Western nations; in many countries, rates fell by ≥70%. However, in 2016, Sidney et al1 reported that in the United States, a substantial deceleration in the decline of all cardiovascular disease, coronary heart disease, and stroke mortality rates began over the past 5 years, signaling a dramatic shift. Prompted by this report, Lloyd-Jones suggested that perhaps we are now just beginning to “reap what we have sown” in the obesity epidemic over the past several decades. It is not a new concept that the Western world’s obesity epidemic can affect population health. What is less well documented is whether the epidemic obesity is beginning to reverse long-standing declines in disease incidence. A recent report from the Centers of Disease Control and Prevention indicates that between 2014 and 2015, age-adjusted death rates in the United States increased for 8 of 10 leading causes of death, including cardiovascular disease rates. Given that heart disease accounts for >30% of all deaths in the United States, the 0.9% increase in age-adjusted mortality from heart disease is of particular concern

Response by Arora et al to Letter Regarding Article, "Twenty Year Trends and Sex Differences in Young Adults Hospitalized With Acute Myocardial Infarction: The ARIC Community Surveillance Study"

In Response: In a recent investigation from ARIC (Atherosclerosis Risk in Communities Study ), we analyzed 28 732 acute myocardial infarction (AMI) hospitalizations sampled among black and white patients aged 35 to 74 years. We observed that an increasing percentage of the AMI hospitalizations from 1995 to 2014 were young patients (35–54 years), and that the increase was especially pronounced among women. We also noted that young women with AMI were less likely to receive guideline-based therapies compared to young men

Stroke mortality, clinical presentation and day of arrival: The atherosclerosis risk in communities (ARIC) study

Background. Recent studies report that acute stroke patients who present to the hospital on weekends have higher rates of 28-day mortality than similar patients who arrive during the week. However, how this association is related to clinical presentation and stroke type has not been systematically investigated. Methods and Results. We examined the association between day of arrival and 28-day mortality in 929 validated stroke events in the ARIC cohort from 1987-2004. Weekend arrival was defined as any arrival time from midnight Friday until midnight Sunday. Mortality was defined as all-cause fatal events from the day of arrival through the 28th day of followup. The presence or absence of thirteen stroke signs and symptoms were obtained through medical record review for each event. Binomial logistic regression was used to estimate odds ratios and 95 confidence intervals (OR; 95 CI) for the association between weekend arrival and 28-day mortality for all stroke events and for stroke subtypes. The overall risk of 28-day mortality was 9.6 for weekday strokes and 10.1 for weekend strokes. In models controlling for patient demographics, clinical risk factors, and event year, weekend arrival was not associated with 28-day mortality (0.87; 0.51, 1.50). When stratified by stroke type, weekend arrival was not associated with increased odds of mortality for ischemic (1.17, 0.62, 2.23) or hemorrhagic (0.37; 0.11, 1.26) stroke patients. Conclusions. Presence or absence of thirteen signs and symptoms was similar for weekday patients and weekend patients when stratified by stroke type. Weekend arrival was not associated with 28-day all-cause mortality or differences in symptom presentation for strokes in this cohort

The Case for Drone-assisted Emergency Response to Cardiac Arrest: An Optimized Statewide Deployment Approach

BACKGROUND Despite evidence linking rapid defibrillation to out-of-hospital cardiac arrest (OHCA) survival, bystander use of automatic external defibrillators (AEDs) remains low, due in part to AED placement and accessibility. AED-equipped drones may improve time-to-defibrillation, yet the benefits and costs are unknown.METHODS We designed drone deployment networks for the state of North Carolina using mathematical optimization models to select drone stations from existing infrastructure by specifying the number of stations and the targeted AED arrival time. Expected outcomes were evaluated over the drone's lifespan (4 years). We estimated the following parameters: proportion of OHCAs within a targeted AED delivery time, bystander utilization of AEDs, survival/neurological status, and incremental cost per quality-adjusted life year (QALY).RESULTS Statewide, 16,503 adults aged 18 or older were expected to experience OHCA with an attempted resuscitation over 4 years. Compared to no drone network, all proposed drone networks were expected to improve survival outcomes. For example, assuming 46% of OHCAs have bystanders willing to use an AED, a 500-drone network decreased the median time of defibrillator arrival from 7.7 to 2.7 minutes compared to no drone network. Expected survival rates doubled (24.5% versus 12.3%), resulting in an additional 30,267 QALYs ($858/incremental QALY). If just 4.5% of OHCAs had willing bystanders, 13.8% of victims would have survived. Sensitivity analysis demonstrated that an AED drone network remained cost-effective over a wide range of assumptions.CONCLUSIONS With proper integration into existing systems, large-scale networks for drone AED delivery have the potential to substantially improve OHCA survival rates while remaining cost-effective. Public health researchers should consider advocating for feasibility studies and policy development surrounding drones

Vital exhaustion and sudden cardiac death in the Atherosclerosis Risk in Communities Study

Objective Vital exhaustion (VE), a construct defined as lack of energy, increased fatigue and irritability, and feelings of demoralisation, has been associated with cardiovascular events. We sought to examine the relation between VE and sudden cardiac death (SCD) in the Atherosclerosis Risk in Communities (ARIC) Study. Methods The ARIC Study is a predominately biracial cohort of men and women, aged 45-64 at baseline, initiated in 1987 through random sampling in four US communities. VE was measured using the Maastricht questionnaire between 1990 and 1992 among 13 923 individuals. Cox proportional hazards models were used to examine the hazard of out-of-hospital SCD across tertiles of VE scores. Results Through 2012, 457 SCD cases, defined as a sudden pulseless condition presumed due to a ventricular tachyarrhythmia in a previously stable individual, were identified in ARIC by physician record review. Adjusting for age, sex and race/centre, participants in the highest VE tertile had an increased risk of SCD (HR 1.48, 95% CI 1.17 to 1.87), but these findings did not remain significant after adjustment for established cardiovascular disease risk factors (HR 0.94, 95% CI 0.73 to 1.20). Conclusions Among participants of the ARIC study, VE was not associated with an increased risk for SCD after adjustment for cardiovascular risk factors

Tv viewing and incident venous thromboembolism: The atherosclerotic risk in communities study

TV viewing is associated with risk of arterial vascular diseases, but has not been evaluated in relation to venous throm-boembolism (VTE) risk in Western populations. In 1987–1989, the Atherosclerosis Risk in Communities Study obtained information on the frequency of TV viewing in participants aged 45–64 and followed them prospectively. In individuals free of prebaseline VTE (n=15, 158), we used a Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of incident VTE according to frequency of TV viewing (“Never or seldom”, “Sometimes”, “Often” or “Very often”). During the 299,767 person-years of follow-up, we identified 691 VTE events. In a multivariable-adjusted model, the frequency of TV viewing showed a positive dose–response relation with VTE incidence (P for trend=0.036), in which “very often” viewing TV carried 1.71 (95% CI 1.26–2.32) times the risk of VTE compared with “never or seldom” viewing TV. This association to some degree was mediated by obesity (25% mediation, 95% CI 10.7–27.5). Even among individuals who met a recommended level of physical activity, viewing TV “very often” carried 1.80 (1.04–3.09) times the risk of VTE, compared to viewing TV “never or seldom”. Greater frequency of TV viewing was independently associated with increased risk of VTE, partially mediated by obesity. Achieving a recommended physical activity level did not eliminate the increased VTE risk associated with frequent TV viewing. Avoiding frequent TV viewing as well as increasing physical activity and controlling body weight might be beneficial for VTE prevention

High-density lipoprotein cholesterol and venous thromboembolism in the Longitudinal Investigation of Thromboembolism Etiology (LITE)

We determined prospectively the risk of venous thromboembolism (VTE) in relation to baseline high-density lipoprotein cholesterol (HDL-c) in 19 049 participants of the Longitudinal Investigation of Thromboembolism Etiology (LITE), which was composed of 14 490 participants of the Atherosclerosis Risk in Communities (ARIC) study and 4559 participants of the Cardiovascular Health Study (CHS). In addition, we determined the risk of VTE in relation to baseline subtractions of HDL (HDL2 and HDL3) and apolipoprotein A-l (apoA-l) in 14 488 participants of the ARIC study. Age-adjusted incidence rates of VTE by HDL-c quartile ranged from 1.64 to 1.91 per 1000 person-years in men and 1.40 to 1.94 per 1000 person-years in women; however, there was no apparent trend of VTE incidence across HDL-c quartiles for either sex. The multivariate adjusted hazard ratios of VTE by HDL-c quartiles (with quartile 4 as the reference) were nonsignificant for both sexes and ranged between 0.91 and 0.99 for men and 0.78 and 1.22 for women. Results did not differ in separate evaluations of idiopathic and secondary VTE. In the ARIC study, there was no trend of VTE hazard ratios across quartiles of HDL2, HDL3, or apoA-l. Low HDL-c does not appear to be an important VTE riskfactor

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

Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction

Background: Smoking is well-recognized as a risk factor for heart failure (HF). However, few studies have evaluated the prospective association of cigarette smoking and smoking cessation with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) as distinct phenotypes. Objectives: The aim of this study was to quantify the association of cigarette smoking and smoking cessation with the incidence of HFpEF and HFrEF. Methods: In 9,345 ARIC (Atherosclerosis Risk In Communities) study White and Black participants without history of HF at baseline in 2005 (age range 61-81 years), we quantified the associations of several established cigarette smoking parameters (smoking status, pack-years, intensity, duration, and years since cessation) with physician-adjudicated incident acute decompensated HF using multivariable Cox models. Results: Over a median follow-up of 13.0 years, there were 1,215 incident HF cases. Compared with never smokers, current cigarette smoking was similarly associated with HFpEF and HFrEF, with adjusted HRs ∼2. There was a dose-response relationship for pack-years of smoking and HF. A more extended period of smoking cessation was associated with a lower risk of HF, but significantly elevated risk persisted up to a few decades for HFpEF and HFrEF. Conclusions: All cigarette smoking parameters consistently showed significant and similar associations with HFpEF and HFrEF. Smoking cessation significantly reduced the risk of HF, but excess HF risk persisted for a few decades. Our results strengthened the evidence that smoking is an important modifiable risk factor for HF and highlighted the importance of smoking prevention and cessation for the prevention of HF, including HFpEF