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INTRODUCTION: Educational attainment is an important social determinant of health (SDOH) for cardiovascular disease (CVD). However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the US, especially in individuals with atherosclerotic cardiovascular disease (ASCVD). In this nationally representative study, we assessed the association between educational attainment and the risk of all-cause and cardiovascular (CVD) mortality in the general adult population and in adults with ASCVD in the US. METHODS: We used data from the 2006-2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of educational attainment (< high school (HS), HS/General Education Development (GED), some college, and ≥ College) in the overall population and in adults with ASCVD. Cox proportional hazards models were used to examine the multivariable-adjusted associations between educational attainment and all-cause and CVD mortality. RESULTS: The sample comprised 210,853 participants (mean age 46.3), representing ~ 189 million adults annually, of which 8% had ASCVD. Overall, 14.7%, 27%, 20.3%, and 38% of the population had educational attainment < HS, HS/GED, Some College, and ≥ College, respectively. During a median follow-up of 4.5 years, all-cause age-adjusted mortality rates were 400.6 vs. 208.6 and 1446.7 vs. 984.0 for the total and ASCVD populations for < HS vs ≥ College education, respectively. CVD age adjusted mortality rates were 82.1 vs. 38.7 and 456.4 vs 279.5 for the total and ASCVD populations for < HS vs ≥ College education, respectively. In models adjusting for demographics and SDOH, < HS (reference = ≥ College) was associated with 40-50% increased risk of mortality in the total population and 20-40% increased risk of mortality in the ASCVD population, for both all-cause and CVD mortality. Further adjustment for traditional risk factors attenuated the associations but remained statistically significant for < HS in the overall population. Similar trends were seen across sociodemographic subgroups including age, sex, race/ethnicity, income, and insurance status. CONCLUSIONS: Lower educational attainment is independently associated with increased risk of all-cause and CVD mortality in both the total and ASCVD populations, with the highest risk observed for individuals with < HS education. Future efforts to understand persistent disparities in CVD and all-cause mortality should pay close attention to the role of education, and include educational attainment as an independent predictor in mortality risk prediction algorithms.
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Enfermedades Cardiovasculares , Humanos , Adulto , Estados Unidos/epidemiología , Persona de Mediana Edad , Enfermedades Cardiovasculares/epidemiología , Escolaridad , Factores de Riesgo , Etnicidad , Modelos de Riesgos ProporcionalesRESUMEN
PURPOSE OF REVIEW: The burden of heart failure (HF) in the United States and worldwide is projected to rise. Prevention of HF can curb the burden of this chronic syndrome, but current approaches are limited. This review discusses team-based strategies aimed to prevent HF. RECENT FINDINGS: Individuals at high risk for developing HF can be identified using HF risk scores, biomarkers, and cardiac imaging. Electronic medical records (EMR) can integrate clinical data to estimate HF risk and identify individuals who may benefit most from preventive therapies. Team-based interventions can lead to enhanced adherence to medications, optimization of medical management, and control of risk factors. Multifaceted interventions involve EMR-based strategies, pharmacist- and nurse-led initiatives, involvement of community personnel, polypills, and digital solutions. SUMMARY: Team-based strategies aimed to prevent HF incorporate a broad group of personnel and tools. Despite implementation challenges, existing resources can be efficiently utilized to facilitate team-based approaches to potentially reduce the burden of HF.
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Insuficiencia Cardíaca , Biomarcadores , Técnicas de Imagen Cardíaca , Insuficiencia Cardíaca/prevención & control , Humanos , Farmacéuticos , Factores de Riesgo , Estados UnidosRESUMEN
PURPOSE OF REVIEW: The burden of obesity worldwide is high and projected to rise. Obesity increases the risk of several cardiovascular diseases and cardiometabolic risk factors; hence, utilizing effective long-term therapies for obesity is of utmost importance. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as effective therapies that achieve substantial weight loss and improve cardiometabolic risk. The purpose of this review is to discuss the role of GLP-1RAs in obesity management. RECENT FINDINGS: Two subcutaneous GLP-1RAs, liraglutide and semaglutide, have been evaluated in several clinical trials for weight loss. Liraglutide achieves a mean weight loss of 4-7 kg, and more than 50% of treated individuals achieve 5% or more weight loss. Semaglutide has a greater impact on weight loss, with a mean weight loss of 9-16 kg, and more than 50% of treated individuals achieve 10-15% or more weight loss. These results led to regulatory approval of these agents for weight loss in individuals with obesity, regardless of diabetes status. In addition to weight loss, the benefits of GLP-1RAs extend to other risk factors, such as glycemic control and blood pressure. Gastrointestinal symptoms are the most frequently encountered adverse events with incidences between 5 and 30%. Finally, the cost remains one of the most critical challenges that limit GLP-1RAs use. GLP-1RAs have robust weight loss benefits and are expected to have a critical role in the management of obesity in the coming years. Upcoming studies will evaluate the durability of weight loss achieved with GLP-1RAs and the impact on cardiovascular outcomes.
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Diabetes Mellitus Tipo 2 , Manejo de la Obesidad , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Receptor del Péptido 1 Similar al Glucagón/agonistas , Receptor del Péptido 1 Similar al Glucagón/uso terapéutico , Humanos , Hipoglucemiantes/uso terapéutico , Liraglutida/uso terapéutico , Obesidad/complicaciones , Obesidad/tratamiento farmacológico , Pérdida de PesoRESUMEN
PURPOSE OF REVIEW: Type 2 diabetes is frequently accompanied by obesity, nonalcoholic fatty liver disease, chronic kidney disease, and cardiovascular disease, which collectively contribute to the high burden of cardiometabolic disease. This review discusses cardiometabolic disease management, strategies to implement cardiometabolic centers to deliver care, and dedicated programs to train the next generation of cardiometabolic experts. RECENT FINDINGS: Sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist have demonstrated beneficial effects across cardiometabolic conditions. However, utilization of effective pharmacotherapies is low in clinical practice, in part due to clinical inertia and traditional sharp delineation in clinical responsibilities of specialists. Multidisciplinary clinics and population-health models can provide comprehensive care but require investment in physical and information technology infrastructure as well as in training and accreditation. Post-internal medicine residency cardiometabolic health training programs have been proposed. Implementing cardiometabolic centers in health systems involves reshaping current practices. Training programs focused on cardiometabolic health are needed to address the growing burden of disease and specific training needs in this ever-expanding area.
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Enfermedades Cardiovasculares , Diabetes Mellitus Tipo 2 , Enfermedad del Hígado Graso no Alcohólico , Acreditación , Enfermedades Cardiovasculares/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Humanos , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/tratamiento farmacológico , Obesidad/complicacionesRESUMEN
There is growing evidence that estradiol (E2) enhances fear extinction memory consolidation. However, it is unclear how E2 influences the nodes of the fear extinction network to enhance extinction memory. This study begins to delineate the neural circuits underlying the influence of E2 on fear extinction acquisition and consolidation in female rats. After fear conditioning (day 1), naturally cycling female rats underwent extinction learning (day 2) in a low-E2 state, receiving a systemic administration of either E2 or vehicle prior to extinction training. Extinction memory recall was then tested 24 hr later (day 3). We measured immediate early gene c-fos expression within the extinction network during fear extinction learning and extinction recall. During extinction learning, E2 treatment increased centrolateral amygdala c-fos activity and reduced lateral amygdala activity relative to vehicle. During extinction recall, E2-treated rats exhibited reduced c-fos expression in the centromedial amygdala. There were no group differences in c-fos expression within the medial prefrontal cortex or dorsal hippocampus. Examining c-fos ratios with the infralimbic cortex (IL) revealed that, despite the lack of group differences within the IL, E2 treatment induced greater IL activity relative to both prelimbic cortex and central amygdala (CeA) activity during extinction memory recall. Only the relationship between IL and CeA activity positively correlated with extinction retention. In conclusion, E2 appears to modify interactions between the IL and the CeA in females, shifting from stronger amygdalar modulation of fear during extinction learning to stronger IL control during extinction recall. © 2016 Wiley Periodicals, Inc.
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Núcleo Amigdalino Central/efectos de los fármacos , Corteza Cerebral/efectos de los fármacos , Estradiol/farmacología , Extinción Psicológica/efectos de los fármacos , Miedo/efectos de los fármacos , Animales , Núcleo Amigdalino Central/metabolismo , Corteza Cerebral/metabolismo , Condicionamiento Clásico , Femenino , Proteínas del Tejido Nervioso/metabolismo , Proteínas Proto-Oncogénicas c-fos/metabolismo , Ratas , Ratas Sprague-DawleyRESUMEN
BACKGROUND AND AIMS: Social determinants of health (SDOH) are key for the identification of populations at increased risk of atherosclerotic cardiovascular disease (ASCVD). However, whether at the individual level SDOH improve current ASCVD risk prediction paradigms beyond traditional risk factors and the coronary artery calcium (CAC) score, is unknown. We evaluated the interplay between CAC and SDOH in ASCVD risk prediction. METHODS: MESA is a prospective study of US adults free of clinical ASCVD at baseline. We used an SDOH index inclusive of 14 determinants from 5 domains. The index ranged 0-1 and was divided into quartiles, with higher ones representing worse SDOH. Cox regression was used to evaluate the adjusted associations between CAC, SDOH, their interplay, and ASCVD events. The C-statistic was computed to assess improvement in risk discrimination for prediction of ASCVD events. RESULTS: We included 6479 MESA participants (50% with CAC = 0, 24% CAC>100). ASCVD incidence increased with increasing CAC scores across SDOH quartiles. The lowest incidence was noted in those with CAC = 0 and favourable SDOH (2/1000 person-years) and highest in those with CAC>100 and most unfavourable SDOH (20.6/1000 person-years). While CAC was strongly associated with ASCVD across SDOH quartiles, SDOH was weakly associated with ASCVD across CAC strata. CAC improved the discriminatory ability of all prediction models beyond traditional risk factors, the improvement in C-statistic ranging +0.02 - +0.05. Improvements with SDOH were smaller, and were none on top of CAC. CONCLUSIONS: CAC improves ASCVD risk stratification across the spectrum of social vulnerability, while SDOH fail to improve risk prediction beyond traditional RFs and CAC.
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Aterosclerosis , Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Calcificación Vascular , Adulto , Humanos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Calcio , Enfermedades Cardiovasculares/epidemiología , Estudios Prospectivos , Vasos Coronarios/diagnóstico por imagen , Medición de Riesgo , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiología , Aterosclerosis/diagnóstico , Aterosclerosis/epidemiología , Factores de Riesgo , Calcio de la DietaRESUMEN
In a nationally representative population-based study of US adults, the authors sought to examine the association between body mass index (BMI) and all-cause and cardiovascular disease (CVD) mortality in a nationally representative sample of adults with and without atherosclerotic cardiovascular disease (ASCVD), and further stratified by age, sex, and race/ethnicity. The study used data from 2006 to 2015 National Health Interview Survey and categorized participants into the following BMI categories: normal weight (20-24.9), overweight (25-29.9), obesity class 1 (30-34.9), obesity class 2 (35-39.9), and obesity class 3 (≥40 kg/m2). Multivariable Cox proportional hazards models were used to assess the risk of all-cause and CVD mortality across successively increasing BMI categories overall, and by sociodemographic subgroups. A total of 210,923 individuals were included in the final analysis. In the population without ASCVD, the risk of all-cause and CVD mortality was lower in overweight and higher in obesity classes 2 and 3, compared with normal weight, with the highest risk observed in the young adult (age 18-39) population. Elderly adults (65 and above) and populations with ASCVD exhibited a BMI-mortality paradox. In addition, Hispanic individuals did not show a relationship between BMI and mortality compared with non-Hispanic White and Black adults. In conclusion, being overweight was associated with decreased risk, whereas obesity class 3 was consistently associated with increased risk of all-cause and CVD mortality in adults without ASCVD, particularly young adults. BMI-mortality paradox was noted in ASCVD, elderly, and non-Hispanic adults.
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Enfermedades Cardiovasculares , Anciano , Adulto Joven , Humanos , Adolescente , Adulto , Índice de Masa Corporal , Enfermedades Cardiovasculares/epidemiología , Sobrepeso/epidemiología , Etnicidad , Obesidad/epidemiologíaRESUMEN
This study examined the relationship between a validated measure of socioeconomic deprivation, such as the Area Deprivation Index (ADI), and morbid obesity. We used cross-sectional data on adult patients (≥18 years) in the Houston Methodist Cardiovascular Disease Health System Learning Registry (located in Houston, Texas, USA) between June 2016 and July 2021. Each patient was grouped by quintiles of ADI, with higher quintiles signaling greater deprivation. BMI was calculated using measured height and weight with morbid obesity defined as ≥ 40 kg/m2. Multivariable logistic regression models were used to examine the association between ADI and morbid obesity adjusting for demographic (age, sex, and race/ethnicity) factors. Out of the 751,174 adults with an ADI ranking included in the analysis, 6.9 % had morbid obesity (n = 51,609). Patients in the highest ADI quintile had a higher age-adjusted prevalence (10.9 % vs 3.3 %), and about 4-fold odds (aOR, 3.8; 95 % CI = 3.6, 3.9) of morbid obesity compared to the lowest ADI quintile. We tested for and found interaction effects between ADI and each demographic factor, with stronger ADI-morbid obesity association observed for patients that were female, Hispanic, non-Hispanic White and 40-65 years old. The highest ADI quintile also had a high prevalence (44 %) of any obesity (aOR, 2.2; 95 % CI = 2.1, 2.2). In geospatial mapping, areas with higher ADI were more likely to have higher proportion of patients with morbid obesity. Census-based measures, like the ADI, may be informative for area-level obesity reduction strategies as it can help identify neighborhoods at high odds of having patients with morbid obesity.
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Background Although there is research on the impact of social determinants of health (SDOHs) on cardiovascular health, most existing evidence is based on individual SDOH components. We evaluated the impact of cumulative SDOH burden on cardiovascular risk factors, subclinical atherosclerosis, and incident cardiovascular disease events. Methods and Results We included 6479 participants from the MESA (Multi-Ethnic Study of Atherosclerosis). A weighted aggregate SDOH score representing the cumulative number of unfavorable SDOHs, identified from 14 components across 5 domains (economic stability, neighborhood and physical environment, community and social context, education, and health care system access) was calculated and divided into quartiles (quartile 4 being the least favorable). The impact of cumulative SDOH burden on cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, and obesity), systemic inflammation, subclinical atherosclerosis, and incident cardiovascular disease was evaluated. Increasing social disadvantage was associated with increased odds of all cardiovascular risk factors except dyslipidemia. Smoking was the risk factor most strongly associated with worse SDOH (odds ratio [OR], 2.67 for quartile 4 versus quartile 1 [95% CI, 2.13-3.34]). Participants within SDOH quartile 4 had 33% higher odds of increased high-sensitivity C-reactive protein (OR, 1.33 [95% CI, 1.11-1.60]) and 31% higher risk of all cardiovascular disease (hazard ratio, 1.31 [95% CI, 1.03-1.67]), yet no greater burden of subclinical atherosclerosis (OR, 1.01 [95% CI, 0.79-1.29]), when compared with those in quartile 1. Conclusions Increasing social disadvantage was associated with more prevalent cardiovascular risk factors, inflammation, and incident cardiovascular disease. These findings call for better identification of SDOHs in clinical practice and stronger measures to mitigate the higher SDOH burden among the socially disadvantaged to improve cardiovascular outcomes.
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Aterosclerosis , Enfermedades Cardiovasculares , Humanos , Factores de Riesgo , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Determinantes Sociales de la Salud , Inflamación , Factores de Riesgo de Enfermedad CardiacaRESUMEN
BACKGROUND: The contemporary burden and characteristics of coronary atherosclerosis, assessed using coronary computed tomography angiography (CCTA), is unknown among asymptomatic adults with diabetes and prediabetes in the United States. The pooled cohort equations and coronary artery calcium (CAC) score stratify atherosclerotic cardiovascular disease risk, but their association with CCTA findings across glycemic categories is not well established. METHODS: Asymptomatic adults without atherosclerotic cardiovascular disease enrolled in the Miami Heart Study were included. Participants underwent CAC and CCTA testing and were classified into glycemic categories. Prevalence of coronary atherosclerosis (any plaque, noncalcified plaque, plaque with ≥1 high-risk feature, maximal stenosis ≥50%) assessed by CCTA was described across glycemic categories and further stratified by pooled cohort equations-estimated atherosclerotic cardiovascular disease risk and CAC score. Adjusted logistic regression was used to evaluate the associations between glycemic categories and coronary outcomes. RESULTS: Among 2352 participants (49.5% women), the prevalence of euglycemia, prediabetes, and diabetes was 63%, 30%, and 7%, respectively. Coronary plaque was more commonly present across worsening glycemic categories (euglycemia, 43%; prediabetes, 58%; diabetes, 69%), and similar pattern was observed for other coronary outcomes. In adjusted analyses, compared with euglycemia, prediabetes and diabetes were each associated with higher odds of any coronary plaque (OR, 1.30 [95% CI, 1.05-1.60] and 1.75 [1.17-2.61], respectively), noncalcified plaque (OR, 1.47 [1.19-1.81] and 1.99 [1.38-2.87], respectively), and plaque with ≥1 high-risk feature (OR, 1.65 [1.14-2.39] and 2.53 [1.48-4.33], respectively). Diabetes was associated with stenosis ≥50% (OR, 3.01 [1.79-5.08]; reference=euglycemia). Among participants with diabetes and estimated atherosclerotic cardiovascular disease risk <5%, 46% had coronary plaque and 10% had stenosis ≥50%. Among participants with diabetes and CAC=0, 30% had coronary plaque and 3% had stenosis ≥50%. CONCLUSIONS: Among asymptomatic adults, worse glycemic status is associated with higher prevalence and extent of coronary atherosclerosis, high-risk plaque, and stenosis. In diabetes, CAC was more closely associated with CCTA findings and informative in a larger population than the pooled cohort equations.
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Aterosclerosis , Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Diabetes Mellitus , Placa Aterosclerótica , Estado Prediabético , Adulto , Humanos , Femenino , Masculino , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/complicaciones , Estado Prediabético/diagnóstico , Estado Prediabético/epidemiología , Enfermedades Cardiovasculares/complicaciones , Florida/epidemiología , Constricción Patológica/complicaciones , Protestantismo , Angiografía Coronaria/métodos , Estudios Prospectivos , Placa Aterosclerótica/epidemiología , Placa Aterosclerótica/complicaciones , Factores de RiesgoRESUMEN
Background: Infarct size following ST-elevation myocardial infarction (STEMI) is an important determinate of left ventricular (LV) dysfunction and cardiovascular morbidity and mortality. Cardiac magnetic resonance feature tracking (CMR-FT) is a technique that allows for the assessment of myocardial function via quantification of longitudinal, radial, and circumferential strain. We investigated the association between CMR-FT-derived myocardial global strain and myocardial recovery. Methods: A prospective study on patients presenting with STEMI treated with primary percutaneous coronary intervention (PCI) was conducted. CMR imaging was obtained at two interval time points, the baseline within 2 weeks of hospital discharge and follow-up at 6 months. Strain analysis was performed via FT-CMR, and recovery was quantified by the area of late gadolinium enhancement (LGE). Results: A total of n = 14 patients met inclusion and exclusion criteria and were analyzed. There was a significant reduction in the infarct size, as measured by LGE mass percentage of the left ventricular muscle mass, between the initial and follow-up CMR (19.7%, IQR 12.2-23.9 vs. 17.1%, IQR 8.3-22.5, p = 0.04). Initial strain parameters were inversely correlated with the initial edema mass and the decrease in LGE mass between the initial and follow-up CMR. All LV global strains had high accuracy for the prediction of a reduction in LGE mass by 50% or more. Conclusions: LV global strains measured after primary PCI can predict the extent of myocardial recovery.
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The extent to which cumulative social disadvantage-defined as aggregate social risk resulting from multiple co-occurring adverse social determinants of health (SDOH)-affects the risk of all-cause mortality, independent of demographic and clinical risk factors, is not well understood. The objective of this study was to examine the association between cumulative social disadvantage, measured using a comprehensive 47-factor SDOH framework, and mortality in a nationally representative sample of adults in the United States. The authors conducted secondary analysis of pooled data for 63,540 adult participants of the 2013-2015 National Death Index-linked National Health Interview Survey. Age-adjusted mortality rates (AAMRs) were reported by quintiles of aggregate SDOH burden, with higher quintiles denoting greater social disadvantage. Cox proportional hazards models were used to examine the association between cumulative social disadvantage and risk of all-cause mortality. AAMR increased significantly with greater SDOH burden, ranging from 631 per 100,000 person-years (PYs) for participants in SDOH-Q1 to 1490 per 100,000 PYs for those in SDOH-Q5. In regression models adjusted for demographics, being in SDOH-Q5 was associated with 2.5-fold higher risk of mortality, relative to Q1 (adjusted hazard ratio [aHR] = 2.57 [95% confidence interval, CI = 1.94-3.41]); the observed association persisted after adjusting for comorbidities, with over 2-fold increased risk of mortality for SDOH-Q5 versus Q1 (aHR = 2.02 [95% CI = 1.52-2.67]). These findings indicate that cumulative social disadvantage is associated with increased risk of all-cause mortality, independent of demographic and clinical factors. Population level interventions focused on improving individuals' social, economic, and environmental conditions may help reduce the burden of mortality and mitigate persistent disparities.
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Determinantes Sociales de la Salud , Adulto , Humanos , Estados Unidos/epidemiología , Factores de RiesgoRESUMEN
OBJECTIVE: This study examined the association between social determinants of health (SDOH) burden and overweight/obesity in a nationally representative sample of adults in the United States. METHODS: Data for 161,795 adults aged ≥18 years from the 2013 to 2017 National Health Interview Survey were used. A total of 38 SDOH were aggregated to create a cumulative SDOH score, which was divided into quartiles (Q1-Q4) to denote levels of SDOH burden. Prevalence of overweight and obesity was examined across SDOH quartiles in the total population and by age, sex, and race/ethnicity. Multinomial logistic regression models were used to analyze the association between SDOH quartiles and overweight/obesity, adjusting for relevant covariates. RESULTS: There was a graded increase in obesity prevalence with increasing SDOH burden. At nearly each quartile, overweight and obesity rates were higher for middle-aged and non-Hispanic Black adults compared with their counterparts; additional differences were observed by sex. In fully adjusted models, SDOH-Q4 was associated with 15%, 50%, and 70% higher relative prevalence of overweight, obesity class 1 and 2, and obesity class 3, respectively, relative to SDOH-Q1. CONCLUSIONS: Cumulative social disadvantage, denoted by higher SDOH burden, was associated with increased odds of obesity, independent of clinical and demographic factors.
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Sobrepeso , Determinantes Sociales de la Salud , Adolescente , Adulto , Humanos , Persona de Mediana Edad , Obesidad/epidemiología , Sobrepeso/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Although ME countries have a high burden of atherosclerotic cardiovascular disease (ASCVD), the cardiovascular health status among ME immigrants in the US has not been studied in detail. This study aims to characterize the cardiovascular health status (CVD risk factors and ASCVD burden) among ME immigrants in the US. METHODS: We used 2012-2018 data from the National Health Interview Survey, a US nationally representative survey. ME origin, CVD risk factors, and ASCVD status were self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US. RESULTS: Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.4% vs 27.4%) and obesity (21.4% vs 31.4%) were significantly lower in ME vs NHW participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only insufficient physical activity was higher among ME individuals. ME immigrants living in the US for 10 years or more reported higher age-adjusted prevalence of hypertension, hyperlipidemia, and ASCVD. CONCLUSIONS: ME immigrants in the US have lower odds of hypertension and obesity, and of having a suboptimal CRF profile compared to US-born NHWs. Further studies are needed to determine whether these findings are related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.
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OBJECTIVE: Health-related expenditures resulting from diabetes are rising in the U.S. Medication nonadherence is associated with worse health outcomes among adults with diabetes. We sought to examine the extent of reported cost-related medication nonadherence (CRN) in individuals with diabetes in the U.S. RESEARCH DESIGN AND METHODS: We studied adults age ≥18 years with self-reported diabetes from the National Health Interview Survey (NHIS) (2013-2018), a U.S. nationally representative survey. Adults reporting skipping doses, taking less medication, or delaying filling a prescription to save money in the past year were considered to have experienced CRN. The weighted prevalence of CRN was estimated overall and by age subgroups (<65 and ≥65 years). Logistic regression was used to identify sociodemographic characteristics independently associated with CRN. RESULTS: Of the 20,326 NHIS participants with diabetes, 17.6% (weighted 2.3 million) of those age <65 years reported CRN, compared with 6.9% (weighted 0.7 million) among those age ≥65 years. Financial hardship from medical bills, lack of insurance, low income, high comorbidity burden, and female sex were independently associated with CRN across age groups. Lack of insurance, duration of diabetes, current smoking, hypertension, and hypercholesterolemia were associated with higher odds of reporting CRN among the nonelderly but not among the elderly. Among the elderly, insulin use significantly increased the odds of reporting CRN (odds ratio 1.51; 95% CI 1.18, 1.92). CONCLUSIONS: In the U.S., one in six nonelderly and one in 14 elderly adults with diabetes reported CRN. Removing financial barriers to accessing medications may improve medication adherence among these patients, with the potential to improve their outcomes.
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Diabetes Mellitus , Cumplimiento de la Medicación , Adolescente , Adulto , Anciano , Comorbilidad , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/epidemiología , Femenino , Gastos en Salud , Humanos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Compelling results from clinical trials supporting intensive risk-reduction therapies to reduce associated morbidity and mortality in patients with established atherosclerotic cardiovascular disease (ASCVD) provided the impetus for medical societies to integrate these evidence-based results into clinical practice guidelines. Current evidence, however, points toward gaps in the management of patients with established ASCVD. Some of these gaps are related to barriers to guideline implementation, and strategies are needed to overcome these barriers. In this review, we propose a framework incorporating comprehensive tools for enhanced guideline-directed management in secondary prevention of ASCVD. This aid includes a 13-point checklist with supporting educational and system-based tools for effective evidence-based pharmacological and nonpharmacological care. This proposed tool targets primary care providers and cardiologists in the outpatient setting who provide direct medical care for patients with established ASCVD.
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Aterosclerosis , Enfermedades Cardiovasculares , Aterosclerosis/diagnóstico , Aterosclerosis/prevención & control , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Lista de Verificación , Humanos , Pacientes Ambulatorios , Prevención SecundariaRESUMEN
Introduction: Elevation of cardiac troponin I (cTn-I) is associated with coronary artery disease (CAD) in asymptomatic patients with end-stage renal disease (ESRD) receiving hemodialysis. We aim to investigate the diagnostic value of chronically elevated cTn-I in ESRD patients presenting with an acute rise in serum cTn-I levels. Methods: We performed a retrospective analysis of 364 patients. Using coronary angiography, we correlated baseline elevation of cTn-I with the severity of CAD when hemodialysis patients present with acute symptomatic elevation in serum cTn-I. Results: In hemodialysis patients presenting with a rise in serum cTn-I above baseline levels, 59% had severe CAD, and 17% had no angiographic evidence of CAD. Hemodialysis patients with severe CAD had significantly higher baseline cTn-I levels compared to patients with non-severe CAD or normal coronaries (p < 0.0001). Baseline elevation of cTn-I in the severe CAD group was correlated with the degree of CAD occlusion (r2 0.56, p < 0.0001), fitting a positive linear model. Furthermore, baseline cTn-I differentiates between patients with and without severe CAD with a test accuracy of 0.72 (95% CI, 0.69-0.75, p < 0.001). At a value of ≥0.2 ng/mL (cutoff for myocardial necrosis), the specificity of baseline cTn-I for underlying severe CAD was 0.95. Conclusions: Elevated baseline cTn-I has good accuracy for anticipating more advanced angiographic CAD when hemodialysis patients present with a symptomatic rise in serum cTn-I above baseline levels. Baseline elevation of cTn-I can be used for cardiac disease risk management in hemodialysis patients presenting with symptoms suggestive of CAD.
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Major depressive disorder (MDD) is the most common non-motor manifestation of Parkinson's disease (PD) affecting 50% of patients. However, little is known about the cognitive correlates of MDD in PD. Using a computer-based cognitive task that dissociates learning from positive and negative feedback, we tested four groups of subjects: (1) patients with PD with comorbid MDD, (2) patients with PD without comorbid MDD, (3) matched patients with MDD alone (without PD), and (4) matched healthy control subjects. Furthermore, we used a mathematical model of decision-making to fit both choice and response time data, allowing us to detect and characterize differences between the groups that are not revealed by cognitive results. The groups did not differ in learning accuracy from negative feedback, but the MDD groups (PD patients with MDD and patients with MDD alone) exhibited a selective impairment in learning accuracy from positive feedback when compared to the non-MDD groups (PD patients without MDD and healthy subjects). However, response time in positive feedback trials in the PD groups (both with and without MDD) was significantly slower than the non-PD groups (MDD and healthy groups). While faster response time usually correlates with poor learning accuracy, it was paradoxical in PD groups, with PD patients with MDD having impaired learning accuracy and PD patients without MDD having intact learning accuracy. Mathematical modeling showed that both MDD groups (PD with MDD and MDD alone) were significantly slower than non-MDD groups in the rate of accumulation of information for stimuli trained by positive feedback, which can lead to lower response accuracy. Conversely, modeling revealed that both PD groups (PD with MDD and PD alone) required more evidence than other groups to make responses, thus leading to slower response times. These results suggest that PD patients with MDD exhibit cognitive profiles with mixed traits characteristic of both MDD and PD, furthering our understanding of both PD and MDD and their often-complex comorbidity. To the best of our knowledge, this is the first study to examine feedback-based learning in PD with MDD while controlling for the effects of PD and MDD.
RESUMEN
One barrier to interpreting past studies of cognition and major depressive disorder (MDD) has been the failure in many studies to adequately dissociate the effects of MDD from the potential cognitive side effects of selective serotonin reuptake inhibitors (SSRIs) use. To better understand how remediation of depressive symptoms affects cognitive function in MDD, we evaluated three groups of subjects: medication-naïve patients with MDD, medicated patients with MDD receiving the SSRI paroxetine, and healthy control (HC) subjects. All were administered a category-learning task that allows for dissociation between learning from positive feedback (reward) vs. learning from negative feedback (punishment). Healthy subjects learned significantly better from positive feedback than medication-naïve and medicated MDD groups, whose learning accuracy did not differ significantly. In contrast, medicated patients with MDD learned significantly less from negative feedback than medication-naïve patients with MDD and healthy subjects, whose learning accuracy was comparable. A comparison of subject's relative sensitivity to positive vs. negative feedback showed that both the medicated MDD and HC groups conform to Kahneman and Tversky's (1979) Prospect Theory, which expects losses (negative feedback) to loom psychologically slightly larger than gains (positive feedback). However, medicated MDD and HC profiles are not similar, which indicates that the state of medicated MDD is not "normal" when compared to HC, but rather balanced with less learning from both positive and negative feedback. On the other hand, medication-naïve patients with MDD violate Prospect Theory by having significantly exaggerated learning from negative feedback. This suggests that SSRI antidepressants impair learning from negative feedback, while having negligible effect on learning from positive feedback. Overall, these findings shed light on the importance of dissociating the cognitive consequences of MDD from those of SSRI treatment, and from cognitive evaluation of MDD subjects in a medication-naïve state before the administration of antidepressants. Future research is needed to correlate the mood-elevating effects and the cognitive balance between reward- and punishment-based learning related to SSRIs.