Associations between TCA cycle plasma metabolites and fatigue in black females with systemic lupus erythematosus: An untargeted metabolomics pilot study.

OBJECTIVE: In this pilot study, we used untargeted metabolomics to identify biochemical mechanisms or biomarkers potentially underlying SLE-related fatigue. METHODS: Metabolon conducted untargeted metabolomic plasma profiling using ultrahigh performance liquid chromatography/tandem mass spectrometry on plasma samples of 23 Black females with systemic lupus erythematosus (SLE) and 21 no SLE controls. Fatigue phenotypes of general fatigue, physical fatigue, mental fatigue, reduced activity, and reduced motivation were measured with the reliable and valid Multidimensional Fatigue Inventory (MFI). RESULTS: A total of 290 metabolites were significantly different between the SLE and no SLE groups, encompassing metabolites related to glycolysis, TCA cycle activity, heme catabolism, branched chain amino acids, fatty acid metabolism, and steroids. Within the SLE group, controlling for age and co-morbidities, TCA cycle metabolites of alpha-ketoglutarate (AKG) and succinate were statistically significantly associated (p < .05) with physical and general fatigue. CONCLUSION: While pervasive perturbations in the entire TCA cycle have been implicated as a potential mechanism for fatigue, our results suggest individual metabolites of AKG and succinate may be potential biomarkers or targets of intervention for fatigue symptom management in SLE. Additionally, perturbations in heme metabolism in the SLE group provide additional insights into mechanisms that promote systemic inflammation.

Factors related to cognitive performance among black caregivers of persons living with a chronic illness: An exploratory study.

This study investigated factors associated with cognitive performance among Black caregivers of persons living with two chronic conditions: dementia or cancer. Fifty-six Black caregivers of people living with dementia or cancer were recruited from clinic and community sources. Variables measured included: depression, anxiety, stress, sleep, fatigue, and caregiver burden. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA). Descriptive statistics and non-parametric analyses were conducted to identify factors related to MoCA scores. Caregivers were 58.3 years of age and predominantly female. The average MoCA score was 25.23. Gender and education, along with positive appraisal of caregiving were significantly associated with cognitive performance. Several other factors approached significance including cohabitation with the care recipient, fatigue, and stress due to perceived individual and institutional racism. Our findings suggest several factors that warrant further investigation for understanding the relationship between caregiving and cognitive performance in Black caregivers of people living with cancer or dementia.

Sex Differences in Cardiac Risk Factors in Young Adults: A Secondary Analysis and Surveillance Study.

BACKGROUND: Coronary artery disease (CAD) is increasing in young adults, and greater understanding of their cardiac risk factors is essential to ensure effective prevention. Given the sex differences in CAD observed in older adults, understanding sex differences in risk factors for this younger group of adults is important. Having insight of cardiac risk factors and sex differences in the young adult population is essential to creating personalized strategies for prevention in nursing care and in this age group. OBJECTIVES: The aims of this study were to determine the differences in CAD risk factors for young adult men and women and examine which factors are related to CAD early in life, ultimately to guide approaches for CAD prevention in primary care. METHODS: In this secondary analysis, 125 017 community-dwelling young adults were evaluated for health behaviors considered as risk factors for CAD. The 2017 Behavior Risk Factor Surveillance System database from the Center for Disease Control was utilized. This database contains questions asked of young adults that would help with risk management for chronic diseases like CAD. Young adults in this article were defined as being between 18 and 44 years of age. RESULTS: Men reported more cardiovascular risk factors than women and developed risk factors at an earlier age. Women had greater percentages of obesity and low activity levels. In this population, those with hypertension had the highest odds ratio for developing CAD. CONCLUSIONS: Differences between men and women in CAD risk factors included lifestyle and other chronic conditions. Greater prevention efforts should focus on these differences in young men and women to reduce risk factors and prevent the development of CAD.

The association between social determinants of health and patient-centred outcomes in adults with heart failure with reduced ejection fraction.

AIMS: To explore the associations between social determinants of health and patient-centred outcomes among adults with chronic heart failure with reduced ejection fraction. DESIGN: Cross-sectional online self-report survey. METHODS: A survey assessing social determinants of health (demographics, socio-economic position, affordability of care and social support) and patient-centred outcomes, including the Kansas City Cardiomyopathy Questionnaire-12 and validated measures of medication adherence, treatment satisfaction, treatment burden and mental health, was completed by 512 adults with chronic heart failure with a reduced ejection fraction between 06 March and 29 June 2020. Multivariable analyses included linear and logistic regression. RESULTS: Female gender, having a care partner, and being offered financial assistance with medications were associated with worse health status, while perceiving medication as affordable and being married were associated with better health status. Females and having Medicaid, dual Medicaid/Medicare or no medical insurance were associated with a higher likelihood of depression, and non-white race/ethnicity was associated with less depression. Medication adherence was lower in patients having a care partner and offered financial assistance. Patients being offered financial and medication management assistance were more likely to be overwhelmed by the treatment burden, whereas those having some college education were less so. CONCLUSIONS: Social determinants of health are associated with patients' disease-specific health status, mental health and treatment satisfaction and burden. These findings underscore the importance of assessing social determinants of health in clinical practice and the need for developing and testing novel strategies to determine whether they improve patients' health. IMPACT: The relationship between social determinants of health- and patient-centred outcomes was assessed; affordability of care and social support factors were most strongly associated with outcomes for patients with chronic heart failure and reduced ejection fraction, underscoring the importance of assessing social determinants of health in routine clinical care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Social determinants of health data could potentially inform care delivery for patients with heart failure and reduced ejection fraction by helping to identify those who require additional support to manage their symptoms, access care and adhere to treatment. Social support and affordability of treatment were associated with most patient-centred outcomes, suggesting these factors may provide clinicians with an indicator of a patient's level of general well-being that could be assessed during routine follow-up care. REPORTING METHOD: This research followed the STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION: Adults who have heart failure with reduced ejection fraction that consented to participate in the study provided the data used for all analyses reported on in the manuscript. Service users, caregivers or members of the public had no involvement in the study.

Lay Stakeholders in Science and Research Initiative: A Science Advisory From the American Heart Association.

The American Heart Association (AHA) is the largest not-for-profit funder of cardiovascular and cerebrovascular disease research in the United States. It has supported research of independent scientists for 7 decades with the goal of finding novel discoveries that will reduce death and disability from these diseases and ultimately improve overall health. In 2014, the AHA approved a pilot initiative to include lay stakeholders (patients, caregivers, and passionate advocates) in its research and science operations. The initiative was based on the premise that lay stakeholders would add a unique and necessary perspective that would improve decisions concerning research funding, research direction, and scientific guidelines. The AHA developed a framework for the initiative that defined lay stakeholder, created a volunteer recruitment and training program, established policies for incorporating lay stakeholders into science operations, and set metrics for evaluating the initiative over time. It has instituted creative ways to engage lay volunteers and to foster lay and scientist cooperation. Program assessments have been consistently positive and have identified needed future improvements. The benefits of lay/scientist collaboration have far exceeded the AHA's expectations. The AHA will continue to strengthen lay volunteer engagement throughout its science and research operations; to focus on developing a larger, diverse group of qualified lay stakeholders; to educate scientists on how to communicate research effectively to the public and donors; and to retain the respect of donors for the rigors of its research funding, scientific statements, and clinical guidelines.

Sphinganine is associated with 24-h MAP in the non-sleepy with OSA.

INTRODUCTION: Excessive daytime sleepiness is a debilitating symptom of obstructive sleep apnea (OSA) linked to cardiovascular disease, and metabolomic mechanisms underlying this relationship remain unknown. We examine whether metabolites from inflammatory and oxidative stress-related pathways that were identified in our prior work could be involved in connecting the two phenomena. METHODS: This study included 57 sleepy (Epworth Sleepiness Scale (ESS) ≥ 10) and 37 non-sleepy (ESS < 10) participants newly diagnosed and untreated for OSA that completed an overnight in-lab or at home sleep study who were recruited from the Emory Mechanisms of Sleepiness Symptoms Study (EMOSS). Differences in fasting blood samples of metabolites were explored in participants with sleepiness versus those without and multiple linear regression models were utilized to examine the association between metabolites and mean arterial pressure (MAP). RESULTS: The 24-h MAP was higher in sleepy 92.8 mmHg (8.4) as compared to non-sleepy 88.8 mmHg (8.1) individuals (P = 0.03). Although targeted metabolites were not significantly associated with MAP, when we stratified by sleepiness group, we found that sphinganine is significantly associated with MAP (Estimate = 8.7, SE = 3.7, P = 0.045) in non-sleepy patients when controlling for age, BMI, smoking status, and apnea-hypopnea index (AHI). CONCLUSION: This is the first study to evaluate the relationship of inflammation and oxidative stress related metabolites in sleepy versus non-sleepy participants with newly diagnosed OSA and their association with 24-h MAP. Our study suggests that Sphinganine is associated with 24 hour MAP in the non-sleepy participants with OSA.

Association of physical activity with arterial stiffness among Black adults.

Arterial stiffness is a precursor for the development of hypertension and premature cardiovascular disease (CVD). Physical activity has been associated with lower arterial stiffness among largely White populations, but the types of activity required and whether these findings apply to Black adults remain unknown. We examined whether physical activity levels were associated with arterial stiffness among Black adults in two independent cohorts. In the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity, 378 Black adults (age 52.8 ± 10.3, 39.7% male) without known CVD living in Atlanta, GA were recruited. Arterial stiffness was measured as pulse wave velocity (PWV). Total and domain-specific physical activity were assessed by self-report. Multiple linear regression models were used to investigate differences across physical activity levels after adjusting for age, sex, CVD risk factors, and socioeconomic status. Findings were validated in an independent cohort of Black adults (n = 55, age 50.4 ± 9.2, 23.6% male). After adjustment for covariates, lower arterial stiffness was associated with higher self-reported levels of sport/exercise (6.92 ± 1.13 vs 7.75 ± 1.14, p < 0.001, highest vs lowest quartile) and home/life activities (7.34 ± 1.24 vs 7.73 ± 1.07, p = 0.04, highest vs lowest quartile), but not work, active living, or the overall physical activity scores. These findings were replicated in the independent cohort where higher levels of sport/exercise remained associated with lower arterial stiffness (6.66 ± 0.57 vs 8.21 ± 0.66, p < 0.001, highest vs lowest quartile). Higher levels of sport/exercise and home/life-related physical activities (in comparison to occupational physical activity) are associated with lower arterial stiffness in Black adults.

The Utility of Nursing Notes Among Medicare Patients With Heart Failure to Predict 30-Day Rehospitalization: A Pilot Study.

BACKGROUND: For patients with heart failure (HF), there have been efforts to reduce the risk of 30-day rehospitalization, such as developing predictive models using electronic health records. Few previous studies used clinical notes to predict 30-day rehospitalization. OBJECTIVE: The aim of this study was to assess the utility of nursing notes versus discharge summaries to predict 30-day rehospitalization among patients with HF. METHODS: In this pilot study, we used free-text discharge summaries and nursing notes collected from a tertiary hospital. We randomly selected 500 Medicare patients with HF. We followed the natural language processing and machine learning pipeline for data analysis. RESULTS: Thirty-day rehospitalization risk prediction using discharge summaries (n = 500) produced an area under the receiver operating characteristic curve of 0.74 (Bag of Words + Neural Network). Thirty-day rehospitalization risk prediction using nursing notes (n = 2046) resulted in an area under the receiver operating characteristic curve of 0.85 (Bag of Words + Neural Network). CONCLUSION: Nursing notes provide a superior input to risk models for 30-day rehospitalization in Medicare patients with HF compared with discharge summaries.

Testing of a health-related quality of life model in patients with heart failure: A cross-sectional, correlational study.

Psychological symptoms, physical symptoms, and behavioral factors can affect health-related quality of life (HRQOL) through different pathways, but the relationships have not been fully tested in prior theoretical models. The purpose of this study was to examine direct and indirect relationships of demographic (age), biological/physiological (comorbidity), psychological (depressive symptoms), social (social support), physical (physical symptoms and functional status), and behavioral (dietary sodium adherence) factors to HRQOL. Data from 358 patients with heart failure were analyzed using structural equation modeling. There was a good model fit: Chi-square = 5.488, p = .241, RMSEA = .032, CFI = .998, TLI = .985, and SRMR = .018. Psychological symptoms, physical symptoms, and demographic factors were directly and indirectly associated, while behavioral and biological/physiological factors were indirectly associated with HRQOL through different pathways. Behavioral factors need to be included, and psychological factors and physical factors need to be separated in theoretical models of HRQOL.

Patient-centered Outcomes in HFrEF Following a Worsening Heart Failure Event: A Survey Analysis.

BACKGROUND: Heart failure is a chronic disease punctuated by intermittent exacerbations that require hospitalization or intravenous diuretic therapy. The association of worsening heart failure events (WHFEs) with patient-centered outcomes in heart failure with reduced ejection fraction (HFrEF) remains unexplored. METHODS AND RESULTS: Patients with HFrEF completed an online survey assessing health status, medication adherence, treatment satisfaction, treatment burden, and medication costs and affordability. Patients with and without WHFEs were compared on all study variables, with adjustment for patient characteristics using linear or logistic regression. Overall, 512 patients (52.0% WHFEs) were included. Patients with WHFEs more commonly had depression (55.3% vs 24.0%), anxiety (46.2% vs 17.9%), and insomnia (77.8% vs 44.7%; P < 0.001 for all). Patients with WHFEs had lower adjusted mean Kansas City Cardiomyopathy Questionnaire values (52.9 vs 56.0) and Satisfaction with Medications Questionnaire values (70.5 vs 72.6) and higher Treatment Burden Questionnaire scores (51.1 vs 45.1; P < 0.001). Medication-related beliefs and long-term concerns were independently associated with nonadherence in patients with WHFE (adjusted odds ratios: 4.2 and 5.2, respectively; P < 0.01 for both). Patients with WHFE incurred 50.0% higher median monthly out-of-pocket HF prescription medication costs and less often perceived HF medications to be affordable. CONCLUSIONS: WHFE is associated with several adverse impacts on patients with HFrEF. Additional support is warranted to manage symptoms, comorbidities, and HF treatments to improve adherence and outcomes.

Changes in sleepiness and 24-h blood pressure following 4 months of CPAP treatment are not mediated by ICAM-1.

OBJECTIVE: Continuous positive airway pressure (CPAP) therapy reduces circulating intercellular adhesion molecule 1 (ICAM-1) in adults with obstructive sleep apnea (OSA). ICAM-1 levels may affect the daytime sleepiness and elevated blood pressure associated with OSA. We evaluated the association of changes from baseline in ICAM-1 with changes of objective and subjective measures of sleepiness, as well as 24-h ambulatory blood pressure monitoring (ABPM) measures, following 4 months of CPAP treatment. METHODS: The study sample included adults with newly diagnosed OSA. Plasma ICAM-1, 24-h ABPM, Epworth Sleepiness Scale (ESS), and psychomotor vigilance task (PVT) were obtained at baseline and following adequate CPAP treatment. The associations between changes in natural log ICAM-1 and changes in the number of lapses on PVT, ESS score, and 24-h mean arterial blood pressure (MAP) were assessed using multivariate regression models, controlling for a priori baseline covariates of age, sex, BMI, race, site, smoking status, physical activity, anti-hypertensive medications, AHI, and daily hours of CPAP use. RESULTS: Among 140 adults (83% men), mean (± SD) body mass index (BMI) was 31.5 ± 4.2 kg/m2, and apnea-hyopnea index (AHI) was 36.8 ± 15.3 events/h. Sleepiness measures, although not ICAM-1 or ABPM measures, improved significantly following CPAP treatment. We observed no statistically significant associations between the change in ICAM-1 and changes in sleepiness, MAP, or other ABPM measures. CONCLUSION: Changes in ICAM-1 levels were not related to changes in sleepiness or ABPM following CPAP treatment of adults with OSA. Future work should explore whether or not other biomarkers may have a role in mediating these treatment outcomes in adults with OSA.

Caregiver Strain and Heart Failure Patient Clinical Event Risk: An Extension of Previous Work.

BACKGROUND: In a study of Italian heart failure patient-caregiver dyads, greater caregiver strain significantly predicted lower patient clinical event risk. OBJECTIVE: The purpose of this secondary analysis was to examine this relationship in a sample from the United States. METHODS: Data came from 92 dyads who participated in a self-care intervention. Logistic regression was used to test the relationship between baseline strain (Bakas Caregiving Outcomes Scale, divided into tertiles) and patient likelihood of events (heart failure hospitalization/emergency visit or all-cause mortality) over 8 months. RESULTS: Nearly half of patients (n = 40, 43.5%) had an event. High (vs low) caregiver strain was associated with a 92.7% event-risk reduction, but with substantial variability around the effect (odds ratio, 0.07; 95% confidence interval, 0.01-0.63; P = .02). CONCLUSIONS: Although findings were similar to the Italian study, the high degree of variability and contrasting findings to other studies signal a level of complexity that warrants further investigation.

Sociodemographic and clinical correlates of diabetes self-efficacy in adults with type 2 diabetes and comorbid heart failure.

Heart failure (HF) is a comorbidity that complicates type 2 diabetes mellitus (T2D) management and increases the chance of death. However, little is known concerning factors related to diabetes self-efficacy in comorbid HF. This secondary data analysis was aimed at describing sociodemographic and clinical correlates of diabetes self-efficacy in adults with T2D and comorbid HF. A correlational design was used to analyze cross-sectional baseline data from a randomized study of 180 participants that tested a 6-month integrated self-care intervention targeting adults with concomitant HF and T2D. Participants were enrolled from one of four large urban-tertiary hospitals in Atlanta, GA, during 2010-2013. Data were collected from medical records and self-report. We used stepwise multiple linear regressions to examine variables associated with diabetes self-efficacy. The participants' mean age was 58.1 ± 10.7 years and the majority were male (n = 118; 65.6%) and African American (n = 119; 66.1%). Good self-rated health and presence of implantable cardioverter-defibrillator (ICD) had significant positive relationships with diabetes self-efficacy, while taking both oral antiglycemic medication and insulin, history of depression, cardiac pacemaker, and taking digitalis were negatively related. These variables collectively explained 22.4% of the variation in diabetes self-efficacy. One study implication is that using self-rated health provides a quick, patient-centered assessment to evaluate patient health status. Further studies are warranted to ascertain the pathways linking ICD, pacemaker, and digitalis treatment with diabetes self-efficacy.

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association.

INTRODUCTION: In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035. METHODS: We used data from the 2014 Health and Retirement Survey to estimate hours of informal caregiving for individuals with CVD by age/sex/race using a zero-inflated binomial model and controlling for sociodemographic factors and health conditions. Costs of informal caregiving were estimated separately for hypertension, coronary heart disease, heart failure, stroke, and other heart disease. We analyzed data from a nationally representative sample of 16 731 noninstitutionalized adults ≥54 years of age. The value of caregiving hours was monetized by the use of home health aide workers' wages. The per-person costs were multiplied by census population counts to estimate nation-level costs and to be consistent with other American Heart Association analyses of burden of CVD, and the costs were projected from 2015 through 2035, assuming that within each age/sex/racial group, CVD prevalence and caregiving hours remain constant. RESULTS: The costs of informal caregiving for patients with CVD were estimated to be $61 billion in 2015 and are projected to increase to $128 billion in 2035. Costs of informal caregiving of patients with stroke constitute more than half of the total costs of CVD informal caregiving ($31 billion in 2015 and $66 billion in 2035). By age, costs are the highest among those 65 to 79 years of age in 2015 but are expected to be surpassed by costs among those ≥80 years of age by 2035. Costs of informal caregiving for patients with CVD represent an additional 11% of medical and productivity costs attributable to CVD. CONCLUSIONS: The burden of informal caregiving for patients with CVD is significant; accounting for these costs increases total CVD costs to $616 billion in 2015 and $1.2 trillion in 2035. These estimates have important research and policy implications, and they may be used to guide policy development to reduce the burden of CVD on patients and their caregivers.

Nutrition intervention in heart failure: should consumption of the DASH eating pattern be recommended to improve outcomes?

Heart failure (HF) is a chronic, systemic disorder that presents a serious and growing public health problem due to its high prevalence, mortality, and cost of care. Due to the aging of the population and medical advances that prolong the life of HF patients, more effective, widespread strategies for improved HF management in this rapidly growing patient population are needed. While the prevalence of malnutrition in HF patients has been well characterized, evidence is limited regarding the effects of specific macro- and micronutrient deficiencies on HF outcomes and their interaction with other aspects of HF management, including pharmacotherapy. There is a mounting appreciation for the effects of nutritional intervention on pathophysiology, treatment, and outcomes in patients with HF. Heart-healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), carry importance for the prevention and treatment of hypertension. While preliminary evidence looks promising regarding effects of DASH eating pattern consumption on ventricular function and 30-day hospitalizations in HF patients, more research is needed to confirm its effects on short-term and long-term HF outcomes while better understand underlying mechanisms in the context of HF pharmacotherapy.

Essential considerations in developing attention control groups in behavioral research.

Attention control groups strengthen randomized controlled trials of behavioral interventions, but researchers need to give careful consideration to the attention control activities. A comparative effectiveness research framework provides an ideal opportunity for an attention control group as a supplement to standard care, so participants potentially receive benefit regardless of group assignment. The anticipated benefit of the control condition must be independent of the study outcome. Resources needed for attention control activities need to be carefully considered and ethical considerations carefully weighed. In this paper we address nine considerations for the design and implementation of attention control groups: (1) ensure attention control activities are not associated with the outcome; (2) avoid contamination of the intervention or control group; (3) design comparable control and intervention activities; (4) ensure researcher training to adequately administer both treatment arms; (5) design control activities to be interesting and acceptable to participants; (6) evaluate attention control activities; (7) consider additional resources needed to implement attention control activities; (8) quantifying the effects of attention control and intervention groups; and (9) ethical considerations with attention control groups. Examples from the literature and ongoing research are presented. Careful planning for the attention control group is as important as for the intervention group. Researchers can use the considerations presented here to assist in planning for the best attention control group for their study.

Recruitment Strategies and Costs Associated With Enrolling People With Insomnia and High Blood Pressure Into an Online Behavioral Sleep Intervention: A Single-Site Pilot Study.

BACKGROUND: Recruitment in clinical research is a common challenge and source of study failure. The reporting of recruitment methods and costs in hypertension trials is limited especially for smaller, single-site trials, online intervention trials, and trials using newer online recruitment strategies. OBJECTIVE: The aims of this study are to describe and examine the feasibility of newer online-e-mail recruitment strategies and traditional recruitment strategies used to enroll participants with insomnia and high blood pressure into an online behavioral sleep intervention study (Sleeping for Heart Health). METHODS: The 16 online-e-mail-based and traditional recruitment strategies used are described. Recruitment strategy feasibility was examined by study interest and enrollee yields, conversion rates, and costs (direct, remuneration, labor, and cost per enrollee). RESULTS: From August 2014 to October 2015, 183 people were screened and 58 (31.7%) enrolled in the study (51.1 ± 12.9 years, 63.8% female, 72.4% African American, 136 ± 12/88 ± 7 mm Hg, 87.9% self-reported hypertension, 67.2% self-reported antihypertensive medication use). The recruitment strategies yielding the highest enrollees were the university hospital phone waiting message system (25.4%), Craigslist (22.4%), and flyers (20.3%) at a per enrollee cost of $42.84, $98.90, and $128.27, respectively. The university hospital phone waiting message system (55.6%) and flyers (54.5%) had the highest interested participant to enrolled participant conversion rate of all recruitment strategies. CONCLUSION: Approximately 70% of all enrolled participants were recruited from the university hospital phone waiting message system, Craigslist, or flyers. Given the recruitment challenges that most researchers face, we encourage the documenting, assessing, and reporting of detailed recruitment strategies and associated recruitment costs so that other researchers may benefit.

Insomnia Symptoms Are Associated With Abnormal Endothelial Function.

BACKGROUND: Insomnia is a prevalent sleep disorder, and it has been increasingly associated with cardiovascular morbidity and mortality. The reasons for this relationship are not completely understood but may involve endothelial dysfunction. In this study, we hypothesized that insomnia symptoms would be associated with reduced endothelial function. METHODS: Working adults (n = 496, 67.5% female, 78.6% white, mean age 48.7 [SD, 10.8] years, body mass index 28.2 [SD, 6.7] kg/m, diabetes 5.8%, hypertension 20.0%, hyperlipidemia 17.9%, heart disease 2.6%) enrolled in the Emory-Georgia Tech Predictive Health Institute study completed baseline demographic, clinical, depression (Beck Depression Inventory II), anxiety (General Anxiety Disorder 7), sleep (Pittsburg Sleep Quality Index), and noninvasive endothelial function (brachial artery flow-mediated dilation [FMD]) measures. Insomnia symptoms were defined as subjective sleep latency of 30 minutes or longer, nighttime or early morning awakenings, and/or sleep medication use occurring 3 times or more per week in the past month. RESULTS: Insomnia symptoms were reported by 39.5% of participants. Multivariable regression models showed that insomnia symptoms, age, baseline artery diameter, and dyslipidemia were inversely related to FMD. After adjusting for age, baseline artery diameter, and dyslipidemia, participants reporting insomnia symptoms had lower FMD than did participants reporting better sleep (adjusted FMD mean, 6.13% [SD, 0.28%] vs 6.83% [SD, 0.26%], P = .035). CONCLUSION: In this study, insomnia symptoms were associated with reduced FMD. Research examining the therapeutic benefits of treating insomnia on endothelial function and future cardiovascular risk is warranted.

Relationship of Health Literacy of Heart Failure Patients and Their Family Members on Heart Failure Knowledge and Self-Care.

We explored the relationships among patients' and family members' (FMs) health literacy, heart failure (HF) knowledge, and self-care behaviors using baseline data from HF patients and their FMs ( N = 113 pairs) in a trial of a self-care intervention. Measures included Rapid Estimate of Adult Literacy in Medicine, Atlanta HF Knowledge Test, a heart failure Medication Adherence Scale, and sodium intake (24-hr urine and 3-day food record). Patients with low health literacy (LHL) were more likely to have lower HF knowledge ( p < .001) and trended to poorer medication adherence ( p = .077) and higher sodium intake ( p = .072). When FMs had LHL, FMs were more likely to have lower HF knowledge ( p = .001) and patients trended toward higher sodium intake ( p = .067). When both patients and FMs had LHL, lowest HF knowledge and poorest medication adherence were observed ( p < .027). The health literacy of both patient and FM needs to be considered when designing interventions to foster self-care.

Methylation of Apoptosis-Associated Speck-Like Protein With a Caspase Recruitment Domain and Outcomes in Heart Failure.

BACKGROUND: Heart failure (HF) is associated with inflammation characterized by the formation of the inflammasome, which triggers maturation of inflammatory cytokines. Apoptosis-associated speck-like protein with a caspase recruitment domain (ASC), a vital component of the inflammasome, is controlled through epigenetic modification, which may be a candidate pathway for worsening HF. This study examined the inflammasome pathway in HF and the relationships between ASC CpG methylation and outcomes in HF. METHODS AND RESULTS: Stored samples from 155 HF outpatients (ejection fraction 29.9 ± 14.9%) were analyzed for percentage methylation of 7 CpG sites in the intron region preceding exon 1 of the ASC gene. ASC methylation was inversely related to ASC mRNA (r = -0.33; P < .001) and protein (r = -0.464; P < .001). ASC methylation had a positive linear relationship with ejection fraction (r = 0.85; P < .001), quality of life (r = 0.83; P < .001), and 6-minute walk test (r = 0.59; P = .023) and a negative linear relationship with depression (r = -0.81; P < .001) and anxiety (r = -0.75; P < .001). Higher ASC methylation was associated with a lower risk for clinical events (hazard ratio [HR] 0.16; P = .025), whereas higher protein (HR = 1.78; P = .045) and mRNA expression (HR = 1.18; P = .05) were associated with a greater risk. CONCLUSIONS: Increased methylation of CpG sites in the intron region of ASC is associated with improved outcomes in HF. The associated decrease in ASC expression implicates this inflammatory mediator as a possible driver of HF outcomes and may represent a therapeutic target.