Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality.

BACKGROUND: Five modifiable risk factors are associated with cardiovascular disease and death from any cause. Studies using individual-level data to evaluate the regional and sex-specific prevalence of the risk factors and their effect on these outcomes are lacking. METHODS: We pooled and harmonized individual-level data from 112 cohort studies conducted in 34 countries and 8 geographic regions participating in the Global Cardiovascular Risk Consortium. We examined associations between the risk factors (body-mass index, systolic blood pressure, non-high-density lipoprotein cholesterol, current smoking, and diabetes) and incident cardiovascular disease and death from any cause using Cox regression analyses, stratified according to geographic region, age, and sex. Population-attributable fractions were estimated for the 10-year incidence of cardiovascular disease and 10-year all-cause mortality. RESULTS: Among 1,518,028 participants (54.1% of whom were women) with a median age of 54.4 years, regional variations in the prevalence of the five modifiable risk factors were noted. Incident cardiovascular disease occurred in 80,596 participants during a median follow-up of 7.3 years (maximum, 47.3), and 177,369 participants died during a median follow-up of 8.7 years (maximum, 47.6). For all five risk factors combined, the aggregate global population-attributable fraction of the 10-year incidence of cardiovascular disease was 57.2% (95% confidence interval [CI], 52.4 to 62.1) among women and 52.6% (95% CI, 49.0 to 56.1) among men, and the corresponding values for 10-year all-cause mortality were 22.2% (95% CI, 16.8 to 27.5) and 19.1% (95% CI, 14.6 to 23.6). CONCLUSIONS: Harmonized individual-level data from a global cohort showed that 57.2% and 52.6% of cases of incident cardiovascular disease among women and men, respectively, and 22.2% and 19.1% of deaths from any cause among women and men, respectively, may be attributable to five modifiable risk factors. (Funded by the German Center for Cardiovascular Research (DZHK); ClinicalTrials.gov number, NCT05466825.).

Adherence to Mediterranean diet and subsequent cognitive decline in men with cardiovascular disease.

Backgrounds and aims: Evidence from recent years highlighted the importance of the Mediterranean diet for brain health. We investigated the association between adherence to Mediterranean diet and change in cognitive functions two decades later in patients with cardiovascular disease (CVD).Methods: Participants were men with a history of CVD, who previously participated in the Bezafibrate Infarction Prevention (BIP) trial between 1990 and 1997, had a food diary record, and underwent cognitive evaluations 14.6 ± 1.9 years (T1) and 19.9 ± 1.0 years after baseline (T2) as part of the BIP Neurocognitive study (n = 200, mean age at 57.3 ± 6.3 years). Adherence to the Mediterranean diet was determined from the self-administered 4-day food diary record, with patients categorized into high, middle and poor levels of adherence if they received >5, 4-5 and <4 points, respectively. Cognitive function was assessed using the NeuroTrax computerized battery. Linear mixed models were applied.Results: Among the 200 patients, 52 (26%) had poor adherence, 98 (49%) had middle adherence and 50 (25%) had high levels of adherence to the Mediterranean diet. Those categorized to the poor adherence level had poorer cognitive function at T1 compared to the other groups. Additionally, poor vs. high level of adherence was associated with a greater decline in overall cognitive performance [z-score = -0.23 and 95% confidence interval (CI), -0.43;-0.04; p = 0.021] and in visual spatial functions (-0.46 95% CI, -0.86;-0.06; p = 0.023).Conclusion: This study stresses the possible role of the Mediterranean diet in men with a high vascular burden and may set the ground for future intervention to reduce their risk for cognitive decline.

Association of socioeconomic status measures with physical activity and subsequent frailty in older adults.

BACKGROUND: Despite increased recognition, frailty remains a significant public health challenge. OBJECTIVE: we aimed to assess the role of education and income, as well as neighborhood socioeconomic status, on physical activity and subsequent frailty in older adults. METHODS: Using a population-based cohort of older adults, this study examined the relationship between socioeconomic status (SES) factors, physical activity and frailty. The study included 1,799 participants (mean [SD], 74.6 (6.2), 53.3% female) from the "National Health and Nutrition Survey of Older Adults Aged 65 and Over in Israel", conducted in 2005-2006. A follow-up interview was performed 12-14 years later in a subgroup of 601 subjects (mean [SD], age 84[4]; 56% women). Self-reported leisure-time physical activity (LTPA) was measured at both baseline and follow-up. SES measures were assessed at baseline. Frailty was measured at follow-up, using the Fried's Phenotype Model. RESULTS: All SES measures were strongly and positively associated with LTPA (all p < 0.001). Eighty-two participants (14%) were classified as frail at follow-up. After age and sex adjustment and accounting for attrition bias using inverse probability weighting, baseline LTPA (OR = 2.77, 95% CI: 1.57-4.90, for inactivity; OR = 1.41, 95% CI: 0.75-2.68, for insufficient activity, compared with sufficient activity, Ptrend < 0.001) was inversely associated with incident frailty. The association persisted after further adjustment for SES and comorbidity. CONCLUSION: Among older individuals, multiple SES measures were positively associated with LTPA, which was a strong predictor of lower subsequent frailty risk.

Midlife resting heart rate, but not its visit-to-visit variability, is associated with late-life frailty status in men with coronary heart disease.

BACKGROUND: Autonomic imbalance is linked with multiple health conditions, yet its associations with frailty were rarely studied. We assessed the relationship of resting heart rate (RHR) and visit-to-visit heart rate variability (HRV) with future frailty among elderly men with coronary heart disease (CHD). METHODS: Three-hundred-six community-dwelling men with CHD who participated in the Bezafibrate Infarction Prevention (BIP) trial (1990-1998; mean age 56.6 ± 6.5 years) underwent assessment of physical frailty in 2011-2013 (mean age 77.0 ± 6.4 years). Mean RHR and visit-to-visit HRV were calculated from electrocardiogram as indicators of autonomic imbalance. Nominal logistic and linear regression models were used to assess the relationships of RHR and HRV with frailty status and its components (i.e. gait speed, grip strength, weight loss, exhaustion and activity), respectively. Adjustments were made for various demographic, clinical and metabolic covariates. RESULTS: Of the 306 men, 81 (26%) were frail and 117 (38%) were prefrail. After controlling for potential confounders, RHR, but not visit-to-visit HRV, was associated with higher odds of being prefrail [OR = 1.44 (95%CI 1.15, 1.79)] and frail [OR = 1.35 (95%CI 1.03, 1.77)]. Each 5-bpm increase in RHR was associated with weaker grip (ß= -1.12 ± 0.32 kg; p-value < .001) and slower gait speed (ß = 0.19 ± 0.08s/m; p-value = .022). CONCLUSIONS: Midlife RHR may be associated with late-life frailty in men with CHD.

Angina pectoris severity and late-life frailty among men with cardiovascular disease.

OBJECTIVE: We investigated the association between severity of angina pectoris (AP) and subsequent late-life frailty among men with cardiovascular disease (CVD). METHOD: A subset of 351 men (mean age at baseline 56.7 ± 6.5 years) who previously participated in the Bezafibrate Infarction Prevention, BIP trial (1990-1997) underwent a neurovascular evaluation as part of the BIP Neurocognitive study 15.0 ± 3.0 years after baseline (T1) and a frailty evaluation according to Fried 19.9 ± 1.0 years after baseline (T2). Severity of AP was assessed at baseline of the BIP trial using the Canadian Cardiovascular Society angina classification. We assessed the odds of being in the advanced rank of frailty status (robust, pre-frail, and frail) using ordered logistic regression. RESULTS: Among 351 participants, 134 (38.2%) were classified as pre-frail and 100 (28.5%) as frail. Frailty was found among 42% participants in the AP class ≥2 and among 26% participants in the AP class <2. Adjusting for demographic, health-related and cognitive variables, odds ratio (OR), and 95% confidence interval (95% CI) for advanced rank of frailty was 2.68 (95% CI: 1.29-5.59) comparing AP class ≥2 to AP class <2. DISCUSSION: Among men with CVD, severity of AP should be taken into risk consideration due to its strong association with late-life frailty, particularly among inactive participants and participants with cerebral microvascular damage.

Overweight, Obesity, and Late-Life Sarcopenia Among Men With Cardiovascular Disease, Israel.

INTRODUCTION: Little is known about the association between obesity and sarcopenia - age-related loss of muscle mass and function - among patients with cardiovascular disease. We investigated the association between overweight, obesity, and sarcopenia among community-dwelling men in Israel with cardiovascular disease. METHODS: A subset of 337 men (mean age at baseline 56.7 [SD, 6.5]) who previously (1990-1997) participated in the Bezafibrate Infarction Prevention trial underwent a neurovascular evaluation as part of the Bezafibrate Infarction Prevention Neurocognitive Study 15.0 (SD, 3.0) years after baseline and a sarcopenia evaluation 19.9 (SD, 1.0) years after baseline. We applied a multinomial logistic model to estimate odds ratios and 95% CIs for 3 categories of sarcopenia: no evidence of sarcopenia (ie, robust), probable sarcopenia, and sarcopenia. RESULTS: We found sarcopenia among 54.3% of participants with obesity (body mass index [BMI, in kg/m2] ≥30.0), 37.0% of participants who were overweight (25.0 ≤ BMI ≤29.9), and 24.8% of participants with normal weight (BMI 18.5 to 24.9). In a comparison of BMI ≥25.0 and BMI <25.0, adjusting for covariates, the odds ratio of having probable sarcopenia was 3.27 (95% CI, 1.68-6.36) and having sarcopenia was 5.31 (95% CI, 2.50-11.27). CONCLUSION: We found a positive association between obesity and late-life sarcopenia and suggest that obesity might be an important modifiable risk factor related to sarcopenia among men with cardiovascular disease.

Adherence to a Mediterranean diet by vegetarians and vegans as compared to omnivores.

To assess adherence to the Mediterranean Diet (MedD) by vegetarians and vegans compared to omnivores, we recruited an internet-based convenience sample of 565, 151 and 514 Israeli (>20 years) vegans, vegetarians and omnivores. Studies assessing vegetarians' and vegans' adherence to the Mediterranean Diet (MedD) are scarce. We recruited an internet-based convenience sample of 565, 151 and 514 Israeli vegans, vegetarians and omnivores, mostly female with a normal weight. We assessed their MedD scores (MedDS) and their food groups' consumption by two food frequency questionnaires: (1) Trichopoulou's MedDS (range 0-9); (2) Literature-based MedDS (LBMedDS) (range 0-18). We found that vegans tend to consume significantly more legumes, nuts, fruits and vegetables than omnivores. The multivariable-adjusted odds for high MedDS (a score ≥4) (compared to omnivores) assessed by Trichopoulou's score were: 32.35-fold higher in vegans (95% CI, 21.43-48.84) and 3.13-fold higher in vegetarians (95% CI, 2.06-4.76). Using the LBMedDS, vegans had 2.30-fold higher odds for high MedD adherence (a score ≥12) and vegetarians 1.66-fold higher odds compared to omnivores. In conclusion, we found a higher MedD adherence among vegans and vegetarians compared to omnivores.

C-reactive protein in midlife is associated with depressive symptoms two decades later among men with coronary heart disease.

Aim: We investigated the relationship between midlife C-reactive protein (CRP) levels in men with coronary heart disease (CHD) and depressive symptoms at old age. CRP levels were measured in a subset of patients with CHD, who previously participated in a secondary prevention trial.Methods: Depressive symptoms were evaluated in survivors of the original cohort 15.0 ± 3 and 19.9 ± 1 years later (T1, n = 463 and T2, n = 314 respectively) using the Geriatric Depression Scale (GDS), 15-item version. Logistic regression was used to estimate ORs and 95%CIs for presence of potentially clinically significant depressive symptoms (GDS ≥5) at T1 and T2.Results: Adjusting for demographic and health-related variables, the OR (95%CI) for GDS ≥5 was 1.23 (0.65-2.33); p = .53 at T1 and 2.36 (1.16-4.83); p = .018 at T2 in the top CRP tertile compared to the others. Similarly, consistently high CRP levels in the top tertile at baseline and 2 years later, were associated with OR of 2.85 (95%CI 1.29-6.30); p = .01 for GDS ≥5 at T2.Conclusions: Presence and persistence of low-grade inflammation in men with CHD during midlife are associated with increased risk of depressive symptoms twenty years later. Among middle aged men with CHD, low-grade inflammation may provide an important added value for prediction of depression in old age.

Use of Repeated Blood Pressure and Cholesterol Measurements to Improve Cardiovascular Disease Risk Prediction: An Individual-Participant-Data Meta-Analysis.

The added value of incorporating information from repeated blood pressure and cholesterol measurements to predict cardiovascular disease (CVD) risk has not been rigorously assessed. We used data on 191,445 adults from the Emerging Risk Factors Collaboration (38 cohorts from 17 countries with data encompassing 1962-2014) with more than 1 million measurements of systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol. Over a median 12 years of follow-up, 21,170 CVD events occurred. Risk prediction models using cumulative mean values of repeated measurements and summary measures from longitudinal modeling of the repeated measurements were compared with models using measurements from a single time point. Risk discrimination (C-index) and net reclassification were calculated, and changes in C-indices were meta-analyzed across studies. Compared with the single-time-point model, the cumulative means and longitudinal models increased the C-index by 0.0040 (95% confidence interval (CI): 0.0023, 0.0057) and 0.0023 (95% CI: 0.0005, 0.0042), respectively. Reclassification was also improved in both models; compared with the single-time-point model, overall net reclassification improvements were 0.0369 (95% CI: 0.0303, 0.0436) for the cumulative-means model and 0.0177 (95% CI: 0.0110, 0.0243) for the longitudinal model. In conclusion, incorporating repeated measurements of blood pressure and cholesterol into CVD risk prediction models slightly improves risk prediction.

Cancer incidence in Holocaust male survivors-An Israeli cohort study.

Previous studies, often using proxy exposure assessment and not controlling for individual risk factors, suggested higher cancer risk in Holocaust survivors. We have used individual-level data from a male cohort of Israeli civil servants recruited in 1963 to investigate cancer incidence in Holocaust survivors, controlling for potential confounders. The analysis included 4,669 Europe-born subjects; 689 exposed = E (immigrated to Israel after 1939 and reported of being in Nazi camps during World War II); 2,307 potentially exposed = PE (immigrated to Israel after 1939 and reported of not being in Nazi camps); and 1,673 non-exposed = NE (immigrated to Israel prior to 1939). Vital status and cancer incidence in the cohort were determined based on national registries. Socioeconomic level, health behaviors and cancer incidence were compared between the groups and Cox proportional hazards regression models adjusting for potential confounders assessed hazard risk ratios for cancer by exposure status. All-cause mortality was studied as a competing risk. In total, 241, 682, and 522 cancer cases were diagnosed in the E, PE, and NE, respectively. Compared with the NE, all-site cancer incidence was higher in the E (HR = 1.13, 95%CI 0.97-1.32) but not in the PE. All-cause mortality competed with all-site invasive cancer incidence in the E group (HR = 1.18, 95%CI 1.02-1.38). Colorectal and lung cancer seemed to be positively though non-significantly associated with the exposure while prostate cancer was not. Male Holocaust survivors may be at a weakly increased risk for all-site, colorectal and lung cancer. The role of age at exposure and residual confounding should be further investigated.

Angina pectoris severity among coronary heart disease patients is associated with subsequent cognitive impairment.

BACKGROUND: The relationship between coronary heart disease (CHD) and cognitive function is not completely elucidated. We examined the association between severity of angina pectoris (AP) in mid-life and subsequent cognitive impairment among CHD patients. METHODS: Severity of AP according to the Canadian Cardiovascular Society angina classification was assessed in a subgroup of people with chronic CHD, who previously participated in a secondary prevention trial. Cognitive performance was evaluated 15±3 years later, using a validated set of computerized cognitive tests (Neurotrax Computerized Cognitive Battery; computing index scores summarizing performance in each cognitive domain and a global cognitive score). We compared the risk of cognitive deficits in participants with AP class >2 to those with AP≤2, adjusting for vascular risk factors, common carotid-intima media thickness (CC-IMT), and presence of carotid plaques. RESULT: Among 535 participants (mean age at baseline 57.9±6.6 y; 95% males), AP class >2 was associated with subsequent poorer performance on tests of memory and attention compared to those with AP class ≤2 (ß=-4.3±1.8; P=0.016 and ß=-3.6±1.7; P=0.029, respectively) and with a higher risk of having impairment in these domains [odds ratio (95% confidence interval)=1.83 (1.11-3.02); P=0.019 and 2.36 (1.34-4.16); P=0.003, for memory and attention, respectively]. These results were similar after controlling for vascular risk factors; however, the association of AP with memory domain attenuated after adjustment for CC-IMT or presence of carotid plaques. CONCLUSIONS: In people with preexisting CHD, severity of AP is associated with late-life poorer cognitive performance, independent of other vascular risk factors.

Inflammation and future risk of symptomatic heart failure in patients with stable coronary artery disease.

BACKGROUND: Heart failure (HF) carries poor prognosis in coronary artery disease (CAD) patients despite advances in therapy. Inflammation predicts recurrent cardiovascular events in CAD patients. It is unknown whether increased levels of inflammatory markers are associated with incident HF in these patients. AIM: The aims of this study were to evaluate the association between inflammatory markers and future HF risk in patients with stable CAD and to explore possible mediation by myocardial infarction (MI). METHODS: The study comprised 2,945 patients with stable CAD without HF at baseline during a median follow-up of 7.9 years. Inflammatory baseline markers were the basis of this study. RESULTS: Heart failure was diagnosed in 508 patients (17.2%). Patients who developed HF were older and had more often previous MI, diabetes, hypertension, and peripheral vascular disease. Baseline levels of C-reactive protein (CRP), fibrinogen, and white blood cells (WBCs) were significantly higher in patients who developed HF compared with those who did not. Age-adjusted incident HF rates were related to elevated baseline inflammatory markers in a dose-response manner. Adjusting for multiple confounders, the HF hazard ratios were 1.38 (95% CI 1.11-1.72), 1.33 (95% CI 1.07-1.66), and 1.36 (95% CI 1.10-1.68) for the third tertiles of CRP, fibrinogen, and WBC levels, respectively. Hazard ratio for the fifth quintile of a combined "inflammation score" was 1.83 (95% CI 1.40-2.39). Mediation by MI preceding the HF onset during follow-up accounted for 10.4%, 10.8%, and 8.6% of the association of subsequent HF with CRP, fibrinogen, and WBC, respectively. CONCLUSIONS: Increased levels of CRP, fibrinogen, and WBC are independently related to the incidence of HF in patients with stable CAD.

Smoking and risk of coronary heart disease in younger, middle-aged, and older adults.

OBJECTIVES: We investigated associations of smoking and coronary heart disease (CHD) by age. METHODS: Data came from the Pooling Project on Diet and Coronary Heart Disease (8 prospective studies, 1974-1996; n = 192,067 women and 74,720 men, aged 40-89 years). RESULTS: During follow-up, 4326 cases of CHD were reported. Relative to never smokers, CHD risk among current smokers was highest in the youngest and lowest in the oldest participants. For example, among women aged 40 to 49 years the hazard ratio was 8.5 (95% confidence interval [CI] = 5.0, 14) and 3.1 (95% CI = 2.0, 4.9) among those aged 70 years or older. The largest absolute risk differences between current smokers and never smokers were observed among the oldest participants. Finally, the majority of CHD cases among smokers were attributable to smoking. For example, attributable proportions of CHD by age group were 88% (40-49 years), 81% (50-59 years), 71% for (60-69 years), and 68% (≥ 70 years) among women who smoked. CONCLUSIONS: Among smokers, the majority of CHD cases are attributable to smoking in all age groups. Smoking prevention is important, irrespective of age.

Glycated hemoglobin measurement and prediction of cardiovascular disease.

IMPORTANCE: The value of measuring levels of glycated hemoglobin (HbA1c) for the prediction of first cardiovascular events is uncertain. OBJECTIVE: To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease (CVD) risk. DESIGN, SETTING, AND PARTICIPANTS: Analysis of individual-participant data available from 73 prospective studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment. MAIN OUTCOMES AND MEASURES: Measures of risk discrimination for CVD outcomes (eg, C-index) and reclassification (eg, net reclassification improvement) of participants across predicted 10-year risk categories of low (<5%), intermediate (5% to <7.5%), and high (≥ 7.5%) risk. RESULTS: During a median follow-up of 9.9 (interquartile range, 7.6-13.2) years, 20,840 incident fatal and nonfatal CVD outcomes (13,237 coronary heart disease and 7603 stroke outcomes) were recorded. In analyses adjusted for several conventional cardiovascular risk factors, there was an approximately J-shaped association between HbA1c values and CVD risk. The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate, but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein. The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 (95% CI, 0.7350 to 0.7517). The addition of information on HbA1c was associated with a C-index change of 0.0018 (0.0003 to 0.0033) and a net reclassification improvement of 0.42 (-0.63 to 1.48) for the categories of predicted 10-year CVD risk. The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting, random, or postload plasma glucose levels. CONCLUSIONS AND RELEVANCE: In a study of individuals without known CVD or diabetes, additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk.

Cognitive decline after stroke: relation to inflammatory biomarkers and hippocampal volume.

BACKGROUND AND PURPOSE: Inflammation may contribute to cognitive impairment after stroke. Inflammatory markers are associated with hippocampal atrophy. We tested whether markers of inflammation, erythrocyte sedimentation rate (ESR), and serum levels of C-reactive protein are associated with reduced hippocampal volume and poor cognitive performance among stroke survivors. METHODS: We analyzed 368 consecutive cases from our prospective study of first-ever mild-moderate stroke patients. MRI, cognitive tests, and inflammatory markers were determined. Patients were reevaluated 6 and 12 months after the event. RESULTS: ESR remained unchanged in follow-up examinations, suggesting a chronic inflammation background in some patients. Higher levels of C-reactive protein and ESR were associated with worse performance in cognitive tests, particularly memory scores. This association was maintained for ESR (but not C-reactive protein) after adjustment for confounders (P=0.002). Patients with smaller hippocampi had inferior cognitive results. Moreover, in a multivariate regression model, higher ESR values (but not C-reactive protein) were related to reduced hippocampal volume (P=0.049). CONCLUSIONS: This report shows a strong relationship between ESR and hippocampal volume, as well as with cognitive performance among poststroke patients. This could plausibly relate to incipient cognitive decline via hippocampal pathways.

Socioeconomic status indicators and incidence of heart failure among men and women with coronary heart disease.

BACKGROUND: Low socioeconomic status (SES) is associated with increased coronary heart disease (CHD) risk. Little is known about the relationship between SES and heart failure (HF) incidence among CHD patients. METHODS AND RESULTS: The association among education, occupation, and HF risk was studied in 2,951 CHD patients, free of HF at baseline, participating in a clinical trial, correcting for the competing risk of death. Over 8 years of close follow-up, 511 patients developed HF. These patients were older, and had higher frequency of metabolic risk factors and advanced CHD than HF-free counterparts. Age-adjusted HF incidence rate/1,000 person-years increased from 20.4 to 30.0 among patients with academic and elementary education, respectively. The rate for "blue collar" occupation was 25.1 compared with 18.5 among "academic"/"white collar" occupations combined. Adjusting for sex, obesity, diabetes, metabolic syndrome, peripheral vascular disease, hypertension, and myocardial infarction number, the HF hazard ratios [HRs] were 0.85 (95% confidence interval [CI] 0.70-1.03) and 0.76 (95% CI 0.58-0.99) for high-school and academic education versus elementary education, respectively. HR for "blue collar" compared with "academic"/"white collar" occupations was 1.30 (95% CI 0.97-1.74). CONCLUSIONS: SES indicators (mainly education) are associated with HF incidence among CHD patients. The association is only marginally explained by possible confounders or known mediators such as hypertension and myocardial infarction.

Ethnicity and long-term prognosis after myocardial infarction: a population-based cohort study.

BACKGROUND: Health disparities are systematic differences in health, favoring members of advantaged over disadvantaged groups in the society. This study examines the contribution of multiple socioeconomic status (SES) measures to ethnic differences in after myocardial infarction (MI) prognosis. METHODS: Patients aged 65 years and younger (n=1040) belonging to Ashkenazi and Mizrahi advantaged and disadvantaged ethnic groups discharged from 8 hospitals in central Israel after incident MI in 1992-1993, were followed up through 2005 for all-cause mortality, recurrent MI, heart failure, and ischemic stroke. RESULTS: Advantaged Ashkenazi had higher education, income, employment, and neighborhood SES compared with disadvantaged Mizrahi. Cardiovascular risk factors varied among the different ethnic groups. Results showed that the association between ethnic group and all outcomes differed substantially between models that included a single SES measure and those that included multiple measures. For example, the hazard ratio for mortality in disadvantaged Mizrahi compared with advantaged Ashkenazi was 1.87 [95% confidence interval (CI), 1.40-2.48] in a model adjusting only for demographic variables; 1.58 (95% CI, 1.18-2.12) in a model adjusting also for income; and 1.03 (95% CI, 0.74-2.04) in a model adjusting for all measured SES indicators. Further adjustment for clinical variables did not appreciably change the results. CONCLUSIONS: Findings show that a wide array of modifiable social factors shaped by income, education, and neighborhood socioeconomic conditions can explain ethnic health differences and highlight the importance of using multivariable models of SES.

Depression and anxiety following myocardial infarction and their inverse associations with future health behaviors and quality of life.

BACKGROUND: Post-myocardial infarction (MI) depression and anxiety were found to predict prognosis and quality of life. PURPOSE: The purpose of this study was to test a behavioral pathway from post-MI depression/anxiety to future quality of life. METHODS: This is a longitudinal cohort study. Five hundred forty patients (≤65 years old) filled out questionnaires after a first MI, including socio-demographics, pre-MI health status and behaviors, MI severity, social support, sense of coherence, depression, and anxiety. Reports of health behaviors were obtained 5 years and of quality of life 10 years later. RESULTS: A structural equations model confirmed that depression and anxiety were directly related to poorer quality of life 10 years later. These relationships were partly mediated by a positive association between anxiety and health behaviors at 5 years and a negative one between depression and health behaviors. CONCLUSIONS: The opposite effects of anxiety and depression underscore the need to attend to both emotional reactions to MI while encouraging preventive health behaviors.

Body height and late-life cognition among patients with atherothrombotic disease.

BACKGROUND/AIMS: Height is associated with a lower risk of stroke and dementia. We tested the hypothesis that higher stature is also associated with better cognitive performance, and examined whether these associations were mediated through the extent of vascular disease. METHODS: A subgroup of patients (mean age at baseline 57.9±6.6 y; 94.6% males) with coronary heart disease who previously participated in a clinical trial (1990 to 1997) was assessed for cognitive function and measures of atherosclerosis 15±3 years later. Cognitive performance was assessed using the Mindstreams computerized battery. Measures of overall battery performance and in specific cognitive domains were obtained, and a score of ≤85 (1 SD below the mean) was defined as cognitive impairment overall and in a specific domain. We compared the risk of cognitive impairment and means of cognitive scores by quartiles of height. RESULTS: Among 536 patients, 23.2% were cognitively impaired. After controlling for potential risk factors and correcting for multiple comparisons, odds ratios for impairment in the visual-spatial domain decreased with increasing height quartiles (P for trend =0.018), and odds ratio (95% confidence interval) associated with being at the top versus the bottom quartile was 0.40 (0.18-0.88). An increment of 1 SD of height was associated with a higher global score (ß=1.98; 95% confidence interval, 0.73-4.49; P=0.004) and with higher executive function, attention, and visual-spatial scores. CONCLUSIONS: Among our sample of coronary heart disease patients, a higher stature is associated with a lower risk of impairment in the visual-spatial function and with better cognitive performance.

Diet Quality and Incident Frailty in Adults 65 Years or Older: The Israeli Longitudinal Study on Aging.

OBJECTIVE: To prospectively examine the association between diet quality and frailty incidence in the oldest-old age group. METHODS: We studied an older adult (65+ years) cohort participating in the Israeli National Health and Nutrition Survey of Older Adults in 2005-2006 (T1 [N=1799]). Survivors of T1 were contacted, and between 2017 and 2019, an extensive interview and a functional assessment were conducted (T2) of 604 past participants. A 24-hour dietary recall, assessed at T1, was used to calculate the Healthy Eating Index (HEI-2015) score. A frailty index based on an accumulation of deficits, including clinical, functional, and cognitive measures, was computed. Frail participants at T1 were excluded from the analysis. Logistic regression models were constructed to assess the association of HEI-2015 score with frailty incidence. Inverse probability weighting was used to minimize selection bias due to attrition. RESULTS: Of the 479 T2 participants analyzed (mean [SD] age, 84 [5] years; 50% women), 225 (46%) were classified as frail. Frail participants were older, were less educated, and had a lower household income and a higher comorbidity burden at baseline than non-frail participants. After adjustment for sociodemographic and lifestyle factors, a higher HEI-2015 score was associated with decreased odds of incident frailty (odds ratio, 0.57 [95% CI, 0.35 to 0.91] for the upper tertile and 0.66 [95% CI, 0.42 to 1.06] for the middle tertile compared with the lower tertile; Ptrend=.02). CONCLUSION: In this cohort study of oldest-old participants, improved diet quality was inversely associated with frailty incidence in a dose-dependent manner.