Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies.

BACKGROUND: One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease. METHODS: We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries. RESULTS: In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures. CONCLUSIONS: The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressures seems to be a valid indicator of the presence of subclinical atherosclerosis and may be considered for use in biomarker, Mendelian randomization and similar studies.

Micro-scale pedestrian streetscapes and physical activity in Hispanic/Latino adults: Results from HCHS/SOL.

We examined associations of micro-scale environment attributes (e.g., sidewalks, street crossings) with three physical activity (PA) measures among Hispanic/Latino adults (n = 1776) living in San Diego County, CA. Systematic observation was used to quantify micro-scale environment attributes near each participant's home. Total PA was assessed with accelerometers, and PA for transportation and recreation were assessed by validated self-report. Although several statistically significant interactions between individual and neighborhood characteristics were identified, there was little evidence micro-scale attributes were related to PA. An important limitation was restricted environmental variability for this sample which lived in a small area of a single county.

Neighborhood built environments and Hispanic/Latino adults' physical activity in the U.S.: The Hispanic community health study/study of Latinos community and surrounding areas study.

Despite experiencing health inequities, less is known about neighborhood environments and physical activity among Hispanic/Latino adults compared to other populations. We investigated this topic in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Hispanic/Latino adults in the San Diego, California area of the U.S. completed measures of overall moderate-to-vigorous physical activity (MVPA) via accelerometry and domain-specific MVPA via questionnaire at Visits 1 (2008-2011; n = 4086) and 2 (2014-2017; n = 1776), ~6 years apart. 800-m home neighborhood buffers were used to create objective measures of residential, intersection, and retail density, bus/trolley stops, greenness, parks, and recreation area at Visit 1. Regression models tested the association of each neighborhood feature with MVPA at Visit 1 and over 6 years, adjusting for individual characteristics and neighborhood socioeconomic deprivation. At Visit 1, those in neighborhoods with higher vs. lower retail density or recreation area (+1 vs. -1 standard deviation from the mean) engaged in 10% more overall MVPA and 12-22% more active transportation. Those in neighborhoods with higher vs. lower residential density engaged in 22% more active transportation. Those in neighborhoods with higher vs. lower greenness and park count engaged in 14-16% more recreational MVPA. Neighborhood features were unassociated with changes in MVPA over 6 years. Although changes in MVPA over time were similar across neighborhoods, Hispanic/Latino adults living in neighborhoods with design features supportive of walking and recreational activity (e.g., greater residential and retail density, more parks and recreation facilities) were consistently more active. Improving neighborhood environments appears important for supporting physical activity among Hispanic/Latino adults.

Association of Premature Menopause With Risk of Abdominal Aortic Aneurysm in the Women's Health Initiative.

OBJECTIVE: To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history. SUMMARY OF BACKGROUND DATA: Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women. METHODS: This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017. RESULTS: Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early men-arche. Women with premature menopause were more likely to be overweight, Black, have >20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA. CONCLUSIONS: This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.

Neighborhood Socioeconomic Deprivation and Depression Symptoms in Adults From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Socioeconomic factors appear to impact mental health conditions such as depression, but little is known about the relative and combined role of neighborhood and personal socioeconomic deprivation among Hispanics/Latinos. This study examined cross-sectional associations of neighborhood and personal socioeconomic deprivation with depression symptoms in a US Hispanic/Latino population from the San Diego Field Center of the Hispanic Community Health Study/Study of Latinos (n = 3,851). Depression symptoms were assessed with the ten-item Centers for Epidemiological Studies in Depression Scale. Neighborhood socioeconomic deprivation was a composite of eleven variables (e.g., neighborhood income, education, employment, household crowding). Greater personal socioeconomic deprivation based on education, income, and employment was generally associated with higher depression symptoms, including after adjusting for neighborhood socioeconomic deprivation. Greater neighborhood socioeconomic deprivation was associated with higher depression symptoms in females but not males, but the association in females became non-significant when adjusting for personal socioeconomic deprivation. Neighborhood socioeconomic deprivation did not significantly interact with personal socioeconomic deprivation in relation to depression symptoms. The present findings support the association of personal socioeconomic status with mental health (indicated by depression symptoms) among Hispanic/Latino populations, whereas neighborhood socioeconomic deprivation did not relate to depression beyond the impact of personal indicators.

Lipoprotein(a) levels and risk of abdominal aortic aneurysm in the Women's Health Initiative.

OBJECTIVE: Few studies have prospectively examined the associations of lipoprotein(a) [Lp(a)] levels with the risk of abdominal aortic aneurysm (AAA), especially in women. Accounting for commonly recognized risk factors, we investigated the baseline Lp(a) levels and the risk of AAA among postmenopausal women participating in the ongoing national Women's Health Initiative. METHODS: Women's Health Initiative participants with baseline Lp(a) levels available who were beneficiaries of Medicare parts A and B fee-for-service at study enrollment or who had aged into Medicare at any point were included. Participants with missing covariate data or known AAA at baseline were excluded. Thoracic aneurysms were excluded owing to the different pathophysiology. The AAA cases and interventions were identified using the International Classification of Diseases, 9th and 10th revision, codes and Current Procedural Terminology codes from claims data. Hazard ratios were computed using Cox proportional hazard models according to the quintiles of Lp(a). RESULTS: The mean age of the 6615 participants included in the analysis was 65.3 years. Of the 6615 participants, 66.6% were non-Hispanic white, 18.9% were black, 7% were Hispanic and 4.7% were Asian/Pacific Islander. Compared with the participants in the lowest Lp(a) quintile, those in higher quintiles were more likely to be overweight, black, and former or current smokers, to have hypertension, hyperlipidemia, and a history of cardiovascular disease, and to use menopausal hormone therapy and statins. During 65,476 person-years of follow-up, with a median of 10.4 years, 415 women had been diagnosed with an AAA and 36 had required intervention. More than one half had required intervention for a ruptured AAA. We failed to find a statistically significant association between Lp(a) levels and incident AAA. Additional sensitivity analyses stratified by race, with exclusion of statin users and alternative categorizations of Lp(a) using log-transformed levels, tertiles, and a cutoff of >50 mg/dL, were conducted, which did not reveal any significant associations. CONCLUSIONS: We found no statistically significant association between Lp(a) levels and the risk of AAA in a large and well-phenotyped sample of postmenopausal women. Women with high Lp(a) levels were more likely to be overweight, black, and former or current smokers, and to have hypertension, hyperlipidemia, and a history of cardiovascular disease, or to use hormone therapy and statins compared with those with lower Lp(a) levels. These findings differ from previous prospective, case-control, and meta-analysis studies that had supported a significant relationship between higher Lp(a) levels and an increased risk of AAA. Differences in the association could have resulted from study limitations or sex differences.

Health insurance status and type associated with varying levels of glycemic control in the US: The multi-ethnic study of atherosclerosis (MESA).

AIMS: To investigate associations of health insurance with measures of glucose metabolism, and whether associations vary by diabetes status or insurance type. METHODS: Cross-sectional analysis of baseline data from the Multi-Ethnic Study of Atherosclerosis. Cohort a priori stratified by age <65 (N = 3,665) and ≥65 years (N = 2,924). Multivariable linear and logistic regression assessed associations between insurance and fasting glucose, HOMA-IR, and prevalent diabetes, controlling for relevant confounders, including age, sex, race/ethnicity, income, and education. RESULTS: In participants <65, compared to uninsured, having any insurance was associated with lower fasting glucose in participants with diabetes (Mean Difference = -20.4 mg/dL, P = 0.01), but not in participants without diabetes. Compared to Private insurance, uninsured participants had higher fasting glucose (Mean Difference = 3.8 mg/dL, P = 0.03), while participants with Medicaid had higher HOMA-IR (Mean Difference = 3.5 mg/dL, P < 0.01). In participants ≥65, compared to Private insurance, uninsured participants (Mean Difference = 7.5 mg/dL, P = 0.02), and participants with Medicaid only (Mean Difference = 19.9 mg/dL, P < 0.01) or Medicare + Medicaid (Mean Difference = 5.2 mg/dL, P = 0.03) had higher fasting glucose. CONCLUSIONS: In this large multiethnic cohort, having any insurance was associated with significantly lower fasting glucose for individuals with diabetes. Levels of fasting glucose and insulin resistance varied across different insurance types.

Hypertension in Hispanics/Latinos: Epidemiology and Considerations for Management.

ABSTRAC: PURPOSE OF REVIEW: Hispanic/Latino Americans are among the fastest growing ethnic populations in the United States (US). Hypertension, in particular uncontrolled hypertension, is a significant source of cardiovascular morbidity and mortality in this population. In this review, we outline the epidemiology of hypertension and certain considerations in the management of hypertension in this heterogeneous population. RECENT FINDINGS: Substantial variation in hypertension prevalence and control exists among different ethnic subgroups of Hispanics. More specifically, and in the community, outcomes for hypertension management are less favorable, suggesting that suboptimal hypertension control may be the result of social factors. In this regard, community-based interventions have shown promise in addressing these shortfalls. Nonetheless, significant barriers to effective hypertension care exist in the Hispanic community, including the increasing prevalence of comorbidities that impact hypertension such as obesity. Pharmacologic therapies for hypertension have been highly effective in Hispanic subjects participating in clinical trials. Notably, studies that disaggregate Hispanics by their ancestral origin may provide greater insight into the sources of ethnic disparities. Culturally tailored interventions may improve hypertension management and outcomes in Hispanic populations. Additional population and clinical trials in Hispanic patients of different ancestral heritages are needed.

Life's Simple 7 and Peripheral Artery Disease: The Multi-Ethnic Study of Atherosclerosis.

INTRODUCTION: In 2010, the American Heart Association initiated Life's Simple 7 with the goal of significantly improving cardiovascular health by the year 2020. The association of Life's Simple 7 with risk of peripheral artery disease has not been thoroughly explored. METHODS: Racially diverse individuals from the Multi-Ethnic Study of Atherosclerosis (2000-2012) were followed for incident peripheral artery disease (ankle brachial index ≤0.90) and decline in ankle brachial index (≥0.15) over approximately 10 years of follow-up. Cox and logistic regression were used to assess associations of individual Life's Simple 7 components (score 0-2) and overall Life's Simple 7 score (score 0-14) with incident peripheral artery disease and ankle brachial index decline, respectively, adjusted for age, sex, race/ethnicity, education, and income. Analyses were performed in 2016-2018. RESULTS: Of 5,529 participants, 251 (4.5%) developed incident peripheral artery disease; 419 (9.8%) of 4,267 participants experienced a decline in ankle brachial index. Each point higher for the overall Life's Simple 7 score was associated with a 17% lower rate of incident peripheral artery disease (hazard ratio=0.83, 95% CI=0.78, 0.88, p<0.001). Additionally, each point higher in overall Life's Simple 7 was associated with a 0.94-fold lower odds of decline in ankle brachial index (OR=0.94, 95% CI=0.87, 0.97, p=0.003). Four components (smoking, physical activity, glucose, and blood pressure) were associated with incident peripheral artery disease and two (smoking and glucose) with decline in ankle brachial index. CONCLUSIONS: Better cardiovascular health as measured by Life's Simple 7 is associated with lower incidence of peripheral artery disease and less decline in ankle brachial index. Use of the Life's Simple 7 to target modifiable health behaviors may aid in decreasing the population burden of peripheral artery disease-related morbidity and mortality.

Relation of Sex Hormone Levels With Prevalent and 10-Year Change in Aortic Distensibility Assessed by MRI: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Women experience a steeper decline in aortic elasticity related to aging compared to men. We examined whether sex hormone levels were associated with ascending aortic distensibility (AAD) in the Multi-Ethnic Study of Atherosclerosis. METHODS: We studied 1,345 postmenopausal women and 1,532 men aged 45-84 years, who had serum sex hormone levels, AAD measured by phase-contrast cardiac magnetic resonance imaging, and ejection fraction>50% at baseline. Among these participants, 457 women and 548 men returned for follow-up magnetic resonance imaging 10-years later. Stratified by sex, and using mixed effects linear regression methods, we examined associations of sex hormones (as tertiles) with baseline and annual change in log-transformed AAD (mm Hg-110-3), adjusting for demographics, body size, lifestyle factors, mean arterial pressure, heart rate, hypertensive medication use (and in women, for hormone therapy use and years since menopause). RESULTS: The mean (SD) age was 65 (9) for women and 62 (10) years for men. AAD was lower in women than men (P < 0.001). In adjusted cross-sectional analysis, the highest tertile of free testosterone (compared to lowest) in women was significantly associated with lower AAD [-0.10 (-0.19, -0.01)] and the highest tertile of estradiol in men was associated with greater AAD [0.12 (0.04, 0.20)]. There were no associations of sex hormones with change in AAD over 10 years, albeit in a smaller sample size. CONCLUSIONS: Lower free testosterone in women and higher estradiol in men were associated with greater aortic distensibility at baseline, but not longitudinally. Sex hormone levels may account for differences in AAD between women and men.

Race/ethnic and sex disparities in the non-alcoholic fatty liver disease-abdominal aortic calcification association: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND AND AIMS: This study investigated the associations of non-alcoholic fatty liver disease (NAFLD) and abdominal aortic calcification (AAC) volume and density, and whether these relationships vary by race/ethnicity and/or sex, information that are limited in current literature. METHODS: We studied 1004 adults from the Multi-Ethnic Study of Atherosclerosis to assess the relationship between NAFLD (liver-to-spleen ratio <1) and the following measures of AAC: presence (volume score >0, using Poisson regression); change in volume score (increasing vs. no change, using Poisson regression); and morphology (volume and density score, where volume score >0, using linear regression); and interaction by race/ethnicity and sex. RESULTS: Among Blacks, those with NAFLD had greater prevalence for AAC compared to Whites regardless of sex (Prevalence Ratio [PR] = 1.41, CI = 1.15-1.74, p-interaction = 0.02). Concurrent interaction by race/ethnicity and sex was found comparing Chinese and Blacks to Whites (p-interaction = 0.017 and 0.042, respectively) in the association between NAFLD and the prevalence of increasing AAC. Among women, this relationship was inverse among Chinese (PR = 0.59, CI = 0.28-1.27), and positive among Whites (PR = 1.34, CI = 1.02-1.76). This finding was reversed evaluating the men counterpart. Black men also had a positive association (PR = 1.86, CI = 1.29-2.70), which differed from the inverse relationship among White men, and was greater compared to Black women (PR = 1.45, CI = 1.09-1.94). NAFLD was unrelated to AAC morphology. CONCLUSIONS: NAFLD was related to the presence of AAC, however, limited to Blacks. Significant concurrent interaction by race/ethnicity (Chinese and Blacks vs. Whites) and sex was found in the relationship between NAFLD and increasing AAC. These findings suggest disparities in the pathophysiologic pathways in which atherosclerosis develops.

Associations of cardiovascular disease risk factors with abdominal aortic calcium volume and density: The Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND AND AIMS: Abdominal aortic calcium (AAC) predicts future cardiovascular disease (CVD) events and all-cause mortality independent of CVD risk factors. The standard AAC score, the Agatston, up-weights for greater calcium density, and thus models higher calcium density as associated with increased CVD risk. We determined associations of CVD risk factors with AAC volume and density (separately). METHODS: In a multi-ethnic cohort of community living adults, we used abdominal computed tomography scans to measure AAC volume and density. Multivariable linear regression was used to determine the period cross-sectional independent associations of CVD risk factors with AAC volume and AAC density in participants with prevalent AAC. RESULTS: Among 1413 participants with non-zero AAC scores, the mean age was 65 ± 9 years, 52% were men, 44% were European-, 24% were Hispanic-, 18% were African-, and 14% were Chinese Americans (EA, HA, AA, and CA respectively). Median (interquartile range, IQR) for AAC volume was 628 mm3 (157-1939 mm3), and mean AAC density was 3.0 ± 0.6. Compared to EA, each of HA, AA, and CA had lower natural log (ln) AAC volume, but higher AAC density. After adjustments for AAC density, older age, ever smoking history, higher systolic blood pressure, elevated total cholesterol, reduced HDL cholesterol, statin and anti-hypertensive medication use, family history of myocardial infarction, and alcohol consumption were significantly associated with higher ln(AAC volume). In contrast, after adjustments for ln(AAC volume), older age, ever smoking history, higher BMI, and lower HDL cholesterol were significantly associated with lower AAC density. CONCLUSIONS: Several CVD risk factors were associated with higher AAC volume, but lower AAC density. Future studies should investigate the impact of calcium density of aortic plaques in CVD.

Ankle-brachial index predicts change over time in functional status in the San Diego Population Study.

BACKGROUND: Peripheral artery disease (PAD) affects millions of people, both in the U.S. and worldwide. Even when asymptomatic, PAD and the ankle-brachial index (ABI), the major clinical diagnostic criterion for PAD, are associated with decreased functional status and quality of life, as well as mobility impairment. Whether the ABI or change in the ABI predicts decline in functional status over time has not been previously assessed in a population-based setting. METHODS: Participants were 812 non-Hispanic white, African American, Hispanic, and Asian men and women from the San Diego Population Study (SDPS) who attended a baseline examination (1994-1998), and follow-up clinic examination approximately 11 years later. The Medical Outcomes Study 36-Item Short Form (SF-36) was obtained at both the baseline and follow-up examinations, and the summary performance score (SPS) at the follow-up examination. Associations of the baseline ABI and clinically relevant change in the ABI (<-0.15 vs ≥-0.15) with change in SF-36 scores over time were assessed using growth curve models, a type of mixed model that accounts for within participant correlation of measurements over time, and using linear regression for SPS. Models were adjusted for baseline age, sex, race/ethnicity, body mass index, ever smoking, physical activity, hypertension, diabetes, and dyslipidemia. RESULTS: Mean ± standard deviation (SD) for the baseline ABI was 1.11 ± 0.10, and 50.8 ± 9.0 for the baseline Physical Component Score (PCS), 50.1 ± 9.5 for the baseline Mental Component Score (MCS), and 11.2 ± 1.9 for the SPS at the follow-up examination. In fully adjusted models, each SD lower of the baseline ABI was significantly associated with an average decrease over time of 0.6 (95% confidence interval [CI], -1.1 to -0.1; P = .02) units on SF-36 PCS. Each SD lower of the baseline ABI was also significantly associated with an average decrease over time of 1.2 units (95% CI, -2.3 to -0.2; P = .02) on the SF-36 physical functioning subscale, and a decrease of 1.3 units (95% CI, -2.3 to -0.3; P = .01) on the SF-36 energy/vitality subscale in fully adjusted models. Baseline ABI was not significantly associated with change in the SF-36 MCS over time, or the SPS at the follow-up examination. Change in the ABI was not associated with SF-36 PCS, MCS, or the SPS. CONCLUSIONS: In this multiethnic population of healthy middle-aged community-living men and women, we showed that participants with a lower baseline ABI had declines in functional status over 11 years. Findings suggest that small differences in the ABI, even within the normal range, may identify subclinical lower extremity PAD, which in turn may help to identify individuals at risk for declining functional status with age.

Difference by sex but not by race/ethnicity in the visceral adipose tissue-depressive symptoms association: the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Prior studies have investigated the association of clinical depression and depressive symptoms with body weight (i.e. body mass index (BMI) and waist circumference), but few have examined the association between depressive symptoms and intra-abdominal fat. Of these a limited number assessed the relationship in a multi-racial/ethnic population. METHODS: Using data on 1017 men and women (45-84 years) from the Multi-Ethnic Study of Atherosclerosis (MESA) Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between elevated depressive symptoms (EDS) and CT-measured visceral fat mass at L2-L5 with multivariable linear regression models. EDS were defined as a Center for Epidemiological Studies Depression score ≥16 and/or anti-depressant use. Covariates included socio-demographics, inflammatory markers, health behaviors, comorbidities, and body mass index (BMI). Race/ethnicity (Whites [referent group], Chinese, Blacks and Hispanics) and sex were also assessed as potential modifiers. RESULTS: The association between depressive symptoms and visceral fat differed significantly by sex (p=0.007), but not by race/ethnicity. Among men, compared to participants without EDS, those with EDS had greater visceral adiposity adjusted for BMI and age (difference=122.5 cm2, 95% CI=34.3, 210.7, p=0.007). Estimates were attenuated but remained significant after further adjustment by socio-demographics, inflammatory markers, health behaviors and co-morbidities (difference=94.7 cm2, 95% CI=10.5, 178.9, p=0.028). Among women, EDS was not significantly related to visceral adiposity in the fully adjusted model. CONCLUSIONS: Sex, but not race/ethnicity, was found to modify the relationship between EDS and visceral fat mass. Among men, a significant positive association was found between depressive symptoms and visceral adiposity. No significant relationship was found among women.

Evaluation of Medicare claims data to ascertain peripheral vascular events in the Women's Health Initiative.

OBJECTIVE: Capturing long-term outcomes from large clinical databases by use of claims data is a potential strategy for improving efficiency while reducing study costs. We sought to compare the use of Medicare data with data from the Women's Health Initiative (WHI) to determine peripheral vascular events, as defined by the WHI study design. METHODS: We studied participants from the WHI with both adjudicated outcomes and links to Medicare enrollment and utilization data through 2007. Outcomes of interest included hospitalizations for treatment of abdominal aortic aneurysm (AAA), lower extremity peripheral artery disease (LE PAD), and carotid artery stenosis (CAS). Events determined by WHI adjudication were compared with events defined by coding algorithms using diagnosis and procedure codes from Medicare data with a pilot data set and then validated with a test data set. We assessed agreement by a κ statistic and evaluated reasons for disagreement. RESULTS: In the pilot set, records from 50,511 participants were analyzed. Agreement between the Centers for Medicare and Medicaid Services and WHI for admissions with a diagnosis but no treatment procedures for vascular conditions was poor (κ, 0.02-0.18). On the basis of WHI outcome data collection, vascular treatment procedures occurred in 29 participants for AAA, 204 for LE PAD events, and 281 for CAS. Medicare hospital claims recorded 41 treatments for AAA, 255 for LE PAD, and 317 for CAS. For participants with a Centers for Medicare and Medicaid Services-captured vascular procedure and a record adjudicated by WHI, κ values for treatment procedures were 0.81 for AAA, 0.77 for PAD, and 0.93 for CAS. For vascular procedures identified by WHI but not by Medicare hospital data (n = 82), 55% were captured by Medicare physician claims. Conversely, for treatments identified by Medicare hospital data but not captured by WHI adjudication (n = 57), 74% had physician claims consistent with the procedure. Fifteen participants with AAA or LE PAD procedures in hospital claims had medical records available for review, and nine of these had definitive documentation of procedures that were not captured by the WHI adjudication process. Estimated positive predictive value of Medicare data was 91% to 94% for AAA, 92% to 95% for LE PAD, and 94% to 99% for CAS. Available test set data (n = 50,253) yielded generally similar results with κ of 0.77 for AAA, 0.79 for LE PAD, and 0.94 for CAS. CONCLUSIONS: Medicare data appear useful for identifying vascular treatment procedures for WHI participants. Medicare hospital claims identify more procedures than WHI does, with high positive predictive value, but also may not capture some procedures identified in WHI.

Trends in C-reactive protein levels in US adults from 1999 to 2010.

C-reactive protein (CRP) is a well-known biomarker of systemic inflammation and cardiovascular disease. We investigated the trends in prevalence of elevated CRP levels (>3.0 mg/L) in a general population of US adults. Data from 27,214 subjects aged ≥20 years in the 1999-2010 National Health and Nutrition Examination Survey were analyzed. After adjustment for age, sex, race/ethnicity, body mass index (weight (kg)/height (m)(2)), and medications for lowering blood pressure, glucose, and lipids, the prevalence of elevated CRP decreased significantly from 36.7% in 1999-2002 to 32.0% in 2007-2010, corresponding to a decrease in mean CRP level from 1.92 to 1.66 mg/L (both P < 0.001). The trend remained significant after additional adjustment for several traditional cardiovascular risk factors and use of different medications, including statins. However, the decreasing trends were attenuated after additional adjustment for total bilirubin (P = 0.08 and 0.02), which increased from 0.62 to 0.73 mg/dL over 12 years (P < 0.001). The decreasing trend of CRP levels is encouraging and may be related to the increase in total bilirubin levels. Such trends may be explained in part by the increasing use of medications such as statins, which can increase bilirubin levels and decrease CRP levels.

Emotional and cognitive health correlates of leisure activities in older Latino and Caucasian women.

This study examined differences in the frequency of leisure activity participation and relationships to depressive symptom burden and cognition in Latino and Caucasian women. Cross-sectional data were obtained from a demographically matched subsample of Latino and Caucasian (n = 113 each) postmenopausal women (age ≥60 years), interviewed in 2004-2006 for a multiethnic cohort study of successful aging in San Diego County. Frequencies of engagement in 16 leisure activities and associations between objective cognitive performance and depressive symptom burden by ethnicity were identified using bivariate and linear regression, adjusted for physical functioning and demographic covariates. Compared to Caucasian women, Latinas were significantly more likely to be caregivers and used computers less often. Engaging in organized social activity was associated with fewer depressive symptoms in both groups. Listening to the radio was positively correlated with lower depressive symptom burden for Latinas and better cognitive functioning in Caucasians. Cognitive functioning was better in Latinas who read and did puzzles. Housework was negatively associated with Latinas' emotional health and Caucasians' cognitive functioning. Latino and Caucasian women participate in different patterns of leisure activities. Additionally, ethnicity significantly affects the relationship between leisure activities and both emotional and cognitive health.

Ethnicity and risk factors for change in the ankle-brachial index: the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: The aim of this study was to determine the risk factors for conversion from a normal to either a low or high ankle-brachial index (ABI). METHODS: Participants in the Multi-Ethnic Study of Atherosclerosis who had two separate measurements of the ABI over a 3-year time period were assessed. RESULTS: At baseline, the mean age was 62 years and 50% were women, 28% African American, 12% Chinese, 22% Hispanic and 38% non-Hispanic White. Of the 5514 participants with a baseline ABI between 0.90 and 1.40, 89 (1.6%) had an ABI < or = 0.90 ("low ABI group") and 71 (1.3%) had an ABI > or = 1.40 ("high ABI group") 3 years later. On multivariable analysis, the odds for having progressed into the low ABI group were significantly increased for higher baseline age, hypertension, diabetes, greater pack-years of cigarette smoking, and homocysteine levels. The odds for progression into the high ABI group were increased for male gender and higher body mass index. Compared with non-Hispanic Whites, African Americans had a significantly higher odds for progression to the low ABI group (odds ratio [OR]: 2.24, 95% confidence interval [CI]: 1.29-3.88) while having a reduced odds for progression to the high ABI group (OR: 0.50, 95% CI: 0.24-1.00). Neither Chinese nor Hispanic ethnicity was significantly associated with progression to either ABI group. CONCLUSIONS: The risk factors for progression to a low or high ABI were distinct and African Americans were at increased risk for progression to a low ABI but at decreased risk for progression into the high ABI group.

The association between lipoprotein-associated phospholipase A2 and cardiovascular disease and total mortality in vascular medicine patients.

INTRODUCTION: In some community-based studies, lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) has been shown to be independently predictive of future fatal and nonfatal cardiovascular disease (CVD) events. We tested the hypothesis that Lp-PLA(2) is independently predictive of mortality in high-risk patients from a vascular laboratory. METHODS: Between 1990 and 1994, patients seen in the previous 10 years for noninvasive lower extremity arterial testing were invited to return for a vascular examination of the lower extremities. By medical record review, we identified 2265 eligible patients; of these, 508 returned for interviews, blood collection, and arterial examination and represent those who had survived, could be located, and were willing to participate. The 508 subjects were followed up for an average of 6.7 years until the end of the study period on December 31, 2001. Vital status was ascertained by multiple searches of the Social Security Death Index. The primary outcomes for this study were time to any, CVD, and coronary heart disease (CHD) mortality. RESULTS: The mean age was 68.2 years, 88% were men, 87% were non-Hispanic white, 39.1% were diagnosed with peripheral arterial disease only, 9.2% with other CVD only, and 28.5% with both peripheral arterial disease and other CVD. During the entire follow-up period, 299 (59.7%) patients died, 167 from CVD, of which 88 deaths were due to coronary heart disease. With adjustment for CVD risk factors and baseline peripheral arterial disease and other CVD, an increment of one standard deviation in Lp-PLA(2) activity was associated with a 40% higher risk for CHD mortality at 5 years of follow-up (P = .04). Additional adjustment for triglycerides, high-density lipoprotein, and low-density lipoprotein cholesterol reduced this association to nonsignificance (hazard risk, 1.12). CONCLUSION: In a vascular laboratory patient population, higher levels of LpPLA(2) mass and activity were not significantly associated with total, CVD, or CHD mortality at 5 years of follow-up and after adjustment for traditional CVD risk factors and the presence of PAD and other CVD at baseline. An apparent elevated risk of CHD death associated with elevated Lp-PLA2 was largely explained by associated elevations in lipids and lipoproteins.