Cost-Effectiveness of a Household Salt Substitution Intervention: Findings From 20 995 Participants of the Salt Substitute and Stroke Study.

BACKGROUND: SSaSS (Salt Substitute and Stroke Study), a 5-year cluster randomized controlled trial, demonstrated that replacing regular salt with a reduced-sodium, added-potassium salt substitute reduced the risks of stroke, major adverse cardiovascular events, and premature death among individuals with previous stroke or uncontrolled high blood pressure living in rural China. This study assessed the cost-effectiveness profile of the intervention. METHODS: A within-trial economic evaluation of SSaSS was conducted from the perspective of the health care system and consumers. The primary health outcome assessed was stroke. We also quantified the effect on quality-adjusted life-years (QALYs). Health care costs were identified from participant health insurance records and the literature. All costs (in Chinese yuan [¥]) and QALYs were discounted at 5% per annum. Incremental costs, stroke events averted, and QALYs gained were estimated using bivariate multilevel models. RESULTS: Mean follow-up of the 20 995 participants was 4.7 years. Over this period, replacing regular salt with salt substitute reduced the risk of stroke by 14% (rate ratio, 0.86 [95% CI, 0.77-0.96]; P=0.006), and the salt substitute group had on average 0.054 more QALYs per person. The average costs (¥1538 for the intervention group and ¥1649 for the control group) were lower in the salt substitute group (¥110 less). The intervention was dominant (better outcomes at lower cost) for prevention of stroke as well as for QALYs gained. Sensitivity analyses showed that these conclusions were robust, except when the price of salt substitute was increased to the median and highest market prices identified in China. The salt substitute intervention had a 95.0% probability of being cost-saving and a >99.9% probability of being cost-effective. CONCLUSIONS: Replacing regular salt with salt substitute was a cost-saving intervention for the prevention of stroke and improvement of quality of life among SSaSS participants.

Recommendations for Cardiovascular Health and Disease Surveillance for 2030 and Beyond: A Policy Statement From the American Heart Association.

The release of the American Heart Association's 2030 Impact Goal and associated metrics for success underscores the importance of cardiovascular health and cardiovascular disease surveillance systems for the acquisition of information sufficient to support implementation and evaluation. The aim of this policy statement is to review and comment on existing recommendations for and current approaches to cardiovascular surveillance, identify gaps, and formulate policy implications and pragmatic recommendations for transforming surveillance of cardiovascular disease and cardiovascular health in the United States. The development of community platforms coupled with widespread use of digital technologies, electronic health records, and mobile health has created new opportunities that could greatly modernize surveillance if coordinated in a pragmatic matter. However, technology and public health and scientific mandates must be merged into action. We describe the action and components necessary to create the cardiovascular health and cardiovascular disease surveillance system of the future, steps in development, and challenges that federal, state, and local governments will need to address. Development of robust policies and commitment to collaboration among professional organizations, community partners, and policy makers are critical to ultimately reduce the burden of cardiovascular disease and improve cardiovascular health and to evaluate whether national health goals are achieved.

Global tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review.

The purpose of this review is to emphasize the role of tobacco prevention and control in cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention, including the importance of these endpoints for measuring the full impact of tobacco-related policies, programs, and practices. In this review, we describe an overview of tobacco control interventions that have led to substantial declines in tobacco use and the relationship between these declines with CVH and CVD. We review interventions that have had success in high-income countries (HICs) as well as those that are gaining traction in low- and middle-income countries (LMICs). We emphasize the challenges to comprehensive tobacco prevention and control strategies faced by LMICs, and highlight the special role of cardiovascular health professionals in achieving CVH promotion and CVD prevention endpoints through tobacco control. Tobacco prevention and control strategies have a strong scientific basis, yet a distinct gap remains between this evidence and implementation of tobacco control policies, particularly in LMICs. Health professionals can contribute to tobacco control efforts, especially through patient-level clinical interventions, when supported by a health care system and government that recognize and support tobacco control as a critical strategy for CVH promotion and CVD prevention. Understanding, supporting, and applying current and evolving policies, programs, and practices in tobacco prevention and control is the province of all health professionals, especially those concerned with CVH promotion and CVD prevention. A new tobacco control roadmap from the World Heart Federation provides a strong impetus to the needed interdisciplinary collaboration.

Incidence and Case Fatality at the County Level as Contributors to Geographic Disparities in Stroke Mortality.

BACKGROUND: Is the high stroke mortality in the Southeastern parts of the United States driven by differences in stroke incidence or case-fatality? This question remains unanswered. Differences in incidence would underscore the need for stroke prevention, while differences in case fatality would call for improved stroke care. METHODS: Quartiles of US counties were defined by stroke mortality, and this gradient was related with stroke incidence and stroke case fatality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, where 1,317 incident stroke events (of which 242 were fatal) occurred among 29,650 participants. RESULTS: There was a significant (p = 0.0025) gradient of fatal stroke events in REGARDS (quartile 4 vs. quartile 1 (Q4/Q1) hazard ratio 1.95, 95% CI 1.35-2.81), demonstrating the consistency of REGARDS with national mortality data. The gradient for incident stroke (fatal + nonfatal) was also significant (p = 0.0023; Q4/Q1 hazard ratio 1.29, 95% CI 1.10-1.52). The gradient for stroke case-fatality was marginally significant (p = 0.058), though the OR for Q4/Q1 (1.71, 95% CI 1.13-2.25) was large. CONCLUSIONS: Both stroke incidence and case-fatality in REGARDS appear to be contributing, underscoring the need for strengthening both stroke prevention and acute stroke care in order to reduce the disparity.

Evidence-Based Policy Making: Assessment of the American Heart Association's Strategic Policy Portfolio: A Policy Statement From the American Heart Association.

BACKGROUND: American Heart Association (AHA) public policy advocacy strategies are based on its Strategic Impact Goals. The writing group appraised the evidence behind AHA's policies to determine how well they address the association's 2020 cardiovascular health (CVH) metrics and cardiovascular disease (CVD) management indicators and identified research needed to fill gaps in policy and support further policy development. METHODS AND RESULTS: The AHA policy research department first identified current AHA policies specific to each CVH metric and CVD management indicator and the evidence underlying each policy. Writing group members then reviewed each policy and the related metrics and indicators. The results of each review were summarized, and topic-specific priorities and overarching themes for future policy research were proposed. There was generally close alignment between current AHA policies and the 2020 CVH metrics and CVD management indicators; however, certain specific policies still lack a robust evidence base. For CVH metrics, the distinction between policies for adults (age ≥20 years) and children (<20 years) was often not considered, although policy approaches may differ importantly by age. Inclusion of all those <20 years of age as a single group also ignores important differences in policy needs for infants, children, adolescents, and young adults. For CVD management indicators, specific quantitative targets analogous to criteria for ideal, intermediate, and poor CVH are lacking but needed to assess progress toward the 2020 goal to reduce deaths from CVDs and stroke. New research in support of current policies needs to focus on the evaluation of their translation and implementation through expanded application of implementation science. Focused basic, clinical, and population research is required to expand and strengthen the evidence base for the development of new policies. Evaluation of the impact of targeted improvements in population health through strengthened surveillance of CVD and stroke events, determination of the cost-effectiveness of policy interventions, and measurement of the extent to which vulnerable populations are reached must be assessed for all policies. Additional attention should be paid to the social determinants of health outcomes. CONCLUSIONS: AHA's public policies are generally robust and well aligned with its 2020 CVH metrics and CVD indicators. Areas for further policy development to fill gaps, overarching research strategies, and topic-specific priority areas are proposed.

Findings from Project HeartBeat! Their importance for CVD prevention.

Project HeartBeat! was a longitudinal "growth" study of cardiovascular disease (CVD) risk factors and body composition in childhood and adolescence. Its findings demonstrate patterns of change from ages 8 to 18 years in anthropometric indicators of adiposity, blood lipid components, and blood pressure measurements, as well as the varying inter-relations among these patterns. Especially noteworthy are differences among associations between the two components of BMI (kg/m(2))-the lean or fat-free mass index, and the fat mass index-and each of several CVD risk factors. Policy development and public health recommendations for CVD prevention beginning in childhood have evolved over 30 years or more. A new impetus to action is the recognized increase in the prevalence of childhood overweight and obesity. Intervention to prevent obesity can have a major impact in preventing CVD risk factors more broadly. Opportunities to strengthen interventions for CVD prevention in childhood and adolescence include updated algorithms for monitoring body composition, blood lipids, and blood pressure throughout childhood and adolescence through use of the Project HeartBeat! study results.

Patient-reported health status in coronary heart disease in the United States: age, sex, racial, and ethnic differences.

BACKGROUND: Coronary heart disease (CHD) affects 15.8 million Americans. However, data on the national impact of CHD on health-related quality of life, particularly among people of different age, sex, racial, and ethnic groups, are limited. METHODS AND RESULTS: Using data from the 2000 and 2002 Medical Expenditure Panel Survey, we examined various measures of patient-reported health status, including health-related quality of life, in the CHD and non-CHD populations and differences in the measures among demographic subgroups. These measures included short-form generic measures (Short Form 12; Mental Component Summary-12 and Physical Component Summary-12) and EuroQol Group measures (EQ-5D index and EQ visual analog scale). Ordinary least-squares regressions were used to adjust for sociodemographic characteristics, risk factors, comorbidities, and proxy report. The adjusted difference between the CHD and non-CHD populations was -1.2 for Mental Component Summary-12 (2.4% of the score in the non-CHD population), -4.6 for Physical Component Summary-12 (9.2%), -0.04 for EQ-5D (4.6%), and -7.3 for EQ visual analog scale (9.0%) (all P<0.05). Differences among demographic subgroups were observed. Particularly, compared with whites, the differences between CHD and non-CHD in blacks were bigger in all measures except Physical Component Summary-12. A significantly bigger difference in Mental Component Summary-12 also was observed among Hispanics compared with non-Hispanics. CONCLUSIONS: CHD is associated with significant impairment of health-related quality of life and other patient-reported health status in the US adult population. Differences in the impairment associated with CHD exist across different age, racial, and ethnic groups. In addition to preventing CHD, effective public health interventions should be aimed at improving health-related quality of life and perceived health status in the CHD population, especially the most vulnerable groups.

Regional differences in African Americans' high risk for stroke: the remarkable burden of stroke for Southern African Americans.

PURPOSE: The stroke mortality rate for African Americans aged 45 to 64 years is 3 to 4 times higher than for whites of the same age, with a decreasing black-to-white mortality ratio with increasing age. There is also a "STROKE BELT" with higher stroke mortality in the southeastern United States. This study assesses if there are also geographic variations in the magnitude of the excess stroke mortality for African Americans. METHODS: The age- and sex-specific black-to-white mortality ratio was calculated for each of 26 states with a sufficient African American population for stable estimates. The southern excess was calculated as the percentage excess of southern over nonsouthern rates. RESULTS: Across age and sex strata, the black-to-white stroke mortality ratio was consistently higher for southern states, with an average black-to-white stroke mortality ratio that ranged from 6% to 21% higher among southern states than in nonsouthern states. CONCLUSIONS: The increase in stroke mortality rates for African Americans in southern states is even larger than expected. That southern states that are not part of the "STROKE BELT" (Virginia and Florida) also have an elevated black-to-white mortality ratio suggests the mechanism of higher risk for African Americans may be independent of the causes contributing to "STROKE BELT."

Building bridges: a partnership between professional nursing and the Centers for Disease Control and Prevention to reduce the burden of heart disease and stroke.

The escalating burden of heart disease and stroke in the United States, coupled with the complexity of public health goals to prevent and control chronic diseases, warrant new strategies and partners. The 2.7 million nurses in the United States represent the nation's largest healthcare profession and, through their professional organizations, constitute a strategic partner for the Centers for Disease Control and Prevention (CDC) Heart Disease and Stroke Programs. In addition, because heart disease and stroke rank first and third among leading causes of death in women in the United States, and 95% of nurses are women, nurses represent an important population to target with preventive cardiovascular health approaches. The authors describe a proposed CDC strategic partnership with professional nursing organizations, including goals aimed at improving the capacity of nurses as change agents in the area of heart disease and stroke, as well as promoting change among the change agents to reduce nurses' risk for cardiovascular disease. The primary goals of the partnership between key professional nursing organizations and the CDC Cardiovascular Health (CVH) Programs follow: (1) share information and develop effective communication; (2) link with key professional and community organizations; (3) assess capabilities and expertise that nursing organizations can add to CDC's internal and external partnerships, including the Public Health Action Plan; (4) explore possible linkages with the CDC-funded state-level heart disease and stroke prevention programs and emerging CDC stroke networks; (5) develop, disseminate, and apply evidence-based guidelines to improve outcomes of care; and (6) develop policy and environment strategies in work-site settings to prevent heart disease and stroke in women and among the membership of professional nursing organizations. The development and implementation of a CDC CVH Program Professional Nurse Partnership have strong potential for enhancing collaborative public health efforts to prevent heart disease and stroke, and to improve cardiovascular outcomes for hypertension, high cholesterol, myocardial infarction, stroke, and heart failure.