Physical Activity and Long-Term Mortality Risk in Older Adults with and without Cardiovascular Disease: A Nationwide Cohort Study.

AIMS: To evaluate the association between physical activity (PA) levels and mortality among older adults, to determine whether it differs according to cardiovascular disease (CVD) status, and to assess the optimal weekly duration of PA associated with subsequent survival. METHODS: Participants (n = 1,799) were drawn from a national survey conducted from 2005 to 2006, constituting Israeli adults aged ≥65 years. Sociodemographic, clinical, behavioral, and psychosocial data were collected via interview at study entry. Based on a detailed PA questionnaire and according to published guidelines, participants were classified as sufficiently active, insufficiently active, and inactive. CVD status was self-reported. Mortality data (last follow-up, December 2016) were obtained from the Israeli Ministry of Health. Using Cox models, inverse probability weighted hazard ratios (HRs) for mortality, based on propensity score, were estimated for PA categories. RESULTS: Among the participants at baseline (mean age, 74.6 years), 559 (31.1%) were sufficiently active, 506 (28.1%) were insufficiently active, and 734 (40.8%) were inactive. During follow-up (mean, 9.0 years), 684 participants (38.0%) died. PA was inversely associated with mortality, with propensity score-adjusted HRs (95% confidence intervals) of 0.84 (0.71-1.01) in insufficiently and 0.73 (0.61-0.88) in sufficiently active participants (ptrend < 0.001). No PA-by-CVD interaction was detected on multiplicative scale (p = 0.36) or additive scale (p = 0.58). A monotonic survival benefit was observed until ∼150 min of PA per week, beyond which no further gain was apparent. CONCLUSIONS: In a nationwide cohort of older adults, nearly 70% did not meet the guideline for PA. PA engagement was inversely associated with long-term mortality risk, similarly in individuals with and without CVD. A maximum survival advantage was achieved at around 150 min of exercise per week.

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.

Non-alcoholic fatty liver disease and cognitive function in middle-aged adults: the CARDIA study.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is associated with cardiovascular disease (CVD) risk factors that have been linked to cognitive decline. Whether NAFLD is associated with cognitive performance in midlife remains uncertain. METHODS: Coronary Artery Risk Development in Young Adults study participants with CT examination and cognitive assessment at Y25 (2010-2011; n = 2809) were included. Cognitive function was reassessed at Y30. NAFLD was defined according to liver attenuation and treated both continuously and categorically (using ≤ 40 and ≤ 51 Hounsfield units to define severity) after exclusion for other causes of liver fat. Cognitive tests including the Digit Symbol Substitution (processing speed), Rey Auditory Verbal Learning (verbal memory), and Stroop (executive function) were analyzed with standardized z-scores. Linear models were constructed to (a) examine the cross-sectional associations of NAFLD with cognitive scores and (b) evaluate its predictive role in 5-year change in cognitive performance. RESULTS: Participants' mean age (Y25) was 50.1 (SD 3.6) years (57% female; 48% black), with 392 (14%) having mild NAFLD and 281 (10%) having severe NAFLD. NAFLD was positively associated with CVD risk factors and inversely associated with cognitive scores. However, after adjustment for CVD risk factors, no associations were shown between NAFLD and cognitive scores (all ßs ≈ 0). Similarly, no associations were observed with 5-year cognitive decline. CVD history, hypertension, smoking, diabetes and hypertriglyceridemia showed stronger associations with baseline cognitive scores and were predictive of subsequent cognitive decline (all P ≤ .05). CONCLUSION: Among middle-aged adults, inverse associations between NAFLD and cognitive scores were attenuated after adjustment for CVD risk factors, with the latter predictive of poorer cognitive performance both at baseline and follow-up.

Recent trends in cardiovascular disease deaths: a state specific perspective.

BACKGROUND: The rate of decline in cardiovascular disease (CVD) mortality has lessened nationally. How these findings apply to specific states or causes of CVD deaths is not known. Examining these trends at the state level is important to plan local interventions. METHODS: We analyzed CVD mortality trends in Minnesota (MN) using the U.S. Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Trends were analyzed by age, sex, type of CVD and location of death. RESULTS: CVD mortality rates in MN declined in 2000-2009 and then leveled off in 2010-2018, paralleling national rates. Age- and sex-adjusted CVD mortality decreased by 3.7% per year in 2000-2009 (average annual percent changes [AAPC]: -3.7; 95% CI: - 4.8, - 2.6) with no change observed in 2010-2018. Those aged 65-84 years had the most rapid early decline in CVD mortality (AAPC: -5.9, 95% CI: - 6.2, - 5.7) and had less improvement in 2010-2018 (AAPC: -1.8, 95% CI: - 2.2, - 1.5), and the younger age group (25-64 years) now experiences the most adverse trends (AAPC: 1.2, 95% CI: 0.7-1.8). Coronary heart disease (CHD) and cerebrovascular disease had the largest relative decreases in mortality in 2000-2009 (CHD AAPC: -5.2; 95% CI: - 6.5,-3.9; cerebrovascular disease AAPC: -4.4, 95% CI: - 5.2, - 3.6) with no change 2010-2018. Heart failure (HF)/cardiomyopathy followed similar trends with a 2.5% decrease (AAPC 95% CI: - 3.5, - 1.5) per year in 2000-2009 and no change in 2010-2018. Deaths from other CVD also decreased in the early time period (AAPC: -1.6, 95% CI: - 2.7, - 0.5) but increased in 2010-2018 (AAPC: 1.9, 95% CI: 0.5, 3.3). In- and out-of-hospital death rates improved in 2000-2009 with a slowing in improvement for in-hospital death and no further improvement for out-of-hospital death in 2010-2018. CONCLUSION: Concerning CVD mortality trends occurred in MN. In the most recent decade (2010-2018) mortality from all CVD subtypes plateaued or even increased. CVD mortality among the younger age groups increased as well. These data are congruent with adverse national trends supporting their generalizability. These adverse trends underscore the urgent need for CVD prevention and treatment, as well as continued surveillance to assess progress at the state and national level.

Cancer and mortality in relation to traffic-related air pollution among coronary patients: Using an ensemble of exposure estimates to identify high-risk individuals.

BACKGROUND: Moderate correlations were previously observed between individual estimates of traffic-related air pollution (TRAP) produced by different exposure modeling approaches. This induces exposure misclassification for a substantial fraction of subjects. AIM: We used an ensemble of well-established modeling approaches to increase certainty of exposure classification and reevaluated the association with cancers previously linked to TRAP (lung, breast and prostate), other cancers, and all-cause mortality in a cohort of coronary patients. METHODS: Patients undergoing percutaneous coronary interventions in a major Israeli medical center from 2004 to 2014 (n = 10,627) were followed for cancer (through 2015) and mortality (through 2017) via national registries. Residential exposure to nitrogen oxides (NOx) -a proxy for TRAP- was estimated by optimized dispersion model (ODM) and land use regression (LUR) (rPearson = 0.50). Mutually exclusive groups of subjects classified as exposed by none of the methods (high-certainty low-exposed), ODM alone, LUR alone, or both methods (high-certainty high-exposed) were created. Associations were examined using Cox regression models. RESULTS: During follow-up, 741 incident cancer cases were diagnosed and 3051 deaths occurred. Using a ≥25 ppb cutoff, compared with high-certainty low exposed, the multivariable-adjusted hazard ratios (95% confidence intervals) for lung, breast and prostate cancer were 1.56 (1.13-2.15) in high-certainty exposed, 1.27 (0.86-1.86) in LUR-exposed alone, and 1.13 (0.77-1.65) in ODM-exposed alone. The association of the former category was strengthened using more extreme NOx cutoffs. A similar pattern, albeit less strong, was observed for mortality, whereas no association was shown for cancers not previously linked to TRAP. CONCLUSIONS: Use of an ensemble of TRAP exposure estimates may improve classification, resulting in a stronger association with outcomes.

[THE ASSOCIATION BETWEEN EXPOSURE TO TRAUMA AND MENTAL ILLNESS AMONG WORK MIGRANTS AND ASYLUM SEEKERS IN ISRAEL: A SURVEY AT THE OPEN CLINIC, PHYSICIANS FOR HUMAN RIGHTS, 2012-2013].

INTRODUCTION: In 2012, 183,896 work migrants and 47,704 asylum-seekers and work-migrants arrived in Israel. These populations are at high-risk for depression, anxiety and posttraumatic stress disorder (PTSD). The Open Clinic of Physicians for Human Rights (PHR) delivers free medical and mental health services to these individuals. AIMS: To evaluate exposure to traumatic events, and compare the prevalence and risk for PTSD, depression and anxiety symptoms between work-migrants and asylum-seekers. METHODS: An analytical cross-sectional study of adults visiting the Open Clinic was conducted. Participants completed self-report questionnaires including information on demographics and exposure to traumas, depression, anxiety and PTSD. Statistical models were constructed to predict outcome variables of PTSD, depression and anxiety as dichotomist variables using a logistic regression, and association odds ratio (OR) and confidence interval (CI) on 95% level. RESULTS: There were 241 participants; 165 asylum-seekers, 76 work-migrants. Work-migrants were exposed to more traumatic events. A total of 17-31% met PTSD criteria. Significantly more asylum-seekers met PTSD criteria. A total of 43%-50% met criteria for depression and/or anxiety, with no between-group differences. Significant association was found between immigration status and PTSD risk. Exposure to traumatic events was significantly associated with the prediction of PTSD, depression and anxiety. DISCUSSION: Exposure to traumatic events was high among the Open Clinic service users, specifically work-migrants. Prevalence and risk for post-traumatic symptoms were significantly higher among asylum-seekers. It is important to conduct further research, in order to characterize risk and resilience factors in this excluded population, and to plan language and culture-competent mental health services.

Fracture Risk Assessment With FRAX Using Real-World Data in a Population-Based Cohort From Israel.

The predictive value of the World Health Organization's Fracture Risk Assessment Tool (FRAX) was evaluated using real-world community data. A population-based cohort of 141,320 women aged 50-90 years (median age, 58 years; interquartile range, 54-67) in 2004 was extracted from the central database of a large Israeli health-care services provider and insurer. Retrospective FRAX scores were calculated using computerized health records and compared with actual incidence of major osteoporotic fractures (MOFs) during the following 10 years. Fracture proportions of 6.9% for MOFs and 2.2% for hip fractures were expected, as opposed to 13.5% and 2.9% observed. The area under the receiver operating characteristic curve (AUC) of FRAX scores calculated without the inclusion of bone mineral density (BMD) data was 0.65 (95% confidence interval: 0.65, 0.66) for MOF and 0.82 (95% confidence interval: 0.81, 0.82) for hip fracture. A total of 16,578 subjects had BMD data at the index date, and their risk estimates based solely on BMD exhibited lower predictive performance for both MOFs (AUC = 0.62 vs. 0.65; P = 0.003) and hip fractures (AUC = 0.78 vs. 0.84; P < 0.001) as compared with FRAX. FRAX scores based on electronic health records provided reasonable discrimination despite some underestimation of the absolute risk of nonhip fractures. Integration of FRAX with routine clinical systems could increase implementation in daily practice and improve risk detection, especially for patients without BMD data.

Do heart failure status and psychosocial variables moderate the relationship between leisure time physical activity and mortality risk among patients with a history of myocardial infarction?

BACKGROUND: Leisure time physical activity (LTPA) is inversely related to mortality risk among patients with a history of myocardial infarction (MI). The aims were to explore if heart failure (HF) status and psychosocial variables moderate the association. METHODS: Participants (n = 1169) were from a multi-center prospective cohort study. Information on LTPA (none, irregular,1-150, 151-300 and >300 weekly minutes), depression, social support and other prognostic indicators were collected 10-13 years after index MI. Cox regressions were conducted, adjusting for potential confounders. In case of significant moderation by HF-status or psychosocial variables, stratified analyses were performed. RESULTS: During follow-up (M = 8.4 years), 25.6 % of the sample had died. LTPA was inversely associated with mortality (p for trend < 0.01 in all models). HF did not, but psychosocial variables did, moderate the association. In the LTPA category 1-150 weekly minutes, patients with a high level of depression had a lower mortality risk in comparison to those with a low level (hazard ratios (95 % confidence intervals) were 0.43 (0.25, 0.75) versus 0.69 (0.36, 1.32)), and patients with a low level of social support had a lower mortality risk in comparison to those with a high level (0.40 (0.21, 0.77) versus 0.71 (0.39, 1.27)). In the category >300 min, patients with a high level of social support had a lower mortality risk than those with a low level (0.38 (0.19, 0.79) versus 0.51 (0.30, 0.87)). CONCLUSIONS: LTPA was inversely related to mortality risk of post-MI patients. HF did not moderate the relationship; depression and social support partially did.

The predictive ability of ABSI compared to BMI for mortality and frailty among older adults.

Introduction: To study the utility of A Body Shape Index (ABSI) alongside body mass index (BMI) to predict mortality and frailty in an aging community population. Materials and methods: Participants (n = 1,580) were drawn from the first Israeli national health and nutrition survey of older adults ("Mabat Zahav") conducted from 2005 to 2006, constituting adults aged ≥65 years. Socio-demographic, clinical, behavioral, and psychosocial data were collected. Baseline weight, height, and waist circumference (WC) were measured and expressed as the allometric indices BMI (kg/m2) and ABSI, a BMI-independent measure of abdominal obesity [WC/(BMI2/3*m1/2)]. Mortality follow-up lasted through 2019. Frailty was assessed in 2017-2019 by the Fried Biological Phenotype in a sub-cohort of 554 survivors. Cox and logistic regression models assessed associations of BMI and ABSI with mortality and frailty. Results: At baseline, mean [SD] age was 74.5 [6.1] years, and 52.4% were women. The correlation between BMI and WC Z scores was 0.71, reduced to -0.11 for BMI and ABSI. Over a median follow-up of 13 years, 757 deaths occurred. The multivariable-adjusted hazard ratios (95% CIs) for mortality per standard deviation increase in BMI and ABSI were 1.07 (0.99;1.17) and 1.13 (1.05;1.21), respectively. Among participants assessed for frailty, 77 (14%) met the frailty criteria. After multivariable adjustment, the odds ratios (95% CIs) for frailty were 0.83 (0.69-1.01) for BMI and 1.55 (1.34-1.79) for ABSI. Discussion: In a nationwide cohort of older adults, ABSI was independently associated with mortality risk. Furthermore, ABSI, but not BMI, was a strong predictor of frailty.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity.

Importance: Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown. Objective: To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity. Design, Setting, and Participants: Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years. Exposure: Time-dependent cumulative mean SBP. Main Outcomes and Measures: The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH. Results: Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type. Conclusions and Relevance: The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Contemporary trends in heart failure with reduced and preserved ejection fraction after myocardial infarction: a community study.

Major changes have recently occurred in the epidemiology of myocardial infarction (MI) that could possibly affect outcomes such as heart failure (HF). Data describing trends in HF after MI are scarce and conflicting and do not distinguish between preserved and reduced ejection fraction (EF). We evaluated temporal trends in HF after MI. All residents of Olmsted County, Minnesota (n = 2,596) who had a first-ever MI diagnosed in 1990-2010 and no prior HF were followed-up through 2012. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Both early-onset (0-7 days after MI) and late-onset (8 days to 5 years after MI) HF were examined. Changes in patient presentation were noted, including fewer ST-segment-elevation MIs, lower Killip class, and more comorbid conditions. Over the 5-year follow-up period, 715 patients developed HF, 475 of whom developed it during the first week. The age- and sex-adjusted risk declined from 1990-1996 to 2004-2010, with hazard ratios of 0.67 (95% confidence interval (CI): 0.54, 0.85) for early-onset HF and 0.63 (95% CI: 0.45, 0.86) for late-onset HF. Further adjustment for patient and MI characteristics yielded hazard ratios of 0.86 (95% CI: 0.66, 1.11) and 0.63 (95% CI: 0.45, 0.88) for early- and late-onset HF, respectively. Declines in early-onset and late-onset HF were observed for HF with reduced EF (<50%) but not for HF with preserved EF, indicating a change in the case mix of HF after MI that requires new prevention strategies.

Measuring frailty in heart failure: a community perspective.

BACKGROUND: Frailty, an important prognostic indicator in heart failure (HF), may be defined as a biological phenotype or an accumulation of deficits. Each method has strengths and limitations, but their utility has never been evaluated in the same community HF cohort. METHODS: Southeastern Minnesota residents with HF were recruited from 2007 to 2011. Frailty according to the biological phenotype was defined as 3 or more of: weak grip strength, physical exhaustion, slowness, low activity and unintentional weight loss >10 lb in 1 year. Intermediate frailty was defined as 1 to 2. The deficit index was defined as the proportion of deficits present out of 32 deficits. RESULTS: Among 223 patients (mean age 71 ± 14, 61% male), 21% were frail and 48% intermediate frail according to the biological phenotype. The deficit index ranged from 0.02-0.75, with a mean (SD) of 0.25 (0.13). Over a mean follow-up of 2.4 years, 63 patients died. After adjustment for age, sex and ejection fraction, patients categorized as frail by the biological phenotype had a 2-fold increased risk of death compared to those with no frailty, whereas a 0.1 unit increase in the deficit index was associated with a 44% increased risk of death. Both measures predicted death equally (C-statistics: 0.687 for biological phenotype and 0.700 for deficit index). CONCLUSION: The deficit index and the biological phenotype equally predict mortality. As the biological phenotype is not routinely assessed clinically, the deficit index, which can be ascertained from medical records, is a feasible alternative to ascertain frailty.

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.

Cumulative exposure to particulate matter air pollution and long-term post-myocardial infarction outcomes.

INTRODUCTION: Chronic environmental exposure to particulate matter <2.5µm in diameter (PM2.5) has been associated with cardiovascular disease; however, the effect of air pollution on myocardial infarction (MI) survivors is not clear. We studied the association of chronic exposure to PM2.5 with death and recurrent cardiovascular events in MI survivors. METHODS: Consecutive patients aged ≤65years admitted to all medical centers in central Israel after first-MI in 1992-1993 were followed through 2005 for cardiovascular events and 2011 for survival. Data on sociodemographic and prognostic factors were collected at baseline and during follow-up. Residential exposure to PM2.5 was estimated for each patient based on data recorded at air quality monitoring stations. Cox and Andersen-Gill proportional hazards models were used to study the pollution-outcome association. RESULTS: Among the 1120 patients, 469 (41.9%) died and 541 (48.3%) experienced one or more recurrent cardiovascular event. The adjusted hazard ratios associated with a 10µg/m(3) increase in PM2.5 exposure were 1.3 (95% CI 0.8-2.1) for death and 1.5 (95% CI 1.1-1.9) for multiple recurrences of cardiovascular events (MI, heart failure and stroke). CONCLUSION: When adjustment for socio-demographic factors is performed, cumulative chronic exposure to PM2.5 is positively associated with recurrence of cardiovascular events in patients after a first MI.

Cancer Incidence and Survival Among Patients Following an Acute Coronary Syndrome.

To examine the role of acute coronary syndrome (ACS) in subsequent cancer incidence and survival, 2 cohorts of patients hospitalized with ACS were matched 1:1 by gender and age (±3 years) to cardiovascular disease (CVD)-free patients from 2 cycles of the Israeli National Health and Nutrition Surveys. Data on all-cause mortality were retrieved from national registries. Cancer incidence with death treated as a competing event, overall survival, and mortality risk associated with incident cancer as a time-dependent variable were compared between the groups. Our cohort included 2,040 cancer-free matched pairs (mean age of 60±14 years, 42.5% women). Despite higher rates of smokers and patients with hypertension and diabetes mellitus, 10-year cumulative cancer incidence was significantly lower in the ACS group compared with CVD-free group (8.0% vs 11.4%, p = 0.02). This decreased risk was more pronounced in women than men (pinteraction = 0.05). Although being free of CVD meant a significant (p <0.001) survival advantage in the general cohort, this advantage faded once a cancer diagnosis was made (p = 0.80). After adjustment for sociodemographic and clinical covariates, the hazard ratios for mortality associated with a cancer diagnosis were 2.96 (95% confidence interval: 2.36 to 3.71) in the ACS group versus 6.41 (95% confidence interval: 4.96 to 8.28) in the CVD-free group (Pinteraction<0.001). In conclusion, in this matched cohort, ACS was associated with a lower risk of cancer and mitigated the excess risk of mortality associated with cancer incidence.

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.

Association between myocardial infarction and fractures: an emerging phenomenon.

BACKGROUND: Data on the association between myocardial infarction (MI) and fractures are scarce. Recent changes in the epidemiology of MI justify exploring this relationship. We evaluated whether MI constitutes a risk factor for osteoporotic fracture and examined secular trends in this association. METHODS AND RESULTS: Consecutive Olmsted County, Minnesota, residents with incident MI diagnosed in 1979 to 2006 and community control subjects individually matched (1:1) to cases on age, sex, and year of onset (n=6642) were followed up through 2009. Outcome measures were time to osteoporotic fracture, overall and by anatomic site, and death. Fracture incidence rates were stable in controls but increased markedly over time among MI cases. Accordingly, although an overall excess of fracture risk after MI was observed (adjusted hazard ratio, 1.32; 95% confidence interval, 1.12 to 1.56), substantial temporal variations were noted (1979 to 1989: hazard ratio, 0.81; 95% confidence interval, 0.58 to 1.12; 1990 to 1999: hazard ratio, 1.47; 95% confidence interval, 1.10 to 1.96; 2000 to 2006: hazard ratio, 1.73; 95% confidence interval, 1.32 to 2.27; P for trend <0.001). Trends were similar regardless of age, sex or fracture site. Conversely, the overall hazard ratio for death in MI cases versus controls did not change materially despite a continuous decline in 30-day case fatality rate (12.5% in 1979 to 1989; 6.7% in 2000 to 2006). Observed changes in the baseline prevalence of cardiovascular risk factors, MI characteristics, and comorbidities did not fully account for the trends in fracture risk. CONCLUSIONS: Over the past decades, the association between MI and osteoporotic fractures increased steadily. The trend is consistent with the displacement of post-MI outcomes toward noncardiovascular events, highlighting the need for comprehensive prevention strategies to accommodate the changing epidemiology of MI.

Smoking reduction at midlife and lifetime mortality risk in men: a prospective cohort study.

Previous studies have not shown a survival advantage for smoking reduction. The authors assessed survival and life expectancy according to changes in smoking intensity in a cohort of Israeli working men. Baseline smokers recruited in 1963 were reassessed in 1965 (n = 4,633; mean age, 51 years) and followed up prospectively for mortality through 2005. Smoking intensity at both time points was self-reported and categorized as none, 1-10, 11-20, and ≥21 cigarettes per day. Change between smoking categories was noted, and participants were classified as increased (8%), maintained (65%), reduced (17%), or quit (10%) smoking. During a median follow-up of 26 (quartiles 1-3: 16-35) years, 87% of participants died. Changes in intensity were associated with survival. In multivariable-adjusted models, the hazard ratios for mortality were 1.14 (95% confidence interval (CI): 0.99, 1.32) among increasers, 0.85 (95% CI: 0.77, 0.95) among reducers, and 0.78 (95% CI: 0.69, 0.89) among quitters, compared with maintainers. Inversely, the adjusted odds ratios of surviving to age 80 years were 0.77 (95% CI: 0.60, 0.98), 1.22 (95% CI: 1.01, 1.47), and 1.33 (95% CI: 1.07, 1.66), respectively. The survival benefit associated with smoking reduction was mostly evident among heavy smokers and for cardiovascular disease mortality. These results suggest that decreasing smoking intensity should be considered as a risk-reduction strategy for heavy smokers who cannot quit abruptly.

Association of Diet Quality With Longevity and Successful Aging in Israeli Adults 65 Years or Older.

Importance: To our knowledge, the role of overall diet quality in successful aging has not been conclusively demonstrated. Objective: To prospectively examine the association between diet quality and longevity and successful aging in a population-based cohort of older adults. Design, Setting, and Participants: Participants in "Mabat Zahav" (the Israeli National Health and Nutrition Survey of Older Adults), an older adult cohort (aged ≥65 years) consisting of a random sample of 1770 individuals, were recruited from July 2005 to December 2006 (time 1 [T1]). Survivors of T1 were again contacted and asked to participate in a second interview. From May 2017 to June 2019 (time 2 [T2]), an extensive face-to-face interview and a functional assessment were conducted in each participant's home in a subsample of 604 participants from T1, representing 72.7% of 820 surviving individuals who were able to complete interviews and assessments. Exposures: A 24-hour dietary recall, assessed at T1, was used to calculate scores from the 2015 version of the Healthy Eating Index (HEI-2015) (scores range from 0 [worst diet] to 100 [best diet]). Main Outcomes and Measures: Time to death, with follow-up lasting through June 2019, and successful aging. The latter, based on T2 assessment, was defined as (objectively measured) preserved physical and cognitive function and (subjective) mental well-being and favorable self-rated health. Inverse probability weighting was used in the analysis to minimize attrition bias. Results: At T1, the study included 1770 participants (mean [SD] age, 74.6 [6.2] years; 943 women [53%]). On average, participants with higher HEI-2015 scores had healthier lifestyles and higher socioeconomic status at T1. During a median follow-up duration of 12.6 years (IQR, 7.6-13.2 years), 893 deaths occurred. Among the 596 T2 participants analyzed (mean [SD] age, 84.1 [4.4] years; 334 [56%] women), 242 (40%) met successful aging criteria. After adjustment for sociodemographic and lifestyle risk factors, a higher HEI-2015 score was inversely associated with mortality (hazard ratios, 0.85; 95% CI, 0.72-0.99 in the upper tertile and 0.83; 95% CI, 0.71-0.98 in the middle tertile vs the lower tertile; P = .04 for trend) and was positively associated with successful aging (odds ratios, 1.73; 95% CI, 1.10-2.72 in the upper tertile and 1.30; 95% CI, 0.83-2.03 in the middle tertile vs the lower tertile; P = .03 for trend). Conclusions and Relevance: In this cohort study of older adults in Israel, improved diet quality was associated with increased longevity and successful aging in a dose-dependent manner. These data contribute to the body of literature that suggests diet quality is associated with aging in the older age group.