Notable paradoxical phenomena in associations between cardiovascular health score, subclinical and clinical cardiovascular disease in the community: The Framingham Heart Study.

IMPORTANCE: Cardiovascular Health (CVH) scores are inversely associated with prevalent subclinical (SubDz) and incident cardiovascular disease (CVD). However, the majority of people who develop CVD have intermediate or ideal CVH scores, while many with poor CVH profiles escape CVD development. OBJECTIVE: To describe the prevalence of paradoxical relations among CVH, SubDz, and CVD. DESIGN: Cohort study, Framingham Study data collected prospectively (1995-2016). SETTING: Population-based. PARTICIPANTS: 7,627 participants (mean age 49 years, 53% women) attending Offspring examinations 6/7 and Third Generation examinations 1/2. EXPOSURES: CVH score (range 0-14) constructed from poor, intermediate, or ideal status for each metric (smoking, diet, physical activity, blood pressure, body mass index, fasting glucose, total cholesterol); and prevalent SubDz (≥1 of: increased carotid intimal media thickness, CIMT; left ventricular hypertrophy, LVH; microalbuminuria, MA; elevated ankle brachial index, ABI; coronary artery calcium score ≥100,CAC). MAIN OUTCOME(S) AND MEASURE(S): Ideal CVH (scores 12-14), intermediate CVH (scores 8-11), and poor CVH (0-7). We described three distinct paradoxical phenomena, involving combinations of CVH, SubDz, and CVD, and generated CVD incidence rates and predicted CVD probabilities for all combinations. RESULTS: We observed 842 CVD events (median follow-up 13.7 years); 1,663 participants had SubDz. Most individuals with poor CVH (78%) or SubDz (57% for CIMT to 77% for LVH) did not develop CVD on follow-up. Among participants with incident CVD, the majority had intermediate or ideal CVH (68%) or absent SubDz (46% for CAC to 96% for ABI) at baseline. We observed similar paradoxical results in relations between CVH and prevalent SubDz. Poor CVH and prevalent SubDz were each associated with higher CVD incidence rates compared to intermediate or ideal CVH and absent SubDz, respectively. The predicted CVD probability was nearly three-times greater among participants with poor (22%) versus intermediate or ideal CVH (8%). Mean CVD predicted probabilities were nearly three (26% vs. 10% for MA) to six-times (29% vs. 5% for CAC) greater among participants with SubDz versus without SubDz. Findings were consistent within age and sex strata. CONCLUSIONS AND RELEVANCE: Although poor CVH and SubDz presence are associated with CVD incidence, paradoxical phenomena involving CVH, SubDz, and CVD are frequently prevalent in the community. Further studies to elucidate biological mechanisms underlying these phenomena are warranted.

Prevalence, Predictors, Progression, and Prognosis of Hypertension Subtypes in the Framingham Heart Study.

Background The epidemiology of hypertension subtypes has not been well characterized in the recent era. Methods and Results We delineated the prevalence, predictors, progression, and prognostic significance of hypertension subtypes in 8198 Framingham Heart Study participants (mean age, 46.5 years; 54% women). The prevalence of hypertension subtypes was as follows: nonhypertensive (systolic blood pressure [SBP] <140 mm Hg and diastolic blood pressure [DBP] <90 mm Hg), 79%; isolated systolic hypertension (ISH; SBP ≥140 mm Hg and DBP <90 mm Hg), 8%; isolated diastolic hypertension (SBP <140 mm Hg and DBP ≥90 mm Hg), 4%; and systolic-diastolic hypertension (SDH; SBP ≥140 mm Hg and DBP ≥90 mm Hg), 9%. The prevalence of ISH and SDH increased with age. Analysis of a subsample of nonhypertensive participants demonstrated that increasing age, female sex, higher heart rate, left ventricular mass, and greater left ventricular concentricity were predictors of incident ISH and SDH. Higher baseline DBP was associated with the risk of developing isolated diastolic hypertension and SDH, whereas higher SBP was associated with all 3 hypertension subtypes. On follow-up (median, 5.5 years), isolated diastolic hypertension often reverted to nonhypertensive BP (in 42% of participants) and ISH progressed to SDH (in 26% of participants), whereas SDH frequently transitioned to ISH (in 20% of participants). During follow-up (median, 14.6 years), 889 participants developed cardiovascular disease. Compared with the nonhypertensive group (referent), ISH (adjusted hazard ratio [HR], 1.57; 95% CI, 1.30-1.90) and SDH (HR, 1.66; 95% CI, 1.36-2.01) were associated with increased cardiovascular disease risk, whereas isolated diastolic hypertension was not (HR, 1.03; 95% CI, 0.68-1.57). Conclusions Hypertension subtypes vary in prevalence with age, are dynamic during short-term follow-up, and exhibit distinctive prognoses, underscoring the importance of blood pressure subphenotyping.

Conjoint Associations of Adherence to Physical Activity and Dietary Guidelines With Cardiometabolic Health: The Framingham Heart Study.

Background The conjoint associations of adherence to the recent physical activity and dietary guidelines with the metabolic syndrome (MetS) are incompletely understood. Methods and Results We evaluated 2379 FHS (Framingham Heart Study) Third Generation participants (mean age, 47 years; 54.4% women) attending examination cycle 2. We examined the cross-sectional relations of adherence to the 2018 Physical Activity Guidelines for Americans (binary; moderate-to-vigorous physical activity ≥150 versus <150 min/wk) and 2015 Dietary Guidelines for Americans (binary; 2015 Dietary Guidelines for Americans Adherence Index ≥median versus

A Contemporary Approach to Hypertensive Cardiomyopathy: Reversing Left Ventricular Hypertrophy.

PURPOSE OF REVIEW: To highlight pharmacological and non-pharmacological approaches to reversing hypertensive left ventricular hypertrophy (LVH). We identify high-risk phenotypes that may benefit from aggressive blood pressure (BP) management to prevent incident outcomes such as the development of atherosclerotic cardiovascular disease, stroke, and heart failure. RECENT FINDINGS: LVH is a modifiable risk factor. Intensive BP lowering (systolic BP < 120 mmHg) induces greater regression of electrocardiographic LVH than standard BP targets. The optimal agents for inducing LVH regression include renin-angiotensinogen-aldosterone system inhibitors and calcium channel blockers, although recent meta-analyses have demonstrated superior efficacy of non-hydrochlorothiazide diuretics. Novel agents (such as sacubitril/valsartan) and non-pharmacological approaches (like bariatric surgery) hold promise but longitudinal studies assessing their impact on clinical outcomes are needed. LVH regression is achievable with appropriate therapy with first-line antihypertensive agents. Additional studies are warranted to assess if intensive BP lowering in high-risk groups (such as blacks, women, and malignant LVH) improves outcomes.

Familial Clustering of Aortic Size, Aneurysms, and Dissections in the Community.

BACKGROUND: Ruptured aortic aneurysm and aortic dissections are potentially preventable disorders associated with high mortality. Screening of individuals at risk may translate into elective surgical interventions and lowered mortality. It is uncertain if the risk of aortic dilation of varying degrees aggregates within families. METHODS: We investigated the risk of having thoracic and abdominal aortic sizes in the highest quartile (measured by computed tomography scans and indexed for body size) if at least 1 parent did so in the Framingham Heart Study cohorts, and estimated the incidence rates and hazard ratios of developing aortic aneurysm or dissection among first-degree relatives of those with aortic aneurysm or dissection, in comparison with age- and sex-matched controls (1:10 for aortic aneurysm and 1:100 for aortic dissection) using the Danish nationwide administrative registries. RESULTS: In the Framingham Heart Study, offspring (n=235) whose parent(s) had a sex- and age-standardized aortic size in the upper quartile had a multivariable-adjusted ≈3-fold increased odds ratio of belonging to the upper quartile themselves. In Denmark, a total of 68 939 individuals (mean age, 42 years) had a first-degree relative with aortic aneurysm and 7209 persons (mean age, 39 years) had a first-degree relative with aortic dissection. During an average follow-up of 7 years, first-degree relatives of patients with aortic aneurysm and dissection had a hazard ratio of 6.70 (95% CI, 5.96-7.52) for developing aortic aneurysm and a hazard ratio of 9.24 (95% CI, 5.53-15.44) for dissection in comparison with matched controls. These estimates remained unchanged on adjusting for several comorbidities, including prevalent hypertension, bicuspid aortic valve, and the Marfan syndrome. For both aortic aneurysm and dissections, the absolute event rates approached 1 per 1000 person-years for first-degree relatives versus 11 to 13 (aortic aneurysm) and 2 to 3 (aortic dissections) per 100 000 person-years among controls. CONCLUSIONS: Increased aortic size, a precursor of aortic aneurysm and a risk factor for dissection, clusters in families. The incidence rates of aortic aneurysm and dissections approach the incidence rates of other common cardiovascular conditions in first-degree relatives, supporting the use of systematic screening for these conditions.

Cardiovascular Health in St. Louis Bosnian-Americans.

In Bosnia and Herzegovina, cardiovascular disease accounts for nearly 50% of deaths. Cardiovascular health of resettled Bosnian-Americans has not been well-characterized. Our study aimed to quantify cardiovascular risk in Bosnian-Americans in St. Louis, the largest non-European center of resettlement. Seven community screenings focused on Bosnian-Americans were held. Cardiovascular risk was calculated to stratify individuals into low (<10%), moderate (10-20%), and high (>20%) risk. Those with self-reported coronary heart disease (CHD) or risk equivalent were considered high-risk. Two-hundred fifty Bosnian-Americans were screened; 51% (n = 128) consented to the IRB-approved study. Twenty-one percent were smokers, 33% obese, and 33% had hypertension. Excluding risk equivalent individuals, 5.7% of subjects were high-risk, increasing to 26.6% when including high-risk equivalents. Lipid abnormalities include elevated triglycerides (29.0%) and low HDL (50.0%). Compared to general American population studies, Bosnian-Americans have greater ten-year hard CHD risk. A community-based approach identified potential culturally-based lifestyle interventions including diet, exercise, and smoking.