Design of a Novel Intervention Model to Address Cardiovascular Health Disparities in the Rural Underserved Community of Phillips County Arkansas.

Devastating health-related disparities driven by an entanglement of factors disproportionately impact the underserved, low-wealth, and minority community of Phillips county (PC) in the Arkansas Delta Region (ADR). Cardiovascular disease continues to increase with widespread consequences on the local economy, health care systems, and population. Health care and community-based systems have been unsuccessful in reducing out-of-hospital cardiac death, particularly in the ADR, for many reasons. Herein, we share the strategy behind, planning, and goals of The Arkansas Lincoln Project, a novel neighborhood-based strategy bridging the gap between residents, social resources, and health care services in PC.

Mental Disorders, Substance Use Disorders, and Psychotropic Medication Use Among Sudden-Death Victims.

OBJECTIVE: The authors sought to estimate the prevalence of mental and substance use disorders and psychotropic medication prescriptions among working-age sudden-death victims. METHODS: Using a written protocol, the authors screened for sudden deaths attended by emergency medical services (EMS) in a large metropolitan county in North Carolina from March 1, 2013, to February 28, 2015. Sudden-death cases were adjudicated by three cardiologists. Mental health and chronic disease diagnoses and treatments were abstracted from EMS, medical examiner, toxicology, and autopsy reports and from clinical records for the past 5 years before death. RESULTS: Sudden death was identified for 399 adults ages 18-64 years, 270 of whom had available medical records. Most sudden-death victims were White (63%) and male (65%), had a comorbid condition such as hypertension or respiratory disease, and had a mean±SD age of death of 53.6±8.8 years. Most victims (59%) had at least one mental health or substance use disorder documented in a recent medical record; 76%-78% of victims with a mental disorder had a documented psychotropic medication prescription. However, fewer than one-half (41%) had a documented referral to a mental health professional. The most common diagnostic categories were depressive, anxiety, and alcohol-related disorders. Almost one-half (46%) of the victims had a recent psychotropic prescription, most commonly antidepressants (29%) and benzodiazepines (19%). CONCLUSIONS: Mental illness, substance use disorders, and psychotropic medication prescriptions were prevalent among sudden-death victims. The health care needs of these individuals may be better addressed by collaborative care for general medical and mental disorders.

A case-crossover analysis of the relationship of air pollution with out-of-hospital sudden unexpected death in Wake County, North Carolina (2013-2015).

Out-of-hospital sudden unexpected deaths are non-accidental deaths that occur without obvious underlying causes and may account for 10% of natural deaths before age 65. Short-term exposure to ambient air pollution is associated with all-cause (non-accidental) and cause-specific (e.g., cardiovascular) mortality, and with immediate exposures often yielding the highest magnitude risk estimates. Few studies have focused on short-term exposure to air pollution and sudden unexpected deaths. Using the University of North Carolina Sudden Unexpected Death in North Carolina population, we examine associations between short-term criteria air pollutant exposures with sudden unexpected deaths using a time-stratified case-crossover design, with data on criteria air pollutants from the Environmental Protection Agency's Air Quality System. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression with air pollutant exposures scaled to roughly inter-quartile ranges; models were adjusted for average temperature and relative humidity on event day and preceding 3 days. Potential for confounding by co-pollutants were examined in two pollutant models. ORs for PM2.5 at lag day 1 were elevated (adjusted OR for 5 µg/m3 increase: 1.17 (0.98, 1.40)), and were robust to co-pollutant adjustment. Elevated odds were observed for SO2 at lag day 0, and reduced odds for O3 at lag day 0; however, these associations were somewhat attenuated toward the null (SO2) or were not robust (O3) to co-pollutant adjustment. This analysis in a racially and socioeconomically diverse cohort, with a more inclusive definition of sudden unexpected death than is typically employed offers evidence that PM2.5 may be a clinically relevant trigger of sudden unexpected deaths in susceptible individuals.

Under-reporting of sudden unexpected death in epilepsy.

The identification and characterization of sudden unexpected deaths in epilepsy (SUDEP) may be improved, helping to optimize prevention and intervention. We set out to assess the frequency and demographic and clinical characteristics of SUDEP cases in a sudden death cohort. All out-of-hospital deaths were investigated from March 1, 2013 to February 28, 2015 in Wake County, NC, attended by the Emergency Medical Services. Cases were screened and adjudicated by three physicians to identify sudden death cases from any cause among free-living adults, aged 18-64. In total, 399 sudden death victims were identified during this two-year period. Seizure history, demographic and clinical characteristics, and healthcare utilization patterns were assessed from death records, emergency response scene reports, and medical records. Sudden death cases with a history of seizures were summarized by an experienced chart abstractor (SC) and adjudicated by an experienced neurologist (OD). We then compared demographic and clinical characteristics and healthcare utilization patterns of neurologist-identified SUDEP cases to other sudden death victims in our population-based registry of sudden death from any cause. SUDEP accounted for 5.3% of sudden deaths. However, seizures or complications of seizures were only considered the primary cause of death on death certificates in 1.5% of sudden deaths. SUDEP cases were more likely to have a history of alcohol abuse. Mental health disorders and a low level of medication compliance and healthcare utilization were common among SUDEP victims. SUDEP accounts for approximately 5.3% of sudden deaths from any cause in individuals aged between 18 and 64. Death certificates underestimate the burden of sudden death in epilepsy, attributing only 1.5% of sudden deaths to seizures or complications of seizures. Accurate documentation of epileptic disorders on death certificates is essential for the surveillance of SUDEP. Further, interventions that promote better use of medical services and patient engagement with healthy living practices may reduce sudden deaths in epilepsy.

Exploring links between greenspace and sudden unexpected death: A spatial analysis.

Greenspace has been increasingly recognized as having numerous health benefits. However, its effects are unknown concerning sudden unexpected death (SUD), commonly referred to as sudden cardiac death, which constitutes a large proportion of mortality in the United States. Because greenspace can promote physical activity, reduce stress and buffer air pollutants, it may have beneficial effects for people at risk of SUD, such as those with heart disease, hypertension, and diabetes mellitus. Using several spatial techniques, this study explored the relationship between SUD and greenspace. We adjudicated 396 SUD cases that occurred from March 2013 to February 2015 among reports from emergency medical services (EMS) that attended out-of-hospital deaths in Wake County (central North Carolina, USA). We measured multiple greenspace metrics in each census tract, including the percentages of forest, grassland, average tree canopy, tree canopy diversity, near-road tree canopy and greenway density. The associations between SUD incidence and these greenspace metrics were examined using Poisson regression (non-spatial) and Bayesian spatial models. The results from both models indicated that SUD incidence was inversely associated with both greenway density (adjusted risk ratio [RR] = 0.82, 95% credible/ confidence interval [CI]: 0.69-0.97) and the percentage of forest (adjusted RR = 0.90, 95% CI: 0.81-0.99). These results suggest that increases in greenway density by 1 km/km2 and in forest by 10% were associated with a decrease in SUD risk of 18% and 10%, respectively. The inverse relationship was not observed between SUD incidence and other metrics, including grassland, average tree canopy, near-road tree canopy and tree canopy diversity. This study implies that greenspace, specifically greenways and forest, may have beneficial effects for people at risk of SUD. Further studies are needed to investigate potential causal relationships between greenspace and SUD, and potential mechanisms such as promoting physical activity and reducing stress.

Sudden Unexpected Death in North Carolina (SUDDEN): methodology review and screening results.

OBJECTIVES: This paper describes the methodology for a prospective, community-based study of sudden unexpected death in Wake County, North Carolina. METHODS: From 1 March to 29 June 2013, data of presumed cardiac arrest cases were captured from Wake County Emergency Medical Services. Participants were screened into the presumed sudden unexpected death group based on specific and sequential screening criteria, and medical and public records were collected for each participant in this group. A committee of independent cardiologists reviewed all data to determine final inclusion/exclusion of each participant into registry. RESULTS: We received 398 presumed cardiac arrest referrals. Of these, 105 participants, age 18-65 years old, were identified as presumed sudden unexpected deaths. The primary reason for exclusion was survival to hospital (38%). Ninety-five per cent of participants in the presumed sudden unexpected death group experienced an unwitnessed death. Hypertension was present in almost 50%, while dyslipidaemia and diabetes mellitus were present in almost 25% of the same group. In addition, the presumed sudden unexpected death group includes 67.6% males (95% CI 58 to 76) whereas the control group only included 58.9% (95% CI 46 to 55) males. CONCLUSIONS: Participant identification and data collection processes identify presumed sudden unexpected death cases and secure medical and public data for screening and final adjudication. The study infrastructure developed in Wake County will allow its expansion to other counties in North Carolina. Preliminary data indicate the study presently focuses on a population demographically representative of North Carolina.

Effect of left ventricular diastolic dysfunction on outcomes of atrial fibrillation ablation.

Left ventricular diastolic dysfunction (LVDD) is an important pathogenic factor for atrial fibrillation (AF). There are few data on the effect of LVDD on recurrence of AF after catheter ablation. A cohort of 124 patients (59.9 ± 11.7 years, 73.9% male, and 55% with paroxysmal AF) with recalcitrant AF and normal left ventricular systolic function (left ventricular ejection fraction ≥50%) undergoing ablation was studied. Each patient underwent transthoracic echocardiography, and LVDD was meticulously graded using rhythm-independent (AF or sinus rhythm) transmitral and tissue Doppler parameters. Patients underwent catheter ablation of AF using a stepwise protocol. All patients were followed up at 3, 6, and 12 months with recurrent AF (>30 seconds) captured by electrocardiography and/or 7-day monitor. Kaplan-Meier survival analysis and Cox proportional hazards model were used. There was no LVDD in 72 patients (58%), whereas 33 (26.6%), 10 (8.1%), and 9 (7.3%) patients had grades 1, 2, and 3 LVDD, respectively. AF recurred in 49 patients (39.5%) with median time to recurrence of 248 days. Patients with higher grade of LVDD were increasingly more likely to have recurrence (37.5% for no LVDD and 30.3%, 60%, and 66.7% for grades 1, 2, and 3 LVDD, respectively). Significant LVDD (grade 2 or 3) was an independent predictor of recurrence (hazard ratio 2.6, p = 0.009) after adjusting for persistent (vs paroxysmal) AF and left atrial volume. In conclusion, patients with more severe LVDD have a higher risk of AF recurrence after catheter ablation. These patients may derive less benefit from ablation or may require a more extensive ablation approach.

Evaluation of an integrated bipolar and unipolar ablation device.

OBJECTIVE: Bipolar lesion creation is accepted as the most effective method to create transmural atrial ablations. However, the creation of an ablation pattern on the left and the right atrium with current bipolar devices is difficult on the beating heart. We have evaluated a novel integrated ablation device that creates both bipolar and unipolar lesions in a linear pattern on the beating porcine heart. METHODS: Using six porcine models, we evaluated the effectiveness of creating beating heart ablation lesions by transmurality and conduction block. Isolating lesions were created on the left and right atria of the beating porcine heart. After we created sequential bipolar and unipolar lesions, we confirmed conduction block and examined the lesion depth histologically. RESULTS: Linear lesions were created successfully on the surface of the beating porcine heart. Conduction block at 20 mV was confirmed at all isolated areas, and 96.4% of the lesion sections had full thickness and were transmural at histology. CONCLUSIONS: This device enables unipolar and bipolar lesion creation in a linear and low-profile manner, enabling effective creation of a biatrial lesion pattern on the epicardial surface of the beating heart.

Relation of atrial fibrillation burden and N-terminal pro-brain natriuretic peptide.

Previous studies have noted a correlation between the presence of atrial fibrillation (AF) and elevated brain natriuretic peptide hormone level, although the exact nature of this association is unclear. Understanding the relation between AF and brain natriuretic peptide may enhance care for this patient population. The aim of this study was to establish the relationship between AF burden and N-terminal pro-brain natriuretic peptide (NT-proBNP) level. One hundred eighty-four patients who presented to the University of North Carolina electrophysiology clinic with AF underwent baseline questionnaires, laboratory testing (including NT-proBNP), echocardiography, and 1-week ambulatory rhythm monitoring. Multivariate linear regression was used to determine the association between AF burden and NT-proBNP level. Increased AF burden was associated with increased NT-proBNP level, and this association remained significant after adjusting for possible confounders. Compared with a 0% AF burden, those with an AF burden of 1% to 25% had a nearly 1.5-fold increase (p = 0.102), those with an AF burden of 26% to 99% had a nearly fourfold increase (p <0.001), and those with an AF burden of 100% had a nearly 4.5-fold increase (p <0.001). In conclusion, AF burden as assessed by continuous 1-week ambulatory rhythm monitoring is directly associated with NT-proBNP level. NT-proBNP may act as a useful surrogate for assessing AF burden.