Trends in California Cardiovascular Disease Mortality: Sex-Race/Ethnicity Disparity and Income Inequality.

OBJECTIVE: To examine the cardiovascular disease (CVD)-related death trends and the relationship between CVD deaths and sex, race/ethnicity, and income in California from January 1, 1999, to December 31, 2021. METHODS: The age-adjusted death rate (AADR) per 100,000 population attributable to ischemic heart disease (IHD), hypertensive heart disease (HHD) and heart failure (HF), stroke, and CVD combined were calculated using CDC WONDER (Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research) for California, 1999 to 2021. We used a joinpoint log-linear regression model to determine trends in CVD death. Income disparities were assessed using the slope index of inequality and health concentration index. RESULTS: Between 1999 and 2021, overall death rates for CVD decreased significantly (average annual percent change, -2.2% [95% confidence interval: -2.6%, -1.7%]), IHD (-3.7% [-4.3%, -3.1%]), and stroke (-2.0% [-2.8%, -1.2%]) and increased for HHD (2.0% [0.6%, 3.5%]) and HF (2.0% [1.3%, 2.7%]). The AADR of combined CVD first decreased significantly (1999-2014; all P<.001), then increased significantly after COVID-19 (P=.02). The AADR of IHD decreased significantly (1999-2019; all P<.001) and then increased after the COVID-19 pandemic but was not statistically significant (P=.15). The AADR of HHD (2014-2021) and HF (2013-2021) increased significantly (all P<.001), and this increase accelerated after COVID-19. The AADR of stroke decreased (1999-2009), then increased after COVID-19 but was not statistically significant (P=.07). Our results revealed significant disparities with CVD death being disproportionately higher among male, non-Hispanic Black, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Asian, and poorer populations. CONCLUSION: All the death rates that were decreasing, stagnant, or increasing prior to the COVID-19 pandemic increased after the pandemic. We found increasingly adverse outcomes among the poor and racial/ethnic minority populations.

Off-duty deviance: Organizational policies and evidence for two prevention strategies.

Anecdotal evidence suggests that organizations are increasingly concerned with employee off-duty deviance (ODD), yet management research has rarely investigated this type of deviant behavior. We define ODD as behaviors committed outside the workplace or when off-duty that are deviant by organizational and/or societal standards, jeopardize the employee's status within the organization, and threaten the interests and well-being of the organization and its stakeholders. Three studies are presented to better understand the relevance of ODD to modern organizations and then to understand potential approaches to reduce the incidence of ODD. The first study provides a qualitative review of publicly available ODD policies within the Fortune 500; the results showed that 13.4% of the Fortune 500 had a publicly available ODD policy, with the majority prohibiting criminal forms of ODD to protect the firm's reputation. The next 2 studies examine the efficacy of different approaches to reduce criminal ODD: policy adoption and personnel selection. In the second study, a longitudinal, quasi-experimental design showed a significant-albeit modest-reduction in criminal ODD following the adoption of a conduct policy. In the third and final study, a criterion-related validity design supported the predictive validity of general mental ability and prior deviance in predicting criminal ODD. This compendium of studies provides an initial empirical investigation into ODD and offers implications relevant to the deviance literature, policy development, and personnel selection.

Multimodality imaging in transcatheter aortic valve replacement.

Transcatheter aortic valve replacement is a major advance that has dramatically changed our approach to elderly patients with severe aortic stenosis. This advance has been made possible by innovative device and delivery improvements, coupled with rapid developments in multimodality imaging. Multimodality imaging draws from multiple imaging fields and is central to patient evaluation and treatment. The primary modalities to date include transthoracic echocardiography and transesophageal echocardiography, computed tomography, and fluoroscopy. Each of these modalities carries a different weight in the various stages of patient selection, procedural guidance, monitoring, and follow-up. Multimodality imaging ensures optimal device selection, delivery, and patient safety, and will continue to advance as the next generation of aortic valve devices further advance cardiovascular care.

California ACC goals.

MISSION: To advocate for accessible, highest quality, cost-effective cardiovascular care for Californians. The purpose of the Chapter shall be to contribute to the prevention of cardiovascular diseases, to ensure optimal quality care for the individuals with such diseases, and to foster the highest professional ethical standards.

Current and future alternatives to warfarin for the prevention of stroke in atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice and is associated with a nearly 5-fold increase in the risk of stroke. Warfarin has been the cornerstone of treatment to reduce stroke risk in AF patients for decades. Although effective in preventing thrombosis, warfarin is difficult to manage and is associated with a 1% to 7% yearly risk of major hemorrhage. Until recently, there were no effective oral alternatives to warfarin. Dabigatran etexilate, a direct thrombin inhibitor, was approved in 2010 for the reduction of stroke and systemic embolism in patients with nonvalvular AF, and the factor Xa inhibitor rivaroxaban was approved for a similar indication in 2011. Other late-stage orally administered agents that may be approved for this indication include apixaban and edoxaban; others at earlier stages of development will be discussed in this review as well. Nonpharmacological approaches to stroke prevention include left atrial appendage removal, ligation, or occlusion. This review examines advances in the management of stroke risk in AF patients, focusing on recently marketed and late-stage modalities. The advent of alternatives to warfarin for reducing stroke risk in AF patients may improve physicians' ability to offer safe and effective stroke prevention in all AF patients.

Prevalence and echocardiographic features of iatrogenic atrial septal defect after catheter-based mitral valve repair with the MitraClip system.

OBJECTIVES: Review the prevalence, echocardiographic features and potential predictors of iatrogenic ASD (iASD) created with the MitraClip guiding catheter. BACKGROUND: Catheter-based repair of mitral regurgitation (MR) with the MitraClip device (Abbott Vascular, Menlo Park, CA), is performed through a 22-French transseptal guiding catheter. The echocardiographic prevalence of iASDs after the MitraClip procedure has not been reported. METHODS: Thirty subjects undergoing MitraClip repair during the roll-in phase of the EVEREST II randomized trial who had baseline, 30 day, 6 and 12 month transthoracic echocardiograms (TTEs) available for review were included. Patients who underwent surgery for MR within the first 12 months were excluded. Residual iASD size, right ventricular (RV) size, left atrial (LA) volume, and tricuspid/MR grade were quantified. RESULTS: iASDs were found at 12 months in 8 patients (27%) with a mean diameter of 6.6 ± 3.1 mm. Subjects with iASD at 12 months had more residual MR, increased TR and a trend toward larger LA volumes than non-iASD patients. 83% of non-ASD patients were free from MR > 2+ at 12 mos. vs. 38% of those with iASD (p=0.016). There were no other significant associations between clinical and echocardiographic variables and the persistence of iASD. CONCLUSIONS: After MitraClip repair, persistent iASDs occur at a rate comparable to reports after other transseptal interventional procedures and do not appear hemodynamically significant. Patients with persistent iASDs had less MR reduction at 12-months and a trend toward larger LA volumes, suggesting that increased LA pressure may be a mechanism for persistent iASD.

Obesity and physical fitness in California school children.

BACKGROUND: Obesity rates have reached epidemic proportions in the United States and California. Thus, the California Department of Education began a series of steps to address the increase in obesity and decline in fitness in the 6.3 million public school children in California. We evaluated serial changes in obesity and fitness in California school children following implementation of prevention steps in all California public schools. METHODS: The California Department of Education implemented changes in school nutrition and exercise programs aimed at reducing obesity and improving fitness. Outcome results were monitored by performing Physical Fitness Testing on 8.4 million students (5th, 7th, and 9th grade) for body composition, aerobic capacity, flexibility, and upper body, abdominal, and truncal strength using the Cochran-Armitage trend test and multivariable logistic regression models. RESULTS: Overall fitness improved from 2003 to 2008. Serial changes in body composition, aerobic capacity, flexibility, and upper body, abdominal, and truncal strength improved or remained stable within school as students progressed from 5th to 7th to 9th grade. However, students entering 5th grade were more obese every year, and this early obesity was not reversible within the school programs. CONCLUSIONS: Following prevention measures within California public schools, obesity and fitness levels have stabilized. However, continued increases in early entrance (5th grade) obesity will require additional efforts directed at preschool and elementary students to completely stop and reverse this obesity epidemic.

Effect of percutaneous mitral repair with the MitraClip device on mitral valve area and gradient.

AIMS: Percutaneous repair of mitral regurgitation (MR) by leaflet apposition using a clip deployed via transseptal catheterisation is undergoing evaluation. METHODS AND RESULTS: In order to detect the potential for clinically significant left ventricular inflow obstruction after percutaneous repair, we measured mitral valve area (MVA) and mean transmitral gradient (MVG) echocardiographically in 96 patients implanted with a clip followed for up to 24 months. By planimetry, the mean MVA decreased from 6.0 +/- 1.3 cm2 to 3.6 +/- 1.2 cm2 (p < 0.05) (range 1.9 to 7.6 cm2) after clip placement, and remained unchanged after 24 months of follow-up (3.5 +/- 0.8 cm2). The mean MVG increased after clip placement from 1.7 +/- 0.9 mmHg to 4.1 +/- 2.2 mmHg (p < 0.05), and did not increase further to 24 months (3.8 +/- 1.9 mmHg). There were no differences in MVA or MVG between patients who received 1-clip (69%) and those receiving 2-clips (31%). Patients with functional MR (23%) had a slightly smaller MVA, both at baseline and after clip placement, but did not differ from degenerative MR patients at later follow-up. After 2 years of follow-up, no patient required surgery for LV inflow obstruction. CONCLUSIONS: Mitral repair with the MitraClip device for MR decreases MVA without significant mitral obstruction. After 2 years of follow-up, no patient required surgery for LV inflow obstruction, and these results were not influenced by the use of more than 1 clip or the aetiology of MR.

Leader--member exchange, differentiation, and psychological contract fulfillment: a multilevel examination.

Prior integrations of the leader-member exchange (LMX) and psychological contract literatures have not clarified how within-group LMX differentiation influences employees' attitudes and behaviors in the employment relationship. Therefore, using a sample of 278 members and managers of 31 intact work groups at 4 manufacturing plants, the authors examined how LMX operating at the within-group level (relative LMX, or RLMX) and the group level influenced perceptions of psychological contract fulfillment and employee-level outcomes. Controlling for individual-level perceptions of LMX quality, results indicated a positive relationship between RLMX and fulfillment, which was strengthened as group-level variability in LMX quality increased. Perceptions of fulfillment mediated the relationship between RLMX and performance and sportsmanship behaviors. The importance of conceptualizing LMX as simultaneously operating at multiple levels is highlighted.

Use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker therapy to reduce cardiovascular events in high-risk patients: Part 1.

Cardiovascular disease is understood as a continuum; risk factors induce a pathophysiologic cascade that culminates in end-organ failure. The renin-angiotensin system (RAS) influences multiple aspects of the pathophysiology via hemodynamic and nonhemodynamic effects. Many long-term clinical trials provide overwhelming evidence of benefits of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) across the cardiovascular continuum, including benefits regarding hypertension, myocardial infarction, stroke, renal disease, and heart failure. Trials also indicate additive or synergistic effects of combination therapy in renal disease and heart failure, a possibility supported by the basic biochemistry of the agents. Discussion of these trials is included in part 1 of this 2-part review. Part 2 of the review will discuss the extensive interaction of the RAS with the cellular and molecular pathophysiology of cardiovascular disease and the cross-continuum effects of ARBs and ACE inhibitors, which raise the possibility that RAS inhibition can offer protection in high-risk patients who do not have symptoms. The benefits of combined ACE inhibitor/ARB therapy in high-risk patients await confirmation; ongoing clinical research in this area will be discussed.

Use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy to reduce cardiovascular events in high-risk patients: part 2.

As presented previously in Part 1 of this 2-part article, many long-term clinical trials provide overwhelming evidence of the benefits of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) across the cardiovascular continuum. Trials also indicate additive or synergistic effects of combination therapy in renal disease and heart failure. Part 2, which is presented here, discusses the extensive interaction of the renin-angiotensin system (RAS) with the cellular and molecular pathophysiology of cardiovascular disease and the cross-continuum effects of ARBs and ACE inhibitors, which raises the possibility that RAS inhibition can offer protection in high-risk patients who do not have symptoms. Although trial evidence supports the effectiveness of monotherapy, the benefits of combined ACE inhibitor/ARB therapy in high-risk patients await confirmation. Ongoing clinical research will provide new and important information regarding the efficacy of specific combination (ACE inhibitor/ARB) therapies.

Dobutamine stress echocardiography in preoperative and long-term postoperative risk assessment of elderly patients.

The authors reviewed all negative preoperative dobutamine stress echocardiograms (DSEs) performed over a 3-year period to determine the value of negative DSE for preoperative risk assessment in elderly patients. All patients with negative DSE performed for preoperative evaluation were followed. Cardiac event rates during and after the operative procedure were determined for hard end points (nonfatal myocardial infarction, cardiac death) and soft end points (emergency room visits, hospitalization for unstable angina, congestive heart failure, coronary angioplasty, coronary artery bypass graft surgery). Results noted that DSEs were negative for ischemia in 82 preoperative evaluations. Group 1 (age >/=65; n=41) had hard and soft event rates per patient/year of 0.97% and 7.3%, while group 2 (age <65; n=41) had hard and soft event rates per patient/year of 0.81% and 10.8%. There were no significant differences in event rates between the two groups (p=NS). In conclusion, the authors found that negative DSEs predict low cardiac event rates in elderly patients during the perioperative and long-term postoperative periods, which are not significantly different from the cardiac event rates in a younger cohort.

The role of fair treatment and rewards in perceptions of organizational support and leader-member exchange.

This study examined a model of the antecedents and consequences of perceived organizational support (POS) and leader-member exchange (LMX). It was predicted that organizational justice (procedural and distributive justice) and organizational practices that provide recognition to the employee (feelings of inclusion and recognition from upper management) would influence POS. For LMX, it was predicted that leader reward (distributive justice and contingent rewards) and punishment behavior would be important antecedents. Results based on a sample of 211 employee-supervisor dyads indicated that organizational justice, inclusion, and recognition were related to POS and contingent rewards were related to LMX. In terms of consequences, POS was related to employee commitment and organizational citizenship behavior, whereas LMX predicted performance ratings.