The Burden of Cardiovascular Diseases Among US States, 1990-2016.

Importance: Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes. Design, Setting, and Participants: Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017. Exposures: Residing in the United States. Main Outcomes and Measures: Cardiovascular disease disability-adjusted life-years (DALYs). Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors. Conclusions and Relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

Sex hormone levels in patients with sudden cardiac arrest.

BACKGROUND: Sex hormones are known to have significant effects on the pathophysiology of cardiovascular disease. OBJECTIVE: The purpose of this study was to study the association between sex hormone levels and sudden cardiac arrest (SCA). METHODS: In the ongoing Oregon Sudden Unexpected Death Study (catchment population approximately 1 million), cases of SCA were compared with matched controls. Testosterone and estradiol levels were measured from blood samples drawn at the time of the SCA event in cases and during a routine visit in controls. RESULTS: Among cases (n = 149, age 64.1 ± 11.7 years, 73.2% male), compared to controls (n = 149, 64.2 ± 11.6 years, 72.5% male), median testosterone levels were significantly lower in males (4.4 vs 5.4 ng/mL, P = .01). Median estradiol levels were higher in male (68 vs 52 pg/mL, P <.001) and female cases (54 vs 36 pg/mL, P <.001). In multivariate analysis, higher testosterone levels were associated with lower SCA odds only in males (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.58-0.96, P = .02). Higher estradiol levels were associated with higher SCA odds in both males (OR 2.0, 95% CI 1.5-2.6, P <.001) and females (OR 3.5, 95% CI 1.9-6.4, P <.001). A higher testosterone/estrogen ratio was associated with lower SCA odds in males only (OR 0.5, 95% CI 0.4-0.7, P <.001). In a canine model of SCA, plasma testosterone levels were not significantly altered by the cardiac arrest event. CONCLUSION: We observed significant differences in sex hormone levels in patients who suffered SCA, with potential mechanistic implications. The role of sex hormones in the genesis of fatal ventricular arrhythmias warrants further exploration.

Elevated plasma free fatty acids are associated with sudden death: a prospective community-based evaluation at the time of cardiac arrest.

BACKGROUND: In cohort studies, elevated levels of plasma nonesterified free fatty acids (NEFAs) have been associated with increased risk of sudden cardiac death (SCD) in men, but blood samples were drawn several years before SCD. OBJECTIVE: To confirm this relationship by evaluating levels of plasma NEFAs at the time of the SCD event in a group of both men and women. METHODS: From the ongoing Oregon Sudden Unexpected Death Study, we compared levels of plasma NEFAs in 149 SCD cases presenting with ventricular fibrillation (mean age 64 ± 12 years; 73% men) and 149 age- and sex-matched controls with coronary artery disease. Plasma was processed from blood drawn at the time of arrest (cases) and at a routine visit (controls). The levels of plasma NEFAs were compared after categorizing into quartiles on the basis of control values. Conditional logistic regression was used to predict adjusted odds ratio for SCD associated with plasma NEFA levels per increased quartile. RESULTS: The plasma NEFA levels were significantly higher in SCD cases than in controls (median 0.39 mmol/L [interquartile range 0.28-0.60 mmol/L] vs 0.32 mmol/L [interquartile range 0.20-0.49 mmol/L]; P = .002). There were no significant differences in body mass index, smoking, and diabetes. The odds ratio for SCD was 1.42 (95% confidence interval 1.14-1.78) per quartile increase in the plasma NEFA level (P = .002). Individuals with plasma NEFA levels above the prespecified cutoff point of 0.32 mmol/L were at increased risk of SCD (odds ratio 2.00; 95% confidence interval 1.20-3.34; P = .008). CONCLUSION: These findings strengthen the role of plasma NEFA as a potential biomarker for the assessment of SCD risk.

Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.

BACKGROUND: The global burden of atrial fibrillation (AF) is unknown. METHODS AND RESULTS: We systematically reviewed population-based studies of AF published from 1980 to 2010 from the 21 Global Burden of Disease regions to estimate global/regional prevalence, incidence, and morbidity and mortality related to AF (DisModMR software). Of 377 potential studies identified, 184 met prespecified eligibility criteria. The estimated number of individuals with AF globally in 2010 was 33.5 million (20.9 million men [95% uncertainty interval (UI), 19.5-22.2 million] and 12.6 million women [95% UI, 12.0-13.7 million]). Burden associated with AF, measured as disability-adjusted life-years, increased by 18.8% (95% UI, 15.8-19.3) in men and 18.9% (95% UI, 15.8-23.5) in women from 1990 to 2010. In 1990, the estimated age-adjusted prevalence rates of AF (per 100 000 population) were 569.5 in men (95% UI, 532.8-612.7) and 359.9 in women (95% UI, 334.7-392.6); the estimated age-adjusted incidence rates were 60.7 per 100 000 person-years in men (95% UI, 49.2-78.5) and 43.8 in women (95% UI, 35.9-55.0). In 2010, the prevalence rates increased to 596.2 (95% UI, 558.4-636.7) in men and 373.1 (95% UI, 347.9-402.2) in women; the incidence rates increased to 77.5 (95% UI, 65.2-95.4) in men and 59.5 (95% UI, 49.9-74.9) in women. Mortality associated with AF was higher in women and increased by 2-fold (95% UI, 2.0-2.2) and 1.9-fold (95% UI, 1.8-2.0) in men and women, respectively, from 1990 to 2010. There was evidence of significant regional heterogeneity in AF estimations and availability of population-based data. CONCLUSIONS: These findings provide evidence of progressive increases in overall burden, incidence, prevalence, and AF-associated mortality between 1990 and 2010, with significant public health implications. Systematic, regional surveillance of AF is required to better direct prevention and treatment strategies.

Low rate of secondary prevention ICDs in the general population: multiple-year multiple-source surveillance of sudden cardiac death in the Oregon Sudden Unexpected Death Study.

INTRODUCTION: Sudden cardiac death (SCD) is a large public health problem that warrants on-going evaluation in the general population. While single-year community-based studies have been performed there is a lack of studies that have extended evaluation to multiple years in the same community. METHODS AND RESULTS: From the on-going Oregon Sudden Unexpected Death Study, we analyzed prospectively identified SCD cases in Multnomah County, Ore, (population ≈700,000) from February 1, 2002 to January 31, 2005. Detailed information ascertained from multiple sources (first responders, clinical records, and medical examiner) was analyzed. A total of 1,175 SCD cases were identified (61% male) with a mean age of 65 ± 18 years for men versus 70 ± 20 for women (P < 0.001). The overall incidence rate for the period was 58/100,000 residents/year. One-quarter (24.6%) was ≤ 55 years of age. The most common initial rhythm was ventricular tachycardia or fibrillation (39% of cases, survival 27%) followed by asystole (36%, survival 0.7%) and pulseless electrical activity (23%, survival 6%). Among subjects that underwent resuscitation, the rate of survival to hospital discharge was 12% and overall survival to hospital discharge irrespective of resuscitation was 8%. Of the 68 survivors, 16 (24%) received a secondary prevention ICD. CONCLUSION: We report annualized SCD incidence from a multiple-year, multiple-source community-based study, with higher than expected rates of women and subjects age ≤ 55 years. The low implantation rate of secondary prevention ICDs is likely to be multifactorial, but there are potential implications for recalibration of the projected need for ICD implantation; larger and more detailed studies are warranted.