Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

Applying the Principles of Trauma-Informed Care to the Evaluation and Management of Patients Who Undergo Metabolic and Bariatric Surgery

Evaluation of relevant psychosocial variables is an important aspect of comprehensive, high-quality metabolic and bariatric surgery (MBS) care. Given the high rates of adverse childhood experience (ACEs) and other forms of trauma experienced later in life reported by individuals with class III obesity, it is time to apply the principles of trauma-informed care to the multidisciplinary care of MBS patients. This narrative review begins with a summary of the literature on the psychosocial functioning of individuals who present for MBS. Emphasis is placed upon the relationship between ACEs, class III obesity, and MBS. Trauma-informed care is defined, and its principles are applied to the MBS care continuum. The paper ends with a recommendation on how the field of MBS can integrate trauma-informed care into clinical practice and future research.

Primary prevention of cardiovascular diseases among women in a South Asian population: a descriptive study of modifiable risk factors

OBJECTIVE

The aim of this study was the assessment of modifiable risk factors of cardiovascular diseases (CVD) among women versus men at a newly developed preventive cardiology clinic of a large tertiary care cardiac centre in Pakistan.

DESIGN

Observational study.

SETTING

Tertiary care cardiac hospital in Karachi, Pakistan.

PARTICIPANTS

Data for this study were obtained retrospectively from a prospectively collected ongoing registry. We have included all female and male individuals who have presented or were referred to our clinic for primary prevention. All the participants had no history of ischaemic heart disease.

OUTCOME MEASURE

In this study, we evaluated the CVD risk factors, estimated risk of CVD, and glycaemic and cholesterol control at baseline and at subsequent follow-ups for high-risk patients.

RESULTS

A total of 535 patients, 314 females, were included with a mean age of 48.3±12.5 years. At baseline, 57.9% (128) of men versus 73.2% (230) of women (p<0.001) were known cases of hypertension (HTN); 18.1% (40) vs 26.8% (84) (p=0.019) were diabetic; 40.5% (89) vs 9.2% (29) (p<0.001) were tobacco users; 26.0% (56) vs 3.2% (10) (p<0.001) were smokers; and 26.9% (57) vs 50.5% (153) had BMI ≥30 kg/m2, respectively.Baseline atherosclerotic cardiovascular disease (ASCVD) risk score was available for 348 (65%), 61.5% (136) of men versus 67.5% (212) of women. The median ASCVD risk score was 6.8% (2.8%-16.1%) vs 2.25% (1%-5.1%) (p<0.001 for men and women, respectively). The ASCVD risk score was ≥20% (high risk) for 22.1% (30) vs 1.9% (4), while the ASCVD risk score was <5% (low risk) for 40.4% (55) vs 74.1% (157) of men and women, respectively.A repeat ASCVD assessment at a median follow-up of 49.5 (7.0-231) days was available for 259 (48.4%) patients, 26.2% (58) of men vs 64% (201) of women, respectively. The median follow-up ASCVD score was 6.55% (2.8%-15.4%) vs 2.1% (0.9%-4.8%) (p<0.001 with ≥20% (high risk) in 19% (11) vs 2% (4) and <5% (low risk) in 34.5% (20) vs 77.1% (155) of men and women, respectively).

CONCLUSIONS

There is a high prevalence of modifiable risk factors for atherosclerotic CVD such as HTN, diabetes and obesity in women as compared with men, but interestingly, ASCVD risk score at the baseline as well as at the follow-up is high in men versus women. Some other non-modifiable risk factors like age, gender and blood lipid profile may also contribute to this difference between the high prevalence of risk factors and low ASCVD risk score in women. With appropriate follow-up and proper counselling, the looming CVD can be better prevented in this population. A dedicated preventive cardiology clinic for the identification of high-risk women and systematic follow-up is needed to predict their actual CVD risk.

TRIAL REGISTRATION

NCT06503341.

Chemical analysis of electronic cigarette liquids (e-liquids) and direct nicotine quantitation using surface-assisted flowing atmospheric-pressure afterglow desorption/ionization mass spectrometry (SA-FAPA-MS)

Ambient desorption/ionization mass spectrometry (ADI-MS) has been widely used for direct analysis of real samples without sample preparation or separation. Studies on the quantification of low molecular weight compounds in complex matrices with ADI-MS remain scarce. In this paper, we report the application of surface-assisted flowing atmospheric-pressure afterglow mass spectrometry (SA-FAPA-MS) for fast qualitative screening of electronic cigarette liquid (e-liquids) ingredients and direct quantification of nicotine. The quantification approach is rapid, uses a deuterated D4-nicotine standard spike, and does not require a preceding chromatography step or other methods to remove the complex sample matrix. Selected e-liquids were directly applied on thin-layer chromatography (TLC) plate surfaces (normal phase (NP) silica, reversed phase (RP) modified silica, cyano (CN) modified silica, and dimethyl (RP2) modified silica) after dilution and internal standard spiking. The plates served purely as sample carriers and no analyte separation was performed. Promising qualitative results were obtained, demonstrating the ability to detect nicotine alkaloids using this approach and the ability to differentiate e-liquids based on their flavor variations. In addition, dimethyl- (RP2-) and cyano-modified (CN-) silica surfaces were selected for quantification based on performance results of previous studies. It was shown that results were in high accordance with high-performance liquid chromatography (HPLC) experiments with lowest deviations <3% on dimethyl surfaces. Additional quantitative experiments including a certified reference material achieved equally satisfying results with lowest deviations of -1.1% from the certified nicotine content. For nicotine, detection limits down to the fmol range (96 fmol on CN and 20 fmol on RP2) were obtained. A detailed comparison of glass surfaces with functionalized surfaces showed that the functionalized surfaces were superior in terms of sample application reproducibility, mass spectra quality, sensitivity, and information density. Thus, functionalized thin-layer surfaces are considered promising tools for both qualitative and quantitative ADI-MS analysis of complex samples.

Life's simple 7 and its association with trajectories in depressive symptoms among urban middle-aged adults

BACKGROUND

The American Heart Association Life's Simple 7 (LS7) is a composite metric assessing cardiovascular health on a scale of 0-14 comprised of nutrition, physical activity, cigarette use, body mass index, blood pressure, cholesterol and glucose.

METHODS

Using data from the Healthy Aging in Neighborhoods of Diversity across the Life Span study [n = 1465, Age at visit 1 (v1: 2004-2009): 30-66 y, 41.7 % male, 60.6 % African American], we investigated associations of trajectories in depressive symptoms (2004-2017) with Life's simple 7 scores after ∼8.6 years follow-up (2013-2017). Analyses used group-based zero-inflated Poisson trajectory (GBTM) models and multiple linear or ordinal logistic regression. GBTM analyses generated two classes of depressive symptoms trajectories ("low declining" and "high declining"), based on intercept and slope direction and significance.

RESULTS

Overall, "high declining depressive symptoms" vs. the "low declining" group was associated with -0.67 ± 0.10 lower scores on LS7 total score (P < 0.001) in analyses adjusted for age, sex, race and the inverse mills ratio. This effect was markedly attenuated to -0.45 ± 0.10 score-points (P < 0.001) upon adjustment for socio-economic factors and to -0.27 ± 0.10 score-points (P < 0.010) in fully adjusted analyses, with a stronger association detected among women (β ± SE: -0.45 ± 0.14, P = 0.002). An association between elevated depressive symptoms over time ("high declining" vs "low declining") and LS7 total score was detected among African American adults (β ± SE: -0.281 ± 0.131, p = 0.031, full model). Moreover, the "high declining" vs. "low declining" depressive symptoms group was associated with a lower score on LS7 physical activity (β ± SE: -0.494 ± 0.130, P < 0.001).

CONCLUSIONS

Poorer cardiovascular health was linked to higher depressive symptoms over time.

There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness

Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.

Long term environmental variability modulates the epigenetics of maternal traits of kelp crabs in the coast of Chile

The methylation of DNA is an environmentally inducible epigenetic mechanism reflecting the short-term ecological and environmental background of populations. Marine invertebrate populations, which spread along a latitudinal cline, are particularly suitable for profiling DNA methylation, due to the heterogenous environmental conditions experienced. We used the MSAP (Methylation Sensitive Amplified Polymorphism) technique to investigate the natural variation in DNA methylation of different female's tissues (muscle, gonads, and gills) and early-stage eggs from five populations of the kelp crab Taliepus dentatus, distributed along a latitudinal cline in the coast of Chile. We assessed whether, (1) the distribution of DNA methylation profiles can be associated with the temporal variability of long term (18 years) climatologies (sea surface temperature, turbidity and productivity) and (2) the epigenetic diversity of eggs is related to the population-level phenotypic variability of several maternal investment traits (egg volume, egg weight, egg lipids and fecundity). The DNA methylation of eggs correlated positively and negatively with the long term variability in productivity and sea surface temperature, respectively. Furthermore, the diversity of DNA methylation of eggs correlated positively with the population-level phenotypic variability of several maternal investment traits, suggesting a key role of epigenetic mechanisms in generating phenotypic variability at population level for this species. We provide evidence of a strong link between the temporal variability of long term climatologies with the epigenetic profiles of key early ontogenetic traits associated with the maternal investment of kelp crabs. These modulating mechanisms can hence contribute early to phenotypic variability at population levels in response to local and past environmental fluctuation.

Association between parity and markers of inflammation: The multi-ethnic study of atherosclerosis

Introduction

Multiparity has been associated with increased risk of cardiovascular disease (CVD). Inflammation may be a mechanism linking parity to CVD. We investigated the association between parity and later-life markers of inflammation.

Methods

We studied 3,454 female MESA participants aged 45-84, free of CVD, who had data on parity and inflammatory markers. Parity was categorized as 0 (reference), 1-2, 3-4, or ≥5. Linear regression was used to evaluate the association between parity and natural log-transformed levels of fibrinogen, D-dimer, GlycA, high sensitivity C-reactive protein (hsCRP), and interleukin-6 (IL-6).

Results

Mean age was 62 ± 10 years. The proportion of women with nulliparity, 1-2, 3-4, and ≥5 live births were 18, 39, 29, and 14%, respectively. There was no association between parity and fibrinogen. Women with grand multiparity (≥5 live births) had 28, 10, and 18% higher levels of hsCRP, IL-6 and D-dimer, respectively, compared to nulliparous women, after adjustment for demographic factors. After additional adjustment for CVD risk factors, women with 1-2 and 3-4 live births had higher hsCRP and women with 1-2 live births had higher GlycA.

Conclusion

In this diverse cohort of middle-to-older aged women, we found that higher parity was associated with some inflammatory markers; however, these associations were largely attenuated after adjustment for CVD risk factors. There was no clear dose-response relationship between parity and these inflammatory markers. Future studies are needed to evaluate how inflammation may influence the link between parity and CVD and whether healthy lifestyle/pharmacotherapies targeting inflammation can reduce CVD risk among multiparous women.

Clinical trial registration

The MESA cohort design is registered at clinicaltrials.gov as follows: https://clinicaltrials.gov/ct2/show/NCT00005487.

Associations of endogenous sex hormone levels with the prevalence and progression of valvular and thoracic aortic calcification in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Sex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants.

METHODS

We studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately.

RESULTS

The mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors.

CONCLUSIONS

In this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Multimorbidity in cardiovascular disease and association with life satisfaction: a Chinese national cross-sectional study

BACKGROUND

The coexistence of multiple chronic conditions is very common in cardiovascular disease (CVD). However, the prevalence of CVD multimorbidity in China and its influence on life satisfaction have not been reported. This study aimed to investigate the proportions of 12 chronic comorbid diseases in CVD and the associations of multimorbidity with life satisfaction in patients with CVD.

METHODS

We conducted a cross-sectional study in a nationally representative sample of 3478 participants with CVD aged 45 years or more who participated in the China Health and Retirement Longitudinal Study 2015. Correlations of multimorbidity with 12 chronic diseases in CVD and life satisfaction were investigated using logistic regression models, after adjusting for 12 covariates.

RESULTS

The proportion of multimorbidity among participants with CVD was 93.3% (89.4% for middle-aged adults and 95.4% for older adults; 92.9% for men and 93.5% for women). The proportion of participants with CVD multimorbidity who were dissatisfied with life was 11.2%, significantly higher than those without any chronic diseases (χ²=5.147, p=0.023). Life satisfaction in patients with CVD decreased with increased number of comorbidities (χ²=45.735, p<0.001). Kidney disease (OR=1.933, 95% CI: 1.483 to 2.521), memory-related diseases (MRDs) (OR=1.695, 95% CI: 1.149 to 2.501) and dyslipidaemia (OR=1.346, 95% CI: 1.048 to 1.729) were significantly associated with reduced life satisfaction when adjusting for 12 covariates.

CONCLUSIONS

In this nationally representative cross-sectional study, life satisfaction was reduced by multimorbidity of CVD. Kidney disease had the greatest influence on life satisfaction in patients with CVD, followed by dyslipidaemia and MRDs. Our study emphasises the importance of preventing of chronic diseases in adults with CVD.

Gender Differences in Patient-Reported Outcomes Among Adults With Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) accounts for approximately one third of deaths in women. Although there is an established relationship between positive patient experiences, health‐related quality of life, and improved health outcomes, little is known about gender differences in patient‐reported outcomes among ASCVD patients. We therefore compared gender differences in patient‐centered outcomes among individuals with ASCVD.

Methods and Results

Data from the 2006 to 2015 Medical Expenditure Panel Survey, a nationally representative US sample, were used for this study. Adults ≥18 years with a diagnosis of ASCVD, ascertained by International Classification of Diseases, Ninth Revision (ICD‐9) codes and/or self‐reported data, were included. Linear and logistic regression were used to compare self‐reported patient experience, perception of health, and health‐related quality of life by gender. Models adjusted for demographics, socioeconomic status, and comorbidities. There were 21 353 participants included, with >10 000 (47%‐weighted) of the participants being women, representing ≈11 million female adults with ASCVD nationwide. Compared with men, women with ASCVD were more likely to experience poor patient–provider communication (odds ratio 1.25 [95% confidence interval 1.11–1.41]), lower healthcare satisfaction (1.12 [1.02–1.24]), poor perception of health status (1.15 [1.04–1.28]), and lower health‐related quality of life scores. Women with ASCVD also had lower use of aspirin and statins, and greater odds of ≥2 Emergency Department visits/y.

Conclusions

Women with ASCVD were more likely to report poorer patient experience, lower health‐related quality of life, and poorer perception of their health when compared with men. These findings have important public health implications and require more research towards understanding the gender‐specific differences in healthcare quality, delivery, and ultimately health outcomes among individuals with ASCVD.

Adverse childhood experiences (ACEs) and cardiovascular development from childhood to early adulthood: study protocol of the Niagara Longitudinal Heart Study

INTRODUCTION

Recent reviews have found substantial links between a toxic childhood environment including child abuse and severe household dysfunction and adult cardiovascular disease (CVD). Collectively referred to as adverse childhood experiences (ACEs), this toxic environment is prevalent among children, with recent Canadian estimates of child abuse at 27%-32%, and severe household dysfunction at 49%. Based on these prevalence rates, the potential effect of ACEs on CVD is more significant than previously thought. Yet, how ACEs amplify the risk for later CVD remains unclear. Lifestyle risk factors only partially account for this connection, instead directing attention to the interaction between psychosocial factors and physiological mechanisms such as inflammation. The Niagara Longitudinal Heart Study (NLHS) examines how ACEs influence cardiovascular health (CVH) from childhood to early adulthood. Integrating the stress process and biological embedding models, this study examines how psychosocial and physiological factors in addition to lifestyle factors explain the relationship between ACEs and CVH.

METHODS

This follow-up study combines three baseline studies from 2007 to 2012 that collected CVH measures including child blood pressure, heart rate, left ventricular structure and function, arterial stiffness indices and baroreflex sensitivity on 564 children. Baseline data also include anthropometric, biological, lifestyle, behavioural, and psychosocial measures that varied across primary studies. Now over 18 years of age, we will recruit and retest as many participants from the baseline studies as possible collecting data on ACEs, CVH, anthropometric, lifestyle and psychosocial measures as well as blood, saliva and hair for physiological biostress markers.

ETHICS AND DISSEMINATION

Ethics approval has been received for the NLHS follow-up. Written consent to participate in the follow-up study is obtained from each participant. Results testing all proposed hypotheses will be submitted for publication in peer-reviewed journals.

Endogenous Sex Hormones and Endothelial Function in Postmenopausal Women and Men: The Multi-Ethnic Study of Atherosclerosis

Background: The relationship of endogenous sex hormones (SH) with vascular endothelial function and with cardiovascular disease (CVD) is incompletely understood. We examined the associations between SH and endothelial function measured by brachial artery flow-mediated dilation (FMD). Materials and Methods: We included 1368 postmenopausal women and 1707 men, free of clinical CVD, participating in MESA Visit 1 (2000-2002). Serum SH [total testosterone, SH binding globulin (SHBG), dehydroepiandrosterone (DHEA), estradiol] were measured; free testosterone was calculated. The percent FMD difference (%FMD) was measured by high-resolution ultrasound. Using multivariable-adjusted linear regression, we tested the cross-sectional associations of SH (log transformed, compared per one SD increment) with %FMD. Results: The mean age of women and men were 64.2 and 61.4 years, respectively. Among women, after adjusting for demographics, CVD risk factors, and hormone therapy, higher SHBG was associated with greater %FMD [β = 0.215% (95% CI 0.026-0.405)], whereas higher free testosterone was associated with a smaller %FMD [-0.209% (-0.402, -0.017)]. Estradiol and DHEA were not associated with %FMD in women after multivariable adjustment. There was an age interaction, with higher free testosterone and lower SHBG associated with worse FMD in women <65 years of age, but not in those ≥65 years (p = 0.04). We did not see similar associations in men. Conclusions: A more androgenic SH profile of higher free testosterone and lower SHBG was associated with worse %FMD in postmenopausal women. Changes in SH with aging and menopause may result in vascular changes in women. Further studies are needed to assess longitudinal changes in SH levels and their association with vascular function.

Aspirin use in central retinal arterial occlusion to prevent ischaemic stroke: a retrospective cohort study in Taiwan

OBJECTIVE

To understand the efficacy of aspirin use for preventing ischaemic stroke after central retinal artery occlusion (CRAO).

DESIGN

The retrospective cohort study was conducted using the National Health Insurance Research Database from 1998 to 2013.

SETTING

A population-based study.

PARTICIPANTS

A total of 9437 participants with newly diagnosed CRAO were identified. Participants who had a previous stroke and/or retinal vascular occlusion, were aged <20 years and used aspirin 3 months before the event were excluded. There were 3778 eligible participants matched by propensity score, and they were divided into aspirin (n=434) and aspirin-naive (n=1736) groups after the matching.

METHODS

Cox proportional hazard models and cumulative survival curves were used to assess ischaemic stroke in the study groups, along with log-rank tests to compare group differences.

MAIN OUTCOME MEASURES

Incidence of ischaemic stroke in the aspirin and aspirin-naive groups 1 year after CRAO.

RESULTS

Of the 3778 patients with newly diagnosed CRAO, 151 (4%) had a subsequent ischaemic stroke within 1 year. The risk was especially high during the first week of the CRAO. No difference between the aspirin and aspirin-naive groups was found in risk of ischaemic stroke, haemorrhagic stroke, gastrointestinal bleeding, major bleeding, acute coronary syndrome, retinal vein occlusion, new-onset glaucoma, undergoing panretinal photocoagulation or all-cause mortality. Risk factors for ischaemic stroke within 1 year of CRAO included male gender (p=0.031; HR=1.46) and age (p=0.032; HR=1.14).

CONCLUSIONS

Aspirin use after a CRAO showed no benefit on attenuating the risk of ischaemic stroke. The risk of ischaemic stroke was increased after CRAO especially during the first week. Male gender and age were risk factors for ischaemic stroke after CRAO.

Gender, blood pressure, and cardiovascular and renal outcomes in adults with hypertension from the Systolic Blood Pressure Intervention Trial

BACKGROUND

To determine if the effects of intensive lowering of systolic blood pressure (goal of less than 120 mmHg) versus standard lowering (goal of less than 140 mmHg) upon cardiovascular, renal, and safety outcomes differed by gender.

METHODS

Nine thousand three hundred and sixty-one men and women aged 50 years or older with systolic blood pressure of 130 mmHg or greater, taking 0-4 antihypertensive medications, and with increased risk of cardiovascular disease, but free of diabetes, were randomly assigned to either a systolic blood pressure target of less than 120 mmHg (intensive treatment) or a target of less than 140 mmHg (standard treatment). The primary composite outcome encompassed incident myocardial infarction, heart failure, other acute coronary syndromes, stroke, or cardiovascular-related death. All-cause mortality, renal outcomes, and serious adverse events were also assessed.

RESULTS

Compared with the standard treatment group, the primary composite outcome in the intensive treatment group was reduced by 16% [hazard ratio 0.84 (0.61-1.13)] in women, and by 27% in men [hazard ratio 0.73 (0.59-0.89), P value for interaction between treatment and gender is 0.45]. Similarly, the effect of the intensive treatment on individual components of the primary composite outcome, renal outcomes, and overall serious adverse events was not significantly different according to gender.

CONCLUSION

In adults with hypertension but not with diabetes, treatment to a systolic blood pressure goal of less than 120 mmHg, compared with a goal of less than 140 mmHg, resulted in no heterogeneity of effect between men and women on cardiovascular or renal outcomes, or on rates of serious adverse events.ClinicalTrials.gov number, NCT01206062.

A comparison between two healthy diet scores, the modified Mediterranean diet score and the Healthy Nordic Food Index, in relation to all-cause and cause-specific mortality

High adherence to healthy diets has the potential to prevent disease and prolong life span, and healthy dietary pattern scores have each been associated with disease and mortality. We studied two commonly promoted healthy diet scores (modified Mediterranean diet score (mMED) and the Healthy Nordic Food Index (HNFI)) and the combined effect of the two scores in association with all-cause and cause-specific mortality (cancer, CVD and ischaemic heart disease). The study included 38 428 women (median age of 61 years) from the Swedish Mammography Cohort. Diet and covariate data were collected in a questionnaire. mMED and HNFI were generated and categorised into low-, medium- and high-adherence groups, and in nine combinations of these. Multivariable-adjusted hazard ratios (HR) of register-ascertained mortality and 95 % CI were calculated in Cox proportional hazards regression analysis. During follow-up (median: 17 years), 10 478 women died. In the high-adherence categories compared with low-adherence categories, the HR for all-cause mortality was 0·76 (95 % CI 0·70, 0·81) for mMED and 0·89 (95 % CI 0·83, 0·96) for HNFI. Higher adherence to mMED was associated with lower mortality in each stratum of HNFI in the combined analysis. In general, mMED, compared with HNFI, was more strongly associated with a lower cause-specific mortality. In Swedish women, both mMED and HNFI were inversely associated with all-cause and cardiovascular mortality. The combined analysis, however, indicated an advantage to be adherent to the mMED. The present version of HNFI did not associate with mortality independent of mMED score.

Psychological Factors and Their Association with Ideal Cardiovascular Health Among Women and Men

BACKGROUND

The cardiovascular effects of stress and other psychological factors may be different between women and men. We assessed whether self-perceived adverse psychological factors were associated with achievement of ideal cardiovascular health (CVH) as measured by the American Heart Association's Life's Simple Seven (LS7) and whether this differed by sex.

METHODS

This was a cross-sectional study of employees from a large healthcare organization. The LS7 metrics (smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose) were each scored as ideal (2), intermediate (1), or poor (0). Total scores were categorized as optimal (11-14), average (9-10), and inadequate (0-8). Using logistic regression, we tested whether psychological factors obtained by questionnaire (self-perceived stress, low life satisfaction, hopelessness, sadness, depression, and anxiety) were associated with CVH, after adjustment for age, ethnicity, and education.

RESULTS

Among 9,056 participants, the mean (SD) age was 43 (12) years, 74% were women, 57% Hispanic/Latino, 17% white, and 16% black. Stress was associated with reduced odds of having optimal/average CVH [OR 0.58 (95% CI 0.50-0.66) and 0.63 (0.50-0.81), for women and men, respectively]. Similarly, depression was associated with reduced odds of optimal/average CVH [0.58 (0.43-0.78) and 0.44 (0.26-0.76), for women and men, respectively]. Low life satisfaction, hopelessness, sadness, and anxiety were also associated with statistically significantly lower odds of optimal/average CVH in women, but not in men; however, there were no interactions by sex.

CONCLUSIONS

In an ethnically diverse population, both women and men with several adverse self-perceived psychological factors were less likely to have optimal or adequate CVH. Future studies are needed to determine whether addressing psychological stressors can improve CVH.

Paleogenetic study on the 17th century Korean mummy with atherosclerotic cardiovascular disease

While atherosclerotic cardiovascular disease (ASCVD) is known to be common among modern people exposed to various risk factors, recent paleopathological studies have shown that it affected ancient populations much more frequently than expected. In 2010, we investigated a 17^th century Korean female mummy with presumptive ASCVD signs. Although the resulting report was a rare and invaluable conjecture on the disease status of an ancient East Asian population, the diagnosis had been based only on anatomical and radiological techniques, and so could not confirm the existence of ASCVD in the mummy. In the present study, we thus performed a paleogenetic analysis to supplement the previous conventional diagnosis of ASCVD. In aDNA extracted from the same Korean mummy, we identified the risk alleles of seven different SNPs (rs5351, rs10757274, rs2383206, rs2383207, rs10757278, rs4380028 and rs1333049) that had already been revealed to be the major risk loci of ASCVD in East Asian populations. The reliability of this study could be enhanced by cross-validation using two different analyses: Sanger and SNaPshot techniques. We were able to establish that the 17^th century Korean female had a strong genetic predisposition to increased risk of ASCVD. The current paleogenetic diagnosis, the first of its kind outside Europe, re-confirms its utility as an adjunct modality for confirmatory diagnosis of ancient ASCVD.

Leisure-time Physical Activity and Sedentary Behaviour in Older People: The Influence of Sport Involvement on Behaviour Patterns in Later Life

Given the dramatic demographic change underway in most industrialized nations, the health of older adults is a major concern, particularly given the prevalence of sedentary behaviours and physical inactivity among ageing populations. Researchers have suggested sport participation in later life promotes other health-related behaviours, however, these relationships are poorly understood. It is possible for individuals to be classified as sufficiently active and still spend most of their day involved in sedentary pursuits. Moreover, there is little information on older sport participants' use of time compared to leisurely active or inactive peers and whether type of physical activity involvement is associated with differences in older adults' behaviour patterns. With this in mind, data from 1,723 respondents (65 years and older) who completed the sport module of the 2010 Canadian General Social Survey-Time Use were used to investigate the influence of physical activity involvement (competitive sport vs. non-competitive sport vs. physically active leisure vs. inactivity) on time spent in leisure-time physical activity and sedentary behaviours. Results indicated that competitive sport participants spent less time engaging in sedentary behaviours compared to the physically active leisure or inactive respondents; however, sport participants (both competitive and non-competitive) also spent less time engaging in leisure-time physical activities than the physically active leisure group. Implications of these findings to assumptions related to the activity levels of older sport participants, suggestions for future research, and considerations for sport-related interventions aimed at enhancing health in older adulthood are discussed.