Social and Psychosocial Determinants of Racial and Ethnic Differences in Cardiovascular Health in the United States Population

The U-shape relationship between the aggregate index of systemic inflammation and depression in American adults: A cross-sectional study

BACKGROUND

This investigation aims to examine the connection between the aggregate index of systemic inflammation (AISI) and depression, using data from the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

We conducted a cross-sectional study using data from the NHANES collected between 2005 and 2018. Depression was assessed via the patient health questionnaire-9. To investigate the connection between AISI and the prevalence of depression, we employed weighted multivariable logistic regression models as well as restricted cubic spline (RCS) models. This study also performed subgroup and interaction analyses to further explore these associations. Additionally, threshold effect and saturation effect analyses were conducted to identify potential inflection points for AISI and depression. Finally, we compared the area under the curve (AUC) values from receiver operating characteristic (ROC) analyses to assess the diagnostic capability of the optimal model for depression.

RESULTS

This study initially recruited 29,092 individuals, of whom 2596 had depression. After adjusting for potential confounders, we discovered a higher AISI was significantly linked with an higher risk of depression when comparing the highest to the lowest quantile of AISI (odds ratio: 1.205; 95 % confidence interval: 1.019-1.424; P = 0.032). Marital status interacted with AISI to influence the prevalence of depression (P for trend = 0.0275). The curve for participants was U-shaped, with an optimal AISI value of 828.8, and a non-linear relationship was found between AISI and depression (P for log-likelihood ratio test <0.001). ROC analysis indicated that AISI had a stronger discriminative ability and accuracy in predicting depression compared to other inflammatory biomarkers.

CONCLUSIONS

The AISI level exhibited a U-shaped association with depression, indicating that maintaining AISI within a reasonable range may help reduce the prevalence of depression.

Associations between education and ideal cardiovascular health metrics across 36 low- and middle-income countries

BACKGROUND

The relationship between education and cardiovascular health (CVH) metrics in low- and middle-income countries (LMICs) remains unclear. This study explores the associations between education and ideal cardiovascular health score (CVHS), as well as seven CVH metrics.

METHODS

This cross-sectional study extracted data from the STEPwise approach to surveillance surveys in 36 LMICs between 2010 and 2020. We assessed CVHS using the sum score in seven metrics defined by American Heart Association: (1) ≥ 150 min/week of moderate, or 75 min/week of vigorous activity, or an equivalent combination; (2) BMI < 25 kg/m2 for non-Asians (< 23 kg/m2 for Asians); (3) fruit and vegetable intake ≥ 4.5 servings per day; (4) nonsmoking; (5) blood pressure < 120/80 mmHg (untreated); (6) total cholesterol < 200 mg/dL (untreated); and (7) fasting blood glucose < 100 mg/dL (untreated). The ideal CVHS score ranged from 5 to 7. We disaggregated prevalence of ideal CVHS and seven metrics by education, and constructed Poisson regression models to adjust for other socioeconomic factors.

RESULTS

Among 81,327 adult participants, the overall ideal CVHS prevalence for the studied countries was highest among individuals with primary education (52.9%, 95% CI: 51.0-54.9), surpassing those of other education levels - 48.0% (95% CI: 44.6-51.3, P = 0.003) for those with no education and 39.1% (95% CI: 36.5-41.8, P < 0.001) for those with tertiary education. Five (ideal physical activity, BMI, blood pressure, total cholesterol, and blood glucose) in seven CVH metrics peaked among participants with primary or secondary education. For instance, the prevalence of ideal blood pressure among individuals with primary education was 34.4% (95% CI: 32.7-36.1), higher than the prevalence in other education levels, ranging from 28.6% to 32.3%. These patterns were concentrated in low-income countries and lower-middle-income countries, while in upper-middle-income countries, the prevalence of ideal CVHS increased with higher education levels, ranging from 15.4% for individuals with no education to 33.1% for those with tertiary education.

CONCLUSIONS

In LMICs, the association between education and ideal CVHS, along with several CVH metrics, exhibited un inverted U-shape, which may be closely related to the different stages of epidemiologic transition.

Food Insecurity and Its Cardiovascular Implications in Underresourced Communities

BACKGROUND

Food insecurity is linked to poorer cardiovascular health (CVH) outcomes, particularly in underresourced communities, where social determinants of health play a critical role. Despite the recognized connections, there remains a lack of empirical evidence delineating the implications of food insecurity on CVH. CVH, a broader concept than cardiovascular disease, encompasses the overall well-being of the cardiovascular system and is supported by favorable lifestyle choices and physiological metrics. Particularly in underresourced communities, the study of CVH could provide valuable insights for early intervention and targeted public health initiatives. This study aimed to fill this knowledge gap.

METHODS AND RESULTS

We conducted a cross-sectional analysis of baseline data from the E-DUCASS (Educational Strategy on a Vulnerable Population to Improve Cardiovascular Health and Food Insecurity) program (NCT05379842), a 24-month randomized study targeting participants at risk for food insecurity. CVH was assessed using the Life's Essential 8 score. The sample included 451 participants aged 12 to 80 years, stratified by age (30.6% children [aged 12-19 years], 35.9% young adults [aged 20-39 years], and 33.5% adults [aged 40-80 years]) and sex (42.1% men and 57.9% women). The mean CVH score was 65.1 (95% CI, 63.9-66.4), with diet, physical activity, nicotine exposure, and body mass index being the lowest-scoring metrics. Food insecurity significantly influenced CVH; those participants with severe food insecurity had lower CVH scores than those without (effect size, -2.83 [95% CI, -5.10 to -0.56]; P<0.05).

CONCLUSIONS

Our findings highlight the negative association between food insecurity and CVH in underresourced Mediterranean communities. These results underscore the need for strategies aimed at reducing cardiovascular risk, potentially through health literacy programs like E-DUCASS, that focus on improving lifestyle and alleviating food insecurity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05379842.

Determinants of Racial and Ethnic Differences in Maternal Cardiovascular Health in Early Pregnancy

BACKGROUND

Suboptimal cardiovascular health (CVH) in pregnancy is associated with adverse maternal and offspring outcomes. To guide public health efforts to reduce disparities in maternal CVH, we determined the contribution of individual- and neighborhood-level factors to racial and ethnic differences in early pregnancy CVH.

METHODS

We included nulliparous individuals with singleton pregnancies who self-identified as Hispanic, non-Hispanic Black (NHB), or non-Hispanic White (NHW) and participated in the nuMoM2b cohort study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be). First-trimester CVH was quantified using 6 routinely assessed factors in pregnancy included in the American Heart Association Life's Essential 8 score (0-100 points), in which higher scores indicate better CVH. Oaxaca-Blinder decomposition evaluated the extent to which racial and ethnic differences in CVH were explained by differences in individual- and neighborhood-level factors (age, socioeconomic characteristics, psychosocial factors, nativity, perceived racial discrimination, and area deprivation index).

RESULTS

Among 9104 participants, the mean age was 26.8 years, 18.7% identified as Hispanic, 15.6% identified as NHB, and 65.8% identified as NHW. Mean (SD) CVH scores were 76.7 (14.1), 69.8 (15.1), and 79.9 (14.3) in the Hispanic, NHB, and NHW groups, respectively (P<0.01). The individual- and neighborhood-level factors evaluated explained all differences in CVH between Hispanic and NHW groups and 82% of differences between NHW and NHB groups. Racial and ethnic differences in educational attainment explained the greatest proportion of differences in CVH. If mean years of education among the Hispanic (14.0 [2.5]) and NHB (13.4 [2.4]) groups were the same as the NHW (15.8 [2.4]) group, mean CVH scores would be higher by 2.98 points (95% CI, 2.59-3.37) in the Hispanic and 4.28 points (95% CI, 3.77-4.80) in NHB groups.

CONCLUSIONS

Racial and ethnic differences in early pregnancy CVH were largely explained by differences in individual- and neighborhood-level factors.

Getting to the Heart of the Matter: Exploring the Intersection of Cardiovascular Disease, Sex and Race and How Exercise, and Gut Microbiota Influence these Relationships

Cardiovascular disease (CVD) is the leading cause of death worldwide, with physical inactivity being a known contributor to the global rates of CVD incidence. CVD incidence, however, is not uniform with recognized sex differences as well and racial and ethnic differences. Furthermore, gut microbiota have been associated with CVD, sex, and race/ethnicity. Researchers have begun to examine the interplay of these complicated yet interrelated topics. This review will present evidence that CVD (risk and development), and gut microbiota are distinct between the sexes and racial/ethnic groups, which appear to be influenced by acculturation, discrimination, stress, and lifestyle factors like exercise. Furthermore, this review will address the beneficial impacts of exercise on the cardiovascular system and will provide recommendations for future research in the field.

Atherosclerosis and the Bidirectional Relationship Between Cancer and Cardiovascular Disease: From Bench to Bedside, Part 2 Management

The first part of this review highlighted the evolving landscape of atherosclerosis, noting emerging cardiometabolic risk factors, the growing impact of exposomes, and social determinants of health. The prominent role of atherosclerosis in the bidirectional relationship between cardiovascular disease and cancer was also discussed. In this second part, we examine the complex interplay between multimorbid cardio-oncologic patients, cardiometabolic risk factors, and the harmful environments that lend a "syndemic" nature to these chronic diseases. We summarize management strategies targeting disordered cardiometabolic factors to mitigate cardiovascular disease and explore molecular mechanisms enabling more tailored therapies. Importantly, we emphasize the early interception of atherosclerosis through multifactorial interventions that detect subclinical signs (via biomarkers and imaging) to treat modifiable risk factors and prevent clinical events. A concerted preventive effort-referred to by some as a "preventome"-is essential to reduce the burden of atherosclerosis-driven chronic diseases, shifting from mere chronic disease management to the proactive promotion of "chronic health".

Psychological and socio-economic correlates of cardiovascular health among young adults in Puerto Rico

Objective

We aimed to determine the relationship between socioeconomic and psychological factors and overall cardiovascular health (CVH), as defined by the American Heart Association's Life's Essential 8 (LE8), among young adults in Puerto Rico.

Methods

Participants were 2156 young adults, between the ages of 18-29 years, enrolled in the PR-OUTLOOK study. The analysis included survey, laboratory, and physical measurement data collected from September 2020 to November 2023. Assessed socioeconomic indicators included food insecurity, housing instability, economic insecurity, and subjective social standing. Evaluated psychological factors comprised symptoms of depression, anxiety, post-traumatic stress, and overall perceived stress. LE8 scores were calculated and classified as suboptimal (poor/intermediate range) vs. ideal CVH. Logistic regression models estimated associations between each socioeconomic and psychological measure and suboptimal CVH, and dominance analysis assessed the importance of each measure.

Results

Participants' mean age was 22.6 (SD = 3.1), 60.9 % were female, about one-third (34.2 %) had high school education or less, and over one-third had public or no health insurance (38.4 %). Participants reporting socioeconomic adversity (i.e., high food insecurity, housing instability and economic insecurity, and low subjective social standing) and elevated psychological symptoms (i.e., symptoms of anxiety, depression, post-traumatic stress, and overall perceived stress) had lower CVH scores. However, in the adjusted analysis, only lower subjective social standing (OR = 1.38, 95 % CI = 1.13-1.69) and elevated symptoms of anxiety (OR = 1.63, 95 % CI = 1.25-2.13) and depression (OR = 1.30, 95 % CI = 1.03-1.65) emerged as the primary contributors to suboptimal CVH (vs. ideal).

Conclusion

Efforts to preserve and enhance CVH among young Puerto Ricans on the island should target these factors.

Abnormal blood pressure and pediatric obesity phenotype: Red flags for clinical practice

BACKGROUND AND AIMS

systolic and diastolic blood pressure values identify different subtypes of Primary Hypertension. In pediatric age, hypertension is often related to obesity. Characterization of an individual's Blood Pressure (BP) status needs multiple measurements in the course of time, but this is rarely the case, principally in everyday pediatrics. Thus, the finding of abnormal BP values even in a single routine check visit should need a special attention. The aim of this study was to evaluate if even a single abnormal measurement could be a marker of metabolic risk, according to clinical and/or metabolic phenotype and subtypes of hypertension in a population of overweight/obese children and adolescents.

METHODS AND RESULTS

We reviewed data from 489 overweight-obese children and adolescents. BP values were classified according to American Academy of Pediatrics Guidelines (2017). Considering study design, we used the term "Abnormal" instead of "High" BP. Data on lipid profile, glucose metabolism and ultrasonographic pattern of the liver were recorded. Mean age was 9.4 ± 2.5 years: 76.9% had normal BP values. Children with Abnormal BP harbored more frequently an unfavorable metabolic profile. Children with Abnormal Systolic-Diastolic BP values had higher BMI z-score and Waist to Height ratio (p = 0.022 and p = 0.032). Hepatic Steatosis was detected in 4.5%, 14.8 % and 17.6 % of children with normal, abnormal systolic and abnormal systo-diastolic blood pressure, respectively. (p < 0.001).

CONCLUSION

Identification of abnormal BP subtypes even in a single measurement could be useful for identification of specific clinical-metabolic phenotypes allowing an individual targeted management of obesity-related comorbidities.

Cardiovascular health metrics and all-cause mortality in osteoarthritis, inflammatory arthritis, and unclassified arthritis patients: a national prospective cohort study

BACKGROUND

Arthritis notably elevates mortality risk. It remains unclear whether the cardiovascular health (CVH) metrics improves the risk of all-cause mortality in patients with all types of arthritis.

METHODS

This study data from the National Health and Nutrition Examination Survey to probe the link between CVH and all-cause mortality among arthritis sufferers in the United States. CVH evaluation employed the Life's Essential 8 metrics. Mortality outcomes were scrutinized using Cox proportional hazard regression models. Additionally, a restricted cubic spline analysis delineated the linear relationship between CVH and mortality. The study also delved into the singular impact of each CVH component on mortality.

RESULTS

In the cohort of 5919 patients with arthritis, improved CVH was linked to lower all-cause mortality. Specifically, each 10-point increment in CVH score was associated with a substantial decline in all-cause mortality risk [unadjusted hazard ratio (HR): 0.77, 95% Confidence Interval (95% CI): 0.71-0.83, P < 0.001]. Adjustments for age, sex, race, and social determinants of health further refined the HR to 0.72 (95% CI: 0.67-0.79, P < 0.001). Higher versus lower CVH scores at baseline markedly reduced mortality risk, with the most substantial decrease seen in those with ideal CVH metrics (HR: 0.39, 95% CI: 0.26-0.59, P < 0.001). Similar results were not observed in patients with inflammatory arthritis, but were seen in those with osteoarthritis or degenerative arthritis, and unknown types of arthritis.

CONCLUSION

Ideal CVH substantially decreases all-cause mortality risk among patients with arthritis, confirming the critical role of CVH in arthritis management. This study advocates for CVH interventions as part of comprehensive arthritis treatment plans.

Social Determinants of Cardiovascular Health in Asian Americans: A Scientific Statement From the American Heart Association

To achieve cardiovascular health (CVH) equity in the United States, an understanding of the social and structural factors that contribute to differences and disparities in health is necessary. The Asian American population is the fastest-growing racial group in the United States but remains persistently underrepresented in health research. There is heterogeneity in how individual Asian American ethnic groups experience CVH and cardiovascular disease outcomes, with certain ethnic groups experiencing a higher burden of adverse social conditions, disproportionately high burden of suboptimal CVH, or excess adverse cardiovascular disease outcomes. In this scientific statement, upstream structural and social determinants that influence CVH in the Asian American population are highlighted, with particular emphasis on the role of social determinants of health across disaggregated Asian American ethnic groups. Key social determinants that operate in Asian American communities include socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors. The role of underlying structural factors such as health, social, and economic policies and structural racism is also discussed in the context of CVH in Asian Americans. To improve individual-, community-, and population-level CVH and to reduce CVH disparities in Asian American ethnic subgroups, multilevel interventions that address adverse structural and social determinants are critical to achieve CVH equity for the Asian American population. Critical research gaps for the Asian American population are given, along with recommendations for strategic approaches to investigate social determinants of health and intervene to reduce health disparities in these communities.

External Validation of the American Heart Association PREVENT Cardiovascular Disease Risk Equations

Importance

The American Heart Association's Predicting Risk of Cardiovascular Disease Events (PREVENT) equations were developed to extend and improve on previous cardiovascular disease (CVD) risk assessments for the purpose of treatment initiation and patient-clinician communication.

Objective

To assess prognostic capabilities, calibration, and discrimination of the PREVENT equations in a study sample representative of the noninstitutionalized, US general population.

Design, Setting, and Participants

This prognostic study used data from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2010 data cycles. Participants included adults for whom 10-year follow-up data were available. Data curation and analyses took place from December 2023 through May 2024.

Main Outcomes and Measures

Primary measures were risk estimated by the PREVENT equations, as well as risk estimates from the previous Pooled Cohort Equations (PCEs). The primary outcome was composite CVD-related mortality at 10 years of follow-up. Additional analyses compared the PREVENT equations against the PCEs. Model discrimination was assessed with receiver-operator characteristic curves and Harrell C statistic from proportional hazard regression; model calibration was determined as the slope of predicted versus observed risk.

Results

The study cohort, accounting for NHANES complex survey design, consisted of 172.9 million participants (mean age, 45.0 years [95% CI, 44.6-45.4 years]; 52.1% women [95% CI, 51.5%-52.6%]). In analyses adjusted for the NHANES survey design, a 1% increase in PREVENT risk estimates was statistically significantly associated with increased CVD mortality risk (hazard ratio, 1.090; 95% CI, 1.087-1.094). PREVENT risk scores demonstrated excellent discrimination (C statistic, 0.890; 95% CI, 0.881-0.898) but moderate underfitting of the model (calibration slope, 1.13; 95% CI, 1.06-1.21). PREVENT risk models performed statistically significantly better than the PCEs, as assessed by the net reclassification index (0.093; 95% CI, 0.073-0.115).

Conclusions and Relevance

In this prognostic study of the PREVENT equations, PREVENT risk estimates demonstrated excellent discrimination and only modest discrepancies in calibration. These findings provided evidence supporting utilization of the PREVENT equations for application in the intended population as suggested by the American Heart Association.

The effects of adverse and positive experiences on cardiovascular health in Australian children

BACKGROUND

Limited evidence suggests that positive experiences in childhood may promote cardiovascular health, providing additional opportunities for prevention and early intervention. This study aimed to examine the effects of adverse and positive experiences on cardiovascular health in late childhood.

METHODS

Data sources: Longitudinal Study of Australian Children (N = 1874).

EXPOSURES

Adverse and positive experiences assessed repeatedly (age 0-11 years).

OUTCOMES

Cardiovascular health (high versus low or moderate) quantified by four health behaviors (diet, physical activity, cigarette smoking, and sleep) and four health factors (body mass index, non-high-density lipoprotein, blood pressure, and blood glucose) (age 11-12 years) as per the American Heart Association's Life's Essential 8 metrics.

ANALYSES

Separate generalized linear models with log-Poisson links were used to estimate the effects of adverse and positive experiences on cardiovascular health, adjusting for confounders.

RESULTS

Children exposed to multiple adverse experiences (≥ 2) were less likely to have high cardiovascular health (RR = 0.82, 95% CI = 0.67 to 1.02) than those not exposed. Children exposed to multiple positive experiences (≥ 2) were more likely to have high cardiovascular health (RR = 1.14, 95% CI = 0.94 to 1.38) than those not exposed. Stratified analyses suggested that exposure to multiple positive experiences might buffer the detrimental effects of multiple adverse experiences on cardiovascular health.

CONCLUSIONS

Both adverse and positive experiences were found to be modestly associated with cardiovascular health in Australian children. Future research and practice should not only consider addressing childhood adversity but also use a strengths-based approach to promoting positive experiences to improve cardiovascular health.

Rationale, design, and participant characteristics of the FAITH! Heart Health+ study: An exploration of the influence of the social determinants of health, stress, and structural racism on African American cardiovascular health

BACKGROUND

African Americans (AAs) face cardiovascular health (CVH) disparities linked to systemic racism. The 2020 police killing of Mr. George Floyd in Minneapolis, Minnesota, alongside the COVID-19 pandemic, exacerbated adverse psychosocial factors affecting CVH outcomes among AAs. This manuscript describes the study protocol and participant characteristics in an ancillary study exploring the relationship between biopsychosocial factors and CVH among AAs.

METHODS

Using a community-based participatory approach, a mixed-methods ancillary study of 58 AA participants from an overarching randomized control trial (RCT) was conducted. Baseline RCT health assessments (November 2020) provided sociodemographic, medical, and clinical data. Subsequent health assessments (February-December 2022) measured sleep quality, psychosocial factors (e.g., high-effort coping), biomarkers (e.g., cortisol), and cardiovascular diagnostics (e.g., cardio-ankle vascular index). CVH was assessed using the American Heart Association Life's Simple 7 (LS7) (range 0 to 14, poor to ideal) and Life's Essential 8 (LE8) scores (range 0 to 100, low to high). Correlations between these scores will be examined. Focus group discussions via videoconferencing (March to April 2022) assessed psychosocial and structural barriers, along with the impact of COVID-19 and George Floyd's killing on daily life.

RESULTS

Participants were predominantly female (67%), with a mean age of 54.6 [11.9] years, high cardiometabolic risk (93% had overweight/obesity and 70% hypertension), and moderate LE8 scores (mean 57.4, SD 11.5).

CONCLUSION

This study will enhance understanding of the associations between biopsychosocial factors and CVH among AAs in Minnesota. Findings may inform risk estimation, patient care, and healthcare policies to address CVD disparities in marginalized populations.

Neighborhood-Level Disparities in Hypertension Prevalence and Treatment Among Middle-Aged Adults

Importance

Hypertension in middle-aged adults (35-50 years) is associated with poorer health outcomes in late life. Understanding how hypertension varies by race and ethnicity across levels of neighborhood disadvantage may allow for better characterization of persistent disparities.

Objective

To evaluate spatial patterns of hypertension diagnosis and treatment by neighborhood socioeconomic position and racial and ethnic composition.

Design, Setting, and Participants

In this cross-sectional study of middle-aged adults in Cuyahoga County, Ohio, who encountered primary care in 2019, geocoded electronic health record data were linked to the area deprivation index (ADI), a neighborhood disadvantage measure, at the US Census Block Group level (ie, neighborhood). Neighborhoods were stratified by ADI quintiles, with the highest quintile indicating the most disadvantage. Data were analyzed between August 7, 2023, and June 1, 2024.

Exposure

Essential hypertension.

Main Outcomes and Measures

The primary outcome was a clinician diagnosis of essential hypertension. Spatial analysis was used to characterize neighborhood-level patterns of hypertension prevalence and treatment. Interaction analysis was used to compare hypertension prevalence by racial and ethnic group within similar ADI quintiles.

Results

A total of 56 387 adults (median [IQR] age, 43.1 [39.1-46.9] years; 59.8% female) across 1157 neighborhoods, which comprised 3.4% Asian, 31.1% Black, 5.5% Hispanic, and 60.0% White patients, were analyzed. A gradient of hypertension prevalence across ADI quintiles was observed, with the highest vs lowest ADI quintile neighborhoods having a higher hypertension rate (50.7% vs 25.5%) and a lower treatment rate (61.3% vs 64.5%). Of the 315 neighborhoods with predominantly Black (>75%) patient populations, 200 (63%) had a hypertension rate greater than 35% combined with a treatment rate of less than 70%; only 31 of 263 neighborhoods (11.8%) comprising 5% or less Black patient populations met this same criterion. Compared with a spatial model without covariates, inclusion of ADI and percentage of Black patients accounted for 91% of variation in hypertension diagnosis prevalence among men and 98% among women. Men had a higher prevalence of hypertension than women across race and ADI quintiles, but the association of ADI and hypertension risk was stronger in women. Sex prevalence differences were smallest between Black men and women, particularly in the highest ADI quintile (1689 [60.0%] and 2592 [56.0%], respectively).

Conclusions and Relevance

These findings show an association between neighborhood deprivation and hypertension prevalence, with disparities observed particularly among Black patients, emphasizing a need for structural interventions to improve community health.

Addition of Social Determinants of Health to Coronary Heart Disease Risk Prediction: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Social determinants of health (SDoH) are associated with cardiovascular risk factors and outcomes; however, they are absent from risk prediction models. We aimed to assess if the addition of SDoH improves the predictive ability of the MESA (Multi-Ethnic Study of Atherosclerosis) Risk Score.

METHODS AND RESULTS

This was a community-based prospective population cohort study that enrolled 6286 men and women, ages 45-84 years, who were free of clinical coronary heart disease (CHD) at baseline. Data from 10-year follow-up were examined for CHD events, defined as myocardial infarction, fatal CHD, resuscitated cardiac arrest, and revascularization in cases of anginal symptoms. Participants included 53% women with average age of 62 years. When adjusting for traditional cardiovascular risk factors, SDoH, and coronary artery calcium, economic strain, specifically low family income, was associated with a greater risk of CHD events (hazard ratio [HR], 1.42 [95% CI, 1.17-1.71], P value<0.001). Area under the curve of risk prediction with SDoH was 0.822, compared with 0.816 without SDoH. The calibration slope was 0.860 with SDoH and 0.878 in the original model.

CONCLUSIONS

Significant associations were found between economic/financial SDoH and CHD risk factors and outcomes. Incorporation of SDoH into the MESA Risk Score did not improve predictive ability of the model. Our findings do not support the incorporation of SDoH into current risk prediction algorithms.

The determinants of mental health inequalities between Chinese migrants and non-migrants during the Shanghai 2022 lockdown: a Blinder-Oaxaca decomposition

BACKGROUND

The mental health inequality between migrants and non-migrants was exacerbated by the COVID-19 pandemic. Identifying key determinants of this inequality is essential in promoting health equity.

METHODS

This cross-sectional study recruited Shanghai residents by purposive sampling during the city-wide lockdown (from April 29 to June 1, 2022) using an online questionnaire. Migration statuses (non-migrants, permanent migrants, and temporary migrants) were identified by migration experience and by household registration in Shanghai. Mental health symptoms (depression, anxiety, loneliness, and problematic anger) were assessed by self-report scales. The nonlinear Blinder-Oaxaca decomposition was used to quantify mental health inequality (i.e., differences in predicted probabilities between migration groups) and the contribution of expected correlates (i.e., change in predicted probability associated with variation in the correlate divided by the group difference).

RESULTS

The study included 2738 participants (771 [28.2%] non-migrants; 389 [14.2%] permanent migrants; 1578 [57.6%] temporary migrants). We found inequalities in depression (7.1%) and problematic anger (7.8%) between permanent migrants and non-migrants, and inequalities in anxiety (7.3%) and loneliness (11.3%) between temporary migrants and non-migrants. When comparing permanent migrants and non-migrants, age and social capital explained 12.7% and 17.1% of the inequality in depression, and 13.3% and 21.4% of the inequality in problematic anger. Between temporary migrants and non-migrants, age and social capital also significantly contributed to anxiety inequality (23.0% and 18.2%) and loneliness inequality (26.5% and 16.3%), while monthly household income (20.4%) and loss of monthly household income (34.0%) contributed the most to anxiety inequality.

CONCLUSIONS

Significant inequalities in depression and problematic anger among permanent migrants and inequalities in anxiety and loneliness among temporary migrants were observed. Strengthening social capital and economic security can aid in public health emergency preparedness and promote mental health equity among migrant populations.

Neighborhood-level social determinants of health and cardioprotective behaviors among church members in New Orleans, Louisiana

BACKGROUND

Favorable neighborhood-level social determinants of health (SDoH) are associated with lower cardiovascular disease risk. Less is known about their influence on cardioprotective behaviors. We evaluated the associations between neighborhood-level SDoH and cardioprotective behaviors among church members in Louisiana.

METHODS

Participants were surveyed between November 2021 to February 2022, and were asked about health behaviors, aspects of their neighborhood, and home address (to link to census tract and corresponding social deprivation index [SDI] data). Logistic regression models were used to assess the relation of neighborhood factors with the likelihood of engaging in cardioprotective behaviors: 1) a composite of healthy lifestyle behaviors [fruit and vegetable consumption, physical activity, and a tobacco/nicotine-free lifestyle], 2) medication adherence, and 3) receipt of routine medical care within the past year.

RESULTS

Participants (n = 302, mean age: 63 years, 77% female, 99% Black) were recruited from 12 churches in New Orleans. After adjusting for demographic and clinical factors, perceived neighborhood walkability or conduciveness to exercise (odds ratio [OR]=1.25; 95% CI: 1.03, 1.53), availability of fruits and vegetables (OR=1.23; 95% CI: 1.07, 1.42), and social cohesion (OR=1.55; 95% CI: 1.22, 1.97) were positively associated with the composite of healthy lifestyle behaviors. After multivariable adjustment, SDI was in the direction of association with all three cardioprotective behavior outcomes, but associations were not statistically significant.

CONCLUSIONS

In this predominantly Black, church-based population, neighborhood-level SDoH including the availability of fruits and vegetables, walkability or conduciveness to exercise, and social cohesion were associated with cardioprotective behaviors. Findings reiterate the need to address adverse neighborhood-level SDoH in the design and implementation of health interventions.

Modifiable risk factors of inequalities in hypertension: analysis of 100 million health checkups recipients

Inequalities in health behaviors are thought to contribute to inequalities in hypertension. This study examined the extent to which modifiable mediating factors explain income inequalities in hypertension. This repeated cross-sectional study used data from National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) from 2009 to 2015. Those aged between 40 and 74 were enrollees in the Specific Health Checkups. Hypertension was defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90, or the use of antihypertensive medication. The mediating effects of exercise, obesity, smoking, and alcohol drinking on the association between income, as an indicator of SES, and hypertension were determined by the Karlson-Holm-Breen (KHB) method. The mean age of the 68,684,025 men and 59,118,221 women was 54.7 (SD = 9.6) and 56.7 (SD = 10.0) years, respectively. Prevalence of hypertension was higher in the lowest income group (48.6% for men, 40.2% for women) than in the highest income group (33.3% for men, 21.5% for women). Inequalities tended to increase over time. Inequalities were larger among those who did not use antihypertensive medication. Modifiable risks explained 10.6% of the association between income and hypertension for men and 15.1% for women. In men, drinking and obesity explained 8.8% and 5.5% of the inequalities in hypertension, respectively. In women, obesity explained 18.8%. Exercise increased the proportion mediated over time. Smoking explained 5.5% among women taking antihypertensive medication. There were health inequalities in hypertension among Japanese adults, and the modifiable risk factors partially explained the inequalities.

Screening for social determinants of health among populations at risk for MASLD: a scoping review

Background

Social determinants of health (SDoH) have been associated with disparate outcomes among those with metabolic dysfunction-associated steatotic liver disease (MASLD) and its risk factors. To address SDoH among this population, real-time SDoH screening in clinical settings is required, yet optimal screening methods are unclear. We performed a scoping review to describe the current literature on SDoH screening conducted in the clinical setting among individuals with MASLD and MASLD risk factors.

Methods

Through a systematic literature search of MEDLINE, Embase, and CINAHL Complete databases through 7/2023, we identified studies with clinic-based SDoH screening among individuals with or at risk for MASLD that reported pertinent clinical outcomes including change in MASLD risk factors like diabetes and hypertension.

Results

Ten studies (8 manuscripts, 2 abstracts) met inclusion criteria involving 148,151 patients: 89,408 with diabetes and 25,539 with hypertension. Screening was primarily completed in primary care clinics, and a variety of screening tools were used. The most commonly collected SDoH were financial stability, healthcare access, food insecurity and transportation. Associations between clinical outcomes and SDoH varied; overall, higher SDoH burden was associated with poorer outcomes including elevated blood pressure and hemoglobin A1c.

Conclusion

Despite numerous epidemiologic studies showing associations between clinical outcomes and SDoH, and guidelines recommending SDoH screening, few studies describe in-clinic SDoH screening among individuals with MASLD risk factors and none among patients with MASLD. Future research should prioritize real-time, comprehensive assessments of SDoH, particularly among patients at risk for and with MASLD, to mitigate disease progression and reduce MASLD health disparities.

Development and Validation of the American Heart Association's PREVENT Equations

BACKGROUND

Multivariable equations are recommended by primary prevention guidelines to assess absolute risk of cardiovascular disease (CVD). However, current equations have several limitations. Therefore, we developed and validated the American Heart Association Predicting Risk of CVD EVENTs (PREVENT) equations among US adults 30 to 79 years of age without known CVD.

METHODS

The derivation sample included individual-level participant data from 25 data sets (N=3 281 919) between 1992 and 2017. The primary outcome was CVD (atherosclerotic CVD and heart failure). Predictors included traditional risk factors (smoking status, systolic blood pressure, cholesterol, antihypertensive or statin use, and diabetes) and estimated glomerular filtration rate. Models were sex-specific, race-free, developed on the age scale, and adjusted for competing risk of non-CVD death. Analyses were conducted in each data set and meta-analyzed. Discrimination was assessed using the Harrell C-statistic. Calibration was calculated as the slope of the observed versus predicted risk by decile. Additional equations to predict each CVD subtype (atherosclerotic CVD and heart failure) and include optional predictors (urine albumin-to-creatinine ratio and hemoglobin A1c), and social deprivation index were also developed. External validation was performed in 3 330 085 participants from 21 additional data sets.

RESULTS

Among 6 612 004 adults included, mean±SD age was 53±12 years, and 56% were women. Over a mean±SD follow-up of 4.8±3.1 years, there were 211 515 incident total CVD events. The median C-statistics in external validation for CVD were 0.794 (interquartile interval, 0.763-0.809) in female and 0.757 (0.727-0.778) in male participants. The calibration slopes were 1.03 (interquartile interval, 0.81-1.16) and 0.94 (0.81-1.13) among female and male participants, respectively. Similar estimates for discrimination and calibration were observed for atherosclerotic CVD- and heart failure-specific models. The improvement in discrimination was small but statistically significant when urine albumin-to-creatinine ratio, hemoglobin A1c, and social deprivation index were added together to the base model to total CVD (ΔC-statistic [interquartile interval] 0.004 [0.004-0.005] and 0.005 [0.004-0.007] among female and male participants, respectively). Calibration improved significantly when the urine albumin-to-creatinine ratio was added to the base model among those with marked albuminuria (>300 mg/g; 1.05 [0.84-1.20] versus 1.39 [1.14-1.65]; P=0.01).

CONCLUSIONS

PREVENT equations accurately and precisely predicted risk for incident CVD and CVD subtypes in a large, diverse, and contemporary sample of US adults by using routinely available clinical variables.

Efficacy of a culturally tailored mobile health lifestyle intervention on cardiovascular health among African Americans with preexisting risk factors: The FAITH! Trial

Background

African Americans have a higher prevalence of cardiovascular risk factors, leading to higher cardiovascular disease mortality than White adults. Our culturally tailored mobile health (mHealth) lifestyle intervention (FAITH! App) has previously demonstrated efficacy in promoting ideal cardiovascular health in African Americans.

Methods

We conducted a secondary analysis from a cluster randomized controlled trial among African-Americans from 16 churches in Minnesota that compared the FAITH! App to a delayed intervention control group. A subgroup of participants with ≥ 1 diagnosis of overweight/obesity, hyperlipidemia, hypertension, or diabetes was examined. The primary outcome was a change in LS7 score-a measure of cardiovascular health ranging from poor to ideal (range 0-14 points)-at 6-months post-intervention.

Results

The analysis included 49 participants (intervention group: n = 20; mean age 58.8 years, 75% female; control group: n = 29, mean age 52.5 years, 76% female) with no significant baseline differences in cardiovascular risk factors. Compared to the control group, the intervention group showed a greater increase in LS7 score across all cardiovascular risk factors at 6-months post-intervention, with statistically significant differences among those with overweight/obesity (intervention effect 1.77, p < 0.0001) and 2+ or 3+ cardiovascular risk factors (1.00, p = 0.03; 1.09, p = 0.04). The intervention group demonstrated a higher increase in the percentage of participants with intermediate or ideal LS7 scores than the control group, although these differences were not statistically significant.

Conclusions

Our culturally tailored mHealth lifestyle intervention was associated with significant increases in LS7 scores among African Americans with preexisting cardiovascular risk factors, suggesting its efficacy in improving cardiovascular health among this population.

Human Immunodeficiency Virus as a Risk Factor for Cardiovascular Disease

The developments in HIV treatments have increased the life expectancy of people living with HIV (PLWH), a situation that makes cardiovascular disease (CVD) in that population as relevant as ever. PLWH are at increased risk of CVD, and our understanding of the underlying mechanisms is continually increasing. HIV infection is associated with elevated levels of multiple proinflammatory molecules, including IL-6, IL-1β, VCAM-1, ICAM-1, TNF-α, TGF-β, osteopontin, sCD14, hs-CRP, and D-dimer. Other currently examined mechanisms include CD4 + lymphocyte depletion, increased intestinal permeability, microbial translocation, and altered cholesterol metabolism. Antiretroviral therapy (ART) leads to decreases in the concentrations of the majority of proinflammatory molecules, although most remain higher than in the general population. Moreover, adverse effects of ART also play an important role in increased CVD risk, especially in the era of rapid advancement of new therapeutical options. Nevertheless, it is currently believed that HIV plays a more significant role in the development of metabolic syndromes than treatment-associated factors. PLWH being more prone to develop CVD is also due to the higher prevalence of smoking and chronic coinfections with viruses such as HCV and HBV. For these reasons, it is crucial to consider HIV a possible causal factor in CVD occurrence, especially among young patients or individuals without common CVD risk factors.

Social, Behavioral, and Metabolic Risk Factors and Racial Disparities in Cardiovascular Disease Mortality in U.S. Adults : An Observational Study

BACKGROUND

Cardiovascular disease (CVD) mortality is persistently higher in the Black population than in other racial and ethnic groups in the United States.

OBJECTIVE

To examine the degree to which social, behavioral, and metabolic risk factors are associated with CVD mortality and the extent to which racial differences in CVD mortality persist after these factors are accounted for.

DESIGN

Prospective cohort study.

SETTING

NHANES (National Health and Nutrition Examination Survey) 1999 to 2018.

PARTICIPANTS

A nationally representative sample of 50 808 persons aged 20 years or older.

MEASUREMENTS

Data on social, behavioral, and metabolic factors were collected in each NHANES survey using standard methods. Deaths from CVD were ascertained from linkage to the National Death Index with follow-up through 2019.

RESULTS

Over an average of 9.4 years of follow-up, 2589 CVD deaths were confirmed. The age- and sex-standardized rates of CVD mortality were 484.7 deaths per 100 000 person-years in Black participants, 384.5 deaths per 100 000 person-years in White participants, 292.4 deaths per 100 000 person-years in Hispanic participants, and 255.1 deaths per 100 000 person-years in other race groups. In a multiple Cox regression analysis adjusted for all measured risk factors simultaneously, several social (unemployment, low family income, food insecurity, lack of home ownership, and unpartnered status), behavioral (current smoking, lack of leisure-time physical activity, and sleep <6 or >8 h/d), and metabolic (obesity, hypertension, and diabetes) risk factors were associated with a significantly higher risk for CVD death. After adjustment for these metabolic, behavioral, and social risk factors separately, hazard ratios of CVD mortality for Black compared with White participants were attenuated from 1.54 (95% CI, 1.34 to 1.77) to 1.34 (CI, 1.16 to 1.55), 1.31 (CI, 1.15 to 1.50), and 1.04 (CI, 0.90 to 1.21), respectively.

LIMITATION

Causal contributions of social, behavioral, and metabolic risk factors to racial and ethnic disparities in CVD mortality could not be established.

CONCLUSION

The Black-White difference in CVD mortality diminished after adjustment for behavioral and metabolic risk factors and completely dissipated with adjustment for social determinants of health in the U.S. population.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Social and economic factors and black-white disparities in cardiovascular health: A decomposition analysis

Background

Cardiovascular health (CVH) in Black adults, and particularly in Black women, has lagged behind White adults for decades and contributes to higher mortality rates for Black adults. We quantified the contribution of five social and economic factors to observed racial disparities in CVH by gender.

Methods

We analyzed data from N = 8,019 adults aged ≥20 years free of cardiovascular disease assessed in the National Health and Nutrition Examination Survey, 2011-2018. Social and economic factors included self-reported education, income, employment, food security, and marital status. CVH was measured using eight behavioral and clinical indicators. We utilized Kitagawa-Blinder-Oaxaca decomposition to quantify gendered racial differences in CVH accounted for by these factors.

Results

Black women (mean CVH = 79.3) had a lower age-adjusted CVH score compared to White women (mean CVH = 82.3) (mean difference [MD] = -3.01; 95% CI: -5.18, -0.84). Social and economic factors accounted for a 3.26-point disadvantage (95% CI: -4.12, -2.40) and a 0.25-point CVH score advantage due to factors not accounted for in the model. In women, income had the largest coefficient associated with CVH score (b = -1.48; 95% CI: -2.04, -0.92). Among men, social and economic factors accounted for a 2.27-point disadvantage (95% CI: -2.97, -1.56) with educational attainment being the largest coefficient associated with CVH score (b = -1.55; 95% CI: -2.03, -1.06). However, the disadvantage in men was offset by a 1.99 CVH score advantage that was not accounted for by factors in the model resulting in no racial difference in age-adjusted CVH score (MD = -0.28; 95% CI: -3.78, 3.22).

Conclusions

Racial differences in social and economic factors may contribute a large portion to the observed disparity in CVH between U.S. Black and White women.

Multimodal data-driven prognostic model for predicting new-onset ST-elevation myocardial infarction following emergency percutaneous coronary intervention

OBJECTIVES

We developed a nomogram model derived from inflammatory indices, clinical data, and imaging data to predict in-hospital major adverse cardiac and cerebrovascular events (MACCEs) following emergency percutaneous coronary intervention (PCI) in patients with new-onset ST-elevation myocardial infarction (STEMI).

METHODS

Patients with new-onset STEMI admitted between June 2020 and November 2022 were retrospectively reviewed. Data pertaining to coronary angiograms, clinical data, biochemical indices, and in-hospital clinical outcomes were derived from electronic medical records. Lasso regression model was employed to screen risk factors and construct a prediction model.

RESULTS

Overall, 547 patients with new-onset STEMI who underwent PCI were included and assigned to the training cohort (n = 384) and independent verification cohort (n = 163). Six clinical features (age, diabetes mellitus, current smoking, hyperuricemia, neutrophil-to-lymphocyte ratio, and Gensini score) were selected by LASSO regression to construct a nomogram to predict the risk of in-hospital MACCEs. The area-under-the-curve (AUC) values for in-hospital MACCEs risk in the training and independent verification cohorts were 0.921 (95% CI 0.881-0.961) and 0.898 (95% CI 0.821-0.976), respectively. It was adequately calibrated in both training cohort and independent verification cohorts, and predictions were correlated with actual outcomes. Decision curve analysis demonstrated that the nomogram was capable of predicting in-hospital MACCEs with good clinical benefit.

CONCLUSIONS

Our prediction nomogram based on multi-modal data (inflammatory indices, clinical and imaging data) reliably predicted in-hospital MACCEs in new-onset STEMI patients with emergency PCI. This prediction nomogram can enable individualized treatment strategies.

Price Increases Versus Upcoding As Drivers Of Emergency Department Spending Increases, 2012-19

Recent studies document a substantial increase in emergency department (ED) spending in the past decade, even though the number of ED visits per capita has remained relatively stable. Price increases and upcoding are sometimes cited as possible explanations, but their relative impacts are not known. We analyzed Blue Cross Blue Shield claims for patients of all ages who received care in EDs in five states in 2012 and 2019. We used estimates from spending regressions and regressions explaining coding intensity to decompose changes in spending between 2012 and 2019 into components attributable to price increases, changes in patient characteristics or treatment intensity, and upcoding. Prices accounted for at least half of the increase in ED spending per visit for four of the five states we examined. Increases in spending attributable to upcoding were notable but generally not as large. Future research should explore the associations between local market conditions, such as consolidation and ownership type, and both price increases and upcoding.

Cardiovascular Health by Life's Essential 8 and Associations With Coronary Artery Calcium in South Asian American Adults in the MASALA Study

South Asian Americans experience high cardiovascular disease risk. We evaluated the distribution and correlates of cardiovascular health (CVH) summarized by the Life's Essential 8 (LE8) score among South Asian adults. In participants of the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study, the association of demographic, social, and cultural factors with LE8 score was evaluated with t tests and analysis of variance. The association of LE8 score with coronary artery calcium (CAC) was evaluated with adjusted logistic regression. There were 556 women (mean age 55.9 years [SD 8.7], mean LE8 score 67.2 (SD 12.6) and 608 men (mean age 57.5 years [SD 9.9], mean LE8 score 61.9 (SD 13.1). Among women and men, the LE8 CVH score was higher in participants with higher annual family income, higher educational attainment, and fewer depressive symptoms. Overall, there was 26% lower odds of any CAC for each 10-point higher LE8 score (odds ratios [OR] 0.74, 95% confidence intervals [CI] 0.66 to 0.83), with similar magnitude of association in women and men. Participants with a high LE8 CVH score had 82% lower odds of CAC (OR 0.18, 95% CI 0.09 to 0.33), and participants with an intermediate LE8 CVH score had 38% lower odds of CAC (OR 0.62, 95% CI 0.41 to 0.94) than did participants with a low LE8 CVH score, with similar findings stratified by gender. In conclusion, in this cohort of South Asian Americans, most adults had suboptimal CVH assessed by the LE8 score. Higher LE8 score correlated with lower odds of any CAC.

Diabetes-Related Cardiovascular and All-Cause Mortality in Asian American Subgroups

Background

Asian Americans experience heterogeneity in cardiovascular risk factors and cardiovascular disease, with a particularly high burden of diabetes in several Asian subgroups.

Objectives

The objectives of this study were to quantify diabetes-related mortality in Asian American subgroups and compare this with Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

Methods

Using national-level vital statistics data and concurrent population estimates, age-standardized mortality rates and proportional mortality from diabetes-related mortality were calculated for non-Hispanic Asian (and subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese), Hispanic, non-Hispanic Black, and non-Hispanic White populations in the United States, 2018-2021.

Results

Diabetes-related deaths numbered 45,249 in non-Hispanic Asian, 159,279 in Hispanic, 209,281 in non-Hispanic Black, and 904,067 in non-Hispanic White individuals. Among Asian Americans, age-standardized mortality rates of diabetes-related mortality with cardiovascular disease as underlying cause ranged from 10.8 (95% CI: 9.9-11.6) per 100,000 in Japanese females to 19.9 (95% CI: 18.9-20.9) per 100,000 in Filipina females, and from 15.3 (95% CI: 13.9-16.8) per 100,000 in Korean males to 37.8 (95% CI: 36.1-39.5) per 100,000 in Filipino males. The proportion of all deaths related to diabetes was higher in all Asian subgroups (9.7%-16.4% for females; 11.8%-19.2% for males) compared with non-Hispanic Whites (8.5% for females; 10.7% for males). The highest proportion of diabetes-related deaths occurred in Filipino adults.

Conclusions

There was an approximately 2-fold variation in diabetes-related mortality among Asian American subgroups, with Filipino adults experiencing the greatest burden. All Asian subgroups experienced higher proportional mortality for diabetes-related mortality compared with non-Hispanic White individuals.