High serum copper as a risk factor of all-cause and cause-specific mortality among US adults, NHANES 2011-2014

Background

Several studies have shown that serum copper levels are related to coronary heart disease, diabetes, and cancer. However, the association of serum copper levels with all-cause, cause-specific [including cardiovascular disease (CVD) and cancer] mortality remains unclear.

Objectives

This study aimed to prospectively examine the association of copper exposure with all-cause, CVD, and cancer mortality among US adults.

Methods

The data for this analysis was obtained from the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2014. Mortality from all-causes, CVD, and cancer mortality was linked to US National Death Index mortality data. Cox regression models were used to estimate the association between serum copper levels and all-cause, CVD, and cancer mortality.

Results

A total of 2,863 adults were included in the main study. During the mean follow-up time of 81.2 months, 236 deaths were documented, including 68 deaths from cardiovascular disease and 57 deaths from cancer. The weighted mean overall serum copper levels was 117.2 ug/L. After adjusting for all of the covariates, compared with participants with low (1st tertile, <103 μg/L)/medium (2st tertile, 103-124 μg/L) serum copper levels, participants with high serum copper levels (3rd tertile, ≥124 μg/L) had a 1.75-fold (95% CI, 1.05-2.92)/1.78-fold (1.19,2.69) increase in all-cause mortality, a 2.35-fold (95% CI, 1.04-5.31)/3.84-fold (2.09,7.05) increase in CVD mortality and a 0.97-fold (95% CI, 0.28-3.29)/0.86-fold (0.34,2.13) increase in cancer mortality. In addition, there was a linear dose-response association between serum copper concentration with all-cause and CVD mortality (P for nonlinear > 0.05).

Conclusions

This prospective study found that serum copper concentrations were linearly associated with all-cause and CVD mortality in US adults. High serum copper levels is a risk factor for all-cause and CVD mortality.

Association of serum five heavy metals level with all-cause and cause-specific mortality: a large population-based cohort study

The study aimed to explore the association between five heavy metals exposure (Cadmium, Lead, Mercury, Manganese, and Selenium) and mortality [all-cause, cardiovascular disease (CVD), and cancer-related]. We integrated the data into the National Health and Nutrition Examination Survey from 2011 to 2018 years. A total of 16,092 participants were recruited. The link between heavy metals exposure and mortality was analyzed by constructing a restricted cubic spline (RCS) curve, Cox proportional hazard regression model, and subgroup analysis. The RCS curve was used to show a positive linear relationship between Cadmium, Lead, and all-cause mortality. In contrast, there was a negative linear correlation between Mercury and all-cause mortality. Additionally, Manganese and Selenium also had a J-shaped and L-shaped link with all-cause mortality. The positive linear, positive linear, negative liner, J-shaped, and L-shaped relationships were observed for Cadmium, Lead, Mercury, Manganese, and Selenium and CVD mortality, respectively. Cadmium, Lead, Mercury, and Selenium were observed to exhibit positive linear, U-shaped, negative linear, and L-shaped relationships with cancer-related mortality, respectively. There was an increase and then a decrease in the link between Manganese and cancer-related morality. This study revealed the correlation between the content of different elements and different types of mortality in the U.S. general population.

Effect of orthostatic hypotension on long-term prognosis of elderly patients with stable coronary artery disease: a retrospective cohort study

Background

The long-term prognosis of patients with stable coronary artery disease (CAD) combined with orthostatic hypotension (OH) has rarely been reported. This research was designed to examine whether OH increases the risk of all-cause mortality and cardiovascular death among patients with stable CAD.

Methods

We retrospectively analyzed retired military personnel over 65 years of age who were hospitalized at the General Hospital of Southern Theater Command of the Chinese People's Liberation Army between March and July 2010. A total of 924 patients with stable CAD were included, among whom 263 had OH. The risk of all-cause mortality and cardiovascular death in OH and non-OH groups were analyzed with the Cox proportional hazards models, and restricted cubic spline plots were utilized for subgroup analyses. Furthermore, competing risk models were applied for sensitivity analyses.

Results

The median age of the patients was 82.00 (80.00-85.00) years. Over 159 months of follow-up, the loss to follow-up rate was 2.27%, and all-cause mortality was observed in 574 (63.57%) patients, including 184 with OH. Moreover, cardiovascular death occurred in 127 patients (13.73%), with 58 cases associated with OH. Although the relationship between OH and all-cause mortality was non-significant [body mass index (BMI) < 25 group, adjusted hazard ratio (HR) = 1.10 with a 95% confidence interval (CI): 0.82-1.40; BMI ≥ 25 group, adjusted HR = 1.30, 95% CI: 0.98-1.70], it was independently related to a growing risk of cardiovascular death (adjusted HR = 1.80, 95% CI: 1.20-2.60). This finding was further validated by using a competing risk model (subdistribution HR = 1.74, 95% CI: 1.22-2.49). Moreover, age, low-density lipoprotein cholesterol, and frequency of hospital admissions were identified as risk factors of cardiovascular death among patients with OH (P < 0.05).

Conclusion

Our study, based on retired military personnel with stable CAD, found that OH led to a significantly higher risk of cardiovascular death, but it was not noticeably associated with all-cause mortality on long-term prognosis.

Association between migraine and cardiovascular disease mortality: A prospective population-based cohort study

OBJECTIVE

The study assessed the association between migraine and cardiovascular disease (CVD) mortality in the US population.

BACKGROUND

Previous studies have drawn different conclusions about the association between migraine and CVD mortality based on different populations; therefore, it is important to explore the relationship between migraine and CVD mortality in the US population.

METHODS

This prospective cohort study included 10,644 participants from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Participants who reported having severe headache or migraine were classified as having migraine. Mortality data were obtained by linkage of the cohort database to the National Death Index as of December 31, 2019. Based on the International Classification of Diseases, Tenth Revision, CVD mortality includes the following disease codes: I00-I09 (acute rheumatic fever and chronic rheumatic heart diseases), I11 (hypertensive heart disease), I13 (hypertensive heart and renal disease), I20-I25 (ischemic heart diseases), I26-I28 (pulmonary embolism and other acute pulmonary heart diseases), I29 (various cardiovascular diseases caused by different reasons), I30-I51 (other forms of heart disease), and I60-I69 (cerebrovascular diseases). Data were analyzed from October to November 2022.

RESULTS

Among 10,644 adults included in the study (mean age, 46.4 [0.3] years, 5430 men [47.4%]), 2106 (20.4%) had migraine. During a median follow-up period of 201 months, there were 3078 all-cause deaths and 997 CVD deaths. Compared to individuals without migraine, those with migraine had an adjusted hazard ratio (HR) of 1.30 (95% confidence interval [CI], 1.04-1.62; p = 0.019) for CVD mortality and 1.23 (95% CI, 1.13-1.35; p < 0.001) for all-cause mortality. In subgroup analyses, migraine was associated with CVD mortality in participants who were women (HR, 1.43; 95% CI, 1.06-1.93), aged < 45 years (HR, 1.69; 95% CI, 1.04-2.76), non-Hispanic White (HR, 1.42; 95% CI, 1.09-1.86), those with a body mass index < 30 kg/m2 (HR, 1.36; 95% CI, 1.03-1.78), former or current smokers (HR, 1.36; 95% CI, 1.00-1.85), former or current alcohol drinkers (HR, 1.33; 95% CI, 1.03-1.72), and those without metabolic syndrome (HR, 1.31; 95% CI, 1.01-1.71). The association between migraine and CVD mortality was robust in sensitivity analyses, after excluding participants who died within 2 years of follow-up (HR, 1.31; 95% CI, 1.05-1.65) or those with a history of cancer at baseline (HR, 1.28; 95% CI, 1.01-1.62).

CONCLUSIONS

Migraine was associated with a higher CVD mortality rate in the US population.

Changes in Diet Quality over 10 Years and Subsequent Mortality from Cardiovascular Disease in the Multiethnic Cohort Study

This study investigated how diet quality changes over a ten-year period, assessed using the following four diet quality indexes, the Healthy Eating Index-2015 (HEI-2015), Alternative Healthy Eating Index-2010 (AHEI-2010), alternate Mediterranean Diet (aMED), and Dietary Approaches to Stop Hypertension (DASH), were related to mortality from cardiovascular disease (CVD) in the Multiethnic Cohort Study. The analysis included 61,361 participants who completed both the 1993-1996 baseline survey and the 2003-2008 10-year follow-up surveys. Over the mean follow-up period of 13 years after the 10-year survey, 4174 deaths from CVD were identified. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox models. Increases in diet quality scores were associated with a reduced risk of CVD mortality for all indexes: HRs per one SD increment of 0.94 to 0.99 (HR (95% CI), 0.96 (0.92-1.01) for HEI-2015, 0.96 (0.91-1.01) for AHEI-2010, 0.99 (0.94-1.04) for aMED, and 0.94 (0.89-0.99) for DASH) in men and 0.88 to 0.92 (0.88 (0.84-0.92) for HEI-2015, 0.90 (0.85-0.95) for AHEI-2010, 0.89 (0.84-0.95) for aMED, and 0.92 (0.87-0.96) for DASH) in women. The inverse association generally did not vary by race and ethnicity, age, body mass index, smoking, and hypertension in each sex. Our findings suggest that improving diet quality and maintaining a high-quality diet over time may help reduce the risk of CVD mortality and could also be beneficial for those at higher risk of CVD.

Birth Weight in Consecutive Pregnancies and Maternal Cardiovascular Disease Mortality Among Spontaneous and Iatrogenic Term Births: A Population-Based Cohort Study

Knowledge on the association between offspring birth weight and long-term risk of maternal cardiovascular disease (CVD) mortality is often based on firstborn infants without consideration of women's consecutive births. We studied long-term CVD mortality according to offspring birth weight patterns among women with spontaneous and iatrogenic term deliveries in Norway (1967-2020). We constructed birth weight quartiles (Qs) by combining standardized birth weight with gestational age in quartiles (Q1, Q2/Q3, and Q4) for the women's first 2 births. Mortality was estimated using Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). Changes in offspring birth weight quartiles were associated with long-term maternal CVD mortality. Compared with women who had 2 term infants in Q2/Q3, women with a first offspring in Q2/Q3 and a second in Q1 had higher mortality risk (HR = 1.33, 95% CI: 1.18, 1.50), while risk was lower if the second offspring was in Q4 (HR = 0.78, 95% CI: 0.67, 0.91). The risk increase associated with having a first infant in Q1 was eliminated if the second offspring was in Q4 (HR = 0.99, 95% CI: 0.75, 1.31). These patterns were similar for women with iatrogenic and spontaneous deliveries. Inclusion of information from subsequent births revealed heterogeneity in maternal CVD mortality which was not captured when using only information based on the first offspring.

How to Keep the Balance between Red and Processed Meat Intake and Physical Activity Regarding Mortality: A Dose-Response Meta-Analysis

BACKGROUND

Non-communicable diseases have become a major threat to public health, with cardiovascular diseases (CVDs) and cancer being the top two causes of death each year.

OBJECTIVE

Our objective is to evaluate the balanced association between the effect of red and processed meat intake on the risk of death and the effect of physical activity on the risk of mortality, where the risk of death includes all causes, CVDs, and cancers.

METHODS

We searched electronic databases, including PubMed, ISI Web of Science, Embase, and the Cochrane Library, for prospective studies reporting risk estimates for the association between the intake of red and processed meat, walking, and muscle-strengthening activity (MSA) and the risk of mortality from all causes, CVDs, and cancer. We extracted fully adjusted effect estimates from original studies and performed a summary analysis using the fixed and random-effect models.

RESULTS

A conventional meta-analysis showed that red meat and processed meat were positively associated with the risk of mortality, and daily steps and MSA were negatively associated with the risk of death. Further analysis of the dose-response relationship showed that a risk reduction (20%) from 39.5 min/week of MSA or 4100 steps/d was equivalent to an increased risk of all-cause mortality from a daily intake of 103.4 g/d of red meat or 50 g/d of processed meat. The risk was further decreased as the number of steps per day increased, but the risk reversed when the MSA exceeded the threshold (39.5 min/week).

CONCLUSIONS

Adherence to physical activity is an effective way to reduce the risk of mortality due to meat intake. However, the total intake of red meat and processed meat should be controlled, especially the latter. Walking is recommended as the main daily physical activity of choice, while MSAs are preferred when time is limited, but it should be noted that longer MSAs do not provide additional benefits.

Older Employees

Stress is a key driver of cardiovascular disease (CVD), yet the contribution of psychosocial stressors to the development of CVD has not been systematically examined in United States (U.S.) populations. The objective of this study was to assess prospective associations of adverse childhood experiences (ACEs), social isolation, and job strain with CVD mortality. Data were from the large, nationally representative, population-based Health and Retirement Study (HRS). ACEs, social isolation and job strain were assessed using validated survey instruments at baseline between 2006-2008, and death information was followed up through 2018. Cox proportional hazards regression models were used to examine prospective associations of ACEs, social isolation, and job strain with CVD mortality among 4046 older employees free from CVD at baseline. During 42,149 person-years of follow-up time, 59 death cases of CVD were reported. After adjustment for covariates, ACEs and job strain were significantly associated with increased risk of CVD mortality (aHR and 95% CI = 3.67 [1.59, 8.48] and 2.24 [1.21, 4.11], respectively), whereas social isolation demonstrated an inflated but nonsignificant association (aHR and 95% CI = 1.62 [0.72, 3.66]). These findings highlight the role of psychosocial exposures as novel and clinically relevant risk factors for CVD.

Association of aspirin with all-cause and cardiocerebrovascular mortality in patients with metabolic associated fatty liver disease

BACKGROUND

Studies on aspirin's effects on metabolic-associated fatty liver disease (MAFLD) are limited. The aim of this study was to assess the association between aspirin and all-cause and cardiovascular disease (CVD) mortality in individuals with MAFLD.

METHODS

Data were acquired from the National Health And Nutrition Examination Survey (NHANES) III. MAFLD diagnosis was consistent with that of international expert consensus. The independent association between aspirin and all-cause and CVD mortality in participants with MAFLD was evaluated by multiple Cox regression. Stratified analyses and interaction tests were performed to investigate whether covariates modified the association between aspirin and MAFLD mortality.

RESULTS

Of 4594 eligible participants, 3,162 (68.83%) never took aspirin (0 times/month), 962 (20.94%) took it occasionally (1-14 times/month) and 470 (10.23%) took it regularly (≥15 times/month). Multiple cox regression showed that aspirin was not associated with overall mortality for MAFLD individuals. Stratified analysis revealed that in middle-aged (45-59 years) participants with MAFLD, occasional aspirin use was associated with low all-cause mortality risk (HR = 0.61, 95% CI = 0.43-0.86), while there was no significant association between aspirin and all-cause mortality among the young or the elderly.

CONCLUSIONS

We found that the association between aspirin and all-cause MAFLD mortality varies by both age and frequency of administration. More prospective studies are needed to explore aspirin's influence on MALFD mortality.

Association of Objective and Self-Reported Sleep Duration With All-Cause and Cardiovascular Disease Mortality: A Community-Based Study

Background Previous studies found an association between self-reported sleep duration and mortality. This study aimed to compare the effects of objective and self-reported sleep duration on all-cause and cardiovascular disease (CVD) mortality. Methods and Results A total of 2341 men and 2686 women (aged 63.9±11.1 years) were selected from the SHHS (Sleep Heart Health Study). Objective sleep duration was acquired using in-home polysomnography records, and self-reported sleep duration on weekdays and weekends was based on a sleep habits questionnaire. The sleep duration was categorized as ≤4 hours, 4 to 5 hours, 5 to 6 hours, 6 to 7 hours, 7 to 8 hours, and >8 hours. Multivariable Cox regression analysis was used to investigate the association of objective and self-reported sleep duration with all-cause and CVD mortality. During a mean follow-up period of 11 years, 1172 (23.3%) participants died, including 359 (7.1%) deaths from CVD. All-cause and CVD mortality rates decreased gradually with increasing objective sleep duration. In multivariable Cox regression analysis, the greatest association for all-cause and CVD mortality was with an objective sleep duration of 5 hours or shorter. In addition, we found a J-shaped association of self-reported sleep duration on both weekdays and weekends with all-cause and CVD mortality. Self-reported short (≤4 hours) and long (>8 hours) sleep duration on weekdays and weekends were associated with an increased risk of all-cause and CVD mortality compared with 7 to 8 hours sleep duration. Furthermore, a weak correlation was observed between objective and self-reported sleep duration. Conclusions This study showed that both objective and self-reported sleep duration were associated with all-cause and CVD mortality, but with different characteristics. Registration URL: https://clinicaltrials.gov/ct2/show/NCT00005275; Unique identifier: NCT00005275.

Dietary Zinc Intake and All-Cause and Cardiovascular Mortality in Korean Middle-Aged and Older Adults

We aimed to investigate the association between dietary zinc intake and total deaths, cancer, and cardiovascular disease death. In this prospective, 10-year, community-based cohort analysis, data from 143,050 adult participants (aged 40 years and older) were analyzed. Dietary zinc intake at baseline was assessed using a food frequency questionnaire. Harrell’s C-index was used to determine the optimal cut-off of dietary zinc intake with the log-rank test. Using the Cox proportional hazards regression models, the association between dietary zinc intake and all-cause, cancer, and cardiovascular disease mortality was estimated using hazard ratios and 95% confidence intervals. During the mean 10.1 years of follow-up, 5436 participants expired, of whom 2355 died due to cancer and 985 died due to cardiovascular causes. After adjustment for confounders, dietary zinc intake was inversely associated with all-cause mortality (≤5.60 mg/day vs. >7.98 mg/day; hazard ratio, 1.13; 95% confidence interval, 1.01−1.25) and cardiovascular disease mortality (≤5.12 mg/day vs. >7.28 mg/day; hazard ratio, 1.42; 95% confidence interval, 1.11−1.81) but not with cancer mortality (≤5.60 mg/day vs. >10.08 mg/day; hazard ratio, 1.09; 95% confidence interval, 0.90−1.33). Dietary zinc intake was associated with a lower risk of all-cause mortality and cardiovascular disease mortality but not with cancer mortality. Our findings could suggest that recommending optimal dietary zinc intake is helpful for human health.

Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018

Background Disparities in cardiovascular disease (CVD) outcomes persist across the United States. Social determinants of health play an important role in driving these disparities. The current study aims to identify the most important social determinants associated with CVD mortality over time in US counties. Methods and Results The authors used the Agency for Healthcare Research and Quality's database on social determinants of health and linked it with CVD mortality data at the county level from 2009 to 2018. The age-standardized CVD mortality rate was measured as the number of deaths per 100 000 people. Penalized generalized estimating equations were used to select social determinants associated with county-level CVD mortality. The analytic sample included 3142 counties. The penalized generalized estimating equation identified 17 key social determinants of health including rural-urban status, county's racial composition, income, food, and housing status. Over the 10-year period, CVD mortality declined at an annual rate of 1.08 (95% CI, 0.74-1.42) deaths per 100 000 people. Rural counties and counties with a higher percentage of Black residents had a consistently higher CVD mortality rate than urban counties and counties with a lower percentage of Black residents. The rural-urban CVD mortality gap did not change significantly over the past decade, whereas the association between the percentage of Black residents and CVD mortality showed a significant diminishing trend over time. Conclusions County-level CVD mortality declined from 2009 through 2018. However, rural counties and counties with a higher percentage of Black residents continued to experience higher CVD mortality. Median income, food, and housing status consistently predicted higher CVD mortality.

Association of Systemic Immune Inflammation Index with All-Cause, Cardiovascular Disease, and Cancer-Related Mortality in Patients with Cardiovascular Disease: A Cross-Sectional Study

Objective

Our research was designed to investigate the relationship between systemic immune inflammation (SII) index and all-cause, cardiovascular disease (CVD), and cancer-related mortality in patients with CVD.

Methods

We used the National Health and Nutrition Examination Survey data from 1999 to 2018 to conduct this study. The association between SII index and all-cause, CVD, and cancer-related mortality in patients with CVD was examined using restricted cubic splines (RCS), Cox proportional hazard models, and subgroup analysis, respectively. CVD was defined as a composite of five outcomes of CVD, including coronary heart disease (CHD), congestive heart failure (CHF), angina pectoris, myocardial infarction, and stroke. Additionally, the link between SII index and all-cause, CVD, and cancer-related mortality in patients with a composite of five outcomes of CVD was also explored.

Results

In total, 5329 participants were included. The RCS also showed a U-curve correlation between SII index and the all-cause, CVD, and cancer-related mortality in patients with CVD. As compared with the individuals with lowest quartile of SII index, hazard ratios with 95% confidence intervals for all-cause, CVD, and cancer-related mortality across the quartiles were (1.202 (0.981, 1.474), 1.184 (0.967, 1.450), and 1.365 (1.115, 1.672)), (1.116 (0.815, 1.527), 1.017 (0.740, 1.398), and 1.220 (0.891, 1.670)), and (1.202 (0.981, 1.474), 1.184 (0.967, 1.450), and 1.365 (1.115, 1.672)), respectively, in the full-adjusted model. The SII index also had a U-shaped relationship with all-cause, CVD, and cancer-related mortality in patients with CHD, angina, and myocardial infarction. Additionally, the U-shaped relationship between SII index and all-cause, and cancer-related mortality also exists in CHF, and stroke. However, there was a positive linear correlation between SII index and CVD mortality in patients with CHF, and stroke.

Conclusion

In the United States general population, the correlation between SII index and all-cause, CVD, and cancer-related mortality showed a U-shaped curve in patients with CVD.

Synergy of arsenic with smoking in causing cardiovascular disease mortality: A cohort study with 27 follow-up years in China

Background

To explore the patterns of the exposure-response relationship between arsenic exposure and cardiovascular disease (CVD) mortality and investigate the effect of cigarette smoking on the association.

Methods

Seven thousand seven hundred thirty-five tin miners with at least 10 years of arsenic exposure were enrolled since 1992 and followed up for 27 years. Each individual's air arsenic exposure at workplace was calculated by time weighted average arsenic concentration × exposure months. Detailed information on smoking was collected at baseline, and information on smoking status was collected for five consecutive years from 1992 to 1996. Hazard ratio (HR) and 95% confidence interval (CI) for the risk of CVD were estimated using Cox proportional hazards models.

Results

A total of 1,046 CVD deaths occurred in this cohort over 142,287.7 person-years of follow up. We firstly reported that for equal cumulative exposure, participants exposed to higher concentrations over shorter duration had a higher risk of CVD mortality than those exposed to lower concentration over longer duration. The HR and 95% CI were 1.38 (95%CI: 1.03-1.85) in participants exposed to arsenic concentration (45.5-99.5 mg/m³), 1.29 (95%CI: 1.02-1.67) in 99.5-361.0 mg/m³. Further, participants with age at first exposure <18 years had a significantly higher risk of morality from CVD, cerebrovascular and heart diseases than those with ≥18 years. Finally, all synergy indices were greater than 1 (range, 1.11-2.39), indicating that the joint effect of arsenic exposure and cigarette smoking on CVD mortality was greater than the sum of their individual effect.

Conclusions

Exposure to air arsenic at workplace is adversely associated with mortality from CVD, especially among smokers younger than 18 years and smokers.

Association of hormone receptor status with cardiovascular disease mortality in 399,209 patients with stage I to III breast cancer: A population-based study

Adjuvant endocrine therapy (AET) is known to reduce the risk of hormone receptor-positive (HR+) breast cancer (BC) recurrence and mortality rates, but its impact on cardiovascular disease (CVD) events is unclear. The primary objective of this study was to analyze the association of HR status with CVD mortality in patients with stage I to III BC. A retrospective study of patients with stage I to III BC was conducted using the 2004 to 2016 Surveillance, Epidemiology, and End Results (SEER) database, and patients were grouped according to their HR status. Propensity score matching (PSM) was used to adjust for heterogeneity between the groups. The cumulative incidence rate of CVD mortality was evaluated via a cumulative incidence curve. Univariate and multivariate Fine and Gray's competing risk regression models were used to identify risk factors associated with CVD mortality. In total, 399,209 patients with BC were included in this study, and 329,958 patients (82.65%) were HR-positive. The cumulative incidence of CVD death was 8.28% in stage I to III BC patients. In the constituent ratio analysis, primary BC was the leading cause of death (45.29%, N = 31,465), followed by heart disease (16.07%, N = 11,166). Compared to the second year following BC diagnosis, the risk of CVD-specific death gradually increased. After PSM, 65,952 pairs of patients were matched, which led to the equilibrium of all variables between the HR-negative cohort and HR+ cohort. Multivariate analysis indicated that HR status was not significantly associated with the risk of CVD mortality, with a hazard ratio of 1.01 (P = .895). This study highlights the importance of understanding the associations between risk factors and CVD for BC patients. HR status was not associated with the risk of CVD mortality in this study.

Association of Egg Consumption with Risk of All-Cause and Cardiovascular Disease Mortality: A Systematic Review and Dose-Response Meta-Analysis of Observational Studies

BACKGROUND

Recent studies have reported conflicting associations between egg consumption and the risk of all-cause or cardiovascular disease (CVD) mortality, including ischemic heart disease (IHD) mortality and stroke mortality. With accumulating evidence, up-to-date evidence about the association should be synthesized.

OBJECTIVES

We aimed to assess the association of the risk of all-cause and CVD mortality with egg consumption.

METHODS

We searched the PubMed, Embase, and Web of Science databases through 3 November, 2021 for observational studies conducted in participants ≥18 y of age and which provided ORs, RRs, or HRs and 95% CIs for ≥3 egg consumption categories or for increased intake of egg addressing the associations of interest. A random-effects model was used to pool the reported risk estimates. Restricted cubic splines were used to examine the dose-response association.

RESULTS

Twenty-four articles with 48 reports (25 for all-cause mortality, 11 for CVD mortality, 6 for IHD mortality, and 6 for stroke mortality) involving 11,890,695 participants were included. Intake of each 1-egg/d increment was associated with increased risk of all-cause mortality (RR: 1.06; 95% CI: 1.02, 1.10; P = 0.008), but the association was restricted to women, Americans, and studies with adjustments for hyperlipidemia. Egg consumption was linearly associated with CVD mortality only in participants >60 y of age, Americans, studies with follow-up duration ≥15 y, and studies with adjustments for hyperlipidemia (P ≤ 0.018). No significant association was found between egg consumption and IHD or stroke mortality (P ≥ 0.080).

CONCLUSIONS

Egg consumption was linearly associated with a modestly increased risk of all-cause mortality and, in older participants, Americans, and studies with longer follow-up or adjustments for hyperlipidemia, CVD mortality. These findings suggest that it may be prudent to avoid high egg consumption.

Variations in Dietary Patterns Defined by the Healthy Eating Index 2015 and Associations with Mortality: Findings from the Dietary Patterns Methods Project

BACKGROUND

It is currently unknown if within high-quality dietary intake there exist distinct dietary patterns associated with health benefits that are identifiable with multidimensional dietary pattern analyses. The purpose of this study was to identify specific dietary patterns and groups therein and their associations with all-cause, CVD, and cancer mortality.

METHODS

We conducted sex-specific k-means cluster analyses within Healthy Eating Index 2015 (HEI-2015) quintile 5 in 3 US cohorts [NIH-American Association of Retired Persons Diet and Health Study (AARP), the Multiethnic Cohort (MEC), Women's Health Initiative Observational Study (WHI OS)], clusters ranging from n = 1190 to n = 12,007. Characterizations incorporated HEI-2015 overall and component-specific percentage adherence goals, using untruncated and truncated radar graphs and shape analyses. Using cohort- and sex-specific Cox proportional hazards models, associations of quintile 5 clusters with all-cause, cardiovascular disease (CVD), and cancer mortality were evaluated relative to quintile 1.

RESULTS

In each cohort sex-specific sample, 3 identified clusters included 16%-62% of participants, providing evidence for variation within high-quality dietary intake. Clusters revealed commonalities in total fruits and whole fruits intakes that exceeded goals and high sodium intake. Dairy and whole grain intakes oftentimes fell below goal. Some clusters were in addition characterized by total vegetables, greens & beans, and seafood & plant protein intakes exceeding goals. All high-quality dietary patterns were associated with a multivariable-adjusted significant 15%-26% lower risk of all-cause death than diet intake in quintile 1 (except for cluster 2 in WHI OS), and with a 16%-25% lower risk of CVD mortality in the AARP and MEC cohorts. Cancer mortality results were inconsistent.

CONCLUSIONS

Multiple ways to achieve a high-quality diet were identified and significant associations with lower all-cause and CVD mortality were seen in some cohorts.

Day-to-day variation in sleep duration is associated with increased all-cause mortality

STUDY OBJECTIVES

There is a paucity of data on the association between day-to-day variation in sleep pattern and all-cause mortality. We aimed to investigate whether day-to-day variation in sleep duration and onset of sleep are associated with cardiovascular and all-cause mortality.

METHODS

We used data belonging to 388 unique patients from the Midlife in the United States 2 Biomarker study (2004-2009). Information on sleep onset, duration, and sleep-wake cycles was collected for 7 consecutive days using the Actiwatch device. Sleep irregularity was assessed using mean and standard deviations in sleep duration and time of onset of sleep over 7 days. Cox proportional regression analysis and the Fine and Gray subdistribution method were used with all-cause and cardiovascular mortality, respectively.

RESULTS

Over a median of 8.6 years of follow-up, 37 patients died, including 10 deaths resulting from cardiovascular causes. There was no statistically significant increase in cardiovascular mortality with variation in sleep duration in the highest vs the lowest tertile (hazard ratio, 4.00; 0.45-35.48; P = .21). However, increased all-cause mortality was seen in the highest vs the lowest tertile (hazard ratio, 3.99; 1.33-11.94; P = .01). Multivariable model adjusting for confounders had higher all-cause mortality with increased sleep duration variation in the highest vs the lowest tertile: hazard ratio, 4.85; 1.52-15.49; P < .01).

CONCLUSIONS

Day-to-day variation in sleep duration is associated with increased all-cause mortality but not cardiovascular mortality after adjusting for mean sleep duration, inflammation, diabetes, age, body mass index, renal function, and blood pressure. Irregularity in the onset of sleep is not associated with all-cause mortality or cardiovascular mortality.

CITATION

Katamreddy A, Uppal D, Ramani G, et al. Day-to-day variation in sleep duration is associated with increased all-cause mortality. J Clin Sleep Med. 2022;18(3):921-926.

Association Between Initiation, Intensity, and Cessation of Smoking and Mortality Risk in Patients With Cardiovascular Disease: A Cohort Study

Objectives: To examine the effect of smoking status, smoking intensity, duration of smoking cessation and age of smoking initiation on the risk of all-cause and cause-specific mortality among cardiovascular disease (CVD) patients.

Design: A population-based prospective cohort study.

Setting: The National Health Interview Survey (NHIS) in the U.S. that were linked to the National Death Index (NDI).

Participants: 66,190 CVD participants ≥ 18 years of age who were interviewed between 1997 and 2013 in the NHIS linked to the NDI through December 31, 2015.

Outcome Measures: The primary outcome was all-cause mortality and the secondary outcome was cause-specific mortality including CVD mortality and cancer mortality.

Results: During the mean follow-up of 8.1 years, we documented 22,518 deaths (including 6,473 CVD deaths and 4,050 cancer deaths). In the overall CVD population, former and current smokers had higher risk of all-cause (Former smokers: hazard ratios (HRs), 1.26; 95% confidence interval (CI), 1.21–1.31, P < 0.001; Current smokers: HRs, 1.96; 95%CI, 1.86–2.07, P < 0.001), CVD (Former smokers: HRs, 1.12; 95%CI, 1.05–1.21, P = 0.001; Current smokers: HRs, 1.80; 95%CI, 1.64–1.97, P < 0.001) and cancer mortality (Former smokers: HRs, 1.49; 95%CI, 1.35–1.64, P < 0.001; Current smokers: HRs, 2.78; 95%CI, 2.49–3.09, P < 0.001) than never smokers. Furthermore, similar results were observed when the study subjects were stratified according to the type of CVD. Among current smokers, the risk for cancer mortality increased as the daily number of cigarettes increased, regardless of the specific type of CVD. However, the association of the risk for all-cause and CVD mortality with smoking intensity did not present a dose-response relationship. In participants with angina pectoris or stroke, smoking intensity was inversely associated with deaths from CVD. In addition, the risk for all-cause, CVD and cancer mortality declined as years of smoking cessation increased. Finally, the relative risk of all-cause mortality was not significantly different in individuals with a younger age of smoking initiation.

Conclusions: CVD patients who are smokers have an increased risk of all-cause, CVD and cancer mortality, and the risk decreases significantly after quitting smoking. These data further provide strong evidence that supports the recommendation to quit smoking for the prevention of premature deaths among individuals with CVD.

Intake of Fish and Marine n-3 Polyunsaturated Fatty Acids and Risk of Cardiovascular Disease Mortality: A Meta-Analysis of Prospective Cohort Studies

Previous epidemiological studies have investigated the association of fish and marine n-3 polyunsaturated fatty acids (n-3 PUFA) consumption with cardiovascular disease (CVD) mortality risk. However, the results were inconsistent. The purpose of this meta-analysis is to quantitatively evaluate the association between marine n-3 PUFA, fish and CVD mortality risk with prospective cohort studies. A systematic search was performed on PubMed, Web of Science, Embase and MEDLINE databases from the establishment of the database to May 2021. A total of 25 cohort studies were included with 2,027,512 participants and 103,734 CVD deaths. The results indicated that the fish consumption was inversely associated with the CVD mortality risk [relevant risk (RR) = 0.91; 95% confidence intervals (CI) 0.85−0.98]. The higher marine n-3 PUFA intake was associated with the reduced risk of CVD mortality (RR = 0.87; 95% CI: 0.85–0.89). Dose-response analysis suggested that the risk of CVD mortality was decreased by 4% with an increase of 20 g of fish intake (RR = 0.96; 95% CI: 0.94–0.99) or 80 milligrams of marine n-3 PUFA intake (RR = 0.96; 95% CI: 0.94–0.98) per day. The current work provides evidence that the intake of fish and marine n-3 PUFA are inversely associated with the risk of CVD mortality.

Combined Effect of Lead Exposure and Allostatic Load on Cardiovascular Disease Mortality-A Preliminary Study

This study explores the combined effect of lead (Pb) exposure and an index of chronic physiological stress on cardiovascular disease mortality using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2008 linked to 1999-2014 National Death Index data. Chronic physiological stress was measured using the allostatic load (AL) index, which was formed by analyzing markers from the cardiovascular, inflammatory, and metabolic systems, with Pb levels, assessed using blood lead levels (BLL). The dataset was analyzed with statistical techniques to explore (a) the relationship between Pb exposure and AL, and (b) the combined role of Pb and AL on cardiovascular disease mortality. Results indicated that AL was more elevated in those with BLLs above the 50th percentile in the US population and that those with elevated AL were more likely to have high BLL. Finally, the interaction of AL and BLL significantly increased the likelihood of cardiovascular disease mortality. These findings highlight the need for considering the totality of exposures experienced by populations to build holistic programs to prevent Pb exposure and reduce stressors to promote optimal health outcomes and reduce cardiovascular mortality risk.

Dose-response relationships between polypharmacy and all-cause and cause-specific mortality among older people

Background

Although medicines are prescribed based on clinical guidelines and expected to benefit patients, both positive and negative health outcomes have been reported associated with polypharmacy. Mortality is the main outcome, and information on cause-specific mortality is scarce. Hence, we investigated the association between different levels of polypharmacy and all-cause and cause-specific mortality among older adults.

Method

The English Longitudinal Study of Ageing is a nationally representative study of people aged 50+. From 2012/2013, 6 295 individuals were followed up to April 2018 for all-cause and cause-specific mortality. Polypharmacy was defined as taking 5–9 long-term medications daily and heightened polypharmacy as 10+ medications. Cox proportional hazards regression and competing-risks regression were used to examine associations between polypharmacy and all-cause and cause-specific mortality, respectively.

Results

Over a 6-year follow-up period, both polypharmacy (19.3%) and heightened polypharmacy (2.4%) were related to all-cause mortality, with hazard ratios of 1.51 (95% CI: 1.05–2.16) and 2.29 (95% CI: 1.40–3.75) respectively, compared with no medications, independently of demographic factors, serious illnesses and long-term conditions, cognitive function, and depression. Polypharmacy and heightened polypharmacy also showed 2.45 (95% CI: 1.13–5.29) and 3.67 (95% CI: 1.43–9.46) times higher risk of cardiovascular disease deaths, respectively. Cancer mortality was only related to heightened polypharmacy.

Conclusion

Structured medication reviews are currently advised for heightened polypharmacy, but our results suggest that greater attention to polypharmacy in general for older people may reduce adverse effects and improve older adults’ health.

Comorbidities and the risk of cardiovascular disease mortality among racially diverse patients with breast cancer

BACKGROUND

Women who have coexisting comorbidities at the time of breast cancer diagnosis have an increased risk of breast cancer and overall mortality. However, the associations between newly diagnosed comorbidities and the risk of cardiovascular disease (CVD) mortality among these patients have not been examined.

METHODS

The authors compared the associations between coexisting and newly diagnosed CVD, type 2 diabetes, and hypertension and the risk of CVD mortality among patients with breast cancer identified in the Missouri Cancer Registry. In total, 33,099 women who had incident invasive breast cancer with inpatient and outpatient hospital discharge data within 2 years after breast cancer diagnosis were included: 9.3% were Black. Subdistribution hazard ratios (sdHRs) and 95% CIs were calculated for the risk of CVD-related mortality using adjusted Cox proportional hazards regression models, accounting for a competing risk of breast cancer deaths.

RESULTS

Within the first 2 years after breast cancer, the most reported newly diagnosed comorbidity was hypertension (9%), followed by CVD (4%), and type 2 diabetes (2%). CVD mortality was increased in women who had newly diagnosed CVD (sdHR, 2.49; 95% CI, 2.09-2.99), diabetes (sdHR, 2.16; 95% CI, 1.68-2.77), or hypertension (sdHR, 2.06; 95% CI, 1.71-2.48) compared with women who did not have these conditions. Associations were similar by race. The strongest association was among women who received chemotherapy and then developed CVD (sdHR, 3.82; 95% CI, 2.69-5.43).

CONCLUSIONS

Monitoring for diabetes, hypertension, and CVD from the time of breast diagnosis may reduce CVD mortality.

County-Level Factors Associated With Cardiovascular Mortality by Race/Ethnicity

Background

Persistent racial/ethnic disparities in cardiovascular disease (CVD) mortality are partially explained by healthcare access and socioeconomic, demographic, and behavioral factors. Little is known about the association between race/ethnicity‐specific CVD mortality and county‐level factors.

Methods and Results

Using 2017 county‐level data, we studied the association between race/ethnicity‐specific CVD age‐adjusted mortality rate (AAMR) and county‐level factors (demographics, census region, socioeconomics, CVD risk factors, and healthcare access). Univariate and multivariable linear regressions were used to estimate the association between these factors; R² values were used to assess the factors that accounted for the greatest variation in CVD AAMR by race/ethnicity (non‐Hispanic White, non‐Hispanic Black, and Hispanic/Latinx individuals). There were 659 740 CVD deaths among non‐Hispanic White individuals in 2698 counties; 100 475 deaths among non‐Hispanic Black individuals in 717 counties; and 49 493 deaths among Hispanic/Latinx individuals across 267 counties. Non‐Hispanic Black individuals had the highest mean CVD AAMR (320.04 deaths per 100 000 individuals), whereas Hispanic/Latinx individuals had the lowest (168.42 deaths per 100 000 individuals). The highest CVD AAMRs across all racial/ethnic groups were observed in the South. In unadjusted analyses, the greatest variation (R²) in CVD AAMR was explained by physical inactivity for non‐Hispanic White individuals (32.3%), median household income for non‐Hispanic Black individuals (24.7%), and population size for Hispanic/Latinx individuals (28.4%). In multivariable regressions using county‐level factor categories, the greatest variation in CVD AAMR was explained by CVD risk factors for non‐Hispanic White individuals (35.3%), socioeconomic factors for non‐Hispanic Black (25.8%), and demographic factors for Hispanic/Latinx individuals (34.9%).

Conclusions

The associations between race/ethnicity‐specific age‐adjusted CVD mortality and county‐level factors differ significantly. Interventions to reduce disparities may benefit from being designed accordingly.

Risk of Cardiovascular Disease Mortality in Relation to Depression and 14 Common Risk Factors

Background

Depression has been linked to a worse prognosis of Cardiovascular disease (CVD), and these two diseases share a variety of common risk factors such as unhealthy lifestyles and chronic medical conditions. However, the potential role of these common risk factors in modulating the association between depression and CVD mortality and whether the co-occurrence of depression and a specific common risk factor has a cumulative impact on CVD mortality are still largely unknown.

Methods

We pooled data from 2005–2014 of Nation health and nutritional examination survey, leading to a study population of 22,177 adults. The Patient Health Questionnaire was employed to assess the depression symptoms, and information on CVD mortality was obtained from the linked mortality file of NHANES. Fourteen common risk factors of depression and CVD were included in this study.

Results

Based on the interaction analyses, we found overweight was protective for the risk of CVD death in depressive participants, but not in people without depression. Moreover, relative risk-based analyses indicated a mutually promotive effect of depression and baseline CVD or living alone on CVD mortality.

Conclusion

The novel findings in our study may facilitate risk stratification in the clinical programs targeting CVD mortality and help to shed light on the differential pathophysiological mechanisms in the depression-mediated elevation of CVD mortality.

Time-Varying Depressive Symptoms and Cardiovascular and All-Cause Mortality: Does the Risk Vary by Age or Sex?

Background

Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the association between depressive symptoms and all‐cause and cardiovascular disease (CVD) mortality.

Methods and Results

The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time‐varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus <4) and all‐cause and CVD mortality were measured using Cox proportional hazard models adjusting for demographic and clinical risk factors. All results were stratified by age or sex and by self‐reported health status. Of 29 491 participants, 3253 (11%) had baseline elevated depressive symptoms. Mean age was 65 (9.4) years, with 55.1% of participants female, 41.1% Black, and 46.4% had excellent/very good health. Depressive symptoms were measured at baseline, on average 4.9 (SD, 1.5), then 2.1 (SD, 0.4) years later. Neither age nor sex moderated the association between elevated time‐varying depressive symptoms and all‐cause or CVD mortality (all‐cause: age 45–64 years adjusted hazard ratio [aHR], 1.38; 95% CI, 1.18–1.61 versus age ≥65 years aHR,1.36; 95% CI, 1.23–1.50; P=0.05; CVD: age 45–64 years aHR, 1.17; 95% CI, 0.90–1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06–1.50; P=0.54; all‐cause: males aHR, 1.46; 95% CI, 1.29–1.64 versus female aHR, 1.34; 95% CI, 1.19–1.50; P=0.35; CVD: male aHR, 1.32; 95% CI, 1.08–1.62 versus female aHR, 1.22; 95% CI, 1.00–1.47; P=0.64). Similar results were observed when stratified by self‐reported health status.

Conclusions

Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.

A Greater Flavonoid Intake Is Associated with Lower Total and Cause-Specific Mortality: A Meta-Analysis of Cohort Studies

Introduction: The links between flavonoid intake and mortality were previously evaluated in epidemiological studies. The aim of the present study was to perform a systematic review and meta-analysis of cohort studies evaluating the link of flavonoid consumption with total and cause-specific mortality. Methods: Prospective cohort studies reporting flavonoid intake and mortality data published up to 30th April 2019 (without language restriction) were searched using PubMed, Scopus and EMBASE database. Generic inverse variance methods and random effects models were used to synthesize pooled and quantitative data. Sensitivity analysis was also performed by a leave-one-out method. Results: Overall, 16 articles met the inclusion criteria (nine studies were performed in Europe, five in the USA, one in Asia and one in Oceania); a total of 462,194 participants (all adults aged >19 years) with 23,473 mortality cases were included in the final analysis. The duration of follow-up ranged from 4.8 to 28 years. Most of the studies assessed flavonoid intake using food frequency questionnaires, whereas four studies used interviews and 1 study used 4-day food records. The meta-analysis showed that flavonoid consumption was inversely and significantly associated with total (relative risk (RR): 0.87, 95% confidence interval (CI) = 0.77–0.99) and cardiovascular disease mortality risk (RR: 0.85, 95%CI = 0.75–0.97), but not cancer (0.86, 95%CI = 0.65–1.14) mortality risk. These findings remained robust in sensitivity analyses. Conclusions: The present findings highlight the potential protective role of flavonoids against total and cause-specific mortality. These results support the recommendations for flavonoid-rich foods intake to prevent chronic diseases.

Gender difference in the association of serum selenium with all-cause and cardiovascular mortality

Objectives: The relationship between selenium and all-cause mortality has been inconsistent from observational studies and clinical trials. The present study aimed to reveal the relationship between serum selenium and all-cause and cardiovascular disease (CVD) mortality and the potential gender differences.Methods: All participants were recruited from the 1999-2006 National Health and Nutrition Examination Survey (NHANES). Participants with available serum selenium data were followed up until 31 December 2015. Cox proportional hazards models were performed to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for all-cause and CVD mortality according to baseline selenium level in quartiles. Multivariable-adjusted spline curves were performed to detect non-linearity in relationships.Results: There were 2,903 subjects (50.7% female) included in this study. The mean age was 61.9 ± 13.7 years, and the mean selenium levels were 136.4 ± 19.6 ug/L. A total of 858 (29.6%) cases of all-cause mortality and 126 (4.3%) CVD mortality occurred during the median follow-up duration of 10.2 years. On average, deceased participants had lower serum selenium levels, (135.1 ± 22.3 vs. 137.0 ± 18.4 ug/L; P = 0.02). Serum selenium was also lower in female than male (134.7 ± 19.7 vs. 138.2 ± 19.4 ug/L; P < 0.01). Comparing with the lowest quartile, participants with the highest selenium concentration had a lower risk for all-cause (HR: 0.60, 95%CI: 0.45, 0.78; P < 0.01, P for trend<0.01) and CVD mortality (HR: 0.73, 95%CI: 0.37, 1.43; P = 0.36, P for trend = 0.90). Selenium was significantly associated with all-cause and CVD mortality among both males and females, but only associated with CVD mortality in among females.Conclusion: This study demonstrated significant relationship between serum selenium and all-cause mortality in both genders, but the relationship with CVD mortality was only significant in females.

Frailty index as a predictor of all-cause and cause-specific mortality in a Swedish population-based cohort

Frailty is a complex manifestation of aging and associated with increased risk of mortality and poor health outcomes. However, younger individuals (under 65 years) are less-studied in this respect. Also, the relationship between frailty and cause-specific mortality in community settings is understudied. We used a 42-item Rockwood-based frailty index (FI) in the Swedish Adoption/Twin Study of Aging (n=1477; 623 men, 854 women; aged 29-95 years) and analyzed its association with all-cause and cause-specific mortality in up to 30-years of follow-up. Deaths due to cardiovascular disease (CVD), cancer, dementia and other causes were considered as competing risks. The FI was independently associated with increased risk for all-cause mortality in younger (<65 years; HR per increase in one deficit 1.11, 95%CI 1.07-1.17) and older (≥65 years; HR 1.07, 95%CI 1.04-1.10) women and in younger men (HR 1.05, 95%CI 1.01-1.10). In cause-specific mortality analysis, the FI was strongly predictive of CVD mortality in women (HR per increase in one deficit 1.13, 95%CI 1.09-1.17), whereas in men the risk was restricted to deaths from other causes (HR 1.07, 95%CI 1.01-1.13). In conclusion, the FI is a strong mortality predictor especially among younger individuals and its associations with cause-specific mortality are sex-specific.

Is There a Dose-Response Relationship between Tea Consumption and All-Cause, CVD, and Cancer Mortality?

BACKGROUND

A small change in tea consumption at population level could have large impact on public health. However, the health benefits of tea intake among Americans are inconclusive.

OBJECTIVE

To evaluate the association between tea consumption and all-causes, cardiovascular disease (CVD) and cancer mortality in the Aerobics Center Longitudinal study (ACLS).

METHODS

11808 participants (20-82 years) initially free of CVD and cancers enrolled in the ACLS and were followed for mortality. Participants provided baseline self-report of tea consumption (cups/day). During a median follow-up of 16 years, 842 participants died. Of others, 250 died from CVD, and 345 died from cancer, respectively. A Cox proportional hazard model was used to produce hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Compared with participants consuming no tea, tea drinkers had a survival advantage ( Log-2 = 10.2, df = 3, P = 0.017); however, the multivariate hazard ratios (HRs) of all-cause mortality for those drinking 1-7, 8-14, and >14 cups/week were 0.95 (95% CI, 0.81-1.12), 1.00 (95% CI, 0.82-1.22), and 0.98 (95% CI, 0.76-1.25), respectively (P for linear trend = 0.83). The multivariate HR were 1.16 (95% CI, 0.86-1.56), 1.22 (95% CI, 0.85-1.76), and 0.94 (95% CI, 0.56-1.54) for CVD mortality (P for linear trend = 0.47), and 0.97 (95% CI, 0.75-1.25), 0.85 (95% CI, 0.60-1.16), and 0.94 (95% CI, 0.64-1.38) for cancer mortality (P for trend = 0.62).

CONCLUSIONS

There were week or null relationships between tea consumption and mortality due to all-cause, CVD disease or cancer were observed in ACLS.

Long-Term PM2.5 Exposure and Respiratory, Cancer, and Cardiovascular Mortality in Older US Adults

The impact of chronic exposure to fine particulate matter (particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5)) on respiratory disease and lung cancer mortality is poorly understood. In a cohort of 18.9 million Medicare beneficiaries (4.2 million deaths) living across the conterminous United States between 2000 and 2008, we examined the association between chronic PM2.5 exposure and cause-specific mortality. We evaluated confounding through adjustment for neighborhood behavioral covariates and decomposition of PM2.5 into 2 spatiotemporal scales. We found significantly positive associations of 12-month moving average PM2.5 exposures (per 10-μg/m3 increase) with respiratory, chronic obstructive pulmonary disease, and pneumonia mortality, with risk ratios ranging from 1.10 to 1.24. We also found significant PM2.5-associated elevated risks for cardiovascular and lung cancer mortality. Risk ratios generally increased with longer moving averages; for example, an elevation in 60-month moving average PM2.5 exposures was linked to 1.33 times the lung cancer mortality risk (95% confidence interval: 1.24, 1.40), as compared with 1.13 (95% confidence interval: 1.11, 1.15) for 12-month moving average exposures. Observed associations were robust in multivariable models, although evidence of unmeasured confounding remained. In this large cohort of US elderly, we provide important new evidence that long-term PM2.5 exposure is significantly related to increased mortality from respiratory disease, lung cancer, and cardiovascular disease.

The Effects of Urinary Albumin and Hypertension on All-Cause and Cardiovascular Disease Mortality in Korea

BACKGROUND

Urinary albumin levels and hypertension (HTN) are independently associated with an increased risk of all-cause mortality. The effect of albuminuria on mortality in the absence or presence of HTN is uncertain. This study aimed to evaluate the effect of albuminuria and HTN on all-cause and cardiovascular disease (CVD) mortality.

METHODS

Mortality outcomes for 32,653 Koreans enrolled in a health screening including measurements of the urinary albumin/creatinine ratio (UACR) at baseline and median follow-up of 5.13 years. Receiver operating characteristic curve analyses were performed in UACR and the cut-point was 5.42 mg/g. The participants for UACR at the cut-point of 5.42 μg/mg were categorized into UACR < 5.42 or UACR ≥ 5.42. HTN status was categorized as No HTN or HTN (defined as the absence or presence HTN).

RESULTS

The median (interquartile) baseline UACRs were higher in those who died than in survivors. Subjects with a UACR ≥ 5.42 mg/g without or with HTN showed a similar increased risk for all-cause mortality and CVD mortality, even after adjusting for known CVD risk factors compared to those with no HTN/UACR < 5.42 (reference), (all-cause mortality; hazard ratio [HR] 1.48; 95% confidence interval [CI] 1.02–2.15: HR 1.47; 95% CI 0.94–2.32, respectively), (CVD mortality; HR 5.75; 95% CI 1.54–21.47: HR 5.87; 95% CI 1.36–25.29)

CONCLUSIONS

The presence of urinary albumin and HTN is a significant determinant of CVD and death. Urinary albumin might be more attributable to CVD and all-cause mortality than HTN.

Dietary Flavonoid and Lignan Intake and Mortality in Prospective Cohort Studies: Systematic Review and Dose-Response Meta-Analysis

Recent evidence has suggested that flavonoid and lignan intake may be associated with decreased risk of chronic and degenerative diseases. The aim of this meta-analysis was to assess the association between dietary flavonoid and lignan intake and all-cause and cardiovascular disease (CVD) mortality in prospective cohort studies. A systematic search was conducted in electronic databases to identify studies published from January 1996 to December 2015 that satisfied inclusion/exclusion criteria. Risk ratios and 95% confidence intervals were extracted and analyzed using a random-effects model. Nonlinear dose-response analysis was modeled by using restricted cubic splines. The inclusion criteria were met by 22 prospective studies exploring various flavonoid and lignan classes. Compared with lower intake, high consumption of total flavonoids was associated with decreased risk of all-cause mortality (risk ratio = 0.74, 95% confidence intervals: 0.55, 0.99), while a 100-mg/day increment in intake led to a (linear) decreased risk of 6% and 4% of all-cause and CVD mortality, respectively. Among flavonoid classes, significant results were obtained for intakes of flavonols, flavones, flavanones, anthocyanidins, and proanthocyanidins. Only limited evidence was available on flavonoid classes and lignans and all-cause mortality. Findings from this meta-analysis indicated that dietary flavonoids are associated with decreased risk of all-cause and CVD mortality.

Leukocyte Telomere Length and All-Cause, Cardiovascular Disease, and Cancer Mortality: Results From Individual-Participant-Data Meta-Analysis of 2 Large Prospective Cohort Studies

We studied the associations of leukocyte telomere length (LTL) with all-cause, cardiovascular disease, and cancer mortality in 12,199 adults participating in 2 population-based prospective cohort studies from Europe (ESTHER) and the United States (Nurses' Health Study). Blood samples were collected in 1989-1990 (Nurses' Health Study) and 2000-2002 (ESTHER). LTL was measured by quantitative polymerase chain reaction. We calculated z scores for LTL to standardize LTL measurements across the cohorts. Cox proportional hazards regression models were used to calculate relative mortality according to continuous levels and quintiles of LTL z scores. The hazard ratios obtained from each cohort were subsequently pooled by meta-analysis. Overall, 2,882 deaths were recorded during follow-up (Nurses' Health Study, 1989-2010; ESTHER, 2000-2015). LTL was inversely associated with age in both cohorts. After adjustment for age, a significant inverse trend of LTL with all-cause mortality was observed in both cohorts. In random-effects meta-analysis, age-adjusted hazard ratios for the shortest LTL quintile compared with the longest were 1.23 (95% confidence interval (CI): 1.04, 1.46) for all-cause mortality, 1.29 (95% CI: 0.83, 2.00) for cardiovascular mortality, and 1.10 (95% CI: 0.88, 1.37) for cancer mortality. In this study population with an age range of 43-75 years, we corroborated previous evidence suggesting that LTL predicts all-cause mortality beyond its association with age.

Prospective cohort study: Cinacalcet-mediated lowering of PTH level and cardiovascular disease mortality in younger Korean patients with stage 5 CKD at a Korean secondary hospital

WHAT IS KNOWN AND OBJECTIVES

Cinacalcet may reduce cardiovascular disease (CVD) mortality in elderly patients with chronic kidney disease (CKD). However, previous studies of the clinical responses to cinacalcet have exhibited discrepancies due to highly variable baseline levels of parathyroid hormone (PTH), kidney function and age. Little is known about the true effect of cinacalcet on stage 5 CKD. The objective of the current observational study was to evaluate whether cinacalcet-mediated lowering of PTH levels improves all-cause mortality and cardiovascular disease mortality in younger stage 5 CKD patients (mean age <55 years).

METHODS

This prospective, cohort study reviewed the electronic medical records (EMRs) of CKD patients (n=540) with secondary hyperparathyroidism (SHPT) for a period of 36 months. Of 540 patients, 104 subjects met the inclusion criteria and were included in the final evaluation (mean serum iPTH 688.7 pg/mL). Patients were divided into a cinacalcet group (n=43) and a non-cinacalcet group (n=61).

RESULTS AND DISCUSSION

Comparing the cinacalcet group to the non-cinacalcet group, Cox proportional hazard modelling found that all-cause mortality was five (31.3%) in the cinacalcet group and three (15.8%) in the non-cinacalcet group for patients with serum levels of PTH>600 pg/mL [P=.277, hazard ratio 2.213, 95% confidence interval (CI): 0.529-9.262]. Cardiovascular disease mortality (CVD: heart disease) occurred in two (5.3%) in the cinacalcet group and one (2.1%) in the non-cinacalcet group [P=.425, HR 2.611, 95% CI: 0.228-9.939]. Overall, there were no significant differences in CVD mortality between the two groups.

WHAT IS NEW AND CONCLUSION

Cinacalcet was not associated with decreases in all-cause mortality or CVD mortality in younger stage 5 CKD patients with high PTH levels (>600 pg/mL). This could be explained by the diversity of the population in terms of the patient's age, health insurance policies, target serum level of biochemical and PTH, and glomerular filtration rate (GFR) at admission. These data, although based on an observational study, indicate that adding cinacalcet to the current standard care for younger stage 5 CKD patients should be re-evaluated.

Calcium intake and mortality from all causes, cancer, and cardiovascular disease: the Cancer Prevention Study II Nutrition Cohort

BACKGROUND

Calcium intake may be important for bone health, but its effects on other outcomes, including cardiovascular disease (CVD) and cancer, remain unclear. Recent reports of adverse cardiovascular effects of supplemental calcium have raised concerns.

OBJECTIVE

We investigated associations of supplemental, dietary, and total calcium intakes with all-cause, CVD-specific, and cancer-specific mortality in a large, prospective cohort.

DESIGN

A total of 132,823 participants in the Cancer Prevention Study II Nutrition Cohort, who were followed from baseline (1992 or 1993) through 2012 for mortality outcomes, were included in the analysis. Dietary and supplemental calcium information was first collected at baseline and updated in 1999 and 2003. Multivariable-adjusted Cox proportional hazards models with cumulative updating of exposures were used to calculate RRs and 95% CIs for associations between calcium intake and mortality.

RESULTS

During a mean follow-up of 17.5 y, 43,186 deaths occurred. For men, supplemental calcium intake was overall not associated with mortality outcomes (P-trend > 0.05 for all), but men who were taking ≥1000 mg supplemental calcium/d had a higher risk of all-cause mortality (RR: 1.17; 95% CI: 1.03, 1.33), which was primarily attributed to borderline statistically significant higher risk of CVD-specific mortality (RR: 1.22; 95% CI: 0.99, 1.51). For women, supplemental calcium was inversely associated with mortality from all causes [RR (95% CI): 0.90 (0.87, 0.94), 0.84 (0.80, 0.88), and 0.93 (0.87, 0.99) for intakes of 0.1 to <500, 500 to <1000, and ≥1000 mg/d, respectively; P-trend < 0.01]. Total calcium intake was inversely associated with mortality in women (P-trend < 0.01) but not in men; dietary calcium was not associated with all-cause mortality in either sex.

CONCLUSIONS

In this cohort, associations of calcium intake and mortality varied by sex. For women, total and supplemental calcium intakes are associated with lower mortality, whereas for men, supplemental calcium intake ≥1000 mg/d may be associated with higher all-cause and CVD-specific mortality.

Coffee consumption and mortality from all causes, cardiovascular disease, and cancer: a dose-response meta-analysis

Several studies have analyzed the relationship between coffee consumption and mortality, but the shape of the association remains unclear. We conducted a dose-response meta-analysis of prospective studies to examine the dose-response associations between coffee consumption and mortality from all causes, cardiovascular disease (CVD), and all cancers. Pertinent studies, published between 1966 and 2013, were identified by searching PubMed and by reviewing the reference lists of the selected articles. Prospective studies in which investigators reported relative risks of mortality from all causes, CVD, and all cancers for 3 or more categories of coffee consumption were eligible. Results from individual studies were pooled using a random-effects model. Twenty-one prospective studies, with 121,915 deaths and 997,464 participants, met the inclusion criteria. There was strong evidence of nonlinear associations between coffee consumption and mortality for all causes and CVD (P for nonlinearity < 0.001). The largest risk reductions were observed for 4 cups/day for all-cause mortality (16%, 95% confidence interval: 13, 18) and 3 cups/day for CVD mortality (21%, 95% confidence interval: 16, 26). Coffee consumption was not associated with cancer mortality. Findings from this meta-analysis indicate that coffee consumption is inversely associated with all-cause and CVD mortality.

Impairments in hearing and vision impact on mortality in older people: the AGES-Reykjavik Study

OBJECTIVE

to examine the relationships between impairments in hearing and vision and mortality from all-causes and cardiovascular disease (CVD) among older people.

DESIGN

population-based cohort study.

PARTICIPANTS

the study population included 4,926 Icelandic individuals, aged ≥67 years, 43.4% male, who completed vision and hearing examinations between 2002 and 2006 in the Age, Gene/Environment Susceptibility-Reykjavik Study (AGES-RS) and were followed prospectively for mortality through 2009.

METHODS

participants were classified as having 'moderate or greater' degree of impairment for vision only (VI), hearing only (HI), and both vision and hearing (dual sensory impairment, DSI). Cox proportional hazard regression, with age as the time scale, was used to calculate hazard ratios (HR) associated with impairment and mortality due to all-causes and specifically CVD after a median follow-up of 5.3 years.

RESULTS

the prevalence of HI, VI and DSI were 25.4, 9.2 and 7.0%, respectively. After adjusting for age, significantly (P < 0.01) increased mortality from all causes, and CVD was observed for HI and DSI, especially among men. After further adjustment for established mortality risk factors, people with HI remained at higher risk for CVD mortality [HR: 1.70 (1.27-2.27)], whereas people with DSI remained at higher risk of all-cause mortality [HR: 1.43 (1.11-1.85)] and CVD mortality [HR: 1.78 (1.18-2.69)]. Mortality rates were significantly higher in men with HI and DSI and were elevated, although not significantly, among women with HI.

CONCLUSIONS

older men with HI or DSI had a greater risk of dying from any cause and particularly cardiovascular causes within a median 5-year follow-up. Women with hearing impairment had a non-significantly elevated risk. Vision impairment alone was not associated with increased mortality.

Blood pressure in early adulthood, hypertension in middle age, and future cardiovascular disease mortality: HAHS (Harvard Alumni Health Study)

OBJECTIVES

We sought to examine the association of early adulthood blood pressure with cardiovascular disease (CVD) mortality, while accounting for middle-age hypertension.

BACKGROUND

Elevated blood pressure in middle age is an established CVD risk factor, but evidence for association with measurements earlier in life is sparse.

METHODS

The HAHS (Harvard Alumni Health Study) is a cohort study of 18,881 male university students who had their blood pressure measured at university entry (1914 to 1952; mean age 18.3 years) and who responded to a questionnaire mailed in either 1962 or 1966 (mean age 45.8 years) in which physician-diagnosed hypertension status was reported. Study members were subsequently followed for mortality until the end of 1998.

RESULTS

Following adjustment for age, body mass index, smoking, and physical activity at college entry, compared with men who were normotensive according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria (<120/<80 mm Hg), there was an elevated risk of coronary heart disease (CHD) mortality (1,917 deaths) in those who were pre-hypertensive (120 to 139/80 to 89 mm Hg) (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.07 to 1.36), stage 1 (140 to 159/90 to 99 mm Hg) (HR: 1.46; 95% CI: 1.25 to 1.70), and stage 2 hypertensive (≥160/≥100 mm Hg) (HR: 1.89; 95% CI: 1.46 to 2.45), incremental across categories (p(trend) < 0.001). After additionally accounting for middle-age hypertension, estimates were somewhat attenuated, but the pattern remained. Similar associations were apparent for total and CVD mortality, but not stroke mortality.

CONCLUSIONS

Higher blood pressure in early adulthood was associated with elevated risk of all-cause mortality, CVD, and CHD, but not stroke, several decades later. Effects largely persisted after taking into account mediation by middle-age hypertension. Thus, the long-term benefits of blood pressure lowering in early adulthood are promising, but supporting trial data are required.

Body mass index, waist circumference and waist-hip ratio: which is the better discriminator of cardiovascular disease mortality risk?: evidence from an individual-participant meta-analysis of 82 864 participants from nine cohort studies

Few studies have examined both the relative magnitude of association and the discriminative capability of multiple indicators of obesity with cardiovascular disease (CVD) mortality risk. We conducted an individual-participant meta-analysis of nine cohort studies of men and women drawn from the British general population resulting in sample of 82 864 individuals. Body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) were measured directly. There were 6641 deaths (1998 CVD) during a mean of 8.1 years of follow-up. After adjustment, a one SD higher in WHR and WC was related to a higher risk of CVD mortality (hazard ratio [95% CI]): 1.15 (1.05-1.25) and 1.15 (1.04-1.27), respectively. The risk of CVD mortality also increased linearly across quintiles of both these abdominal obesity markers with a 66% increased risk in the highest quintile of WHR. In age- and sex-adjusted models only, BMI was related to CVD mortality but not in any other analyses. No major differences were revealed in the discrimination capabilities of models with BMI, WC or WHR for cardiovascular or total mortality outcomes. In conclusion, measures of abdominal adiposity, but not BMI, were related to an increased risk of CVD mortality. No difference was observed in discrimination capacities between adiposity markers.

Effects of statin medication on mortality risk associated with type 2 diabetes in older persons: the population-based AGES-Reykjavik Study

OBJECTIVE

To examine if the beneficial effect of statin medication on mortality seen in randomised clinical trials of type 2 diabetes applies equally to observational studies in the general population of older people.

DESIGN

A prospective, population-based cohort study.

SETTING

Reykjavik, Iceland.

PARTICIPANTS

5152 men and women from the Age, Gene/Environment Susceptibility-Reykjavik Study, mean age 77 years, range of 66-96 years.

MAIN OUTCOME MEASURE

Cardiovascular and all-cause mortalities and the RR of dying according to statin use and history of coronary heart disease (CHD) in persons with type 2 diabetes and those without diabetes with a median follow-up time of 5.3 years, until end of 2009.

RESULTS

The prevalence of type 2 diabetes was 12.4% of which 35% used statins. Statin use was associated with a 50% (95% CI 8% to 72%) lower cardiovascular mortality and 53% (29% to 68%) lower all-cause mortalities in persons with diabetes. For those without diabetes, statin use was associated with a 16% (-24% to 43%) lower cardiovascular and 30% (11% to 46%) lower all-cause mortalities. Persons with diabetes using statins had a comparable risk of cardiovascular and all-cause mortality to that of the general population without diabetes. The effect was independent of the level of glycaemic control.

CONCLUSION

This observational study lends important support to existing data from randomised clinical trials. These data suggest that in the general population of older people with diabetes, statin medication markedly reduces the excess cardiovascular and all-cause mortality risk, irrespective of the presence or absence of coronary heart disease or glucose-lowering medication.

Cold surge: a sudden and spatially varying threat to health?

While cold surge is one of the most conspicuous features of the winter monsoon in East Asia, its impact on human health remains underexplored. Based on the definition by the Central Weather Bureau in Taiwan, we identified four cold surges between 2000 and 2003 and collected the cardiovascular disease mortality data 2 weeks before and 2 weeks after these events. We attempted to answer the following research questions: 1) whether the cold surges impose an adverse and immediate effect on cardiovascular mortality; 2) whether the people living in temperate zones have a higher tolerance of extreme temperature drop than those in the subtropics. With geographic weighting techniques, we not only found that the cardiovascular disease mortality rates increased significantly after the cold surges, but also discovered a spatially varying pattern of tolerance to cold surges. Even within a small study area such as Taiwan, human reaction to severe weather drop differs across space. Needless to say, in the U.S., these findings should be considered in redirecting policy to address populations living in warm places when extreme temperature drops occur.