1
|
Cai J, Pirzada A, Baldoni PL, Heiss G, Kunz J, Rosamond WD, Youngblood ME, Aviles-Santa ML, Gallo LC, Isasi CR, Kaplan R, Lash JP, Lee DJ, Llabre MM, Schneiderman N, Wassertheil-Smoller S, Talavera GA, Daviglus ML. Cumulative All-Cause Mortality in Diverse Hispanic/Latino Adults : A Prospective, Multicenter Cohort Study. Ann Intern Med 2024; 177:303-314. [PMID: 38437694 DOI: 10.7326/m23-1990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND All-cause mortality among diverse Hispanic/Latino groups in the United States and factors underlying mortality differences have not been examined prospectively. OBJECTIVE To describe cumulative all-cause mortality (and factors underlying differences) by Hispanic/Latino background, before and during the COVID-19 pandemic. DESIGN Prospective, multicenter cohort study. SETTING Hispanic Community Health Study/Study of Latinos. PARTICIPANTS 15 568 adults aged 18 to 74 years at baseline (2008 to 2011) of Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and other backgrounds from the Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California. MEASUREMENTS Sociodemographic, acculturation-related, lifestyle, and clinical factors were assessed at baseline, and vital status was ascertained through December 2021 (969 deaths; 173 444 person-years of follow-up). Marginally adjusted cumulative all-cause mortality risks (11-year before the pandemic and 2-year during the pandemic) were examined using progressively adjusted Cox regression. RESULTS Before the pandemic, 11-year cumulative mortality risks adjusted for age and sex were higher in the Puerto Rican and Cuban groups (6.3% [95% CI, 5.2% to 7.6%] and 5.7% [CI, 5.0% to 6.6%], respectively) and lowest in the South American group (2.4% [CI, 1.7% to 3.5%]). Differences were attenuated with adjustment for lifestyle and clinical factors. During the pandemic, 2-year cumulative mortality risks adjusted for age and sex ranged from 1.1% (CI, 0.6% to 2.0%; South American) to 2.0% (CI, 1.4% to 3.0%; Central American); CIs overlapped across groups. With adjustment for lifestyle factors, 2-year cumulative mortality risks were highest in persons of Central American and Mexican backgrounds and lowest among those of Puerto Rican and Cuban backgrounds. LIMITATION Lack of data on race and baseline citizenship status; correlation between Hispanic/Latino background and site. CONCLUSION Differences in prepandemic mortality risks across Hispanic/Latino groups were explained by lifestyle and clinical factors. Mortality patterns changed during the pandemic, with higher risks in persons of Central American and Mexican backgrounds than in those of Puerto Rican and Cuban backgrounds. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Jianwen Cai
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (J.C., M.E.Y.)
| | - Amber Pirzada
- Institute for Minority Health Research, University of Illinois Chicago, Chicago, Illinois (A.P., M.L.D.)
| | - Pedro L Baldoni
- Bioinformatics Division, Walter and Eliza Hall Institute of Medical Research, and Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia (P.L.B.)
| | - Gerardo Heiss
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (G.H., W.D.R.)
| | - John Kunz
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (J.K.)
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (G.H., W.D.R.)
| | - Marston E Youngblood
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (J.C., M.E.Y.)
| | - M Larissa Aviles-Santa
- Division of Clinical and Health Services Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland (M.L.A.)
| | - Linda C Gallo
- Department of Psychology, San Diego State University, San Diego, California (L.C.G., G.A.T.)
| | - Carmen R Isasi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (C.R.I., S.W.)
| | - Robert Kaplan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, and Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington (R.K.)
| | - James P Lash
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois (J.P.L.)
| | - David J Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida (D.J.L.)
| | - Maria M Llabre
- Department of Psychology, University of Miami, Miami, Florida (M.M.L., N.S.)
| | - Neil Schneiderman
- Department of Psychology, University of Miami, Miami, Florida (M.M.L., N.S.)
| | - Sylvia Wassertheil-Smoller
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (C.R.I., S.W.)
| | - Gregory A Talavera
- Department of Psychology, San Diego State University, San Diego, California (L.C.G., G.A.T.)
| | - Martha L Daviglus
- Institute for Minority Health Research, University of Illinois Chicago, Chicago, Illinois (A.P., M.L.D.)
| |
Collapse
|
2
|
Zègre-Hemsey JK, Cheskes S, Johnson AM, Rosamond WD, Cunningham CJ, Arnold E, Schierbeck S, Claesson A. Challenges & barriers for real-time integration of drones in emergency cardiac care: Lessons from the United States, Sweden, & Canada. Resusc Plus 2024; 17:100554. [PMID: 38317722 PMCID: PMC10838948 DOI: 10.1016/j.resplu.2024.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
Importance Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality in the US and Europe (∼600,000 incident events annually) and around the world (∼3.8 million). With every minute that passes without cardiopulmonary resuscitation or defibrillation, the probability of survival decreases by 10%. Preliminary studies suggest that uncrewed aircraft systems, also known as drones, can deliver automated external defibrillators (AEDs) to OHCA victims faster than ground transport and potentially save lives. Objective To date, the United States (US), Sweden, and Canada have made significant contributions to the knowledge base regarding AED-equipped drones. The purpose of this Special Communication is to explore the challenges and facilitators impacting the progress of AED-equipped drone integration into emergency medicine research and applications in the US, Sweden, and Canada. We also explore opportunities to propel this innovative and important research forward. Evidence review In this narrative review, we summarize the AED-drone research to date from the US, Sweden, and Canada, including the first drone-assisted delivery of an AED to an OHCA. Further, we compare the research environment, emergency medical systems, and aviation regulatory environment in each country as they apply to OHCA, AEDs, and drones. Finally, we provide recommendations for advancing research and implementation of AED-drone technology into emergency care. Findings The rates that drone technologies have been integrated into both research and real-life emergency care in each country varies considerably. Based on current research, there is significant potential in incorporating AED-equipped drones into the chain of survival for OHCA emergency response. Comparing the different environments and systems in each country revealed ways that each can serve as a facilitator or barrier to future AED-drone research. Conclusions and relevance The US, Sweden, and Canada each offers different challenges and opportunities in this field of research. Together, the international community can learn from one another to optimize integration of AED-equipped drones into emergency systems of care.
Collapse
Affiliation(s)
| | - Sheldon Cheskes
- Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
| | - Anna M. Johnson
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, United States
| | - Wayne D. Rosamond
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, United States
| | | | - Evan Arnold
- North Carolina State University, Institute for Transportation Research and Education, United States
| | - Sofia Schierbeck
- Centre for Resuscitation Science, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Claesson
- Centre for Resuscitation Science, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
3
|
Sloane KL, Gottesman RF, Johansen MC, Jones Berkeley S, Coresh J, Kucharska-Newton A, Rosamond WD, Schneider ALC, Koton S. Stroke Subtype and Risk of Subsequent Hospitalization: The Atherosclerosis Risk in Communities Study. Neurology 2024; 102:e208035. [PMID: 38181329 PMCID: PMC11023038 DOI: 10.1212/wnl.0000000000208035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/13/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Risk of readmission after stroke differs by stroke (sub)type and etiology, with higher risks reported for hemorrhagic stroke and cardioembolic stroke. We examined the risk and cause of first readmission by stroke subtype over the years post incident stroke. METHODS Atherosclerosis Risk in Communities (ARIC) study participants (n = 1,412) with first-ever stroke were followed up for all-cause readmission after incident stroke. Risk of first readmission was examined by stroke subtypes (cardioembolic, thrombotic/lacunar, and hemorrhagic [intracerebral and subarachnoid]) using Cox and Fine-Gray proportional hazards models, adjusting for sociodemographic and cardiometabolic risk factors. RESULTS Among 1,412 participants (mean [SD] age 72.4 [9.3] years, 52.1% women, 35.3% Black), 1,143 hospitalizations occurred over 41,849 person-months. Overall, 81% of participants were hospitalized over a maximum of 26.6 years of follow-up (83% of participants with thrombotic/lacunar stroke, 77% of participants with cardioembolic stroke, and 78% of participants with hemorrhagic stroke). Primary cardiovascular and cerebrovascular diagnoses were reported for half of readmissions. Over the entire follow-up period, compared with cardioembolic stroke, readmission risk was lower for thrombotic/lacunar stroke (hazard ratio [HR] 0.82, 95% CI 0.71-0.95) and hemorrhagic stroke (HR 0.74, 95% CI 0.58-0.93) in adjusted Cox proportional hazards models. By contrast, there was no statistically significant difference among subtypes when adjusting for atrial fibrillation and competing risk of death. Compared with cardioembolic stroke, thrombotic/lacunar stroke was associated with lower readmission risk within 1 month (HR 0.66, 95% CI 0.46-0.93) and during 1 month-1 year (HR 0.78, 95% CI 0.62-0.97), and hemorrhagic stroke was associated with lower risk during 1 month-1 year (HR 0.60, 95% CI 0.41-0.87). There was no significant difference between subtypes in readmission risk during later periods. DISCUSSION Over 26 years of follow-up, 81% of stroke participants experienced a readmission. Cardiovascular and cerebrovascular diagnoses at readmission were most common across stroke subtypes. Though cardioembolic stroke has previously been reported to confer higher risk of readmission, in this study, the readmission risk was not statistically significantly different between stroke subtypes or over different periods when accounting for the competing risk of death.
Collapse
Affiliation(s)
- Kelly L Sloane
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Rebecca F Gottesman
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Michelle C Johansen
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Sara Jones Berkeley
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Josef Coresh
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Anna Kucharska-Newton
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Wayne D Rosamond
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Andrea L C Schneider
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| | - Silvia Koton
- From the Department of Neurology (K.L.S., A.L.C.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; National Institute of Neurological Disorders and Stroke Intramural Research Program (R.F.G.), NIH, Bethesda, MD; Department of Neurology (M.C.J.), School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (S.J.B, A.K.-N., W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill; Department of Epidemiology (J.C., S.K.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Epidemiology (A.K.-N.), College of Public Health, University of Kentucky, Lexington; Department of Biostatistics (A.L.C.S.), Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; and School of Health Professions (S.K.), Faculty of Medicine, Tel Aviv University, Israel
| |
Collapse
|
4
|
Sen S, Logue L, Logue M, Otersen E, Mason E, Moss K, Curtis J, Hicklin D, Nichols C, Rosamond WD, Gottesman RF, Beck J. Dental Caries, Race and Incident Ischemic Stroke, Coronary Heart Disease, and Death. Stroke 2024; 55:40-49. [PMID: 38018831 PMCID: PMC10841981 DOI: 10.1161/strokeaha.123.042528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/19/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Dental caries is a highly prevalent disease worldwide. In the United States, untreated dental caries is present in >1 in 5 adults. The objective of this study was to determine the relationship between dental caries and incident ischemic stroke, coronary heart disease (CHD) events, and death. METHODS The dental cohort (n=6351) of the ARIC study (Atherosclerosis Risk in Communities) was followed for incident ischemic stroke, CHD event, and all-cause mortality. Of all the participants at visit 4 (n=11 656), those who were unable to go through dental examination, or with prevalent ischemic stroke and CHD events, were excluded. The full-mouth dental examination was conducted at visit 4 (1996-1998), assessing dental caries. The dose response of decayed, missing, and filled surfaces due to caries was assessed and related to the outcome. Outcomes were assessed through the end of 2019. Additionally, the effect of regular dental care utilization on dental caries was evaluated. RESULTS Participants with ≥1 dental caries had an increased risk of stroke (adjusted hazard ratio [HR], 1.40 [95% CI, 1.10-1.79]) and death (adjusted HR, 1.13 [95% CI, 1.01-1.26]) but not for CHD events (adjusted HR, 1.13 [95% CI, 0.93-1.37]). The association of dental caries and ischemic incident stroke was significantly higher in the African American population compared with the White subgroup (interaction term P=0.0001). Increasing decayed, missing, and filled surfaces were significantly associated with stroke (adjusted HR, 1.006 [95% CI, 1.001-1.011]) and death (adjusted HR, 1.003 [95% CI, 1.001-1.005]) but not CHD (adjusted HR, 1.002 [95% CI, 1.000-1.005]). Regular dental care utilization lowered (adjusted odds ratio, 0.19 [95% CI, 0.16-0.22]; P<0.001) the chance of caries. CONCLUSIONS Among the cohort, dental caries was independently associated with the risk of ischemic stroke and death, with the effect higher in African American participants. Regular dental care utilization was associated with a lower chance of caries, emphasizing its relevance in the prevention of these events.
Collapse
Affiliation(s)
- Souvik Sen
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, SC
| | - Lawson Logue
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, SC
| | - Makenzie Logue
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, SC
| | - Elizabeth Otersen
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, SC
| | - Emma Mason
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, SC
| | - Kevin Moss
- Division of Comprehensive Oral Health/Periodontology, University of North Carolina, Chapel Hill, NC
| | - James Curtis
- Department of Dentistry, Prisma Health Medical Group, Columbia, SC
| | - David Hicklin
- Department of Dentistry, Prisma Health Medical Group, Columbia, SC
| | - Cynthia Nichols
- Department of Dentistry, Prisma Health Medical Group, Columbia, SC
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, MD
| | - James Beck
- Division of Comprehensive Oral Health/Periodontology, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
5
|
Johnson AM, Rosamond WD. What does the COVID-19 pandemic reveal about out-of-hospital cardiac arrest? Insights from the Canadian EMS response. Resuscitation 2024; 194:110096. [PMID: 38135015 DOI: 10.1016/j.resuscitation.2023.110096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States.
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| |
Collapse
|
6
|
Browder SE, Rosamond WD. Preventing Heart Failure Readmission in Patients with Low Socioeconomic Position. Curr Cardiol Rep 2023; 25:1535-1542. [PMID: 37751036 PMCID: PMC10863623 DOI: 10.1007/s11886-023-01960-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the current burden of heart failure (HF) in the United States, specifically in patients with low socioeconomic position (SEP), and synthesize recommendations to prevent HF-related hospital readmissions in this vulnerable population. RECENT FINDINGS As treatments have improved, HF-related mortality has declined over time, resulting in more patients living with HF. This has led to an increase in hospitalizations, however, putting excess strain on our healthcare system. HF patients with low SEP are a particularly vulnerable group, as they experience higher rates of hospitalization and readmission compared to their high SEP counterparts. The Hospital Readmission Reduction Program (HRRP) was created to motivate interventions that reduce hospital readmissions across diseases, with HF being a primary target. Numerous readmission prevention efforts have been suggested to target the pre-hospitalization, hospitalization, and post-hospitalization phases, including addressing social determinants of health (SDoH), improving coordination of care, optimizing discharge plans, and improving adherence to follow-up care and medication regimens. Many of these proposed interventions show promise in reducing HF-related readmissions and issues surrounding adequate caregiver support may be particularly important to reduce readmissions among persons in low SEP. Reducing HF-related hospital readmissions is possible, even in vulnerable populations like those with low SEP, but this will require coordinated efforts across the healthcare system and throughout the life course of these patients. Caregiver support is a necessary part of optimized care for low SEP HF patients and future efforts should consider interventions that support these caregivers.
Collapse
Affiliation(s)
- Sydney E Browder
- UNC Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA.
| | - Wayne D Rosamond
- UNC Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA
| |
Collapse
|
7
|
LaValley EA, Sen S, Mason E, Logue M, Trivedi T, Moss K, Beck J, Rosamond WD, Gottesman RF. Dental Caries a Risk Factor for Intracerebral Hemorrhage. Cerebrovasc Dis 2023; 53:98-104. [PMID: 37231788 PMCID: PMC10988391 DOI: 10.1159/000530568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/23/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Streptococcus mutans is a known cause of dental caries that contains a collagen-binding protein, Cnm, and exhibits inhibition of platelet aggregation and matrix metalloproteinase-9 activation. This strain has been linked to aggravation of experimental intracerebral hemorrhage (ICH) and may be a risk factor for ICH. The purpose of this study was to test the association between dental caries and incident ICH. METHODS The presence of dental caries and periodontal disease was assessed in subjects from the Dental Atherosclerosis Risk in Communities (DARIC) study without prior stroke or ICH. This cohort was followed for incident ICH over a period of 10 years. Cox regression was used to compute crude and adjusted hazards ratio from the dental assessment. RESULTS Among 6,315 subjects, dental surface caries and/or root caries were recorded in 1,338 (27%) subjects. Of those, 7 (0.5%) had incident ICH over a period of 10 years following the visit 4 assessment. Of the remaining 4,977 subjects, 10 (0.2%) had incident ICH. Those with dental caries versus those without dental caries were slightly younger (mean age 62.0 ± 5.7 vs. 62.4 ± 5.6, p = 0.012), had a greater proportion of males (51 vs. 44%, p < 0.001), African Americans (44 vs. 10%, p < 0.001), and were hypertensive (42 vs. 31%, p < 0.001). The association between caries and ICH was significant (crude HR 2.69, 95% CI 1.02-7.06) and strengthened after adjustment for age, gender, race, education level, hypertension, and periodontal disease (adjusted HR 3.88, 95% CI 1.34-11.24). CONCLUSION Dental caries is a potential risk for incident ICH after caries detection. Future studies are needed to determine if treatment of dental caries can reduce the risk of ICH.
Collapse
Affiliation(s)
- Elizabeth A LaValley
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, South Carolina, USA
| | - Souvik Sen
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, South Carolina, USA
| | - Emma Mason
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, South Carolina, USA
| | - Makenzie Logue
- Department of Neurology, University of South Carolina, School of Medicine, Columbia, South Carolina, USA
| | - Tushar Trivedi
- Department of Neurology, Regional Medical Center, Orangeburg, South Carolina, USA
| | - Kevin Moss
- Division of Comprehensive Oral Health/Periodontology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - James Beck
- Division of Comprehensive Oral Health/Periodontology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| |
Collapse
|
8
|
Koton S, Chen J, Johansen MC, Pike JR, Mosley T, Rosamond WD, Schneider A, Gottesman RF, Coresh J. Abstract P468: Time Trends in Severity of Incident Ischemic Stroke in the Atherosclerosis Risk in Communities Study From 1987 to 2018. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Background:
Stroke severity at hospital admission is the most important clinical predictor of short- and long-term functional outcome and mortality after stroke. Decreases in stroke severity over the last two decades have been reported in some countries; however, data on stroke severity from large prospective cohort studies in the US are not available for recent years. We studied trends in stroke severity of incident ischemic stroke from 1987 to 2018 in the prospective Atherosclerosis Risk in Communities (ARIC) study.
Methods:
Severity of stroke on admission was determined through review of ARIC hospital charts for incident ischemic strokes using the National Institutes of Health Stroke Scale (NIHSS). Events with inadequate information for NIHSS score determination were excluded (n=209). Severity was categorized as minor, NIHSS≤5; mild, 6-10; moderate, 11-15; and severe, ≥16. Mean NIHSS scores by year were presented by age group (Figure) and trends in NIHSS score from 1987 to 2018 were studied with linear regression model. Changes in the proportion of minor stroke compared to more severe stroke (NIHSS>5) were assessed using logistic regression. Multivariable models included age at stroke, sex, race-center, and baseline education level, hypertension, BMI, diabetes and smoking status as covariates.
Results:
Among 15,661 participants (age 45-64) free of stroke at baseline (1987-89), 1,036 incident stroke cases with severity scores (NIHSS: 638 [61.6%] minor, 222 [21.4%] mild, 88 [8.5%] moderate and 88 [8.5%] severe) were included. Mean age (SD) at incident stroke was 69.5 (9.9) years, 55.2% women and 26.8% Black. For each 1-year calendar time, the adjusted estimate for the continuous NIHSS score was -0.026 (SE=0.040), p=0.5109, and the adjusted OR (95% CI) for NIHSS≤5 compared to NIHSS>5 was 0.99 (0.97, 1.01).
Conclusion:
Among participants with incident ischemic stroke in the prospective ARIC study, no clear decrease in severity of stroke was observed from 1987 to 2018.
Collapse
Affiliation(s)
| | - Jinyu Chen
- UNIVERSITY OF NORTH CAROLINA, Chapel Hill, NC
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Peter KM, Kucharska-Newton A, Wong E, Palta P, Mok Y, Lutsey PL, Rosamond WD. Abstract P256: Psychosocial Risk Factors Are Associated With Lower Cardiovascular Health, Measured by Life’s Essential 8, in the Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Introduction:
Psychosocial factors (social isolation, social support, trait anger, and depressive symptoms) are associated with cardiovascular disease risk factors and incidence; few studies investigate whether they are associated with cardiovascular health (CVH), and none with a new definition of CVH, Life’s Essential 8 (LE8) published by the American Heart Association (AHA).
Hypothesis:
Cross-sectional associations of psychosocial factors and CVH will be inverse, and will be modified by sex and race.
Methods:
We included 11,674 ARIC cohort participants (58% women; 23% Black; mean age 57 (standard deviation (SD): 6) years) who attended Visit 2 (1990-1992) and had complete data. All psychosocial factors and the following LE8 components were measured at Visit 2: nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure. Physical activity and diet were measured at Visit 1 (1987-1989). Psychosocial factors were categorized per standard convention or by tertiles. LE8 was scored per the AHA definition (0-100 range). Associations of each psychosocial factor with continuous LE8 score were assessed using multivariable linear regressions.
Results:
Mean LE8 score was 61 (SD: 15). Poorer scores on psychosocial factor assessments were associated with lower LE8 scores, with the largest magnitude of association for depressive symptoms (Figure). Participants with high levels of depressive symptoms had an LE8 score 8 points lower than those with low levels of depressive symptoms. Stratum-specific estimates and p-values for interaction terms suggested no modification by sex; however psychosocial factors were associated with approximately a 1 point lower LE8 score in White participants than in Black participants.
Conclusion:
Poorer psychosocial health factors were associated with lower CVH among middle-aged men and women in ARIC. Future work could investigate whether psychosocial factors modify the relationship between CVH and incident cardiovascular disease.
Collapse
Affiliation(s)
| | | | - Eugenia Wong
- Univ of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya Palta
- Univ of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | |
Collapse
|
10
|
Liu H, Ishigami J, Mathews LM, Konety SH, Hall ME, Chang P, Ndumele CE, Rosamond WD, Matsushita K. Abstract P176: The Association of Blood Urea Nitrogen With Incident Heart Failure in the Community: The Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Background:
Blood urea nitrogen (BUN) has been shown as a potent predictor of morbidity and mortality in patients with heart failure (HF). Whether BUN levels are associated with incident HF in the general population is unknown.
Methods:
Among 14,263 ARIC participants without a history of HF at baseline (1987-1989) (mean age 54 [SD 5.7] years, Female 54.4%, Black 25.4%), we assessed the association of BUN with incident HF. BUN levels (mg/dL) were divided by quartiles in the primary analysis, and the highest quartile was further divided into tertiles in the secondary analysis (Q1<13, Q2 13-15, Q3 15-17, Q4a 17-19, Q4b 19-21, Q4c >21). We defined HF as hospitalization or death with HF diagnosis and estimated hazard ratios (HRs) using multivariable Cox regression models.
Results:
During a median follow-up of 26.2 years, 3,506 participants developed incident HF (incidence rate 10.7 per 1,000 person-year). When we adjusted for demographic variables, using the lowest quartile (Q1) as the reference, the top quartile (Q4) showed an HR of 1.18 (95% CI 1.08, 1.10) (Model 1 in
Table
). When we subdivided Q4, Q4c showed the highest HR (1.40 [95% CI 1.21, 1.61]). The association was similar after further adjusting for lifestyle and other clinical factors (Model 2 in
Table
). Further adjustment for estimated glomerular filtration rate modestly attenuated the association (Model 3 in
Table
), but HRs remained significant for Q4 as a whole (1.11 [1.01, 1.22]) and Q4c (1.27 [1.09, 1.47]). In subgroup analysis, the association was stronger in Black participants than in White participants (p-for-interaction <0.05).
Conclusion:
In this community-based cohort, higher BUN levels were significantly associated with incident HF. BUN levels are often measured as part of routine clinical care and thus may inform clinicians to identify individuals at risk of HF, particularly in resource-constrained settings with limited availability of measuring HF-specific markers such as natriuretic peptides.
Collapse
Affiliation(s)
- Hairong Liu
- JOHNS HOPKINS UNIVERSITY BLOOMBERG SCHOOL OF PUBLICH HEALTH, baltimore, MD
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Wong E, Jones S, Franceschini N, Allison MA, Garcia L, Wise Thomas S, Shadyab AH, Rosamond WD. Abstract P318: Life’s Essential 8 as a Measure of Cardiovascular Health in the Women’s Health Initiative (WHI). Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction:
In 2022, the American Heart Association (AHA) introduced Life’s Essential 8 (LE8) as an updated definition of cardiovascular health (CVH). Sleep health was added to the original Life’s Simple 7 (LS7), and a new scoring system was developed. We evaluated how LE8 characterizes CVH among women in the WHI.
Hypothesis:
We hypothesized that the average LE8 score would be moderate, with only a small group of WHI participants having high CVH.
Methods:
The WHI recruited 161,808 post-menopausal women from 40 clinical centers in 1993-1998. This analysis included 116,514 women without self-reported CVD, with measured height, weight, and blood pressure, and self-reported smoking history, sleep duration, physical activity, diet, diabetes, and cholesterol at baseline. CVH components were scored from 0-100 based on participants’ achievement of each health factor or behavior. Scores were assigned per AHA guidance with some adaptations made based on data availability. Lacking measured values, glucose and lipid scores were calculated based on history and treatment status of diabetes and high cholesterol. Overall LE8 scores were calculated as the unweighted mean of all components. Scores were further categorized into high (80-100), moderate (50-79), or low (0-49), with higher scores indicating positive CVH.
Results:
The average LE8 score among WHI participants at baseline was 71.5 (standard deviation (SD): 12.5; range 20.6-100) (
Figure
). Overall, sleep scores were high (mean: 86.5, SD 19.1). The lowest scores were found in diet (mean: 39.5, SD 31.3) and physical activity (mean: 47.7, SD: 43.5). LE8 classified 28.1% of WHI participants (32,773/116,514) as having high CVH whereas a prior analysis of LS7 found that 17.7% and 6.1% had ideal levels of 5 and 6-7 CVH components, respectively.
Conclusions:
Based on the new LE8 definition, most women had moderate CVH at study baseline, with approximately a quarter having high CVH. Although sleep health was high, scores for other health behaviors demonstrated considerable room for improvement.
Collapse
Affiliation(s)
- Eugenia Wong
- Univ of North Carolina at Chapel H, Chapel Hill, NC
| | - Sara Jones
- Univ of North Carolina at Chapel H, Chapel Hill, NC
| | | | | | | | | | | | | |
Collapse
|
12
|
McCain C, Martin C, Kerley J, Logue M, Trivedi T, Melikov P, Gottesman RF, Rosamond WD, Sen S. Abstract TMP105: Migraine With Aura Risk Score, Medication Use And Composite Cardiovascular. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
The migraine with aura risk score (MARS) was developed to predict the risk of ischemic stroke in patients with migraine with aura. Certain medications (estrogen replacement therapy-ERT, triptans and ergot alkaloids) have been postulated to increase cardiovascular risk. We tested if MARS or medications increased risk of ischemic stroke, cardiovascular event, and death.
Methods:
Migraine with aura patients (N=430) in the Atherosclerosis Risk in Communities Cohort were considered in this study. Those who had events prior to being evaluated were excluded leaving 420 patients. MARS was calculated at visit 3 (1993-1995) and patients were stratified as low (≤2) and high (≥3) risk groups. Medication uses were recorded on the same visit.
Results:
Of the 420 patients with a history of migraine with aura (age, mean±standard deviation=58.5±5.5, 349 female, 344 white), 49 patients had an ischemic stroke, 79 had a cardiovascular event, and 192 died during a 25-year follow-up period. The high-risk group was noted to have hazards ratio (HR) of 4.41 (95% CI 2.45-7.94) for ischemic stroke, 5.89 (95% CI 3.69-9.38) for cardiovascular event, and 3.56 (95% CI 2.66-4.79) for death, compared with the low-risk group. HR for composite events was 3.60 (95% CI 2.73-4.75). Kaplan-Meier Survival curves are depicted below (Logrank p<0.0001). Among medications only ERT (used in 34%) was associated with a significantly lower risk of composite events (HR 0.63, 95% CI 0.47-0.84), no significant difference for triptans (used in 1%) or ergot alkaloids (used in 4%).
Conclusion:
MARS≥3 increased the risk of composite events. Triptans and ergot alkaloids were not associated with increased risks and ERT was associated with a lower risk of composite events. The MARS finding needs validation in an external dataset and medication effects need confirmation in a randomized clinical trial.
Collapse
Affiliation(s)
| | | | | | | | | | - Petr Melikov
- TEL-AVIV SOURASKY MEDICAL CENTER, Tel Aviv, Israel
| | | | | | | |
Collapse
|
13
|
Logue M, McCain C, Martin C, Suri F, Wasserman BA, Gottesman RF, Rosamond WD, Sen S. Abstract 135: Adiponectin: Potential Mediator Between Central Obesity And Intracranial Atherosclerosis? Stroke 2023. [DOI: 10.1161/str.54.suppl_1.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Prior studies have identified a significant association between Waist-to-Hip Ratio (WHR) and intracranial atherosclerosis (ICAS). Adiponectin, a hormone that improves insulin sensitivity, has been hypothesized to have a protective effect against atherosclerosis. We assessed the association between central obesity-ICAS, and its potential mediation by Adiponectin.
Methods:
In the ARIC cohort a stratified subset of subjects were assessed for adiposity, adiponectin level and ICAS during visit 5 (2011-2013). Adiposity was assessed by body mass index (BMI) and waist to hip ratio (WHR). Central obesity was defined as WHR ≥0.90 for men and ≥0.85 for women. Plasma total and total adiponectin were measured by ELISA. ICAS was assessed for by 3D time-of-flight magnetic resonance angiogram (MRA). Subjects were stratified as those with any ICAS and those without. Multivariable analysis was conducted using multiple logistic regression to test the central obesity-ICAS association.
Results:
A total of 1641 subjects underwent evaluations (age 76.3±5.3, 41% Male, 71% white). Of these subjects 506 (31%) had ICAS detected on MRA. Those with ICAS were older (77±5 vs. 76±5, p<0.001), likely to be male (47% vs. 39%, p=0.001), African American (33% vs. 27%, p=0.006) and hypertensive (72% vs. 64%, p=0.004). Those with ICAS had similar BMI (28.5±5.7 vs. 28.1±5.3, p=0.26) although the WHR was higher (0.94±0.08 vs. 0.92±0.08, p<0.001). Adiponectin levels were lower (10.6±6.7 vs. 12.0±7.5, p<0.001) compared with those without ICAS. Those with central obesity had a lower level of Adiponectin (10.6±6.5 vs. 15.3±8.7, p<0.001). Central obesity was significantly (p=0.01) associated with ICAS (Odds Ratio 1.43, 95%) CI 1.08-1.91) adjusted for age, race, gender, and hypertension, however lost its significance (p=0.06) when Adiponectin is added to the model (Odds Ratio 1.33, 95% CI 0.99-1.80).
Conclusion:
We report a significant inverse association between central obesity, as well as ICAS, with Adiponectin levels. We also report a significant association between central obesity with ICAS that loses its significance after adding Adiponectin to the multivariate model. This result suggests that central obesity effect on ICAS may possibly be mediated by Adiponectin.
Collapse
Affiliation(s)
| | | | | | - Fareed Suri
- CentraCare Neurosciences Stroke Cntr, Saint Cloud, MN
| | | | | | | | | |
Collapse
|
14
|
Mathews L, Ding N, Sang Y, Loehr LR, Shin JI, Punjabi NM, Bertoni AG, Crews DC, Rosamond WD, Coresh J, Ndumele CE, Matsushita K, Chang PP. Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study. J Racial Ethn Health Disparities 2023; 10:118-129. [PMID: 35001343 PMCID: PMC9271140 DOI: 10.1007/s40615-021-01202-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Racial disparities in guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) have not been fully documented in a community setting. METHODS In the ARIC Surveillance Study (2005-2014), we examined racial differences in GDMT at discharge, its temporal trends, and the prognostic impact among individuals with hospitalized HFrEF, using weighted regression models to account for sampling design. Optimal GDMT was defined as beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Acceptable GDMT included either one of BB, MRA, ACEI/ARB or hydralazine plus nitrates (H-N). RESULTS Of 16,455 (unweighted n = 3,669) HFrEF cases, 47% were Black. Only ~ 10% were discharged with optimal GDMT with higher proportion in Black than White individuals (11.1% vs. 8.6%, p < 0.001). BB use was > 80% in both racial groups while Black individuals were more likely to receive ACEI/ARB (62.0% vs. 54.6%) and MRA (18.0% vs. 13.8%) than Whites, with a similar pattern for H-N (21.8% vs. 10.1%). There was a trend of decreasing use of optimal GDMT in both groups, with significant decline of ACEI/ARB use in Whites (- 2.8% p < 0.01) but increasing H-N use in both groups (+ 6.5% and + 9.2%, p < 0.01). Only ACEI/ARB and BB were associated with lower 1-year mortality. CONCLUSIONS Optimal GDMT was prescribed in only ~ 10% of HFrEF patients at discharge but was more so in Black than White individuals. ACEI/ARB use declined in Whites while H-N use increased in both races. GDMT utilization, particularly ACEI/ARB, should be improved in Black and Whites individuals with HFrEF.
Collapse
Affiliation(s)
- Lena Mathews
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Ning Ding
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingying Sang
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura R Loehr
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jung-Im Shin
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Naresh M Punjabi
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wayne D Rosamond
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chiadi E Ndumele
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patricia P Chang
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
15
|
Folsom AR, Tang W, Hong CP, Rosamond WD, Lane JA, Cushman M, Pankratz N. Prediction of venous thromboembolism incidence in the general adult population using two published genetic risk scores. PLoS One 2023; 18:e0280657. [PMID: 36716319 PMCID: PMC9886242 DOI: 10.1371/journal.pone.0280657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/05/2023] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Most strategies for prevention of venous thromboembolism focus on preventing recurrent events. Yet, primary prevention might be possible through approaches targeting the whole population or high-risk patients. To inform possible prevention strategies, population-based information on the ability of genetic risk scores to identify risk of incident venous thromboembolism is needed. MATERIALS AND METHODS We used proportional hazards regression to relate two published genetic risk scores (273-variants versus 5-variants) with venous thromboembolism incidence in the Atherosclerosis Risk in Communities Study (ARIC) cohort (n = 11,292), aged 45-64 at baseline, drawn from 4 US communities. RESULTS Over a median of 28 years, ARIC identified 788 incident venous thromboembolism events. Incidence rates rose more than two-fold across quartiles of the 273-variant genetic risk score: 1.7, 2.7, 3.4 and 4.0 per 1,000 person-years. For White participants, age, sex, and ancestry-adjusted hazard ratios (95% confidence intervals) across quartiles were strong [1 (reference), 1.30 (0.99,1.70), 1.85 (1.43,2.40), and 2.58 (2.04,3.28)] but weaker for Black participants [1, 1.05 (0.63,1.75), 1.37 (0.84,2.22), and 1.32 (0.80,2.20)]. The 5-variant genetic risk score showed a less steep gradient, with hazard ratios in Whites of 1, 1.17 (0.89,1.54), 1.48 (1.14,1.92), and 2.18 (1.71,2.79). Models including the 273-variant genetic risk score plus lifestyle and clinical factors had a c-statistic of 0.67. CONCLUSIONS In the general population, middle-aged adults in the highest quartile of either genetic risk score studied have approximately two-fold higher risk of an incident venous thromboembolism compared with the lowest quartile. The genetic risk scores show a weaker association with venous thromboembolism for Black people.
Collapse
Affiliation(s)
- Aaron R. Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Ching-Ping Hong
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Wayne D. Rosamond
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - John A. Lane
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Mary Cushman
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, United States of America
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, United States of America
| |
Collapse
|
16
|
DeBarmore BM, Zègre-Hemsey JK, Kucharska-Newton AM, Michos ED, Rosamond WD. Patient characteristics and outcomes of acute myocardial infarction presenting without ischemic pain: Insights from the Atherosclerosis Risk in Communities Study. Am Heart J Plus 2023; 25:100239. [PMID: 36713888 PMCID: PMC9879363 DOI: 10.1016/j.ahjo.2022.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 10/20/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
Background Our objective was to describe characteristics of patients presenting with and without ischemic pain among those diagnosed with acute myocardial infarction (MI) using individual-level data from the Atherosclerosis Risk in Communities Study from 2005 to 2019. Methods Acute MI included events deemed definite or probable MI by a physician panel based on ischemic pain, cardiac biomarkers, and ECG evidence. Patient characteristics included age at hospitalization, sex, race/ethnicity, comorbidities (smoking status, diabetes, hypertension, history of previous stroke, MI, or cardiovascular procedure, and history of valvular disease or cardiomyopathy) and in-hospital complications occurring during the event of interest (pulmonary edema, pulmonary embolism, in-hospital stroke, pneumonia, cardiogenic shock, ventricular fibrillation). Analyses were stratified by MI subtype (STEMI, NSTEMI, Unclassified) and patient characteristics and 28-day case fatality was compared between MI presenting with or without ischemic pain. Results Between 2005 and 2019, there were 1711 hospitalized definite/probable MI events (47 % female, 26 % black, and age of 78 [6.7 years]). A smaller proportion of STEMI patients presented without ischemic pain compared to NSTEMI patients (20 % vs 32 %). Race, sex, age, and comorbidity profiles did not differ significantly across ischemic pain presentations. Patients presenting without ischemic pain had a higher 28-day all-cause case fatality after adjusting for age, race, sex, and comorbidities. However, after further adjustment, time from symptom onset to hospital arrival, time to treatment, and in-hospital complications explained the difference in 28-day case fatality between ischemic pain presentations. Conclusions Future research should focus on differences in treatment delay across ischemic pain presentations rather than sex differences in acute coronary syndrome presentation.
Collapse
Affiliation(s)
- Bailey M. DeBarmore
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Anna M. Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health Baltimore, MD, USA
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
17
|
Mathews L, Ding N, Mok Y, Shin J, Crews DC, Rosamond WD, Newton A, Chang PP, Ndumele CE, Coresh J, Matsushita K. Impact of Socioeconomic Status on Mortality and Readmission in Patients With Heart Failure With Reduced Ejection Fraction: The ARIC Study. J Am Heart Assoc 2022; 11:e024057. [DOI: 10.1161/jaha.121.024057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Low socioeconomic status (SES) is associated with a higher risk of heart failure (HF). The contribution of individual and neighborhood SES to the prognosis and quality of care for HF with reduced ejection fraction is not clear yet has important implications.
Methods and Results
We examined 728 participants of the
ARIC
(Atherosclerosis Risk in Communities) study (mean age, 78.2 years; 34% Black participants; 46% women) hospitalized with HF with reduced ejection fraction (ejection fraction <50%) between 2005 and 2018. We assessed associations between education, income, and area deprivation index with mortality and HF readmission using multivariable Cox models. We also evaluated the use of guideline‐directed medical therapy (optimal: ≥3 of ß‐blockers, mineralocorticoid receptor antagonist, angiotensin‐converting enzyme inhibitors, or angiotensin receptor blockers; acceptable: at least 2) at discharge. During a median follow‐up of 3.2 years, 58.7% were readmitted with HF, and 74.0% died. Low income was associated with higher mortality (hazard ratio [HR], 1.52 [95% CI, 1.14–2.04]) and readmission (HR, 1.45 [95% CI, 1.04–2.03]). Similarly, low education was associated with mortality (HR, 1.27 [95% CI, 1.01–1.59]) and readmission (HR, 1.62 [95% CI, 1.24–2.12]). The highest versus lowest area deprivation index quartile was associated with readmission (HR, 1.69 [95% CI, 1.11–2.58]) but not necessarily with mortality. The prevalence of optimal guideline‐directed medical therapy and acceptable guideline‐directed medical therapy was 5.5% and 54.4%, respectively, but did not significantly differ by SES.
Conclusions
Among patients hospitalized with HF with reduced ejection fraction, low SES was independently associated with mortality and HF readmission. A targeted secondary prevention approach that focuses intensive efforts on patients with low SES will be necessary to improve outcomes of those with HF with reduced ejection fraction.
Collapse
Affiliation(s)
- Lena Mathews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- Cicarrone Center for the Prevention of Cardiovascular Disease, Department of Medicine, Divsion of Cardiology Johns Hopkins University Baltimore MD
- School of Medicine, Johns Hopkins University Baltimore MD
| | - Ning Ding
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
| | - Yejin Mok
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
| | - Jung‐Im Shin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
| | - Deidra C. Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- School of Medicine, Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
- Center for Health Equity Johns Hopkins University Baltimore MD
| | - Wayne D. Rosamond
- Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill NC
| | - Anna‐Kucharska Newton
- Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill NC
- College of Public Health University of Kentucky Lexington KY
| | - Patricia P. Chang
- Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill NC
- Division of Cardiology, Department of Medicine University of North Carolina at Chapel Hill Chapel Hill NC
| | - Chiadi E. Ndumele
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- Cicarrone Center for the Prevention of Cardiovascular Disease, Department of Medicine, Divsion of Cardiology Johns Hopkins University Baltimore MD
- School of Medicine, Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
- Center for Health Equity Johns Hopkins University Baltimore MD
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- School of Medicine, Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
| | - Kunihiro Matsushita
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology Johns Hopkins University Baltimore MD
- School of Medicine, Johns Hopkins University Baltimore MD
- Bloomberg School of Public Health, Johns Hopkins University Baltimore MD
| |
Collapse
|
18
|
Commodore-Mensah Y, Mok Y, Gottesman RF, Kucharska-Newton A, Matsushita K, Palta P, Rosamond WD, Sarfo FS, Coresh J, Koton S. Life's Simple 7 at Midlife and Risk of Recurrent Cardiovascular Disease and Mortality after Stroke: The ARIC study. J Stroke Cerebrovasc Dis 2022; 31:106486. [PMID: 35468496 PMCID: PMC9199114 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/06/2022] [Accepted: 03/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of morbidity and mortality among adults in the U.S. Ideal levels of the Life's Simple 7 (LS7) are associated with lower cardiovascular disease (CVD) and all-cause mortality. However, the association of LS7 with CVD, recurrent stroke, and all-cause mortality after incident stroke is unknown. METHODS We used data from the ARIC study, a cohort of 13,508 adults from four US communities, 45-64 years old at baseline (1987-1989). Cardiovascular hospitalizations and mortality were ascertained in follow-up through December 31st, 2017. We defined cardiovascular health (CVH) based on AHA definitions for LS7 (range 0-14) and categorized CVH into four levels: LS7 0-3, 4-6, 7-9, and ≥10 (ideal LS7), according to prior studies. Outcomes included incident stroke, CVD, recurrent stroke, all-cause mortality, and a composite outcome including all the above. Adjusted hazard ratios (95% CI) were estimated with Cox proportional hazards regression models. RESULTS Median (25%-75%) follow-up for incident stroke was 28 (18.6-29.2) years. Participants with incident stroke were 55.7 (SD 5.6) years-old at baseline, 53% were women and 35% Black. Individuals with LS7 score ≥10 had 65% lower risk (HR: 0.35; 95% CI: 0.29-0.41) of incident stroke than those with LS7 4-6 (reference group). Of 1,218 participants with incident stroke, 41.2% (n=502) had composite CVD and 68.3% (n=832) died during a median (25%-75%) follow-up of 4.0 (0.76-9.95) years. Adjusted HR (95% CI) for stroke survivors with LS7≥10 at baseline were 0.74 (0.58-0.94) for the composite outcome, 0.38(0.17-0.85) for myocardial infarction, 0.60 (0.40-0.90) for heart failure, 0.63 (0.48-0.84) for all-cause mortality, and 0.65 (0.39-1.08) for recurrent stroke. CONCLUSIONS Good and excellent midlife cardiovascular health are associated with lower risks of incident stroke and CVD after stroke. Clinicians should stress the importance of a healthy lifestyle for primary and secondary CVD prevention.
Collapse
Affiliation(s)
- Yvonne Commodore-Mensah
- Johns Hopkins School of Nursing; Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology.
| | - Yejin Mok
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology.
| | - Rebecca F Gottesman
- Johns Hopkins School of Nursing; Johns Hopkins School of Medicine, Department of Neurology.
| | | | - Kunihiro Matsushita
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology.
| | - Priya Palta
- Columbia University Irving Medical Center, Departments of Medicine and Epidemiology.
| | - Wayne D Rosamond
- University of North Carolina, Gillings School of Global Public Health.
| | - Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, School of Medical, Sciences.
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology.
| | - Silvia Koton
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology; Tel Aviv University, Sackler Faculty of Medicine, Stanley Steyer School of Health Professions.
| |
Collapse
|
19
|
Ding N, Shah AM, Blaha MJ, Chang PP, Rosamond WD, Matsushita K. Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction. J Am Coll Cardiol 2022; 79:2298-2305. [DOI: 10.1016/j.jacc.2022.03.377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 12/14/2022]
|
20
|
Lutz BJ, Kucharska-Newton AM, Jones SB, Psioda MA, Gesell SB, Coleman SW, Johnson AM, Radman MD, Levy S, Bettger JP, Freburger JK, Chou A, Celestino J, Rosamond WD, Bushnell CD, Duncan PW. Familial caregiving following stroke: findings from the comprehensive post-acute stroke services (COMPASS) pragmatic cluster-randomized transitional care study. Top Stroke Rehabil 2022; 30:436-447. [PMID: 35603644 DOI: 10.1080/10749357.2022.2077520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Stroke patients discharged home often require prolonged assistance from caregivers. Little is known about the real-world effectiveness of a comprehensive stroke transitional care intervention on relieving caregiver strain. OBJECTIVES To describe the effect of the COMPASS transitional care (COMPASS-TC) intervention on caregiver strain and characterize the types, duration, and intensity of caregiving. METHODS The cluster-randomized COMPASS pragmatic trial evaluated the effectiveness of COMPASS-TC versus usual care with patients with mild stroke and TIA at 40 hospitals in North Carolina, USA. Of 5882 patients enrolled, 4208 (71%) identified a familial caregiver. A follow-up Caregiver Questionnaire, including the Modified Caregiver Strain Index, was administered at approximately three months post-discharge. Demographics and frequency, duration, and intensity of caregiving were compared between groups. RESULTS 1228 caregivers (29%) completed the questionnaire. Completion was positively associated with older patient age, white race, and spousal relationship. One-third of the caregivers provided ≥30 hours of care per week and 889 (79%) provided care ≥9 weeks. Average standardized caregiver strain was 21.9 (0-100), increasing with stroke severity and comorbidity burden. Women caregivers reported higher strain than men. Treatment allocation was not associated with caregiver strain. CONCLUSIONS This sample of mild stroke and TIA survivors received significant assistance from familial caregivers. However, caregiver strain was relatively low. Findings support the importance of familial caregiving in stroke, the continued disproportionate burden on women within the family, and the need for future research on caregiver support.
Collapse
Affiliation(s)
- Barbara J. Lutz
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, North Carolina, USA
| | - Anna M. Kucharska-Newton
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sara B. Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew A. Psioda
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabina B. Gesell
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sylvia W. Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna M. Johnson
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Samantha Levy
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Janet K Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, USA
| | - Aileen Chou
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, USA
| | - Joan Celestino
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Pamela W. Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
21
|
Johnson AM, Cunningham CJ, Zégre-Hemsey JK, Grewe ME, DeBarmore BM, Wong E, Omofoye F, Rosamond WD. Out-of-Hospital Cardiac Arrest Bystander Defibrillator Search Time and Experience With and Without Directional Assistance: A Randomized Simulation Trial in a Community Setting. Simul Healthc 2022; 17:22-28. [PMID: 34081062 PMCID: PMC8633074 DOI: 10.1097/sih.0000000000000582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Probability of survival after out-of-hospital cardiac arrest (OHCA) doubles when a bystander initiates cardiopulmonary resuscitation and uses an automated external defibrillator (AED) rapidly. National, state, and community efforts have increased placement of AEDs in public spaces; however, bystander AED use remains less than 2% in the United States. Little is known about the effect of giving bystanders directional assistance to the closest public access AED. METHODS We conducted 35 OHCA simulations using a life-sized manikin with participants aged 18 through 65 years who searched for public access AEDs in 5 zones on a university campus. Zones varied by challenges to pedestrian AED acquisition and number of fixed AEDs. Participants completed 2 searches-first unassisted and then with verbal direction to the closest AED-and we compared AED delivery times. We conducted pretest and posttest surveys. RESULTS In all 5 zones, the median time from simulated OHCA onset to AED delivery was lower when the bystander received directional assistance. Time savings (minutes:seconds) varied by zone, ranging from a median of 0:53 (P = 0.14) to 3:42 (P = 0.02). Only 3 participants immediately located the closest AED without directional assistance; more than half reported difficulty locating an AED. CONCLUSIONS These findings may inform strategies to ensure that AEDs are consistently marked and placed in visible, accessible locations. Continued emphasis on developing strategies to improve lay bystanders' ability to locate and use AEDs may improve AED retrieval times and OHCA outcomes.
Collapse
Affiliation(s)
- Anna M. Johnson
- 123 West Franklin Street, Suite 410, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| | - Christopher J. Cunningham
- 321 South Columbia Street, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| | - Jessica K. Zégre-Hemsey
- Campus Box 7460, Carrington Hall, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460
| | - Mary E. Grewe
- 160 North Medical Drive, Brinkhous-Bullitt Building, 2nd Floor #220-237, North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7064
| | - Bailey M. DeBarmore
- 123 West Franklin Street, Suite 410, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| | - Eugenia Wong
- 123 West Franklin Street, Suite 410, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| | - Fola Omofoye
- 321 South Columbia Street, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| | - Wayne D. Rosamond
- 123 West Franklin Street, Suite 410, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516
| |
Collapse
|
22
|
Logue M, Sen S, Suri F, Wasserman B, Gottesman RF, Rosamond WD. Abstract TMP76: Association Of Adiposity With Intracranial Atherosclerosis. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tmp76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Adiposity, as measured by Body Mass Index (BMI) and Waist-to-Hip Ratio (WHR), is associated with ischemic stroke. However, association with Intercranial Atherosclerosis has not been well-established in the United States. We assessed the hypothesis that adiposity is associated with asymptomatic intracranial atherosclerosis (ICAS).
Methods:
BMI was calculated as weight (kg)/height (m)
2
. The ratio of waist (umbilical level) to hip (maximum buttocks) circumference (WHR) was calculated as a measure of fat distribution. In the ARIC cohort, a stratified subset (N=1145) underwent 3D time-of-flight MR angiogram and 3D high-isotropic resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease trial. In this study, we evaluated the relationship between BMI as well as WHR, and significant asymptomatic ICAS, defined as ≥50% stenosis. Student t-tests were performed to test continuous variables, and X
2
test was used to compare categorical variables. Analysis of covariance (ANCOVA) was used for multivariate testing.
Results:
Among subjects who underwent vascular imaging, 1033 (90%) had <50% ICAS and 112 (10%) had ≥50% ICAS. At the time of assessment, those with ≥50% ICAS were older (age 79±5 vs. 76±5, p<0.001), and had higher systolic blood pressure or SBP (134±19 vs. 130±18, p=0.02), compared with those with <50% ICAS. The BMI was higher (29.1±6.7 vs. 28.1±5.2), although the difference was statistically borderline significant (p=0.06). The WHR was higher (0.95±0.07 vs. 0.93±0,08), the difference being statistically significant (p=0.01). The difference remained significant after adjustment for age and SBP (p=0.02).
Conclusion:
We report a significant association between WHR, a measure of central adiposity, and ≥50% ICAS. This may be one of the first reported associations between central adiposity and ICAS. These results emphasize the importance of adiposity distribution in addition to overall adiposity, as a risk factor for significant asymptomatic ICAS.
Collapse
Affiliation(s)
| | - Souvik Sen
- UNIVERSITY OF SOUTH CAROLINA, Columbia, SC
| | | | | | | | | |
Collapse
|
23
|
Koton S, Pike JR, Johansen M, Knopman DS, Lakshminarayan K, Mosley T, Patole S, Rosamond WD, Schneider ALC, Sharrett AR, Wruck L, Coresh J, Gottesman RF. Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study. JAMA Neurol 2022; 79:271-280. [PMID: 35072712 PMCID: PMC8787684 DOI: 10.1001/jamaneurol.2021.5080] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Ischemic stroke is associated with increased risk of dementia, but the association of stroke severity and recurrence with risk of impaired cognition is not well known. OBJECTIVE To examine the risk of dementia after incident ischemic stroke and assess how it differed by stroke severity and recurrence. DESIGN, SETTING, AND PARTICIPANTS The Atherosclerosis Risk in Communities (ARIC) study is an ongoing prospective cohort of 15 792 community-dwelling individuals from 4 US states (Mississippi, Maryland, Minnesota, and North Carolina). Among them, 15 379 participants free of stroke and dementia at baseline (1987 to 1989) were monitored through 2019. Data were analyzed from April to October 2021. Associations between dementia and time-varying ischemic stroke incidence, frequency, and severity were studied across an average of 4.4 visits over a median follow-up of 25.5 years with Cox proportional hazards models adjusted for sociodemographic characteristics, apolipoprotein E, and vascular risk factors. EXPOSURES Incident and recurrent ischemic strokes were classified by expert review of hospital records, with severity defined by the National Institutes of Health Stroke Scale (NIHSS; minor, ≤5; mild, 6-10; moderate, 11-15; and severe, ≥16). MAIN OUTCOMES AND MEASURES Dementia cases adjudicated through expert review of in-person evaluations, informant interviews, telephone assessments, hospitalization codes, and death certificates. In participants with stroke, dementia events in the first year after stroke were not counted. RESULTS At baseline, the mean (SD) age of participants was 54.1 (5.8) years, and 8485 of 15 379 participants (55.2%) were women. A total of 4110 participants (26.7%) were Black and 11 269 (73.3%) were White. A total of 1378 ischemic strokes (1155 incident) and 2860 dementia cases were diagnosed 1 year or more after incident stroke in participants with stroke, or at any point after baseline in participants without stroke, were identified through December 31, 2019. NIHSS scores were available for 1184 of 1378 ischemic strokes (85.9%). Risk of dementia increased with both the number and severity of strokes. Compared with no stroke, risk of dementia by adjusted hazard ratio was 1.76 (95% CI, 1.49-2.00) for 1 minor to mild stroke, 3.47 (95% CI, 2.23-5.40) for 1 moderate to severe stroke, 3.48 (95% CI, 2.54-4.76) for 2 or more minor to mild strokes, and 6.68 (95% CI, 3.77-11.83) for 2 or more moderate to severe strokes. CONCLUSIONS AND RELEVANCE In this study, risk of dementia significantly increased after ischemic stroke, independent of vascular risk factors. Results suggest a dose-response association of stroke severity and recurrence with risk of dementia.
Collapse
Affiliation(s)
- Silvia Koton
- Department of Nursing, The Stanley Steyer School of Health Professions, Tel Aviv University, Tel Aviv, Israel,Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | | | - Michelle Johansen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Thomas Mosley
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Shalom Patole
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Wayne D. Rosamond
- Department of Epidemiology, University of North Carolina, Chapel Hill
| | | | - A. Richey Sharrett
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Lisa Wruck
- Duke Clinical Research Institute, Durham, North Carolina
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
24
|
Arora S, Cavender MA, Chang PP, Qamar A, Rosamond WD, Hall ME, Rossi JS, Kaul P, Caughey MC. Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study. Eur Heart J Acute Cardiovasc Care 2021; 10:1048-1055. [PMID: 38086075 PMCID: PMC11020253 DOI: 10.1093/ehjacc/zuaa051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/08/2018] [Indexed: 04/18/2024]
Abstract
BACKGROUND The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern. METHODS We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures. RESULTS A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01). CONCLUSION Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
Collapse
Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Patricia P Chang
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Arman Qamar
- Division of Cardiology, Brigham and Women’s Hospital, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Prashant Kaul
- Division of Cardiology, Piedmont Heart Institute, USA
| | - Melissa C Caughey
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| |
Collapse
|
25
|
Arora S, Cavender MA, Chang PP, Qamar A, Rosamond WD, Hall ME, Rossi JS, Kaul P, Caughey MC. Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study. Eur Heart J Acute Cardiovasc Care 2021; 10:1048-1055. [PMID: 30958029 PMCID: PMC6854299 DOI: 10.1177/2048872619842983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/08/2018] [Indexed: 06/03/2023]
Abstract
BACKGROUND The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern. METHODS We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures. RESULTS A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01). CONCLUSION Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
Collapse
Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Patricia P Chang
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Arman Qamar
- Division of Cardiology, Brigham and Women’s Hospital, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Prashant Kaul
- Division of Cardiology, Piedmont Heart Institute, USA
| | - Melissa C Caughey
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| |
Collapse
|
26
|
Schilsky S, Sotres-Alvarez D, Rosamond WD, Heiss G, Stevens J, Butera N, Cai J, Carlson JA, Cuthbertson C, Daviglus M, LeCroy MN, Pirzada A, Evenson KR. The association of Step-based metrics and adiposity in the Hispanic community Health Study/Study of Latinos. Prev Med Rep 2021; 24:101655. [PMID: 34976702 PMCID: PMC8684028 DOI: 10.1016/j.pmedr.2021.101655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/15/2021] [Accepted: 11/30/2021] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Examine cross-sectional and longitudinal associations of accelerometer measured step volume (steps/day) and cadence with adiposity and six-year changes in adiposity in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). METHODS HCHS/SOL's target population was 60% female with a mean age of 41 years. Cross-sectional (n = 12,353) and longitudinal analyses (n = 9,077) leveraged adjusted complex survey regression models to examine associations between steps/day, and cadence with weight (kg), waist circumference (cm) and body mass index (kg/m2). Effect measure modification by covariates was examined. RESULTS Lower steps/day and intensity was associated with higher adiposity at baseline. Compared to those in the highest quartile of steps/day those in the lowest quartile have 1.42 95% CI (1.19, 1.70) times the odds of obesity. Compared to those in the highest categories of cadence step-based metrics, those in the lowest categories had a 1.62 95% CI (1.36, 1.93), 2.12 95% CI (1.63, 2.75) and 1.41 95% CI (1.16, 1.70) odds of obesity for peak 30-minute cadence, brisk walking and faster ambulation and bouts of purposeful steps and faster ambulation, respectively. Compared to those with the highest stepping cadences, those with the slowest peak 30-minute cadence and fewest minutes in bouts of purposeful steps and faster ambulation had 0.72 95% CI (0.57, 0.89) and 0.82 95% CI (0.60, 1.14) times the odds of gaining weight, respectively. CONCLUSION Inverse cross-sectional relationships were found for steps/day and cadence and adiposity. Over a six-year period, higher step intensity but not volume was associated with higher odds of gaining weight.
Collapse
Affiliation(s)
| | | | | | | | - June Stevens
- University of North Carolina, Chapel Hill NC, USA
| | - Nicole Butera
- George Washington University School of Public Health, Washington, DC, USA
| | - Jianwen Cai
- University of North Carolina, Chapel Hill NC, USA
| | | | | | - Martha Daviglus
- Albert Einstein College of Medicine, Bronx NY, USA
- Feinberg School of Medicine, Chicago IL, USA
| | | | - Amber Pirzada
- University of Illinois College of Medicine, Chicago IL, USA
| | | |
Collapse
|
27
|
Johnson AM, Cunningham CJ, Arnold E, Rosamond WD, Zègre-Hemsey JK. Impact of Using Drones in Emergency Medicine: What Does the Future Hold? Open Access Emerg Med 2021; 13:487-498. [PMID: 34815722 PMCID: PMC8605877 DOI: 10.2147/oaem.s247020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/02/2021] [Indexed: 12/28/2022] Open
Abstract
The use of unmanned aerial vehicles or "drones" has expanded in the last decade, as their technology has become more sophisticated, and costs have decreased. They are now used routinely in farming, environmental surveillance, public safety, commercial product delivery, recreation, and other applications. Health-related applications are only recently becoming more widely explored and accepted. The use of drone technology in emergency medicine is especially promising given the need for a rapid response to enhance patient outcomes. The purpose of this paper is to describe some of the main current and expanding applications of drone technology in emergency medicine and to describe challenges and future opportunities. Current applications being studied include delivery of defibrillators in response to out-of-hospital cardiac arrest, blood and blood products in response to trauma, and rescue medications. Drones are also being studied and actively used in emergency response to search and rescue operations as well as disaster and mass casualty events. Current challenges to expanding their use in emergency medicine and emergency medical system (EMS) include regulation, safety, flying conditions, concerns about privacy, consent, and confidentiality, and details surrounding the development, operation, and maintenance of a medical drone network. Future research is needed to better understand end user perceptions and acceptance. Continued technical advances are needed to increase payload capacities, increase flying distances, and integrate drone networks into existing 9-1-1 and EMS systems. Drones are a promising technology for improving patient survival, outcomes, and quality of life, particularly for those in areas that are remote or that lack funds or infrastructure. Their cost savings compared with ground transportation alone, speed, and convenience make them particularly applicable in the field of emergency medicine. Research to date suggests that use of drones in emergency medicine is feasible, will be accepted by the public, is cost-effective, and has broad application.
Collapse
Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Evan Arnold
- Institute for Transportation Research and Education, North Carolina State University, Raleigh, NC, USA
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | |
Collapse
|
28
|
Bushnell CD, Kucharska-Newton AM, Jones SB, Psioda MA, Johnson AM, Daras LC, Halladay JR, Prvu Bettger J, Freburger JK, Gesell SB, Coleman SW, Sissine ME, Wen F, Hunt GP, Rosamond WD, Duncan PW. Hospital Readmissions and Mortality Among Fee-for-Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster-Randomized Pragmatic Trial. J Am Heart Assoc 2021; 10:e023394. [PMID: 34730000 PMCID: PMC9075395 DOI: 10.1161/jaha.121.023394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS-TC (Comprehensive Post-Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all-cause and stroke-specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee-for-service claims linked with COMPASS cluster-randomized trial data, we performed intention-to-treat analyses for 30-day, 90-day, and 1-year unplanned all-cause and stroke-specific readmissions and all-cause mortality between INV and UC groups, with 90-day unplanned all-cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all-cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1-year all-cause readmissions, stroke-specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS-TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
Collapse
Affiliation(s)
| | - Anna M Kucharska-Newton
- Department of Epidemiology College of Public Health University of Kentucky Lexington KY.,Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Sara B Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Matthew A Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Anna M Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | | | - Jacqueline R Halladay
- Department of Family Medicine University of North Carolina School of Medicine Chapel Hill NC
| | | | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pittsburgh PA
| | - Sabina B Gesell
- Division of Public Health Sciences Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston-Salem NC
| | - Sylvia W Coleman
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Mysha E Sissine
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Fang Wen
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Gary P Hunt
- Cecil G Sheps Center for Health Services Research University of North Carolina at Chapel Hill NC
| | - Wayne D Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Pamela W Duncan
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| |
Collapse
|
29
|
Freburger JK, Pastva AM, Coleman SW, Peter KM, Kucharska-Newton AM, Johnson AM, Psioda MA, Duncan PW, Bushnell CD, Rosamond WD, Jones SB. Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries s Discharged Home following a Stroke: Findings from the COMPASS Trial. Arch Phys Med Rehabil 2021; 103:882-890.e2. [PMID: 34740596 DOI: 10.1016/j.apmr.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVES To examine the effect of a comprehensive transitional care model on the utilization of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DESIGN Cluster randomized pragmatic trial Setting: 41 acute care hospitals in North Carolina. PARTICIPANTS 2,262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (standard deviation [SD]) age of 74.9 (10.2) years and a mean (SD) NIH stroke scale score of 2.3 (3.7). INTERVENTION Comprehensive transitional care model (COMPASS-TC) which consisted of a 2-day follow-up phone call from the post-acute care coordinator (PAC) and 14-day in-person visit with the PAC and advanced practice provider. MAIN OUTCOME MEASURES Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. RESULTS Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (HR=1.20 [0.95 - 1.52]) compared to usual care. This estimate was robust to additional covariate adjustment (HR=1.23 [0.93-1.64]). Both clinical and non-clinical factors (i.e., insurance, geography) were predictors of SNF/IRF use. CONCLUSIONS COMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.
Collapse
Affiliation(s)
- Janet K Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, Suite 210, 100 Technology Dr, Pittsburgh, PA 15219-3130.
| | - Amy M Pastva
- Duke University School of Medicine, DUMC Box 104002, 311 Trent Drive, Durham, NC, 27710
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Kennedy M Peter
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599; Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Ave, Lexington, KY, 40536
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Matthew A Psioda
- Department of Biostatistics, Gillings School of Global Public Health, 135 University of North Carolina at Chapel Hill, Dauer Dr, Chapel Hill, NC 27599
| | - Pamela W Duncan
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | | |
Collapse
|
30
|
Rosamond WD, Kucharska‐Newton AM, Jones SB, Psioda MA, Lutz BJ, Johnson AM, Coleman SW, Schilsky SR, Patel MD, Duncan PW. Emergency department utilization after hospitalization discharge for acute stroke: The COMprehensive Post-Acute Stroke Services (COMPASS) study. Acad Emerg Med 2021; 29:369-371. [PMID: 34657341 DOI: 10.1111/acem.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Wayne D. Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Anna M. Kucharska‐Newton
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
- Department of Epidemiology College of Public Health University of Kentucky Lexington Kentucky USA
| | - Sara B. Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Matthew A. Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Barbara J. Lutz
- School of Nursing University of North Carolina Wilmington Wilmington North Carolina USA
| | - Anna M. Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Sylvia W. Coleman
- Department of Neurology Wake Forest Baptist Health Winston‐Salem North Carolina USA
| | - Samantha R. Schilsky
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Mehul D. Patel
- Department of Emergency Medicine School of Medicine The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Pamela W. Duncan
- Department of Neurology Wake Forest Baptist Health Winston‐Salem North Carolina USA
| |
Collapse
|
31
|
Wright JD, Folsom AR, Coresh J, Sharrett AR, Couper D, Wagenknecht LE, Mosley TH, Ballantyne CM, Boerwinkle EA, Rosamond WD, Heiss G. The ARIC (Atherosclerosis Risk In Communities) Study: JACC Focus Seminar 3/8. J Am Coll Cardiol 2021; 77:2939-2959. [PMID: 34112321 PMCID: PMC8667593 DOI: 10.1016/j.jacc.2021.04.035] [Citation(s) in RCA: 189] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/13/2021] [Indexed: 02/08/2023]
Abstract
ARIC (Atherosclerosis Risk In Communities) initiated community-based surveillance in 1987 for myocardial infarction and coronary heart disease (CHD) incidence and mortality and created a prospective cohort of 15,792 Black and White adults ages 45 to 64 years. The primary aims were to improve understanding of the decline in CHD mortality and identify determinants of subclinical atherosclerosis and CHD in Black and White middle-age adults. ARIC has examined areas including health disparities, genomics, heart failure, and prevention, producing more than 2,300 publications. Results have had strong clinical impact and demonstrate the importance of population-based research in the spectrum of biomedical research to improve health.
Collapse
Affiliation(s)
- Jacqueline D Wright
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA.
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Couper
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lynne E Wagenknecht
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Thomas H Mosley
- Memory Impairment and Neurodegenerative Dementia Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Eric A Boerwinkle
- School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gerardo Heiss
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
32
|
Mediano MFF, Mok Y, Coresh J, Kucharska-Newton A, Palta P, Lakshminarayan K, Rosamond WD, Matsushita K, Koton S. Prestroke Physical Activity and Adverse Health Outcomes After Stroke in the Atherosclerosis Risk in Communities Study. Stroke 2021; 52:2086-2095. [PMID: 33784831 PMCID: PMC8154698 DOI: 10.1161/strokeaha.120.032695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE The association of physical activity (PA) before stroke (prestroke PA) with long-term prognosis after stroke is still unclear. We examined the association of prestroke PA with adverse health outcomes in the ARIC study (Atherosclerosis Risk in Communities). METHODS We included 881 participants with incident stroke occurring between 1993 and 1995 (visit 3) and December 31, 2016. Follow-up continued until December 31, 2017 to allow for at least 1-year after incident stroke. Prestroke PA was assessed using a modified version of the Baecke questionnaire in 1987 to 1989 (visit 1) and 1993 to 1995 (visit 3), evaluating PA domains (work, leisure, and sports) and total PA. We used Cox proportional hazards models to quantify the association between tertiles of accumulated prestroke PA levels over the 6-year period between visits 1 and 3 and mortality, risk of cardiovascular disease, and recurrent stroke after incident stroke. RESULTS During a median follow-up of 3.1 years after incident stroke, 676 (77%) participants had adverse outcomes. Highest prestroke total PA was associated with decreased risks of all-cause mortality (hazard ratio, 0.78 [95% CI, 0.63-0.97]) compared with lowest tertile. In the analysis by domain-specific PA, highest levels of work PA were associated with lower risk for all-cause (hazard ratio, 0.77 [95% CI, 0.62-0.96]) and cardiovascular mortality (hazard ratio, 0.45 [95% CI, 0.29-0.70]), and highest levels of leisure PA were associated with lower all-cause mortality (hazard ratio, 0.72 [95% CI, 0.58-0.89]) compared with lowest tertile of PA. No significant associations for sports PA were observed. CONCLUSIONS Higher levels of total prestroke PA as well as work and leisure PA were associated with lower risk of mortality after incident stroke. Public health strategies to increase lifetime PA should be encouraged to decrease long-term mortality after stroke.
Collapse
Affiliation(s)
- Mauro F. F. Mediano
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Department of Research and Education, National Institute of Cardiology, Rio de Janeiro, Brazil
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Yejin Mok
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Anna Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Priya Palta
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Silvia Koton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
33
|
Rowen NP, Kim D, Rayala HP, Reiter AH, Rosamond WD. Abstract MP49: Application Of A Novel Assessment Of County-level Cardiovascular Health Profile And Its Association With County-level Disease Rates. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.mp49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The AHA’s definition of cardiovascular health (CVH) is based on seven metrics known as Life’s Simple 7 (LS7): smoking, diet, obesity, physical inactivity, high blood cholesterol, high blood pressure, and diabetes. Although used to evaluate CVH at the national and individual level, its use as a local county-level measure of CVH has not yet been studied. Our objective was to create a modification of LS7 using publicly available data to estimate county-level CVH and to determine its association with CVH outcomes in all 100 counties of North Carolina (NC).
Methods and Results:
Using data on all the LS7 metrics collected by the CDC, USDA, BRFSS, and Community Health Assessments, we created a Modified LS7 scoring system, calculated scores for all 100 counties in NC, and created a regression model that predicts county-level hospital discharge rates for diseases and disorders of the circulatory system (Figure 1). Modified LS7 scores ranged from 60.8 to 80.6 (median = 73.1, SD = 3.9). Hospital discharge rates per 100,000 population ranged from 753.4 to 2223.4 (median = 1345.6, SD = 328.7). We found a negative correlation (R-squared = 0.610) between Modified LS7 scores and county-level hospital discharge rates. Counties in the mountain and piedmont regions had significantly higher mean Modified LS7 scores (74.3, 95% CI: 73.5-75.2; 73.9, 95% CI: 72.8-75.0) and lower mean discharge rates (1167.1, 95% CI: 1074.7-1259.5; 1273.9, 95% CI: 1181.4-1366.2) than counties in the coastal plains region (70.7, 95% CI: 69.4-72.0; 1612.3, 95% CI: 1518.5-1706.1). Studentized residuals and leverage points were used to identify five low performing counties and two high performing counties of interest for further analyses.
Conclusions:
The coastal region of NC was found to have significantly higher CVH risk and poorer CVH outcomes compared to the piedmont and mountain regions. The Modified LS7 model provides a novel approach to examine county-level variation in CVH that had previously only been reported at the national, state or individual level.
Collapse
|
34
|
Mediano MF, Mok Y, Coresh J, Kucharska-newton A, Palta P, Lakshminarayan K, Rosamond WD, Matsushita K, Koton S. Abstract 059: Pre-stroke Physical Activity Is Associated With Lower Mortality Risk After Stroke In The Atherosclerosis Risk In Communities (ARIC) Study. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The association between pre-stroke PA and long-term stroke outcomes is still unclear. We examined the association of pre-stroke PA with adverse health outcomes after incident stroke in the ARIC study.
Methods:
We included 881 participants with incident ischemic or hemorrhagic stroke occurring between 1993-1995 and December 31
st
, 2016. Follow-up for all-cause and cardiovascular disease (CVD) mortality, CVD or recurrent stroke occurred through December 31
st
, 2017, allowing for at least 1-year of follow-up after incident stroke. Pre-stroke total and domain-specific (work, sports and leisure) PA was assessed with the modified Baecke questionnaire at the baseline visit (1987-1989) and in 1993-1995. The total PA score was calculated by summing scores at both visits. Distribution-based tertiles of the summed score were derived. Cox proportional hazards models estimated the hazard ratios of adverse outcomes by tertiles of pre-stroke PA, adjusted for demographic and clinical characteristics.
Results:
During a median follow-up of 3.1 years after incident stroke, 77% participants developed adverse outcome. Compared to low pre-stroke PA, high pre-stroke PA was associated with a lower risk of all-cause mortality (HR=0.78; 95% CI: 0.63-0.97, Table). In the analysis by domain-specific PA, the risk of all-cause mortality was lowest among participants in the highest tertile of work PA (HR; 95% CI=0.77; 0.62-0.96) and leisure PA (HR=0.72; 95% CI: 0.58 to 0.89) compared to the lowest tertiles. The risk of CVD mortality was also lower in the highest tertile of work PA (HR=0.45; 95% CI: 0.29-0.70) compared to the lowest tertile.
Conclusions:
Higher levels of total pre-stroke PA, as well as work and leisure PA, were associated with a lower risk of mortality after incident stroke. Strategies to increase lifetime PA should be encouraged to decrease long-term mortality after stroke.
Collapse
Affiliation(s)
| | | | | | | | | | - Kamakshi Lakshminarayan
- Div of Epidemiology and Community Health, Sch of Public Health, Univ of Minnesota,, Minneapolis, MN
| | | | | | | |
Collapse
|
35
|
Wong E, Rosamond WD, Patel MD, Waller A. Abstract 045: Declines In Acute Myocardial Infarction And Stroke Emergency Department Visits Observed During Covid-19 Restrictions In North Carolina. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Efforts to control the COVID-19 pandemic brought sweeping social change, with stay-at-home orders and physical distancing mandates in 43 of 50 states by April 2020. Early on, isolated studies around the world described reduced hospital admissions. Reports from some US hospitals also described declines in catheterization laboratory activations, and acute myocardial infarction (AMI) and stroke admissions. However, there have been few population-based analyses of emergency department (ED) visits to verify these initial reports and describe longer term impacts of the pandemic on care seeking behavior.
Hypothesis:
We hypothesized that AMI and stroke ED visits in North Carolina (NC) would decrease substantially after a statewide stay-at-home order was announced on March 27, 2020.
Methods:
We analyzed all ED visits from January 5 to August 28, 2020 using data collected by the NC Disease Event Tracking and Epidemiologic Collection Tool, a syndromic surveillance system that automatically gathers ED data in near-real time for all EDs in NC. Counts of AMI and stroke/transient ischemic attack (TIA) were ascertained using ICD-10-CM diagnosis codes. We compared weekly 2020 ED visit data before and after NC’s stay-at-home order, and to 2019 ED visit data.
Results:
Overall ED volume declined by 44% in the weeks before and after the stay-at-home order (
Figure
) while the prior year’s ED volume stayed steady at ~100,000 visits per week. From January 5 to March 28, there were 593 AMI and 791 stroke/TIA visits per week on average. By April 11, ED visits reached a nadir at 426 AMI and 543 stroke/TIA visits per week, representing a 28% and 31% decrease, respectively. Since June, AMI and stroke/TIA ED visits have rebounded slightly but have yet to reach pre-pandemic levels.
Conclusions:
We observed swift declines in AMI and stroke/TIA ED visits following NC’s stay-at-home order. These findings potentially reflect the avoidance of medical care due to fears of COVID-19 exposure and may eventually result in higher associated case fatality.
Collapse
|
36
|
Caughey MC, Vaduganathan M, Arora S, Qamar A, Mentz RJ, Chang PP, Yancy CW, Russell SD, Shah SJ, Rosamond WD, Pandey A. Racial Differences and Temporal Obesity Trends in Heart Failure with Preserved Ejection Fraction. J Am Geriatr Soc 2021; 69:1309-1318. [PMID: 33401338 PMCID: PMC8286810 DOI: 10.1111/jgs.17004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/13/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Obesity increases with age, is disproportionately prevalent in black populations, and is associated with heart failure with preserved ejection fraction (HFpEF). An "obesity paradox," or improved survival with obesity, has been reported in patients with HFpEF. The aim of this study was to examine whether racial differences exist in the temporal trends and outcomes associated with obesity among older patients with HFpEF. DESIGN Community surveillance of acute decompensated heart failure (ADHF) hospitalizations, sampled by stratified design from 2005 to 2014. SETTING Atherosclerosis Risk in Communities Study (NC, MS, MD, MN). PARTICIPANTS A total of 10,147 weighted hospitalizations for ADHF (64% female, 74% white, mean age 77 years), with ejection fraction ≥50%. MEASUREMENTS ADHF classified by physician review, HFpEF defined by ejection fraction ≥50%. Body mass index (BMI) calculated from weight at hospital discharge. Obesity defined by BMI ≥30 kg/m2 , class III obesity by BMI ≥40 kg/m2 . RESULTS When aggregated across 2005-2014, the mean BMI was higher for black compared to white patients (34 vs 30 kg/m2 ; P < .0001), as was prevalence of obesity (56% vs 43%; P < .0001) and class III obesity (24% vs 13%; P < .0001). Over time, the annual mean BMI and prevalence of class III obesity remained stable for black patients, but steadily increased for white patients, with annual rates statistically differing by race (P-interaction = .04 and P = .03, respectively). For both races, a U-shaped adjusted mortality risk was observed across BMI categories, with the highest risk among patients with a BMI ≥40 kg/m2 . CONCLUSION Black patients were disproportionately burdened by obesity in this decade-long community surveillance of older hospitalized patients with HFpEF. However, temporal increases in mean BMI and class III obesity prevalence among white patients narrowed the racial difference in recent years. For both races, the worst survival was observed with class III obesity. Effective strategies are needed to manage obesity in patients with HFpEF.
Collapse
Affiliation(s)
- Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University; Chapel Hill, NC
| | | | - Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill; Chapel Hill, NC
| | - Arman Qamar
- Section of Interventional Cardiology & Vascular Medicine, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, IL
| | | | - Patricia P. Chang
- Division of Cardiology, University of North Carolina at Chapel Hill; Chapel Hill, NC
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University; Chicago, IL
| | | | - Sanjiv J. Shah
- Division of Cardiology, Northwestern University; Chicago, IL
| | - Wayne D. Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill; Chapel Hill, NC
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern; Dallas, TX
| |
Collapse
|
37
|
Lowe F, Sen S, Adam HS, Demmer R, Wasserman BA, Rosamond WD, Moss K, Beck JD, Gottesman RF. Abstract P626: Periodontal Disease is Independently Associated With Cerebral Small Vessel Disease. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Prior studies have shown the association between periodontal disease, lacunar strokes and cognitive impairment. Using the Atherosclerosis Risk in Communities (ARIC) cohort study we investigated the relationship between periodontal disease (PD) and the development of MRI verified small vessel disease.
Methods:
Using the ARIC database data we extracted data for 1143 (mean age 77 years, 76% white, 24% African-American and 45% male) participants assessed for PD (N=800) versus periodontal health (N=343). These participants were assessed for small vessel disease on 3T MRI as measured by the log of white matter hyperintensity volume (WMHV). WMHV were derived from a semiautomated segmentation of FLAIR images. Student t-test was then used to evaluate the relationship between small vessel disease as the log of WMHV in subjects with PD or periodontal health. Based on WMHV the patients were grouped into quartiles and the association of PD with WMHV were tested using the group in periodontal health and lowest quartile of WMHV as the reference groups. Multinomial logistic regression was used to compute crude and adjusted odds ratio (OR) for the higher quartiles of WMHV compared to the reference quartile.
Results:
There was a significant increase in the presence of small vessel disease measured as log WMHV in the PD cohort as compared to periodontal health cohort with p= 0.023 on Independent Sample t-est. Based on WMHV the subjects were grouped into quartiles 0-6.41, >6.41-11.56, >11.56-21.36 and >21.36 cu mm3). PD was associated with only the highest quartile of WMHV on univariate (crude OR 1.77, 95% CI 1.23-2.56) and multivariable (adjusted OR 1.61, 95% CI 1.06-2.44) analyses. The later was adjusted for age, race, gender, hypertension, diabetes and smoking.
Conclusion:
Based on this prospective cohort there is data to suggest that PD may be associated with cerebral small vessel disease. Maintaining proper dental health may decrease future risk for the associated lacunar strokes and vascular cognitive impairment.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Kevin Moss
- Univ of North Carolina at CH, Chapel Hill, NC
| | | | | |
Collapse
|
38
|
Kodumuri N, Sen S, La Valley EA, Suri F, Wasserman BA, Gottesman RF, Rosamond WD, Moss K, Beck JD. Abstract MP43: Paradoxical Response to Antibodies in Periodontal Microbes in Subjects With Intracranial Atherosclerotic Stenosis. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.mp43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Previously we have shown that periodontal disease and systemic inflammation are related to intracranial atherosclerosis (ICAS) in Atherosclerosis Risk In Communities study (ARIC). In this study we evaluated the relationship between serum antibodies against periodontal pathogens and ICAS.
Methods:
In this ongoing, prospective, longitudinal community-based cohort study, participants were assessed for antibodies to periodontal organisms including Porphyrmonas
gingivalis
(PG), Prevotella
intermedia
(PI), Prevotella
nigrescens
(PN), Bacteriodes
forsythensis
(BF), Treponema
denticola
(TD), Actinobacillus
actinomycetemcomitans
(AA), Campylobacter
rectus
(CR), Eikenella
corrodens
(EC), Fusobacterium
nucleatum
(FN), Peptostreptococcus
micros
(PM), Selenomonas
noxia
(SN), Capnocytophaga
ochracea
(CO), Veillonella
parvula
(VP), Streptococcus
sanguinis
(SS), Streptococcus
intermedius
(SI), Streptococcus
oralis
(SO), Actinomycosis
viscosis
(AV) and Helicobacter
pylori
(HP). These participants underwent 3D time-of-flight magnetic resonance angiography (MRA) to evaluate ICAS. Log mean antibody (IgG), CRP and IL-6 levels were compared using t-test between groups with and without ≥50% ICAS.
Results:
In this ARIC cohort, 1066 participants were assessed by MRA for ICAS. Serum CRP and IL-6 data were available for all and IgG levels were available for 772 participants. The log mean IgG level was significantly lower for patients with ≥50% ICAS versus patients with <50% ICAS in four organisms: PN (1.69 vs 1.80,
p= 0.03
), BF (1.30 vs 1.38,
p=0.05
), CO (1.23 vs 1.33,
p= 0.04
), FN (0.87 vs 1.01,
p=0.02
). The log mean IgG was also lower for CR, EC, SN, VP, SI, SO and AV though not significant. Log mean CRP was higher in the ≥50% ICAS group versus the <50% ICAS group (0.58 vs. 0.47,
p < 0.001
). Log mean IL-6 levels were also higher but not significant (0. 17 vs. 0.11,
p= 0.07
).
Conclusion:
Higher levels of systemic inflammatory markers (CRP, IL-6) are associated with significant ICAS, but we report a significantly lower level of IgG antibodies to specific periodontal pathogens (PN, BF, CO and FN) in patients with ≥50% ICAS. This paradoxical finding may represent the effect of systemic inflammation and oxidative stress on IgG levels to periodontal bacteria.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Kevin Moss
- Univ of North Carolina at CH, Chapel Hill, NC
| | | |
Collapse
|
39
|
La Valley EA, Sen S, Curtis J, Gottesman RF, Rosamond WD, Moss K, Beck JD. Abstract P441: Dental Caries a Risk Factor for Intracerebral Hemorrhage. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Streptococcus mutans is a known cause of dental caries that contains a collagen-binding protein, Cnm, and shows inhibition of platelet aggregation and matrix metalloproteinase-9 activation. This strain has been linked to aggravation of experimental intracerebral hemorrhage (ICH) and may be a risk factor for intracerebral hemorrhage.
Methods:
Presence of dental caries was assessed in subjects from the Dental Atherosclerosis in Communities Study (DARIC) without prior stroke or intracerebral hemorrhage. This cohort was followed for a period of incident intracerebral hemorrhage, subsequently verified by chart abstraction. Cox regression with time-dependent covariate was used to compute crude and adjusted hazards ratio stratified as <15 years and ≥15 years from the initial dental assessment.
Results:
Among 6506 subjects, dental caries were recorded in 1227 (19%) subjects. 47 (1%) had ICH over a period of 30 years. Those with dental caries versus those without dental caries had a greater proportion of younger (mean age 61.8±5.6 vs. 62.5±5.6, p<0.001), male (24% vs. 16%, p<0.001), African-American (53% vs 12%, p<0.001) and hypertensive (24% vs. 16%, p<0.001) patients. The association between dental caries and ICH in the first 15 years was not higher (crude HR 1.0, 95% CI 0.4-2.3) and remained so after adjusting for age, gender, race, and hypertension (adj. HR 1.1, 95% CI 0.5-2.9). The association between caries and ICH in the second 15 years was higher (crude HR 3.7, 95% CI 1.1-12.0) and strengthened after adjustment (adjusted OR 4.5, 95% CI 1.3-15.5). This is depicted in the Kaplan-Meier curve below.
Conclusion:
We report a significant association between dental caries and ICH. Future studies are needed to determine if early treatment of dental caries can reduce the risk of ICH.
Collapse
Affiliation(s)
| | | | | | | | | | - Kevin Moss
- Univ of North Carolina at CH, Chapel Hill, NC
| | | |
Collapse
|
40
|
Goff DC, Khan SS, Lloyd-Jones D, Arnett DK, Carnethon MR, Labarthe DR, Loop MS, Luepker RV, McConnell MV, Mensah GA, Mujahid MS, O'Flaherty ME, Prabhakaran D, Roger V, Rosamond WD, Sidney S, Wei GS, Wright JS. Bending the Curve in Cardiovascular Disease Mortality: Bethesda + 40 and Beyond. Circulation 2021; 143:837-851. [PMID: 33617315 PMCID: PMC7905830 DOI: 10.1161/circulationaha.120.046501] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
More than 40 years after the 1978 Bethesda Conference on the Declining Mortality from Coronary Heart Disease provided the scientific community with a blueprint for systematic analysis to understand declining rates of coronary heart disease, there are indications the decline has ended or even reversed despite advances in our knowledge about the condition and treatment. Recent data show a more complex situation, with mortality rates for overall cardiovascular disease, including coronary heart disease and stroke, decelerating, whereas those for heart failure are increasing. To mark the 40th anniversary of the Bethesda Conference, the National Heart, Lung, and Blood Institute and the American Heart Association cosponsored the "Bending the Curve in Cardiovascular Disease Mortality: Bethesda + 40" symposium. The objective was to examine the immediate and long-term outcomes of the 1978 conference and understand the current environment. Symposium themes included trends and future projections in cardiovascular disease (in the United States and internationally), the evolving obesity and diabetes epidemics, and harnessing emerging and innovative opportunities to preserve and promote cardiovascular health and prevent cardiovascular disease. In addition, participant-led discussion explored the challenges and barriers in promoting cardiovascular health across the lifespan and established a potential framework for observational research and interventions that would begin in early childhood (or ideally in utero). This report summarizes the relevant research, policy, and practice opportunities discussed at the symposium.
Collapse
Affiliation(s)
- David Calvin Goff
- Division of Cardiovascular Sciences (D.C.G., G.S.W.), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Sadiya Sana Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., D.L-J., M.R.C., D.R.L.)
| | - Donald Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., D.L-J., M.R.C., D.R.L.)
| | - Donna K Arnett
- College of Public Health, University of Kentucky, Lexington (D.K.A.)
| | - Mercedes R Carnethon
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., D.L-J., M.R.C., D.R.L.)
| | - Darwin R Labarthe
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., D.L-J., M.R.C., D.R.L.)
| | - Matthew Shane Loop
- Department of Biostatistics (M.S.L.), Gillings School of Global Public Health, University of North Carolina Chapel Hill
| | - Russell V Luepker
- School of Public Health, University of Minnesota, Minneapolis (R.V.L.)
| | - Michael V McConnell
- Department of Medicine, Cardiovascular Medicine, School of Medicine, Stanford University, CA (M.V.M.)
- Google Health, Palo Alto, CA (M.V.M.)
| | - George A Mensah
- Center for Translation Research and Implementation Science (G.A.M.), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Mahasin S Mujahid
- Department of Epidemiology, School of Public Health, University of California, Berkeley (M.S.M.)
| | | | - Dorairaj Prabhakaran
- Public Health Foundation of India, Gurgaon (D.P.)
- Centre for Chronic Disease Control, New Delhi, India (D.P.)
- London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
| | - Véronique Roger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (V.R.)
| | - Wayne D Rosamond
- Department of Epidemiology (W.D.R.), Gillings School of Global Public Health, University of North Carolina Chapel Hill
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland (S.S.)
| | - Gina S Wei
- Division of Cardiovascular Sciences (D.C.G., G.S.W.), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Janet S Wright
- Office of the Surgeon General, US Department of Health and Human Services, Washington, DC (J.S.W.)
| |
Collapse
|
41
|
Koton S, Sang Y, Schneider ALC, Rosamond WD, Gottesman RF, Coresh J. Trends in Stroke Incidence Rates in Older US Adults: An Update From the Atherosclerosis Risk in Communities (ARIC) Cohort Study. JAMA Neurol 2020; 77:109-113. [PMID: 31566685 DOI: 10.1001/jamaneurol.2019.3258] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Determining whether the previously reported decreased stroke incidence rates from 1987 to 2011 among US adults 65 years and older in the Atherosclerosis Risk in Communities (ARIC) study continued to decrease subsequently can help guide policy and planning efforts. Objective To evaluate whether stroke incidence declines among older adults in the ARIC study continued after 2011. Design, Setting, and Participants ARIC is a community-based prospective cohort study including 15 792 individuals aged 45 to 64 years at baseline (1987-1989), selected by probability sampling from residents of Forsyth County, North Carolina; Jackson, Mississippi (black individuals only); the northwestern suburbs of Minneapolis, Minneapolis; and Washington County, Maryland (ie, center). The present study included ARIC participants free of stroke at baseline, followed up through December 31, 2017. Data were collected through personal interviews and physical examinations during study visits, annual/semiannual telephone interviews, and active surveillance of discharges from local hospitals. Stroke events were adjudicated by study-physicians reviewers. Analysis began September 2018. Main Outcomes and Measures The main outcome was stroke incidence rates, which were computed with 95% CIs stratifying the analysis by age and calendar time. Trends in adjusted incidence rates were assessed using Poisson regression incidence rate ratios. Models included calendar time, age, sex, race/center, and time-varying risk factors (hypertension, diabetes, coronary heart disease, cholesterol-lowering medication use, and smoking). Results Of 14 357 ARIC participants with 326 654 person-years of follow-up, the mean (SD) age at baseline was 54.1 (5.8) years and 7955 (55.4%) were women. From 1987 to 2017, a total of 1340 incident strokes occurred among ARIC participants, and among them, 1028 (76.7%) occurred in participants 65 years and older. Crude incidence rates of stroke for participants 65 years and older decreased progressively from 1987 to 2017. Incidence rates, adjusted for age, sex, race/center, and time-varying risk factors, decreased by 32% (95% CI, 23%-40%) per 10 years in participants 65 years and older. Findings were consistent across decades, sex, and race. Conclusions and Relevance Validated total stroke incidence rates in adults 65 years and older decreased over the last 30 years in the ARIC cohort. The decrease in rates previously reported for 1987 to 2011 extends for the subsequent 6 years in men and women as well as in white and black individuals.
Collapse
Affiliation(s)
- Silvia Koton
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,School of Public Health, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Yingying Sang
- School of Public Health, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Andrea L C Schneider
- School of Public Health, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.,School of Medicine, Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Rebecca F Gottesman
- School of Public Health, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.,School of Medicine, Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Josef Coresh
- School of Public Health, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
42
|
Pastva AM, Coyle PC, Coleman SW, Radman MD, Taylor KM, Jones SB, Bushnell CD, Rosamond WD, Johnson AM, Duncan PW, Freburger JK. Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study. Arch Phys Med Rehabil 2020; 102:532-542. [PMID: 33263286 DOI: 10.1016/j.apmr.2020.09.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.
Collapse
Affiliation(s)
- Amy M Pastva
- Duke University School of Medicine, Durham, North Carolina.
| | - Peter C Coyle
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
| | - Sylvia W Coleman
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Meghan D Radman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karen M Taylor
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Sara B Jones
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Wayne D Rosamond
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna M Johnson
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pamela W Duncan
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Janet K Freburger
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
| | | |
Collapse
|
43
|
Sharma K, Mok Y, Kwak L, Agarwal SK, Chang PP, Deswal A, Shah AM, Kitzman DW, Wruck LM, Loehr LR, Heiss G, Coresh J, Rosamond WD, Solomon SD, Matsushita K, Russell SD. Predictors of Mortality by Sex and Race in Heart Failure With Preserved Ejection Fraction: ARIC Community Surveillance Study. J Am Heart Assoc 2020; 9:e014669. [PMID: 32924735 PMCID: PMC7792380 DOI: 10.1161/jaha.119.014669] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) accounts for half of heart failure hospitalizations, with limited data on predictors of mortality by sex and race. We evaluated for differences in predictors of all‐cause mortality by sex and race among hospitalized patients with HFpEF in the ARIC (Atherosclerosis Risk in Communities) Community Surveillance Study. Methods and Results Adjudicated HFpEF hospitalization events from 2005 to 2013 were analyzed from the ARIC Community Surveillance Study, comprising 4 US communities. Comparisons between clinical characteristics and mortality at 1 year were made by sex and race. Of 4335 adjudicated acute decompensated heart failure cases, 1892 cases (weighted n=8987) were categorized as HFpEF. Men had an increased risk of 1‐year mortality compared with women in adjusted analysis (hazard ratio [HR], 1.27; 95% CI, 1.06–1.52 [P=0.01]). Black participants had lower mortality compared with White participants in unadjusted and adjusted analyses (HR, 0.79; 95% CI, 0.64–0.97 [P=0.02]). Age, heart rate, worsening renal function, and low hemoglobin were associated with increased mortality in all subgroups. Higher body mass index was associated with improved survival in men, with borderline interaction by sex. Higher blood pressure was associated with improved survival among all groups, with significant interaction by race. Conclusions In a diverse HFpEF population, men had worse survival compared with women, and Black participants had improved survival compared with White participants. Age, heart rate, and worsening renal function were associated with increased mortality across all subgroups; high blood pressure was associated with decreased mortality with interaction by race. These insights into sex‐ and race‐based differences in predictors of mortality may help strategize targeted management of HFpEF.
Collapse
Affiliation(s)
- Kavita Sharma
- Division of Cardiology The Johns Hopkins Hospital Baltimore MD
| | - Yejin Mok
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Lucia Kwak
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Patricia P Chang
- Department of Medicine University of North Carolina Chapel Hill NC
| | - Anita Deswal
- Section of Cardiology Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston TX
| | - Amil M Shah
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Dalane W Kitzman
- Cardiology and Geriatrics Sections Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Lisa M Wruck
- Duke Clinical Research InstituteCenter for Predictive Medicine Durham NC
| | - Laura R Loehr
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Gerardo Heiss
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Josef Coresh
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Wayne D Rosamond
- Department of Epidemiology University of North Carolina Chapel Hill NC
| | - Scott D Solomon
- Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Kunihiro Matsushita
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | |
Collapse
|
44
|
Zègre-Hemsey JK, Grewe ME, Johnson AM, Arnold E, Cunningham CJ, Bogle BM, Rosamond WD. Delivery of Automated External Defibrillators via Drones in Simulated Cardiac Arrest: Users' Experiences and the Human-Drone Interaction. Resuscitation 2020; 157:83-88. [PMID: 33080371 DOI: 10.1016/j.resuscitation.2020.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest (OHCA) in the United States is approximately 10%. Automatic external defibrillators (AEDs) are effective when applied early, yet public access AEDs are used in <2% of OHCAs. AEDs are often challenging for bystanders to locate and are rarely available in homes, where 70% of OHCAs occur. Drones have the potential to deliver AEDs to bystanders efficiently; however, little is known about the human-drone interface in AED delivery. OBJECTIVES To describe user experiences with AED-equipped drones in a feasibility study of simulated OHCA in a community setting. METHODS We simulated an OHCA in a series of trials with age-group/sex-matched participant pairs, with one participant randomized to search for a public access AED and the other to call a mock 9-1-1 telephone number that initiated the dispatch of an AED-equipped drone. We investigated user experience of 17 of the 35 drone recipient participants via semi-structured qualitative interviews and analyzed audio-recordings for key aspects of user experience. RESULTS Drone recipient participants reported largely positive experiences, highlighting that this delivery method enabled them to stay with the victim and continue cardiopulmonary resuscitation. Concerns were few but included drone arrival timing and direction as well as bystander safety. Participants provided suggestions for improvements in the AED-equipped drone design and delivery procedures. CONCLUSION Participants reported positive experiences interacting with an AED-equipped drone for a simulated OHCA in a community setting. Early findings suggest a role for drone-delivered AEDs to improve bystander AED use and improve outcomes for OHCA victims.
Collapse
Affiliation(s)
- Jessica K Zègre-Hemsey
- School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, Campus Box 7460, Chapel Hill, NC 27599-7460.
| | - Mary E Grewe
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, 160 North Medical Drive, Brinkhous-Bullitt Building, 2nd Floor #220-237, Chapel Hill, NC 27599-7064
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 123 West Franklin Street, Suite 410, Chapel Hill, NC 27516
| | - Evan Arnold
- Institute for Transportation Research and Education, North Carolina State University, 909 Capability Dr, Research IV, Raleigh, NC 27606
| | - Christopher J Cunningham
- School of Medicine, University of North Carolina at Chapel Hill, 321 South Columbia Street, Chapel Hill, NC 27516
| | - Brittany M Bogle
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 123 West Franklin Street, Suite 410, Chapel Hill, NC 27516
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 123 West Franklin Street, Suite 410, Chapel Hill, NC 27516
| |
Collapse
|
45
|
Rosamond WD, Johnson AM, Bogle BM, Arnold E, Cunningham CJ, Picinich M, Williams BM, Zègre-Hemsey JK. Drone Delivery of an Automated External Defibrillator. N Engl J Med 2020; 383:1186-1188. [PMID: 32937053 PMCID: PMC7523534 DOI: 10.1056/nejmc1915956] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | - Anna M Johnson
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Evan Arnold
- North Carolina State University, Raleigh, NC
| | | | | | | | | |
Collapse
|
46
|
Lutz BJ, Reimold AE, Coleman SW, Guzik AK, Russell LP, Radman MD, Johnson AM, Duncan PW, Bushnell CD, Rosamond WD, Gesell SB. Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff. Gerontologist 2020; 60:1071-1084. [PMID: 32275060 PMCID: PMC7427484 DOI: 10.1093/geront/gnaa029] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a chronic, complex condition that disproportionally affects older adults. Health systems are evaluating innovative transitional care (TC) models to improve outcomes in these patients. The Comprehensive Post-Acute Stroke Services (COMPASS) Study, a large cluster-randomized pragmatic trial, tested a TC model for patients with stroke or transient ischemic attack discharged home from the hospital. The implementation of COMPASS-TC in complex real-world settings was evaluated to identify successes and challenges with integration into the clinical workflow. RESEARCH DESIGN AND METHODS We conducted a concurrent process evaluation of COMPASS-TC implementation during the first year of the trial. Qualitative data were collected from 4 sources across 19 intervention hospitals. We analyzed transcripts from 43 conference calls with hospital clinicians, individual and group interviews with leaders and clinicians from 9 hospitals, and 2 interviews with the COMPASS-TC Director of Implementation using iterative thematic analysis. Themes were compared to the domains of the RE-AIM framework. RESULTS Organizational, individual, and community factors related to Reach, Adoption, and Implementation were identified. Organizational readiness was an additional key factor to successful implementation, in that hospitals that were not "organizationally ready" had more difficulty addressing implementation challenges. DISCUSSION AND IMPLICATIONS Multifaceted TC models are challenging to implement. Facilitators of implementation were organizational commitment and capacity, prioritizing implementation of innovative delivery models to provide comprehensive care, being able to address challenges quickly, implementing systems for tracking patients throughout the intervention, providing clinicians with autonomy and support to address challenges, and adequately resourcing the intervention. CLINICAL TRIAL REGISTRATION NCT02588664.
Collapse
Affiliation(s)
- Barbara J Lutz
- School of Nursing, University of North Carolina at Wilmington
| | | | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy K Guzik
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Laurie P Russell
- Division of Public Health Sciences, Wake Forest University Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Sabina B Gesell
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
47
|
Engeda JC, Lhachimi SK, Rosamond WD, Lund JL, Keyserling TC, Safford MM, Colantonio LD, Muntner P, Avery CL. Projections of incident atherosclerotic cardiovascular disease and incident type 2 diabetes across evolving statin treatment guidelines and recommendations: A modelling study. PLoS Med 2020; 17:e1003280. [PMID: 32845900 PMCID: PMC7449387 DOI: 10.1371/journal.pmed.1003280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 07/22/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Experimental and observational research has suggested the potential for increased type 2 diabetes (T2D) risk among populations taking statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, few studies have directly compared statin-associated benefits and harms or examined heterogeneity by population subgroups or assumed treatment effect. Thus, we compared ASCVD risk reduction and T2D incidence increases across 3 statin treatment guidelines or recommendations among adults without a history of ASCVD or T2D who were eligible for statin treatment initiation. METHODS AND FINDINGS Simulations were conducted using Markov models that integrated data from contemporary population-based studies of non-Hispanic African American and white adults aged 40-75 years with published meta-analyses. Statin treatment eligibility was determined by predicted 10-year ASCVD risk (5%, 7.5%, or 10%). We calculated the number needed to treat (NNT) to prevent one ASCVD event and the number needed to harm (NNH) to incur one incident case of T2D. The likelihood to be helped or harmed (LHH) was calculated as ratio of NNH to NNT. Heterogeneity in statin-associated benefit was examined by sex, age, and statin-associated T2D relative risk (RR) (range: 1.11-1.55). A total of 61,125,042 U.S. adults (58.5% female; 89.4% white; mean age = 54.7 years) composed our primary prevention population, among whom 13-28 million adults were eligible for statin initiation. Overall, the number of ASCVD events prevented was at least twice as large as the number of incident cases of T2D incurred (LHH range: 2.26-2.90). However, the number of T2D cases incurred surpassed the number of ASCVD events prevented when higher statin-associated T2D RRs were assumed (LHH range: 0.72-0.94). In addition, females (LHH range: 1.74-2.40) and adults aged 40-50 years (LHH range: 1.00-1.14) received lower absolute benefits of statin treatment compared with males (LHH range: 2.55-3.00) and adults aged 70-75 years (LHH range: 3.95-3.96). Projected differences in LHH by age and sex became more pronounced as statin-associated T2D RR increased, with a majority of scenarios projecting LHHs < 1 for females and adults aged 40-50 years. This study's primary limitation was uncertainty in estimates of statin-associated T2D risk, highlighting areas in which additional clinical and public health research is needed. CONCLUSIONS Our projections suggest that females and younger adult populations shoulder the highest relative burden of statin-associated T2D risk.
Collapse
Affiliation(s)
- Joseph C. Engeda
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Stefan K. Lhachimi
- Research Group Evidence-Based Public Health, Leibniz Institute for Epidemiology and Prevention Research (BIPS), Bremen, Germany
- Department for Health Services Research, Institute for Public Health and Nursing, University of Bremen, Bremen, Germany
| | - Wayne D. Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jennifer L. Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Thomas C. Keyserling
- Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Lisandro D. Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Christy L. Avery
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| |
Collapse
|
48
|
Pandey A, Vaduganathan M, Arora S, Qamar A, Mentz RJ, Shah SJ, Chang PP, Russell SD, Rosamond WD, Caughey MC. Temporal Trends in Prevalence and Prognostic Implications of Comorbidities Among Patients With Acute Decompensated Heart Failure: The ARIC Study Community Surveillance. Circulation 2020; 142:230-243. [PMID: 32486833 PMCID: PMC7654711 DOI: 10.1161/circulationaha.120.047019] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with heart failure (HF) have multiple coexisting comorbidities. The temporal trends in the burden of comorbidities and associated risk of mortality among patients with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) are not well established. METHODS HF-related hospitalizations were sampled by stratified design from 4 US areas in 2005 to 2014 by the community surveillance component of the ARIC study (Atherosclerosis Risk in Communities). Acute decompensated HF was classified by standardized physician review and a previously validated algorithm. An ejection fraction <50% was considered HFrEF. A total of 15 comorbidities were abstracted from the medical record. Mortality outcomes were ascertained for up to 1-year postadmission by linking hospital records with death files. RESULTS A total of 5460 hospitalizations (24 937 weighted hospitalizations) classified as acute decompensated HF had available ejection fraction data (53% female, 68% white, 53% HFrEF, 47% HFpEF). The average number of comorbidities was higher for patients with HFpEF versus HFrEF, both for women (5.53 versus 4.94; P<0.0001) and men (5.20 versus 4.82; P<0.0001). There was a significant temporal increase in the overall burden of comorbidities, both for patients with HFpEF (women: 5.17 in 2005-2009 to 5.87 in 2010-2013; men: 4.94 in 2005-2009 and 5.45 in 2010-2013) and HFrEF (women: 4.78 in 2005-2009 to 5.14 in 2010-2013; men: 4.62 in 2005-2009 and 5.06 in 2010-2013; P-trend<0.0001 for all). Higher comorbidity burden was significantly associated with higher adjusted risk of 1-year mortality, with a stronger association noted for HFpEF (hazard ratio [HR] per 1 higher comorbidity, 1.19 [95% CI, 1.14-1.25] versus HFrEF (HR, 1.10 [95% CI, 1.05-1.14]; P for interaction by HF type=0.02). The associated mortality risk per 1 higher comorbidity also increased significantly over time for patients with HFpEF and HFrEF, as well (P for interaction with time=0.002 and 0.02, respectively) Conclusions: The burden of comorbidities among hospitalized patients with acute decompensated HFpEF and HFrEF has increased over time, as has its associated mortality risk. Higher burden of comorbidities is associated with higher risk of mortality, with a stronger association noted among patients with HFpEF versus HFrEF.
Collapse
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Sameer Arora
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Arman Qamar
- Division of Cardiology, Department of Internal Medicine, New York University School of Medicine, New York, NY
| | | | - Sanjiv J. Shah
- Division of Cardiology, Department of Internal Medicine, Northwestern University School of Medicine, Chicago, IL
| | - Patricia P. Chang
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stuart D. Russell
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, NC
| |
Collapse
|
49
|
Duncan PW, Bushnell CD, Jones SB, Psioda MA, Gesell SB, D'Agostino RB, Sissine ME, Coleman SW, Johnson AM, Barton-Percival BF, Prvu-Bettger J, Calhoun AG, Cummings DM, Freburger JK, Halladay JR, Kucharska-Newton AM, Lundy-Lamm G, Lutz BJ, Mettam LH, Pastva AM, Xenakis JG, Ambrosius WT, Radman MD, Vetter B, Rosamond WD. Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006285. [PMID: 32475159 DOI: 10.1161/circoutcomes.119.006285] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
Collapse
Affiliation(s)
- Pamela W Duncan
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Cheryl D Bushnell
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Matthew A Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center (M.A.P.), University of North Carolina at Chapel Hill
| | - Sabina B Gesell
- Social Sciences and Health Policy, Division of Public Health Sciences (S.B.G.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Ralph B D'Agostino
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Mysha E Sissine
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sylvia W Coleman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | | | - Adrienne G Calhoun
- Area Agency on Aging, Piedmont Triad Regional Council, Kernersville, NC (B.F.B.-P., A.G.C.)
| | - Doyle M Cummings
- Brody School of Medicine, East Carolina University, Greenville, NC (D.M.C.)
| | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Science, University of Pittsburgh, PA (J.K.F.)
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (J.R.H.)
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | - Barbara J Lutz
- University of North Carolina at Wilmington School of Nursing (B.J.L.)
| | - Laurie H Mettam
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Amy M Pastva
- Duke University School of Medicine, Durham, NC (J.P.-B., A.M.P.)
| | - James G Xenakis
- Department of Biostatistics, Gillings School of Global Public Health (J.G.X.), University of North Carolina at Chapel Hill
| | - Walter T Ambrosius
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Meghan D Radman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| |
Collapse
|
50
|
Sivaraj K, Arora S, Slehria T, Chang P, Weickert T, Qamar A, Vaduganathan M, Cavender MA, Rosamond WD, Vavalle JP. Abstract 209: Prevalence and Prognostic Significance of Aortic Stenosis in Patients With Acute Decompensated Heart Failure: The Atherosclerosis Risk in Communities Study. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Heart failure (HF) patients with aortic stenosis (AS) constitute a high-risk population posing diagnostic and therapeutic challenges. Few studies have characterized the burden of AS in patients admitted with acute decompensated HF (ADHF), stratified by ejection fraction (EF).
Methods:
The Atherosclerosis Risk in Communities study conducted community-based surveillance of a random sample of ADHF hospitalizations for residents ≥55 years of age in four US communities. ADHF cases were subclassified as having reduced (HFrEF) or preserved (HFpEF) EF using a 50% cutoff. AS severity was determined from echocardiogram reports obtained during abstracted hospitalizations. Odds of moderate or severe AS in patients with varying sex and race, and odds of all-cause 1-year mortality in those with higher AS severity were estimated using multivariable logistic regression.
Results:
From 2005-2014, there were 14,289 weighted ADHF hospitalizations of whom 7,357 had HFrEF (45.0% female, 36.6% black) and 6,932 HFpEF (62.9% female, 26.5% black). The prevalence of moderate or severe AS was 5.67% in HFrEF and 9.43% in HFpEF. Patients with higher AS severity were older than those with none or mild AS in both HFrEF ([mean age] 79.7 vs. 74.4 years, p<0.0001) and HFpEF (81.7 vs. 76.3 years, p<0.0001). No difference in odds of higher AS severity was detected between females and males in both HFrEF (5.49% vs. 5.81%, OR: 1.03, 95% CI: 0.83-1.27) and HFpEF (9.10% vs. 9.99%, OR: 0.89, 95% CI: 0.75-1.06). Moderate or severe AS was more likely in whites than blacks in both HFrEF (8.32% vs. 1.67%, OR: 0.23, 95% CI: 0.17-0.32) and HFpEF (11.1% vs. 6.38%, OR: 0.70, 95% CI: 0.56-0.88). Higher AS severity was independently associated with increased all-cause 1-year mortality after ADHF hospitalization in both HFrEF (44.3% vs. 30.5%, OR: 1.25, 95% CI: 1.16-1.35) and HFpEF (33.4% vs. 26.1%, OR: 1.16, 95% CI: 1.08-1.24).
Conclusion:
In ADHF patients with HFrEF or HFpEF, whites are more affected by AS than blacks, as are older patients when compared to their younger counterparts. Higher AS severity in ADHF patients is independently associated with all-cause mortality at 1 year after hospitalization, regardless of EF.
Collapse
|