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Background: Adults who maintain ideal cardiovascular health (CVH) profiles up to midlife have lower risk of several chronic diseases and better quality of life. Some evidence suggests that individual-level exposures earlier in life shape midlife CVH, but the impact of neighborhood-level exposures over the life course remains understudied., Methods and Results: Participants were 3017 Black and White men and women aged 18 to 30 years at baseline (1985-1986), recruited from Birmingham, Alabama; Minneapolis, Minnesota; Chicago, Illinois; and Oakland, California, as part of the CARDIA (Coronary Artery Risk Development in Young Adults) study. Measures of the neighborhood food and physical activity environment were linked to participant addresses collected at baseline. CVH was measured on the basis of the American Heart Association's Life's Simple 7 criteria in young adulthood and 30 years later (2015-2016) when participants were midlife (aged 48-60 years). Associations of young adult neighborhood food environment and physical activity resources with midlife CVH (moderate versus high and low versus high) were examined using multinomial logistic regression. Models were adjusted for young adult sociodemographic factors. Participants who lived farther away from a major park in young adulthood were more likely to have low versus high CVH scores (odds ratio, 1.54 [95% CI, 1.22-1.96]) and more likely to have moderate versus high CVH scores (odds ratio, 1.39 [95% CI, 1.12-1.73]) in midlife. No other neighborhood measures were significantly associated with CVH., Conclusions: Young adulthood may be a sensitive period in which having convenient access to physical activity-promoting resources may help them establish healthy habits that can carry into midlife.

Background: This study examined the longitudinal associations of baseline psychosocial stress subgroups with cardiovascular disease (CVD) events and whether social support, neighborhood cohesion, and physical activity modified these associations in the Multi-Ethnic Study of Atherosclerosis (MESA)., Methods and Results: Data from 6,349 adults (aged: 62.2±10.2 years; 52.9% women) from the MESA study with no prior CVD in 2000-2002 were used in this analysis. Latent class analysis (LCA) was used to specify distinct psychosocial stress subgroups based on self-reported stressors stemming from respondents' neighborhood and social environment. Adjudicated CVD events (fatal and nonfatal events) were ascertained annually through the year 2019. Cox proportional hazards models were used to examine the associations between subgroup membership and CVD events. Five distinct psychosocial stress subgroups were identified via LCA and were labeled 'moderate neighborhood noise' (12.1%), 'excessive neighborhood noise' (6.4%), 'multiple high stressors' (6.3%), 'high discrimination' (21.4%), and 'optimal' (53.8%). By the year 2019, 1,121 participants had experienced a CVD event. Membership in the 'high discrimination' (HR: 1.29; 95%CI: 1.10, 1.51) subgroup was associated with higher risk of a CVD event when adjusted for sociodemographic characteristics and cardiovascular health metrics. Neither social support, neighborhood cohesion, nor physical activity modified this association ( p s>0.05)., Conclusions: Distinct subgroups of individuals with high self-reported psychological distress-particularly related to discrimination and chronic stress are associated with high incident cardiovascular events.

Background We investigated associations of childhood abuse with 4 cardiovascular disease risk factors in adulthood, and whether exposure to nurturing and household organization in childhood mitigated these associations. Methods and Results The CARDIA (Coronary Artery Risk Development in Young Adults) study (baseline examination, 1985-1986) was used to examine associations of childhood exposures (measured retrospectively at the year 15 examination) with incident obesity, type 2 diabetes, hypertension, and hyperlipidemia (assessed from baseline to year 30). Race- and sex-stratified Cox proportional hazards models were used to examine associations of exposure to childhood abuse with incident cardiovascular disease risk factors. Interaction terms between exposure to abuse and exposure to nurturing relationship and household organization were included to test for effect modifications. Exposure to occasional/frequent abuse (versus no abuse) was associated with incident type 2 diabetes among White men (hazard ratio [HR], 1.81; 95% CI, 1.06-3.08). Exposure to low versus no abuse was associated with incident hyperlipidemia among White men (HR, 1.35; 95% CI, 1.09-1.67) and White women (HR, 1.26; 95% CI, 1.01-1.56). Risks of incident hyperlipidemia were higher for White women who experienced abuse and lived in dysfunctional households (HR, 3.61; 95% CI, 1.62-8.05) or households with low levels of organization (HR, 2.05; 95% CI, 1.25-3.36) compared with White women who experienced abuse but lived in well-organized households (HR, 0.66; 95% CI, 0.41-1.06). Similar patterns were seen for Black men who lived in dysfunctional households (HR, 3.62; 95% CI, 1.29-10.12) or households with low organization (HR, 2.01; 95% CI, 1.08-3.72). Conclusions We identified race- and sex-specific associations of childhood exposures with incident cardiovascular disease risk factors. The associations of household organization and dysfunction with cardiovascular disease risks merits further investigation.

Background Residential segregation, a geospatial manifestation of structural racism, is a fundamental driver of racial and ethnic health inequities, and longitudinal studies examining segregation's influence on cardiovascular health are limited. This study investigates the impact of segregation on hypertension in a multiracial and multiethnic cohort and explores whether neighborhood environment modifies this association. Methods and Results Leveraging data from a diverse cohort of adults recruited from 6 sites in the United States with 2 decades of follow-up, we used race- and ethnicity-stratified Cox models to examine the association between time-varying segregation with incident hypertension in 1937 adults free of hypertension at baseline. Participants were categorized as residing in segregated and nonsegregated neighborhoods using a spatial-weighted measure. We used a robust covariance matrix estimator to account for clustering within neighborhoods and assessed effect measure modification by neighborhood social or physical environment. Over an average follow-up of 7.35 years, 65.5% non-Hispanic Black, 48.1% Chinese, and 53.7% Hispanic participants developed hypertension. Net of confounders, Black and Hispanic residents in segregated neighborhoods were more likely to develop hypertension relative to residents in nonsegregated neighborhoods (Black residents: hazard ratio [HR], 1.33; 95% CI, 1.09-1.62; Hispanic residents: HR, 1.33; 95% CI, 1.04-1.70). Results were similar but not significant among Chinese residents (HR, 1.20; 95% CI, 0.83-1.73). Among Black residents, neighborhood social environment significantly modified this association such that better social environment was associated with less pronounced impact of segregation on hypertension. Conclusions This study underscores the importance of continued investigations of groups affected by the health consequences of racial residential segregation while taking contextual neighborhood factors, such as social environment, into account.

Background Assessment of the social determinants of post-hospital cardiac care is needed. We examined the association and predictive ability of neighborhood-level determinants (area deprivation index, ADI), readmission risk, and mortality for heart failure, myocardial ischemia, and atrial fibrillation. Methods and Results Using a retrospective (January 1, 2011-December 31, 2018) analysis of a large healthcare system, we assess the predictive ability of ADI on 30-day and 1-year readmission and mortality following hospitalization. Cox proportional hazards models analyzed time-to-event. Log rank analyses determined survival. C-statistic and net reclassification index determined the model's discriminative power. Covariates included age, sex, race, comorbidity, number of medications, length of stay, and insurance. The cohort (n=27 694) had a median follow-up of 46.5 months. There were 14 469 (52.2%) men and 25 219 White (91.1%) patients. Patients in the highest ADI quintile (versus lowest) were more likely to be admitted within 1 year of index heart failure admission (hazard ratio [HR], 1.25; 95% CI, 1.03‒1.51). Patients with myocardial ischemia in the highest ADI quintile were twice as likely to be readmitted at 1 year (HR, 2.04; 95% CI, 1.44‒2.91]). Patients with atrial fibrillation living in areas with highest ADI were less likely to be admitted within 1 year (HR, 0.79; 95% CI, 0.65‒0.95). As ADI increased, risk of readmission increased, and risk reclassification was improved with ADI in the models. Patients in the highest ADI quintile were 25% more likely to die within a year (HR, 1.25 1.08‒1.44). Conclusions Residence in socioeconomically disadvantaged communities predicts rehospitalization and mortality. Measuring neighborhood deprivation can identify individuals at risk following cardiac hospitalization.

Background Black Americans have a higher risk of hypertension compared with White Americans. Perceived discrimination is a plausible explanation for these health disparities. Few studies have examined the impact of perceived discrimination on the incidence of hypertension among a racially diverse sample. Our study examined associations of everyday and lifetime discrimination with incidence of hypertension and whether these associations varied by sex, discrimination attribution, and racial residential segregation. Methods and Results The study included 3297 Black, Hispanic, Chinese, and White participants aged 45 to 84 years from the Multi-Ethnic Study of Atherosclerosis who were without hypertension at exam 1 (2000-2002) and who completed at least 1 of 5 follow-up exams (2002-2018). Cox proportional hazards regression was used to estimate associations of perceived discrimination with incident hypertension. Over the follow-up period, 49% (n=1625) of participants developed hypertension. After adjustment for age, sex, socioeconomic status, hypertension risk factors, and study site, Black participants reporting any lifetime discrimination (compared with none) were more likely to develop hypertension (hazard ratio [HR], 1.35; 95% CI, 1.07-1.69). In fully adjusted models, everyday discrimination (high versus low) was associated with a lower risk for hypertension among Hispanic participants (HR, 0.73; 95% CI, 0.55-0.98). Statistically significant interactions of perceived discrimination (everyday and lifetime) with sex, discrimination attribution, and racial residential segregation were not observed. Conclusions This study suggests that lifetime, but not everyday discrimination is associated with incident hypertension in Black Americans.

Background Life expectancy in the United States has recently declined, in part attributable to premature cardiometabolic mortality. We characterized national trends in premature cardiometabolic mortality, overall, and by race-sex groups. Methods and Results Using death certificates from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research, we quantified premature deaths (<65 years of age) from heart disease, cerebrovascular disease, and diabetes mellitus from 1999 to 2018. We calculated age-adjusted mortality rates (AAMRs) and years of potential life lost (YPLL) from each cardiometabolic cause occurring at <65 years of age. We used Joinpoint regression to identify an inflection point in overall cardiometabolic AAMR trends. Average annual percent change in AAMRs and YPLL was quantified before and after the identified inflection point. From 1999 to 2018, annual premature deaths from heart disease (117 880 to 128 832), cerebrovascular disease (18 765 to 20 565), and diabetes mellitus (16 553 to 24 758) as an underlying cause of death increased. By 2018, 19.7% of all heart disease deaths, 13.9% of all cerebrovascular disease deaths, and 29.1% of all diabetes mellitus deaths were premature. AAMRs and YPLL from heart disease and cerebrovascular disease declined until the inflection point identified in 2011, then remained unchanged through 2018. Conversely, AAMRs and YPLL from diabetes mellitus did not change through 2011, then increased through 2018. Black men and women had higher AAMRs and greater YPLL for each cardiometabolic cause compared with White men and women, respectively. Conclusions Over one-fifth of cardiometabolic deaths occurred at <65 years of age. Recent stagnation in cardiometabolic AAMRs and YPLL are compounded by persistent racial disparities.

Background Childhood adversity and trauma have been shown to be associated with poorer cardiovascular disease (CVD) outcomes in adulthood. However, longitudinal studies of this association are rare. Methods and Results Our study used the CARDIA (Coronary Artery Risk Development in Young Adults) Study, a longitudinal cohort that has followed participants from recruitment in 1985-1986 through 2018, to determine how childhood psychosocial environment relates to CVD incidence and all-cause mortality in middle age. Participants (n=3646) completed the Childhood Family Environment (CFE) questionnaire at the year 15 (2000-2001) CARDIA examination and were grouped by high, moderate, or low relative CFE adversity scores. We used sequential multivariable regression models to estimate hazard ratios of incident (CVD) and all-cause mortality. Participants were 25.1±3.6 years old, 47% black, and 56% female at baseline and 198 participants developed CVD (17.9 per 10 000 person-years) during follow-up. CVD incidence was >50% higher for those in the high CFE adversity group compared with those in the low CFE adversity group. In fully adjusted models, CVD hazard ratios (95% CI) for participants who reported high and moderate CFE adversity versus those reporting low CFE adversity were 1.40 (0.98-2.11) and 1.25 (0.89-1.75), respectively. The adjusted hazard ratios for all-cause mortality was 1.68 (1.17-2.41) for those with high CFE adversity scores and 1.55 (1.11-2.17) for those with moderate CFE adversity scores. Conclusions Adverse CFE was associated with CVD incidence and all-cause mortality later in life, even after controlling for CVD risk factors in young adulthood.

Background While prior studies have linked the neighborhood environment and development of subclinical atherosclerosis, it is unknown whether living in neighborhoods with greater availability of "unhealthy" food outlets (fast-food chain restaurants and convenience stores) is associated with risk of developing coronary artery calcification ( CAC ). Methods and Results We included 2706 CARDIA study (Coronary Artery Risk Development in Young Adults) participants who underwent CAC measurement during follow-up years 15 (2000-2001), 20 (2005-2006), and 25 (2010-2011). Neighborhood features examined included percentage of all food outlets that were convenience stores and fast-food chain restaurants within a 3-km Euclidean buffer distance from each participant's residence. Econometric fixed effects models, which by design control for all time-invariant covariates, were used to model the longitudinal association between simultaneous within-person change in percentage food outlet and change in CAC . At baseline (year 15), 9.7% of participants had prevalent CAC . During 10 years of follow-up, 21.1% of participants developed CAC . Each 1-SD increase in percentage of convenience stores was associated with a 1.34 higher odds of developing CAC (95% CI : 1.04, 1.72) after adjusting for individual- and neighborhood-level covariates; however, there was no significant association between increased percentage of fast-food chain restaurants and developing CAC (odds ratio=1.15; 95% CI : 0.96, 1.38). There were no significant associations between increases in either food outlet percentage and progression of CAC . Conclusions Our findings suggest that increases in the relative availability of convenience stores in participants' neighborhoods is related to the development of CAC over time.

Background Smoke-free legislation has been associated with reductions in secondhand smoke exposure and cardiovascular disease. However, it remains unknown whether smoke-free policies are associated with reductions in blood pressure ( BP ). Methods and Results Longitudinal data from 2606 nonsmoking adult participants of the CARDIA (Coronary Artery Risk Development in Young Adults) Study (1995-2011) were linked to state, county, and local-level 100% smoke-free policies in bars, restaurants, and/or nonhospitality workplaces based on participants' census tract of residence. Mixed-effects models estimated associations of policies with BP and hypertension trajectories over 15 years of follow-up. Fixed-effects regression estimated associations of smoke-free policies with within-person changes in systolic and diastolic BP and hypertension. Models were adjusted for sociodemographic, health-related, and policy/geographic covariates. Smoke-free policies were associated with between-person differences and within-person changes in systolic BP . Participants living in areas with smoke-free policies had lower systolic BP on average at the end of follow-up compared with those in areas without policies (adjusted predicted mean differences [in mm Hg]: restaurant: -1.14 [95% confidence interval: -2.15, -0.12]; bar: -1.52 [-2.48, -0.57]; workplace: -1.41 [-2.32, -0.50]). Smoke-free policies in restaurants and bars were associated with mean within-person reductions in systolic BP of -0.85 (-1.61, -0.09) and -1.08 (-1.82, -0.34), respectively. Only restaurant policies were associated with a significant within-person reduction in diastolic BP , of -0.58 (-1.15, -0.01). Conclusions While the magnitude of associations was small at the individual level, results suggest a potential mechanism through which reductions in secondhand smoke because of smoke-free policies may improve population-level cardiovascular health.

Background: Epidemiologic studies have yielded mixed findings on the association of psychosocial stressors with cardiovascular disease (CVD) risk. In this study, we examined associations of stressful life events (SLE) and social strain with incident coronary heart disease (CHD) and stroke (overall, and for hemorrhagic and ischemic strokes) independent of sociodemographic characteristics, and we evaluated whether these relationships were explained by traditional behavioral and biological risk factors., Methods and Results: Data from approximately 82 000 Women's Health Initiative Observational Study participants were used for the SLE and social strain analyses, respectively. Participants were followed for events for up to 18.0 years (median, 14.0). Separate Cox proportional hazards models were generated to estimate associations of each stress measure with incident CVD. After adjusting for sociodemographic characteristics and depressive symptoms, higher SLE and social strain were associated with higher incident CHD and stroke (each P trend <0.05). Hazard ratios and 95% confidence intervals were 1.12 (1.01, 1.25) for incident CHD and 1.14 (1.01, 1.28) for incident stroke among participants reporting high versus low SLE. Findings were similar for social strain. Associations were attenuated with further adjustment for mediating behavioral and biological risk factors. Findings were similar for associations of SLE with ischemic stroke and hemorrhagic stroke, but social strain was only associated with ischemic stroke., Conclusions: Higher SLE and social strain were associated with higher incident CVD independent of sociodemographic factors and depressive symptoms, but not behavioral and biological risk factors., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)