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Purpose: This study validated incident and recurrent ischemic stroke identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10) hospital discharge diagnosis codes. Methods: Using electronic health records (EHR) of adults (≥18 years) receiving care from Kaiser Permanente Southern California with ICD‐10 hospital discharge diagnosis codes of ischemic stroke (I63.x, G46.3, and G46.4) between October 2015 and September 2020, we identified 75 patients with both incident and recurrent stroke events (total 150 cases). Two neurologists independently evaluated validity of ICD‐10 codes through chart reviews. Results: The positive predictive value (PPV, 95% CI) for incident stroke was 93% (95% CI: 88%, 99%) and the PPV for recurrent stroke was 72% (95% CI: 62%, 82%). The PPV for recurrent stroke improved after applying a gap of 20 days (PPV of 75%; 95% CI: 63%, 87%) or removing hospital admissions related to stroke‐related procedures (PPV of 78%; 95% CI: 68%, 88%). Conclusion: The ICD‐10 hospital discharge diagnosis codes for ischemic stroke showed a high PPV for incident cases, while the PPV for recurrent cases were less optimal. Algorithms to improve the accuracy of ICD‐10 codes for recurrent ischemic stroke may be necessary. [ABSTRACT FROM AUTHOR]

Introduction: In the United States, there has been controversy over whether treatment of mild‐to‐moderate hypertension during pregnancy conveys more benefit than risk. Objective: The objective of the study was to compare risks and benefits of treatment of mild‐to‐moderate hypertension during pregnancy. Methods: This retrospective cohort study included 11,871 pregnant women with mild‐to‐moderate hypertension as defined by blood pressure (BP) values from three Kaiser Permanente regions between 2005 and 2014. Data were extracted from electronic health records. Dynamic marginal structural models with inverse probability weighting and informative censoring were used to compare risks of adverse outcomes when beginning antihypertensive medication treatment at four BP thresholds (≥155/105, ≥150/100, ≥145/95, ≥140/90 mm Hg) compared with the recommended threshold in the United States at that time, ≥160/110 mm Hg. Outcomes included preeclampsia, preterm birth, small‐for‐gestational‐age (SGA), Neonatal Intensive Care Unit (NICU) care, and stillbirth. Primary analyses allowed 2 weeks for medication initiation after an elevated BP. Several sensitivity and subgroup (i.e., race/ethnicity and pre‐pregnancy body mass index) analyses were also conducted. Results: In primary analyses, medication initiation at lower BP thresholds was associated with greater risk of most outcomes. Comparing the lowest (≥140/90 mm Hg) to the highest BP threshold (≥160/110 mm Hg), we found an excess risk of preeclampsia (adjusted Risk Difference (aRD) 38.6 per 100 births, 95% Confidence Interval (CI): 30.6, 46.6), SGA (aRD: 10.2 per 100 births, 95% CI: 2.6, 17.8), NICU admission (aRD: 20.2 per 100 births, 95% CI: 12.6, 27.9), and stillbirth (1.18 per 100 births, 95% CI: 0.27, 2.09). The findings did not reach statistical significance for preterm birth (aRD: 2.5 per 100 births, 95% CI: −0.4, 5.3). These relationships were attenuated and did not always reach statistically significance when comparing higher BP treatment thresholds to the highest threshold (i.e., ≥160/110 mm Hg). Sensitivity and subgroup analyses produced similar results. Conclusions: Initiation of antihypertensive medication at mild‐to‐moderate BP thresholds (140–155/90–105 mm Hg; with the largest risk consistently associated with treatment at 140/90 mm Hg) may be associated with adverse maternal and neonatal outcomes. Limitations include inability to measure medication adherence. [ABSTRACT FROM AUTHOR]

Purpose: Our objective was to calculate the positive predictive value (PPV) of the ICD‐9 diagnosis code for angioedema when physicians adjudicate the events by electronic health record review. Our secondary objective was to evaluate the inter‐rater reliability of physician adjudication. Methods: Patients from the Cardiovascular Research Network previously diagnosed with heart failure who were started on angiotensin‐converting enzyme inhibitors (ACEI) during the study period (July 1, 2006 through September 30, 2015) were included. A team of two physicians per participating site adjudicated possible events using electronic health records for all patients coded for angioedema for a total of five sites. The PPV was calculated as the number of physician‐adjudicated cases divided by all cases with the diagnosis code of angioedema (ICD‐9‐CM code 995.1) meeting the inclusion criteria. The inter‐rater reliability of physician teams, or kappa statistic, was also calculated. Results: There were 38 061 adults with heart failure initiating ACEI in the study (21 489 patient‐years). Of 114 coded events that were adjudicated by physicians, 98 angioedema events were confirmed for a PPV of 86% (95% CI: 80%, 92%). The kappa statistic based on physician inter‐rater reliability was 0.65 (95% CI: 0.47, 0.82). Conclusions: ICD‐9 diagnosis code of 995.1 (angioneurotic edema, not elsewhere classified) is highly predictive of angioedema in adults with heart failure exposed to ACEI. [ABSTRACT FROM AUTHOR]

Purpose A pre‐licensure clinical trial of a two‐dose cytosine phosphoguanine adjuvanted hepatitis B vaccine (HEPLISAV‐B® [Dynavax, USA]; HepB‐CpG vaccine) found an unanticipated numerical imbalance in acute myocardial infarction (AMI) compared to recipients of a three‐dose aluminum adjuvanted hepatitis B vaccine (ENGERIX‐B® [GlaxoSmithKline, Belgium]; HepB‐alum vaccine). A post‐licensure study was required to compare AMI rates among recipients of HepB‐CpG vaccine and HepB‐alum vaccine. Individuals with diabetes mellitus (DM), who are at higher risk of AMI, comprise more than half of the post‐licensure study cohort. To inform the ongoing post‐licensure study, we examined the association between AMI and receipt of HepB‐alum vaccine in individuals with DM. Methods: We conducted a case–control study nested in a cohort of individuals with DM ages ≥40 years at Kaiser Permanente Southern California using electronic health records. AMI cases from 2012 to 2017 were identified by principal discharge diagnosis and matched 1:1 with randomly selected controls. The adjusted odds ratio (aOR) for receipt of ≥1 HepB‐alum vaccine dose was compared for AMI cases and controls using conditional logistic regression. We subsequently performed the same matched case–control analysis stratified by year. Results: Of 8138 matched case–control pairs, 17.4% of cases and 15.0% of controls received HepB‐alum vaccine. The aOR of HepB‐alum vaccination comparing cases and controls was 0.97 (95% confidence interval 0.87–1.08). Similarly, there was no significant association between HepB‐alum vaccine and AMI in any of the study years. Conclusions: HepB‐alum vaccination was not associated with AMI in individuals with DM. This finding will provide contextual insight for the ongoing post‐licensure study of HepB‐CpG vaccine. [ABSTRACT FROM AUTHOR]

Beta-blocker practice patterns in chronic kidney disease patients with atrial fibrillation transitioning to hemodialysis There were 20 (5.1%) patients who switched from a dialyzable beta-blocker to a nondialyzable beta-blocker, and 13 (8.2%) who switched from a nondialyzable beta-blocker to a dialyzable beta-blocker. Mean heart rates were well below 110 bpm, the target recommended by national guidelines, in all beta-blocker groups.[4] Overall, 131 (23.9%) patients discontinued beta-blockers after transition to hemodialysis. [Extracted from the article]

OBJECTIVE: To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN: Retrospective cohort study. SETTING: Seven US healthcare delivery systems. PARTICIPANTS: Adults with left ventricular systolic dysfunction receiving an implantable cardioverter‐defibrillator (ICD) for primary prevention. MEASUREMENTS: Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0‐3, 4‐5, 6‐7 and 8‐16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS: Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4‐8), with 98% having at least two comorbidities. During a mean 2.2 years of follow‐up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14‐3.31] for 4‐5 comorbidities; HR = 2.25 [95% CI = 1.25‐4.05] for 6‐7 comorbidities; and HR = 2.91 [95% CI = 1.54‐5.50] for 8‐16 comorbidities). Participants with 8‐16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43‐3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67‐6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07‐2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS: In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation. [ABSTRACT FROM AUTHOR]

Aim: To determine whether high triglycerides (TG) in the presence of statin‐controlled LDL‐C influence the risk of cardiovascular disease (CVD) among patients with diabetes in real‐world clinical practice. Materials and methods: We identified adults with diabetes from the Southern California and Pacific Northwest regions of Kaiser Permanente. We included patients undergoing statin therapy with LDL‐C from 40‐100 mg/dL who were not undergoing other lipid‐lowering therapies and had a prior diagnosis of atherosclerotic CVD or at least one other CVD risk factor. We grouped patients into high TG (200‐499 mg/dL; n = 5542) or normal TG (<150 mg/dL, n = 22 411) from January 2010 through December 2016 to compare incidence rates and rate ratios of first non‐fatal myocardial infarction (MI), non‐fatal stroke, unstable angina and coronary revascularization. We adjusted multivariable analyses for age, sex, race/ethnicity, smoking status, blood pressure, HbA1c, serum creatinine, presence of ischaemic heart disease and study site. Results: Adjusted rate ratios for the four outcomes were all statistically significantly different. The incidence rate for non‐fatal MI was 30% higher in the high TG group (rate ratio, 1.30; 95% CI, 1.08‐1.58; P = 0.006). The rate was 23% higher for non‐fatal stroke (1.23, 1.01‐1.49, P = 0.037), 21% higher for coronary revascularization (rate ratio, 1.21; 95% CI, 1.02‐1.43; P = 0.027) and was, non‐significantly, 33% higher for unstable angina (rate ratio, 1.33; 95% CI, 0.87‐2.03; P = 0.185). Conclusions: Despite statin‐controlled LDL‐C levels, CV events were greater among patients with diabetes and high TG levels. Because we controlled for cardiometabolic risk factors, it is likely that the difference in TG levels contributed to the excess risk observed in patients with high TGs. [ABSTRACT FROM AUTHOR]

OBJECTIVES To assess multimorbidity burden and its association with clinical outcomes in adults with heart failure (HF) according to sex, age, and HF type. DESIGN Retrospective cohort study. SETTING Five healthcare delivery systems across the United States. PARTICIPANTS Adults with HF (N=114,553). MEASUREMENTS We characterized participants with respect to the presence of 26 chronic conditions categorized into quartiles based on overall burden of comorbidity (<5, 5–6, 7–8, ≥9). Outcomes included all‐cause death and hospitalization for HF or any cause. Multivariable Cox regression was used to evaluate the adjusted association between categorized burden of multimorbidity burden and outcomes. RESULTS: Individuals with more morbidities were more likely to die than those with fewer then 5 morbidities (5–6 morbidities: adjusted hazard ratio (aHR)=1.27 (95% confidence interval (CI)=1.24–1.31; 7–8 morbidities: aHR=1.52, 95% CI=1.48–1.57; ≥9 morbidities: aHR=1.92, 95% CI=1.86–1.99). There was a graded, higher adjusted rate of any‐cause hospitalization associated with 5 or 6 (aHR=1.28, 95% CI=1.25–1.30), 7 or 8 (aHR=1.47, 95% CI=1.44–1.50), or 9 or more (aHR=1.77, 95% CI=1.73–1.82) morbidities (vs <5). Similar findings were observed for HF‐specific hospitalization in those with 5 or 6 (aHR=1.22, 95% CI=1.19–1.26), 7 or 8 (aHR=1.39, 95% CI=1.34–1.44), or 9 or more (aHR 1.68, 95% CI=1.61–1.74) morbidities (vs <5). Consistent findings were seen according to sex, age group, and HF type (preserved, reduced, borderline HF), in the association between categorical burden of multimorbidity and outcomes especially prominent in individuals younger than 65. CONCLUSION: After adjustment, higher levels of multimorbidity predicted worse HF outcomes and may be an important consideration in strategies to improve clinical and person‐centered outcomes. J Am Geriatr Soc 66:2305–2313, 2018. [ABSTRACT FROM AUTHOR]

Objectives To explore barriers to anticoagulation in older adults with atrial fibrillation ( AF) at high risk of stroke and to identify opportunities for interventions that might increase use of oral anticoagulants ( OACs). Design Retrospective cohort study. Setting Two large community-based AF cohorts. Participants Individuals with ischemic stroke surviving hospitalization (N = 1,405, mean age 79). Measurements Using structured chart review, reasons for nonuse of OAC were identified, and 1-year poststroke survival was assessed. Logistic regression was used to identify correlates of OAC nonuse. Results Median CHA2 DS2- VASc score was 5, yet 44% of participants were not prescribed an OAC at discharge. The most-frequent (nonmutually exclusive) physician reasons for not prescribing OAC included fall risk (26.7%), poor prognosis (19.3%), bleeding history (17.1%), participant or family refusal (14.9%), older age (11.0%), and dementia (9.4%). Older age (odds ratio ( OR) = 8.96, 95% confidence interval ( CI) = 5.01-16.04 for aged ≥85 vs <65) and disability ( OR = 12.58, 95% CI = 5.82-27.21 for severe vs no deficit) were the most-important independent predictors of nonuse of OACs. By 1 year, 42.5% of those not receiving an OAC at discharge had died, versus 19.1% of those receiving an OAC ( P < .001), far higher than recurrent stroke rates. Conclusion Despite very high stroke risk, more than 40% of participants were not discharged with an OAC. Dominant reasons included fall risk, poor prognosis, older age, and dementia. These individuals' high 1-year mortality rate confirmed their high level of comorbidity. To improve anticoagulation decisions and outcomes in this population, future research should focus on strategies to mitigate fall risk, improve assessment of risks and benefits of anticoagulation in individuals with AF, and determine whether newer anticoagulants are safer in complex elderly and frail individuals. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the effectiveness of an automated telephone system reminding patients with hypertension and/or cardiovascular disease to obtain overdue medication refills. The authors compared the intervention with usual care among patients with an overdue prescription for a statin or lisinopril-hydrochlorothiazide (lisinopril-HCTZ). The primary outcome was refill rate at 2 weeks. Secondary outcomes included time to refill and change in low-density lipoprotein cholesterol and blood pressure. Significantly more patients who received a reminder call refilled their prescription compared with the usual-care group (statin cohort: 30.3% vs 24.9% [P<.0001]; lisinopril-HCTZ cohort: 30.7% vs 24.2% [P<.0001]). The median time to refill was shorter in patients receiving the reminder call (statin cohort: 29 vs 36 days [P<.0001]; lisinopril-HCTZ cohort: 24 vs 31 days [P<.0001]). There were no statistically significant differences in mean low-density lipoprotein cholesterol and blood pressure. These findings suggest the need for interventions that have a longer-term impact. [ABSTRACT FROM AUTHOR]

Objective: To compare traditional cardiovascular (CV) risk factor management among patients with rheumatoid arthritis (RA) to that of matched non-RA controls within a large US managed care setting.Methods: Adult patients with RA and age- and sex-matched general population (general controls) or osteoarthritis (OA) controls were identified between January 1, 2007 and December 31, 2011. We compared health care utilization, measurement, treatment, and treatment target achievement of traditional CV risk factors among subgroups of CV comorbidity during 1 year of followup between RA and controls.Results: A total of 9,440 RA patients, 31,009 general controls, and 10,352 OA controls were included. The proportions with measurements (blood pressure [BP], low-density lipoprotein [LDL] cholesterol, or hemoglobin A1c ), treatment (antihypertensive, statin, or anti-diabetes mellitus medications), and treatment target achievement were slightly higher in patients with RA compared with general controls. Controlling for other factors, RA patients were more likely to have a measurement of BP (odds ratio [OR] 16.77 [95% confidence interval (95% CI) 10.01-28.08]) or LDL cholesterol (OR 1.25 [95% CI 1.13-1.39]), and to receive antihypertensive (OR 1.84 [95% CI 1.47-2.30]) or anti-diabetic medications (OR 1.26 [95% CI 1.01-1.56]) compared to general controls. RA was not associated with receiving a statin (OR 1.01 [95% CI 0.92-1.12]); however, a target LDL level was more likely to be achieved in RA compared to general controls (OR 1.27 [95% CI 1.17-1.37]) as well as target levels of BP and hemoglobin A1c . These results were consistent with results for OA controls except for a lower probability of receiving a statin in RA compared to OA.Conclusion: Traditional CV risk factors in patients with RA were not less aggressively managed compared to non-RA controls. [ABSTRACT FROM AUTHOR]

Many adults with elevated clinic blood pressure (BP) have lower BP when measured outside the clinic. This phenomenon, the "white-coat effect," may be larger among older adults, a population more susceptible to the adverse effects of low BP. The authors analyzed data from 257 participants in the Jackson Heart Study with elevated clinic BP (systolic/diastolic BP [SBP/DBP] ≥140/90 mm Hg) who underwent ambulatory BP monitoring (ABPM). The white-coat effect for SBP was larger for participants 60 years and older vs those younger than 60 years in the overall population (12.2 mm Hg, 95% confidence interval [CI], 9.2-15.1 mm Hg and 8.4 mm Hg, 95% CI, 5.7-11.1, respectively; P=.06) and among those without diabetes or chronic kidney disease (15.2 mm Hg, 95% CI, 10.1-20.2 and 8.6 mm Hg, 95% CI, 5.0-12.3, respectively; P=.04). After multivariable adjustment, clinic SBP ≥150 mm Hg vs <150 mm Hg was associated with a larger white-coat effect. Studies are needed to investigate the role of ABPM in guiding the initiation and titration of antihypertensive treatment, especially among older adults. [ABSTRACT FROM AUTHOR]

Visits with nonprimary care providers such as optometrists may be missed opportunities for the detection of high blood pressure (BP). For this study, normotensive adults with at least 12 months of health plan membership on January 1, 2009 (n=1,075,522) were followed-up for high BP through March 14, 2011. Of 111,996 patients with a BP measurement ≥140/90 mm Hg, 82.7% were measured during primary care visits and 17.3% during nonprimary care visits. Individuals with a BP ≥140/90 mm Hg measured during nonprimary care visits were older and more likely to be male and non-Hispanic white. The proportion of patients with follow-up and false-positives were comparable between primary and nonprimary care. The main nonprimary care specialty to identify a first BP ≥140/90 mm Hg was ophthalmology/optometry with 24.5% of all patients. Results suggest that expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension. [ABSTRACT FROM AUTHOR]

To assess the burden associated with hypertension, reliable estimates for the prevalence of pediatric hypertension are vital. For this cross-sectional study of 237,248 youths aged 6 to 17 years without indication of secondary hypertension, blood pressure (BP) was classified according to age, sex, and height using standards from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents as prehypertension with at least 1 BP ≥90th percentile and as hypertension with 3 BPs ≥95th percentile. The prevalence of prehypertension and hypertension were 31.4% and 2.1%, respectively. An additional 21.4% had either 1 (16.6%) or 2 (4.8%) BPs ≥95th percentile. Based on this large population-based study using routinely measured BP from clinical care, a remarkable proportion of youth (6.9%) has hypertension or nearly meets the definition of hypertension with 2 documented BPs in the hypertensive range. [ABSTRACT FROM AUTHOR]

To assess the burden associated with hypertension, reliable estimates for the prevalence of pediatric hypertension are vital. For this cross-sectional study of 237,248 youths aged 6 to 17 years without indication of secondary hypertension, blood pressure ( BP) was classified according to age, sex, and height using standards from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents as prehypertension with at least 1 BP ≥90th percentile and as hypertension with 3 BPs ≥95th percentile. The prevalence of prehypertension and hypertension were 31.4% and 2.1%, respectively. An additional 21.4% had either 1 (16.6%) or 2 (4.8%) BPs ≥95th percentile. Based on this large population-based study using routinely measured BP from clinical care, a remarkable proportion of youth (6.9%) has hypertension or nearly meets the definition of hypertension with 2 documented BPs in the hypertensive range. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the effectiveness of a telephonic outreach program to improve blood pressure ( BP) control among patients with hypertension. The authors identified adults 18 years and older with uncontrolled BP within the previous 12 months. Patients received either an automated telephone call advising them to have a walk-in BP check (n=31,619) or usual care (n=33,154). The primary outcome was BP control at 4 weeks. Significantly more patients who received the intervention achieved BP control compared with the usual care group (32.5% vs 23.7%; P<.0001). Patients in the intervention arm with cardiovascular disease, chronic kidney disease, or diabetes mellitus achieved better BP control. Older age, female sex, and having a household income above the median were associated with BP control. When designing quality-improvement interventions to increase BP control rates, health care organizations should consider utilizing an automated telephone outreach campaign. [ABSTRACT FROM AUTHOR]

J Clin Hypertens (Greenwich). 2012;14:694-700 ©2012 Wiley Periodicals, Inc. Low medication adherence may explain part of the high prevalence of apparent treatment-resistant hypertension (aTRH). The authors assessed medication adherence and aTRH among 4026 participants taking ≥3 classes of antihypertensive medication in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) trial using the 4-item Morisky Medication Adherence Scale (MMAS). Low adherence was defined as an MMAS score ≥2. Overall, 66% of participants taking ≥3 classes of antihypertensive medication had aTRH. Perfect adherence on the MMAS was reported by 67.8% and 70.9% of participants with and without aTRH, respectively. Low adherence was present among 8.1% of participants with aTRH and 5.0% of those without aTRH ( P<.001). Among those with aTRH, female sex, residence outside the US stroke belt or stroke buckle, physical inactivity, elevated depressive symptoms, and a history of coronary heart disease were associated with low adherence. In the current study, a small percentage of participants with aTRH had low adherence. [ABSTRACT FROM AUTHOR]

J Clin Hypertens (Greenwich). 2012;14:165-171. ©2012 Wiley Periodicals, Inc. The association between within-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and all-cause and cardiovascular (CVD) mortality was examined using the Third National Health and Nutrition Survey (n=15,317). Three SBP and DBP readings were taken by physicians during a single medical evaluation. Within-visit variability for each participant was defined using the standard deviation of SBP and DBP across these measurements. Mortality was assessed over 14 years (n=3848 and n=1684 deaths from all causes and CVD, respectively). After age, sex, and race-ethnicity adjustment, the hazard ratios (95% confidence intervals) for all-cause mortality associated with the 4 highest quintiles of within-visit standard deviation of SBP (2.00-2.99 mm Hg, 3.00-3.99 mm Hg, 4.00-5.29 mm Hg, and ≥5.30 mm Hg) compared with participants in the lowest quintile of within-visit standard deviation of SBP (<2.0 mm Hg) were 1.04 (0.87-1.26), 1.09 (0.92-1.29), 1.06 (0.88-1.28), and 1.13 (0.95-1.33), respectively ( P=.136). The analogous hazard ratios for CVD mortality were 0.95 (0.69-1.32), 0.96 (0.67-1.36), 0.95 (0.74-1.23), and 1.04 (0.80-1.35), respectively ( P=.566). No association with mortality was present after further adjustment and when modeling within-visit standard deviation of SBP as a continuous variable. Standard deviation of DBP was not associated with mortality. [ABSTRACT FROM AUTHOR]

It remains unclear whether abdominal obesity increases cardiovascular disease (CVD) risk independent of the metabolic abnormalities that often accompany it. Therefore, the objective of this study was to evaluate the independent effects of abdominal obesity vs. metabolic syndrome and diabetes on the risk for incident coronary heart disease (CHD) and stroke. The Framingham Offspring, Atherosclerosis Risk in Communities, and Cardiovascular Health studies were pooled to assess the independent effects of abdominal obesity (waist circumference >102 cm for men and >88 cm for women) vs. metabolic syndrome (excluding the waist circumference criterion) and diabetes on risk for incident CHD and stroke in 20,298 men and women aged ≥45 years. The average follow-up was 8.3 (s.d. 1.9) years. There were 1,766 CVD events. After adjustment for demographic factors, smoking, alcohol intake, number of metabolic syndrome components, and diabetes, abdominal obesity was not significantly associated with an increased risk of CVD (hazard ratio (HR) (95% confidence interval): 1.09 (0.98, 1.20)). However, after adjustment for demographics, smoking, alcohol intake, and abdominal obesity, having 1-2 metabolic syndrome components, the metabolic syndrome and diabetes were each associated with a significantly increased risk of CVD (2.12 (1.80, 2.50), 2.82 (1.92, 4.12), and 5.33 (3.37, 8.41), respectively). Although abdominal obesity is an important clinical tool for identification of individuals likely to possess metabolic abnormalities, these data suggest that the metabolic syndrome and diabetes are considerably more important prognostic indicators of CVD risk. [ABSTRACT FROM AUTHOR]

Objective. Data entry errors may occur in body weights and heights assessed during routine medical care. These errors may affect data quality markedly and create a large number of biologically implausible values. To address this issue, we evaluated the quality of body weight and height measures for children based on sequential health care encounters. Methods. We evaluated the weight and height data of children aged 0-18 years receiving care at Kaiser Permanente Southern California medical centers. Error rates were calculated before and after excluding implausible values for height and weight as recorded in the electronic medical chart reviews. Results. The error rates in weight and height data of children aged <2, 2-5, 6-9, 10-13, 14-18 years were 0.4%, 0.7%, 1.0%, 1.0% and 0.7%, respectively. The most frequently identified errors were implausibly low values for height and implausibly high values for weight. After excluding implausible values, the error rates were 0.4%, 0.4%, 0.6%, 0.4% and 0.1%, respectively. The sensitivity of our approach to detect errors was 10.9%, 36.6%, 32.9%, 59.2%, and 82.5%, respectively. Conclusions. Error rates in weight and height recorded in the electronic medical record during routine medical care are low, raising the potential for this information to be used for population care management. With little effort and with the recording of this information at each encounter, error rates can be further lowered to avoid misclassification of children as obese. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined trends in body mass index (BMI) and the prevalence of overweight and obesity among Chinese adults between 1991 and 1999-2000. The prevalence of overweight and obesity among men has increased from 9.6% to 20.0% and 0.6% to 3.0%, respectively. There was greater relative increases in the prevalence of obesity among older age groups in South China and rural areas. It stresses the need for national programs in weight maintenance and reduction.

Objective Stroke is a leading cause of death and long-term disability in China. The objective of this study was to examine the relation between alcohol consumption and risk for stroke among Chinese men. Methods We conducted a prospective cohort study among 64,338 Chinese men aged ≥40 years who were free of stroke at baseline. Data on frequency and type of alcohol consumed were collected at the baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 to 2000, which included determining vital status, interviewing participants or proxies, and obtaining hospital and medical records for incident and fatal strokes. Results Over the course of 493,351 person-years of follow-up, we documented 3,434 incident strokes (1,848 stroke deaths). After adjustment for age, body mass index, physical activity, urbanization (urban vs rural), geographic variation (north vs south), cigarette smoking, history of diabetes, and education, compared with nondrinkers, relative risk (95% confidence interval) of incident stroke was 0.92 (0.80-1.06) for participants consuming 1 to 6 drinks/week, 1.02 (0.93-1.13) for those consuming 7 to 20 drinks/week, 1.22 (1.07-1.38) for those consuming 21 to 34 drinks/week, and 1.22 (1.08-1.37) for those consuming 35 or more drinks per week ( p for linear trend < 0.0001). The corresponding relative risks for stroke mortality were 0.93 (0.76-1.14), 0.98 (0.85-1.13), 1.15 (0.95-1.38), and 1.30 (1.11-1.52), respectively ( p for linear trend = 0.0004; p for quadratic trend = 0.03). Interpretation These results suggest that heavy alcohol drinking may increase the risk for stroke in Chinese men and should be the target of strategies for prevention. Ann Neurol 2007 [ABSTRACT FROM AUTHOR]

The article discusses a study which determined which measures of adiposity has the strongest association with cardiovascular disease risk factors. Adult participants of the third National Health and Nutrition Examination Survey were examined. It was found that waist circumference has the stronger association with cardiovascular disease risk factors.

The article discusses a study on the prevalence and risk factors of overweight and obesity in the general adult population in China. Male subjects had higher education, income, alcohol consumption, cigarette smoking and waist circumference. Age-specific prevalence of overweight was higher among female subjects compared with men after age 45 years. Prevalence of a body mass index (BMI) for men and women was 46.9% and 51.7%, respectively.

Background: Blood pressure (BP) trajectories from young adulthood through middle age are associated with cardiovascular risk. We examined the associations of hypertension risk factors with BP trajectories among a large diverse sample., Methods and Results: We analyzed data from young adults, aged 18 to 39 years, with untreated BP <140/90 mm Hg at baseline from Kaiser Permanente Southern California (N=355 324). We used latent growth curve models to identify 10-year BP trajectories and to assess the associations between characteristics in young adulthood and BP trajectories. We identified the following 5 distinct systolic BP trajectories, which appeared to be determined mainly by the baseline BP with progressively higher BP at each year: group 1 (lowest BP trajectory, 7.9%), group 2 (26.5%), group 3 (33.0%), group 4 (25.4%), and group 5 (highest BP trajectory, 7.3%). Older age (adjusted odds ratio for 30-39 versus 18-29 years, 1.23 [95% CI, 1.18-1.28]), male sex (13.38 [95% CI, 12.80-13.99]), obesity (body mass index ≥30 versus 18.5-24.9 kg/m 2 , 14.81 [95% CI, 14.03-15.64]), overweight (body mass index 25-29.9 versus 18.5-24.9 kg/m 2 , 3.16 [95% CI, 3.00-3.33]), current smoking (1.58 [95% CI, 1.48-1.67]), prediabetes (1.21 [95% CI, 1.13-1.29]), diabetes (1.60 [95% CI, 1.41-1.81]) and high low-density lipoprotein cholesterol (≥160 versus <100 mg/dL, 1.52 [95% CI, 1.37-1.68]) were associated with the highest BP trajectory (group 5) compared with the reference group (group 2)., Conclusions: Traditional hypertension risk factors including smoking, diabetes, and elevated lipids were associated with BP trajectories in young adults, with obesity having the strongest association with the highest BP trajectory group.

Background Direct oral anticoagulants (DOACs) are widely used in patients with nonvalvular atrial fibrillation for stroke prevention. However, long-term adherence to DOACs and clinical outcomes in real-world clinical practice is not well understood. This study evaluated long-term medication adherence patterns to DOAC therapy and clinical outcomes in a large US integrated health care system. Methods and Results We included adult patients with nonvalvular atrial fibrillation who newly initiated DOACs between 2012 and 2018 in Kaiser Permanente Southern California. Long-term (3.5 years) adherence trajectories to DOAC were investigated using monthly proportion of days covered and group-based trajectory models. Factors associated with long-term adherence trajectories were investigated. Multivariable Poisson regression analyses were used to investigate thromboembolism and major bleeding events associated with long-term adherence trajectories. Of 18 920 patients newly initiating DOACs, we identified 3 DOAC adherence trajectories: consistently adherent (85.2%), early discontinuation within 6 months (10.6%), and gradually declining adherence (4.2%). Predictors such as lower CHA 2 DS 2 -VASc (0-1 versus ≥5) and previous injurious falls were associated with both early discontinuation and gradually declining adherence trajectories. Early discontinuation of DOAC therapy was associated with a higher risk of thromboembolism (rate ratio, 1.40; 95% CI, 1.05-1.86) especially after 12 months from DOAC initiation but a lower risk of major bleed compared with consistent adherence (rate ratio, 0.48; 95% CI, 0.30-0.75), specifically during the first 12 months following DOAC initiation. A gradual decline in adherence to DOACs was not statistically significantly associated with thromboembolism outcomes compared with consistent adherence. Conclusions Although a large proportion of patients with nonvalvular atrial fibrillation were adherent to DOAC therapy over 3.5 years, early discontinuation of DOAC was associated a higher risk of thromboembolic events. Future tailored interventions for early discontinuers may improve clinical outcomes.

Background Previous reports suggest that the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may upregulate angiotensin-converting enzyme 2 receptors and increase severe acute respiratory syndrome coronavirus 2 infectivity. We evaluated the association between ACEI or ARB use and coronavirus disease 2019 (COVID-19) infection among patients with hypertension. Methods and Results We identified patients with hypertension as of March 1, 2020 (index date) from Kaiser Permanente Southern California. Patients who received ACEIs, ARBs, calcium channel blockers, beta blockers, thiazide diuretics (TD), or no therapy were identified using outpatient pharmacy data covering the index date. Outcome of interest was a positive reverse transcription polymerase chain reaction test for COVID-19 between March 1 and May 6, 2020. Patient sociodemographic and clinical characteristics were identified within 1 year preindex date. Among 824 650 patients with hypertension, 16 898 (2.0%) were tested for COVID-19. Of those tested, 1794 (10.6%) had a positive result. Overall, exposure to ACEIs or ARBs was not statistically significantly associated with COVID-19 infection after propensity score adjustment (odds ratio [OR], 1.06; 95% CI, 0.90-1.25) for ACEIs versus calcium channel blockers/beta blockers/TD; OR, 1.10; 95% CI, 0.91-1.31 for ARBs versus calcium channel blockers/beta blockers/TD). The associations between ACEI use and COVID-19 infection varied in different age groups ( P -interaction=0.03). ACEI use was associated with lower odds of COVID-19 among those aged ≥85 years (OR, 0.30; 95% CI, 0.12-0.77). Use of no antihypertensive medication was significantly associated with increased odds of COVID-19 infection compared with calcium channel blockers/beta blockers/TD (OR, 1.32; 95% CI, 1.11-1.56). Conclusions Neither ACEI nor ARB use was associated with increased likelihood of COVID-19 infection. Decreased odds of COVID-19 infection among adults ≥85 years using ACEIs warrants further investigation.

Background: More accurate and reliable stroke risk prediction tools are needed to optimize anticoagulation decision making in patients with atrial fibrillation (AF). We developed a new AF stroke prediction model using the original Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) AF cohort and externally validated the score in a separate, contemporary, community-based inception AF cohort, ATRIA-Cardiovascular Research Network (CVRN) cohort., Methods and Results: The derivation ATRIA cohort consisted of 10 927 patients with nonvalvular AF contributing 32 609 person-years off warfarin and 685 thromboembolic events (TEs). The external validation ATRIA-CVRN cohort included 25 306 AF patients contributing 26 263 person-years off warfarin and 496 TEs. Cox models identified 8 variables, age, prior stroke, female sex, diabetes mellitus, heart failure, hypertension, proteinuria, and eGFR<45 mL/min per 1.73 m(2) or end-stage renal disease, plus an age×prior stroke interaction term for the final model. Point scores were assigned proportional to model coefficients. The c-index in the ATRIA cohort was 0.73 (95% CI, 0.71 to 0.75), increasing to 0.76 (95% CI, 0.74 to 0.79) when only severe events were considered. In the ATRIA-CVRN, c-indexes were 0.70 (95% CI, 0.67 to 0.72) and 0.75 (95% CI, 0.72 to 0.78) for all events and severe events, respectively. The C-index was greater and net reclassification improvement positive comparing the ATRIA score with the CHADS2 or CHA2DS2-VASc scores., Conclusions: The ATRIA stroke risk score performed better than existing risk scores, was validated successfully, and showed improvement in predicting severe events, which is of greatest concern. The ATRIA score should improve the antithrombotic decision for patients with AF and should provide a secure foundation for the addition of biomarkers in future prognostic models.