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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. [ABSTRACT FROM AUTHOR]

BACKGROUND Both hypertensive and atherosclerotic processes contribute to common carotid artery intima-media thickness (CCA-IMT). Elevated CCA-IMT may be indicative of subclinical cerebrovascular disease; however, its role in the absence of concomitant carotid artery plaque is uncertain, and few studies have examined associations in Black populations. MATERIALS AND METHODS At cohort visit 3 (1993–1995) a subset of stroke-free participants (641 Blacks and 702 Whites, mean age 63) from the Atherosclerosis Risk in Communities (ARIC) study was imaged by brain MRI and carotid ultrasound. A CCA-IMT >0.9 mm was considered elevated. Asymptomatic brain lesions ≥3 mm were considered silent brain infarctions (SBI). Subcortical SBI measuring 3 to <20 mm were considered lacunes. Associations between elevated CCA-IMT and SBI were analyzed with Poisson regression. RESULTS Elevated CCA-IMT was identified in 168 participants (16% of Blacks, 10% of Whites), and SBI were observed in 156 (15% of Blacks, 8% of Whites). Elevated CCA-IMT was strongly related to anterior circulation SBI, posterior circulation SBI, and lacunes. After adjustments, elevated CCA-IMT remained associated with greater number of lacunes in Blacks ([prevalence ratio, PR] = 1.60; 95% confidence interval [CI]: 1.02–2.51), but not Whites (PR = 0.85; 95% CI: 0.35–2.04); P value for interaction = 0.12. Among Black participants without concomitant carotid plaque, elevated CCA-IMT was associated with twice the number of lacunes (PR = 2.00; 95% CI: 1.05–3.82). CONCLUSIONS In older Black adults, elevated CCA-IMT is independently associated with lipohyalinosis of the cerebral small vessels, irrespective of concomitant carotid plaque and vascular risk factors. [ABSTRACT FROM AUTHOR]

Background: Carotid intima-medial thickness (IMT) is an indicator of subclinical atherosclerosis and medial hypertrophy, and is easily quantified by ultrasonography. Although carotid IMT has been associated with systemic cardiovascular disease, its relation to silent brain infarctions (SBI) is not well established. The etiology of SBI is multifactorial; likely causes include atherosclerotic and thrombotic obstructions, microthrombi, and lipohyalinosis. Because arterial IMT reflects both atherogenesis and hypertensive remodeling, we hypothesized that elevated carotid IMT would be associated with SBI. Methods: The Atherosclerosis Risk in Communities (ARIC) study is an observational cohort of 15,792 black and white participants from 4 US communities. At visit 3 (1993-1995) a subset of stroke-free study participants (N=1,346) was screened by brain MRI and carotid ultrasound. IMT was averaged bilaterally, from 12 posterior wall measurements along a 1 cm segment of the distal common carotid artery up to the bifurcation. Consistent with European Society of Cardiology recommendations, IMT > 0.9 mm was considered elevated. Asymptomatic brain lesions ≥3 mm in diameter were considered SBI. Prevalence ratios (PRs) for number of SBI lesions associated with elevated IMT were analyzed using Poisson regression, adjusted for age, race-center, sex, current smoking, hypertension, diabetes, and hyperlipidemia. Model fit was ascertained by the deviance to degree of freedom ratio. Results: Of 1,346 individuals, 170 (13%) were classified with elevated IMT. Mean IMT was 1.0 ± 0.2 mm vs. 0.7 ± 0.1 mm for those with and without elevated IMT. Study participants with elevated IMT were more often male (49% vs. 38%; p=0.006), black (60% vs. 46%; p=0.0007), and older (64 vs. 62 years; p=0.0001); with a greater prevalence of both hypertension (65% vs. 42%; p<0.0001) and diabetes (27% vs. 13%; p<0.0001). SBI were detected in 157 individuals with a collective total of 247 lesions. A total of 30 (18%) participants with elevated IMT had at least one SBI lesion, compared to 127 (11%) with normal IMT (p=0.009). Elevated IMT was associated with 70% greater number of SBI lesions (PR=1.7; 95% CI: 1.3 - 2.3; p=0.0008). After adjustment for cardiovascular risk factors, elevated IMT remained associated with a 40% greater SBI count (PR= 1.4; 95% CI: 1.0 - 1.9; p=0.05). Conclusions: Although elevated IMT is often classified by a conservative 0.9 mm cut-point, it is a continuum, with advanced wall thickening (>1.5 mm) recognized as plaque. In this analysis from the ARIC Study, asymptomatic individuals classified with elevated IMT had mild wall thickening (mean IMT = 1.0 mm), which nonetheless was associated with greater number of SBI lesions. This association remains robust after adjustment for cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

Peripheral artery disease (PAD) has not only been associated with recurrent hospitalization for acute decompensated heart failure (ADHF) but is also associated with chronic kidney disease (CKD), a known risk factor for worse heart failure outcomes. The interaction of CKD with PAD in post-discharge ADHF outcomes is not well known. Since 2005, hospitalizations for ADHF were sampled from 4 US regions by the Atherosclerosis Risk in Communities (ARIC) study and classified by physician review. We examined the adjusted association of PAD with 1-year ADHF readmissions, in patients with and without CKD (defined by glomerular filtration rate [GFR] ≤60 mL/min/1.73 m2 [stage 3a or worse]). From 2005 to 2018, there were 1049 index hospitalizations for patients with ADHF (mean age 77 years, 66 % white) with creatinine data, who were discharged alive. Of these, 155 (15 %) had PAD and 66 % had CKD. In comparison to those without PAD, patients with PAD had more comorbid conditions and higher 1-year ADHF readmission rates, irrespective of CKD status. After adjustment, PAD was associated with a greater risk of 1-year ADHF readmissions, both for patients with concomitant CKD (HR, 1.70; 95 % CI: 1.29–2.24) and those without CKD (HR, 1.97; 95 % CI: 1.14–3.40); p- interaction = 0.8. Among patients hospitalized with ADHF, those with concurrent PAD have more prevalent cardiovascular comorbidities and higher likelihood of 1-year ADHF readmission, irrespective of CKD status. Integrating a more holistic approach in management of patients with concomitant heart failure, PAD and CKD may be an important strategy to improve the prognosis in this vulnerable population. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Sex differences are known to exist in the management of older patients presenting with acute myocardial infarction (AMI). Few studies have examined the incidence and risk factors of AMI among young patients, or whether clinical management differs by sex.Methods: The Atherosclerosis Risk in Communities (ARIC) Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified by physician review, using a validated algorithm. Medications and procedures were abstracted from the medical record. Our study population was limited to young patients aged 35 to 54 years.Results: From 1995 to 2014, 28 732 weighted hospitalizations for AMI were sampled among patients aged 35 to 74 years. Of these, 8737 (30%) were young. The annual incidence of AMI hospitalizations increased for young women but decreased for young men. The overall proportion of AMI admissions attributable to young patients steadily increased, from 27% in 1995 to 1999 to 32% in 2010 to 2014 ( P for trend=0.002), with the largest increase observed in young women. History of hypertension (59% to 73%, P for trend<0.0001) and diabetes mellitus (25% to 35%, P for trend<0.0001) also increased among young AMI patients. Compared to young men, young women presenting with AMI were more often black and had a greater comorbidity burden. In adjusted analyses, young women had a lower probability of receiving lipid-lowering therapies (relative risk [RR]=0.87; 95% confidence interval [CI], 0.80-0.94), nonaspirin antiplatelets (RR=0.83; 95% CI, 0.75-0.91), beta blockers (RR=0.96; 95% CI, 0.91-0.99), coronary angiography (RR=0.93; 95% CI, 0.86-0.99) and coronary revascularization (RR = 0.79; 95% CI, 0.71-0.87). However, 1-year all-cause mortality was comparable for women versus men (HR=1.10; 95% CI, 0.83-1.45).Conclusions: The proportion of AMI hospitalizations attributable to young patients increased from 1995 to 2014 and was especially pronounced among women. History of hypertension and diabetes among young patients admitted with AMI increased over time as well. Compared with young men, young women presenting with AMI had a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these changes is needed to improve care of young patients with AMI. [ABSTRACT FROM AUTHOR]

Background: The dramatic decrease in mortality from acute myocardial infarction (AMI) in recent decades has not transferred to younger age groups, especially young women. However, the incidence and management patterns of AMI among young patients are not well known. Methods: The ARIC Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified using a validated algorithm. Analysis was limited to patients aged 35-74 years. The proportion of AMI hospitalizations attributable to young patients (35-54 years) was examined across 5-year intervals and relative probabilities of guideline-directed therapies were compared between young women and men, adjusted for race, location, and year of hospitalization. Results: From 1995-2014, a total of 28,732 weighted hospitalizations for AMI were sampled among patients aged 35-74. Of these, 8,737 (30%) were young. The proportion of AMI attributable to young patients steadily increased (27% to 32%; p for trend <0.0001), with the largest increase among women (21% to 31%, p for trend <0.0001), Figure. Prevalence of hypertension (59% to 73%; p<0.0001) and diabetes (25% to 35%; p for trend <0.0001) also increased among young patients. Compared with young men, young women with AMI were more often black (52% vs. 41%), and more likely to have hypertension (71% vs. 64%), diabetes mellitus (39% vs. 26%), and chronic kidney disease (24% vs. 19%). In adjusted analyses, young women had a lower probability of receiving lipid lowering therapies (RR = 0.64; 95% CI: 0.50 - 0.80), non-aspirin antiplatelets (RR = 0.63; 95% CI: 0.51 - 0.77), beta blockers (RR = 0.78; 95% CI: 0.62 - 0.99), coronary angiography (RR = 0.82; 95% CI: 0.68 - 0.99), and coronary revascularization (RR = 0.66; 95% CI: 0.57 - 0.78). Conclusion: The proportion of AMI hospitalizations attributable to young patients increased from 1995-2014, and was especially pronounced among women. Prevalence of diabetes and hypertension also increased. Compared with young men, young women presenting with AMI had greater comorbidity burden and a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these differences is needed to improve care for young patients with AMI. [ABSTRACT FROM AUTHOR]