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Objective To evaluate the trends in cardiovascular, ischemic heart disease (IHD), stroke, and heart failure mortality in the stroke belt in comparison with the rest of the United States. Patients and Methods We evaluated the nationwide mortality data of all Americans from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2018. Cause-specific deaths were identified in the stroke belt and nonstroke belt populations using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. The relative percentage gap was estimated as the absolute difference computed relative to nonstroke belt mortality. Piecewise linear regression and age-period-cohort modeling were used to assess, respectively, the trends and to forecast mortality across the 2 regions. Results The cardiovascular mortality rate (per 100,000 persons) was 288.3 (95% CI, 288.0 to 288.6; 3,684,273 deaths) in the stroke belt region and 251.2 (95% CI, 251.0 to 251.3; 13,296,164 deaths) in the nonstroke belt region. In the stroke belt region, age-adjusted mortality rates due to all cardiovascular causes (average annual percentage change [AAPC] in mortality rates, −2.4; 95% CI, −2.8 to −2.0), IHD (AAPC, −3.8; 95% CI, −4.2 to −3.5), and stroke (AAPC, −2.8; 95% CI, −3.4 to −2.1) declined from 1999 to 2018. A similar decline in cardiovascular (AAPC, −2.5; 95% CI, −3.0 to −2.0), IHD (AAPC, −4.0; 95% CI, −4.3 to −3.7), and stroke (AAPC, −2.9; 95% CI, −3.2 to −2.2) mortality was seen in the nonstroke belt region. There was no overall change in heart failure mortality in both regions (PAAPC>.05). The cardiovascular mortality gap was 11.8% in 1999 and 15.9% in 2018, with a modest reduction in absolute mortality rate difference (~7 deaths per 100,000 persons). These patterns were consistent across subgroups of age, sex, race, and urbanization status. An estimated 101,953 additional cardiovascular deaths need to be prevented from 2020 to 2025 in the stroke belt to ameliorate the gap between the 2 regions. Conclusion Despite the overall decline, substantial geographic disparities in cardiovascular mortality persist. Novel approaches are needed to attenuate the long-standing geographic inequalities in cardiovascular mortality in the United States, which are projected to increase.

Background Performance of Pooled Cohort Equations (PCEs) for atherosclerotic cardiovascular disease (ASCVD) risks varied across populations. Whether the recently developed Prediction for ASCVD Risk in China (China-PAR) model could accurately predict cardiovascular risks in real practice remains unclear. Methods A population-based cohort study in rural Beijing in the “stroke belt” in North China was used to externally validate PCE and China-PAR models for 5-year ASCVD risk prediction. Expected 5-year prediction risk using China-PAR model was compared with PCE (white). The models were assessed for calibration, discrimination, and reclassification. Results Among 11,169 adults aged 40 to 79 years over a median 6.44 years of follow-up, 1,921 participants developed a first ASCVD event during total 70,951 person-years. China-PAR model fairly predicted ASCVD risk in men but overestimated by 29.4% risk in women (calibration χ2 = 81.4, P Conclusions China-PAR outperformed PCE in 5-year ASCVD risk prediction in this rural Northern Chinese population at average population risk level, fairly predicted risk in men, but overestimated risk in women; however, China-PAR did not meaningfully improve the accuracy of discrimination and reclassification at individual risk level.

Background Dietary patterns and associations with incident heart failure (HF) are not well established in the United States. Objectives The purpose of this study was to determine associations of 5 dietary patterns with incident HF hospitalizations among U.S. adults. Methods The REGARDS (REasons for Geographic and Racial Differences in Stroke) trial is a prospective cohort of black and white adults followed from 2003 to 2007 through 2014. Inclusion criteria included completion of a food frequency questionnaire and no baseline coronary heart disease or HF. Five dietary patterns (convenience, plant-based, sweets, Southern, and alcohol/salads) were derived from principal component analysis. The primary endpoint was incident HF hospitalization. Results This study included 16,068 participants (mean age 64.0 ± 9.1 years, 58.7% women, 33.6% black participants, 34.0% residents of the stroke belt). After a median of 8.7 years of follow-up, 363 participants had incident HF hospitalizations. Compared with the lowest quartile, the highest quartile of adherence to the plant-based dietary pattern was associated with a 41% lower risk of HF in multivariable-adjusted models (hazard ratio: 0.59; 95% confidence interval: 0.41 to 0.86; p = 0.004). Highest adherence to the Southern dietary pattern was associated with a 72% higher risk of HF after adjusting for age, sex, and race and for other potential confounders (education, income, region of residence, total energy intake, smoking, physical activity, and sodium intake; hazard ratio: 1.72; 95% confidence interval: 1.20 to 2.46; p = 0.005). However, the association was attenuated and no longer statistically significant after further adjusting for body mass index in kg/m2, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease. No statistically significant associations were observed with incident HF with reduced or preserved ejection fraction hospitalizations and the dietary patterns. No associations were observed with the other 3 dietary patterns. Conclusions Adherence to a plant-based dietary pattern was inversely associated with incident HF risk, whereas the Southern dietary pattern was positively associated with incident HF risk.

The Southern dietary pattern, derived within the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, is characterised by high consumption of added fats, fried food, organ meats, processed meats and sugar-sweetened beverages and is associated with increased risk of several chronic diseases. The aim of the present study was to identify characteristics of individuals with high adherence to this dietary pattern. We analysed data from REGARDS, a national cohort of 30 239 black and white adults ≥45 years of age living in the USA. Dietary data were collected using the Block 98 FFQ. Multivariable linear regression was used to calculate standardised beta coefficients across all covariates for the entire sample and stratified by race and region. We included 16 781 participants with complete dietary data. Among these, 34·6 % were black, 45·6 % male, 55·2 % resided in stroke belt region and the average age was 65 years. Black race was the factor with the largest magnitude of association with the Southern dietary pattern (Δ = 0·76 sd, P < 0·0001). Large differences in Southern dietary pattern adherence were observed between black participants and white participants in the stroke belt and non-belt (stroke belt Δ = 0·75 sd, non-belt Δ = 0·77 sd). There was a high consumption of the Southern dietary pattern in the US black population, regardless of other factors, underlying our previous findings showing the substantial contribution of this dietary pattern to racial disparities in incident hypertension and stroke.

Background Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES). Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions Focusing on reducing D-CC and Con times may help to achieve the DTN time of

Strokes are a leading cause of morbidity and mortality in the United States, especially in the "stroke belt" of the southeast. Up to 65% of stroke patients access care by calling 9-1-1. The primary objective of this study is to measure the accuracy of emergency medical dispatchers (EMD) and paramedics, in the prehospital identification of stroke.The study was based at Grady Emergency Medical Services, which is Atlanta, Georgia's public emergency medical services (EMS) provider. A retrospective analysis of all medically related 9-1-1 calls to Grady EMS classified as "stroke" between January 1, 2012, and December 31, 2012 was performed. A database was created using deterministic linkage between records from Grady EMS, Grady Hospital Emergency Department (ED), and the Grady Hospital Stroke Registry. Patients excluded were less than 18 years of age, had previous or concurrent head injuries, were transferred from another inpatient facility, and/or had incomplete patient records in any one of the three databases. Descriptive analysis, linear regression, and logistic multivariable regression were performed to discover the accuracy of stroke identification and contributory prehospital factors.A total of 548 patients were included: 475 were transported with EMS impression of stroke and 73 with an impression other than stroke. The median age was 59 years, 87.4% were black, and 52.6% were female. Paramedics adhered to all seven elements of the Grady EMS stroke protocol in 76.4% (n = 363) of suspected stroke cases. Sensitivity and positive predictive value for paramedic stroke identification was 76.2% and 49.3%, respectively, and for EMD, was 48.9% and 24%, respectively. Identification of hemorrhagic strokes had a relatively lower sensitivity. Paramedics were more likely to positively identify strokes when the Cincinnati Prehospital Stroke Scale (CPSS) screen was positive, or when classified by EMD as stroke. Paramedics were less likely to identify stroke in female patients. Paramedics' diagnostic accuracy was similar regardless of their adherence to the EMS stroke care protocol.EMD and EMS personnel in a large city in the Southeastern United States, with high stroke prevalence, had a relatively high sensitivity in identifying acute stroke patients. Paramedic accuracy was augmented by positive CPSS screening and by EMD recognition of stroke.

In the United States, stroke incidence and related mortality have declined in the past half century.1,2 This drop is largely because of better recognition and control of modifiable cardiovascular disease risk factors.3,4 There remain significant racial disparities however, and studies and surveillance programs consistently show higher rates of stroke and stroke-related mortality in native born blacks when compared with non-Hispanic whites (NHW).5–9 Nowhere is this racial disparity more evident than in the stroke belt, an area in the Southeastern United States with disproportionately high rates of stroke.10–12 Although a higher prevalence of cardiovascular disease risk factors, specifically hypertension, diabetes mellitus, obesity, and cigarette smoking, account for much of the excess stroke risk, it remains unclear why these cardiovascular comorbidities, and other lifestyle-related risk factors, cluster in this region of the United States, particularly in blacks.13–15 Multiple explanations have been proposed, but the medical community has yet to offer a fully satisfactory explanation for what is driving stroke mortality in the ≈700 hot spot counties of the stroke belt.16 A clue is that these counties also have higher proportions of black residents and unemployment, as well as lower educational status, median income, and healthcare use.16 While often ignored in the medical literature, a history of slavery, and ongoing social segregation, racial discrimination, and economic inequality, provide a historical precedent for the phenotype of poor cardiovascular health observed in several predominantly black communities. Although many reports depict the racial disparities and skew in stroke risk factors in this region of the United States, a PubMed search using the words slavery, slave, stroke, stroke belt, and cardiovascular disease returned no relevant articles. Our goal is to review the historical evidence and test the strength of association …

BackgroundM2 occlusions may result in poor outcomes and potentially benefit from endovascular therapy. Data on the rate of M2 strokes is lacking.MethodologyPatients with acute ischemic stroke discharged over a period of 3 years from a tertiary level hospital in the ‘stroke belt’ were evaluated for M2 occlusions on baseline vascular imaging. Regional and national incidence was calculated from discharge and multicounty data.ResultsThere were 2739 ICD-9 based AIS discharges. M2 occlusions in 116 (4%, 95% CI 3.5% to 5%) patients constituted the second most common occlusion site. The median National Institute of Health Stroke Scale (NIHSS) score was 12 (IQR 5–18). Good outcomes were observed in 43% (95% CI 34% to 53%), poor outcomes in 57% (95% CI 47% to 66%), and death occurred in 27% (95% CI 19% to 37%) of patients. Receiver operating characteristics curves showed the NIHSS to be predictive of outcomes (area under the curve 0.829, 95% CI 0.745 to 0.913, p3 for NIHSS score ≥9 versus 30 (±34)cm3 for NIHSS score ConclusionM2 occlusions can present with serious neurological deficits and cause significant morbidity and mortality. Patients with M2 occlusions and higher baseline deficits (NIHSS score ≥9) may benefit from endovascular therapy, thus potentially expanding the category of acute ischemic strokes amenable to intervention.

The disparities in stroke mortality between blacks and whites, as well as the increased stroke mortality in the "stroke belt" have long been noted. The reasons for these disparities have yet to be fully explained. The association between trace element status and cardiovascular diseases, including stroke, has been suggested as a possible contributor to the disparities in stroke mortality but has not been fully explored. The purpose of this study is to investigate distributions of four trace elements (arsenic, mercury, magnesium, and selenium) in the environment in relation to stroke risk. The study population (N=27,770) is drawn from the Reasons for Geographic and Racial Disparities in Stroke (REGARDS) cohort. Environmental distribution of each trace element was determined using data from the United States Geological Survey (USGS) and was categorized in quartiles. A proportional hazards model, adjusted for demographic data and stroke risk factors, was used to examine the association of interest. The results showed that higher selenium levels in the environment were associated with increased stroke risk, and the hazard ratio for the 4th quartile compared to the 1st quartile was 1.33 (95% CI: 1.09, 1.62). However, there was no statistically significant relationship between environmental arsenic, mercury or magnesium and the risk of stroke. Because of dietary and non-dietary exposure as well as bioavailability, further research using biomarkers is warranted to examine the association between these trace elements and the risk of stroke.

Purpose To examine racial differences in healthcare utilization and costs for persons with aphasia (PWA) being treated in acute care hospitals in North Carolina (NC). Methods NC Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) data from 2011–2012 were analyzed to examine healthcare utilization and costs of care for stroke patients with aphasia. Analyses emphasized length of stay, charges and cost of general hospital services. Generalized linear models (GLM) were constructed to determine the impact of demographic characteristics, stroke/illness severity, and observed hospital characteristics on utilization and costs. Hospital fixed effects were included to yield within-hospital estimates of disparities. Results GLM models demonstrated that Blacks with aphasia experienced 1.9 days longer lengths of stay compared to Whites with aphasia after controlling for demographic characteristics, 1.4 days controlling for stroke/illness severity, 1.2 days controlling for observed hospital characteristics, and ~ 1 extra day controlling for unobserved hospital characteristics. Similarly, Blacks accrued ~$2047 greater total costs compared to Whites after controlling for demographic characteristics, $1659 controlling for stroke/illness severity, $1338 controlling for observed hospital characteristics, and ~$1311 greater total costs after controlling for unobserved hospital characteristics. Conclusions In the acute hospital setting, Blacks with aphasia utilize greater hospital services during longer hospitalizations and at substantially higher costs in the state of NC. A substantial portion of the adjusted difference was related to the hospital treating the patient. However, even after controlling for the hospital, the differences remained clinically and statistically significant.

The Omega-3 Index (O3I; erythrocyte EPA+DHA as a percent of total fatty acids) is inversely related to risk for cardiovascular disease (CVD). The cardioprotective target O3I is 8%-12%. O3I levels in American regions with high CVD risk are poorly characterized.To determine the O3I in individuals participating in a Seafood Nutrition Partnership (SNP) survey in seven US cities in the CVD "belt."Fingerstick blood samples were analyzed for the O3I.The SNP cohort (n = 2177) had a mean (SD) O3I of 4.42% (1.12%). Only 1.2% were in the desirable range, whereas 42% had an undesirable (4%) O3I. The mean (SD) O3I in a subset of 772 SNP subjects who were matched for age and sex with the Framingham study was 4.6% (1.2%) compared 5.3% (1.6%) in the Framingham cohort (p 0.0001).Individuals in the CVD "belt" had relatively low O3I levels. Since in other settings, a low O3I is associated with increased risk for CVD, this may be one factor contributing to the higher risk for CVD in this region of the US.

Aims A recently described phenomenon is that of myocardial infarction (MI) events that meet criteria for MI, but that have very low peak troponin elevations, so-called ‘microsize MI’. These events are very common and associated with increased risk of all-cause mortality. Our aim is to compare risk factors for microsize MI vs. usual MI events. Methods and results Among 24 470 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort free of coronary heart disease at baseline, heart-related hospitalizations were expert adjudicated for MI using published guidelines. Myocardial infarctions were classified as microsize MI (peak troponin Conclusion The similarities in risk profiles suggest a possible common aetiology and should encourage clinicians to both treat reversible risk factors for microsize MI and to initiate secondary prevention strategies following these events until this emerging clinical entity is better understood. Future studies should further assess the clinical outcomes of these two entities and their effect on future management.

Background and Purpose— The stroke belt is described as an 8-state region with high stroke mortality across the southeastern United States. Using spatial statistics, we identified clusters of high stroke mortality (hot spots) and adjacent areas of low stroke mortality (cool spots) for US counties and evaluated for regional differences in county-level risk factors. Methods— A cross-sectional study of stroke mortality was conducted using Multiple Cause of Death data (Centers for Disease Control and Prevention) to compute age-adjusted adult stroke mortality rates for US counties. Local indicators of spatial association statistics were used for hot-spot mapping. County-level variables were compared between hot and cool spots. Results— Between 2008 and 2010, there were 393 121 stroke-related deaths. Median age-adjusted adult stroke mortality was 61.7 per 100 000 persons (interquartile range=51.4–74.7). We identified 705 hot-spot counties (22.4%) and 234 cool-spot counties (7.5%); 44.5% of hot-spot counties were located outside of the stroke belt. Hot spots had greater proportions of black residents, higher rates of unemployment, chronic disease, and healthcare utilization, and lower median income and educational attainment. Conclusions— Clusters of high stroke mortality exist beyond the 8-state stroke belt, and variation exists within the stroke belt. Reconsideration of the stroke belt definition and increased attention to local determinants of health underlying small area regional variability could inform targeted healthcare interventions.

Background: The Stroke Belt is a region of the United States with elevated stroke incidence and prevalence of stroke risk factors. Physical inactivity is an important stroke risk factor, but little is known about whether current physical activity levels differ between Stroke Belt and non-Stroke Belt states. In this nationally representative study, we determined whether unadjusted and adjusted physical activity levels differ between the Stroke Belt region and the rest of the United States. Methods: Using 2017 Behavioral Risk Factor Surveillance System data, we conducted bivariate analyses to obtain unadjusted physical activity levels in Stroke Belt and non-Stroke Belt states. Logistic regressions that controlled for sociodemographic and stroke risk factors were created to estimate adjusted associations between Stroke Belt residence and physical activity. Results: A higher percentage of Stroke Belt residents were inactive (Stroke Belt: 35.3%, non-Stroke Belt: 29.4%) and failed to meet physical activity guidelines (Stroke Belt: 53.7%, non-Stroke Belt: 47.8%) compared to non-Stroke Belt residents. Stroke Belt residence was significantly associated with lower odds of meeting physical activity guidelines in a model that adjusted for sociodemographic factors only (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.78-0.91) and one that adjusted for both sociodemographic and stroke risk factors (OR: 0.87, 95% CI: 0.81-0.93). Conclusions: The considerably lower physical activity levels and likelihood of meeting physical activity guidelines in Stroke Belt residents compared to their non-Stroke Belt counterparts demonstrates a need for clinician attention and public health interventions to increase regular physical activity as part of a stroke reduction strategy in this region.

Background The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data. Aim The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil. Methods This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status. Results The mean standardized stroke mortality in São Paulo decreased from 66 to 46-7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo. Conclusions In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28-5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

To identify approximately 500 cases of incident cognitive impairment (ICI) in a large, national sample adapting an existing cognitive test-based case definition and to examine relationships of vascular risk factors with ICI.Participants were from the REGARDS study, a national sample of 30,239 African-American and White Americans. Participants included in this analysis had normal cognitive screening and no history of stroke at baseline, and at least one follow-up cognitive assessment with a three-test battery (TTB). Regression-based norms were applied to TTB scores to identify cases of ICI. Logistic regression was used to model associations with baseline vascular risk factors.We identified 495 participants with ICI of 17,630 eligible participants. In multivariable modeling, income (OR 1.83 CI 1.27,2.62), stroke belt residence (OR 1.45 CI 1.18,1.78), history of transient ischemic attack (OR 1.90 CI 1.29,2.81), coronary artery disease(OR 1.32 CI 1.02,1.70), diabetes (OR 1.48 CI 1.17,1.87), obesity (OR 1.40 CI 1.05,1.86), and incident stroke (OR 2.73 CI 1.52,4.90) were associated with ICI.We adapted a previously validated cognitive test-based case definition to identify cases of ICI. Many previously identified risk factors were associated with ICI, supporting the criterion-related validity of our definition.

Background and Purpose— We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors. Methods— Population level access to PSCs within 60 minutes was estimated using validated models of prehospital time accounting for critical prehospital time intervals and existing road networks. We examined the association between geographic factors, demographic factors, and access to care. Multivariable models quantified the association between demographics and PSC access for the entire United States and then stratified by urbanicity. Results— Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance (87% major cities, 59% minor cities, 9% suburbs, and 1% rural). PSC access was lower in stroke belt states (44% versus 69%). Non-whites were more likely to have access than whites (77% versus 62%), and Hispanics were more likely to have access than non-Hispanics (78% versus 64%). Demographics were not meaningfully associated with access in major cities or suburbs. In smaller cities, there was less access in areas with lower income, less education, more uninsured, more Medicare and Medicaid eligibles, lower healthcare utilization, and healthcare resources. Conclusions— There are significant geographic disparities in access to PSCs. Access is limited in nonurban areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Selecting demographic and healthcare factors is strongly associated with access to care in smaller cities, but not in other areas, including major cities.

Background Stroke is a costly and debilitating disease that disproportionately affects blacks. Despite the efficacy of statins, evidence suggests racial disparities may exist in statin prescribing. Methods and Results We analyzed discharge medications for participants hospitalized for an ischemic stroke during follow‐up of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Medications on admission and discharge were abstracted from medical records. Among the 666 eligible incident strokes (2003–2013), analyses were restricted to 323 participants who were not statin users at the time of admission and had no history of atrial fibrillation. Overall, 48.7% were prescribed a statin on discharge. In the Stroke Belt, participants aged 65 years and older were 47% less likely to be discharged on a statin compared with those younger than 65 years (relative risk [ RR ], 0.53; 95% CI , 0.38–0.74). This association was not observed in non–Stroke Belt residents. Outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin ( RR , 1.42; 95% CI , 1.04–1.94), while no black:white association was present among Stroke Belt residents ( RR , 0.93; 95% CI , 0.69–1.26; P for interaction=0.228). Compared with women, men in the Stroke Belt were 31% less likely to be discharged on a statin ( RR , 0.69; 95% CI , 0.50–0.94) while men outside the Stroke Belt were more likely to be discharged on a statin ( RR , 1.38; 95% CI , 0.99–1.92; P for interaction=0.004). Conclusions Statin discharge prescribing may differ among Stroke Belt and non–Stroke Belt residents, particularly in older Americans and men.

Background and purpose Galectin-3 is a biomarker of atherosclerotic and cardiovascular disease, and may be a useful marker for ischaemic stroke risk. Methods The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled and examined 30 239 US participants between 2003 and 2007 (41% black, 59% white and 55% in the southeastern stroke belt). Baseline galectin-3 was measured in 526 subjects with incident ischaemic stroke over 5.4 years and in a cohort random sample (CRS) of 947 participants. Cox proportional hazards models were used to calculate hazard ratios (HRs) of ischaemic stroke by quartiles of galectin-3. Results In the CRS, galectin-3 was significantly higher with older age, black race, female sex, body mass index, hypertension, diabetes mellitus and kidney disease, and also in those who developed incident stroke. Participants with galectin-3 levels in the fourth versus first quartile had a 2.3-fold increased stroke risk [95% confidence interval (CI) 1.6, 3.4] in an unadjusted model. An interaction with age was found (P = 0.06), and therefore age-stratified analyses were performed. Amongst those younger than age 64, baseline galectin-3 in the second–fourth quartiles was associated with increased stroke risk (HR 3.0, 95% CI 1.6, 5.5) compared to the first quartile in an age-, race- and sex-adjusted model. The HR was 2.0 (95% CI 1.0, 4.0) with multivariable adjustment. There was no association amongst older participants. Conclusions Galectin-3 was associated with incident ischaemic stroke in younger but not older individuals. Confirmation of this finding, and elucidation of its implications for stroke pathophysiology and prevention, is needed.

Research on trace elements and the effects of their ingestion on human health is often seen in scientific literature. However, little research has been done on the distribution of trace elements in the environment and their impact on health. This paper examines what characteristics among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study are associated with levels of environmental exposure to arsenic, magnesium, mercury, and selenium. Demographic information from REGARDS participants was combined with trace element concentration data from the US Geochemical Survey (USGS). Each trace element was characterized as either low (magnesium and selenium) or high (arsenic and mercury) exposure. Associations between demographic characteristics and trace element concentrations were analyzed with unadjusted and adjusted logistic regression models. Individuals who reside in the Stroke Belt have lower odds of high exposure (4th quartile) to arsenic (OR 0.33, CI 0.31, 0.35) and increased exposure to mercury (OR 0.65, CI 0.62, 0.70) than those living outside of these areas, while the odds of low exposure to trace element concentrations were increased for magnesium (OR 5.48, CI 5.05, 5.95) and selenium (OR 2.37, CI 2.22, 2.54). We found an association between levels of trace elements in the environment and geographic region of residence, among other factors. Future studies are needed to further examine this association and determine whether or not these differences may be related to geographic variation in disease.

Background and Purpose— Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina. Methods— Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke ( International Classification of Diseases, Ninth Revision codes: 430–434, 436, 437.1). Age- and race-stroke–specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites. Results— Of the 84 179 stroke hospitalizations, 31 137 (37.0%) were from patients aged P P =0.004); however, this increase was mainly driven by a 17.3% rise among blacks ( P =0.001), with no difference seen among whites ( P =0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged P Conclusions— The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

The Mediterranean diet (MedDiet) is recommended by the current Dietary Guidelines for Americans, yet little is known about the perceived barriers and benefits to the diet in the U.S., particularly in the Stroke Belt (SB). Thus, the purpose of this study was to examine MedDiet adherence and perceived knowledge, benefits, and barriers to the MedDiet in the U.S. A cross-sectional study was conducted on 1447 participants in the U.S., and responses were sorted into geographic groups: the SB, California (CA), and all other US states (OtherUS). Linear models and multivariable linear regression analysis was used for data analysis. Convenience, sensory factors, and health were greater barriers to the MedDiet in the SB group, but not the OtherUS group (p &lt, 0.05). Weight loss was considered a benefit of the MedDiet in the SB (p &lt, 0.05), while price and familiarity were found to be less of a benefit (p &lt, 0.05). Respondents with a bachelor&rsquo, s degree or greater education had greater total MEDAS scores (p &lt, 0.05) and obese participants had a lower MedDiet adherence score (p &lt, 0.05). Our results identify key barriers and benefits of the MedDiet in the SB which can inform targeted MedDiet intervention studies.

Inadequate control of high systolic blood pressure in older adults has been largely attributable to poor control of overall hypertension (HTN). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines emphasize the importance of controlling isolated systolic HTN in older adults. The study examined demographics, self-reported health information, and clinical measures as predictors of uncontrolled HTN among individuals taking antihypertensive medications. The Community Initiative to Eliminate Stroke, a stroke risk factor screening and prevention project, collected data in two North Carolina counties. Statistical modeling of predictors included odds ratios (ORs) and logistic regression analyses. Of the 2663 participants, 43.5% and 22.8% had uncontrolled systolic and diastolic HTN, respectively. African Americans were more likely to have uncontrolled systolic (60%) or diastolic HTN (70.9%) compared with whites (40% and 29.1%, respectively). Participants 55 years and older were more likely to have uncontrolled systolic HTN compared with younger individuals. Regression analyses showed that race (OR, 1.239; P=.00), age (OR, 1.683; P=.00), and nonadherence with medications (OR, 2.593; P=.00) were significant predictors of uncontrolled systolic HTN. Future interventions should focus on improving management of isolated systolic HTN in older adults and African Americans to increase overall control of HTN.

Objective: To assess whether there are differences in the strength of association with incident stroke for specific periods of life in the Stroke Belt (SB). Methods: The risk of stroke was studied in 24,544 black and white stroke-free participants, aged 45+, in the Reasons for Geographic and Racial Differences in Stroke study, a national population-based cohort enrolled 2003–2007. Incident stroke was defined as first occurrence of stroke over an average 5.8 years of follow-up. Residential histories (city/state) were obtained by questionnaire. SB exposure was quantified by combinations of SB birthplace and current residence and proportion of years in SB during discrete age categories (0–12, 13–18, 19–30, 31–45, last 20 years) and entire life. Proportional hazards models were used to establish association of incident stroke with indices of exposure to SB, adjusted for demographic, socioeconomic (SES), and stroke risk factors. Results: In the demographic and SES models, risk of stroke was significantly associated with proportion of life in the SB and with all other exposure periods except birth, ages 31–45, and current residence. The strongest association was for the proportion of the entire life in SB. After adjustment for risk factors, the risk of stroke remained significantly associated only with proportion of residence in SB in adolescence (hazard ratio 1.17, 95% confidence interval 1.00–1.37). Conclusions: Childhood emerged as the most important period of vulnerability to SB residence as a predictor of future stroke. Improvement in childhood health circumstances should be considered as part of long-term health improvement strategies in the SB.

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

ObjectiveThe objective of the present study was to examine the relationship of dietary fried fish consumption and risk of cardiovascular events and all-cause mortality.DesignProspective cohort study among participants of the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who resided in the USA.SettingThe primary outcome measures included the hazard ratios (HR) of incident CVD including first incident fatal or non-fatal ischaemic stroke or myocardial infarction and all-cause mortality, based on cumulative average fish consumption ascertained at baseline.SubjectsParticipants (n 16 479) were enrolled between 2003 and 2007, completed the self-administered Block98 FFQ and were free of CVD at baseline.ResultsThere were 700 cardiovascular events over a mean follow-up of 5·1 years. After adjustment for sociodemographic variables, health behaviours and other CVD risk factors, participants eating ≥2 servings fried fish/week (v. ConclusionsFried fish intake of two or more servings per week is associated with an increased risk of cardiovascular events. Given the increased intake of fried fish in the stroke belt and among African Americans, these data suggest that dietary fried fish intake may contribute to geographic and racial disparities in CVD.

Background Because residents of the southeastern United States experience disproportionally high rates of cardiovascular disease (CVD), it is important to develop effective lifestyle interventions for this population. Methods The primary objective was to develop and evaluate a dietary, physical activity (PA) and weight loss intervention for residents of the southeastern US. The intervention, given in eastern North Carolina, was evaluated in a 2 year prospective cohort study with an embedded randomized controlled trial (RCT) of a weight loss maintenance intervention. The intervention included: Phase I (months 1–6), individually-tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7–12), option of a 16-week weight loss intervention for those with BMI ≥ 25 kg/m2 offered in 2 formats (16 weekly group sessions or 5 group sessions and 10 phone calls) or a lifestyle maintenance intervention; and Phase III (months 13–24), weight loss maintenance RCT for those losing ≥ 8 lb with all other participants receiving a lifestyle maintenance intervention. Change in diet and PA behaviors, CVD risk factors, and weight were assessed at 6, 12, and 24 month follow-up. Results Baseline characteristics (N = 339) were: 260 (77 %) females, 219 (65 %) African Americans, mean age 56 years, and mean body mass index 36 kg/m2. In Phase I, among 251 (74 %) that returned for 6 month follow-up, there were substantial improvements in diet score (4.3 units [95 % CI 3.7 to 5.0]), walking (64 min/week [19 to 109]), and systolic blood pressure (−6.4 mmHg [−8.7 to −4.1]) that were generally maintained through 24 month follow-up. In Phase II, 138 (57 group only, 81 group/phone) chose the weight loss intervention and at 12 months, weight change was: −3.1 kg (−4.9 to −1.3) for group (N = 50) and −2.1 kg (−3.2 to −1.0) for group/phone combination (N = 75). In Phase III, 27 participants took part in the RCT. At 24 months, weight loss was −2.1 kg (−4.3 to 0.0) for group (N = 51) and −1.1 kg (−2.7 to 0.4) for combination (N = 72). Outcomes for African American and whites were similar. Conclusions The intervention yielded substantial improvement in diet, PA, and blood pressure, but weight loss was modest. Trial registration clinicaltrials.gov Identifier: NCT01433484 Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3370-9) contains supplementary material, which is available to authorized users.

Purpose Recent evidence suggests early-life factors correlate with atrial fibrillation (AF). We hypothesized that AF-related mortality, similar to stroke mortality, is elevated for individuals born in the southeastern United States. Methods We estimated 3-year (1999-2001) average AF-related mortality rates by using U.S. vital statistics for 55- to 89-year-old white (136,573 AF-related deaths) and black subjects (8,288 AF-related deaths). We estimated age- and sex-adjusted odds of AF-related (contributing cause) mortality associated with birth state, and birth within the U.S. stroke belt (SB), stratified by race. SB results were replicated with the use of 1989-1991 data. Results Among black subjects, four contiguous birth states were associated with statistically significant odds ratios ≥ 1.25 compared with the national average AF-related mortality. The four highest-risk birth states for blacks also predicted elevated AF-related mortality among white subjects, but patterns were attenuated. The odds ratio for AF-related mortality associated with SB birth was 1.19 (confidence interval 1.13-1.25) for black and 1.09 (CI 1.07-1.12) for white subjects when we adjusted for SB adult residence. Conclusions Place of birth predicted AF-related mortality, after we adjusted for place of adult residence. The association of AF-related mortality and SB birth parallels that of other cardiovascular diseases and may likewise indicate an importance of early life factors in the development of AF.

Stroke mortality rates and prevalence of several chronic diseases are higher in Southern populations and blacks in the US. This study examined the relationships of race (black, white) and region (Stroke Belt, Stroke Buckle, other) with selected nutrient intakes among black and white American men (n = 9229). The Block 98 FFQ assessed dietary intakes and multivariable linear regression analysis was used to examine whether race and region were associated with intakes of fiber, saturated fat, trans fat, sodium, potassium, magnesium, calcium, and cholesterol. Race and region were significant predictors of most nutrient intakes. Black men consumed 1.00% lower energy from saturated fat compared with white men [multivariable-adjusted β: 1.00% (95% CI = −0.88, −1.13)]. A significant interaction between race and region was detected for trans fat (P < 0.0001), where intake was significantly lower among black men compared with white men only in the Stroke Belt [multivariable-adjusted β: −0.21 (95% CI = −0.11, −0.31)]. Among black men, intakes of sodium, potassium, magnesium, and calcium were lower, whereas cholesterol was higher, compared with white men (P < 0.05 for all). Comparing regions, men in the Stroke Buckle had the lowest intakes of fiber, potassium, magnesium, and calcium compared with those in the Stroke Belt and other regions; men in both the Stroke Buckle and Stroke Belt had higher intakes of cholesterol compared with those in other regions (P < 0.005 for all). Given these observed differences in dietary intakes, more research is needed to understand if and how they play a role in the health disparities and chronic disease risks observed among racial groups and regions in the US.

Background: Omega-3 fatty acids from fish have been shown to have favorable effects on platelet aggregation, blood pressure, lipid profile, endothelial function, and ischemic stroke risk, but there are limited data on racial and geographic differences in fish consumption. Methods: Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national cohort study that recruited 30,239 participants age ≥45 years with oversampling from the southeastern Stroke Belt and Buckle and African Americans (AAs). Centralized phone interviewers obtained medical histories and in-home examiners measured weight and height. Dietary data for this cross-sectional analysis were collected using the self-administered Block98 Food Frequency Questionnaire (FFQ). Adequate intake of nonfried fish was defined as consumption of ≥2 servings per week based on American Heart Association guidelines. After excluding the top and bottom 1% of total energy intake and individuals who did not answer 85% or more of questions on the FFQ, the analysis included 21,675 participants. Results: Only 5,022 (23%) participants consumed ≥2 servings per week of nonfried fish. In multivariable analysis, factors associated with inadequate intake of nonfried fish included living in the Stroke Belt (vs non-Belt) (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.77–0.90) and living in the Stroke Buckle (vs non-Belt) (OR 0.89, 95% CI 0.81–0.98); factors associated with ≥2 servings per week of fried fish included being AA (vs white) (OR 3.59, 95% CI 3.19–4.04), living in the Stroke Belt (vs non-Belt) (OR 1.32, 95% CI 1.17–1.50), and living in the Stroke Buckle (vs non-Belt) (OR 1.17, 95% CI 1.00–1.36). Conclusions: Differential consumption of fish may contribute to the racial and geographic disparities in stroke.

Background: Understanding how the timing of exposure to the US Stroke Belt (SB) influences stroke risk may illuminate mechanisms underlying the SB phenomenon and factors influencing population stroke rates. Methods: Stroke mortality rates for United States–born black and white people aged 30–80 years were calculated for 1980, 1990, and 2000 for strata defined by birth state, state of adult residence, race, sex, and birth year. Four SB exposure categories were defined: born in a SB state (North Carolina, South Carolina, Georgia, Tennessee, Arkansas, Mississippi, or Alabama) and lived in the SB at adulthood; non-SB born but SB adult residence; SB-born but adult residence outside the SB; and did not live in the SB at birth or in adulthood (reference group). We estimated age-, sex-, and race-adjusted odds ratios for stroke mortality associated with timing of SB exposure. Results: Elevated stroke mortality was associated with both SB birth and, independently, SB adult residence, with the highest risk among those who lived in the SB at birth and adulthood. Compared to those living outside the SB at birth and adulthood, odds ratios for SB residence at birth and adulthood for black subjects were 1.55 (95% confidence interval 1.28, 1.88) in 1980, 1.47 (1.31, 1.65) in 1990, and 1.34 (1.22, 1.48) in 2000. Comparable odds ratios for white subjects were 1.45 (95% confidence interval 1.33, 1.58), 1.29 (1.21, 1.37), and 1.34 (1.25, 1.44). Patterns were similar for every race, sex, and age subgroup examined. Conclusion: Stroke Belt birth and adult residence appear to make independent contributions to stroke mortality risk.

Background: Among African-Americans, and in southern US states, the rates of stroke are high but the reported prevalences of atrial fibrillation (AF) are low. We hypothesized that the reported ethnic and regional distributions of AF are affected by the sensitivity of the methods that were used to detect AF in previous reports.Methods: A total of 18 833 black and white participants from the US national REasons For Geographic And Racial Differences In Stroke (REGARDS) study were included in this analysis. Levels of sensitivity to detect AF, from least to most sensitive, were created for combinations of self-report (SR) and ECG methods, as follows: (1) SR plus ECG, (2) ECG alone, (3) SR alone, and (4) SR or ECG. Geographic regions were dichotomized as Stroke Belt (the southern US states) and non-Stroke Belt. Logistic regression analysis estimated the odd ratios of AF associated with the Stroke Belt and black ethnicity for each diagnostic combination.Results: Residence in the Stroke Belt was significantly associated with AF when diagnosed by SR plus ECG (multivariable-adjusted OR, 0.66; 95% CI, 0.47 to 0.92), but not when diagnosed with SR or ECG (OR, 0.95; 95% CI, 0.85 to 1.06). Similarly, for the 4 methods used to detect AF, the strength of the association between black ethnicity and AF progressively decreased with increasing test sensitivity (ORs: 0.20, 0.40, 0.70, 0.71, respectively).Conclusions: The association of AF with residence in the Stroke Belt and black ethnicity was inversely related to the sensitivity of the method used to detect AF: as test sensitivity increased, the association became attenuated. This may partially explain the lower reported prevalence of AF in populations and regions with higher stroke rates.

Background and Purpose— The purpose of this study was to examine whether there are disparities in use of stroke secondary prevention services because disparities in stroke outcomes have been found among older adults, women, racial minorities, and within Stroke Belt states. Methods— Using the nationally-representative 2005 Behavior Risk Factor Surveillance System, we examined self-reported use of 11 stroke secondary prevention services queried in the survey. We used multivariable logistic regression to examine the association between service use and age, sex, race, and Stroke Belt state residence, controlling for other socio-demographic and health care access characteristics. Results— Among 11 862 adults with a history of stroke, 16% were 80 or older, 54% were women, 13% were non-Hispanic black, and 23% lived within a Stroke Belt state. Overall service use varied: 31% reported poststroke outpatient rehabilitation, 57% regular exercise, 66% smoking cessation counseling, and 91% current use of antihypertensive medications. Age 80 or older was not associated with lower use of any of the 11 services. Women were less likely to report poststroke outpatient rehabilitation and regular exercise when compared with men (probability values ≤0.005); there were no sex-based differences in use of the 9 other services. Blacks were less likely to report pneumococcal vaccination when compared with whites, but were more likely to report poststroke outpatient rehabilitation (probability values ≤0.005); there were no race-based differences in use of the 9 other services. Stroke Belt state residence was not associated with lower use of any of the 11 services. Conclusions— Use of many stroke secondary prevention services was suboptimal. We did not find consistent age, sex, racial, or Stroke Belt state residence disparities in care.

Background Heart failure (HF) and cognitive impairment are both common in older adults. However, the association between the two has not been well studied. Methods and Results We explored the relationship between very probable HF, determined by self-reported symptoms, and cognitive impairment, defined as four or fewer correct on the Six-item Screener, in 14,089 participants of the Reasons for Geographic and Racial Differences in Stroke cohort. We determined the effect of adding demographic, socioeconomic status (SES), health behavior, and comorbidity covariates. In the univariate model, participants with very probable HF were 1.51 (95% confidence interval: 1.15–1.96) times more likely to have cognitive impairment than those without HF. As covariates were added to the model, the relationship between HF and cognitive impairment was attenuated and lost statistical significance after adjustment for depression. Demographic variables, Stroke Belt location (1.28 [1.11–1.48]), SES factors, prior stroke (1.43 [1.18–1.73]), and depression (1.66 [1.38–2.01]) remained significant in the multivariable model. Higher hemoglobin was associated (0.95 [0.9–1.00]) with modestly reduced odds of cognitive impairment. Conclusions The relationship between cognitive impairment and HF can be accounted for by multiple demographic and SES factors, and by comorbidities, some of which are modifiable. Persons with HF and cognitive impairment should be screened for anemia and depression.

Understanding the reasons for overweight and obesity is critical to addressing the obesity epidemic. Often the decision to lose weight is based as much on one's self-perception of being overweight as on inherent health benefits.Examine the relationships between self-reported health and demographic factors and measured health risk status and the misperception of actual weight status.Cross-sectional study of factors associated with self-perceived overweight status in participants who self-selected to participate in stroke risk factor screenings. Participants were asked, "Are you overweight?" before their body mass index (BMI) was determined from measured weight and self-reported height. Demographics including, sex, race, education, and location; and health status variables including level of exercise and history of high blood pressure and cholesterol were collected.Mean BMI for the group was 30 kg/m(2). Most women (53.1%) perceived themselves to be overweight, whereas most men (59.6%) perceived themselves not to be overweight. Factors related to misperception of weight status varied by actual BMI category. Among individuals with normal BMI, sedentary individuals had 63% higher odds of misperceiving themselves as overweight. Sedentary individuals with obese BMI were at 55% reduced odds of misperceiving themselves as normal weight.Active obese and overweight individuals may be more likely to incorrectly perceive themselves as normal weight, and thus misperceive their risk for stroke. Thus, it is not enough to only counsel individuals to be active. Physicians and other health professionals need to counsel their clients to both be active and to attain and maintain a healthy weight.

Background and Purpose— Most Stroke Belt studies define exposure based on residence at stroke onset. We assessed whether residence in the Stroke Belt during childhood confers extra stroke risk in adulthood, even among people who left the region. Methods— Stroke-free Health and Retirement Study participants (n=18 070) followed up (average, 8.4 years) for first stroke (1452 events) were classified as living in 1 of 7 Stroke Belt states in childhood or at study enrollment (average age, 63 years). We used Cox proportional-hazards models to compare stroke risk for people who had never lived in the Stroke Belt with those who had lived there at both ages, in childhood only, or in adulthood only. Results— Compared with never having lived in the Stroke Belt, the hazard ratio for Stroke Belt residence in both childhood and adulthood was 1.23 (95% CI, 1.06, 1.43) and for Stroke Belt residence in childhood only was 1.25 (95% CI, 1.02, 1.55). Stroke Belt residence at enrollment but not during childhood was not significantly related to stroke risk (hazard ratio=1.01; 95% CI, 0.70, 1.46), but the small sample in this group resulted in wide CIs. Results changed little after risk factor adjustment, including comprehensive adult socioeconomic measures. Subgroup analyses found similar patterns by sex and birth cohort. In contrast, blacks who had lived in the Stroke Belt in childhood only did not appear to have significantly elevated stroke risk compared with blacks who had never lived in the Stroke Belt. Conclusions— The excess stroke risk for people who had lived in Stroke Belt states during childhood implicates early life exposures in the etiology of the Stroke Belt.

Introduction Cardiovascular disease is the leading cause of death in the United States, and mortality rates are higher among African Americans than among people of other races/ethnicities. We aimed to understand how African American adults and adolescents conceptualize cardiovascular health and perceive related barriers and facilitators. Methods This qualitative study was conducted as formative research for a larger study, Heart Healthy Lenoir, which aimed to reduce cardiovascular disease disparities among African Americans in eastern North Carolina, part of the widely-known "stroke belt" that runs through the southeastern United States. Using photovoice, a community-based participatory research method, we conducted eight 90-minute photovoice sessions with 6 adults and 9 adolescents in Lenoir County, North Carolina. Topics for each discussion were selected by participants and reflected themes related to cardiovascular health promotion. All sessions were transcribed and coded using a data-driven, inductive approach. Results Participants conceptualized cardiovascular health to have mental, spiritual, and social health dimensions. Given these broad domains, participants acknowledged many ecological barriers to cardiovascular health; however, they also emphasized the importance of personal responsibility. Facilitators for cardiovascular health included using social health (eg, family/community relationships) and spiritual health dimensions (eg, understanding one's body and purpose) to improve health behaviors. Conclusion The perspectives of African American adults and adolescents elicited through this formative research provided a strong foundation for Heart Healthy Lenoir's ongoing engagement of community members in Lenoir County and development and implementation of its intervention to prevent cardiovascular disease.

OBJECTIVE To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes. RESEARCH DESIGN AND METHODS Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study. RESULTS Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern “Stroke Belt”). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]). CONCLUSIONS Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.

Disparities in atrial fibrillation (AF)-related stroke and mortality persist, especially racial disparities, within the US "Stroke Belt." This study identified barriers to optimal stroke prevention to develop a framework for clinician education. A comprehensive educational needs assessment was developed focusing on clinicians within the Stroke Belt. The mixed qualitative-quantitative approach included regional surveys and one-on-one clinician interviews. Identified contributors to disparities included implicit racial biases, lack of awareness of racial disparities in AF stroke risk, and lack of effective multicultural awareness and training. Additional barriers affecting disparities included patient medical mistrust and clinician-patient communication challenges. General barriers included lack of consistency in assessing stroke and anticoagulant-related bleeding risk, underuse of standardized risk assessment tools, discomfort with novel anticoagulants, and patient education deficiencies. Effective cultural competency training is one strategy to reduce disparities in AF-related stroke and mortality by improving implicit clinician bias, addressing medical mistrust, and improving clinician-patient communication.

Introduction: The excess stroke mortality among African Americans and Southerners is well known. Because a higher proportion of the population living in the ‘Stroke Belt’ is African American, then a portion of the estimated excess risk of stroke death traditionally associated with African-American race may be attributable to geography (i.e., race and geography are ‘confounded’). In this paper we estimate the proportion of the excess stroke mortality among African Americans that is attributable to geography. Methods: The numbers of stroke deaths at the county level are available from the vital statistics system of the US. A total of 1,143 counties with a population of at least 500 whites and 500 African Americans were selected for these analyses. The black-to-white stroke mortality ratio was estimated with and without adjustment for county of residence for those aged 45–64 and for those aged 65 and over. The difference in the stroke mortality ratio before versus after adjustment for county provides an estimate of the proportion of the excess stroke mortality inappropriately attributed to race (that is in fact attributable to geographic region). Results: For ages 45–64, the black-to-white stroke mortality ratio was reduced from 3.41 to 3.04 for men, and from 2.82 to 2.60 for women, suggesting that between 10 and 15% of the excess mortality traditionally attributed to race is rather due to geography. Over the age of 65, the black-to-white stroke mortality ratio was reduced from 1.31 to 1.27 for men, and from 1.097 to 1.095 for women, suggesting that between 2 and 13% of the excess mortality attributed to black race is actually attributable to geography. The reductions of all the four age strata gender groups were highly significant. Discussion: These results suggest that a significant, although relatively small, proportion of the excess mortality traditionally attributed to race is rather a factor of geography.

Purpose: To provide a descriptive analysis of the stroke features in a population of patients from a large urban hospital within the ‘stroke belt’, with the intention of stimulating interest in creating similar comprehensive databases across the country; the differential population features that may contribute to the increased incidence of ischemic and hemorrhagic stroke within the ‘stroke belt’ can thus be better studied and understood. Background: Strokes account for approximately 5–10% of all deaths in the western world. Within a geographically nondescript region in the Southern United States known as the ‘stroke belt’, however, the incidence of stroke is 1.5–2 times greater than in other regions of the country. Despite the relatively high incidence of stroke within the ‘stroke belt’, very little information is available regarding the differential population features that distinguish stroke patients within this region from those in other parts of the country. Design/Methods: During the period September 1, 1995 to August 31, 1998, data for 506 patients meeting criteria for stroke as outlined in the National Survey of Stroke were entered into the ‘Adult Brain Attack Database’ at the Medical College of Virginia Hospitals of Virginia Commonwealth University. The data were analyzed using descriptive statistics. Results: Of the 506 patients entered into the database 281 experienced their first stroke during the data collection period. Of these individuals, 60.5% (n = 170) were female (mean age 60.6). The mean age in men presenting with new stroke (n = 111) was 62.5. African-Americans represented the predominant ethnic group making up 63.3% (n = 178) of all first stroke patients. The three most common risk factors among deceased ischemic stroke patients (3.2%; n = 9) included hypertension (58.3%), alcohol abuse (41.6%) and cigarette smoking (33.3%). Among ischemic stroke survivors, the three most common risk factors included hypertension (53.6%), prior neurovascular disease (36.2%) and cigarette smoking (28.0%). Risk factors among hemorrhagic stroke patients included hypertension (42.0%), cigarette smoking (26.3%) and alcohol abuse (21.1%). The most common complication associated with stroke across all subtypes was hypertension with an overall prevalence of 9.3%. The use of antiplatelet and antihypertensive therapy at discharge among stroke patients in whom such data was recorded was 58.8% (179/289) and 48.9% (132/270), respectively. Discussion: Future studies comparing data from the Richmond, Va. stroke database with data from other regions of the country outside the ‘stroke belt’ may allow for differentiation of the population features that contribute to the increased prevalence of stroke within the ‘stroke belt’.

The southeastern region of the United States is known as the "stroke belt" because of excess stroke mortality in this region compared to the rest of the country. However, whether a similar geographic variation in heart failure mortality exists is unknown. Using the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research publicly available compressed mortality data files and 2000 United States population as the standard, we estimated age-adjusted heart failure and stroke mortality rates per 100,000 for patients of all ages, men and women, and all races during 1979 through 1998 in the United States and mapped rates at the state level. Age-adjusted heart failure mortality rate for the 6 contiguous southeastern states (Alabama, Arkansas, Mississippi, Oklahoma, Louisiana, and Georgia) was 31.0/100,000, which was 69% higher than the national rate of 18.3/100,000. This geographic disparity was similar in African-Americans (32.9/100,000 in the southeast vs 21.7/100,000 nationally) and whites (30.8/100,000 in the southeast vs 18.1/100,000 nationally). These findings suggest that, in addition to the stroke belt, the southeastern region of the United States may also be burdened by a "heart failure belt." To better understand the causes of excess stroke mortality in the stroke belt, the National Institutes of Health has funded the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (n = 30,239, >1/2 from the southeastern region), which provides a unique opportunity to study the underlying causes of excess heart failure mortality in the heart failure belt.

Background Life's Simple 7 is a new metric based on modifiable health behaviors and factors that the American Heart Association uses to promote improvements to cardiovascular health ( CVH ). We hypothesized that better Life's Simple 7 scores are associated with lower incidence of cognitive impairment. Methods and Results For this prospective cohort study, we included RE asons for Geographic And Racial Differences in Stroke ( REGARDS ) participants aged 45+ who had normal global cognitive status at baseline and no history of stroke (N=17 761). We calculated baseline Life's Simple 7 score (range, 0 to 14) based on smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting glucose. We identified incident cognitive impairment using a 3‐test measure of verbal learning, memory, and fluency obtained a mean of 4 years after baseline. Relative to the lowest tertile of Life's Simple 7 score (0 to 6 points), odds ratios of incident cognitive impairment were 0.65 (0.52, 0.81) in the middle tertile (7 to 8 points) and 0.63 (0.51, 0.79) in the highest tertile (9 to 14 points). The association was similar in blacks and whites, as well as outside and within the Southeastern stroke belt region of the United States. Conclusions Compared with low CVH , intermediate and high CVH were both associated with substantially lower incidence of cognitive impairment. We did not observe a dose‐response pattern; people with intermediate and high levels of CVH had similar incidence of cognitive impairment. This suggests that even when high CVH is not achieved, intermediate levels of CVH are preferable to low CVH .

Racial differences have been observed in stroke-related knowledge and knowledge of specific stroke risk factors and stroke prevention practices. Using data from 134 male stroke survivors, racial differences in overall knowledge, risk factor knowledge, and stroke prevention practices were examined using the Stroke Knowledge Test. Knowledge that diabetes doubles ones risk of stroke was present in 48% of the participants, while knowledge of aspirin in the prevention of stroke by stopping blood clot formation was reported in 83% of the participants. Findings indicate participants were knowledgeable that obesity increased risk of stroke (71%) and high blood pressure was the most important stroke risk factor (70%). Participants indicated knowledge that diet, exercise, and controlling blood pressure and cholesterol reduces risk of stroke (86%). In regression models, there were no significant race differences in overall stroke knowledge or the odds of knowledge of information related to stroke risk factors and stroke prevention practices after adjusting for age, education, and marital status. Although stroke-related knowledge did not differ by race, stroke survivors exhibited gaps in stroke knowledge particularly of knowledge of common risk factors. These factors should be considered in approaches to improve stroke-related knowledge in all stroke survivors.

Abstract —A workshop to describe and then seek possible causes for the increased stroke mortality in the southeastern United States briefly considered 30 suspected correlates and discussed in more detail the 10 thought to be most likely. Recent age-adjusted stroke mortality rates in adults from industrialized countries reveal marked geographic differences. Age-adjusted statewide stroke mortality rates also differ, and they are higher in the Southeast than elsewhere in the United States. For five southeastern coastal states in the heart of the “Stroke Belt,” excess stroke mortality has been present at least since 1930. In a 20-year follow-up of 10 000 veterans, the Stroke Belt had a 25% increase in all-cause mortality and congestive heart failure. A potential cause of increased fatal stroke included hypertension, which was more frequent in the Stroke Belt. No consistent patterns of lifestyle differences or of differences in potassium or calcium intake seemed to explain the higher rates of fatal strokes in the Stroke Belt; however, detailed investigations of smaller populations in localized areas seem warranted. Some data suggest a relationship between socioeconomic status and the Stroke Belt effect. Other differences in the Southeast that could explain, at least partially, the Stroke Belt effect include presence of soft water throughout most of the area, decreased antioxidant intake, and differences in the use of medical care and in the response to antihypertensive drugs. On the basis of available information, the three most likely explanations or partial explanations for the Stroke Belt are increased levels of blood pressure, localized differences in socioeconomic status, and toxic environmental factor(s). Two major recommendations were made: (1) to encourage both patient and caregiver to use all currently available means of decreasing morbidity and mortality by controlling blood pressures at or below normal levels and by reducing other risk factors and (2) to seek precise information about relationships of identified possible causes of increased morbidity and mortality in the Stroke Belt.

Background and Purpose We sought to determine whether the “Stroke Belt” has continued to shift and to assess variation in geographic patterns by age, sex, and race. Methods Mortality data for Health Service Areas for 1988 to 1992 were used for analyses of geographic mortality patterns for stroke by race, sex, and age (50, 70, and 90 years). Results In 1988 to 1992, considerable geographic variation in stroke mortality was demonstrated for each sex/race group. In black and white women and men, previously described high mortality in the southeastern United States persisted. Mortality rates were generally higher in the South than in the North and in the East than in the West. Compared with data from 1962 to 1988, there was a continuation of the previously described westward shift of high-rate areas to the Mississippi River valley, a trend more marked at age 50 years than at 70 or 90 years. Although rates in the Pacific region were low overall, a surprising area of high rates was seen in southern California among women at all three ages examined. Conclusions In whites, rapid declines in stroke mortality in the Southeast have left West South Central states with relatively high mortality rates; this trend may continue as younger cohorts age. However, rates in the Southeast also remain high, especially for blacks.

Background and Purpose The southeastern United States has stroke mortality rates above the national average. The causes for this excess mortality are unknown; however, lower socioeconomic status (SES) is a risk factor for stroke, and the lower SES in the Southeast is a potential cause. In this report we assess the proportion of the excess stroke mortality attributable to SES. Methods The more than 400 000 participants in the National Longitudinal Mortality Study were categorized into three regions: the coastal plain region of North Carolina, South Carolina, and Georgia (“stroke buckle”); the remainder of these states plus five other southern states (“stroke belt”); and the remainder of the United States. The stroke mortality rates were calculated with and without adjustment for SES, and the proportion of the excess mortality attributable to SES was estimated. Results In persons between the ages of 35 and 54 years, stroke mortality in the stroke buckle is estimated to be more than twice that of the rest of the nation and 1.7 times greater for ages 55 to 74 years. For persons in the stroke belt, the stroke mortality was 1.3 times greater than that in the rest of the nation for the ages of 35 to 54 and 55 to 74 years. Less than 16% of this excess stroke morality was attributable to SES. Conclusions SES does not appear to be a major contributor to the excess mortality in the southeastern United States. Of additional concern is the stroke buckle region, which was shown to have stroke mortality rates substantially greater than those in the traditionally recognized stroke belt.

Geographic variations in adverse health outcomes have long been recognized in the United States, with specific focus on the southeastern region of the country. Cerebrovascular disease mortality rates have identified the Southeast as the "stroke belt" for decades, though rates are also high for other hypertension-related diseases including ischemic heart disease, diabetes, and end-stage renal disease. The increased cerebrovascular disease mortality in the Southeast has prompted intervention and research efforts. This paper provides a descriptive profile of the hypertensive end-organ diseases in this area to guide research efforts and to gauge changes in health outcomes and risks. In addition to mortality from stroke, this assessment identified excessive risks from diabetes, ischemic heart disease, and end-stage renal disease for some states in the Southeast. Trend variations in health outcomes were also detected.

Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios for stroke. Older age, female sex, African American race and Hispanic ethnicity, unemployed status, diabetes, hypertension, history of stroke, and permanent atrial fibrillation were positively associated with ischemic stroke, whereas body mass index >30 kg/m2 was inversely associated with stroke (P1.0 were all in the South: North Carolina, Mississippi, and Oklahoma. Regional efforts to increase primary prevention in the “stroke belt” or to better educate dialysis patients on the signs of stroke so that they may promptly seek care may improve stroke care and outcomes in dialysis patients.

Objective To determine the association between race, region and pre-diabetes. Method The study used 2003–2007 United States baseline data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study for this cross-sectional analysis. Participants in this study were 45 years or older at recruitment. Logistic regression was used to assess whether race and region are associated with pre-diabetes independent of demographics, socioeconomic factors and risk factors. Results Twenty-four percent of the study participants (n = 19,889) had pre-diabetes. The odds ratio (95% confidence interval) for having pre-diabetes was 1.28 (1.19–1.36) for blacks relative to whites and 1.18 (1.10–1.26) for people living in the Stroke Belt region relative to the other parts of the United States. The odds of having pre-diabetes for Stroke Belt participants changed minimally after additional adjustment for race (OR = 1.20; 1.13–1.28), age and sex (OR = 1.24; 1.16–1.32), socioeconomic status (OR = 1.22; 1.15–1.31) and risk factors (OR = 1.26; 1.17–1.35). In the adjusted model, being black was independently associated with pre-diabetes (OR = 1.19; 1.10–1.28). Conclusion The prevalence of pre-diabetes was higher for both blacks and whites living in the Stroke Belt relative to living outside the Stroke Belt, and the prevalence of pre-diabetes was higher for blacks independent of region.