Search

Black heart transplant recipients have a higher mortality rate than white recipients 6–12 months after transplant. Whether there are racial disparities in post-transplant stroke incidence and all-cause mortality following post-transplant stroke among cardiac transplant recipients is unknown. Using a nationwide transplant registry, we assessed the association between race and incident post-transplant stroke using logistic regression and the association between race and mortality among adults who survived a post-transplant stroke using Cox proportional hazards regression. We found no evidence of an association between race and the odds of post-transplant stroke (OR = 1.00, 95% CI: 0.83–1.20). The median survival time of those with a post-transplant stroke in this cohort was 4.1 years (95% CI: 3.0, 5.4). There were 726 deaths among the 1139 patients with post-transplant stroke, including 127 deaths among 203 Black patients and 599 deaths among 936 white patients. Among post-transplant stroke survivors, Black transplant recipients experienced a 23% higher rate of mortality compared to white recipients (HR = 1.23, 95% CI: 1.00–1.52). This disparity is strongest in the period beyond the first 6 months and appears to be mediated by differences in the post-transplant setting of care between Black and white patients. The racial disparity in mortality outcomes was not evident in the past decade. The improved survival of Black patients in the recent decade may reflect overall protocol improvements for heart transplant recipients irrespective of race, such as advancements in surgical techniques and immediate postoperative care as well as increased awareness about reducing racial disparities. [ABSTRACT FROM AUTHOR]

To evaluate the association between interpregnancy interval (IPI) and risk for gestational diabetes mellitus (GDM). We conducted a retrospective cohort study among singleton, non-anomalous, live birth pregnancies of 5,705,812 pregnant individuals in the United States from 2016 to 2018. We examined IPI of 4–<6 months, 6–11 months, 12–17 months, 24–35 months, 36–47 months, 48–59 months, 60–71 months, and ≥72 months in comparison to the reference interval of 18–23 months in relation to risk for GDM. We used logistic regression to evaluate the association between IPI and risk for GDM. There is a significantly increased risk for GDM associated with IPIs of 6–11 months and 12–17 months compared to the reference of 18–23 months (adjusted Odds Ratio [aOR] 1.05, 95% CI: 1.03–1.07; aOR 1.02, 95% CI: 1.01–1.03). The risk for GDM is greater for longer IPIs (36–47 months aOR 1.10, 95% CI: 1.05–1.08; 48–59 months aOR 1.11, 95% CI: 1.09–1.13; 60–71 months aOR 1.14, 95% CI: 1.12–1.16; ≥72 months aOR 1.31, 95% CI: 1.30–1.33). Our findings support the growing evidence that shorter and longer IPI increase the risk of GDM in pregnant individuals. Screening guidelines for detection of GDM may need to be re-evaluated and updated to include longer IPIs (≥36 months) as a risk factor for earlier screening prior to current recommendation of 24 weeks gestational age. [ABSTRACT FROM AUTHOR]

Background: Long-term exposure to ambient air pollution has been associated with impaired cognitive function and vascular disease in older adults, but little is known about these associations among people with concerns about memory loss.Objective: To examine associations between exposures to fine particulate matter and residential proximity to major roads and markers of small vessel disease.Methods: From 2004-2010, 236 participants in the Massachusetts Alzheimer's Disease Research Center Longitudinal Cohort participated in neuroimaging studies. Residential proximity to major roads and estimated 2003 residential annual average of fine particulate air pollution (PM2.5) were linked to measures of brain parenchymal fraction (BPF), white matter hyperintensities (WMH), and cerebral microbleeds. Associations were modeled using linear and logistic regression and adjusted for clinical and lifestyle factors.Results: In this population (median age [interquartile range] = 74 [12], 57% female) living in a region with median 2003 PM2.5 annual average below the current Environmental Protection Agency (EPA) standard, there were no associations between living closer to a major roadway or for a 2μg/m3 increment in PM2.5 and smaller BPF, greater WMH volume, or a higher odds of microbleeds. However, a 2μg/m3 increment in PM2.5 was associated with -0.19 (95% Confidence Interval (CI): -0.37, -0.005) lower natural log-transformed WMH volume. Other associations had wide confidence intervals.Conclusions: In this population, where median 2003 estimated PM2.5 levels were below the current EPA standard, we observed no pattern of association between residential proximity to major roads or 2003 average PM2.5 and greater burden of small vessel disease or neurodegeneration. [ABSTRACT FROM AUTHOR]

Background: The medical and recreational use of marijuana is now legal in some parts of the United States; the health effects are unknown. We aimed to evaluate associations between recent marijuana use and exhaled nitric oxide (eNO) and pulmonary function.Methods: We performed a cross-sectional study of 10,327 US adults participating in the National Health and Nutrition Examination Survey in the years 2007 to 2012. We examined associations between marijuana use and eNO, FEV1, FVC, the FEV1/FVC ratio, and forced expiratory flow (midexpiratory phase) (FEF25%-75%) by weighted linear regression.Results: In the study population, there were 4,797 never users, 4,084 past marijuana users, 555 participants who used marijuana 5 to 30 days before the examination, and 891 participants who used marijuana 0 to 4 days before the examination. Current marijuana use in the past 4 days was associated with 13% lower eNO (95% CI, -18% to 8%). FVC was higher in past users (75 mL; 95% CI, 38-112) and current users in the past 5 to 30 days (159 mL; 95% CI, 80-237) and in users within 0 to 4 days of the examination (204 mL; 95% CI, 139-270) compared with never users. All associations remained unchanged and statistically significant in sensitivity analyses excluding current and past tobacco users.Conclusions: Current marijuana use was associated with lower levels of eNO and higher FVC. The lower eNO in marijuana smokers suggests that short-term exposure to marijuana may, like tobacco, acutely affect the pulmonary vascular endothelium and impair airflow through the small airways. [ABSTRACT FROM AUTHOR]

We investigated associations between ambient air pollution and microvessel function measured by peripheral arterial tonometry between 2003 and 2008 in the Framingham Heart Study Offspring and Third Generation Cohorts. We measured particulate matter with aerodynamic diameter ≤2.5 µm (PM2.5), black carbon, sulfates, particle number, nitrogen oxides, and ozone by using fixed monitors, and we determined moving averages for 1–7 days preceding vascular testing. We examined associations between these exposures and hyperemic response to ischemia and baseline pulse amplitude, a measure of arterial tone (n = 2,369). Higher short-term exposure to air pollutants, including PM2.5, black carbon, and particle number was associated with higher baseline pulse amplitude. For example, higher 3-day average PM2.5 exposure was associated with 6.3% higher baseline pulse amplitude (95% confidence interval: 2.0, 10.9). However, there were no consistent associations between the air pollution exposures assessed and hyperemic response. Our findings in a community-based sample exposed to relatively low pollution levels suggest that short-term exposure to ambient particulate pollution is not associated with vasodilator response, but that particulate air pollution is associated with baseline pulse amplitude, suggesting potentially adverse alterations in baseline vascular tone or compliance. [ABSTRACT FROM PUBLISHER]

The article discusses a study on whether levels of particle matter air pollution lower than the present U.S. National Ambient Air Quality Standards raise the risk of ischemic stroke. The research involved 1,705 Boston area patients with confirmed ischemic stroke and abstracted information at the time of the onset of symptom and clinical characteristics. Results revealed that exposure to particulate matter air pollution at levels deemed safe by the U.S. EPA increases the risk of ischemic stroke.

Background: Some herbal supplements may contain lead.Objective: To examine whether use of specific herbal dietary supplements during the last 30 days is associated with blood lead levels in US men and women.Design: Cross-sectional analysis.Study Population: NHANES participants from 1999-2004, a representative sample of the civilian non-institutionalized US population.Measurements: Lead was measured in blood. Associations between lead and self-reported supplement use were estimated using multivariable regression weighted to account for NHANES sampling. Herbal supplements investigated were those previously reported to contain high heavy metal content: Ayurvedic or traditional Chinese medicine herbs, echinacea, ginkgo, ginseng, St. John's wort, and "other" herbs (specifically, kava, valerian, black cohosh, bee pollen, and nettle).Main Results: Among 6,712 women > or =20 years, those using herbal supplements had lead levels that were 10% higher than non-users (95% CI 3%-17%, p = 0.005). Women using Ayurvedic or traditional Chinese medicine herbs, St. John's wort, and "other" herbs had lead levels 24% (95% CI 5%-45%, p = 0.01), 23% (95% CI 4%-46%), p = 0.02), and 21% (95% CI 2%-44%, p = 0.03) higher, respectively, than non-users. No significant associations were observed between herb use and lead levels among men (n = 6,095). Among reproductive-aged women (16-45 years), herbal supplement users had lead levels 20% higher than non-users (95% CI 5%-34%, p = 0.008). In contrast, garlic and other dietary supplements were not associated with higher lead levels.Conclusion: Use of specific herbal supplements is associated with higher blood lead levels among women. Our data suggest testing guidelines for herbal supplements and regulations limiting lead in supplements are needed. [ABSTRACT FROM AUTHOR]

Background: The effects of weather on West Nile virus (WNV) mosquito populations in the United States have been widely reported, but few studies assess their overall impact on transmission to humans. Objectives: We investigated meteorologic conditions associated with reported human WNV cases in the United States. Methods: We conducted a case-crossover study to assess 16,298 human WNV cases reported to the Centers for Disease Control and Prevention from 2001 to 2005. The primary outcome measures were the incidence rate ratio of disease occurrence associated with mean weekly maximum temperature, cumulative weekly temperature, mean weekly dew point temperature, cumulative weekly precipitation, and the presence of ⩾ 1 day of heavy rainfall (⩾ 50 mm) during the month prior to symptom onset. Results: Increasing weekly maximum temperature and weekly cumulative temperature were similarly and significantly associated with a 35-83% higher incidence of reported WNV infection over the next month. An increase in mean weekly dew point temperature was significantly associated with a 9-38% higher incidence over the subsequent 3 weeks. The presence of at least 1 day of heavy rainfall within a week was associated with a 29-66% higher incidence during the same week and over the subsequent 2 weeks. A 20-mm increase in cumulative weekly precipitation was significantly associated with a 4-8% increase in incidence of reported WNV infection over the subsequent 2 weeks. Conclusions: Warmer temperatures, elevated humidity, and heavy precipitation increased the rate of human WNV infection in the United States independent of season and each others' effects. [ABSTRACT FROM AUTHOR]

Background: Case fatality rates after acute myocardial infarction (MI) have decreased markedly over the last 3 decades. Some subgroups may have benefited more than others, but this hypothesis has not been evaluated in a large nationally representative cohort. Accordingly, we sought to assess long-term temporal trends in mortality after hospitalization for MI and to assess whether these trends differ by sex, race, or age in a cohort of elderly patients.Methods: We studied a cohort of 4.9 million Medicare beneficiaries >or=65 years hospitalized for MI between 1984 and 2003 and calculated the proportion that died inhospital, within 30 days, and within 1 year of hospitalization. We used multivariable risk models to estimate relative and absolute changes in case fatality rate according to race, sex, and age groups.Results: After adjustment for age, sex, and race, between 1984 and 2003, there was a 54.3% (95% CI 53.7%-54.8%), 39.7% (95% CI 39.1%-40.3%), and 23.0% (95% CI 22.5%-23.5%) reduction in the risk of inhospital, 30-day, and 1-year mortality, respectively. Relative and absolute reductions were greater in whites than in blacks, with the biggest differences observed for 1-year mortality. Small and inconsistent differences were seen by sex after stratifying by race. Patients aged >or=90 years experienced the smallest relative reductions in case fatality rates, with the biggest differences observed for 1-year mortality.Conclusions: Among US Medicare beneficiaries, short-term MI case fatality rates have decreased significantly in all groups, but more so among whites than blacks. Additional studies are needed to clarify the basis for these observations. [ABSTRACT FROM AUTHOR]

Background: Muscle effects are the most common reported adverse effects of 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins). However, in placebo-controlled trials the incidence of muscle pain is most often similar for placebo and active control groups.Objective: We sought to evaluate whether statin use was associated with a higher prevalence of musculoskeletal pain in a nationally representative sample.Methods: Cross-sectional analysis using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2002. Participants were 3,580 adults > or =40 years without arthritis who were interviewed at home and examined in a mobile examination center. Participants were asked about sociodemographic characteristics, health conditions, medication use, and musculoskeletal pain. Height, weight, blood pressure, ankle brachial index, and cholesterol were measured.Measurements and Main Results: Prevalence and adjusted odds ratios (OR) of any musculoskeletal pain and musculoskeletal pain in 4 different anatomical regions (neck/upper back, upper extremities, lower back, and lower extremities) by statin use during the last 30 days. Among statin users (n = 402), 22.0% (95%CI 18.0-26.7%) reported musculoskeletal pain in at least 1 anatomical region during the last 30 days, compared with 16.7% (95%CI 15.1-18.4%) of those who did not use a statin. Compared to persons who did not use statins, those who used statins had multivariable-adjusted odds ratios (95%CI; p value) of 1.50 (1.07-2.11; p = .01) for any musculoskeletal pain, 1.59 (1.04-2.44, p = .03) for lower back pain, and 1.50 (1.02-2.22, p = .03) for lower extremity pain.Conclusion: Musculoskeletal pain is common in adults > or =40 years without arthritis. In this nationally representative sample, statin users were significantly more likely to report musculoskeletal pain. [ABSTRACT FROM AUTHOR]

United States firefighters have a high on-duty fatality rate, and coronary heart disease is the leading cause. Seasonality affects the incidence of cardiovascular events in the general population, but its effects on firefighters are unknown. This study statistically examined the seasonal and annual variation of all on-duty coronary heart disease deaths among US firefighters between 1994 and 2004 using the chi-square distribution and Poisson regression model of the monthly fatality counts. It also examined the effect of ambient temperature (apparent as well as wind chill temperature) on coronary heart disease fatalities during the study span using a time-stratified, case-crossover study design. When grouped by season, we observed the distribution of the 449 coronary heart disease fatalities to show a relative peak in winter (32%) and relative nadir in spring (21%). This pattern was significantly different (p=0.005) from the expected distribution under the null hypothesis of season having no effect. The pattern persisted in additional analyses, stratifying the deaths by the type of duty in which the firefighters were engaged at the time of their deaths. In the Poisson regression model of the monthly fatality counts, the overall goodness-of-fit between the actual and predicted case counts was excellent (χ42=16.63; p=0.002). Two distinct peaks were detected: one in January-February and the other in August-September. Overall temperature was not associated with increased risk of on-duty death. After allowing for different effects of temperature in mild/hot versus cold periods, a 1°C increase was not protective in cold weather; nor did it increase the risk of death in warmer weather. The findings of this study reveal statistical evidence for excess coronary heart disease deaths among firefighters during winter; however, the temporal pattern of coronary heart disease deaths was not linked to temperature variation. The seasonal pattern was also found to be independent of duty-related risks. [ABSTRACT FROM AUTHOR]

BACKGROUND: Long-term exposure to particulate air pollution has been associated with an increased risk of dying from cardiopulmonary and ischemic heart disease, yet few studies have evaluated cardiovascular end points other than mortality. We investigated the relationship between long-term exposure to traffic and occurrence of acute myocardial infarction (AMI) in a case-control study. METHODS: A total of 5,049 confirmed cases of AMI were identified between 1995 and 2003 as part of the Worcester Heart Attack Study, a community-wide study examining changes over time in the incidence of AMI among greater Worcester, Massachusetts, residents. Population controls were selected from Massachusetts resident lists. We used cumulative traffic within 100 m of subjects' residence and distance from major roadway as proxies for exposure to traffic-related air pollution. We estimated the relationship between exposure to traffic and occurrence of AMI using logistic regression, and we adjusted for the following potential confounders: age, sex, section of the study area, point sources emissions of particulate matter with aerodynamic diameter < 2.5 µm, area socioeconomic characteristics, and percentage of open space. RESULTS: An increase in cumulative traffic near the home was associated with a 4% increase in the odds of AMI per interquartile range [95% confidence interval (CI), 2-7%], whereas living near a major roadway was associated with a 5% increase in the odds of AMI per kilometer (95% CI, 3-6%). CONCLUSIONS: These results provide support for an association between long-term exposure to traffic and the risk of AMI. [ABSTRACT FROM AUTHOR]

We determined the relationship of alcohol consumption and Medicare costs among 4,392 participants in the Cardiovascular Health Study (CHS), a longitudinal, population-based cohort study of adults age 65 or over in four U.S. communities. We assessed 5-year Parts A and B costs and self-reported intake of beer, wine, and liquor at baseline. Among both sexes, total costs were approximately $2,000 lower among consumers of >1-6 drinks per week than abstainers. The lower costs associated with moderate drinking were most apparent among participants with cardiovascular disease (CVD) and for hospitalization costs for CVD among healthy participants. Former drinkers had the highest costs. [ABSTRACT FROM AUTHOR]

Objectives: We developed a source documentation approach that identified fluoride content of drinking water at the state or local level to estimate fluoride concentrations from public water systems. We then compared estimates from this approach with estimates obtained from a single source, the 1992 Centers for Disease Control and Prevention (CDC) Fluoridation Census.Methods: We used residential histories from a case-control study. For each residence we attempted to determine fluoride concentrations using the 1992 CDC Fluoridation Census. For the source documentation method we utilized multiple sources from state and local contacts to verify and collect additional data. We compared the fluoride estimates obtained by the two methods.Results: When fluoride values were found using both methods, there was good correlation (Kendall's tau = 0.85; 95% confidence interval = 0.79, 0.90) and concordance was 96 percent. We obtained over 99 percent of the fluoride values needed using source documentation as compared to 49 percent of the values needed when we used a single publication. When fluoride values were missing using the 1992 CDC Fluoridation Census, 21 percent had source documentation estimates of at least 0.7 ppm.Conclusions: Researchers need to consider limitations of using a secondary data source to estimate fluoride in drinking water, particularly in studies where exposure to fluoride is the primary exposure of interest. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- To study whether obese individuals, who are at higher risk for diabetes and disparities in care than nonobese individuals, are more likely to have undiagnosed diabetes. RESEARCH DESIGN AND METHODS -- We performed an analysis of 5,514 adult participants in the 1999-2004 National Health and Nutrition Examination Survey. Particpants were interviewed about sociodemographic and medical data, including whether they had been diagnosed with diabetes, and were examined for height, weight, and fasting plasma glucose level ≥126 mg/dl or by previous physician diagnosis. After categorizing participants into normal weight, overweight, and obese according to BMI, the prevalance and diagnosis of diabetes across BMI categories was compared using χsup2;. RESULTS-- Of the 9.8% (weighted sample) of participants who had diabetes, based on fasting glucose levels and self-reported diagnosis, 28.1% were undiagnosed, translating to an estimated 5.2 million people in the U.S. population. The proportion undiagnosed was not significantly different among normal-weight (22.2%), overweight (32.5%), or obese adults (27.4%). Nevertheless, obese adults comprise more than half of the undiagnosed diabetes cases (2.7 million). Relative to normal-weight adults, the adjusted odds ratio (OR) for having undiagnosed diabetes was 1.50 (0.73-3.08) in overweight and 1.37 (0.72-2.63) in obese adults. CONCLUSIONS-- Despite a higher underlying risk of diabetes and widespread clinical recognition of this higher risk, obesity does not increase the likelihood that an individual's diabetes will be diagnosed. [ABSTRACT FROM AUTHOR]

Focuses on a study in which the monthly mortality from coronary artery disease among residents of Hawaii were examined to determine whether seasonality in mortality exists in a tropical climate with little variation in temperature. Number of islands Hawaii consists of; What was used in the study as a proxy for incidence of respiratory infection; How annual periodicity was tested; Results of the study.

BACKGROUND: There are limited data regarding the relationship between cannabinoids and metabolic processes. Epidemiologic studies have found lower prevalence rates of obesity and diabetes mellitus in marijuana users compared with people who have never used marijuana, suggesting a relationship between cannabinoids and peripheral metabolic processes. To date, no study has investigated the relationship between marijuana use and fasting insulin, glucose, and insulin resistance. METHODS: We included 4657 adult men and women from the National Health and Nutrition Examination Survey from 2005 to 2010. Marijuana use was assessed by self-report in a private room. Fasting insulin and glucose were measured via blood samples after a 9-hour fast, and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated to evaluate insulin resistance. Associations were estimated using multiple linear regression, accounting for survey design and adjusting for potential confounders. RESULTS: Of the participants in our study sample, 579 were current marijuana users and 1975 were past users. In multivariable adjusted models, current marijuana use was associated with 16% lower fasting insulin levels (95% confidence interval [CI], -26, -6) and 17% lower HOMA-IR (95% CI, -27, -6). We found significant associations between marijuana use and smaller waist circumferences. Among current users, we found no significant dose-response. CONCLUSIONS: We found that marijuana use was associated with lower levels of fasting insulin and HOMA-IR, and smaller waist circumference. [ABSTRACT FROM AUTHOR]

Objective: This study examined the frequency and temporal trends of alcohol use among women with and without myocardial infarction (MI) in the United States. Method: We pooled yearly surveys from the nationally representative Behavioral Risk Factor Surveillance System between 1997 and 2008. Subjects for this study were 1,186,951 women, of whom 50,055 had a previous MI. Yearly weighted prevalence rates and frequencies of drinking behaviors were calculated for alcohol use in women with and without previous MI. Results: Fewer post-MI women consumed alcohol than other women (24% vs. 46%), but the prevalence of drinking increased over time in both groups. Nearly one third of post-MI women and half of all women consumed more than one drink per day. Heavy episodic drinking (four or more drinks per day) increased over time in both groups. After multivariable adjustment, post-MI women were less likely to report any drinking or consuming more than one drink per day, but the prevalence of heavy episodic drinking and the increasing trends over time were similar in both groups. Conclusions: Heavy alcohol use and heavy episodic drinking among women in the United States increased over the past decade, regardless of MI history. Although this may have reflected the influence of national guidelines on alcohol consumption, the increase in heavy episodic drinking suggests that better efforts to educate clinicians and women about the harms from excessive alcohol are required. [ABSTRACT FROM AUTHOR]

Objective To examine associations of proximity to major roadways, sustained exposure to fine particulate matter (PM 2.5 ), and acute exposure to ambient air pollutants with adipokines and measures of glucose homeostasis among participants living in the northeastern United States. Methods We included 5958 participants from the Framingham Offspring cohort examination cycle 7 (1998–2001) and 8 (2005–2008) and Third Generation cohort examination cycle 1 (2002–2005) and 2 (2008–2011), who did not have type 2 diabetes at the time of examination visit. We calculated 2003 annual average PM 2.5 at participants' home address, residential distance to the nearest major roadway, and daily PM 2.5 , black carbon (BC), sulfate, nitrogen oxides (NO x ), and ozone concentrations. We used linear mixed effects models for fasting glucose, insulin, and homeostasis model assessment of insulin resistance (HOMA-IR) which were measured up to twice, and used linear regression models for adiponectin, resistin, leptin, and hemoglobin A1c (HbA1c) which were measured only once, adjusting for demographics, socioeconomic position, lifestyle, time, and seasonality. Results The mean age was 51 years and 55% were women. Participants who lived 64 m (25th percentile) from a major roadway had 0.28% (95% CI: 0.05%, 0.51%) higher fasting plasma glucose than participants who lived 413 m (75th percentile) away, and the association appeared to be driven by participants who lived within 50 m from a major roadway. Higher exposures to 3- to 7-day moving averages of BC and NO x were associated with higher glucose whereas the associations for ozone were negative. The associations otherwise were generally null and did not differ by median age, sex, educational attainment, obesity status, or prediabetes status. Conclusions Living closer to a major roadway or acute exposure to traffic-related air pollutants were associated with dysregulated glucose homeostasis but not with adipokines among participants from the Framingham Offspring and Third Generation cohorts. [ABSTRACT FROM AUTHOR]

The study seeks to describe the use of dietary supplements promoted for cardiovascular health and the relation between supplement use and coronary artery disease (CAD) and the presence of major CAD risk factors. The aim is also to explore whether use of medications for the treatment of cardiovascular disease or diabetes mellitus (DM) is associated with supplement use. We performed a cross-sectional analysis of the 1999 to 2002 National Health and Nutrition Examination Survey (NHANES) of 6,671 adults (representing 119.3 million US adults) aged ≥40 years. We categorized adults into 4 nonoverlapping groups as (1) having reported CAD or stroke (CAD/stroke), (2) DM without CAD/stroke, (3) hypertension (HTN) or hypercholesterolemia (HC) without CAD/stroke or DM (HTN/HC), or (4) none of these conditions (no reported CAD/CAD risk) and performed weighted (NHANES) multiple logistic regression to determine the odds of using supplements (reference group, no reported CAD/CAD risk). After controlling for sociodemographics, health, and lifestyle factors, we found that persons with CAD/Stroke used more supplements (any), vitamin E, folic acid, and niacin, and less fish oil. Those with DM used less coenzyme Q10, and adults with HTN/HC used more supplements (any), herbs (any), and ginseng. Adults with CAD/stroke who used medications for the treatment of cardiovascular disease or DM were more likely to use folic acid compared with those who did not use medications for these conditions. In adults with CAD/stroke, DM, or HTN/HC, those who did not use medications for these conditions were more likely to use herbs and other select supplements. In conclusion, use of dietary supplements is common in those with CAD or CAD risks. [Copyright &y& Elsevier]

Provides information on a study that described the type, location and severity of occupational hand injuries among patients from several occupational health clinics in five New England states. Methodology of the study; Results and discussion on the study.

Background: It remains unknown whether estimated glomerular filtration rate (eGFR) using the refit Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation without a term for race is associated with mortality and the need for kidney replacement therapy (KRT) differentially between Black and White heart transplant recipients., Methods: We studied 25,900 adults included in the Scientific Registry of Transplant Recipients. We classified recipients into six categories of eGFR (< 30, 30 to < 45, 45 to < 60, 60 to < 90, 90 to < 120, ≥ 120 ml/min/1.73 m 2 ) using the race-neutral CKD-EPI refit equation, and assessed survival with multivariable adjusted Cox proportional hazards regression., Results: The association between pre-transplant race-neutral eGFR and mortality varied by race (P interaction  = 0.006). Compared to White patients with an eGFR of 90-120 ml/min/1.73 m 2 , the mortality rates were 57% (95% CI 1.25, 1.98), 29% (95% CI 1.11, 1.51), 34% (95% CI 1.19, 1.52), and 19% (95% CI 1.06, 1.33) higher in Black patients with an eGFR less than 30, 30-45, 45-60, and 60-90 ml/min/1.73m 2 , respectively; and 53% (95% CI 1.28, 1.82), 49% (95% CI 1.33, 1.66), and 23% (95% CI 1.11, 1.35) higher among White patients with an eGFR less than 30, 30-45, and 45-60 ml/min/1.73 m 2 , respectively. The association between pre-transplant eGFR and the need for KRT during follow-up was similar between Black and White patients (P interaction  = 0.57)., Conclusions: Worsening pre-transplant eGFR using the new race-neutral CKD-EPI refit equation was associated with a higher rate of post-heart transplant mortality and KRT in Black and White recipients. The racial disparity in post-heart transplant mortality was narrower in the setting of severe kidney dysfunction., (© 2024. The Author(s) under exclusive licence to Italian Society of Nephrology.)

Background: Influenza vaccination and lipid lowering therapy (LLT) are evidence-based interventions with substantial benefit for individuals with established atherosclerotic cardiovascular disease (ASCVD). However, levels of influenza immunization and LLT use are low, possibly due to pervasive fear-based misinformation uniquely targeting vaccines and LLT. Whether being unvaccinated for influenza predicts lower utilization of LLT is unknown., Objectives: We tested the hypothesis that American adults with ASCVD who are unvaccinated for influenza have lower use of LLT even after accounting for traditional factors associated with underuse of preventive therapies., Methods: We pooled 2017, 2019, and 2021 survey data from the Behavioral Risk Factor Surveillance System (BRFSS), and selected respondents aged 40 to 75 years with self-reported ASCVD. We used logistic regression models adjusted for potential confounders to examine the association between influenza vaccination and self-reported LLT use. We performed a sensitivity analysis with multiple imputation to account for missing data. All analyses accounted for complex survey weighting., Results: Of 66,923 participants with ASCVD, 55% reported influenza vaccination in the last year and 76% reported using LLT. Being unvaccinated for influenza was associated with lower odds of LLT use (OR 0.54; 95% CI 0.50, 0.58; P< .001). In a multivariable regression model adjusting for demographics and comorbidities, this association remained statistically significant (aOR 0.58, 95% CI 0.52, 0.64, P < .001). After additional adjustment for preventive care engagement, health care access, and use patterns of other cardiovascular medications this association persisted (aOR 0.66; 95% CI 0.60, 0.74; P < .001). There were no significant differences across subgroups, including those with and without hyperlipidemia., Conclusions: Unvaccinated status for influenza was independently associated with 34% lower odds of LLT use among American adults with ASCVD after adjustment for traditional factors linked to underuse of preventive therapies. This finding identifies a population with excess modifiable ASCVD risk, and supports investigation into nontraditional mechanisms driving underuse of preventive therapies, including fear-based misinformation., Competing Interests: Conflict of interest None of the authors have relevant conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Black heart transplant recipients are more likely to receive induction immunosuppression compared to other races because of higher rates of acute rejection, graft failure, and mortality. However, it is not known whether contemporary induction immunosuppression improves their post-transplant outcomes. To evaluate whether Black patients who were prescribed induction immunosuppression therapy have lower all-cause mortality or graft-failure rates compared to those who were not, we studied Black U.S. adult heart transplant recipients in the Scientific Registry of Transplant Recipients database (2008-2018). We used multivariable Cox proportional hazards regression analysis to compare the hazards of all-cause mortality or graft failure as a composite, for patients who were prescribed induction immunosuppression and those who were not. Among 5160 recipients, 2787 (54.0%) were prescribed induction immunosuppression and 2373 (46.0%) were not. There was no evidence of survival differences according to induction immunosuppression for the composite of all-cause mortality or graft failure (aHR = 1.13, 95% CI 0.96-1.32), mortality (aHR = 1.14, 95% CI 0.97-1.34), graft failure (aHR = 1.05, 95% CI 0.82-1.34) and acute rejection (aHR = 1.00, 95% CI 0.89-1.12). Given the side effects of treatment, future guidelines should reconsider the recommendation for induction immunosuppression among Black patients., (© 2022 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background In the general population, Black children have a higher incidence of stroke and all-cause mortality after stroke than White children. Beginning 6 months following cardiac transplantation, Black children have higher mortality than White children. However, whether there are racial and ethnic disparities in incidence and all-cause mortality following perioperative stroke among pediatric cardiac transplant recipients is unknown. Methods and Results Using the Scientific Registry of Transplant Recipients, we studied children who underwent their first heart transplant in the United States between January 1994 and September 2019. Using multivariable logistic regression, we assessed the association between race and ethnicity and perioperative stroke. We used multivariable piecewise Cox regression to examine the association between race and ethnicity and mortality among survivors of perioperative stroke. Among 8224 children who had a first cardiac transplant, 255 (3%) had a perioperative stroke. Black children had 32% lower odds of perioperative stroke compared with White children (adjusted odds ratio, 0.68 [95% CI, 0.46-0.996]). Following perioperative stroke, mortality rates were similar for Black and White children in the first 6 months (adjusted hazard ratio [HR], 0.99 [95% CI, 0.44-2.26]). However, Black children had a higher mortality rate than White children beyond 6 months (adjusted HR, 3.36 [95% CI, 1.22-9.22]). Conclusions Among pediatric cardiac transplant recipients, Black children have a lower incidence of perioperative stroke than White children. Among survivors of perioperative stroke, mortality is initially similar by race and ethnicity, but beyond 6 months, Black children have over a 3-fold higher mortality rate than White children. Identifying and intervening on potential differences in care is essential to addressing these disparities.

Background: Many studies have reported that long-term air pollution exposure is associated with increased mortality rates. These investigations have been criticized for failure to control for omitted, generally personal, confounders. Study designs that are robust to such confounders can address this issue., Methods: We used a self-controlled design for survival analysis. We stratified on each person in the Medicare cohort between 2000 and 2015 who died, and examined whether PM 2.5 , O 3 and NO 2 exposures predicted in which follow-up period the death occurred. We used conditional logistic regression stratified on person and controlled for nonlinear terms in calendar year and age. By design slowly varying covariates such as smoking history, BMI, diabetes and other pre-existing conditions, usual alcohol consumption, sex, race, socioeconomic status, and green space were controlled by matching each person to themselves., Results: There were 6,452,618 deaths in the study population in the study period. We observed a 5.37% increase in the mortality rate (95% CI 4.67%, 6.08%) for every 5 μg/m 3 increase in PM 2.5 , a 1.98% (95% CI 1.61%, 2.36%) increase for 5 ppb increment in O 3 , and a 2.10% decrease (95% CI 1.88%, 2.33%) for a 5 ppb increase in NO 2 . When restricted to persons whose PM 2.5 exposure never exceeded 12 μg/m 3 in any year between 2000 and 2015, the effect size increased for PM 2.5 (12.71% (11.30, 14.15)), and the signs of O 3 and NO 2 reversed (-0.26% (-0.88, 0.35) for O 3 and 1.77% increase (1.40, 2.13) for NO 2 ). Effect sizes were larger for Blacks (e.g. 7.71% (5.46, 10.02) for PM 2.5 )., Conclusion: There is strong evidence that the association between annual exposure to PM 2.5 and mortality is not confounded by individual or neighborhood covariates, and continues below the standard. The effects of O 3 and NO 2 are difficult to disentangle., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Heavy cannabis use is known to have an adverse impact on cardiovascular and cerebrovascular outcomes in the general population and in patients presenting for surgery. However, there have been no studies that have focused on patients undergoing vascular surgical procedures. The objective of this study was to determine the perioperative risk of cannabis use disorder (CUD), primarily cardiovascular risk, in perioperative vascular surgery patients., Methods: Using the National Inpatient Sample from 2006 to 2015, we conducted a retrospective cohort study involving those undergoing one of six elective and emergent vascular surgical procedures (carotid endarterectomy [CEA], infrainguinal bypasses, open abdominal aortic aneurysm repair, aortobifemoral bypass, endovascular aortic aneurysm repair, or peripheral arterial endovascular procedures). Patients with CUD identified by the International Classification of Diseases, 9th edition, were matched with patients without CUD in a 1:1 ratio using propensity scores. The primary outcome was perioperative myocardial infarction (MI). Secondary outcomes include stroke, sepsis, deep vein thrombosis, pulmonary embolus, acute kidney injury requiring dialysis, respiratory failure, in-hospital mortality, total cost, and length of stay., Results: We identified a total cohort of 510,007 patients. Over the study period, the recorded prevalence of CUD increased from 1.3/1000 to 10.3/1000 admissions (P < .001). After propensity score matching the cohort consisted of 4684 patients. Those with CUD had a higher incidence of perioperative MI (3.3% vs 2.1%; odds ratio [OR], 1.56; 95% confidence interval [CI], 1.09-2.24; P = .016) and perioperative stroke (5.5% vs 3.5%; OR, 1.59; 95% CI, 1.20-2.12; P = .0013) than patients without CUD. In a sensitivity analysis, where the risk was evaluated separately by type of procedure, the higher incidence of perioperative stroke was primarily seen among those undergoing CEA. Patients with CUD had a lower incidence of sepsis (3.3% vs 5.1%; OR, 0.64; 95% CI, 0.47-0.85; P = .0024). We obtained similar results in a sensitivity analysis that included all patients in the complete unmatched cohort and adjusted for confounding using logistic regression models accounting for the survey design, although the findings of sepsis and stroke failed to reach statistical significance after correcting for multiple testing (MI P = .001; stroke P = .031; sepsis P = .009)., Conclusions: CUD was associated with a significantly higher incidence of perioperative MI in vascular surgery patients. Those with CUD had a greater incidence of diagnosis of acute perioperative stroke when undergoing CEA. Owing to limitations in administrative data, it is unclear if this represents a true effect or selection bias. These findings warrant further investigation in a prospective cohort., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Evidence remains equivocal regarding the association of inflammation, a precursor to cardiovascular disease, and acute exposures to ambient air pollution from traffic-related particulate matter. Though youth with type 1 diabetes are at higher risk for cardiovascular disease, the relationship of inflammation and ambient air pollution exposures in this population has received little attention., Objectives: Using five geographically diverse US sites from the racially- and ethnically-diverse SEARCH for Diabetes in Youth Cohort, we examined the relationship of acute exposures to PM 2.5 mass, Atmospheric Dispersion Modeling System (ADMS)-Roads traffic-related PM concentrations near roadways, and elemental carbon (EC) with biomarkers of inflammation including interleukin-6 (IL-6), c-reactive protein (hs-CRP) and fibrinogen., Methods: Baseline questionnaires and blood were obtained at a study visit. Using a spatio-temporal modeling approach, pollutant exposures for 7 days prior to blood draw were assigned to residential addresses. Linear mixed models for each outcome and exposure were adjusted for demographic and lifestyle factors identified a priori., Results: Among the 2566 participants with complete data, fully-adjusted models showed positive associations of EC average week exposures with IL-6 and hs-CRP, and PM 2.5 mass exposures on lag day 3 with IL-6 levels. Comparing the 25th and 75th percentiles of average week EC exposures resulted in 8.3% higher IL-6 (95%CI: 2.7%,14.3%) and 9.8% higher hs-CRP (95%CI: 2.4%,17.7%). We observed some evidence of effect modification for the relationships of PM 2.5 mass exposures with hs-CRP by gender and with IL-6 by race/ethnicity., Conclusions: Indicators of inflammation were associated with estimated traffic-related air pollutant exposures in this study population of youth with type 1 diabetes. Thus youth with type 1 diabetes may be at increased risk of air pollution-related inflammation. These findings and the racial/ethnic and gender differences observed deserve further exploration., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The association between particulate pollution and cardiovascular morbidity and mortality is well established. While the cardiovascular effects of nationally regulated criteria pollutants (e.g., fine particulate matter [PM 2.5 ] and nitrogen dioxide) have been well documented, there are fewer studies on particulate pollutants that are more specific for traffic, such as black carbon (BC) and particle number (PN). In this paper, we synthesized studies conducted in the Greater Boston Area on cardiovascular health effects of traffic exposure, specifically defined by BC or PN exposure or proximity to major roadways. Large cohort studies demonstrate that exposure to traffic-related particles adversely affect cardiac autonomic function, increase systemic cytokine-mediated inflammation and pro-thrombotic activity, and elevate the risk of hypertension and ischemic stroke. Key patterns emerged when directly comparing studies with overlapping exposure metrics and population cohorts. Most notably, cardiovascular risk estimates of PN and BC exposures were larger in magnitude or more often statistically significant compared to those of PM 2.5 exposures. Across multiple exposure metrics (e.g., short-term vs. long-term; observed vs. modeled) and different population cohorts (e.g., elderly, individuals with co-morbidities, young healthy individuals), there is compelling evidence that BC and PN represent traffic-related particles that are especially harmful to cardiovascular health. Further research is needed to validate these findings in other geographic locations, characterize exposure errors associated with using monitored and modeled traffic pollutant levels, and elucidate pathophysiological mechanisms underlying the cardiovascular effects of traffic-related particulate pollutants. Implications : Traffic emissions are an important source of particles harmful to cardiovascular health. Traffic-related particles, specifically BC and PN, adversely affect cardiac autonomic function, increase systemic inflammation and thrombotic activity, elevate BP, and increase the risk of ischemic stroke. There is evidence that BC and PN are associated with greater cardiovascular risk compared to PM 2.5 . Further research is needed to elucidate other health effects of traffic-related particles and assess the feasibility of regulating BC and PN or their regional and local sources.

Acute exposure to cold dry air is a trigger of bronchoconstriction, but little is known about how daily outdoor temperature influences lung function.We investigated associations of temperature from a model using satellite remote sensing data with repeated measures of lung function among 5896 participants of the Framingham Heart Study Offspring and Third Generation cohorts residing in the Northeastern US. We further tested if temperature modified previously reported associations between pollution and lung function. We constructed linear mixed-effects models, and assessed departures from linearity using penalised splines.In fully adjusted linear models, 1-, 2- and 7-day average temperatures were all associated with lower lung function: each 5°C higher previous-week temperature was associated with a 20 mL lower (95% CI -34---6) forced expiratory volume in 1 s. There was significant effect modification by season: negative associations of temperature and lung function were present in winter and spring only. Negative associations between previous-day fine particulate matter and lung function were present during unseasonably warm but not unseasonably cool days, with a similar pattern for other pollutants.We speculate that temperature-related differences in lung function may be explained by behavioural changes on relatively warm days, which may increase outdoor exposures., Competing Interests: Conflict of interest: M.B. Rice reports grants from the American Thoracic Society Foundation, American Lung Association and National Institutes of Environmental Health Sciences, during the conduct of the study; and she is the vice chair of the American Thoracic Society's Environmental Health Policy Committee. Conflict of interest: W. Li has nothing to disclose. Conflict of interest: E.H. Wilker reports grants from the National Institutes of Health and US Environmental Protection Agency, during the conduct of the study. Conflict of interest: D.R. Gold reports grants from the National Institutes of Health and US Environmental Protection Agency, during the conduct of the study. Conflict of interest: J. Schwartz has nothing to disclose. Conflict of interest: A. Zanobetti reports grants from the National Institutes of Health, US Environmental Protection Agency and Health Effect Institute, during the conduct of the study. Conflict of interest: P. Koutrakis reports a grant from US Environmental Protection Agency (RD-835872-01), during the conduct of the study. Conflict of interest: I. Kloog has nothing to disclose. Conflict of interest: G.R. Washko reports grants from the National Institutes of Health and BTG Interventional Medicine, grants and other support from Boehringer Ingelheim and Janssen Pharmaceuticals, other support from Genentech, Quantitative Imaging Solutions, PulmonX, Regeneron, ModoSpira, Toshiba and GlaxoSmithKline, outside the submitted work; G.R. Washko's spouse works for Biogen, which is focused on developing therapies for fibrotic lung disease. Conflict of interest: G.T. O'Connor reports personal fees from AstraZeneca and grants from Janssen Pharmaceuticals, outside the submitted work. Conflict of interest: M.A. Mittleman reports grants from the National Institutes of Health and US Environmental Protection Agency, during the conduct of the study., (Copyright ©ERS 2019.)

Background: In recent years, the number of states that have legalized medical marijuana or retail sales has increased, bringing potential changes of marijuana use pattern among the general population. However, health effects of acute and chronic marijuana use on many relevant health outcomes, including renal function, remain largely unexamined. In this study, we aimed to assess the association between recent and past marijuana use and renal function., Methods: We conducted a cross-sectional study among 13,995 US adults aged 18 to 59 years in the National Health and Nutrition Examination Survey from 2007 to 2014. We examined associations between marijuana use and serum creatinine concentration, estimated glomerular filtration rate (eGFR), and odds of having stage 2 or greater chronic kidney disease using weighted multivariable linear regression., Results: In the study population, 6483 were never users, 5499 were past users, and 2013 were current users. Marijuana use did not have a significant association with serum creatinine, eGFR, or odds of having stage 2 or greater chronic kidney disease. Serum creatinine and eGFR had an increasing trend comparing past and current users with never users that did not reach statistical significance. All associations remained unchanged in the sensitivity analysis restricted to people without cardiovascular disease., Conclusions: We did not observe any clinically significant association between current or past self-reported marijuana use and measures of kidney function., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We evaluated the association between short-term exposure to ambient ozone air pollution and stroke hospital admissions among adult residents of South Carolina (SC). Data on all incident stroke hospitalizations from 2002 to 2006 were obtained from the SC Office of Research and Statistics. Ozone exposure data were obtained from the US Environmental Protection Agency's Hierarchical Bayesian Model. A semi-symmetric bidirectional case-crossover design was used to examine the association between ozone exposure on lag days 0-2 (0 to 2 days before admission) and stroke hospitalization. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). No significant associations were observed between short-term ozone exposure and hospitalization for all stroke (e.g., lag day 0: OR=0.98; 95% CI=0.96, 1.00) or ischemic stroke (lag day 0: OR=0.98; 95% CI=0.96, 1.01). Risk of hospitalization for hemorrhagic stroke appeared to be higher among African Americans than European Americans; however, the majority of these associations did not reach statistical significance. Among adults in SC from 2002 to 2006, there was no evidence of an association between ozone exposure and risk of hospitalization for all stroke or ischemic stroke; however, African Americans may have an increased risk of hemorrhagic stroke.

Introduction: The United States Environmental Protection Agency (U.S. EPA*) currently regulates individual air pollutants on a pollutant-by-pollutant basis, adjusted for other pollutants and potential confounders. However, the National Academies of Science concluded that a multipollutant regulatory approach that takes into account the joint effects of multiple constituents is likely to be more protective of human health. Unfortunately, the large majority of existing research had focused on health effects of air pollution for one pollutant or for one pollutant with control for the independent effects of a small number of copollutants. Limitations in existing statistical methods are at least partially responsible for this lack of information on joint effects. The goal of this project was to fill this gap by developing flexible statistical methods to estimate the joint effects of multiple pollutants, while allowing for potential nonlinear or nonadditive associations between a given pollutant and the health outcome of interest., Methods: We proposed Bayesian kernel machine regression (BKMR) methods as a way to simultaneously achieve the multifaceted goals of variable selection, flexible estimation of the exposure-response relationship, and inference on the strength of the association between individual pollutants and health outcomes in a health effects analysis of mixtures. We first developed a BKMR variable-selection approach, which we call component-wise variable selection, to make estimating such a potentially complex exposure-response function possible by effectively using two types of penalization (or regularization) of the multivariate exposure-response surface. Next we developed an extension of this first variable-selection approach that incorporates knowledge about how pollutants might group together, such as multiple constituents of particulate matter that might represent a common pollution source category. This second grouped, or hierarchical, variable-selection procedure is applicable when groups of highly correlated pollutants are being studied. To investigate the properties of the proposed methods, we conducted three simulation studies designed to evaluate the ability of BKMR to estimate environmental mixtures responsible for health effects under potentially complex but plausible exposure-response relationships. An attractive feature of our simulation studies is that we used actual exposure data rather than simulated values. This real-data simulation approach allowed us to evaluate the performance of BKMR and several other models under realistic joint distributions of multipollutant exposure. The simulation studies compared the two proposed variable-selection approaches (component-wise and hierarchical variable selection) with each other and with existing frequentist treatments of kernel machine regression (KMR). After the simulation studies, we applied the newly developed methods to an epidemiologic data set and to a toxicologic data set. To illustrate the applicability of the proposed methods to human epidemiologic data, we estimated associations between short-term exposures to fine particulate matter constituents and blood pressure in the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study, a prospective cohort study of elderly subjects. To illustrate the applicability of these methods to animal toxicologic studies, we analyzed data on the associations between both blood pressure and heart rate in canines exposed to a composition of concentrated ambient particles (CAPs) in a study conducted at the Harvard T. H. Chan School of Public Health (the Harvard Chan School; formerly Harvard School of Public Health; Bartoli et al. 2009)., Results: We successfully developed the theory and computational tools required to apply the proposed methods to the motivating data sets. Collectively, the three simulation studies showed that component-wise variable selection can identify important pollutants within a mixture as long as the correlations among pollutant concentrations are low to moderate. The hierarchical variable-selection method was more effective in high-dimension, high-correlation settings. Variable selection in existing frequentist KMR models can incur inflated type I error rates, particularly when pollutants are highly correlated. The analyses of the MOBILIZE data yielded evidence of a linear and additive association of black carbon (BC) or Cu exposure with standing diastolic blood pressure (DBP), and a linear association of S exposure with standing systolic blood pressure (SBP). Cu is thought to be a marker of urban road dust associated with traffic; and S is a marker of power plant emissions or regional long-range transported air pollution or both. Therefore, these analyses of the MOBILIZE data set suggest that emissions from these three source categories were most strongly associated with hemodynamic responses in this cohort. In contrast, in the Harvard Chan School canine study, after controlling for an overall effect of CAPs exposure, we did not observe any associations between DBP or SBP and any elemental concentrations. Instead, we observed strong evidence of an association between Mn concentrations and heart rate in that heart rate increased linearly with increasing concentrations of Mn. According to the positive matrix factorization (PMF) source apportionment analyses of the multipollutant data set from the Harvard Chan School Boston Supersite, Mn loads on the two factors that represent the mobile and road dust source categories. The results of the BKMR analyses in both the MOBILIZE and canine studies were similar to those from existing linear mixed model analyses of the same multipollutant data because the effects have linear and additive forms that could also have been detected using standard methods., Conclusions: This work provides several contributions to the KMR literature. First, to our knowledge this is the first time KMR methods have been used to estimate the health effects of multipollutant mixtures. Second, we developed a novel hierarchical variable-selection approach within BKMR that is able to account for the structure of the mixture and systematically handle highly correlated exposures. The analyses of the epidemiologic and toxicologic data on associations between fine particulate matter constituents and blood pressure or heart rate demonstrated associations with constituents that are typically associated with traffic emissions, power plants, and long-range transported pollutants. The simulation studies showed that the BKMR methods proposed here work well for small to moderate data sets; more work is needed to develop computationally fast methods for large data sets. This will be a goal of future work.

Background: Habitual moderate alcohol consumption is associated with a lower risk of acute myocardial infarction (MI), whereas heavy (binge) drinking is associated with higher cardiovascular risk. However, less is known about the immediate effects of alcohol consumption on the risk of acute MI and whether any association differs by beverage type or usual drinking patterns., Methods: We conducted a case-crossover analysis of 3869 participants from the Determinants of Myocardial Infarction Onset Study who were interviewed during hospitalization for acute MI in one of the 64 medical centers across the United States in 1989-1996. We compared the observed number of times that each participant consumed wine, beer, or liquor in the hour preceding MI symptom onset with the expected frequency based on each participant's control information, defined as the number of times the participant consumed alcohol in the past year., Results: Among 3869 participants, 2119 (55%) reported alcohol consumption in the past year, including 76 within 1 hour before acute MI onset. The incidence rate of acute MI onset was elevated 1.72-fold (95% confidence interval [CI] = 1.37-2.16) within 1 hour after alcohol consumption. The association was stronger for liquor than for beer or wine. The higher rate was not apparent for daily drinkers. For the 24 hours after consumption, there was a 14% lower rate (relative risk = 0.86 [95% CI = 0.79-0.95]) of MI compared with periods with no alcohol consumption., Conclusions: Alcohol consumption is associated with an acutely higher risk of MI in the subsequent hour among people who do not typically drink alcohol daily.

Rationale: Short-term exposure to ambient air pollution has been associated with lower lung function. Few studies have examined whether these associations are detectable at relatively low levels of pollution within current U.S. Environmental Protection Agency (EPA) standards., Objectives: To examine exposure to ambient air pollutants within EPA standards and lung function in a large cohort study., Methods: We included 3,262 participants of the Framingham Offspring and Third Generation cohorts living within 40 km of the Harvard Supersite monitor in Boston, Massachusetts (5,358 examinations, 1995-2011) who were not current smokers, with previous-day pollutant levels in compliance with EPA standards. We compared lung function (FEV1 and FVC) after previous-day exposure to particulate matter less than 2.5 μm in diameter (PM2.5), nitrogen dioxide (NO2), and ozone (O3) in the "moderate" range of the EPA Air Quality Index to exposure in the "good" range. We also examined linear relationships between moving averages of pollutant concentrations 1, 2, 3, 5, and 7 days before spirometry and lung function., Measurements and Main Results: Exposure to pollutant concentrations in the "moderate" range of the EPA Air Quality Index was associated with a 20.1-ml lower FEV1 for PM2.5 (95% confidence interval [CI], -33.4, -6.9), a 30.6-ml lower FEV1 for NO2 (95% CI, -60.9, -0.2), and a 55.7-ml lower FEV1 for O3 (95% CI, -100.7, -10.8) compared with the "good" range. The 1- and 2-day moving averages of PM2.5, NO2, and O3 before testing were negatively associated with FEV1 and FVC., Conclusions: Short-term exposure to PM2.5, NO2, and O3 within current EPA standards was associated with lower lung function in this cohort of adults.

Background: Smoking marijuana has been reported to increase risk of myocardial infarction (MI) immediately after use, but less is known about the long-term impact of marijuana use among patients with established coronary disease., Methods: The Determinants of MI Onset Study is a multicenter inception cohort study of myocardial infarction (MI) patients enrolled in 1989 to 1996 and followed up for mortality using the National Death Index. In an initial analysis of 1,935 MI survivors followed up for a median of 3.8 years, we found an increased mortality rate among marijuana users. The current article includes 3,886 Determinants of MI Onset Study patients followed up for up to 18 years. We used Cox proportional hazards models to calculate the hazard ratio and 95% CI for the association between marijuana use and mortality and a propensity score matched analysis to further control confounding., Results: Over up to 18 years of follow-up, 519 patients died, including 22 of the 109 reporting marijuana use in the year before their MI. There was no statistically significant association between marijuana use and mortality. Compared with nonusers, the mortality rate was 29% higher (95% CI 0.81-2.05, P = .28) among those reporting any marijuana use., Conclusions: Habitual marijuana use among patients presenting with acute MI was associated with an apparent increased mortality rate over the following 18 years that did not reach nominal statistical significance. Larger studies with repeated measures of marijuana use are needed to definitively establish whether there are adverse cardiovascular consequences of smoking marijuana among patients with established coronary heart disease., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Left or codominant coronary arterial circulation may represent less well-balanced myocardial perfusion and thus confer worse prognosis in acute coronary syndrome, especially for culprit lesions arising from the left coronary artery., Methods and Results: We related left and codominance, relative to right dominance, with in-hospital mortality in 207 926 percutaneous coronary interventions (PCI) for acute coronary syndromes from July 1, 2009 through June 30, 2010 in the National Cardiovascular Data Registry Cath Percutaneous Coronary Intervention (CathPCI) Registry database version 4. Generalized estimating equations and logistic regression analyses were used in unadjusted and multivariable adjusted models. Models were adjusted using the validated National Cardiovascular Data Registry mortality risk model. We performed subgroup analyses and formally tested for effect modification by the epicardial coronary artery containing the culprit lesion. Left coronary dominance was associated with higher in-hospital mortality in unadjusted (odds ratio=1.29, 95% confidence interval [CI], 1.17-1.42) and adjusted models (1.19, 95% CI, 1.06-1.34). Codominance was associated with worsened mortality only in adjusted models (odds ratio=1.16, 95% CI, 1.01-1.34). Addition of coronary dominance to the National Cardiovascular Data Registry risk model did not materially change model discrimination or calibration. The odds of death for left versus right dominance among those with left circumflex or left main culprit lesions was 1.25 (95% CI, 1.02-1.53), for right coronary artery lesions was 1.19 (95% CI, 0.83-1.71), and for left anterior descending artery lesions was 1.09 (95% CI, 0.93-1.28). There was no statistical evidence for effect modification by culprit lesion vessel (P=0.8)., Conclusions: Left and codominance are associated with modestly increased post-percutaneous coronary intervention in-hospital mortality in patients with acute coronary syndrome. Confirmation of these findings with angiographic core laboratory verification of coronary dominance and longer term follow-up will be desirable.

Context: Previous studies have examined the associations of individual clinical risk factors with risk of peripheral artery disease (PAD), but the combined effects of these risk factors are largely unknown., Objective: To estimate the degree to which the 4 conventional cardiovascular risk factors of smoking, hypertension, hypercholesterolemia, and type 2 diabetes are associated with the risk of PAD among men., Design, Setting, and Participants: Prospective study of 44,985 men in the United States without a history of cardiovascular disease at baseline in 1986; participants in the Health Professionals Follow-up Study were followed up for 25 years until January 2011. The presence of risk factors was updated biennially during follow-up., Main Outcome Measure: Clinically significant PAD defined as limb amputation or revascularization, angiogram reporting vascular obstruction of 50% or greater, ankle-brachial index of less than 0.90, or physician-diagnosed PAD., Results: During a median follow-up of 24.2 years (interquartile range, 20.8-24.7 years), there were 537 cases of incident PAD. Each risk factor was significantly and independently associated with a higher risk of PAD after adjustment for the other 3 risk factors and confounders. The age-adjusted incidence rates were 9 (95% CI, 6-14) cases/100,000 person-years (n = 19 incident cases) for 0 risk factors, 23 (95% CI, 18-28) cases/100,000 person-years (n = 99 incident cases) for 1 risk factor, 47 (95% CI, 39-56) cases/100,000 person-years (n = 176 incident cases) for 2 risk factors, 92 (95% CI, 76-111) cases/100,000 person-years (n = 180 incident cases) for 3 risk factors, and 186 (95% CI, 141-246) cases/100,000 person-years (n = 63 incident cases) for 4 risk factors. The multivariable-adjusted hazard ratio for each additional risk factor was 2.06 (95% CI, 1.88-2.26). Men without any of the 4 risk factors had a hazard ratio of PAD of 0.23 (95% CI, 0.14-0.36) compared with all other men in the cohort. In 96% of PAD cases (95% CI, 94%-98%), at least 1 of the 4 risk factors was present at the time of PAD diagnosis. The population-attributable risk associated with these 4 risk factors was 75% (95% CI, 64%-87%). The absolute incidence of PAD among men with all 4 risk factors was 3.5/1000 person-years., Conclusion: Among men in this cohort, smoking, hypertension, hypercholesterolemia, and type 2 diabetes account for the majority of risk associated with development of clinically significant PAD.

Objective: Previous studies of cardiomyopathy among children perinatally infected with HIV were conducted before the routine use of HAART. Nucleoside analogs [nucleoside reverse transcriptase inhibitors (NRTIs)], the backbone of HAART, have been associated with mitochondrial toxicity, which can lead to cardiomyopathy. We evaluated the association of HAART and specific NRTIs associated with mitochondrial toxicity, on development of cardiomyopathy among perinatally HIV-infected children., Design: Three thousand and thirty-five perinatally HIV-infected children enrolled in a US-based multicenter prospective cohort study were followed for cardiomyopathy, defined as a clinical diagnosis or initiation of digoxin, from 1993 to 2007., Methods: Cox models were used to estimate the effects of HAART and NRTIs on cardiomyopathy, identify predictors of cardiomyopathy among HAART users, and estimate the association between development of cardiomyopathy and mortality., Results: Ninety-nine cases of cardiomyopathy were identified over follow-up (incidence rate: 5.6 cases per 1000 person-years) at a median age of 9.4 years. HAART was associated with a 50% lower incidence of cardiomyopathy compared with no HAART use (95% confidence interval: 20%, 70%). Zalcitabine (ddC) use, however, was associated with an 80% higher incidence of cardiomyopathy. Among HAART users, older age at HAART initiation, ddC use before HAART initiation, initiating a HAART regimen containing zidovudine (ZDV), and a nadir CD4 percentage less than 15% were independently associated with a higher rate of cardiomyopathy. Cardiomyopathy was associated with a six-fold higher mortality rate., Conclusion: HAART has dramatically decreased the incidence of cardiomyopathy among perinatally HIV-infected children. However, they remain at increased risk for cardiomyopathy and ongoing ZDV exposure may increase this risk.

Background: The relationship between residential proximity to roadway and long-term survival after acute myocardial infarction (AMI) is unknown. We investigated the association between distance from residence and major roadway and 10-year all-cause mortality after AMI in the Determinants of Myocardial Infarction Onset Study (Onset Study), hypothesizing that living closer to a major roadway at the time of AMI would be associated with increased risk of mortality., Methods and Results: The Onset Study enrolled 3886 individuals hospitalized for AMI in 64 centers across the United States from 1989 to 1996. Institutionalized patients, those providing only post office boxes, and those whose addresses could not be geocoded were excluded, leaving 3547 patients eligible for analysis. Addresses were geocoded, and distance to the nearest major roadway was assigned. Cox regression was used to calculate hazard ratios, with adjustment for personal characteristics (age, sex, race, education, marital status, distance to nearest acute care hospital), clinical characteristics (smoking, body mass index, comorbidities, medications), and neighborhood-level characteristics derived from US Census block group data (household income, education, urbanicity). There were 1071 deaths after 10 years of follow-up. In the fully adjusted model, compared with living >1000 m, hazard ratios (95% confidence interval) for living ≤100 m were 1.27 (1.01-1.60), for 100 to ≤200 m were 1.19 (0.93-1.60), and for 200 to ≤1000 m were 1.13 (0.99-1.30) (P(trend)=0.016)., Conclusions: In this multicenter study, living close to a major roadway at the time of AMI was associated with increased risk of all-cause 10-year mortality; this relationship persisted after adjustment for individual and neighborhood-level covariates.

Background: Pregnancy is associated with marked maternal cardiovascular/hemodynamic changes. A greater number of pregnancies may be associated with long-term subclinical changes in left ventricular (LV) remodeling., Methods: Among 2,234 white, black, Hispanic, and Chinese women (mean age 62 years) in the MESA, we used linear regression to relate live births and cardiac magnetic resonance imaging LV measures. Covariates included age, ethnicity, height, income, education, birth country, smoking, menopause, and oral contraceptive duration. Models were additionally adjusted for potential mediators: systolic blood pressure, antihypertensive use, total/high-density lipoprotein cholesterol, triglycerides, diabetes, and body mass index. We performed sensitivity analyses excluding 763 women in the lowest socioeconomic group: annual income <$25,000 and lower high school level of education., Results: With each live birth, LV mass increased 1.26 g; LV end-diastolic volume, 0.74 mL; and LV end-systolic volume, 0.45 mL; LV ejection fraction decreased 0.18% (P trend <0.05). Changes were most notable for the category of women with ≥5 pregnancies. Upon adjustment for potential biologic mediators, live births remained positively associated with LV mass and end-systolic volume. Live births remained significantly associated with LV end-systolic, end-diastolic volumes, and LV mass (P trend ≤0.02) after excluding women in the lowest socioeconomic group., Conclusions: Number of live births is associated with key LV structural and functional measures in middle to older ages, even after adjustment for sociodemographic factors and cardiovascular disease risk factors. Hemodynamic changes during pregnancy may be associated with cardiac structure/function beyond childbearing years., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Musculoskeletal symptoms are common adverse effects of statins, yet little is known about the prevalence of musculoskeletal pain and statin use in the general population., Methods: We conducted a cross-sectional study of the National Health and Nutrition Examination Survey 1999-2004. We estimated the prevalence of self-reported musculoskeletal pain according to statin use and calculated prevalence ratio estimates of musculoskeletal pain obtained from adjusted multiple logistic regression modeling., Results: Among 5170 participants without arthritis, the unadjusted prevalence of musculoskeletal pain was significantly higher for statin users reporting pain in any region (23% among statin users, 95% confidence interval [CI], 19-27, compared with 18% among those not using statins, 95% CI, 17-20; P=.02) and in the lower extremities (12% among statin users, 95% CI, 8-16, compared with 8% among those not using statins, 95% CI, 7-9; P=.02). Conversely, among 3058 participants with arthritis, statin use was not associated with higher musculoskeletal pain in any region. After controlling for confounders, among those without arthritis, statin use was associated with a significantly higher prevalence of musculoskeletal pain in any region, the lower back, and the lower extremities (adjusted prevalence ratios: 1.33 [CI, 1.06-1.67]; 1.47 [CI, 1.02-2.13]; 1.59 [CI, 1.12-2.22], respectively). Among participants with arthritis, no association was observed between musculoskeletal pain and statin use on adjusted analyses., Conclusion: In this population-based study, statin use was associated with a higher prevalence of musculoskeletal pain, particularly in the lower extremities, among individuals without arthritis. Evidence that statin use was associated with musculoskeletal pain among those with arthritis was lacking., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Although moderate alcohol drinkers have lower rates of incident coronary artery disease than abstainers, much less is known about the health effects of different patterns of alcohol use in women with established coronary artery disease. In the Determinants of Myocardial Infarction Onset Study, 1,253 women hospitalized for acute myocardial infarction (MI) at 64 centers nationwide from 1989 to 1996 were followed for mortality through December 31, 2007. Of the women, 761 (61%) reported abstention in the year before their MIs, 280 (22%) reported consumption of <1 serving/week, 75 (6%) reported consumption of 1 to 3 servings/week, and 137 (11%) reported consumption of ≥3 servings/week. Using Cox proportional-hazards models, the associations between total weekly volume of consumption, drinking days per week, drinks per drinking day, and beverage type with 10-year mortality were investigated, adjusting for clinical and socioeconomic potential confounders. Compared with abstention, adjusted hazard ratios were 0.66 (95% confidence interval 0.50 to 0.86) for <1 serving/week, 0.65 (95% confidence interval 0.38 to 1.11) for 1 to 3 servings/week, and 0.65 (95% confidence interval 0.38 to 1.11) for ≥3 servings/week (p for trend = 0.008). No differences were found by beverage type, and generally inverse associations of drinking frequency and quantity with mortality were found. In conclusion, in women who survive MI, moderate drinking is associated with a decreased risk for mortality, with no clear differences on the basis of pattern or beverage type. These results suggest that women who survive MI need not abstain from alcohol, but any derived benefit would appear to occur well below currently recommended limits in alcohol consumption., (Copyright © 2012 Elsevier Inc. All rights reserved.)

DNA methylation has been associated with age-related disease. Intra-individual changes in gene-specific DNA methylation over time in a community-based cohort has not been well described. We estimated the change in DNA methylation due to aging for nine genes in an elderly, community-dwelling cohort of men. Seven hundred and eighty four men from the Veterans Administration Normative Aging Study who were living in metropolitan Boston from 1999-2009 donated a blood sample for DNA methylation analysis at clinical examinations repeated at approximately 3-5 year intervals. We used mixed effects regression models. Aging was significantly associated with decreased methylation of GCR, iNOS and TLR2 and with increased methylation of IFNγ, F3, CRAT and OGG. Obstructive pulmonary disease at baseline modified the effect of aging on methylation of IFNγ (interaction p = 0.04). For participants who had obstructive pulmonary disease at their baseline visit, the rate of change of methylation of IFNγ was -0.05% 5-methyl-cytosine (5-mC) per year (95% CI: -0.22, 0.13), but was 0.14% 5-mC per year (95% CI: 0.05, 0.24) for those without this condition. Models with random slopes indicated significant heterogeneity in the effect of aging on methylation of GCR, iNOS and OGG. These findings suggest that DNA methylation may reflect differential biological aging.

Objectives: This nested case-crossover study examined the association between rushing, distraction and walking on a contaminated floor and the rate of slipping, and whether the effects varied according to weekly hours worked, job tenure and use of slip-resistant shoes., Methods: At baseline, workers from 30 limited-service restaurants in the USA reported average work hours, average weekly duration of exposure to each transient risk factor and job tenure at the current location. Use of slip-resistant shoes was determined. During the following 12 weeks, participants reported weekly their slip experience and exposures to the three transient exposures at the time of slipping. The case-crossover design was used to estimate the rate ratios using the Mantel-Haenszel estimator for person-time data., Results: Among 396 participants providing baseline information, 210 reported one or more slips with a total of 989 slips. Rate of slipping was 2.9 times higher when rushing as compared to working at a normal pace (95% CI 2.5 to 3.3). Rate of slipping was also significantly increased by distraction (rate ratio (RR) 1.7, 95% CI 1.5 to 2.0) and walking on a contaminated floor (RR 14.6, 95% CI 12.6 to 17.0). Use of slip-resistant shoes decreased the effects of rushing and walking on a contaminated floor. Rate ratios for all three transient factors decreased monotonically as job tenure increased., Conclusion: The results suggest the importance of these transient risk factors, particularly floor contamination, on rate of slipping in limited-service restaurant workers. Stable characteristics, such as slip-resistant shoes, reduced the effects of transient exposures.

Objectives: Slips and falls are a leading cause of injury at work. Few studies, however, have systematically examined risk factors of slipping outside the laboratory environment. This study examined the association between floor surface characteristics, slip-resistant shoes, floor cleaning frequency and the risk of slipping in limited-service restaurant workers., Methods: 475 workers from 36 limited-service restaurants from three major chains in six states in the USA were recruited to participate in a prospective cohort study of workplace slipping. Kitchen floor surface roughness and coefficient of friction (COF) were measured in eight working areas and then averaged within each restaurant. The use of slip-resistant shoes was determined by examining the participant's shoes and noting the presence of a 'slip-resistant' marking on the sole. Restaurant managers reported the frequency of daily kitchen floor cleaning. Participants reported their slip experience and work hours weekly for up to 12 weeks. The survey materials were made available in three languages: English, Spanish and Portuguese. The associations between rate of slipping and risk factors were assessed using a multivariable negative binomial generalised estimating equation model., Results: The mean of individual slipping rate varied among the restaurants from 0.02 to 2.49 slips per 40 work hours. After adjusting for age, gender, BMI, education, primary language, job tenure and restaurant chain, the use of slip-resistant shoes was associated with a 54% reduction in the reported rate of slipping (95% CI 37% to 64%), and the rate of slipping decreased by 21% (95% CI 5% to 34%) for each 0.1 increase in the mean kitchen COF. Increasing floor cleaning frequency was significantly associated with a decreasing rate of slipping when considered in isolation but not after statistical adjustment for other factors., Conclusion: These results provide support for the use of slip-resistant shoes and measures to increase COF as preventive interventions to reduce slips, falls and injuries.

Objective: Standard precautions are advocated for reducing the number of injuries caused by needles and sharp medical devices ("sharps injuries"), but the effectiveness of gloves in preventing such injuries has not been established. We evaluated factors associated with gloving practices and identified associations between gloving practices and sharps-injury risk., Design: Usual-frequency case-crossover study., Setting: Thirteen medical centers in the United States and Canada., Participants: Six hundred thirty-six healthcare workers who presented to employee health clinics after sharps injury., Methods: Structured telephone questionnaires were administered to assess usual behaviors and circumstances at the time of injury., Results: Of 636 injured healthcare workers, 195 were scrubbed in an operating room or procedure suite when injured, and 441 were injured elsewhere. Nonscrubbed individuals were more commonly gloved when treating patients who were perceived to have a high risk of human immunodeficiency virus, hepatitis B virus, or hepatitis C virus infection than when treating other patients (adjusted odds ratio [aOR], 2.53 [95% confidence interval {CI}, 1.30-4.91]). Nurses (aOR, 0.11 [95% CI, 0.04-0.32]) and other employees (aOR, 0.24 [95% CI, 0.07-0.77]) were less commonly gloved at injury than were physicians and physician trainees. Gloves reduced injury risk in case-crossover analyses (incidence rate ratio [IRR], 0.33 [95% CI, 0.22-0.50]). In scrubbed individuals, involvement in an orthopedic procedure was associated with double gloving at injury (aOR, 13.7 [95% CI, 4.55-41.3]); this gloving practice was associated with decreased injury risk (IRR, 0.20 [95% CI, 0.10-0.42])., Conclusions: Although the use of gloves reduces the risk of sharps injuries in health care, use among healthcare workers is inconsistent and may be influenced by risk perception and healthcare culture. Glove use should be emphasized as a key element of multimodal sharps-injury reduction programs.

In 2004, the first American Heart Association scientific statement on "Air Pollution and Cardiovascular Disease" concluded that exposure to particulate matter (PM) air pollution contributes to cardiovascular morbidity and mortality. In the interim, numerous studies have expanded our understanding of this association and further elucidated the physiological and molecular mechanisms involved. The main objective of this updated American Heart Association scientific statement is to provide a comprehensive review of the new evidence linking PM exposure with cardiovascular disease, with a specific focus on highlighting the clinical implications for researchers and healthcare providers. The writing group also sought to provide expert consensus opinions on many aspects of the current state of science and updated suggestions for areas of future research. On the basis of the findings of this review, several new conclusions were reached, including the following: Exposure to PM <2.5 microm in diameter (PM(2.5)) over a few hours to weeks can trigger cardiovascular disease-related mortality and nonfatal events; longer-term exposure (eg, a few years) increases the risk for cardiovascular mortality to an even greater extent than exposures over a few days and reduces life expectancy within more highly exposed segments of the population by several months to a few years; reductions in PM levels are associated with decreases in cardiovascular mortality within a time frame as short as a few years; and many credible pathological mechanisms have been elucidated that lend biological plausibility to these findings. It is the opinion of the writing group that the overall evidence is consistent with a causal relationship between PM(2.5) exposure and cardiovascular morbidity and mortality. This body of evidence has grown and been strengthened substantially since the first American Heart Association scientific statement was published. Finally, PM(2.5) exposure is deemed a modifiable factor that contributes to cardiovascular morbidity and mortality.

Studies have reported a possible link between cocaine use and risk for cardiovascular events. The aim of this study was to examine the association between self-reported cocaine use and physician-diagnosed myocardial infarction (MI) in the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994. Odds ratios (ORs) were estimated using logistic regression models adjusted for age and additionally for gender, race, and other MI risk factors, which accounted for the complex sampling design. In the group aged 18 to 59 years, there was no statistically significant association between any exposure to cocaine and MI (age-adjusted OR 1.56, 95% confidence interval [CI] 0.44 to 5.50, p = 0.48; multivariate-adjusted OR 1.06, 95% CI 0.30 to 3.73, p = 0.92). Participants who reported using cocaine >10 times had a nonsignificant higher prevalence of MI (age-adjusted OR 3.13, 95% CI 0.80 to 12.25, p = 0.10; multivariate-adjusted OR 1.84, 95% CI 0.46 to 7.29, p = 0.40). However, participants aged 18 to 45 years who reported >10 occasions of cocaine use had a significantly elevated prevalence of MI in age-adjusted models (OR 4.60, 95% CI 1.12 to 18.88, p = 0.035). The association was attenuated in multivariate-adjusted models (OR 3.84, 95% CI 0.98 to 15.07, p = 0.054). The lifetime prevalence of cocaine use increased from 14% in NHANES III to 19% in NHANES 2005-2006. In conclusion, these data support a substantial association between cocaine use and MI; the temporal trend in cocaine use may increase the occurrence of MI, particularly in younger populations.