Search

BackgroundCardiovascular disease (CVD) is the leading cause of mortality among Haitians, having surpassed HIV in the last decade. Understanding the natural history of CVD in Haitians, including the age of onset, prevalence, incidence, and role of major risk factors and social determinants, is urgently needed to develop prevention and treatment interventions.Aim 1: Establish a population-based cohort of 3000 adults from Port-au-Prince and assess the prevalence of CVD risk factors and diseases and their association with social and environmental determinants.Aim 2: Determine the incidence of CVD risk factors and CVD during 2–3.5 years of follow-up and their association with social and environmental determinants.MethodsThe Haiti CVD Cohort is a longitudinal observational study of 3000 adults> 18 years in Port-au-Prince (PAP), Haiti. The study population is recruited using multistage random sampling from census blocks. Adults receive blood pressure (BP) measurements in the community and those with elevated BP are referred to the Groupe Haitien d’Etude Sarcome de Kaposi et des Infections Opportunistes Clinic for care. After informed consent, participants undergo a clinical exam with medical history. BP, electrocardiogram, echocardiogram, a study questionnaire on health behaviors, and laboratory specimens. Every 6 months, BP is remeasured. At 12 and 24 months, clinical exams and questionnaires are repeated. Labs are repeated at 24 months. Adjudicated study outcomes include the prevalence and incidence of CVD risk factors (hypertension, diabetes, obesity, dyslipidemia, kidney disease, inflammation, poor diet, smoking, and physical inactivity) and events (myocardial infarction, heart failure, stroke, and CVD mortality). We also measure social determinants including poverty. Depression, stress, social isolation, food insecurity, and lead exposure. Blood, urine, and stool samples are biobanked at study enrollment.DiscussionThe Haiti CVD Cohort is the largest population-based cohort study evaluating CVD risk factors and CVD among adults in urban Haiti with the goal of understanding the drivers of the CVD epidemic in Haiti. Study outcomes are comparable with existing international cohorts, and the biobank will provide important data for future research. Our goal is to translate findings from this study into pragmatic prevention and treatment interventions to fight the CVD epidemic in Haiti.

This cohort study evaluates the performance of the pooled cohort equations in estimating the risk of atherosclerotic cardiovascular disease risk by body mass index range., Key Points Question What is the performance of the pooled cohort equations (PCE) for estimation of atherosclerotic cardiovascular disease (ASCVD) risk by body mass index? Findings In this pooled analysis of 8 longitudinal cohort studies that included 37 311 adults, the PCE demonstrated acceptable model discrimination but significantly overestimated risk of atherosclerotic cardiovascular disease in individuals with higher body mass index, with better calibration near clinical decision thresholds and less optimal calibration for the groups at highest risk. Incorporation of usual clinical measures of obesity did not result in more accurate risk estimation compared with standard PCE. Meaning These findings suggest that the PCE could be used as a risk-estimation tool to guide prevention and treatment strategies in adults across clinical BMI categories, but may overestimate risk of ASCVD for individuals in overweight and obese categories., Importance Obesity is a global health challenge and a risk factor for atherosclerotic cardiovascular disease (ASVCD). Performance of the pooled cohort equations (PCE) for ASCVD risk by body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) is unknown. Objective To assess performance of the PCE across clinical BMI categories. Design, Setting, and Participants This cohort study used pooled individual-level data from 8 community-based, prospective, longitudinal cohort studies with 10-year ASCVD event follow-up from 1996 to 2016. We included all adults ages 40 to 79 years without baseline ASCVD or statin use, resulting in a sample size of 37 311 participants. Data were analyzed from August 2017 to July 2020. Exposures Participant BMI category: underweight (

Introduction The impact of atrial arrhythmias on coronavirus disease 2019 (COVID‐19)‐associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID‐19. Methods An observational cohort study of 1053 patients with severe acute respiratory syndrome coronavirus 2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30‐day mortality was assessed with multivariable analysis. Results Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared with patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B‐type natriuretic peptide, C‐reactive protein, ferritin and d‐dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; p

Background: Despite potential harm that can result from polypharmacy, real-world data on polypharmacy in the setting of heart failure (HF) are limited. We sought to address this knowledge gap by studying older adults hospitalized for HF derived from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Methods: We examined 558 older adults aged ≥65 years with adjudicated HF hospitalizations from 380 hospitals across the United States. We collected and examined data from the REGARDS baseline assessment, medical charts from HF-adjudicated hospitalizations, the American Hospital Association annual survey database, and Medicare’s Hospital Compare website. We counted the number of medications taken at hospital admission and discharge; and classified each medication as HF-related, non-HF cardiovascular-related, or noncardiovascular-related. Results: The vast majority of participants (84% at admission and 95% at discharge) took ≥5 medications; and 42% at admission and 55% at discharge took ≥10 medications. The prevalence of taking ≥10 medications (polypharmacy) increased over the study period. As the number of total medications increased, the number of noncardiovascular medications increased more rapidly than the number of HF-related or non-HF cardiovascular medications. Conclusions: Defining polypharmacy as taking ≥10 medications might be more ideal in the HF population as most patients already take ≥5 medications. Polypharmacy is common both at admission and hospital discharge, and its prevalence is rising over time. The majority of medications taken by older adults with HF are noncardiovascular medications. There is a need to develop strategies that can mitigate the negative effects of polypharmacy among older adults with HF.

Background Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the association between depressive symptoms and all‐cause and cardiovascular disease (CVD) mortality. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time‐varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus P =0.05; CVD: age 45–64 years aHR, 1.17; 95% CI, 0.90–1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06–1.50; P =0.54; all‐cause: males aHR, 1.46; 95% CI, 1.29–1.64 versus female aHR, 1.34; 95% CI, 1.19–1.50; P =0.35; CVD: male aHR, 1.32; 95% CI, 1.08–1.62 versus female aHR, 1.22; 95% CI, 1.00–1.47; P =0.64). Similar results were observed when stratified by self‐reported health status. Conclusions Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.

BACKGROUND Because medication adherence is linked to better diabetes outcomes, numerous interventions have aimed to improve adherence. However, suboptimal adherence persists and necessitate continued research into intervention strategies. This study evaluated the effectiveness of an intervention that combined storytelling and peer support to improve medication adherence and health outcomes in adults with diabetes. METHODS Living Well with Diabetes was a cluster randomized controlled trial. Intervention participants received a six-month, 11-session peer-delivered behavioral diabetes self-care program over the phone. Control participants received a self-paced general health program. Outcomes were changes in medication adherence and physiologic measures (hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol, body mass index). RESULTS Of the 403 participants with follow-up data, mean age was 57 (±SD 11), 78% were female, 91% were African American, 56.4% had high school education or less, and 70% had an annual income of < $20,000. At follow-up, compared to controls, intervention participants had greater improvement in medication adherence (β = -0.25 [95% CI -0.35, -0.15]). Physiologic measures did not change significantly in either group. Intervention participants had significant improvements in beliefs about the necessity of medications (β = 0.87 [95% CI 0.27, 1.47]) concerns about the negative effects of medication (β = -0.91 [95% CI -1.35, -0.47]), and beliefs that medications are harmful (β = -0.50 [95% CI -0.89, -0.10]). In addition, medication use self-efficacy significantly improved in intervention participants (β = 1.0 [95% CI 0.23, 1.76]). 473 individuals were enrolled in the study and randomized. DISCUSSION Living Well intervention resulted in improved medication adherence, medication beliefs, and medication use self-efficacy but not improved risk factor levels.

Background The Life’s Simple 7 (LS7) metric incorporates health behaviors (body mass index, diet, smoking, physical activity) and health factors (blood pressure, cholesterol, glucose) to estimate an individual’s level of cardiovascular health. The association between cardiovascular health and incident hypertension is unresolved. Hypertension’s threshold was recently lowered and it is unclear if better cardiovascular health is associated with lower risk of incident hypertension with the updated threshold or in a multirace cohort. We sought to assess the association between better LS7 score and risk of incident hypertension among Black and White adults using a 130/80 mm Hg hypertension threshold. Methods and Results We determined the association between LS7 metric and incident hypertension in the REGARDS (Reasons for Geographic and Racial Disparities in Stroke) study, including participants free of baseline hypertension (2003–2007) who completed a second visit between 2013 and 2016. Hypertension was defined as systolic/diastolic blood pressure ≥130/80 mm Hg or antihypertensive medication use. Each LS7 component was assigned 0 (poor), 1 (intermediate), or 2 (ideal) points. We generated a 14‐point score by summing points. Among 2930 normotensive participants (20% Black, 80% White), the median (25th–75th percentiles) LS7 total score was 9 (8–10) points. Over a median follow‐up of 9 years, 42% developed hypertension. In the fully adjusted model, each 1‐point higher LS7 score had a 6% lower risk of incident hypertension (risk ratio, 0.94 per 1 point; 95% CI, 0.92–0.96). Conclusions Better cardiovascular health was associated with lower risk of incident hypertension using a 130/80 mm Hg hypertension threshold among Black and White adults.

Introduction: Diabetes medications can substantially lower blood sugar, thereby improving health outcomes. Despite substantial efforts targeting this issue, diabetes medication adherence remains suboptimal. We present the development and implementation of an intervention emphasizing peer modeling and support as strategies to improve medication adherence. Methods: Program adaptation, pretesting, and peer coach training were combined in an iterative process with community stakeholders. Peer coaches were community residents who had diabetes or took care of family members with diabetes. Study participants were community-dwelling adults taking diabetes oral medications who reported medication non-adherence or wanted help taking their medications. Results: The resulting intervention consisted of a six-month, 11-session telephone-delivered program. Nineteen peer coaches were trained and certified to deliver the intervention. The 473 study participants were mostly African-Americans (91%), women (79%), and low-income (70% reporting annual income

Patients with cancer may be at increased risk of severe coronavirus disease 2019 (COVID-19), but the role of viral load on this risk is unknown. We measured SARS-CoV-2 viral load using cycle threshold (CT) values from reverse transcription-polymerase chain reaction assays applied to nasopharyngeal swab specimens in 100 patients with cancer and 2914 without cancer who were admitted to three New York City hospitals. Overall, the in-hospital mortality rate was 38.8% among patients with a high viral load, 24.1% among patients with a medium viral load, and 15.3% among patients with a low viral load (P, Graphical Abstract, HIGHLIGHTS • High admission viral load predicts mortality in hospitalized patients with and without cancer • Patients with hematologic malignancies have higher viral loads than patients without cancer • Viral load results may assist clinicians in caring for hospitalized patients with COVID-19

Background: Socially determined vulnerabilities (SDVs) to health disparities often cluster within the same individual. SDVs are separately associated with increased risk of heart failure (HF). The objective of this study was to determine the cumulative effect of SDVs to health disparities on incident HF hospitalization. Methods and Results: Using the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study, we studied 25 790 participants without known HF and followed them for 10+ years. Our primary outcome was an incident HF hospitalization through December 31, 2016. Guided by the Healthy People 2020 framework for social determinants of health, we examined 10 potential SDVs. We retained SDVs associated with incident HF hospitalization ( P P for trend, 0.001). We observed no significant associations for older individuals. Conclusions: A greater number of SDVs significantly increased risk of incident HF hospitalization among adults

RationaleCOVID-19-associated respiratory failure offers the unprecedented opportunity to evaluate the differential host response to a uniform pathogenic insult. Prior studies of Acute Respiratory Distress Syndrome (ARDS) have identified subphenotypes with differential outcomes. Understanding whether there are distinct subphenotypes of severe COVID-19 may offer insight into its pathophysiology.ObjectivesTo identify and characterize distinct subphenotypes of COVID-19 critical illness defined by the post-intubation trajectory of Sequential Organ Failure Assessment (SOFA) score.MethodsIntubated COVID-19 patients at two hospitals in New York city were leveraged as development and validation cohorts. Patients were grouped into mild, intermediate, and severe strata by their baseline post-intubation SOFA. Hierarchical agglomerative clustering was performed within each stratum to detect subphenotypes based on similarities amongst SOFA score trajectories evaluated by Dynamic Time Warping. Statistical tests defined trajectory subphenotype predictive markers.Measurements and Main ResultsDistinct worsening and recovering subphenotypes were identified within each stratum, which had distinct 7-day post-intubation SOFA progression trends. Patients in the worsening suphenotypes had a higher mortality than those in the recovering subphenotypes within each stratum (mild stratum, 29.7% vs. 10.3%, p=0.033; intermediate stratum, 29.3% vs. 8.0%, p=0.002; severe stratum, 53.7% vs. 22.2%, pConclusionsThere are clear worsening and recovering subphenotypes of COVID-19 respiratory failure after intubation, which are more predictive of outcomes than baseline severity of illness. Organ dysfunction trajectory may be well suited as a surrogate for research in COVID-19 respiratory failure.At a Glance CommentaryScientific Knowledge on the SubjectCOVID-19 associated respiratory failure leads to a significant risk of morbidity and mortality. It is clear that there is heterogeneity in the viral-induced host response leading to differential outcomes, even amongst those treated with mechanical ventilation. There are many studies of COVID-19 disease which use intubation status as an outcome or an inclusion criterion. However, there is less understanding of the post intubation course in COVID-19.What This Study Adds to the FieldWe have developed and validated a novel subphenotyping model based on post-intubation organ dysfunction trajectory in COVID-19 patients. Specifically, we identified clear worsening and recovering organ dysfunction trajectory subphenotypes, which are more predictive of outcomes than illness severity at baseline. Dynamic inflammatory markers and ventilator variables rather than baseline severity of illness, demographics and comorbidities differentiate the worsening and recovering subphenotypes. Trajectory subphenotypes offer a potential road map for understanding the evolution of critical illness in COVID-19.

Cardiovascular disease (CVD) is the number one cause of death among 5-year cancer survivors. Survivors see many providers and poor coordination may contribute to worse CVD risk factor control. We sought to determine associations between fragmentation and CVD risk factor control among survivors overall and by self-rated health.We included REGARDS participants aged 66+ years who (1) had a cancer history; (2) reported diabetes, hypertension, or hyperlipidemia; and (3) had continuous Medicare coverage. Twelve-month ambulatory care fragmentation was calculated using the Bice-Boxerman Index (BBI). We determined associations between fragmentation and CVD risk factors, defining "control" as fasting glucose 126 mg/dL or non-fasting glucose 200 mg/dL for diabetes; blood pressure 140/90 mmHg for hypertension; and total cholesterol240 mg/dL, low-density lipoprotein cholesterol 160 mg/dL, or high-density lipoprotein cholesterol40 mg/dL for hyperlipidemia.The 1002 cancer survivors (2+ years since cancer treatment) had mean age of 75 years, 39% were women, and 23% were Black. Among individuals with diabetes (N = 225), hypertension (N = 660), and hyperlipidemia (N = 516), separately, approximately 60% had CVD risk factor control. Overall, more fragmented care was not associated with worse control. However, among cancer survivors with excellent, very good, or good health, more fragmentation was associated with a decreased likelihood of diabetes control (OR 0.78, 95% CI 0.61-0.99), adjusting for confounders.More fragmented care was associated with worse glycemic control among cancer survivors with diabetes who reported excellent, very good, or good health. Associations were not observed for control of hypertension or hyperlipidemia.Reducing fragmentation may support glucose control among survivors with diabetes.

OBJECTIVE To identify and prioritize patient- and rheumatologist-perceived barriers to achieving disease control. METHODS Patients with rheumatoid arthritis (RA) and rheumatologists from the Corrona registry were invited by e-mail to participate in nominal groups. Two separate lists of barriers were created, 1 from RA patient-only nominal groups and the other from rheumatologist-only nominal groups, and barriers were sorted into themes. Next, using an online survey, a random sample of RA patients from the Corrona registry were asked to rank their top 3 barriers to achieving disease control. RESULTS Four nominal groups totaling 37 RA patients identified patient barriers to achieving control of RA activity that were classified into 17 themes. Three nominal groups totaling 25 rheumatologists identified barriers that were classified into 11 themes. The financial aspects of RA care ranked first for both types of nominal groups, while medication risk aversion ranked second among the perceived barriers of the physician nominal group and third among those of the RA patient nominal group. Among the 450 RA patients surveyed, 77% considered RA a top health priority, and 51% reported being aware of the treat-to-target strategy for RA care; the 3 most important patient-perceived challenges to achieving disease control were RA prognosis uncertainty, medication risk aversion, and the financial/administrative burden associated with RA care. CONCLUSION There are common, potentially modifiable, patient- and rheumatologist-reported barriers to achieving RA disease control, including perceived medication risk aversion, suboptimal treatment adherence, and suboptimal patient-physician communication regarding the benefits of tight control of disease activity in RA. Addressing these obstacles may improve adherence to goal-directed RA care.

Highlights • Findings of left and right sided heart disease on the presentation electrocardiogram are associated with death in COVID-19 • Right bundle branch block in COVID-19 is likely secondary to acute right ventricular distension, and could represent the at-risk right ventricle. • Markers of left ventricular stiffness (atrial premature contractions, prolonged intraventricular conduction, and ischemic repolarization abnormalities) are associated with death., Background Coronavirus disease 2019 (COVID-19) is a respiratory syndrome with high rates of mortality, and there is a need for easily obtainable markers to provide prognostic information. We sought to determine whether the electrocardiogram (ECG) on hospital presentation provides prognostic information, specifically related to death. Methods and Results We performed a retrospective cohort study in patients with COVID-19 who had an ECG at or near hospital admission. Clinical characteristics and ECG variables were manually abstracted from the electronic health record and first ECG. Our primary outcome was death. There were 756 patients who presented to a large New York City teaching hospital with COVID-19 who underwent an ECG. The mean age was 63.3 ± 16 years, 37% were women, 61% of patients were nonwhite, and 57% had hypertension; 90 (11.9%) died. In a multivariable logistic regression that included age, ECG, and clinical characteristics, the presence of one or more atrial premature contractions (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.23–5.36, P = .01), a right bundle branch block or intraventricular block (OR 2.61, 95% CI 1.32–5.18, P = .002), ischemic T-wave inversion (OR 3.49, 95% CI 1.56–7.80, P = .002), and nonspecific repolarization (OR 2.31, 95% CI 1.27–4.21, P = .006) increased the odds of death. ST elevation was rare (n = 5 [0.7%]). Conclusions We found that patients with ECG findings of both left-sided heart disease (atrial premature contractions, intraventricular block, repolarization abnormalities) and right-sided disease (right bundle branch block) have higher odds of death. ST elevation at presentation was rare., Graphical Abstract Image, graphical abstract

Among 29,701 Black and White participants aged 45 years and older in the Reasons forGeographic and Racial Difference in Stroke (REGARDS) study, allostatic load (AL) was defined asthe sum score of established baseline risk-associated biomarkers for which participants exceeded aset cutoff point. Cox proportional hazard regression was utilized to determine the association of ALscore with all-cause and cancer-specific mortality, with analyses stratified by body-mass index, agegroup, and race. At baseline, Blacks had a higher AL score compared with Whites (Black mean ALscore: 2.42, SD: 1.50, White mean AL score: 1.99, SD: 1.39, p &lt, 0.001). Over the follow-up period,there were 4622 all-cause and 1237 cancer-specific deaths observed. Every unit increase in baselineAL score was associated with a 24% higher risk of all-cause (HR: 1.24, 95% CI: 1.22, 1.27) and a 7%higher risk of cancer-specific mortality (HR: 1.07, 95% CI: 1.03, 1.12). The association of AL withoverall- and cancer-specific mortality was similar among Blacks and Whites and across age-groups,however the risk of cancer-specific mortality was higher among normal BMI than overweight orobese participants. In conclusion, a higher baseline AL score was associated with increased risk ofall-cause and cancer-specific mortality among both Black and White participants. Targetedinterventions to patient groups with higher AL scores, regardless of race, may be beneficial as astrategy to reduce all-cause and cancer-specific mortality.

Peer support provides benefits across varied health concerns. As opposed to simple offer of support, however, predictors of and importance of levels of participation are not well understood. Analyses of 7 peer support interventions, with 1,612 participants address these questions, first identifying characteristics that predict participation, and then examining whether, controlling for those characteristics, participation itself predicts benefit, using reduced HbA1c as an indicator of benefit. From the U.S. (5 sites), Hong Kong, and the UK, interventions shared emphases on peer supporters helping adults with type 2 diabetes improve disease management. Common data included pre/post hemoglobin A1c (HbA1c), contacts of participants with peer supporters, health literacy, availability/satisfaction with support for diabetes management from family/clinical team, and gender, age, education, and years with diabetes. From structural equation modeling, significant findings indicated 1) older age and lower levels of support for diabetes management predicted more contacts with peer supporters, and 2) more contacts predicted lower levels of final HbA1c. Effects of contacts on HbA1c included those with baseline HbA1c > 7.5% or > 9%. No contacts and tertiles of low, moderate, and high contacts showed a linear, dose-response relationship with final HbA1c (p < 0.001). Baseline and covariate-adjusted, final HbA1c was 8.19% versus 7.85% for those with no and high contacts, respectively. Among those using insulin (29.7%), only those in the high group achieved greater benefit than those with no contacts. Reflecting other findings that peer support reaches/benefits those at greater disadvantage, those reporting less social support for diabetes management were more likely to participate in peer support. Participation in turn predicted better glycemic control across levels of baseline glycemic control and in a dose response relationship across levels of participation. Disclosure G.X. Ayala: None. J.C. Chan: None. A. Cherrington: None. J.P. Elder: None. E.B. Fisher: Research Support; Self; Merck Foundation, Sanofi China. M. Heisler: None. A. Howard: None. H. Parada: None. M. Safford: None. D. Simmons: None. T.S. Tang: None. Funding Merck Foundation; Eli Lilly and Company Foundation; Bristol-Myers Squibb Foundation

Both diabetes and hypertension increase risk for mild cognitive impairment (MCI) and both rely on medications for control. MCI may impede medication adherence, but this has not been well studied. We examined the association between MCI, defined as missing ≥3 items on the validated Six-Item Screener (SIS), and 19 self-reported barriers to medication taking. Negative binomial logistic regression adjusted for demographic characteristics, physical and mental health, social support, depressive symptoms, and total medication count. Participants in a cluster randomized trial (n=1243; all African Americans with persistently uncontrolled hypertension; 62% female; 43% with diabetes) testing interventions to improve BP control, were studied at baseline. Patients with diabetes were older (59 vs. 56 yrs.), took more medications (14 vs. 9), and were significantly more likely to report too many daily doses (20% vs. 14%; p Disclosure D.M. Cummings: Research Support; Self; Novo Nordisk Inc. S. Singh: None. A. Adams: None. S.P. Patil: Research Support; Self; Novo Nordisk Inc. S. Hart: None. A. Cherrington: None. J. Halladay: None. J.B. Ringel: None. E. Baquero: None. M. Safford: None. Funding National Heart, Lung, and Blood Institute (4UH3HL130691)

Background: Diabetes (DM) is more prevalent among rural adults in the U.S. However, it is unclear if coronary heart disease (CHD) risk among adults with DM varies by urbanicity. Methods: This study included 3,578 of the REGARDS Study participants with DM at baseline (2003-07). Each participant’s address was categorized as urban, large rural, small rural or isolated small rural tract using Rural and Urban Commuting Areas categories. Incident CHD events through 12/31/2016 were adjudicated. Cox regression with robust standard errors accounting for geographic clustering was used to obtain hazard ratios and 95% CIs. Results: Mean age of participants was 64.8 years, 56% were women, and 60% were Black adults. At baseline, 82.5% lived in urban, 10.7% in large rural, 5.3% in small rural and 1.5% in isolated small rural tracts. During a median 9.4 years, 358 incident CHD events occurred. CHD incidence among those in isolated small rural tracts was doubled compared to urban tracts, while those in large or small rural tracts had similar rates as those in urban tracts (Table). Controlling for individual-level and community-level factors minimally attenuated the association. Conclusion: Differences in the environmental attributes of these communities may contribute to the increased risk of CHD in isolated rural areas. Disclosure G. Malla: None. D. Long: None. A. Cherrington: None. M. Safford: None. D.M. Cummings: Research Support; Self; Novo Nordisk Inc. T.P. McAlexander: None. S. De Silva: None. S. Judd: None. B. Hidalgo: None. E.B. Levitan: Advisory Panel; Self; Amgen. Consultant; Self; Novartis Pharmaceuticals Corporation. Research Support; Self; Amgen. A.P. Carson: Research Support; Self; Amgen. Funding National Institute of Neurological Disorders and Stroke; National Institutes of Health; Department of Health and Human Services (U01NS041588); Centers for Disease Control and Prevention (U01DP006302)

Objective To characterize patients with coronavirus disease 2019 (covid-19) in a large New York City medical center and describe their clinical course across the emergency department, hospital wards, and intensive care units. Design Retrospective manual medical record review. Setting NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical center in New York City. Participants The first 1000 consecutive patients with a positive result on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to the emergency department or were admitted to hospital between 1 March and 5 April 2020. Patient data were manually abstracted from electronic medical records. Main outcome measures Characterization of patients, including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition. Results Of the first 1000 patients, 150 presented to the emergency department, 614 were admitted to hospital (not intensive care units), and 236 were admitted or transferred to intensive care units. The most common presenting symptoms were cough (732/1000), fever (728/1000), and dyspnea (631/1000). Patients in hospital, particularly those treated in intensive care units, often had baseline comorbidities including hypertension, diabetes, and obesity. Patients admitted to intensive care units were older, predominantly male (158/236, 66.9%), and had long lengths of stay (median 23 days, interquartile range 12-32 days); 78.0% (184/236) developed acute kidney injury and 35.2% (83/236) needed dialysis. Only 4.4% (6/136) of patients who required mechanical ventilation were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at three to four days, and at nine days. As of 30 April, 90 patients remained in hospital and 211 had died in hospital. Conclusions Patients admitted to hospital with covid-19 at this medical center faced major morbidity and mortality, with high rates of acute kidney injury and inpatient dialysis, prolonged intubations, and a bimodal distribution of time to intubation from symptom onset.

BackgroundOutcomes following heart failure (HF) hospitalizations are poor, with 90‐day mortality rates of 15% to 20%. Although prior studies found associations between individual social determinants of health (SDOH) and post‐discharge mortality, less is known about how an individuals’ total burden ofSDOHaffects 90‐day mortality.Methods and ResultsWe included participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study who were Medicare beneficiaries aged ≥65 years discharged alive after an adjudicatedHFhospitalization. Guided by the Healthy People 2020 Framework, we examined 9SDOH. First, we examined age‐adjusted associations between eachSDOHand 90‐day mortality; those associated with 90‐day mortality were used to create anSDOHcount. Next, we determined the hazard of 90‐day mortality by theSDOHcount, adjusting for confounders. Over 10 years, 690 participants were hospitalized forHFat 440 unique hospitals in the United States; there were a total of 79 deaths within 90 days. Overall, 28% of participants had 0SDOH, 39% had 1, and 32% had ≥2. Compared with those with 0, the age‐adjusted hazard ratio for 90‐day mortality among those with 1SDOHwas 2.89 (95% CI, 1.46–5.72) and was 3.06 (1.51–6.19) among those with ≥2SDOH. The adjusted hazard ratio was 2.78 (1.37–5.62) and 2.57 (1.19–5.54) for participants with 1SDOHand ≥2, respectively.ConclusionsWhile having any of theSDOHstudied here markedly increased risk of 90‐day mortality after anHFhospitalization, a greater burden ofSDOHwas not associated with significantly greater risk in our population.

ObjectiveTo characterize patients with coronavirus disease 2019 (COVID-19) in a large New York City (NYC) medical center and describe their clinical course across the emergency department (ED), inpatient wards, and intensive care units (ICUs).DesignRetrospective manual medical record review.SettingNewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), a quaternary care academic medical center in NYC.ParticipantsThe first 1000 consecutive patients with laboratory-confirmed COVID-19.MethodsWe identified the first 1000 consecutive patients with a positive RT-SARS-CoV-2 PCR test who first presented to the ED or were hospitalized at NYP/CUIMC between March 1 and April 5, 2020. Patient data was manually abstracted from the electronic medical record.Main outcome measuresWe describe patient characteristics including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition.ResultsAmong the first 1000 patients, 150 were ED patients, 614 were admitted without requiring ICU-level care, and 236 were admitted or transferred to the ICU. The most common presenting symptoms were cough (73.2%), fever (72.8%), and dyspnea (63.1%). Hospitalized patients, and ICU patients in particular, most commonly had baseline comorbidities including of hypertension, diabetes, and obesity. ICU patients were older, predominantly male (66.9%), and long lengths of stay (median 23 days; IQR 12 to 32 days); 78.0% developed AKI and 35.2% required dialysis. Notably, for patients who required mechanical ventilation, only 4.4% were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at 3-4 and 9 days. As of April 30, 90 patients remained hospitalized and 211 had died in the hospital.ConclusionsHospitalized patients with COVID-19 illness at this medical center faced significant morbidity and mortality, with high rates of AKI, dialysis, and a bimodal distribution in time to intubation from symptom onset.

The objective of this study was to determine whether attainment of clinical and lifestyle targets varied by race and sex among adults with diabetes onset in older adulthood. This study included 1420 black and white adults from the REGARDS study without diabetes at baseline (2003-07) but with diabetes onset at the follow-up exam (2013-16). Attainment of clinical targets (A1c8%; blood pressure 140/90 mmHg; and statin use) and lifestyle targets (not smoking; physical activity≥ 4 times/week; and moderate/no alcohol use) was assessed at the follow-up exam. Modified Poisson regression was used to obtain prevalence ratios (PR) for meeting clinical and lifestyle targets stratified by race and sex, separately. The mean age was 71.5 years, 53.6% were female, and 46.1% were black. The majority were aware of their diabetes status (85.7%) and used oral or injectable hypoglycemic medications (64.8%). Overall, 39.4% met all 3 clinical targets and 18.8% met all 3 lifestyle targets. Meeting A1c and blood pressure targets were similar by race and sex. Statin use was more prevalent for men than women among white adults (PR = 1.13; 95% CI = 0.99-1.29) and black adults (PR = 1.23; 95% CI = 1.06-1.43). For lifestyle factors, the non-smoking prevalence was similar by race and sex, while white men were more likely than white women to be physically active. Although the attainment of each clinical and lifestyle target separately was generally high among adults with diabetes onset in older adulthood, race and sex differences were apparent. Comprehensive management of clinical and lifestyle factors in people with diabetes remains suboptimal.

Associations between hypertension and some cardiovascular diseases are stronger in black versus white adults. We examined associations of hypertension, hypertension duration and control with incident heart failure (HF) in black and white REasons for Geographic And Racial Differences in Stroke study participants (n = 25 770) who were followed for incident HF hospitalization (n = 947) from enrollment in 2003-2007 through 2015. Hypertension was defined, using updated US guidelines, as systolic or diastolic blood pressure (BP) ≥130/80 mmHg or antihypertensive medication use. Duration was assessed at baseline, and control was defined as treated BP

Objectives. To determine factors that explain the higher Black:White cardiovascular disease (CVD) mortality rates among US adults. Methods. We analyzed data from the Reasons for Geographic and Racial Differences in Stroke study from 2003 to 2017 to estimate Black:White hazard ratios (HRs) for CVD mortality within subgroups younger than 65 years and aged 65 years or older. Results. Among 29 054 participants, 41.0% who were Black and 54.9% who were women, 1549 CVD deaths occurred. Among participants younger than 65 years, the demographic-adjusted Black:White CVD mortality HR was 2.23 (95% confidence interval [CI] = 1.87, 2.65) and 1.21 (95% CI = 1.00, 1.47) after full adjustment. Among participants aged 65 years or older, the demographic-adjusted Black:White CVD mortality HR was 1.58 (95% CI = 1.39, 1.79) and 1.12 (95% CI = 0.97, 1.29) after full adjustment. When we used mediation analysis, socioeconomic status explained 21.2% (95% CI = 13.6%, 31.4%) and 38.0% (95% CI = 20.9%, 61.7%) of the Black:White CVD mortality risk difference among participants younger than 65 years and aged 65 years or older, respectively. CVD risk factors explained 56.6% (95% CI = 42.0%, 77.2%) and 41.3% (95% CI = 22.9%, 65.3%) of the Black:White CVD mortality difference for participants younger than 65 years and aged 65 years or older, respectively. Conclusions. The higher Black:White CVD mortality risk is primarily explained by racial differences in socioeconomic status and CVD risk factors.

Background Studies examining incident heart failure (HF) have been limited to select populations. To examine incident HF with broader generalizability, there is need to assemble a HF-free cohort using a geographically-diverse sample. We aimed to develop and validate a simple medication-based strategy for assembling a HF-free cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods We examined REGARDS participants with ≥6 months of Medicare inpatient and outpatient claims data at the time of the baseline in-home study examination. To assemble a HF-free cohort, we identified and excluded participants taking HF-specific medications. To validate this approach, we evaluated event rates among this cohort and assessed diagnostic performance using Medicare claims-based definitions of HF as the referent standard. Results Among 28,884 eligible participants, 3125 were excluded from the proposed HF-free cohort, leaving a total of 25,759 (89%) participants. Depending on the Medicare definition used as the referent, the negative predictive value of this approach ranged from 95.0–99.2%. Negative predictive value was stable across age, sex, and race strata. Conclusions The approach to assemble a HF-free cohort in REGARDS can serve as the basis for future studies to examine incident HF in REGARDS and similar studies.

Introduction: Whether plasma lipid levels are associated with stroke risk remains controversial, with even less data for American blacks versus whites. Hypothesis: We hypothesized that abnormal lipid levels are not associated with stroke incidence in either blacks or whites. Methods: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study recruited 30,283 black and white individuals aged 45+ from the contiguous U.S. between 2003 to 2007, participants with a history of stroke at baseline were excluded. Participants were followed until 2018 for stroke events following the WHO definition and confirmed by review of medical records. The association of lipid measures with stroke were assessed using Cox regression models adjusted for traditional CVD risk factors and an age-x-race interaction term. Results: With 27,714 participants (mean age 64.85± 9.43, 59.5% white and 55.4% female), over a median of 11 years of follow up, 1,415 stroke events occurred, of which 599 among blacks. After adjusting for traditional stroke risk factors, there were modest associations between higher total cholesterol and higher LDL, but not higher triglycerides, with stroke risk. There was no evidence of a race interaction. Overall, HDL levels were not associated with stroke risk. However, when stratified by race, whites had a reduced risk of stroke with higher HDL-C, whereas no association was seen among blacks (p-interaction 0.09). Conclusion: In REGARDs, there was a modest association of cholesterol measures with stroke risk. The association for HDL with stroke may be influenced by race, with a less strong association among blacks than among whites.

Background: Stark regional and racial disparities in diabetes prevalence exist in the US. Community-level factors (e.g., median income) have been associated with higher diabetes prevalence. However, few studies have investigated how community-level spatial polarization, specifically in race and income, may relate to diabetes burden. Objective: To investigate the association between the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and income at the community-level, and individual-level diabetes prevalence. Methods: This analysis included 24,752 Black and White adults age ≥ 45 years at baseline (2003-2007) from the REGARDS Study. The ICE measure quantifies the concentration of community affluence and poverty in a census tract using both income and race jointly, with values ranging from -1 (most deprived) to +1 (most privileged). Diabetes was defined as fasting glucose ≥ 126 mg/dL or random glucose ≥ 200 mg/dL or use of diabetes medication. Modified Poisson regression was used to obtain prevalence ratios and 95% CI for the association of ICE quartiles with prevalent diabetes. Results: The overall prevalence of diabetes was 21% and was highest for adults living in the most deprived census tracts (28.3%) and lowest for those living in the most privileged census tracts (12.5%). The association between ICE and prevalent diabetes was graded in crude analyses but attenuated after adjustment for individual-level sociodemographic, lifestyle and clinical factors (Table). Conclusion: Communities with greater polarization in race and income had a higher burden of diabetes. This association was mostly explained by individual-level socioeconomic and lifestyle factors. Further investigation of community-level attributes and how they relate to individual-level factors that increase diabetes risk is needed.

Background: Individual social vulnerabilities to health disparities increase the risk of developing hypertension and lower life expectancy, but their cumulative effect on these outcomes is unknown. Methods: Using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, we included participants aged 45 years or older without hypertension at baseline (i.e., systolic/diastolic blood pressure Results: Among 5425 participants (mean±SD age of 63±10 years, 24% black, and 54% female), 1785 (33%) participants developed hypertension and 1135 (21%) participants died. A greater proportion of black participants developed hypertension and died than did white participants (hypertension, 38% vs 31%; death, 25% vs 20%). The associations between vulnerability count and both hypertension and death were stronger in white participants than black participants (p-value for vulnerability count*race interaction: hypertension = 0.042, death =0.021; Figure 1). Conclusions: The relative effect of multiple social vulnerabilities on hypertension development may be stronger in white adults than black adults. Nonetheless, black adults experience the highest absolute rates of hypertension in all subpopulations.

Background: AF-related thromboembolism increases risk of stroke. Stroke symptoms in the absence of a stroke diagnosis may represent “whispering strokes,” but their association with AF has not been well explored. Objective: To examine cross-sectionally the association between AF and self-reported stroke symptoms in the absence of a stroke diagnosis, and whether associations differ by anticoagulant use. Methods: We examined data from 27,072 REGARDS participants without a history of stroke or transient ischemic attack (TIA) at baseline. The presence, type, and cumulative number of self-reported stroke symptoms were compared between participants with and without self-reported history or ECG evidence of AF. Logistic regression models examined associations between AF and stroke symptoms, adjusting for sociodemographic, socioeconomic, stroke risk factors, and geographic characteristics. To investigate the possibility of stroke symptoms representing embolic stroke, results were stratified by anticoagulant or antiplatelet agent use. Results: The mean age of the sample was 64.4(±9.4), 55.3% were women, and 59.2% were black; 2,124 had evidence of AF. Twenty-nine percent of adults with AF and 17% of those without AF reported at least one stroke symptom. Compared to those without AF, the odds ratio (OR) of any stroke symptom was 2.21 (95% CI 1.88-2.58) among adults with AF not using an anticoagulant or antiplatelet agent and 1.93 (95% CI 1.62-2.30) for those on Aspirin or Plavix only ( Table 1 ). Associations were non-significant for those using Warfarin. Similar patterns were observed by each type and cumulative number of stroke symptoms. Conclusion: The association between AF and stroke symptoms suggests that some stroke symptoms in the absence of a stroke diagnosis may represent sub-clinical or “whispering strokes.” The attenuation of this association with Warfarin use but not antiplatelet agents supports the possibility that stroke symptoms in the absence of a stroke diagnosis represent undiagnosed embolic stroke.

Background: Higher serum urate (SU) levels were shown to causally increase the risk for sudden cardiac death (SCD) in a Mendelian randomization analysis of white adults, most of whom had coronary heart disease (CHD). It is unclear if these results are generalizable to more racially diverse adults without CHD. Objective: To assess the risk for SCD and incident CHD associated with SU levels in adults without a history of CHD using data from a large, population-based cohort of US black and white men and women ≥45 years of age, the REason for Geographic And Racial Differences in Stroke (REGARDS) study. Methods: We conducted a case-cohort analysis of REGARDS study participants without a history of CHD at baseline between 2003 and 2007. Participants were followed for SCD or incident CHD (i.e., myocardial infarction or CHD death excluding SCD) from baseline through December 31, 2013. Baseline SU levels were measured in a random sample of participants (n=840) and among 235 participants with SCD and 851 participants with incident CHD. Results: Participants with higher SU levels were older and more likely to be black and male. The crude hazard ratio (95%CI) per 1 mg/dL higher SU level was 1.26 (1.14, 1.40) for SCD and 1.17 (1.09, 1.26) for incident CHD. Analyses modeling SU levels using splines supported that these associations were linear. After multivariable adjustment, higher SU levels remained associated with an increased risk for SCD, but not for incident CHD ( Table ). There was no effect modification in the association of SU levels with SCD or incident CHD by either age, gender, race or chronic kidney disease. However, the increased risk for SCD associated with higher SU levels was present in whites but not among blacks. Limitations: The study has limited statistical power for subgroup comparisons. Race differences in the association between SU levels and SCD require further investigation. Conclusions: In adults without a history of CHD, higher SU levels appear to be an independent risk factor for SCD, but no association was detected with incident CHD.

Introduction: APOL1 nephropathy risk variants unique to African- ancestry (AA) populations, have an established role in ESRD and cardiovascular outcomes. Ongoing research efforts are now focused on identifying the potential mechanisms resulting in disease phenotypes. While APOL1 is suggested to alter inflammatory pathways in vivo, few studies have assessed if APOL1 risk variants are associated with inflammatory biomarkers in population studies. Hypothesis: We hypothesized that APOL1 variants are associated with inflammatory biomarkers among AA participants from the REGARDS cohort. Methods: We used baseline data on 10,605 AAs aged ≥45 years from the REGARDS cohort. The primary exposure was the presence of APOL1 genotypes assessed using additive, recessive and dominant genetic models. Inflammatory biomarkers were C-reactive protein [CRP], white blood cell count [WBC], serum albumin [sALB], and platelet count [PLT]. We categorized each biomarker into quartiles with the lowest quartile as a reference category. We also created an indicator variable (1 vs. 0) which assigned 1 point for having at least one of three inflammation biomarkers (CRP, WBC, sALB) in the high category(quartile 4[q4] for CRP and WBC, quartile 1 [q1] for sALB) indicative of an abnormal inflammatory profile(AIP). We examined the association between APOL1 and each inflammatory biomarker using multinomial logistic regression models adjusting for age, sex, prevalent conditions (history of stroke, history of coronary heart disease, hypertension, and dyslipidemia), estimated glomerular filtration rate, and principal component of ancestry. We used logistic regression to examine the association between APOL1 and AIP with similar adjustment for covariates. We further stratified the models by diabetes status. Results: Approximately 58% (6,185/10,605) of individuals had at least one APOL1 risk variant. There were 5,916 individuals with no elevated inflammatory levels while 215 had AIP. Those with AIP were more likely to be female, current smokers, and have diabetes. APOL1 was independently associated with PLT and sALB on adjusted associations under additive models [PLT: Odds ratio [OR] (95% confidence interval [95%CI]) = 1.12(1.00-1.28), sALB: OR (95%CI) =1.19(1.06-1.33), OR represents q4 vs q1]. Additionally, APOL1 was associated with a lower odds of AIP (OR 0.93, 95% CI, 0.87-1.00, additive model). Among those with diabetes (N=3,097), the APOL1 risk genotype was associated with lower odds of AIP under a recessive model (OR 0.73, 95% CI, 0.56-0.96) and an additive model (OR 0.86, 95% CI: 0.75-0.98); the results were not significant among those without diabetes. Conclusion: APOL1 risk genotypes are associated with inflammatory biomarkers in a community-based AA sample. These relationships are strongest among those with diabetes.

Background: In addition to traditional measures of cardiovascular health, individuals value the ability to conduct activities of daily living (ADLs) and physical and mental function. Whether myocardial infarction (MI) contributes to declines in these patient-centered health priorities is not known. Objective: To evaluate the association of history of MI with impairments in ADLs and physical and mental function. Methods: We included participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study without history of stroke who completed a study visit and interview in 2013-2016. Participants reported whether they had no difficulty (assigned a valued of 0), some difficulty (assigned a value of 1), or would require help (assigned a value of 2) conducting 12 basic and instrumental ADLs. We summed values across the 12 ADLs to create a score. Higher ADL impairment scores indicate more impairment. We calculated Physical and Mental Component Summary (PCS and MCS) scores from the 12-Item Short Form Health Survey. Higher PCS and MCS scores represent better function. History of MI included clinician-adjudicated MI, self-reported MI, or evidence of MI on electrocardiogram. We used logistic regression to compare prevalence of at least one ADL impairment and linear regression to compare ADL, PCS, and MCS scores between participants with and without history of MI. Results: Among 12,221 participants, 16% (n = 1,960) had a history of MI. The average age at the time of the interview was 72 (SD 8) years, 56% of the population was female, and 36% was black. Compared to participants without a history of MI, participants with a history of MI were more likely to have at least one ADL impairment and had higher average ADL impairment scores and lower average PCS and MCS scores ( Table ). Conclusion: History of MI was associated with more impairments in ADLs and worse physical and mental function in this study population. These findings suggest that prevention of MI may help prevent or delay declines functional status.

Introduction: Previous investigations of the association of a healthy dietary pattern, the Mediterranean (Med) diet, and risk of sudden cardiac death (SCD) are limited and generally have not examined possible differences in those with and without a history of coronary heart disease (CHD). Studies of the associations of a posteriori -derived dietary patterns and risk of SCD are lacking. We conducted analyses of the associations of these dietary patterns with risk of SCD in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Hypothesis: We hypothesized that the Med diet score and adherence to the plant-based dietary pattern would be inversely associated with risk of SCD, adherence to the convenience and Southern dietary patterns would be positively associated with risk of SCD, and that these associations would differ by history of CHD. Methods: REGARDS enrolled 30,239 white and black adults aged ≥45 years from 2003-2007. Participants completed a food frequency questionnaire at baseline, from which 5 dietary patterns were derived through factor analysis: convenience, plant-based, sweets, Southern, and alcohol and salads. Med diet scores were calculated and categorized into 3 groups. SCD events were expert adjudicated. Cox proportional hazards regression was used to model the associations of the dietary patterns and score with SCD events, adjusting for sociodemographics, lifestyle factors, energy intake, anthropometrics, medical conditions, and medications, and stratifying by history of CHD. Results: After excluding participants with missing diet and covariate data and those lost to follow-up, 21,066 participants were included in the analysis. Mean (SD) age was 64.9 (9.3) years, 56.0% were women, 33.2% were black, and 385 (1.8%) experienced SCD during a mean (SD) follow-up of 9.2 (3.4) years. In those without a history of CHD, Med diet score was significantly and inversely associated with risk of SCD (hazard ratio [HR] for group 3 vs. group 1 [referent]: 0.55; 95% confidence interval [CI]: 0.35-0.89; p trend = 0.02), but none of the a posteriori -derived dietary patterns were associated with risk of SCD. However, in those with a history of CHD, Med diet score was not associated with risk of SCD, but the convenience dietary pattern was significantly and positively associated with risk of SCD (HR for quartile 4 vs. quartile 1 [referent]: 1.74; 95% CI: 1.08-2.78; p trend = 0.04), and the sweets dietary pattern was significantly and inversely associated with risk of SCD (HR for quartile 4 vs. quartile 1: 0.56; 95% CI: 0.33-0.94; p trend = 0.01). Conclusions: The associations of dietary patterns with risk of SCD in REGARDS participants differed by history of CHD.

Introduction: Although social determinants of health (SDOH) were shown to be individually associated with incident stroke, few studies explored the effect of multiple SDOH within the same individuals on incident stroke. To address this limitation, we operationalized SDOH as a count and examined its association with incident stroke. This approach is practically appealing in clinical settings - it is easy to calculate and interpret. Hypothesis: We hypothesized that a greater number of SDOH within individuals would be significantly associated with a higher risk of incident stroke. Methods: REGARDS is a prospective cohort of 30,239 black and white adults aged > 45 years recruited in 2003-2007. Sociodemographic, medical history, and stroke risk factors were collected at baseline. To define exposure, we followed the Healthy People 2020 framework, and initially used 10 SDOH to represent 5 domains: education, health, social, economic and neighborhood factors. We selected SDOH that were significantly associated with incident stroke: race, education, income, zip code poverty, health insurance, social isolation, and residence in states with poor public health infrastructure. We then created a primary exposure - a count of SDOH for each individual. The outcome was expert adjudicated incident strokes. Cox proportional hazards models examined associations between a count of SDOH (0, 1, 2, 3+) and incident stroke, adjusting for confounders. Results: This study included 27,813 individuals free from stroke at baseline. We observed 1470 incident strokes during the follow-up. A significant interaction between SDOH count and age resulted in stratification at 75 years. In fully adjusted Cox models, among individuals Conclusions: Individuals

Introduction: Studies of incident heart failure (HF) have provided insights into key risk factors for the disease but have been limited to select populations that often lack geographic, racial, and gender diversity. There is a need to assemble a HF-free cohort using a contemporary, geographically diverse sample. Aim: To develop and validate a strategy for assembling a HF-free cohort from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods: To assemble a HF-free cohort, we identified and excluded REGARDS participants who were taking HF-specific medications at baseline including: digoxin without atrial fibrillation, angiotensin converting enzyme inhibitor/angiotensin receptor blocker plus beta-blocker in the absence of hypertension, carvedilol, spironolactone, loop diuretic or a combination of hydralazine and nitrates. We then examined the subgroup of REGARDS participants with at least 6 months of Medicare claims at the time of the baseline assessment; we evaluated diagnostic performance (negative predictive value, positive predictive value, sensitivity and specificity) using three Medicare claims-based definitions of HF as the referent standard: Hospitalization for HF, Principal Diagnosis of HF, and Any Diagnosis of HF. Results: Among 28,884 eligible participants, 3,125 used HF-specific medications at baseline, leaving 25,759 (89%) participants in the proposed HF-free cohort. Participants in the HF-free cohort had a lower prevalence of coronary disease, atrial fibrillation, and diabetes compared to excluded participants. Depending on the Medicare definition used as the referent, the percent of the HF-free cohort without evidence of HF based on Medicare claims (the negative predictive value) ranged from 95.0-99.2% (Table 1). Negative predictive value was stable across age, sex, and race strata. Conclusions: This medication-based strategy to assembling a HF-free cohort in REGARDS can serve as a basis for future studies to examine incident HF in REGARDS and similar studies.

Background: Cardiovascular disease is the leading cause of mortality among Haitian adults, having surpassed HIV in the last decade. The natural history of CVD in Haitians including the age of onset, incidence, and role of major risk factors and social determinants is urgently needed to develop prevention and treatment interventions. Objective: This study fills this gap by establishing the first population-representative longitudinal cohort of adults in metropolitan Port-au-Prince to estimate the prevalence and incidence of cardiovascular risk factors, diseases, and associated poverty-related determinants. Methods: The cohort will include 3,000 adults ≥ 18 years, followed for 2-3.5 years, using multistage random sampling from census blocks. Randomly-generated GPS locations were selected in proportion to the estimated population of each block. Community health workers identify one household systematically at each location, collect household information and measure blood pressure during a single visit. Two adults who live in each household are randomly selected to participate in the longitudinal study. Data is collected at baseline and every six months on risk factors (hypertension, diabetes, obesity, dyslipidemia, kidney disease, poor diet, smoking, physical inactivity, and inflammation) and diseases (myocardial infarction, heart failure, stroke and CVD mortality) using AHA definitions. We also measure stress, social isolation, depression, food insecurity and blood lead exposure. Blood, urine, and stool samples are biobanked at enrollment. We report the first 7 months of prevalence data. Results: A total of 585 households (response rate 97%) were surveyed with 566 participants enrolled (51% response rate). The majority of participants are women (73%) with median age 38.5 years with 30% 18-30 years. Over 90% live in extreme poverty ( 30 kg/m 2 ), and 5.1% diabetes. Heart failure was the most common CVD (9.8%), followed by angina/MI (5.6%), and stroke (3.3%). Impact: This study will provide invaluable insights into the epidemiology of CVD in Haiti. The study also builds a platform for comparison research with existing US CVD cohorts. Our goal is to translate findings from this study into pragmatic prevention and treatment interventions to fight the CVD epidemic in Haiti and in Haitian immigrants in the US.

Introduction: Abnormal plasma lipid levels associate with coronary heart disease (CHD) risk. Race interaction for these associations are not established. Hypothesis: We hypothesized that the association of HDL, LDL, and triglyceride with CHD is stronger in whites versus blacks. Methods: The REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort recruited 30,283 black and white individuals aged 45+ from the contiguous U.S. from 2003-7. Participants were followed until December 31, 2016 for CHD events (i.e., myocardial infarction or CHD death), participants with history of CHD at baseline were excluded. Cox regression models were used to assess the association between baseline lipids and incident CHD events adjusting for traditional cardiovascular risk factors. Results: With 23,894 participants (57.8% white and 58.4% female, mean age 64.11± 9.32), over a median 9.9 years of follow-up, 1,487 CHD events occurred (615 among blacks). Overall, higher total Cholesterol, LDL cholesterol, and triglycerides were associated with increased risk of CHD in both blacks and whites with no evidence of a race interaction (Table 1). For HDL, the point estimate was more protective in whites (HR 0.90) than in blacks (HR 0.98), but the interaction was non-significant (p=0.15). However, when HDL was stratified into clinical categories ( Conclusion: Total cholesterol, LDL, and triglycerides predict CHD risk equally in blacks and whites in the REGARDS study, however there is heterogeneity in the protective effect by race, especially when traditional clinical categories are used. In whites, higher HDL is associated with reduced risk, whereas in blacks the association is not maintained. These findings suggest that HDL levels are a more viable metric for white than blacks to predict CHD risk.

Background: Multiple socially determined vulnerabilities (SDV) to health disparities often cluster within the same individual. Previous studies have shown that SDV are separately associated with increased risk of heart failure (HF). As there may be a cumulative effect of these SDVs in the same individual, understanding their joint impact on the incidence of HF is critical. Methods: REGARDS is a national prospective cohort study that recruited 30,239 adults Results: The 25,790 participants were followed for a median of 10.1 years (IQR 6.5, 11.9); their mean age at baseline was 64.8, 55%% were women, and 40% were blacks. In age-adjusted models, Black race, low educational attainment, low annual household income, zip code poverty, poor public health infrastructure, and lack of health insurance were significantly associated with incident HF. In fully adjusted models, among those 45-64 years, compared to having no SDV, having a SDV was significantly associated with incident HF, with a trend toward a higher count conferring greater risk (Fig. 1). There was no association in other age groups. Conclusions: An increased number of SDVs was associated with risk of incident HF hospitalization among adults

Background Claims-based algorithms are commonly used to identify sepsis in health services research because the laboratory features required to define clinical criteria may not be available in administrative data. Methods We evaluated claims-based sepsis algorithms among adults in the US aged ≥65 years with Medicare health insurance enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Suspected infections from baseline (2003–2007) through December 31, 2012 were analyzed. Two claims-based algorithms were evaluated: (1) infection plus organ dysfunction diagnoses or sepsis diagnoses (Medicare-Implicit/Explicit) and (2) Centers for Medicare and Medicaid Services Severe Sepsis/Septic Shock Measure diagnoses (Medicare-CMS). Three classifications based on clinical criteria were used as standards for comparison: (1) the sepsis-related organ failure assessment (SOFA) score (REGARDS-SOFA), (2) “quick” SOFA (REGARDS-qSOFA), and (3) Centers for Disease Control and Prevention electronic health record criteria (REGARDS-EHR). Results There were 2217 suspected infections among 9522 participants included in the current study. The total number of suspected infections classified as sepsis was 468 for Medicare-Implicit/Explicit, 249 for Medicare-CMS, 541 for REGARDS-SOFA, 185 for REGARDS-qSOFA, and 331 for REGARDS-EHR. The overall agreement between Medicare-Implicit/Explicit and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR was 77, 79, and 81%, respectively, sensitivity was 46, 53, and 57%, and specificity was 87, 82, and 85%. Comparing Medicare-CMS and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR, agreement was 77, 87, and 85%, respectively, sensitivity was 27, 41, and 36%, and specificity was 94, 92, and 93%. Events meeting the REGARDS-SOFA classification had a lower 90-day mortality rate (140.7 per 100 person-years) compared with the Medicare-CMS (296.1 per 100 person-years), REGARDS-qSOFA (238.6 per 100 person-years), Medicare-Implicit/Explicit (219.4 per 100 person-years), and REGARDS-EHR classifications (201.8 per 100 person-years). Conclusion Claims-based sepsis algorithms have high agreement and specificity but low sensitivity when compared with clinical criteria. Both claims-based algorithms identified a patient population with similar 90-day mortality rates as compared with classifications based on qSOFA and EHR criteria but higher mortality relative to SOFA criteria.

BACKGROUND: Whether patients’ reports of gaps in care coordination reflect clinically significant problems is unclear. OBJECTIVE: To determine any association between patient-reported gaps in care coordination and patient-reported preventable adverse outcomes. DESIGN AND PARTICIPANTS: We administered a cross-sectional survey on experiences with healthcare to participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were ≥ 65 years old. Of the 15,817 participants in REGARDS at the time of our survey (August 2017–November 2018), 11,138 completed the survey. We restricted the sample to participants who reported ≥ 2 ambulatory visits and ≥ 2 ambulatory providers in the past year (N = 7568). MAIN MEASURES: We considered 7 gaps in ambulatory care coordination, elicited with previously validated questions. We considered 4 outcomes: (1) a test that was repeated because the doctor did not have the result of the first test, (2) a drug-drug interaction that occurred due to multiple prescribers, (3) an emergency department visit that could have been prevented by better communication among providers, and (4) a hospital admission that could have been prevented by better communication among providers. We used logistic regression to determine the association between ≥ 1 gap in care coordination and ≥ 1 preventable outcome, adjusting for potential confounders. KEY RESULTS: The average age of the sample was 77.0 years; 55% were female, and 34% were African-American. More than one-third of participants (38.1%) reported ≥ 1 gap in care coordination and nearly one-tenth (9.8%) reported ≥ 1 preventable outcome. Having ≥ 1 gap in care coordination was associated with an increased odds of ≥ 1 preventable outcome (adjusted odds ratio 1.55; 95% confidence interval 1.33, 1.81). CONCLUSIONS: Participants’ reports of gaps in care coordination were associated with an increased odds of preventable adverse outcomes. Future interventions should leverage patients’ observations to detect and resolve gaps in care coordination. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06047-y) contains supplementary material, which is available to authorized users.

BACKGROUND: Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE: To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS: We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003–2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES: We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS: The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION: High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health. SUPPLEMENTARY INFORMATION: The online version of this article (10.1007/s11606-020-06305-z) contains supplementary material, which is available to authorized users.

Objectives Patient-Reported Outcomes Measurement Information System (PROMIS) measures can monitor patients with chronic illnesses outside of healthcare settings. Unfortunately, few applications that collect electronic PROMIS measures are designed using inclusive design principles that ensure wide accessibility and usability, thus limiting use by older adults with chronic illnesses. Our aim was to establish the feasibility of using an inclusively designed mobile application tailored to older adults to report PROMIS measures by examining (1) PROMIS scores collected with the application, (2) patient-reported usability of the application, and (3) differences in usability by age. Design Cross-sectional feasibility study. Setting Inpatient and outpatient cardiac units at an urban academic medical center. Participants A total of 168 English- and Spanish-speaking older adults with heart failure. Intervention Participants used an inclusively designed mobile application to self-report PROMIS measures. Measurements Eleven PROMIS Short-Form questionnaires (Anxiety, Ability to Participate in Social Roles and Activities, Applied Cognition-Abilities, Depression, Emotional Distress-Anger, Fatigue, Global Mental Health, Global Physical Health; Pain Interference, Physical Function, Sleep Disturbance), and a validated health technology usability survey measuring Perceived Ease-of-Use and Usefulness of the application. Results Overall, 27% of participants were between 65 and 74 years of age, 10% were 75 years or older, 63% were male, 32% were white, and 96% had two or more medical conditions. There was no missing PROMIS data, and mean PROMIS scores showed the greatest burden of pain, fatigue, and physical function in the sample. Usability scores were high and not associated with age (Perceived Ease-of-Use P = .77; Perceived Usefulness P = .91). Conclusion It is feasible for older adults to use an inclusively designed application to report complete PROMIS data with high perceived usability. To ensure data completeness and the opportunity to study multiple domains of physical, mental, and social health, future work should use inclusive design principles for applications collecting PROMIS measures among older adults. J Am Geriatr Soc 68:1313-1318, 2020.

Background Experimental and observational research has suggested the potential for increased type 2 diabetes (T2D) risk among populations taking statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, few studies have directly compared statin-associated benefits and harms or examined heterogeneity by population subgroups or assumed treatment effect. Thus, we compared ASCVD risk reduction and T2D incidence increases across 3 statin treatment guidelines or recommendations among adults without a history of ASCVD or T2D who were eligible for statin treatment initiation. Methods and findings Simulations were conducted using Markov models that integrated data from contemporary population-based studies of non-Hispanic African American and white adults aged 40–75 years with published meta-analyses. Statin treatment eligibility was determined by predicted 10-year ASCVD risk (5%, 7.5%, or 10%). We calculated the number needed to treat (NNT) to prevent one ASCVD event and the number needed to harm (NNH) to incur one incident case of T2D. The likelihood to be helped or harmed (LHH) was calculated as ratio of NNH to NNT. Heterogeneity in statin-associated benefit was examined by sex, age, and statin-associated T2D relative risk (RR) (range: 1.11–1.55). A total of 61,125,042 U.S. adults (58.5% female; 89.4% white; mean age = 54.7 years) composed our primary prevention population, among whom 13–28 million adults were eligible for statin initiation. Overall, the number of ASCVD events prevented was at least twice as large as the number of incident cases of T2D incurred (LHH range: 2.26–2.90). However, the number of T2D cases incurred surpassed the number of ASCVD events prevented when higher statin-associated T2D RRs were assumed (LHH range: 0.72–0.94). In addition, females (LHH range: 1.74–2.40) and adults aged 40–50 years (LHH range: 1.00–1.14) received lower absolute benefits of statin treatment compared with males (LHH range: 2.55–3.00) and adults aged 70–75 years (LHH range: 3.95–3.96). Projected differences in LHH by age and sex became more pronounced as statin-associated T2D RR increased, with a majority of scenarios projecting LHHs < 1 for females and adults aged 40–50 years. This study’s primary limitation was uncertainty in estimates of statin-associated T2D risk, highlighting areas in which additional clinical and public health research is needed. Conclusions Our projections suggest that females and younger adult populations shoulder the highest relative burden of statin-associated T2D risk., Joseph Engada and colleagues model the reduction in cardiovascular disease risk across three statin treatment guidelines., Author summary Why was this study done? Statins are a widely prescribed medication used to prevent atherosclerotic cardiovascular disease (ASCVD). Past research has suggested the potential for increased type 2 diabetes (T2D) risk among populations taking statins. Few studies have compared statin-associated benefits (ASCVD prevention) and statin-associated harms (increased T2D incidence) using different statin treatment guidelines and recommendations in contemporary U.S. populations or by population subgroups defined by age and sex. What did the researchers do and find? We developed a simulation model to compare statin treatment guidelines and recommendations in a U.S. population without T2D or a previous ASCVD event by synthesizing data from contemporary population-based studies with published meta-analyses. Using the model, our projections suggested that the number of ASCVD events prevented was at least twice as large as the number of incident cases of T2D incurred. However, the number of T2D cases incurred surpassed the number of ASCVD events prevented when higher statin-associated T2D relative risks (RRs) were assumed. Our models also suggest that females and the youngest adults received lower absolute benefits of statin treatment compared with males and the oldest adults. Projected differences by age and sex also were more pronounced as the effect of statins on T2D was increased. For females and younger populations, a majority of these scenarios suggested that the number of new T2D cases was greater than the number of ASCVD events prevented. What do these findings mean? Our projections suggested that females and younger adult populations shoulder the highest relative burden of statin-associated T2D risk. Clinical and public health research to more precisely quantify statin’s effects on T2D is needed given the sensitivity of projections to this simulation parameter.

PURPOSE: Cognitive behavioral therapy (CBT)–based programs delivered by trained community members could improve functioning and pain in individuals who lack access to such programs. We tested the effectiveness of a peer-delivered diabetes self-management program integrating CBT principles in improving physical activity, functional status, pain, quality of life (QOL), and health outcomes in individuals with diabetes and chronic pain. METHODS: In this community-based, cluster-randomized controlled trial, intervention participants received a 3-month, peer-delivered, telephone-administered program. Attention control participants received a peer-delivered general health advice program. Outcomes were changes in functional status and pain (Western Ontario and McMaster Universities Osteoarthritis Index), QOL (Short Form 12), and physiologic measures (hemoglobin A(1c), systolic blood pressure, body mass index); physical activity was the explanatory outcome. RESULTS: Of 195 participants with follow-up data, 80% were women, 96% African Americans, 74% had annual income

Patients with cancer may be at increased risk of severe coronavirus disease 2019 (COVID-19), but the role of viral load on this risk is unknown We measured SARS-CoV-2 viral load using cycle threshold (CT) values from reverse transcription-polymerase chain reaction assays applied to nasopharyngeal swab specimens in 100 patients with cancer and 2914 without cancer admitted to three New York City hospitals Overall, the in-hospital mortality rate was 39 5% among patients with a high viral load (CT25), 25 6% among patients with a medium viral load (CT 25-30), and 15 7% among patients with a low viral load (CT30;P0 001) Similar findings were observed in patients with cancer (high, 45 0% mortality;medium, 29 2%;low, 13 9%;P=0 003) Patients with hematologic malignancies had higher median viral loads (CT=25 0) than patients without cancer (CT=29 2;P=0 0039) SARS-CoV-2 viral load results may offer vital prognostic information for patients with and without cancer who are hospitalied with COVID-19