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Background: Is the high stroke mortality in the Southeastern parts of the United States driven by differences in stroke incidence or case-fatality? This question remains unanswered. Differences in incidence would underscore the need for stroke prevention, while differences in case fatality would call for improved stroke care. Methods: Quartiles of US counties were defined by stroke mortality, and this gradient was related with stroke incidence and stroke case fatality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, where 1,317 incident stroke events (of which 242 were fatal) occurred among 29,650 participants. Results: There was a significant (p = 0.0025) gradient of fatal stroke events in REGARDS (quartile 4 vs. quartile 1 (Q4/Q1) hazard ratio 1.95, 95% CI 1.35-2.81), demonstrating the consistency of REGARDS with national mortality data. The gradient for incident stroke (fatal + nonfatal) was also significant (p = 0.0023; Q4/Q1 hazard ratio 1.29, 95% CI 1.10-1.52). The gradient for stroke case-fatality was marginally significant (p = 0.058), though the OR for Q4/Q1 (1.71, 95% CI 1.13-2.25) was large. Conclusions: Both stroke incidence and case-fatality in REGARDS appear to be contributing, underscoring the need for strengthening both stroke prevention and acute stroke care in order to reduce the disparity.

Background/Aims: Acute kidney injury (AKI) frequently occurs in hospitalized patients. In this study, we determined prehospitalization characteristics associated with AKI in community-dwelling adults hospitalized for a serious infection. Methods: We used prospective data from 30,239 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national cohort of community-dwelling adults ≥45 years old. We identified serious infection hospitalizations between 2003 and 2012. Using the Kidney Disease Improving Global Outcomes (KDIGO) criteria, we defined AKI as an increase in serum creatinine (sCr) ≥0.3 mg/dl from the first inpatient sCr measurement during the first 7 hospitalization days. We excluded individuals with a history of renal transplant or preexisting end-stage renal disease as well as individuals with Results: Over a median follow-up of 4.5 years (interquartile range 2.4-6.3), we included 2,074 serious infection hospitalizations among 1,543 individuals. AKI occurred in 296 of 2,074 hospitalizations (16.5%). On multivariable analysis, prehospitalization characteristics independently associated with AKI among individuals hospitalized for a serious infection included a history of diabetes [odds ratio (OR) 1.38; 95% CI 1.02-1.89], increased cystatin C (OR 1.73 per SD; 95% CI 1.20-2.50), and increased albumin-to-creatinine ratio (OR 1.19 per SD; 95% CI 1.007-1.40). Sex, race, hypertension, myocardial infarction, estimated glomerular filtration rate, high-sensitivity C-reactive protein, and the use of nonsteroidal anti-inflammatory, statin, or antihypertensive medications were not associated with AKI. Conclusions: Community-dwelling adults with a history of diabetes or increased cystatin C or albumin-to-creatinine ratio are at increased risk for AKI after hospitalization for a serious infection. These findings may be used to identify individuals at high risk for AKI.

Aims To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes. Methods We included 22,807 black and white men and women aged 45–98 years at baseline (2003–2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥ 4 on the 4-item Centers for Epidemiologic Studies of Depression Scale. Participants were classified as having diabetes, prediabetes, or no prediabetes/diabetes based on glucose levels and diabetes medication use. All-cause mortality events were available through 2018 and adjudicated CVD mortality events were available through 2015. Results During follow-up, there were 5383 all-cause deaths, of which 1585 were adjudicated CVD deaths. The mean survival time was lower for participants with elevated depressive symptoms than those without elevated depressive symptoms for those with diabetes, prediabetes, and no prediabetes/diabetes. In multivariable adjusted models, elevated depressive symptoms increased the risk of all-cause mortality for those with diabetes (HR = 1.15; 95% CI = 1.00–1.32), prediabetes (HR = 1.56; 95% CI = 1.28–1.91), and neither prediabetes/diabetes (HR = 1.34; 95% CI = 1.19–1.50) (p for interaction = 0.0342). Findings were similar for CVD mortality. Conclusion Elevated depressive symptoms increased the risk of all-cause and CVD mortality among individuals with and without diabetes, with a stronger magnitude of association observed among those with prediabetes. This underscores the need for assessing depressive symptoms across the glycemic spectrum, including those with prediabetes.

Introduction Given its known role in activating inflammatory and neurohormonal pathways, psychological stress may be an important yet understudied risk factor for incident heart failure (HF). Hypothesis We hypothesized that high perceived stress levels would be associated with incident HF with reduced ejection fraction (HFrEF) and incident HF with preserved ejection fraction (HFpEF). Methods We utilized data from the national REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a large prospective biracial cohort study that enrolled community-dwellers aged 45 years and older between 2003 and 2007. We included participants free of suspected HF at baseline who completed the 4-item Perceived Stress Scale (PSS-4) questionnaire. Our primary outcome was the first adjudicated HF hospitalization or HF death through the end of 2016. We used sequentially-adjusted Cox proportional hazard models to determine if stress was independently associated with incident HF, adjusting for sociodemographics, medical comorbidities, and physiologic parameters. Results Among 25,785 participants of mean age 64 years, 55% were female and 40% were black. Over a median follow-up of 10.1 years, 1109 (4.3%) had an incident HF event (356 HFpEF events and 465 HFrEF events). Compared to participants in the lowest PSS-4 quartile, participants in the highest quartile were more likely to be female, black, and have annual household incomes Conclusions Elevated stress was associated with incident HFpEF but not HFrEF.

Key Points Question Are there differences between Black and White patients in the use of hospice and intensity of end-of-life treatment? Findings In this cohort study of 1212 decedents, Black individuals were significantly less likely to use hospice and more likely to have multiple emergency department visits and hospitalizations and undergo intensive treatment in the last 6 months of life compared with White individuals regardless of cause of death. Meaning Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice care and the intensity of end-of-life treatment remain., Importance Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. Objective To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. Design, Setting, and Participants This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. Main Outcomes and Measures The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. Results The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P, This cohort study uses data from the Reasons for Geographic and Racial Differences in Stroke study to examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.

The beta blockers carvedilol, bisoprolol, and sustained-release metoprolol succinate reduce readmissions and mortality among patients with heart failure with reduced ejection fraction (HFrEF), based upon clinical trial and registry studies. Results from these studies may not generalize to the typical patient with HFrEF. We conducted a retrospective cohort study of beneficiaries in the Medicare 5% sample hospitalized for HFrEF between 2007 and 2013 and were discharged alive. We compared the 30-day and 365-day heart failure (HF) readmission, all-cause readmission, and mortality rates between beneficiaries who filled a prescription for an evidence-based beta blocker and those who did not after being hospitalized for HFrEF. Out of 12,127 beneficiaries hospitalized for HFrEF, 20% were readmitted for HF, 62% were readmitted for any cause, and 27% died within 365 days. In competing risk models adjusted for demographics, healthcare utilization, and comorbidities, beta blocker use was associated with a lower risk of HF readmission between 8-365 days post discharge (hazard ratio 0.79 [95% confidence interval 0.76, 0.82]), but was not significantly associated with all-cause readmission (1.02 [0.97-1.07]). In Cox models adjusted for the same covariates, beta blocker use was associated with lower mortality 8-365 days post discharge (0.65 [0.60-0.71]). Results were similar when follow up was truncated at 30 days post discharge. Increasing the use of beta blockers following HFrEF hospitalization may not decrease all-cause readmissions among Medicare beneficiaries, but may reduce HF-specific readmissions and mortality.

Objective: To clarify the patient characteristics associated with seeking medical help for insomnia. Methods: A consecutive sample (n = 700) of adults attending a nonurgent primary care appointment was screened for sleep problems. A follow-up mailed survey then assessed insomnia symptoms, daytime impairment, beliefs about sleep, medication use, sleepiness and fatigue, and medical help-seeking. Results: Fifty-two percent of patients with probable insomnia reported discussing this with a physician. Multivariate logistic regression analyses indicated that discussing one’s probable insomnia with a physician was independently associated with having a greater number of medical conditions (OR, 2.19 [95% CI, 1.13 to 4.22]), being more highly educated (1.67 [95% CI, 1.11 to 2.51]), sleeping less per night (OR, 0.71 [95% CI, 0.52 to 0.96]), and greater perceived daytime impairment due to insomnia (OR, 2.07 [95% CI, 1.06 to 4.03]). Conclusions: Primary care patients often seek medical help when they experience insomnia. Clinical treatment ought to especially target poor sleepers presenting with significant insomnia-related impairment, medical morbidity, or both. Future research should further clarify the role of medical and psychiatric comorbidities and determine whether resolution of insomnia and its consequences improves the outcomes of common medical conditions.

Introduction Racial disparities have been documented in hematopoietic cell transplantation (HCT), a complex and expensive therapeutic modality for hematologic malignancies. Prior work suggests that racial minorities in the US have lower rates of utilization of HCT compared to White patients. However, the available literature on racial disparities in HCT is limited, particularly with regard to lymphoma patients. Objectives The objective of this study was to determine if racial differences exist in utilization of HCT for lymphoma by comparing transplant activity to disease incidence rates between 2013-2016. Methods This was a retrospective cohort study using publicly available data from the Center for International Blood and Marrow Transplant Research; Surveillance, Epidemiology, End Results program; and US Census Bureau. All patients in the US who underwent HCT for Hodgkin lymphoma (HL) and Non-Hodgkin lymphoma (NHL) between 2013-2016 were included. Patients with unknown race or multiple races were excluded. We assessed transplant utilization by calculating the transplant utilization rate (TUR) for each disease, separately. Rates were operationalized as the number of transplants performed per 100 new cases of the disease diagnosed in the US during the same time period. Results There were a total of 18,569 transplants for HL and NHL included. Table 1 shows patient characteristics by transplant type. During the same time period, age-adjusted incidence rates [95% confidence interval (CI)] for HL for Whites, Blacks, Asians/Pacific Islanders (API), and American Indians/Alaska Natives (AI) were 2.65 (2.59-2.71), 2.61 (2.46-2.77), 1.24 (1.14-1.36), and 1.00 (0.73-1.34) cases/100,000 persons at risk, respectively. Incidence rates were higher for NHL for the same racial groups at 20.22 (20.05-20.38), 14.44 (14.06-14.82), 13.53 (13.16-13.90), and 8.75 (7.82-9.75), respectively. Transplant and incidence data were consistent from 2013-2016. There were no significant differences in TURs for HL between racial groups. However, Whites with NHL had a higher TUR than Blacks [7.02 (95% CI 6.90-7.13) vs 4.75 (95% CI 4.49-5.02), p Conclusion Autologous HCT for NHL is underutilized for Black patients compared to White patients in the US. Additional research is needed to understand the reasons for this difference.

The 2018 AHA/ACC cholesterol guideline considers adults with a history of ≥2 atherosclerotic cardiovascular disease (ASCVD) events as being at very high risk for future events. We compared the risk for ASCVD events following a myocardial infarction (MI) among patients with a prior history of ASCVD

This study examines the association between inflammatory biomarkers and risk of cancer mortality by race. Data were obtained from 1,856 participants in the prospective REGARDS cohort who were cancer-free at baseline, and analyzed in relation to cancer mortality prospectively. Biomarkers were log-transformed and categorized into tertiles due to non-normal distributions, and Cox proportional hazard regression models were utilized to compute hazard ratios with 95% confidence intervals using robust sandwich methods. Individuals in the highest tertile of IL-6 had over a 12-fold increased risk of cancer mortality (HR: 12.97, 95% CI: 3.46-48.63); those in the highest tertile of IL-8 had over a 2-fold increased risk of cancer mortality (HR: 2.21, 95% CI: 0.86-5.71), while those in the highest tertile of IL-10 had over a 3-fold increased risk of cancer mortality (HR: 3.06, 95% CI: 1.35-6.89). In race-stratified analysis, each unit increase in IL-6 was associated with increased risk of cancer mortality among African-Americans (HR: 3.88, 95% CI: 1.17-12.88) and Whites (5.25, 95% CI: 1.24-22.31). If replicated in larger, racially diverse prospective cohorts, these results suggest that cancer patients may benefit from clinical or lifestyle approaches to regulate systemic inflammation as a cancer prevention strategy.

Although it makes up only 15-20% of all strokes, intracerebral hemorrhage (ICH) is a particularly lethal form of this potentially disabling condition. A recent meta-analysis of 122 studies concluded that the 1-year survival following ICH was 46%, and the 5-year survival was only 29%.1 Furthermore, quality of life for survivors is often very limited.2 A thorough understanding of how to prevent these events is therefore a high priority. In this issue of Circulation , the study by Walsh and colleagues sheds light on several important findings that suggest where attention should be directed to prevent these types of strokes.3 High blood pressure has long been associated with both ischemic and hemorrhagic strokes, and this study including 958 white, 880 black, and 766 Hispanic ICH cases and the same number of age- and sex-matched controls confirmed this strong association overall and by location of the stroke. Two main findings relate to blood pressure: First, high blood pressure was associated with ICH for all ethnicities, and second, this study also showed the large role of untreated high blood pressure on the risk for ICH.

Madeline R Sterling,1 Amy L Shaw,2 Peggy BK Leung,1 Monika M Safford,1 Christine D Jones,3 Emma K Tsui,4 Diana Delgado5 1Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA; 2Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA; 3Division of Hospital Medicine, University of Colorado, Denver, CO, USA; 4Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA; 5Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, NY, USA. Background: Home care workers (HCWs), which include home health aides and personal care aides, are increasingly used by heart failure (HF) patients for post-acute care and long-term assistance. Despite their growing presence, they have largely been left out of HF research and interventions. This systematic review was aimed to 1) describe utilization patterns of HCWs by adults with HF, 2) examine the effect of HCWs on HF outcomes, and 3) review HF interventions that involve HCWs. Methods: Five electronic databases (Ovid MEDLINE, Ovid EMBASE, Cochrane Library [Wiley], CINAHL [EBSCO], and AgeLine [EBSCO]) were searched from inception through August 4, 2017. The yield was screened using prespecified inclusion and exclusion criteria. Two authors independently reviewed references and a third reviewer acted as an arbitrator when needed. Data were extracted from articles that met the inclusion criteria. The Downs and Black checklist was used for quality assessment. Due to study heterogeneity, a narrative synthesis was conducted. Results: Of the 7,032 studies screened, 13 underwent full-text review, and six met the inclusion criteria. Two descriptive studies found that adults with HF who live alone and have functional and cognitive deficits utilize HCWs. While three retrospective cohort studies examined the association between having an HCW post-HF hospitalization and readmission rates, their findings were conflicting. One quasi-experimental study found that an HCW-delivered educational intervention improved HF patients’ self-care abilities. Overall, despite some significant findings, the studies assessed were of poor-to-fair quality (Downs and Black score range: 10–16 [28 total points]), with most lacking methodological rigor. Conclusion: Although HCWs are quite common, the literature on these paraprofessionals in HF is limited. Given the paucity of research in this area and the low quality of studies reviewed here, additional research is warranted on the potential role of HCWs in HF self-care and on outcomes among adults with HF. Keywords: home care workers, congestive heart failure, home health care, systematic review, health services research, quality of care, home health aides

ObjectiveTo examine the perspectives of adults with heart failure (HF) about numerical concepts integral to HF self-care.SettingThis qualitative study took place at an urban academic primary care practice.ParticipantsThirty men and women aged 47–89 years with a history of HF were recruited to participate. Eligibility criteria included: a history of HF (≥1 year), seen at the clinic within the last year, and a HF hospitalisation within the last 6 months. Non-English speakers and those with severe cognitive impairment were excluded.MethodsIn-depth semistructured interviews were conducted. Participants were interviewed about numeracy across three domains of HF self-care: (1) monitoring weight,(2) maintaining a diet low in salt and (3) monitoring blood pressure. Interviews were audio-taped, transcribed verbatim and analysed using grounded theory and word cloud techniques.ResultsFive key themes reflecting participants’ attitudes towards numerical concepts pertaining to weight, diet and blood pressure were identified: (1) Communication between healthcare providers and patients is a complex, multistage process; (2) Patients possess a wide range of knowledge and understanding; (3) Social and caregiver support is critical for the application of numerical concepts; (4) Prior health experiences shape outlook towards numerical concepts and instructions and (5) Fear serves as a barrier and a facilitator to carrying out HF self-care tasks that involve numbers. The findings informed a theoretical framework of health numeracy in HF.ConclusionEffective communication of numerical concepts which pertain to HF self-care is highly variable. Many patients with HF lack basic understanding and numeracy skills required for adequate self-care. As such, patients rely on caregivers who may lack HF training. HF-specific training of caregivers and research that seeks to elucidate the intricacies of the patient–caregiver relationship in the context of health numeracy and HF self-care are warranted.

The objective of this study was to test the feasibility of video discharge education to improve self-efficacy in dealing with medication barriers around hospital discharge. We conducted a single-arm intervention feasibility trial to evaluate the use of video education in participants who were being discharged home from the hospital. The scores of pre- and post-intervention self-efficacy involving medication barriers were measured. We also assessed knowledge retention, patient and nursing feedback, follow-up barrier assessments, and hospital revisits. A total of 40 patients participated in this study. Self-efficacy scores ranged from 5 to 25. Median pre- and post-intervention scores were 21.5 and 23.5, respectively. We observed a median increase of 2.0 points from before to after the intervention (p = 0.046). In total, 95 percent of participants reported knowledge retention and 90 percent found the intervention to be helpful. Video discharge education improved patient self-efficacy surrounding discharge medication challenges among general medicine inpatients. Patients and nurses reported satisfaction with the video discharge education.

RationaleChronic hypersensitivity pneumonitis (CHP) is a distinct form of interstitial lung disease caused by an inhaled environmental antigen. Some patients with CHP develop progressive pulmonary fibrosis and varying degrees of symptom severity, with heterogeneous impact on functioning and overall well-being. There are no universally accepted diagnostic criteria, few FDA-approved (Food and Drug Administration) therapies and no standardised approach to identifying an antigen. The impact that living with CHP has on patients’ quality of life is understudied, preventing the identification of patient-centred research questions and endpoints for future CHP clinical trials.ObjectivesWe explored patients’ experiences, perceptions and expectations of living with CHP.MethodsWe conducted semistructured interviews with patients with CHP. Patients were recruited using a purposive heterogeneous sampling strategy. Interviews were audio recorded and transcribed verbatim. Data were analysed using the grounded theory method.ResultsEighteen patients were interviewed. Six major themes emerged from the interviews: (1) suffering due to lack of knowledge and uncertainty, (2) hypervigilance, (3) psychosocial, (4) physical impacts, (5) interpersonal and (6) self-perception and identity. The need to identify and avoid an antigen played a prominent role across the themes and subthemes.ConclusionsWe identified several key influences on quality of life in patients with CHP that have not been adequately explored. The prevalence of these influences should be quantified, and they should be included in quality of life assessment and should guide the development of targeted interventions to improve quality of life in this patient population.

Purpose Adult secondhand tobacco smoke (SHS) exposure is related to stroke and coronary heart disease (CHD) risk, but long-term effects are less clear. We evaluated whether childhood SHS exposure affects subsequent stroke or CHD risk among adult black and white never-smokers followed for stroke and CHD. Methods In this prospective cohort study, inverse probability weights were calculated to correct for bias due to attrition and survey nonresponse. Cox proportional hazards models were used to assess hazard ratios and 95% confidence intervals for stroke or CHD, separately, by number of childhood household smokers. Results Of 13,142 eligible participants, 6136 had childhood SHS exposure assessed. Baseline mean (SD) age was 63.5 (9.0), 65% were female, 30% black, 46% reported 0 childhood household smokers, 36% reported 1, and 18% reported 2+. In 60,649 person-years, 174 strokes were observed (2.9% of participants), and in 45,195 person-years, 114 CHD events were observed (2.1% of participants). The weighted and adjusted hazard ratios (95% confidence intervals) of stroke for 2+ versus 0 childhood household smokers was 1.66 (1.29–2.13) and was 1.15 (0.82–1.59) for CHD. Conclusions We observed a significant association between childhood SHS exposure and stroke, but not CHD, after age 45 years and adjusting for missing information.

INTRODUCTION: African-Americans (blacks) have higher risk of stroke and coronary heart disease (CHD) - collectively referred to here as cardiovascular disease (CVD), than Caucasian-Americans (whites). Though partly explained by traditional cardiovascular risk factors, half of the excess risk in blacks is not explained by known risk factors. Recent data suggest increased risk of CVD and mortality in individuals with clonal hematopoiesis, which often presents as cytopenia. Using peripheral blood cytopenia as a marker of clonal hematopoiesis, we examined the association between cytopenia and risk of CVD and mortality in blacks and whites. METHODS: The REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study enrolled 30,239 US black and white adults between 2003 and 2007 (41% black). Socio-demographics and medical history were obtained by telephone interview, and laboratory studies (including complete blood count [CBC]) and physical exam from an in-home visit at baseline. Participants or their proxies were contacted every 6 months to ascertain CVD events, hospitalizations or deaths, and medical records were reviewed to confirm these events. Cytopenia was defined using thresholds in Table 1 as presence of 2 or more of the following: i) hemoglobin in age-, sex-, and race-specific lowest 5th percentile; ii) white cell count in race-specific lowest 5th percentile; iii) platelet count in lowest 5th percentile, and iv) macrocytosis (MCV >98fL). Participants with pre-baseline history of stroke (for analyses including stroke or CVD mortality) or CHD (for analyses including CHD or CVD mortality) and those with missing CBC were excluded. Cox proportional hazards models were used to calculate hazard ratios (HRs) of incident CVD and mortality associated with cytopenia. Models adjusted for socio-demographics (Model 1), Framingham stroke or CHD risk factors (Model 2), and estimated glomerular filtration rate and C-reactive protein (Model 3) were used. Differences in the association of cytopenia with outcomes by race were tested using cross-product interaction terms, using a p of RESULTS: The study included 19,544 participants who were followed for a median of ~9 years. There were 798 (4.3% of those at risk) incident stroke cases and 727 (4.3%) incident CHD cases; 1033 (5.3%) died of CVD, and 3933 (20.1%) died of all-causes. Cytopenia was present in 378 (1.9%) participants, ranging from 0.9% to 3.5% in blacks, 1.4 to 3.9% in whites, 1.6 to 3.9% in men, and 0.9 to 1.8% in women, with increasing prevalence by age. There was no association between cytopenia and stroke or CHD risk in any model. However, cytopenia was associated with increased risk of all-cause mortality (HR=1.73, 95%CI: 1.34-2.22), and CVD mortality (HR=1.56, 95% CI: 1.11-2.19) in the extended risk factor Model 3 and also in CVD risk factor adjusted model (Model 2), with little evidence of confounding (Table 2). While the race by cytopenia interaction term was not significant in any model for incident CHD or mortality, the interaction for cytopenia by race for stroke was statistically significant (p-interaction=0.08) in Model 2. The HR of stroke for cytopenia in blacks was 0.86 (95%CI: 0.46-1.61), and for whites was 1.96 (95%CI: 1.0-3.82). CONCLUSION: In this large biracial cohort, cytopenia was associated with increased all-cause and CVD mortality. Cytopenia was a race-specific risk factor for stroke affecting white Americans but not black Americans. With growing knowledge on the role of clonal hematopoiesis in CVD risk and mortality, further work is needed to determine if our phenotype of cytopenia is accurate in classifying clonal hematopoiesis and for determining the mortality risk. Given these findings, assessing clonal hematopoiesis and outcomes related to clonal hematopoiesis in diverse populations is critical to understanding the interactions between somatic mutations in hematopoietic cells and CVD/mortality risk. Disclosures Safford: Amgen: Research Funding.

Importance Atherosclerotic cardiovascular disease (ASCVD) kills approximately 1 in every 3 US women. Current cholesterol, hypertension, and aspirin guidelines recommend calculating 10-year risk of ASCVD using the 2013 Pooled Cohort Equations (PCE). However, numerous studies have reported apparent overestimation of risk with the PCE, and reasons for overestimation are unclear. Objective We evaluated the predictive accuracy of the PCE in the Women’s Health Initiative (WHI), a multiethnic cohort of contemporary US postmenopausal women. We evaluated the effects of time-varying treatments such as aspirin and statins, and ascertainment of additional ASCVD events by linkage with the Centers for Medicare and Medicaid Services (CMS) claims. Design, Setting, and Participants The WHI recruited the largest number of US women (n = 161 808) with the racial/ethnic, geographic, and age diversity of the general population (1993-1998). For this study, we included women aged 50 to 79 (n = 19 995) participating in the WHI with data on the risk equation variables at baseline and who met the guideline inclusion and exclusion criteria. Median follow-up was 10 years. Main Outcomes and Measures For this study, ASCVD was defined as myocardial infarction, stroke, or cardiovascular death. Results Among the 19 995 women (mean [SD] age, 64 [7.3] years; 8305 [41.5%] white, 7688 [38.5%] black, 3491 [17.5%] Hispanic, 103 [0.5%] American Indian, 321 [1.6%] Asian/Pacific Islander, and 87 [0.4%] other/unknown), a total of 1236 ASCVD events occurred in 10 years and were adjudicated through medical record review by WHI investigators. The WHI-adjudicated observed risks were lower than predicted. The observed (predicted) risks for baseline 10-year risk categories less than 5%, 5% to less than 7.5%, 7.5% to less than 10%, and 10% or more were 1.7 (2.8), 4.4 (6.2), 5.3 (8.7), and 12.4 (18.2), respectively. Small changes were noted after adjusting for time-dependent changes in statin and aspirin use. Among women 65 years or older enrolled in Medicare, WHI-adjudicated risks were also lower than predicted, but observed (predicted) risks became aligned after including events ascertained by linkage with CMS for additional surveillance for events: 3.8 (4.3), 7.1 (6.4), 8.3 (8.7), and 18.9 (18.7), respectively. Similar results were seen across ethnic/racial groups. Overall, the equations discriminated risk well (C statistic, 0.726; 95% CI, 0.714-0.738). Conclusions and Relevance Without including surveillance for ASCVD events using CMS, observed risks in the WHI were lower than predicted by PCE as noted in several other US cohorts, but risks were better aligned after including CMS events. Trial Registration ClinicalTrials.gov identifier:NCT00000611

Background Previously, we reported on associations between dietary patterns and incident acute coronary heart disease ( CHD ) in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Here, we investigated the associations of dietary patterns and a dietary index with recurrent CHD events and all‐cause mortality in REGARDS participants with existing CHD . Methods and Results We included data from 3562 participants with existing CHD in REGARDS . We used Cox proportional hazards regression to examine the hazard of first recurrence of CHD events—definite or probable MI or acute CHD death—and all‐cause mortality associated with quartiles of empirically derived dietary patterns (convenience, plant‐based, sweets, Southern, and alcohol and salads) and the Mediterranean diet score. Over a median 7.1 years (interquartile range, 4.4, 8.9 years) follow‐up, there were 581 recurrent CHD events and 1098 deaths. In multivariable‐adjusted models, the Mediterranean diet score was inversely associated with the hazard of recurrent CHD events (hazard ratio for highest score versus lowest score, 0.78; 95% confidence interval, 0.62–0.98; P T rend =0.036). The Southern dietary pattern was adversely associated with the hazard of all‐cause mortality (hazard ratio for Q4 versus Q1, 1.57; 95% confidence interval, 1.28–1.91; P Trend P T rend =0.014). Conclusions The Southern dietary pattern was associated with a greater hazard of all‐cause mortality in REGARDS participants. Greater adherence to the Mediterranean diet was associated with both a lower hazard of recurrent CHD events and all‐cause mortality.

Objective: To identify the contribution of individual and neighborhood factors to the racial disparity in diabetes incidence among older adults. Methods: This study included 7,304 black and white adults, aged 45-91 years at baseline (2003-07), without prevalent diabetes. Incident diabetes was assessed at the 2nd in-home exam (2014-16) using plasma glucose or use of diabetes medications. Modified Poisson regression, stratified by sex, was used to obtain risk ratios. Mediation analyses using the change in beta coefficient method and bootstrapping were done to evaluate the contribution of socioeconomic, anthropometric, lifestyle, clinical and neighborhood factors, grouped separately and all factors combined. Results: The risk of diabetes was 75% higher for black women compared with white women and 35% higher for black men compared with white men (Table). Among men, only lifestyle factors were significant mediators of the racial disparity. In contrast, among women, all grouped factors, except clinical, were significant mediators. When taking into account all factors combined, only 4.2% and 28.1% of the racial disparity was explained for men and women, respectively. Conclusion: Although the factors underlying the racial disparity varied by sex, the excess diabetes risk for black vs. white adults remained after accounting for individual and neighborhood factors. Disclosure A.P. Carson: Research Support; Self; Amgen Inc.. D. Long: None. A. Cherrington: Advisory Panel; Self; AstraZeneca. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Consultant; Self; Novo Nordisk Inc.. G.R. Dutton: None. V.J. Howard: None. T. Brown: Research Support; Self; Amgen Inc., AstraZeneca. C. Moy: None. M. Cushman: None. M. Safford: None. G. Howard: None.

Background Haemostatic balance represented by low protein C (PC) and elevated factor VIII (FVIII) has been inconsistently associated with stroke and coronary heart disease (CHD) risk. Objective This article assesses whether an elevated FVIII and a low PC would increase cardiovascular risk more than either individually. Patients and Methods REGARDS recruited 30,239 black and white U.S. participants aged ≥ 45 years between 2003 and 2007. FVIII and PC were measured in a case–cohort sample of 646 stroke, 654 CHD, and a 1,104-person random sample with follow-up for approximately 4.5 years. Hazard ratios (HRs) were estimated using Cox models adjusted for demographic and cardiovascular risk factors. Results Elevated FVIII (per standard deviation [SD] increase) was associated with increased risk of both stroke (HR, 1.26; 95% confidence interval [CI], 1.08, 1.46) and CHD (HR, 1.52; 95% CI, 1.29, 1.79), while there was no association of PC per SD decrease. For PC, there was a trend towards increased cardiovascular disease risk in the lowest values (bottom 5%). For stroke, there was no interaction between FVIII and low PC (p interaction = 0.55). For CHD, the adjusted HR of FVIII per SD increase was significantly greater with PC in the bottom 5% (HR, 3.59; 95% CI, 1.39, 8.29) than PC in the upper 95% (HR, 1.45; 95% CI, 1.23, 1.71; p interaction = 0.07). Conclusion Higher FVIII was associated with both CHD and stroke risk and the risk potentiated by low PC for CHD. Findings demonstrate that risks for cardiovascular diseases conferred by adverse levels of haemostasis biomarkers may be augmented by levels of other biomarkers.

AimsRelatively little is known about the health outcomes associated with very low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) mainly because of the small numbers of individuals with such extreme values included in clinical trials. We, therefore, investigated the association between low and very low HDL-C concentration at baseline and incident all-cause-mortality, death from malignant disease (i.e. cancer), and with fatal or non-fatal incident coronary heart disease (CHD) in individuals from the Reasons for Geographical And Racial Differences in Stroke (REGARDS) study.Methods and resultsAnalysis was based on 21 751 participants from the REGARDS study who were free of CHD, other cardiovascular disease, and cancer at baseline and were categorized by baseline HDL-C into ConclusionLow HDL-C was associated with reduced risk of incident CHD in black participants suggesting a potential HDL paradox for incident CHD. Very low HDL-C in women was significantly associated with cancer mortality in a fully adjusted complete case model.

Background: APOL1 renal risk variants are strongly associated with chronic kidney disease in Black adults, but reported associations with cardiovascular disease (CVD) have been conflicting. Methods: We examined associations of APOL1 with incident coronary heart disease (n=323), ischemic stroke (n=331), and the composite CVD outcome (n=500) in 10 605 Black participants of the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Primary analyses compared individuals with APOL1 high-risk genotypes to APOL1 low-risk genotypes in Cox proportional hazards models adjusted for CVD risk factors and African ancestry. Results: APOL1 high-risk participants were younger and more likely to have albuminuria at baseline than APOL1 low-risk participants. The risk of incident stroke, coronary heart disease, or composite CVD end point did not significantly differ by APOL1 genotype status in multivariable models. The association of APOL1 genotype with incident composite CVD differed by diabetes mellitus status ( P interaction =0.004). In those without diabetes mellitus, APOL1 high-risk genotypes associated with greater risk of incident composite CVD (hazard ratio, 1.67; 95% confidence interval, 1.12–2.47) compared with those with APOL1 low-risk genotypes in multivariable adjusted models. This latter association was driven by ischemic strokes (hazard ratio, 2.32; 95% confidence interval, 1.33–4.07), in particular, those related to small vessel disease (hazard ratio, 5.10; 95% confidence interval, 1.55–16.56). There was no statistically significant association of APOL1 genotypes with incident CVD in subjects with diabetes mellitus. The APOL1 high-risk genotype was associated with higher stroke risk in individuals without but not those with chronic kidney disease in fully adjusted models. Conclusions: APOL1 high-risk status is associated with CVD events in community-dwelling Black adults without diabetes mellitus.

Background Many patients with RA do not achieve guideline-recommended treat-to-target (T2T) goals in clinical practice. Little is known about the challenges that patients and rheumatologists face when attempting to achieve better control of RA disease activity. Objectives To identify and prioritise patient- and rheumatologist-perceived barriers to achieving RA disease activity control. Methods Participants were recruited from the Consortium of Rheumatology Researchers of North America (Corrona) registry and invited to participate in nominal groups (NGs), 4 with patients and 3 with rheumatologists. Each group generated a list of barriers to reaching RA disease control (patients) and T2T goals (rheumatologists). Two separate lists containing the generated items were created and were subjected to a card sort procedure to create common themes. A random sample of Corrona RA patients were invited by email to complete a compensated online survey and asked to rank their top 3 barriers. A weighted score was assigned for each barrier by considering the number of respondents who ranked it and the priority rank they assigned. The barriers/themes were sorted into domains. The patient survey also included knowledge items about T2T strategy and attitudes about RA treatment. Results Nominal groups with 37 RA patients identified 17 themes to achieving control of RA activity. Similarly, 8 themes emerged from the physician NGs, 7 of which were also found in the patient NGs (table 1). Cost of RA care was ranked highest by both patients and physicians, while medication risk aversion ranked second and third among the physician- and patient-generated barriers, respectively. We sent 1694 invitations to complete the survey and 450 patients with RA for whom clinical data was available responded within 3 weeks. There were no differences in age, sex, or disease duration between survey- respondents and non-respondents. A higher proportion of respondents were college-educated. A total of 344 (77%) respondents considered RA to be a high priority for their health, 225 (51%) reported being familiar with T2T as a treatment strategy, and 312 (85%) displayed core beliefs favouring medications. Among the challenges to controlling RA disease activity, the domain that received the highest score was unpredictability of RA and its treatment (figure 1). Symptoms and illness burden domain received the second highest score, followed by the health system factors domain (figure 1). Conclusions There are common patient- and physician-perceived barriers to achieving RA disease control. From the patient perspective important barriers are unpredictability of how RA may progress, medication risk aversion and cost of RA care. Addressing these barriers, when possible, may improve goal-directed RA care. Acknowledgements Pfizer IGLC, Corrona Disclosure of Interest None declared

Background Cardiovascular disease (CVD) is the most common cause of death among patients with inflammatory arthritis (IA) such as rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS). Objectives This study is the formative work to help design a patient-centred intervention for a CVD risk reduction program for patients with IA. Methods We conducted a qualitative study guided by Bandura’s Social Cognitive Theory, placing special focus on knowledge about the relationship between arthritis and CVD as well as barriers and facilitators to receiving healthcare related to CVD risk such as screening and management for hyperlipidemia. Participants had to have either RA, PsA or AS and were recruited from a single academic centre. Data were analysed thematically. Results We conducted three focus groups with a total of 17 participants. Mean age of participants was 56 (SD ±7.7) years; 15 were women; 3 were on a statin; and 1 previously had a stroke. The majority of the participants were Five themes emerged: 1) Need for more information about IA and medications; 2) Lack of education about CVD risk and IA; 3) CVD risk reduction as an integrated lifestyle modification; 4) Uses for peer support around relevant CVD risk factor mitigation approaches; and 5) Improving doctor-patient communication about RA. The themes that emerged in our study showed that the majority of these IA patients were not aware of the relationship between CVD and IA, and were very interested in learning about IA, medication side effects, and prognosis of IA. These participants wanted to learn first about IA and, as a secondary goal, learn about their CVD risk in the context of their IA rather than as a new condition. Conclusions Providing a clear understanding about systemic effects of IA and how to treat it will be needed before focusing on CVD risk reduction. By doing so, there will be better opportunity for the CVD risk reduction program to succeed. Disclosure of Interest I. Navarro-Millan: None declared, S. Young: None declared, S. Shurbaji: None declared, C. McDavid: None declared, A. Cornelius-Schecter: None declared, B. Johnson: None declared, A. Cherrington Grant/research support from: Boehringer Ingleheim, Consultant for: Novo Nordisk, Astra Zeneca, L. Fraenkel: None declared, J. Curtis: None declared, M. Safford Grant/research support from: Amgen, Inc

Objective To determine the proportion of primary lipid screening among patients with rheumatoid arthritis (RA) and compare it with those among patients with diabetes mellitus (DM) and patients with neither RA nor DM, and to assess whether primary lipid screening varied according to the health care provider (rheumatologist versus non-rheumatologist). Methods We analyzed claims data from US private and public health plans from 2006-2010. Eligibility requirements included continuous medical and pharmacy coverage for ≥12 months (baseline period) and >2 physician diagnoses and relevant medications to define RA, DM, RA and DM, or neither condition. Among the 330,695 eligible participants, we calculated the proportion with a lipid profile ordered during the 2 years following baseline. Time-varying Cox proportional hazard models were used to determine the probability of hyperlipidemia screening in participants with RA according to provider specialty. Results More than half of the patients were ages 41-71 years. Among patients with RA (n = 12,182), DM (n = 62,834), RA and DM (n = 1,082), and those who did not have either condition (n = 167,811), the proportion screened for hyperlipidemia was 37%, 60%, 55%, and 41%, respectively. Patients with RA who visited a rheumatologist and a non-rheumatology clinician during follow-up had a 55% (95% confidence interval 1.36-1.78) higher screening probability than those who only visited a rheumatologist. Conclusion Primary lipid screening was suboptimal among patients with RA. It was also lower for patients with DM and minimally different from the general population. Screening was higher for RA patients who received care from both a rheumatologist and a non-rheumatologist (e.g., primary care physician).

Importance African Americans and individuals of African ancestry have a higher risk of stroke compared with non-Hispanic white individuals. Identifying the source of this disparity could provide an opportunity for clinical stroke risk stratification and more targeted therapy. Whether sickle cell trait (SCT) is an indicator of increased risk of ischemic stroke among African Americans is still unclear. Objective To examine whether SCT is associated with a higher risk of incident ischemic stroke among African Americans. Design, Setting, and Participants This meta-analysis assessed the association of SCT with the risk of incident ischemic stroke. Four large, prospective, population-based studies with African American cohorts were assessed: Jackson Heart Study (September 1, 2005, through December 31, 2012), Multi-Ethnic Study of Atherosclerosis (July 1, 2002, through December 31, 2012), Reasons for Geographic and Racial Differences in Stroke (January 1, 2003, through December 31, 2014), and Women’s Health Initiative (October 1, 1998, through December 31, 2012). Using a Cox proportional hazards regression model adjusted for major stroke risk factors, this study estimated the hazard ratio for incident ischemic stroke associated with SCT. Data analysis was performed from July 10, 2016, to February 2, 2017. Interventions or Exposures Participants’ SCT status determined by polymerase chain reaction assay genotyping or a combination of whole-exome sequencing and imputation. Main Outcomes and Measures Incident ischemic stroke. Results This meta-analysis included 19 464 African American individuals (1520 with SCT, 17 944 without SCT, and 620 with ischemic stroke) from 4 studies, with a mean (SD) age of 60.0 (13.0) years (5257 [27.0%] men and 14 207 [73.0%] women). No differences were found in the distribution of risk factors for ischemic stroke comparing participants with and those without SCT at study visit 1 in each cohort. The crude incidence of ischemic stroke was 2.9 per 1000 person-years (95% CI, 2.2-4.0 per 1000 person-years) among those with SCT and 3.2 per 1000 person-years (95% CI, 2.7-3.8 per 1000 person-years) among those without SCT. After stroke risk factors were adjusted for, the hazard ratio of incident ischemic stroke independently associated with SCT in the meta-analysis of all 4 cohorts was 0.80 (95% CI, 0.47-1.35;P = .82). The results of the meta-analysis were similar to those of individual cohorts, in which the results were also similar. Conclusions and Relevance Sickle cell trait may not be associated with incidence of ischemic stroke among African Americans. The results of this study suggest performing a more thorough clinical evaluation of a stroke patient with SCT rather than assuming that SCT is the etiologic factor for the stroke.

Background It is unknown whether causes and temporal patterns of 30‐day readmission vary between heart failure (HF) with preserved ejection fraction ( HF p EF ) and HF with reduced ejection fraction ( HF r EF ). We sought to address this question by examining a 5% national sample of Medicare beneficiaries. Methods and Results We included individuals who experienced a hospitalization for HF p EF or HF r EF between 2007 and 2013. We identified causes of 30‐day readmission based on primary discharge diagnosis and further classified causes of readmission as HF ‐related, non– HF cardiovascular‐related, and non–cardiovascular‐related. We calculated the cumulative incidence of these classifications for HF p EF and HF r EF in a competing risks model and calculated subdistribution hazard ratios of these classifications by comparing those with HF p EF and those with HF r EF . Among 60 640 Medicare beneficiaries, we identified 13 785 unique older adults hospitalized with HF p EF and 15 205 who were hospitalized with HF r EF . Noncardiovascular diagnoses represented the most common causes of 30‐day readmission ( HF p EF : 59%; HF r EF : 47%), a pattern that was observed for each week of the 30‐day study period for both HF p EF and HF rEF participants. In comparing readmission diagnoses in an adjusted model, non–cardiovascular‐related diagnoses were more common and HF ‐related diagnoses were less common in HF pEF participants. Conclusions Non–cardiovascular‐related diagnoses represented the most common causes of 30‐day readmission following HF hospitalization for each week of the 30‐day postdischarge period. HF diagnoses were less common among those with HF p EF compared with HF r EF . Future interventions aimed at reducing 30‐day readmissions following an HF hospitalization would benefit from an increased focus on noncardiovascular comorbidity and interventions that target HF p EF and HF r EF separately.

Background Contact with the healthcare system represents an opportunity for individuals who discontinue statins to re‐initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk‐lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re‐initiation among patients with history of a myocardial infarction. Methods and Results Medicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re‐initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case‐crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re‐initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re‐initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with lipid panel testing was 2.65 (1.93–3.65), outpatient primary care was 1.31 (1.23–1.40), and outpatient cardiologist care was 1.38 (1.28–1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with emergency department visits was 1.77 (1.31–2.40), coronary heart disease ( CHD ) hospitalizations was 3.16 (2.41–4.14) and non–coronary heart disease hospitalizations was 1.73 (1.49–2.01). Conclusions The weaker association of routine versus acute healthcare utilization with statin re‐initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.

Background: Paid home care workers (HCWs) represent one of the fastest growing sectors of the US workforce and healthcare industry. They are increasingly utilized by home-dwelling adults with heart failure (HF) for long term assistance and post-acute care. Yet, little is known about the perspectives of HCWs regarding their role in HF management and as part of the healthcare team. Objective: We sought to understand the perspectives of HCWs who take care of adults with HF as the foundation for the development of future intervention(s). Methods: We conducted 8 focus groups with English and Spanish-speaking HCWs at the 1199SEIU’s Home Care Industry Education Fund, a non-profit organization that oversees the training of 65,000 HCWs from 50 home care agencies across NYC. Eligibility criteria included taking care of a client with HF within the last year and being a HCW for at least 2 years. Purposeful sampling ensured equal representation of English and Spanish speaking HCWs. Focus groups were audio recorded and professionally transcribed. Data were organized using qualitative software and analyzed using grounded theory. Results: The 46 participants were mean age of 49 years (SD 10), 45 (98%) were female, 17 (37%) were Black, 25 (54%) were Hispanic, and 42 (91%) had at least a high school education. Participants had been HCWs for 16 years (8.4 SD) and spent 3.5 days per week (1.8 SD) with HF clients. Seven major themes emerged: 1. HF has an unpredictable disease course, which is frightening to HCWs. “One minute we’re watching TV and the next, he crumps.” 2. HCWs often assist with HF management , although most have not received HF training. “Over time, you pick up on the symptoms - the shortness of breath, the swollen legs. But, I’ve never received HF training.” 3. Communication is fragmented. ?No one at the agency picks up the phone, so I just take him to the emergency room instead.? 4. HCWs are ignored by the healthcare team. “We’re with the clients all day, more than anyone else. So why aren’t we included in the conversation?” 5. Role definition is lacking . “The agency doesn’t make clear who we are or what we do. We aren’t just the help!” 6. Delicate family dynamics. “I’m always in the middle and I can’t afford to lose my job.” 7. Social isolation and burnout. “I’m with her all day, and she has Dementia too. It’s hard -- I’ve literally got nobody to talk to.” Conclusions and Implications: Our findings suggest that while HCWs are frequently involved in their clients’ HF management, most have not received formal HF training or resources. Additionally, despite spending so much time caring for their clients, they often feel invisible to healthcare providers. HF-specific training, as well as interventions that aim to integrate HCWs into the healthcare team, may improve HCWs’ HF knowledge and the quality of care delivered to adults with HF.

Background: Hypertension is a major risk factor for heart failure (HF), but associations of hypertension with HF may vary by race and gender. Objective: To assess race and gender differences in the association between hypertension and incident HF hospitalization in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods: REGARDS participants without suspected baseline HF (n = 25,759) were followed from study entry in 2003-2007 through 2014 with adjudication of incident HF hospitalizations (n = 855). Hypertension was defined as systolic or diastolic blood pressure ≥ 140/90 mmHg or self-reported antihypertensive medication use. Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CIs) for the association between hypertension and HF hospitalization in subgroups separately by race or gender, with each subgroup model adjusted for race, gender, age, income, region of residence, health insurance, body mass index, smoking, history of coronary heart disease, diabetes, reduced estimated glomerular filtration rate, total cholesterol, statin use, physical activity, perceived stress, and depressive symptoms. Results: The mean age of the population was 64.5 years, 40.0% were black and 55.0% were female. The prevalence of hypertension was 57.1% and more common among blacks (69.3%) compared to whites (48.9%) but similar among males (56.5%) and females (57.6%). Over a median follow-up of 8.4 years, incidence rates for HF hospitalization were 4.19, 4.46, 5.14 and 4.29 per 1,000 person-years for whites, blacks, males and females, respectively. After multivariable adjustment, the association between hypertension and HF was stronger among blacks versus whites (HR 2.28 vs HR 1.50, p-interaction=0.04) and similar among males and females (HR 1.61 vs HR 1.83, p-interaction=0.19). ( Figure ) Conclusion: Hypertension may be a stronger risk factor for incident HF among blacks versus whites. This finding may be due to disparities in hypertension severity, control, or duration.

Background: Statins are effective for the primary and secondary prevention of coronary heart disease (CHD) events. However, studies from the early 2000s have suggested that many patients have low adherence to statin therapy. Objective: To analyze trends in adherence among US adults initiating treatment with a statin. Methods: We identified US adults 21-64 years of age with commercial health insurance in Marketscan and ≥65 years of age with government health insurance through Medicare who initiated statin therapy in 2007-2014. Three populations were analyzed, those initiating statin therapy 1) following myocardial infarction (n=52,828 in Marketscan, n=148,745 in Medicare), 2) with diabetes without a history of CHD (n=565,573 in Marketscan, n=42,411 in Medicare), and 3) without diabetes or a history of CHD (n=2,134,501 in Marketscan, n=105,948 in Medicare). Adherence to statin therapy was defined by having a statin available to take for ≥80% of the 365 days following treatment initiation. Results: Adherence to statin therapy increased in each population analyzed ( Figure ). In 2014, 68.1% and 62.7% of patients initiating treatment following myocardial infarction in Marketscan and Medicare, respectively were adherent to their statin. Less than half of patients initiating treatment with diabetes without CHD and without diabetes or CHD in Marketscan and Medicare were adherent to their statin. Adherence to statin therapy in the overall Marketscan and Medicare populations was higher among men (relative risk [95% CI] 1.16 [1.15, 1.18] and 1.10 [1.08, 1.12], respectively), and those with cardiologist visits (1.22 [1.21, 1.24] and 1.27 [1.25, 1.30], respectively), and lower among those with kidney disease diagnosed after treatment initiation (0.89 [0.85, 0.94] and 0.92 [0.88, 0.96], respectively). Conclusion: Adherence to statins improved slightly between 2007 and 2014 but remains suboptimal. Management by a cardiologist is associated with better adherence to statins.

Social determinants contribute to disparities in incident CHD but it is not known if they have an additive effect. We hypothesized that having more socially determined vulnerabilities to health disparities is associated with increased risk of incident CHD in the REGARDS study, a large biracial prospective cohort with physiological and survey measures. Experts adjudicated incident fatal and nonfatal CHD over 10 years of follow-up. Vulnerabilities included black race, low education, low income, and Southeastern US residence. The risks for CHD outcomes associated with 1, 2, and 3+ vs 0 vulnerabilities were calculated with Cox proportional hazards models adjusted for medical conditions, functional status, health behaviors, and physiologic variables. Of the 19,645 participants free of CHD at baseline (mean age 64 years, 57% women), 16% had 0 vulnerabilities, 36% had 1, 29% had 2, and 18% had 3+. Increasing numbers of vulnerabilities were associated with higher incidence (Figure) and risk of CHD that attenuated somewhat after multivariable adjustment (Table). These findings may provide a method of risk stratification useful for population health management.

Aims/hypothesis: Ideal cardiovascular health (ICH) is associated with lower risk of incident diabetes, but whether this association varies by baseline glycemia (normal [ Methods: This study included 7,662 non-Hispanic whites and African Americans from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study without prevalent diabetes at baseline (2003-2006), who completed the follow-up exam (2013-2016). Participants were categorized as having ideal, intermediate or poor cardiovascular health, as defined by the AHA 2020 Impact Goals, based on baseline ICH components (total cholesterol, blood pressure, dietary intake, tobacco use, physical activity and body-mass index (BMI)). We categorized participants based on their total number of components that were ideal (0-1 “poor”, 2-3 “intermediate”, and 4+ “ideal”). Incident rate ratios (IRR) were calculated using modified poisson regression adjusting for age, sex, education, income, race, alcohol use, estimated glomerular filtration rate, urine albumin:creatinine ratio and high-sensitivity C-reactive protein. After confirming significant interactions with multiplicative interaction terms and application of likelihood ratio test, we stratified by glycemic status (normal vs. impaired fasting glucose). Results: Among REGARDS participants (mean age 63.0 [SD 8.4] years, 56% female, 26% African American), there were 560 incident diabetes cases (median follow-up 9.5 years). Overall, those with 2-3 and 4+ ICH components vs. 0-1 components had 31% (IRR 0.69; 95% CI 0.61, 0.79) and 71% lower (IRR 0.29; 95% CI 0.20, 0.42) risk of diabetes, respectively. Among 5,930 participants with normal fasting glucose, these risks were 36% (IRR 0.64; 95% CI 0.52, 0.79) and 80% lower (IRR 0.20; 95% CI 0.10, 0.37), while among 1,732 participants with baseline impaired fasting glucose these risks were 8% (IRR 0.92; 95% CI 0.80,1.07) and 13% lower (IRR 0.87; 95% CI 0.58,1.30) (p for interaction by baseline glucose status Conclusions/interpretation: Meeting an increasing number of ideal levels of dietary intake, physical activity, smoking, blood pressure, cholesterol and BMI was associated with a dose-dependent lower risk of diabetes for individuals with normal fasting glucose but not impaired fasting glucose. This suggests the AHA 2020 guidelines may be more effective for primordial versus primary prevention of diabetes among middle-aged and older adults.

Background: Cognitive impairment is as high as 70% among adults with heart failure (HF) and its prevalence increases with the duration and severity of HF. However, little is known about the prevalence of cognitive impairment early in the course of HF. This is important, as high cognitive impairment at diagnosis would suggest that earlier screening would be warranted. We examined the prevalence and correlates of cognitive impairment among adults with incident HF. Methods: We used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, an observational, longitudinal cohort study of 30,239 community-dwelling adults > 45 recruited from 2003 to 2007. Blacks and residents of the stroke belt were oversampled. Global cognitive status was assessed annually by telephone with the Six-item Screener (SIS) and the diagnosis of incident HF was validated by physicians using medical records and standard clinical criteria. Participants who were hospitalized for incident HF from 2004 until 2016 with a SIS completed > 1 month but < 18 months before the index hospitalization were included. After determining the prevalence of cognitive impairment among this cohort, we identified which of their baseline characteristics were independently associated with cognitive impairment using multivariable logistic regression. We then compared the prevalence of cognitive impairment among adults with incident HF to the prevalence of cognitive impairment among age, sex, and race matched participants without HF, stratifying by 10-year Framingham Coronary Heart Disease Risk Scores (FRS) ( 20%). Results: Of the 436 participants with incident HF, 14.9% had cognitive impairment. In an age-adjusted model, older age (OR 1.04 [95% CI 1.01 - 1.08], black race (OR 1.88 [95% 1.08-3.28]), < high school education (OR 1.89 [95% 1.02-3.51]), and anticoagulation (OR 3.01 [95% 1.05 - 8.63]) were independently associated with higher odds of cognitive impairment, whereas female sex (OR 0.54 [95% 0.31 - 0.94]) was associated with lower odds of cognitive impairment. The prevalence of cognitive impairment among participants with incident HF was higher than the prevalence of cognitive impairment among controls with low FRS (9.4%) but was less than the prevalence of cognitive impairment among controls with high FRS (21.9%). Conclusion: The prevalence of cognitive impairment among adults with incident HF was greater than the prevalence of cognitive impairment among matched participants with low CHD risk, but less than the prevalence of cognitive impairment among matched participants with the highest CHD risk. This suggests that the majority of cognitive decline in HF may occur later in the course of the disease. Increased awareness of cognitive impairment among newly diagnosed patients, as well as ways to mitigate cognitive decline in the context of HF management, are warranted.

Background Cause of death is often not available in administrative claims data. Objective To develop claims-based algorithms to identify deaths due to fatal cardiovascular disease (CVD; i.e., fatal coronary heart disease [CHD] or stroke), CHD, and stroke. Methods Reasons for Geographic and Racial Differences in Stroke (REGARDS) study data were linked with Medicare claims to develop the algorithms. Events adjudicated by REGARDS study investigators were used as the gold standard. Stepwise selection was used to choose predictors from Medicare data for inclusion in the algorithms. C-index, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were used to assess algorithm performance. Net reclassification index (NRI) was used to compare the algorithms to an approach of classifying all deaths within 28 days following hospitalization for myocardial infarction and stroke to be fatal CVD. Results Data from 2,685 REGARDS participants with linkage to Medicare, who died between 2003 and 2013, were analyzed. The C-index for discriminating fatal CVD from other causes of death was 0.87. Using a cut-point that provided the closest observed-to-predicted number of fatal CVD events, the sensitivity was 0.64, specificity 0.90, PPV 0.65 and NPV 0.90. The algorithms resulted in a positive NRIs compared with using deaths within 28 days following hospitalization for myocardial infarction and stroke. Claims-based algorithms for discriminating fatal CHD and fatal stroke performed similarly to fatal CVD. Conclusion The claims-based algorithms developed to discriminate fatal CVD events from other causes of death performed better than the method of using hospital discharge diagnosis codes.

Importance Higher circulating fibroblast growth factor 23 (FGF23) concentrations are associated with cardiovascular disease events linked to heart failure, but associations of FGF23 with coronary heart disease (CHD) have been less consistent. Objective To determine the association of plasma FGF23 concentrations with incident CHD and whether this association differs by race, sex, or chronic kidney disease status. Design, Setting, and Participants We examined the association of FGF23 concentrations with incident CHD risk within the Reasons for Geographic and Racial Differences in Stroke study, a prospective cohort of black and white adults 45 years and older enrolled between January 2003 and October 2007 with follow-up through December 31, 2011. Using a case-cohort design, we measured FGF23 concentrations in 829 participants who developed incident CHD and in 812 participants randomly selected from the Reasons for Geographic and Racial Differences in Stroke study cohort (cohort random sample). To account for the stratified sampling design, the cohort random sample was weighted back to the original cohort overall (n = 22 127). Cox proportional hazards models were used to examine the association of FGF23 concentration with incident CHD, adjusting for CHD risk factors and kidney function. In prespecified analyses, we examined whether race, sex, or chronic kidney disease modified the association of FGF23 concentration with incident CHD. Exposures Plasma C-terminal FGF23 concentrations. Main Outcomes and Measures Investigator-adjudicated incident CHD events. Results Of the 22 127 participants in the weighted cohort random sample, 13 059 (58.9%) were female and 9435 (42.6%) were black, and the mean age was 64.3 (95% CI, 63.7-64.9) years. Greater age, lower estimated glomerular filtration rate, higher urine albumin to creatinine ratio, and female sex were associated with higher FGF23 concentration at baseline. In multivariable models adjusted for established CHD risk factors and kidney function, higher FGF23 concentrations were associated with greater risk of CHD (hazard ratio [HR] comparing fourth with first quartile, 2.15; 95% CI, 1.35-3.42). The magnitude and strength of these associations differed by sex. However, these differences were no longer observed when adjusting for hormone therapy in women (men: HR comparing fourth with first quartile, 2.40; 95% CI, 1.30-4.42; women: HR comparing fourth with first quartile, 2.34; 95% CI, 1.04-5.27) or when using sex-specific FGF23 quartiles (men: HR comparing fourth with first quartile, 2.65; 95% CI, 1.43-4.90; women: HR comparing fourth with first quartile, 2.26; 95% CI, 1.02-5.03). Conclusions and Relevance Higher FGF23 concentrations were associated with greater risk of CHD. Heterogeneity in the association by sex may be caused by differences in the distribution of plasma FGF23 concentrations or the use of hormone therapy in men vs women.

Objective Cross-sectional studies suggest an association between weight cycling and psychological status. Although this is often interpreted as suggesting that weight cycles "cause" psychological distress, the relationship could be bidirectional. This study provides a prospective analysis of the bidirectional association between weight variability and psychological status over an 8-year period in overweight/obese adults with Type 2 diabetes. Method Data were from the first 8 years of Look AHEAD, a randomized controlled trial comparing health outcomes in individuals with Type 2 diabetes assigned to an intensive lifestyle intervention designed to produce weight loss or a diabetes education and support control group. Psychological status (mental health, depressive symptoms, binge eating) was assessed via surveys and were examined in relation to weight variability at both baseline and year 8. Weight variability was derived from 8 possible annual measurements from participants who had a minimum of 3 consecutive body weight measurements (N = 4,774) and operationalized as the number of year-to-year cycles and the coefficient of variation across all available weight measurements. Results Controlling for study group, higher baseline scores on mental health (Short Form-36 Mental Component Summary) and lower levels of depressive symptomatology (Beck Depression Inventory) and binge eating (Questionnaire on Eating and Weight Patterns) were associated with significantly less subsequent weight variability. The prospective association between weight variability and psychological status at year 8 was less robust. Conclusions These results suggest that the cross-sectional relationship between weight variability and psychological status is due primarily to poorer psychological function preceding greater weight instability. (PsycINFO Database Record

Background Historically, women have been less likely than men to receive guideline-recommended statin therapy for the secondary prevention of myocardial infarction (MI). Objectives The authors examined contemporary sex differences in prescription fills for high-intensity statin therapy following an MI, overall and across population subgroups, and assessed whether sex differences were attenuated following recent efforts to reduce sex disparities in the use of cardiovascular disease preventive therapies. Methods The authors studied 16,898 (26% women) U.S. adults Results In 2014 to 2015, 56% of men and 47% of women filled a high-intensity statin following hospital discharge for MI. Adjusted risk ratios for filling a high-intensity statin comparing women with men were 0.91 (95% CI: 0.90 to 0.92) in the total population, 0.91 (95% CI: 0.89 to 0.92) among those with no prior statin use, and 0.87 (95% CI: 0.85 to 0.90) and 0.98 (95% CI: 0.97 to 1.00) for those taking low/moderate-intensity and high-intensity statins prior to their MI, respectively. Women were less likely than men to fill high-intensity statins within all subgroups analyzed, and the disparity was largest in the youngest and oldest adults and for those without prevalent comorbid conditions. Conclusions Despite recent efforts to reduce sex differences in guideline-recommended therapy, women continue to be less likely than men to fill a prescription for high-intensity statins following hospitalization for MI.

Screening interventions can produce very different treatment outcomes, depending on the reasons why patients had been unscreened in the first place. Economists have paid scant attention to these complexities and their implications for evaluating screening programs. In this paper, we propose a simple economic framework to guide policy-makers and analysts in designing and evaluating the impact of screening on treatment uptake. We apply these insights to several salient empirical examples that illustrate the different kinds of effects screening programs might produce. Our empirical examples focus on contexts relevant to the top cause of death in the United States, heart disease. We find that currently undiagnosed patients differ from currently diagnosed patients in important ways, leading to lower predicted uptake of recommended treatment if these patients were diagnosed. Additionally, changes in the composition of diagnosed patients can produce misleading conclusions during policy analysis, such as spurious reductions in measured health system performance as screening expands.

Introduction: The relationship between myocardial infarction and brain infarction remains incompletely understood. Magnetic resonance imaging (MRI) offers excellent characterization of infarction in both the heart and brain. Methods: We performed a retrospective cross-sectional study at our hospital to evaluate the association between myocardial infarction and brain infarction as detected on MRI. We identified all adult patients who underwent both cardiac MRI and brain MRI within 6 months of each other during the period 2014-2017. Myocardial infarction was identified by the presence of myocardial scar on delayed enhancement cardiac MRI. A neuroradiologist investigator reviewed all brain MRI studies to characterize acute and chronic infarcts. In secondary analyses, we evaluated the association between myocardial infarction and cortical versus subcortical brain infarction. The chi-square test was use to compare categorical variables. Results: We identified 211 adults who underwent cardiac MRI and brain MRI within 6 months of each other. Myocardial infarction was present in 66 (31.3%) of cardiac MRIs. Brain infarction was present in 112 (53.1%) of brain MRIs, 61 (28.9%) of which were cortical infarcts, 33 (15.6%) subcortical, and 18 (8.5%) posterior fossa. Myocardial infarction was more common in patients with brain infarction (41.1%; 95% confidence interval [CI], 31.9-50.8%) than in patients without brain infarction (20.2%; 95% CI, 12.8-29.5%) ( P = 0.001). In secondary analyses, myocardial infarction was most common in patients with cortical brain infarcts (50.8%; 95% CI, 37.7-63.9%), less common in patients with only subcortical infarcts (27.3%; 95% CI, 13.3-45.5%), and least common in those with no brain infarcts ( P value for comparison among groups, < 0.001). Conclusions: We found an association between myocardial infarction and brain infarction on MRI. The association was strongest between myocardial infarcts and cortical brain infarcts.

Introduction: Between 1960 and 2006, stroke mortality in the U.S. has declined a remarkable 65% for white men (123.4 ◊ 42.8 per 100,000), 61% for white women (108.6 ◊42.3 per 100,000), 67% for non-white men (178.4 ◊ 59.5 per 100,000) and 70% for non-white women (175.2 ◊ 52.0 per 100,000). With hypertension being the predominant risk factor for stroke, we examined the population shift in systolic blood pressure (SBP) levels over this period. Methods: The Charleston Heart Study (CHS) and Evan County Study (EC) were population-based cohorts recruiting black and white participants in the early 1960’s, conducted in the coastal plain regions of SC and GA respectively. REasons for Geographic And Racial Differences in Stroke (REGARDS) is a population-based study recruiting black and white participants in the contiguous U.S. For purposes of this report, CHS/EC participants were limited to those over 45 years, and REGARDS participants were restricted to residents of the coastal plain of NC/SC/GA. Results: SBP data are available on 1,988 whites and 1,172 blacks from CHS/EC, and from 4,057 whites and 2,237 blacks from REGARDS. Dramatic changes in the distribution of SBP have occurred over these 40+ years, with the 25 th percentile of CHS/EC being consistently above the 75 th percentile for REGARDS (see figure). For example, for whites aged 65-74, the 25 th , 50 th , and 75 th percentile of SBP in CHS/EC was 144-162-184 mmHg, compared to 118-126-137 mmHg in REGARDS. For blacks, the corresponding percentiles were 158-180-204 mmHg in CHS/EC, and 119-129-140 mmHg in REGARDS. In CHS/EC, 125 of 1988 (6%) whites, and 245 of 1172 (20%) blacks had a SBP of 200+ mmHg; compared to only 4 of 4057 (0.1%) whites and 3 of 2235 (0.1%) blacks in REGARDS. Discussion: A dramatic shift in the distribution of systolic blood pressure, likely related to both population shifts in blood pressure and the advent of antihypertensive therapy, is likely a major contributor to the steep decline in stroke mortality.

Introduction: The duration of heightened stroke risk after acute myocardial infarction (MI) remains uncertain. Methods: We performed a retrospective cohort study using inpatient and outpatient claims data from 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries ≥66 years of age. Our exposure of acute MI and the outcome of ischemic stroke were ascertained using previously validated ICD-9- CM diagnosis codes. To exclude periprocedural strokes from percutaneous coronary intervention, we only included strokes occurring after discharge from acute MI hospitalization. Patients were censored at the time of ischemic stroke, death, end of Medicare coverage, or September 30, 2015. We fit Cox regression models separately for the groups with and without acute MI to examine its association with ischemic stroke after adjustment for demographics, stroke risk factors, and Charlson comorbidities. We used the corresponding survival probabilities to compute the hazard ratio (HR) in each 4-week interval after discharge. Confidence intervals (CI) were computed using the nonparametric bootstrap method. Results: Among 1,746,476 beneficiaries, 46,182 were hospitalized for acute MI and 80,466 for ischemic stroke. Compared to patients without acute MI, patients with acute MI were older (mean age 79.0 vs 73.1 years) and had more stroke risk factors. After adjustment for demographics, stroke risk factors, and Charlson comorbidities, the risk of ischemic stroke was highest in the first 4 weeks after discharge from the MI hospitalization (HR, 2.7; 95% CI, 2.3-3.2), remained substantially elevated during weeks 5-8 (HR, 2.0; 95% CI, 1.6-2.4) and weeks 9-12 (HR, 1.6; 95% CI, 1.3-2.0), and was no longer significantly elevated afterward (Figure). Conclusions: Acute MI is associated with a substantially elevated short-term risk of ischemic stroke which appears to extend beyond the 30-day period enshrined in current stroke etiological classification systems.

BACKGROUND African Americans are disproportionately affected by both HIV and hypertension. Failure to modify risk factors for cardiovascular disease and chronic kidney disease such as hypertension among HIV-infected patients may attenuate the benefits conferred by combination antiretroviral therapy. In the general population, African Americans with hypertension are less likely to have controlled blood pressure than whites. However, racial differences in blood pressure control among HIV-infected patients are not well studied. METHODS We conducted a cross-sectional study evaluating racial differences in hypertension prevalence, treatment, and control among 1,664 patients attending the University of Alabama at Birmingham HIV Clinic in 2013. Multivariable analyses were performed to calculate prevalence ratios (PR) with 95% confidence intervals (CI) as the measure of association between race and hypertension prevalence and control while adjusting for other covariates. RESULTS The mean age of patients was 47 years, 77% were male and 54% African-American. The prevalence of hypertension was higher among African Americans compared with whites (49% vs. 43%; p = 0.02). Among those with hypertension, 91% of African Americans and 93% of whites were treated (p = 0.43). Among those treated, 50% of African Americans versus 60% of whites had controlled blood pressure (systolic blood pressure

Background Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined. Methods We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003-2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence. Results Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates. Conclusions Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

We thank Dr. Zhuang and colleagues for their comments on our study [(1)][1]. They question how the addition of race to standardized risk models would improve the c-statistic for predicting sudden cardiac death (SCD). In addition, they clarify that current guidelines do not consider race when

Objectives To prospectively assess the effects of newly developed chronic conditions on changes in health-related quality of life (HRQoL) in postmenopausal women. Design Prospective cohort study. Setting Forty clinical centers in the United States. Participants Women aged 50 to 79 enrolled in the Women's Health Initiative Observational Study during 1993–98 (N = 75,198). Measurements Onset of seven chronic conditions (hypertension, heart disease, stroke, cancer, osteoporosis, diabetes mellitus, arthritis), HRQoL based on the Medical Outcomes Study 36-item Short Form survey (SF-36), and change in HRQoL from baseline to Year 3 in scores on the Physical (PCS) and Mental (MCS) Component Summary of the SF-36. Results Each of the seven chronic conditions was statistically significantly associated with HRQoL for physical and mental health. Women with incident stroke had the greatest decline in HRQoL for physical and mental health (PCS: 10.2, 95% confidence interval (CI) = 8.3–12.1; MCS: 10.4, 95% CI = 8.8–12.1), which exceeded minimal clinically important differences (MCID). Having more new chronic conditions was associated with greater decrease in HRQoL. Declines in HRQoL in women with two or more chronic conditions exceeded MCID. Those with heart disease and stroke had the largest decline in physical health, and those with stroke and arthritis had the greatest decline in mental health. For all conditions other than stroke and diabetes mellitus, the more recently a condition was diagnosed, the greater the decrease in PCS. For stroke and cancer, a similar pattern was observed for MCS. Conclusion The more conditions a woman developed, the greater reduction in HRQoL she experienced. Declines in HRQoL in women with stroke, cancer, and some combinations exceeded MCID. Findings from this study might lead to more-effective patient-centered approaches to health care for women with multiple chronic conditions.

We examined claims-based approaches for identifying a study population free of coronary heart disease (CHD) using data from 8,937 US blacks and whites enrolled during 2003–2007 in a prospective cohort study linked to Medicare claims. Our goal was to minimize the percentage of persons at study entry with self-reported CHD (previous myocardial infarction or coronary revascularization). We assembled 6 cohorts without CHD claims by requiring 6 months, 1 year, or 2 years of continuous Medicare fee-for-service insurance coverage prior to study entry and using either a fixed-window or all-available look-back period. We examined adding CHD-related claims to our “base algorithm,” which included claims for myocardial infarction and coronary revascularization. Using a 6-month fixed-window look-back period, 17.8% of participants without claims in the base algorithm reported having CHD. This was reduced to 3.6% using an all-available look-back period and adding other CHD claims to the base algorithm. Among cohorts using all-available look-back periods, increasing the length of continuous coverage from 6 months to 1 or 2 years reduced the sample size available without lowering the percentage of persons with self-reported CHD. This analysis demonstrates approaches for developing a CHD-free cohort using Medicare claims.