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Background: We examined the clinical effectiveness of beta-blockers considered evidenced-based to heart failure and reduced ejection fraction (HFrEF) and their recommended target doses in older adults with HF and preserved ejection fraction (HFpEF)., Methods: In OPTIMIZE-HF (2003-2004) linked to Medicare (2003-2008), of the 10,570 older (age ≥ 65 years, mean, 81 years) adults with HFpEF (EF ≥ 40%, mean 55%), 8373 had no contraindications to beta-blocker therapy. After excluding 4614 patients receiving pre-admission beta-blockers, the remaining 3759 patients were potentially eligible for new discharge prescriptions for beta-blockers and 1454 received them. We assembled a propensity-matched cohort of 1099 pairs of patients receiving beta-blockers and no beta-blockers, balanced on 115 baseline characteristics. Evidence-based beta-blockers for HFrEF, namely, carvedilol, metoprolol succinate, and bisoprolol and their respective guideline-recommended target doses were 50, 200, and 10mg/day., Results: During 6 years of follow-up, new discharge prescriptions for beta-blockers had no association with the primary composite endpoint of all-cause mortality or HF rehospitalization (hazard ratio, 1.03; 95% confidence interval {CI}, 0.94-1.13; p=0.569). This association did not vary by beta-blocker evidence class or daily dose. Hazard ratios for all-cause mortality and HF rehospitalization were 0.99 (95% CI, 0.90-1.10; p=0.897) and 1.17 (95% CI, 1.03-1.34; p=0.014), respectively. The latter association lost significance when higher EF cutoffs of ≥45%, ≥50% and ≥55% were used., Conclusions: Initiation of therapy with beta-blockers considered evidence-based for HFrEF and in target doses recommended for HFrEF had no association with the composite or individual endpoints of all-cause mortality or HF rehospitalization in HFpEF., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The DQB1 locus is located in the major histocompatibility complex (MHC) class II region and involved in immune response. We identified 20 polymorphic sites in a 228 bp fragment of exon 2, one of the most critical regions of the MHC DQB1 gene, in 60 Nigerian goats. Four sites are located in the peptide binding region, and 10 amino acid substitutions are peculiar to Nigerian goats, compared with published sequences. A significantly higher ratio of nonsynonymous/synonymous substitutions (dN/dS) suggests that allelic sequence evolution is driven by balancing selection (P < 0.01). In silico functional analysis using PANTHER predicted that substitution P56R, with a subPSEC score of -4.00629 (Pdeleterious = 0.73229), is harmful to protein function. The phylogenetic tree from consensus sequences placed the two northern breeds closer to each other than either was to the southern goats. This first report of sequence diversity at the DQB1 locus for any African goat breed may be useful in the search for disease-resistant genotypes.

Background: Low seat belt use and higher crash rates contribute to persistence of motor vehicle crashes as the leading cause of teenage death. Service-learning has been identified as an important component of public health interventions to improve health behavior., Methodology: A service-learning intervention was conducted in eleven selected high schools across the United States in the 2011-2012 school year. Direct morning and afternoon observations of seat belt use were used to obtain baseline observations during the fall semester and post-intervention observations in the spring. The Mann-Whitney U test for 2 independent samples was used to evaluate if the intervention was associated with a statistically significant change in seat belt use. We identified factors associated with seat belt use post-intervention using multivariable logistic regression., Results: Overall seat belt use rate increased by 12.8%, from 70.4% at baseline to 83.2% post-intervention (p<0.0001). A statistically significant increase in seat belt use was noted among white, black, and Hispanic teen drivers. However, black and Hispanic drivers were still less likely to use seat belts while driving compared to white drivers. Female drivers and drivers who had passengers in their vehicle had increased odds of seat belt use., Conclusion: A high school service-learning intervention was associated with improved seat belt use regardless of race, ethnicity, or gender, but did not eliminate disparities adversely affecting minority youth. Continuous incorporation of service-learning in high school curricula could benefit quality improvement evaluations aimed at disparities elimination and might improve the safety behavior of emerging youth cohorts., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Heart failure (HF) is the leading cause of hospitalization for Medicare beneficiaries. Nearly half of all HF patients have diastolic HF or HF with preserved ejection fraction (HF-PEF). Because these patients were excluded from major randomized clinical trials of neurohormonal blockade in HF there is little evidence about their role in HF-PEF., Methods: The aims of the American Recovery & Reinvestment Act-funded National Heart, Lung, and Blood Institute-sponsored "Neurohormonal Blockade and Outcomes in Diastolic Heart Failure" are to study the long-term effects of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists in four separate propensity-matched populations of HF-PEF patients in the OPTIMIZE-HF (Organized Program to Initiate Life-Saving Treatment in Hospitalized Patients with Heart Failure) registry. Of the 48,612 OPTIMIZE-HF hospitalizations occurring during 2003-2004 in 259 U.S. hospitals, 20,839 were due to HF-PEF (EF ≥40%). For mortality and hospitalization we used Medicare national claims data through December 31, 2008., Results: Using a two-step (hospital-level and hospitalization-level) probabilistic linking approach, we assembled a cohort of 11,997 HF-PEF patients from 238 OPTIMIZE-HF hospitals. These patients had a mean age of 75 years, mean EF of 55%, were 62% women, 15% African American, and were comparable with community-based HF-PEF cohorts in key baseline characteristics., Conclusions: The assembled Medicare-linked OPTIMIZE-HF cohort of Medicare beneficiaries with HF-PEF with long-term outcomes data will provide unique opportunities to study clinical effectivenss of various neurohormonal antagonists with outcomes in HF-PEF using propensity-matched designs that allow outcome-blinded assembly of balanced cohorts, a key feature of randomized clinical trials., (Published by Elsevier Ireland Ltd.)

Background: Prior studies found that only about half of stroke patients arrived at hospitals via emergency medical services (EMSs), yet since then, there have been efforts to increase public awareness that time is brain. Using contemporary Get With the Guidelines-Stroke data, we assessed nationwide EMS use by stroke patients., Methods and Results: We analyzed data from 204 591 patients with ischemic and hemorrhagic stroke admitted to 1563 Get With the Guidelines-Stroke participating hospitals with data on National Institute of Health Stroke Score and insurance status. Hospital arrival by EMSs was observed in 63.7% of patients. Older patients, those with Medicaid and Medicare insurance, and those with severe stroke were more likely to activate EMSs. In contrast, minority race and ethnicity and living in rural communities were associated with decreased odds of EMS use. EMS transport was independently associated with earlier arrival (onset-to-door time, ≤3 hours; adjusted odds ratio, 2.00; 95% confidence interval, 1.93-2.08), prompter evaluation (more patients with door-to-imaging time, ≤25 minutes; odds ratio, 1.89; 95% confidence interval, 1.78-2.00), more rapid treatment (more patients with door-to-needle time, ≤60 minutes; odds ratio, 1.44; 95% confidence interval, 1.28-1.63), and more eligible patients to be treated with tissue-type plasminogen activator if onset is ≤2 hours (67% versus 44%; odds ratio, 1.47; 95% confidence interval, 1.33-1.64)., Conclusions: Although EMS use is independently associated with more rapid evaluation and treatment of stroke, more than one third of stroke patients fail to use EMSs. Interventions aimed at increasing EMS activation should target populations at risk, particularly younger patients and those of minority race and ethnicity.

Background: The role of angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure and preserved ejection fraction remains unclear., Methods: Of the 10,570 patients aged ≥65 years with heart failure and preserved ejection fraction (≥40%) in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (2003-2004) linked to Medicare (through December 2008), 7304 were not receiving angiotensin receptor blockers and had no contraindications to ACE inhibitors. After excluding 3115 patients with pre-admission ACE inhibitor use, the remaining 4189 were eligible for new discharge prescriptions for ACE inhibitors, and 1706 received them. Propensity scores for the receipt of ACE inhibitors, calculated for each of the 4189 patients, were used to assemble a cohort of 1337 pairs of patients, balanced on 114 baseline characteristics., Results: Matched patients had a mean age of 81 years and mean ejection fraction of 55%, 64% were women, and 9% were African American. Initiation of ACE inhibitor therapy was associated with a lower risk of the primary composite end point of all-cause mortality or heart failure hospitalization during 2.4 years of median follow-up (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84-0.99; P = .028), but not with individual end points of all-cause mortality (HR, 0.96; 95% CI, 0.88-1.05; P = .373) or heart failure hospitalization (HR, 0.93; 95% CI, 0.83-1.05; P = .257)., Conclusion: In hospitalized older patients with heart failure and preserved ejection fraction not receiving angiotensin receptor blockers, discharge initiation of ACE inhibitor therapy was associated with a modest improvement in the composite end point of total mortality or heart failure hospitalization but had no association with individual end point components., (Published by Elsevier Inc.)

Introduction. Motor vehicle crashes are the leading cause of death among US children aged 4-14 years. In theory, health provider counseling about Child Passenger Safety (CPS) could be a useful deterrent. The data about the effectiveness of CPS dissemination is sparse, but existing results suggest that providers are not well informed. Moreover, there is insufficient evidence to determine whether provider counseling about CPS is effective. Methods. We therefore assessed CPS best practice knowledge among 217 healthcare workers at hospitals in seven cities throughout the USA and evaluated the impact of a brief, lunch and learn educational intervention with a five-item questionnaire. Attendees were comprised of physicians, nurses, social workers, pediatric residents, and pediatric trauma response teams. Results. Pre-post survey completion was nearly 100% (216 of 217 attendees). Participation was fairly evenly distributed according to age (18-29, 30-44, and 45+ years). More than 80% of attendees were women. Before intervention, only 4% of respondents (9/216) answered all five questions correctly; this rose to 77% (167/216) (P < 0.001, using a Wilcoxon signed-rank test) after intervention. Conclusion. Future research should consider implementation and controlled testing of comparable educational programs to determine if they improve dissemination of CPS best practice recommendations in the long term.

Background: Most studies of heart failure (HF) in Medicare beneficiaries have excluded patients age <65 years. We examined baseline characteristics, quality of care, and outcomes among younger and older Medicare beneficiaries hospitalized with HF in the Alabama Heart Failure Project., Methods: Of the 8049 Medicare beneficiaries discharged alive with a primary discharge diagnosis of HF in 1998-2001 from 106 Alabama hospitals, 991 (12%) were younger (age <65 years). After excluding 171 patients discharge to hospice care, 7867 patients were considered eligible for left ventricular systolic function (LVSF) evaluation and 2211 patients with left ventricular ejection fraction <45% and without contraindications were eligible for angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy., Results: Nearly half of the younger HF patients (45% versus 22% for ≥65 years; p<0.001) were African American. LVSF was evaluated in 72%, 72%, 70% and 60% (overall p<0.001) and discharge prescriptions of ACE inhibitors or ARBs were given to 83%, 77%, 75% and 75% of eligible patients (overall p=0.013) among those <65, 65-74, 75-84 and ≥85 years respectively. During 9 years of follow-up, all-cause mortality occurred in 54%, 61%, 71% and 80% (overall p<0.001) and hospital readmission due to worsening HF occurred in 65%, 60%, 55% and 48% (overall p<0.001) of those <65, 65-74, 75-84 and ≥85 years respectively., Conclusion: Medicare beneficiaries <65 years with HF, nearly half of whom were African American generally received better quality of care, had lower mortality, but had higher re-hospitalizations due to HF., (Published by Elsevier Ireland Ltd.)

Background: Sheep is important in the socio-economic lives of people around the world. It is estimated that more than half of our once common livestock breeds are now endangered. Since genetic characterization of Nigerian sheep is still lacking, we analyzed ten morphological traits on 402 animals and 15 microsatellite DNA markers in 384 animals of the 4 Nigerian sheep breeds to better understand genetic diversity for breeding management and germplasm conservation., Results: Morphological traits of Uda and Balami were significantly (P < 0.05) higher than Yankasa, which were both higher than West African Dwarf (WAD) sheep. Stepwise discriminant analysis showed tail length, rump height, chest girth, ear length and chest depth as the most discriminating variables for classification. Mahalanobis distances show the least differentiation between Uda and Balami and the largest between WAD and Balami sheep. While 93.3% of WAD sheep were correctly assigned to their source genetic group, 63.9% of Yankasa, 61.2% of Balami and 45.2% of Uda were classified correctly by nearest neighbour discriminant analysis. The overall high Polymorphism Information Content (PIC) of all microsatellite markers ranged from 0.751 to 0.927 supporting their use in genetic characterization. Expected heterozygosity was high for all loci (0.783 to 0.93). Mean heterozygote deficiency across all populations (0.171 to 0.534) possibly indicate significant inbreeding (P < 0.05). Mean values for FST, FIT and FIS statistics across all loci were 0.088, 0.394 and 0.336 respectively. Yankasa and Balami are the most closely related breeds (DA = 0.184) while WAD and Balami are the farthest apart breeds (DA = 0.665), which is coincident with distance based on morphological analysis and population structure assessed by STRUCTURE., Conclusions: These results suggest that within-breed genetic variation in Nigerian sheep is higher than between-breeds and may be a valuable tool for genetic improvement and conservation. The higher genetic variability in Yankasa suggests the presence of unique ancestral alleles reflecting the presence of certain functional genes which may result in better adaptability in more agro-ecological zones of Nigeria. These genetic characteristics are potentially useful in planning improvement and conservation strategies in Nigerian indigenous sheep.

Background: Little is known about the association of rheumatic heart disease (RHD) with incident heart failure (HF) among older adults., Design: Cardiovascular Health Study, a prospective cohort study., Methods: Of the 4,751 community-dwelling adults ≥ 65 years, free of prevalent HF at baseline, 140 had RHD, defined as self-reported physician-diagnosed RHD along with echocardiographic evidence of left-sided valvular disease. Propensity scores for RHD, estimated for each of the 4,751 participants, were used to assemble a cohort of 720, in which 124 and 596 participants with and without RHD, respectively, were balanced on 62 baseline characteristics., Results: Incident HF developed in 33% and 22% of matched participants with and without RHD, respectively, during 13 years of follow-up (hazard ratio when RHD was compared to no-RHD 1.60; 95% confidence interval 1.13-2.28; P = 0.008). Pre-match unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios (95% confidence intervals) for RHD-associated incident heart failure were 2.04 (1.54-2.71; P < 0.001), 1.32 (1.02-1.70; P = 0.034), and 1.55 (1.14-2.11; P = 0.005), respectively. RHD was not associated with all-cause mortality (HR 1.09; 95% CI 0.82-1.45; P = 0.568)., Conclusion: RHD is an independent risk factor for incident HF among community-dwelling older adults free of HF, but has no association with mortality.

Background: The role of renin-angiotensin inhibition in older patients with systolic heart failure with chronic kidney disease remains unclear., Methods: Of the 1665 patients (aged≥65 years) with systolic heart failure (ejection fraction<45%) and chronic kidney disease (estimated glomerular filtration rate<60 mL/min/1.73 m(2)), 1046 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the receipt of these drugs, estimated for each of the 1665 patients, were used to assemble a matched cohort of 444 pairs of patients receiving and not receiving these drugs who were balanced on 56 baseline characteristics., Results: During more than 8 years of follow-up, all-cause mortality occurred in 75% and 79% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.74-0.996; P=.045). There was no significant association with heart failure hospitalization (HR, 0.86; 95% CI, 0.72-1.03; P=.094). Similar mortality reduction (HR, 0.83; 95% CI, 0.70-1.00; P=.046) occurred in a subgroup of matched patients with estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 171 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was associated with a significant reduction in all-cause mortality (HR, 0.72; 95% CI, 0.55-0.94; P=.015) and heart failure hospitalization (HR, 0.71; 95% CI, 0.52-0.95; P=.023)., Conclusion: Discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant modest reduction in all-cause mortality in older patients with systolic heart failure with chronic kidney disease, including those with more advanced chronic kidney disease., (Published by Elsevier Inc.)

Objectives: Widowhood is associated with increased mortality. However, to what extent this association is independent of other risk factors remains unclear. In the current study, we used propensity score matching to design a study to examine the independent association of widowhood with outcomes in a balanced cohort of older adults in the United States., Methods: We used public-use copies of the Cardiovascular Health Study data obtained from the National Heart, Lung, and Blood Institute. Of the 5,795 community-dwelling older men and women aged 65 years and older in Cardiovascular Health Study, 3,820 were married and 1,436 were widows or widowers. Propensity scores for widowhood, estimated for each of the 5,256 participants, were used to assemble a cohort of 819 pairs of widowed and married participants who were balanced on 74 baseline characteristics. The 1,638 matched participants had a mean (± standard deviation) age of 75 (± 6) years, 78% were women, and 16% African American., Results: All-cause mortality occurred in 46% (374/819) and 51% (415/819) of matched married and widowed participants, respectively, during more than 11 years of median follow-up (hazard ratio associated with widowhood, 1.18; 95% confidence interval, 1.03-1.36; p = .018). Hazard ratios (95% confidence intervals) for cardiovascular and noncardiovascular mortalities were 1.07 (0.87-1.32; p = .517) and 1.28 (1.06-1.55; p = .011), respectively. Widowhood had no independent association with all-cause or heart failure hospitalization or incident cardiovascular events., Conclusions: Among community-dwelling older adults, widowhood was associated with increased mortality, which was independent of confounding by baseline characteristics and largely driven by an increased noncardiovascular mortality. Widowhood had no independent association with hospitalizations or incident cardiovascular events.

Aging is often associated with increased systolic blood pressure and decreased diastolic blood pressure. Isolated systolic hypertension or an elevated systolic blood pressure without an elevated diastolic blood pressure is a known risk factor for incident heart failure in older adults. In the current study, we examined whether isolated diastolic hypotension, defined as a diastolic blood pressure <60 mm Hg and a systolic blood pressure ≥100 mm Hg, is associated with incident heart failure. Of the 5795 Medicare-eligible community-dwelling adults age ≥65 years in the Cardiovascular Health Study, 5521 were free of prevalent heart failure at baseline. After excluding 145 individuals with baseline systolic blood pressure <100 mm Hg, the final sample included 5376 participants, of whom 751 (14%) had isolated diastolic hypotension. Propensity scores for isolated diastolic hypotension were calculated for each of the 5376 participants and used to match 545 and 2348 participants with and without isolated diastolic hypotension, respectively, who were balanced on 58 baseline characteristics. During >12 years of median follow-up, centrally adjudicated incident heart failure developed in 25% and 20% of matched participants with and without isolated diastolic hypotension, respectively (hazard ratio associated with isolated diastolic hypotension: 1.33 [95% CI: 1.10-1.61]; P=0.004). Among the 5376 prematch individuals, multivariable-adjusted hazard ratio for incident heart failure associated with isolated diastolic hypotension was 1.29 (95% CI: 1.09-1.53; P=0.003). As in isolated systolic hypertension, among community-dwelling older adults without prevalent heart failure, isolated diastolic hypotension is also a significant independent risk factor for incident heart failure.

Background and Purpose: Framingham calculators are typically implemented in 1-on-1 settings to determine if a patient is at high risk for development of cardiovascular disease in the next 10 years. Because health care administrative datasets are including more clinical information, we explored how well administrative data-derived Framingham scores could identify persons who would have stroke develop in the next year., Methods: Using a nested case-control design, we compared all 313 persons who had a first-time stroke at 5 Veterans Administration Medical Centers with a random sample of 25,361 persons who did not have a first-time stroke in 2008. We compared Framingham scores and risk using administrative data available at the end of 2007., Results: Stroke patients had higher risk profile than controls: older age, higher systolic blood pressure and total cholesterol, more likely to have diabetes, cardiovascular disease, left ventricular hypertrophy, and more likely to use treatment for blood pressure (P<0.05). The mean Framingham generalized cardiovascular disease score (18.0 versus 14.5) as well as the mean Framingham stroke-specific score (13.2 versus 10.2) was higher for stroke cases than controls (both P<0.0001). The c-statistic for the generalized cardiovascular disease score was 0.68 (95% CI, 0.65-0.70) and for the stroke score was 0.64 (95% CI, 0.62-0.67)., Conclusions: Persons who had a stroke develop in the next year had a worse Framingham risk profile, as determined by administrative data. Future studies should examine how to improve the stroke predictive tools and to identify the appropriate populations and uses for applying stroke risk predictive tools.

Background: The association between a history of cancer and mortality has not been studied in a propensity-matched population of community-dwelling older adults., Methods: Of the 5795 participants in the Cardiovascular Health Study, 827 (14%) had self-reported physician-diagnosed cancer at baseline. Propensity scores for cancer were used to assemble a cohort of 789 and 3118 participants with and without cancer respectively who were balanced on 45 baseline characteristics. Cox regression models were used to determine the association between cancer and all-cause mortality among matched patients, and to identify independent predictors of mortality among unmatched cancer patients., Results: Matched participants had a mean (SD) age of 74 (6) years, 57% were women, 10% were African Americans, and 38% died from all causes during 12 years of follow-up. All-cause mortality occurred in 41% and 37% of matched participants with and without a history of cancer respectively (hazard ratio when cancer was compared with no cancer, 1.16; 95% confidence interval, 1.02-1.31; P=0.019). Among those with cancer, older age, male gender, smoking, lower than college education, fair-to-poor self-reported health, coronary artery disease, diabetes mellitus, chronic kidney disease, left ventricular hypertrophy, increased heart rate, low hemoglobin and low baseline albumin were associated with increased risk of mortality., Conclusions: Among community-dwelling older adults, a history of cancer was associated with increased mortality and among those with cancer, several socio-demographic variables and morbidities predicted mortality. These findings suggest that addressing traditional risk factors for cardiovascular mortality may help improve outcomes in older adults with a history of cancer., (Published by Elsevier Ltd.)

Background: The relationship between stage of chronic kidney disease (CKD) and incident heart failure (HF) remains unclear., Methods: Of the 5,795 community-dwelling adults ≥65 years in the Cardiovascular Health Study, 5,450 were free of prevalent HF and had baseline estimated glomerular filtration rate (eGFR: ml/min/1.73 m(2)) data. Of these, 898 (16%) had CKD 3A (eGFR 45-59 ml/min/1.73 m(2)) and 242 (4%) had CKD stage ≥3B (eGFR <45 ml/min/1.73 m(2)). Data on baseline proteinuria were not available and 4,310 (79%) individuals with eGFR ≥60 ml/min/1.73 m(2) were considered to have no CKD. Propensity scores estimated separately for CKD 3A and ≥3B were used to assemble two cohorts of 1,714 (857 pairs with CKD 3A and no CKD) and 557 participants (148 CKD ≥3B and 409 no CKD), respectively, balanced on 50 baseline characteristics., Results: During 13 years of follow-up, centrally-adjudicated incident HF occurred in 19, 24 and 38% of pre-match participants without CKD (reference), with CKD 3A [unadjusted hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.20-1.63; p < 0.001] and with CKD ≥3B (HR 3.37; 95% CI 2.71-4.18; p < 0.001), respectively. In contrast, among matched participants, incident HF occurred in 23 and 23% of those with CKD 3A and no CKD, respectively (HR 1.03; 95% CI 0.85-1.26; p = 0.746), and 36 and 28% of those with CKD ≥3B and no CKD, respectively (HR 1.44; 95% CI 1.04-2.00; p = 0.027)., Conclusions: Among community-dwelling older adults, CKD is a marker of incident HF regardless of stage; however, CKD ≥3B, not CKD 3A, has a modest independent association with incident HF., (Copyright © 2011 S. Karger AG, Basel.)

Objectives: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare-eligible older African Americans., Design: The Cardiovascular Health Study., Setting: Four U.S. states., Participants: Seven hundred ninety-five pairs of community-dwelling Medicare-eligible African-American and white adults aged 65 and older, balanced according to age and sex., Measurements: Data on self-reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline., Results: Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60-0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56-0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59-1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00-8.28; P<.001), and the association between race and pneumococcal vaccination lost significance when adjusted for influenza vaccination alone (OR=0.81, 95% CI=0.63-1.03; P=.09)., Conclusion: The strong association between receipt of influenza and pneumococcal vaccinations suggests that patient and provider attitudes toward vaccination, rather than traditional confounders such as education and income, may help explain the underuse of pneumococcal vaccination in older African Americans., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Background: Little is known about the epidemiology of stroke in chronic systolic and diastolic heart failure (HF) patients in normal sinus rhythm (NSR) receiving angiotensin-converting enzyme (ACE) inhibitors. Because all HF patients in the Digitalis Investigation Group (DIG) trial (N=7788) were in NSR and nearly all were receiving ACE inhibitors, a survey-based stroke-sub-study was conducted but its findings have never been published., Methods: DIG investigators confirmed a total 222 cases of stroke of which 144 had neurological deficit ≥24 h. We used logistic regression models to determine predictors of incident stroke among all 7788 patients and predictors of neurological deficit ≥24 h and all-cause mortality among 222 stroke patients., Results: Age ≥65 years (adjusted odds ratio {AOR}, 1.36; 95% confidence interval {CI}, 1.02-1.80; P=0.035), nonwhite race (AOR, 0.65; 95% CI, 0.42-0.99; P=0.047), hypertension (AOR, 1.46; 95% CI, 1.11-1.94; P=0.008), diabetes mellitus (AOR, 1.37; 95% CI, 1.03-1.82; P=0.030), and cardiomegaly (AOR, 1.39; 95% CI, 1.03-1.86; P=0.030) were independent predictors of stroke. However, among those with stroke, nonwhites had higher odds of neurological deficits ≥24 h (AOR, 2.86; 95% CI, 1.01-8.07; P=0.047) and death (AOR, 3.28; 95% CI, 1.30-8.30; P=0.012)., Conclusion: Older age, hypertension, diabetes and cardiomegaly were associated with increased incidence of stroke among HF patients with NSR receiving ACE inhibitors. The association of race and stroke, however, was complex. While nonwhite race was associated with decreased risk of stroke, among those with stroke, nonwhite race was associated with increased stroke severity and mortality., (Published by Elsevier Ireland Ltd.)

Background: Compared with serum potassium levels 4-5.5 mEq/L, those <4 mEq/L have been shown to increase mortality in chronic heart failure (HF). Expert opinions suggest that serum potassium levels >5.5 mEq/L may be harmful in HF. However, little is known about the safety of serum potassium 5-5.5 mEq/L., Methods: Of the 7788 chronic HF patients in the Digitalis Investigation Group trial, 5656 had serum potassium 4-5.5 mEq/L. Of these, 567 had mild hyperkalemia (5-5.5 mEq/L) and 5089 had normokalemia (4-4.9 mEq/L). Propensity scores for mild hyperkalemia were used to assemble a balanced cohort of 548 patients with mild hyperkalemia and 1629 patients with normokalemia. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for association between mild hyperkalemia and mortality during a median follow-up of 38 months., Results: All-cause mortality occurred in 36% and 38% of matched patients with normokalemia and mild hyperkalemia respectively (HR, 1.07; 95% CI, 0.90-1.26; P=0.458). Unadjusted, multivariable-adjusted, and propensity-adjusted HRs for mortality associated with mild hyperkalemia were 1.33 (95% CI, 1.15-1.52; P<0.0001), 1.16 (95% CI, 1.01-1.34; P=0.040) and 1.13 (95% CI, 0.98-1.31; P=0.091) respectively. Mild hyperkalemia had no association with cardiovascular or HF mortality or all-cause or cardiovascular hospitalization., Conclusion: Serum potassium 4-4.9 mEq/L is optimal and 5-5.5 mEq/L appears relatively safe in HF. Despite lack of an intrinsic association , the bivariate association of mild-hyperkalemia with mortality suggests that it may be useful as a biomarker of poor prognosis in HF., (Published by Elsevier Ireland Ltd.)

Background: The association between hyperuricemia and incident heart failure (HF) is relatively unknown., Methods: Of the 5461 community-dwelling older adults, >or=65 years, in the Cardiovascular Health Study without HF at baseline, 1505 had hyperuricemia (baseline serum uric acid >or=6 mg/dL for women and >or=7 mg/dL for men). Using propensity scores for hyperuricemia, estimated for each participant using 64 baseline covariates, we were able to match 1181 pairs of participants with and without hyperuricemia., Results: Incident HF occurred in 21% and 18% of participants respectively with and without hyperuricemia during 8.1 years of mean follow-up (hazard ratio {HR} for hyperuricemia versus no hyperuricemia, 1.30; 95% confidence interval {CI}, 1.05-1.60; P=0.015). The association between hyperuricemia and incident HF was significant only in subgroups with normal kidney function (HR, 1.23; 95% CI, 1.02-1.49; P=0.031), without hypertension (HR, 1.31; 95% CI, 1.03-1.66; P=0.030), not receiving thiazide diuretics (HR, 1.20; 95% CI, 1.01-1.42; P=0.044), and without hyperinsulinemia (HR, 1.35; 95% CI, 1.06-1.72; P=0.013). Used as a continuous variable, each 1 mg/dL increase in serum uric acid was associated with a 12% increase in incident HF (HR, 1.12; 95% CI, 1.03-1.22; P=0.006). Hyperuricemia had no association with acute myocardial infarction or all-cause mortality., Conclusions: Hyperuricemia is associated with incident HF in community-dwelling older adults. Cumulative data from our subgroup analyses suggest that this association is only significant when hyperuricemia is a marker of increased xanthine oxidase activity but not when hyperuricemia is caused by impaired renal elimination of uric acid., (Published by Elsevier Ireland Ltd.)

Background: Hypokalemia is common in heart failure (HF) and is associated with increased mortality. Potassium supplements are commonly used to treat hypokalemia and maintain normokalemia. However, their long-term effects on outcomes in chronic HF are unknown. We used a public-use copy of the Digitalis Investigation Group (DIG) trial dataset to determine the associations of potassium supplement use with outcomes using a propensity-matched design., Methods: Of the 7788 DIG participants with chronic HF, 2199 were using oral potassium supplements at baseline. We estimated propensity scores for potassium supplement use for each patient and used them to match 2131 pairs of patients receiving and not receiving potassium supplements. Matched Cox regression models were used to estimate associations of potassium supplement use with mortality and hospitalization during 40 months of median follow-up., Results: All-cause mortality occurred in 818 (rate, 1327/10,000 person-years) and 802 (rate, 1313/10,000 person-years) patients respectively receiving and not receiving potassium supplements (hazard ratio {HR} when potassium supplement use was compared with nonuse, 1.05; 95% confidence interval {CI}, 0.94-1.18; P=0.390). All-cause hospitalizations occurred in 1516 (rate, 4777/10,000 person-years) and 1445 (rate, 4120/10,000 person-years) patients respectively receiving and not receiving potassium supplements (HR, 1.15; 95% CI, 1.05-1.26; P=0.004). HRs (95% CI) for hospitalizations due to cardiovascular causes and worsening HF were respectively 1.19 (95% CI, 1.08-1.32; P=0.001) and 1.27 (1.12-1.43; P<0.0001)., Conclusion: The use of potassium supplements in chronic HF was not associated with mortality. However, their use was associated with increased hospitalization due to cardiovascular causes and progressive HF., (Published by Elsevier Ireland Ltd.)

Introduction: Ischemic heart disease (IHD) is common in heart failure (HF), yet the association between incident coronary revascularization and mortality in these patients has not been examined in a propensity-matched study., Methods: In the Digitalis Investigation Group trial, 2853 patients without coronary revascularization and 120 patients with coronary revascularization during the first three years were alive at the end of three years. We used propensity scores to match 119 and 357 patients with and without coronary revascularization. Matched Cox regression models were used to estimate hazard ratio (HR) and 95% confidence interval (CI) for mortality during the fourth year of follow-up, for all patients and by the mean left ventricular ejection fraction (LVEF) of 35%., Results: Coronary revascularization was associated with higher mean LVEF (36% versus 32%; p<0.0001) and prevalence of angina pectoris (48% versus 32%; p<0.0001) but fewer prior myocardial infarction (80% versus 87%; p=0.023), all of which were balanced post-match. All-cause mortality occurred in 5.9% and 6.2% patients respectively with and without coronary revascularization (HR for coronary revascularization, 0.95; 95% CI, 0.39-2.32; p=0.910). HR for mortality associated with coronary revascularization for patients with LVEF < or = 35% and >35% were respectively 1.34 (95% CI, 0.48-3.71; p=0.578) and 0.61 (95% CI, 0.13-2.87; p=0.532)., Conclusion: Chronic HF patients with IHD receiving coronary revascularization were more likely to have angina and higher LVEF. However, in a balanced propensity-matched cohort, there was no association between coronary revascularization and mortality. The LVEF-associated variation in mortality needs to be prospectively studied., (Published by Elsevier Ireland Ltd.)

Hypertension is a risk factor for incident heart failure (HF). However, the effect of uncontrolled blood pressure (BP) on incident HF in older adults with hypertension has not been prospectively examined in propensity-matched studies. Of the 5795 Cardiovascular Health Study participants, > or =65 years, 2562 with self-reported physician-diagnosed hypertension had no baseline HF. Of these, 1391 had uncontrolled hypertension, defined as systolic BP (SBP) > or =140 (n = 1373) or diastolic BP > or =90 mm Hg (n = 18). Propensity scores for uncontrolled hypertension, calculated for each participant, were used to assemble a cohort of 1021 pairs of participants with controlled and uncontrolled hypertension who were balanced on 31 baseline characteristics. Centrally adjudicated incident HF developed in 23% and 26% of participants with controlled and uncontrolled hypertension respectively during 13 years of follow-up (matched hazard ratio [HR] when uncontrolled hypertension was compared with controlled hypertension, 1.39; 95% confidence interval [CI], 1.12 to 1.73; P = .003). HRs (95% CI) for incident HF for those with (n = 503) and without (n = 1539) chronic kidney disease (CKD) were 1.73 (95% CI, 1.26 to 2.38; P = .001) and 1.08 (95% CI, 0.87 to 1.34; P = .486) respectively (P for interaction, .012). Compared with participants with controlled hypertension, HRs for incident HF associated with SBP 140 to 159 and > or =160 mm Hg were 1.06 (95% CI, 0.86 to 1.31; P = .572) and 1.58 (95% CI, 1.27 to 1.96; P < .0001), respectively. In community-dwelling older adults with hypertension, those with uncontrolled (versus controlled) BP have increased risk of new-onset HF, which is more pronounced in those with SBP > or =160 mm Hg and with CKD., (Published by Elsevier Inc.)

Several recent population-based studies have provided insight into the clinical importance and impact of overactive bladder (OAB). Although OAB can affect anyone at any age, the prevalence tends to increase with advancing age. Diuretic use is also common among older adults, as the prevalence of clinical conditions such as hypertension and heart failure requiring its use increases markedly with age. By causing increased formation of urine by the kidneys, diuretics increase urinary frequency and may cause urinary urgency and incontinence. This review provides a summary of available data, focusing on the association between OAB and diuretic use in the elderly. Although there is very little research work in this area, available studies have provided insight into the possible contribution of diuretic use to OAB in the elderly. Based on a recent report, OAB symptoms are common among older adults using diuretics, particularly the loop-type, and are associated with poor quality of life. More studies are required to fully understand the association between diuretic use and OAB, particularly its impact on health-related quality of life.

Aims: Atrial fibrillation (AF)-associated poor outcomes in heart failure (HF) are often attributed to older age, advanced disease, and comorbidity burden of HF patients with AF. Therefore, we examined the effect of AF on outcomes in a propensity-matched study in which patients with and without AF were well balanced on all measured baseline characteristics., Methods and Results: Of the 2708 advanced chronic systolic HF patients in the Beta-Blocker Evaluation of Survival Trial, 653 had a history of AF. Propensity scores for AF were calculated for each patient and were used to assemble a cohort of 487 pairs of patients with and without AF who were balanced on 74 baseline characteristics. Matched Cox regression analyses were used to estimate associations of AF with outcomes during 23 months of mean follow-up. All-cause mortality occurred in 187 (rate, 2046/10,000 person-years of follow-up) and 181 (rate, 1885/10,000 person-years) matched patients with and without AF, respectively [matched hazard ratio (HR) when AF was compared with no-AF 1.03, 95% confidence interval (CI) 0.79-1.33; P = 0.84]. Heart failure hospitalization occurred in 215 (rate, 3171/10,000 person-years) and 184 (rate, 2405/10,000 person-years) matched patients with and without AF, respectively (matched HR when AF was compared with no-AF 1.28, 95% CI 1.00-1.63; P = 0.049). Hazard ratios and 95% CIs for AF-associated HF hospitalization for bucindolol and placebo groups were, respectively, 1.08 (0.81-1.43) and 1.54 (1.17-2.03; P for interaction = 0.09)., Conclusion: A history of AF had no intrinsic association with mortality but was associated with HF hospitalization in chronic systolic HF.

Prospective population studies of incident heart failure (HF) are often limited by difficulties in assembling HF-free cohorts. In this study, public-use copies of the Cardiovascular Health Study (CHS) data sets were used to determine the sensitivity, specificity, and positive and negative predictive values of orthopnea and paroxysmal nocturnal dyspnea (PND), with and without the use of medications used in CHS HF criteria (diuretics plus digoxin or vasodilators), in the diagnosis of prevalent HF and in the assembly of a relatively HF-free population. Of the 5,771 community-dwelling older adults aged > or =65 years, 803 had orthopnea, 660 had PND, 1,075 had either symptom, 388 had both symptoms, 547 were using HF medications, and 4,315 had neither symptom and were not using HF medications. Definite HF was centrally adjudicated in 272 participants. The sensitivity, specificity, and positive and negative predictive values for either orthopnea or PND were 52% (95% confidence interval [CI] 46% to 58%), 83% (95% CI 82% to 84%), 13% (95% CI 11% to 15%), and 97% (95% CI 97% to 98%), respectively, and those for either orthopnea or PND or the use of HF medications were 77% (95% CI 72% to 82%), 77% (95% CI 76% to 79%), 14% (95% CI 13% to 16%), and 99% (95% CI 98% to 99%), respectively. In conclusion, only <20% of those with either orthopnea or PND had definite HF, which limits their usefulness in the diagnosis of prevalent HF in the community. However, nearly 99% (negative predictive value) of those with neither symptom nor using HF medications also did not have HF, which may be useful as a simple and inexpensive tool in assembling relatively HF-free cohorts for prospective population studies of incident HF.

The majority of heart failure (HF) patients are older adults and most HF-related adverse events occur in these patients. However, the independent association of age and outcomes in HF is not clearly determined. We categorized 7788 ambulatory HF patients who participated in the Digitalis Investigation Group (DIG) trial as younger (< 65 years) and older (> or = 65 years). Propensity scores for older age were calculated for each patient and used to match 2381 pairs of younger and older patients. The associations of older age with mortality and hospitalization during a median 40 months of follow-up were assessed using matched Cox regression models. All-cause mortality occurred in 877 older patients versus 688 younger patients (hazard ratio when older age was compared with younger age (HR)=1.26; 95% confidence interval (CI)=1.12-1.41; p<0.0001). Older patients, when compared with propensity-matched younger patients, also had significantly higher mortality rates due to cardiovascular causes (HR=1.14; 95% CI=1.00-1.30; p=0.044) and worsening heart failure causes (HR=1.32; 95% CI=1.07-1.62; p=0.009). No significant association was found between age and hospitalization due to all causes (HR=1.08; 95% CI=0.99-1.18; p=0.084) and cardiovascular causes (HR=1.03; 95% CI=0.93-1.13; p=0.622). However, hospitalization due to HF was significantly increased in older patients (HR=1.14; 95% CI=1.01-1.28; p=0.041). In ambulatory HF patients, older age although associated with increased mortality, was not associated with increased hospitalizations except for those due to worsening HF.

Diuretic use and overactive bladder syndrome are common in older adults. However, the relationship between the two has not been well studied. Data were collected by self-administered questionnaires including the Urge Urinary Distress Inventory (Urge-UDI) and the Urge Incontinence Impact Questionnaire (Urge-IIQ), and by outpatient chart abstraction. Patients (n=172) had a mean age of 79+/-7.5 (+/-S.D.), 76% were women, and 48% were African Americans; 76% had hypertension, 32% had heart failure, and 66% were receiving diuretics (57% loop diuretics). Overall, 72%, 68%, and 73% of patients, respectively, reported urinary frequency, urgency and urge incontinence. Diuretic use was associated with increased frequency (81% versus 55% non-diuretic; odds ratio (OR)=3.48; 95% confidence interval (CI)=1.73-7.03) and urgency (74% versus 57% non-diuretic; OR=2.17; 95% CI=1.11-4.24) but not with incontinence (OR=1.74; 95% CI=0.87-3.50). When adjusted for propensity scores, diuretic use had independent associations with frequency (adjusted OR=3.09; 95% CI=1.20-7.97) and urgency (adjusted OR=2.50; 95% CI=1.00-6.27). In addition to frequency and urgency, loop diuretic use was also associated with incontinence (OR=2.54; 95% CI=1.09-5.91), which lost significance after propensity adjustment (adjusted OR=1.88; 95% CI=0.57-6.17). Overall summary mean Urge-IIQ score was 1.83+/-0.85 with 1.75+/-0.86, 1.68+/-0.76, and 2.03+/-0.88, respectively, for no diuretic, non-loop, and loop-diuretic patients (one-way analysis of variance (ANOVA) p=0.063). Overactive bladder symptoms were common among ambulatory older adults and were associated with diuretic use, and had stronger associations with loop diuretic use.

Background: Chronic kidney disease (CKD) and diabetes mellitus (DM) are common comorbidities in heart failure (HF) and each is associated with poor outcomes. However, the effects of multimorbidity related to having both CKD and DM compared to CKD alone have not been well studied in a propensity-matched population of chronic HF patients., Methods: Of the 7788 ambulatory chronic HF patients in the Digitalis Investigation Group trial, 3527 had CKD, of whom 1095 had DM. Based on the absence or presence of DM, patients were categorized CKD-only and CKD-DM, respectively. Propensity scores for CKD-DM were calculated for each patient and were used to match 987 pairs of CKD-only and CKD-DM patients. Hazard ratios (HR) and 95% confidence intervals (CI) comparing CKD-DM patients with CKD-only patients were estimated using matched Cox regression models., Results: All-cause mortality occurred in 47.0% (rate, 1783/10,000 person-years of follow-up) of CKD-DM patients and 39.6% (rate, 1414/10,000 person-years) of CKD-only patients (HR when CKD-DM is compared with CKD-only, 1.25; 95%-CI, 1.07-1.46; p=0.006). All-cause hospitalization occurred in 75.4% (rate, 5710/10,000 person-years) and 67.8% (rate, 4213/10,000 person-years) of CKD-DM and CKD-only patients respectively (HR, 1.32; 95%-CI, 1.15-1.52; p<0.0001). Respective HR and 95%-CI for other outcomes were: cardiovascular mortality (1.27; 1.06-1.52; p=0.009), HF mortality (1.34; 1.04-1.72; p=0.025); cardiovascular hospitalization (1.29; 1.12-1.49; p=0.001) and HF hospitalization (1.37; 1.16-1.63; p<0.0001)., Conclusions: Compared with comorbidity due to CKD alone, multimorbidity with CKD and DM was associated with poor outcomes in chronic HF patients.

The independence of association between elevated jugular venous pressure (JVP) and outcomes in heart failure (HF) has not been well studied. The objective of propensity-matched study was to determine if an elevated JVP had intrinsic associations with outcomes in chronic systolic and diastolic HF. Of the 7,788 participants in the Digitalis Investigation Group trial, 1,020 (13%) had elevated JVP at baseline. Propensity scores for elevated JVP were estimated for all patients based on 32 baseline characteristics and were used to match 827 pairs of patients with normal and elevated JVP. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated to compare outcomes associated with elevated versus normal JVP during 34 months of median follow-up. Before matching, all-cause mortality occurred in 31% and 47% (unadjusted HR 1.70, 95% CI 1.54 to 1.88, p <0.0001), and all-cause hospitalization occurred in 60% and 71% (unadjusted HR 1.35, 95% CI 1.25 to 1.47, p <0.0001) of patients with normal and elevated JVP, respectively. After matching, all-cause mortality occurred in 48% and 45% (matched HR 0.95, 95% CI 0.80 to 1.12, p = 0.521), and all-cause hospitalization occurred in 70% and 70% (matched HR 0.97, 95% CI 0.87 to 1.09, p = 0.613) of patients with normal and elevated JVP, respectively. Elevated JVP had no intrinsic associations with cardiovascular mortality (matched HR 0.93, 95% CI 0.77 to 1.12, p = 0.440) or hospitalization for HF (matched HR 0.94, 95% CI 0.78 to 1.14, p = 0.532). In conclusion, an elevated JVP is a marker of higher burden of sickness and poor outcomes. However, elevated JVP had no intrinsic association with mortality or hospitalization in chronic HF.

The association between isolated systolic hypertension (ISH) and incident heart failure (HF) has not been prospectively studied in a propensity-matched population of ambulatory older adults. Of the 5795 participants in the public-use copy of the Cardiovascular Health Study data set, 5248 had diastolic blood pressure <90 mm Hg and were free of HF at baseline. Of these, 2000 (38%) had ISH, defined as average seated systolic blood pressure > or =140 mm Hg. Propensity scores for baseline ISH were calculated for each participant (based on 64 baseline covariates) and were used to match 1260 pairs of participants with and without ISH. Matched Cox regression models were used to estimate the association of ISH with incident HF during a mean follow-up of 8.7 years. Matched participants (n=2520) had a mean (+/-SD) age of 74 (+/-6) years, 60% were women, 16% were nonwhites, 18% developed new-onset HF, and 35% died. Incident HF developed in 20% (rate: 242/10,000 person-years) and 16% (rate: 194/10,000 person-years) of participants with and without ISH, respectively (matched hazard ratio when ISH was compared with no ISH: 1.26; 95% CI: 1.04 to 1.51; P=0.016). Prematch unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios (95% CIs) for ISH-associated incident HF were, respectively, 1.72 (1.51 to 1.97; P<0.0001), 1.35 (1.18 to 1.56; P<0.0001), and 1.22 (1.04 to 1.44; P=0.016). ISH had no association with all-cause mortality (matched hazard ratio: 1.03; 95% CI: 0.88 to 1.19; P=0.732). In conclusion, in a propensity-matched cohort of community-dwelling older adults who were well balanced in 64 baseline covariates, ISH was associated with increased risk of incident HF but had no association with all-cause mortality.

The association between peripheral arterial disease (PAD) and outcomes has not been studied in a propensity-matched population of community-dwelling older adults. A public-use copy of the Cardiovascular Health Study (CHS) data was analyzed to test the hypothesis that baseline PAD is associated with increased all-cause mortality and cardiovascular morbidity. Of the 5,795 CHS participants, 5,630 had data on baseline ankle-brachial index, and 767 had PAD, defined as ankle-brachial index <0.9. Propensity scores for PAD were calculated for each participant using 66 baseline covariates and were used to match 679 pairs of participants with and without PAD. Matched Cox regression models were used to estimate associations of PAD with outcomes during a median follow-up period of 7.5 years. Overall, 55% of matched participants died from all causes during 9,958 patient-years of follow-up. All-cause mortality occurred in 61% (rate 8,710/100,000 patient-years) and 50% (rate 6,503/100,000 patient-years) of participants, respectively, with and without PAD (matched hazard ratio for PAD vs no PAD 1.47, 95% confidence interval (CI) 1.23 to 1.76, p <0.0001). Prematch unadjusted, multivariable-adjusted, and propensity-adjusted hazard ratios for PAD-associated all-cause mortality were 2.90 (95% CI 2.61 to 3.21, p <0.0001), 1.53 (95% CI 1.36 to 1.71, p <0.0001), and 1.57 (95% CI 1.39 to 1.78, p <0.0001), respectively. Matched hazard ratios for PAD for incident heart failure and symptomatic PAD were 1.32 (95% CI 1.00 to 1.73, p = 0.052) and 3.92 (95% CI 2.13 to 7.21, p <0.0001), respectively. In conclusion, in a propensity-matched well-balanced population of community-dwelling older adults, baseline PAD was associated with increased all-cause mortality and cardiovascular morbidity.

Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in patients with chronic heart failure (HF) and are associated with poor outcomes. However, the impact of multimorbidity due to DM and CKD on outcomes, relative to co-morbidity due to DM alone, has not been well studied in these patients. Of the 7,788 patients with chronic HF in the Digitalis Investigation Group trial, 2,218 had DM. We categorized these patients into those with DM alone (DM-only n = 1,123) and those with both DM and CKD (DM-CKD n = 1,095). Propensity scores for DM-CKD, calculated for each of the 2,218 patients, were used to match 699 pairs of patients with DM-only or DM-CKD. Matched Cox regression models were used to estimate associations between DM-CKD and outcomes. All-cause mortality occurred in 44% (rate 1,648/10,000 person-years) of patients with DM-CKD and 39% (rate 1,349/10,000 person-years of follow-up) of patients with DM-only (hazard ratio when DM-CKD was compared with DM-only 1.34, 95% confidence interval [CI] 1.11 to 1.62, p = 0.003). All-cause hospitalization occurred in 76% (rate 5,799/10,000 person-years) and 73% (rate 4,909/10,000 person-years) of patients with DM-CKD and DM-only, respectively (hazard ratio 1.16, 95% CI 0.99 to 1.36, p = 0.064). Respective hazard ratios for other outcomes were cardiovascular mortality 1.33 (95% CI 1.07 to 1.66, p = 0.010), HF mortality 1.41 (95% CI 1.02 to 1.96, p = 0.040), cardiovascular hospitalization 1.17 (95% CI 0.99 to 1.39, p = 0.064), and HF hospitalization 1.26 (95% CI 1.03 to 1.55, p = 0.026). In conclusion, compared with co-morbidity due to DM alone, the presence of multimorbidity due to DM and CKD was associated with increased mortality and morbidity in patients with chronic HF.

Aims: Potassium homeostasis is essential for normal myocardial function, and low serum potassium may cause fatal arrhythmias. However, the association of low potassium and long-term mortality and morbidity in heart failure (HF) is largely unknown., Methods and Results: We studied 6845 HF patients in the Digitalis Investigation Group trial with serum potassium levels < or =5.5 mEq/L. Of these, 1189 had low potassium (<4 mEq/L). Propensity scores for low potassium were calculated for each patient and were used to match 1187 low-potassium patients with 1187 normal-potassium (4-5.5 mEq/L) patients. Effects of low potassium on outcomes were assessed using matched Cox regression analyses. All-cause mortality occurred in 379 (rate, 1103/10 000 person-years) normal-potassium and 441 (rate, 1330/10 000 person-years) low-potassium patients, respectively, during 3437 and 3315 years of follow-up [hazard ratio (HR), 1.25; 95% confidence interval (CI), 1.07-1.46; P = 0.006]. Cardiovascular mortality occurred in 297 (864/10 000 person-years) normal-potassium and 356 (1074/10 000 person-years) low-potassium patients (HR, 1.27; 95% CI, 1.06-1.51; P = 0.009). Cardiovascular hospitalization occurred in 610 (rate, 2553/10 000 person-years) normal-potassium and 637 (rate, 2855/10 000 person-years) low-potassium patients (HR, 1.13; 95% CI, 0.99-1.29; P = 0.082)., Conclusion: In a cohort of ambulatory chronic systolic and diastolic HF patients who were balanced in all measured baseline covariates, serum potassium <4 mEq/L was associated with increased mortality, with a trend towards increased hospitalization.

The objective of this study was to determine the prevalence of depressive symptoms in Jamaican adolescents and examine its association with individual and family factors. We used an abbreviated form of the Beck's Depression Inventory II (BDI-II) to assess depressive symptoms among 748 students, attending public high schools in the parish of Hanover Jamaica. In the analysis, we classified adolescents with scores in the upper quartile of the depressive symptom score as having depressive symptoms. Multivariate logistic regression was used to determine the predictors of depressive symptoms. 14.2% of participants reported depressive symptoms. There was association between engagement in sexual activity [Odds Ratio (OR) = 1.61, 95% Confidence Interval (CI) = 1.02-2.51], parental monitoring of adolescent activity (OR=2.04, 95%CI=1.33 -3.12), maternal affection and support (OR= 4.07, 95%CI= 2.62-6.33), and paternal affection and support (OR= 1.58, 95%CI= 1.05-2.39) with self reported depressive symptoms at the bivariate level. In the final model, depressive symptoms was associated with perceived lack of maternal affection and support (OR= 4.06, 95%CI= 2.61-6.32) and showed marginal association with being sexually experienced (OR= 1.59, 95%CI= 1.00-2.52). As most homes are female-headed, establishing support systems for the mother to take care of their adolescent children may decrease the odds of depressive symptoms. Sexually experienced adolescents may require screening for depression. Further research is required to fully explore all factors that could predispose Jamaican adolescents to depression.

Individual and family factors have been hypothesized to influence adolescent sexual behavior, but the extent to which this is true for adolescents in Jamaica as a whole and for those in rural areas in particular, has not been well studied. The objective of this study was to identify individual and family factors associated with initiation of sexual activity before the age of 16 among rural adolescents in Jamaica. We analyzed data for 469 sexually experienced adolescents attending public high schools in the rural parish of Hanover. Multivariate logistic regression was used to predict independent influences of these factors. The mean age at sexual debut was 11 years for boys and 15 years for girls. Early adolescent sexual activity was associated with liberal attitudes about negative sexual outcomes (OR = 1.96, 95%CI = 1.34-2.87) and first sexual partner not being a steady boyfriend or girlfriend (OR = 4.19, 95%CI = 1.62-10.84). Female gender (OR = 0.16, 95%CI = 0.07-0.36) and older age at time of survey were protective (OR = 0.40, 95%CI = 0.32-0.52). Girls who were early starters were more likely to have been initiated by partners who were not steady boyfriends. They also reported liberal attitude towards negative sexual outcomes. Boys were mainly influenced by liberal attitude towards negative sexual outcomes. Being older was protective for both genders. Considering the high rates of HIV and adolescent pregnancy in this population, reproductive health programs that attempt to delay age at first sex should begin early in primary school before adolescents become sexually active.

Objective: To clarify the association between childhood pregnancy and risk of stillbirth., Study Design: We analyzed singleton and twin pregnancies that occurred in children (10-14 years old) in the United States from 1989 to 2000. We estimated the absolute and relative risks of stillbirth by using 15- to19-year-old and 20- to 24-year-old mothers as comparison groups., Results: The analysis involved 17.8 million singletons and 337,904 individual twins. The rate of stillbirth was highest in pediatric mothers for both singletons (12.8/1000) and twins (56/1000) compared with adolescent (6.8/1000 in singletons and 29/1000 in twins) and mature (5.5/1000 in singletons and 20/1000 in twins) mothers. After adjusting for confounding characteristics, pediatric mothers continued to exhibit significantly elevated risk for stillbirth in both singletons (odds ratio, 1.57; 95%CI, 1.49-1.66) and twins (odds ratio, 1.97; 95%CI, 1.42-2.73). Preterm birth rather than small size for gestational age was revealed by means of sequential modeling to account for the excess risk of stillbirth observed in pediatric gravidas., Conclusion: Pregnancy in childhood is a risk factor for stillbirth; shortened gestation rather than reduction in fetal growth is the mediating pathway.