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Arterial stiffness is a precursor for the development of hypertension and premature cardiovascular disease (CVD). Physical activity has been associated with lower arterial stiffness among largely White populations, but the types of activity required and whether these findings apply to Black adults remain unknown. We examined whether physical activity levels were associated with arterial stiffness among Black adults in two independent cohorts. In the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity, 378 Black adults (age 52.8 ± 10.3, 39.7% male) without known CVD living in Atlanta, GA were recruited. Arterial stiffness was measured as pulse wave velocity (PWV). Total and domain-specific physical activity were assessed by self-report. Multiple linear regression models were used to investigate differences across physical activity levels after adjusting for age, sex, CVD risk factors, and socioeconomic status. Findings were validated in an independent cohort of Black adults ( n = 55, age 50.4 ± 9.2, 23.6% male). After adjustment for covariates, lower arterial stiffness was associated with higher self-reported levels of sport/exercise (6.92 ± 1.13 vs 7.75 ± 1.14, p < 0.001, highest vs lowest quartile) and home/life activities (7.34 ± 1.24 vs 7.73 ± 1.07, p = 0.04, highest vs lowest quartile), but not work, active living, or the overall physical activity scores. These findings were replicated in the independent cohort where higher levels of sport/exercise remained associated with lower arterial stiffness (6.66 ± 0.57 vs 8.21 ± 0.66, p < 0.001, highest vs lowest quartile). Higher levels of sport/exercise and home/life-related physical activities (in comparison to occupational physical activity) are associated with lower arterial stiffness in Black adults.

Background:Early trauma (general, emotional, physical, and sexual abuse before age 18 years) has been associated with both cardiovascular disease risk and lifestyle-related risk factors for cardiovascular disease, including smoking, obesity, and physical inactivity. Despite higher prevalence, the association between early trauma and cardiovascular health (CVH) has been understudied in Black Americans, especially those from low-income backgrounds, who may be doubly vulnerable. Therefore, we investigated the association between early trauma and CVH, particularly among low-income Black Americans.Methods:We recruited 457 Black adults (age 53±10, 38% male) without known cardiovascular disease from the Atlanta, GA, metropolitan area using personalized, community-based recruitment methods. The Early Trauma Inventory was administered to assess overall early traumatic life experiences which include physical, sexual, emotional abuse, and general trauma. Our primary outcome was the American Heart Association Life’s Simple 7, which is a set of 7 CVH metrics, including 4 lifestyle-related factors (smoking, body mass index, physical activity, and diet) and three physiologically measured health factors (blood pressure, total blood cholesterol, and blood glucose). We used linear regression models adjusting for age, sex, socioeconomic status, and depression to test the association between early trauma and CVH and tested the early trauma by household income (Results:Higher levels of early trauma were associated with lower Life’s Simple 7 scores (β, −0.05 [95% CI, −0.09 to −0.01],P=0.02, per 1 unit increase in the Early Trauma Inventory score) among lower, but not higher, income Black participants (Pvalue for interaction=0.04). Subtypes of early trauma linked to Life’s Simple 7 were general trauma, emotional abuse, and sexual abuse. Exploratory analyses demonstrated that early trauma was only associated with the body mass index and smoking components of Life’s Simple 7.Conclusions:Early trauma, including general trauma, emotional abuse, and sexual abuse, may be associated with worse CVH among low-, but not higher-income Black adults.

ObjectiveTo simultaneously examine multiple individual-level neighbourhood perceptions and psychosocial characteristics and their relationships with cardiovascular health (CVH) among blacks.DesignCross-sectional study.SettingSubjects were recruited between 2016 and 2018 via convenience sampling.Participants385 Black men and women, age 30–70 living in the Atlanta metropolitan area (Georgia, USA).Primary outcome measureIndividual’s CVH was summarised as a composite score using American Heart Association’s Life’s Simple 7 (LS7) metrics.MethodsWe implemented unsupervised learning (k-means) and supervised learning (Bayesian Dirichlet process clustering) to identify clusters based on 11 self-reported neighbourhood perception and psychosocial characteristics. We also performed principal component analysis to summarise neighbourhood perceptions and psychosocial variables and assess their associations with LS7 scores.ResultsK-means and Bayesian clustering resulted in 4 and 5 clusters, respectively. Based on the posterior distributions, higher LS7 scores were associated with better neighbourhood perceptions and psychosocial characteristics, including neighbourhood safety, social cohesion, activities with neighbours, environmental mastery, purpose in life, resilient coping and no depression. Taken together, the first principal components of neighbourhood perceptions and psychosocial characteristics were associated with an increase of 0.07 (95% CI −0.17 to 0.31) and 0.31 (95% CI 0.06 to 0.55) in LS7 score, respectively, after accounting for age, sex, household income and education level.ConclusionBoth neighbourhood perception and psychosocial domains were related to CVH, but individual psychosocial characteristics appeared to contribute to CVH most. Approaches that acknowledge the importance of factors in both domains may prove most beneficial for enhancing resilience and promoting CVH among black communities.

Introduction: Arterial stiffness is a precursor for development of hypertension and premature cardiovascular disease (CVD). Physical activity has been associated with lower arterial stiffness among largely White populations, but the types of activity required and whether these findings apply to Blacks remain unknown. We examined whether physical activity levels were associated with arterial stiffness among Blacks in two independent cohorts. Methods: In the Morehouse-Emory Cardiovascular (MECA) Center for Health Equity, 458 Black adults (age 53 ± 10, 39% male) without known CVD living in Atlanta, GA were recruited. Arterial stiffness was measured as pulse wave velocity (PWV) using applanation tonometry (Sphygmocor Inc). Total and domain specific physical activity (work, active living, household, and sport/exercise) were assessed by self-report using the Jackson Heart Study Physical Activity Questionnaire. Multiple linear regression models were used to investigate differences after adjusting for age, gender, blood pressure, diabetes, and smoking. Change in the Framingham Risk Score (FRS) was tested as a potential mediator. Findings were validated in the Emory-Morehouse Partnership to Reduce Cardiovascular Health Disparities (META-Health) --another independent cohort of Black adults (n=60, age 50 ± 10, 25% male). Results: Lower arterial stiffness was associated with higher self-reported levels of sport/exercise (Beta = -0.54 [-1.03, -0.05], p=0.03, highest versus lowest quartile), but not work, active living, household-related physical activities, or the overall physical activity scores. 26.9% of this improvement appeared to be mediated through changes in FRS factors. These findings were confirmed in an independent group of Blacks in META-Health where higher levels of sport/exercise remained associated with lower arterial stiffness (Beta = -1.46 [-2.80, -0.12], p=0.03, highest versus lowest quartile). Conclusion: Higher sport/exercise related physical activity is associated with lower arterial stiffness in Blacks, an association that is only partially attributable to a lower traditional CVD risk factor burden.

Background: Despite well-documented cardiovascular disparities between racial groups, within-race determinants of cardiovascular health among Black adults remain understudied. Factors promoting cardiovascular resilience among Black adults in particular warrant further investigation. Our objective was to examine whether individual psychosocial resilience and neighborhood-level cardiovascular resilience were associated with better cardiovascular health in Black adults, measured utilizing Life’s Simple 7 (LS7) scores. Methods: We assessed LS7 scores in 389 Black adults (mean age, 53±10 years; 39% men) living in Atlanta, Georgia. A composite score of individual psychosocial resilience was created by assessing environmental mastery, purpose in life, optimism, resilient coping, and depressive symptoms. Neighborhood-level cardiovascular resilience was separately determined by the census tract-level rates of cardiovascular mortality/morbidity events. Generalized linear mixed regression models were used to examine the association between individual psychosocial resilience, neighborhood cardiovascular resilience, and LS7 scores. Results: Higher individual psychosocial resilience was significantly associated with higher LS7 (β=0.38 [0.16–0.59] per 1 SD) after adjustment for sociodemographic factors. Similarly, higher neighborhood-level cardiovascular resilience was significantly associated with higher LS7 (β=0.23 [0.02–0.45] per 1 SD). When jointly examined, high individual psychosocial resilience (>median) was independently associated with higher LS7 (β=0.73 [0.31–1.17]), whereas living in high-resilience neighborhoods (>median) was not. The largest difference in LS7 score was between those with high and low psychosocial resilience living in low-resilience neighborhoods (8.38 [7.90–8.86] versus 7.42 [7.04–7.79]). Conclusions: Individual psychosocial resilience in Black adults is associated with better cardiovascular health.

Background Cardiovascular disease incidence, prevalence, morbidity, and mortality have declined in the past several decades; however, disparities persist among subsets of the population. Notably, blacks have not experienced the same improvements on the whole as whites. Furthermore, frequent reports of relatively poorer health statistics among the black population have led to a broad assumption that black race reliably predicts relatively poorer health outcomes. However, substantial intraethnic and intraracial heterogeneity exists; moreover, individuals with similar risk factors and environmental exposures are often known to experience vastly different cardiovascular health outcomes. Thus, some individuals have good outcomes even in the presence of cardiovascular risk factors, a concept known as resilience. Methods and Results The MECA (Morehouse‐Emory Center for Health Equity) Study was designed to investigate the multilevel exposures that contribute to “resilience” in the face of risk for poor cardiovascular health among blacks in the greater Atlanta, GA, metropolitan area. We used census tract data to determine “at‐risk” and “resilient” neighborhoods with high or low prevalence of cardiovascular morbidity and mortality, based on cardiovascular death, hospitalization, and emergency department visits for blacks. More than 1400 individuals from these census tracts assented to demographic, health, and psychosocial questionnaires administered through telephone surveys. Afterwards, ≈500 individuals were recruited to enroll in a clinical study, where risk biomarkers, such as oxidative stress, and inflammatory markers, endothelial progenitor cells, metabolomic and micro RNA profiles, and subclinical vascular dysfunction were measured. In addition, comprehensive behavioral questionnaires were collected and ideal cardiovascular health metrics were assessed using the American Heart Association's Life Simple 7 measure. Last, 150 individuals with low Life Simple 7 were recruited and randomized to a behavioral mobile health (eHealth) plus health coach or eHealth only intervention and followed up for improvement. Conclusions The MECA Study is investigating socioenvironmental and individual behavioral measures that promote resilience to cardiovascular disease in blacks by assessing biological, functional, and molecular mechanisms. REGISTRATION URL : https://www.clini​caltr​ials.gov . Unique identifier: NCT 03308812.

Introduction: While cardiovascular disease (CVD) morbidity and mortality is particularly pronounced among Black Americans, there is a great deal of intra-racial heterogeneity within the population. Our objective was to identify novel circulating biomarkers (extracellular miRNA and metabolites) that predict cardiovascular health (CVH) within Blacks, while providing insight into CVD pathophysiology. Hypothesis: We hypothesize that an integrative analysis of miRNA and metabolomics profiles will enable a systems biology approach to understanding CVH as defined by the American Heart Association's Life’s Simple 7 (LS7) score within Blacks. Methods: Platelet free plasma (PFP) was collected from 382 Black adults (age 53 + 10, 40% male) without known CVD living in Atlanta, GA. CVH was determined by LS7 scores calculated from measured blood pressure, blood glucose, cholesterol, body mass index (BMI), and self-reported exercise, diet, and smoking. In the discovery phase, next generation sequencing was performed on PFP samples from 20 participants with low CVH (LS7 < 6) and 20 with high CVH (LS7 > 10). DESeq was used to identify differentially expressed miRNAs. In the validation phase, RT-qPCR was used to assess levels of eight miRNAs in 382 samples. Spearman correlation and linear regression analyses were performed to assess ability of miRNA levels to predict LS7. High-resolution metabolomics profiling was performed on all 382 samples. Integrative analysis of miRNA, metabolomics profiles, and clinical domains of CVH (LS7) was performed using the program xMWAS to determine connectivity among these markers. Results: RNA sequencing identified 13 extracellular miRNAs differentially expressed between low CVH and high CVH (FDR < 0.05). Analysis of data from validation phase found the expression of four extracellular miRNAs (miRs-122, -150, -30c, -769-3p) significantly correlated with LS7. Metabolome wide association study (MWAS) identified 141 features that were differentially expressed between low and high CVH with false discovery rate of Conclusions: CVH in Blacks is associated with distinct extracellular miRNA and metabolomics profiles, and these molecular profiles are associated with pathways linked to vascular dysfunction. Integrative analysis revealed connectivity between miRNA-metabolome networks and clinical domains of CVH. This novel method represents an unique opportunity to gain insights into epigenetic and environmental influences on CVD disparities.

Introduction: Sleep is hypothesized to be a contributing factor towards disparities in cardiovascular disease (CVD). It has been demonstrated that Black Americans have worse sleep quality compared to other ethnic groups, but within group differences have not been studied. Whether overall sleep quality and patterns affect cardiovascular health (CVH) among Blacks has yet to be elucidated. Hypothesis: Black individuals reporting worse sleep quality and patterns will have poor CVH as measured by the American Heart Association’s Life’s Simple 7 (LS7) scores. Methods: We recruited 499 Black adults (age 53 ± 10, 38% male) without known CVD from the Atlanta, GA metropolitan area. Sleep quality and patterns were assessed by the Pittsburgh Sleep Quality Index (PSQI) which includes sleep quality, nighttime disturbance, efficiency (amount of time slept while in bed), daytime dysfunction, duration, need of medications and latency (time required to fall asleep). CVH was determined by LS7 scores calculated from measured blood pressure, glucose, cholesterol, body mass index (BMI), and self-reported exercise, diet, and smoking, and categorized into poor (0-8), intermediate (9-10), and ideal (11-14). Multinomial logistic regression was used to examine the relationship between sleep and the odds of intermediate (vs. poor) and ideal (vs. poor) CVH categories after adjusting for age, gender, household income, education, marital status, and employment status. Results: A total of 55 (11%), 107 (21%), and 337 (67%) participants had ideal, intermediate, and poor LS7 scores, respectively. Those reporting PSQI-assessed poor sleep quality (OR 0.50, 95% CI [0.33 - 0.78]), longer latency (OR 0.50, 95% CI [0.36 - 0.70]), disturbance (OR 0.45, 95% CI [0.26 - 0.77]) and daytime dysfunction (OR 0.52, 95% CI [0.31 - 0.89]) had significantly lower adjusted odds of having ideal CVH. Daytime dysfunction was significantly associated with lower adjusted odds of having ideal blood pressure (OR 0.57, 95% CI [0.38 - 0.87]), glucose (OR 0.71, 95% CI [0.51 - 0.98]), and physical activity (OR 0.58, 95% CI [0.36 - 0.93]). Similarly, longer latency was significantly associated with lower adjusted odds of having ideal BMI (OR 0.72, 95% CI [0.54 - 0.95]), blood pressure (OR 0.71, 95% CI [0.55 - 0.92]), and cholesterol (OR 0.73, 95% CI [0.55 - 0.98]). PSQI-assessed shorter sleep duration was not associated with poor overall CVH, but was associated with significantly lower adjusted odds of having ideal blood pressure (OR 0.77, 95% CI [0.61 - 0.99]). Conclusion: Among Black Americans, poor sleep in terms of quality, nighttime disturbance, daytime dysfunction and longer latency, was associated with worse overall CVH or its components. Whether addressing sleep quality in Blacks will improve CVH and outcomes needs to be studied.

Introduction: Early trauma (e.g. general, emotional, physical, and sexual abuse before age 18) has been associated with both cardiovascular disease (CVD) risk and lifestyle-related risk factors for CVD including smoking, obesity, and physical inactivity. However, previous studies have primarily focused on White participants, despite the fact that early trauma is more common in Blacks. In particular, the role played by low socioeconomic status (SES) in this population has been relatively understudied. Hypothesis: Black individuals reporting early trauma will have worse cardiovascular health (CVH) as measured by the American Heart Association’s Life’s Simple 7 (LS7) scores and these associations will vary by SES. Methods: We recruited 499 Black adults (age 53 ± 10, 38% male) without CVD from the Atlanta, GA metropolitan area. The Early Trauma Inventory (ETI) was administered to assess physical, sexual, emotional abuse and general trauma. CVH was determined by LS7 scores calculated from measured blood pressure, blood glucose, cholesterol, body mass index (BMI), and self-reported exercise, diet, and smoking and was categorized as poor (0-8), intermediate (9-10), and ideal (11-14). Multinomial logistic regression was used to examine the relationship between early trauma and the odds of intermediate (vs. poor) and ideal (vs. poor) CVH categories after adjusting for age, gender, household income, education, marital status, employment status, and depression. After testing for interaction between ETI and SES, stratified analysis was conducted separately on individuals with low and high SES (defined as household income less or greater than $50,000 per year, respectively). Results: A total of 55 (11%), 107 (21%), and 337 (67%) participants had ideal, intermediate, and poor LS7 scores, respectively. In the full cohort, higher levels of early trauma were associated with lower adjusted odds of ideal LS7 scores (OR 0.94, 95% CI [0.88 - 1.00] per 1 SD increase in the ETI score). In SES-stratified analyses, higher levels of early trauma (OR 0.91, 95% CI [0.84 - 0.98]), in particular emotional (OR 0.74, 95% CI [0.59 - 0.94]) and sexual abuse (OR 0.69, 95% CI [0.49 - 0.96]), were significantly associated with lower adjusted odds of ideal LS7 scores among lower, but not higher, SES Black participants (p value for interaction =0.03). Among the CVH components, emotional and sexual abuse were both associated with significantly lower adjusted odds of ideal BMI (OR 0.81, 95% CI [0.68-0.97] and OR 0.72, 95% CI [0.56-0.93], respectively) in low SES participants. Conclusion: Early trauma, particularly emotional and sexual abuse, was associated with worse CVH among Black individuals with lower SES. Further research is needed to investigate the mechanisms through which economic disadvantage potentiates the adverse influence of early trauma on CVH in Black individuals.

Background Neighborhood environment is increasingly recognized as an important determinant of CVH among Black adults. Most research to date has focused on negative aspects of the neighborhood environment, with little attention being paid to the specific positive features, in particular the social environment, that promote cardiovascular resilience among Black adults. Objective We examined whether better neighborhood physical and social characteristics are associated with ideal CVH among Black adults, as measured by Life's Simple 7 (LS7) scores. Methods We recruited 392 Black adults (age 53 ± 10, 39% male) without known CV disease living in Atlanta, GA. Seven neighborhood domains were assessed via questionnaire: aesthetic quality, walking environment, safety, food access, social cohesion, activity with neighbors, and violence. CVH was determined by LS7 scores calculated from measured blood pressure, glucose, cholesterol, body mass index (BMI), and self-reported exercise, diet, and smoking, and categorized into poor (0-8), intermediate (9-10), and ideal (11-14). Multinomial logistic regression was used to examine the association between neighborhood characteristics and the odds of intermediate/ideal CVH categories compared to poor CVH after adjustment for age, gender, household income, education, marital status, and employment status. Results Better scores in the neighborhood domains of social cohesion and activity with neighbors were significantly associated with higher adjusted odds of ideal LS7 scores (OR 2.02, 95% CI [1.36 - 3.01] and 1.71 [1.20 - 2.45] per 1 standard deviation [SD] increase in respective scores). These associations were stronger for both social cohesion (OR 2.61, 95% CI [1.48 - 4.61] versus 1.40 [0.82 - 2.40]) and activity with neighbors (OR 1.82, 95% CI [1.15 - 2.86] versus 1.53 [0.84 - 2.78]) in Black women compared to men. Specifically, better scores in social cohesion were associated with higher odds of ideal CVH in exercise (OR 1.73 [1.16 - 2.59]), diet (OR 1.90 [1.11 - 3.26]), and BMI (OR 1.52 [1.09 - 2.09]); better scores in activity with neighbors were also similarly associated with higher odds of ideal CVH in exercise (OR 1.48 [1.00 - 2.19]), diet (OR 2.15 [1.23 - 3.77]), and BMI (OR 1.45 [1.07 - 1.98]; per 1 SD in respective scores). Conclusion More desirable neighborhood characteristics, particularly social cohesion and activity with neighbors, were associated with better CVH among Black adults.

Rationale: Blacks compared with whites have a greater risk of adverse cardiovascular outcomes. Impaired regenerative capacity, measured as lower levels of circulating progenitor cells (CPCs), is a novel determinant of adverse outcomes; however, little is known about racial differences in CPCs. Objective: To investigate the number of CPCs, PC-mobilizing factors, PC mobilization during acute myocardial infarction and the predictive value of CPC counts in blacks compared with whites. Methods and Results: CPCs were enumerated by flow cytometry as CD45med + blood mononuclear cells expressing CD34+, CD133+, VEGF2R+, and CXCR4+ epitopes in 1747 subjects, mean age 58.4±13, 55% male, and 26% self-reported black. Patients presenting with acute myocardial infarction (n=91) were analyzed separately. Models were adjusted for relevant clinical variables. SDF-1α (stromal cell-derived factor-1α), VEGF (vascular endothelial growth factor), and MMP-9 (matrix metallopeptidase-9) levels were measured (n=561), and 623 patients were followed for median of 2.2 years for survival analysis. Blacks were younger, more often female, with a higher burden of cardiovascular risk, and lower CPC counts. Blacks had fewer CD34+ cells (−17.6%; [95% confidence interval (CI), −23.5% to −11.3%]; P P P P =0.04) compared with whites. The association between lower CPC counts and black race was not affected by risk factors or cardiovascular disease. Results were validated in a separate cohort of 411 patients. Blacks with acute myocardial infarction had significantly fewer CPCs compared with whites ( P =0.02). Blacks had significantly lower plasma MMP-9 levels ( P P =0.03) and whites (hazard ratio, 1.79; [95% CI, 1.09–2.94]; P =0.02) without significant interaction. Conclusions: Black subjects have lower levels of CPCs compared with whites which is partially dependent on lower circulating MMP-9 levels. Impaired regenerative capacity is predictive of adverse outcomes in blacks and may partly account for their increased risk of cardiovascular events.

Smoking is an important risk factor in the development of heart failure with preserved ejection (HFpEF), and previous reports have identified smoking as a significant predictor of death in this population. However, the relation between smoking and heart failure-specific outcomes has not been examined in patients with HFpEF. This analysis included 1,717 patients (mean age = 71 ± 10 years; 50% men; 78% white) with HFpEF enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial from the Americas. Smoking was ascertained by self-reported history and categorized as never, former, or current. Multivariable Cox regression was used to examine the risk of hospitalization for heart failure, death, and cardiovascular death across smoking categories. There were 116 current smokers (7%), 871 former smokers (51%), and 729 never smokers (42%) in this analysis. Current smoking was associated with an increased risk of hospitalization for heart failure (never: hazard ratio [HR] 1.0; former: HR 1.25, 95% confidence interval [CI] 0.99 to 1.57; current: HR 1.68, 95% CI 1.08 to 2.61), death (never: HR 1.0; former: HR 1.02, 95% CI 0.81 to 1.29; current: HR 1.82, 95% CI 1.19 to 2.78), and cardiovascular death (never: HR 1.0; former: HR 1.00, 95% CI 0.74 to 1.35; current: HR 1.85, 95% CI 1.09 to 3.24) compared with former or never smokers in a multivariable model adjusted for cardiovascular risk factors. A similar increased risk of hospitalization for heart failure (former: HR 1.0; current: HR 1.54, 95% CI 1.01, 2.36), death (former: HR 1.0; current: HR 1.81, 95% CI 1.19, 2.75), and cardiovascular death (former: HR 1.0; current: HR 1.76, 95% CI 1.04, 2.98) was observed for current smokers when we limited the analysis to those with a history of smoking. In conclusion, current smoking is associated with an increased risk for adverse outcomes in HFpEF, including hospitalization for heart failure. Smoking cessation strategies possibly have a role to reduce the risk for adverse cardiovascular outcomes in patients with HFpEF.

Rationale: Circulating progenitor cells (CPCs) mobilize in response to ischemic injury, but their predictive value remains unknown in acute coronary syndrome (ACS). Objective: We aimed to investigate the number of CPCs in ACS compared with those with stable coronary artery disease (CAD), relationship between bone marrow PCs and CPCs, and whether CPC counts predict mortality in patients with ACS. Methods and Results: In 2028 patients, 346 had unstable angina, 183 had an acute myocardial infarction (AMI), and the remaining 1499 patients had stable CAD. Patients with ACS were followed for the primary end point of all-cause death. CPCs were enumerated by flow cytometry as mononuclear cells expressing a combination of CD34+, CD133+, vascular endothelial growth factor receptor 2+, or chemokine (C-X-C motif) receptor 4+. CPC counts were higher in subjects with AMI compared those with stable CAD even after adjustment for age, sex, race, body mass index, renal function, hypertension, diabetes mellitus, hyperlipidemia, and smoking; CD34+, CD34+/CD133+, CD34+/CXCR4+, and CD34+/VEGFR2+ CPC counts were 19%, 25%, 28%, and 142% higher in those with AMI, respectively, compared with stable CAD. There were strong correlations between the concentrations of CPCs and the PC counts in bone marrow aspirates in 20 patients with AMI. During a 2 (interquartile range, 1.31–2.86)-year follow-up period of 529 patients with ACS, 12.4% died. In Cox regression models adjusted for age, sex, body mass index, heart failure history, estimated glomerular filtration rate, and AMI, subjects with low CD34+ cell counts had a 2.46-fold (95% confidence interval, 1.18–5.13) increase in all-cause mortality, P =0.01. CD34+/CD133+ and CD34+/CXCR4+, but not CD34+/VEGFR2+ PC counts, had similar associations with mortality. Results were validated in a separate cohort of 238 patients with ACS. Conclusions: CPC levels are significantly higher in patients after an AMI compared with those with stable CAD and reflect bone marrow PC content. Among patients with ACS, a lower number of hematopoietic-enriched CPCs are associated with a higher mortality.

Background Oxidative stress (OS) may be a key mechanism underlying the development of atrial fibrillation (AF) in experimental studies, but data in humans remain limited. Objective Systemic OS can be estimated by measurements of circulating levels of the aminothiols including glutathione, cysteine, and their oxidized products. We tested the hypothesis that the redox potentials of glutathione (E h GSH) and cysteine will be associated with prevalent and incident AF. Methods Plasma levels of aminothiols were measured in 1439 patients undergoing coronary angiography, of whom 148 (10.3%) had a diagnosis of AF. After a median follow-up of 6.3 years, 104 of 917 patients (11.5%) developed incident AF. Multivariate logistic regression and Cox regression models were used to determine whether OS markers were independent predictors of prevalent and incident AF after adjustment for traditional risk factors, heart failure, coronary artery disease, and high-sensitivity C-reactive protein level. Results For each 10% increase in E h GSH, the odds of prevalent AF was 30% higher (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.1–1.7; P = .02) and 90% higher (OR 1.9; 95% CI 1.3–2.7; P = .004) when the median was used as a cutoff. The E h GSH level above the median was more predictive of chronic AF (OR 4.0; 95% CI 1.3–12.9; P = .01) than of paroxysmal AF (OR 1.7; 95% CI 1.1–2.7; P = .03). Each 10% increase in E h GSH level was associated with a 40% increase in the risk of incident AF (hazard ratio 1.4; 95% CI 1.1–1.7; P = .01). Conclusion Increased OS measured by the redox potentials of glutathione is associated with prevalent and incident AF. Therapies that modulate OS need to be investigated to treat and prevent AF.

Background Previous studies have shown increased cardiovascular (CV) risk with both high (>60mg/dl) and low concentrations of high-density lipoprotein cholesterol (HDL-C). The effect of elevated HDL-C levels (>60mg/dL) at differing LDL-C concentrations on outcomes is unknown. Purpose To study the relationship between elevated HDL-C levels (>60mg/dl) in relation to LDL-C concentration (greater vs less than 70mg/dL) and adverse CV outcomes in an at-risk population. Methods Participants included 5,746 individuals (mean age 63.3±12.4 years, 35% female, 23% African American) enrolled in the cardiovascular biobank. Individuals were stratified by HDL-C categories ( Results Over a median follow-up of 6.2 years (25th-75th percentiles = 3.3–8.0 years), a total of 286 MIs, 691 CV deaths and 1,093 all-cause deaths occurred. Individuals with HDL-C ≥60 mg/dL (n=632) had an increased risk of all-cause mortality with an LDL-C ≥70mgdL (HR 1.59; 95% CI=1.10–2.29, p=0.013) after adjustment for the aforementioned variables. This association was not statistically significant with LDL-C Conclusion Elevated HDL-C levels is associated with increased all-cause mortality with an LDL-C ≥70mg/dL, though does not appear to be associated with worse outcomes when LDL-C is

Background Educational attainment is an indicator of socioeconomic status and is inversely associated with coronary artery disease risk. Whether educational attainment level ( EAL ) among patients with coronary artery disease influences outcomes remains understudied. Methods and Results Patients undergoing cardiac catheterization had their highest EAL assessed using options of elementary/middle school, high school, college, or graduate education. Primary outcome was all‐cause mortality and secondary outcomes were a composite of cardiovascular death/non‐fatal myocardial infarction and non‐fatal myocardial infarction during follow‐up. Cox models adjusted for clinically relevant confounders were used to analyze the association of EAL with outcomes. Among 6318 patients (63.5 years, 63% men, 23% black) enrolled, 16%, 42%, 38%, and 4% had received graduate or higher, college, high school, and elementary/middle school education, respectively. During 4.2 median years of follow‐up, there were 1066 all‐cause deaths, 812 cardiovascular deaths/non‐fatal myocardial infarction, and 276 non‐fatal myocardial infarction. Compared with patients with graduate education, those in lower EAL categories (elementary/middle school, high school, or college education) had a higher risk of all‐cause mortality (hazard ratios 1.52 [95% CI 1.11–2.09]; 1.43 [95% CI 1.17–1.73]; and 95% CI 1.26 [1.03–1.53], respectively). Similar findings were observed for secondary outcomes. Conclusions Low educational attainment is an independent predictor of adverse outcomes in patients undergoing angiographic coronary artery disease evaluation. The utility of incorporating EAL into risk assessment algorithms and the causal link between low EAL and adverse outcomes in this high‐risk patient population need further investigation.

Background Factors promoting cardiovascular health in the face of high risk, ie, resilience, are unknown and may identify novel areas of intervention for reducing racial health disparities. We examined neighborhood perceptions and psychological attributes of blacks living in high and low cardiovascular–risk neighborhoods, as potential characteristics of resilience promoting cardiovascular health. Methods and Results We identified 1433 blacks residing in census tracts of Atlanta, GA , with higher‐than‐expected (“high” risk) or lower‐than‐expected (“low” risk) rates of cardiovascular mortality, hospitalizations, and emergency department visits during 2010–2014. Domains of psychosocial well‐being and neighborhood quality were assessed via telephone survey between August 2016 and October 2016. Using multilevel logistic regression, odds of reporting better resilient characteristics were compared between individuals living in low‐ versus high‐risk neighborhoods. Those from low‐risk (versus high‐risk) neighborhoods reported better neighborhood aesthetic quality (odds ratio [ OR ], 1.84), healthy food access ( OR , 1.69), and absence of violence ( OR , 0.67). Individuals from low‐risk neighborhoods reported greater optimism ( OR , 1.38), purpose in life ( OR , 1.42), and fewer depressive symptoms ( OR , 0.69). After full adjustment, these associations remained significant for neighborhood factors (aesthetic quality, healthy food access, violence) and psychosocial well‐being (purpose in life). We found no evidence of differences in self‐reported cardiovascular risk factors or disease history between low‐ versus high‐risk neighborhoods. Conclusions Positive neighborhood environments and psychological characteristics are associated with low cardiovascular–risk neighborhoods, despite similar prevalence of cardiovascular risk factors, in the census tracts studied. These factors may confer cardiovascular resilience among blacks.

Introduction Despite the growing interest in place as a determinant of health, areas that promote rather than reduce cardiovascular disease (CVD) in blacks are understudied. We performed an ecologic analysis to identify areas with high levels of CVD resilience and risk among blacks from a large southern, US metropolitan area. Methods We obtained census tract-level rates of cardiovascular deaths, emergency department (ED) visits, and hospitalizations for black adults aged 35 to 64 from 2010 through 2014 for the Atlanta, Georgia, metropolitan area. Census tracts with substantially lower rates of cardiovascular events on the basis of neighborhood socioeconomic status were identified as resilient and those with higher rates were identified as at risk. Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CIs) of being classified as an at-risk versus resilient tract for differences in census-derived measures. Results We identified 106 resilient and 121 at-risk census tracts, which differed in the rates per 5,000 person years of cardiovascular outcomes (mortality, 8.13 vs 13.81; ED visits, 32.25 vs 146.3; hospitalizations, 26.69 vs 130.0), despite similarities in their median black income ($46,123 vs $45,306). Tracts with a higher percentage of residents aged 65 or older (odds ratio [OR], 2.29; 95% CI, 1.41-3.85 per 5% increment) and those with incomes less than 200% of the federal poverty level (OR, 1.19; 95% CI, 1.02-1.39 per 5% increment) and greater Gini index (OR, 1.56; 95% CI, 1.19- 2.07 per 0.05 increment) were more likely to be classified as at risk than resilient neighborhoods. Discussion Despite matching on median income level, at-risk neighborhoods for CVD among black populations were associated with a higher prevalence of socioeconomic indicators of inequality than resilient neighborhoods.

Introduction: Intra-racial heterogeneity in cardiovascular health (CVH) among Blacks is understudied, and more research is needed to identify factors promoting CVH among Blacks. Neighborhood environment is increasingly recognized as an important determinant of CV risk and health, Yet whether specific features of neighborhood physical and social environments may promote CV resilience among Blacks has been underexplored. Hypothesis: Better neighborhood characteristics are associated with ideal CVH among Black adults, measured as Life’s Simple 7 (LS7) scores. Methods: We recruited 392 Black adults (age 53 ± 10, 39% male) without known CV disease in Atlanta, GA, who resided in 199 residential neighborhood (defined as census tracts). Seven neighborhood domains were assessed via questionnaire: aesthetic quality, walking environment, safety, food access, social cohesion, activity with neighbors, and violence. CVH was determined by LS7 scores calculated from measured blood pressure, glucose, cholesterol, body mass index (BMI), and self-reported exercise, diet, and smoking, and categorized into poor (0-8), intermediate (9-10), and ideal (11-14). Multinomial logistic regression was used to examine the association between neighborhood characteristics and the odds of intermediate/ideal CVH categories compared to poor CVH after adjustment for age, gender, household income, education, marital status, and employment status. Results: A total of 53 (14%), 110 (28%), and 229 (58%) participants had ideal, intermediate, and poor LS7 scores, respectively. Better scores in the neighborhood domains of social cohesion and activity with neighbors were significantly associated with higher adjusted odds of ideal LS7 scores (OR 1.95, 95% CI [1.32 - 2.90] and 1.65 [1.16 - 2.35] per 1 standard deviation [SD] increase in respective scores). Specifically, better scores in social cohesion were associated with higher odds of ideal CVH in exercise (OR 1.73 [1.16 - 2.59]), diet (OR 1.99 [1.14 - 3.48]), and BMI (OR 1.51 [1.09 - 2.09]); better scores in activity with neighbors were also similarly associated with higher odds of ideal CVH in exercise (OR 1.47 [0.99 - 2.19]), diet (OR 2.37 [1.32 - 4.26]), and BMI (OR 1.44 [1.05 - 1.96]; per 1 SD in respective scores). Aesthetic quality, walking environment, safety, food access, and violence were not significantly associated with overall CVH categories in the adjusted models. Conclusion: More desirable neighborhood characteristics, particularly social cohesion and activity with neighbors, were associated with better CVH among Black adults. Further research is needed to investigate whether interventions to improve neighborhood qualities lead to better CVH in Blacks.

Introduction: Arterial stiffness is associated with cardiovascular (CV) risk factors and adverse cardiovascular events. While inter-racial differences in arterial stiffness have been reported, factors contributing to intra-racial differences within Blacks are less known. We examined whether neighborhood characteristics and personal resilience factors were associated with arterial stiffness among Blacks. Hypothesis: More desirable neighborhood characteristics and greater personal resilience are associated with reduced arterial stiffness. Methods: We examined 385 Black adults (age 53 ± 10, 40% male) without known CV disease living in Atlanta, GA. Arterial stiffness was measured as augmentation index (AIX) and pulse wave velocity (PWV) using applanation tonometry (Sphygmocor Inc). Perceived residential neighborhood characteristics in 7 domains: aesthetic quality, walking environment, safety, food access, social cohesion, activity with neighbors, and violence were determined. Personal resilience was also assessed using standard questionnaires on experience of discrimination, environmental mastery, purpose in life, optimism, resilient coping, and depressive symptoms. Multiple linear regression models were used to examine the differences of arterial stiffness between the highest and the lowest tertiles of neighborhood characteristics and personal resilience factors after adjustment for age, gender, systolic blood pressure, body mass index, household income, education, marital status, and employment status. Results: Higher composite scores of neighborhood characteristics were associated with lower AIX (β=-3.42, 95% CI [-6.42 to -0.41], P=0.026; highest vs lowest tertiles). Specifically, higher scores of safety (β=-4.26, 95% CI [-7.34 to -1.17], P=0.007) and social cohesion (β=-4.62 [-7.64 to -1.61], P=0.003) were associated with lower AIX (highest vs lowest tertiles for both). For factors of personal resilience, higher scores in purpose in life (β=-4.89 [-7.88 to -1.90], P=0.001) and resilient coping (β=-3.26 [-6.36 to -0.15], P=0.040) were significantly associated with lower AIX (highest vs lowest tertiles for both). There were no significant associations between PWV and scores of neighborhood characteristics or personal resilience factors. Conclusion: In a study examining the impact of neighborhood and markers of resilience on arterial stiffness in an exclusively Black cohort, we found that better neighborhood characteristics and personal resilience factors were associated with lower pulse wave reflections (AIX).

Neighborhood socioeconomic status (nSES) is associated with cardiovascular morbidity and mortality in the general population; however, its effect on high-risk patients with prevalent coronary artery disease (CAD) is unclear. We hypothesized "double jeopardy," whereby the association between nSES and adverse outcomes would be greater in high-risk patients with heart failure (HF) and/or previous myocardial infarction (MI) compared with those without. We followed 3,635 patients (mean age 63.2 years, 42% with HF, 25% with previous MI) with known or suspected CAD over a median of 3.3 years for all-cause death and cardiovascular death or nonfatal MI. Patients were categorized by a composite nSES score, and proportional hazards models were used to determine the association between nSES and outcomes. Cross-product interaction terms for previous MI × nSES and HF × nSES were analyzed. Compared with high nSES patients, low nSES patients had increased risk of all-cause death (hazard ratio [HR] = 1.61; 95% confidence interval [CI] = 1.20, 2.15) and cardiovascular death or MI (subdistribution HR [sHR] = 1.82; 95% CI = 1.30, 2.54). Associations were more pronounced among patients without HF or previous MI. Low nSES patients without HF had a higher risk of all-cause death (HR = 2.27; 95% CI = 1.41, 3.65) compared with those with HF (HR = 1.21; 95% CI = 0.82, 1.77, P interaction = 0.04). Similarly, low nSES patients without previous MI had a higher risk of cardiovascular death or MI (sHR = 2.72; 95% CI = 1.73, 4.28) compared with those with previous MI (sHR = 1.02; 95% CI = 0.58, 1.81, P interaction = 0.02). In conclusion, low nSES was independently associated with all-cause death and cardiovascular death or MI in patients with CAD; however, associations were greater in patients without HF or previous MI compared with those with HF or MI.

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults lowered the threshold of hypertension compared to the American College of Obstetricians and Gynecologists (ACOG) guidelines used to define hypertensive disorders of pregnancy. We sought to describe the impact of reclassifying hypertension for reproductive-aged women in the United States using the 2017 ACC/AHA guidelines. We analyzed data from a cohort of women 20–44 years of age from the 2011–2014 National Health and Nutrition Examination Survey (n=2311), and sampling weights were used to obtain nationally-representative hypertension prevalence estimates. Additional analyses were performed on subgroups of low-risk women (n=2110) and those currently or previously pregnant (n=1298). The prevalence of hypertension by ACOG and 2017 ACC/AHA guidelines was 10.2% (95% CI, 8.7%−11.6%) and 18.9% (95% CI, 16.8%−21.1%), respectively. Results were similar in a cohort of low-risk women were currently or previously pregnant. This study suggests that adoption of ACC/AHA guidelines for hypertension would increase the number of reproductive-aged women with hypertension by approximately two-fold. Further studies are needed to determine the safety and efficacy of lower blood pressure targets, as well as the potential impact on risk assessment and obstetric care, in this specialized population. Summary Approximately twice as many women of reproductive age will have a diagnosis of hypertension by 2017 ACC/AHA guidelines compared to ACOG guidelines.

Living in neighborhoods characterized by poverty may act as a chronic stressor that results in physiological dysregulation of the sympathetic nervous system. No previous study has assessed neighborhood poverty with hemodynamic, neuroendocrine, and immune reactivity to stress. We used data from 632 patients with coronary artery disease. Patients’ residential addresses were geocoded and merged with poverty data from the 2010 American Community Survey at the census-tract level. A z-transformation was calculated to classify census tracts (neighborhoods) as either having ‘high’ or ‘low’ poverty. Systolic blood pressure, diastolic blood pressure, heart rate, rate-pressure product, epinephrine, interleukin-6, and high-sensitivity C-reactive protein were measured before and after a public speaking stress task. Multilevel models were used for repeated measures and accounting for individuals nested within census tracts. Adjusted models included demographics, lifestyle and medical risk factors, and medication use. Another set of models included propensity scores weighted by the inverse probability of neighborhood status for sex, age, race, and individual-level income. The mean age was 63 years and 173 were women. After adjusting for potential confounders, participants living in high (vs. low) poverty neighborhoods had similar hemodynamic values at rest and lower values during mental stress for systolic blood pressure (157 mmHg vs. 161 mmHg; p = 0.07), heart rate (75 beats/min vs. 78 beats/min; p = 0.02) and rate-pressure product (11839 mmHg x beat/min vs 12579 mmHg x beat/min; p = 0.01). P-values for neighborhood poverty-by-time interactions were < 0.05. Results were similar in the propensity weighted models. There were no significant differences in inflammatory and epinephrine responses to mental stress based on neighborhood poverty status. A blunted hemodynamic response to mental stress was observed among participants living in high poverty neighborhoods. Future studies should explore whether neighborhood poverty and blunted hemodynamic response to stress translate into differences in long-term cardiovascular outcomes.

Introduction Social cohesion is a positive neighborhood characteristic defined by feelings of connectedness and solidarity within a community. Studies have found significant associations between social cohesion and cardiovascular disease (CVD) risk factors and outcomes. Inflammation is one potential physiological pathway linking social cohesion to CVD development, but few studies have evaluated the relationship between social cohesion and inflammatory biomarkers. Prior research has also established that race and gender can modify the effects of neighborhood features, including social cohesion, on CVD risk factors and outcomes. This study aimed to examine the association between social cohesion and the inflammatory biomarkers interleukin-6 (IL-6) and C-reactive protein (CRP) in a cohort of African American and White women and men. Materials and methods Data from the Morehouse and Emory Team Up to Eliminate Health Disparities (META-Health) Study were used to assess the association between social cohesion and inflammation among African American (n = 203) and White (n = 176) adults from the Atlanta metropolitan area. Social cohesion was measured using the social cohesion subscale from the Neighborhood Health Questionnaire. Inflammatory biomarkers were measured from plasma frozen at −70 °C. Multivariable linear regression analyses were conducted, controlling for demographic, clinical, behavioral, and psychosocial factors sequentially. Interaction by race and gender was also examined. Results In models adjusted for age, race, gender, and education, social cohesion was significantly associated with lower levels of IL-6 (β = −0.06, p = 0.03). There was a significant race × social cohesion interaction (p = 0.04), and a marginally significant gender × race × social cohesion interaction (p = 0.09). In race-stratified models controlling for age, gender, and education, social cohesion was associated with lower IL-6 levels in African Americans (β = −0.11, p = 0.01), but not Whites (β = 0.01, p = 0.91). In fully adjusted race- and gender-stratified models, social cohesion was associated with lower levels of IL-6 in African American women only (β = −0.15, p = 0.003). CRP was not associated with social cohesion in fully adjusted models. Conclusion The association between social cohesion and lower levels of IL-6 is modified by gender and race, with the strongest association emerging for African American women. Although the pathways through which social cohesion impacts inflammation remain unclear, it is possible that for African American women social cohesion manifests through neighborhood networks.

Introduction: Clinical trials have shown increased survival at lower blood pressures, but low diastolic blood pressure (DBP) is associated with increased cardiovascular (CV) events and mortality. The suggested mechanism in patients with coronary artery disease (CAD) is limitation in coronary blood flow; however, evidence is lacking. We investigated the association between DBP, biomarkers of myocardial injury, and incident events in patients with CAD. Methods: We assessed 2448 individuals (aged 65±12 years, 68% male, median follow-up 4.5 years) with stable CAD undergoing cardiac catheterization. Those with acute coronary syndromes or heart failure with reduced ejection fraction were excluded. DBP was categorized into 10 mm Hg increments. Biomarkers of myocardial damage (high sensitivity cardiac troponin-I [hs-cTnI] and soluble urokinase plasminogen activating receptor [suPAR]) were dichotomized at their median values. DBP 80-89 mmHg was used as the referent group and individuals were followed for MACE (CV death or non-fatal myocardial infarction) and all-cause mortality. Results: After adjusting for relevant demographic and clinical covariates, individuals with DBP < 60 mm Hg had increased odds of elevated hs-cTnI (OR = 1.75; 95% CI = 1.05, 2.90) and suPAR (OR = 1.73; 95% CI = 1.09, 2.76) compared to the referent group. Additionally, DBP < 60 mm Hg was associated with increased risk of MACE (HR = 2.01; 95% CI = 1.24, 3.25) and all-cause mortality (HR = 2.18; 95% CI = 1.50, 3.19). Adding hs-cTnI and suPAR into the Cox proportional hazards model attenuated the association between DBP < 60 mmHg and MACE (HR =1.63, 95% CI 0.91, 2.91), but not all-cause mortality (HR = 1.67, 95% CI = 1.06, 2.63). Conclusion: In patients with CAD, low DBP is associated with biomarkers of myocardial injury and incident events. Aggressive blood pressure control may be harmful in these patients, and further investigation is warranted to determine appropriate blood pressure targets in patients with CAD.

Background: Excess rates of cardiovascular (CV) disease in African-Americans, relative to Whites, have been well-documented. However, factors promoting CV health in the face of high risk, i.e. CV resilience, are unknown and may identify novel areas for intervention in reducing racial health disparities. Methods: Using data obtained from the Georgia Hospital Association, we identified age-, sex-, and income-matched neighborhoods (census tracts) in Atlanta, GA, with higher-than-expected (“high risk") or lower-than-expected (“low risk") rates of CV morbidity and mortality for African-Americans from 2010-2014. African-Americans from low risk (N = 742) and high risk (N = 753) neighborhoods were surveyed. Several domains of psychosocial well-being and neighborhood quality were assessed as features of resilience, in addition to individual demographic, socioeconomic and medical history variables. Ordinal logistic regression was used to determine odds of resilient characteristics among individuals living in neighborhoods at low versus high risk. Results: After adjustment for age, sex, household income, education, marital status and occupation, African-Americans living in low compared to high risk neighborhoods reported better overall neighborhood quality (odds ratio [OR] 1.25; 95% confidence interval [CI] 1.01, 1.57), driven by better aesthetic quality (OR 1.42; CI 1.17, 1.73), more safety (OR 1.34; CI 1.10, 1.62), absence of violence (OR 1.42; CI 1.10, 1.83) and better access to healthy foods (OR 1.50; CI 1.24, 1.82). Additionally, individuals from low compared to high risk neighborhoods reported greater environmental mastery (OR 1.33; CI 1.03, 1.71), purpose in life (OR 1.22, CI 1.01, 1.48), optimism (OR 1.28; CI 1.05, 1.55) and resilient coping (OR 1.33; CI 1.04, 1.70), while also reporting less depressive symptoms (OR 0.78; CI 0.63, 0.98). There were no reported differences in CV risk factors or disease, religious practices, spirituality or experiences of discrimination between low and high risk neighborhoods. Conclusions: African-Americans living in neighborhoods at lower risk for CVD morbidity and mortality reported better neighborhood quality and psychosocial well-being than individuals from neighborhoods at higher risk. Neighborhood and personal psychosocial determinants of health may confer resilience to CVD in African-American individuals and communities.

Low diastolic blood pressure (DBP) is associated with increased risk of cardiovascular events. In patients with coronary artery disease (CAD), limitations in coronary blood flow and immune activity are implicated mechanisms, but evidence is lacking. We investigated the association between DBP, biomarkers of myocardial injury, inflammation, immune activation and incident events in patients with CAD.We studied 2448 adults (mean age 65 ± 12 years, 68% male, median follow-up 4.5 years) with CAD. DBP was categorized into 10 mm Hg increments. Biomarkers of myocardial injury (high sensitivity cardiac troponin-I [hs-cTnI]) and immune activity/inflammation (soluble urokinase plasminogen activator receptor [suPAR]) were dichotomized at their median values. DBP 70-79 mm Hg was used as the referent group, and individuals were followed prospectively for adverse outcomes.After adjusting for demographic and clinical covariates, individuals with DBP 60 mm Hg had increased odds of elevated levels of hs-cTnI (OR = 1.68; 95% CI = 1.07, 2.65) and suPAR (OR = 1.71; 95% CI = 1.10, 2.65) compared to the referent group. Additionally, DBP 60 mm Hg was associated with increased adjusted risk of cardiovascular death or MI (HR = 2.04; 95% CI = 1.32, 3.16) and all-cause mortality (HR = 2.41; 95% CI = 1.69, 3.45).In patients with CAD, DBP 60 mm Hg is associated with subclinical myocardial injury, immune/inflammatory dysregulation and incident events. Aggressive BP control may be harmful in these patients, and further investigation is warranted to determine appropriate BP targets in patients with CAD.

Background The associations between high‐sensitivity troponin I (hsTnI) levels and coronary artery disease (CAD) severity and progression remain unclear. We investigated whether there is an association between hsTnI and angiographic severity and progression of CAD and whether the predictive value of hsTnI level for incident cardiovascular outcomes is independent of CAD severity. Methods and Results In 3087 patients (aged 63±12 years, 64% men) undergoing cardiac catheterization without evidence of acute myocardial infarction, the severity of CAD was calculated by the number of major coronary arteries with ≥50% stenosis and the Gensini score. CAD progression was assessed in a subset of 717 patients who had undergone ≥2 coronary angiograms >3 months before enrollment. Patients were followed up for incident all‐cause mortality and incident cardiovascular events. Of the total population, 11% had normal angiograms, 23% had nonobstructive CAD , 20% had 1‐vessel CAD, 20% had 2‐vessel CAD, and 26% had 3‐vessel CAD . After adjusting for age, sex, race, body mass index, smoking, hypertension, diabetes mellitus history, and renal function, hsTnI levels were independently associated with the severity of CAD measured by the Gensini score (log 2 ß=0.31; 95% confidence interval, 0.18–0.44; P CAD progression (log 2 ß=0.36; 95% confidence interval, 0.14–0.58; P =0.001). hsTnI level was also a significant predictor of incident death, cardiovascular death, myocardial infarction, revascularization, and cardiac hospitalizations, independent of the aforementioned covariates and CAD severity. Conclusions Higher hsTnI levels are associated with the underlying burden of coronary atherosclerosis, more rapid progression of CAD , and higher risk of all‐cause mortality and incident cardiovascular events. Whether more aggressive treatment aimed at reducing hsTnI levels can modulate disease progression requires further investigation.

Background Although diastolic blood pressure ( DBP ) is independently associated with an increased risk of adverse cardiovascular outcomes in the general population, it is unclear if a similar relationship exists in patients with heart failure with preserved ejection fraction. Methods and Results This analysis included 1703 (mean age, 72±10 years; 50% men; 78% white) patients with heart failure with preserved ejection fraction enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial from the Americas who were treated for hypertension. Multivariable Cox regression was used to examine the risk of hospitalization for heart failure, death, and cardiovascular death associated with DBP . The relationship between hospitalization for heart failure and DBP was linear, with an increased risk observed with decreasing DBP values (≥90 mm Hg: referent; 80–89 mm Hg: hazard ratio [HR], 1.44; 95% confidence interval [CI], 0.85–2.44; 70–79 mm Hg: HR , 1.18; 95% CI , 0.69–2.01; 60–69 mm Hg: HR , 1.54; 95% CI , 0.90–2.63; HR , 2.12; 95% CI , 1.20–3.74; P =0.0055 for trend). The associations of DBP with death (≥90 mm Hg: HR , 1.86; 95% CI , 1.12–3.06; 80–89 mm Hg: HR , 1.23; 95% CI , 0.89–1.70; 70–79 mm Hg: referent; 60–69 mm Hg: HR , 1.20; 95% CI , 0.90–1.59; HR , 1.68; 95% CI , 1.21–2.33) and cardiovascular death (≥90 mm Hg: HR , 2.02; 95% CI , 1.10–3.71; 80–89 mm Hg: HR , 1.17; 95% CI , 0.77–1.79; 70–79 mm Hg: referent; 60–69 mm Hg: HR , 1.16; 95% CI , 0.80–1.70; HR , 1.85; 95% CI , 1.21–2.82) were nonlinear, with a greater risk of each outcome observed with DBP values ≥90 and Conclusions DBP values ≥90 and DBP targets to reduce the risk of adverse events in patients with heart failure with preserved ejection fraction.

Purpose To examine the association between residence in neighborhoods with high rates of incarceration and cardiometabolic disease among nonincarcerated individuals. Methods We used data from two community cohort studies (n = 1368) in Atlanta, Georgia–META-Health and Predictive Health (2005–2012)—to assess the association between neighborhood incarceration rate and cardiometabolic disease, adjusting for individual-level and neighborhood-level factors. We also examined the interaction between race and neighborhood incarceration rate. Results Individuals living in neighborhoods with high incarceration rates were more likely to have dyslipidemia (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.03–2.09) and metabolic syndrome (OR = 1.67; 95% CI = 1.07–2.59) in fully adjusted models. Interactions between race and neighborhood incarceration rate were significant; black individuals living in neighborhoods with high incarceration rates were more likely to have hypertension (OR = 1.59; 95% CI = 1.01–2.49), dyslipidemia (OR = 1.77; 95% CI = 1.12–2.80), and metabolic syndrome (OR = 1.80; 95% CI = 1.09–2.99). Conclusions Black individuals living in neighborhoods with high rates of incarceration have worse cardiometabolic health profiles. Criminal justice reform may help reduce race-specific health disparities in the United States.

It is unknown whether the association of high-sensitivity troponin I (hs-TnI) with adverse cardiovascular outcomes varies by the presence of chronic kidney disease (CKD). We examined the association of hs-TnI with adverse cardiovascular outcomes in those with and without CKD in 4,107 (mean age, 64 years; 63% men; 20% black) patients from the Emory Cardiovascular Biobank who underwent coronary angiography. CKD (n = 1,073) was defined as estimated glomerular filtration rate 30 mg/g at baseline. Cox regression was used to compute hazard ratios (HR) for the association between hs-TnI levels (per doubling of hs-TnI: log2[hs-TnI] + 1) and death, cardiovascular death, and major adverse cardiac events (MACE), separately. Hs-TnI was a stronger predictor of death (CKD: HR 1.23, 95% confidence interval [CI] 1.15 to 1.31; no CKD: HR 1.11, 95% CI 1.05 to 1.17, p-interaction = 0.023), cardiovascular death (CKD: HR 1.24, 95% CI 1.14 to 1.34; no CKD: HR 1.15, 95% CI 1.07 to 1.22, p-interaction = 0.12), and MACE (CKD: HR 1.18, 95% CI 1.11 to 1.25; no CKD: HR 1.11, 95% CI 1.06 to 1.16, p-interaction = 0.095) in CKD compared with non-CKD. The association between hs-TnI and death in patients with CKD was stronger for patients without obstructive coronary artery disease (no obstructive coronary artery disease: HR 1.60, 95% CI 1.27 to 2.01; obstructive coronary artery disease: HR 1.19, 95% CI 1.11 to 1.27, p-interaction = 0.041). In conclusion, hs-TnI is a stronger predictor of adverse cardiovascular events in patients who have CKD than those without, even in the absence of obstructive coronary artery disease. Hs-TnI may identify CKD patients who are high risk for adverse cardiovascular outcomes in whom aggressive risk factor modification strategies are warranted.

The pooled cohort Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator is designed to improve cardiovascular risk estimation compared with the Framingham Risk Score, particularly in blacks. Although the ASCVD risk score better predicts mortality and incident cardiovascular disease in blacks, less is known about its performance for subclinical vascular disease measures, including arterial stiffness and carotid intima-media thickness. We sought to determine if the ASCVD risk score better identifies subclinical vascular disease in blacks compared with the Framingham risk score. We calculated both the Framingham and ASCVD cohort risk scores in 1,231 subjects (mean age 53 years, 59% female, 37% black) without known cardiovascular disease and measured the extent of arterial stiffness, as determined by pulse wave velocity (PWV), central pulse pressure (CPP), and central augmentation index (CAIx), and subclinical atherosclerosis, as determined by carotid-IMT (C-IMT). Compared with whites, blacks had higher CAIx (23.9 ± 10.2 vs 22.1 ± 9.6%, p = 0.004), CPP (36.4 ± 10.5 vs 34.9 ± 9.8 mmHg, p = 0.014), PWV (7.6 ± 1.5 vs 7.3 ± 1.3 m/s, p = 0.004), and C-IMT (0.67 ± 0.10 vs 0.65 ± 0.10 mm, p = 0.005). In a multivariable analysis including race and Framingham risk score, race remained an independent predictor of all measures of subclinical vascular disease; however, models with race and the ASCVD risk score showed that race was not an independent predictor of subclinical vascular disease. In conclusion, greater subclinical vascular disease in blacks was not estimated by the Framingham risk score. The new ASCVD risk score provided a better estimate of racial differences in vascular function and structure.

Background Being unmarried is associated with decreased survival in the general population. Whether married, divorced, separated, widowed, or never‐married status affects outcomes in patients with cardiovascular disease has not been well characterized. Methods and Results A prospective cohort (inception period 2003–2015) of 6051 patients (mean age 63 years, 64% male, 23% black) undergoing cardiac catheterization for suspected or confirmed coronary artery disease was followed for a median of 3.7 years (interquartile range: 1.7–6.7 years). Marital status was stratified as married (n=4088) versus unmarried (n=1963), which included those who were never married (n=451), divorced or separated (n=842), or widowed (n=670). The relationship between marital status and primary outcome of cardiovascular death and myocardial infarction was examined using Cox regression models adjusted for clinical characteristics. There were 1085 (18%) deaths from all causes, 688 (11%) cardiovascular‐related deaths, and 272 (4.5%) incident myocardial infarction events. Compared with married participants, being unmarried was associated with higher risk of all‐cause mortality (hazard ratio [HR]: 1.24; 95% confidence interval [ CI ], 1.06–1.47), cardiovascular death ( HR : 1.45; 95% CI , 1.18–1.78), and cardiovascular death or myocardial infarction ( HR : 1.52; 95% CI, 1.27–1.83). Compared with married participants, the increase in cardiovascular death or myocardial infarction was similar for the participants who were divorced or separated (HR: 1.41; 95% CI , 1.10–1.81), widowed (HR: 1.71; 95% CI , 1.32–2.20), or never married (HR: 1.40; 95% CI , 0.97–2.03). The findings persisted after adjustment for medications and other socioeconomic factors. Conclusions Marital status is independently associated with cardiovascular outcomes in patients with or at high risk of cardiovascular disease, with higher mortality in the unmarried population. The mechanisms responsible for this increased risk require further study.

Background Lower levels of circulating progenitor cells (PCs) reflect impaired endogenous regenerative capacity and are associated with aging, vascular disease, and poor outcomes. Whether biologic sex and sex hormones influence PC numbers remains a subject of controversy. We sought to determine sex differences in circulating PCs in both healthy persons and patients with coronary artery disease, and to determine their association with sex hormone levels. Methods and Results In 642 participants (mean age 48 years, 69% women, 23% black) free from cardiovascular disease, we measured circulating PC counts as CD45 med+ mononuclear cells coexpressing CD34 and its subsets expressing CD133, chemokine (C‐X‐C motif) receptor 4, and vascular endothelial growth factor receptor 2 epitopes using flow cytometry. Testosterone and estradiol levels were measured. After adjustment for age, cardiovascular risk factors, and body mass, CD34 + (β=−23%, P + /CD133 + (β=−20%, P =0.001), CD34 + /chemokine (C‐X‐C motif) receptor 4–positive (β=−24%, P + /chemokine (C‐X‐C motif) receptor 4–positive/CD133 + (β=−21%, P =0.001) PC counts, but not vascular endothelial growth factor receptor 2‐positive PC counts were lower in women compared with men. Estradiol levels positively correlated with hematopoietic, but not vascular endothelial growth factor receptor 2‐ positive PC counts in women ( P Conclusions Women have lower circulating hematopoietic PC levels compared with men. Estrogen levels are modestly associated with PC levels in women. Since PCs are reflective of endogenous regenerative capacity, these findings may at least partly explain the rise in adverse cardiovascular events in women with aging and menopause.

Background— Food deserts (FD), neighborhoods defined as low-income areas with low access to healthy food, are a public health concern. We evaluated the impact of living in FD on cardiovascular risk factors and subclinical cardiovascular disease (CVD) with the hypothesis that people living in FD will have an unfavorable CVD risk profile. We further assessed whether the impact of FD on these measures is driven by area income, individual household income, or area access to healthy food. Methods and Results— We studied 1421 subjects residing in the Atlanta metropolitan area who participated in the META-Health study (Morehouse and Emory Team up to Eliminate Health Disparities; n=712) and the Predictive Health study (n=709). Participants’ zip codes were entered into the United States Food Access Research Atlas for FD status. Demographic data, metabolic profiles, hs-CRP (high-sensitivity C-reactive protein) levels, oxidative stress markers (glutathione and cystine), and arterial stiffness were evaluated. Mean age was 49.4 years, 38.5% male and 36.6% black. Compared with those not living in FD, subjects living in FD (n=187, 13.2%) had a higher prevalence of hypertension and smoking, higher body mass index, fasting glucose, and 10-year risk for CVD. They also had higher hs-CRP ( P =0.014), higher central augmentation index ( P =0.015), and lower glutathione level ( P =0.003), indicative of increased oxidative stress. Area income and individual income, rather than food access, were associated with CVD risk measures. In a multivariate analysis that included food access, area income and individual income, both low-income area and low individual household income, were independent predictors of a higher 10-year risk for CVD. Only low individual income was an independent predictor of higher hs-CRP and augmentation index. Conclusions— Although living in FD is associated with a higher burden of cardiovascular risk factors and preclinical indices of CVD, these associations are mainly driven by area income and individual income rather than access to healthy food.

Background Endogenous regenerative capacity, assessed as circulating progenitor cell (PC) numbers, is an independent predictor of adverse outcomes in patients with cardiovascular disease. However, their predictive role in heart failure (HF) remains controversial. We assessed the relationship between the number of circulating PCs and the pathogenesis and severity of HF and their impact on incident HF events. Methods and Results We recruited 2049 adults of which 651 had HF diagnosis. PCs were enumerated by flow cytometry as CD45med + blood mononuclear cells expressing CD34, CD133, vascular endothelial growth factor receptor-2, and chemokine (C-X-C motif) receptor 4 epitopes. PC subsets were lower in number in HF and after adjustment for clinical characteristics in multivariable analyses, a low CD34 + and CD34 + /CXCR + cell count remained independently associated with a diagnosis of HF ( P + , CD34 + /CD133 + , and CD34 + /CXCR4 + ) were independent predictors of all-cause death (hazard ratio 2.0, 1.6, 1.6-fold higher mortality, respectively; P + /VEGF + ) were independent predictors of mortality in patients with HF with preserved ejection fraction only (hazard ratio, 5.0; P =0.001). Conclusions PC levels are lower in patients with HF, and lower PC counts are strongly and independently predictive of mortality. Strategies to increase PCs and exogenous stem cell therapies designed to improve regenerative capacity in HF, especially, in HF with preserved ejection fraction, need to be further explored.

Introduction: Individuals with poorly-controlled HIV have high levels of plasma soluble urokinase plasminogen activator receptor (suPAR), a marker of immune activation associated with all-cause mortality, incident myocardial infarction and HIV-associated nephropathy in HIV-positive individuals. Data is conflicting regarding the effect of viral suppression on suPAR levels in HIV-positive individuals, or how these levels compare to individuals without HIV. Hypothesis: HIV-positive individuals with undetectable viral loads (VLs) will have similar levels of suPAR compared to individuals without HIV. Methods: Plasma suPAR was measured by ELISA in 273HIV-positive (70% Black [n=167], age 42 ± 8 years, 86% female [n=240], 56% detectable viral load [n=150]) and 276 HIV-negative (63% Black [n=169], age 40 ± 9 years, 96% female [n=265]) outpatients. Demographics, medical history and laboratory samples were collected. Results: Compared to HIV-negative individuals, HIV-positive subjects were older (p=0.01), less likely to be female (p2 , p2 , p=0.004). Median suPAR level was similar for HIV-negative and HIV-positive subjects with undetectable VLs (2436 [1908, 3380] vs. 2667 [1966, 4034] pg/mL, p=0.256), and both were significantly lower compared to HIV-positive subjects with detectable VLs (4252 [3099, 5369] pg/mL, p Within HIV-positive subjects, a detectable viral load was an independent predictor for high suPAR (OR 2.37 [95% CI 1.07-5.25], p=0.03) after controlling for age, race, sex, body mass, smoking history, hypertension, diabetes, eGFR and CD4+ count. Conclusions: In conclusion,HIV-positive individuals with undetectable VLs have similar levels of suPAR compared to those without HIV. Lower suPAR levels may account for the lower incidence of cardiovascular events and HIV nephropathy in patients with well-controlled HIV.

Introduction: Over 7 million Americans are current or former prisoners. Blacks are imprisoned at rates 4 to 10 times greater than Whites. While personal incarceration history is associated with greater all-cause mortality and incident cardiovascular disease (CVD), the impact of high neighborhood rates of incarceration on CVD risk in non-incarcerated individuals is unknown. Hypothesis: High neighborhood incarceration rate, defined as the upper quartile, is associated with poor individual CVD risk profile. Methods: A total of 1368 subjects from the Atlanta area (mean age 49 ± 10 years, 62% female [n=850], 41% Black [n=560]) were recruited from two community cohorts. Zip codes were used to link neighborhood incarceration and crime rates to individual pooled risk scores (ASCVD), risk factors for CVD including hypertension, dyslipidemia and impaired fasting glucose (IFG), and biomarkers including high-sensitivity C-reactive protein (hsCRP) and the homeostatic model assessment for insulin resistance (HOMA-IR). Results: High neighborhood incarceration rate was associated with high ASCVD risk score (OR=1.41, 95% CI=1.02, 1.95), hypertension (OR=1.48, 95% CI=1.05, 2.07) and dyslipidemia (OR=1.45, 95% CI=1.04, 2.04), after controlling for relevant demographic, socioeconomic and behavioral covariates. Tests for interaction with race were significant: Black individuals living in areas with high incarceration rates were more likely to have hypertension (OR=1.63, 95% CI=1.03, 2.58), dyslipidemia (OR=1.80, 95% CI=1.15, 2.83), IFG (OR=1.77, 95% CI=1.04, 3.03), and elevated HOMA-IR (OR=2.04, 95% CI=1.20, 3.47); Whites were more likely to have an elevated hsCRP (OR=1.81, 95% CI=1.02, 3.22). Conclusions: In conclusion, high neighborhood incarceration rate is associated with a worse CVD risk profile; this effect was more pronounced in Blacks. Neighborhood exposure to increased incarceration rates, particularly in Black communities, represents an additional health disparity that warrants further investigation.

Plasma soluble urokinase-type plasminogen activator receptor (suPAR) level is a strong predictor of adverse outcomes in patients with CAD. Women have higher suPAR levels, but the reason underlying this sex difference and its prognostic implication is unclear. We studied determinants of sex

At HDL-C levels >60mg/dl, its atheroprotective functions may be impaired given recent findings in the general population. The purpose of this study is to investigate the relationship between elevated HDL-C (>60mg/dl) and adverse CV outcomes in an at-risk population Participants included 3,112

INTRODUCTION:Access to adequate prenatal care (PNC) is a goal of HealthyPeople 2020. However, not all pregnancies in the U.S. are guaranteed this benefit, particularly in States that have not expanded Medicaid or have high concentrations of pregnancies in undocumented women. To address this gap, our

Unlike traditional beta receptor antagonists, nebivolol activates nitric oxide. We hypothesized that therapy with nebivolol compared with metoprolol would improve arterial stiffness, increase levels of circulating progenitor cells (PC), and decrease oxidative stress (OS). In a randomized, double–blind, cross–over study, 30 hypertensive subjects received either once daily nebivolol or metoprolol succinate for 3 months each. Pulse wave velocity and augmentation index were measured using tonometry. Flow cytometry was used to measure circulating PC. OS was measured as plasma aminothiols. Measurements were performed at baseline, and repeated at 3 and 6 months. No significant differences were present between the levels of OS, arterial stiffness, and PC numbers during treatment with metoprolol compared with nebivolol. In subgroup analyses of beta–blocker naive subjects (n = 19), nebivolol reduced pulse wave velocity significantly compared with metoprolol (−1.4 ± 1.9 vs. −0.1 ± 2.2; P = .005). Both nebivolol and metoprolol increased circulating levels of CD34+/CD133 + PC similarly ( P = .05), suggesting improved regenerative capacity.

Background: Circulating hematopoietic enriched progenitor cells (PCs) predict adverse cardiovascular outcomes in patients with coronary artery disease (CAD). The additive predictive role of endothelial enriched PCs expressing vascular endothelial growth factor receptor (VEGF) remains controversial.