American Heart Association Scientific Statement Research Articles

Cardio-Oncology Rehabilitation (CORE) Exercise Prescription and Programming: A PRACTICAL GUIDE.

Patients with cancer almost universally report diminished health-related quality of life. Many patients experience persistent fatigue and most have below-average exercise capacities. Despite the publication of exercise guidelines for cancer survivors that encourage physical activity, few patients exercise on a regular basis. Cardiovascular disease is a major cause of death in early-stage malignancies. Exercise training has been demonstrated to decrease cardiovascular events in patients with cancer. In addition, regular exercise improves exercise capacity, reduces fatigue, and improves quality of life in cancer survivors. A 2019 American Heart Association scientific statement, endorsed by the American Cancer Society, provided a framework and rationale for partnering with existing multidimensional, interdisciplinary outpatient cardiac rehabilitation programs to provide supervised exercise training and risk factor control services for patients with cancer and cancer survivors: cardio-oncology rehabilitation. In addition, the American College of Sports Medicine has published recommendations for cancer exercise training. This article provides practical suggestions for incorporating patients with cancer into cardiac rehabilitation and for patient-specific exercise prescription. Illustrative patient case examples are provided.

Is Developmental Screening Enough in High-Risk Populations?

In this issue of Pediatrics, Sananes et al1 leverage the Pediatric Heart Network Single Ventricle Reconstruction Trial to describe developmental and behavioral concerns in a cohort of children with hypoplastic left heart syndrome and related single right ventricle conditions. The Pediatric Heart Network recognized the importance of conducting developmental screening as recommended by the American Academy of Pediatrics (AAP)2,3 in this population at high risk for neurodevelopmental concerns.The researchers evaluate how well a diagnostic developmental evaluation at 14 months of age, with the Bayley Scales of Infant Development-II,4 and developmental screening at 3, 4, and 5 years of age, with the Ages & Stages Questionnaire (ASQ),5 predicted the outcome of “developmental functioning” as measured by the Adaptive Score on the Behavior Assessment System for Children-2 (BASC-2)6 at 6 years of age.There were some correlations between early developmental evaluations and later outcomes at age 6 years, such as a “failure” (scoring 2 SDs below the mean) on the Psychomotor Developmental Index of the Bayley Scales of Infant Development-II at age 14 months having a relatively good sensitivity (0.79) to identify lower adaptive skills at 6 years of age. In general, however, researchers in this study found that scores on the Bayley Scales of Infant Development-II at 14 months had a low positive predictive value for the BASC-2 Adaptive Scores at age 6 years. Some domains of the ASQ, including the personal-social, problem-solving, and communication scales, were correlated with 6-year-old BASC-2 Adaptive Scores, with “fail” ratings for problem-solving and personal-social domains at age 4 to 5 years having PPVs ranging from 75 to 93. Additionally, rates of parent-reported behavior problems on the BASC-2 were significantly higher at age 6 than at younger ages.It is helpful to understand specific domains and tasks that assessment tools measure. The BASC-2 is a broad-based behavioral rating scale and measures different constructs than the Bayley Scales of Infant Development-II and ASQ and differs from other measures of adaptive functioning.A signature developmental profile described in children with congenital heart disease (CHD) involves a “low severity, high prevalence” pattern of deficits.7 Thus, children may have mild deficits across numerous domains of development and behavior that subsequently culminate in impairments in day-to-day functioning. More subtle challenges in attention regulation and executive functioning are common in children with CHD and may not present functional impact until school-age. These concepts underscore the importance of in depth, multidisciplinary diagnostic evaluations at critical time points in development as recommended in the AAP-approved American Heart Association scientific statement on neurodevelopmental evaluation and treatment7 and guidelines for incorporating formal neurodevelopmental follow-up programs into cardiac care.8 Targeted neurodevelopmental evaluations should be conducted in addition to ongoing AAP-recommended developmental screening and surveillance for all children.2,3In this study, it was reassuring that more than three-quarters of children who passed the ASQ screening at younger ages subsequently scored within the average range on BASC-2 at age 6 years. Authors of this study raise important issues about developmental screening, surveillance, and evaluation in children with CHD as well as other high-risk pediatric populations, including those with conditions and risk factors associated with neurologic injury and developmental delay or disability). These issues include the following:The work of Sananes et al1 has implications for pediatric and surgical specialties. Implementing developmental screening within populations known to be at high risk can serve as a touchpoint to discuss developmental implications of chronic diseases as well as offer hope and support. When children have been diagnosed with developmental delays or are known to be at risk for delays, a proactive developmental support approach is important. A blended approach including developmental surveillance, screening, and diagnostic evaluations is logical. Unlike with many medical conditions, a named diagnosis is not required for a child to access and benefit from developmental interventions such as physical, occupational, and speech-language therapy and Part C Early Intervention programming.

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association.

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Abstract 228: Evaluation of Telephone-Assisted Cardiopulmonary Resuscitation Performance Recommendations for Out-Of-Hospital Sudden Cardiac Arrest

Introduction: Telephone-assisted CPR (T-CPR) may improve bystander CPR (B-CPR) rates and survival from sudden cardiac arrest (SCA). The American Heart Association (AHA) has specified performance measures to ensure rapid provision of T-CPR instructions. Few studies have examined whether these individual T-CPR recommendations are associated with SCA outcomes. Objectives: We sought to assess whether the 2012 AHA Scientific Statement’s T-CPR evaluation metrics are associated with increased B-CPR and survival from SCA. We hypothesized that recognition of arrest and compliance with the T-CPR protocol will result in increased likelihood of B-CPR. Methods: We conducted a retrospective assessment of non-traumatic SCAs from the Singapore T-CPR Pan-Asian Resuscitation Outcomes Study. We modeled the likelihood of receipt of B-CPR and survival to hospital discharge controlling for potential confounders. Exposure variables were identified from the Scientific Statement including adherence to T-CPR algorithms, dispatcher recognition of need for CPR, barriers to CPR (yes/no), and time intervals. Results: From 7/2012-2016, the Singapore T-CPR registry contained 3,224 adjudicated SCA events. Mean age was 67±19, 62% of the patients were male, and 87% of the arrests occurred in the home; of these arrests, 75% received T-CPR and 4% survived to hospital discharge. Compliance with the T-CPR protocol algorithm was not associated with an increased likelihood of B-CPR and survival (p=ns, both). Dispatcher recognition of the need for CPR was associated with a 24.9 (12.9-47.9) increased likelihood of B-CPR p<0.01, but was not associated with survival (OR: 1.77(0.37-8.45)). Recognized barriers to CPR were associated with a lower likelihood of B-CPR and survival (p<0.05, both). B-CPR was associated with a 2.40 (1.04-5.45) increased likelihood of survival (p=0.04). Call time to dispatch of EMS of <2 min was associated with a 1.33 (1.07-1.67) p=0.01 increased likelihood of receipt of B-CPR. Conclusion: Rapid dispatch of EMS (<2 min) and successful recognition of need for CPR increased the likelihood of B-CPR. B-CPR was associated with a two-fold increased likelihood of survival. Future work should consider refining T-CPR evaluation metrics using a data driven approach.

Personal-Level Protective Actions Against Particulate Matter Air Pollution Exposure: A Scientific Statement From the American Heart Association.

Since the publication of the last American Heart Association scientific statement on air pollution and cardiovascular disease in 2010, unequivocal evidence of the causal role of fine particulate matter air pollution (PM2.5, or particulate matter ≤2.5 μm in diameter) in cardiovascular disease has emerged. There is a compelling case to provide the public with practical personalized approaches to reduce the health effects of PM2.5. Such interventions would be applicable not only to individuals in heavily polluted countries, high-risk or susceptible individuals living in cleaner environments, and microenvironments with higher pollution exposures, but also to those traveling to locations with high levels of PM2.5. The overarching motivation for this document is to summarize the current evidence supporting personal-level strategies to prevent the adverse cardiovascular effects of PM2.5, guide the use of the most proven/viable approaches, obviate the use of ineffective measures, and avoid unwarranted interventions. The significance of this statement relates not only to the global importance of PM2.5, but also to its focus on the most tested interventions and viable approaches directed at particulate matter air pollution. The writing group sought to provide expert consensus opinions on personal-level measures recognizing the current uncertainty and limited evidence base for many interventions. In doing so, the writing group acknowledges that its intent is to assist other agencies charged with protecting public health, without minimizing the personal choice considerations of an individual who may decide to use these interventions in the face of ongoing air pollution exposure.

Assessing and Addressing Cardiovascular Health in LGBTQ Adults: A Scientific Statement From the American Heart Association.

There is mounting evidence that lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adults experience disparities across several cardiovascular risk factors compared with their cisgender heterosexual peers. These disparities are posited to be driven primarily by exposure to psychosocial stressors across the life span. This American Heart Association scientific statement reviews the extant literature on the cardiovascular health of LGBTQ adults. Informed by the minority stress and social ecological models, the objectives of this statement were (1) to present a conceptual model to elucidate potential mechanisms underlying cardiovascular health disparities in LGBTQ adults, (2) to identify research gaps, and (3) to provide suggestions for improving cardiovascular research and care of LGBTQ people. Despite the identified methodological limitations, there is evidence that LGBTQ adults (particularly lesbian, bisexual, and transgender women) experience disparities across several cardiovascular health metrics. These disparities vary by race, sex, sexual orientation, and gender identity. Future research in this area should incorporate longitudinal designs, elucidate physiological mechanisms, assess social and clinical determinants of cardiovascular health, and identify potential targets for behavioral interventions. There is a need to develop and test interventions that address multilevel stressors that affect the cardiovascular health of LGBTQ adults. Content on LGBTQ health should be integrated into health professions curricula and continuing education for practicing clinicians. Advancing the cardiovascular health of LGBTQ adults requires a multifaceted approach that includes stakeholders from multiple sectors to integrate best practices into health promotion and cardiovascular care of this population.

Relationship between Apical Periodontitis and Metabolic Syndrome and Cardiovascular Events: A Cross-Sectional Study.

Aim: Both apical periodontitis (AP) and metabolic syndrome (MetS) are associated with atherosclerotic cardiovascular disease (ACVD), the main cause of cardiovascular events. The aim of this study was to investigate the prevalence of AP and the oral inflammatory burden in control subjects and patients suffering cardiovascular events, analyzing the possible association between AP and the oral inflammatory burden with MetS. Materials and Methods: Using a cross-sectional design, 83 patients suffering a cardiovascular event were recruited in the study group (SG), and 48 patients without cardiovascular events were included in the control group (CG). Periapical index (PAI) was used to diagnose AP, and total dental index (TDI) was used to assess the total oral inflammatory burden. Diagnosis of MetS was made by meeting three or more American Heart Association Scientific Statement components. Results: In the multivariate logistic regression analysis, the number of teeth with AP (OR = 2.3; 95% C.I. = 1.3–4.3; p = 0.006) and TDI scores (OR = 1.5; 95% C.I. = 1.2–1.9; p = 0.001), significantly correlated with cardiovascular events. MetS was strongly associated (OR = 18.0; 95% C.I. = 6.5–49.7; p = 0000) with cardiovascular events. Higher TDI scores were significantly associated with MetS (OR = 1.3; 95% C.I. = 1.1–1.6; p = 0.003. Neither the number of root-filled teeth (RFT) (OR = 0.9; 95% C.I. = 0.6–1.3; p = 0.61) nor the number of teeth with apical periodontitis (OR = 1.1; 95% C.I. = 0.8–1.7; p = 0.49) were associated with MetS. Conclusions: Apical periodontitis is significantly associated with cardiovascular events. Total oral inflammatory burden assessed by TDI, but not AP alone, is associated with MetS.

Prevalence and prognosis of the 2018 vs 2008 AHA definitions of apparent treatment‐resistant hypertension in high‐risk hypertension patients

Resistant hypertension was defined according to the 2008 scientific statement as office blood pressure≥140/90mm Hg and the 2018 scientific statement as office blood pressure≥130/80mm Hg. We investigated the prognostic significance of lowered blood pressure threshold for defining resistant hypertension in the 2018 American Heart Association scientific statement compared with that in the 2008 scientific statement. The participants of this prospective cohort were enrolled from December 2013 to November 2018. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and heart failure hospitalization. Renal event was defined as a≥50% decline in estimated glomerular filtration rate or progression to end-stage renal disease. A total of 206 patients among 2018 (10.2%) were diagnosed with resistant hypertension by the previous definition (≥140/90mm Hg), and 276 patients among 2011 (13.7%) were diagnosed with resistant hypertension by the updated definition (≥130/80mm Hg). During a median follow-up of 4.5years, 33 MACEs (3.7 per 1000 patient-years) and 164 renal events (19.9 per 1000 patient-years) occurred in the study population. Treatment-resistant hypertension groups had a higher incidence rate of MACEs and renal events than the control groups. In multivariate Cox proportional hazards regression analysis, resistant hypertension by both definitions was significantly associated with increased risk of MACE and renal event. Both the previous and updated definitions of resistant hypertension were significant predictors of MACEs and renal events. This finding supports the adoption of the updated criteria for resistant hypertension in clinical practice.

Underutilization of Treatment for Black Adults With Apparent Treatment-Resistant Hypertension: JHS and the REGARDS Study.

Resistant hypertension, defined as blood pressure levels above goal while taking ≥3 classes of antihypertensive medication or ≥4 classes regardless of blood pressure level, is associated with increased cardiovascular disease risk. The 2018 American Heart Association Scientific Statement on Resistant Hypertension recommends healthy lifestyle habits and thiazide-like diuretics and mineralocorticoid receptor antagonists for adults with resistant hypertension. The term apparent treatment-resistant hypertension (aTRH) is used when pseudoresistance cannot be excluded. We estimated the use of healthy lifestyle factors and recommended antihypertensive medication classes among US Black adults with aTRH. Data were pooled for Black participants in the JHS (Jackson Heart Study) in 2009 to 2013 (n=2496) and the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) in 2013 to 2016 (n=3786). Outcomes included lifestyle factors (not smoking, not consuming alcohol, ≥75 minutes of vigorous-intensity or ≥150 minutes of moderate or vigorous physical activity per week, and body mass index <25 kg/m2) and recommended antihypertensive medications (thiazide-like diuretics and mineralocorticoid receptor antagonists). Overall, 28.3% of participants who reported taking antihypertensive medication had aTRH. Among participants with aTRH, 14.5% and 1.2% had ideal levels of 3 and 4 of the lifestyle factors, respectively. Also, 5.9% of participants with aTRH reported taking a thiazide-like diuretic, and 9.8% reported taking a mineralocorticoid receptor antagonist. In conclusion, evidence-based lifestyle factors and recommended pharmacological treatment are underutilized in Black adults with aTRH. Increased use of lifestyle recommendations and antihypertensive medication classes specifically recommended for aTRH may improve blood pressure control and reduce cardiovascular disease-related morbidity and mortality among US Black adults. Graphic Abstract A graphic abstract is available for this article.

Abstract P125: Genes And Pathways Associated With Apparent Treatment-resistant Hypertension In Patients With Chronic Kidney Disease: An Analysis Of The Cric Study

Patients with chronic kidney disease (CKD) have a 4-fold increased risk of developing apparent treatment-resistant hypertension (aTRH) compared with the general population. This study aimed to identify key genes and pathways associated with aTRH based on data from the Chronic Renal Insufficiency Cohort (CRIC) study. In this study, 823,094 whole-genome single-nucleotide polymorphisms (SNPs) of 3,024 patients (1,215 with aTRH defined by 2018 American Heart Association Scientific Statements and 1,809 without aTRH) were used for the analysis. First, we identified 997 significant (p&lt;0.05) genes associated with aTRH using the SNP-set kernel association test (SKAT) analysis after controlling for race, gender, body mass index, and diabetes. The top 5 significant genes identified were NMNAT3 (p=1.2х10-4, coding for an enzyme that catalyzes nicotinamide adenine dinucleotide synthesis), SLC2A13 (p=1.4х10-4, coding for a glucose transporter), PTBP1 (p=1.7х10-4, coding for an RNA-binding protein that controls alternative splicing), IZUMO4 (p=1.9х10-4, coding for a protein that facilitates fertilization), and CCDC9 (p=1.9х10-4, coding for coiled-coil domain-containing protein 9). Next, we performed gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses based on significant genes obtained from SKAT analysis. The identified top 5 GO pathways were “Metaphase plate congression” (p=1.3х10-4), “Histone deacetylase binding” (p=1.3х10-4), “Transcription regulatory region DNA binding” (p=1.7х10-4), “Cytokine-mediated signaling pathway” (p=1.8х10-4), and “Phosphotyrosine residue binding” (p=6.6х10-4). The top 5 KEGG pathways identified were “RNA degradation” (p=1.1х10-4), “Viral carcinogenesis” (p=1.5х10-4), “PD-L1 expression and PD-1 checkpoint pathway in cancer” (p=5.2х10-4), “NF-kappa B signaling pathway” (p=6.5х10-4) and “Bacterial invasion of epithelial cells” (p=9.6х10-4). Thus, these findings may provide new insights into molecular mechanisms underlying aTRH in patients with chronic kidney disease, e.g., the NF-kappa B signaling pathway may contribute to the development of aTRH through enhanced inflammatory responses.

Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction

BackgroundComplex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States. MethodsWe conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition. ResultsThe prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition. ConclusionIn addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.

Should Lipoprotein(a) be Measured in Youth?

Should Lipoprotein(a) be Measured in Youth?

Meditation and Cardiovascular Health in the US

The 2017 American Heart Association Scientific Statement on meditation and cardiovascular risk suggested that meditation may be considered as an adjunct to guideline-directed cardiovascular risk-reduction interventions. Meditation could potentially increase physical and mental relaxation, leading to improved outcomes after a major cardiovascular event. We hypothesized that meditation is associated with lower cardiovascular risk in the US general population. Using data from the 2012 and 2017 National Health Interview Survey, we identified all patients with hypercholesterolemia, systemic hypertension (SH), diabetes mellitus (DM), stroke, and coronary artery disease (CAD), as well as those who reported that they meditate. Multivariable logistic regression analyses were performed to evaluate the association between meditation and risk of hypercholesterolemia, SH, DM, stroke, and CAD, adjusting for potential confounders. Of 61,267 the National Health Interview Survey participants, 5,851 (9.6%) participated in some form of meditation. After adjusting for age, gender, body mass index, race, marital status, cigarette smoking, sleeping duration, and depression, meditation was independently associated with a lower prevalence of hypercholesterolemia (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.54 to 0.79; p = 0.001), SH (OR 0.86; 95% CI 0.75 to 0.99; p = 0.04), diabetes (OR 0.70; 95% CI 0.59 to 0.84; p = 0.0001), stroke (OR 0.76; 95% CI 0.58 to 0.99; p = 0.04), or CAD (OR 0.51; 95% CI 0.39 to 0.66; p <0.001), compared with those who did not meditate. In conclusion, using a large national database, we found that meditation is associated with a lower prevalence of cardiovascular risks factors and disease.

Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association.

A substantial body of research suggests that efforts to prevent pediatric obesity may benefit from targeting not just what a child eats, but how they eat. Specifically, child obesity prevention should include a component that addresses reasons why children have differing abilities to start and stop eating in response to internal cues of hunger and satiety, a construct known as eating self‐regulation. This review summarizes current knowledge regarding how caregivers can be an important influence on children's eating self‐regulation during early childhood. First, we discuss the evidence supporting an association between caregiver feeding and child eating self‐regulation. Second, we discuss what implications the current evidence has for actions caregivers may be able to take to support children's eating self‐regulation. Finally, we consider the broader social, economic, and cultural context around the feeding environment relationship and how this intersects with the implementation of any actions. As far as we are aware, this is the first American Heart Association (AHA) scientific statement to focus on a psychobehavioral approach to reducing obesity risk in young children. It is anticipated that the timely information provided in this review can be used not only by caregivers within the immediate and extended family but also by a broad range of community‐based care providers.

Abstract 282: Long Term Exercise And Women With Heart Disease

A sedentary lifestyle has long been recognized as a risk factor for heart disease. Although little data exists on the relationship of exercise based on gender in the risk factor analysis, most guidelines support the importance of exercise in the prevention and treatment of heart disease. Bach (2020) published the American Heart Association scientific statement of long-term exercise and cardiovascular events that provides guidance for clinicians recommending exercise. A recent survey of 395 women living with varying types of heart disease revealed that although many had been referred to cardiac rehabilitation, many did not exercise on a routine basis. Interestingly, the barriers to attending cardiac rehab were relatively sparse. Eleven (3%) women who met criteria identified that their insurance wouldn’t cover cardiac rehab. Travel was a barrier for nine(3 %) patients, 21 (6%) patients identified distance as a barrier and eight(2%) couldn’t get off work to attend. The worrisome component is that now, only 27.86% of the participants exercise on a routine basis. This has implications for morbidity in the future as Mediano, Leifer, Cooper, et al (2018) identify in the evaluation of baseline physical activity and outcomes in heart failure. In this population, living in both suburban and rural areas are not conducive to exercise. Although the number of urban participants who exercise is higher than the other geographic areas, the percentage is still unsatisfactory. The next steps for clinicians: •Develop a realistic evidence-based exercise prescription OR •Develop an interdisciplinary team of exercise physiologists, nurses, respiratory therapists and physical therapists who can identify specific exercise plans that meet the needs and resources of the female patient with heart disease. •Participate with communities to develop a mindset for exercise. •Participate in developing infrastructure for exercise facilities, trails, and other resources needing development, especially in rural areas.

Sleep Duration and Cardiovascular Health in a Representative Community Population (from NHANES, 2005 to 2016)

The 2016 American Heart Association Scientific Statement on sleep duration and cardiovascular risk suggested that optimal sleep duration is critical for cardiovascular health, with both long and short sleep duration associated with adverse health outcomes. We examined the relation between sleep duration and cardiovascular health among the general population in the United States from 2005 to 2016. We sought to investigate associations between sleep duration and the prevalence of coronary artery disease, heart failure (HF), stroke, hypertension, diabetes mellitus (DM), and hyperlipidemia. Using the National Health and Nutrition Examination Survey, we identified all patients with HF, coronary artery disease, hypertension, hyperlipidemia, DM, and stroke from 2005 to 2016. Multivariable logistic regression analyses were performed to adjust for age, sex, body mass index (BMI), marital status, educational level, physical activity, sedentary activity, depression, blood pressure, lipid profiles, and hemoglobin. In total, 32,152 National Health and Nutrition Examination Survey participants responded to the sleep survey. Both short sleepers (<7 hours, n = 12,027) and long sleepers (>9 hours, n = 1,058) were older and more likely to have a higher BMI than optimal sleepers (7 to 9 hours, n = 19,067; all p values <0.05). After adjusting for confounding variables and in comparison to those with optimal sleep duration, short sleep duration was associated with a higher prevalence of previous stroke (odds ratio [OR] 1.45; 95% confidence intervals [CI] 1.23 to 1.70), HF (OR 1.65; 95% CI 1.40 to 1.95), DM (OR 1.35; 95% CI 1.23 to 1.49), and hyperlipidemia (OR 1.12; 95% CI 1.04 to 1.22), whereas long sleep duration was associated with a higher prevalence of previous stroke (OR 1.81; 95% CI 1.37 to 2.34) and HF (OR 1.47; 95% CI 1.08 to 1.97). In conclusion, both long and short sleep durations were associated with poor cardiovascular health in this cross-sectional study.

Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity, mortality, and healthcare use. Great strides have been made in stroke prevention and rhythm control strategies, yet reducing the incidence of AF has been slowed by the increasing incidence and prevalence of AF risk factors, including obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, and other modifiable lifestyle-related factors. Fortunately, many of these AF drivers are potentially reversible, and emerging evidence supports that addressing these modifiable risks may be effective for primary and secondary AF prevention. A structured, protocol-driven multidisciplinary approach to integrate lifestyle and risk factor management as an integral part of AF management may help in the prevention and treatment of AF. However, this aspect of AF management is currently underrecognized, underused, and understudied. The purpose of this American Heart Association scientific statement is to review the association of modifiable risk factors with AF and the effects of risk factor intervention. Implementation strategies, care pathways, and educational links for achieving impactful weight reduction, increased physical activity, and risk factor modification are included. Implications for clinical practice, gaps in knowledge, and future directions for the research community are highlighted.

Abstract P119: Non-exercise Cardiorespiratory Fitness Prediction Equations: Accuracy Over Time in Apparently Healthy Adults

Introduction: Mortality risk predictions are improved with routine assessment of cardiorespiratory fitness (CRF). Accordingly, an American Heart Association Scientific Statement suggests routine clinical assessment of CRF in apparently healthy adults minimally using non-exercise prediction equations, which can be calculated from common health metrics. However, no study has assessed the ability of non-exercise CRF prediction equations to accurately detect longitudinal changes. Hypothesis: Changes in estimated CRF (eCRF) would be related to directly-measured changes, yet appreciable misclassification would occur at the individual level. Methods: The sample included 987 apparently healthy adults (324 females; mean±SD age 43.1±10.4 years) who completed 2 cardiopulmonary exercise tests (CPX) at least 3 months apart (3.2±5.4 years follow-up). The change in eCRF from 27 distinct non-exercise prediction equations was compared to the change in directly-measured CRF determined from CPX. A change of ≥5% was used to classify participants as having a directional increase or decrease in CRF. Analysis included Pearson product moment correlations, standard error of estimate (SEE) values, the Benjamini-Hochberg procedure to compare eCRF with directly-measured CRF, and chi-squared tests to examine the impact of follow-up time on the percentage of participants correctly identified as having a directional increase or decrease in CRF. Results: The change in eCRF from each equation was correlated to the change in directly-measured CRF ( P &lt;0.001) with R 2 values ranging from 0.06-0.43 and SEE values ranging from 0.9-5.9 ml·kg -1 ·min -1 . For 16 of the 27 equations, the change in eCRF was significantly different from the change in directly-measured CRF. When classifying directional changes, the prediction equations correctly categorized an average of 54% of individuals as having increased, decreased, or no change in CRF. When examining the influence of follow-up time, the average percentage of individuals correctly classified as having a directional increase in CRF was greater when the time between tests was ≤8months (54%) compared to ≥2years (28%). In contrast, the average percentage correctly classified as having a directional decrease in CRF was lower with tests ≤8months apart (8%) compared to ≥2years (73%). Conclusions: As hypothesized, discernible variability was found in the accuracy between non-exercise prediction equations and the ability of equations to accurately assess changes in directly-measured CRF over time. Considering the appreciable error that prediction equations had with detecting even directional changes in CRF, these results suggest eCRF may have limited clinical utility.

Pet Ownership and Cardiovascular Health in the US General Population

The 2013 American Heart Association Scientific Statement on pet ownership and cardiovascular risk suggested that dog ownership is probably associated with decreased cardiovascular risk. Several studies have been shown that pet ownership, particularly of dogs, is associated with increased physical activity levels, social support, and improved outcomes after a major cardiovascular event. We hypothesized that pet ownership is associated with a lower risk of cardiovascular disease in the US general population. Using the National Health and Nutrition Examination Survey, we identified all patients with heart failure, coronary artery disease, systemic hypertension (SH), diabetes mellitus, and stroke between 1999 and 2016. Multivariable analyses were performed to adjust for demographic factors such as age, gender, marital status, education, co-morbidities, cigarette smoking, family income, working hours, sleeping duration, depression, and lipid profiles. Of 42,038 National Health and Nutrition Examination Survey participants, 10,905 (31%) were inquired about pet ownership. Pet owners were older, less likely to be women or widowed, and more likely to be white, more educated, tobacco users, and work more than 35 hours per week than non-owners (all p values <0.05). Pet owners had higher hemoglobin, lower low-density lipoprotein cholesterol, and a lower prevalence of DM, SH, and stroke (all p values <0.05). After adjusting for potential confounders, pet ownership (either cat or dog ownership) was independently associated with a lower prevalence of SH (odds ratio 0.67; 95% confidence interval 0.49 to 0.89; p = 0.01), but not heart failure, coronary artery disease, DM, or stroke, compared with non-owners. In conclusions, using a large national database, we found that pet ownership is associated with a decreased prevalence of SH. Further longitudinal studies are needed to draw a conclusion on the protective effect of pet ownership in patients with cardiovascular disease.

419 The use of ST/HR Hysteresis as a Diagnostic Tool During Treadmill Exercise Stress Echo

Exercise stress test limitations including relatively low reported sensitivity has prompted research into analysis methods beyond traditional ST-segment depression criteria. ST/HR hysteresis has demonstrated relatively higher diagnostic accuracy as acknowledged by the American Heart Association Scientific Statement (2013). The aim of the present study is to assess the sensitivity and specificity of ST/HR Hysteresis for identifying CAD within a large tertiary referral centre. Data from Exercise Stress Echo (ESE) reports performed at a large tertiary referral centre between October 2017 and May 2018 (n=318) analysed retrospectively. Uninterpretable ECGs (n=24), bundle branch blocks (n=40) , and those with “non-diagnostic” ESE reports (n=33) excluded. ST/HR Hysteresis values calculated via GE-CASE Stress System (leads aVL, aVR, V1 excluded). Positive hysteresis was based on a partition value of ≥0.015mV and compared against a reference test of stress echo to determine sensitivity and specificity. Identification of ‘CAD’ for the purpose of analysis was based upon a positive ESE displaying a new inducible wall-motion abnormality. 225 tests remained after exclusions (24 positive, 201 negative) Both positive ESE and hysteresis occurred in 18 cases (sensitivity-=75%). Of 201 negative tests, 123 displayed negative hysteresis (specificity=62%). ST/HR hysteresis used during ESE does not display superior sensitivity and specificity within this population compared to that of traditional ST-segment criteria reference values. Further research is required using ECG-only based EST, ideally with coronary angiography as the reference test, to explore the potential utility of ST/HR Hysteresis as a diagnostic tool.