Burden Of Cardiovascular Disease Risk Factors Research Articles

Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study

Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. Full funding sources are listed at the end of the paper (see Acknowledgments).

Burden of Cardiovascular Disease Risk Factors Over 13.5 Years in a Rural and Urban South Indian Cohort in Comparison with Global Data

Background: India has high mortality rates from cardiovascular disease (CVD). Understanding the trends and identifying modifiable determinants of CVD risk factors will guide preventive strategies and support policy making. Methods: We estimated the prevalence and incidence of CVD risk factors (overweight, obesity, central obesity, type 2 diabetes (T2D), hypertension, hypercholesterolemia and hypertriglyceridemia) in 962 (male 519) non-migrant adults from Vellore, South India, studied in i) 1998-2002 (baseline, mean age 28.2 years) and ii) 2013-2014 (follow-up, mean age 41.7 years). Prevalence was compared with the Non-Communicable Disease Risk Collaboration (global) data. Incidence was compared with another Indian cohort from New Delhi (NDBC). Regression analysis was used to test baseline predictors of incident CVD risk factors. Findings: The prevalence of CVD risk factors at 28 and 42 years was 17% and 51% for overweight/obesity, 19% and 59% for central obesity, 3% and 16% for type 2 diabetes, 2% and 19% for hypertension and 15% and 30% for hypertriglyceridemia. The prevalence of type 2 diabetes at baseline and follow-up and hypertension at follow-up was comparable with or exceeded that in high income countries despite lower obesity rates. The incidence of most risk factors was lower in Vellore than in the NDBC. Weight gain from 15 to 28 years, and 28-year waist circumference, strongly predicted incident type 2 diabetes, hypertension and hypertriglyceridemia. After adjusting for these, rural residents had a higher incidence of type 2 diabetes and hypertension. Interpretation: A high prevalence of CVD risk factors is evident at a young age among Indians compared with high and upper-middle income countries. The rural prevalence is catching up with urban rates. Adiposity predicted higher risk factors, but the prevalence of hypertension and T2D is higher than expected given a relatively low obesity prevalence in global terms. This suggests greater sensitivity to adiposity and/or other unmeasured causal factors, among Indians. The increasing burden of CVD risk factors in India reinforces the need for strengthening CVD risk-prevention strategies, particularly in rural India and starting from a young age. Funding Statement: British Heart Foundation, UK and Christian Medical College, Vellore, India Declaration of Interests: None. Ethics Approval Statement: The study was approved by the institutional ethics committee of the Christian Medical College, Vellore and all participants provided informed consent.

Abstract P245: Impact of Depressive and Anxiety Symptoms on All Cause Mortality Among Andean Hispanics: Result From the PREVENCION Study

Introduction: Depressive/anxiety symptoms are associated with mortality among patients with established cardiovascular disease (CVD). These symptoms are also associated with higher burden of CVD risk factors. Few studies have examined whether the association between psychological symptoms and mortality is independent of CVD risk factors in community-based samples, and no study to date has focused on Andean Hispanic adults. In this study, we examined the association between depressive/anxiety symptoms and 10-year all-cause mortality among community-based Andean Hispanic adults, after adjusting for demographic and CVD risk factors. Hypothesis: Depressive/anxiety symptoms are independently associated with 10-year all-cause mortality among Andean Hispanic adults. Methods: Participants included 551 adults (57.7% female, mean baseline age=50.9 years [SD=16.8]) enrolled in the Peruvian Study of Cardiovascular Disease (PREVENCION). Depressive/anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale. Cox proportional-hazards models were used to examine associations between depressive/anxiety symptoms and all-cause mortality. Results: Mean depressive and anxiety symptom scores were 5.7 (SD=3.5) and 7.6 (3.6), respectively. There were 42 events (7.6%) reported at the 10-year follow-up. In unadjusted models, depressive symptoms were significantly associated with all-cause mortality (HR=1.25, 95% Confidence Intervals [CI]=1.14-1.37). After controlling for demographic factors and CVD risk factors (Figure 1), depressive symptoms remained significantly associated with all-cause mortality (HR=1.18, 95% CI=1.06-1.31). No associations were found between anxiety symptoms and all-cause mortality in unadjusted or adjusted models. Conclusion: Depressive symptoms were associated with 10-year all-cause mortality among Andean Hispanic adults even after adjusting for demographic and CVD risk factors. Future studies should examine associations with cause-specific mortality.

Antihypertensive Effectiveness of Perindopril Arginine and Indapamide Single-Pill Combination According to Body Mass Index: Findings from the FORSAGE Study.

IntroductionOverweight and obesity are increasing worldwide and are associated with an increased risk for cardiovascular disease (CVD). The aim of this study was to examine the burden of CVD risk factors among normal weight, overweight, and obese subjects with hypertension, and to evaluate the effectiveness of switching to a single-pill combination (SPC) of perindopril arginine/indapamide for blood pressure (BP) control in overweight and obese subjects treated in routine clinical practice.MethodsFORSAGE was a 3-month, multicenter, observational, open-label study conducted in Russian patients with uncontrolled arterial hypertension under previous antihypertensive therapy. Subjects were switched to the full-dose perindopril arginine 10 mg/indapamide 2.5 mg SPC. BP was assessed at 2 weeks, 1 month, and 3 months, and serum creatinine and general health status at 3 months. The present post hoc analysis of the FORSAGE study results explored the effectiveness of perindopril arginine/indapamide SPC in patients with arterial hypertension with regard to baseline body mass index (BMI): normal (< 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), and obese (≥ 30 kg/m2).ResultsA total of 1969 patients were recruited, but BMI data were available for 1963 patients, two-thirds of whom were women. The distribution of BMI groups was as follows: < 25 kg/m2 (16.7%), overweight (48.7%), and obese (34.7%). Overweight or obese patients had more concomitant diseases such as diabetes mellitus or history of stroke, higher BP levels, serum cholesterol and creatinine, and lower glomerular filtration rates. Switching to perindopril arginine/indapamide SPC was associated with a statistically significant reduction in BP as early as the second week of treatment. At 3 months, systolic blood pressure (SBP)/diastolic blood pressure (DBP) had decreased significantly by 39.3/18.8 mmHg in the normal BMI group, 39.8/18.8 mmHg in overweight, and 39.4/18.7 mmHg in obese groups. The magnitude of the BP reduction was independent of BMI. Achievement of target BP (< 140/90 mmHg) was good in all groups, but lower in obese subjects (70.9%) than in overweight subjects (78.1%) or those with a normal BMI (81.8%) (P < 0.0001 for both comparisons).ConclusionsIn subjects with uncontrolled BP on existing antihypertensive therapy, switching to perindopril arginine 10 mg/indapamide 2.5 mg was associated with statistically significant decreases in BP and higher rates of target BP achievement in all BMI groups, including more than 70% of overweight and obese patients.Trial RegistrationISRCTN ID, ISRCTN14315146 (retrospectively registered 18/11/2019).Electronic supplementary materialThe online version of this article (10.1007/s40119-020-00162-x) contains supplementary material, which is available to authorized users.

1465-P: Cardiovascular Risk Factors among Young Adults with Diabetes in the U.S.

Although the prevalence of diabetes (DM) among young adults age 18 to 44 years in the United States (U.S.) has increased in the past two decades, little is known about how cardiovascular disease (CVD) risk factors for DM complications in this age group compare to older adults with DM. We used data from the National Health and Nutrition Examination Survey from 2007-2016 to characterize young adults with and without DM by CVD risk factors and compared the differences to middle- aged and older adults (aged ≥45 years). DM was defined by self-report or by A1c levels ≥ 6.5% among those without self-reported diabetes. Measures included demographics, health insurance, and CVD risk factors. Absolute difference in difference was calculated as the difference in prevalence by DM status among young adults minus the difference by DM status among middle-aged and older adults. Among young adults in the U.S., DM prevalence was 3.5%, corresponding to 3.6 million people with DM. As expected, participants of both age groups with DM had higher levels of adiposity, hypertension, high cholesterol, and chronic kidney disease (CKD), and lower levels of physical activity, compared to those without (Table). However, the difference in adiposity and high cholesterol by DM status was greater among young adults compared to middle-aged and older adults. Young adults with DM have a high burden of CVD risk factors that could lead to future increases in morbidity and mortality. Disclosure S. Saydah: None. C. Mercado: None. K.R. Siegel: None. E.W. Gregg: None. G. Imperatore: None.

Cardiovascular disease risk factor burden and cognition: Implications of ethnic diversity within the Hispanic Community Health Study/Study of Latinos.

ObjectiveHispanics/Latinos have some of the highest prevalence rates for cardiovascular disease risk factors, but stark differences exist by self-reported background. Cardiovascular disease risk factors negatively impact cognition in Hispanics/Latinos; less is known about these relationships by Hispanic/Latino backgrounds. We investigated cognitive associations with cardiovascular disease risk factor burden in a diverse cohort, the Hispanic Community Health Study/Study of Latinos.MethodsBaseline data from this observational study of cardiovascular disease and its antecedents was collected from 2008–2011. We included 7,121 participants 45–74 years old from Central American, Cuban, Dominican, Mexican, Puerto Rican, or South American backgrounds. Dichotomous indicators for hypertension, diabetes, hypercholesterolemia, obesity, and smoking were evaluated and totaled, with participants grouped by lowest (0–2), middle (3) or highest (4–5) burden. Cognitive testing included the Brief Spanish English Verbal Learning Test, letter fluency, and digit symbol substitution.ResultsIn separate fully-adjusted linear regression models, lower fluency and digit symbol substitution performance were restricted to the highest compared to the lowest burden group; whereas the middle burden group displayed impaired memory performance compared to the lowest burden group (p-values≤0.05). Background interacted with burden for learning and memory performance. That is, the association of burden level (i.e., lowest, middle, or highest) with cognitive performance was modified by background (e.g., Mexicans vs Cuban).ConclusionsHispanics/Latinos with higher levels of cardiovascular disease risk factor burden displayed lower levels of cognitive performance, with learning and memory performance modified by background.

Cancer Survivorship and Subclinical Myocardial Damage.

Cancer survivors might have an excess risk of cardiovascular disease (CVD) resulting from toxicities of cancer therapies and a high burden of CVD risk factors. We sought to evaluate the association of cancer survivorship with subclinical myocardial damage, as assessed by elevated high-sensitivity cardiac troponin T (hs-cTnT) test results. We included 3,512 participants of the Atherosclerosis Risk in Communities Study who attended visit 5 (2011-2013) and were free of CVD (coronary heart disease, heart failure, or stroke). We used multivariate logistic regression to evaluate the cross-sectional associations of survivorship from any, non-sex-related, and sex-related cancers (e.g., breast, prostate) with elevated hs-cTnT (≥14 ng/L). Of 3,512 participants (mean age, 76 years; 62% women; 21% black), 19% were cancer survivors. Cancer survivors had significantly higher odds of elevated hs-cTnT (OR = 1.26, 95% CI: 1.03, 1.53). Results were similar for survivors of non-sex-related and colorectal cancers, but there was no association between survivorship from breast and prostate cancers and elevated hs-cTnT. Results were similar after additional adjustments for CVD risk factors. Survivors of some cancers might be more likely to have elevated hs-cTnT than persons without prior cancer. The excess burden of subclinical myocardial damage in this population might not be fully explained by traditional CVD risk factors.

Abstract P105: Less Walkable Neighborhoods Are Associated With Worse Cardiovascular Risk Profile

Introduction: There is mounting evidence that neighborhoods that have low levels of walkability have higher burdens of cardiovascular disease (CVD) risk factors such as obesity and hypertension. However, few studies have examined the impact of walkability on overall cardiovascular risk. Hypothesis: We hypothesized that residents living in less walkable communities have a higher burden of cardiovascular risk factors and a greater predicted risk for future CVD events. Methods: We assembled a cross-sectional sample of community dwelling adults aged 40-74 on January 1, 2008 from the CANHEART cohort. We ascertained systolic blood pressure, HDL and total cholesterol, smoking status, and diabetes status using a combination of EMR, clinical laboratory databases, and health administrative databases. The primary outcome was an estimated total 10-year cardiovascular disease risk of ≥ 7.5% using the ACC/AHA Pooled Cohort risk score. Walkability was measured using a validated index and divided into quintiles from lowest (Q1) to highest (Q5). The associations were tested using linear and logistic regression with cluster-robust standard errors, adjusting for confounders. Results: In total, 44,448 individuals were included in the analysis. Individuals living in less walkable areas had a higher predicted 10-year CVD risk than those living in highly walkable areas. The association was non-linear, as individuals living in neighborhoods of mid-range walkability (Q3) were even more likely to have an estimated 10-year CVD risk exceeding 7.5% in comparison to those in Q5 (OR = 1.33, (1.23, 1.45)). Conversely, we observed monotonic associations between decreasing walkability and higher mean systolic blood pressure (Q1 vs. Q5: +2.73 mmHg, 95% CI: +2.11, + 3.35) and odds of diabetes (Q1 vs. Q5: OR = 1.29, 95% CI: 1.13, 1.47). Dose-response associations were also observed between decreasing walkability and lower HDL cholesterol (Q1 vs. Q5: -1.93 mg/dl, 95% CI: -2.32, -1.16) and likelihood of being a current smoker (Q1 vs. Q5: OR = 0.76, 95% CI: 0.67, 0.85). Conclusions: Residents living in less walkable neighborhoods had a higher burden of CVD risk factors and a higher estimated risk of future CVD. Conversely, the likelihood of smoking was higher in more walkable neighborhoods, suggesting this may be an area to focus smoking cessation efforts.

FITNESS AND 10-YEAR RISK OF MORTALITY AMONG ADULTS ≥70 YEARS OLD AT THE EXTREMES OF CARDIOVASCULAR DISEASE RISK FACTOR BURDEN: THE FIT PROJECT

Traditional cardiovascular disease (CVD) risk factors have a decreased predictive strength with increasing age. We sought to determine if fitness could improve risk stratification among older adults at the extremes of CVD risk factor burden. We studied 6,509 patients ≥70 years of age without CVD

Improving Cardiovascular Disease Knowledge among Rural Participants: The Results of a Cluster Randomized Trial.

Cardiovascular disease (CVD) is a major cause of death and disability, especially among people living in the rural, southern United States. Rural African Americans are often diagnosed with CVD earlier in life, and they bear a disproportionate burden of CVD risk factors, morbidity, and mortality. Health equity among historically underserved, rural populations can potentially be attained through culturally relevant interventions that teach people skills to stay well and avoid CVD-related risk and diagnoses. The purpose of this secondary analysis was to determine the effect of an evidence-based intervention on cardiovascular health knowledge and the stages of change toward the action and maintenance phases. The pre-test-post-test data were obtained during a cluster randomized trial involving twelve rural churches that were randomized to intervention (n = 6) and control (n = 6) groups. Participants (n = 115) in the intervention group received a cardiovascular health intervention, and those (n = 114) in the control group could receive the intervention following the study’s completion. The data were analyzed using a linear mixed model to compare group differences from pre-test to post-test. The cardiovascular health promotion intervention significantly improved cardiovascular health knowledge and was associated with advancements in the stages of change toward the action and maintenance phases.

Abstract P006: Cardiovascular Disease Risk Factor Burden is Associated With Hearing Loss in Young Men: The Hispanic Community Health Study/Study of Latinos

Introduction: Over 30 million Americans suffer from hearing loss (HL). Studies suggest that established cardiovascular disease (CVD) risk factors may contribute to the pathophysiology of the inner ear. However, the aggregate effect of CVD risk factors on hearing is not well understood. Hypothesis: We hypothesized that high CVD risk burden is associated with worse hearing. Methods: We assessed younger (ages 18-34) and older (ages 55-64) Hispanic Community Health Study / Study of Latinos participants who underwent audiometry in 2008-11. After excluding those with conductive pathology and asymmetric HL, we randomly chose one ear for analysis. Puretone thresholds were obtained at 0.5-8 kHz; puretone average (PTA) was calculated using thresholds at 0.5, 1, 2, and 4 kHz. Low CVD risk burden was defined as having all of: blood pressure (BP) &lt;120/&lt;80 mmHg; total cholesterol &lt;180 mg/dL; not currently smoking; and not having prevalent diabetes. High CVD risk burden was defined as ≥ 2 of: diabetes; currently smoking; BP &gt;160/&gt;100 mmHg (or antihypertensive use); and total cholesterol &gt;240 mg/dL (or statin use). By age group and sex, we estimated hearing thresholds per frequency with linear regression models adjusted for noise exposure. Least squares estimates were calculated using strata-specific means of covariates. Estimates were compared via t-tests. Data were weighted for all analyses and accounted for clustering. Results: Among younger and older individuals in the target population (51.9% female), 28.8% had low and 5.5% had high CVD risk. Younger men with high CVD risk had worse PTA than young men with low risk (7.7 dB HL [7.0-8.4] vs. 10.5 dB HL [8.4-12.5], p =0.02), and had significantly worse thresholds at 1,3,4,6 kHz than those with low risk ( Figure ). There was no difference in PTA or thresholds at any frequency by CVD risk burden in young women, older men, or older women. Conclusions: CVD risk burden is associated with HL among young men, but not young women or older adults. CVD risk burden may be useful for identifying young men at risk for HL.

Cardiovascular risk factor burden in Africa and the Middle East across country income categories: a post hoc analysis of the cross-sectional Africa Middle East Cardiovascular Epidemiological (ACE) study

BackgroundA significant number of cardiovascular disease (CVD)-related deaths occur in developing countries. An increasing prevalence of CVD is associated with a change in the macro-economy of these countries. In this post hoc analysis, CVD risk factor (CVDRF) prevalence is evaluated across countries based on national income in the Africa and Middle East Region (AfME).MethodsData from the Africa Middle East Cardiovascular Epidemiological (ACE) study were used; a cross-sectional study in 14 AfME countries (94 clinics) from July 2011–April 2012, which evaluated CVDRF prevalence in stable adult outpatients. World Bank definitions were used to classify countries as low-income (LI), lower-middle-income (LMI), upper-middle-income (UMI) or high-income (HI) countries. Four thousand three hundred seventy-eight subjects were recruited where 260 (6%), 1324 (30%), 1509 (35%) and 1285 (29%) were from LI, LMI, UMI, and HI countries, respectively.ResultsOf all the CVDRFs evaluated, almost two-thirds of the study population across the national income groups had abdominal obesity and dyslipidemia. Countries in the HI category were associated with a higher prevalence of diabetes (32%), obesity (44%) and smoking (16%). UMI and HI countries were associated with higher clustering of CVDRFs where at least one-third of subjects having four or more CVDRFs. Lower income countries had lower blood pressure control rates and lower percentages of outpatients achieving LDL-cholesterol targets.ConclusionThe burden of CVDRFs in stable outpatients is high across the national income categories in the AfME region, with HI countries showing a higher prevalence of CVDRFs. The high burden in lower income countries is associated with sub-optimal control of dyslipidemia and hypertension. Lowering the CVDRF burden would need specific public health actions in line with positive changes in the macro-economy of these countries.Trial registrationThe ACE trial is registered under NCT01243138.

Low Levels of Endothelial Progenitor Cells and Their Association with Systemic Inflammation and Monocyte Activation in Older HIV-Infected Men

Endothelial progenitor cells (EPCs) repair damaged vascular endothelium, and low circulating EPC levels have been associated with cardiovascular disease (CVD). CD34+/KDR+ EPCs are commonly reported in the literature and CD34+/CD133+/KDR+ EPCs are rare in circulation but highly specific for endothelial lineage. HIV-infected (HIV+) adults have chronic inflammation and increased CVD risk, but the relationship between CVD, vascular inflammation, and EPCs in HIV remains unclear. In a pilot study, EPCs were measured in 57 HIV+ men [≥50 years old, HIV-1 RNA <50 copies/ml on antiretroviral therapy (ART)] by real-time flow cytometry using cellular immaturity (CD34 and/or CD133) and endothelial commitment (KDR) markers. Fasting inflammatory biomarker levels were measured by ELISA. Median age was 57 years; CD4+ T lymphocyte count was 570 cells/mm3. Prevalent CVD risk factors included 16% diabetes, 28% hypertension, 53% dyslipidemia, and 33% smoking. Median (interquartile range) EPC values were CD34+/KDR+ 0.1 (0.0-0.9) cells/105 peripheral blood mononuclear cells (PBMCs) and CD34+/CD133+/KDR+ 0.1 (0.0-0.9) cells/105 PBMCs. We observed a high prevalence of undetectable CD34+/KDR+ (40%) and CD34+/CD133+/KDR+ EPCs (44%). Men with undetectable EPCs were more likely to have ≥2 CVD risk factors, lower interleukin-6 (IL-6), and higher sCD163 levels. In these older HIV+ men on suppressive ART, CD34+/KDR+ and CD34+/CD133+/KDR+ EPC levels were low and often undetectable. Undetectable EPC levels were associated with greater CVD risk factor burden, lower IL-6 (consistent with decreased EPC production stimulus), and higher sCD163 (consistent with monocyte activation and prior CVD associations) levels, suggesting a potential relationship between EPCs and atherosclerotic burden in this population.

Nutrition education for cardiovascular disease prevention in individuals with spinal cord injuries: study protocol for a randomized controlled trial

BackgroundIndividuals with chronic spinal cord injuries (SCIs) have an increased prevalence of cardiovascular disease (CVD) and associated risk factors compared with age-matched control subjects. Exercise has been shown to improve selected CVD risk factors in individuals with SCI, but using nutrition education as an intervention has not been evaluated in this population. This paper describes our research plan for evaluating the effect of nutrition education on individuals with SCI. In the present study, called Eat Smart, Live Better, we are using a randomized controlled design to test an intervention adapted from an existing evidence-based program that showed a positive effect on nutrition knowledge and behavior of older adults from the general population. There will be an inpatient group (n = 100) and a community group (n = 100). The aims of our study are to compare the intervention and control groups for (1) changes in nutritional behavior, nutritional knowledge, and dietary quality by participants in the program; (2) levels of adiposity and metabolic CVD risk factors at 12-month follow-up; and (3) differential effects among individuals with SCI in the acute rehabilitation setting and those living in the community.Methods/designThis is a randomized controlled trial of nutrition education. The treatment groups receive six nutrition education sessions. The control groups receive the one “standard of care” nutrition lecture that is required by the Commission on Accreditation of Rehabilitation Facilities. Treatment groups include both an inpatient group, comprising patients who have been admitted to an acute rehabilitation facility because of their recent SCI, and an outpatient group, consisting of community-dwelling adults who are at least 1 year after their SCI. A total of 200 participants will be randomized 1:1 to the intervention or control group, stratified by location (acute rehabilitation facility or community dwelling).DiscussionTo our knowledge, this will be the first reported study of nutrition education in individuals with SCI. The low cost and feasibility of the intervention, if shown to improve nutritional behavior, suggests that it could be implemented in rehabilitation facilities across the country. This has the potential of lowering the burden of CVD and CVD risk factors in this high-risk population.Trial registrationClinicalTrials.gov, NCT02368405. Registered on February 10, 2015.

Temporal trends in cardiovascular disease risk factor profiles in a population-based schizophrenia sample: a repeat cross-sectional study

BackgroundPeople with schizophrenia have an increased burden of cardiovascular diseases (CVD); however, little is known about the cardiovascular risk factor profiles of non-institutionalised individuals with schizophrenia. This study estimated the...

Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis

ObjectivesPatients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD). We aimed to assess the impact of CVD risk factors, including potential sex differences, and RA-specific variables...

Atherosclerosis is not accelerated in rheumatoid arthritis of low activity or remission, regardless of antirheumatic treatment modalities.

RA associates with increased cardiovascular disease (CVD) morbidity and mortality due to accelerated atherosclerosis, attributed to both classical risk factors and chronic inflammation. The aim of this study was to test the hypothesis that effective disease control over 3 years modifies acceleration of atherosclerosis in RA. Consecutive, non-diabetic RA patients previously examined by ultrasonography for subclinical atherosclerosis were re-evaluated after 3.2 (0.2) years, provided that they were in remission/low disease activity (DAS28 <3.2) for at least 75% of this period. Patients (n = 139) were demographically matched with 139 non-diabetic, non-RA control individuals studied in parallel. Patients and controls (mean age of 56 years at baseline) had a comparable burden of classical CVD risk factors. Patients' pulse wave velocity (reflecting arterial stiffness) changed by 0.07 m/s/year and left carotid intima-media thickness (reflecting wall hypertrophy) increased by 0.009 mm/year; formation of new atheromatic plaques in carotid and/or femoral arterial beds occurred in 22%. Multivariate analysis after correcting for all classical CVD risk factors and anti-hypertensive/lipid-lowering therapies demonstrated no significant differences between patients and controls in any of the subclinical atherosclerosis indices. Changes in all atherosclerosis indices from baseline to end of follow-up were comparable between those 56 patients treated with biologic DMARDs and their demographically matched patients treated with synthetic DMARDs. Effective disease control may abrogate any RA-specific effect on the progression of atherosclerosis regardless of treatment. Whether early and sustained RA control translates to the CVD outcomes expected in the general population should be examined in prospective studies.

Carotid β-stiffness index is associated with slower processing speed but not working memory or white matter integrity in healthy middle-aged/older adults.

Aging is associated with increased carotid artery stiffness, a predictor of incident stroke, and reduced cognitive performance and brain white matter integrity (WMI) in humans. Therefore, we hypothesized that higher carotid stiffness/lower compliance would be independently associated with slower processing speed, higher working memory cost, and lower WMI in healthy middle-aged/older (MA/O) adults. Carotid β-stiffness (P < 0.001) was greater and compliance (P < 0.001) was lower in MA/O (n = 32; 64.4 ± 4.3 yr) vs. young (n = 19; 23.8 ± 2.9 yr) adults. MA/O adults demonstrated slower processing speed (27.4 ± 4.6 vs. 35.4 ± 5.0 U/60 s, P < 0.001) and higher working memory cost (-15.4 ± 0.14 vs. -2.2 ± 0.05%, P < 0.001) vs. young adults. Global WMI was lower in MA/O adults (P < 0.001) and regionally in the frontal lobe (P = 0.020) and genu (P = 0.009). In the entire cohort, multiple regression analysis that included education, sex, and body mass index, carotid β-stiffness index (B = -0.53 ± 0.15 U, P = 0.001) and age group (B = -4.61 ± 1.7, P = 0.012, adjusted R2 = 0.4) predicted processing speed but not working memory cost or WMI. Among MA/O adults, higher β-stiffness (B = -0.60 ± 0.18, P = 0.002) and lower compliance (B = 0.93 ± 0.26, P = 0.002) were associated with slower processing speed but not working memory cost or WMI. These data suggest that greater carotid artery stiffness is independently and selectively associated with slower processing speed but not working memory among MA/O adults. Carotid artery stiffening may modulate reductions in processing speed earlier than working memory with healthy aging in humans.NEW & NOTEWORTHY Previously, studies investigating the relation between large elastic artery stiffness, cognition, and brain structure have focused mainly on aortic stiffness in aged individuals with cardiovascular disease risk factors and other comorbidities. This study adds to the field by demonstrating that the age-related increases in carotid artery stiffness, but not aortic stiffness, is independently and selectively associated with slower processing speed but not working memory among middle-aged/older adults with low cardiovascular disease risk factor burden.

Traditional and HIV-specific risk factors for cardiovascular morbidity and mortality among HIV-infected adults in Brazil: a retrospective cohort study.

BackgroundAntiretroviral therapy (ART) agents potentially associated with adverse metabolic profiles are commonly used in low- and middle-income countries. We assessed risk factors for cardiovascular disease (CVD)-related morbidity and mortality in a cohort of HIV-infected, ART-treated adults in Rio de Janeiro, Brazil.MethodsHospital records and mortality data between 2000–2010 were examined for incident CVD-related ICD-10 and Coding of Death in HIV diagnoses among adults ≥18 years old on ART, enrolled in an observational cohort. Poisson regression models assessed associations between demographic and clinical characteristics and ART agent or class on CVD event risk.ResultsOf 2960 eligible persons, 109 had a CVD event (89 hospitalizations, 20 deaths). Participants were 65 % male, 54 % white, and had median age of 37 and 4.6 years on ART. The median nadir CD4+ T lymphocyte count was 149 cells/mm3. The virologic suppression rate at the end of study follow-up was 60 %. In multivariable models, detectable HIV-1 RNA prior to the event, prior CVD, less time on ART, age ≥40 at study baseline, nadir CD4+ T lymphocyte count ≤50 cells/mm3, non-white race, male gender, and a history of hypertension were significantly associated with CVD event incidence (p < 0.05), in order of decreasing strength. In multivariate models, cumulative use of tenofovir, zidovudine, efavirenz and ritonavir-boosted atazanavir, darunavir and/or lopinavir were associated with decreased CVD event risk. Recent tenofovir and boosted atazanavir use were associated with decreased risk, while recent stavudine, nevirapine and unboosted nelfinavir and/or indinavir use were associated with increased CVD event risk.ConclusionsVirologic suppression and preservation of CD4+ T-lymphocyte counts were as important as traditional CVD risk factor burden in determining incident CVD event risk, emphasizing the overall benefit of ART on CVD risk and the need for metabolically-neutral first- and second-line ART in resource-limited settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1735-4) contains supplementary material, which is available to authorized users.

Addressing the growing burden of non-communicable disease by leveraging lessons from infectious disease management.

In recent decades, low– and middle–income countries (LMICs) have achieved decreased morbidity and mortality associated with infectious diseases and poor maternal– and child–health (MCH). However, despite these advances, LMICs now face an additional burden with the inexorable rise of non–communicable diseases (NCDs). Deaths due to NCDs in LMICs are expected to increase from 30.8 million in 2015 to 41.8 million by 2030 [1]. While improvements in life expectancy, lifestyle and urbanisation go some way to explaining why more people in LMICs are affected by NCDs, it is less clear why these populations are contracting NCDs at a younger age and with worse outcomes than in high–income countries (HICs) [2]. Despite having a lower cardiovascular disease risk factor burden, LMIC populations have a four–fold higher mortality rate from cardiovascular events than HIC populations [3] in part due to a lack of access to quality, integrated health services and the poor availability of early interventions and effective NCD prevention programmes. The HIV/AIDS epidemic was the last time the world confronted a global health challenge that so disproportionately caused premature adult deaths in LMICs. The conclusion is unavoidable: the time to act is now. Prevention of NCDs at a population and an individual level is key and requires policy and structural changes. We have a unique opportunity to learn from the successes of infectious disease control programmes in LMICs and leverage these to address the growing NCD burden. Translatable learnings include: 1) emphasizing primary prevention, particularly in those at highest risk; 2) targeting service delivery to high–risk populations; 3) enabling access to adequate, affordable care at community level; 4) engendering patient empowerment and involving people affected by chronic conditions; 5) enabling access to quality drugs and adherence programmes; 6) regularly measuring the effectiveness and impact of programmes to ensure their appropriateness and improvement; and 7) creating an environment of health financing for universal coverage. Innovations to counter the emerging NCD epidemic must encompass both prevention and the delivery of care. Infectious disease programmes have used task–shifting, where less skilled health workers and community members are involved in delivery of health services. In India, we have seen this used for NCDs in the Arogya Kiran model where the existing health workforce was overstretched. Volunteers and teachers successfully delivered diabetes and hypertension screening and management to over 600 000 people [4]. Patient empowerment, and community involvement in health care delivery and governance, will be critical in tackling NCDs, since most are chronic conditions, which initially present silently and require long–term management [5]. In Malawi, recognizing the close relationship of HIV infection and cardiovascular diseases has led to screening for hypertension being integrated into HIV care [6]. In Ghana, decentralised community–based hypertension care, using digital technology, is helping to empower patients to manage their own disease: a model that is again adapted from HIV management [7]. We are also starting to see examples in India of MCH care coupled with life–long NCD screening and awareness programmes [8]. While these examples of managing the dual burden of infectious diseases and NCDs are encouraging, more needs to be done. The largest gap is in NCD prevention. Tackling the obesity epidemic and wrestling with the issues around curbing tobacco sales and smoking are rightly high on the NCD prevention agenda. The greatest opportunity is preventing a tobacco–related epidemic in sub–Saharan Africa where smoking levels are still low. Health budgets and development assistance for health must allocate resources commensurate with the dual disease burden. Health spending of governments in LMICs has tripled over the past 20 years, but remains low [9]. In addition, more health care models should consider diversified revenue streams or hybrid financing (eg, tiered payment schemes) to ensure sustainability. If equity is to be improved, patients need access to quality health care, through sustainable health–financing systems for universal health coverage, while reducing out–of–pocket expenditure for the under–served population. Photo: © Nana Kofi Acquah/Novartis Foundation Implementing such models will require strong government leadership and interventions, and partnerships across the public and private sectors. Some public–private partnerships (PPPs) in infectious diseases have demonstrated their potential to catalyze the delivery of, and access to, prevention and care through providing complementary strengths [10]. The private sector draws on its business and scientific expertise, focusing on strong results–based operations, whereas the public sector brings a wealth of expertise in implementation with equity, management and documentation. The end–users of the services, including patients and health care providers, also need to be included from the outset to ensure that the models are people–centered, co–created, adapted to prevailing contextual nuances, and sustainable. If we build on what we have learnt from infectious disease management, we could have a transformational impact on the growing NCD burden.