Differences In Cardiovascular Disease Mortality Research Articles

Abstract 4828: Effect of county-level income and rurality on cardiovascular disease mortality among Asian and Pacific Islander breast cancer survivors in the US, 2000-2018

Abstract Purpose: To examine differences in cardiovascular disease (CVD) mortality by county-level income and rurality for Asian versus Pacific Islander (PI) breast cancer survivors. Background: Asian and PI individuals experience varying cancer burden, and prior studies have reported disparities in treatment-related CVD mortality among breast cancer survivors by socioeconomic status and race and ethnicity. However, the impact of county-level income and rurality on CVD mortality among Asian and PI breast cancer survivors, separately, are not well described. Methods: We included 60,184 Non-Hispanic Asian and PI women diagnosed with first primary, invasive breast cancer between 2000-2017 in the U.S. Surveillance, Epidemiology, and End Results program (aged 18-84, survived 12+ months, and received initial surgery). We estimated the hazard ratio (HR) of CVD mortality using Cox proportional hazard models assessing the impact of county-level income (median household income: low = <$75,000; high [ref] = ≥$75,000) and rurality (urban [ref] = metropolitan counties, population ≥ 250,000; rural = nonmetropolitan counties), separately for Asian and PI breast cancer survivors. Models adjusted for continuous age, stage (localized, regional/distant), and year of breast cancer diagnosis (2000-2004, 2005-2009, 2010-2017). We calculated 10-year cumulative CVD mortality for Asian and PI women accounting for competing risks (e.g., non-CVD deaths). Results: Of 55,602 Asian and 4,582 PI breast cancer survivors, 1,114 Asian and 178 PI women died from CVD through 2018 (median follow-up, Asian = 6.0 years; PI = 5.5 years). PI women had a higher median age at breast cancer diagnosis (57 vs. 55 years) and more advanced stage (37% vs. 33%) than Asian women. Among Asian breast cancer survivors, low county-level income was associated with elevated CVD mortality (HR = 1.17, 95% CI = 1.04, 1.31), but not rurality (HR = 1.20, 95% CI = 0.91, 1.58). For PI breast cancer survivors, there were no significant associations observed for low county-level income (HR = 0.83, 95% CI = 0.60, 1.14) or rurality (HR = 1.11, 95% CI = 0.76, 1.61). At 10 years after breast cancer diagnosis, 1 in 40 Asian women and 1 in 20 PI women died of CVD. Conclusion: Asian breast cancer survivors living in low-income counties had heightened risk of CVD mortality compared with those living in higher income counties, highlighting potential healthcare access barriers to cancer survivorship care. Although PI women did not experience significant differences in CVD mortality across groups of county-level income and rurality, they had twice as high absolute risk of CVD mortality than Asian women, warranting further investigation. Future studies that disaggregate Asian and PI individuals into more diverse and granular ethnicity groups are needed to understand heterogeneity in breast cancer survivorship outcomes. Citation Format: Katherine L. Ho, Cody Ramin, Jaimie Z. Shing, Kekoa Taparra, Jacqueline B. Vo. Effect of county-level income and rurality on cardiovascular disease mortality among Asian and Pacific Islander breast cancer survivors in the US, 2000-2018 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4828.

Early elevation of high-sensitivity C-reactive protein as a predictor for cardiovascular disease incidence and all-cause mortality: a landmark analysis

We investigated the association between early elevation of high-sensitivity C-reactive protein (hsCRP) and cardiovascular disease (CVD) incidence, all-cause mortality, and CVD mortality. We analyzed 6567 participants from the Korean Genome and Epidemiology Study_Ansan_Ansung cohort between 2005 and 2018. The Kaplan–Meier curves and modified Cox regression by Fine and Gray were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for CVD incidence, all-cause mortality, CVD mortality, cancer mortality, and mortality from other causes. Landmark analyses were performed at the first (2007–2008) and second (2009–2010) follow-up periods, with early elevation defined as hsCRP > 2 mg/L. At the first and second landmark points, the early hsCRP elevation group had a higher incidence of CVD and all-cause mortality. At first landmark point, the adjusted HRs (95% CIs) were 1.37 (1.08–1.74) for incident CVD and 1.26 (1.04–1.53) for all-cause mortality, respectively. At second landmark point, the adjusted HRs in the early hsCRP elevation group were 1.45 (1.12–1.89) for incident CVD and 1.34 (1.10–1.63) for all-cause mortality, respectively. However, there were no significant differences in CVD mortality and cancer mortality between the groups. In conclusion, early elevation of serum hsCRP is a predictor of incident CVD and all-cause mortality. The timing of hsCRP increase is also a significant predictor of incident CVD, even considering the competing risk. Regular hsCRP testing may help monitor hsCRP trends and develop individualized treatment plans for CVD prevention.

MP-453085-9 SEX DIFFERENCES IN ALL-CAUSE AND CVD MORTALITY ASSOCIATED WITH NEW-ONSET INCIDENT ATRIAL FIBRILLATION: THE VITAL STUDY

Conflicting data exist as to whether women with atrial fibrillation (AF) are at higher risk of adverse outcomes and mortality than men. To examine the association between a new diagnosis of AF and cardiovascular (CV) outcomes and death in women as compared to men. We prospectively examined the association between incident AF and non-fatal cardiovascular disease (CVD) (stroke, myocardial infarction, or heart failure) and CV mortality and total mortality among 12,693 women and 12,285 men without a prior history of CVD or AF from the VITAL study. Multivariable Cox proportional-hazards - models with updated time-varying covariates, and comparison test were used to assess for sex differences. During a median follow-up of 6.3 years, 459 women and 554 men developed new-onset AF. After multivariable adjustment for CVD risk factors, women with incident AF had similarly high relative risks of subsequent non-fatal CVD (HR 5.6; 95% CI, 4.1-7.6) as men (HR 4.9; 95% CI, 3.7-6.5) with no significant difference (p=0.36). In contrast, incident AF was associated with significantly higher multivariable-adjusted relative risks for subsequent CVD mortality in women (HR 6.1; 95% CI, 3.5-10.5) as compared to men (HR 2.0; 95% CI, 1.0-4.0); p, for difference= 0.01. The magnitude of the HR for the association between incident AF and total mortality was also significantly greater in women (HR 3.4; 95% CI, 2.5-4.6) as compared to men (HR 1.8; 95% CI, 1.3-2.5); p, difference= 0.005. In multivariable models that further controlled for interim non-fatal CVD events, incident AF remained significantly associated with higher risks of CVD mortality (HR 22; 95% CI, 1.3-4.0) and total mortality (HR 1.7; 95% CI 1.2-2.3) in women; however, the relative risk elevations were completely attenuated in men (HR 0.7; 95% CI 0.3-1.4 for CVD mortality; HR 1.0; 95% CI 0.7-1.4 for total mortality; p for difference 0.009 and 0.02 respectively). In a prospective cohort of women and men without baseline AF or CVD, the magnitudes of the relative risk elevations for CVD and all-cause mortality associated with incident AF were greater in women as compared to men. As opposed to men, the elevation in risk persisted for women even after controlling for interim CVD events, suggesting that other factors beyond interim CVD events account for the elevated mortality risk associated with AF in women.

Abstract MP15: Mediation Effects of Social, Behavioral, and Metabolic Risk Factors on Racial Disparities in Cardiovascular Disease Mortality in US Adults

Background: Traditional cardiovascular disease (CVD) risk factors contribute to racial disparities in CVD mortality. However, there are scarce data on the role of social determinants in these disparities. Methods: A nationally representative sample of 50,808 individuals aged ≥20 years from NHANES 1999-2018 were included in the analysis. Data on social, behavioral, and metabolic factors were collected in each NHANES survey. CVD deaths were ascertained from linkage to the National Death Index with follow-up through 2019. Multiple mediation analysis was used to simultaneously investigate the contribution of each risk factor to racial differences in CVD mortality. Results: Over an average 9.4 years of follow-up, 2,589 CVD deaths were confirmed. Age- and sex-adjusted CVD mortality rates (95% CI) per 100,000 were 380.1 (334.0, 437.3) in White, 479.6 (393.3, 592.5) in Black, 288.2 (214.1, 397.8) in Hispanic, and 251.2 (140.9, 502.8) in other racial/ethnic populations. After adjusting for all risk factors in the table, individuals who were unemployed, had a low family income, did not own a home, were not married or living with a partner, were a current smoker, reported no leisure time physical activity, slept <6 hours or >8 hours per day, had obesity, hypertension, diabetes, or hypercholesterolemia, or had an albumin-to-creatinine ratio ≥30 mg/g or estimated glomerular filtration rate <60 ml/min/1.73 m 2 were at significantly higher risk for CVD mortality. After adjusting for the above risk factors, the hazard ratio (95% CI) for the Black-White difference in CVD mortality decreased from 1.54 (1.34, 1.77) to 0.86 (0.75, 1.00). Family income, not being married or living with a partner, not owning a home, and unemployment explained 24.8%, 20.8%, 14.5%, and 12.8% of Black-White differences in CVD mortality, respectively. Conclusion: Social determinants of health play an important role in racial disparities in CVD mortality. These findings call for public health interventions beyond lifestyle changes and medical treatment.

Abstract P116: Racial/Ethnic and Nativity Differences in Cardiovascular Disease Mortality in the United States: Insights From the National Health Interview Survey 1999-2018

Background: Racial/ethnic disparities in cardiovascular disease (CVD) deaths continue to persist, despite advances in preventive strategies. Few studies have examined disparities in CVD deaths by nativity status (US- vs. foreign-born). Objective: To assess differences in CVD deaths by nativity status across racial/ethnic groups in the US. Methods: Using a cross-sectional design, we pooled data from 1999-2018 National Health Interview Survey, with linked death records through 2019. Outcome, cardiovascular related deaths (CVD & CVA) was modelled, in years, as time from interview till year of death, or last date of follow-up (December 31, 2019). Nativity status was defined as US- or foreign-born. We used Cox proportional hazards regression to estimate differences in CVD deaths across racial/ethnic groups (White, Black, Asian, Indigenous American, and Hispanic adults) stratifying by nativity status. Models were sequentially adjusted for sociodemographic and CVD risk factors. Results: We included 172,896,665 adults (16% US-born, 84% foreign-born). During median 10 follow-up years, 3.41 CVD deaths /1,000person-years occurred. Among US-born adults, age-and sex-adjusted CVD death rates were 34% higher among Non-Hispanic Black adults (Hazard Ratio: 1.34; 95% CI, 1.29–1.39), 23% higher among Indigenous Americans (HR: 1.23; 95% CI, 1.00–1.52) compared to Non-Hispanic White adults [Table] . In the fully adjusted models, CVD death rates were 6% and 23% lower among Black (HR: 0.94 [95% CI, 0.89–0.99]) and Hispanic (HR: 0.77 [95% CI, 0.70–0.84]) adults. Compared to US-born White adults, CVD death was lower in foreign-born White (HR: 0.74; 95% CI, 0.66–0.82), Black (HR: 0.57; 95% CI, 0.45-0.73), Hispanic (HR: 0.55; 95% CI, 0.50–0.61), and Asian (HR: 0.61; 95% CI, 0.53–0.71) adults, respectively. Conclusions: Overall, CVD deaths were lower among foreign- than US-born adults. Although, there were some racial/ethnic differences in CVD deaths, we found evidence of persistent survival advantage among foreign-born adults.

Abstract P115: Ethnic Differences in Cardiovascular Disease Deaths Among African American, African Immigrant and Afro-Caribbean Adults in the 1999-2018 National Health Interview Surveys

Background: Black persons are an heterogenous group in the US and bear a disparate higher burden of worse cardiovascular disease (CVD) outcomes. Our objective was to examine ethnic differences in CVD mortality among Black subgroups; African Americans(AAs); African Immigrants(AIs); and Afro Caribbeans(ACs). Methods: We analyzed the 1999-2018 National Health Interview Survey data, prospectively linked to mortality records in the National Death Index on 23,169,679 Black adults. The outcomes was CVD mortality, defined as CVD and cerebrovascular deaths, which was modelled as time till death (in years). This was calculated from each survey year till time of death or December 31, 2019 (administrative censoring) for those who survived. Using multivariable Cox proportional hazards regression analyses to model the survival function, we evaluated differences in CVD-and cerebrovascular-cause specific deaths among the three groups with progressive adjustment for age, sex, socioeconomic status and CVD risk factors. Results: With median of 10 years of mortality follow-up, there were 2.44, and 1.86 CVD deaths per 1,000 person-years among AA, and foreign born black adults (AIs and ACs combined), respectively. CVD mortality hazard was 81% lower in AIs [hazard ratio [HR], 0.19 (95% CI, 0.13–0.29], Table ) and 54% lower in ACs [HR, 0.46 (95% CI, 0.40–0.53], than among AAs. Compared to AAs, age-and sex-adjusted CVD mortality hazard was lower among AIs by 66% [HR, 0.34 (95% CI, 0.23–0.51], Table ) and ACs (HR, 0.46 [95% CI, 0.40–0.53]) by 54% (unchanged from unadjusted). In the fully adjusted model with SES and CVD risk factors adjustment, ACs had 41% lower adjusted CVD mortality hazard than AA adults (HR, 0.59 [95% CI, 0.45–0.77]). Conclusions: Cardiovascular deaths were higher among US-born AAs than foreign-born ACs. Nativity status is an important determinant of CVD mortality, and the heterogeneity of this population should be considered in health disparities research and interventions.

Sex Differences in Cardiovascular Disease Mortality in Brazil between 1996 and 2019.

Background: cardiovascular diseases (CVD) are Brazil’s leading causes of death in women and men. This study analyzed age-adjusted death rate (DRaj) trends from all causes of death (ACD), CVD, ischemic heart disease (IHD), and stroke in women and men aged 35 to 74 years from 1996 to 2019. Methods: We analyzed DRaj trends for all causes of death (ACD), CVD, IHD, and stroke. Data were from the Ministry of Health mortality database. Joinpoint Regression Program™ performed trend analysis and adjustments in death rates. Average annual percentage change (AAPC) determined the intensity of changes. Results: In women, DRaj reduced for ACD (AAPC = −1.6%); CVD (AAPC = −2.6%); IHD (AAPC = −1.9%); and stroke (AAPC = −4.6%) (p < 0.001 for all). In men, ACD reduced from 1996 to 2004 (AAPC = −0.9%; p < 0.001), from 2012 to 2019 (AAPC = −1.9%; p < 0.001), and unchanged from 2004 to 2012; CVD (AAPC = −2.1%); IHD (AAPC = −1.5%); stroke (AAPC = −4.9%) (p < 0.001 for all) reduced from 1996 to 2019. From 1996 to 2019, the male/female ratio for ACD remained unchanged. CVD increased from 1.58 to 1.83, IHD from 1.99 to 2.30, and stroke from 1.52 to 1.83. Conclusion: ACD, CVD, IHD, and stroke were reduced more significantly in women, and the ratio of CVD, IHD, and CVD in men and women increased more in men. Future studies will be needed to determine the main factors responsible for a better outcome in women.

Racial differences in cardiovascular disease mortality among cancer survivors.

12075 Background: Cancer survivors have an elevated risk of death from cardiovascular disease (CVD). Whether the risk differs by race/ethnicity and cancer type has not been fully explored in the U.S. Methods: Data from survivors of top 23 cancers diagnosed at ages 20 to 64 years during 2000-2018 were obtained from 17 Surveillance, Epidemiology, and End Results registries. Risks for CVD death among survivors relative to the general population were calculated using standardized mortality ratios (SMRs) in each racial/ethnic group: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Non-Hispanic Asian or Pacific Islander (API), and Non-Hispanic American Indian (AI). Among survivors, the risks were compared by race/ethnicity using cause-specific proportional hazards models for competing risks, controlling for year of diagnosis, age at diagnosis, sex, stage (when appropriate), and the first course of treatment receipt (surgery, radiotherapy, chemotherapy). Results: Among 2,806,515 survivors (NHW, 68%; NHB, 13%; Hispanic, 12%; API, 7%; AI, 0.5%), 57,883 CVD deaths occurred during 6.4 person-years of mean follow-up (32 per 10,000). Cancer survivors overall were at increased risk of CVD death compared to their general population counterpart with an SMR of 1.76 among API (95% CI = 1.69-1.84; 8.7 excess deaths per 10,000), 1.49 among AI (95% CI = 1.33-1.68; 11.9 excess deaths per 10,000), 1.46 among Hispanic (95% CI = 1.41-1.50; 7.4 excess deaths per 10,000), 1.30 among NHB (95% CI = 1281-1.33; 14.9 excess deaths per 10,000), and 1.13 among NHW (95% CI = 1.12-1.14; 3.4 excess deaths per 10,000) survivors. Compared with NHW survivors, the adjusted hazard of CVD death was statistically significantly higher among NHB survivors for 23/23 cancers and among AI survivors for 9/18 cancers but was statistically significantly lower among Hispanic survivors for 5/23 cancers and among API survivors for 10/23 cancers, with no significant difference otherwise. The highest hazards ratios (HRs) were among NHB survivors of melanoma (HR = 3.19, 95% CI = 2.11-4.83); breast (HR = 2.73, 95% CI = 2.57-2.89); pancreatic (HR = 2.63, 95% CI = 2.19-3.16); and testicular (HR = 2.59, 95% CI = 1.62-4.14) cancers, whereas the lowest HRs were among API survivors of head and neck (HR = 0.53, 95% CI = 0.44-0.63) and cervical (HR = 0.57, 95% CI = 0.41-0.80) cancers and Hispanic survivors of cervical cancer (HR = 0.59, 95% CI = 0.46-0.75). Conclusions: The risk of CVD death differs considerably among cancer survivors by race/ethnicity and cancer types, highlighting the need for targeted prevention and surveillance in primary care. Future studies are needed to identify factors that contribute to this variation in order to inform efforts towards mitigating risk.

Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999-2018

After decades of decline, the US cardiovascular disease mortality rate flattened after 2010, and racial and ethnic differences in cardiovascular disease mortality persisted. To examine 20-year trends in cardiovascular risk factors in the US population by race and ethnicity and by socioeconomic status. A total of 50 571 participants aged 20 years or older from the 1999-2018 National Health and Nutrition Examination Surveys, a series of cross-sectional surveys in nationally representative samples of the US population, were included. Calendar year, race and ethnicity, education, and family income. Age- and sex-adjusted means or proportions of cardiovascular risk factors and estimated 10-year risk of atherosclerotic cardiovascular disease were calculated for each of 10 two-year cycles. The mean age of participants ranged from 49.0 to 51.8 years and the proportion of women from 48.2% to 51.3% in the surveys. From 1999-2000 to 2017-2018, age- and sex-adjusted mean body mass index increased from 28.0 (95% CI, 27.5-28.5) to 29.8 (95% CI, 29.2-30.4); mean hemoglobin A1c increased from 5.4% (95% CI, 5.3%-5.5%) to 5.7% (95% CI, 5.6%-5.7%) (both P < .001 for linear trends). Mean serum total cholesterol decreased from 203.3 mg/dL (95% CI, 200.9-205.8 mg/dL) to 188.5 mg/dL (95% CI, 185.2-191.9 mg/dL); prevalence of smoking decreased from 24.8% (95% CI, 21.8%-27.7%) to 18.1% (95% CI, 15.4%-20.8%) (both P < .001 for linear trends). Mean systolic blood pressure decreased from 123.5 mm Hg (95% CI, 122.2-124.8 mm Hg) in 1999-2000 to 120.5 mm Hg (95% CI, 119.6-121.3 mm Hg) in 2009-2010, then increased to 122.8 mm Hg (95% CI, 121.7-123.8 mm Hg) in 2017-2018 (P < .001 for nonlinear trend). Age- and sex-adjusted 10-year atherosclerotic cardiovascular disease risk decreased from 7.6% (95% CI, 6.9%-8.2%) in 1999-2000 to 6.5% (95% CI, 6.1%-6.8%) in 2011-2012, then did not significantly change. Age- and sex-adjusted body mass index, systolic blood pressure, and hemoglobin A1c were consistently higher, while total cholesterol was lower in non-Hispanic Black participants compared with non-Hispanic White participants (all P < .001 for group differences). Individuals with college or higher education or high family income had consistently lower levels of cardiovascular risk factors. The mean age- and sex-adjusted 10-year risk of atherosclerotic cardiovascular disease was significantly higher in non-Hispanic Black participants compared with non-Hispanic White participants (difference, 1.4% [95% CI, 1.0%-1.7%] in 1999-2008 and 2.0% [95% CI, 1.7%-2.4%] in 2009-2018]). This difference was attenuated (-0.3% [95% CI, -0.6% to 0.1%] in 1999-2008 and 0.7% [95% CI, 0.3%-1.0%] in 2009-2018) after further adjusting for education, income, home ownership, employment, health insurance, and access to health care. In this serial cross-sectional survey study that estimated US trends in cardiovascular risk factors from 1999 through 2018, differences in cardiovascular risk factors persisted between Black and White participants; the difference may have been moderated by social determinants of health.

County-level phenomapping to identify disparities in cardiovascular outcomes: An unsupervised clustering analysis: Short title: Unsupervised clustering of counties and risk of cardiovascular mortality

IntroductionSignificant heterogeneity in cardiovascular disease (CVD) risk and healthcare resource allocation has been demonstrated in the United States, but optimal methods to capture heterogeneity in county-level characteristics that contribute to CVD mortality differences are unclear. We evaluated the feasibility of unsupervised machine learning (ML)-based phenomapping in identifying subgroups of county-level social and demographic risk factors with differential CVD outcomes. MethodsWe performed a cross-sectional study using county-level data from 2008 to 2018 from the Centers for Disease Control (CDC) WONDER platform and the 2020 Robert Wood Johnson County Health Rankings program. Unsupervised clustering was performed on 46 facets of population characteristics spanning the demographic, health behaviors, socioeconomic, and healthcare access domains. Spatial autocorrelation was assessed using the Moran’s I test, and temporal trends in age-adjusted CVD outcomes were evaluated using linear mixed effect models and least square means. ResultsAmong 2676 counties, 4 county-level phenogroups were identified (Moran’s I p-value <0.001). Phenogroup 1 (N ​= ​924; 24.5%) counties were largely white, suburban households with high income and access to healthcare. Phenogroup 2 counties (N ​= ​451; 16.9%) included predominantly Hispanic residents and below-average prevalence of CVD risk factors. Phenogroup 3 (N ​= ​951; 35.5%) counties included rural, white residents with the lowest levels of access to healthcare. Phenogroup 4 (350; 13.1%) comprised counties with predominantly Black residents, substantial cardiovascular comorbidities, and physical and socioeconomic burdens. Least square means in age-adjusted cardiovascular mortality over time increased in a stepwise fashion from 223 in phenogroup 1 to 317 per 100,000 residents in phenogroup 4. ConclusionsUnsupervised ML-based clustering on county-level population characteristics can identify unique phenogroups with differential risk of CVD mortality. Phenogroup identification may aid in developing a uniform set of preventive initiatives for clustered counties to address regional differences in CVD mortality.

Black-White Differences in Cardiovascular Disease Mortality: A Prospective US Study, 2003-2017.

Objectives. To determine factors that explain the higher Black:White cardiovascular disease (CVD) mortality rates among US adults.Methods. We analyzed data from the Reasons for Geographic and Racial Differences in Stroke study from 2003 to 2017 to estimate Black:White hazard ratios (HRs) for CVD mortality within subgroups younger than 65 years and aged 65 years or older.Results. Among 29 054 participants, 41.0% who were Black and 54.9% who were women, 1549 CVD deaths occurred. Among participants younger than 65 years, the demographic-adjusted Black:White CVD mortality HR was 2.23 (95% confidence interval [CI] = 1.87, 2.65) and 1.21 (95% CI = 1.00, 1.47) after full adjustment. Among participants aged 65 years or older, the demographic-adjusted Black:White CVD mortality HR was 1.58 (95% CI = 1.39, 1.79) and 1.12 (95% CI = 0.97, 1.29) after full adjustment. When we used mediation analysis, socioeconomic status explained 21.2% (95% CI = 13.6%, 31.4%) and 38.0% (95% CI = 20.9%, 61.7%) of the Black:White CVD mortality risk difference among participants younger than 65 years and aged 65 years or older, respectively. CVD risk factors explained 56.6% (95% CI = 42.0%, 77.2%) and 41.3% (95% CI = 22.9%, 65.3%) of the Black:White CVD mortality difference for participants younger than 65 years and aged 65 years or older, respectively.Conclusions. The higher Black:White CVD mortality risk is primarily explained by racial differences in socioeconomic status and CVD risk factors.

Heartbeat: reducing inequities in cardiovascular disease mortality

Cardiovascular disease (CVD) remains a leading cause of death in Europe with persistent geographic and socioeconomic inequities even though overall CVD mortality has declined substantially over the past 30 years....

Differences in Cardiovascular Mortality Risk among African Americans in the Minnesota Heart Survey: 1985-2015 vs The Atherosclerosis Risk in Communities Study Cohort: 1987-2015.

Geographic differences in cardiovascular disease (CVD) mortality among African Americans (AAs) are well-established, but not well-characterized. Using the Minnesota Heart Survey (MHS) and Atherosclerosis Risk in Communities (ARIC) Study, we aimed to assess whether CVD risk factors drive geographic disparities in CVD mortality among AAs. ARIC risk factors were measured between1987-1989 from a population-based sample of AAs, aged 45 to 64 years, living in Jackson, MS and Forsyth County, NC. Similar measures were made at MHS baseline, 1985, in AAs from Minneapolis-St. Paul, MN. CVD mortality was identified using ICD codes for underlying cause of death. We compared MHS and ARIC on CVD death rates using Poisson regression, risk factor prevalences, and hazard ratios using Cox regression. After CVD risk factor adjustment, AA men in MHS had 3.4 (95% CI: 2.1, 4.7) CVD deaths per 1000 person-years vs 9.9 (95% CI: 8.7, 11.1) in ARIC. AA women in MHS had 2.7 (95% CI: 1.8, 3.6) CVD deaths per 1000 person-years vs 6.7 (95% CI: 6.0, 7.4) in ARIC. A 2-fold higher CVD mortality rate remained in ARIC vs MHS after additional adjustment for education and income. ARIC had higher total cholesterol, hypertension, diabetes, and BMI, as well as less education and income than MHS. Risk factor hazard ratios of CVD death did not differ. The CVD death rate was lower in AAs in Minnesota (MHS) than AAs in the Southeast (ARIC). While our findings support maintaining low risk for CVD prevention, differences in CVD mortality reflect unidentified geographic variation.

Psychosocial and socioeconomic determinants of cardiovascular mortality in Eastern Europe: A multicentre prospective cohort study.

BackgroundEastern European countries have some of the highest rates of cardiovascular disease (CVD) mortality, much of which cannot be adequately accounted for by conventional CVD risk factors. Psychosocial and socioeconomic factors may affect risk of CVD, but relatively few studies on this issue have been undertaken in Eastern Europe. We investigated whether various psychosocial factors are associated with CVD mortality independently from each other and whether they can help explain differences in CVD mortality between Eastern European populations.MethodsParticipants were from the Health, Alcohol and Psychological factors in Eastern Europe (HAPIEE) cohort study in Russia, Poland and the Czech Republic, including a total of 20,867 men and women aged 43–74 years and free of CVD at baseline examination during 2002–2005. Participants were followed-up for CVD mortality after linkage to national mortality registries for a median of 7.2 years.ResultsDuring the follow-up, 556 participants died from CVD. After mutual adjustment, six psychosocial and socioeconomic factors were associated with increased risk of CVD death: unemployment, low material amenities, depression, being single, infrequent contacts with friends or relatives. The hazard ratios [HRs] for these six factors ranged between 1.26 [95% confidence interval 1.14–1.40] and 1.81 [95% confidence interval 1.24–2.64], fully adjusted for each other, and conventional cardiovascular risk factors. Population-attributable fractions ranged from 8% [4%–13%] to 22% [11%–31%] for each factor, when measured on average across the three cohorts. However, the prevalence of psychosocial and socioeconomic risk factors and their HRs were similar between the three countries. Altogether, these factors could not explain why participants from Russia had higher CVD mortality when compared to participants from Poland/Czech Republic. Limitations of this study include measurement error that could lead to residual confounding; and the possibilities for reverse causation and/or unmeasured confounding from observational studies to lead to associations that are not causal in nature.ConclusionsSix psychosocial and socioeconomic factors were associated with cardiovascular mortality, independent of each other. Differences in mortality between cohorts from Russia versus Poland or Check Republic remained unexplained.

A systematic literature review of methods of incorporating mortality in cost-effectiveness analyses of lipid-lowering therapies

Aims: Cost effectiveness analysis (CEA) is a useful tool for estimating the value of an intervention in relation to alternatives. In cardiovascular disease (CVD), CEA is especially important, given the high economic and clinical burden. One key driver of value is CVD mortality prevention. However, data used to inform CEA parameters can be limited, given the difficulty in demonstrating statistically significant mortality benefit in randomized clinical trials (RCTs), due in part to the frequency of fatal events and limited trial durations. This systematic review identifies and summarizes whether published CVD-related CEAs have incorporated mortality benefits, and the methodology among those that did.Materials and methods: A systematic literature review was conducted of CEAs of lipid-lowering therapies published between 2000–2017. Health technology assessments (HTA) and full-length manuscripts were included, and sources of mortality data and methods of applying mortality benefits were extracted. Results were summarized as proportions of articles to articulate common practices in CEAs of CVD.Results: This review identified 100 studies for inclusion, comprising 93 full-length manuscripts and seven HTA reviews. Among these, 99% assumed a mortality benefit in the model. However, 87 of these studies that incorporated mortality differences did so despite the trials used to inform model parameters not demonstrating statistically significant differences in mortality. None of the 12 studies that used statistically significant findings from an individual RCT were based on active control studies. In a sub-group analysis considering the 60 CEAs that incorporated a direct mortality benefit, 48 (80%) did not have RCT evidence for statistically significant benefit in CVD mortality.Limitations and conclusions: The finding that few CEA models included mortality inputs from individual RCTs of lipid-lowering therapy may be surprising, as one might expect that treatment efficacy should be based on robust clinical evidence. However, regulatory requirements in CVD-related RCTs often lead to insufficient sample sizes and observation periods for detecting a difference in CVD mortality, which results in the use of intermediate outcomes, composite end-points, or meta-analysis to extrapolate long-term mortality benefit in a lifetime CEA.

Prospective cohort study: Cinacalcet-mediated lowering of PTH level and cardiovascular disease mortality in younger Korean patients with stage 5 CKD at a Korean secondary hospital.

Cinacalcet may reduce cardiovascular disease (CVD) mortality in elderly patients with chronic kidney disease (CKD). However, previous studies of the clinical responses to cinacalcet have exhibited discrepancies due to highly variable baseline levels of parathyroid hormone (PTH), kidney function and age. Little is known about the true effect of cinacalcet on stage 5 CKD. The objective of the current observational study was to evaluate whether cinacalcet-mediated lowering of PTH levels improves all-cause mortality and cardiovascular disease mortality in younger stage 5 CKD patients (mean age <55years). This prospective, cohort study reviewed the electronic medical records (EMRs) of CKD patients (n=540) with secondary hyperparathyroidism (SHPT) for a period of 36months. Of 540 patients, 104 subjects met the inclusion criteria and were included in the final evaluation (mean serum iPTH 688.7pg/mL). Patients were divided into a cinacalcet group (n=43) and a non-cinacalcet group (n=61). Comparing the cinacalcet group to the non-cinacalcet group, Cox proportional hazard modelling found that all-cause mortality was five (31.3%) in the cinacalcet group and three (15.8%) in the non-cinacalcet group for patients with serum levels of PTH>600pg/mL [P=.277, hazard ratio 2.213, 95% confidence interval (CI): 0.529-9.262]. Cardiovascular disease mortality (CVD: heart disease) occurred in two (5.3%) in the cinacalcet group and one (2.1%) in the non-cinacalcet group [P=.425, HR 2.611, 95% CI: 0.228-9.939]. Overall, there were no significant differences in CVD mortality between the two groups. Cinacalcet was not associated with decreases in all-cause mortality or CVD mortality in younger stage 5 CKD patients with high PTH levels (>600pg/mL). This could be explained by the diversity of the population in terms of the patient's age, health insurance policies, target serum level of biochemical and PTH, and glomerular filtration rate (GFR) at admission. These data, although based on an observational study, indicate that adding cinacalcet to the current standard care for younger stage 5 CKD patients should be re-evaluated.

Racial Differences in 20-Year Cardiovascular Mortality Risk Among Childhood and Young Adult Cancer Survivors.

Whether cardiovascular disease (CVD) risk differs according to race and cancer type among survivors of childhood or young adulthood cancers is unknown. Data from the years 1973-2011 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) registries. Cases were categorized by ICD-0-3/WHO 2008 Adolescent and Young Adult classification. CVD death was determined by ICD-10 codes for diseases of the heart, atherosclerosis, cerebrovascular diseases, or other diseases of the arteries. Cox proportional hazards models were fitted to evaluate the hazard ratio (HR) and 95% confidence intervals (CIs) for the effects of race on time-to-event outcomes. A total of 164,316 cases of childhood and young adult primary cancers were identified. There were 43,335 total and 1466 CVD deaths among Black and White survivors. Black survivors had higher risks of all-cause mortality (HR: 1.75, 95% CI: 1.70-1.7) and CVD mortality (HR: 2.13, 95% CI: 1.85-2.46) compared to White survivors. The increased risk of CVD for Black survivors compared to White survivors persisted at 5-years (HR: 2.38, 95% CI: 1.83-3.10), 10-years (HR: 2.59, 95% CI: 2.09-3.21), and 20-years (HR: 2.31, 95% CI: 1.95-2.74) postdiagnosis, and varied by cancer type, with the highest HRs for melanoma (HR: 8.16, 95% CI: 1.99-33.45) and thyroid cancer (HR: 3.43, 95% CI: 1.75-6.73). Black survivors of childhood or young adulthood cancers have a higher risk of CVD mortality compared to Whites that varies by cancer type. Knowledge of at-risk populations is important to guide surveillance recommendations and behavioral interventions. Further study is needed to understand the etiology of racial differences in CVD mortality in this population.

Differences in cardiovascular disease mortality between local authorities in England: an ecological analysis

BackgroundLarge inequalities in age-standardised mortality rates of cardiovascular disease (CVD) exist at the local authority level within England, with particular areas consistently having the highest rates. Higher deprivation is associated with higher CVD mortality, but we know little about how the demographics and environments of local areas contribute to variations in mortality rates. The aim of this study was to explore the extent to which demographic, health, and environmental factors explain differences in all ages and premature CVD mortality between local authorities in England. MethodsAll data were sourced for each local authority in England. Outcome variables were age-standardised CVD mortality for all ages and those under 75 years in 2012–14. Data obtained were prevalence of ethnic and socioeconomic groups from the UK 2011 census; Public Health England data on index of multiple deprivation (IMD) score; prevalence of smoking, physical activity, obesity and overweightness; and Ordnance Survey environmental data on percentage of food shops, eating out shops, green or blue space, sporting facilities, and health facilities. We used the Akaike Information Criterion to assess which types of variables provided the best statistical model to explain variation in CVD mortality between local authorities. FindingsInclusion of health, demographic, environment, and IMD variables provided the best fit for explaining variation in CVD mortality at all ages (adjusted r2=0·60). Indian and Pakistani ethnicity and the IMD score in local authorities remained significantly associated with the outcome, with corresponding p values all less than 0·01. CVD mortality was 44 per 100 000 population greater in areas with the highest proportions of Indian and Pakistani ethnicities and 110 per 100 000 greater in the most deprived local authorities than in the least deprived areas. For CVD mortality below age 75, exclusion of environmental data improved the fit of the model (adjusted r2=0·82). Overweight prevalence (p=0·0481), Indian (p=0·0111), Pakistani (p=0·0003), and Bangladeshi (p=0·003) ethnicity, and the IMD score (p<0·0001) all remained significantly associated with premature CVD mortality when the best fitting model was used. Premature mortality was 13 per 100 000 and 18–25 per 100 000 greater in local authorities where the proportion of overweight people and Asian ethnicities was highest. Premature mortality in the most deprived local authorities was 68 per 100 000 greater than in the least deprived authorities. InterpretationThese findings are valuable for understanding which factors might be most useful for local authorities to target to reduce CVD mortality. This study combined a large amount of existing data; however, it was conducted at an ecological level, so analyses using individual-level mortality outcomes are also needed. FundingThe authors' posts are funded by the British Heart Foundation.

Do repeated risk factor measurements influence the impact of education on cardiovascular mortality?

ObjectiveIt has been questioned if the excess cardiovascular disease (CVD) mortality by lower educational level can be fully explained by conventional modifiable CVD risk factors. Our objective was to examine...

Cardiovascular Disease Mortality in Asian Americans

BackgroundAsian Americans are a rapidly growing racial/ethnic group in the United States. Our current understanding of Asian-American cardiovascular disease mortality patterns is distorted by the aggregation of distinct subgroups. ObjectivesThe purpose of the study was to examine heart disease and stroke mortality rates in Asian-American subgroups to determine racial/ethnic differences in cardiovascular disease mortality within the United States. MethodsWe examined heart disease and stroke mortality rates for the 6 largest Asian-American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) from 2003 to 2010. U.S. death records were used to identify race/ethnicity and cause of death by International Classification of Diseases-10th revision coding. Using both U.S. Census data and death record data, standardized mortality ratios (SMRs), relative SMRs (rSMRs), and proportional mortality ratios were calculated for each sex and ethnic group relative to non-Hispanic whites (NHWs). ResultsIn this study, 10,442,034 death records were examined. Whereas NHW men and women had the highest overall mortality rates, Asian Indian men and women and Filipino men had greater proportionate mortality burden from ischemic heart disease. The proportionate mortality burden of hypertensive heart disease and cerebrovascular disease, especially hemorrhagic stroke, was higher in every Asian-American subgroup compared with NHWs. ConclusionsThe heterogeneity in cardiovascular disease mortality patterns among diverse Asian-American subgroups calls attention to the need for more research to help direct more specific treatment and prevention efforts, in particular with hypertension and stroke, to reduce health disparities for this growing population.