Disparities In Cardiovascular Disease Mortality Research Articles

Impact of increasing workforce racial diversity on black-white disparities in cardiovascular disease mortality

BackgroundStructural racism’s influence on workforce policies and practices presents possible upstream targets for assessing and reducing racial health disparities. This study is the first to examine workforce racial diversity in...

Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association.

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the United States, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the United States are estimated to be the single largest contributor to the excess risk for cardiovascular disease among Black versus White adults. Worsening disparities in cardiovascular disease and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the United States. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the American Heart Association made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in cardiovascular disease mortality and morbidity. The American Heart Association is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders and public, private, and community organizations to address barriers across multiple socioecological levels.

Rural-urban disparities in cardiovascular disease mortality vary by poverty level and region.

To examine rural and urban disparities in cardiovascular disease (CVD) death rates by poverty level and region. Using 2021 county-level population and mortality data for CVD deaths listed as the underlying cause among adults aged 35-64 years, we calculated age-standardized CVD death rates and rate ratios (RR) for 4 categories of counties: high-poverty rural, high-poverty urban, low-poverty rural, and low-poverty urban (referent). Results are presented nationally and by US Census region. Rural and urban disparities in CVD mortality varied markedly by poverty and region. Nationally, the CVD death rate was highest among high-poverty rural areas (191 deaths per 100,000, RR: 1.76, CI: 1.73-1.78). By region, Southern high-poverty rural areas had the highest CVD death rate (256 deaths per 100,000) and largest disparity relative to low-poverty urban areas (RR: 2.05; CI: 2.01-2.09). In the Midwest and West, CVD death rates among high-poverty areas were higher than low-poverty areas, regardless of rural or urban classification. Results reinforce the importance of prioritizing high-poverty rural areas, especially in the South, in efforts to reduce CVD mortality. These efforts may need to consider socioeconomic conditions and region, in addition to rural and urban disparities.

Exploring the role of blood pressure in the black-white disparity in cardiovascular disease mortality: a causal mediation analysis

BackgroundCardiovascular diseases (CVDs) are the leading cause of death in the USA, and high blood pressure is a major risk factor for CVD. Despite the overall declining rates of CVD...

The Epidemiology of Cardiovascular Disease in African American Patients with Myeloid Neoplasms: A SEER Data Analysis

Introduction: Cardiovascular disease (CVD) mortality rates are higher in cancer survivors compared to the general population. Numerous studies have reported racial disparities in CVD mortality among cancer survivors. However, there is a lack of research exploring CVD mortality specifically in African American (AA) patients (pts) with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). To address this gap, we conducted a comprehensive population-based study to analyze cardiovascular mortality in the AA population with MDS and MPN. Methods and Statistical analysis: In Surveillance, Epidemiology, and End Results (SEER) database using the 17 registries, we identified cases of essential thrombocythemia (ET), Polycythemia Vera (PV), Primary Myelofibrosis (PMF), and Myelodysplastic syndromes (MDS) in AA population diagnosed between 2001-2020, with the diagnosis age >=20. CVD deaths included deaths from heart diseases, hypertension without heart disease, cerebrovascular diseases, atherosclerosis, and diabetes mellitus, based on the SEER Causes of Death Register and International Classification of Diseases (10th Revision, ICD10). Death rates were calculated by dividing the number of deaths over person-years of follow-up. We also estimated the standardized mortality ratios (SMR by dividing the observed cardiovascular deaths rates in our sample over expected CVD death rates of general population with no cancer, matched to age, gender and ethnicity. All analyses were performed by SEER*Stat 8.4.1.2 and R 4.2.2. Results: The study included 8135 patients, with following diagnoses: ET (n= 2317), PV (n= 1231), PMF (n= 377) and MDS (n= 4210). Overall, 2640 of the total study population (32.45%) died, of which 39.5% were CVD deaths. The mean follow up for PV, ET, PMF and MDS cohorts was 6.44, 5.95, 3.67 and 3.82 years, respectively (Table 1). The CVD mortality rate per 1,000 person-years in PV, ET and PMF subgroups were 17.9, 14.95, and 29.6, respectively. Notably, the rate was highest in the MDS subgroup, 40.37 compared to other subgroups (P<0.01). Comparing the CVD mortality of each risk group to the general US AA population, we observed significantly increased CVD SMRs. These were highest in PMF and MDS (SMR, 3.07; 95% CI, 2.2-4.16 and 2.25; 95% CI, 2.08-2.43, respectively), followed by PV (SMR, 1.75; 95% CI, 1.47-2.06) and ET (SMR, 1.67; 95% CI, 1.45-1.92).When comparing CVD mortality to the general CVD mortality rate in the AA population, we found higher rates across all age groups, including SMR, 13.16; 95% CI, 4.27- 30.72 in 20-29 yrs, SMR, 5.4; 95% CI, 2.95- 9.06 in 30-39 yrs, (SMR, 2.20; 95% CI, 1.92- 2.52) in 60-69 yrs, (SMR, 1.87; 95% CI, 1.67- 2.1) in 70-79 yrs (Figure 1). Conclusion: Our analysis highlights the magnitude of CVD-related deaths in the AA population with MDS and MPN. Among studied subgroups, the impact was highest in patients with MDS. This could be explained by a shared mechanism of CVD pathogenesis with MDS and clonal hematopoiesis of indeterminate potential (CHIP). In addition, we report a higher risk of CVD mortality at younger ages in AA pts relative to older age group. Because CVD-related mortality is high in AA with MDS and MPN, introduction of preventative cardiology services after diagnosis might be warranted to improve survival.

Environmental correlates of mortality: How does air pollution contribute to geographic disparities in cardiovascular disease mortality?

Environmental correlates of mortality: How does air pollution contribute to geographic disparities in cardiovascular disease mortality?

Social, behavioral, and metabolic risk factors for racial disparities in cardiovascular disease mortality in US adults

Abstract Background Cardiovascular disease (CVD) mortality is persistently higher in the Black population than in other race and ethnicity groups in the US. Purpose To determine whether social, behavioral, and metabolic risk factors mediate racial disparities in CVD mortality and to assess the contribution of these risk factors to CVD mortality in the US general population. Methods A nationally representative sample of 50,808 individuals aged ≥20 years from National Health and Nutrition Examination Surveys (NHANES) 1999-2018 were included in the analysis. Data on social, behavioral, and metabolic factors were collected in each NHANES survey using standard methods. CVD deaths were ascertained from linkage to the National Death Index with follow-up through 2019. Results Over an average of 9.4 years of follow-up, 2,598 CVD deaths were confirmed. In a multivariable Cox regression model stratified by NHANES cycle and adjusted for age, sex, race, and social, behavioral, and metabolic risk factors simultaneously, individuals who were unemployed, had a lower family income, did not own a home, were not married nor living with a partner, were current smokers, reported no leisure-time physical activity, slept <6 or >8 hours/day, had obesity, hypertension, or diabetes, or had an albumin-to-creatinine ratio ≥30 mg/g or estimated-glomerular filtration rate <60 ml/min/1.73 m2 were at significantly higher risk for CVD mortality. After adjusting for these risk factors, hazard ratios (95% CI) of CVD mortality for Black individuals compared to White individuals decreased from 1.54 (1.34-1.77) to 0.86 (0.75-1.00). Social risk factors explained 72.9% Black-White differences in CVD mortality in a multivariable mediation analysis. The population attributable fractions (95% CI) for the top five risk factors for CVD mortality were 12.5% (5.6-19.3%) for hypertension, 10.6% (6.9-14.3%) for albuminuria, 9.4% (5.3-13.6) for physical inactivity, 9.1% (4.6-13.7%) for family income-to-poverty ratio <300%, and 7.2% (4.5-9.9%) for estimated-glomerular filtration rate <60 ml/min/1.73 m2 in the US general population. Conclusion Social, behavioral, and metabolic risk factors fully explained the Black-White difference in CVD mortality. Hypertension, albuminuria, physical inactivity, low family income, and reduced kidney function are leading risk factors for CVD mortality in the US population.

Abstract 15576: The Association of Structural Racism With Cardiovascular Disease Death Rates

Background Structural racism is an upstream influencer of social determinants of health, which impact cardiovascular disease (CVD) death rates. The association between structural racism and CVD death rates has not been conclusively quantified, and this association may vary by race/ethnicity. Method Year 2020 census data on disparities in income, wealth, education, employment, and digital access and segregation were available at the census block group level and were used to quantify structural racism’s effects. Data from each block group and its 9 nearest neighbors were used to compute the structural racism sub-scores for that block group, which were transformed to a scale of 1-100 based on 100 quantiles. The composite score was then calculated as the weighted sum of the sub-scores (weights in Table 1). Mean structural racism score (SRS), weighted by population of each block group, was computed for each county in the United States. Then SRS was fit as the exposure in linear models controlling for state and predicting 2020 county-level CVD death rates per 100,000 adults for all residents, non-Hispanic Black (NHB) residents, non-Hispanic White (NHW) residents, and Hispanic residents, as reported by the Centers for Disease Control. Results: Data from 50 states and the District of Columbia were used (3137 counties). A 1-point higher SRS score (range 1-100) was associated with 1.0 (95% CI: 0.8, 1.3) more CVD deaths per 100,000 adults. Among NHB residents, there were 1.5 (95% CI: 1.0, 2.0) more CVD deaths per 1-point higher SRS score. Among Hispanic and NHW residents, CVD deaths were 0.8 (95% CI: 0.4, 1.2) and 0.6 (95% CI: 0.3, 0.8) higher per 1-point higher SRS. Conclusion: Structural racism is associated with greater CVD mortality among all United States residents, but the magnitude of association is greatest among NHB residents. Eliminating structural racism is likely to reduce CVD mortality of all residents while reducing race-based disparities in CVD mortality.

Association between racial residential segregation and Black-White disparities in cardiovascular disease mortality

Racial residential segregation is associated with racial health inequities, but it is unclear if segregation may exacerbate Black-White disparities in cardiovascular disease (CVD) mortality. This study aimed to assess associations between Black-White residential segregation, CVD mortality rates among non-Hispanic (NH) Black and NH White populations, and Black-White disparities in CVD mortality. This cross-sectional study analyzed Black-White residential segregation, as measured by county-level interaction index, of US counties, county-level CVD mortality among NH White and NH black adults aged 25 years and older, and county-level Black-White disparities in CVD mortality in years 2014 to 2017. Age-adjusted, county-level NH Black CVD mortality rates and NH White cardiovascular disease mortality rates, as well as group-level relative risk ratios for Black-White cardiovascular disease mortality, were calculated. Sequential generalized linear models adjusted for county-level socioeconomic and neighborhood factors were used to estimate associations between residential segregation and cardiovascular mortality rates among NH Black and NH White populations. Relative risk ratio tests were used to compare Black-White disparities in the most segregated counties to disparities in the least segregated counties. We included 1,286 counties with ≥5% Black populations in the main analysis. Among adults aged ≥25 years, there were 2,611,560 and 408,429 CVD deaths among NH White and NH Black individuals, respectively. In the unadjusted model, counties in the highest tertile of segregation had 9% higher (95% CI, 1%-20% higher, P=.04) rates of NH Black CVD mortality than counties in the lowest tertile of segregation. In the multivariable adjusted model, the most segregated counties had 15% higher (95% CI, 0.5% to 38% higher, P=.04) rates of NH Black CVD mortality than the least segregated counties. In the most segregated counties, NH Black individuals were 33% more likely to die of CVD than NH White individuals (RR 1.33, 95% CI 1.32 to 1.33, P < .001). Counties with increased Black-White residential segregation have higher rates of NH Black CVD mortality and larger Black-White disparities in CVD mortality. Identifying the causal mechanisms through which racial residential segregation widens disparities in CVD mortality requires further study.

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 &lt;6 hours or &gt;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 &lt;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 P362: Racial Disparities in Cardiovascular Disease Mortality: Mediation by Socioeconomic Factors and Statin Use (The ELSA-Brasil Study)

Background: Statins are an effective strategy to reduce CVD risk, however, treatment goals are not achieved especially among Blacks and “Pardos” in Brazil. Hypothesis: Socioeconomic differences and lack of statin treatment for primary CVD prevention can explain part of the elevated mortality risk of Blacks and “Pardos”. Methods: Data from the ELSA-Brasil cohort (15,105 civil servants, from 6 state capital cities), excluding Asians, Indigenous, those with prevalent CVD and missing information about race or statin use. Race was self-reported as Black, “Pardo” or White. Brazilian guidelines at baseline (2008) were used to define those eligible for statin treatment. Cox survival analysis determined the risk of CVD mortality for Black and “Pardo” compared to White (adjusted by age, sex, hypertension, diabetes, LDL-c, BMI and smoking). We used inverse odds ratio weighting technique to calculate mediation for socioeconomic factors (SEF) (education, income, and having health insurance) and statin use when indicated to determine the natural direct and indirect effects of race on CVD mortality. We estimated the percent mediation as the percent change between β coefficients with and without weights applied. Results: Among the 13,396 individuals, the mean age was 52±9 years, 55.2% were women, 54.2% were White, and 10.2% were taking statins. Adjusted Black and “Pardo”/White CVD mortality HR was 1.91 (CI 95% = 1.30-2.81, p&lt;0,001). The direct effect of race on CVD mortality when considering the weight of SEF was 1.37 (CI 95% = 0.86-2.19) and considering the weight of statin use was 2.01 (CI 95% =1.36-2.98). SEF explained 51.5% (CI 95% = 17.0-60.2) and not using statins when indicated explained 7.8% (CI 95% = 4.2-23.3) of the racial inequality observed in CVD mortality risk (Table 1). Conclusions: The higher Black and “Pardo”/White CVD mortality risk is primarily explained by racial differences in SEF. Not using statins when there is indication for treatment increases in about 8% the CVD mortality risk for Blacks and “Pardos” compared to Whites.

County-level geographic disparities in cardiovascular disease mortality among US breast cancer survivors, 2000-2018.

Disparities in cardiovascular disease mortality among breast cancer survivors are documented, but geographic factors by county-level socioeconomic status (SES) and rurality are not well described. We analyzed 724 518 women diagnosed with localized or regional stage breast cancer between 2000 and 2017 within Surveillance, Epidemiology, and End Results Program-18 with follow-up until 2018. We calculated relative risks (RRs) of cardiovascular disease mortality using Poisson regression, accounting for age- and race-specific rates in the general population, according to county-level quintiles of SES (measured by Yost index), median income, and rurality at breast cancer diagnosis. We also calculated 10-year cumulative mortality risk of cardiovascular disease accounting for competing risks. Cardiovascular disease mortality was 41% higher among breast cancer survivors living in the lowest SES (RR = 1.41, 95% confidence interval [CI] = 1.36 to 1.46, Ptrend < .001) and poorest (RR = 1.41, 95% CI = 1.36 to 1.47, Ptrend < .001) counties compared with the highest SES and wealthiest counties, and 24% higher for most rural relative to most urban counties (RR = 1.24, 95% CI = 1.17 to 1.30, Ptrend < .001). Disparities for the lowest SES relative to highest SES counties were greatest among younger women aged 18-49 years (RR = 2.32, 95% CI = 1.90 to 2.83) and aged 50-59 years (RR = 2.01, 95% CI = 1.77 to 2.28) and within the first 5 years of breast cancer diagnosis (RR = 1.53, 95% CI = 1.44 to 1.64). In absolute terms, however, disparities were widest for women aged 60+ years, with approximately 2% higher 10-year cumulative cardiovascular disease mortality risk in the poorest compared with wealthiest counties. Geographic factors at breast cancer diagnosis were associated with increased cardiovascular disease mortality risk. Studies with individual- and county-level information are needed to inform public health interventions and reduce disparities among breast cancer survivors.

Paradox of telemedicine: building or neglecting trust and equity

Paradox of telemedicine: building or neglecting trust and equity

The Impact of Medicaid Expansion on Black-White Disparities in Cardiovascular Disease Mortality.

Cardiovascular disease (CVD) is a leading cause of mortality among U.S. adults, especially low-income and uninsured adults. Non-Hispanic Black adults, who are overrepresented among low-income and uninsured populations, are disproportionately burdened by CVD mortality compared with non-Hispanic White adults. Medicaid expansion is associated with improved insurance coverage and access to care among low-income adults as well as reduced CVD mortality. It is unclear whether Medicaid expansion has reduced the Black-White disparity in CVD mortality. This study estimated a difference-in-differences model to compare changes in county-level CVD mortality ratios between expansion and non-expansion states. Findings indicate that Medicaid expansion is not associated with a statistically significant reduction in Black-White disparities in CVD mortality (β = -.039; p =.30). In conclusion, Medicaid expansion may be associated with improved health outcomes and access to care overall; however, it is insufficient to overcome other (i.e., social and economic) drivers of racial/ethnic disparities in CVD mortality.

Trends in Regional Disparity in Cardiovascular Mortality in Korea, 1983-2019.

Despite remarkable reduction in cardiovascular disease (CVD) mortality, the burden has remained the leading cause of death. Since little research has focused on regional disparity in CVD mortality, this study aims to investigate its spatiotemporal trends in Korea from 1983 to 2019. Using the causes of death statistics in Korea, we analyzed the geographic variation in deaths from CVDs from 1983 to 2019. The sex and age-standardized mortality rate was calculated according to the 17 administrative regions. The analyses include all diseases of the circulatory system (International Classification of Diseases-10 codes, I00-I99), along with the following 6 subcategories which were not mutually exclusive: total heart disease (I00-I13 and I20-I51), hypertensive heart disease (I10-I13), ischemic heart disease (I20-I25), myocardial infarction (I21-I23), heart failure (I50), and cerebrovascular disease (I60-I69). Overall, heart failure death rate increased across all regions, and other CVD death rates showed a decreasing trend. Regional disparity in mortality was substantial in the early 1980s but converged over time. In all types of cardiovascular mortality, Busan, Ulsan and Gyeongnam remained the highest, although they showed a downward trend like other regions. Jeju continued to have a relatively low CVD mortality rate. The regional disparity substantially decreased compared to the 1980s. However, the relatively high burden of CVD mortality in the southeastern region has not been fully resolved.

Abstract 12928: The Impact of Medicaid Expansion on Black - White Disparities in Cardiovascular Disease Mortality

Introduction: Cardiovascular disease (CVD) is a leading cause of mortality among US adults, especially low-income and uninsured adults. Non-Hispanic Black adults, who are overrepresented in these at-risk populations, are disproportionately burdened by poor cardiovascular health and CVD-related premature mortality. Medicaid expansion is associated with reduced CVD mortality overall, however research suggests that Medicaid expansion has had fewer impacts on health outcomes among non-Hispanic Black adults relative to non-Hispanic White adults. Therefore, it is unclear whether Medicaid expansion has lessened the disparate burden of CVD on this population. This study investigated the relationship between Medicaid expansion and Black-White disparities in CVD mortality. Methods: We estimated a difference-in-differences model using mortality data (2011 – 2019) from the Wide-Ranging Online Data for Epidemiologic Research (WONDER) system to compare changes in Black-White CVD mortality ratios between counties in expansion and non-expansion states. The age-adjusted mortality ratio (AAMR) was calculated by dividing the county-year age-adjusted mortality rate for non-Hispanic Black adults (ages 45 – 64) by the county-year age-adjusted mortality rate for non-Hispanic White adults. The final sample consisted of 1,720 county-year observations. Results: From 2011 – 2019, the AAMR was significantly higher among counties in expansion states ( p &lt;0.001). Controlling for county-level factors, Medicaid expansion was associated with a 2.01% decrease in the AAMR in CVD, but this relationship was not statistically significant (Figure 1). County-level rate of cardiologists per 100,000 and median household income were associated with a significant increase in the AAMR. Conclusion: Medicaid expansion may be associated with reduced CVD mortality overall; however, it is insufficient to counteract social and economic drivers of racial disparities in CVD mortality.

The influence of individual and neighborhood-level characteristics on rural-urban disparities in cardiovascular disease mortality among U.S. women diagnosed with breast and gynecologic cancers

ObjectiveRural-urban disparities exist in cancer and cardiovascular disease (CVD) mortality. Investigations of CVD mortality among breast and gynecologic cancer (BGC) survivors from rural/urban communities are limited. We evaluated the influence of individual and neighborhood-level factors on rural-urban disparities in CVD mortality among BGC survivors. MethodsData were from 1,139,767 women aged ≥20 years from the Surveillance, Epidemiology, and End Results program who were diagnosed with BGC from 2000 to 2016 that was merged with Area Health Resource Files for neighborhood-level factors (smoking, cancer screening, primary care provider density and socioeconomic index). Standardized mortality ratios (SMRs) for CVD mortality were calculated and multilevel Cox models, accounting for competing events, were used to estimate hazards ratios (HR) and 95% confidence intervals (CI). ResultsThe average age of BGC survivors was 60 years, with 10.3% of them living in rural counties. During a median follow-up of 5.1 years, 47,995 CVD deaths occured. Women with BGC had excess CVD mortality compared to general population women (SMR 6.05; CI: 6.00–6.11). This risk was highest among women aged <50 years (SMR = 27.16; CI: 25.74–28.62). In models adjusted for demographics, cancer stage and cancer therapy, women with BGC in rural communities had higher CVD deaths than those in urban communities (HR = 1.10, CI:1. 05–1.15). Additional adjustment for neighborhood-level characteristics attenuated the relation of rurality with CVD mortality (HR = 1.02, CI: 0.98–1.07). ConclusionsBGC survivors living in rural communities have elevated risk of CVD mortality. Neighborhood-level characteristics explained the rural-urban disparities in CVD mortality observed among BGC survivors.

Marked Disparities in Cardiovascular Disease Mortality by Levels of Happiness and Life Satisfaction in the United States

Background: Theimpact of happiness and life satisfaction on cardiovascular disease (CVD) mortality is not well-studied. Using a longitudinal dataset, we examined the association between levels of happiness/life satisfaction and CVD mortality in the United States.&#x0D; Methods: We analyzed the 2001 National Health Interview Survey (NHIS) prospectively linked to 2001-2014 mortality records in the National Death Index (NDI) (N=30,933). Cox proportional hazards regression was used to model survival time as a function of happiness, life satisfaction, and sociodemographic and behavioral characteristics.&#x0D; Results: In Cox models with 14 years of mortality follow-up, CVD mortality risk was 59% higher (hazard ratio [HR]=1.59; 95% CI=1.26,2.02) in adults with little or no happiness, controlling for age, and 30% higher (HR=1.30; 95% CI=1.01,1.67) in adults with little/no happiness, controlling for sociodemographic, behavioral and health characteristics, when compared with adults reporting happiness most or all of the time. Mortality risk was 81% higher (HR=1.81; 95% CI=1.40,2.34) in adults who were very dissatisfied with their life, controlling for age, and 39% higher (HR=1.39; 95% CI=1.05,1.82) in adults who were very dissatisfied, controlling for all covariates, when compared with adults who were very satisfied.&#x0D; Conclusions and Implications for Translation: Adults with lower happiness and life satisfaction levels had significantly higher CVD mortality risks than those with higher happiness and life satisfaction levels. Subjective well-being is an important determinant of CVD mortality.&#x0D; Key words: • Happiness • Life satisfaction • Cardiovascular • Mortality • Longitudinal • Social determinants&#x0D; &#x0D; Copyright © 2020 Lee and Singh. Published by Global Health and Education Projects, Inc. This is an open-access arti-cle distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Rural-Urban Disparities in Cardiovascular Disease Mortality Among Middle-Age Men in China.

Rural-urban health disparities are still poorly understood, due to a considerable gap in knowledge, while a looming heart disease and stroke epidemic in China has caused global concern. This report attempts to fill in the knowledge gaps to examine if rural-urban disparities in heart disease and stroke mortality have widened, which population cohorts have experienced the greatest mortality growth and disparities, and if rurality still matters in China. Age-specific data from 2002 to 2016 published in the China Health Yearbooks were analyzed with the Joinpoint Regression Program. The results reveal that China faces a fast growing cardiovascular disease epidemic with widening rural-urban disparities. Rural death rates have grown higher than urban rates along with fast rising rural mortality, and the fastest increasing rates are found among rural men in younger age groups. These findings inspire further research into the causes of the disparities.

A balancing act: racial disparities in cardiovascular disease mortality among women diagnosed with breast cancer.

The cardiotoxic effects of breast cancer therapies are well documented in clinical trials. However, clinical trials often underrepresent those at highest risk for cardiovascular disease (CVD)related outcomes and have limited generalizability to the larger breast cancer population. In addition, racial differences in treatment-associated CVD mortality have yet to be explored. In this study, we sought to quantify the relationship between breast cancer therapies and CVD mortality, and explore whether this effect differed between non-Hispanic black (NHB) and white (NHW) women. Using data from the Georgia Cancer Registry, we identified women diagnosed with a first primary invasive breast cancer [2010-2014], residing in the metropolitan Atlanta area (n=3,580 NHB; n=4,923 NHW), and followed them for mortality through December 31, 2018. Exposures of interest included therapies with potential cardiotoxic effects including chemotherapy and hormone therapy, which are routinely collected by the GCR. Individual agents are not captured within the GCR, therefore trastuzumab was identified using natural language processing of textual descriptions. We used propensity score weighted Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between each treatment modality and CVD mortality among the overall cohort and by race. In the overall cohort, similar hazards of CVD mortality were found among women treated with chemotherapy (HR =1.10, 95% CI: 0.62, 1.96) and hormone therapy (HR =0.94, 95% CI: 0.59, 1.50), compared to women who did not receive the respective treatments. In contrast, women treated with trastuzumab had a higher hazard of CVD mortality compared to women not treated with trastuzumab (HR =2.05, 95% CI: 0.76, 5.52). In race-specific models, hormone therapy was associated with a higher hazard of CVD mortality among NHB women (HR =2.18, 95% CI: 0.78, 6.12), but not NHW women (HR =0.66, 95% CI: 0.39, 1.13). Similar, albeit attenuated, associations were found for chemotherapy. We were unable to investigate race-specific effects of trastuzumab due to low prevalence and insufficient number of events. In our study, we observed more pronounced associations of chemotherapy and hormone therapy with CVD mortality among NHB women, for whom we know have greater CVD-related comorbidities at breast cancer diagnosis. Patients may benefit from treatment plans that find a balance between curative breast cancer treatment and prevention of CVD-related events and mortality. CVD-related outcomes may be most relevant for women with hormone receptor positive disease due to shared risk factors (e.g., obesity, tobacco use, physical activity) and longer survival.