Hospitalization For Coronary Heart Disease Research Articles

Long-term exposure to specific humidity and cardiovascular disease hospitalizations in the US Medicare population

BACKGROUND AND AIM: Most studies that evaluate associations of weather on human health focus on temperature. Less is known about health effects of humidity. We evaluated associations of long-term exposure to specific humidity with cardiovascular disease (CVD), coronary heart disease (CHD) and cerebrovascular disease (CBV) hospitalization. METHODS: We constructed an open cohort consisting of all fee-for-service Medicare beneficiaries, aged ≥65, living in the contiguous US from 2000 through 2016 (~63 million individuals). We assessed zip code level annual (January-December), summer (June-August) and winter (December-February) average specific humidity and specific humidity variability (standard deviation) for each year, based on daily specific humidity estimates from the Gridded Surface Meteorological dataset (~4km spatial resolution). To estimate associations of specific humidity with first CVD, CHD and CBV hospitalization, we used Cox-equivalent Poisson models. RESULTS:After adjustment for individual and area-level indicators and temperature, higher annual and summer average specific humidity and lower winter average specific humidity were associated with an increased risk of CVD, CHD and CBV hospitalization. For summer average specific humidity, we found HRs of 1.07 (95%CI: 1.07, 1.08) for CVD hospitalization, 1.08 (95%CI: 1.08, 1.09) for CHD hospitalization and 1.07 (95%CI: 1.07, 1.08) for CBV hospitalization per IQR increase (4.0 g of water vapor/kg of dry air). Higher annual, summer and winter specific humidity variability were also associated with increased risk of CVD, CHD and CBV hospitalization. Associations of annual and summer average specific humidity were strongest for beneficiaries eligible for Medicaid and for beneficiaries with an unknown or other race. CONCLUSIONS:Among this cohort of US Medicare beneficiaries, higher annual and summer average specific humidity and higher annual, summer and winter specific humidity variability were positively associated with CVD, CHD, and CBV hospitalization. Associations were modified by race and Medicaid eligibility. KEYWORDS: humidity, cardiovascular diseases, climate

Impacts of Ambient Carbon Monoxide on Hospital Admissions and Hospitalization Expenditures for Three Cardiorespiratory Diseases in 74 Cities of China

BACKGROUND AND AIM: Evidence about health burden and economic loss of cardiorespiratory diseases (CRDs) caused by ambient carbon monoxide (CO) is sparse. We aimed to assess health burden as well as economic loss caused by coronary heart disease (CHD), stroke and lower respiratory infections (LRI) attributed to ambient CO in multiple cities in China. METHODS: Hospital admission and expenditures data were obtained from urban employee-based basic medical insurance scheme (UEBMI) of the national health insurance system in China. We performed a three-stage time-series analysis approach based on Generalized Linear Model controlling for potential confounding factors to examine the association between ambient CO and hospitalization data of CHD, stroke and LRI in 74 cities of China from January 1, 2015 to December 31, 2017. We conducted subgroup analyses by geographical region, gender and age (15-64 and ≥65), and tested the robustness of the results in two-pollutant models and sensitive analyses. RESULTS:We found that the average daily concentration of ambient CO across 74 cities from 2015 to 2017 was 1.10 mg/m³ (SD: 0.62). For a 1 mg/m³ increase in CO concentrations, the largest excess risks (ERs) were 3.82% (95% CI: 1.27% to 6.44%) at lag04 for CHD, 3.14% (95% CI: 1.90% to 4.38%) at lag0 for stroke and 2.71% (95% CI: 1.21% to 4.23%) at lag01 for LRI. Moreover, we observed that 4.50%, 3.33% and 2.97% of CHD, stroke and LRI related hospital admissions during 2015 to 2017 could be attributed to ambient CO in included cities, and the annualized attributable numbers of hospitalization expenditures were enormous, with 490 million CNY (US$ 73 M), 371 million CNY (US$ 55 M) and 217 million CNY (US$ 32 M) for CHD, stroke and LRI, respectively. CONCLUSIONS:Our study provides robust evidence for substantial excess hospitalization burden of CHD, stroke and LRI attributable to ambient CO based on multi-city analyses. KEYWORDS: Air pollution, Cardiovascular diseases, Environmental epidemiology, Traffic-related, Respiratory outcomes

Air pollution and cardiovascular disease hospitalization - Are associations modified by greenness, temperature and humidity?

Background:Studies have observed associations between long-term air pollution and cardiovascular disease hospitalization. Little is known, however, about effect modification of these associations by greenness, temperature and humidity.Methods:We constructed an open cohort consisting of all fee-for-service Medicare beneficiaries, aged ≥ 65, living in the contiguous US from 2000 through 2016 (∼63 million individuals). We assigned annual average PM2.5, NO2 and ozone zip code concentrations. Cox-equivalent Poisson models were used to estimate associations with first cardiovascular disease (CVD), coronary heart disease (CHD) and cerebrovascular disease (CBV) hospitalization.Results:PM2.5 and NO2 were both positively associated with CVD, CHD and CBV hospitalization, after adjustment for potential confounders. Associations were substantially stronger at the lower end of the exposure distributions. For CVD hospitalization, the hazard ratio (HR) of PM2.5 was 1.041 (1.038, 1.045) per IQR increase (4.0 μg/m3) in the full study population and 1.327 (1.305, 1.350) per IQR increase for a subgroup with annual exposures always below 10 μg/m3 PM2.5. Ozone was only positively associated with CVD, CHD and CBV hospitalization for the low-exposure subgroup (<40 ppb). Associations of PM2.5 were stronger in areas with higher greenness, lower ozone and Ox, lower summer and winter temperature and lower summer and winter specific humidity.Conclusion:PM2.5 and NO2 were positively associated with CVD, CHD and CBV hospitalization. Associations were more pronounced at low exposure levels. Associations of PM2.5 were stronger with higher greenness, lower ozone and Ox, lower temperature and lower specific humidity.

Association of NT-ProBNP, Blood Pressure, and Cardiovascular Events: The ARIC Study

BackgroundAlthough intensive blood pressure reduction has cardiovascular benefits, the absolute benefit is greater in those at higher cardiovascular disease (CVD) risk. ObjectivesThis study examined whether N-terminal pro–B-type natriuretic peptide (NT-proBNP) helps identify subjects at higher risk for CVD events across systolic blood pressure (SBP), diastolic blood pressure (DBP), or pulse pressure (PP) categories. MethodsParticipants from the ARIC (Atherosclerosis Risk In Communities) study visit 4 (1996 to 98) were grouped according to SBP, DBP, or PP categories and further stratified by NT-proBNP categories. Cox regression models were used to estimate hazard ratios for incident CVD (coronary heart disease, ischemic stroke, or heart failure hospitalization) and mortality across combined NT-proBNP and/or BP categories, adjusting for CVD risk factors. ResultsThere were 9,309 participants (age: 62.6 ± 5.6 years; 58.3% women) with 2,416 CVD events over a median follow-up of 16.7 years. Within each SBP, DBP, or PP category, a higher category of NT-proBNP (100 to <300 or 300 pg/ml, compared with NT-proBNP <100 pg/ml) was associated with a graded increased risk for CVD events and mortality. Participants with SBP 130 to 139 mm Hg but NT-proBNP ≥300 pg/ml had a hazards ratio of 3.4 for CVD (95% confidence interval: 2.44 to 4.77) compared with a NT-proBNP of <100 pg/ml and SBP of 140 to 149 mm Hg. ConclusionsElevated NT-proBNP is independently associated with CVD and mortality across SBP, DBP, and PP categories and helps identify subjects at the highest risk. Participants with stage 1 hypertension but elevated NT-proBNP had greater cardiovascular risk compared with those with stage 2 SBP but lower NT-proBNP. Future studies are needed to evaluate use of biomarker-based strategies for CVD risk assessment to assist with initiation or intensification of BP treatment.

Outdoor light at night and risk of coronary heart disease among older adults: a prospective cohort study.

We estimated the association between outdoor light at night at the residence and risk of coronary heart disease (CHD) within a prospective cohort of older adults in Hong Kong. Over a median of 11 years of follow-up, we identified 3772 incident CHD hospitalizations and 1695 CHD deaths. Annual levels of outdoor light at night at participants' residential addresses were estimated using time-varying satellite data for a composite of persistent night-time illumination at ∼1 km2 scale. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of the association between outdoor light at night at the residence and risk of CHD. The association between light at night and incident CHD hospitalization and mortality exhibited a monotonic exposure-response function. An interquartile range (IQR) (60.0 nW/cm2/sr) increase in outdoor light at night was associated with an HR of 1.11 (95% CI: 1.03, 1.18) for CHD hospitalizations and 1.10 (95% CI: 1.00, 1.22) for CHD deaths after adjusting for both individual and area-level risk factors. The association did not vary across strata of hypothesized risk factors. Among older adults, outdoor light at night at the residence was associated with a higher risk of CHD hospitalizations and deaths. We caution against causal interpretation of these novel findings. Future studies with more detailed information on exposure, individual adaptive behaviours, and potential mediators are warranted to further examine the relationship between light at night and CHD risk.

Abstract 15749: Sex-differences in Coronary Heart Disease Between Individuals With Familial Hypercholesterolemia and Controls in Norway During 1992-2017

Introduction: During the last 30 years, treatment of familial hypercholesterolemia (FH) has been revolutionized, but it is not known if both sexes equally benefit in these advances, and whether this could have affected the sex difference in risk of coronary heart disease (CHD). We aimed to study sex difference in the risk of CHD between men and women with FH compared to non-FH men and women. Methods: We obtained data on CHD hospitalization and death from Norwegian health registries in 4,525 individuals diagnosed with FH between 1992 and 2014 and an age and sex matched control population of 88,892. The sex distribution was about 50/50 between women and men, and the mean age at start of follow-up was 36 years. Results: The cumulative incidence of CHD (FH vs. non-FH controls) in women and men are shown in Figure 1 with a clear increased risk in FH compared to controls. The cumulative incidence starts to increase at a younger age in men compared with women, both in FH and non-FH controls. This corresponds to an age adjusted 2.6-fold higher risk of CHD in men compared with women in both the FH and control population. In the FH population, men aged 20-39 years had a hazard ratio (HR) of 5.3 (95% CI: 2.6-10.9) compared with women, whereas the corresponding HR between women and men in non-FH controls was 3.7 (95% CI: 2.6-5.3). There was no significant interaction between sex and FH status, indicating that the excess risk in men was similar in FH and non-FH controls. Stratified by sex and adjusted for age, we found that both men and women with FH had a 2-fold higher risk of CHD than controls. The highest excess risk was observed in ages 20-30 years with a of HR= 4.5 (95% CI: 2.2-9.2) and a HR of= 5.5 (95%CI: 4.60-9.34) in women and men, respectively. Conclusions: The risk of CHD among individuals with FH was higher in men than in women in all age groups presented, with no differences between the FH sample and the non-FH controls. However, the relative risk in FH compared with controls was similar for both sexes.

The role of public health versus invasive coronary interventions in the decline of coronary heart disease mortality

Purpose: There has been considerable debate on the extent to which the decline in coronary heart disease (CHD) mortality has been caused by better control of coronary risk factors in the general population or is the result of invasive coronary interventions in symptomatic individuals. MethodsUsing the Myocardial Infarction Data Acquisition System, a statewide database of all cardiovascular hospital admissions in New Jersey, we examined time trends in incidence of death from CHD in the Years 2000–2014 in persons with a history of hospitalization for CHD in the previous 10 years and those without such a history. ResultsOver the 10-year study period, there was a marked decline in CHD-related mortality in both persons with a history of CHD and persons without a history of CHD. The decline occurred across all gender, racial, and age groups and was higher in those without a prior history of CHD. ConclusionsThis adds more evidence that the decline in CHD was not only because of advanced invasive medical and surgical treatments but also equally because of improved lifestyle, pharmacologic treatment of risk factors for CHD, and public health interventions.

Prospective Study of Eating Habits as a Predictor of Incident Coronary Heart Disease Hospitalization and Mortality: The 2004 Canadian Community Health Survey

Abstract Objectives Eating habits such as skipping breakfast and snacking are increasingly common practices among North American adults; however, their long-term effects on incident coronary heart disease (CHD) outcomes remain unknown. Previous studies of breakfast skipping and/or eating frequency and cardiometabolic risk have suggested plausible biological pathways for either a protective or harmful relationship to exist, especially when other cardiometabolic risk factors such as diabetes, hypertension, and obesity are present. The objectives of this study were to assess whether long-term associations exist between eating habits (skipping breakfast and eating frequency) and incident CHD (hospitalization and mortality risk), and whether these are intensified by the presence of cardiometabolic risk factors. Methods Skipping breakfast (yes/no) and eating frequency (times per day) were assessed via a 24-hour dietary recall in a nationally representative sample of 13,587 adults (aged ≥18 years) in the 2004 Canadian Community Health Survey (CCHS), who were free of CHD and cancer. Data from the CCHS 2.2 were linked to the population-based Discharge Abstract Database and Canadian Mortality Database to determine the incidence of CHD hospitalization and mortality in the subsequent 9 years. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). Results During follow-up, 762 cases of CHD hospitalization and mortality were documented. Skipping breakfast was not associated with risk of CHD hospitalization and mortality in all participants together (multivariable-adjusted HR = 1.02, 95% CI: 0.74–1.39) or within baseline risk factor subgroups (hypertension: n = 2472; 0.95, 0.55–1.64; diabetes: n = 826; 1.38, 0.65–2.93; BMI ≥ 30 kg/m2: n = 2942; 1.43, 0.84–2.43). Similarly, no associations were observed between eating frequency and risk of CHD hospitalization and mortality. Conclusions Skipping breakfast and eating frequency were not associated with either increased or decreased risk of CHD hospitalization and mortality in this cohort of Canadian adults. Funding Sources Nova Scotia Health Research Foundation Development and Innovative Grant and a Nova Scotia Health Authority Research Foundation New Investigator Grant to LEC.

P818Incidence of coronary heart disease in patients with familiar hypercholesterolemia compared to age- and sex- matched controls

Abstract Background Familial hypercholesterolemia (FH) is caused by mutations leading to high levels of low-density lipoprotein cholesterol (LDL-C) in the blood. The primary aim was to describe mutations in a large sample of individuals with FH, and compare risk of first-time hospitalization for coronary heart disease (CHD) and acute myocardial infarction (AMI) between FH mutation carriers and healthy controls. The secondary aim was to compare risk of death and re-hospitalization among FH mutation carriers and controls with a first event of CHD and AMI. Methods This study is a prospective matched cohort study comprising a sample of 5691 persons with FH and 119 511 age- and sex- matched controls randomly selected from the general Norwegian population. Information on CHD and AMI were obtained from Norwegian Patient Registry, the Cardiovascular Disease in Norway project and the Norwegian Cause of Death Registry. Endpoints are defined according to the International Classification of Diseases, version 9 (ICD9) or version 10 (ICD10). Risk among persons with FH will be compared to healthy controls in terms of hazard ratios (HR) from Cox regression with follow-up time calculated from time of FH-diagnosis for the person with FH in each matched set. Results In total 51.8% (n=61866) of the combined sample were women with mean age 49.0±20.3 years, whereas 48.2% (n=57645) were men with mean age 46.8±19.6 years. There were 236 different FH mutations registered among the FH mutation carriers. The most frequent mutation was 313+1g&gt;A, that accounted for 20.7% (n=1178) of the total, followed by C210G with 12.1% (n=690). Results for incidence of CHD, AMI, and mortality after CHD and AMI and readmission rates are not yet available but will be presented at the conference. Acknowledgement/Funding The study is funded by South-Eastern Norway Regional Health Authority

Interactive effect between temperature and fine particulate matter on chronic disease hospital admissions in the urban area of Tianjin, China

ABSTRACT This study focuses on effects of fine particulate matter (PM2.5) on chronic disease under different levels of temperature. We obtained type 2 diabetes, cerebral stroke and coronary heart disease hospital admissions (HAs) from five hospitals in urban Tianjin as well as the concentrations of PM2.5, nitrogen dioxide (NO2) and sulphur dioxide (SO2). We used distributed lag nonlinear models to explore nonlinear and lag effects of PM2.5. In single-pollutant models, PM2.5 was positively associated with type 2 diabetes, cerebral stroke and coronary heart disease HAs, with strongest effects at lag1, lag0 and lag06, respectively. The corresponding relative risk rates (RR%) were 1.836%, 2.083% and 6.428%. In co-pollutant models, the correlation between PM2.5 and HAs on high-temperature days was generally stronger than that on low-temperature days. This study indicated that PM2.5 can increase HA rates for these chronic diseases, and effects of PM2.5 on high-temperature days were stronger than that on low-temperature days.

Temporal Trends in Cardiovascular Hospital Discharges Following a Mass Chlorine Exposure Event in Graniteville, South Carolina.

Background: On January 6, 2005, a train derailed in Graniteville, South Carolina, releasing nearly 60,000 kg of toxic chlorine gas. The disaster left nine people dead and was responsible for hundreds of hospitalizations and outpatient visits in the subsequent weeks. While chlorine gas primarily affects the respiratory tract, a growing body of evidence suggests that acute exposure may also cause vascular injury and cardiac toxicity. Here, we describe the incidence of cardiovascular hospitalizations among residents of the zip codes most affected by the chlorine gas plume, and compare the incidence of cardiovascular discharges in the years leading up to the event (2000–2004) to the incidence in the years following the event (2005–2014).Methods: De-identified hospital discharge information was collected from the South Carolina Revenue and Fiscal Affairs Office for individuals residing in the selected zip codes for the years 2000 to 2014. A quasi-experimental study design was utilized with a population-level interrupted time series model to examine hospital discharge rates for Graniteville-area residents for three cardiovascular diagnoses: hypertension (HTN), acute myocardial infarction (AMI), and coronary heart disease (CHD). We used linear regression with autoregressive error correction to compare slopes for pre- and post-spill time periods. Data from the 2000 and 2010 censuses were used to calculate rates and to provide information on potential demographic shifts over the course of the study.Results: A significant increase in hypertension-related hospital discharge rates was observed for the years following the Graniteville chlorine spill (slope 8.2, p < 0.001). Concurrent changes to CHD and AMI hospital discharge rates were in the opposite direction (slopes −3.2 and −0.3, p < 0.01 and 0.14, respectively). Importantly, the observed trend cannot be attributed to an aging population.Conclusions: An unusual increase in hypertension-related hospital discharge rates in the area affected by the Graniteville chlorine spill contrasts with national and state-level trends. A number of factors related to the spill may be contributing the observation: disaster-induced hypertension, healthcare services access issues, and, possibly, chlorine-induced susceptibility to vascular pathologies. Due to the limitations of our data, we cannot determine whether the individuals who visited the hospital were the ones exposed to chlorine gas, however, the finding warrants additional research. Future studies are needed to determine the etiology of the increase and whether individuals exposed to chlorine are at a heightened risk for hypertensive heart disease.

Riesgo cardiovascular en la disminución leve-moderada de la tasa de filtrado glomerular, diabetes y enfermedad coronaria en un área del sur de Europa

Introduction and objectivesIndividuals with mild to moderately decreased estimated glomerular filtration rate (eGFR=30-59 mL/min/1.73 m2) are considered at high risk of cardiovascular disease (CVD). No studies have compared this risk in eGFR=30-59, diabetes mellitus (DM), and coronary heart disease (CHD) in regions with a low incidence of CHD. MethodsWe performed a retrospective cohort study of 122 443 individuals aged 60-84 years from a region with a low CHD incidence with creatinine measured between January 1, 2010 and December 31, 2011. We identified hospital admissions due to CHD (myocardial infarction, angina) or CVD (CHD, stroke, or transient ischemic attack) from electronic medical records up to December 31, 2013. We estimated incidence rates and Cox regression adjusted subdistribution hazard ratio (sHR) including competing risks in patients with eGFR=30-59, DM and CHD, or combinations, compared with individuals without these diseases. ResultsThe median follow-up was 38.3 [IQR, 33.8-42.7] months. Adjusted sHR for CHD in individuals with eGFR=30-59, DM, eGFR=30-59 plus DM, previous CHD, CHD plus DM, and CHD plus eGFR=30-59 plus DM, were 1.34 (95%CI, 1.04-1.74), 1.61 (95%CI, 1.36-1.90), 1.96 (95%CI, 1.42-2.70), 4.33 (95%CI, 3.58-5.25), 7.05 (5.80-8.58) and 7.72 (5.72-10.41), respectively. The corresponding sHR for CVD were 1.25 (95%CI, 1.06-1.46), 1.56 (95%CI, 1.41-1.74), 1.83 (95%CI, 1.50-2.23), 2.86 (95%CI, 2.48-3.29), 4.54 (95%CI, 3.93-5.24), and 5.33 (95%CI, 4.31-6.60). ConclusionsIn 60- to 84-year-olds with eGFR=30-59, similarly to DM, the likelihood of being admitted to hospital for CHD and CVD was about half that of individuals with established CHD. Thus, eGFR=30-59 does not appear to be a coronary-risk equivalent. Individuals with CHD and DM, or eGFR=30-59 plus DM, should be prioritized for more intensive risk management.Full English text available from: www.revespcardiol.org/en

Cardiovascular risk in mild to moderately decreased glomerular filtration rate, diabetes and coronary heart disease in a southern European region.

Individuals with mild to moderately decreased estimated glomerular filtration rate (eGFR=30-59mL/min/1.73m2) are considered at high risk of cardiovascular disease (CVD). No studies have compared this risk in eGFR=30-59, diabetes mellitus (DM), and coronary heart disease (CHD) in regions with a low incidence of CHD. We performed a retrospective cohort study of 122443 individuals aged 60-84 years from a region with a low CHD incidence with creatinine measured between January 1, 2010 and December 31, 2011. We identified hospital admissions due to CHD (myocardial infarction, angina) or CVD (CHD, stroke, or transient ischemic attack) from electronic medical records up to December 31, 2013. We estimated incidence rates and Cox regression adjusted subdistribution hazard ratio (sHR) including competing risks in patients with eGFR=30-59, DM and CHD, or combinations, compared with individuals without these diseases. The median follow-up was 38.3 [IQR,33.8-42.7] months. Adjusted sHR for CHD in individuals with eGFR=30-59, DM, eGFR=30-59 plus DM, previous CHD, CHD plus DM, and CHD plus eGFR=30-59 plus DM, were 1.34 (95%CI, 1.04-1.74), 1.61 (95%CI, 1.36-1.90), 1.96 (95%CI, 1.42-2.70), 4.33 (95%CI, 3.58-5.25), 7.05 (5.80-8.58) and 7.72 (5.72-10.41), respectively. The corresponding sHR for CVD were 1.25 (95%CI, 1.06-1.46), 1.56 (95%CI, 1.41-1.74), 1.83 (95%CI, 1.50-2.23), 2.86 (95%CI, 2.48-3.29), 4.54 (95%CI, 3.93-5.24), and 5.33 (95%CI, 4.31-6.60). In 60- to 84-year-olds with eGFR=30-59, similarly to DM, the likelihood of being admitted to hospital for CHD and CVD was about half that of individuals with established CHD. Thus, eGFR=30-59 does not appear to be a coronary-risk equivalent. Individuals with CHD and DM, or eGFR=30-59plus DM, should be prioritized for more intensive risk management.

Factors Associated With Hospitalization Costs of Coronary Heart Disease in Township Hospitals in Rural China.

In large proportions of rural areas in many developing countries, health care delivery system is less developed and is less likely to be equipped to conduct sophisticated treatment for coronary heart disease (CHD) patients locally. This study aims at describing the status quo of and exploring factors associated with hospitalization costs of CHD in township hospitals where only drug therapy was available for CHD conditions. We collected data of inpatients with CHD from discharge records from 10 township hospitals in rural Liaoning from December 2013 to December 2014. We used multilevel linear regression to analyze the factors associated with CHD hospitalization costs. A total of 4635 inpatients were included in the analysis. We found that the average hospitalization costs were 6249.97 RMB (US$1012.47) with the average of 8.89 days of hospitalization in township hospitals in Liaoning. Age, gender, length of stay, the number of times of admissions, by which route was hospitalized, and type of CHD were all the factors significantly associated with hospitalization costs of CHD in township hospitals. The factors associated with hospitalization costs of CHD in township hospitals in rural China showed some different features from the existing studies. When the government designs the related policy, the policy makers need to consider the specific feature of hospitalization costs of CHD in township hospitals in rural areas.

Effects of ambient carbon monoxide on daily hospitalizations for cardiovascular disease: a time-stratified case-crossover study of 460,938 cases in Beijing, China from 2013 to 2017

BackgroundEvidence focused on exposure to ambient carbon monoxide (CO) and the risk of hospitalizations for cardiovascular diseases (CVD) is lacking in developing countries. This study aimed to examine the effect of CO exposure on hospitalizations for CVD in Beijing, China.MethodsA total of 460,938 hospitalizations for cardiovascular diseases were obtained from electronic hospitalization summary reports from 2013 to 2017. A time-stratified case-crossover design was conducted to investigate the association between CO exposure and hospitalizations for total and cause-specific CVD, including coronary heart disease (CHD), atrial fibrillation (AF), and heart failure (HF). Stratified analysis was also conducted by age group (18–64 years and ≥ 65 years) and sex.ResultsLinear exposure-response curves for the association between ambient CO exposure and hospitalizations for CVD was observed. Ambient CO was positively associated with hospitalizations for total CVD and CHD. However, the observed increased risk was not statistically significant for hospitalizations for AF and HF. The strongest effect of CO concentration was observed on the current- and previous-day of exposure (lag 0–1 day). For a 1 mg/m3 increase in a 2-day moving average CO concentration, an increase of 2.8% [95% confidence interval (CI): 2.2 to 3.3%] and 3.0% (95% CI: 2.4 to 3.6%) in daily hospital admissions for CVD and CHD were estimated, respectively. This association was robust after adjusting for other copollutants and did not vary by age group and sex.ConclusionsAmbient CO exposure increased the risk of hospitalizations for CVD, especially for CHD in Beijing. Further studies are warranted to explore the association between ambient CO and hospitalizations for AF and HF.

Abstract 17237: Physical Inactivity, Mortality and Incident Coronary Heart Disease in Blacks: The Jackson Heart Study

Introduction: Despite reductions in overall mortality in recent decades, blacks continue to have higher death rates compared to whites. According to a recent CDC report, blacks were more likely to have a higher prevalence of unhealthy behaviors such as physical inactivity/sedentariness compared to whites. We assessed the associations between physical activity (PA) and incident coronary heart disease (CHD) and overall mortality in blacks in the Jackson Heart Study (JHS). Methods: Among the 5306 participants enrolled in JHS at baseline (2000-2004), we examined overall mortality through 2016, and among 3507 participants without prevalent CHD at baseline, clinically adjudicated incident CHD events (CHD hospitalizations and fatal myocardial infarction). Based on participant responses and the American Heart Association’s Life’s Simple 7 metrics, participants were classified as having poor (0 minutes/week), intermediate (&amp;rt;0 and &amp;lt;75 minutes/week) or ideal (&amp;lt;=150 minutes/week) PA based on number of minutes of moderate of vigorous PA per week. Cox proportional hazard ratios (HR) were used to assess the relationships between PA categories and incident CHD and overall mortality. Results: Through 2016, there were 992 deaths (18.7% mortality rate) with higher rates in men (21.5%) compared with women (17.1%, p&amp;lt;0.0001). After adjustment for age, sex, education, systolic blood pressure, hypertension medications, diabetes, cholesterol, alcohol use and current smoking at baseline, poor PA was associated with increased mortality (HR 1.53, 95% CI 1.18, 1.98) compared to those with ideal PA. However, there was no significant difference in incident CHD events between those with ideal and poor PA (HR 1.05, 95% CI 0.66, 1.67). Compared with ideal PA, there was no significant difference in mortality in those with intermediate PA (HR 1.23, 95% CI 0.93, 1.62). Conclusions: In a large community-based cohort of blacks, lower PA was associated with higher overall mortality but was not associated with increased risk of incident CHD events.

Mortality and cardiovascular disease burden of uncontrolled diabetes in a registry-based cohort: the ESCARVAL-risk study

BackgroundDespite the epidemiological evidence about the relationship between diabetes, mortality and cardiovascular disease, information about the population impact of uncontrolled diabetes is scarce. We aimed to estimate the attributable risk associated with HbA1c levels for all-cause mortality and cardiovascular hospitalization.MethodsProspective study of subjects with diabetes mellitus using electronic health records from the universal public health system in the Valencian Community, Spain 2008–2012. We included 19,140 men and women aged 30 years or older with diabetes who underwent routine health examinations in primary care.ResultsA total of 11,003 (57%) patients had uncontrolled diabetes defined as HbA1c ≥6.5%, and, among those, 5325 participants had HbA1c ≥7.5%. During an average follow-up time of 3.3 years, 499 deaths, 912 hospitalizations for coronary heart disease (CHD) and 786 hospitalizations for stroke were recorded. We observed a linear and increasingly positive dose-response of HbA1c levels and CHD hospitalization. The relative risk for all-cause mortality and CHD and stroke hospitalization comparing patients with and without uncontrolled diabetes was 1.29 (95 CI 1.08,1.55), 1.38 (95 CI 1.20,1.59) and 1.05 (95 CI 0.91, 1.21), respectively. The population attributable risk (PAR) associated with uncontrolled diabetes was 13.6% (95% CI; 4.0–23.9) for all-cause mortality, 17.9% (95% CI; 10.5–25.2) for CHD and 2.7% (95% CI; − 5.5-10.8) for stroke hospitalization.ConclusionsIn a large general-practice cohort of patients with diabetes, uncontrolled glucose levels were associated with a substantial mortality and cardiovascular disease burden.

Healthcare Utilization and Statin Re-Initiation Among Medicare Beneficiaries With a History of Myocardial Infarction.

BackgroundContact with the healthcare system represents an opportunity for individuals who discontinue statins to re‐initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk‐lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re‐initiation among patients with history of a myocardial infarction.Methods and ResultsMedicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re‐initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case‐crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re‐initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re‐initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with lipid panel testing was 2.65 (1.93–3.65), outpatient primary care was 1.31 (1.23–1.40), and outpatient cardiologist care was 1.38 (1.28–1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with emergency department visits was 1.77 (1.31–2.40), coronary heart disease (CHD) hospitalizations was 3.16 (2.41–4.14) and non–coronary heart disease hospitalizations was 1.73 (1.49–2.01).ConclusionsThe weaker association of routine versus acute healthcare utilization with statin re‐initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.

Using ecological propensity score to adjust for missing confounders in small area studies.

SummarySmall area ecological studies are commonly used in epidemiology to assess the impact of area level risk factors on health outcomes when data are only available in an aggregated form. However, the resulting estimates are often biased due to unmeasured confounders, which typically are not available from the standard administrative registries used for these studies. Extra information on confounders can be provided through external data sets such as surveys or cohorts, where the data are available at the individual level rather than at the area level; however, such data typically lack the geographical coverage of administrative registries. We develop a framework of analysis which combines ecological and individual level data from different sources to provide an adjusted estimate of area level risk factors which is less biased. Our method (i) summarizes all available individual level confounders into an area level scalar variable, which we call ecological propensity score (EPS), (ii) implements a hierarchical structured approach to impute the values of EPS whenever they are missing, and (iii) includes the estimated and imputed EPS into the ecological regression linking the risk factors to the health outcome. Through a simulation study, we show that integrating individual level data into small area analyses via EPS is a promising method to reduce the bias intrinsic in ecological studies due to unmeasured confounders; we also apply the method to a real case study to evaluate the effect of air pollution on coronary heart disease hospital admissions in Greater London.

Secondary Prevention in Younger vs. Older Coronary Heart Disease Patients-Insights from the German Subset of the EUROASPIRE IV Survey.

Evidence is limited on implementation of secondary prevention guidelines for coronary heart disease (CHD) in clinical practice and variations between younger and elder patients. We investigated the control of cardiovascular risk factors in German patients with CHD enrolled in the European-wide EUROASPIRE IV survey, stratified by younger (18-69years) and older (70-79years) age groups. Eligible subjects were identified via the hospitals' patient information system and invited to attend a study visit 6months to 3years after hospitalization for CHD (myocardial infarction, ischemia, angioplasty/stent, coronary bypass grafting). Information on lifestyle and medication was collected by interview. Five hundred thirty-six patients were recruited in 2012-2013 (median age 69years [IQR 62-74years], 18% female, 44% ≥70years of age, median time between index hospitalization and study visit 1.8 [1.1-2.5] years). Proportion of CHD patients receiving recommended drug therapy was 89% for platelet inhibitors (younger vs. older patients 93 vs. 84%, p<0.01), 83% for statins (83 vs. 85%, p=0.9), and 83% for beta-blockers (87 vs. 79%, p=0.02). Uncontrolled blood pressure was observed in 45% (40 vs. 50%, p=0.02), LDL cholesterol levels >2.5mmol/l in 53% (56 vs. 49%, p=0.1), and HbA1c levels >7% in diabetic patients in 39% (45 vs. 32%, p=0.1). Eighty-five percent were overweight (86 vs. 85%, p=0.8), 37% were obese (41 vs. 31%, p=0.01), and 10% reported currently smoking (17 vs. 3%, p<0.01). Although most CHD patients received the drug classes recommended by guidelines, treatment goals were frequently not achieved. Elderly subjects had a less favorable pattern, which may reflect multi-morbidity and weaker identification with treatment targets. National CHD prevention strategies should focus not only on enhancing lifestyle modifications and reaching treatment targets, but also on highlighting the different needs in older individuals.