bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P146: The Effects of Lifestyle Interventions on Blood Pressure in Postpartum Women: A Systematic Review
Authors: Murray Horwitz Mara E , Bredy Grayce S , Tabani Alaina
Published: March 2023

Introduction:
One in 3 parous individuals has a pregnancy complication that indicates increased risk for future hypertension, diabetes, or heart disease. Lifestyle modification is recommended to reduce chronic disease risk after complicated pregnancies. However, little is known about the effect of lifestyle interventions on blood pressure in postpartum women. Thus, our objective was to evaluate the effects of postpartum lifestyle interventions on blood pressure. We hypothesized that postpartum lifestyle interventions would be associated with a decrease in blood pressure.

Methods:
We conducted a systematic literature review of six databases (Google, Google Scholar, Embase, Clinical Trials.gov, Cochrane Central, and PubMed) for relevant articles published through May 12, 2022. We considered for inclusion any randomized controlled trial or quasi-experimental, cohort, or case-control study that evaluated a postpartum lifestyle intervention and included blood pressure as an outcome. We excluded non-English publications and articles published before 2010. Two researchers independently identified eligible publications via title and abstract screening followed by full-text review, then extracted relevant data; a third researcher resolved any discrepancies. Due to the heterogeneity of the included studies, we were not able to conduct statistical testing.

Results:
In total 2,564 unique publications underwent title and abstract screening, of which 32 underwent full-text review, and eight met the inclusion criteria. Six of the included studies were randomized controlled trials, and five had relatively small sample sizes (<100). In studies that reported race, nearly all participants identified as White (82%-100%). Seven of the studies required participants to have a history of a pregnancy complication, most often preeclampsia. Interventions usually involved diet and exercise counseling; only two included supervised exercise. Mean blood pressure declined from baseline to follow-up in all of the studies, however in none was there a statistically significant difference in blood pressure change between the intervention and control groups. While not statistically significant, the interventions that included supervised exercise appeared to be associated with greater blood pressure reductions when compared with control, than were the unsupervised interventions.

Conclusions:
In conclusion, we found no statistically significant effects of postpartum lifestyle interventions on blood pressure. Supervised exercise interventions appeared most promising. The evidence is limited to a handful of published studies (n=8) characterized by small sample sizes and a lack of racial diversity. Additional research with more diverse populations and supervised exercise interventions are warranted.
Abstract P152: Joint Association of Sugar- and Artificially-Sweetened Beverage Consumption and Physical Activity and Risk of Type 2 Diabetes in US Adults
Authors: Pacheco Lorena S , Tobias Deirdre K , Li Yanping , Bhupathiraju Shilpa N , Willett Walter , Ludwig David S , Ebbeling Cara B , Haslam Danielle , Drouin-chartier Jean-Philippe , Hu Frank B , Guasch Marta
Published: March 2023

Background:
Consumption of sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) and physical activity are independently associated with type 2 diabetes (T2D) risk; however, it is unknown whether there is an interaction of SSB/ASB intake and physical activity on risk of T2D.

Methods:
We examined the independent and joint associations between habitual SSB/ASB intake and physical activity with incident T2D risk among 196,101 women and men from the Nurses’ Health Study (NHS, 1980-2016), NHSII (1991-2017), and Health Professional’s Follow-up Study (HPFS, 1986-2016), who were free from chronic diseases at baseline. Cox proportional hazards regressions were used to estimate hazard ratios and 95% confidence intervals (HR; CI), adjusting for demographic and lifestyle T2D risk factors.

Results:
There were 20,430 incident T2D cases over follow-up of 36, 26, and 30 years in NHS, NHSII, and HPFS, respectively. In multivariable-adjusted models, we confirmed that participants with higher SSBs, ASBs and lower physical activity were independently at higher T2D risk, compared to lower intakes and higher activity levels. In joint analyses for these exposures, participants who did not meet physical activity guidelines and consumed gt 2 servings/day of SSBs had a significantly higher risk of T2D than those who met physical activity guidelines and never/rarely consumed SSBs (1.51; 1.43, 1.60); we observed similar findings for ASBs: 1.29; 1.23, 1.36). Among participants who met physical activity guidelines, those who consumed gt 2 servings/day of SSBs had a HR of 1.23 (1.16, 1.30); the HR for ASBs was 1.07 (1.02, 1.13). Consistent results were observed for women and men.

Conclusions:
Long-term habitual intake of SSBs or ASBs combined with lower physical activity was associated with higher risk of T2D in three large prospective cohort studies. These findings suggest that even when individuals are physically active, higher consumption of SSBs is associated with a higher risk of T2D. Our results support recommendations and policies to limit the intake of SSB and increase physical activity levels.
Abstract P154: Diabetes Risk Factor Control and Infection Risk in Older Adults: The ARIC Study
Authors: Wang Caroline , Ishigami Junichi , Lutsey Pamela L , Echouffo Tcheugui Justin B , Fang Michael , Selvin Elizabeth
Published: March 2023

Introduction:
Diabetes has been tied to infection risk in mechanistic studies. However, the relationship between diabetes and infection hasn't been well documented in epidemiologic studies, especially in vulnerable older adult populations.

Hypothesis:
We hypothesize that diabetes will be associated with increased risk of inpatient and outpatient infection in older adults.

Methods:
We conducted a prospective cohort analysis of diabetes and ‘any’ and ‘hospitalized infection’ with data from the Atherosclerosis Risk in Communities (ARIC) study. Infection outcomes were ascertained with ICD9/10 codes from Medicare CMS outpatient claims and hospital discharge diagnoses (follow up from (Visit 5) 2011-2013 to December 31, 2019). We calculated the 8-year cumulative incidence of ‘any’ or ‘hospitalized” infection using Kaplan-Meier analysis. We used Cox regression to examine the association between diabetes and infection and adjusted for confounders.

Results:
We included 2,154 participants (mean age at Visit 5: 74.4 years, 51.4% female). During median follow up of 2.91 years, there were 1,141 incident infections and 661 incident hospitalizations with infection. Compared to those without diabetes, older adults with diabetes had higher cumulative incidence of any infection (69% vs 63%) and hospitalized infection (36% vs 27%)(Figure).This excess risk remained after adjusting for confounders, with adjusted HR for ‘any’ infection indicating a higher but non-significant risk in diabetic older patients [HR:1.12, 95% CI (0.99, 1.26)], and adjusted HR for ‘hospitalized” infection indicating a significantly higher risk in diabetic older patients [HR:1.37, 95% CI (1.16, 1.63)].

Conclusion:
Given the aging American population and COVID-19 pandemic, it is critical to identify factors that increase susceptibility to infection in older adults. Our study suggests diabetes confers an increased risk for hospitalized infection in older adults. Improving diabetes management may reduce infection-related morbidity and mortality.
Abstract P155: Modifiable Lifestyle Factors, Genetic Risk, and Incident Peripheral Artery Disease Among Individuals With Type 2 Diabetes: A Prospective Study
Authors: Qian Frank , Zhu Kai , Lu Qi , Liu Rui , Qiu Zixin , Li Lin , Pan An , Liu Gang
Published: March 2023

Background:
Individuals with type 2 diabetes (T2D) are at elevated risk of developing peripheral artery disease (PAD). Whether healthy lifestyle can reduce this risk, particularly in individuals genetically predisposed to PAD, is unknown.

Aims:
To evaluate the association between modifiable lifestyle factors with incident PAD among individuals with T2D, both overall and stratified by genetic risk of PAD.

Methods:
We included 19,368 individuals with T2D from the UK Biobank, who were free of PAD and cardiovascular disease. We defined a low-risk lifestyle score with 1 point assigned for each of the following: non-current smoking, regular physical activity, adhering to a high-quality diet, moderate alcohol consumption, maintaining a normal waist-hip ratio, sleeping 7-8 hours/day. A polygenic risk score (PRS) including 19 single nucleotide polymorphisms was constructed. Multivariable-adjusted Cox models were used to calculate the hazard ratio (HR) and 95% confidence interval (CI).

Results:
After a median 7.6 years of follow-up, 325 incident cases of PAD were documented. There was an inverse association between the low-risk lifestyle score and incident PAD, with HR (95%CI) of 0.73 (0.54, 1.03), 0.43 (0.30, 0.60), and 0.42 (0.30, 0.60) for 2, 3, and ≥4 compared with ≤1. The PRS was associated with an increased risk of PAD, with HR (95%CI) of 1.16 (1.03, 1.31) per-SD increment. A more favorable lifestyle was able to partially mitigate the risk of increased genetic susceptibility to PAD (
Figure 1
). In mediation analysis, 42.4% of the association could be attributable to risk factors including inflammation, atherogenic lipoproteins, and impaired hepatic/renal function.

Conclusion:
A combined set of modifiable lifestyle factors was associated with a substantially lower risk of incident PAD among individuals with T2D and may be able to partially mitigate an underlying genetic predisposition for PAD. Our findings highlight the importance of improving adherence to these factors in the primary prevention of PAD among individuals with T2D.
Abstract P156: Use of Continuous Glucose Monitoring for Risk-Stratification in Older Adults With Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study
Authors: Fang Michael , Jeon Yein , Echouffo Tcheugui Justin B , Shin Jung-Im , Coresh Josef , Selvin Elizabeth
Published: March 2023

Introduction:
The American Diabetes Association (ADA) recommends individualizing treatment for older adults with diabetes based on their burden of comorbidities. However, implementing this recommendation in practice is challenging. Glucose excursions and variability may be markers of declining health that can identify high-risk older patients.

Hypothesis:
Glucose abnormalities are associated with comorbidities in older adults with diabetes.

Methods:
We conducted a cross-sectional analysis of 319 with type 2 diabetes (mean age 83 years) in the Atherosclerosis Risk in Communities Study (visit 9, 2021-2022). Participants wore continuous glucose monitoring (CGM) sensors for up to 14 days. We calculated four clinical measures from CGM data: mean glucose, standard deviation of glucose, % time with hypoglycemia (glucose <54 mg/dl), and % time with hyperglycemia (glucose>180 mg/dl). Based on ADA guidelines for older adults, we examined 6 comorbidities (defined using information from clinical examinations and medical records). We examined the association between CGM measures and comorbidities with logistic regression.

Results:
The prevalence of comorbidities ranged from 2% (dementia) to 66% (chronic kidney disease). Increased time with hypoglycemia was significantly associated with cardiovascular disease, chronic kidney disease, depression, and poor functional status
(Table)
. In contrast, comorbid conditions were not consistently related to mean glucose, standard deviation of glucose, or hyperglycemia.

Conclusion:
Hypoglycemia was common in those older adults with diabetes who had poor physical functioning and major comorbidities. CGM captures hypoglycemic episodes and may be a useful tool to supplement traditional risk assessment.
Abstract P158: Intake of Chocolate by Subtypes and Risk of Type 2 Diabetes: Results From Three Prospective Cohort Studies
Authors: Liu Binkai , Zhu Lu , Hu Yang , Manson Joann E , Sun Qi
Published: March 2023

Backgrounds:
Cocoa and cocoa flavonoids may exert health benefits including improving insulin sensitivity and lowering type 2 diabetes (T2D) risk. Previous studies have reported inverse associations between chocolate consumption and T2D risk, although it is largely unknown regarding whether the associations differ between dark chocolate and milk chocolate. The objective of this study is to prospectively examine the associations between the consumption of dark chocolate, milk chocolate, and total chocolate, and the risk of T2D, in three large cohort studies with repeat dietary measurements over 10 years of follow-up.

Methods:
Data from three prospective cohorts in the United States were used, including Nurses’ Health Study (2006-2020), Nurses’ Health Study II (2007-2019), and Health Professionals Follow-Up Study (2006-2020). Dark and milk chocolate consumption information was assessed at baseline and updated every 4 years through a validated food frequency questionnaire. Chocolate consumption was categorized into 4 groups: never or <1 serving/month, 1 serving/month to 1 serving/week, 1-4 servings/week, and ≥5 servings/week. Self-reported T2D cases were confirmed using a supplementary questionnaire. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between total, dark, and milk chocolate intake, and the risk of T2D.

Results:
After adjusting for lifestyle and dietary risk factors for diabetes, compared to participants who never or rarely eat chocolate, those who consumed any chocolate ≥5 servings/week had a 22% (95% CI: 10% to 32%; p for trend = 0.0003) lower rate of T2D. For dark chocolate, those who consumed ≥5 servings/week had a non-significant 16% (95% CI: -2% to 31%; p for trend = 0.005) lower rate of T2D than those who never or rarely eat dark chocolate. The associations between milk chocolate intake and T2D risk are largely null. Spline regression shows an L-shaped non-linear dose-response relationship between total chocolate intake and the risk of T2D (p=0.02 for curvature). The risk reduction plateaus when the total chocolate intake is higher than 5 servings/week. There is a linear dose-response association between dark chocolate intake with the risk of T2D (p=0.006 for linearity).

Conclusion:
Higher consumption of total chocolate and especially dark chocolate was significantly associated with a lower risk of type 2 diabetes. These findings support the potential cardiometabolic benefits of consuming chocolates that are rich in flavonoids.
Abstract P162: Sex Differences in Cardiometabolic Biomarkers During Pre-Diabetes
Authors: Yoshida Yilin , Chen Zhipeng , Li Changwei , Mauvais-Jarvis Franck
Published: March 2023

Background:
Diabetes (DM) diminishes female protection against cardiovascular disease (CVD). Women with DM face excess CVD risk than men partly due to women’s greater deterioration in risk factors before DM. In this study, we compared sex differences in biomarkers that reflect distinct pathophysiological pathways during the pre-diabetes (pre-DM) stage.

Method:
A cross-sectional analysis was performed based on pooled data from Atherosclerosis Risk in Communities Study and the Jackson Heart Study. We used multivariable linear regressions to examine the associations between sex and biomarkers (log-transformed) representative of inflammation, lipoprotein, adipokine, kidney function, cardiac injury/stress, and thrombosis, adjusted for age, race, and BMI, among CVD-free individuals with pre-DM. We validated the results in a sensitivity analysis, including those that eventually progressed into DM during the follow-up. We used the false discovery rate method to adjust multiple comparisons.

Results:
Among 5975 individuals with pre-DM, the mean age was 54.2 years, 2853 (48%) were women, and 2022 (34%) were non-Hispanic blacks. In the adjusted models, inflammatory biomarkers, including high-sensitivity c-reactive proteins (β coefficient 0.2, P=2.9 x 10
-9
), fibrinogen (β 0.19, P=2.8E-12), and absolute lymphocyte (β 0.25, P=2.54 x 10
-7
), and cardiac injury/stress biomarker, NT-proBNT (β 0.14, P=0.0002) were higher in women than men with pre-DM. Additionally, lipoprotein(a) (β 0.19, P=4.96 x 10
-13
) and apolipoproteins A1 (β 0.61, P=2.81x 10
-120
), and adipokines including leptin (β 1.1, P=2.62 x 10
-123
) and adiponectin (β 0.56, P=1.94 x 10
-12
) were all higher in women with pre-DM. In contrast, kidney function markers, albumin (β -0.24, P=2.79 x 10
-9
) and creatinine (β -1.1, P=1x 10
-100
), and thrombosis biomarker, homocysteine (β -0.5, P=9.09 x 10
-19
) were higher in men with pre-DM than in their women counterparts. These sex differences remained generally unchanged among 2320 individuals that progressed into DM.

Conclusion:
Biomarkers differ significantly between sexes during the pre-DM state. The inflammatory, lipoprotein, adipokine, and cardiac stress biomarkers were higher in women with pre-DM, while kidney function and thrombosis biomarkers were higher in men with pre-DM. Future mechanistic studies are warranted to delineate pathophysiological pathways characterized by these biomarkers contributing to sex disparities of CVD risk in DM.
Abstract P165: Key Tenets for Lifestyle Programs Aiming to Improve Hypertension Control and Cardiovascular Health
Authors: Abbas Amena , Jordan Julia , Davis Rachel , Robinson Shaquira , Morns Cagney
Published: March 2023

Introduction:
Promoting lifestyle changes, such as consuming a healthier diet, engaging in exercise, and quitting smoking can help control hypertension (HTN) and reduce the risk of adverse cardiac outcomes. To support public health practitioners and health care providers, the Centers for Disease Control and Prevention’s (CDC) Division for Heart Disease and Stroke Prevention (DHDSP) sought to develop a set of key tenets of lifestyle programs that support successful implementation and impact on HTN-related outcomes.

Hypothesis:
No a priori hypotheses.

Methods:
We conducted rapid evaluations of three lifestyle programs identified first through a broad call for nominations and then a panel of experts for final selections. We also performed a literature review to assess the landscape of lifestyle programs focused on managing HTN. To build upon these findings, a rigorous mixed-methods evaluation of a local YMCA’s (St. Louis Gateway Region) implementation of a Blood Pressure Self-Monitoring (BPSM) program was conducted to describe program characteristics and innovations and assess HTN outcomes.

Results:
The evaluation of a local YMCA included 333 participants with HTN (2018-2020) and reported a statistically significant average reduction of 2.6 mmHg in SBP from baseline to 16-week follow-up. Based on comprehensive findings from the project, DHDSP identified the following four key tenets for an effective program: 1) Implementing programs in community settings provides an opportunity to offer programming where people are already gathering and can build trust and commitment. Findings from rapid evaluation of a program held at churches and other community locations demonstrated increased BP control rates from 66.2% to 71.5% at 12-week follow-up. 2) A team-based approach with clinical and non-clinical staff allows for more impactful and effective implementation. Evaluation results demonstrated completion of a program with trained lifestyle coaches was associated with a decrease of 7.3 mmHg in SBP and 5.7 mmHg in DBP over a 16-week period. 3) Programs with shorter durations (between 3-24 weeks) allow for those not able to commit to a longer program to still benefit from learning to control BP and reduce other risk factors. Findings from rapid evaluation of a three-week program resulted in increased BP control from 28.4% to 61.3% by end of program period. 4) Targeting multiple lifestyle behaviors provide the opportunity to closely match participant needs with the type of activities that work best for them. Rapid evaluation of a 12-week program focused on exercise, diet, and reducing stress demonstrated an increase in BP control from 76.9% to 82.2%.

Conclusion:
Findings can be used as a resource to link patients to effective BP control and management programs that have implemented these key tenets. Strategies highlighted may also provide considerations for replication in other communities.
Abstract P170: The Association of Urinary Cadmium and Zinc With Lower Extremity Amputations. Evidence From the Strong Heart Study
Authors: Galvez-Fernandez Marta , Bhatt Kishan A , Ravalli Filippo , Goessler Walter , Zhang Ying , Fretts Amanda M , Umans Jason G , Sanchez Tiffany , Ujueta Francisco , Lamas Gervasio A , Fabsitz Richard R , Navas-Acien Ana
Published: March 2023

Background:
Cadmium is a cardiotoxic divalent metal that accumulates in the liver and kidney. It resembles the essential metal zinc, replacing it in numerous enzymes and proteins. Zinc plays a major role in insulin function. Glucose dyshomeostasis increases the loss of zinc through the urine. Cadmium has been associated with peripheral artery disease and critical limb ischemia, conditions that lead to limb amputations. Chelation treatment with edetate disodium, an agent that facilitates the excretion of cadmium from the body, was beneficial for individuals with critical limb ischemia and diabetes in several small studies. This study evaluated the association of urinary levels of cadmium and zinc with amputations in a population with a high burden of diabetes from Arizona, Oklahoma, North Dakota and South Dakota.

Hypothesis:
We hypothesize that urinary cadmium and zinc levels are related to prevalent amputations in the SHS cohort.

Methods:
We included 2,724 participants from the Strong Heart Study, a population-based cohort study in 12 American Indian communities, recruited in 1989-1991 and followed for amputations through 1998-1999. Trained staff identified amputations of the lower extremity through visual examination at the baseline visit. We censored traumatic amputations. Baseline metal levels in spot urine samples were divided by urinary creatinine to account for urine dilution.

Results:
Mean age was 56.4 years, 41.5% participants were male, and 42% had diabetes. We identified a total of 35 (1.3%) amputations of the lower extremities during the study period. Median urinary levels were 0.97 μg/g for cadmium and 0.56 mg/g for zinc. Higher levels of urinary cadmium and zinc were positively associated with the presence of amputations. The odds ratios of prevalent amputations for an IQR of cadmium and zinc distribution were 1.54 (1.00, 2.38) and 2.24 (1.48, 3.39), respectively, in models adjusted for sociodemographic, lifestyle (tobacco and alcohol intake), and other factors (BMI, hypertension and diabetes status, HDL and LDL-cholesterol, and estimated glomerular filtration rate). The associations remained after further adjustment for fasting plasma glucose levels. Urinary cadmium and zinc levels were positively correlated (r=0.24, P<0.001).

Conclusions:
Urinary cadmium and zinc were positively associated with the presence of lower extremity amputations in American Indian adults with a high burden of diabetes. These results support the current evidence of cadmium as a cardiometabolic risk factor, and the potential role of impaired zinc metabolism, reflected as increased urinary zinc excretion, in vascular complications of diabetes.
Abstract P172: Per- and Polyfluoroalkyl Substances (PFASs), Apolipoprotein and the Risk of Coronary Heart Disease: A Case-Control Pilot Study
Authors: Zhu Lu , Hu Yang , Wang Molin , Furtado Jeremy D , Grandjean Philippe , Sacks Frank M , Rimm Eric B , Sun Qi
Published: March 2023

The association of PFASs with blood lipids, lipoproteins and apolipoproteins, and coronary heart disease (CHD) risk are inconsistent in previous studies. The aim of current study is to examine the potential association between plasma PFASs, blood lipoproteins and their subspecies defined by apolipoproteins, and whether PFASs are associated with CHD risk.A case-control study was conducted in 100 men and 102 women aged 45-70 years. We leveraged 101 participants from HPFS and NHS who were initially free of cardiovascular disease and developed a fatal or non-fatal myocardial infarction during follow-up, and randomly matched controls in a 1:1 ratio for age, smoking status, and date of blood draw. Seven plasma PFASs measurements were examined at baseline, including perfluorohexane sulfonic acid (PFHxS), perfluorooctanoic acid (PFOA), total perfluorooctane sulfonic acid (PFOS), branched PFOS (brPFOS), linear PFOS (nPFOS), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PFDA), with all mean CVs <20%. Pearson correlation was applied to study the relationship between PFASs, lipoproteins and subspecies; Conditional logistic regression model was conducted to test the association between PFASs and CHD risk; a mediating effect model was used to assess how blood lipids and apolipoprotein subspecies mediate the association between PFASs and CHD risk.After multivariable adjustments, we did not find significant associations between PFAS and lipids, except for PFHxS and high-density lipoprotein cholesterol (HDL-C) with a significant positive association (r=0.19, p=0.046). For subspecies with apolipoprotein (apo) C-III, we observed non-significant inverse associations between plasma PFAS concentrations and the subspecies of HDL-C, low-density lipoprotein cholesterol (LDL-C) and VLDL-C that contain only apoC-III. For those without ApoC-III, the directions of most associations are positive. Strong associations were demonstrated between PFNA, PFDA and HDL-C with ApoE (r=0.42, p=0.00004; r=0.27, p=0.004, respectively). In addition, elevated PFOS concentrations were associated with higher relative risk of CHD (HR=1.04, p=0.02), especially for branched PFOS (HR=1.18, p=0.003), and these association were largely dose dependent (PFOS: p for linearity = 0.009; brPFOS: 0.0007). Mediation analysis illustrated no mediating effect regarding blood lipids and apolipoprotein subspecies on the association of interest, except for HDL-C on the association between PFOS, nPFOS and CHD risk (%mediated=25%, p=0.03; %mediated=36%, p=0.03, separately).Our results suggest that there is a linear positive dose-response relationship between PFOS and CHD risk, but the association is probably not mediated by subspecies with/without Apo C-III or Apo E.
Abstract P177: Circulating Ketone Bodies and Mortality in Heart Failure: A Community Cohort Study
Authors: Oyetoro Rebecca , Conners Katie , Joo Jungnam , Turecamo Sarah , Sampson Maureen , Wolska Anna , Remaley Alan T , Connelly Margery A , Otvos James D , Larson Nicholas B , Bielinski Suzette J , Shearer Joseph J , Roger Véronique L
Published: March 2023

Background:
Heart failure (HF) is associated with metabolic alterations, including ketogenesis. However, determinants of ketogenesis and risk of mortality in HF is not defined. Total ketone bodies (KB) include β-hydroxybutyrate, acetoacetate, and acetone and can be measured in plasma by nuclear magnetic resonance (NMR). The aim of this study is to determine the relationship between KB and clinical characteristics in a community HF cohort and to assess the association between KB and all-cause mortality.

Methods:
A population-based cohort of 1,389 HF patients was prospectively enrolled between 2003 and 2012. Plasma KB was measured by LP4
NMR LipoProfile
® assay/test on the Vantera® NMR analyzer platform. A conditional inference tree method (ctree R Package) was used to determine optimal KB group cut points. Associations between clinical characteristics and KB were measured with Wilcoxon rank sum test and Pearson’s Chi-squared test. Kaplan-Meier method estimated survival. Cox regression analyses were used to estimate associations between KB concentrations and mortality.

Results:
Among the 1,382 HF patients with KB measurements, the median age was 78 years (IQR 68-84) and 52% were men. Median KB was 180 μM (IQR 134-308). Patients were divided into two groups with lower KB (≤471.5 μM) and higher KB (>471.5 μM). Patients with higher KB (N=210) had lower BMI, higher BNP, and were more likely to be in the New York Heart Association class III-IV; however, these patients were less likely to have hyperlipidemia, coronary disease, or diabetes mellitus (P < 0.05). Age, sex, creatinine, ejection fraction, or Meta-Analysis Global Group in Chronic HF (MAGGIC) score did not differ by KB group. Higher KB was associated with worse survival (figure). After adjustment for the MAGGIC score, higher KB was associated with increased risk of mortality (HR 1.3; 95% CI, 1.08-1.48).

Conclusions:
In this community HF cohort, higher KB was associated with increased mortality, independent of the MAGGIC score.
Abstract P179: Development and Implementation of a Large, Multi-Center Survey of Patients With Heart Failure
Authors: Chamberlain Alanna M , Hade Erinn M , Haller Irina V , Horne Benjamin D , Benziger Catherine P , Killian Jill M , Weston Susan A , Manemann Sheila M , Roger Veronique L
Published: March 2023

Background:
Most patients with heart failure (HF) have multimorbidity which may cause difficulties with self-management. Understanding the determinants of successful self-management and the resources patients draw upon to effectively manage their health is fundamental to designing new practice models to improve outcomes in HF.

Methods:
We developed a survey guided by the Chronic Care Model to understand the distribution of patient-centric factors, including health literacy, social support, self-management, and functional and mental status in patients with HF. The survey was administered to HF patients from 4 health care systems participating in PCORnet® (the National Patient-Centered Clinical Research Network). Patients were identified utilizing data available in the PCORnet common data model on or after 1/1/2013 at 1 health system and on or after 1/1/2015 at 3 health systems: age ≥30 years, ≥2 HF diagnostic codes, and ≥1 HF-related prescription (positive predictive value of algorithm: 81%).

Results:
A total of 10,662 patients with HF were identified, 9684 were mailed a survey, and 3330 completed a survey (response rate: 35%). Responders were older than non-responders (74 vs. 71 years), less racially diverse (3% vs. 12% non-White), less likely to have reduced ejection fraction (EF; 22% vs. 27% with EF <40%), and had higher prevalence of most chronic conditions. Responders reported their health was generally good or fair, they frequently had cardiovascular comorbidities, more than half had difficulty climbing stairs, and more than 10% reported difficulties with bathing, preparing meals, and using transportation (Table). Nearly 80% of patients had family or friends sit with them during a doctor visit, and most (54%) manage their health by themselves.

Conclusion:
More than half of patients with HF manage their health by themselves even though most bring someone along to their health care appointments. Increased understanding of self-management resources may guide the development of interventions to improve HF outcomes.
Abstract P180: Disparities in Occurrence of Stroke Among Heart Failure Patients- A Case Control Study Evaluating Impact of Community Socioeconomic Distress Index
Authors: Witrick Brian , Annie Frank , Kimble Wes , Sokos George , Bianco Christopher , Rinehart Sarah , Dotson Timothy , Hendricks Brian
Published: March 2023

Introduction:
Ischemic stroke is common complication among heart failure patients. Community-level socio-economic distress has been linked to adverse clinical outcomes in prior research. However, few to no studies have examined the relationship between neighborhood level socio-economic distress and stroke within a population of heart failure patients exclusively.

Hypothesis:
Odds of stroke among patients with heart failure are higher in neighborhoods with increased socio-economic distress, controlling for patient demographic and clinical comorbidities.

Methods:
Two separate cohorts of heart failure patients were assembled using ICD9/10 codes to identify all patients with a heart failure diagnosis seen at West Virginia University Hospital Systems (WVU Medicine) between 2008 and 2020 and Charleston Area Medical Center (CAMC) between 2017 and 2020. Cases were defined as heart failure patients with a diagnosis of ischemic stroke. Controls were defined as heart failure patients without a diagnosis of stroke and were matched to cases 4:1 on five-year age grouping and sex at birth. Distressed communities index (DCI) was linked to clinical data by patient zip code of residence. Neighborhoods with a DCI above 75 were classified as distressed, while those below were noted as non-distressed. Multivariable conditional logistic regression was used to identify significant associations at the 95% confidence level within each cohort separately.

Results:
In total there were 26,532 unique heart failure patients in the WVU Medicine cohort and 20,070 in the CAMC cohort. Of these, 10.3% (n=2,741) of the WVU Medicine cohort and 4.5% (n=900) of the CAMC cohort met the case definition of having had a diagnosis of stroke. Among patients in the WVU Medicine cohort with heart failure who experienced a stroke, 47.1% (n=1,291) were male and had an average age of 72.4 (± 12.9). In the CAMC cohort, among heart failure patients who experienced a stroke, 51.1% (n=460) were male and the average age was 70.9 (± 11.8). After controlling for demographics and clinical comorbidities, conditional logistic regression analyses identified a statistically significant association between neighborhood-level socio-economic distress in both the WVU Medicine cohort (OR = 1.31; 95% CI = 1.20 - 1.44) and the CAMC cohort (OR = 1.29; 95% CI = 1.027 - 1.454).

Conclusion:
Neighborhood-level socio-economic distress was associated with prevalence of stroke among heart failure patients. This is a critical finding for rural states, such as West Virginia, as it has the ability to inform placement of new satellite clinics among large hospital systems, or government funded clinics, such as federally qualified health centers, to address inequities in care for patients living in medically underserved communities.
Abstract P182: Post-Discharge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure
Authors: Khodneva Yulia , Oparil Suzanne , Levitan Emily B , Arora Pankaj , PRESLEY CAROLINE , Cherrington Andrea
Published: March 2023

Background:
Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7-14 days after hospital discharge to improve HF outcomes. This study objective was to examine post-discharge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care.

Methods:
Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010-2019, were included and the claims analyzed for ambulatory care utilization (any, primary care, cardiology or endocrinology) within 60 days after hospital discharge. Restricted mean survival time regression, adjusted for socio-demographics and clinical factors, examined the time to first ambulatory visit. Multivariable-adjusted Poisson regression estimated prevalence ratios (PR) of primary and specialty care post-discharge visits.

Results:
Among 9,867 Medicaid-covered adults with diabetes and first hospitalization for HF, [mean age 53.7, SD 9.2 years, 47.4% African American, 10.9% Hispanic/other, 65.4% women], 26.5% had an ambulatory visit within 0-7 days, 15.1% - 8-14 days, 31.0% - 15-60 days and 26.8% - no visit; 71% saw primary care, 12% - cardiology and 1.6% - endocrinology. Compared to Non-Hispanic white adults, African American and Hispanic/other ethnicity adults were less likely to see primary care (adjusted PR 95% Confidence Interval [CI] 0.96 [0.91-1.00], and 0.91 [0.89-0.98], respectively), and their visits occurred later (by 1.8 day, p=0.0006 and by 2.8 days, p=0.0016, respectively). Having 4 or more additional comorbidities was associated with both primary care and cardiology visits (aPR [95% CI] 1.59 [1.35-1.87], and 1.45 [1.01-2.09], respectively).

Conclusion:
More than a half of Medicaid-covered adults with diabetes and HF in Alabama did not receive post-discharge ambulatory care follow-up as recommended by guidelines. African American and Hispanic/other ethnicity adults were less likely to receive recommended post-discharge ambulatory care for comorbid diabetes and HF.
Abstract P183: Systolic Dysfunction is Associated With Increased Occurrence and Worse Outcomes of Periprocedural Cardiovascular Adverse Events After Transcatheter Aortic Valve Replacement
Authors: Kumi Dennis , Gwira-Tamattey Edwin , Vardar Ufuk , Patel Birju , Karki Sadichhya
Published: March 2023

Background:
Transcatheter aortic valve replacement (TAVR) rate continues to ascend nationwide as per the transcatheter valve therapy registry, and this calls for even better strategies to aim for negligible complication rates. Current practice relies on surgically derived risk models. We set out to assess the impact of systolic dysfunction on perioperative cardiovascular adverse events.

Hypothesis:
The presence of systolic dysfunction is associated with increased frequency and poorer outcomes of periprocedural cardiovascular adverse events among patients undergoing TAVR.

Method:
A retrospective cohort study was designed using data obtained from the 2016 to 2018 combined National Inpatient Sample (NIS) database. The current procedural terminology (CPT) Codes of ICD-10 were used to identify patients admitted for TAVR. They were then dichotomized into two cohorts based on the presence of systolic dysfunction. Primary outcomes were death, length of stay, total charge, composite of all cardiovascular perioperative adverse events and composite of all cardiovascular perioperative adverse events and death. Secondary outcomes were individual cardiovascular perioperative adverse events for all TAVR admissions and subsequently for patients with post-TAVR cardiac dysfunction. Multivariate linear and logistic regressions were used to adjust for confounders.

Results:
There was a total of 145,640 admissions for TAVR among whom were 16,980 with systolic dysfunction. Details of outcomes of study are summarized in table 1 below.

Conclusion:
Among inpatients who underwent TAVR, systolic dysfunction is associated with higher odds of mortality, composite of all cardiovascular adverse events and composite of death and all cardiovascular adverse events. There was increased odds of periprocedural cardiac dysfunction, particularly with increased cardiogenic shock. There was increased length of stay and total charge.
Abstract P189: Sexual Minority Status Disparities in Life’s Simple 7 and Life’s Essential 8 Cardiovascular Health Scores, a French Nationwide Population-Based Study
Authors: Deraz Omar , Caceres Billy A , Streed Carl G , Beach Lauren B , Jouven Xavier , Touvier Mathilde , Goldberg Marcel , Zins Marie , Empana Jean-Philippe
Published: March 2023

A higher burden of cardiovascular disease risk factors has been reported in sexual minority populations (SM), such as lesbian, gay, bisexual, and non-heterosexual, compared to heterosexual populations. Therefore, primordial prevention, i.e., preventing risk factor onset in the first place, may be a relevant preventative strategy in this population. This study aimed to quantify the associations of SM status in each sex with Life’s Simple 7 (LS7) and Life’s Essential 8 (LE8) cardiovascular health (CVH) scores. The CONSTANCES study is a multicentric study that recruited randomly selected adults in 24 health examination centers in 21 cities in the French European territory. Sexual minority status was based on self-reported lifetime sexual behavior and categorized as lesbian, gay, bisexual, or heterosexual. The study included 169,434 CVD-free participants (53.64% women, mean age: 46.00 years). Among 90879 women, 555 were lesbian, 3149 bisexual, and 84363 heterosexual. Among 78555 men, 2421 were gay, 2748 bisexual, and 70994 heterosexual. Overall, 2812 women and 2392 men declined to answer. In women, the prevalence of high LS7 scores (12-14) ranged from 9.00% (declined to answer) to 12.38% (bisexual), whereas in men, it ranged from 4.06% (declined to answer) to 9.17% (gay). In multivariate analyses (Table 1), lesbian and bisexual women had lower LS7 score compared to heterosexual women. However, this was observed only among those who had never been pregnant (p for interaction <0.05). Conversely, gay and bisexual men living in urban areas had higher LS7 score compared to heterosexual men, while those living in rural areas had lower LS7 score than their heterosexual counterparts (p for interaction <0.05). Findings were consistent when using the LE8 score but with stronger effect sizes (Table 1). This study supports the presence of CVH disparities in sexual minority adults and may help identify vulnerable populations for prioritizing primordial CVD prevention.
Abstract P190: Social Determinants of Cardiovascular Health in Sexual Minority Adults: A Systematic Review
Authors: Sharma Yashika , Doan Danny , Hughes Tonda L , Caceres Billy A
Published: March 2023

Introduction:
Sexual minority (e.g., lesbian, gay, bisexual, queer) adults appear to be at higher risk of cardiovascular disease (CVD) than heterosexual adults. Although social determinants of health have been shown to contribute to cardiovascular health (CVH) disparities in the general population, there is a dearth of research examining these determinants in sexual minority adults.

Objective:
Using the World Health Organization’s definition of social determinants of health, we conducted a systematic literature review to synthesize and critique existing evidence on social determinants of CVH among sexual minority adults.

Methods:
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and performed a comprehensive search of literature published between January 2011 and March 2022. Studies were included if they were peer-reviewed, English-language, and examined associations between social determinants of health and CVH outcomes among sexual minority individuals 18 years old or older. CVH outcomes were CVD risk factors (including diabetes, hypertension, hyperlipidemia, and obesity) and CVD conditions (such as stroke, heart attack, and coronary artery disease). We performed quality appraisal using the Joanna Briggs Institute Critical Appraisal Checklists for Analytical Cross-Sectional Studies and Cohort Studies.

Results:
Our search retrieved 2,133 studies, of which 18 met the inclusion criteria. Of these, 16 were cross-sectional and two used longitudinal designs. All 18 studies had a low risk of bias. The majority (n = 17) included predominantly White samples. Overall, the findings were mixed. Stressful life events were associated with elevated CVD risk. Individuals who reported living in more supportive environments had lower odds of being overweight; however, greater disclosure of sexual minority status was associated with higher odds of being overweight. Living in rural settings was associated with higher odds of obesity and hypertension. Experiences of discrimination were not associated with any CVH outcomes. Findings for interpersonal trauma (e.g., adulthood trauma, childhood trauma), education, religious activity, and relationship status were mixed. No studies examined social determinants at the structural level.

Conclusions/Implications:
Findings highlight social determinants that may serve as targets of clinical and public health interventions to improve the CVH of sexual minority adults. Future longitudinal research is needed that includes more diverse samples and examines multi-level social determinants of CVH, including at the social and structural levels.
Abstract P192: Assessment of Medical Trainee Identification of Cardiovascular Disease Risk Factors in the LGBTQ Community: A Quality Improvement Initiative
Authors: Burgess Kisha L , Adeniyi Adeyinka , Nyange Christabel , Chandora Akshay , Lee Hee , Seo Yuna , Charaf Christine , Chang Eric Y
Published: March 2023

Introduction:
Cardiovascular disease (CVD) is the leading cause of death worldwide. However, the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) population experiences significant disparities in CVD risk factors, placing them at higher risk for developing CVD. Assessing and addressing risk factors (RF) in this population requires identifying and addressing modifiable barriers in a timely fashion. We aimed to evaluate trainee assessment of CVD RF in the LGBTQ community while identifying potential barriers as opportunities for intervention.

Methods:
This was a multi-institutional study performed at three academic training programs in Georgia. An anonymous questionnaire was used to assess trainees' (interns, residents, and medical students) identification and perception of CVD RF in the LGBTQ community. The data was compiled and analyzed to identify perceived barriers to LGBTQ CVD RF assessment by medical trainees.

Results:
A total of 168 surveys were returned. More than a third (37%; 62/168) of trainees noted that the LGBTQ community is at increased risk of developing CVD compared to their cisgender heterosexual peers. Only 3.6% (6/168) reported complete confidence in assessing CVD risk factors in the LGBTQ community. The most identified (90%; 152/168) RF was environmental stress such as discrimination, rejection, and violence followed by HIV/AIDs (83%; 139/168) and hormone replacement therapies (81%; 136/168). Almost half (48%; 77/161) of trainees noted that they address risk factors for CVD in the LGBTQ community less than 25% of the time, listing a lack of knowledge of the unique risk factors in the LGBTQ community 45% (69/152) as the most significant barrier.

Conclusion:
Identifying and addressing unique CVD RF in LGBTQ populations is pivotal to improving overall CVD outcomes. Medical teaching teams and training programs can play a leading role in educating trainees about these unique risk factors and helping to address knowledge barriers. Our study demonstrates that medical trainees are largely unaware that the LGBTQ community is at increased risk for CVD, presenting a significant opportunity to address cardiovascular health disparities in this community through intentional changes in the structure of medical education.