bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P073: Diabetes and All Cause and Cause-specific Mortality in 111,300 Mexican Women With Healthcare Coverage
Authors: Lozano-Esparza Susana , Lopez-Ridaura Ruy , Ortiz-Panozo Eduardo , González-Villalpando Clicerio , Aguilar-Salina Carlos , Hernández-Ávila Juan Eugenio , Hernández-Ávila Mauricio , Lajous Martín
Published: July 2021

Introduction:
In high-income countries, mortality rates have a twofold increment in subjects with diabetes compared to the general population. Few prospective studies have evaluated the impact of diabetes on mortality in low- and middle-income countries. In Mexico, a five-fold higher mortality due to diabetes was recently reported. Limited access to medical care could explain this poor prognosis.

Hypothesis:
Among women with healthcare coverage in Mexico, diabetes confers a mortality risk similar to what is observed in high-income countries.

Methods:
We evaluated diabetes in relation to all cause and cause-specific mortality in a prospective cohort of 111,300 disease-free women (except for diabetes) with healthcare coverage in the Mexican Teachers’ Cohort. We identified 5,514 (5%) participants who self-reported a diagnosis of diabetes at baseline in 2006-08. Between 2006 and 2015 we identified deaths using the employer’s database and next of kin reports and obtained date and cause of death of 802 women from national mortality databases. In multivariable Cox models we adjusted for sociodemographic factors, healthcare institution, use of preventive health services, body mass index, hypertension, smoking, and physical activity.

Results:
Among participants (42 ± 7.5 years), age-adjusted mortality rate was 4.59 per 1000 person-years (95%CI 3.27, 5.92) for women with diabetes and 1.28 per 1000 person-years (95%CI 1.01, 1.54) for women without diabetes. In multivariable models comparing diabetics versus non diabetics, the hazard ratio (HR) for all-cause mortality was 3.27 (95%CI 2.73, 3.90). The HR for cardiovascular mortality was 3.78 (95%CI 2.46, 5.54), for renal disease mortality 16.89 (95%CI 9.78, 29.4), and for death from infections 7.55 (95%CI 3.58, 15.3).

Conclusions:
In women with healthcare coverage in Mexico, diabetes was associated with a worse prognosis than what is observed in high-income countries, particularly for deaths due to renal disease and infections.
Abstract P081: Psychosocial Resources Are Protective of Diabetes Among African Americans in the Jackson Heart Study
Authors: Glover LáShauntá , Bertoni Alain , Hill-Golden Sherita , Baltrus Peter , Min Yuan-I , Carnethon Mercedes , Taylor Herman , Sims Mario
Published: July 2021

Introduction:
African Americans (AAs) have among the highest prevalence of type 2 diabetes in the U.S. Research has shown that positive affect and supportive networks are associated with better health outcomes and may improve regulation of physiological processes. We examined the extent to which psychosocial resources were protective of diabetes outcomes among a sample of 5,306 AAs.

Hypothesis:
Psychosocial resource measures are inversely associated with prediabetes and diabetes [defined by hemoglobin (Hb)A1c categories] and prevalent diabetes (defined by self-report diabetes status and medication use).

Methods:
Using data from the Jackson Heart Study (JHS), we evaluated the cross-sectional associations of four psychosocial-resource indicators (social support, optimism, religiosity, social networks) with two diabetes outcomes [1) HbA1c categories: normal (HbA1c ≤ 5.7%), at risk/pre-diabetic (5.7% < HbA1c < 6.5%), diabetic (HbA1c ≥ 6.5%) and 2) prevalent diabetes (vs. no diabetes)]. For each psychosocial-resource measure, we created high vs. low categories (median split) and continuous standard deviation (SD) units. Associations with HbA1c categories were examined using multinomial logistic regression to estimate odds ratios (OR 95% confidence interval-CI) of pre-diabetes (vs. normal) and diabetes (vs. normal). Associations with prevalent diabetes were examined using Poisson regression to estimate prevalence ratios (PR 95% CI) of diabetes (vs. no diabetes). Models adjusted for demographics, SES, waist circumference, health behaviors, and depression.

Results:
Participants with diabetes reported fewer psychosocial resources than those with pre-diabetes and normal HbA1c (
p
<0.01). After full adjustment, 1-SD unit increase in
social support
was associated with an 11% lower odds of pre-diabetes (vs. normal HbA1c) (OR 0.89, 95% CI 0.81-0.99). High (vs. low)
religiosity
was associated with an increased odds of diabetes (vs. normal Hba1c) (OR 1.29, 95% CI 1.01-1.64) after full adjustment.
Optimism
and
social networks
were only associated with lower diabetes prevalence after adjustment for demographics and education, respectively.

Conclusion:
With the exception of religiosity, psychosocial-resource measures were inversely associated with diabetes. Social support and social networks, especially, should be considered when addressing the reduction of diabetes burden among AAs.
Abstract P086: A Population-based Study of the Bidirectional Association Between Sleep Apnea and Diabetes in Three Prospective US Cohorts
Authors: Huang Tianyi , Lin Brian , Stampfer Meir , Tworoger Shelley , Redline Susan , Hu Frank
Published: July 2021

Introduction:
Both sleep apnea and diabetes are strong cardiovascular disease (CVD) risk factors with substantial healthcare burden. It is hypothesized that intermittent hypoxemia and sleep fragmentation resulting from sleep apnea may contribute to diabetes through inflammation, insulin resistance and glucose intolerance. Conversely, pre-existing diabetes may promote sleep apnea development through increased abnormalities in autonomic nervous system activity and ventilatory control due to peripheral neuropathy, or through effects on inflammatory pathways. However, no population-based study has simultaneously evaluated the potential bidirectional association between these two highly prevalent disorders.

Methods:
We followed 161,824 participants from the Nurses' Health Study (NHS; 2002-2012), NHSII (1995-2013), and the Health Professional Follow-up Study (1996-2012) who were free of diabetes, CVD and cancer at baseline. Cox proportional hazards model was used to estimate hazard ratios (HR) for developing diabetes according to sleep apnea status. In parallel, we used similar approaches to estimate risk of developing sleep apnea according to diabetes status among 167,277 participants free of sleep apnea, CVD and cancer at baseline. In all 3 cohorts, diagnoses of diabetes or sleep apnea were identified by validated self-reports.

Results:
Similar results were observed across 3 cohorts. In the pooled analysis, 9,370 incident diabetes cases were identified during follow-up. After adjusting for age, sex, menopausal status in women, smoking, alcohol drinking, diet quality, physical activity, sleep duration, regular physical exams, and hypertension, the HR (95% CI) for diabetes was 2.28 (2.07, 2.51) comparing those with versus without sleep apnea. The association was attenuated but remained statistically significant after accounting for waist circumference (WC) and BMI (HR: 1.57; 95% CI: 1.42, 1.73). By contrast, we documented 9,409 incident sleep apnea cases during follow-up. Compared with those without diabetes, the multivariable HR (95% CI) for sleep apnea prior to adjustment for BMI and WC was 1.44 (1.25, 1.67) in individuals with diabetes. Although there was no overall association after the adjustment (HR: 1.04; 95% CI: 0.95, 1.14), an increased risk was observed among those with diabetes who used insulin compared with those without diabetes (HR: 1.38; 95% CI: 1.11, 1.72).

Conclusions:
Sleep apnea is independently associated with an increased risk of diabetes, whereas insulin-dependent diabetes is associated with a higher risk of sleep apnea. Clinical awareness of this bidirectional association may improve prevention and treatment of both diseases and reduce their adverse impact on CVD. Future research aimed at elucidating the mechanisms that underlie each association may identify novel intervention targets.
Abstract P092: Adolescent and Young Adult Women Have Low Cardiovascular Disease Awareness
Authors: Gooding Holly C , Brown Courtney , Stamoulis Caterina , Revette Anna C , DeFerranti Sarah D
Published: July 2021

Introduction:
The American Heart Association (AHA) Go Red for Women campaign has substantially improved awareness of heart disease among adult women over the past fifteen years, as demonstrated by triennial surveys of women ages 25 years and older. Little is known about awareness among younger women, who represent a key time in the life course for primordial prevention. We hypothesized that adolescent and young adult women 15 to 24 years of age would have lower rates of heart disease awareness than women 25 years of age and older.

Methods:
We assessed awareness of heart disease and prevention efforts among young women ages 15-24 years using the AHA National Women’s Health Study survey. Participants were a random convenience sample of 103 women recruited from the waiting rooms of two clinical practices (one community health center and one academic medical center). We performed statistical comparisons of this cohort to responses from the 2012 AHA National Women’s Health Study survey of 168 women ages 25-34 years using the chi-square test (binary responses).

Results:
Only 13 (13%) adolescent and young adult women correctly identified heart disease as the leading cause of death in women. This was significantly lower than the rate of awareness of adult women overall in 2012 (56% of 2432) and of women ages 25-34 years (44% of 168) (p<0.001 for both comparisons). Almost half of the young women surveyed in the current study [(n= 44 (43%)] said they were not at all informed about heart disease. While physicians emerged as the preferred source of information about heart disease among participants, the majority [n=64 (62%)] had never spoken to a health care professional about their risk of heart disease. Most young women surveyed worried little [n = 44 (43%)] or not at all [n = 40 (39%)] about heart disease; mood disorders were the most common concern in this age group, followed by sexual health issues. Despite a lack of general awareness about heart disease, many young women did report engaging in activities known to reduce the risk of heart disease, including getting regular exercise [n = 81 (79%)], maintaining healthy blood pressure [n = 76 (74%)], reducing sugar intake [n = 48 (47%)], and losing weight [n = 48 (47%)]. A significantly higher proportion of women ages 15-24 years aimed to maintain a healthy blood pressure and get regular exercise compared to those ages 24-34 (p<0.02), whereas a similar proportion aimed to lose weight and reduce sugar intake (p>0.7).

Conclusions:
Adolescent and young adult women are largely unaware of heart disease as the leading cause of death in women. As the antecedents of heart disease begin in childhood and adolescence, these findings demonstrate a major unmet need. Given most young women are not worried about heart disease at this life stage, campaigns to promote heart healthy behaviors should underscore the benefits of these prevention behaviors to mood and emotional health.
Abstract P094: Sex Differences in Fitness Outcomes After Participation in a Park-Based After school Program Among Minority Youth
Authors: Messiah Sarah E , D'Agostino Emily M , Patel Hersila H , Hansen Eric , Mathew M. Sunil , Okeke Deidre , Nardi Maria
Published: July 2021

Introduction:
Only 18% of high school girls compared with 37% of boys are reported to meet national physical activity guidelines, but much less is known about sex differences in fitness levels during the elementary and middle school years. This study aimed to describe sex differences in longitudinal fitness outcomes after participation in Fit2Play
TM
, a park-based afterschool health and wellness program targeting high risk youth ages 6-to-14 years old.

Hypothesis:
It was hypothesized that over time boys would have more improvement in (1) cardiorespiratory fitness via the Progressive Aerobic Cardiovascular Endurance Run (PACER) and 400 meter run test; (2) strength via 1-minute timed push-ups and sit-ups; and (3) flexibility via the sit-and-reach test, versus girls.

Methods:
Youth who participated in Fit2Play
TM
for either 1, 2 or 3 school years between 2010-2016 (N=2129, mean age 9.1 years, 52% Hispanic, 48% non-Hispanic black, 54% male) participated in a fitness battery at the beginning and end of the school year(s). Effects of length of Fit2Play
TM
participation on fitness outcomes were assessed via 3-level repeated measures analysis stratified by sex and adjusted for child sociodemographics, weight category, area poverty, and year.

Results:
Adjusted models showed significant improvements for both boys and girls in the PACER and 400 meter run tests (p<0.001 for both), with greater magnitude of effects and dose-response trends for girls after up to 3 years of participation in Fit2Play
TM
. Specifically, from baseline to 1, 2 and 3 years of program participation, girls demonstrated 8% (95% CI: 0.87, 0.97), 14% (95% CI: 0.77, 0.96), and 23% (95% CI: 0.65, 0.92) mean improvement in 400 meter run times versus 9% (95% CI: 0.86, 0.96), 9% (95% CI: 0.82, 1.01), and 17% (95% CI: 0.70, 0.98) for boys, respectively (p<0.001 for all). Significant strength improvements were found for both boys and girls for push-ups (p<.01 for both, though 4%, 11% and 12% higher magnitude of effects in girls vs. boys for 1, 2 and 3 years of participation, respectively), and only girls for sit-ups (p<.001).

Conclusions:
Park-based afterschool physical activity programs have the potential to improve fitness performance in all youth, and particularly girls. Future research should further examine sex differences in the effects of park and other community based programs to ultimately reduce sex disparities in youth fitness, particularly in light of the current youth obesity epidemic that continues to challenge our nation.
Abstract P096: Trends in Lifestyle Habits in US Youth Ages 6 to 19 Years: National Health and Nutrition Examination Survey 2003 to 2014
Authors: Perak Amanda M , Ning Hongyan , Van Horn Linda V , de Ferranti Sarah D , Lloyd-Jones Donald M
Published: July 2021

Introduction:
The AHA emphasizes healthy lifestyle habits in 4 domains for pediatric cardiovascular health: nutrition, body size, physical activity, and smoking. We tested the hypothesis that in recent years among US youth, nutrition and smoking improved, while body size and physical activity did not.

Methods:
We analyzed cross-sectional data in 15,712 youths aged 6-19 years from 6 NHANES surveys: 2003-04, 2005-06, 2007-08, 2009-10, 2011-12, and 2013-14. We applied survey weights to generate US population-level estimates and used multivariate linear regression to test for time-dependent linear trends in lifestyle habits, separately by sex and age group (6-11 vs. 12-19 years).

Results:
See Table. Favorable linear trends were seen across age and sex groups in many nutrient intakes, particularly total energy, solid fats, and added sugars; fiber intake also improved among 6-11 year-old youths. However, prevalence of ideal intakes as defined by clinical guidelines remained low. Favorable trends were also seen in smoking and secondhand smoke exposure. On the other hand, body mass index and waist to height ratio showed no time-dependent trends, except for a small increasing linear trend in the prevalence of obesity for 12-19 year-old youths. Similarly, for physical activity and screen time, the only significant linear trend was decreasing mean physical activity among 12-19 year-old females.

Conclusions:
US youth have generally improved nutrition and avoidance of smoking in recent years, although these habits remain suboptimal in the population. Body size and physical activity are not improving, and may be worsening in adolescents.
Abstract P098: Plasma Levels of Persistent Organochlorine Pollutants, Blood Pressure and Hypertension: A Longitudinal Study
Authors: Donat-Vargas Carolina , Åkesson Agneta , Tornevi Andreas , Wennberg Maria , Sommar Johan , Kiviranta Hannu , Rantakokko Panu , Bergdahl Ingvar A
Published: July 2021

Background:
Persistent organochlorine pollutants (POPs) include several groups of synthetic compounds with high lipophilic and bioaccumulative potential that accumulate in the food chain. Despite their long-term ban, they are still of concern and the general population is constantly exposed to these pollutants at low doses through diet. POPs are proposed to be involved in the atherosclerotic process and to cause endothelial cell dysfunction. We assess longitudinally whether plasma concentrations of different POPs were associated with blood pressure (BP) and risk of hypertension in middle-aged women and men.

Methods:
Study subjects were 850 participants in the Västerbotten Intervention Programme with two blood samples and BP measurements, 10 years apart, during 1990 to 2003 (baseline) and during 2001 to 2013 (follow-up). The POP measured were the fungicide hexachlorobenzene (HCB), the insecticide dichlorodiphenyl-trichloroethane (DDT) –and its persistent metabolite p,p′-dichlorodiphenyl-dichloroethylene (DDE)– and the dioxin-like and non-dioxin-like polychlorinated biphenyls (DL-PCBs, NDL-PCBs). We used generalized estimated equations to assess the associations.

Results:
At both sampling occasions, about 50% had hypertension. DL-PCBs and DDE, but not NDL-PCBs or HCB, were associated with hypertension, while only the association for DL-PCB remained statistically significant after lipid-standardization and adjustment for BMI and total plasma lipids. The multivariable-adjusted OR of hypertension based on repeated measurements were
1.50
(95% CI: 1.07-2.11) for DL-PCBs (3
rd
vs.
1
st
tertile of lipid-standardized POPs). In stratified adjusted analyses, ORs for those born after 1950 increased
: 3.99
(95% CI: 2.15-7.43), while no association was observed among those born earlier. For DEE, when non-adjustment for BMI, the OR of hypertension were
1.43
(95% CI: 1.04, 1.97).

Conclusions:
Based on repeated measurements, the accumulated exposure to the pollutants DL-PCBs and DDE, although less clear for the latter, may disrupt the normal BP levels. Individuals born after 1950 –when early-life exposure to these substances became common– may be pre-disposed for these effects.
Abstract P107: Differences in Cardiovascular Mortality Risk Among African Americans in the Minnesota Heart Survey, 1985-2015, versus African Americans in the Atherosclerosis Risk in Communities Study (ARIC) Cohort: 1987-2015
Authors: George Kristen M , Folsom Aaron R , Steffen Lyn M , Wagenknecht Lynne E , Mosley Thomas H
Published: July 2021

Geographic differences in CVD mortality across the U.S. are well-established, but frequently overlooked. ARIC enrolled African Americans (AA) from Jackson, MS and Forsyth County, NC, areas of the Southeast with some of the highest CVD mortality rates, especially among AAs. The Minnesota Heart Survey enrolled AAs from Minnesota where CVD rates are among the lowest. However, it is not known whether AAs in Minnesota also have low rates. Using these two cohorts, we assessed whether CVD-related mortality risk among AAs differs by region.

Baseline measures of CVD risk factors for MHS were taken in 1985 from a population based sample of AAs, ages 45 to 65, living in the Minneapolis-St. Paul metropolitan area. These same measures were made at ARIC visit 1 (1987-89) in AA participants of the same age residing in Jackson, MS and Forsyth County, NC. CVD and total mortality were identified using ICD codes for underlying cause of death from State and National Death Index records in both cohorts. We compared MHS and ARIC on CVD death rates using Poisson regression, prevalence of risk factors, and risk factor hazard ratios using Cox regression.

After risk factor adjustment, AA men in MHS had a rate of 5.2 (95% CI: 3.2, 7.2) CVD deaths per 1000 person-years compared to 15.1 (95% CI: 13.1, 17.1) for AA men in ARIC. For AA women, MHS had 4.1 (95% CI: 2.7, 5.5) CVD deaths per 1000 person-years versus 10.2 (95% CI: 9.0, 11.4) in ARIC. CVD mortality rates were higher in Jackson than Forsyth County within ARIC. CVD death rates paralleled risk factor prevalence at baseline. Compared to MHS, ARIC had significantly higher total cholesterol (215 vs. 202 mg/dL), albeit higher HDL cholesterol (55 vs. 53 mg/dL), as well as higher anti-hypertensive medication use (41 vs. 30%), diabetes (13 vs. 11%) and BMI (30 vs. 29 kg/m
2
), while smoking did not differ. Despite risk factor differences, hazard ratios of CVD death associated with each risk factor did not differ between studies even after inclusion of a competing risk of non-CVD death.

In conclusion, the CVD death rate was lower in AAs in MHS than in AAs residing in the Southeast in ARIC largely due to lower risk factor levels, since the hazard of CVD death for each risk factor did not differ. Study differences reflect incompletely identified geographic variation that need further exploration, especially in the context of health disparities, but support maintaining low risk as a key to CVD prevention.
Abstract P144: Cardiovascular Risk Assessment in Western Honduras; An Epidemiological Perspective
Authors: Godoy Rivas Carlos A , Montalván Eleazar E , Urrutia Samuel A , Rodríguez Aida A , Ordoñez Eva E , Murillo Axel A , Rivera Ricardo J , Duarte Karla G , Viana Artemisa J , Aguilera José L , Young Laura , Torres Karla P , Ahmed Haitham
Published: July 2021

Background:
Cardiovascular Disease (CVD) epidemiology varies significantly among Low and Middle-Income Countries. Honduras is the Central American country with the highest ischemic heart disease and CVD mortality rates. The objective of this study is to provide an epidemiologic perspective of CVD in Western Honduras by analyzing cardiovascular (CV) risk in a population of Hispanics/mestizos and calculating their predicted CVD mortality using Cardiovascular Risk Assessment Scores (CVRAS) such as AHA/ACC Pooled-Cohort Equations (PCEs), Framingham Risk Score (FRS) and Multi-Ethnic Study on Atherosclerosis (MESA) Risk Score.

Methods:
Data was derived from Torres et al study, which was a cross-sectional, primary-prevention study, including 382 subjects between 45-75 years, in Copán, Honduras, between November 2016 and January 2017.

Results:
Out of 379 subjects meeting inclusion criteria, 38% (143 of 379) were male and 62% (237 of 379) were female. Age was 57 ± 8.2 for men and 58 ± 7.7 for women. Prevalence of hypertension was 49.7% (71 of 143) in men and 47.7% (113 of 237) in women; 91.3% (168 of 184) were being treated. DM was present in 19% (27 of 143) of men and 22.1% (52 of 237) of women; 96.2% (75 of 79) were being treated. Obesity was 24.5% (35 of 143) in men and 24.1% (57 of 237) in women. Total cholesterol was ≥ 200 mg/dl in 63.1% (239 of 379) of subjects, 21.8% (52 of 239) were taking lipid-lowering medications. For men and women respectively; AHA/ACC-PCEs was ≥7.5% (high-risk) in 62.2% (89 of 143) and 29.8% (71 of 237), FRS was ≥20% in 46.2% (66 of 143) and 15.2% (36 of 237), and MESA Risk Score was ≥7.5% in 70.6% (101 of 143) and 17.7% (42 of 237).

Conclusions:
After collecting anthropometric and laboratory data, calculation of CVRAS showed significantly elevated rates of high-CV risk patients according to all 3 scores. This is the first study of its type in Honduras. Efforts should be made to aggressively reduce CVD risk factors, and follow this cohort of subjects to better understand CVD morbidity and mortality in Western Honduras.
Abstract P145: Ideal Cardiovascular Health and Incidence of Atherosclerotic Cardiovascular Disease in a Large Integrated Health Care System
Authors: Rana Jamal S , Liu Jennifer , Moffet Howard , Karter Andrew J , Jaffe Marc , Go Alan S , Sidney Stephen
Published: July 2021

Background:
The American Heart Association (AHA) introduced the concept of cardiovascular health (CVH) and defined “ideal,” “intermediate,” and “poor” CVH categories for adults based on cardiovascular disease risk factors and health behaviors. We sought to examine the association between these levels of CVH and incident atherosclerotic cardiovascular disease (ASCVD) events in a large diverse population.

Methods:
In a large integrated healthcare delivery system in Northern California , we gathered 6 AHA metrics (smoking status, physical activity, body mass index, blood pressure, total cholesterol, and blood glucose) during 2013-2014, graded on a scale of 0 to 2, with 2 indicating "ideal" status, 1 "intermediate" status, and 0 "poor" status. Points were summed to define three categories of Poor (0-6), Intermediate (7-9) and Ideal (10-12) CVH. ASCVD was defined as non-fatal myocardial infarction (MI), fatal coronary heart disease (CHD) and fatal and non-fatal stroke from electronic medical records and state death certificates during 2015. Incident ASCVD rates per 100,000 person-years were calculated.

Results:
Among 1,103,583 adult members (55.5% female) receiving outpatient care with all 6 metrics, there were 194,957 (17.7%) age 18-39, 585,449 (53.0%) age 40-64, and 323,177 (29.3%) age >65 years. There were 74,737 (6.8%) Blacks, 171,058 (15.5%) Hispanics and 225,303 (20.4%) Asian/Pacific Islanders. Poor CVH was present in 240,831 (21.8%), Intermediate in 584,013 (52.9%) and Ideal CVH in 278,739 (25.3%). During 2015, incidence of overall ASCVD, CHD (non-fatal MI and fatal CHD) and stroke (fatal and non-fatal stoke) was lower with better CVH metrics (p < 0.0001 for trend) (Figure).

Conclusions:
In a diverse “real world” population, a significantly lower incident of ASCVD was noted among individuals with Ideal CVH. This indicates continued need for large scale efforts to track and improve cardiovascular risk factors and behaviors.
Abstract P146: Public Health Surveillance Reveals an Increase in Health Care Utilization for Generic versus Brand-name Warfarin Users
Authors: Leclerc Jacinthe , Blais Claudia , Rochette Louis , Hamel Denis , Guénette Line , Poirier Paul
Published: July 2021

Background:
Even with many direct oral anticoagulant options, brand-name or generic warfarin is still widely used to prevent atherothrombotic events in cardiology. Federal standards regulate bioequivalence of generic vs. brand-name drugs through comparative bioavailability studies but does not regulate clinical equivalence nor tolerability in a “real-life” settings. Through public health surveillance, we have evaluated the impact of the generic warfarin commercialization on health care utilization: emergency room (ER) consultations or hospitalizations.

Methods:
We used an interrupted time series analysis using the Quebec Integrated Chronic Disease Surveillance System, a surveillance system from the second populous province in Canada (~8.3 million in 2017). Rates of health care utilization for warfarin users (n=280,158) aged ≥ 66 years were calculated for 6-month periods, 5 years before up to 15 years after warfarin commercialization (from January 1996 to January 2016). Periods before and after generic warfarin commercialization were compared by negative binomial segmented regression models for all users with a specific variable for generic or brand-name users. Sensitivity analyses were also conducted.

Results:
Generic warfarin analogs (n=5) were commercialized from January 2001. There was an approximated mean rate of 1134 ER or hospitalizations for 1000 brand-name and generic users per 6-month period, similar before and after generics commercialization. After generics commercialization, there was an immediate increase in rates of health care utilization for generic (9.9%) vs. brand-name users (0%), a statistically significant difference (9.9% [95% confidence interval: 4.4% to 15.5%],
p
= 0.0001). Rates of health care utilization remained stable and higher for generic vs. brand-name users throughout the period after generics commercialization.

Conclusion:
Among generic warfarin users, we observed an increased rates of health care utilization soon after generics commercialization. Risk and survival analysis studies controlling for potential confounders are required to deepen this pharmacovigilance signal as stricter licensing process may be required.
Abstract P152: Health Informatics: A New Hope for Familial Hypercholesterolemia
Authors: Joseph Amy P , Mullett Charles J , Armistead Matthew , Cox Jeff , Denney Michael , Neal William A , Pyles Lee A
Published: July 2021

Introduction:
Electronic Health Records (EHRs) benefit record keeping, information collation, error prevention, and charge capture. They provide a large database of clinical information that can be used for research. Sorting vast amounts of data manually is inefficient, hence, an effectual, validated method is required to uncover information from large sets of data and generate knowledge.

The U.S., and especially West Virginia, has a tremendous burden of cardiovascular disease (CVD). Undiagnosed Familial Hypercholesterolemia (FH) is an important factor for CVD in the U.S. FH results in elevated levels of LDL from childhood and early atherosclerotic disease. We are interested in better screening processes for FH. One method is to detect adults with coronary artery disease (CAD) and determine if their lipid levels are indicative of FH. Relatives and children can then be screened for FH and treated. Efficient identification of a CAD phenotype from EHRs is an important initial step in this screening process.

Hypothesis:
We hypothesized that a CAD phenotype detection algorithm that uses discrete data elements from EHRs can be validated as a precursor to detection of FH.

Methods:
We developed an algorithm to detect a CAD phenotype, which searched through discrete data elements, such as diagnoses lists (ICD-10) and procedure (CPT) codes. Direct inspection of EHR discrete data avoided the need for artificial intelligence, such as natural language processing.

The algorithm was applied to a cohort of 1,000 patients with varying characteristics. We then determined which patients had CAD by systematically going through EHRs.

Following this, we revised the algorithm by refining the constraints under which it operated. We ran the algorithm again on the same 1,000 patients, and determined the accuracy of the modified algorithm.

Results:
Manual validation of the 1,000 patients resulted in 413 with CAD and 587 without. The original algorithm distinguished 488 CAD positive patients and 512 CAD negative patients. This was 89% accurate, 96% sensitive, and 85% specific.

After revising the algorithm and applying it to the same cohort, it determined that there were 474 CAD patients and 526 without CAD. This was 93% accurate, 99% sensitive, and 89% specific.

Conclusion:
EHR usage has created a large pool of minable clinical data. However, without an efficient method to obtain inferences from it, the information cannot be effectually utilized. We have created an algorithm that detects CAD on a large scale with high accuracy. It has proven to be useful among a varied patient population. Since the constraints that are used, such as ICD codes and CPT codes, are universal, it can be utilized across many hospital systems; although, local validation is prudent. Using this algorithm can select a population with a propensity for FH, thereby allowing us to screen and manage patients with undiagnosed FH or other familial dyslipidemias.
Abstract P160: Relationship of Physical Function and Quality of Life in Elderly Patients With Acute Decompensated Heart Failure: The Rehabilitation Therapy in Older Acute Heart Failure Patients (The REHAB-HF Trial)
Authors: Aladin Amer I , Whellan David , Mentz Robert , Reeves Gordon , Duncan Pamela , Malaver Diego , Rosenberg Paul , Fitzgerald Kathleen , Kitzman Dalane
Published: July 2021

Introduction:
Older patients with acute decompensated heart failure (ADHF) have impaired physical function (PF) and reduced quality of life (QOL). However, the relationship between impairments in PF and QOL are unknown but relevant to clinical practice and design of targeted intervention trials in this high-risk population.

Methods:
We assessed 202 consecutive patients hospitalized with ADHF in the multicenter Rehabilitation Therapy in Older Acute HF Patients (REHAB-HF) Trial. Standard measures of PF included the Short Physical Performance Battery (SPPB), a validated PF outcome measure in frail elderly, and 6-minute Walking Distance (6MWD). QOL was assessed by Kansas City Cardiomyopathy Questionnaire (KCCQ). Pearson’s correlation statistics examined associations between PF and QOL. Stepwise regressions were performed to identify independent predictors of QOL including PF measures, demographics, and disease severity indicators (NYHA class, previous hospitalizations, duration of current hospitalization, and number of HF signs and symptoms).

Results:
Participants were 72±7.5 years, BMI 33.2±8.8 kg/m
2
, 54% women, 52% non-white, 52% with reduced ejection fraction, and 44% with previous hospitalizations within 6 months. Participants had marked deficits in PF (SPPB 6.0±2.5 units, 6MWD 185±99 meters) and low QOL (KCCQ Physical Limitation Score (PLS) 47.3±23.8). There were modest but highly significant correlations of QOL measures with SPPB, 6MWD, and number of HF symptoms and signs (Table). Using stepwise regressions, 6MWD and BMI were modest, significant independent predictors of QOL (partial r=0.18, p=0.012 and partial r=-0.27, p=0.0003, respectively), while SPPB, demographics, and HF severity indicators were not.

Conclusion:
In older, hospitalized ADHF patients, PF and QOL are both severely impaired, but are only modestly related. PF and QOL assess unique domains of impairment and provide complementary information for characterizing clinically meaningful patient-oriented outcomes in ADHF.
Abstract P161: Self-Management Resources in Heart Failure: A Prospective Community Study
Authors: Fabbri Matteo , Manemann Sheila , Boyd Cynthia , Wolff Jennifer , Chamberlain Alanna , Weston Susan , Yost Kathleen , Finney Rutten Lila , Griffin Joan , Killian Jill , Roger Veronique
Published: July 2021

Introduction:
Little is known about the characteristics and resources that enable patients with heart failure (HF) to engage in effective self-management. To address this gap in knowledge, we measured personal and health care resources for self-management and examined associations with mortality among patients with HF.

Methods:
We surveyed 5543 residents of 11 counties in Southeast Minnesota with a first-ever code for HF [International Classification of Disease, Ninth Revision code 428 or Tenth Revision code I50] between 1/1/2013 and 3/31/2016. Self-management resources were measured with the health care and personal subscales of the Chronic Illness Resources Survey (CIRS), both of which included 3 questions on a 5-point scale. The responses were averaged and participants were categorized as low if the mean score was below the median of the distribution (range from 1 to 5). The survey was returned by 2866 participants (response rate 52%) and those with complete data on the main items of interest were retained for analysis (N=2212). Cox proportional hazards regression was used to determine the association between each subscale and mortality.

Results:
Among 2212 participants (mean age 72.8 years, 54.1% men) the median health care score was 4, while the personal score was 3. Those with low health care resources were older and less educated than those with a higher score (p<0.05), while those with low personal resources had less comorbidities and lower education attainment compared to those with a higher score (p<0.05). After a mean (SD) follow-up of 1.3 ± 0.6 years, 207 deaths occurred. Low levels of both self-management resources were associated with an increased risk of death compared with patients with high levels (Table).

Conclusions:
Having limited self-management resources is associated with an increased risk of mortality among patients with HF. Thus, interventions aimed at supporting self-management among patients with HF may improve outcomes.
Abstract P169: Antibodies to Citrullinated Protein Antigens (ACPA), Left Ventricular Mass and Ejection Fraction in the Multi-Ethnic Study of Atherosclerosis
Authors: Hughes-Austin Jan M , Katz Ronit , Majka Darcy S , Criqui Michael H , Robinson William H , Firestein Gary S , Hundley W G , Ix Joachim H
Published: July 2021

Background:
Antibodies to citrullinated proteins (ACPA) are elevated in patients with rheumatoid arthritis (RA) and have been linked to altered left ventricular (LV) structure and function in RA. ACPA are detectable years before RA onset and in some individuals who do not develop RA. Among individuals without RA and without heart failure in MESA, we investigated associations between ACPA, LV mass, and LV ejection fraction (LVEF).

Methods:
In a cross-sectional subsample of 1232 MESA participants, we measured ACPA using a multiplex array of 38 different ACPA. Each ACPA was defined as positive (+) if > 95
th
percentile cut-off in MESA. Number of (+) ACPA were summed for each participant (range 0-38). We compared ACPA(-) to ACPA(+) participants, and examined the association of number of ACPA with both outcomes. LVmass (g) and LVEF (%) were measured on cardiac MRI. We analyzed associations using generalized linear regression and adjusted for covariates listed in the table.

Results:
Mean age was 65 years. The sample was 50% women, 40% Caucasian; and 31% had ≥ 1 (+) ACPA. Among ACPA(+) participants, median number (+) was 2 (IQR 1-6). ACPA(+) participants were similar to ACPA(-) participants in age, gender, and race/ethnicity, but had higher IL-6 levels. Mean LVmass for ACPA(+) vs ACPA(-) participants was 147g(39) and 146g(39), respectively; mean LVEF was 69%(7) and 70%(8), respectively. In adjusted analysis, LVmass and LVEF did not differ significantly between ACPA(+) and ACPA(-) participants. However, for every higher number of (+) ACPA, LVEF was 0.07% lower (p=0.02). Among individual ACPA, antibodies to Filaggrin 48-65 arg2v1cyc (p=0.04), histone 2B (p=0.01), and histone 2Bcit (p=0.02) were significantly associated with lower LVEF. No individual ACPA was associated with LVmass.

Conclusion:
In community-dwelling individuals without RA or heart failure, greater numbers of detectable ACPA were associated with lower LVEF, but not LVmass. Future studies are required to determine whether ACPA are associated with incident heart failure.
Abstract P223: Cardiometabolic Disease Costs Associated With an Unhealthy Diet in the United States
Authors: Jardim Thiago , Mozaffarian Dariush , Abrahams-Gessel Shafika , Sy Stephen , Lee Yujin , Junxiu Liu , Huang Yue , Wilde Parke , Micha Renata , Gaziano Thomas
Published: July 2021

Introduction:
Despite the clear association between poor diet and cardiometabolic diseases (CMD) and the overall economic burden of such conditions, the costs of an unhealthy diet pattern have not been assessed for the US population.

Aim:
Estimate the costs of CMD related to suboptimal intakes of 10 specific dietary factors in the US adult population.

Methods:
A validated microsimulation model (CVD PREDICT) was populated by weighted sampling (with replacement) of individuals aged 35–85y from the 2009-2010 and 2011-2012 National Health and Nutrition Examination Surveys (NHANES), in order to create an US representative model population. Consumption of 10 foods/nutrients associated with CMD were assessed: fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, and sodium. Cardiovascular disease progression and events were simulated and annual healthcare costs estimations were calculated. The model compared reported consumption of the 10 food/nutrients in the NHANES surveys to a hypothetical situation in which the consumption level of these nutrients were optimal. Each food/nutrient was assessed individually and combined. Estimates were stratified by gender, age, race and insurance.

Results:
The 2012 annual cost of an unhealthy diet was $USD 280 (Acute $USD 236, Chronic $USD 40 and Drug $USD 4) per adult. Individually the food/nutrient consumed below optimal levels that imposed the highest CMD economic burden was nuts/seeds ($USD 75) while non-optimal red meat consumption was associated with the lowest cost per person ($USD 3). Unhealthy diet costs of CMD by gender, age group, race and insurance are provided in table 1. The annual unhealthy diet cost of CMD in the US was $USD 44.9bn in 2012. Acute care costs represent 84.3% of this total ($USD 37.9bn).

Conclusions:
Suboptimal diet accounts for substantial CMD costs in the US, highlighting the need for timely implementation of diet policies to address these burdens.
Abstract P224: Higher Fruit and Vegetable Intake Was Associated With Lower Total and Cause-Specific Mortality in a Nonlinear Dose-Response Manner
Authors: Wang Dong D , Bhupathiraju Shilpa N , Li Yanping , Rosner Bernard A , Sun Qi , Rimm Eric B , Manson JoAnn E , Willett Walter C , Hu Frank B
Published: July 2021

Introduction:
The strength and dose-response relationship between fruit and vegetable intake and mortality are still subjects of debate.

Hypothesis:
We hypothesized that higher fruit and vegetable intake was associated with lower total and cause-specific mortality in a nonlinear dose-response manner.

Methods:
We followed 66,719 women from the Nurses’ Health Study (1984-2012) and 42,016 men from the Health Professionals Follow-up Study (1986-2012) who were free from cardiovascular disease (CVD), cancer and diabetes at baseline. Diet was assessed using food frequency questionnaires at baseline and updated every 2 to 4 years.

Results:
Our study documented 28,333 deaths during follow-up. The 3rd quintile of fruit and vegetable intake was associated with the lowest hazard ratio (HR) of total mortality (HR, 0.87, 95% CI, 0.83-0.90,
P
nonlinear
<0.001) compared to the 1st quintile. The nonlinear dose-response relationship plateaued at about 5 servings/day (svg/d), but above that level, higher intake was not associated with additional risk reduction. We found similar nonlinear associations for CVD, cancer and respiratory disease mortality. Compared to fruit and vegetable intake <1.5 svg/d, the intake level ≥5 svg/d was associated with HRs (95% CI) of 0.84 (0.75-0.93), 0.82 (0.72-0.93) and 0.55 (0.44-0.67) for cancer, CVD and respiratory disease mortality, respectively. Among individual fruits and vegetables, the associations of intakes with mortality were heterogeneous. Higher intakes of most fruit and vegetable subgroups were associated with lower total mortality, whereas higher intake of starchy vegetable such as peas and corn was not associated with total mortality.

Conclusions:
Higher fruit and vegetable intake was associated with lower mortality; the lowest mortality was observed among those who consumed 5 servings of fruit and vegetables per day (2 servings of fruit and 3 servings of vegetables daily). Our findings also suggest the presence of heterogeneity in the health benefits of individual fruits and vegetables.
Abstract P249: Differential Response to a Lifestyle Intervention Between Parents and Non-parents
Authors: Bramante Carolyn T , Thornton Rachel L , Pilla Scott J , Maruthur Nisa , Venkataramani Maya , Clark Jeanne M
Published: July 2021

Background:
Understanding and preventing cardiovascular disease among parents is important for reducing intergenerational transfer of cardiovascular disease. Prior research has not examined the effect of lifestyle interventions among parents compared to non-parents. We performed a retrospective analysis of the Look AHEAD (Action for Health in Diabetes) trial to assess outcome differences between participants with children younger than 18 years living in the home (referred to as parents) and those without (referred to as non-parents).

Methods:
Look AHEAD randomized adults aged 45-75 years with type 2 diabetes and BMI>25kg/m
2
to an intensive lifestyle intervention aimed at weight loss, or to a diabetes support and education (control) arm. We examined effects of the intervention at 12 months on objectively measured change in weight (percent of baseline) and cardiovascular risk factors, and change in self-reported dietary intake. To determine whether parenting modified these outcomes, we used linear regression (continuous outcomes) or logistic regression (categorical outcomes) with a multiplicative interaction term for parenting status and treatment arm, adjusted for sociodemographic and clinical characteristics. Modeled results of the interaction are presented.

Results:
Among 4,547 participants at baseline, 699 (15%) were parents. Parents were younger than non-parents (54.1 vs 59.0 years, p<0.001); more likely to be black (20.2% vs 15.4%) or Hispanic (19.3% vs 12.5%), p<0.001; and more likely to have a professional degree (6.7% vs 5.0%) or no high school education (8.5% vs 5.7%), p<0.001. Age-adjusted baseline prevalence of chronic disease was similar for parents and non-parents. In response to the intervention (treatment minus control arm), parents lost less weight than non-parents, (-7.1% vs -8.3%, p=0.019); and had less improvement in waist circumference (-5.6cm vs -7.2cm, p=0.008). There were trends towards parents having less improvement in triglycerides (-6.0mg/dl vs -17.7mg/dl, p=0.060) and servings of sweets/fats consumed per day (-0.4 vs -0.6, p=0.055).

Conclusions:
In a clinical trial of an intensive lifestyle intervention for patients with type 2 diabetes, participants with children living in the home had less favorable response to the intervention for change in weight and waist circumference. More research is needed to understand the association of parenthood with health behaviors to optimize cardiovascular risk reduction interventions for parents.
Abstract P250: Insulin Resistance During Pregnancy is Inversely Associated With Gynoid Fat Distribution Postpartum
Authors: Ingram Katherine H , Lopez Roxanna
Published: July 2021

An association between abdominal adiposity and insulin resistance is well-established. Recent research indicates that subcutaneous fat accumulation in the lower body may be associated with higher levels of insulin sensitivity.

Hypothesis:
This pilot study tested the hypothesis that the distribution of body fat in the lower body after pregnancy is negatively associated with gestational insulin resistance.

Methods:
In 32 nulliparous pregnant women (age 27±4.5, BMI 29.5±7.9, 69% non-hispanic white), the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) was computed from fasting glucose and insulin at 24-28 weeks gestation. Body composition was assessed at mid-gestation (18-20 weeks) and at four weeks post-partum. Total body fat was estimated via bioelectrical impedance (InBody 720) and skinfold thicknesses were measured at seven sites. Dual-energy xray absorptiometry (DXA) measures of regional fat (gynoid, visceral, and leg) were obtained post-partum only. Gestational weight gain was monitored by medical records. Partial correlation analyses were controlled for age and race and then analyses were repeated controlling for baseline (mid-gestation) body fat percent. HOMA-IR was log-transformed for normality.

Results:
HOMA-IR was associated with post-partum body fat (
r
=0.45,
p
< .05) and adiposity in the trunk region (
r
=0.58, 0.57 and 0.52 for DXA visceral fat, suprailiac skinfold, and abdominal skinfold, respectively,
p
< .01), but not with gestational weight gain (
r
=.07,
p
= ns), DXA gynoid region (
r
= 0.26,
p
= ns), or any other leg measure. When analyses were further controlled for baseline body fat, post-partum measures of lower-body adiposity were strongly and negatively correlated with HOMA-IR (
r
= -0.66, -0.48, and -0.48 for thigh skinfold, DXA gynoid, and DXA leg, respectively,
p
< .05 for all). Neither DXA visceral fat (
r
= .23;
p
= ns) nor any other post-partum fat measures were associated with HOMA-IR when controlling for baseline body fat.

Conclusions:
Gestational insulin resistance was negatively associated with post-partum thigh fat accumulation, independent of overall body fat. These data indicate that insulin sensitivity may be associated with the ability to store fat in the lower body and should warrant further study of subcutaneous leg fat as a metabolically “healthy” storage depot.