bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract MP085: Cognitive Impairment Mediates the Impact of Short Sleep Duration on Mortality in Individuals with Cardiovascular or Cerebrovascular Disease
Authors: Fernandez-Mendoza Julio , He Fan , Vgontzas Alexandros N , Liao Duanping , Bixler Edward O
Published: July 2021

Background:
Cardiovascular disease (CVD) and cerebrovascular disease (CBV) have been associated with short sleep duration and mortality. Furthermore, short sleep duration has been associated with impaired cognition. Most studies have been limited by using self-report measures and treating sleep duration as a sole, independent predictor, thus, its role in predicting mortality is still not well-established.

Hypothesis:
We hypothesized that 1) short sleep duration increases the impact of CVD and CBV on mortality and 2) cognitive impairment mediates the association of short sleep duration with mortality in those with CVD or CBV.

Methods:
We addressed this question in the Penn State Adult Cohort, a random, general population sample of 1,741 men and women (48.7 ± 13.5 years) who were studied in the sleep laboratory and followed-up for 16.7 ± 4.6 years. CVD was defined by a history of heart disease, including hypertension or diabetes, and CBV by a history of stroke. Polysomnographic (PSG) total sleep time was classified as normal (≥ 6 hours) and short (< 6 hours) sleep duration based on the median of the cohort. All individuals underwent a comprehensive neuropsychological evaluation, including Symbol Digit Modalities Test, Trail Making Test, Benton Visual Retention Test, Thurstone Word Fluency Test, and Mini-Mental State Examination. We tested the interaction between CVD, CBV and PSG sleep duration on mortality using Cox proportional hazard models controlling for multiple potential confounders.

Results:
The hazard ratios (95%CI) of mortality associated with CVD and CBV were 0.9 (0.6-1.3) and 1.3 (0.5-3.1) for individuals with normal sleep duration and 1.8 (1.3-2.5) and 2.4 (1.3-4.4) for individuals with short sleep duration (P-interaction < .05). In individuals with CVD or CBV, short sleep duration was associated with impaired processing speed, executive attention, and short-term memory (all Ps < .05). Cognitive impairment significantly mediated the impact of short sleep duration on mortality in those with CVD or CBV [proportion of mediation effects were 6.5% (1.4%-18.6%), 4.5% (0.4%-14.2%), and 6.2% (1.0%-18.4%) for processing speed, executive attention and short-term memory, respectively].

Conclusions:
The risk of mortality associated with CVD and CBV is significantly increased in those with short sleep duration. Although cognitive impairment significantly mediated this association, its modest effect suggests that future studies should examine other underlying mechanisms linking short sleep duration with mortality in individuals with CVD or CBV.
Abstract P028: MY Program - Modified Yoga After Cardiac Surgery Reduces Stress, Pain and Anxiety
Authors: McGonigle Sharon , Styra Rima , St.Jacques Arianne , Bailey Barbara , Dimas Michelle
Published: July 2021

Introduction:
Despite the physical benefits associated with cardiac surgery procedures, between 30-60% of all patients experience moderate to high levels of anxiety and/or depression, which can remain elevated up to 6 months post surgery. Traditional postoperative education classes do not provide an avenue for patients and families to deal with their physical and mental stress. Studies indicate that a holistic class, allowing individuals to focus on their inner-self would prove to have positive outcomes. We hypothesized that a modified yoga program (MY Program), tailored to the physical needs of post cardiac surgery patients, would have a positive effect on participants perceived stress, pain and anxiety levels.

Method:
Postoperative cardiac surgery patients at our institution were eligible to participate in our innovative MY Program during their hospitalization. Sessions were held twice weekly in an education room on the surgical ward, and were led by a certified yoga instructor. Participants were seated, with all positions and postures (asanas) being modified for a seated position. The forty-five minute sessions started and finished with relaxation and meditation, including the incorporation of breathing exercises that are modified to account for post-operative difficulties such as splinting. The patients completed two questionnaires: anxiety questions of the HADS (Hamilton Anxiety and Depression Scale) and a survey regarding their overall experience post-yoga.

Results:
There were 112 participants, of which 61% ( 68 of 112) were male, age range of 20 to 89. Female patients reported experiencing lower levels of state anxiety compared to men, although not statistically significant (
p
= .11). Overall feelings of anxiety were relatively low-moderate amongst the participants post-yoga anxiety scores. Post-yoga questionnaire data analysis indicated that 98.8% (110 of 112) of patients found the session helpful, 91.1% (102 of 112) thought the setting was comfortable, 93.7% (104 of 112) would attend the class again, 100% (112 of 112) of patients would recommend the class to others, 89.2% (99 of 112) found that the session helped with their pain after surgery, 97.4% (109 of 112) reported that the session helped with their stress, and 91.7% (102 of 112) of patients found that their breathing improved after the class. Overall, males and females agreed on their satisfaction with the yoga intervention.

Conclusion:
Cardiac surgery is physically and mentally challenging for patients and families. Educational sessions do not currently provide adequate stress and anxiety relief. The MY program demonstrated that a holistic yoga class, incorporating breathing exercises, meditation and relaxation techniques reduced levels of stress, pain and anxiety in participants.
Abstract P034: Comparison of the Prognostic Value of 1,5-anhydroglucitol (1,5-AG) and the Oral Glucose Tolerance Test (OGTT) in the Atherosclerosis Risk in Communities (ARIC) Study
Authors: Warren Bethany , Lee Alexandra K , Ballantyne Christie , Hoogeveen Ron , Pankow James S , Kottgen Anna , Selvin Elizabeth
Published: July 2021

Introduction:
1,5-AG is a biomarker that reflects hyperglycemic excursions. Unlike the OGTT, 1,5-AG requires only a single blood draw and is a non-fasting test. It is unknown if 1,5-AG could serve as a substitute for OGTT and whether it provides complementary information to fasting glucose (FG) for prediction of diabetes and long-term clinical outcomes.

Methods:
We included 6,711 ARIC participants without diagnosed diabetes, chronic kidney disease (CKD), and CVD that attended visit 4 (1996-98). Participants were followed for up to 18 years for incident diagnosed diabetes, CKD, CVD, and all-cause mortality. We used Harrell’s C-statistic from Cox models to compare the prognostic value of 1,5-AG to OGTT beyond a base model of demographic factors and body mass index. Restricted cubic splines (4 knots) were used to flexibly model the biomarkers with each of the outcomes.

Results:
Both OGTT and 1,5-AG provided information beyond the base model for risk discrimination of incident diagnosed diabetes (
p
<0.05; Table). However, OGTT provided statistically significantly more information than 1,5-AG (difference in C-statistic: 0.087 (95%CI, 0.075, 0.099)). While 1,5-AG otherwise did not provide more information for future outcomes than the base model, OGTT statistically significantly improved the base model for prediction of CKD, CVD, and all-cause mortality. For incident diagnosed diabetes, inclusion of FG in the models maintained that OGTT provided more information than 1,5-AG for risk discrimination. Inclusion of all three biomarkers (FG, 1,5-AG, and OGTT) was not statistically significantly better than a model with FG and OGTT for future diagnosed diabetes (
p
=0.687).

Conclusion:
1,5-AG could not sufficiently substitute for the OGTT as a test to identify those at risk of future diabetes. Additionally, glycemic excursions captured by 1,5-AG did not provide additional prognostic value beyond glucose-based tests among those without diagnosed diabetes, suggesting the utility of 1,5-AG is limited to persons with overt diabetes.
Abstract P043: Higher Levels of CRP and IL-6 are Associated With Femoral Artery Plaque Presence, but Not Plaque Characteristics: The San Diego Population Study (SDPS)
Authors: Suder Natalie , Barinas-Mitchell Emma , Allison Matthew , Criqui Michael , Ix Joachim , Jenny Nancy , Wassel Christina
Published: July 2021

Introduction:
The potential involvement of c-reactive protein (CRP), interleukin (IL)-6 and intracellular adhesion molecule (ICAM)-1 in the destabilization, erosion, or rupture of arterial plaque, particularly plaques in the lower extremity arteries is not well-established. Thus, we sought to determine whether circulating levels of CRP, IL-6, and ICAM-1 were associated with the presence, burden, and characteristics of femoral artery plaques.

Methods:
The San Diego Population Study is a prospective, population-based, multi-ethnic cohort of 1103 men and women averaged age 70 at a follow up exam taking place from 2007-11. At this exam, B-mode ultrasound was used to measure plaque presence, burden, and characteristics, including total plaque area (TPA), mean grey-scale median (GSM), and presence of calcification. Plaques were assessed in the left and right superficial and common femoral arteries. Plaque presence was defined as any plaque in any arterial segment, while plaque burden was total number of plaques summed over all four segments. Circulating CRP, ICAM-1, and IL-6 were also measured at this exam. Associations of CRP, IL-6, and ICAM-1 with plaque presence and burden were assessed using logistic and zero-inflated Poisson regression, respectively. Among those with plaque, linear and logistic regression were used to assess associations of the biomarkers with plaque characteristics. All models adjusted for age, sex, race/ethnicity, BMI, BP, statin use, smoking status, diabetes, peripheral artery disease, and chronic kidney disease.

Results:
Higher circulating CRP was significantly associated with plaque presence with participants in the highest quartile of CRP having 1.8 times higher odds of having femoral plaque compared to those in the lowest quartile. Participants in the highest quartiles of CRP and IL-6 were significantly more likely to have greater plaque burden compared to those in the lowest quartiles (CRP OR=1.64, 95% CI=1.09-2.44; IL-6 OR=1.65, 95%CI=1.06-2.55). No associations were observed between circulating biomarkers and plaque characteristics, including TPA, GSM, or calcification.

Conclusions:
Higher levels of circulating CRP and IL-6 are associated with greater plaque burden in the femoral arteries of participants in the SDPS; however, these biomarkers do not appear to be associated with characteristics of femoral artery plaques. These results are consistent with findings in the carotid and coronary arteries.
Abstract P059: Multiple Cause-of-Death Analysis Reveals Under Reporting of Disease Burden for Diabetes
Authors: Hastings Katherine G , Hu Jiaqi , Marques Nadejda , Daza Eric J , Cullen Mark , Palaniappan Latha
Published: July 2021

Introduction:
Despite being considerably under reported as the underlying cause of death on death certificates, and consequently on mortality figures, diabetes is among the ten leading causes of death in the U.S. A multiple cause-of-death analysis shows the extent to which diabetes is associated with other leading causes of death.

Hypothesis:
Analysis of multiple-cause-of-death will confirm prevalence rates of diabetes among racial/ethnic minority populations, demonstrate the impact of diabetes in association with other causes of death, and highlight variations of burden of disease among different racial/ethnic groups.

Methods:
Causes of death were identified using the Multiple Cause Mortality Files of the National Center for Health Statistics from 2003 to 2012. Age-adjusted mortality rates were calculated for diabetes both as the underlying cause of death (UCD) and as multiple causes of death (MCD) by racial/ethnic groups (NHWs, Blacks, Asians, and Hispanic/Latinos). Frequencies and proportions were calculated by race/ethnicity groups. Linear regression model was used for number of causes per death.

Results:
A total of 2,335,198 decedents had diabetes listed as MCD in the U.S. national death records from 2003-2012. Mortality rates of diabetes as MCD were 3.4 times than UCD for Asians, 2.9 times for Blacks, 2.9 times for Hispanics and 3.7 times for NHWs (Figure). Minority populations had higher proportion of deaths with diabetes reported as MCD than NHWs (1.7 times higher for Hispanics, 1.5 times higher for Blacks and Asians). Adjusting for age, gender, and race/ethnicity, there were 1.7 more causes per death co-occurred for diabetes decedents compared to decedents who died due to all other causes (95% CI: 1.714, 1.718).

Conclusions:
Our findings underscore the importance of a multiple-cause-of-death approach in the analyses for a more comprehensive understanding of the impact of diabetes.
Abstract P061: Blood Pressure Control in the Outpatient Setting Among Patients with Diabetes: The Guideline Advantage
Authors: Bower Julie K , Patel Sejal , Khan Yosef , Langabeer James R , Foraker Randi E
Published: July 2021

Introduction:
Blood pressure (BP) screening and control is often suboptimal in patients with diabetes, a population in whom cardiovascular disease (CVD) is the leading cause of morbidity and mortality. Hypertension in the context of diabetes uniquely increases risk for CVD incidence and mortality. The aim of this study was to describe the burden of uncontrolled BP among patients with diabetes seen in the outpatient setting and factors associated with BP control using data from a large, electronic health record (EHR) data registry.

Methods:
Outpatient EHR data were analyzed from The Guideline Advantage™ (TGA), a joint quality improvement initiative of the American Heart Association, American Diabetes Association, and American Cancer Society. Data were compiled from patients aged ≥18 years seen at >70 individual clinics across the U.S. “Uncontrolled BP” was defined as measured BP ≥140/90mmHg at the most recent outpatient visit with or without a clinical diagnosis of hypertension. Logistic regression was used to examine factors associated BP control status.

Results:
We observed 1,710,702 BP measurements among 216,947 unique patients. The population was 42% male (n= 91,062) with a mean age of 49 years; 19% (n=41,714) of patients had BP ≥140/90 mmHg at their most recent outpatient visit and 8% of the population had a history of diabetes (n= 18,242). Patients with diabetes had 1.15 times the odds of BP ≥140/90 mmHg at their most recent outpatient visit [aOR(95% CI): 1.15 (1.11-1.20)]. Among patients with a diabetes history, the following factors were associated with uncontrolled BP: race/ethnicity [(aOR: 2.81 (2.48-3.19) for non-Hispanic blacks compared to non-Hispanic whites, 1.44 (1.31-1.57) for multiracial patients versus non-Hispanic whites] , sex [aOR: 1.28 (1.25-1.31)] for males compared to females], age [aOR per 10-year increase in age: 1.22 (1.21-1.23)], and time since diabetes diagnosis [aOR per 1-year increase in time since diagnosis: 0.99(0.98-1.00)].

Conclusions:
Uncontrolled BP disproportionately impacts diabetes patients in the outpatient setting. Among these patients, BP control status differed by race/ethnicity, sex, and age. Additionally, patients were more likely to have uncontrolled BP ≥140/90 mmHg closer to the time of their diabetes diagnoses (i.e. time since diagnosis was inversely associated with BP control status). Additional investigation to identify underlying patient- and provider-level factors contributing to these observed differences will be particularly important moving forward for accountable care organizations to meet metrics for equitable quality care delivery across patient subgroups.
Abstract P079: Biological Markers of Stress and Unhealthy Assimilation Behaviors Vary According to Reason for Immigration: the Africans in America Study
Authors: Baker Rafeal L , Utumatwishima Jean N , Bingham Brianna A , Ricks Madia , Mabundo Lilian S , Udahogora Margaret , Berrigan David , Chung Stephanie T , Sumner Anne E
Published: July 2021

The relationship between the biological effect of stress, reason for immigration and unhealthy assimilation behaviors has not been studied in African immigrants to the United States. Therefore, in 88 African immigrants to the United States (age 41±10, (mean±SD), range 22-61y, male 65% (57 of 88)) we used the allostatic load score (ALS) to assess the biological response to stress. ALS was calculated using 10 variables from 3 domains; cardiac (SBP, DBP, cholesterol, triglyceride, homocysteine), metabolic (BMI, A1C, albumin, eGFR) and immunological (hsCRP). High-risk was defined by the highest quartile for each variable, except for albumin and eGFR, which used the lowest quartile. One point was assigned if the variable was in the high-risk range and 0 if not. Participants were grouped by reason for immigration: asylum, work, study, marriage, lottery and family reunification. Unhealthy assimilation behaviors were: smoking and alcohol intake. ALS was highest for asylum seekers (3.21±2.16) and lowest for family reunification (1.78±1.35). For the other reasons of immigration, ALS was in the range between these two scores (Figure). Thirty-six percent of asylum seekers were smokers (5 of 14), whereas all other African immigrants were non-smokers (0 of 74) (
P
<0.001). Similarly, self-reported alcohol intake was higher for asylum seekers than for the other reasons for immigration (43% (6 of 14) vs.22% (16 of 74),
P
=0.05). In conclusion, as demonstrated by ALS, asylum seekers experience the highest degree of stress and the most unhealthy assimilation behaviors. However, Africans who come to the United States for family reunification have a low prevalence of unhealthy assimilation behaviors and the lowest ALS. Therefore, reason for immigration may have a significant impact on both health and behavior.
Abstract P082: Racial Disparities in Stroke Recovery: A Large Study Versus Meta-Analysis
Authors: Chhatbar Pratik Y , Bayona Hernan , Zhao Yujing , Ovbiagele Bruce , Feng Wuwei , Adams Robert J , Lackland Daniel T
Published: July 2021

Background:
It is well known that Blacks have a higher stroke-related mortality compared to their White counterparts, but evidence on the influence of Black race on recovery after a stroke is not apparent.

Objective:
To verify our understanding on post-stroke rehabilitation trends between Blacks and Whites with the use of systematic review and meta-analysis.

Methods:
We performed literature search for cohort studies that investigated racial variation issues in stroke motor recovery between January 1970 and March 2016, in which outcome was measured by Functional Independence Measures (FIM) scale. We compared change scores (the difference score between discharge and admission) or endpoint scores (at the time of admission and discharge) as well as length of stay in days between Whites and Blacks by calculating standardized mean differences (Hedge’s
g
) to derive a summary effect size. Random Effects model was used to account for data heterogeneity.

Results:
We identified 7 studies with a total 152,421 subjects, of which one influential study (Ottenbacher et al, 2008) offered a significant weight with 148,871 subjects. So, we performed meta-analysis on the remaining 6 studies (black diamond on the
Figure
) and compared the results with this influential study (maroon square on the
Figure
). We found that Blacks have higher FIM scores at admission and discharge, but poor change FIM scores, despite their shorter stay (about ¾ day) in rehab facility when compared to Whites. Our results contrasted findings of Ottenbacher
et al.
, which did not report change scores, that Whites have higher FIM scores at admission and discharge in spite of their comparable rehab facility stay.

Conclusions:
This meta-analysis identifies a significant evidence gap for current understanding of racial disparities in stroke recovery. At AHA SFRN WISSDOM (Wide spectrum Investigation of Stroke Outcome Disparities on Multiple Levels) center, we aim to address this gap by first-hand analyses of multiple datasets in the near future.
Abstract P087: Use of Tobacco Products Among LGBTQ: Results From 2016 Surveys & Focus Groups
Authors: Giachello Aida L , Vu Thanh-Huyen , Payne Thomas J , Robertson Rose M , Rodriguez Carlos , Groom Allison , Walker Kandi , Hart Joy , Langdon Sarah , Okhomina Victoria , Kesh Anshula , Seale Samantha R , Navas-Nacher Elena , Murillo Erika , Sims Mario , Salazar-Mitchell Patricia , Landry Robyn , Bates-Ambrus Venoncia
Published: July 2021

Background:
Cigarette smoking has been reported to be high among Lesbian, Gay, Bisexual, Transgendered and Queer (LGBTQ) populations. However, in-depth information on perception, knowledge, attitudes and behaviors, is limited.

Methods:
We analyzed 2016 data from the AHA-Tobacco Regulatory Addiction Center (A-TRAC) study on multi-ethnic LGBTQ groups living primarily in Chicago and New York City, ages 18-64, smokers and non-smokers. Twenty-nine focus groups and 99 individual surveys were conducted to obtain socio-demographic-economic characteristic and in-depth information on tobacco use, including cigarette smoking. Atlas.ti and SAS 9.4 were used for data analyses.

Results:
Of 99 participants, 58.8% of LGBTQ individuals reported smoking 100+ cigarettes during their life time; 49.5% (n=49) reported current cigarette smoking; and 17% reported frequent or occasional use of e-cigarette, e-hookah and/or other types of vaping. Age (25+) and low household income (<$20,000) were significantly associated with the use of cigarette smoking. While 70.2% stated that cigarette smoking is very dangerous to health and 43.2% of respondents said that tobacco use is a very serious problem in the LGBTQ community, current smokers were unlikely to quit smoking (67%). Focus group discussions revealed that smoking a cigarette is a form of stress relief, a way of “expressing yourself”, and a way of “fitting in”. Heavy marketing by the tobacco industry as well as stress associated with social discrimination, family and friend rejections and limited income, were also factors identified with tobacco use. These findings were particularly true among transgender women and bisexual men and women.

Conclusions:
Cigarette smoking was high among the LGBTQ individuals in our sample and they seems unlikely to quit. Social stressors appear to be a strong contributing factor. Educational efforts and culturally appropriate messages to this population, are critical.
Abstract P092: Patient Ethnicity Predicts Poor Health Access and Gaps in Perception of Personal Cardiovascular Risk Factors
Authors: Kim Yeunjung , D’Onofrio Gail , Safdar Basmah
Published: July 2021

Background:
Focus of health literacy campaigns has centered around raising awareness. It is unknown whether awareness of cardiovascular risk factors accurately reflects personalization of one’s own cardiovascular risk especially in different ethnic groups.

Methods:
A cross-sectional survey was performed in consecutive patients presenting with chest pain and admitted to a large, urban Chest Pain Center at Yale-New Haven Hospital. A 32-item multiple item questionnaire was administered in English or Spanish to examine knowledge of CHD risk factors. Separately, the personalization of coronary risk factors was determined by having patients list [write in] their individual risk factors for having a heart attack. Multivariate logistic regression model and odds ratios were used to evaluate predictors of misperception, defined as gap between knowledge and personalization of risk.
Primary outcome was the evaluation of ethnic disparities in awareness of cardiovascular risk factors and the patient’s misperceptions on personal risk factors.
Secondary outcome was the
assessment of access to information
in the same population by gender and ethnicity.

Results:
Between Oct 2006-April 2008, 1584 consecutive patients admitted to the Chest Pain Center were screened for eligibility, and 1051 patients were enrolled. Between Hispanic, White, and African American patients, Hispanic patients were least aware of major CHD risk factors. In addition, misperception about personal risk was significantly higher in nonwhite compared to the white participants. This disparity persisted for the major modifiable coronary risk factors including hyperlipidemia and diabetes even when controlled for age, gender, employment, marital status, prior history of CAD and sources of health information.

Conclusion:
Knowledge of CHD risk factors vary by ethnicity. In addition, there are major gaps between awareness and personalization of risk in major modifiable CHD risk factors in different ethnic groups.
Abstract P102: Epigenome-wide Association Study of Measures of Fasting Glucose, Fasting Insulin, and Hba1c in Non-diabetic Individuals of European, African, and Hispanic Ancestry in the Charge Consortium
Authors: Hidalgo Bertha A , Hivert Marie-France , Wessel Jennifer , Guan Weihua , Gondalia Rahul B , Salfati Elias L , Montoro Carnero Elena , Moore Ann Z , Brody Jen , Kriebel Jennifer , Smith Jennifer , Zhao Wei , Ligthart Symen , Hill David , Pankow James S , Chu Audrey Y ,   CHARGE Epigenomics Working Group
Published: July 2021

Background:
Fasting glucose, fasting insulin, and hemoglobin A1c are important glycemic biomarkers and elevated levels of these markers predict future glycemic dysfunction and type-2 diabetes. Several studies have identified DNA methylation sites associated with quantitative glycemic traits and T2D. However, these studies have generally been limited in size. In this project, we aim to identify blood cells methylation signatures associated with three quantitative glycemic traits - fasting glucose (FG), log-transformed fasting insulin (logFI) and hemoglobinA1c (HbA1c) through meta-analysis of DNA methylation data from participating CHARGE Epigenetics Working Group cohorts.

Methods:
We conducted a epigenome-wide meta-analysis of DNA methylation assessed with Illumina BeadChip 450K array on blood-based DNA samples, including 12,681 for FG, 11,224 for logFI, and 6358 for HbA1c, from non-diabetic participants of European, African, and Hispanic ancestry in 10 cohorts from the CHARGE Epigenetics Working Group. Mixed linear regression analyses were performed adjusting for age, sex, smoking status, cell composition, and and technical covariates, with and without adjustment for BMI. A Bonferroni corrected
P
value of 1.1 х 10
–
7
was considered significant.

Results:
In combined multiethnic analysis, methylation at a total of 208 cytosine guanine dinucleotides (CpGs) were significantly associated with FG, 761 CpGs with logFI, and 109 CpGs with HbA1c. Adjustment for BMI substantially reduced the number of DNA methylation loci that met epigenome-wide significance. Biologically putative genes include
CPT1A
and
TXNIP
(FG),
ABCG1
and
CPT1A
(logFI),and
ABCG1 and
MAFG
(HbA1C).

Conclusion:
Our findings suggest that methylation of CpG sites within multiple genes are cross-sectionally associated with glycemic biomarkers. Our results also confirm findings from prior and smaller studies, meriting further evaluation of these methylation sites and genes as novel disease risk markers.
Abstract P129: Confirmatory Factor Analysis of Multivariate Lipid Distributions Across Time and Race/Ethnic Groups: United States, 2003-2012
Authors: Von Holle Ann , North Kari
Published: July 2021

Plasma concentrations of low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides (TG) are important risk factors for metabolic and cardiovascular diseases and are widely-used as targets for therapeutic intervention. Consideration of the multivariate distribution of these lipid traits could be informative for studies involving pleiotropic genetic variants, variants associated with more than one lipid outcome, but featuring only univariate lipid outcome models. Confirmatory factor analysis (CFA) is one way to characterize the multivariate distribution of biologically plausible, related indicators such as lipids with a continuous latent factor. Although CFA has been used to characterize metabolic syndrome, a cardiovascular disease (CVD) risk factor involving many correlated indicators, dyslipidemia is a CVD risk factor that remains relatively unexplored in this literature. Thus, the primary aim of this study is to conduct CFA with LDL-C, HDL-C and TG as indicators representing a single continuous latent lipid factor and assess its suitability as an outcome measure in a United States representative sample by racial/ethnic groups stratified by age and gender over five 2-year time periods (2003-2004, 2005-2006, 2007-2008, 2009-2010, 2011-2012) from NHANES. First, we used principal component analyses (PCA) to visually examine clustering by race and gender in biplots. Second, we tested for scale differences in the lipid factor across a) calendar time and b) racial/ethnic groups (Mexican-American, non-Hispanic White, non-Hispanic Black, Other Hispanic and Other race/ethnicity). All analyses were stratified by medication use, gender and three age groups: 12-19 years, 20 to 49 years and 50-80 years, and adjusted for age and body mass index (BMI). We found significant scale differences across racial/ethnic groups. In particular, the center of the distribution differed across racial/ethnic groups for ages 12-19 years (p<0.0001), 20-49 years (p<0.0001) and 50-80 years (p<0.0001), suggesting joint distributions of TG, HDL-C, and LDL-C vary across racial/ethnic groups. In summary, one continuous latent factor representing all three lipids and their concomitant associations provides a means to characterize lipid values simultaneously and can serve as an outcome when studying exposures influencing multiple lipid values, pleiotropic genetic variants being just one example of many. Differences in the lipid latent factor across racial/ethnic groups emphasizes distinct multivariate distributions necessitating stratification. Limited analyses exist using this CFA framework for lipids, and future efforts considering the joint distribution of lipids may improve our understanding of the genetic architecture of dyslipidemia.
Abstract P131: Effect of a Social Incentive-based Gamification Intervention Using Wearable Devices and Smartphones on Physical Activity: The BE FIT Randomized Clinical Trial
Authors: Patel Mitesh S , Benjamin Emelia J , Volpp Kevin G , Fox Caroline S , Small Dylan S , Massaro Joseph M , Lee Jane J , Hilbert Victoria , Valentino Maureen , Taylor Devon H , Manders Emily S , Mutalik Karen , Zhu Jingsan , Wang Wenli , Murabito Joanne M
Published: July 2021

Background:
Social networks can influence individual health behaviors, but interventions that leverage social incentives within these networks to change health behaviors have not been well examined. The objective of this study was to test the effectiveness of a social incentive-based gamification intervention to increase physical activity in the community.

Methods:
The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial that recruited 206 adults comprising 97 groups of two or three family members in the Framingham Heart Study and occurred between December 2015 and August 2016. Participants used a wearable device or smartphone application to establish a baseline step count and selected a step goal increase for a 12-week primary intervention period and a 12-week follow-up period. Participants in both the control and intervention arms received daily feedback on their performance for 24 weeks. During the first 12 weeks, participants in the intervention arm played a game (including points, levels, and lifelines) with their family members that was designed using insights from behavioral economics to enhance social incentives such as peer support, accountability, and collaboration. The primary outcome was the mean proportion of participant-days the step goal was achieved during the primary intervention period. Secondary outcomes included the mean proportion of participant-days the step goal was achieved during the follow-up period and mean daily steps during the intervention and follow-up periods.

Results:
Participants in the intervention arm achieved step goals on a greater proportion of participant-days and had greater mean daily steps than the control arm during the intervention and follow-up periods (TABLE).

Conclusions:
Among groups of family members in a community, a social incentive-based gamification intervention was effective at increasing physical activity during the 12-week intervention period and effects were sustained during the 12-week follow-up period.
Abstract P175: Can Pediatric Hypertension Criteria be Simplified? A Prediction Analysis of Subclinical Cardiovascular Outcomes From the Bogalusa Heart Study
Authors: Xi Bo , Zhang Tao , Li Shengxu , Shen Wei , Harville Emily , Bazzano Lydia , He Jiang , Chen Wei
Published: July 2021

Background:
Pre-hypertension and hypertension in childhood are defined by sex-, age- and height-specific 90th (or ≥120/80 mmHg) and 95th percentiles of blood pressure (BP), respectively, by the 2004 Fourth Report. However, these cut-offs are complex and cumbersome for use. This study assessed the performance of a simplified BP definition to predict adult hypertension and subclinical cardiovascular disease.

Methods:
The longitudinal cohort consisted of 1,225 adults (530 males, aged 26.3–47.7 years) from the Bogalusa Heart Study, with 27.1 years follow-up since childhood. We used 110/70 and 120/80 mmHg for children (age 6-11 years), and 120/80 and 130/85 mmHg for adolescents (age 12-17 years) as the simplified definitions of childhood pre-hypertension and hypertension, respectively, to compare with the complex definitions. Adult carotid intima-media thickness (CIMT), pulse wave velocity (PWV), and left ventricular mass were measured using digital ultrasound instruments. High CIMT was defined as being above the age-, gender- and race-specific 80th percentile, high PWV as being above the age-, gender-, race- and heart rate-specific 80th percentile and left ventricular hypertrophy as >46.7 g/m
2.7
in women and >49.2 g/m
2.7
in men.

Results:
Compared to normal BP, childhood hypertensives diagnosed by the simplified definition (4.1%, 50/1,225) and the complex definition (4.8%, 59/1,225) were both at higher risk of adult hypertension with hazard ratio=3.1 (95% confidence interval=1.8-5.3) by the simplified definition and 3.2 (2.0-5.0) by the complex definition, high PWV with 3.5 (1.7-7.1) and 2.2 (1.2-4.1), high CIMT with 3.1 (1.7-5.6) and 2.0 (1.2-3.6), and left ventricular hypertrophy with 3.4 (1.7-6.8) and 3.0 (1.6-5.6). The prediction using the two childhood BP definitions for adult hypertension and subclinical cardiovascular disease was also assessed by reclassification or receiver operating characteristic curve analyses.

Conclusions:
The simplified childhood BP definition predicts the risk of adult hypertension and subclinical cardiovascular disease equally as the complex definition does. The simplified pediatric BP cut-offs could be easier to use for screening children at high risk and for targeting early life interventions to reduce the risk of developing cardiovascular disease in later life.
Abstract P176: Impact of Serious Adverse Event Risks on the Cost-effectiveness of Intensive Blood Pressure Goals in Patients Aged ≥75 Years
Authors: Ruiz-Negron Natalia , Bellows Brandon K , Bress Adam P , King Jordan B , Hess Rachel , Beddhu Srinivasan , Zhang Zugui , Berlowitz Dan R , Supiano Mark A , Weintraub William S , Moran Andrew E
Published: July 2021

Background:
Compared to the overall Systolic Blood Pressure Intervention Trial (SPRINT) results, patients aged ≥75 years at baseline had a greater reduction in cardiovascular disease (CVD) events and all-cause mortality with an intensive systolic blood pressure (SBP) goal (<120 mmHg) compared to a standard SBP goal (<140 mmHg). Applying an intensive SBP goal in high-risk older patients represents a major shift in clinical practice and may increase concern for medication-related severe adverse events (SAEs). We hypothesized that the benefits of reduced CVD risk would outweigh the increased costs and SAE risk of intensive vs. standard SBP goals in SPRINT-eligible patients aged ≥75 years even when considering variable SAE risks.

Methods:
A microsimulation health-state transition model of 10,000 patients was created to estimate the CVD events, SAEs, quality-adjusted life years (QALYs), and direct healthcare costs of intensive vs. standard SBP goals. The model assumed patients were adherent to treatment during the median SPRINT follow-up, but that all patients would become non-adherent over 5 years. While adherent, CVD and SAE risks were derived from published SPRINT effect estimates for the ≥75 subgroup. Due to uncertainty in the SAE risk associated with intensive SBP goals in older adults, the intensive arm SAE risk was varied to determine the point at which treatment costs and harms outweighed CVD benefits at accepted willingness-to-pay thresholds. Healthcare costs and health state utilities were derived from national sources and other published estimates.

Results:
If SAE risk was equal to the observed rates in SPRINT, mean lifetime costs and QALYs were $268,000 and 7.85 for the intensive arm, and $262,000 and 7.60 for the standard arm. The resulting incremental cost-effectiveness ratio (ICER) was about $26,000 per QALY gained. However, as SAE risk in the intensive arm increased by 1.5, 2, and 2.5 times, the ICER increased to $33,000, $43,000, and $55,000 per QALY gained, respectively.

Conclusion:
Intensive SBP goals may be a cost-effective way to reduce CVD events and improve survival in patients aged ≥75 years, but safety and cost-effectiveness depend on medication-related SAE risk. However, these results are based on summary data and do not account for clustering of risks at the individual patient level. Thus, more precise prediction of risks and benefits is needed to guide selection of older patients for intensive SBP treatment goals.
Abstract P179: Comparison of Earlier versus Later Orthostatic Hypotension Assessment Times in Middle-Age Adults of the Atherosclerosis Risk in Communities Study (ARIC)
Authors: Juraschek Stephen P , Daya Natalie , Rawlings Andreea M , Appel Lawrence J , Miller Edgar R , Windham B G , Griswold Michael E , Selvin Elizabeth
Published: July 2021

Background:
Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions.

Hypothesis:
Measurements performed immediately after standing will be as informative as measurements performed closer to 3 minutes after standing with regards to symptoms of dizziness or risk of adverse outcomes.

Methods:
OH, defined as a drop in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, was measured up to five times at 25 seconds intervals in middle-aged (range 44 to 66 years) ARIC participants (1987-1989). Associations between each measurement and history of dizziness upon standing were examined via logistic regression. We used Cox models to examine the association between each of five measurements with risk of fall, fracture, syncope, and all-cause mortality over a median follow-up of 23 years.

Results:
In 11,449 participants (mean age 54 years, 54% women, 26% black) 10% reported a history of dizziness upon standing. OH assessed at measurement 1 (performed at a mean of 28 seconds after standing) was associated with risk of fall (
P
= 0.03), fracture (
P
= 0.05), syncope (
P
<0.001), and mortality (
P
< 0.001) (
Table
). Furthermore, measurement 1 was the only measurement associated with higher odds of dizziness upon standing (OR: 1.5;
P
= 0.001). Measurement 2 (performed on average 53 seconds after standing) was associated with all long-term outcomes. Measurements 4 and 5 (mean 100 and 116 seconds after standing) were generally less informative with regards to prospective outcomes than earlier measurements and were not statistically associated with history of dizziness.

Conclusions:
OH measurements obtained, on average, within the first 30 seconds of standing were predictive of long-term adverse health outcomes and were the most strongly related to symptoms of dizziness compared to later measurements. These findings suggest that BP measurements for determining orthostatic hypotension should be performed immediately after standing.
Abstract P209: Dose-Response Relationship Between Dietary Intake of Alpha-linolenic Acid and Risk of Coronary Heart Disease: A Meta-analysis of Prospective Studies
Authors: Wei Jingkai , Xi Yuzhi , Hou Ruixue , Kowalski Alysse , Sun Hao , Chandrasekar Eeshwar K , Ali Mohammed K
Published: July 2021

Introduction:
Previous studies show that alpha-linolenic acid (ALA) is associated with reduced risk of coronary heart disease (CHD). However, it remains unclear whether and how dietary ALA doses are related to CHD.

Hypothesis:
We hypothesized that higher dietary ALA intake is associated with a greater reduction in risk of CHD.

Methods:
We searched PubMed, EMBASE, and Web of Science for prospective studies examining the association between dietary ALA intake and CHD risk. Dietary ALA intake was assigned or measured by self-report. Outcomes were reported as total and fatal CHD and/or myocardial infarction, which were obtained from blinded endpoint assessments or medical records. Two-stage fixed-effects dose-response meta-analyses were conducted to estimate the association between increasing ALA intake (relative to study-specific referents) and CHD.

Results:
Fifteen published articles were identified and included in the meta-analysis (13 cohort studies and 2 randomized controlled trials). The pooled analysis was based on 310,768 individuals with 12,049 events with a mean length of follow-up of 9.6 years. The analysis showed a J-shaped curve between ALA intake and relative risk of total CHD (Chi-square=21.08, p<0.001). ALA intake from 0.3-1.4g/day showed reduced risk of total CHD, while intake ≥2.5g/day was associated with increased risk of CHD, compared to people without ALA intake (Figure 1A). Approximately 1g/day of ALA intake was associated with the lowest risk of total CHD. ALA intake was linearly associated with fatal CHD - every 1g/day increase in ALA intake was associated with an 11% decrease in fatal CHD risk (95% CI: -0.16, -0.05) (Figure 1B).

Conclusion:
The J-shaped dose-response relationship based on our pooled analysis suggests that 1g/day of dietary ALA may be optimal for total CHD prevention. Though a higher dietary ALA intake was associated with reduced risk of fatal CHD, the excess total CHD risk at higher ALA intakes warrants further investigation, especially through randomized controlled trials.
Abstract P210: Sleep Duration and Eating Behavior in Young Adults: Project EAT
Authors: Ogilvie Rachel P , Lutsey Pamela L , Widome Rachel , Laska Melissa N , Neumark-Sztainer Dianne
Published: July 2021

Background:
Short sleep duration appears to put adults at risk for excess energy intake and obesity; less is known specifically about how sleep quantity relates to eating patterns.

Objectives:
We tested the association between sleep duration and eating among young adults, a group especially vulnerable to suboptimal sleep.

Methods:
We used data from Project EAT-III, a cross-sectional study of 1,854 racially/ethnically diverse young adults aged 20-30 from the Minneapolis/St. Paul metropolitan area. The EAT survey assessed: average sleep duration (calculated via weekday and weekend bedtimes and wake times), breakfast skipping, fast food, energy drink, and sport drink consumption. A food frequency questionnaire queried intake of sugar-sweetened, sugar-free, and caffeinated beverages. Linear and logistic regression, adjusted for demographic and behavioral covariates, were used to model the relationship between sleep duration and dietary outcomes. In logistic models, post-estimation commands were used to calculate risk ratios.

Results:
In linear models, participants who slept < 7 hours per night (11.5%) consumed significantly more caffeinated beverages relative to those who slept 7-8 hours per night (Table). In logistic models, those who slept 8-9 hours a night (26.6%) and > 9 hours per night (25.8%) reported a lower risk (0.85 (95% CI 0.70-0.99) and 0.80 (95% 0.63-0.98), respectively) of sports drink consumption, compared to those who slept 7-8 hours a night. Intake of sugar sweetened beverages, sugar-free beverages, energy drinks, breakfast, and fast food did not differ significantly by sleep duration.

Conclusions:
Sleep duration was related to some eating behaviors associated with energy imbalance, but not all. The impact of sleep insufficiency during young adulthood, a pivotal period in the life course, may set lifelong trajectories that may increase cardiovascular risk. Sleep may be an important target to include in interventions and policies aimed at cardiometabolic risk management.
Abstract P240: Clinical Outcomes in Patients With Takotsubo’s Cardiomyopathy Who Have Undergone Cardiac Catherterization at Presentation vs. Those Who Have Not: A Two Community Based Hospitals Experience
Authors: Gorsi Umama , Shafi Muhammad , Roberts Mary , Hedgepeth Chester
Published: July 2021

Background:
Diagnosis of Takotsubo’s Cardiomyopathy (TC) remains a challenge due to similar presentation to acute coronary syndrome. Coronary catheterization (CC) proven clean coronaries is important to diagnose TC. However, it is not uncommon that CC is occasionally delayed due to unstable medical condition and/or high risk for CC. We hypothesized that patients with TC had similar outcomes whether they underwent CC at presentation or were diagnosed using non-invasive imaging techniques.

Methods:
Retrospective chart review of data from Memorial Hospital of Rhode Island and Kent Hospital, two community based hospitals, from June 2008 to March 2016 was done. Thirty nine adult patients > 18 years of age admitted to the intensive care unit or medical floor with chest pain, shortness of breath, elevated troponin, EKG changes, and new non-regional wall motion abnormalities or reduce ejection fraction, with suspected TC were enrolled. Patients were divided into 2 groups based on diagnostic approach of TC: Baseline echo findings suggestive of TC with EF improvement at follow up (non-CC) vs. clean coronaries by CC. Outcomes of the two groups were compared using Chi-square analysis, analysis of variance (ANOVA) and Mann-Whitney Test appropriately.

Results:
Out of 39 patients, 20 underwent CC while 19 did not. Mean age was not different between the 2 groups (69.1±11.8 vs. 62.4±14.0, p= NS) but CC group had more females (95 %, 19 of 20 vs 68.4%, 13 of 19; p=0.031). Most common chief complaint at the time of admission in both groups was shortness of breath (60.0%, 12 of 20 vs 68.4%, 13 of 19; p=0.548). Admission heart rate was significantly higher in non-CC vs. CC patients (102.3± 19.3 vs 85.4±85.4; p=0.007). Third troponin was higher in non-CC group (1.926 ± 2.667 vs 0.775± 1.378, p=0.017). All other admission and in-hospital findings and drug management in both groups were similar. Both CC and non-CC groups had comparable outcomes: intubation (15%, 3 of 20 vs 21.1%, 4 of 19) , heart failure (21.2 %, 4 of 20 vs 15.8%, 3 of 19), shock (0 %, 0 of 20 vs 5.3% 1 of 19 ), stroke (5 %, 1 of 20 vs 0%, 0 of 19), death (5.3 % 1 of 20 vs 5.3% 1 of 19 ), recovery (65%,13 of 20 vs 52.9 % 10 of 19) p=NS for all. ICU admission (42.1%, 8 of 20 vs 52.6%, 10 of 19; p=NS) and length of stay (8.21±7.82 days vs 5.75±5.67 days; p=NS) was not significantly different between the 2 groups. Both groups showed analogous improvement in ejection fraction (21.92 ± 13.96 vs 20.63 ± 13.21; p= 0.835) on a follow up Echo done within 2 weeks to 6 months.

Conclusion:
This study shows no difference in outcomes between TC patients diagnosed with CC or TTE on admission. However, CC should still be done on admission for diagnosis of TC until large non-invasive diagnostic imaging modalities (such as myocardial perfusion echocardiogram) trials show high specificity for diagnosis of TC.