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BACKGROUND: Cardiovascular disease is a leading economic and medical burden in the United States (US). As an important risk factor for cardiovascular disease, hypertension represents a critical point of intervention. Less is known about longitudinal effects of neighborhood deprivation on blood pressure outcomes, especially in light of new hypertension guidelines. METHODS: Longitudinal data from the Dallas Heart Study facilitated multilevel regression analysis of the relationship between neighborhood deprivation, blood pressure change, and incident hypertension over a 9-year period. Factor analysis explored neighborhood perception, which was controlled for in all analyses. Neighborhood deprivation was derived from US Census data and divided into tertiles for analysis. Hypertension status was compared using pre-2017 and 2017 hypertension guidelines. RESULTS: After adjusting for covariates, including moving status and residential self-selection, we observed significant associations between residing in the more deprived neighborhoods and 1) increasing blood pressure over time and 2) incident hypertension. In the fully adjusted model of continuous blood pressure change, significant relationships were seen for both medium (SBP: β=4.81, SE=1.39, p=0.0005; DBP: β=2.61, SE=0.71, p=0.0003) and high deprivation (SBP: β=7.64, SE=1.55, p

Although chronic lung disease (CLD) is common among patients with myocardial infarction (MI), little is known about the influence of CLD on patient management and outcomes following MI.Using the National Cardiovascular Data Registry's ACTION Registry-GWTG, demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after acute MI were compared between patients with (n = 22,624) and without (n = 136,266) CLD. Multivariable adjustment was performed to determine the independent association of CLD with treatments and adverse events.CLD (17.0% of non-ST-elevation MI [NSTEMI] and 10.1% of ST-elevation MI [STEMI] patients) was associated with older age, female sex, and a greater burden of comorbidities. Among NSTEMI patients, those with CLD were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft compared to those without; in contrast, no differences were seen in invasive therapies for STEMI patients with or without CLD. Multivariable-adjusted risk of major bleeding was significantly increased in CLD patients with NSTEMI (13.0% vs 8.1%, OR(adj) = 1.27, 95% CI = 1.20-1.34, P.001) and STEMI (16.0% vs 10.5%, OR(adj) = 1.19, 95% CI = 1.10-1.29, P.001). In NSTEMI, CLD was associated with a higher risk of inhospital mortality (OR(adj) = 1.21, 95% CI = 1.11-1.33); in STEMI no association between CLD and mortality was seen (OR(adj) = 1.05, 95% CI = 0.95-1.17).CLD is common among patients with MI and is independently associated with an increased risk for major bleeding. In NSTEMI, CLD is also associated with receiving less revascularization and with increased in-hospital mortality. Special attention should be given to this high-risk subgroup for the prevention and management of complications after MI.

Modifying risk factors to delay or prevent hypertension is critical for subsequent cardiovascular risk reduction. Therefore, understanding the independent and joint associations between cardiorespiratory fitness, obesity, and systolic blood pressure (SBP) is of major significance. In this study, we assessed the relative contribution of body mass index (BMI) and cardiorespiratory fitness to SBP in a large, healthy population.Blood pressure, BMI, and cardiorespiratory fitness were measured in 35,061 patients seen for a preventive health examination (1990 to present). BMI was treated as a continuous variable and categorized into sex-specific quartiles. Cardiorespiratory fitness was defined as time achieved during maximal exercise testing and categorized into age- and sex-adjusted quintiles. Generalized linear models were used to determine the independent contribution of fitness and BMI on systolic blood pressure estimates.The study group was predominately white men (69%) with an average age of 46 years. Normal-weight subjects had a mean SBP 12 mm Hg lower than in the obese (115 vs 127 mm Hg, P.001), while being high- fit was associated 6 mm Hg difference in mean SBP comparing the highest and lowest fitness quintile (119 vs 125 mm Hg, P.001). Normal-weight individuals with a cardiorespiratory fitness level greater than the first quintile (Q1) had the lowest mean SBP (P.001). Both BMI and cardiorespiratory fitness were associated with SBP (P.001 for both); however, when assessed simultaneously, BMI had a greater impact on SBP estimates than fitness.When comparing lifestyle risk factors BMI and cardiorespiratory fitness, BMI was a more important factor in predicting SBP. Importantly, only modest fitness levels among normal-weight individuals were associated with the lowest systolic blood pressure estimates.

Background Understanding risk factor burden and control as well as perceived risk prior to acute myocardial infarction (MI) presentation may identify gaps in contemporary systems of care. Methods Patients presenting with MI in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With the Guidelines between January 2007 and November 2013 (N = 443,117) were stratified into 5 mutually exclusive risk categories: Framingham Risk Score (FRS) 20% 25,701 (5.8%), diabetes without cardiovascular disease (CVD) 67,779 (15.3%), and prior CVD 184,218 (41.6%). Low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol (non–HDL-C) goals and statin eligibility were determined based on the Third Adult Treatment Panel. Results At presentation, 66.3% met the low-density lipoprotein cholesterol goal, 66.8% met the non–HDL-C goal, 63.7% were nonsmokers, and 65.1% of patients with prior CVD were on aspirin. Only 36.1% of patients met all assessed risk factor control metrics. Overall statin eligibility prior to MI was 60.8%, and 61.1% of statin-eligible patients reported statin use. Conclusion Risk factor control prior to MI was suboptimal, with the majority of individuals failing to meet at least 1 risk factor control metric. More effective system-based interventions are needed to promote adherence to prevention targets.

Emerging data suggest that diabetes mellitus is a risk factor for the progression of established heart failure only in those patients with ischemic cardiomyopathy. Whether diabetes mellitus is a risk factor for the progression from asymptomatic left ventricular systolic dysfunction to symptomatic heart failure in patients with left ventricular dysfunction of an ischemic cause is not known.We performed a retrospective analysis of 2821 patients with asymptomatic left ventricular systolic dysfunction from the Studies of Left Ventricular Dysfunction (SOLVD) Prevention trial. We used adjusted survival analysis to examine the effects of ischemic heart disease and diabetes mellitus on 3 prespecified study end points: (1) development of heart failure (HF) symptoms, (2) HF hospitalization, and (3) death or development of symptoms.There is a statistically significant interaction between the cause of left ventricular systolic dysfunction and diabetes mellitus on the risk of development of heart failure symptoms (P = .020). Patients with ischemic cardiomyopathy and diabetes had an increased risk of progression to symptomatic heart failure (HR = 1.56, P.001), hospitalization for heart failure (HR = 2.16, P.001), and death or development of symptoms (HR = 1.50, P.001), compared with patients with ischemic cardiomyopathy without diabetes. In contrast, diabetes was not associated with an increased risk of reaching these end points in patients with nonischemic cardiomyopathy.Diabetes mellitus is a risk factor for the progression from asymptomatic left ventricular systolic dysfunction to symptomatic heart failure, but this risk appears to be confined to those patients with ischemic cardiomyopathy.

Aldosterone antagonists (AldA) improve survival after myocardial infarction (MI) in patients with left ventricular systolic dysfunction (ejection fraction [EF]40%) concomitant with either clinical heart failure (HF) or diabetes mellitus (DM). Although current American College of Cardiology/American Heart Association guidelines provide a class I recommendation for AldA therapy in such patients, how US practice reflects these recommendations is unclear.Using data from the National Cardiovascular Data Registry ACTION Registry-GWTG, we describe contemporary discharge AldA prescription patterns among 202,213 patients discharged after acute MI from 526 US sites participating in ACTION Registry-GWTG between January 2007 and March 2011.Overall, 10.0% of patients were eligible for AldA without documented contraindication, with only 14.5% of eligible patients receiving AldA at discharge. Among the subset of AldA-eligible patients discharged on otherwise optimal medical therapy (68.9%), AldAs were prescribed to 16.1%. Aldosterone antagonist use was higher in patients with EF40% and clinical HF with or without DM (17.7% and 16.6%, respectively), compared with patients with EF40% and DM without clinical HF (7.8%, P.001 for each). Fewer than 2% of participating centers used AldA in ≥50% of eligible patients.Despite clinical outcome evidence and class I guideline recommendations, AldAs are underused in the United States, with only 1 in 7 eligible patients prescribed AldA at discharge after MI. This contrasts with high use of other evidence-based post-MI medications and identifies a specific gap in translation of evidence into clinical practice.

Background Physical activity (PA) participation differs by ethnicity, but contributing factors and cardiovascular (CV) outcomes related to these disparities are not well understood. We determined whether health beliefs regarding the benefit of PA contribute to ethnic differences in participation and assessed how these differences impact CV mortality. Methods The Dallas Heart Study is a longitudinal study of CV health. We assessed PA participation and health perceptions by questionnaire among 3,018 African American, Hispanic, and white men and women at baseline visit (2000-2002). Participant mortality was obtained through 2008 using the National Death Index. Results African Americans (odds ratio 0.65, 95% CI 0.53-0.80) and Hispanics (odds ratio 0.34, 95% CI 0.26-0.45) were less likely to be physically active compared with whites even after accounting for income, educational status, age, sex, body mass index, diabetes, hypertension, and hyperlipidemia. Beliefs regarding the benefits of PA did not contribute to this disparity, as >94% of individuals felt PA was effective in preventing a heart attack across ethnicity. Physical activity participation was associated with a lower risk of all-cause mortality (hazard ratio [HR] 0.66, 95% CI 0.46-0.93) and CV disease death (HR 0.56, 95% CI 0.32-0.97) in multivariable adjusted models. Similar results were seen when restricting to African Americans (CV disease death, HR 0.57, 95% CI 0.31-1.05). Conclusions Ethnic minorities reported less PA participation, and lack of PA was associated with higher CV mortality overall and among African Americans. Health perception regarding the benefits of PA did not contribute to this difference, indicating there are other ethnic-specific factors contributing to physical inactivity that require future study.

Background Diabetes mellitus is a major public health problem in the United States. We assess the prevalence of diabetes in Dallas County, quantify the association between diabetes and subclinical cardiovascular disease, and assess the use of evidence-based cardiovascular disease risk-modifying therapies. Methods This study uses data from 3392 participants aged 30 to 65 years from the Dallas Heart Study, a probability-based, multiethnic sample of residents living in Dallas County, Texas. Three primary outcomes were examined: (1) diabetes prevalence, (2) adjusted odds ratios for detectable coronary calcium stratified by diabetes diagnosis status, and (3) rates of use of evidence-based cardiovascular disease risk-modifying therapies among subjects with diabetes stratified by diabetes diagnosis status. Results The estimated prevalence of diabetes in Dallas County was 7.8%, with >40% of diabetic patients undiagnosed before participation in the Dallas Heart Study. Both previously diagnosed and previously undiagnosed diabetes were independently associated with the presence of coronary artery calcium (diagnosed: OR 3.55, 95% CI 1.56-8.05) (undiagnosed: OR 2.98, 95% CI 1.39-6.39). The rates of use of aspirin, angiotensin-converting enzyme inhibitors, and statins were suboptimal, and blood pressure and low-density lipoprotein cholesterol targets were rarely met, especially among subjects with previously undiagnosed diabetes. Conclusions Diabetes is prevalent and is associated with subclinical cardiovascular disease; this association is present even at the time of diagnosis. Despite the cardiovascular risk associated with diabetes, evidence-based risk-modifying therapies continue to be underused, and therapeutic targets remain unmet, especially among people unaware of their diabetes diagnosis.

Identification of individuals in the community with left ventricular systolic dysfunction (LVSD) or left ventricular hypertrophy (LVH) may allow earlier initiation of disease-modifying treatment. We performed a comprehensive evaluation of the screening performance of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for LVSD or LVH.In 2,429 subjects without a history of heart failure, myocardial infarction, valvular abnormalities, or a serum creatinine2.0 mg/dL enrolled in the Dallas Heart Study, measurement of BNP and NT-proBNP and cardiovascular magnetic resonance imaging were performed.B-type natriuretic peptide and NT-proBNP were robustly associated with magnetic resonance imaging-defined LVH and LVSD (ejection fraction55%) among men and women (P.0001 for each). In the overall population, neither test discriminated well for LVH or LVSD (area under the receiver operating characteristic curve [AUROC]0.7). Among women, no differences in AUROC were observed between BNP and NT-proBNP. Among men, AUROCs were similar between BNP and NT-proBNP in the overall population, but among subgroups age 50 or older, or with hypertension, the AUROCs for NT-proBNP (0.73-0.79) were higher than for BNP (0.63-0.69, P.05 for each comparison). Compared with subjects with isolated BNP elevation (97.5th percentile), those with isolated NT-proBNP elevation had worse renal function and more LVH and coronary calcium (P.05 for each).Overall, neither BNP nor NT-proBNP accurately discriminated subjects with LVH or LVSD in this predominately young and healthy population-based cohort. However, among high-risk men, NT-proBNP performed slightly better than BNP and comparably with other routinely used screening tests such as prostate-specific antigen measurement for prostate cancer.