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Introduction: Myocardial injury is commonly observed in patients (pts) with Coronarvirus disease 2019 (Covid-19) but its anatomical correlate has not been elucidated. We evaluated the association between presence of transthoracic echocardiographic (TTE) left ventricular (LV) regional wall motion abnormalities (RWMA), myocardial injury and outcomes in Covid-19 pts. Methods: We conducted a cohort study including 7 hospitals in New York City (US) and Milan (Italy) of hospitalized pts with confirmed Covid-19 who had a TTE during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin (cTn) during the hospitalization. Using multivariable logistic regression, we analyzed the association between RWMA, myocardial injury and in-hospital death. Results: Among 305 total pts included in the study, 49 (16%) had RWMA and 44 (14%) had global LV systolic dysfunction. Among those with RWMA, 31/49 (63%) had LV ejection fraction Figure 1 ). Conclusion: In Covid-19 pts, RWMA are associated with typical ACS presentation: chest pain, ST changes and cTn elevations. Accordingly, a large proportion of pts with RWMA who underwent LHC had confirmed ACS warranting PCI. Though myocardial injury was associated with increased risk of in-hospital death regardless of the presence of RWMA, LHC should be considered for pts with RWMA and myocardial injury to rule-out obstructive disease.

Introduction: Myocardial injury is common amongst patients hospitalized with Covid-19 and is associated with a poor prognosis. It is unknown whether its incidence and its mechanisms differ by race and ethnicity. Methods: We conducted a multicenter, international cohort study at 7 hospitals in New York (United States) and Milan (Italy) between March and May 2020. All patients were hospitalized, had laboratory-confirmed Covid-19, and received a transthoracic echocardiogram (TTE) during their hospitalization. We evaluated the association between race/ethnicity and myocardial injury in multivariable logistic regression models. Myocardial injury was defined as any cardiac troponin elevation above the upper limit of normal at each enrolling site. Results: A total of 305 consecutive patients were included, of whom 280 had self-reported race/ethnicity. Key demographic, laboratory and echocardiographic characteristics are presented in the Table. All minority groups had higher incidence of a composite of major echocardiographic abnormalities compared to whites, and Asian and Hispanic patients had increased incidence of RV dysfunction. In multivariable models, compared with Whites, Black (adjOR 2.7 [1.1-6.4]), Asian (adjOR 3.3 [1.1-10.2]), and Hispanic (adjOR 2.8 [1.4-5.8]) patients had increased odds of myocardial injury. After adjusting for baseline demographic and clinical variables, both Asian (adjOR 9.9 [2.6-38.6]) and Hispanic (adjOR 5.7 [2.1-15.6]) patients had increased odds of in-hospital mortality compared with White, but not Black (adjOR 2.0 [0.6-7.0]) patients. Conclusions: Among hospitalized patients with Covid-19 who received a TTE, minority groups had higher incidence of echocardiographic abnormalities and increased risk of myocardial injury. After adjustment for baseline confounders, only Asian and Hispanic patients remained at increased risk for in-hospital mortality.

Background Identifying differences in modifiable lifestyle factors between persons with prehypertension and normal blood pressure (BP) can help improve prevention efforts. Methods Data from the 1999-2004 National Health and Nutrition Examination Survey were analyzed (in 2008) for persons aged at least 20 years (n = 11 194). Differences in five healthy lifestyle characteristics were examined by BP status (normal, prehypertension, and hypertension). Additionally, differences in lifestyle characteristics by sex, race/ethnicity, and education among those with prehypertension were analyzed. Results Overall, 32.8% of adults had a normal BMI, 75.3% did not smoke, 31.3% were regularly physically active, 57.7% were moderate drinkers or nondrinkers, and 28.1% had a low sodium intake; only 2% had all five characteristics. Almost 40% had a normal BP and 30.3% were prehypertensive. Those with prehypertension were less likely to have a normal BMI than normotensive individuals [adjusted odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.56-0.70], to be regularly active (adjusted OR = 0.85, 95% CI = 0.74-0.98), and to moderately/not drink (adjusted OR = 0.88, 95% CI = 0.80-0.97). Those with prehypertension or hypertension were less likely to have at least three or four healthy lifestyle characteristics compared with those with normal BP. Among 3168 persons with prehypertension, some sex, race/ethnic, and education level differences in the prevalence of healthy lifestyles were observed. Conclusion Differences in healthy lifestyle factors were observed by BP status, but the prevalence of healthy lifestyle factors is suboptimal among the population as a whole.

Background and Purpose— Stroke is a major cause of long-term disability in the United States. This study examined the national impact of stroke on health-related quality of life (HRQoL) and disparities in HRQoL across different demographic groups. Methods— Combined 2000 and 2002 Medical Expenditure Panel Survey data were used, which include quality-of-life measures based on the short-form generic measures (SF-12) and the EuroQol Group measures (EQ-5D index and EQ VAS) for 39 680 adults aged >18 years. Stratified analysis and ordinary least square regressions were used to compare HRQoL scores between stroke and nonstroke populations. Results— The study included 1040 noninstitutionalized stroke survivors. After adjustment for sociodemographics, risk factors, and comorbidities, stroke survivors had statistically significantly lower mean scores for mental health (−4.1%), physical health (−7.9%), health utility (−6.9%), and self-rated health (−7.2%) (all P P Conclusions— Stroke significantly impairs HRQoL in the United States. The findings suggest that racial and ethnic disparities in HRQoL among stroke survivors are more pronounced than in the nonstroke population. The burden of nonfatal stroke, especially among racial and ethnic minorities, should be recognized more widely.

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Background— Reducing health disparities remains a major public health challenge in the United States. Having timely access to current data on disparities is important for policy and program development. Accordingly, we assessed the current magnitude of disparities in cardiovascular disease (CVD) and its risk factors in the United States. Methods and Results— Using national surveys, we determined CVD and risk factor prevalence and indexes of morbidity, mortality, and overall quality of life in adults ≥18 years of age by race/ethnicity, sex, education level, socioeconomic status, and geographic location. Disparities were common in all risk factors examined. In men, the highest prevalence of obesity (29.2%) was found in Mexican Americans who had completed a high school education. Black women with or without a high school education had a high prevalence of obesity (47.3%). Hypertension prevalence was high among blacks (39.8%) regardless of sex or educational status. Hypercholesterolemia was high among white and Mexican American men and white women in both groups of educational status. Ischemic heart disease and stroke were inversely related to education, income, and poverty status. Hospitalization was greater in men for total heart disease and acute myocardial infarction but greater in women for congestive heart failure and stroke. Among Medicare enrollees, congestive heart failure hospitalization was higher in blacks, Hispanics, and American Indians/Alaska Natives than among whites, and stroke hospitalization was highest in blacks. Hospitalizations for congestive heart failure and stroke were highest in the southeastern United States. Life expectancy remains higher in women than men and higher in whites than blacks by ≈5 years. CVD mortality at all ages tended to be highest in blacks. Conclusions— Disparities in CVD and related risk factors remain pervasive. The data presented here can be invaluable for policy development and in the planning, implementation, and evaluation of interventions designed to eliminate health disparities.

Background and Purpose— Stroke mortality is higher among US blacks than it is among US whites. Few studies have examined racial and ethnic differences in the prevalence of cardiovascular disease (CVD) risk factors among stroke survivors, especially among Hispanics. Methods— Data are from 96 501 persons aged18 years or older who participated in the 1999, 2000, or 2001 National Health Interview Survey, a continuous annual household-based survey of the US population. Participants reported a history of stroke, hypertension, diabetes, myocardial infarction, and coronary heart disease. Other CVD risk factors were current smoking, overweight/obese, inadequate physical activity, and binge drinking. Results— Stroke was reported by 2.8% of blacks, 1.3% of Hispanics, and 2.2% of whites. Among 2265 stroke survivors, blacks were 1.65-times more likely (95% CI, 1.55 to 1.75) and Hispanics were 0.73-times less likely (95% CI, 0.69 to 0.78) than whites to report hypertension. Hispanics and blacks were more likely than whites to report diabetes ( P P P Conclusions— Racial and ethnic disparities exist in stroke prevalence and CVD risk behaviors and medical history. Targeted secondary prevention will be important in reducing disparities among Hispanic and black stroke survivors.

Unemployment has been associated with poor psychologic well-being. Using data from the 2001 Behavioral Risk Factor Surveillance System, we examined relationships between unemployment and frequent mental distress (FMD), defined as 14 or more mentally unhealthy days during the previous 30 days, among 98,267 men and women aged 25-64 years. The age-standardized prevalence of FMD was 6.6% (standard error, 0.14) among employed adults, 14.0% (2.00) among adults unemployed1 year, and 15.5% (1.18) among those unemployed1 year. After adjustment, the relative odds of FMD were 2.09 (95% confidence interval [CI] = 1.75-2.50) for adults unemployed1 year and 1.88 (95% CI = 1.31-2.71) for adults unemployed1 year compared with employed adults. Similar patterns were observed across gender, race/ethnicity, education, income, and area unemployment groups. Unemployed persons are a population in need of public health intervention to reduce the burden of mental distress. Public health officials should work with government officials to incorporate the health consequences of unemployment into economic policymaking.

Background and Purpose— Stroke is the third-leading cause of death and a leading cause of disability in adults in the United States. In recent years, leaders in the stroke care community identified a national registry as a critical tool to monitor the practice of evidence-based medicine for acute stroke patients and to target areas for continuous quality of care improvements. An expert panel was convened by the Centers for Disease Control and Prevention to recommend a standard list of data elements to be considered during development of prototypes of the Paul Coverdell National Acute Stroke Registry. Methods— A multidisciplinary panel of representatives of the Brain Attack Coalition, professional associations, nonprofit stroke organizations, and federal health agencies convened in February 2001 to recommend key data elements. Agreement was reached among all participants before an element was added to the list. Results— The recommended elements included patient-level data to track the process of delivering stroke care from symptom onset through transport to the hospital, emergency department diagnostic evaluation, use of thrombolytic therapy when indicated, other aspects of acute care, referral to rehabilitation services, and 90-day follow-up. Hospital-level measures pertaining to stroke center guidelines were also recommended to augment patient-level data. Conclusions— Routine monitoring of the suggested parameters could promote community awareness campaigns, support quality improvement interventions for stroke care and stroke prevention in each state, and guide professional education in hospital and emergency system settings. Such efforts would reduce disability and death among stroke patients.

OBJECTIVE: Few studies have investigated risk factors that predispose males to be involved in teen pregnancies. To provide new information on such factors, we examined the relationships of eight common adverse childhood experiences to a male’s risk of impregnating a teenager. METHODS: We conducted a retrospective cohort study using questionnaire responses from 7399 men who visited a primary care clinic of a large health maintenance organization in California. Data included age of the youngest female ever impregnated; the man’s own age at the time; his history of childhood emotional, physical, or sexual abuse; having a battered mother; parental separation or divorce; and having household members who were substance abusers, mentally ill, or criminals. Odds ratios (ORs) for the risk of involvement in a teen pregnancy were adjusted for age, race, and education. RESULTS: At least one adverse childhood experience was reported by 63% of participants, and 34% had at least two adverse childhood experiences; 19% of men had been involved in a teen pregnancy. Each adverse childhood experience was positively associated with impregnating a teenager, with ORs ranging from 1.2 (sexual abuse) to 1.8 (criminal in home). We found strong graded relationships (P < .001) between the number of adverse childhood experiences and the risk of involvement in a teen pregnancy for each of four birth cohorts during the last century. Compared with males with no adverse childhood experiences, a male with at least five adverse childhood experiences had an OR of 2.6 (95% confidence interval [CI] 2.0, 3.4) for impregnating a teenager. The magnitude of the ORs for the adverse childhood experiences was reduced 64 ‐100% by adjustment for potential intermediate variables (age at first intercourse, number of sexual partners, having a sexually transmitted disease, and alcohol or drug abuse) that also exhibited a strong graded relationship to adverse childhood experiences. CONCLUSION: Adverse childhood experiences have an important relationship to male involvement in teen pregnancy. This relationship has persisted throughout four successive birth cohorts dating back to 1900 ‐1929, suggesting that the effects of adverse childhood experiences transcend changing sexual mores and contraceptive methods. Efforts to prevent teen pregnancy will likely benefit from preventing adverse childhood experiences and their associated effects on male behaviors that might mediate the increased risk of teen pregnancy. (Obstet Gynecol 2002; 100:37‐ 45. © 2002 by The American College of Obstetricians and Gynecologists.)

Background Sudden cardiac death (SCD) is a major clinical and public health problem. Methods and Results United States (US) vital statistics mortality data from 1989 to 1998 were analyzed. SCD is defined as deaths occurring out of the hospital or in the emergency room or as “dead on arrival” with an underlying cause of death reported as a cardiac disease (ICD-9 code 390 to 398, 402, or 404 to 429). Death rates were calculated for residents of the US aged ≥35 years and standardized to the 2000 US population. Of 719 456 cardiac deaths among adults aged ≥35 years in 1998, 456 076 (63%) were defined as SCD. Among decedents aged 35 to 44 years, 74% of cardiac deaths were SCD. Of all SCDs in 1998, coronary heart disease (ICD-9 codes 410 to 414) was the underlying cause on 62% of death certificates. Death rates for SCD increased with age and were higher in men than women, although there was no difference at age ≥85 years. The black population had higher death rates for SCD than white, American Indian/Alaska Native, or Asian/Pacific Islander populations. The Hispanic population had lower death rates for SCD than the non-Hispanic population. From 1989 to 1998, SCD, as the proportion of all cardiac deaths, increased 12.4% (56.3% to 63.9%), and age-adjusted SCD rates declined 11.7% in men and 5.8% in women. During the same time, age-specific death rates for SCD increased 21% among women aged 35 to 44 years. Conclusions SCD remains an important public health problem in the US. The increase in death rates for SCD among younger women warrants additional investigation.

Background and Purpose —Elevated serum total homocyst(e)ine [H(e)] is an independent risk factor for stroke. Few studies, however, have examined this association in blacks. Methods —Data from the Third National Health and Nutrition Examination Survey (n=4534), a nationally representative sample of US adults, were used to examine the relationship between H(e) and a physician diagnosis of stroke (n=185) in both black and white adults. Multivariate-adjusted logistic regression analyses were used to examine this relationship. Results —Serum vitamin B 12 and folate concentrations were significantly lower among participants in the highest H(e) quartile (≥12.1 μmol/L) than among participants in the lowest quartile (≤7.4 μmol/L). Those in the highest quartile were older, had higher mean cholesterol and blood pressure levels, and were more likely to smoke and to have completed P =0.265 for race-H(e) interaction term]. The multivariate adjusted OR for the highest quartile versus the lowest was 2.5 (1.1 to 5.5) among whites and 1.4 (0.4 to 4.7) among blacks. Conclusions —In this nationally representative sample of US adults, H(e) concentration was independently associated with an increased likelihood of nonfatal stroke. This association was present in both black and white adults.

Background and Purpose —Although diabetes mellitus (DM) is known to increase the risk of cardiovascular disease (CVD), the effect of impaired glucose tolerance (IGT) on the risk remains unclear. We determined whether IGT was associated with an increased likelihood for stroke and myocardial infarction in a nationally representative sample of US adults. Methods —We evaluated the association between IGT (defined as a fasting glucose level of 140 mg/dL, or a plasma glucose level of >200 mg/dL 2 hours after administration of an oral glucose load) with a self-reported physician diagnosis of stroke and myocardial infarction in 6547 adults aged 40 to 74 years participating in the Third National Health and Nutrition Examination Survey. Multivariate logistic regression analyses were used to investigate these relationships. Results —IGT and DM were observed in 1494 and 1532 adults, respectively. After adjustment for differences in age, gender, race/ethnicity, education, hypertension, cholesterol, body mass index, and cigarette smoking, IGT was not associated with stroke (odds ratio [OR], 0.9; 95% confidence interval [CI], 0.5 to 1.6) or myocardial infarction (OR, 1.1; 95% CI, 0.7 to 1.6). DM was associated with both stroke (OR, 1.6; 95% CI, 1.0 to 2.6) and myocardial infarction (OR, 1.9; 95% CI, 1.3 to 2.8). Conclusions —In contrast to DM, IGT was not associated with an increased likelihood of prevalent nonfatal stroke or myocardial infarction.

Background and Purpose —Platelet glycoprotein IIb/IIIa (GpIIb-IIIa), a membrane receptor for fibrinogen and von Willebrand factor, has been implicated in the pathogenesis of acute coronary syndromes but has not been previously investigated in relation to stroke in young adults. Methods —We used a population-based case-control design to examine the association of the GpIIIa polymorphism P1A2 with stroke in young women. Subjects were 65 cerebral infarction cases (18 patients with and 47 without an identified probable etiology) 15 to 44 years of age from the Baltimore-Washington region and 122 controls frequency matched by age from the same geographic area. A face-to-face interview for vascular disease risk factors and a blood sample for the P1A2 allele and serum cholesterol were obtained from each participant. Logistic regression was used to estimate the odds ratio for one or more P1A2 alleles after adjustment for other risk factors. Results —Among cases and controls, the prevalence rates of one or more P1A2 alleles were 21% and 22% among blacks and 36% and 28% among whites, respectively. This genotype was significantly associated with hypertension only in black control subjects but otherwise not with any of the established vascular risk factors. The adjusted odds ratio for cerebral infarction of one or more P1A2 alleles was 1.1 (confidence interval [CI], 0.6 to 2.3) overall, 0.5 (CI, 0.1 to 7.1) among blacks, and 1.4 (CI, 0.5 to 3.7) among whites. For the cases with an identified probable etiology, the corresponding odds ratios were 3.0 (CI, 0.9 to 10.4) overall, 0.7 (CI, 0.1 to 7.1) among blacks, and 12.8 (CI, 1.2 to 135.0) among whites. Conclusions —No association was found between the P1A2 polymorphism of GpIIIa and young women with stroke. However, subgroup analyses showed that the P1A2 polymorphism of GpIIIa appeared to be associated with stroke risk among white women, particularly those with a clinically identified probable etiology for their stroke. Further work with an emphasis on stroke subtypes and with multiracial populations is warranted.

Physical activity is inversely associated with depressive symptoms, and cigarette smoking is positively associated with depressive symptoms. Data from the first National Health and Nutrition Examination Survey (NHANES I) and the NHANES I Epidemiologic Follow-up study were analyzed to determine whether the relationship between physical activity and self-reported distress (depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale) was different for cigarette smokers and nonsmokers. Logistic regression was used to calculate odds ratios (adjusted for age, race, sex, education, alcohol use, and perceived health status) for depressive symptoms (> or = 16) associated with physical activity and smoking status among 2,054 respondents. At baseline, the odds ratio for depressive symptoms was about 2 times higher for moderately active smokers and nonsmokers, and 3 times higher for low active smokers and nonsmokers, compared with highly active nonsmokers. For 1,132 persons with a low number of depressive symptoms (< 16) at baseline, the incidence of depressive symptoms after 7-9 yr of follow-up was about 2 times higher for low/moderately active smokers and nonsmokers than for highly active nonsmokers. The association between physical activity and the prevalence and incidence of depressive symptoms is not significantly modified by smoking status.

Background and Purpose A serum folate concentration ≤9.2 nmol/L has been associated with elevated levels of plasma homocyst(e)ine. Elevated homocyst(e)ine levels have been associated with ischemic stroke in case-control studies; however, the results from prospective studies have been equivocal. We investigated whether a folate concentration ≤9.2 nmol/L was associated with ischemic stroke in a national cohort. Methods We used data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (n=2006). Cox proportional hazards analyses were used to adjust for differences in follow-up time and covariates. During the 13-year follow-up, 98 ischemic strokes occurred. Results After adjusting for age, race, sex, education, diabetes, history of heart disease, systolic blood pressure, body mass index, hemoglobin level, cigarette smoking, and alcohol intake, participants with a folate concentration ≤9.2 nmol/L were at slightly increased risk for ischemic stroke (relative risk [RR], 1.37; 95% confidence interval [CI], 0.82 to 2.29). There was a folate-race interaction ( P =.11 for interaction term). Whites with a folate concentration ≤9.2 nmol/L had a relative risk of 1.18 (95% CI, 0.67 to 2.08), whereas blacks had a relative risk of 3.60 (95% CI, 1.02 to 12.71). Conclusions These findings suggest that a folate concentration ≤9.2 nmol/L may be a risk factor for ischemic stroke, especially in blacks. However, given the small number of stroke events, additional studies are needed to assess the role of folate in the epidemiology of ischemic stroke.

Most strokes occur among people aged 65 years and older. The increasing proportion of persons who are in this age group underlines the importance for health-care providers to be aware of trends in poststroke survival. We investigated poststroke survival trends from 1985 to 1989 among Medicare beneficiaries. Medicare hospital claim records and enrollment data were obtained on 1 901 439 Medicare patients with a principal diagnosis of stroke occurring during the years 1985 through 1989. Cox proportional hazard techniques were used to compare the 2-year poststroke survival for strokes occurring in 1986, 1987, 1988, and 1989 relative to strokes occurring in 1985. Poststroke survival trends were examined among groups defined by age, race, region, type of stroke, and, for a 20% subset, history of stroke. We observed a modest improvement in poststroke survival from 1985 to 1989 (1989:1985 hazard ratio, 0.96; P < .05). Trends for persons with hemorrhagic stroke showed more improvement (hazard ratio, 0.88; P < .05) than those for persons with ischemic stroke (hazard ratio, 0.98; P < .05). Improvement was also greater among persons without known prior hospitalization for stroke (hazard ratio, 0.94; P < .05) and during periods of follow-up shorter than 2 years. The variations in poststroke survival among subgroups of the population have important implications for the quality of life of stroke survivors and for the future medical and nursing needs of these populations.

Recommendations for identifying persons at high risk for coronary heart disease are based primarily on levels of total and low-density lipoprotein cholesterol. We examined whether, given knowledge of these levels, information on the high-density lipoprotein cholesterol level would improve the prediction of arteriographically documented coronary artery disease among 591 men. We found that even at levels of total and low-density lipoprotein cholesterol considered desirable, high-density lipoprotein cholesterol was inversely related to disease severity. For example, among the 112 men with a total cholesterol level180 mg per dl, the mean occlusion score (representing the overall severity of disease) was 107 among men with a high-density lipoprotein cholesterol levelor = 30 mg per dl vs a mean score of 52 among men with levelsor = 45 mg per dl. Furthermore, men with low levels of both low-density lipoprotein cholesterol (110 mg per dl) and high-density lipoprotein cholesterol (or = 30 mg per dl) had as much occlusive disease as did men with high levels of both lipoprotein fractions. Given information on the ratio of high-density lipoprotein cholesterol to total cholesterol, the actual levels of the lipoprotein fractions did not improve disease prediction. Our results emphasize the importance of considering high-density lipoprotein cholesterol when assessing coronary heart disease risk.

P72 Objective: To examine the association between hyperinsulinemia and blood pressure independent of body mass among nondiabetic white non-Hispanic, black non-Hispanic, and Mexican American adults. Methods: We examined this relationship using data from 8004 adults aged ≥20 years from the Third National Health and Nutrition Examination Survey (1988-1994). Univariate differences in body mass index (BMI), waist-to-hip ratio (WHR), glycosylated hemoglobin (HbA 1c ), fasting plasma glucose and C-peptide were examined between normotensives and hypertensives within each racial or ethnic group. Logistic regression was used to obtain the likelihood of being hypertensive across race specific tertiles of C-peptide adjusting for age, sex, education, BMI, and WHR. Results: The prevalence of hypertension was 21.1% among whites, 24.6% among blacks, and 10.9% among Mexican Americans. Hypertensives were older, with higher BMI, WHR, HbA 1c , fasting plasma glucose, and fasting C-peptide levels than normotensives. Also, the prevalence of hypertension increased significantly with C-peptide level for each of the racial or ethnic groups. Persons with a C-peptide in the upper tertile were more likely to be hypertensive than those with a C-peptide level in the lower tertile after adjustment for age, sex, education, and BMI (Mexican Americans OR=3.3, 95% CI=2.2-4.8; whites OR=2.0, 95% CI=1.5-2.7, blacks OR=2.0, 95% CI=1.3-3.0). Adjustment for WHR attenuated the association between C-peptide and hypertension (Mexican Americans OR=3.0, 95% CI=2.0-4.5; whites OR=1.6,95% CI=1.2-2.2; blacks OR=1.7, 95% CI=1.1-2.6). Conclusion: These results suggest that hyperinsulinemia is associated with hypertension independent of BMI and diabetes. Further, WHR was identified as a confounder and should be taken into account in addition to BMI when evaluating the relationship between C-peptide and hypertension.

0007 Anecdotal evidence and case reports indicate that sudden cardiac death (SCD) occurs in adolescents and young adults. To investigate the epidemiologic pattern and secular trend of SCD among ages 15-34 years, we analyzed US Multiple Causes of Death data from 1989 to 1996. SCD is defined as death due to cardiac disease (ICD-9 codes: 390-398, 402 and 404-429)that occurred out of hospital or in emergency room. This definition has been used in prior studies with reasonable accuracy. Mortality rates were calculated using mid-year population estimates as the denominators, and standardized to 1970. In 1996, 3,000 sudden cardiac deaths occurred for this specific age group, which reflects a 10% increase from 1989 (n=2,719). The leading underlying causes of SCD were ischemic heart disease (ICD codes 410-414, and 429.2), and arrhythmias or cardiomyopathies (ICD codes 425-427), each accounting for 35% of all SCDs. SCD mortality rates were twice as high in men as in women, and increased with age. From 1989 to 1996, age-standardized SCD mortality rates increased in both men (+10%) and women (+31%) ( Figure). Although SCD is relatively rare in US adolescents and young adults, the increased trend of SCD mortality warrants further investigation. This is the first national surveillance report on SCD in young adults. Figure 1.

P40 Objectives: To determine whether the Year 2000 national health objective for cholesterol screening was attained and to identify disparities in cholesterol screening across racial or ethnic and socioeconomic groups. Methods: Using data from the 1999 Behavioral Risk Factor Surveillance System, we estimated the proportion of adults aged ≥20 years who were screened for high blood cholesterol within the preceding 5 years. Results: Overall, an estimated 70.8% of the US population was screened for cholesterol, falling short of the Year 2000 objective of 75%. Screening prevalence was lowest at ages 20-44 years (58.2%) in contrast to ages 45-64 years (81.9%) and ages ≥65 years (87.1%). Screening prevalence was also lowest among Hispanics, especially Hispanic men. The likelihood of screening decreased with decreasing income level (p

Psychosocial factors arising from socioeconomic disadvantage and discrimination may contribute to the excess risk of elevated blood pressure in African-Americans. The purpose of this study was to assess the association of social support and stress with blood pressure in a community-based sample of 25-to 50-year-old black adults in Pitt County, NC. A stratified random sample of dwellings was selected in 1988, and 1,784 black adults (80% of those eligible) were interviewed. Analyses were sex specific and adjusted for age, obesity, and waist/hip ratio. In separate analyses of emotional support, instrumental support, and stress with blood pressure, all associations were in the predicted direction (inverse for support, direct for stress) but were stronger for systolic than for diastolic blood pressure. Differences in systolic blood pressure associated with low support or high stress ranged from 5.2 to 3.6 mmHg in women and 3.5 to 2.5 mmHg in men. In simultaneous regression analyses of support and stress, each of the separate effects was reduced for women, but a sizable aggregate effect of low support and high stress remained [+7.2 mmHg (95% confidence limits = +1.3, +13.1) for systolic blood pressure and +4.0 mmHg (95% confidence limits = +0.1, +7.9) for diastolic blood pressure.

A total of 202 patients with pharyngeal flaps were assessed with nasopharyngoscopy and multiview fluoroscopy to determine the role of lateral pharyngeal wall movement postoperatively. Variations in the construction of flaps resulted in three categories: namely, a long narrow flap with a high insertion, a short broad flap with a low insertion, and an intermediate-size flap that is inserted in a position somewhere between the first two. It was found that in all cases where there was no evidence of velopharyngeal insufficiency, the sole determiner of velopharyngeal closure was the medical excursion of the lateral pharyngeal walls to the sides of the flap. In flap failures, the causes for velopharyngeal insufficiency were inappropriate degree, level, and symmetry of the lateral pharyngeal wall motion. The success of pharyngeal flap surgery depends largely on the preoperative assessment of the velopharyngeal mechanism and the choice of a type of pharyngeal flap that will best assist closure of the velopharyngeal port during speech.

With the help of nasopharyngoscopy, it was possible to delineate specific morphologic changes in the palates of patients with velopharyngeal insufficiency, without an overt cleft and without the triad of symptoms of submucous cleft palate, visible through the oral cavity. Such malformations are part of the broad spectrum of the faulty midline mesodermal fusion of the palate. This anomaly is aptly called occult submucous cleft palate, because it can only be detected by viewing the functioning palate from the nasal surface. The musculus uvulae is either absent or deficient and is frequently associated with some degree of muscular diastasis that does not involve the oral surface. Like the cleft of the secondary palate, the submucous cleft palate often occurs as part of a generalized syndrome of multiple malformations.