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Background: Managing noncommunicable diseases through primary healthcare has been identified as the key strategy to achieve universal health coverage but is challenging in most low- and middle-income countries. Stroke is the leading cause of death and disability in rural China. This study aims to determine whether a primary care-based integrated mobile health intervention (SINEMA intervention) could improve stroke management in rural China., Methods and Findings: Based on extensive barrier analyses, contextual research, and feasibility studies, we conducted a community-based, two-arm cluster-randomized controlled trial with blinded outcome assessment in Hebei Province, rural Northern China including 1,299 stroke patients (mean age: 65.7 [SD:8.2], 42.6% females, 71.2% received education below primary school) recruited from 50 villages between June 23 and July 21, 2017. Villages were randomly assigned (1:1) to either the intervention or control arm (usual care). In the intervention arm, village doctors who were government-sponsored primary healthcare providers received training, conducted monthly follow-up visits supported by an Android-based mobile application, and received performance-based payments. Participants received monthly doctor visits and automatically dispatched daily voice messages. The primary outcome was the 12-month change in systolic blood pressure (BP). Secondary outcomes were predefined, including diastolic BP, health-related quality of life, physical activity level, self-reported medication adherence (antiplatelet, statin, and antihypertensive), and performance in "timed up and go" test. Analyses were conducted in the intention-to-treat framework at the individual level with clusters and stratified design accounted for by following the prepublished statistical analysis plan. All villages completed the 12-month follow-up, and 611 (intervention) and 615 (control) patients were successfully followed (3.4% lost to follow-up among survivors). The program was implemented with high fidelity, and the annual program delivery cost per capita was US$24.3. There was a significant reduction in systolic BP in the intervention as compared with the control group with an adjusted mean difference: -2.8 mm Hg (95% CI -4.8, -0.9; p = 0.005). The intervention was significantly associated with improvements in 6 out of 7 secondary outcomes in diastolic BP reduction (p < 0.001), health-related quality of life (p = 0.008), physical activity level (p < 0.001), adherence in statin (p = 0.003) and antihypertensive medicines (p = 0.039), and performance in "timed up and go" test (p = 0.022). We observed reductions in all exploratory outcomes, including stroke recurrence (4.4% versus 9.3%; risk ratio [RR] = 0.46, 95% CI 0.32, 0.66; risk difference [RD] = 4.9 percentage points [pp]), hospitalization (4.4% versus 9.3%; RR = 0.45, 95% CI 0.32, 0.62; RD = 4.9 pp), disability (20.9% versus 30.2%; RR = 0.65, 95% CI 0.53, 0.79; RD = 9.3 pp), and death (1.8% versus 3.1%; RR = 0.52, 95% CI 0.28, 0.96; RD = 1.3 pp). Limitations include the relatively short study duration of only 1 year and the generalizability of our findings beyond the study setting., Conclusions: In this study, a primary care-based mobile health intervention integrating provider-centered and patient-facing technology was effective in reducing BP and improving stroke secondary prevention in a resource-limited rural setting in China., Trial Registration: ClinicalTrials.gov NCT03185858., Competing Interests: The authors have declared that no competing interests exist.

The Salt Substitute and Stroke Study is an ongoing 5-year large-scale cluster randomized trial investigating the effects of potassium-enriched salt substitute compared to usual salt on the risk of stroke. The study involves 600 villages and 20,996 individuals in rural China. Intermediate risk markers were measured in a random subsample of villages every 12 months over 3 years to track progress against key assumptions underlying study design. Measures of 24-hour urinary sodium, 24-hour urinary potassium, blood pressure and participants' use of salt substitute were recorded, with differences between intervention and control groups estimated using generalized linear mixed models. The primary outcome of annual event rate in the two groups combined was determined by dividing confirmed fatal and non-fatal strokes by total follow-up time in the first 2 years. The mean differences (95% CI) were -0.32 g (-0.68 to 0.05) for 24-hour urinary sodium, +0.77 g (+0.60 to +0.93) for 24-hour urinary potassium, -2.65 mmHg (-4.32 to -0.97) for systolic blood pressure and +0.30 mmHg (-0.72 to +1.32) for diastolic blood pressure. Use of salt substitute was reported by 97.5% in the intervention group versus 4.2% in the control group (P<.0001). The overall estimated annual event rate for fatal and non-fatal stroke was 3.2%. The systolic blood pressure difference and the annual stroke rate were both in line with the statistical assumptions underlying study design. The trial should be well placed to address the primary hypothesis at completion of follow-up., Competing Interests: Disclosures After 24 months, salt substitute has been provided by Jiangsu Sinokone Technology Co. Ltd for free. The company does not participate in any aspect of the study design or implementation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Lowering sodium intake with a reduced-sodium, added potassium salt substitute has been proved to lower blood pressure levels. Whether the same strategy will also reduce the risks of vascular outcomes is uncertain and controversial. The SSaSS has been designed to test whether sodium reduction achieved with a salt substitute can reduce the risk of vascular disease. The study is a large-scale, open, cluster-randomized controlled trial done in 600 villages across 5 provinces in China. Participants have either a history of stroke or an elevated risk of stroke based on age and blood pressure level at entry. Villages were randomized in a 1:1 ratio to intervention or continued usual care. Salt substitute is provided free of charge to participants in villages assigned to the intervention group. Follow-up is scheduled every 6months for 5years, and all potential endpoints are reviewed by a masked adjudication committee. The primary end point is fatal and nonfatal stroke, and the 2 secondary endpoints are total major cardiovascular events and total mortality. The study has been designed to provide 90% statistical power (with 2-sided α = .05) to detect a 13% or greater relative risk reduction for stroke. The power estimate assumes a primary outcome event rate of 3.5% per year and a systolic blood pressure difference of 3.0mm Hg between randomized groups. Recruitment is complete and there are 20,996 participants (about 35 per village) that have been enrolled. Mean age is 65years and 49% are female. There were 73% enrolled on the basis of a history of stroke. The trial is well placed to describe the effects of salt substitution on the risks of vascular disease and death and will provide important policy-relevant data., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Cardiovascular diseases are the leading cause of death and disability in China. High blood pressure caused by excess intake of dietary sodium is widespread and an effective sodium reduction program has potential to improve cardiovascular health., Design: This study is a large-scale, cluster-randomized, trial done in five Northern Chinese provinces. Two counties have been selected from each province and 12 townships in each county making a total of 120 clusters. Within each township one village has been selected for participation with 1:1 randomization stratified by county. The sodium reduction intervention comprises community health education and a food supply strategy based upon providing access to salt substitute. Subsidization of the price of salt substitute was done in 30 intervention villages selected at random. Control villages continued usual practices. The primary outcome for the study is dietary sodium intake level estimated from assays of 24-hour urine., Trial Status: The trial recruited and randomized 120 townships in April 2011. The sodium reduction program was commenced in the 60 intervention villages between May and June of that year with outcome surveys scheduled for October to December 2012. Baseline data collection shows that randomisation achieved good balance across groups., Discussion: The establishment of the China Rural Health Initiative has enabled the launch of this large-scale trial designed to identify a novel, scalable strategy for reduction of dietary sodium and control of blood pressure. If proved effective, the intervention could plausibly be implemented at low cost in large parts of China and other countries worldwide., (© 2013.)

Background: Epidemiological studies have reported an association between self-reported short sleep duration and high blood pressure (BP). Our objective was to examine both cross-sectional and longitudinal associations between objectively measured sleep and BP., Methods: This study is ancillary to the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study. Blood pressure was measured in 2000 and 2001 and in 2005 and 2006. Sleep was measured twice using wrist actigraphy for 3 consecutive days between 2003 and 2005. Sleep duration and sleep maintenance (a component of sleep quality) were calculated. Analyses included 578 African Americans and whites aged 33 to 45 years at baseline. Outcome measures were systolic BP (SBP) and diastolic BP (DBP) levels, 5-year change in BP, and incident hypertension., Results: After we excluded the patients who were taking antihypertensive medications and adjusted for age, race, and sex, shorter sleep duration and lower sleep maintenance predicted significantly higher SBP and DBP levels cross-sectionally as well as more adverse changes in SBP and DBP levels over 5 years (all P < .05). Short sleep duration also predicted significantly increased odds of incident hypertension (odds ratio, 1.37; 95% confidence interval, 1.05-1.78). Adjustment for 16 additional covariates, including snoring and daytime sleepiness, slightly attenuated the associations between sleep and BP. Sleep duration appeared to mediate the difference between African Americans and whites in DBP change over time (P = .02)., Conclusion: Reduced sleep duration and consolidation predicted higher BP levels and adverse changes in BP, suggesting the need for studies to investigate whether interventions to optimize sleep may reduce BP.

Background: Microalbuminuria (MA) is a risk factor for cardiovascular and renal disease. However, little is known about the relation of nutritional factors to MA, especially in individuals without diabetes., Methods: Data collected by the International Population Study on Macronutrients and Blood Pressure from 1997 to 1999 were used to assess relations of multiple dietary factors (energy intake, macronutrients, and micronutrients) independent of lifestyle-related cardiovascular risk factors to MA (urinary albumin excretion, 30 to <300 mg/24 h). The study population included 4,381 Chinese, Japanese, UK, and US men and women without diabetes aged 40 to 59 years (17 population samples) without macroalbuminuria., Results: MA prevalences ranged from 3.1% to 5.5% for men and 2.6% to 4.6% for women in the 4 countries. With adjustment for age and country, the following nutrients considered singly (of 29) were related in logistic regression analyses to MA prevalence ( P < 0.05): for men, inversely, iron, vitamin C and E, estimated total simple sugar, omega-6 fatty acid, polyunsaturated fatty acid, and calcium (all expressed as caloric density) intake; for women, directly, 24-hour urinary sodium excretion and alcohol intake. In multivariate analyses, sugar, iron, polyunsaturated fats, and vitamin C and E intake (in men) and alcohol intake (women only) remained associated with MA ( P < 0.05). MA also was related directly to body mass index ( P < 0.05), blood pressure ( P < 0.001), and smoking ( P > 0.05) and inversely to education ( P < 0.05 in women)., Conclusion: In cross-sectional analyses, several nutrients were related to MA among men. Additional studies are required to confirm these findings.

Blood pressure and prevalence of high blood pressure are greater for northern than southern Chinese. Reasons for these differences are unclear. Relationships of north-south blood pressure differences with multiple dietary factors were investigated in 839 Chinese participants, International Study on Macronutrients and Blood Pressure (INTERMAP), 561 northern, 278 southern, aged 40 to 59 years. Daily nutrient intakes were determined from four 24-hour dietary recalls and 2 timed 24-hour urine collections. Average systolic/diastolic pressure levels were 7.4/6.9 mm Hg higher for northern than southern participants. Southern participants had lower body mass index, sodium intake, sodium/potassium ratio, and higher intake of calcium, magnesium, phosphorus, and vitamins A and C. Considered singly, with control for age and gender, several dietary variables (eg, body mass index, urinary sodium/potassium ratio, urinary sodium, dietary phosphorus, and magnesium) reduced north-south blood pressure differences by > or =10%. Controlled for age and gender, nondietary variables had little effect on north-south blood pressure differences. With inclusion in regression models of multiple dietary variables (sodium, potassium, magnesium or phosphorus, body mass index), north-south blood pressure differences became much smaller (systolic -1.1, diastolic 1.6 mm Hg) and statistically nonsignificant. In conclusion, multiple dietary factors accounted importantly for north-south blood pressure differences. Efforts are needed to improve nutrition in China, especially in the north, as well as in other populations including those in the United States, for prevention and control of adverse blood pressure levels and major adult cardiovascular disease.

Context: Although psychosocial factors are correlated, previous studies on risk factors for hypertension have typically examined psychosocial factors individually and have yielded inconsistent findings., Objective: To examine the role of psychosocial factors of time urgency/impatience (TUI), achievement striving/competitiveness (ASC), hostility, depression, and anxiety on long-term risk of hypertension. DESIGN, SETTING, AND STUDY POPULATION: A population-based, prospective, observational study using participant data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. A total of 3308 black and white adults aged 18 to 30 years (when recruited in 1985 and 1986) from 4 US metropolitan areas and followed up through 2000 to 2001., Main Outcome Measures: Fifteen-year cumulative incidence of hypertension (systolic blood pressure of 140 mm Hg or higher, diastolic blood pressure of 90 mm Hg or higher, or taking antihypertensive medication)., Results: The incidence of hypertension at year 15 was 15% from baseline and 13.6% from year 5. After adjusting for the same set of hypertension risk factors and each of the psychosocial factors of TUI, ASC, hostility, depression, and anxiety in 5 separate logistic regression models, higher TUI and hostility were significantly associated with risk of developing hypertension at 15-year follow-up for the total sample. Compared with the lowest score group, the adjusted odds ratio (OR) for TUI was 1.51 (95% confidence interval [CI], 1.12-2.03) for a score of 1; 1.47 (95% CI, 1.08-2.02) for a score of 2; and 1.84 (95% CI, 1.29-2.62) for a score of 3 to 4 (P for trend =.001). Compared with the lowest quartile group, the adjusted OR for hostility was 1.06 (95% CI, 0.76-1.47) for quartile 2; 1.38 (95% CI, 1.00-1.91) for quartile 3; and 1.84 (95% CI, 1.33-2.54) for quartile 4 (P for trend <.001). No consistent patterns were found for ASC, depression, or anxiety. Race- and sex-specific analyses and multivariable models with simultaneous adjustment for all 5 psychosocial factors and other hypertension risk factors had generally similar results., Conclusion: Among young adults, TUI and hostility were associated with a dose-response increase in the long-term risk of hypertension.

BACKGROUND: The SSaSS (Salt Substitute and Stroke Study) has shown that use of a potassium-enriched salt lowers the risk of stroke, total cardiovascular events, and premature death. The effects on cause-specific cardiac outcomes are reported here. METHODS: SSaSS was an unblinded, cluster-randomised trial assessing the effects of potassium-enriched salt compared with regular salt among 20 995 Chinese adults with established stroke and older age and uncontrolled hypertension. Post hoc efficacy analyses were performed using an intention-to-treat method and a hierarchical Poisson regression model adjusting for clustering to obtain rate ratios and 95% CIs. We assessed acute coronary syndrome, heart failure, arrhythmia, and sudden death. RESULTS: Over a mean 4.74 years follow-up, there were 695 acute coronary syndrome events, 454 heart failure events, 230 arrhythmia events, and 1133 sudden deaths recorded. The rates of events were lower in potassium-enriched salt group for all outcomes but CIs were wide for most: acute coronary syndrome (6.32 versus 7.65 events per 1000 person-years; rate ratio, 0.80 [95% CI, 0.65–0.99]); heart failure (9.14 versus 11.32 events per 1000 person-years; rate ratio, 0.88 [95% CI, 0.60–1.28]); arrhythmia (4.43 versus 6.20 events per 1000 person-years; rate ratio, 0.59 [95% CI, 0.35–0.98]); and sudden death (11.01 versus 11.76 events per 1000 person-years; rate ratio, 0.94 [95% CI, 0.82–1.07]; all P >0.05 with adjustment for multiple comparisons). CONCLUSIONS: These results suggest that use of potassium-enriched salt is more likely to prevent than cause cardiac disease but the post hoc nature of these analyses precludes definitive conclusions. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02092090. [ABSTRACT FROM AUTHOR]

BACKGROUND Health professionals' commitment is needed to address disparities in hypertension control by ancestry, but their perceptions regarding these disparities are understudied. METHODS Cross-sectional mixed methods study in a universal healthcare setting in the Netherlands. Snowball sampling was used to include professionals practicing in a large multicity conglomerate including the capital city. Online surveys were collected, and survey participants were randomly selected for in-depth interviews. We used quantitative and qualitative methods to analyze health professionals' awareness, beliefs, and possible interventions regarding these disparities. RESULTS We analyzed questionnaire data of 77 health professionals (medical doctors n  = 70, nurses = 7), whereas 13 were interviewed. Most professionals were women (59%), general practitioners (81%); and White-European (77%), with 79% caring for patients of diverse ancestry. Disparities in hypertension control by ancestry were perceived to exist nationally (83% [95% CI, 75;91]), but less so in health professionals' own clinics (62% [52;73]), or among their own patients (56% [45;67]). Survey respondents emphasized patient rather than provider-level factors as mediators of poor hypertension control by ancestry. The collection of data on patients' ancestry, updating guidelines, and professional training were considered helpful to reduce disparities. Interviewees further emphasized patient-level factors, but also the need to better educate health professionals and increase their awareness. CONCLUSIONS This explorative study finds that health professionals predominantly attribute disparities in hypertension control to patient-level factors. Awareness of disparities was lower for more proximate healthcare settings. These data emphasize the need to consider health professionals' perceptions when addressing disparities in hypertension control. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to reveal the latest evidence on salt reduction initiatives in China in order to identify the contextual cost-effective interventions, as well as the barriers encountered during China’s long march to reach its population salt reduction goal.Background: Population-based salt reduction has been considered as one of the most cost-effective strategies in the world for the prevention and control of noncommunicable diseases. China, along with its sustained economic growth, faces increasing burdens from chronic diseases such as cardiovascular and kidney diseases. With policy support and cross-sector collaboration, various salt reduction initiatives have been adopted in China in order to reduce such dietary risk, especially since the beginning of this millennium. Methods: This study conducted structured literature reviews in both English and Chinese databases and synthesized the latest evidence on the association of salt intake and health, as well as salt intake among Chinese and population-based salt reduction strategies in China and around the world. Findings: Dietary salt restriction has been found to contribute to the reduction of blood pressure among both the normotensives and hypertensives bringing associated reduced disease burdens and great public health benefits. With gender, ethnic, and regional variations, salt intake levels in the population in China are well above the recommended threshold and physiological need. Admittedly, excessive salt intake precipitates the high prevalence of hypertension and cardiovascular disease among the Chinese. Considering that the majority of the dietary salt is added during cooking in China, salt substitutes, salt restriction tools, and health education are the most common salt reduction initiatives with varying levels of effectiveness and acceptability among the Chinese population. Implication: Overwhelming evidence is in support of a well-coordinated nationwide salt restriction initiative as a key public health strategy for the prevention and control of hypertension and its related diseases. Orchestrated efforts from the government, industries, academia, health professionals, and the general public are required to achieve China’s long-term goal for salt reduction. [ABSTRACT FROM AUTHOR]

Background: Average sodium intake and stroke mortality in northern China are both among the highest in the world. An effective, low-cost strategy to reduce sodium intake in this population is urgently needed. Objective: We sought to determine the effects of a community-based sodium reduction program on salt consumption in rural northern China. Design: This study was a cluster-randomized trial done over 18 months in 120 townships (one village from each township) from five provinces. Sixty control villages were compared to 60 intervention villages that were given access to a reduced-sodium, added-potassium salt substitute in conjunction with a community-based health education program focusing on sodium reduction. The primary outcome was the difference in 24-hour urinary sodium excretion between randomized groups. Results: Among 1,903 people with valid 24-hour urine collections, mean urinary sodium excretion in intervention compared with control villages was reduced by 5.5% (-14mmol/day, 95% confidence interval -26 to -1; p = 0.03), potassium excretion was increased by 16% (+7mmol/day, +4 to +10; p<0.001), and sodium to potassium ratio declined by 15% (-0.9, -1.2 to -0.5; p<0.001). Mean blood pressure differences were -1.1 mm Hg systolic (-3.3 to +1.1; p = 0.33) and -0.7 mm Hg diastolic (-2.2 to +0.8, p = 0.35) and the difference in the proportion with hypertension was -1.3% (-5.1 to 2.5, p = 0.56). Conclusion: There were clear differences in population sodium and potassium intake between villages that were most likely a consequence of increased use of salt substitute. The absence of effects on blood pressure reflects the moderate changes in sodium and potassium intake achieved. Trial Registration: Clinicaltrials.gov identifier: . [ABSTRACT FROM AUTHOR]

Background: The treatment of many chronic illnesses involves long-term pharmaceutical therapy, but it is an ongoing challenge to find effective ways to improve medication adherence to promote good health outcomes. Cardioprotective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes, such as uncontrolled high blood pressure and hyperlipidemia, for patients with coronary heart disease. Poor adherence to cardioprotective medications, however, has been reported as a global health concern among patients with coronary heart disease, and it is particularly a concern in China.Objective: This study aimed to evaluate the efficacy of a mobile health (mHealth) intervention using 2 mobile apps to improve medication adherence and health outcomes.Methods: A randomized, placebo-controlled, 2-arm parallel study was conducted in a major university-affiliated medical center located in Chengdu, China. Participants were recruited by flyers and health care provider referrals. Each participant was observed for 90 days, including a 60-day period of mHealth intervention and a 30-day period of nonintervention follow-up. The study coordinator used WeChat and Message Express to send educational materials and reminders to take medication, respectively. Participants used WeChat to receive both the educational materials and reminders. Participants in the control group only received educational materials. This study received ethics approval from the Duke Health Institutional Review Board (Pro00073395) on May 5, 2018, and was approved by West China Hospital (20170331180037). Recruitment began on May 20, 2018. The pilot phase of this study was registered on June 8, 2016, and the current, larger-scale study was retrospectively registered on January 11, 2021 (ClinicalTrials.gov).Results: We recruited 230 patients with coronary heart disease. Of these patients, 196 completed the baseline survey and received the intervention. The majority of participants were married (181/196, 92.4%), male (157/196, 80.1%), and lived in urban China (161/196, 82.1%). Participants' average age was 61 years, and half were retired (103/191, 53.9%). More than half the participants (121/196, 61.7%) were prescribed at least 5 medications. The mean decrease in medication nonadherence score was statistically significant at both 60 days (t179=2.04, P=.04) and 90 days (t155=3.48, P<.001). Systolic blood pressure and diastolic blood pressure decreased in the experimental group but increased in the control group. The mean decrease in diastolic blood pressure was statistically significant at both 60 days (t160=2.07, P=.04) and 90 days (t164=2.21, P=.03). The mean decrease in systolic blood pressure was significantly different in the groups at 90 days (t165=3.12, P=.002).Conclusions: The proposed mHealth intervention can improve medication adherence and health outcomes, including systolic blood pressure and diastolic blood pressure.Trial Registration: ClinicalTrials.gov NCT02793830; https://clinicaltrials.gov/ct2/show/NCT02793830 and ClinicalTrials.gov NCT04703439; https://clinicaltrials.gov/ct2/show/NCT04703439. [ABSTRACT FROM AUTHOR]

BackgroundStudies on blood pressure (BP) in high-altitude areas are scarce and the results are controversial. Tibetans live in regions at high altitudes, and data on the prevalence of hypertension in this population is not currently well known.MethodsAll Tibetans aged 40 years and older living in the township of Yangbajing (4,300 m) in Tibet, China were invited to participate in the 2009 survey. BP was measured with electronic sphygmomanometers (calibrated by the results of a previous study). Histories of hypertension and medication use were collected through face-to-face interviews. Hypertension was defined as systolic BP (SBP) ≥140 mm Hg and/or diastolic BP (DBP) ≥90 mm Hg, or antihypertensive medication use in the past 2 weeks.ResultsA total of 701 adults (aged 40-89, 42.9% male, 94.9% herdsmen) were recruited. The mean (s.d.) SBP/DBP was 146.6 (31.3)/92.0 (15.7) mm Hg and the prevalence of hypertension was 55.9%. Of note, 61.2% of those with hypertension had stage 2 hypertension (SBP ≥160 or DBP ≥100 mm Hg). At age 70 years and older, the mean (s.d.) SBP/DBP were 182.8 (30.9)/102.6 (13.4) mm Hg. Among those with hypertension (n = 392), only 19.9% were aware of their condition, 2.6% were taking medication, and only one participant had controlled BP.ConclusionAccording to our survey in Yangbajing, Tibetan adults aged 40 years and older living at high altitudes had high BP and prevalence of hypertension with low awareness, treatment, and control. Future studies are needed to clarify the association between BP, altitude, and other possible causes.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.9 [ABSTRACT FROM AUTHOR]

Background Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. Methods Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease–related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. Results In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease–related and total charges were lower by $10 367 and $15 318 compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. Conclusion Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life. [ABSTRACT FROM AUTHOR]